EXPERT COMMENTARY MAJOR FINDINGS
Organizing thoughts on leaders in the field, I think, sends a significant message to beginners that many experts are doing this operation in large numbers safely and with efficacy. The retrospective data, based on more than 12,000 sleeve gastrectomy procedures, represent a large number. Leaks appear to be less than expected, and conversion rate to laparotomy higher than what I would expect. I think patient selection is quite wide and varied, and confirms the universal nature of this operation with very few contraindications (Barret's). There is a consensus on doing more than just stapling to avoid leaks, although nobody is sure what needs to be done exactly (i.e., suturing or buttress or both, gluing?). I like the new classifications of leaks, as treatment will vary depending on the timing appearance of the leak. Many strategies are proposed, and it is unlikely that each individual surgeon will gather enough experience to come up with the best treatment on his or her own. Conservative means seem to be
employed more often. Again, experts seem to move away from very small bougies to avoid leaks and strictures, and this is an important message.
LIMITATIONS
Opinion is a level 5 in the medical evidence-based studies (lowest level), and the consensus statement is not based on randomized studies (regarding, for example, bougie size, distance from pylorus, staple height, buttress material types). Industry and surgeons would like to get an uniform answer on how to perform an ideal sleeve gastrectomy; however, it will require time to do those randomized studies. It may be also that different sizes will be required for men and women, and various individual sizes (sleeve individualized). To this date, we still do not have uniformity for gastric bypass.
WHY IS THIS STUDY IMPORTANT TO THE FIELD?
Once a procedure is well established, we can move to modifications for improvement in a systematic fashion. However, there will continue to be a number of controversial issues that we cannot agree on, which will make teaching and patient outcomes variable.
WHAT SHOULD YOU DO WITH THESE DATA AND THESE FINDINGS?
Use the consensus statement as a caution, especially the preventive measures to avoid leaks and structures; this will likely impact the outcomes of your patients.
MICHEL GAGNER, MD, FRCSC, FACS, FASMBS, FICS, AFC (HON) Clinical Professor of Surgery, Chief, Bariatric and Metabolic Surgery, Montreal, Quebec, Canada
June 2012 • Supplement • Bariatric Times 5S