SLEEVE GASTRECTOMY:
ANATOMIA DI UN DILEMMA TERAPEUTICO
IntroductionLaparoscopy achieves the same anatomic objectives as open bariatric surgery but avoids a large abdominal incision Bariatric surgery is the most effective method for achieving sustained weight loss of considerable degree in individuals with morbid obesitySurgeons should have a clear understanding of the four most commonly discussed operations for morbid obesity at this time:
1)Laparoscopic Roux-en-Y gastric bypass (LRYGB)
2)Laparoscopic adjustable gastric banding (LAGB)
3)Duodenal switch (DS)
4)Laparoscopic sleeve gastrectomy (LSG)
General overview of the various laparoscopic procedures for morbid
obesity
“La chirurgia dell obesita e accetabile
solamente se e efficace e sicura”
EFFICACITA
Perdita di al meno 50% del eccesso ponderale a 1 anno e a 3 anni
SLEEVE GASTRECTOMY
2000
come “ first step”
nelle
“ two stages” procedure
Cauto ottimismo entusiasmo
Esistono “ tendenze” :
la scelta del intervento nel ambito della chirurgia dell obesita, e arbitraria
(Necessita di guidelines )
VANTAGGI DELLA TECNICA
Riduzione dela capacita gastrica senza perdita funzionale
Assenza di dumping a causa della preservazione pylorica
Meccanismo “ ormonale”
DIFETTI
Rischi legati alla linea di sutura
Irreversibilita
Laparoscopic sleeve gastrectomy. A bariatric procedure with multiple indications.
Baltasar A: Cir Esp 2006 May;79 (5): 289-92.
30 patienti
63,1 % BMI (76 % nei vari sottogruppi nei due anni)
“Reduction of the ghrelin – production stomach mass may account for its sureriority to other gasric restrictive procedures…long – term studies are necessary to see if it is a durable procedure.”
Gumbs AA, Gagner M. Sleeve gastrectomy for morbid obesity
Obes.Surg 2007 Jul;17(7):962-9
RISULTATI I
A prospective multicenter study of 163 sleeve gastrectomies: results at 1 and 2 years.
Nocca D et al Obes Surg May2008; 18(5):560-5
EWL
48,9% 6 mesi 59,45% 1 anno
62,02% 18 mesi 61,5% 2 anni
RISULTATI II
Results of laparoscopic sleeve gastrectomy: a prospective study in 135 patients with morbid obesity.
Fuks D et al. Surgery 2009 Jan; 145(1) 106-13
EWL
38,6 6 mesi 49,4 1 anno
RISULTATI III
Feasibility and technique of laparoscopic conversion of adjustable gastric banding to
sleeve gastrectomy
Dapri G, Cadiere GB, Himpens J. Surg Obes. Relat Dis.2009
EWL
16,7% adizionale34,8 % totale(!!)
Laparoscopic sleeve gastrectomy: does bougie size affect mean %EWL? Short –
term outcomes.
Parikh M, Gagner M e altri. Surg Obes Relat Dis. 2008 Jul-Aug; 4(4):528-33
( 40 F vs 60 F) !!!???
MORBIDITA
Complicanze per operatorie
Complicanze post operatorie precoci
Complicanze tardive
COMPLICANZE PER OPERATORIE
Transezione gastrica
Emorragia
Ischemia splenica
Traumatismo hepatico
MORTALITA
0 – 3,2%
Aggarwal et al. Surgery Obes Rel Dis 3 2007;189-194
COMPLICANZE POST OPERATORIE PRECOCI
Fistola
Emorragia
Ascesso
COMPLICANZE POST OPERATORIE TARDIVE
Riflusso
Stenosi
COMPLICANZE
The First International Consensus Summit for Sleeve Gastrectomy (SG), New York City, October 25-27, 2007
SERIE PERSONALE (SLEEVE)
TECNICA
French position - 45 0 -Trocar ( 4+1)
TECNICA Infiltrazione anestesia locale
Ultracision
32 fr
Echelon 2 verdi 4-6 gold
Tissue thickness of human stomach measured on excised gastric speciments from obese patients
Elariny H, Gonzalez H, Wang B. Surg Technol Int 2005;14:119-24
Buscopan Drenagio
SG
Technical considerations
RISULTATI (SLEEVE)
EVOLUZIONE BMI (SLEEVE)
ΓΡΑΦΗΜΑ ΜΕΣΟΥ ΒΜΙ ΓΙΑ ΤΙΣ 3 ΧΡΟΝΙΚΕΣ ΠΕΡΙΟΔΟΥΣ
05
101520253035404550
TIME0 TIME6 TIME12
ΜΕΤΡΗΣΗ ΣΕ ΧΡΟΝΟ 0,6 ΜΗΝΕΣ,1 ΕΤΟΣ
ΜΕ
Η Τ
ΙΜΗ
EVOLUZIONE EWL (SLEEVE)
ΓΡΑΦΗΜΑ ΜΕΣΟΥ EWL (%) ΓΙΑ ΤΙΣ 2 ΧΡΟΝΙΚΕΣ ΠΕΡΙΟΔΟΥΣ
0
10
20
30
40
50
60
70
80
90
TIME6 TIME12
ΜΕ
ΣΗ Τ
ΙΜΗ
(%
)
COMPLICANZE I (SLEEVE)
COMPLICANZE II (SLEEVE)
1 anno
GERD = 11%
The mechanism of weight loss and resultant comorbidity improvement seen after sleeve gastrectomy may be related to gastric restriction or neurohumoral changes due to the gastric resection, or some other unidentified factor(s)
Published complication rates range from 0% to 24%, with an overall reported mortality rate of 0.39% Sleeve gastrectomy is probably at least as effective and durable as adjustable gastric banding at 1 and 3 years after surgery Long-term (5 yr) weight loss and comorbidity resolution data for sleeve gastrectomy have not been reported at this time
SG-1
SG-2
Weight regain or a desire for further weight loss in a super-super-obese patient may require the procedure to be revised to a gastric bypass or BPD with duodenal switch.
Sleeve gastrectomy appears to be a technically easier and/or faster laparoscopic procedure than Roux-en-Y GB or malabsorptive procedures in complex or high-risk patients, including the super-super-obese patient (BMI 60 kg/m2)
Sufficient as a “stand alone” procedure ?
From a technical standpoint, there appears to be no consensus regarding the optimal dilator size that should be used to create the lesser curve conduit (32F-60F !!!)
Complications and outcome of SG
Position Statement ASMBS 2007, Surgery for Obesity and Related Diseases 2007;3:573-6 `
AGB vs SG
Kueper M A et al. World J Surg 2008;32:1462-5
AGB vs SG
Kueper M A et al. World J Surg 2008;32:1462-5
AGB vs SG
Wong S KH et al. Hong Kong Med J 2009; 15:100-9
AGB vs SG
Wong S KH et al. Hong Kong Med J 2009; 15:100-9
In a randomized study comparing gastricbanding with sleeve gastrectomy (n = 80), was
found that the median percentage of excess weight loss at 3 years was 48% for gastric banding and 66% for sleeve gastrectomy
Himpens J et al. Obes Surg 2006;16:1450-6
AGB vs SG