When ? Indications Contraindications ?

Indications First step in Super Super Morbidly Obese Patient Followed by RYGBP or BPD First step to a Non Bariatric second procedure Followed by Hip replacement, Recurrent Incisional Hernia, pull through procedure for UC, etc

Indications Final step in Cohn's disease Final step in ASA IV Morbidly Obese Patient Low EF, Heart ort Kidney transplant Final step if that is the patients choice Final step in Cohn's disease Final step in extremes of age Adolescents ( no needles !!!!!!) Elderly

Indications Final Step after failed Malabsorptive procedure Reversal of JIBP Final step in poor candidate for RYGBP/BPD Smoker, Coumadin, etc Final step in high risk stomach Chile, Colombia, Japan. High incidence of gastric cancer !!

Technical Considerations How to do it

Surgical technique 7 ports Harmonic scalpel 38 Fr boogie LSG was performed using a 7 port technique, 5-12mm, and 2 5-mm trocars. Harmonic scalpel was used to ligate the short gastric vessels beginning 5 cm from the pylorus extending to the GE junction. A 52 or 44 Fr bougie was used to create the sleeve with endolinear staplers 7

Jossart et al

LSG first or final step ? Results

LSG as a first step ?

Probability of Developing Complications after Gastric Bypass according to Weight Livingston et al. Annals of Surg. Nov 2002. 576-582

Review of the Literature Almogy G, Crookes PF, Anthone GJ. Longitudinal gastrectomy as a treatment for the high-risk super-obese patient. Obes Surg. 2004 Apr;14(4):492-7 RESULTS: At 12months: Median weight loss: 44.5 kg, % EWL 45.1%. After 1 year: 40% of the followed patients achieved more than 50% EWL and another 50% needed less medications for their associated co-morbidities

Sleeve to LGB January 2002 to February 2004 N 2186 Primary bariatric procedures performed. N 123 Consecutive laparoscopic sleeve gastrectomies using a 50 F Bougie N 23 Patients completed the second stage LRYGBP. Schauer et al

Results of LSG Operative time 174 ± 51 min Length of stay 3 ± 1.7 days Death 0 EWL one year 46 % Schauer et al

Change in BMI over Time Schauer et al

Down staging Pre-SGL Pre-LRYGB BMI 63 48 ASA IV 56% 1% ASA III 43% 34% Co morbidities 10 6 Sleep Apnea 82% 43% T2DM 60% 23% Peripheral edema 100% 0% Schauer et al

LSG as A Final Step?

RESULTS N 130 LSG between Nov 04 and Jan 07 2.4 female : 1 male Mean age 45.6 (12 -79) years Mean preop. weight was 122.4 (95.5 - 206.1) Kg The mean BMI was 43.2 (30.2 - 75.4) Kg/m2

RESULTS Mean operative time 97 (range: 58 – 180) mins No conversions Mean hospital stay was 3.2 (range: 1 – 19) days. There was no mortality in this series.

RESULTS N 130 24 m 43.2 27.1 67.9 Initial 3 m 6 m 12 m 18 m BMI (Kg/m2) WL (Kg) * %EWL 43.2 36.9 21.0 33.1 32.8 31.2 50.8 29.5 37.4 62.2 28.0 39.5 64.4 27.1 41.7 67.9

Results Age (Yrs) Gender Type of DM Duration Table 1. Total Sample Demographic Characteristics (N=30) Age (Yrs) Gender Type of DM Duration (N=30) (N=30) (N=30) (N=30) 42.3 F - 21(70%) Type I - 3 (10%) <5 years-16(53%) (21-69) M - 9 (30%) Type II - 27 (90%) >5 years-14(47%)

DISCUSSION 58 / 83 62.2 / 67.9 Author No Initial BMI (g/m2) Follow up in (Months) %EWL 1 to 2 years Baltasar Cottam Han Himpens Hammoui Lee Mognol Silecchia Rosenthal 31 126 60 40 118 216 10 41 130 * 65 37 39 55 49 64 57 43.2 3 – 27 12 24 62.3/NR 45/NR 81/NR 58/NR 49/NR 58 / 83 51/NR NR/NR 62.2 / 67.9

Conclusions and questions

Questions that remain open to be answered: What will be the %EWL at 15 years when compared to RGBP ? Will the gastric tube dilate ? What is the best size of the boogie ? Will Ghrelin levels drop and stay down as expected ?

Questions that remain open to be answered: What % of SG will be converted to RYGBP ? Will the long term results be as good as other purely restrictive procedures as LAGB/VBG

Conclusions Not all bariatric patients face the same operative risk Sleeve Gastrectomy is a valid surgical option for weight loss with excellent short term outcomes

Conclusions Unknown long term outcomes May be an option for the very low and very high risk patients Excellent option for the elderly and adolescents

Thank you!