1. Laparoscopic Sleeve Gastrectomy
T Sammour, AG Hill, P Singh, A Ranasinghe
R Babor, H Rahman

2. Obesity in NZ In NZ: 1 in 4 adults are obese
(2007 MOH survey => 26.5%; CI 25.5 – 27.5)
cf Australia “obesity epidemic” in 2001
=> 17% of adults obese
Obesity picture worse in South Auckland…
Lower socioeconomic group
High proportion of Maori and Pacific Islanders

5. Obesity surgery Offered at CMDHB since March 2007
2 Surgeons and nurse specialist
MDT input
Dietician
Endocrinologist
Anaesthetist
Lap sleeve gastrectomy procedure of choice

6. Sleeve Gastrectomy Technique 4 port laparoscopy 36F boogie
4cm from pylorus
Selective re-inforcement
Air leak test
Bands no funding or clinic resources for rechecks, minor complication surgery
Wt loss not as good, and similar complication rate overall.

7. Criteria for Surgery European consensus guidelines * Must
20 – 65 years old
BMI > 40, or ≥ 35 with comorbidities
Must
quit smoking
establish regular exercise program
lose atleast 0.5kg / week between appointments
maintain 3 weeks of Optifast diet pre-operatively
Approx 10kg wt loss expected preop
* Fried et al. Interdisciplinary European guidelines on surgery of severe obesity. Obesity Facts 2008;1:52–58.

8. Audit
Retrospective review of the first 100 patients at Counties Manukau DHB
March 2007 – August 2008
Data collected:
Demographics
Pre-op weight / BMI
Comorbidities (defined by treatment)
Operative variables
Complications / mortality
Weight Loss
Resolution of obesity-related comorbidities
Patient satisfaction score

9. Patients Mean age 42.7 years (20 – 60) Sex Ethnicity
Male 20%
Female 80%
Ethnicity
European 60%
Maori 19%
PI 12%
Mean weight kg (96.7 – 211.9)
Mean BMI 50.2 kg/m2 (36.0 – 73.0)
45 patients super-obese by definition

10. Medical Comorbidities
Diabetic %
All but one patient type II
20% on insulin
HTN on medication 45%
Hyperlipidaemic on medication 25%
OSA on CPAP %
Other Cardiovascular 8%

11. Results Median hospital stay 2 days (1 – 7)
Mean follow-up months (0.9 – 23.3)
Mean weight loss 40.9 kg (4.4 – 78.2)
Median satisfaction 10 (3 – 10)
Mean excess wt loss 63.2% (7.2 – 129)

13. Comorbidity Resolution
Diabetes
48.0% stopped medication
24.0% reduced medication
Hypertension
35.6% stopped medication
24.4% reduced medication
Hyperlipidemia
5 of 25 stopped medication
OSA
9 of 17 came off CPAP

14. Operative morbidity Mortality 0% Major complication 8.0%
1 iatrogenic transected stomach => converted to open
3 staple line leaks
1 requiring laparotomy and suture of pinhole leak
1 stented (distal stricture)
1 normal diag lap on D3, CT leak collection on D22 => perc drain
2 staple line bleeds
1 requiring laparotomy
1 re-laparoscopy and application of surgicell
1 infected haematoma requiring laparotomy
1 critical stricture requiring endoscopic dilation

15. Operative morbidity Minor complication 2.0% Other readmit 6.0%
1 patient had normal diagnostic lap for presumed bleed
1 umbilical hernia requiring open mesh repar
No port site wound infections
No DVT / PE
Other readmit 6.0%
4 readmit for pain / vomiting
1 constipation requiring enema
1 leg pain and swelling => USS no DVT

16. Conclusion
Laparoscopic sleeve gastrectomy has achieved satisfactory weight-loss results, with > 60% excess weight loss in the medium term.
Acceptable complication rate.
Long term weight loss results are awaited.

18. Largest (of two) published RCT
A Prospective Randomized Study Between Laparoscopic Gastric Banding and Laparoscopic Isolated Sleeve Gastrectomy: Results after 1 and 3 Years
Jacques Himpens, MD; Giovanni Dapri, MD; Guy Bernard Cadière,MD, PhD
Department of Gastrointestinal and Obesity Surgery
Saint-Pierre University Hospital, Brussels, Belgium
Obesity Surgery 2006, 16,
Largest (of two) published RCT
80 patients
mean BMI 38
% Excess wt loss at 1yr
Band 41.4%
Sleeve 57.7 % (p = )
% Excess wt loss at 3yrs
Band 48.0%
Sleeve 66.0 % (p = )

19. Complications

20. % Excess wt loss at 6 months
1st published RCT
20 patients
mean BMI 47.5
No post-op complications in either group
% Excess wt loss at 6 months
Band 28.7%
Sleeve 61.4% (p = 0.001)

21. Ghrelin Band (n = 10) Sleeve (n = 10)
Day 1: No change in plasma ghrelin
1 month: Significant increase
6 months: Significant increase
Sleeve (n = 10)
Day 1: Significant decrease
1 month: Remained stable (low)
6 months: Remained stable (low)
Ghrelin is the only consistently reported hunger regulating hormone, produced in the fundus of the stomach. Significantly increased in diet induced weight loss.
In fact, consistent with 5 other studies showing either no change or increase in levels post banding.

22. ASERNIP 2002 - bands Level of evidence:
Average (up to 4 years follow-up).
Safety:
Banding lower short term mortality than VBG and gastric bypass
Not enough long term and morbidity data.
Efficacy:
Banding is as effective, up to 4 years.
Not enough long term data.
Recommendations:
Long-term efficacy of gastric banding remains unproven and further evaluation is recommended.

23. Adelaide 600 bands, 7 years follow-up
Preop BMI 43
25.7% complication rate (10.4% perioperative, 15.3% on long term).