1. Sleeve Gastrectomy Samuel Szomstein, M.D., FACS Associate Director of The Bariatric and Metabolic Institute and Section of Minimally Invasive Surgery Cleveland Clinic Florida Assistant Clinical Professor of Surgery Nova Southeastern University SLEEVE GASTRECTOMY “A new dimension in general and bariatric surgery”

2. Sleeve Gastrectomy Why a New Procedure ?

3. Sleeve Gastrectomy The Mason Era Mc Gregor A, ASBS Website, 1999 Gastric BypassVertical Banded Gastroplasty Mason and Ito, 1967Mason et al, 1982

4. Sleeve Gastrectomy “We need a bariatric procedure that does not cause as much morbidity and does not need as much follow up as the current ones “

5. Sleeve Gastrectomy Potential Advantages If Effective ? No long term complications ? No Int. Hernias ? No malabsorption – No micronutrient deficiency ? No Strictures ? No Marginal Ulcerations ? Maintains oral access to GI and Biliary tract When compared to RYGBP:

6. Sleeve Gastrectomy Potential Advantages If Effective ? Completely removes Ghrelin cell mass No dumping Does not interfere with immunosuppressant Can always be upgraded to RYGBP !? When compared to RYGBP:

7. Sleeve Gastrectomy Potential Advantages If Effective ? No need for adjustments. No needles !!! Removes Ghrelin Cell mass. Loss of appetite !! Creates restriction more than obstruction No need to do yearly endoscopy No/less follow up ? When compared to LAGB:

8. Sleeve Gastrectomy Brief History Evolution of LSG

9. Sleeve Gastrectomy Sleeve gastrectomy was first described in 1988 when Scopinaro's technique of biliopancreatic diversion with distal gastrectomy and gastroileostomy was modified by Hess and simultaneously by Marceau Scopinaro, N., Adami, G. F., Marinari, G. M., Gianetta, E., Traverso, E., Friedman, D., Camerini, G., Baschieri, G., and Simonelli, A. Biliopancreatic Diversion. World J Surg. 1998;22(9):936-46. Hess, D. S. and Hess, D. W. Biliopancreatic Diversion With a Duodenal Switch. Obes.Surg. 1998;8(3):267-82. Marceau, P., Biron, S., St Georges, R., Duclos, M., Potvin, M., and Bourque, R. A. Biliopancreatic Diversion With Gastrectomy As Surgical Treatment of Morbid Obesity. Obes.Surg. 1991;1(4):381-7.

10. Sleeve Gastrectomy 1954 JIBP 1963 JCBP 1967 RYGBP 1978 BPD 1982 VBG 1987 BPD-DS 1990 Banding 1994 Lap RYGBP 1999 Lap BPD / DS Linnear De WindMasonScopinaroMason De MeesterKuzmak Wittgrove Gagner 1998 Lap- Band Belachew LSG

11. Sleeve Gastrectomy Review of the literature Gagner M, Rogula T. Laparoscopic reoperative sleeve gastrectomy for poor weight loss after biliopancreatic diversion with duodenal switch. Obes Surg. 2003 Aug;13(4):649-54 METHODS: Follow-up of 1 case of sleeve gastrectomy for Poor Weight loss after Biliopancreatic Diversion with Duodenal Switch.

12. Sleeve Gastrectomy Laparoscopic Era Step procedure in super super morbidly obese patients to facilitate the laparoscopic approach Gagner described the first laparoscopic BPD-DS in 1999 Ren, C. J., Patterson, E., and Gagner, M. Early Results of Laparoscopic Biliopancreatic Diversion With Duodenal Switch: a Case Series of 40 Consecutive Patients. Obes.Surg. 2000;10(6):514-23.

13. Sleeve Gastrectomy Magenstrasse and Mill Obesity Surgery

14. Sleeve Gastrectomy Magenstrasse and Mill Obesity Surgery

15. Sleeve Gastrectomy Mechanism of Action How does it work ?

16. Sleeve Gastrectomy How doest it work ? Sleeve gastrectomy Creates restriction Removes Ghrelin cells Creates a natural band PYLORUS

17. Sleeve Gastrectomy Gastric Emptying is not affected by Sleeve Gastrectomy or the emptying function of the remnant stomach following sleeve gastrectomy assessed by gastric scintigraphy in morbidly obese patients. Hanna Bernstine 2, Ronit Tzioni Yehoshua 1, David Groshar 2, Nahum Beglaibter 4, Shikora Scott 5, Raul J. Rosenthal 6, Moshe Rubin 1,3 In review

18. Sleeve Gastrectomy RESEARCH ARTICLE Laparoscopic Sleeve Gastrectomy— Volume and Pressure Assessment Ronit T. Yehoshua & Leonid A. Eidelman & Michael Stein & Suzana Fichman & Amir Mazor & Jacopo Chen & Hanna Bernstine & Pierre Singer & Ram Dickman & Scott A. Shikora & Raul J. Rosenthal & Moshe Rubin Received: 11 May 2008 / Accepted: 15 May 2008 # Springer Science + Business Media, LLC 2008

19. Sleeve Gastrectomy Closed pylorus and GE Junction Inject Methylene blue Measured Volume Ronit Yeoshua et al. Obesity Surgery RESEARCH ARTICLE Laparoscopic Sleeve Gastrectomy— Volume and Pressure Assessment

20. Sleeve Gastrectomy StomachSleeve Vol (mean) 1500 cc 130 cc Pressure 34 mmhg 43 mmhg Ronit Yeoshua et al. Obesity Surgery RESEARCH ARTICLE Laparoscopic Sleeve Gastrectomy— Volume and Pressure Assessment

21. Sleeve Gastrectomy

22. Gastrointestinal peptides involved in appetite control Appetite - Pancreatic polypeptide (PP) -Peptide tyrosine-tyrosine (PYY) - Products of preproglucagon: Glucagon-like 1, oxyntomodulin Appetite - Ghrelin

23. Sleeve Gastrectomy Ghrelin plasma levels

24. Sleeve Gastrectomy Regulation of energy balance at Brain Increases hunger: hypothal feeding centers. Humans injected with ghrelin: intense hunger. Suppresses fat utilization in adipose tissue Stimulates gastric emptying Increases cardiac output (possible GH effect) Fundus of Stomach is Primary Source GHRELIN

25. Sleeve Gastrectomy Ghrelin secretion  Negative energy balance  Starvation  Cachexia  Anorexia nervosa  Positive energy balance  Obesity ?  Hyperglycemia  Feeding HighLow

26. Sleeve Gastrectomy  Sleeve gastrectomy:  Decreased plasma ghrelin levels

27. Sleeve Gastrectomy Preliminary results  10 Sleeve gastrectomy patients  2 non-obese controls  Quantification and distribution of ghrelin cells in the stomach Results: Mean number of ghrelin cells Sleeve gastrectomy Control 169 59 p=0.002