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/69304
they reinforce the staple-line of the sleeve. Of these, 57% use buttress on the staple line and 43% over-sew the staple line. • 57.6% of surgeons leave drains in place. Most use closed suction, and 3.4% use a Penrose drain. Changes in weight following LSG reported by respondents are summarized in Table 1. Complications The complication rates from LSG are listed below and are summarized in Table 2: • Gastroesophageal reflux occurred in 6.8±9.2% of patients. • 68.2% of surgeons ordered supplementations postoperatively. • 63.6% of surgeons administer B12. • 85.2% of surgeons prescribe proton pump inhibitors. CONCLUSION Based on the answers provided in the questionnaire, LSG provides weight loss and improvements in comorbidities such as type 2 diabetes. In addition, LSG was found to be more effective than the laparoscopic adjustable gastric band (LAGB) and produces similar results as the Roux-en-Y gastric bypass (RYGB). EXPERT COMMENTARY MAJOR FINDINGS This is an excellent review of the current literature regarding the salient and clinically important issues that surround both the physiologic effects of the LSG as well as the short and midterm results seen in postoperative patients. Of particular importance was the review of the long-term anatomic changes that occur demonstrated by radiographic studies as well as the impact that the LSG has on type 2 diabetes mellitus (T2DM). In my experience, sleeve migration in individuals who have not had an aggressive repair of a hiatal hernia is particularly problematic long term and often requires reoperative intervention to relieve debilitating reflux symptoms. The metabolic and hormonal effects that have been clearly demonstrated now in multiple studies should dispel the misperception that the RYGB is superior in terms of its ability to resolve or improve T2DM, as well as support the LSG's superiority over the LAGB in terms of T2DM resolution. LIMITATIONS The major limitation of this publication is the collection of data was by consensus. As this is self- reported and not subject to review or validation, any definitive conclusions are somewhat speculative. In my PAUL T. CIRANGLE, MD, FACS, FASMBS Laparoscopic Associates of San Francisco, San Francisco, California; and the Surgical Weight Loss Center of Hawaii, Kailua, Hawaii June 2012 • Supplement • Bariatric Times 11S experience and opinion, at this point, the LSG is a nonstandardized procedure in that there is still great variability in how it is technically performed and executed. As this paper nicely demonstrates, long-term results are clearly dependent on the manner in which the procedure is performed and attention to very specific anatomic details. In my 11- year experience with the LSG in more than 2,300 patients, I have seen dramatic differences in outcomes with subtle changes in my technique. In my opinion, the key surgical concepts that need to be standardized are bougie/dilator size, amount of antral resection, use of staple adjuncts (suture vs. buttress vs. nothing), and postoperative nutritional/dietary management/recommendations. WHY IS THIS STUDY IMPORTANT TO THE FIELD? I would like to commend the authors for commenting on "related" procedures, such as the gastric plication and LSG with transit bipartition, as well as the feasibility of performing LSG in the outpatient setting. Only by critically looking (in an unbiased fashion) at our current practice and how we can improve upon it, will we evolve and expand the discipline of metabolic surgery. WHAT SHOULD BE ADDRESSED IN THE FUTURE I believe the following should be addressed in future research: • Formation of a true "LSG consensus panel" of surgeons who have a minimum of 5 years of experience and 1,000 cases to make "conclusions" more valid. • Management of complications as well as atypical and complicated patients should be evidence based and reflective of those surgeons/gastroenterologists who have the greatest experience. • There should be an establishment of single-center/surgeon long-term LSG data.