Bariatric Times - Supplement A - Covidien - (Page 4)

THE 2007 INTERNATIONAL CONSENSUS SUMMIT ON SLEEVE GASTRECTOMY KEY POINTS • It is cautionary to remember that the sleeve formed around a 32French bougie is narrower than the esophagus. • LSG long-term results are encouraging with respect to both loss of weight and quality of life. • There are specific circumstances in which sleeve gastrectomy is an attractive option. than 80 sleeve gastrectomies and we are currently collating our results. This is a somewhat biphasic experience. We were initially encouraged by the results, but after 40 operations we found that there was a 10-percent leak rate. The leaks all occurred at the upper end of the staple line and were evident within four days of surgery. Although three of them settled with conservative management (laparoscopic drainage combined with enteral feeding), one was very persistent and eventually required gastrectomy. After the first two leaks, we routinely sutured the upper half of the staple line, but this did not appear to enhance safety. As a result of this, we moved away from sleeve gastrectomy in favor of gastric bypass, but have returned to the sleeve in the light of Dr. Gagner’s experience with staple-line reinforcement. Initially we used Peristrips®, but I personally find a combination of the largest green cartridge and reinforcement with Seamguard® to give security and hemostasis. It is cautionary to remember that 4 Bariatric Times [ J U N E 2008, the sleeve formed around a 32-French bougie is narrower than the esophagus. It is probably important to ensure that the uppermost firing of the stapler swings to the left of the left crural pillar, thus creating a very small pouch of stomach and preventing encroachment of the staple line upon the esophagus. Since employing staple-line reinforcement and attending to this detail of the final staple firing, we have had no leaks. The median preoperative body mass index (BMI) for the first 53 patients was 51. There have been no conversions to laparotomy, but in one case the operation was abandoned because of a large fatty liver. Laparoscopic sleeve gastrectomy was successfully carried out some months later after weight loss with an intragastric balloon. Long-term results are encouraging with respect to both loss of weight and quality of life. Our current data suggest a median excess weight loss of 71 percent at six years, including patients who have required conversion to gastric bypass or duodenal switch (10% of the total). Apart from the four staple-line leaks, two patients have developed a stricture of the gastric tube, both treated successfully by endoscopic dilatation. There has been one late death from a myocardial infarction. In our institution, we have gastric banding, gastric bypass, sleeve gastrectomy, and duodenal switch available. While this offers the opportunity for choice, it raises the question of when to recommend which procedure. In my opinion, there are specific circumstances in which sleeve gastrectomy is an attractive option. At one end of the weight scale, it seems a particularly appropriate procedure for patients who have lost weight with a gastric band but who require removal of the band (for slippage, erosion, or intolerance to it). Limited experience suggests that these patients do very well after sleeve gastrectomy. At the other end of the weight scale, it is an attractive option for patients with a BMI greater than 60. These are A] patients in whom the long-term results of gastric bypass are sometimes disappointing. While it is probable that sleeve gastrectomy will not achieve better long-term results, it is much easier to convert a sleeve gastrectomy into a bypass or a duodenal switch than it is to reoperate on a failed bypass. Our experience with reoperation is that significant further weight loss can be expected. Sleeve gastrectomy appears particularly suited to patients in whom a bypass procedure is undesirable because of conditions such as inflammatory bowel disease or prior bowel resection. It is a convenient operation to use in patients with large umbilical or incisional hernias or where there is dense scarring and adhesion formation in the mid- or lower abdomen. One of our patients, a professional singer, was concerned that his voice would be adversely affected by a bypass, and now claims that it is stronger after his sleeve than it was preoperatively. What of the generality of patients with BMIs in the range 35 to 55? Our preference is to select bypass if there is significant comorbidity, immobility, or reflux symptoms, but many of these patients would probably do equally well with a sleeve. I am cautious about the use of sleeve gastrectomy in patients with reflux symptoms sufficient to require medication, but our experience so far is that there is a low incidence of these symptoms more than a year postoperatively. An ongoing randomized study in London found no difference between sleeve gastrectomy and gastric bypass with respect to weight loss after one year. Although certain particular situations indicated a preference for an operation type, in my opinion the jury is still out with respect to bypass, sleeve, or band for a large proportion of patients who seek surgical help with weight loss. REFERENCES 1. Johnston D, J Dachtler, HM Sue-Ling, et al. The Magenstrasse and Mill operation for morbid obesity. Obes Surg 2003:13:10–16. SUPPLEMENT

Table of Contents Feed for the Digital Edition of Bariatric Times - Supplement A - Covidien

Bariatric Times - Supplement A - Covidien Contents Laparoscopic Sleeve Gastrectomy: From Magenstrasse And Mill To Sleeve Sleeve Gastrectomy Provides Resoultion of Type-2 Diabetes Without Duodenal Exclusion The Relationship Bewtween The Resected Remnant And Weight Loss Laparoscopic Sleeve Gastrectomy: Results After Two And Five Years Laparoscopic Sleeve Gastrectomy As An Initial Weight Loss Procedure For High-Risk Patients With Morbid Obesity Three-Year Results Of Laparoscopic Sleeve Gastrectomy In The Treatment Of Morbid Obesity In Korea Laparoscopic Sleeve Gastrectomy: Nutritional Concerns And PostOperative Dietary Care Laparoscopic Sleeve Gastrectomy: Prevention And Treatment Of Bleeding Prevention And Treatment Of Gerd/Hiatal Hernia And Stenosis Associated With Sleeve Gastrectomy Laparoscopic Revisions Of Sleeve Gastrectomy Survey Results

Bariatric Times - Supplement A - Covidien

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