Sleeve Gastrectomy – A potential

successor to the Lap RYGB?

By John Liu - TUSM 3

Wednesday, December 10, 2008
General Surgery Clerkship
Newton-Wellesley Hospital
Bariatric Surgery

 In 1966, Dr. Edward Mason (Univ. of Iowa)

performed the first gastric bypass operation
 Goals
 Achieve better health by weight loss
 Minimize side effects and complications (strictures,
anastomotic leaks, nutritional deficiency, reoperations)
 Bariatric Surgery – only proven
method for achieving long term
weight loss
Laparoscopic Adjustable Gastric Banding Open or Lap. Roux-en-Y Gastric Bypass

-EWL 50% - Gold standard, EWL 49-70%

- mortality rate up to 0.05% - mortality rate 0.15%
- reoperative rate 25-50% - reoperative rate 5%
- no nutritional deficiency - moderate nutritional deficiency

Vertical Banded Gastroplasty Biliopancreatic diversion with duodenal switch

-EWL 40-60% -EWL 80-90%

- mortality rate up to 0.05% - mortality rate up to 1.9%
- reoperative rate 14-43% - reoperative rate 4%
- no nutritional deficiency - severe nutritional deficiency

I. Braghetto, O. Korn, H. Valladares, L. Gutierrez, A. Csendes, A. Debandi, J. Castillo, A. Rodriguez, A. M. Burgos, L. Brunet. Laparoscopic Sleeve
Gastrectomy: Surgical Technique, Indications and Clinical Results. Obesity Surgery. 17:1442-1450, 2007
Marceau P; Hould FS; Simard S; Lebel S; Bourque RA; Potvin M, Biliopancreatic diversion with duodenal
switch., World journal of surgery. 1998 Sep;22(9):947-54
Sleeve Gastrectomy

 Removal of 80% of the stomach

 Restrictive Procedure (can be converted to
combination malabsorptive with Duodenal Switch)
 Theoretically
 Advantages: no nutritional deficiency, pyloris is
preserved (no dumping), removal of ghrelin producing
cells in gastric fundus
 Disadvantages: ? %EWL, ? long-term results
SG and Endoscopic Intragastric
Balloon (as a first stage procedure)

LSG

IB

L. Milone, V. Strong, M. Gagner. Laparoscopic Sleeve Gastrectomy is Superior to Endoscopic Intragastric Balloon as a First
Stage Procedure for Super-Obese Patients (BMI > 50). Obesity Surgery. 15:612-617, 2005
Sleeve Gastrectomy and Gastric
Banding

80 total subjects

median BMI & age:

GB 37 & 36
SG 39 & 40

p < 0.0001

J. Himpens, G. Dapri, G. B. Cadiere. A Prospective Randomized Study Between Laparoscopic Gastric Banding and Laparoscopic Isolated Sleeve Gastrectomy: Results
after 1 and 3 Years. Obesity Surgery. 16:1450-1456, 2006
 Sleeve Gastrectomy and RYGB

Karamanakos SN. Vagenas K. Kalfarentzos F. Alexandrides TK. Weight loss, appetite suppression, and changes in fasting and postprandial ghrelin
and peptide-YY levels after Roux-en-Y gastric bypass and sleeve gastrectomy: a prospective, double blind study. Annals of Surgery. 247(3):401-7,
2008 Mar.
 Ghrelin levels after SG and RYGB
700 400

Karamanakos SN. Vagenas K. Kalfarentzos F. Alexandrides TK. Weight loss, appetite suppression, and changes in fasting and postprandial ghrelin and
peptide-YY levels after Roux-en-Y gastric bypass and sleeve gastrectomy: a prospective, double blind study. Annals of Surgery. 247(3):401-7, 2008 Mar.
 Appetite Changes after Sleeve
Gastrectomy and RYGB

Karamanakos SN. Vagenas K. Kalfarentzos F. Alexandrides TK. Weight loss, appetite suppression, and changes in fasting and postprandial ghrelin and
peptide-YY levels after Roux-en-Y gastric bypass and sleeve gastrectomy: a prospective, double blind study. Annals of Surgery. 247(3):401-7, 2008 Mar.
Indications for Sleeve Gastrectomy

 Initial weight loss procedure for the super-obese

(high risk patients with BMI > 60)
 Initial SG, an alternative to Gastric Banding prior to
RYGB to decrease comorbidities associated with
complications during and after surgery2,3
 Stand alone procedure for weight loss in patients
with BMI 35-40
Sleeve Gastrectomy – Surgical
Technique
Lap Sleeve Gastrectomy – Surgical
Technique

5 mm
15 mm I. Braghetto, O. Korn, H. Valladares, L. Gutierrez, A. Csendes, A.
10 mm 12 mm Debandi, J. Castillo, A. Rodriguez, A. M. Burgos, L. Brunet.
Laparoscopic Sleeve Gastrectomy: Surgical Technique, Indications
and Clinical Results. Obesity Surgery. 17:1442-1450, 2007
Lap Sleeve Gastrectomy – Surgical
Technique
Lap Sleeve Gastrectomy – Surgical
Technique
Lap Sleeve Gastrectomy – Surgical
Technique
Lap Sleeve Gastrectomy – Surgical
Technique
Start proximal to pyloris
Start proximal to pyloris
Staple towards incisura angularis
Stapling towards the Angle of His
Angle of His and Left Crus
Into the bag
Extracting the Gastric Fundus
Extracting the Gastric Fundus
The Specimen
Reinforce Staple Junctions
Check for Leaks
Conclusion

 Simple – no anastamosis
 No malabsorption
 Hormonal appetite suppression
 Good short term weight loss
 Long term weight loss?
 Other long term implications?
Acknowledgements
 Dr. Gazmuri and Dr. Partridge for their guidance and advice
on this topic
 Attendings – Dr. Biuckians, Dr. Cronin, Dr. Grady, Dr.
Gryska, Dr. Kahan, Dr. Lanuti, Dr. Lawlor, Dr. Masiakos, Dr.
Millham, Dr. Reinhorn, Dr. Sentissi, Dr. Vernon,
 General Surgery Residents Jen LaFemina, Dzifa Kpodzo,
Jonathon Greer, Sam Rodriguez, Becky, Hagit Bergman, Scott
Regenbogen , Patty Cho, Evan Zucker, Aranya Bagchi, Rachel
Robbins, Alex Hawkins,
 General Surgery MS3&4 colleagues – KC Collins, Matthew
Brady, Kate Anderson, Mika Sumiyoshi, Ben Caplan, Ken
Roach, Emily Rosene, Betzalel Reich
 Employees of NWH
Citations
1. J. Himpens, G. Dapri, G. B. Cadiere. A Prospective Randomized Study Between Laparoscopic Gastric Banding and
Laparoscopic Isolated Sleeve Gastrectomy: Results after 1 and 3 Years. Obesity Surgery. 16:1450-1456, 2006
2. D. Cottam, F. G. Qureshi, S. G Mattar, S. Sharma, S. Holover, G. Bonanomi, R. Ramanathan, P. Schauer.
Laparoscopic Sleeve Gastrectomy as an Initial Weight-Loss Procedure for High Risk Patients with Morbid Obesity.
Surgical Endoscopy. 20:859-863, 2006
3. A. Baltasar, C. Serra, N. Perez, R. Bou, M. Bengochea, L. Ferri. Laparoscopic Sleeve Gastrectomy: A Multi-Purpose
Bariatric Operation. Obesity Surgery. 15:1124-1128, 2005
4. I. Braghetto, O. Korn, H. Valladares, L. Gutierrez, A. Csendes, A. Debandi, J. Castillo, A. Rodriguez, A. M. Burgos,
L. Brunet. Laparoscopic Sleeve Gastrectomy: Surgical Technique, Indications and Clinical Results. Obesity Surgery.
17:1442-1450, 2007
5. Langer FB. Reza Hoda MA. Bohdjalian A. Felberbauer FX. Zacherl J. Wenzl E. Schindler K. Luger A. Ludvik B.
Prager G. Sleeve gastrectomy and gastric banding: effects on plasma ghrelin levels. Obesity Surgery. 15(7):1024-9,
2005 Aug.
6. L. Milone, V. Strong, M. Gagner. Laparoscopic Sleeve Gastrectomy is Superior to Endoscopic Intragastric Balloon as
a First Stage Procedure for Super-Obese Patients (BMI > 50). Obesity Surgery. 15:612-617, 2005
7. Karamanakos SN. Vagenas K. Kalfarentzos F. Alexandrides TK. Weight loss, appetite suppression, and changes in
fasting and postprandial ghrelin and peptide-YY levels after Roux-en-Y gastric bypass and sleeve gastrectomy: a
prospective, double blind study. Annals of Surgery. 247(3):401-7, 2008 Mar.
8. Marceau P; Hould FS; Simard S; Lebel S; Bourque RA; Potvin M, Biliopancreatic diversion with duodenal switch.,
World journal of surgery. 1998 Sep;22(9):947-54
9. M. Gagner, Minimally Edited Laparoscopic Sleeve Gastrectomy,
10. William B. Inabnet, Eric J. DeMaria, Sayeed Ikramuddin. Laparoscopic Bariatric Surgery. Published by Lippincott
Williams & Wilkins, 2004
11. Himpens J. Dapri G. Cadiere GB. A prospective randomized study between laparoscopic gastric banding and
laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years. Obesity Surgery. 16(11):1450-6, 2006 Nov.