Roles of Laparoscopic Sleeve Gastrectomy in Bariatric Surgery Vincent Lau TKOH

Obesity is a global pandemic! Obesity (BMI>30kg/m2) is a global pandemic affecting about 25% of population in the developed countries and 10% of the population in the developing countries1 Age-standardised prevalence of overweight and obesity and obesity alone, ages ≥20 years, by sex, 1980–2013 Ng M, Fleming T, Robinson M et al. Lancet 2014;384:766-781

We are not only the second in World’s GDP, but also… The prevalence of overweight and obesity in children and adolescents is increasing, and we can see the prevalence obesity of Chinese boys and girls is catching up with that of the united state.

Obesity cause 3.4 Millions death in 2010 Obesity is associated with multiple physical and psychological diseases, such as DM, HT, depression and musculoskeletal problems. In 2010, overweight and obesity were estimated to cause 3.4 millions deaths, 4% of years of life lost, and 4% of disability-adjusted left-years (DALYs) worldwide

Prevalence of type 2 DM and We have near 1,400,000,000 people! 11.9% 9.3%

The BMI threshold for Bariatric Surgery is now: 27.5 1991 NIH Consensus Statement BMI > 40 BMI > 35-40 + severe comorbids IFSO-APC Consensus Statements 2011 BMI ≥27.5 + DM or metabolic syndrome Bariatric Surgery needs YOU!

Laparoscopic Sleeve Gastrectomy Significant weight loss DM remission rate comparable with gastric bypass Relative Safer Shorter learning Curve

1st part of 2 stage procedures Particular considerations LSG 1st part of 2 stage procedures Particular considerations ? 2nd stage for those with suboptimal response to LAGB Stand-alone bariatric/metabolic procedures

LSG is increasing performed worldwide in just last few years!

Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity. Sleeve gastrectomy, was initially a part of BPD/DS in super obese patients. Cottman in 2006 showed that SG resulted in significant weight loss and improvement in comorbidities and ASA classes in patients with BMI>60kg/m2 with serious cormorbidities. Some patients was able to undergo 2nd stage surgery resulting in further weight loss. 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 And Other Interventional Techniques: June 2006, Volume 20, Issue 6, pp 859-863

Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity.   Preop 12 mo after stage I 6 mo after stage II p value Mean weight (kg) 177 131 109 <0.05 Body mass index 65 ± 9 49 ± 8 39 ± 8 Co-morbidities 9 ± 3 6 ± 3 2 ± 1 ASA ≥ 3 94% 44% NA

BMI Is Predictive of Higher In-hospital Mortality in Patients Undergoing Laparoscopic Gastric Bypass but Not Laparoscopic Sleeve Gastrectomy or Gastric Banding For gastric bypass, there was an increased of in-hospital mortality (0.01 and 0.02 vs 0.34%; P< 0.01) and major complications (0.93 and 0.99 vs 2.6%; P< 0.01) in the BMI 60kg/m2 or greater group. Villamere J, Gebhart A, Vu S et al. Impact of BMI in Laparoscopic Bariatric Surgery. The American Surgeon 2014; 80: 1039-43 Sleeve gastrectomy, was initially a part of BPD/DS in super obese patients. Cottman in 2006 showed that SG resulted in significant weight loss and improvement in comorbidities and ASA classes in patients with BMI>60kg/m2 with serious cormorbidities. Some patients was able to undergo 2nd stage surgery resulting in further weight loss.

1st part of 2 stage procedures LSG 1st part of 2 stage procedures

Local data: Stand-alone LSG with maximal follow-up up to 6 years 49 patients, 17M & 32F Mean age:44.8 ± 8.9 years Mean BMI: 39.8 ± 4.5kg/m2 Mean FU period : 39.8 ± 4.5 months 75% DM patients 86% HT Duration from OT to trough weight 14.3 ± 8.3 months EWL: by 64.5 ± 21.4% Mean Trough BMI 29.5 ± 4.5kg/m2 ↓ DM 58% ↓ HT 23% ↓LDL-C ↓TG ↑ HDL-C All P< 0.05 by paired T tests

Excess Weight Loss after Sleeve Gastrectomy: A systematic reviews Excess Weight Loss after Sleeve Gastrectomy: A systematic reviews Fischer L, Hildebrandt C, Bruckner T et al. Obesity Surgery;2012:22:721-731 In a recent systematic review including 123 papers describing 12,129 patients, the mean EWL after sleeve gastrectomy is about 59% at 1 year, 64.5% at 2 years and 60.9% at 4 years. This study also showed that the EWL at 2 years is similar to that of gastric bypass surgery5

36 Papers ( n≥100 ) involving 8,785 patients

% EWL is Similar between LSG and LRYGB In Kehagias study, 60 patients were equally randomized to LRYGB or LSG, the mean age and BMI and female to male ratio were similar. The mean BMI was around 45 in each group. It showed that that LSG have significant better EWL in 1st and 2nd years. There was no significant difference in the overall improvement of comorbidities8. Nutritional deficiencies occurred at the same rate in two groups except vitamin b12 deficiency which was more come after LRYGB (p=0.05). There was no mortality in both groups, and complications rate was similar. Kehagias I, Karamanakos SN, Argentou M, et al. Randomized Clinical Trial of Laparoscopic Roux-en-Y Gastric Bypass Versus Laparoscopic Sleeve Gastrectomy for the Management of Patients with BMI<50 kg/m2. Obesity Surgery;2011:21:1650-1656

TABLE 1 Early results of the Swiss Multicentre Bypass or Sleeve Study (SM-BOSS): a prospective randomized trial comparing laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass. Peterli R; Borbely Y; Kern B; Gass M; Peters T; Thurnheer M; Schultes B; Laederach K; Bueter M; Schiesser M Annals of Surgery. 258(5):690-4; discussion 695, 2013 Nov. DOI: 10.1097/SLA.0b013e3182a67426 TABLE 1 . Patient Descriptives © 2013 by Lippincott Williams & Wilkins. 2

FIGURE 1 Early results of the Swiss Multicentre Bypass or Sleeve Study (SM-BOSS): a prospective randomized trial comparing laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass. Peterli R; Borbely Y; Kern B; Gass M; Peters T; Thurnheer M; Schultes B; Laederach K; Bueter M; Schiesser M Annals of Surgery. 258(5):690-4; discussion 695, 2013 Nov. DOI: 10.1097/SLA.0b013e3182a67426 FIGURE 1 . A, Change in BMI (means +/- standard error). B, EBMIL (means). © 2013 by Lippincott Williams & Wilkins. 4

LSG Results in 80% DM remission as compared to Medical Treatment 30 patients in each group All diabetic with morbid obesity BMI: LSG:41.3±6 kg/m2 ; medical treatment 39±5.5 kg/m2 Post LSG: BMI 28.3± 5.4kg/m2 at 18 months, 80% DM remission Leonetti F, Capoccia D, Coccia F et al. Obesity, type 2 Diabetes Mellitus, and other comorbidites;:A prospective cohort study of laparoscopic sleeve gastrectomy vs medical treatment. Arch Surg 2012:8:694-700

LSG is Better than Laparoscopic Adjustable Gastric Banding Mean EWL: 50.6% and 51.8% at 6 and 12 months DM improved in 82.5.% DM patients LABG Mean EWL: 33.9% and 37.8% at 6 and 12 months DM improved in 61.8% DM patients Wang S, Li P, Xiao F et al. Comparison between laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding for morbid obesity: a meta-analysis Obesity Surgery. 23(7):980-6,2013 Jul.

FIGURE 2 Early results of the Swiss Multicentre Bypass or Sleeve Study (SM-BOSS): a prospective randomized trial comparing laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass. Peterli R; Borbely Y; Kern B; Gass M; Peters T; Thurnheer M; Schultes B; Laederach K; Bueter M; Schiesser M Annals of Surgery. 258(5):690-4; discussion 695, 2013 Nov. DOI: 10.1097/SLA.0b013e3182a67426 FIGURE 2 . Reduction in comorbidity 1 year after surgery. No significant difference in cure or improvement of comorbidities between LSG and LRYGB except for GERD (*P = 0.008). GERD indicates gastro esophageal reflux disease; OSAS, obstructive sleep apnea syndrome; T2DM, type 2 diabetes. © 2013 by Lippincott Williams & Wilkins. 5

GBP vs SG GBP Mean EWL 72.5% at 12 months DM remission: Yip S, Plank L, Murphy R. Gastric bypass and sleeve gastrectomy for type 2 diabetes: a systematic review and meta-analysis of outcomes. Obesity Surgery.2013;23:1994-2003

1st part of 2 stage procedures LSG 1st part of 2 stage procedures Stand-alone bariatric/metabolic procedures

LSG as a Revisonal Procedure after Adjustable Gastric Band? Similar EWL % as compared with revision to LRYGB. Ranging from 23% to 74% Higher complications rate as primary procedures All the included studies are cohort studies. Coblijn UK, Verveld CJ,van, Wagensveld BA et al. Laparosopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy as Revisional Procedure after Adjustable Gastric Band- a Systematic review. Obesity Surgery 2013;23:1899-1914

1st part of 2 stage procedures Particular consideration LSG 1st part of 2 stage procedures Particular consideration ? revisional procedure for failing LAGB Stand-alone bariatric/metabolic procedures

Thank You!

TABLE 2 Early results of the Swiss Multicentre Bypass or Sleeve Study (SM-BOSS): a prospective randomized trial comparing laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass. Peterli R; Borbely Y; Kern B; Gass M; Peters T; Thurnheer M; Schultes B; Laederach K; Bueter M; Schiesser M Annals of Surgery. 258(5):690-4; discussion 695, 2013 Nov. DOI: 10.1097/SLA.0b013e3182a67426 TABLE 2 . Perioperative Morbidity © 2013 by Lippincott Williams & Wilkins. 3

EWL of Sleeve, gastric band and gastric bypass in systemic reviews How are the results of SG compared to other bariatric procedures? In most previous reviews, the EWL is better then gastric banding and but not as good as gastric bypass surgery6.

RYGB and SG Alter the defended level of body weight Preventing normal responses to food restriction that make maintaining significant non-surgerically induced weight loss so difficult Both associated with metabolic improvement that are distinct from those that are caused by weight loss alone Similar effects on key metabolic parameters, ingestive behavior, gut hormone secretion

LSG vs LSG+DS BMI 48±9% DM: 51% HT: 62% OSAS 63% 378 patients, EWL at 1 year 53 ± 18% at 12 months, EWL 50±19% at 2 years, and EWL at 51±24% vs 83%±16% at 3 years DM remission: 56% vs 90%; HT remission 54% vs 76%; OSAS 43% vs 74% One 30 days mortality from PE, 30 days complications occurred in 6% vs 8% (P= 0.2) BMI: 48±6% DM: 37% HT: 49% OSAS 51% 422 patients EWL at 1year: 81 ±14% EWL at 2 years: EWL at 3 years: 83±16%

BPD+DS: provides further improvement of associated co- morbidites LSG alone: significant 3 years weight loss, and remission of co-morbidities BPD+DS: provides further improvement of associated co- morbidites Biertho L, Lebel S, Marceau S et al. Laparoscopic sleeve gastrectomy: with or without duodenal switch? A consecutive series of 800 cases. Digestive Surgery. 31(1):48-54, 2014

Table 1. Early and late complications after adjustable gastric banding, gastric bypass, and sleeve gastrectomy. AGB % Ref. SG GBP Early Leak 3.4 [97] 3.6 [37] Bleeding 2.4 [27] Stricture Death [37] and [98] 0.08 [14] 0.2 Late Ablation 60 [40] Reflux 23 Obstruction 3.1 [99] Migration/Erosion 1.6 [100] Dumping 13.3 [34] Slippage 12.5 [101] abdominal pain 9.8 Port 8.4 [102] %EWL< 50% 50 [46] %EWL < 50% 33 [103] [32]

GBP vs SG 1 Studies published between 1 Jan 2007 and 30 April 2012 1375 patients, 3 RCT and 18 prospective and 12 retrospective studies Yip S, Plank L, Murphy R. Gastric bypass and sleeve gastrectomy for type 2 diabetes: a systematic review and meta-analysis of outcomes

Weight and Type 2 diabetes after Bariatric Surgery Systematic review and meta-analysis Buchwald H, Estok R, Fahrbach K et al. The American Journal of Medicine 2009;122:248-256 Table 8. Overview of Weight Loss, Surgical Procedure, and Diabetes Resolution Total Gastric Banding Gastroplasty Gastric Bypass BPD/DS % EBWL 55.9 46.2 55.5 59.7 63.6 % Resolved overall 78.1 56.7 79.7 80.3 95.1 % Resolved <2 y 55 81.4 81.6 94 % Resolved ≥2 y 74.6 58.3 77.5 70.9 95.9

Fig. 1 Forest plot of comparison: (1) LAGB vs LSG in terms of short-term results, outcome: (1.1) resolution of diabetes. Odds ratios are shown with 95 % CIs

Evolution of Sleeve Gastrectomy