A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional
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April 2015 • Supplement A • Bariatric Times A23 5 th INTERNATIONAL CONSENSUS SUMMIT FOR SLEEVE GASTRECTOMY choices may vary from suturing to buttressing. In fact, 45 percent of t hose experts use buttress materials, and 28 percent oversew, which means that nearly three- fourths of the experts do something with the staple line. M ost operators' will fully mobilize the fundus posterior, get adhesions in the lesser sac and anterior to the pancreas (more so behind the antrum) and expose the left crus base to eliminate the presence of a hiatal hernia. Hiatal hernias are closed selectively by most surgeons (>80% of experts closed them routinely). Some surgeons mobilized a fat pad near the gastroesophageal (GE) junction to better identify this area and staple accordingly. Stapling is commenced 1 to 6cm proximal to the pylorus and aiming lateral to the bougie. Strictures are avoided at the incisura angularis by avoiding stapling too close (or tight) to the bougie. One has to avoid stapling the esophagus near the GE junction, as most leaks occur distal or near the GE junction. Appropriate staple height depends on gastric tissue thickness and varies according to the patient's gender, BMI, and stomach site, and tends to decrease from distal to proximal. Appropriate compression time is necessary, especially in thick tissue. Best results on weight loss are achieved in the first two years as in RYGB (>70% excess weight loss [EWL] for BMI less than 50kg/m 2 ), and followed with weight regain and gastric pouch dilatation. At five years, the experts surveyed reported results of 60 percent EWL sustained weight loss (i.e., BMI of 29.8kg/m 2 ). As we can imagine, the lost-to-follow-up rate is about 32.6 percent. COMPLICATIONS Strictures were reported around 2 .2 percent. The experts also reported a leak rate of 2.5 percent, typically occurring several days later near the GE junctions. Increasingly, leaks are treated with e ndoscopically placed fully covered nitinol stents, left in place for several weeks, and drained (34% of experts favored this approach). But some experts recommended a laparoscopic exploration, adding drains and feeding jejunostomy (47%). Chronic leaks are treated with a gastric bypass but more experts (41.5%) are using the new Roux-en-Y fistula-jejunostomy (21.7%), leaving the sleeve in place, a lesser traumatic intervention. Weight loss failures can be treated with a variety of options in selected patients, including re- sleeve gastrectomy, conversion to RYGB, and adding a duodenal switch, which is the most popular option. Conversions for weight loss failures of sleeve to other types of operations were reported to be 4.8 percent, and 2.9 percent for refractory GERD. GERD reflux is improved in 80 percent of patients, but in some it may remain and require either prolonged medical therapy or conversion to RYGB. In fact, experts believe that RYGB is the procedure of choice in this latter instance in over 90 percent of cases. Most participants of the 5th International Conference for Sleeve Gastrectomy are convinced that this bariatric/metabolic operation remains a procedure of choice for weight loss and achieves the best balance in the risk-benefit equation, even including late conversions (7.7%) 5 to 10 years following this modus operandi. REFERENCES 1. Chu C, Gagner M, Quinn T, et al. Two stage laparoscopic BPD-DS: an alternative approach to super- super morbid obesity. Surg Endosc. 2002;16:S069. 2. Hutter MM, Schirmer BD, Jones DB, et al. First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleevegastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann Surg. 2011;254(3):410–420 3. Rebecchi F, Allaix ME, Giaccone C, et al. Gastroesophageal reflux disease and laparoscopic sleeve gastrectomy: a physiopathologic evaluation. Ann Surg. 2014;260(5):909–914 4. Rosenthal RJ; International Sleeve Gastrectomy Expert Panel, Diaz AA, Arvidsson D, Baker RS, et al. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases. Surg Obes Relat Dis. 2012;8(1):8–19 5. Gagner M, Deitel M, Erickson AL, Crosby RD. Survey on laparoscopic sleeve gastrectomy (LSG) at the Fourth International Consensus Summit on Sleeve Gastrectomy. Obes Surg. 2013;23(12):2013–2017