Bariatric Times

Sleeve Gastrectomy 2015

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 A5 5 th INTERNATIONAL CONSENSUS SUMMIT FOR SLEEVE GASTRECTOMY C urrently worldwide there are four common bariatric surgical procedures: laparoscopic adjustable gastric banding (LAGB), laparoscopic Roux-en-Y gastric bypass (RYGB), laparoscopic sleeve gastrectomy (LSG), and the laparoscopic duodenal switch (LDS). Of these procedures, the LSG is increasing in frequency worldwide. The LDS has remained consistent at one percent despite its superior weight loss, lack of recidivism, and vastly superior diabetes resolution when compared to the other procedures. 1 Many surgeons find the side effects of LDS, which include diarrhea, foul smelling gas, and malnutrition, unacceptable. Many also perceive the more distal jejunojejunostomy to be intimidating and duodenal dissection a challenge. Likewise, many surgeons have abandoned the RYGB and gone to the LSG because of the lack of strictures, ulcers, dumping syndrome, or internal hernias. Ideally, we would like an operation that has the side effect profile of the LSG and proximal bowel bypass (whether by hormonal or malabsorptive mechanism) to prevent weight recidivism. In my opinion, the rush for surgeons to do the LSG has little to do with its consistent results. The sleeve, while safe and easier to perform than a bypass, carries with it a very large standard deviation that has been present in every study published so far. Its weight loss, while better than the band, carries the same magnitude of standard deviation (Figure 1). In other words, the sleeve is wonderfully safe but inconsistent. Over the first three years postoperative, the bypass carries similar average weight loss to the sleeve but has a much more uniform response for the population. I believe that consistency comes from the malabsorption component of the surgery and that stomach and intestinal pyloric sparing surgery (SIPS) combines those two features into one operation (Figure 2). To perform SIPS, the surgeon begins by creating a sleeve gastrectomy over a 40 French bougie. Then, the dissection is carried distal to the pylorus, and the duodenum is transected 3cm from the pylorus. Once transected, a single loop of ilium (250cm–350cm proximal to ileocecal valve) is brought up and connected to the proximal duodenum. This arrangement eliminates dumping, ulcers, strictures, and almost all chances of internal herniation. It shows 80- percent weight loss at one-year postoperative with very little standard deviation. Postoperative nutritional deficiencies in SIPS are similar to those after gastric bypass. Side effects of diarrhea and constipation occur in equal frequency to the other operations. While foul smelling stools occur with some frequency after SIPS, many patients do not complain unless • Laparoscopic sleeve gastrectomy (LSG) is increasing in frequency worldwide. • LSG carries with it a very large standard deviation that has been present in the research. • Stomach and intestinal pyloric sparing surgery (SIPS) combines malabsorption and consistency for good results. • SIPS should be reserved for those who have T2DM,BMI above 50kg/m 2 , and/or severely elevated cholesterol. • While it is still early, the data on SIPS are encouraging. KEY POINTS Stomach and Intestine Pyloric Sparing Surgery (SIPS): Viability as a Primary Procedure DANIEL COTTAM, MD Director, Walter Medlin Bariatric Medicine Institute, Salt Lake City, Utah, United States DISCLOSURE: Dr. Cottam reports no conflicts of interest relevant to the content of this article. ADDRESS CORRESPONDENCE TO: Daniel Cottam, MD, Bariatric Medicine Institute, 1046 E. 1st South, Salt Lake City, UT 84102; Phone: (801) 746-2885; E-mail: Bariatric Times. 2015;12(4 Suppl A):A5–A6.

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