SLEEVE GASTRECTOMY:
ANATOMIA DI UN DILEMMA TERAPEUTICO
Introduction
Laparoscopy achieves the same anatomic objectives as open
bariatric surgery but avoids a large abdominal incision
Bariatric surgery is the most effective method for achieving sustained
weight loss of considerable degree in individuals with morbid obesity
Surgeons should have a clear understanding of the four most
commonly discussed operations for morbid obesity at this time:
1)Laparoscopic Roux-en-Y gastric bypass (LRYGB)
2)Laparoscopic adjustable gastric banding (LAGB)
3)Duodenal switch (DS)
4)Laparoscopic sleeve gastrectomy (LSG)
General overview of the various
laparoscopic procedures for morbid
obesity
“La chirurgia dell obesita e accetabile
solamente se e efficace e sicura”
EFFICACITA
Perdita di al meno 50% del eccesso
ponderale a 1 anno e a 3 anni
SLEEVE GASTRECTOMY
2000
come “ first step”
nelle
“ two stages” procedure
Cauto ottimismo
entusiasmo
Esistono “ tendenze” :
la scelta del intervento nel ambito della
chirurgia dell obesita, e arbitraria
(Necessita di guidelines )
VANTAGGI DELLA TECNICA

Riduzione dela capacita gastrica senza
perdita funzionale

Assenza di dumping a causa della
preservazione pylorica

Meccanismo “ ormonale”
DIFETTI

Rischi legati alla linea di sutura

Irreversibilita
Laparoscopic sleeve gastrectomy. A
bariatric procedure with multiple
indications.
Baltasar A: Cir Esp 2006 May;79 (5): 289-92.
30 patienti
63,1 % BMI (76 % nei vari sottogruppi
nei due anni)
“Reduction of the ghrelin – production
stomach mass may account for its
sureriority to other gasric restrictive
procedures…long – term studies are
necessary to see if it is a durable
procedure.”
Gumbs AA, Gagner M. Sleeve gastrectomy for morbid obesity
Obes.Surg 2007 Jul;17(7):962-9
RISULTATI I
A prospective multicenter study of 163 sleeve
gastrectomies: results at 1 and 2 years.
Nocca D et al Obes Surg May2008; 18(5):560-5
EWL
48,9%
6 mesi
62,02% 18 mesi
59,45% 1 anno
61,5% 2 anni
RISULTATI II
Results of laparoscopic sleeve
gastrectomy: a prospective study in 135
patients with morbid obesity.
Fuks D et al. Surgery 2009 Jan; 145(1) 106-13
EWL
38,6 6 mesi
49,4 1 anno
RISULTATI III
Feasibility and technique of laparoscopic
conversion of adjustable gastric banding to
sleeve gastrectomy
Dapri G, Cadiere GB, Himpens J. Surg Obes. Relat Dis.2009
EWL
16,7% adizionale
34,8 % totale(!!)
Laparoscopic sleeve gastrectomy: does
bougie size affect mean %EWL? Short –
term outcomes.
Parikh M, Gagner M e altri. Surg Obes Relat Dis. 2008 Jul-Aug;
4(4):528-33
( 40 F vs 60 F) !!!???
MORBIDITA
Complicanze per operatorie
Complicanze post operatorie precoci
Complicanze tardive
COMPLICANZE PER OPERATORIE

Transezione gastrica

Emorragia

Ischemia splenica

Traumatismo hepatico
MORTALITA
0
– 3,2%
Aggarwal et al. Surgery Obes Rel Dis 3 2007;189-194
COMPLICANZE POST OPERATORIE
PRECOCI

Fistola

Emorragia

Ascesso
COMPLICANZE POST OPERATORIE
TARDIVE

Riflusso

Stenosi
COMPLICANZE
The First International Consensus Summit for Sleeve
Gastrectomy (SG), New York City, October 25-27, 2007
SERIE PERSONALE (SLEEVE)
Pazienti
142
Uomini
Peso
64
150,14
(sd=26)
Donne
Peso
Eta
78
120,47
(sd=19,85)
39,04
( 19 – 60)
TECNICA

French position - 45 0 -Trocar ( 4+1)
TECNICA

Infiltrazione anestesia locale

Ultracision

32 fr

Echelon
 2 verdi
 4-6 gold
Tissue thickness of human stomach measured on excised gastric speciments from obese patients
Elariny H, Gonzalez H, Wang B. Surg Technol Int 2005;14:119-24

Buscopan
 Drenagio
SG
Technical
considerations
RISULTATI (SLEEVE)
LSG
BMI ( kg/m2)
EWL ( %)
Iniziale
45,96 (sd=8,3)
-
6 mesi
34,76 (sd=6,22)
57,16 (sd=20,20)
1 anno
30,51 (sd=6,06)
79,1 (sd=26,64)
EVOLUZIONE BMI (SLEEVE)
ΜΕΗ ΤΙΜΗ
ΓΡΑΦΗΜΑ ΜΕΣΟΥ ΒΜΙ ΓΙΑ ΤΙΣ 3 ΧΡΟΝΙΚΕΣ ΠΕΡΙΟΔΟΥΣ
50
45
40
35
30
25
20
15
10
5
0
TIME0
TIME6
ΜΕΤΡΗΣΗ ΣΕ ΧΡΟΝΟ 0,6 ΜΗΝΕΣ,1 ΕΤΟΣ
TIME12
EVOLUZIONE EWL (SLEEVE)
ΓΡΑΦΗΜΑ ΜΕΣΟΥ EWL (% ) ΓΙΑ ΤΙΣ 2 ΧΡΟΝΙΚΕΣ
ΠΕΡΙΟΔΟΥΣ
ΜΕΣΗ ΤΙΜΗ (%)
90
80
70
60
50
40
30
20
10
0
TIME6
TIME12
COMPLICANZE I (SLEEVE)
Complicanze 6 mezi
Frequenza
Percentuale
Nessuna
142
83.87
Ascesso
5
3.52 %
Fistola
5
3.52 %
Emmoragia
2
1.40 %
Disfagia
1
0.70 %
Sindr. Wernicke
1
0,70 %
Deceduti
2
1,40 %
COMPLICANZE II (SLEEVE)
1 anno
GERD = 11%
SG-1
The mechanism of weight loss and resultant comorbidity improvement
seen after sleeve gastrectomy may be related to gastric restriction or
neurohumoral changes due to the gastric resection, or some other
unidentified factor(s)
Published complication rates range from 0% to 24%, with an overall
reported mortality rate of 0.39%
Sleeve gastrectomy is probably at least as effective and durable as
adjustable gastric banding at 1 and 3 years after surgery
Long-term (5 yr) weight loss and comorbidity resolution data for sleeve
gastrectomy have not been reported at this time
SG-2
Weight regain or a desire for further weight loss in a super-super-obese patient
may require the procedure to be revised to a gastric bypass or BPD with
duodenal switch.
Sleeve gastrectomy appears to be a technically easier and/or faster laparoscopic
procedure than Roux-en-Y GB or malabsorptive procedures in complex or highrisk patients, including the super-super-obese patient (BMI 60 kg/m2)
Sufficient as a “stand alone” procedure ?
From a technical standpoint, there appears to be no consensus regarding the
optimal dilator size that should be used to create the lesser curve conduit (32F60F !!!)
Complications and outcome of SG
Position Statement ASMBS 2007, Surgery for Obesity and
Related Diseases 2007;3:573-6 `
AGB vs SG
Kueper M A et al. World J Surg 2008;32:1462-5
AGB vs SG
Kueper M A et al. World J Surg
2008;32:1462-5
AGB vs SG
Wong S KH et al. Hong Kong Med J 2009; 15:100-9
AGB vs SG
Wong S KH et al. Hong Kong Med J 2009; 15:100-9
AGB vs SG
In a randomized study comparing gastric
banding with sleeve gastrectomy (n = 80), was
found that the median percentage of excess
weight loss at 3 years was 48% for gastric
banding and 66% for sleeve gastrectomy
Himpens J et al. Obes Surg 2006;16:1450-6