SLEEVE GASTRECTOMY E ROUX-EN-Y GASTRIC · PDF fileROUX-EN-Y GASTRIC BYPASS: INDICAZIONI E CONTROINDICAZIONI Maurizio De Luca ... Roux-en-Y Gastric Bypass: ... Mini Gastric Bypass/One

SLEEVE GASTRECTOMY E

ROUX-EN-Y GASTRIC BYPASS:

INDICAZIONI E CONTROINDICAZIONI

Maurizio De Luca

Director Department of Surgery,Castelfranco and Montebelluna (Treviso) Hospital - Italy

International IFSO Delegate for the Italian Society of Bariatric and Metabolic Surgery

Co-Chairman of IFSO Position Statements Committee

Editorial Board Member of "Obesity Surgery Journal"Editorial Board Member of "SOARD" Editorial Board Member of "Scientific World Journal"

Sleeve Gastrectomy

(Gastrectomia Verticale)

Maurizio De Luca

Sleeve Gastrectomia e Roux-en-Y Gastric Bypass: Indicazioni e Controindicazioni

BPD/DS

Sleeve gastrectomy (SG) was first performed in 1988 by Hess and Hess as

part of a hybrid malapsorbitive procedure, the biliopancreatic diversion with

duodenal switch (BPD-DS)

80 EWL% at 24 months

9% Major complications

2 perioperative deaths (pulmonary complications)

Obes Surg. 1998 Jun;8(3):267-82.Biliopancreatic diversion with a duodenal switch.Hess DS, Hess DW.

Maurizio De Luca

Obes Surg. 2003 Dec;13(6):861-4.Early experience with two-stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-superobese patient.Regan JP, Inabnet WB, Gagner M, Pomp A.

In 2003 Regan et al. proposed a splitting of the procedure in two surgical

stages, laparoscopic SG (LSG) in the first stage and LRGBP after an

average 11-month interval (7 patients)

Laparoscopic sleeve gastrectomy with second-stage LRGBP is feasible

and effective procedures based on short-term results

Maurizio De Luca

2009: ASMBS therefore recognizes SG as an acceptable primary bariatric procedure

Maurizio De Luca

Sleeve GastrectomyTechnical aspects

Division of gastro-colic and gastro-splenic ligament

34-40 Frech bougie insertion

Vertical gastrectomy using a linear stapler

Removal of excised stomach from the abdomen

Staple line buttressing and/or oversewing (?)

Maurizio De Luca

Maurizio De Luca

%EWL at 1 year: 58,8%

%EWL at 3 year: 63%



SOARD 2014

SOARD 2014

Complete or near-complete resolution of weight related diseases:

Arterial hypertension: 72.4% of patients (n = 122),

Hyperlipidemia: 61.5% of patients (n = 98)

Obstructive Sleep Apnea: 87% of patients (n = 47)

Type 2 Diabetes ;ellitus 70.9% of patients(n = 143) (range = 46%–100%)

Maurizio De Luca

follow-up rate of 91%.

Maurizio De Luca

SOARD 2014

ABSOLUTE BMI AND DELTA BMI (BMI AT FOLLOW-UP - PREOPERATIVE BMI) AT 1, 3 AND 5 YEARS

Group 1 (n = 61) with BMI≤50

Group 2 (n = 44) with BMI>50

Maurizio De Luca

SOARD 2016

LSG AND T2DM

• 2/11 DM patients in Group 1 remained on hypoglycemic therapy

• 9/9 DM patients of Group 2 had good glycemic control without any medication.

Maurizio De Luca

SOARD 2016

Maurizio De Luca

Ann Surg. 2010

At 5-year follow-up, a mean EWL of 55.0± 6.8% was achieved

Severe reflux might necessitate conversion

Maurizio De Luca

Obes Surg 2010

Maurizio De Luca

Intraoperative complications occurred in 1.8%

Injuries of the spleen (0.40%)

Injuries of the liver (0.11%)

Bleeding (0.11%)

During postoperative hospitalization complications occurred in 5.9%

Staple line leakage was observed in 175 patients (1.5%)

SG Complications

Ann Surg 2016

Complication Chronicity Diagnosis Management

Hemorrhage

(1-6%)

Acute Physical findings, serial CBC

Transfusion with or without laparoscopy/laparotomy

Leak

(1-5%)

Acute/chronic Physical findings, UGI series

Drainage (infrared laparoscopy), antibiotics with or without stenting and/or repair

Abscess

(0,7%)

Chronic CT scan, ultrasound Drainage, antibiotics

Stricture

(0-3,5%)

Chronic Endoscopy, UGI series Endoscopy (dilatation), surgery (seroyotomy)

Nutrient deficiency

(3-23%)

Chronic Physical findings, blood work

Nutritional supplements

GERD

(0-47%)

Chronic History, endoscopy Treatment with proton pump inhibitor

Maurizio De LucaSG Complications

Surg Endosc 2012

230 patients

No GERD (literature is controversial)

Previuos iron or vitamin’s deficiency

History of extensive abdominal surgery

Gastric polyps, Hp+ recurrences

Surgeon experience

Superobese patients (staged surgery)

Indications to Sleeve Gastrectomy

Maurizio De Luca

Bypass Gastrico

(Roux-en-Y Gastric Bypass)

Maurizio De Luca

Sleeve Gastrectomy and Roux-en-Y Gastric Bypass: Indicazioni e Controindicazioni

Dr Ed Mason, IowaRoux-en-Y gastric bypass

Mason EE, Ito C. Gastric bypass in obesity. Surg Clin N Am. 1967; 47: 1345-51

Maurizio De Luca

Dr Ed Mason, IowaRoux-en-Y gastric bypass• 10th May 1966

• no blind loop

• 51 yrs old

• very little protein/caloriemalabsorption

• 100-150cm Roux limb

• vertical lesser curve gastric

pouch excluding fundus

(MacLean, Montreal)

Mason EE, Ito C. Gastric bypass in obesity. Surg Clin N Am. 1967; 47: 1345-51

Maurizio De Luca

‘‘Gastric bypass with asmall, 4-cm-long pouch<30ml’’

15-20ml verticallystapled lesser-curvegastric pouch stays thissize 6-8 years post-op

Late outcome of isolated gastric bypass. MacLean LD et al. Ann Surg 2000; 231: 524-8

Late outcome of isolated gastric bypass Maurizio De Luca

Maurizio De Luca

Drs. Mason and Ito initially developed this procedure in the 1966s

In 1994 Wittgrove and Clark reported the Laparoscopic Roux-en-Y

gastric bypass (LRYGB)

Maurizio De Luca

Obes Surg 1994

Mean percentage excess weight loss (%EWL) was 58.9% at 10+Year.

At 10 years, remission of co-morbidities was 46% for hypertension and

hyperlipidemia and 58% for diabetes mellitus

Thirty patients (9%) had revisional surgery for weight regain.

Sixty-four patients (19.5%) had long-term complications requiring surgery.

Maurizio De Luca

328 patients SOARD 2016

Maurizio De Luca

52 patients out of 89 with metabolic syndrome

The mean post-operative follow-up period was 6.9±2.3 years.

At the end of the follow-up, mean weight loss was 60±24 % EWL

Mean HbA1c level had significantly decreased from 64.8±19.7 to 46.4± 12.9 mmol/l

The number of patients with HT was significantly reduced from 73 % to 54

Overall medication used was reduced from 85 % to 37 % of the patients

Obes Surg 2014

Annals of Surgery October 2013

Maurizio De Luca

Annals of Surgery October 2013

Remission rate of T2DM after RYGB vs LSG (P = 0.006), RYGB vs LAGB (P<0.001), and LSG vs LAGB (P=0.04).

Maurizio De Luca

Maurizio De Luca

Gastric BypassTechnical aspects

AntecolicRetrocolic

Different limb lenght

Internal Hernia after LRYGBP has an incidence of 2.51%

Closure of mesenteric defects is recommended

Maurizio De Luca

Potential hernia sites in LRYGBP:

1)enteroenterostomy mesenteric defect;

2) space between mesentery of Roux limb

and transverse mesocolon (Petersen’s

space)

3) transverse mesocolon defect.

Overall mortality rate at 1, 5, and 10 years was 2.2%, 4.4%, and 8.1%

The rates of marginal ulcer were 0.3%, 0.7%, and 1%

The reoperation rates were 0.3%, 0.8%, and 1.2%

Maurizio De Luca

Obes Surg 2016

Early complications Anastomotic or staple line leaks (0.4% – 5.2%)

Postoperative hemorrhage (1,9 - 4,4%)

Small Bowel obstruction (1% - 9%)

Late complicationsGastrojejunostomy anastomotic stricture (1,9 - 23%)

Marginal ulceration (1%–16%)

Gastrogastric fistula (1,5 – 6%)

Weight regain (20% at 10 year)

Maurizio De Luca

Griffith PS, Birch DW, Sharma AM, Karmali S.Can J Surg. 2012

Our aim was to compare nutritional status after SG and GBP insubjects matched for postoperative weight

Forty-three subjects who underwent SG were matched for age,gender, and 6-month postoperative weight with 43 subjects whounderwent GBP

Maurizio De Luca

After surgery, LDL cholesterol, serum prealbumin, vitamin B12,urinary calcium, and vitamin D concentrations were lower after GBPthan after SG

Some nutritional parameters were specifically altered after GBP,which could be related to malabsorption or other mechanisms, suchas alterations in liver metabolism

Maurizio De Luca

Trends in percentage of procedures worldwide: from 2003 to 2013

Maurizio De Luca

Maurizio De Luca

GERD

No iron or vitamin’s deficiency

No history of extensive abdominal surgery

Pre-operative EGDS: negative

Type 2 Diabetes patients

Surgeon experience

Indications to Gastric Bypass

Maurizio De Luca

Mini Gastric Bypass/One Anastomosis Gastric Bypass

(Bypass con singola anastomosi)

Maurizio De Luca

Sleeve Gastrectomy and Roux-en-Y Gastric Bypass: Indicazioni e Controindicazioni

Maurizio De Luca

The MGB/OAGB combines two major components:

1)First is a long non-obstrutive gastric tube (Collis Gastroplasty), sizedequal to the diameter of the esophagus that rapidly delivers undigestedfood through the non-obstructive wide gastro-jejunostomy into the distaljejunum. This results in an exaggerated “Post-Gastrectomy Syndrome”that restricts the intake of food (without “obstruction”), limits the intake ofsugars, fat and large food boluses, but allows each of these inmoderation.

1)The PGS results in alteration of intestinal transit time, reduced acidsecretion, bloating, decreased appetite, decreased caloric intake.

1)The other component of the MGB is a moderate malabsorption due tothe bilio-pancreatic limb (150 - 250 cm) combined with a Billroth II gastro-jejunostomy that results in significantly more fat malabsorption and fattyfood intolerance then RNY.

MILLS JD. The post-gastrectomy syndrome. Can Med Assoc J. 1953 Sep;69(3):237-42

Eagon JC1, Miedema BW, Kelly KA., Postgastrectomy syndromes. Surg Clin North Am.1992 Apr;72(2):445-65.

Mini Gastric Bypass/One Anastomosis Gastric Bypass (MGB/OAGB)

Maurizio De Luca

Maurizio De Luca

1) This confusion is based upon the bariatric surgeon’srecollection of the failure of the old Mason Loop GastricBypass. In this early configuration, the gastric pouch was veryhigh, short and had a horizontal shape, exposing theesophageal mucosa to caustic alkaline bile reflux coming fromthe jejunal loop.

2) A Billroth II reconstruction of a total or near total gastrectomyis never appropriate and always fails as all general surgeonshave known since the early 1900’s.

3) The antrectomy vs distal gastrectomy and Billroth II isroutinely utilized today by general surgeons, trauma surgeonsand oncologic surgeons around the world.

Lee SW, Tanigawa N, Nomura E, et al. Benefits of intracorporeal gastrointestinalanastomosis following laparoscopic distal gastrectomy. World J Surg Oncol. 2012Dec 12;10:267.

Zang L. [Reconstruction following laparoscopic gastrectomy for gastric cancer].Zhonghua Wei Chang Wai Ke Za Zhi. 2012 Aug;15(8):787-9.


Maurizio De Luca

Maurizio De Luca


Outcomes

Maurizio De Luca

Comparison with Roux-en-Y Gastric Bypass (RYGB)


Maurizio De Luca


One anastomosis vs two anastomosis= relatively simple procedure shorter operative time shorter

learning curve (30 vs 100-500 cases)= absence of complications related to entero-enteric anastomosis

(difficult to reach it by endoscopy)

Absence of mesenteric defects = lower incidence of internal herniation and abdominal pain

Paroz A, Calmes Jm, Giusti V, et al.Internal hernia after laparoscopic Roux-en-Y gastric bypass for morbid obesity: a continuous challange in bariatric surgery. Obes Surg 2006


Maurizio De Luca


different size (1,5 - 3 cm) gastro-jejunostomy. restriction provided by the gastric pouch

= low pressure into the gastric body reduced leak rate= rare stoma stenosis no later dilatation of the gastric pouch

WJ, Wang W. Laparoscopic Roux-en-Y versus mini-gastric bypass for the treatment of morbidobesity: a prospective randomized controlled clinical trial.

Ann Surg 2005


Maurizio De Luca


complete absence of alimentary limb with 150 – 250 cm jejunal bypassed limb

= greater malabsorption better weight reduction 69.4% vs 79.2% at 2 years better weight loss superior diabetes remission

= greater malabsorption higher incidence of malnutrition, anemia oily stool, higher stool frequency (nevertheless similar quality of life)

Lee WJ, Ser KH, Lee YC, et al. Laparoscopic Roux-en-Y vs minigastric bypass for the treatment of morbid obesity: a10 years experience. Obes Surg. 2012


Maurizio De Luca


MGB: Increased bile reflux into the gastric pouch

• acid neutralizing effect low incidence of marginal ulcer

• no evidence of increased risk of gastric cancer due to chronic alkaline bile reflux

MGB: no evidence of higher gastric or esophageal cancer

Hansson LE, Nyren O, Hsing AW et al. The risk of stomach cancer in patients with gastric or duodenal ulcer disease. New Engl J Med 1996


Maurizio De Luca

Take home message: Sleeve, GBP or MGB?

•Expected weight loss

•Speed of weight loss

•Time of surgery

•Comorbidities

•Patients compliance

•RGE

•Previuos iron or vitamin’s deficiency

•History of extensive abdominal surgery

•Gastric polyps, Hp+ recurrences

•Risk of complications

•Surgeon skill and preference

Maurizio De Luca

Maurizio De Luca

Maurizio De Luca

XXV Congresso Nazionale SICOB6-8 Aprile 2017, Fondazione Cini, Venezia

Thank you

Maurizio De [email protected]

Documents

SLEEVE GASTRECTOMY E ROUX-EN-Y GASTRIC · PDF fileROUX-EN-Y GASTRIC BYPASS: INDICAZIONI E CONTROINDICAZIONI Maurizio De Luca ... Roux-en-Y Gastric Bypass: ... Mini Gastric Bypass/One