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SLEEVE GASTRECTOMY E
ROUX-EN-Y GASTRIC BYPASS:
INDICAZIONI E CONTROINDICAZIONI
Maurizio De Luca
Director Department of Surgery,Castelfranco and Montebelluna (Treviso) Hospital - Italy
International IFSO Delegate for the Italian Society of Bariatric and Metabolic Surgery
Co-Chairman of IFSO Position Statements Committee
Editorial Board Member of "Obesity Surgery Journal"Editorial Board Member of "SOARD" Editorial Board Member of "Scientific World Journal"
Sleeve Gastrectomy
(Gastrectomia Verticale)
Maurizio De Luca
Sleeve Gastrectomia e Roux-en-Y Gastric Bypass: Indicazioni e Controindicazioni
BPD/DS
Sleeve gastrectomy (SG) was first performed in 1988 by Hess and Hess as
part of a hybrid malapsorbitive procedure, the biliopancreatic diversion with
duodenal switch (BPD-DS)
80 EWL% at 24 months
9% Major complications
2 perioperative deaths (pulmonary complications)
Obes Surg. 1998 Jun;8(3):267-82.Biliopancreatic diversion with a duodenal switch.Hess DS, Hess DW.
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Obes Surg. 2003 Dec;13(6):861-4.Early experience with two-stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-superobese patient.Regan JP, Inabnet WB, Gagner M, Pomp A.
In 2003 Regan et al. proposed a splitting of the procedure in two surgical
stages, laparoscopic SG (LSG) in the first stage and LRGBP after an
average 11-month interval (7 patients)
Laparoscopic sleeve gastrectomy with second-stage LRGBP is feasible
and effective procedures based on short-term results
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2009: ASMBS therefore recognizes SG as an acceptable primary bariatric procedure
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Sleeve GastrectomyTechnical aspects
Division of gastro-colic and gastro-splenic ligament
34-40 Frech bougie insertion
Vertical gastrectomy using a linear stapler
Removal of excised stomach from the abdomen
Staple line buttressing and/or oversewing (?)
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%EWL at 1 year: 58,8%
%EWL at 3 year: 63%
%EWL at 5 year: 62,3%
%EWL at 8 year: 54,8%
SOARD 2014
SOARD 2014
Complete or near-complete resolution of weight related diseases:
Arterial hypertension: 72.4% of patients (n = 122),
Hyperlipidemia: 61.5% of patients (n = 98)
Obstructive Sleep Apnea: 87% of patients (n = 47)
Type 2 Diabetes ;ellitus 70.9% of patients(n = 143) (range = 46%–100%)
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follow-up rate of 91%.
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SOARD 2014
ABSOLUTE BMI AND DELTA BMI (BMI AT FOLLOW-UP - PREOPERATIVE BMI) AT 1, 3 AND 5 YEARS
Group 1 (n = 61) with BMI≤50
Group 2 (n = 44) with BMI>50
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SOARD 2016
LSG AND T2DM
• 2/11 DM patients in Group 1 remained on hypoglycemic therapy
• 9/9 DM patients of Group 2 had good glycemic control without any medication.
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SOARD 2016
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Ann Surg. 2010
At 5-year follow-up, a mean EWL of 55.0± 6.8% was achieved
Severe reflux might necessitate conversion
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Obes Surg 2010
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Intraoperative complications occurred in 1.8%
Injuries of the spleen (0.40%)
Injuries of the liver (0.11%)
Bleeding (0.11%)
During postoperative hospitalization complications occurred in 5.9%
Staple line leakage was observed in 175 patients (1.5%)
SG Complications
Ann Surg 2016
Complication Chronicity Diagnosis Management
Hemorrhage
(1-6%)
Acute Physical findings, serial CBC
Transfusion with or without laparoscopy/laparotomy
Leak
(1-5%)
Acute/chronic Physical findings, UGI series
Drainage (infrared laparoscopy), antibiotics with or without stenting and/or repair
Abscess
(0,7%)
Chronic CT scan, ultrasound Drainage, antibiotics
Stricture
(0-3,5%)
Chronic Endoscopy, UGI series Endoscopy (dilatation), surgery (seroyotomy)
Nutrient deficiency
(3-23%)
Chronic Physical findings, blood work
Nutritional supplements
GERD
(0-47%)
Chronic History, endoscopy Treatment with proton pump inhibitor
Maurizio De LucaSG Complications
Surg Endosc 2012
230 patients
No GERD (literature is controversial)
Previuos iron or vitamin’s deficiency
History of extensive abdominal surgery
Gastric polyps, Hp+ recurrences
Surgeon experience
Superobese patients (staged surgery)
Indications to Sleeve Gastrectomy
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Bypass Gastrico
(Roux-en-Y Gastric Bypass)
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Sleeve Gastrectomy and Roux-en-Y Gastric Bypass: Indicazioni e Controindicazioni
Dr Ed Mason, IowaRoux-en-Y gastric bypass
Mason EE, Ito C. Gastric bypass in obesity. Surg Clin N Am. 1967; 47: 1345-51
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Dr Ed Mason, IowaRoux-en-Y gastric bypass• 10th May 1966
• no blind loop
• 51 yrs old
• very little protein/caloriemalabsorption
• 100-150cm Roux limb
• vertical lesser curve gastric
pouch excluding fundus
(MacLean, Montreal)
Mason EE, Ito C. Gastric bypass in obesity. Surg Clin N Am. 1967; 47: 1345-51
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‘‘Gastric bypass with asmall, 4-cm-long pouch<30ml’’
15-20ml verticallystapled lesser-curvegastric pouch stays thissize 6-8 years post-op
Late outcome of isolated gastric bypass. MacLean LD et al. Ann Surg 2000; 231: 524-8
Late outcome of isolated gastric bypass Maurizio De Luca
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Drs. Mason and Ito initially developed this procedure in the 1966s
In 1994 Wittgrove and Clark reported the Laparoscopic Roux-en-Y
gastric bypass (LRYGB)
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Obes Surg 1994
Mean percentage excess weight loss (%EWL) was 58.9% at 10+Year.
At 10 years, remission of co-morbidities was 46% for hypertension and
hyperlipidemia and 58% for diabetes mellitus
Thirty patients (9%) had revisional surgery for weight regain.
Sixty-four patients (19.5%) had long-term complications requiring surgery.
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328 patients SOARD 2016
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52 patients out of 89 with metabolic syndrome
The mean post-operative follow-up period was 6.9±2.3 years.
At the end of the follow-up, mean weight loss was 60±24 % EWL
Mean HbA1c level had significantly decreased from 64.8±19.7 to 46.4± 12.9 mmol/l
The number of patients with HT was significantly reduced from 73 % to 54
Overall medication used was reduced from 85 % to 37 % of the patients
Obes Surg 2014
Annals of Surgery October 2013
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Annals of Surgery October 2013
Remission rate of T2DM after RYGB vs LSG (P = 0.006), RYGB vs LAGB (P<0.001), and LSG vs LAGB (P=0.04).
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Gastric BypassTechnical aspects
AntecolicRetrocolic
Different limb lenght
Internal Hernia after LRYGBP has an incidence of 2.51%
Closure of mesenteric defects is recommended
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Potential hernia sites in LRYGBP:
1)enteroenterostomy mesenteric defect;
2) space between mesentery of Roux limb
and transverse mesocolon (Petersen’s
space)
3) transverse mesocolon defect.
Overall mortality rate at 1, 5, and 10 years was 2.2%, 4.4%, and 8.1%
The rates of marginal ulcer were 0.3%, 0.7%, and 1%
The reoperation rates were 0.3%, 0.8%, and 1.2%
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Obes Surg 2016
Early complications Anastomotic or staple line leaks (0.4% – 5.2%)
Postoperative hemorrhage (1,9 - 4,4%)
Small Bowel obstruction (1% - 9%)
Late complicationsGastrojejunostomy anastomotic stricture (1,9 - 23%)
Marginal ulceration (1%–16%)
Gastrogastric fistula (1,5 – 6%)
Weight regain (20% at 10 year)
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Griffith PS, Birch DW, Sharma AM, Karmali S.Can J Surg. 2012
Our aim was to compare nutritional status after SG and GBP insubjects matched for postoperative weight
Forty-three subjects who underwent SG were matched for age,gender, and 6-month postoperative weight with 43 subjects whounderwent GBP
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After surgery, LDL cholesterol, serum prealbumin, vitamin B12,urinary calcium, and vitamin D concentrations were lower after GBPthan after SG
Some nutritional parameters were specifically altered after GBP,which could be related to malabsorption or other mechanisms, suchas alterations in liver metabolism
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Trends in percentage of procedures worldwide: from 2003 to 2013
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GERD
No iron or vitamin’s deficiency
No history of extensive abdominal surgery
Pre-operative EGDS: negative
Type 2 Diabetes patients
Surgeon experience
Indications to Gastric Bypass
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Mini Gastric Bypass/One Anastomosis Gastric Bypass
(Bypass con singola anastomosi)
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Sleeve Gastrectomy and Roux-en-Y Gastric Bypass: Indicazioni e Controindicazioni
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The MGB/OAGB combines two major components:
1)First is a long non-obstrutive gastric tube (Collis Gastroplasty), sizedequal to the diameter of the esophagus that rapidly delivers undigestedfood through the non-obstructive wide gastro-jejunostomy into the distaljejunum. This results in an exaggerated “Post-Gastrectomy Syndrome”that restricts the intake of food (without “obstruction”), limits the intake ofsugars, fat and large food boluses, but allows each of these inmoderation.
1)The PGS results in alteration of intestinal transit time, reduced acidsecretion, bloating, decreased appetite, decreased caloric intake.
1)The other component of the MGB is a moderate malabsorption due tothe bilio-pancreatic limb (150 - 250 cm) combined with a Billroth II gastro-jejunostomy that results in significantly more fat malabsorption and fattyfood intolerance then RNY.
MILLS JD. The post-gastrectomy syndrome. Can Med Assoc J. 1953 Sep;69(3):237-42
Eagon JC1, Miedema BW, Kelly KA., Postgastrectomy syndromes. Surg Clin North Am.1992 Apr;72(2):445-65.
Mini Gastric Bypass/One Anastomosis Gastric Bypass (MGB/OAGB)
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1) This confusion is based upon the bariatric surgeon’srecollection of the failure of the old Mason Loop GastricBypass. In this early configuration, the gastric pouch was veryhigh, short and had a horizontal shape, exposing theesophageal mucosa to caustic alkaline bile reflux coming fromthe jejunal loop.
2) A Billroth II reconstruction of a total or near total gastrectomyis never appropriate and always fails as all general surgeonshave known since the early 1900’s.
3) The antrectomy vs distal gastrectomy and Billroth II isroutinely utilized today by general surgeons, trauma surgeonsand oncologic surgeons around the world.
Lee SW, Tanigawa N, Nomura E, et al. Benefits of intracorporeal gastrointestinalanastomosis following laparoscopic distal gastrectomy. World J Surg Oncol. 2012Dec 12;10:267.
Zang L. [Reconstruction following laparoscopic gastrectomy for gastric cancer].Zhonghua Wei Chang Wai Ke Za Zhi. 2012 Aug;15(8):787-9.
Mini Gastric Bypass/One Anastomosis Gastric Bypass (MGB/OAGB)
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Mini Gastric Bypass/One Anastomosis Gastric Bypass (MGB/OAGB)
Outcomes
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Comparison with Roux-en-Y Gastric Bypass (RYGB)
Mini Gastric Bypass/One Anastomosis Gastric Bypass (MGB/OAGB)
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Comparison with Roux-en-Y Gastric Bypass (RYGB)
One anastomosis vs two anastomosis= relatively simple procedure shorter operative time shorter
learning curve (30 vs 100-500 cases)= absence of complications related to entero-enteric anastomosis
(difficult to reach it by endoscopy)
Absence of mesenteric defects = lower incidence of internal herniation and abdominal pain
Paroz A, Calmes Jm, Giusti V, et al.Internal hernia after laparoscopic Roux-en-Y gastric bypass for morbid obesity: a continuous challange in bariatric surgery. Obes Surg 2006
Mini Gastric Bypass/One Anastomosis Gastric Bypass (MGB/OAGB)
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Comparison with Roux-en-Y Gastric Bypass (RYGB)
different size (1,5 - 3 cm) gastro-jejunostomy. restriction provided by the gastric pouch
= low pressure into the gastric body reduced leak rate= rare stoma stenosis no later dilatation of the gastric pouch
WJ, Wang W. Laparoscopic Roux-en-Y versus mini-gastric bypass for the treatment of morbidobesity: a prospective randomized controlled clinical trial.
Ann Surg 2005
Mini Gastric Bypass/One Anastomosis Gastric Bypass (MGB/OAGB)
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Comparison with Roux-en-Y Gastric Bypass (RYGB)
complete absence of alimentary limb with 150 – 250 cm jejunal bypassed limb
= greater malabsorption better weight reduction 69.4% vs 79.2% at 2 years better weight loss superior diabetes remission
= greater malabsorption higher incidence of malnutrition, anemia oily stool, higher stool frequency (nevertheless similar quality of life)
Lee WJ, Ser KH, Lee YC, et al. Laparoscopic Roux-en-Y vs minigastric bypass for the treatment of morbid obesity: a10 years experience. Obes Surg. 2012
Mini Gastric Bypass/One Anastomosis Gastric Bypass (MGB/OAGB)
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Comparison with Roux-en-Y Gastric Bypass (RYGB)
MGB: Increased bile reflux into the gastric pouch
• acid neutralizing effect low incidence of marginal ulcer
• no evidence of increased risk of gastric cancer due to chronic alkaline bile reflux
MGB: no evidence of higher gastric or esophageal cancer
Hansson LE, Nyren O, Hsing AW et al. The risk of stomach cancer in patients with gastric or duodenal ulcer disease. New Engl J Med 1996
Mini Gastric Bypass/One Anastomosis Gastric Bypass (MGB/OAGB)
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Take home message: Sleeve, GBP or MGB?
•Expected weight loss
•Speed of weight loss
•Time of surgery
•Comorbidities
•Patients compliance
•RGE
•Previuos iron or vitamin’s deficiency
•History of extensive abdominal surgery
•Gastric polyps, Hp+ recurrences
•Risk of complications
•Surgeon skill and preference
Maurizio De Luca
Maurizio De Luca
Maurizio De Luca
XXV Congresso Nazionale SICOB6-8 Aprile 2017, Fondazione Cini, Venezia
Thank you
Maurizio De Lucannwdel@tin.it