1. Sleeve En Y Does Changing the Name Change the Perception? Mitchell Roslin, MD FACS Chief of Bariatric Surgery Lenox Hill Hospital Northern Westchester Hospital Center

2. Disclosures Consultant J&J, Covidien, CR Bard Research Grant Covidien Patent License J&J, CR Bard, Allergan SAB ValenTx, Scientific Intake Founder VentralFix

3. Gastric bypass has been most popular stapling procedure Best balance between outcome and complications? Preferable for sweet eaters because of dumping? Dumping is an important component for weight loss surgery as it deters carbohydrate intake? Tremendous amount of long term data?

4. “A person with a new idea is a crank until the idea succeeds.” Mark Twain Described RYGB Abandoned anemia, bone loss, micronutrient deficiencies 1971 VBG Lesser curvature 2005 International Registry RYGB 67 vs 59 %EBL VBG 0 mortality vs.5% Edward E Mason MD, PHD

5. Harvey SUGERman Compared VBG to RYGB in sweet eaters Big difference in outcome 37% EBL VBG What is a sweet eater? 69% vs 67% wt loss in sweet eaters vs non in rygb Dumping caused sweet aversion? Ann Surg 1987

6. Ten and more years after vertical banded gastroplasty as primary operation for morbid obesity 71 patients BMI 49 – 39 26% 50% ebl High amount of emesis High re operation rate

7. Weight gain after short- and long-limb gastric bypass in patients followed for longer than 10 years. Lloyd MacLean Isolated gastric bypass 83% follow up Progressive wt regain from nadir (2Yr) No differences in short and long limb 20% failure for MO 35% failure for SMO

8. Dumping? Literature contains numerous articles about hyperinsulinemic hypoglycemia None showing relationship between dumping and weight loss Mallory et al: No relationship between wt loss and dumping

9. OBESITY IS A CHRONIC DISEASE 70% of excess weight loss after one year Much higher rate of recidivism than noted

11. Size does not Matter? In cohort that had dgj>2cm, no difference with increasing size Time matters Will be difficult to identify clinical target that is reproducible

12. Physiologic Cause Lesser curvature Restrictive anastomosis No valve Rapid emptying Recidivism maybe based on anatomy, not return of old habits Low glycemic index diet Many eat refined carbs

13. IMPLICATIONS: PRESERVATION OF PYLORUS VS SUPPORTED BYPSS

14. RANDOMIZED TRIAL LAP RYGB VS LAP DS Mean BMI 54 RYGB Mean BMI 55 DS 1 Yr post RYGB = 38 1 Yr post DS = 32 Similar complications Will majority of super obese patients treated with RYGB be morbidly obese?

15. The Duodenal Switch Operation for the Treatment of Morbid Obesity: A 10 Year Experience 701 patients BMI 52 22% BMI >60 58% BMI >50 75% >50% excess wt at five years 67% EBL maintained 40 patients with revision for increased limb length Similar data Hess and Marceau

16. Pyloric Preservation? Bypass with rapid emptying causing inter meal hunger Instead of artificial fixed valve use biologic smart valve Duodenal Switch has most weight loss Sleeve preserves options

17. Introducing the Sleeve En Y Effectiveness of sleeve shows the value of long narrow pouch with pylorus intact Combination of narrow pouch and pylorus limit intake and diarrhea Intestinal bypass plays metabolic role Can lengthen common channel to avoid oily stools and frequent bowel movements

18. Responder Analysis BMI > 50 Nadir response > 1 year 50% EWL, BMI < 40, BMI < 35, BMI <30 13/120 Bands less than 40 270 of 346 RYGB less than 40 10 of 30 VSG 22 of 23 lap DS (majority have not reached nadir Lowest variability in response Does treatment of super morbid obesity require intestinal bypass?