1. Sleeve Gastrectomy as the Primary Procedure
James Ellsmere, MD MSc FRCSC
Surgical Director, Weight Loss Program
QE II Health Sciences Centre
Dalhousie University, Halifax NS

2. Disclosure
Ethicon Endosurg – speaking

3. Sleeve Gastrectomy First used in staged approach for the super obese
Increasingly being used as primary procedure with good weight loss and resolution of obesity related comorbidities
Involves resecting the greater curvature of the stomach
Reduces ghrelin levels for up to a year
Gagner et al. Surg Obes Relat Dis 2009

4. Advantages Low mortality rate (0.39 percent)
Low complication rate (3 to 8 percent)
Low reintervention rate
Preservation of the pylorus
Maintenance of physiological food passage
Avoidance of foreign material

5. Disadvantages Long term follow-up is limited Can exacerbate GERD
Leaks though manageable can be challenging

6. International SG Expert Panel Consensus Statement
Expert panelists were invited to participate according to their publications, knowledge and experience, and identification as surgeons who had performed 500 cases (>12000 cases)
Topics for consensus
patient selection
contraindications
surgical technique
prevention of complications
management of complications
Rosenthal et al. Surg Obes Relat Dis 2012

7. Objectives Review the ASMBS position on SG
Discuss the common criticisms of SG
Nova Scotia experience

8. ASMBS 2011 Position Statement
SG is acceptable option as a primary bariatric procedure
SG has a risk/benefit profile that lies between LAGB and RYGB
Long-term weight regain can occur and, in the case of SG, this could be managed effectively with re-intervention
Informed consent for SG used as a primary procedure should be consistent with consent provided for other bariatric procedures and should include the risk of long-term weight gain

9. Criticisms Earlier data suggest SG only half as good as DS
Lack of long term data does not justify this approach
Why base program on operation where we expect failure to be 30%
Poor outcomes have the potential to tarnish image of bariatric surgery
SG complications though rare can be very challenging to manage

10. Expected Excess Weight Loss
Bougie size 60f
Brethauer et al. Surg Obes Relat Dis 2009

11. Bougie
The bougie is positioned on the lesser curve distal to the point of transection
Too large will decrease expected weight loss
Too small will increase risk of post-op nausea, stenosis and leak
Most surgeons use 32-40F (range 30-60F)

12. Michigan Bariatric Surgery Collaborative
Comparative effectiveness analysis of the safety and effectiveness of SG, RYGB, and LAGB
~ 9,000 patients matched on preoperative risk factors and predictors of weight loss outcomes to deal with the issue of selection bias
Outcomes included complications occurring within 30 days, weight loss, comorbidity resolution, quality of life, and patient satisfaction at 1, 2, and 3 years follow-up

13. Michigan Bariatric Surgery Collaborative
Overall complication rates among patients undergoing SG (6.3%) were significantly lower than for RYGB (10.0%, p<0.0001) but higher than for LAGB (2.4%, p<0.0001)
Serious complication rates were similar for SG (2.4%) and RYGB (2.5%, p=0.736) but higher than for LAGB (1.0%, p<0.0001)
Excess body weight loss at 1-year was 69% RYGB, 60% SG, and 34% LAGB
SG was similarly closer to RYGB than LAGB with regard to resolution of obesity-related comorbidities, quality of life, and patient satisfaction

14. Co-morbidity Remission and Improvement
Brethauer et al. Surg Obes Relat Dis 2009

15. Long-term follow-up after SG

16. NEJM, Vol 351, No.26, December 23, 2004

17. Weight Change (%)

18. Unacceptable Failure Rate
What definition of failure?
EWL < 50 %
Persistent co morbidities
Lack of lifestyle modification (diet & exercise)
How does the failure rate compare?
SG 25-30%
RYGB 20%
LAGB 35-40%
Causes of failure are multifactorial
Addressing anatomical issues without addressing lifestyle issues likely result in poor long term outcomes

19. Poor Outcomes Tarnish Bariatric Surgery
Weight regain though frustrating is accepted complication of bariatric procedures
Debilitating complications like anemia secondary recalcitrant ulcers and internal hernias resulting in short gut syndrome can have a negative lasting effect
Nutritional and Vitamin deficiency requiring hospital admission for management also tarnish image

20. Managing Leaks is Challenging
Early < 48h
repair, drain +/- j tube for feeding
Late > 4 days
drain + j tube for feeding

21. Options if Drainage Persists
Refer to center with experience in endoscopic stenting, clips, glue
If persists, consider RYGB
Stoma appliance

22. Nova Scotia SG Program
The best option for morbidly obese patients is to have access to bariatric surgery program in their home province
Patients who do not develop healthier lifestyle (diet and exercise) will fail any operation over the long term
Patients undergoing malabsorptive procedures should have access to long term follow-up
Deaths or significant number of complications would could potentially shut down program

23. NS Experience 166 patients 136 female (82%)
Mean age 44 years (range 16-68, SD 10)
Mean pre-operative BMI 49.6 (range , SD 7)
Mean operative time 93 min (range , SD 33)
Mean hospital stay 2.6 (2-8, SD 0.8) days
Reoperation rate 1.8%

24. Complications Complication Number (%) Staple line leak 1 (0.6)
Bleeding
2 (1.2)
Sleeve stenosis
Death
Minor
7 (4.2)
Total
10 (6)

25. Postoperative follow-up
Time
(months postop)
%EWL
(Range, SD)
Number of patients/
Total eligible (%) 6
49.3 ( , 13)
99/140 (71) 12
54.24 ( , 19)
59/109 (53) 24
64.4 ( , 31)
12/44 (27)

26. Summary SG is acceptable option as a primary bariatric procedure
SG has a risk/benefit profile that lies between LAGB and LRYGB
Long-term weight regain can occur and, in the case of SG, this could be managed effectively with re-intervention

27. James Ellsmere, MD MSc FRCSC James.Ellsmere@dal.ca
Thank you
James Ellsmere, MD MSc FRCSC

28. Selection Criteria Factor Criteria Weight (adults)
BMI > 40 kg/m2 with no comorbidities
BMI > 35 kg/m2 with obesity-related comorbidity
Weight Loss History
Failure of previous nonsurgical attempts at weight reduction, including nonprofessional programs (i.e. Weight Watchers)
Commitment
Expectation that patient will adhere to post-op care
Follow-up visits with physician's and team members
Recommended medical management, including the use of dietary supplements
Instructions regarding any recommended procedures or tests
Exclusion
Reversible endocrine or other disorders that can cause obesity
Current drug or alcohol abuse
Uncontrolled, severe psychiatric illness
Lack of comprehension of risks, benefits, expected outcomes, alternatives, and lifestyle changes required with bariatric surgery
There is no perfect way to match patient to surgery
Patient should review all options and understand pros and cons
It like most big decisions, it really boils down to your tolerance for risk and your perceived risk reward.
morbidly obese patients wls vs no wls is no brainer. What type of wls is much more diffult to answer and there are many opinions.

29. Nova Scotia WLS Program
BMI > 60
Challenging to perform high quality sleeve with low complication rate
Patients counseled and offered medically supervised diet/exercise plan
Graduate 50% from program with excellent outcomes
BMI 35 – 60
Goal 10lb weight loss prior to sleeve

30. Outcomes
Brethauer et al. Surg Obes Relat Dis 2009

31. Access and Port Placement
Safe access; optimize ports for stapling • Veress needle (left upper quadrant)
• Require 3 × 10- or 12-mm ports to facilitate stapling and camera visualization
Karmali et al. Can J Surg 2010

32. Mobilization of the Greater Curvature
Full mobilization of the greater curvature and posterior aspect of stomach (division of retrogastric adhesions)
Mobilize the greater curvature inside the epiploic arcade, close to the gastric wall, which will be removed; this reduces the specimen size
Lack of adequate retrogastric mobilization increases the risk of leaving a large posterior stomach

33. Distal Transection Point
The distal transection point is measured relative to the pylorus
Too long will decrease expected weight loss
Too short may effect gastric emptying
Most surgeons start 5 cm (range 1-10 cm) proximal to the pylorus
Identification of the distal
point of transection on the
stomach
Avoid pylorus/distal antrum • Most surgeons commence dissection 5–10 cm proximal to the pylorus
• If dissection is too close to the pylorus, the thick area can crack and become
predisposed to leaks and/or the antral pumping mechanism will be affected

34. Bougie
The bougie is positioned on the lesser curve distal to the point of transection
Too large will decrease expected weight loss
Too small will increase risk of post-op nausea, stenosis and leak
Most surgeons use 32-40F (range 30-60F)

35. Stapling The goal is the creation of a uniform gastric tube
Requires optimal visualization and lateral traction on the stomach
Avoid the esophagus - leave 1 cm of fundus as precaution
because the tissue is too thin for the cartridge load, and high gastric leaks are very difficult to manage

36. Staple Line Reinforcement
Staple-line was reinforced by 65.1% of the surgeons; of these, 50.9% over-sew, 42.1% buttress, and 7% do both
Several series without buttress material with 1% bleeding rate, 1% leak rate
Consider optimal staple height, need for tissue compression, clipping bleeders and selectively oversewing
Gagner et al. Surg Obes Relat Dis 2009

37. Staple Line Testing
Intraoperative leak testing with air (gastroscope) and/or methylene blue dye
Consider leaving drain

38. Removing Specimen

39. Sleeve Gastrectomy and Hiatal Hernia Repair
Small cases series
Morbid obesity is risk factor for failed hiatal hernia repair
If large or symptomatic hernia and BMI > 35, hernia repair + sleeve is an option
Post op course similar to sleeve alone

40. Band to Sleeve Small case series
Risk of complications higher than primary operation
If treating band complications, consider two stage approach
Avoid stapling through compromised tissue

41. Low Rate of Complications
High leak occurred in 1.5%
Lower leak in 0.5%
Hemorrhage in 1.1%
Splenic injury in 0.1%
Stenosis in 0.9%
3 mo 6.5% (range 0-83%)
Mortality was 0.2 +/-0.9%
Gagner et al. Surg Obes Relat Dis 2009

42. Patient Decision
Boils down to tolerance for risk and perceived risk reward
Bariatric vs non-operative management question is clear
What’s the best bariatric surgery for the patient is difficult to know
It’s like most big decisions, lots of expert opinion, too many temporal variables to study

43. C. Hoogerboord MB ChB, MMed, S. Wiebe MD, D. Lawlor NP,
Perioperative Outcomes of Laparoscopic Sleeve Gastrectomy, Effectiveness in Short to Medium Term Weight Loss and Improvement in Diabetes Mellitus
C. Hoogerboord MB ChB, MMed, S. Wiebe MD, D. Lawlor NP,
R. Stewart BSc, T. Ransom MD, D. Klassen MD, J. Ellsmere MD, MSc
Department of Surgery, Division of General Surgery, Dalhousie University, Halifax NS

44. Introduction
Laparoscopic Sleeve Gastrectomy (LSG) is increasingly being performed as a stand-alone bariatric procedure with short and medium term weight loss and improvement in obesity associated comorbidities comparable to Laparoscopic Roux-en-Y Gastric Bypass, (LRYGBP) the current gold standard in bariatric surgery.

45. Discussion
LSG is gaining popularity as a final surgical treatment for morbid obesity
Complications are infrequent but most significant for staple line leak (2%), bleeding (1.2%), sleeve stenosis (0.8%) and death (0.19%)1.
Gagner et al. Surg Obes Relat Dis 2009

46. Effectiveness as weight loss procedure confirmed by several studies, 12 and 24 month %EWL 55.8 and 52.4 respectively in a systematic review of Brethauer et al2. More than weight loss seen with LAGB but somewhat less than with LRYGBP3.
Concept of metabolic surgery now recognized by endocrine specialists. LSG led to 2 year remission rate of Type 2 DM of 75% vs 0% with optimal medical therapy in patients with BMI>354.

47. Aim
To review our experience with Laparoscopic Sleeve Gastrectomy (LSG) in terms of perioperative outcomes, effectiveness in inducing weight loss and improvement or resolution of Diabetes Mellitus (DM) over a two year period

48. Methods
A retrospective review of prospectively recorded data was performed for all patients who underwent LSG from September 01, 2007 to June 30, 2011
Patient demographics and perioperative data were collected.
Postoperative follow-up data was obtained at 6, 12 and 24 months and included Percentage Excess Weight Loss (%EWL) for all patients
In the subgroup of 85 patients with a preoperative diagnosis of DM, additional data included HbA1c, AC Glucose and improvement or resolution of Diabetes
Improvement of DM was defined as a decrease in dose or number of anti-diabetic drugs required to control serum glucose whereas resolution was defined as normalization of AC glucose (<5.6mmol/l) and HbA1c (<6.5%) with discontinuation of all anti-diabetic drugs

49. Perioperative Results
166 patients
136 (82%) female
Mean age 44 (range 16-68, SD 10) years
Mean pre-operative BMI 49.6 (range , SD 7)
Mean operative time 93 (Range , SD 33) minutes.
One (0.6%) conversion to laparotomy
Mean hospital stay 2.6 (2-8, SD 0.8) days.
Reoperation rate 1.8%.

50. Complications Complication Number (%) Staple line leak 1 (0.6)
Bleeding
2 (1.2)
Sleeve stenosis
Death
Minor
7 (4.2)
Total
10 (6)

51. Postoperative follow-up
Time
(months postop)
%EWL
(Range, SD)
Number of patients/
Total eligible (%) 6
49.3 ( , 13)
99/140 (71) 12
54.24 ( , 19)
59/109 (53) 24
64.4 ( , 31)
12/44 (27)

52. Number of patients/Total eligible (%)
Time
(months postop)
HbA1c
(Range, SD)
Number of patients/Total eligible (%)
7.6 ( , 1.7) 6
6.3 ( , 1)
50/66 (77) 12
6.5 ( , 1.2)
27/52 (52) 24
6.2 ( , 0.5)
2/19 (11)

53. Time
(months postop)
AC Glucose (mmol/l)
(Range, SD)
8.3 ( , 2.9) 6
6.4 ( , 2.2) 12
6.9 ( , 2.3) 24
5.6 ( , 0.7)

54. Diabetic outcomes at 12 months postop
Resolution: 21/27 (78%)
Improvement: 2/27 (7%)

55. Conclusion
LSG can be performed safely with acceptable complication rates at our institution
It is an effective bariatric procedure and can play an important role as metabolic therapy for DM
Longer term studies are needed

56. Healthcare Economics
Surgery is one arm of an expensive multidisciplinary intervention
Reoperative outcomes are not as good as primary interventions in part because patient group already failed multidisciplinary intervention
It may be more cost effective to offer the multidisciplinary intervention to a new person on the wait list vs revise someone who failed