James Ellsmere, MD MSc FRCSC

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Sleeve Gastrectomy as the Primary Procedure

• James Ellsmere, MD MSc FRCSC
• Surgical Director, Weight Loss Program
• QE II Health Sciences Centre
• Dalhousie University, Halifax NS

2
Disclosure

• Ethicon Endosurg speaking

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Sleeve Gastrectomy

• First used in staged approach for the super obese
• Increasingly being used as primary procedure with
  good weight loss and resolution of obesity
  related comorbidities
• Involves resecting the greater curvature of the
  stomach
• Reduces ghrelin levels for up to a year

Gagner et al. Surg Obes Relat Dis 2009
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Advantages

• Low mortality rate (0.39 percent)
• Low complication rate (3 to 8 percent)
• Low reintervention rate
• Preservation of the pylorus
• Maintenance of physiological food passage
• Avoidance of foreign material

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Disadvantages

• Long term follow-up is limited
• Can exacerbate GERD
• Leaks though manageable can be challenging

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International SG Expert PanelConsensus Statement

• Expert panelists were invited to participate
  according to their publications, knowledge and
  experience, and identification as surgeons who
  had performed 500 cases (gt12000 cases)
• Topics for consensus
• patient selection
• contraindications
• surgical technique
• prevention of complications
• management of complications

Rosenthal et al. Surg Obes Relat Dis 2012
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Objectives

• Review the ASMBS position on SG
• Discuss the common criticisms of SG
• Nova Scotia experience

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ASMBS 2011 Position Statement

• SG is acceptable option as a primary bariatric
  procedure
• SG has a risk/benefit profile that lies between
  LAGB and RYGB
• Long-term weight regain can occur and, in the
  case of SG, this could be managed effectively
  with re-intervention
• Informed consent for SG used as a primary
  procedure should be consistent with consent
  provided for other bariatric procedures and
  should include the risk of long-term weight gain

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Criticisms

• Earlier data suggest SG only half as good as DS
• Lack of long term data does not justify this
  approach
• Why base program on operation where we expect
  failure to be 30
• Poor outcomes have the potential to tarnish image
  of bariatric surgery
• SG complications though rare can be very
  challenging to manage

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Expected Excess Weight Loss
Brethauer et al. Surg Obes Relat Dis 2009
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Bougie

• The bougie is positioned on the lesser curve
  distal to the point of transection
• Too large will decrease expected weight loss
• Too small will increase risk of post-op nausea,
  stenosis and leak
• Most surgeons use 32-40F (range 30-60F)

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Michigan Bariatric Surgery Collaborative

• Comparative effectiveness analysis of the safety
  and effectiveness of SG, RYGB, and LAGB
• 9,000 patients matched on preoperative risk
  factors and predictors of weight loss outcomes to
  deal with the issue of selection bias
• Outcomes included complications occurring within
  30 days, weight loss, comorbidity resolution,
  quality of life, and patient satisfaction at 1,
  2, and 3 years follow-up

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Michigan Bariatric Surgery Collaborative

• Overall complication rates among patients
  undergoing SG (6.3) were significantly lower
  than for RYGB (10.0, plt0.0001) but higher than
  for LAGB (2.4, plt0.0001)
• Serious complication rates were similar for SG
  (2.4) and RYGB (2.5, p0.736) but higher than
  for LAGB (1.0, plt0.0001)
• Excess body weight loss at 1-year was 69 RYGB,
  60 SG, and 34 LAGB
• SG was similarly closer to RYGB than LAGB with
  regard to resolution of obesity-related
  comorbidities, quality of life, and patient
  satisfaction

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Co-morbidity Remission and Improvement
Brethauer et al. Surg Obes Relat Dis 2009
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Long-term follow-up after SG
16
NEJM, Vol 351, No.26, December 23, 2004
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Weight Change ()
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Unacceptable Failure Rate

• What definition of failure?
• EWL lt 50
• Persistent co morbidities
• Lack of lifestyle modification (diet exercise)
• How does the failure rate compare?
• SG 25-30
• RYGB 20
• LAGB 35-40
• Causes of failure are multifactorial
• Addressing anatomical issues without addressing
  lifestyle issues likely result in poor long term
  outcomes

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Poor Outcomes Tarnish Bariatric Surgery

• Weight regain though frustrating is accepted
  complication of bariatric procedures
• Debilitating complications like anemia secondary
  recalcitrant ulcers and internal hernias
  resulting in short gut syndrome can have a
  negative lasting effect
• Nutritional and Vitamin deficiency requiring
  hospital admission for management also tarnish
  image

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Managing Leaks is Challenging

• Early lt 48h
• repair, drain /- j tube for feeding
• Late gt 4 days
• drain j tube for feeding

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Options if Drainage Persists

• Refer to center with experience in endoscopic
  stenting, clips, glue
• If persists, consider RYGB
• Stoma appliance

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Nova Scotia SG Program

• The best option for morbidly obese patients is to
  have access to bariatric surgery program in their
  home province
• Patients who do not develop healthier lifestyle
  (diet and exercise) will fail any operation over
  the long term
• Patients undergoing malabsorptive procedures
  should have access to long term follow-up
• Deaths or significant number of complications
  would could potentially shut down program

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NS Experience

• 166 patients
• 136 female (82)
• Mean age 44 years (range 16-68, SD 10)
• Mean pre-operative BMI 49.6 (range 23.9-73.5, SD
  7)
• Mean operative time 93 min (range 56-232, SD 33)
• Mean hospital stay 2.6 (2-8, SD 0.8) days
• Reoperation rate 1.8

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Complications
Complication Number ()
Staple line leak 1 (0.6)
Bleeding 2 (1.2)
Sleeve stenosis 0
Death 0
Minor 7 (4.2)
Total 10 (6)
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Postoperative follow-up
Time (months postop) EWL (Range, SD) Number of patients/ Total eligible ()
6 49.3 (18.9-92.4, 13) 99/140 (71)
12 54.24 (0.7-95.9, 19) 59/109 (53)
24 64.4 (38.3-101, 31) 12/44 (27)
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Summary

• SG is acceptable option as a primary bariatric
  procedure
• SG has a risk/benefit profile that lies between
  LAGB and LRYGB
• Long-term weight regain can occur and, in the
  case of SG, this could be managed effectively
  with re-intervention

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Thank you

• James Ellsmere, MD MSc FRCSC
• James.Ellsmere_at_dal.ca

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Selection Criteria
Factor Criteria
Weight (adults) BMI gt 40 kg/m2 with no comorbidities BMI gt 35 kg/m2 with obesity-related comorbidity
Weight Loss History Failure of previous nonsurgical attempts at weight reduction, including nonprofessional programs (i.e. Weight Watchers)
Commitment Expectation that patient will adhere to post-op care Follow-up visits with physician's and team members Recommended medical management, including the use of dietary supplements Instructions regarding any recommended procedures or tests
Exclusion Reversible endocrine or other disorders that can cause obesity Current drug or alcohol abuse Uncontrolled, severe psychiatric illness Lack of comprehension of risks, benefits, expected outcomes, alternatives, and lifestyle changes required with bariatric surgery
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Nova Scotia WLS Program

• BMI gt 60
• Challenging to perform high quality sleeve with
  low complication rate
• Patients counseled and offered medically
  supervised diet/exercise plan
• Graduate 50 from program with excellent outcomes
• BMI 35 60
• Goal 10lb weight loss prior to sleeve

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Outcomes
Brethauer et al. Surg Obes Relat Dis 2009
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Access and Port Placement
Karmali et al. Can J Surg 2010
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Mobilization of the Greater Curvature
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Distal Transection Point

• The distal transection point is measured relative
  to the pylorus
• Too long will decrease expected weight loss
• Too short may effect gastric emptying
• Most surgeons start 5 cm (range 1-10 cm) proximal
  to the pylorus

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Bougie

• The bougie is positioned on the lesser curve
  distal to the point of transection
• Too large will decrease expected weight loss
• Too small will increase risk of post-op nausea,
  stenosis and leak
• Most surgeons use 32-40F (range 30-60F)

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Stapling

• The goal is the creation of a uniform gastric
  tube
• Requires optimal visualization and lateral
  traction on the stomach
• Avoid the esophagus - leave 1 cm of fundus as
  precaution

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Staple Line Reinforcement

• Staple-line was reinforced by 65.1 of the
  surgeons of these, 50.9 over-sew, 42.1
  buttress, and 7 do both
• Several series without buttress material with 1
  bleeding rate, 1 leak rate
• Consider optimal staple height, need for tissue
  compression, clipping bleeders and selectively
  oversewing

Gagner et al. Surg Obes Relat Dis 2009
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Staple Line Testing

• Intraoperative leak testing with air
  (gastroscope) and/or methylene blue dye
• Consider leaving drain

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Removing Specimen
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Sleeve Gastrectomy and Hiatal Hernia Repair

• Small cases series
• Morbid obesity is risk factor for failed hiatal
  hernia repair
• If large or symptomatic hernia and BMI gt 35,
  hernia repair sleeve is an option
• Post op course similar to sleeve alone

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Band to Sleeve

• Small case series
• Risk of complications higher than primary
  operation
• If treating band complications, consider two
  stage approach
• Avoid stapling through compromised tissue

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Low Rate of Complications

• High leak occurred in 1.5
• Lower leak in 0.5
• Hemorrhage in 1.1
• Splenic injury in 0.1
• Stenosis in 0.9
• GERD _at_ 3 mo 6.5 (range 0-83)
• Mortality was 0.2 /-0.9

Gagner et al. Surg Obes Relat Dis 2009
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Patient Decision

• Boils down to tolerance for risk and perceived
  risk reward
• Bariatric vs non-operative management question is
  clear
• Whats the best bariatric surgery for the patient
  is difficult to know

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Perioperative Outcomes of Laparoscopic Sleeve
Gastrectomy, Effectiveness in Short to Medium
Term Weight Loss and Improvement in Diabetes
Mellitus

• C. Hoogerboord MB ChB, MMed, S. Wiebe MD, D.
  Lawlor NP,
• R. Stewart BSc, T. Ransom MD, D. Klassen MD,
  J. Ellsmere MD, MSc (jellsmer_at_dal.ca)
• Department of Surgery, Division of General
  Surgery, Dalhousie University, Halifax NS

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Introduction

• Laparoscopic Sleeve Gastrectomy (LSG) is
  increasingly being performed as a stand-alone
  bariatric procedure with short and medium term
  weight loss and improvement in obesity associated
  comorbidities comparable to Laparoscopic
  Roux-en-Y Gastric Bypass, (LRYGBP) the current
  gold standard in bariatric surgery.

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Discussion

• LSG is gaining popularity as a final surgical
  treatment for morbid obesity
• Complications are infrequent but most significant
  for staple line leak (2), bleeding (1.2),
  sleeve stenosis (0.8) and death (0.19)1.

Gagner et al. Surg Obes Relat Dis 2009
46

• Effectiveness as weight loss procedure confirmed
  by several studies, 12 and 24 month EWL 55.8 and
  52.4 respectively in a systematic review of
  Brethauer et al2. More than weight loss seen
  with LAGB but somewhat less than with LRYGBP3.
• Concept of metabolic surgery now recognized by
  endocrine specialists. LSG led to 2 year
  remission rate of Type 2 DM of 75 vs 0 with
  optimal medical therapy in patients with BMIgt354.
  

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Aim

• To review our experience with Laparoscopic
  Sleeve Gastrectomy (LSG) in terms of
  perioperative outcomes, effectiveness in inducing
  weight loss and improvement or resolution of
  Diabetes Mellitus (DM) over a two year period

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Methods

• A retrospective review of prospectively recorded
  data was performed for all patients who underwent
  LSG from September 01, 2007 to June 30, 2011
• Patient demographics and perioperative data were
  collected.
• Postoperative follow-up data was obtained at 6,
  12 and 24 months and included Percentage Excess
  Weight Loss (EWL) for all patients
• In the subgroup of 85 patients with a
  preoperative diagnosis of DM, additional data
  included HbA1c, AC Glucose and improvement or
  resolution of Diabetes
• Improvement of DM was defined as a decrease in
  dose or number of anti-diabetic drugs required to
  control serum glucose whereas resolution was
  defined as normalization of AC glucose
  (lt5.6mmol/l) and HbA1c (lt6.5) with
  discontinuation of all anti-diabetic drugs

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Perioperative Results

• 166 patients
• 136 (82) female
• Mean age 44 (range 16-68, SD 10) years
• Mean pre-operative BMI 49.6 (range 23.9-73.5, SD
  7)
• Mean operative time 93 (Range 56-232, SD 33)
  minutes.
• One (0.6) conversion to laparotomy
• Mean hospital stay 2.6 (2-8, SD 0.8) days.
• Reoperation rate 1.8.

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Complications
Complication Number ()
Staple line leak 1 (0.6)
Bleeding 2 (1.2)
Sleeve stenosis 0
Death 0
Minor 7 (4.2)
Total 10 (6)
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Postoperative follow-up
Time (months postop) EWL (Range, SD) Number of patients/ Total eligible ()
6 49.3 (18.9-92.4, 13) 99/140 (71)
12 54.24 (0.7-95.9, 19) 59/109 (53)
24 64.4 (38.3-101, 31) 12/44 (27)
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Time (months postop) HbA1c (Range, SD) Number of patients/Total eligible ()
0 7.6 (4.5-14.0, 1.7)
6 6.3 (4.5-10.4, 1) 50/66 (77)
12 6.5 (4.4-9.5, 1.2) 27/52 (52)
24 6.2 (5.2-6.6, 0.5) 2/19 (11)
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Time (months postop) AC Glucose (mmol/l) (Range, SD)
0 8.3 (3.3-21.5, 2.9)
6 6.4 (2.2-22.0, 2.2)
12 6.9 (3.7-14.3, 2.3)
24 5.6 (4.2-6.3, 0.7)
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Diabetic outcomes at 12 months postop

• Resolution 21/27 (78)
• Improvement 2/27 (7)

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Conclusion

• LSG can be performed safely with acceptable
  complication rates at our institution
• It is an effective bariatric procedure and can
  play an important role as metabolic therapy for
  DM
• Longer term studies are needed

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Healthcare Economics

• Surgery is one arm of an expensive
  multidisciplinary intervention
• Reoperative outcomes are not as good as primary
  interventions in part because patient group
  already failed multidisciplinary intervention
• It may be more cost effective to offer the
  multidisciplinary intervention to a new person on
  the wait list vs revise someone who failed