Third International Summit: current status of sleeve gastrectomy

Surgery for Obesity and Related Diseases 7 (2011) 749 759 Review article Third International Summit: current status of sleeve gastrectomy Mervyn Deitel, M.D., F.A.S.M.B.S., C.R.C.S.C. a, *, Michel Gagner, M.D., F.A.S.M.B.S., F.A.C.S., F.R.C.S.C. b, Ann L. Erickson, B.A. c, Ross D. Crosby, Ph.D. d a Editor-in-Chief Emeritus and Founding Editor, Obesity Surgery b Department of Surgery, Florida International University Herbert Wertheim College of Medicine, Miami, Florida, and Clinique Michel Gagner MD Inc., Montreal, Quebec, Canada c Neuropsychiatric Research Institute, Fargo, North Dakota d Department of Biomedical Statistics Neuropsychiatric Research Institute, Fargo, North Dakota Received June 2, 2011; accepted July 26, 2011 Abstract Keywords: Background: Laparoscopic sleeve gastrectomy (LSG) has been performed for morbid obesity in the past 10 years. LSG was originally intended as a first-stage procedure in high-risk patients but has become a stand-alone operation for many bariatric surgeons. Ongoing review is necessary regarding the durability of the weight loss, complications, and need for second-stage operations. Methods: The first International Summit for LSG was held in October 2007, the second in March 2009, and this third in December 2010. There were presentations by experts, and, to provide a consensus, a questionnaire was completed by 88 attendees who had 1 year (mean 3.6 1.5, range 1 8) of experience with LSG. Results: The results of the questionnaire were based on 19,605 LSGs performed within 3.6 1.5 years (228.8 275.0 LSGs/surgeon). LSG had been intended as the sole operation in 86.4% of the cases; in these, a second-second stage became necessary in 2.2%. LSG was completed laparoscopically in 99.7% of the cases. The mean percentage of excess weight loss at 1, 2, 3, 4, and 5 years was 62.7%, 64.7%, 64.0%, 57.3%, and 60.0%, respectively. The bougie size was 28 60F (mean 36F, 70% blunt tip). Resection began 1.5 7.0 cm (mean 4.8) proximal to the pylorus. Of the surgeons, 67.1% reinforced the staple line, 57% with buttress material and 43% with oversewing. The respondents excised an estimated 92.9% 8.0% (median 95.0%) of fundus (i.e., a tiny portion is maintained lateral to the angle of His). A drain is left by 57.6%, usually closed suction. High leaks occurred in 1.3% of cases (range 0 10%); lower leaks occurred in.5%. Intraluminal bleeding occurred in 2.0% of cases. The mortality rate was.1%.3%. Conclusion: According to the questionnaire, presentations, and debates, the weight loss and improvement in diabetes appear to be better than with laparoscopic adjustable gastric banding and on par with Roux-en-Y gastric bypass. High leaks are infrequent but problematic. (Surg Obes Relat Dis 2011;7:749 759.) 2011 American Society for Metabolic and Bariatric Surgery. All rights reserved. Morbid obesity; Bariatric surgery; Consensus conference; Laparoscopic sleeve gastrectomy; Diabetes mellitus; Complications; Stents; Outcome *Correspondence: Mervyn Deitel, M.D., F.A.S.M.B.S., C.R.C.S.C., 39 Bassano Road, Toronto, Ontario M2N 2J9, Canada. E-mail: book@obesitysurgery.com Sleeve gastrectomy (SG) is the first part of the duodenal switch (DS) operation. In 2000, bariatric surgeons began performing laparoscopic SG (LSG) as a first-stage operation in high-risk or superobese patients. It was found that many patients lost adequate weight such that a second-stage operation became unnecessary [1 4]. Over the years, the ver- 1550-7289/11/$ see front matter 2011 American Society for Metabolic and Bariatric Surgery. All rights reserved. doi:10.1016/j.soard.2011.07.017

750 M. Deitel et al. / Surgery for Obesity and Related Diseases 7 (2011) 749 759 tical sleeve has been constructed more narrowly and initiated closer to the pylorus, and the indications for LSG have increased. Many surgeons now perform LSG as their standard bariatric operation. It is important to follow the progress of the LSG with respect to the techniques, complications and treatment, and, in particular, the durability of the weight loss. The first International Consensus Summit for Sleeve Gastrectomy was held in New York City, New York, in October 2007 [5]; the second International Consensus Summit was held in Miami Beach, Florida, in March 2009, 17 months after the first summit [6]. For further monitoring, the third International Consensus Summit was held in New York City, New York, in December 2010, 21 months after the second summit. The conference consisted of the following. On the first day, 15 live operations by way of the Internet from various parts of the world were presented to demonstrate techniques, with discussion between the operating surgeons and the attendees. On the second and third days, 80 presentations and discussions on the specific aspects of LSG were conducted In addition, a questionnaire was completed by those experienced in LSG to provide a current consensus on the techniques, effects, and outcomes. The meeting included 475 attendees from 35 countries, including 36 faculty. The program was again ably organized by Cine-Med of Woodbury, Connecticut. There are variations in technique for all bariatric operations. Similarly, various techniques for LSG have been developed, and this conference provided interaction among the world experts. Surgical techniques for LSG Basso, Belanger, Weiner, Rosenthal, Prager, Himpens, Pomp, and Jossart presented various strategies developed by their groups for LSG [3,7 11]. Most surgeons use 5 6 ports and preserve part of the antral pump for better gastric emptying, beginning dissection 3 8 cm proximal to the pylorus. The short gastric vessels are divided, and the gastrophrenic ligament is incised. All posterior gastric attachments are freed to the fundus. The angle of His is exposed, ensuring that there is no hiatal hernia, which, if present, is repaired by posterior crural approximation. Dissection is 1 cm to the left of the esophagus. Belanger cautioned to avoid stapling close to the esophagus in the cardia area [8], and Gagner recommended leaving a dog ear at the angle of His to avoid a leak. A 32 50F blunt tube is inserted by the anesthesiologist to prevent narrowing and stenosis, especially at the incisura angularis. Belanger prefers a 32 34F bougie but not tight (i.e., equivalent to 50F) to avoid stenosis. Basso uses a 36F tube. Rosenthal warned that a too-narrow bougie can result in problems and reported that he has some patients with a larger volume sleeve who are doing very well. The stomach is well exposed before gastric transection. Retrogastric adhesions are taken down as a part of the complete stomach mobilization. Two sequential 4.8/60-mm green cartridge load firings for the antrum are used initially. The bougie is usually passed after the first or second firing, and vertical division is then performed along the tube. However, some surgeons prefer to have the bougie along the lesser curvature to the pylorus before the stapling to avoid stricture at the incisura. Three sequential 4.8/60-mm or 3.5/60-mm cartridges are used to divide the remaining corpus and fundus, with 20 seconds of compression before each firing, pausing 5 seconds between applications. Dissection of the left crus is followed by careful resection of the fundus so as not to coagulate and devitalize stomach close to the esophagus. Most of the surgeons reinforce the staple line, either by a buttress or by sutures applied seromuscular seromuscularly or through-and-through, which decreases bleeding and possibly leaks [7,12 15]. The surgeon should check for leakage (methylene blue or air instillation down the tube) and for bleeding. The sleeve at the end of the procedure should have a volume of 75 120 ml. Gagner favors using a 40F bougie. Increasing leak rates have been reported with small bougie sizes. Parikh et al. [16] compared the use of a 40F and 60F bougie in LSG and did not find significant differences in weight loss. In a show of hands from the audience, one half removes the resected stomach in a retrieval bag and one half without a bag [17]. Belanger warned of postoperative possible vomiting and dehydration, mesenteric venous occlusion, deep venous thrombosis, and severe reflux esophagitis [8]. Most preferred that when endoscopy is necessary in these patients that the surgeon be the one to perform these. Studies related to technique Sabbagh et al. [18] compared the gastric volume 2 years after LSG in patients considered to have treatment failure with the gastric volume of those considered to have treatment success. They prospectively followed up 116 patients after LSG, classifying the outcome using the Bariatric Analysis and Reporting Outcome System scale ( 3 indicating success and 3, failure) [19]. The gastric volume was evaluated by having the patient swallow a mixture of sodium bicarbonate and tartaric acid to produce carbonic gas, followed by a low-dose gastric computed tomography (CT) scan. The preoperative body mass index (BMI) had been 46 kg/m 2. On the day of the CT scan, the percentage of excess weight loss (%EWL) was 64.8%. The mean gastric volume at 2 years was 300 ml (range 150 600), with a mean Bariatric Analysis and Reporting Outcome System score of 4.7. Those with failure had larger gastric volumes ( 400 ml) and required repeat SG or DS. Weiner compared virtual CT images after LSG in the short and long term and compared these to Roux-en-Y gastric bypass (RYGB). With LSG, he found that 32F and

M. Deitel et al. / Surgery for Obesity and Related Diseases 7 (2011) 749 759 751 42F bougies gave a volume of 100 ml, with only a slight difference in the volume of the cylinder. He also found that the tighter bougie resulted in increased gastroesophageal reflux. Within 8 years, the mean sleeve volume had reached 300 ml, with some regain of weight in two thirds of the patients. Restrictive procedures maintain the restriction for a few years (except for gastric banding, where one can adjust the restriction). In the CT images of RYGB, the pouch and/or alimentary limb had also dilated with time, with a loss of restriction. Weiner concluded that LSG as the sole procedure can achieve substantial weight loss, with weight regain after 3 5 years if the sleeve volume increases significantly. Similar weight regain occurs at 3 5 years after RYGB. He believes that for better long-term weight loss after LSG, the antrum size should be reduced. Jaser reported that 70% of bariatric operations in Finland are LSG (first stage or stand alone), with the complication rate decreasing with the learning curve, as also reported by Silecchia et al. [2] and Daskalakis et al. [12]. Mechanisms of action of LSG The gastric sleeve restricts oral intake. Rosenthal presented strong evidence that, in addition, the mechanical effect of LSG is rapid gastric emptying, leading to rapid intestinal transit. Gastrointestinal (GI) series, scintographic studies of gastric emptying, and elevated hindgut intestinal hormones (glucagon-like peptide-1 [GLP-1] and peptide- YY) have confirmed this [20 22]. Shah et al. [23] of India documented a decreased gastric emptying half time and more rapid small bowel transit after LSG. Rosenthal s group has been studying ghrelin cells, which are found mainly in the gastric fundus with basal hyperchromatic nuclei, that are resected in LSG. Ghrelin, a 28- amino acid peptide, produces hunger when the stomach is empty [24]. Ghrelin is increased after laparoscopic adjustable gastric banding (LAGB) and after the classical Scopinaro biliopancreatic diversion (BPD); it is decreased after RYGB and is absent after LSG and DS, a benefit of the latter 2 operations [25,26]. Also, compared with RYGB or Scopinaro BPD, the absence of dumping after LSG represents an advantage for the patient s quality of life [26]. Table 1 Mechanisms of action of laparoscopic sleeve gastrectomy Decreased gastric volume (restriction) Restriction by the pylorus Decreased ghrelin (fasting and meal-stimulated) Increased satiety Faster gastric emptying Increased glucagon-like peptide-1 and peptide-yy Faster small bowel transit time with malabsorption Data from Shah et al. [21]. Table 2 Proposed advantages of laparoscopic sleeve gastrectomy Safer for high-risk, super-obese Simpler to perform Short learning curve Shorter duration of procedure Shorter hospital stay Pylorus preservation Continuity maintained for endoscopy No gastrointestinal segment exclusion Less malabsorption High satiety Good patient tolerance Fewer nutritional deficiencies Satisfactory weight loss Easier to perform if previous laparotomy Good results for diabetes Good stand-alone or first-stage operation Rarely converted to open Easily converted Extremely low mortality Revision for failed band or VBG Weight loss similar to RYGB or DS Convertible to RYGB for reflux Convertible to DS or re-sleeve for more weight loss VBG vertical banded gastroplasty; RYGB Roux-en-Y gastric bypass; DS duodenal switch. Data from Shah et al. [21]. Effect on diabetes and other metabolic disease Todkar et al. [27] documented that after LSG, improvement in the control of type 2 diabetes mellitus (T2DM) is achieved even before weight reduction, a finding also reported by others. They noted that orexigenic ghrelin is also diabetogenic, and its removal adds to T2DM improvement. Shah et al. [21] tabulated the mechanisms of action (Table 1), advantages (Table 2), and limitations (Table 3) of LSG. They also noted increased meal-stimulated peptide-yy and GLP-1. Rizzello et al. [28] emphasized the resolution of T2DM after LSG. They also presented the effect of LSG on T2DM in patients with a BMI 35 kg/m 2. They studied 9 patients with T2DM and a BMI of 30 35 kg/m 2, who also had hypertension, dyslipidemia, and obstructive sleep apnea, which improved remarkably. A normal BMI and normal glycemia were achieved within 6 months, with a mean hemoglobin A1c of 6.0%. T2DM resolved in all but 1 of these patients (88% cured). The patient in whom T2DM did Table 3 Limitations of laparoscopic sleeve gastrectomy Not reversible Long-term results are still awaited Infrequent complications (e.g., high leak difficult to treat) Can be followed by early and/or late GERD GERD gastroesophageal reflux disease. Data from Shah et al. [21].

752 M. Deitel et al. / Surgery for Obesity and Related Diseases 7 (2011) 749 759 not resolve had been diabetic for 20 years, but postoperatively had a decrease of 25 U in the insulin requirement. Rizzello et al. [28] stated that 10-years duration of T2DM is a cutoff for resolution. Rosenthal et al. [29] also found that after LSG, normoglycemia was achieved in most patients; however, patients with T2DM for 5 years did not do as well as those with shorter term T2DM. DePaula et al. [30], in patients with T2DM and a BMI of 21 29 kg/m 2, performed LSG plus ileal interposition proximally, for maximal GLP-1 stimulation, and reported adequate glycemic control (hemoglobin A1c 7%) in 95.7% of patients without diabetic medication; hemoglobin A1c 6% was achieved in 65.2% [30]. Ramos et al. [31] had similar findings with duodenojejunal exclusion and rapid passage to the ileum in patients with a BMI of 30 kg/m 2. Endo et al. [32], from Japan, reported that RYGB is decreasing in Japan because of the danger of cancer in the bypassed stomach. They compared gastric banding, SG, or a sham operation in 30 male Zucker obese diabetic rats [32]. The SG showed faster gastric emptying. The insulin tolerance test at 6 weeks showed improvement with gastric banding and SG, but SG resulted in better glucose control. The serum triglyceride levels improved with gastric banding and SG compared with the sham controls, but the total cholesterol levels were more improved after SG. The resolution of T2DM has been documented by others [33,34]. Regarding T2DM, Basso et al. [7] noted (as had Wei-Jei Lee) that low plasma C-peptide indicates low remaining pancreatic function, indicating poor resolution after surgical intervention [6]. In the resolution of T2DM, LSG has been found to be as successful as RYGB and superior to LAGB [35 38]. Leyba et al. [39] prospectively compared RYGB and SG in 117 patients. The mean operative time for LSG was 82 minutes and for laparoscopic RYGB was 98 minutes (P.05). Differences in the length of stay, complications, improvement in co-morbidities, and %EWL were not significant after 2 years. Deitel [40] discussed why T2DM does not resolve in some patients after bariatric surgery. There could be inadequate weight loss, weight regain, overindulgence in highcaloric foods, lack of compliance with diet and exercise, or inadequate patient education. Also, longstanding uncontrolled T2DM with high hemoglobin A1c (e.g., 10%) could have led to apoptosis and permanent loss of the -cells. Also, surgical technique, such as a pouch or stoma constructed too large, will yield inadequate gastric restriction. However, Deitel cautioned that the diabetes persisting after a bariatric operation could actually be type 1, latent autoimmune diabetes in the adult, which is a slow autoimmune destruction of the -cells with onset at age 30 55 years; latent autoimmune diabetes in the adult should be ruled out particularly, in those with T2DM and a lower BMI [40]. Patients with latent autoimmune diabetes in the adult have low plasma insulin levels, low or absent C-peptide levels, and antibodies to glutamic acid decarboxylase, insulin, and/or -cells. Zhang et al [41] reported the lipid profiles in morbidly obese patients 1 year after LSG. There was a significant decrease in weight and in elevated triglycerides and an increase in high-density lipoprotein cholesterol. There were no changes in low-density lipoprotein or total cholesterol. T2DM resolved in 8 of 13 patients in their study. The problem of hiatal hernia and reflux del Genio et al. [42] performed 24-hour ph manometry and multichannel intraluminal impedance plus endoscopy before LSG in 15 consecutive patients who had no preoperative symptoms of gastroesophageal reflux disease (GERD), hiatal hernia (HH), or Barrett s esophagus. These studies were repeated 1 year after LSG, at which point the mean %EWL was 56%. The studies after weight loss found that the lower esophageal sphincter pressure (LESP) had not changed, but there were increased ineffective secondary waves with an increase in nonacid reflux during the day. A correctly fashioned sleeve was an effective restrictive procedure that increased the postprandial reflux episodes but did not induce GERD. When there had been GERD preoperatively, they approximated the crura during the LSG operation. However, they did not perform LSG in patients with severe reflux. Also, Barrett s esophagus is contraindicated for LSG because of the danger of Barrett s progressing to carcinoma. Karcz of Baumann s group [43] reported on 33 CT examinations with 3-dimensional volumetry after LSG. They found intrathoracic sleeve migration in 36% of patients as a possible cause of persistent regurgitation. Dilation of the sleeve to 200 ml was a common finding, but did not necessarily result in weight regain. Hagen et al. [44] reviewed the high incidence of reflux in the bariatric population. Ayazi et al. [45], with Peter Crookes, had studied 1659 patients with GERD using 24- hour ph monitoring and manometry; increasing obesity correlated with increasing esophageal acid exposure and a lower LESP. Dutta et al. [46] studied 101 patients who were scheduled to undergo RYGB. These patients first underwent esophagogastroduodenoscopy and were matched with nonobese; GERD symptoms were present in 32.6% of the obese versus 18.8% of the controls, and esophagogastroduodenoscopy-proven HH was present in 38.6% of the obese versus 13.8% of the controls. Jossart noted that after RYGB, ulcers can develop, with hemorrhage and perforation, which can be much more serious than GERD. He also stated one should not assume that a sleeve will make GERD worse. Also, after Swedish gastric banding, esophagitis has been reported in 28% of 785 patients [47]. With the DS operation, the sleeve size was 200 ml, the phrenoesophageal ligament was preserved, the antrum was larger, and reflux was not a feature. However, with LSG, the

M. Deitel et al. / Surgery for Obesity and Related Diseases 7 (2011) 749 759 753 sleeve has a volume of 100 ml, a disrupted phrenoesophageal ligament, and a smaller antrum, and postoperative GERD is commonly reported in the long term. In contrast, the sleeve might reduce GERD, because it reduces acid production, removes the fundus, which is the source of relaxation waves to the LESP, and accelerates gastric emptying. A narrow sleeve might worsen reflux by resecting sling fibers and thereby reduce LESP, and narrowing of the sleeve at the angularis might create an obstruction [48]. Most surgeons approximate the crura posteriorly during the LSG if there is an HH [49]. Adrian Heap suggested a modified Hill posterior gastropexy for HH during LSG, although there is danger of puncturing the aorta. Keidar et al. [50] found that a dilated upper sleeve can be associated with severe postoperative gastroesophageal dysmotility and reflux. If significant GERD develops later, one can convert to RYGB [51]. Himpens et al. [52] presented 6-year follow-up data for LSG that had been performed in 2001 and 2002. There was a biphasic pattern of reflux early and late. Similar to the findings from Braghetto et al. [48], they found an increase in GERD to 6 months postoperatively. Up to 6 months, this could be from poor patient compliance, which improves. However, Himpens et al. [52] then found a decrease in GERD to 3 years. From 3 to 6 years, GERD symptoms increased to 21%, usually after meals and never at night, indicating this is not true reflux but stasis. At 3 years, the %EWL was 73%, which at 6 years had decreased to 53%, because the patients had started to consume junk food and carbohydrates. The 6-year increase in reflux paralleled the increase in BMI. At 6 years, there was also fundic regrowth, forming a neostomach. Arvidsson (Kakoulidis et al. [53]) have performed 1000 LSGs, with a leak rate of 1%, no mortality, and reoperations in 6 patients. They regard GERD currently as a contraindication to LSG. Arvidsson reported on LSG in obese patients who had previously undergone fundoplication. He performed LSG in 4 patients with previous antireflux surgery 2 Nissen and 2 Toupet (posterior wrap). With the Nissen, he opened the wrap and repositioned the fundus and could then perform a standard LSG. The hiatal sutures were intact and left in place. After the Toupet procedure, the hemi-fundoplication was firmly attached to the posterior esophageal wall and crural muscles; thus, LSG is more dangerous. Therefore, he performed a modified LSG, leaving the posterior flap of fundus in place behind the esophagus. All operations were uneventful with normal postoperative convalescence. Gagner et al. [6] recommended that in the situation in which an HH had previously been repaired, RYGB or Scopinaro BPD might be a wiser option than LSG. Santoro [54] presented the preliminary results of hiatoplasty and modified antireflux fundoplication performed with LSG. Braghetto et al. [48] had found that dividing the sling fibers decreases the LESP. Santoro submitted 15 obese patients with GERD and HH to hiatoplasty and modified fundoplication (total or partial) followed by LSG. The fundus was kept, and 3 or 4 stitches were placed to preserve the angle of His. The 180 wrap maintained the whole gastric fundus, which saved the sling fibers. The sleeve was fixed in position with omentum, to prevent twisting [54]. A barium upper GI study showed that the HH was corrected in all, and all had improvement in GERD. Residual reflux was detected in 2, and 3 of the 15 patients continued the use of a proton pump inhibitor (PPI). The average %EWL was similar to that after a typical LSG. Deitel [55] warned that low serum calcium, low vitamin D, and elevated parathyroid hormone lead to osteoporosis and fractures. Morbidly obese individuals avoid sunlight, which converts vitamin D in the skin to D 3. Low vitamin D 3 causes decreased intestinal absorption of calcium, which leads to bone resorption. Calcium is absorbed in the duodenum and proximal jejunum, but after RYGB or rapid transit, such as in LSG, malabsorption of calcium and fatsoluble vitamin D results. H2-receptor antagonists (e.g., ranitidine) cause achlorhydria; thus, ingested calcium salts cannot be broken down for absorption. PPIs, in addition, inhibit osteolastic proton pump transport, decreasing osteoclast formation (osteoclasts are necessary for regeneration of healthy bone). After bariatric operations, supplemental vitamin D 3 (e.g., 1000 IU twice daily) and calcium (e.g., 500 mg twice daily) should be prescribed. If PPIs are necessary, a baseline dual-energy X-ray absorptiometry bone mineral density scan should be done and repeated at 1 2 years. PPIs should be stopped when possible. Postoperative complications and their treatment The most dreaded complication of LSG is a leak, reported in 1 7% of patients. Assalia and associates presented a multicenter experience from Israel of 2235 LSG patients, of whom, 38 (1.7%) had a leak. For prevention of complications, they emphasized: (1) not too tight a sleeve; (2) firing the stapler lateral to angle of His; and (3) performing an intraoperative leak test selectively. For a leak in the stable patient, one should ensure that there is adequate ultrasound- or CT-guided or laparoscopic drainage. A leak can be heralded by fever, epigastric pain, tachycardia, and left shoulder tip pain or can be seen on radiologic examination. If the patient is unstable or septic, laparoscopic or open drainage should be performed, and, if necessary, lavage; suture of the leak will usually fail after 2 days. Nothing by mouth and later total parenteral nutrition or nasoenteral feeding are indicated. Leaks after LSG appear worse than leaks after RYGB, but the mortality is still lower despite this. Gagner [56] determined that the log of the bougie diameter is inversely proportional to the percentage of leaks. Neto discussed the major postoperative complications of LSG: leaks and their causes (Table 4), stenosis, and GERD.

754 M. Deitel et al. / Surgery for Obesity and Related Diseases 7 (2011) 749 759 Table 4 Causes of leaks at the angle of His Smaller bougie size Poor blood supply Physiologic obstruction by pylorus Mechanical obstruction by L-shaped sleeve Negative pressure from thorax No remnant stomach to block fistula Long tortuous fistula tracts Sleeve stenosis, which is sometimes difficult to recognize, can keep a fistula open [57,58]. If the endoscope passes through the sleeve, it does not mean that there is no stenosis there can be a spiral sleeve. Endoscopic treatment of stenoses by pneumatic dilation of the stenosis or of the pylorus (or botulinum toxin type A injection into the pyloric musculature to induce relaxation) has relieved back pressure on fistulas. High intraluminal pressure has been found in the LSG [59]. Neto described dilation of strictures with an achalasia balloon inflated to 25 psi. Also, pneumatic dilation with the Rigiflex balloon has been successful to 30 mm (10 25 psi) in progressive sessions (e.g., for 10, 15, 20, and 25 min). An additional session to 35 mm at 25 psi for 25 minutes could be needed. For long stenoses, laparoscopic careful seromyotomy using the hook cautery has been successful [60]. Endoscopic clipping for high leaks or instillation of fibrin or cyanoacrylate sealant in the fistula can be tried [61]. For refractory proximal leaks, endoscopic and/or fluoroscopic placement of a removable stent that slowly expands radially to its maximal diameter, might be necessary. Polyflex (polyester, silicone) stents have the advantage of easy implantation and removal but the disadvantage of frequent dislodgement. Nitinol (nickel-titanium) metal, flexible, thin-walled, silicone-covered or partially covered, self-expanding stents are easier to implant and have less dislodgement but can be difficult to remove because of mucosal growth at the margins [62 67]. Neto s group reported the use of stents in 29 patients Polyflex in 14 (fistula closure in 93%), nitinol in 11 (fistula closure in 91.6%), and endobarrier in 2 (closure in both). There was 1 dislodgement with the Polyflex, and 1 nitinol stent was very difficult to remove. The patient can eat through the stent, but a nasojejunal tube through the stent or a jejunostomy might be optimal for nutrition while the stent is in place. Langer noted that if a stent is left in place too long, it can be very difficult to remove [68]. Nguyen et al. [69] use a stent for a maximum of 6 8 weeks and replaces the stent with another if needed. A stent should not be used for a distal leak because of the possibility of migration. For a long staple-line leak, Court et al. [70] inserted a T-tube laparoscopically, with the arms placed in the lumen, which afforded a controlled fistula that healed. Marre noted that he treats small fistulas conservatively, but large fistulas surgically. Himpens has anastomosed a Roux-jejunal loop to a persistent fistula, maintaining the sleeve. Baltasar required total gastrectomy for 1 refractory leak [67]. Results and durability of LSG Although after LSG, the resolution of co-morbidities and complications are well reported, long-term weight loss data are sparse and not presented in uniform units. At 2 years, Sabbagh et al. [18] reported that the mean %EWL was 67%, and Ser et al. [15] found a %EWL of 75%. Lee et al. [11] found that at 2 years, the BMI was 28 kg/m 2. Weiner et al. [9] at 3 years reported a percentage of excess BMI loss of 56%. Bohdjalian et al. [26] with LSG as the sole bariatric operation found a 3- and 5-year %EWL of 60% and 55%, respectively. Santoro [54] stated from his LSG experience of 8 years, that the %EWL at 1, 5, and 6 years had been 84%, 55%, and 50%, respectively, after LSG as a stand-alone procedure. Arias et al. [10] reported 68% EWL at 2 years and stated that these results with LSG appear to be as good as with any bariatric operation. However, similar to the study of longterm weight after LSG conducted by the American Society for Metabolic and Bariatric Surgery, Arias et al. [10] found that it is difficult to get later follow-up because the patients lived far away and could not afford to return. Himpens et al. [52] presented their 6-year LSG results, using a 34F bougie, maintaining the antrum for peristalsis, and resecting the fundus. The preoperative BMI was 39 kg/m 2 (range 31 57). The patients with a BMI of 35 kg/m 2 had been on a weight loss program preoperatively. Of the 41 patients at 6 years, 28 had undergone only LSG (2 patients underwent resleeve and 11 patients DS). The BMI at 6 years was 31 kg/m 2 in the 30 patients who had only undergone LSG. The BMI was 27 kg/m 2 in the 11 patients who had undergone second-stage DS. In the 30 patients with LSG alone, the %EWL was 77.5% at 3 years and 53.3% at 6 years. In the 11 patients who had undergone LSG plus DS, the %EWL was 60% at 3 years and 71% at 6 years. After 6 years, the mean %EWL was 50%, and, despite late gastroesophageal reflux symptoms in 21% of the patients, patient acceptance remained good. Weiner compared the 5-year results of LSG versus LAGB and LSG versus RYGB with a mean preoperative BMI of 44 kg/m 2 for LAGB, 48 kg/m 2 for RYGB, and 62 kg/m 2 for LSG. There were second operations in 24% with LAGB, 20% with RYGB, and 25% with LSG. The second operation was for LAGB, mainly RYGB; for RYGB, a Fobi ring for pouch enlargement, and occasionally DS; and for LSG, redo sleeve, RYGB, or DS and occasionally omegaloop gastric bypass. In those with LSG plus a second operation at 4 years of follow-up, the weight loss was satisfactory with RYGB, DS, and omega loop.

M. Deitel et al. / Surgery for Obesity and Related Diseases 7 (2011) 749 759 755 Treatment of weight loss failures after LSG Dapri et al. [71] treated inadequate weight loss resulting from a large stomach or neofundus after LSG by resleeve, and warned: (1) beware of the angle of His trap; (2) dissect from left to right (avoid dissecting along the lesser curvature); and (3) leave a drain for a sufficiently long period. For GERD, they converted LSG to RYGB. For inadequate weight loss, after dietary counseling for eating habits has failed, they convert LSG to DS. Where a sizable gastric fundus is confirmed on upper GI series, Iannelli et al. [72] also performs resleeve as an easy second step, using a 34F bougie and a green cartridge with buttressing; resleeve has resulted in substantial weight loss. Where the LSG had been done as a first stage in superobese patients or where there is progressive weight regain, they perform DS, which has led to additional weight loss and improvement in co-morbidities. Biertho of the Quebec group, with a large experience in DS [73], stated that he now offers LSG as a stand-alone procedure, which has decreased the hospital stay and might have fewer complications. DS patients have better weight loss and T2DM resolution, but they have a lower serum albumin and greater risk of nutritional deficiency. Leivonen and Jaser of Finland reviewed 12 patients 59 years old who had undergone LSG 1 year previously. There was more T2DM (50% versus 37%) and significantly more hypertension (100% versus 60%) than in younger patients. Postoperatively the older patients had more complications but no mortality. The elderly required greater supplementation of vitamin D and vitamin B 12. The mean BMI decreased from 48 to 35 kg/m 2 at 1 year. Keidar likewise presented 27 Israeli patients aged 60 72 years, with a %EWL of 69% at 1 year after LSG; significant complications occurred in 3, but there was no mortality. Langer et al. [74] found weight regain at 10 years after all bariatric operations. After LSG, Prager s group reported good weight loss 5 years; however, 8 (11%) of 73 patients underwent conversion to RYGB for weight regain or severe reflux [74]. They have also converted the LSG to a DS or, recently, Larrad BPD for added fat malabsorption. Roslin [75] noted that after RYGB, there is frequently regain of weight after 5 years. The postoperative glucose tolerance test shows hypoglycemia when sweets are taken owing to rapid gastric emptying because the pyloric valve effect has been removed [76]. Patients treat the symptoms of hypoglycemia by snacking. Roslin et al. [75] found that DS is superior, because it maintains pyloric control, with similar weight loss to RYGB for 3 years. Conversions to SG Foletto et al. [77] reported on revision to LSG in 75 patients who had had problems or inadequate weight loss after previous restrictive operations (6 vertical banded gastroplasty, 69 LAGB). There was a greater complication rate than after primary LSG, but no mortality [77]. The percentage of excess BMI loss increased from 29% to 40% at 3 years of follow-up. Four of these patients subsequently underwent DS, which attained satisfactory weight loss. Other presenters also reported that removal of the gastric band and conversion to LSG was prone to increased complications but resulted in weight loss [78 81]. Pomp and Krawczkowski discussed the hazard of leaks and stricture at the site of the previous band in converting to LSG. Changing LAGB to RYGB (or Scopinaro BPD) might be a safer option. Instead, one can remove the band and after 5 months perform LSG (2 steps), especially for band erosion. Hopkins stated that in Australia after LAGB, LSG is done as 2 steps, with band removal as the first step. Rosenthal prefers revision of LAGB to RYGB, especially in the patient with GERD and/or HH, and Pomp advises converting LAGB to RYGB if diabetes, Barrett s esophagus, or significant reflux is present. RYGB that results in insufficient weight loss or weight regain can be revised to a distal gastric bypass, Scopinaro BPD, or DS or have a Fobi ring applied [82 84]. Inabnet noted that RYGB is being converted to LSG for problematic postprandial hypoglycemia (instead of undertaking subtotal pancreatectomy), with improvement in symptoms in 90%. Related operations LSG with Transit Bipartition Santoro et al. [85] modified the LSG for better effect on the metabolic syndrome. LSG alone produced satisfactory weight loss and good quality of life. They perform LSG but, in addition, anastomose the distal end of the divided ileum to the side of the antrum transit bipartition (TB). The stomach is left with 2 exits. They add a jejunectomy, which enhances distal gut GLP-1, improving T2DM. The jejunum is anastomosed end-to-side to the ileum, 80 100 cm proximal to the ileocecal valve [85]. They also resect the omentum, because visceral fat has been linked to insulin resistance, although omentectomy has not been confirmed to improve the metabolic syndrome. They performed LSG alone in 130 patients; however, since 2003, 1301 patients have undergone LSG plus the gastroileal anastomosis, partial jejunectomy, and omentectomy. The TB avoids excluded segments and malabsorption. Complications with TB were related to LSG (gastric fistula 1.5%), and there was no mortality. The follow-up of TB was 8 years. The %EWL after TB at 3 years was 87.5% and at 5 years was 83%. The resolution of T2DM (in 93%) and dyslipidemia was better compared with LSG alone. Radiographic studies showed nutrient transit mainly through the gastroileostomy. Jejunectomy and omentectomy are simple and safe and improve resolution of the metabolic syndrome [85].

756 M. Deitel et al. / Surgery for Obesity and Related Diseases 7 (2011) 749 759 Gastric plication Hopkins noted that LSG is rapidly increasing in Australasia. LSG is good for patients who live vast distances from the surgical weight loss clinics, for whom adjustable gastric banding would be inappropriate. He also presented sleeves created by gastric plication in high-risk morbidly obese patients. In risky cardiac patients, the catastrophic complications of LSG could lead to an unacceptable mortality rate; instead of sleeve resection, he performs gastric plication. Surgeons in Brazil, Spain, and the United States are performing greater curvature plication over a bougie in 2 layers of continuous nonabsorbable suture, after freeing the greater curvature [86]. Talebpour of the Islamic Republic of Iran, with the most experience, has found that the weight loss at 3 years is less than that with standard LSG. Antidiabetic effect of LSG with duodenojejunal bypass Kasama et al. [87] compared LSG versus LSG with duodenojejunal bypass (DJB). The distal antrum is divided at the duodenum, the sleeve is anastomosed to the ileal end of the divided jejunoileum, and the jejunum is anastomosed end-to-side to the ileum [87]. They performed DJB in 26 diabetic patients, with resolution in 93% better than after LSG alone. There are 2 options: a 2-stage procedure first LSG, and if it fails, add DJB; or perform the complete DJB operation at once. However, C-peptide levels 3, patients requiring insulin, and a long duration of T2DM indicate permanent -cell dysfunction. Laparoscopic LSG in outpatients ( 24-h stay) Atlas of Montreal presented his 23-hour program for LSG. The patient is discharged at 7:00 AM. The readmission rate has been 5.8%. These are selected patients no T2DM requiring insulin, no obstructive sleep apnea. The higher risk patients (8.5%) undergo LSG as inpatients. The patients are seen by a surgeon before discharge. The program started in August 2009 after experience with 250 LSGs. Since then, 143 patients have undergone LSG: 59 accepted the operation on the short-stay program after approval by the anesthesiologist; 9 patients were discharged before 12 hours and 38 before 24 hours. There was no death. Two patients were converted to inpatients for mild bleeding but did not require a transfusion. The 2 patients with leaks were treated by stent placement and percutaneous drainage and did well. Reduced access sites for LSG Ramos et al. [88], Lacy et al. [89], and Chouillard et al. [90] reported on LSG in women using natural orifice transluminal endoscopic surgery by way of the vaginal route. Saber et al. [91] reported their considerable experience with very good results in performing the LSG through a single access site. These trocar reduction strategies require considerable expertise. Rosenthal noted that he prefers 6 7 trocar access sites. Costil described LSG using 3 incisions and posterior access to the upper stomach. This approach decreases the operative time and simplifies dissection of the fundus but is limited by the size of the liver. A 12-mm trocar is inserted in the left hypochondrium and a 5-mm trocar in the left flank. The third trocar is inserted near the umbilicus. The stomach is divided 6 cm proximal to the pylorus, using 6-cm staplers and a 36F tube. The stomach is pushed up, and a 30 laparoscope is inserted behind the stomach. The gastric vessels and short gastrics are divided. Two additional staplings complete the division of the stomach. Questionnaire results A questionnaire had been developed for the LSG to provide a current consensus. The questionnaire was completed by 88 participant and attendee surgeons who had performed LSG for 1 year. The data were analyzed by biostatisticians Ross Crosby and Ann Erickson. The data are reported as the mean standard deviation, median and range, or frequency and percentage of valid responses. The total number of LSGs performed by the respondents was 19,605 an average per surgeon of 222.8 275.0 (median 120.0, range 6 1300). The number of years that the respondents had performed LSG was 3.6 1.5 (median 3.0, range 1.0 8.0). In 86.4% of the operations, the LSG had been intended as the sole operation; however, in 2.2% of these, a second stage has thus far been necessary. Of the LSGs, 99.7% were completed laparoscopically without conversion to open surgery. The weight loss reported by the respondents is listed in Table 5. Table 5 Weight evolution reported after LSG* Mean SD Median Range n Weight loss (kg) 1 yr 49.0 23.9 50.0 25 110 13 2 yr 38.8 16.4 40.0 20 70 9 3 yr 38.7 20.7 35.0 20 61 3 4 yr 32.5 46.0 32.5 0 65 2 %EWL 1 yr 62.9 15.4 60.0 30 95 55 2 yr 64.7 14.3 65.0 30 98 45 3 yr 64.0 12.3 61.0 40 90 23 4 yr 57.3 11.9 60.0 30 75 11 5 yr 60.0 8.2 60.0 50 70 4 %EBL 1 yr 62.7 29.1 65.0 5 100 13 2 yr 72.9 17.6 75.0 42 100 11 3 yr 70.8 12.8 70.0 55 90 6 4 yr 62.7 6.4 60.0 58 70 3 5 yr 61.5 12.0 61.5 53 70 2 LSG laparoscopic sleeve gastrectomy; SD standard deviation; %EWL percentage of excess weight loss; %EBL percentage of excess body mass index loss. * Surgeons given option of reporting in units used for their weight loss recording.

M. Deitel et al. / Surgery for Obesity and Related Diseases 7 (2011) 749 759 757 Table 6 Percentage of patients with complications after LSG (n 88)* Complication Percentage of patients Mean SD Median Range High leaks (GE junction) 1.3 2.0.7 0 10 Lower leaks.5 1.8.0 0 10 Hemorrhage 2.0 5.0.6 0 40 Splenic injury.3 1.3.0 0 10 Liver injury.2.9.0 0 7 Stricture.6 1.1.0 0 5 Other 2.4 8.4.0 0 38 GE gastroesophageal; other abbreviations as in Table 5. * Based on 19,605 LSG operations reported by 88 surgeons. The size of the bougie used for the LSG was 36F 4.8F (median 34.5F, range 32F 60F). Of the bougies used, 70% were blunt tipped and 19% were tapered; 6% used a gastroscope. Resection in the antrum began 4.8 1.2 cm (median 5.0, range 1.5 7.0) proximal to the pylorus. The estimated percentage of antrum removed was 44.1% 24.5% (median 50.0%, range 0 95%). A total of 67.1% of the surgeons reported that they reinforce the staple line of the sleeve; of these, 57% use a buttress on the staple line and 43% oversew the staple line. Of the buttresses, 21% use Peristrips, 42% Seamguard, and 33% Duet. The estimated fundus removed was 92.9% 8.0% (median 95.0%); many cautioned to avoid involving the esophagus. A drain is left in place by 57.6% of the surgeons most use closed-suction (Blake/Jackson-Pratt) and 3.4% a Penrose drain. The percentage of complications in these LSGs is listed in Table 6. The most common methods for treatment of leaks included CT-guided drainage, repeat laparoscopy, reoperation, with oversewing if early, nothing by mouth, total parenteral nutrition, nasojejunal feeding tube placement, antibiotics, glue, clip, and distal endoscopic dilation. For persisting leaks, most recommended self-expanding retrievable stents (unlike in the previous questionnaires) or a Roux loop, if needed. The incidence of leaks was greater in revision operations. The percentage of mortality after LSG was.1.3 (median.0, range 0 2.0). Postoperatively, gastroesophageal reflux occurred in 6.8% 9.2% (median 3.0, range 0 50.0%) of patients. Postoperatively, 68.2% of the surgeons order supplements (multivitamins and often vitamin D and calcium), 63.6% administer vitamin B 12, and 85.2% prescribe a PPI (for 4.4 6.3 mo). A total of 65.1% order an upper GI series (postoperative day 1, many selectively), and 74.6% have been performing follow-up upper GI series and/or endoscopy (1 yr routine, or for reflux, weight regain, or dysphagia). LSG is being performed in adolescents by 48.8%, high-risk patients by 89.4%, the elderly by 87.8%, at lower BMI by 73.2%, for T2DM by 90.4%, and for revision of LAGB by 81.9%. Disclosures Mervyn Deitel, Ann L. Erickson, and Ross D. Crosby have nothing to disclose. Michel Gagner is a Consultant for Ethicon EndoSurgery, Olympus, Storz, and Covidien. 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