Teresa LaMasters MD, FACS Minimally Invasive Bariatric Surgeon Iowa Health Weight Loss Specialists Throckmorton Surgical Society May 4, 2012

Laparoscopic Sleeve Gastrectomy Teresa LaMasters MD, FACS Minimally Invasive Bariatric Surgeon Iowa Health Weight Loss Specialists Throckmorton Surgical Society May 4, 2012 Objectives Understand the anatomy of the sleeve gastrectomy t Understand the metabolic effects of weight loss surgery Understand the potential complications 1

Epidemic Obesity 68% Americans are overweight or obese! 12million Americans aremorbidly obese (Atleast 100 lbs. overweight) 15 million Americans with BMI 35 40 300,000 400,000 new morbidly obese patients yearly (Bariatric surgery 240,000/year) Mortality 300,000 deaths/year are obesity related Morbid obesity decreases life expectancy by 5 15 years Looking for a better mousetrap Best weight loss with fewest complications and long term durabilty Bariatrics is in a rapid state of change as we build on knowledge gained over 50 years An additional tool to treat the disease of obesity 2

Vertical Sleeve Gastrectomy Creation of a small tubularized stomach based on the lesser curvature with removal of the remaining stomach remnant. Division begins 5 6 cm from the pylorus and extends up to the angle of His. About 75% of the volume of stomach is removed. Remaining remnant based on lesser curvature to prevent stretching. No bypass of bowel, no anastamosis Restrictive Procedure More recently noted to be a metabolic procedure History Procedure initially described 1988 by Hess and Marceau during duodenal switch and 1993 by Johnston in an isolated form Further development of the VBG (44 69%) and Magenstrasse and Mill (EWL 58% at 1 yr) 3

Vertical Sleeve Gastrectomy Later in 1995 described as staging procedure to LRYGB or DS in high BMI and high risk pts esp in pts with BMI >60 Some of patients with original sleeve did not want to complete second stage. Weight loss 40 60% EWL. Some weight regain after 5 years. Initial sleeve size based on 60F bougie or larger Procedure was then modified to become a stand alone procedure about 2002, more accepted around 2004 Currently increase use as a primary procedure for obesity How does it work? Physiology Restrictive procedure without malabsorption; hormonal component The fundus is removed with most of the ghrelin producing cells Ghrelin cells causing hunger 4

Physiology Effects on incretins, GLP 1 This leads to a similar effect to the gastric bypass in decrease in hunger and craving for sweets with %EWL falling in between the RYGB and the LAGB Similar cure of diabetes Hormone Impacts Ghrelin Hunger GLP 1 Satiety PYY satiety PP satiety Insulin Control LRYGB Sleeve LRYGB Sleeve LRYGB Sleeve LRYGB Sleeve 3 mon 12 mon Sleeve is more than a restrictive technique. Similar changes in intestinal hormones. Ramon et al. Effect of Roux en Y Gastric Bypass vs Sleeve Gastrectomy on Glucose and Gut Hormones: a Prospective Randomized Trial. J Gastrointest Surg 2012 5

Physiology Decreased intrinsic factor and some patients can develop deficiency dfii of Vit B12 or Iron. Suggested faster rate of gastric emptying Potentially less change in absorption of medications?? RCT trials 66 76% EWL 6

Weight loss of Sleeve %EWL varies a lot in the literature, early studies had large variation in technique Most recent studies are demonstrating %EWL of 50 70% and maintained out past 3 years Bellinger, Greenway Obesity Surgery 2010 529 sleeve by a single surgeon at a community hospital with 34 F Bougie %EWL 65.9, 66.1, 64.44 at 1 yr, 2 yr, 3 yrs Chopra et al. Surgical Endoscopy 2012 174 patients with 34 F Bougie %EWL 55.5, 59.2, 58.9% at 1 yr, 2 yr, 3 yrs Weight loss of Sleeve Himpens et al. Annals of Surgery Aug 2010 41 patients 34 F Bougie Surgery in 2001 2002 3 yr mean 72.8% EWL, 6 years maintained 57.3% 3rd International Summit for Sleeve Gastrectomy Questionnaire results 88 surgeons ;19,605 SG procedures %EWL at 1, 2, 3, 4, and 5 years was 62.7%, 64.7%, 64.0%, 57.3%, and 60.0%, respectively Deitel M, Gagner M, Erickson AL, Crosby RD. Third International Summit: current status of sleeve gastrectomy. Surg Obes Relat Dis. 7

ACS Bariatric Surgery Center Network longitudinal database (n=28,616) reported 30 day, 6 month, and 1 year outcomes of LSG, LAGB, and RYGB Risk adjusted morbidity, readmission and reoperation/intervention LAGB>LSG<RYGB No differences in mortality LSG patients had a higher BMI and higher risk profile thanlagbpatients Decrease in BMI and comorbidities LAGB>LSG<RYGB Hutter MM, Schirmer BD, Jones DB, et al. First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann Surg;254:410 20; discussion 20 2. Spanish National Registery 540 SG patients from 17 centers. Morbidity rate was 5.2% and mortality rate 0.36%. Complications were more common in superobese patients, males, and patients >55 years old. Mean percent excess BMI loss (EBL) was 72.4 +/ 31% at 24 months and Bougie caliber was an inverse predictive factor of %EBL at 12 and 24 months. Diabetes remitted in 81% of the patients Hypertension improved in 63.2%. Sanchez Santos R, Masdevall C, Baltasar A, et al. Short and mid term outcomes of sleeve gastrectomy for morbid obesity: the experience of the Spanish National Registry. Obes Surg 2009;19:1203 10. 8

Durability Comparison of Weight Loss Chakravarty et al. Compariscon of LAGB with other bariatric procedures; a systematic review of the randomized controlled trials. The Surgeon 10 (3) (2012) p172 182 9

Complications Michigan Bariatric Surgery Collaborative (MBSC) evaluated d30 day complication rates for 62 bariatric surgeons in 25 hospitals Risk of serious complication after LSG to be 2.2% compared to 0.9% for LAGB and 3.6% for RYGB Birkmeyer NJ, Dimick JB, Share D, et al. Hospital complication rates with bariatric surgery in Michigan. JAMA;304:435 42. International Sleeve Gastrectomy Expert Panel Consensus Statement: Best practice guidelines based on experience of >12,000 cases. Leak rate 0.5 3.9%(1.06%), Stricture 0.06 1.4% (0.35%) GERD 0.5 31% (12.1%) Weight Loss failure or weight regain after 3 years 1 23% (10%) Rosenthal et al. Surgery for Obesity and Related Diseases. 2012 Jan Feb;8(1):8 19 10

240 morbidly obese (BMI = 35 66 kg/m2) patients, randomized to undergo either RYGB or SG 117 patients in the RYGB group and 121 in the SG group Sleeve group had less major and minor complications 11

Effects on Diabetes Gill RS, Birch DW, Shi X, Sharma AM, Karmali S (2010) Sleeve gastrectomy t and type 2 diabetes mellitus: a systematic review. Surg Obes Relat Dis 6:707 713 Lit review of 27 studies and 673 patients Mean baseline BMI 47.4, EWL% mean at 1 year was 47.3% (6.3 74.6%) Resolution of DM 66.2%, improvement 26.9% Effects on Diabetes STAMPEDE March 26, 2012 issue of the New England Journal of Medicine, Schauer et a published Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes. RCT 3 arms; intensive medical diabetes management alone versus laparoscopic Roux en Y gastric bypass or sleeve gastrectomy in 150 obese patients with uncontrolled type 2 diabetes (start Hgb A1C 8.9 9.5 andduration8.2 duration to 8.9 years) After 1 year Hgb A1C was 7.5 for intensive medical diabetes management, 6.4 for Roux en Y gastric bypass, and 6.6 for sleeve gastrectomy 12

STAMPEDE Population Baseline Intensive Medical Therapy Lap Roux en Y Gastric Bypass Lap Sleeve Gastrectomy N total (% female) 50 (62) 50 (58) 50 (78) Mean Duration T2DM, in years 8.9 8.2 8.5 Insulin use, N(%) 22 (44) 22 (44) 22 (44) Mean BMI, kg/m² (%, BMI<35) [BMI, kg/m² range] 36.8 (38) [31.8 42.3] 37.0 (28) [30.6 43.0] 36.2 (36) [28.0 43.0] Mean HbA1c¹, % 8.9 9.3 9.5 Mean FPG², mg/dl 155 193 164 (1) Normal:HbA1c, < 6% (2) Normal FPG, 82 to 110 mg/dl Population consisted of predominately female, moderately obese patients with long standing and uncontrolled T2DM 44% required the use of insulin No statistically significant differences existed between the three groups with regard to baseline characteristics page 25 1 year Outcomes, Impact on T2DM Control Groups IMT LRYGB LSG N (%) 41 50 49 Euglycemia¹ 5 (12.2) 21 (42.0) 18 (36.7) Complete Remission² i 0 (0) 21(42 (42.0) 13(26 (26.5) Partial or Complete Remission² 0 (0) 34 (68.0) 22 (44.9) No Diabetes Medications 0 (0) 38(77.6) 25(51.0) After 1 year Hgb A1C was 7.5 for intensive medical diabetes management, 6.4 for Roux-en-Y gastric bypass, and 6.6 for sleeve gastrectomy Gastric bypass produced the most dramatic results, with 68% of subjects in control without medications; sleeve gastrectomy, with 45% in control without medications. 42% of gastric bypass subjects achieved complete remission; 26.5% of sleeve gastrectomy subjects. page 26 13

Vertical Sleeve Gastrectomy Restrictive but it also has some involvement of GI hormones Ghrehlin, GLP 1, etc Good control of DM in 65 81%, even in long term diabetic patients Rate of weight loss similar to bypass (Rapid) Weight loss between band and bypass about 50 70% EBWL Not Reversible! Unknown risk of weight regain (3 6 kg at >6 years 10%) Technique Trocar placement Mobilization of greater curvature and posterior stomach Exposure of crus repair any hiatal hernia Division of stomach start 2 6 cm from pylorus up through angle of HIS, sized around bougie 32 40F (*36F*) Leak test +/ Omentopexy 14

Trocar placement Surgeon Assistant Blood Supply of the stomach Area most at risk Change of thickness of the stomach from 4.1 4.9 mm thick in the antrum to only 2.1 2.3 mm thick in the fundus 15

Sleeve is a High Pressure System Yehoshua et al. Basal resting pressure of sleeve 19 mmhg Filled pressure sleeve 43 mmhg (32 58) Compared to filled stomach 32 mmhg Vomiting pressure in the abdomen similar to coughing 107 mmhg (Heniford) Avoiding Leaks Avoid over tightening at the incisura angularis that can lead to a functional obstruction 90% Avoid incorporation of esophagus or GE junction at the top of the staple line Use correct staple height for tissue thickness allow good staple formation by adequate time for tissue compression Consider buttress material Bougie size 16

Found in 29 publications from 2003 2011 Leak rate 2.4% Overall most happened after discharge from hospital (more than 10 days 79%) Major complications were significantly less for sleeve gastrectomy patients (4.6%) compared with patients who had laparoscopic gastric bypass (10.6%) or duodenal switch (39.3%) by the same surgeons Complications Nausea and Vomiting /Spasms (30%) Dehydration (5%) Stricture (0.5 3%) Leak (1 3%) 80% delayed Fistula Bleeding (2 4%) Reflux 12% (3 20%) DVT/PE 1% Death 0.1 0.3% Could require conversion to gastric bypass 17

GastroBronchial Fistula Normal Sleeve Fistula Our results 358 Sleeve Gastrectomies since 2008 Volume for 2011 Laparoscopic Sleeve Gastrectomy 223 Comparisons 2009 293 74% Bands, 18% bypass, 2% sleeve, 6% others 2010 0 289 43% Bands, 17% bypass, 28% sleeve, 12% others 2011 296 10% Bands, 7% bypass, 75% sleeve, 8% others 18

Trends 2011 Results 19

Vertical Sleeve Gastrectomy Advantages Better weight loss than Band fewer complications than Bypass Decreased long term complications of other existing procedures Bowel obstruction/no risk of internal hernia Decreased parietal cell mass of remaining stomach and no G J anastomosis, better blood supply lower risk of marginal ulcers Less malabsorption Less risk of major vitamin deficiencies No foreign body/device and No adjustments band dysfunction Vertical Sleeve Gastrectomy Advantages Excellent cure of weight related diseases, especially metabolic syndrome Can be used for patients with contra indications to band (i.e.. lupus), or high risk patients (i.e.. Patients with BMI too high to perform LRYGB safely), appears to have increased gastric emptying py so may be useful in patients with gastroparesis. Technically easier to perform than bypass Can be converted to RYGB if desired or necessary 20

Vertical Sleeve Gastrectomy Disadvantages Not Reversible Newer procedure limited data Total data 15 years current form about 8 years Unclear possibility of weight regain Some early complications can be difficult to manage Not always well covered by insurance Summary Laparoscopic Vertical Sleeve Gastrectomy is a simple procedure, but it is not easy It is non reversible so extra care to reduce/ eliminate complications Very good results Lower risk of long term complications Based on the current published literature, SG has a risk/benefit profile that lies between the laparoscopic p adjustable gastric band and the laparoscopic Roux en Y gastric bypass. Increasing in popularity 21