Symposium reviewThe Second International Consensus Summit for Sleeve Gastrectomy, March 19–21, 2009
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
References (63)
- et al.
Laparoscopic sleeve gastrectomy for morbid obesity: a review
Surg Obes Relat Dis
(2007) - et al.
Laparoscopic sleeve gastrectomy for morbid obesity
Am J Surg
(2008) - et al.
Results of laparoscopic sleeve gastrectomy: a prospective study in 135 patients with morbid obesity
Surgery
(2009) - et al.
Feasibility and technique of laparoscopic conversion of adjustable gastric banding to sleeve gastrectomy
Surg Obes Rel Dis
(2009) - et al.
Endoluminal procedures for bariatric patients: expectations among bariatric surgeons
Surg Obes Rel Dis
(2009) - et al.
Longitudinal gastrectomy as a treatment for the high-risk super-obese patient
Obes Surg
(2004) - et al.
Sleeve gastrectomy in the high-risk patient
Obes Surg
(2006) - et al.
Laparoscopic sleeve gastrectomy as an initial bariatric operation for high-risk patients: initial results in 10 patients
Obes Surg
(2005) - et al.
Laparoscopic sleeve gastrectomy is superior to endoscopic gastric balloon as a first stage procedure for super-obese patients (BMI≥50)
Obes Surg
(2005) - et al.
Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity
Surg Endosc
(2006)
Early experience with two-stage laparoscopic Roux-en-Y gastic bypass as an alternative in the super-super obese patient
Obes Surg
Staged laparoscopic Roux-en-Y: a novel two-stage bariatric operation as an alternative in the super-obese with massively enlarged liver
Obes Surg
Effectiveness of laparoscopic sleeve gastrectomy (first stage of biliopancreatic diversion with duodenal switch) on co-morbidities in super-obese high-risk patients
Obes Surg
Does gastric dilatation limit the success of sleeve gastrectomy as a sole operation for morbid obesity?
Obes Surg
Laparoscopic sleeve gastrectomy: a multi-purpose bariatric operation
Obes Surg
Sleeve gastrectomy as treatment for severe obesity after orthotopic liver transplantation
Obes Surg
Sleeve gastrectomy in a 10-year old child
Obes Surg
Emergency sleeve gastrectomy as rescue treatment for acute gastric necrosis due to type II paraesophageal hernia in an obese woman with gastric banding
Obes Surg
Re-sleeve gastrectomy
Obes Surg
Mid-term follow-up after sleeve gastrectomy as a final approach for morbid obesity
Obes Surg
The first international consensus for sleeve gastrectomy (SG), New York City, October 25–27, 2007
Obes Surg
A prospective randomized study comparing two different techniques for laparoscopic sleeve gastrectomy
Obes Surg
Sleeve gastrectomy for morbid obesity
Obes Surg
Laparoscopic sleeve gastrectomy: surgical technique, indications and clinical results
Obes Surg
Decreased bleeding after laparoscopic sleeve gastrectomy with or without duodenal switch for morbid obesity using a stapled buttressed absorbable polymer membrane
Obes Surg
Vertical gastrectomy for morbid obesity in 216 patients: report of two-year results
Surg Endosc
Laparoscoic sleeve gastrectomy—influence of sleeve size and resected gastric volume
Obes Surg
Sleeve gastrectomy as a bariatric procedure
Surg Obes Relat Dis
Reporting weight loss 2007
Obes Surg
Laparoscopic sleeve gastrectomy without an over-sewing of the staple line
Obes Surg
Laparoscopic sleeve gastrectomy—volume and pressure assessment
Obes Surg
Cited by (304)
Does the use of bioabsorbable mesh for hiatal hernia repair at the time of bariatric surgery reduce recurrence rates? A meta-analysis
2022, Surgery for Obesity and Related DiseasesMenetrier's disease in a morbid obese patient undergoing bariatric surgery: A case report
2022, International Journal of Surgery Case ReportsMetabolic surgery
2022, Current Problems in SurgeryLaparoscopic sleeve gastrectomy for weight loss and treatment of type 2 diabetes mellitus
2021, Journal of Taibah University Medical SciencesSplenic Injury After Sleeve Gastrectomy: A Narrative Review
2023, Bariatric Surgical Practice and Patient Care