2. Clinical Effects of bougie size on outcome of LSG

3. Effects of bougie size on outcome of LSG Thesis Submitted for partial fulfillment of M.D. Degree of General Surgery By Mohamed Elemam Elemam Elshawy (M.B.B.Ch - M.S.) Under Supervision of Prof. Dr. Tarek Mohamed Farid Elbahar Professor of General Surgery Assist. Prof. Mohamed Mahmoud Abouzeid Assistant Professor of General Surgery Dr. Medhat mohamed Helmy khalil Lecturer of General Surgery Faculty of Medicine Ain Shams University 2015

5. Morbid Obesity, Overview Obesity: is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/ or increased health problems.

6. Goal of treatment ● Reduce risk ● Improve obesity related co-morbidities. Goal of treatment ● Reduce risk ● Improve obesity related co-morbidities. The decision of which modalities to use is determined by: Patient's risk status, available resources and initial BMI. The decision of which modalities to use is determined by: Patient's risk status, available resources and initial BMI. An initial weight-loss goal of 10% over 6 months is a realistic target.

7. Non Surgical Management  Diet therapy.  Physical activity.  Pharmacotherapy

8. Medical Treatment has only been minimally successful in short-term and unsuccessful in the long-term Hence, It was the evolution of Bariatric Surgery.

9. Surgical Management It offers the only realistic chance of long-term weight reduction and resolution or improvement of co- morbidities for the majority of patients

10. Bariatric procedures:  Malabsorptive  Restrictive  Combination of the two procedures

11.  Considered a resectional form of M.&M. operation. Emerging as an effective bariatric operation. Especially attractive in high risk populations. With this weight loss procedure, 85% of the greater curvature is removed, leaving a tubularized stomach.

12.  Early 1990s, Hess & Hess first added SG, and simultaneously the DS, as a modification to the BPD.  Late 1990s, Gagner described a two-stage laparoscopic BPD/DS in High risk Super- obese patients.  Early 2010s, LSG was carried out as the first step of a two-stage laparoscopic RYGB.  Mid 2010s, The trend toward SG as a Stand-alone bariatric procedure has gained momentum

13.  Restriction of the capacity of the stomach to volume of 100 ml or less  Hormonal: ↓ Ghrelin  Rapid gastric emptying

16. Gastric Stapling to Complete LSG Exposure & dissection of the greater curvature Insertion of BOUGIE… Size? First Stapler fire Site ?? Division of the short gastric Vs

17. Surge in popularity due to :  Perceived Technical Simplicity  Feasibility  Excellent weight loss outcomes  Avoidance of a foreign body or adjustments  Shortened operating time  Immediate restriction of caloric intake

18.  100% consensus: Lack of Standardization  yields Confusion  95% consensus  following Known Best Practice Techniques  Better Outcome  89% consensus  Ideal Technique  guarantees patient Safety.

19.  Anesthesiologist insert it transorally.  Surgeon carefully positioned in the antrum under laparoscopic vision.  Sizing the Sleeve (Trelles and Gagner, 2007) ICSSG-1  LSG as part of a BPD-DS, 60 -Fr. bougie is used to ensure adequate protein intake.  For primary LSG, we use a 40 -Fr. Bougie  It could be smaller or greater (28-54 Fr.).

20.  Measuring Tool, long thin flexible tube.  Used as a Guide while dividing the Stomach  Unit of measurement  French So as 1 Fr. = 0.333 (1|3) …… So Then The Difference between their sizes is minimal  Is it possible that there are many differences among patients treated with these different types of catheters ? 32 Fr.  1.1 cm 36 Fr.  1.2 cm 40 Fr.  1.3 cm

21.  Bougie Size to be based on:  Patient Input: BMI  Surgeon Technique: how far stapling from the bougie, Oversewing staple line, use of Buttressing material  Type of Sleeve: Stand-alone bariatric procedure or first stage of two stage procedure

22.  ICSSG -2  using Bougie to Size the Sleeve YET  Ideal Bougie Size … no consensus in the review of literature? Smaller Bougie  Tighter Sleeve  more Complications: LEAK STRICTURE Upper GIT Discomfort Postop. Nausea Lareger Bougie  Wider Sleeve  Failure: less EWL Weight Regain

24. Compare the outcome following Laparoscopic Sleeve Gastrectomy when using 36-Fr. versus 40-Fr. calibrated bougie as regard the effects of each on the clinical outcome: Weight loss (EWL) of the patients and possible Complications.

26. Study Randomized Prospective study for 60 cases will be addressed at Ain Shams University hospital, Cairo, Egypt. Patients The patients will be classified into two groups, each will be 30 patients: Group A: 30 morbidly obese patients who will undergo LSG usi ng bougie size 36 Fr. Group B : 30 morbidly obese patients who will undergo LSG using bougie size 40 Fr.

27.  Age: more than 18 years.  Gender: both sexes  BMI > 40 kg/m2 or >35 kg/m2 with co- morbidity.  Bulky eaters  No endocrinal causes for obesity  Psychologically stable.  Sufficient non-surgical trials to reduce weight  Patients over 60 years old.  Contraindication to laparoscopy.  Patient refusal.  Psychological disturbances. Inclusion CriteriaExclusion Criteria

28. History Taking :  Any endocrine disorder  Any comorbidity as DM, HTN  Previous operations  Other systems review  Any Medications intake Examination:  General: V.D, Resp. fitness, CVS symptoms  Local Abdominal exam Investigations:  Labs: Routine Pre-op. labs, TFTs  Radiological: CXR, ECG, ECHO Pre-op. Work up Postop. Follow up Follow up to detect difference between 2 groups as regard:  Postoperative Weight Loss Compare BMI at 0, 1, 6, 12 months  Postoperative Complications  Time Period taken by the patient to return to Work

29. Outcome measures Compare between 2 Groups as regard the rate of the following:  Early Postoperative complications: Upper GIT discomfort manifestations leakage rates, hemorrhage  Late postoperative complications: Strictures reflux gastritis late leakage nutritional complications  Follow up BMI of the patient to assess the weight loss at 0, 1, 6, 12 months

30. Thank You