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 A7 5 th INTERNATIONAL CONSENSUS SUMMIT FOR SLEEVE GASTRECTOMY L aparoscopic sleeve gastrectomy (LSG) is an upcoming primary treatment modality for morbid obesity. It has gained wide popularity as a sole bariatric procedure, becoming the most frequent bariatric procedure in France in 2011 and in the United States in 2013. 1,2 These trends in bariatric surgery are explained by the several advantages that LSG carries over more complex bariatric procedures, such as Roux-en-Y gastric bypass (RYGBP) or duodenal switch (DS), with the absence of all side effects of bypass procedures, specifically dumping syndrome, marginal ulcers, malabsorption, small bowel obstruction, and internal hernia, and a better quality of life over gastric banding. 3 LSG is generally considered a straightforward procedure, but the surgical technique is one of the major determinants of the most feared complication—staple line leak. Recent series 4–6 have reported a leak rate of 1 to 2 percent after LSG. Leak is estimated to be the most serious complication of this procedure due to difficult healing processes using a non- standardized endoscopic approach. Leaks may also be responsible for local or general severe septic complications. Several publications 7,8 have advocated the importance of the learning curve for different bariatric procedures in order to diminish the postoperative complication rate. Even if many surgeons consider LSG a very simple procedure, limited data 9 are found in the literature regarding the experience needed in order to significantly diminish the risk of leak. The purpose of this study was to analyze the correlation between the surgeon's experience and the leak rate after LSG. METHODS AND TECHNIQUE We reviewed a single surgeon's experience (Noel P) since the introduction of LSG (1,800 procedures). Yearly, we compared the leak rate and analyzed for possible risk factors. To our knowledge, this is the largest single-surgeon experience published in the literature. Dr. Noel's personal technique was as follows, including some particularities: • Three-port approach with no liver retractor • Complete posterior dissection of the gastric fundus (Figure 1) • Anterior eversion of the gastric fundus before the last two firings (Figure 2). The patient is placed on the operating table in the French position. The surgeon stands between the legs and the assistant on the left side of the surgeon. Once the pneumoperitoneum is established, a 5-mm port for the camera is placed at one-third of the distance between the xiphoid process and the umbilicus 3 to 5cm lateral to the midline on the left side. Two additional ports are placed: a 15-mm • Dramatic decrease (10 fold) in leak rate after laparoscopic sleeve gastrectomy (LSG) • Complete posterior approach of gastric fundus dissection • Three-port approach for LSG without liver retractor KEY POINTS Does the Surgeon's Experience Interfere with the Leak Rate After Laparoscopic Sleeve Gastrectomy? MARIUS NEDELCU, MD; a,b PATRICK NOEL, MD; a and MICHEL GAGNER, MD, FRCSC, FACS, FASMBS c a Hôpital Prive La Casamance, Aubagne, France; b Centre Hospitalier Universitaire Strasbourg, France; c Hôpital Du Sacre Cœur, Montréal, Canada Bariatric Times. 2015;12(4 Suppl A):A7–A9. DISCLOSURE: Dr. Nedelcu reports no conflicts of interest relevant to the content of this article. Dr. Noel is a speaker or course director for and/or has received honorarium from Olympus (Center Valley, Pennsylvania, United States) and W. L. Gore & Associates, Inc. (Flagstaff, Arizona, United States). Dr. Gagner is a speaker for and/or has received honorarium from the following companies: Olympus, Ethicon (Cincinnati, Ohio, United States), Covidien (North Haven, Connecticut, United States), Medical Innovation Developpement (MID [Dardilly France]), Transenterix (Morrisville, North Carolina, United States), W. L. Gore and Associates, Inc., Boehringer Labs (Phoenixville, Pennsylvania, United States). ADDRESS CORRESPONDENCE TO: Dr. Marius Nedelcu, Digestive and Endocrine Surgery, University Hospital of Strasbourg 1, Place de l'Hôpital, 67091, Strasbourg, France; E-mail:

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