A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional
Issue link: https://bariatrictimes.epubxp.com/i/130204
4th INTERNATIONAL CONSENSUS SUMMIT FOR SLEEVE GASTRECTOMY experts, one video session on surgical mishaps, which was the favorite among participants, and a final consensus voting at the end of the program. We discussed looking for hiatal hernias at the time of SG and making any efforts to close this simultaneously, as this tremendously decreases the postoperative occurrence of gastroesophageal reflux disease (GERD). Several papers touched upon the prevention and treatment of leaks after SG, and it appears that avoidance of stenosis in the mid portion (incisura) is key to avoiding a high-pressure zone above that would distract the staple line and cause it to pop off. Most authors seem to agree that early stenting is the way to go, although a double pigtail technique may also work. For late or persistent leak, a Roux-en-Y anastomosis of jejunum to the fistulous opening appears to solve the problem once and for all, either laparoscopic or open. The controversies debated included the following: 1) Is RYGB better than SG for patients with type 2 diabetes mellitus (T2DM)? 2) Is SG as good as RYGB to revise bands? 3) Triangulation is important: Singleport SG vs. SPIDER SG? 4) Is plicated SG better than plication alone? and 5) Is SG better than AGB for adolescents? CONSENSUS VOTIING Technique. During the consensus voting, we found that a minority of surgeons are stapling close to the pylorus (8% at <3cm). The majority reported stapling <6cm (61% of responders), and 31 percent reported stapling between 4 and 6cm. Regarding bougie size, we saw that surgeons are now increasing the size and going away from 32 Fr. The majority (55%) reported using a size between 36 and 40Fr. Ninety-five percent of surgeons are now agreeing with the concept of closing a hiatal hernia simultaneously during a SG. There is a parallel with the bariatric surgeons who are now closing a hiatal hernia during positioning of an AGB. Concerning postoperative care, 88 percent of surgeons have voted for vitamin and mineral supplementation routinely, and use of proton pomp inhibitors (PPIs) for 2 to 6 weeks (50%), 6 to 12 weeks (35%), and rarely above 12 weeks (10%). Indication. Consensus from voters showed the following regarding groups who should undergo SG: adolescents (76%), elderly (77%), lower body mass index (BMI [30–35kg/m2]) groups (68%), and high-risks patients (95%). Even if patients with T2DM appeared to be a controversial group, with 86 percent of responders saying that they would not hesitate to do a SG for this indication—an increase compared to previous conferences. Also, 94 percent of bariatric surgeon participants agreed that SG was a good intervention to convert a failed AGB. For weight regain, however, the audience was split: 36 percent would continue to observe (or not act surgically), 28 percent would convert to a gastric bypass, and 28 percent would use a duodenal switch (DS) (as a two-stage strategy). Complications. Regarding complications of the SG procedure, the results of survey included the following: 73 percent of surgeons would treat a persistent stenosis after SG present with a gastric bypass; a minority reported using other methods, such as seromyotomy (7%) and gastroplasty (7%). In terms of treatment for an acute leak, a majority would re-laparoscope early and insert drains, while an increasing number of responders just insert a stent (27%). For refractory GERD, the majority reported that they would continue medical treatment (67%) with PPIs, as opposed to early conversion to gastric bypass (33%). Carlin et al4 reported on the effectiveness of SG, RYGB, and AGB to treat patients with morbid obesity using a statewide clinical registry with matched 3,000 patients for each group. They confirmed the effectiveness of SG with a much lower morbidity than the other operations. I believe this finding explains the rising popularity of the SG. REFERENCES 1. 2. 3. 4. 5. Buchwald H, Oien DM. Metabolic/Bariatric Surgery Worldwide 2011. Obes Surg. 2013;23(4):427–436. Deitel M, Gagner M, Erickson AL, Crosby RD. Third International Summit: current status of sleeve gastrectomy. Surg Obes Relat Dis. 2011;7(6):749–759. Gagner M, Deitel M, Kalberer TL, et al. The Second International Consensus Summit for Sleeve Gastrectomy, March 19–21, 2009. Surg Obes Relat Dis. 2009;5(4):476–485. Carlin AM, Zeni TM, English WJ, et al. The comparative effectiveness of sleeve gastrectomy, gastric bypass, and adjustable gastric banding procedures for the treatment of morbid obesity. Ann Surg. 2013;257(5):791–797. Franco JV, Ruiz PA, Palermo M, Gagner M. A review of studies comparing three laparoscopic procedures in bariatric surgery: sleeve gastrectomy, Roux-en-Y gastric bypass and adjustable gastric banding. Obes Surg. 2011;21(9):1458–1468. May 2013 • Supplement A • Bariatric Times A27