2. When ?
Indications
Contraindications ?

3. Indications First step in Super Super Morbidly Obese Patient
Followed by RYGBP or BPD
First step to a Non Bariatric second procedure
Followed by Hip replacement, Recurrent Incisional Hernia, pull through procedure for UC, etc

4. Indications Final step in Cohn's disease
Final step in ASA IV Morbidly Obese Patient
Low EF, Heart ort Kidney transplant
Final step if that is the patients choice
Final step in Cohn's disease
Final step in extremes of age
Adolescents ( no needles !!!!!!)
Elderly

5. Indications Final Step after failed Malabsorptive procedure
Reversal of JIBP
Final step in poor candidate for RYGBP/BPD
Smoker, Coumadin, etc
Final step in high risk stomach
Chile, Colombia, Japan. High incidence of gastric cancer !!

6. Technical Considerations
How to do it

7. Surgical technique 7 ports Harmonic scalpel 38 Fr boogie
LSG was performed using a 7 port technique, 5-12mm, and 2 5-mm trocars.
Harmonic scalpel was used to ligate the short gastric vessels beginning 5 cm from the pylorus extending to the GE junction. A 52 or 44 Fr bougie was used to create the sleeve with endolinear staplers 7

10. Jossart et al

11. LSG first or final step ?
Results

14. LSG as a first step ?

15. Probability of Developing Complications after Gastric Bypass according to Weight
Livingston et al. Annals of Surg. Nov

16. Review of the Literature
Almogy G, Crookes PF, Anthone GJ. Longitudinal gastrectomy as a treatment for the high-risk super-obese patient. Obes Surg Apr;14(4):492-7
RESULTS:
At 12months: Median weight loss: 44.5 kg,
% EWL 45.1%.
After 1 year: 40% of the followed patients achieved more than 50% EWL and another 50% needed less medications for their associated co-morbidities

17. Sleeve to LGB January 2002 to February 2004
N Primary bariatric procedures performed.
N Consecutive laparoscopic sleeve gastrectomies using a 50 F Bougie
N Patients completed the second stage LRYGBP.
Schauer et al

18. Results of LSG Operative time 174 ± 51 min Length of stay 3 ± 1.7 days
Death 0
EWL one year 46 %
Schauer et al

19. Change in BMI over Time
Schauer et al

20. Down staging Pre-SGL Pre-LRYGB BMI 63 48 ASA IV 56% 1% ASA III 43% 34%
Co morbidities
Sleep Apnea 82% 43%
T2DM 60% 23%
Peripheral edema 100% 0%
Schauer et al

22. LSG as A Final Step?

23. RESULTS N 130 LSG between Nov 04 and Jan 07 2.4 female : 1 male
Mean age (12 -79) years
Mean preop. weight was ( ) Kg
The mean BMI was 43.2 ( ) Kg/m2

24. RESULTS Mean operative time 97 (range: 58 – 180) mins No conversions
Mean hospital stay was 3.2 (range: 1 – 19) days.
There was no mortality in this series.

25. RESULTS N 130 24 m 43.2 27.1 67.9 Initial 3 m 6 m 12 m 18 m
BMI (Kg/m2)
WL (Kg) *
%EWL
43.2
36.9
21.0
33.1
32.8
31.2
50.8
29.5
37.4
62.2
28.0
39.5
64.4
27.1
41.7
67.9

26. Results Age (Yrs) Gender Type of DM Duration
Table 1. Total Sample Demographic Characteristics (N=30)
Age (Yrs) Gender Type of DM Duration
(N=30) (N=30) (N=30) (N=30)
F - 21(70%) Type I - 3 (10%) <5 years-16(53%)
(21-69) M - 9 (30%) Type II - 27 (90%) >5 years-14(47%)

27. DISCUSSION 58 / 83 62.2 / 67.9 Author No Initial BMI (g/m2)
Follow up in (Months)
%EWL
1 to 2 years
Baltasar
Cottam
Han
Himpens
Hammoui
Lee
Mognol
Silecchia
Rosenthal 31
126 60 40
118
216 10 41
130 * 65 37 39 55 49 64 57
43.2
3 – 27 12 24
62.3/NR
45/NR
81/NR
58/NR
49/NR /
51/NR
NR/NR /

28. Conclusions and questions

29. Questions that remain open to be answered:
What will be the %EWL at 15 years when compared to RGBP ?
Will the gastric tube dilate ?
What is the best size of the boogie ?
Will Ghrelin levels drop and stay down as expected ?

30. Questions that remain open to be answered:
What % of SG will be converted to RYGBP ?
Will the long term results be as good as other purely restrictive procedures as LAGB/VBG

31. Conclusions Not all bariatric patients face the same operative risk
Sleeve Gastrectomy is a valid surgical option for weight loss with excellent short term outcomes

32. Conclusions Unknown long term outcomes
May be an option for the very low and very high risk patients
Excellent option for the elderly and adolescents

33. Thank you!