Symposium review
The Second International Consensus Summit for Sleeve Gastrectomy, March 19–21, 2009

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Abstract

Background

Sleeve gastrectomy (SG) is a rapid and comparatively simple bariatric operation, which thus far shows good resolution of co-morbidities and good weight loss. The potential peri-operative complications must be recognized and treated promptly. Like other bariatric operations, there are variations in technique. Laparoscopic SG was initially performed for high-risk patients to increase the safety of a second operation. However, indications for SG have been increasing. Interaction among those performing this procedure is necessary, and the Second International Consensus Summit for SG (ICSSG) was held to evaluate techniques and results.

Methods

A questionnaire was filled out by attendees at the Second ICSSG, held March 19–22, 2009, in Miami Beach, and rapid responses were recorded during the consensus part.

Results

Findings are based on 106 questionnaires representing a total of 14,776 SGs. In 86.3%, SG was intended as the sole operation. A total of 81.9% of the surgeons reported no conversions from a laparoscopic to an open SG. Mean ± SD percent excess weight loss was as follows: 1 year, 60.7 ± 15.6; 2 years, 64.7 ± 12.9; 3 years, 61.7 ± 11.4; 4 years 64.6 ± 10.5; >4 years, 48.5 ± 8.7. Bougie size was 35.6F ± 4.9F (median 34.0F, range 16F–60F). The dissection commenced 5.0 ± 1.4 cm (median 5.0 cm, range 1–10 cm) proximal to the pylorus. Staple-line was reinforced by 65.1% of the responders; of these, 50.9% over-sew, 42.1% buttress, and 7% do both. Estimated percent of fundus removed was 95.8 ± 12%; many expressed caution to avoid involving the esophagus. Post-operatively, a high leak occurred in 1.5%, a lower leak in 0.5%, hemorrhage in 1.1%, splenic injury in 0.1%, and later stenosis in 0.9%. Post-operative gastroesophageal reflux (∼3 mo) was reported in 6.5% (range 0–83%). Mortality was 0.2 ± 0.9% (total 30 deaths in 14,776 patients). During the consensus part, the audience responded that there was enough evidence published to support the use of SG as a primary procedure to treat morbid obesity and indicated that it is on par with adjustable gastric banding and Roux-en-Y gastric bypass, with a yes vote at 77%.

Conclusion

SG for morbid obesity is very promising as a primary operation.

Section snippets

Techniques of SG and the weight loss

Escalona of Chile performed laparoscopic SG using the “stapling-first” technique [18]. He finds this technique to be easier, and it creates a comfortable opening into the lesser sac 6 cm proximal to the pylorus. He feels that the stapling-first technique is the best method to remove the entire fundus, and he passes an esophageal retractor, which aids dissection of the left crus. A minority of the audience indicated that they perform the stapling-first technique, but instead first mobilize the

Gastric emptying

Rubin's group in Israel [28] found the mean volume of the entire stomach to be 1,553 mL. After SG, sleeve volume was 129 mL and the volume of the removed stomach was 795 mL. They found a higher pressure in the sleeve, reflecting its markedly lesser distensibility compared to that of the whole stomach and the resected stomach, suggesting a mechanism of weight loss. Tzioni-Yehoshua, working with Rubin, evaluated gastric emptying by scintigraphy after SG with antral preservation. Interestingly, no

The problem of hiatus hernia

Escalona stated that if a hiatal hernia (HH) is present, he repairs it first, and then performs the SG. Rosenthal performs a gastroscopy preoperatively to rule out an HH. He closes an HH posteriorly with 1 or 2 non-absorbable sutures. Jossart uses Ethibond to approximate the crura posteriorly when an HH is present. Himpens pointed out that gastroesophageal reflux (GER) may be a contraindication to SG. Gagner advised that in a situation in which an HH has previously been repaired, he would not

Management of complications

Jacob of Miami noted that leaks have been reported in 0.7–5.2% of SGs. He uses tissue compression by the stapler for a minimum of 20 seconds before firing, to minimize staple-line bleeding. He warns of strictures at the level of the incisura, which can be related to reinforcing sutures placed over the staple-line, too-small bougie size, the bougie being inadvertently pulled back, or hematomas and edema at the incisura. The first line of treatment is endoscopic dilatation (seromyotomy for long

Hormonal studies and effects on type 2 diabetes mellitus

Prager of Austria studied plasma ghrelin, which was markedly decreased after SG but was increased after gastric banding and variable after RYGB [39], [40], [41], [42], [43], [44], [45]. Roslin of New York reported that after 10 years of experience with RYGB in diabetics, dumping and the rise in glucagon-like polypeptide-1 (GLP-1) resulted in postoperative hypoglycemia; patients may then eat more, and some RYGB patients developed diabetes again. Roslin believes that preserving the pyloric valve

Special indications

Arvidsson of Stockholm performed 200 SGs since April 2007 in a prospective trial. Of these, 140 had class 1 obesity (BMI 30–35 kg/m2) as the indication for SG with or without co-morbidity. The SG was commenced 6 cm proximal to the pylorus, with a 32F gastric tube, by using a technique to ensure equal resection of the anterior and posterior gastric wall to avoid twisting of the gastric tube. Mean %EBL was 100 at 1 year, but longer follow-up data are necessary to establish the role of SG in class

SG after previous gastric banding

It was recommended that before performing SG after a previous adjustable gastric banding [52], [53], the band fluid should be removed a few days prior, a radiograph should be performed to view the band and gastric dilatation, and endoscopy should be performed to make sure that the band has not eroded. Preoperatively, the surgeon should obtain the previous operative report, if possible, to be aware of how the banding was done and the sutures placed. Gagner removes the band and tubing and

Emerging techniques of decreased ports and endoscopic devices

Ninh Nguyen of Orange, California, U.S. demonstrated the single-incision laparoscopic surgery (SILS) technique for SG [56]. Through a single incision close to the umbilicus, 3 trocars are placed adjacent to each other, with the patient in the supine position. Then, with the patient in the reverse Trendelenburg position, using the flexible Olympus scope (Olympus Corp., Tokyo, Japan), he fully mobilizes the greater curvature first for better single-instrument retraction. A 34F bougie is passed by

The consensus summit

On the last day of the conference, a consensus was determined by a series of questions voted upon, using Meridia Audience Response (Meridia Audience Response, Philadelphia, PA). The questions were discussed by panels of experts representing SG and the spectrum of bariatric operations, and a final vote was taken on each question, as indicated below. There were about 165 responses per question.

  •  1

    What is the mechanism of action of the SG? Restriction 79%, gastric emptying 0%, hormonal 16%,

Results of the LSG questionnaire

A modified version of the LSG questionnaire developed for the First International Consensus Summit was filled out by the attendees of the current meeting. Questionnaires were completed by 106 surgeons who had performed the LSG for at least 6 months on a minimum of 10 patients. The data were analyzed by Ross D. Crosby, Ph.D., and his biostatistical statistics associates. Data are reported as mean ± SD, median and range, or as frequency and percent of valid responses.

The total number of LSGs

Addendum

On March 27, 2009, Neil Hutcher, Chairman of the Surgical Review Committee, circulated an e-mail announcing that, in recognition of 35 published studies involving more than 2,400 patients and the longer follow-up, the decision was made with the Executive Council of the American Society for Metabolic and Bariatric Surgery that SG be recognized as a primary bariatric operation to be counted toward the Centers of Excellence volume requirements.

For continued surveillance, a Third International

Disclosures

M. Gagner disclosed the following commercial associations that might be a conflict of interest in relation to this article: Covidien: speakers engagements, travel support, consultant's fee; Ethicon Endosurgery: speakers engagements, travel support; Cine-Med Inc.: speakers engagements, educational support; Bariatric Times: writer's fee; Olympus: consultant fee, travel support; Gore: consultant's fee, travel support, speaker engagement; Synovis: research support; Power-Medical: speakers

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