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SLEEVE GASTRECTOMY “A new dimension in general and bariatric surgery”. Samuel Szomstein, M.D., FACS Associate Director of The Bariatric and Metabolic Institute and Section of Minimally Invasive Surgery Cleveland Clinic Florida Assistant Clinical Professor of Surgery

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SLEEVE GASTRECTOMY

“A new dimension in general and bariatric surgery”

Samuel Szomstein, M.D., FACS

Associate Director of The Bariatric and Metabolic Institute and Section of Minimally Invasive Surgery

Cleveland Clinic Florida

Assistant Clinical Professor of Surgery

Nova Southeastern University



The Mason Era

Gastric Bypass

Vertical Banded Gastroplasty

Mason and Ito, 1967

Mason et al, 1982

Mc Gregor A, ASBS Website, 1999



Potential Advantages If Effective ? morbidity and does not need as much follow up as the current ones “

When compared to RYGBP:

  • No long term complications ?

  • No Int. Hernias ?

  • No malabsorption – No micronutrient deficiency ?

  • No Strictures ? No Marginal Ulcerations ?

  • Maintains oral access to GI and Biliary tract


Potential Advantages If Effective ? morbidity and does not need as much follow up as the current ones “

When compared to RYGBP:

  • Completely removes Ghrelin cell mass

  • No dumping

  • Does not interfere with immunosuppressant

  • Can always be upgraded to RYGBP !?


Potential Advantages If Effective ? morbidity and does not need as much follow up as the current ones “

When compared to LAGB:

  • No need for adjustments. No needles !!!

  • Removes Ghrelin Cell mass. Loss of appetite !!

  • Creates restriction more than obstruction

  • No need to do yearly endoscopy

  • No/less follow up ?


Brief History morbidity and does not need as much follow up as the current ones “

Evolution of LSG


Sleeve gastrectomy was first described in 1988 morbidity and does not need as much follow up as the current ones “

when Scopinaro's technique of biliopancreatic

diversion with distal gastrectomy and

gastroileostomy was modified by Hess and

simultaneously by Marceau

Scopinaro, N., Adami, G. F., Marinari, G. M., Gianetta, E., Traverso, E., Friedman, D., Camerini, G., Baschieri, G.,

and Simonelli, A. Biliopancreatic Diversion. World J Surg. 1998;22(9):936-46.

Hess, D. S. and Hess, D. W. Biliopancreatic Diversion With a Duodenal Switch. Obes.Surg. 1998;8(3):267-82.

Marceau, P., Biron, S., St Georges, R., Duclos, M., Potvin, M., and Bourque, R. A. Biliopancreatic Diversion

With Gastrectomy As Surgical Treatment of Morbid Obesity. Obes.Surg. 1991;1(4):381-7.


De Wind morbidity and does not need as much follow up as the current ones “

Mason

Scopinaro

Mason

Linnear

VBG

JIBP

JCBP

RYGBP

BPD

1967

1954

1963

1978

1982

LSG

Wittgrove

De Meester

Kuzmak

Lap

RYGBP

Belachew

Gagner

Lap-

Band

Lap

BPD / DS

BPD-DS

Banding

1994

1987

1990

1998

1999


Review of the literature

Gagner M, Rogula T. Laparoscopic reoperative sleeve gastrectomy for poor weight loss after biliopancreatic diversion with duodenal switch. Obes Surg. 2003 Aug;13(4):649-54

METHODS:

Follow-up of 1 case of sleeve gastrectomy for Poor Weight loss after Biliopancreatic Diversion with Duodenal Switch.

Review of the literature


Laparoscopic Era gastrectomy for poor weight loss after biliopancreatic diversion with duodenal switch. Obes Surg.

Gagner described the first laparoscopic

BPD-DS in 1999

Step procedure in super super morbidly obese patients to facilitate the

laparoscopic approach

Ren, C. J., Patterson, E., and Gagner, M. Early Results of Laparoscopic

Biliopancreatic Diversion With Duodenal Switch: a Case Series of 40

Consecutive Patients. Obes.Surg. 2000;10(6):514-23.


Magenstrasse and mill
Magenstrasse and Mill gastrectomy for poor weight loss after biliopancreatic diversion with duodenal switch. Obes Surg.

Obesity Surgery


Magenstrasse and mill1
Magenstrasse and Mill gastrectomy for poor weight loss after biliopancreatic diversion with duodenal switch. Obes Surg.

Obesity Surgery


Mechanism of Action gastrectomy for poor weight loss after biliopancreatic diversion with duodenal switch. Obes Surg.

How does it work ?


How doest it work sleeve gastrectomy
How doest it work ? gastrectomy for poor weight loss after biliopancreatic diversion with duodenal switch. Obes Surg.Sleeve gastrectomy

  • Creates restriction

  • Removes Ghrelin cells

  • Creates a natural band PYLORUS


In review gastrectomy for poor weight loss after biliopancreatic diversion with duodenal switch. Obes Surg.

Gastric Emptying is not affected by Sleeve Gastrectomy

or the emptying function of the remnant stomach following

sleeve gastrectomy assessed by gastric scintigraphy in

morbidly obese patients.

Hanna Bernstine2, Ronit Tzioni Yehoshua1,

David Groshar2, Nahum Beglaibter4, Shikora Scott5,

Raul J. Rosenthal 6, Moshe Rubin1,3


RESEARCH ARTICLE gastrectomy for poor weight loss after biliopancreatic diversion with duodenal switch. Obes Surg.

Laparoscopic Sleeve Gastrectomy—Volume and Pressure Assessment

Ronit T. Yehoshua & Leonid A. Eidelman &

Michael Stein & Suzana Fichman & Amir Mazor &

Jacopo Chen & Hanna Bernstine & Pierre Singer &

Ram Dickman & Scott A. Shikora & Raul J. Rosenthal &

Moshe Rubin

Received: 11 May 2008 / Accepted: 15 May 2008

# Springer Science + Business Media, LLC 2008


RESEARCH ARTICLE gastrectomy for poor weight loss after biliopancreatic diversion with duodenal switch. Obes Surg.

Laparoscopic Sleeve Gastrectomy—Volume and Pressure Assessment

  • Closed pylorus and GE Junction

  • Inject Methylene blue

  • Measured Volume

Ronit Yeoshua et al. Obesity Surgery


RESEARCH ARTICLE gastrectomy for poor weight loss after biliopancreatic diversion with duodenal switch. Obes Surg.

Laparoscopic Sleeve Gastrectomy—Volume and Pressure Assessment

Stomach Sleeve

Vol (mean) 1500 cc 130 cc

Pressure 34 mmhg 43 mmhg

Ronit Yeoshua et al. Obesity Surgery


Gastrointestinal peptides involved in appetite control
Gastrointestinal peptides involved in appetite control gastrectomy for poor weight loss after biliopancreatic diversion with duodenal switch. Obes Surg.

Appetite

- Pancreatic polypeptide (PP)

-Peptide tyrosine-tyrosine (PYY)

- Products of preproglucagon: Glucagon-like 1, oxyntomodulin

Appetite

- Ghrelin


Ghrelin plasma levels
Ghrelin gastrectomy for poor weight loss after biliopancreatic diversion with duodenal switch. Obes Surg. plasma levels


Regulation of energy balance at Brain gastrectomy for poor weight loss after biliopancreatic diversion with duodenal switch. Obes Surg.

Increases hunger: hypothal feeding centers.

Humans injected with ghrelin: intense hunger.

Suppresses fat utilization in adipose tissue

Stimulates gastric emptying

Increases cardiac output (possible GH effect)

Fundus of Stomach is Primary Source

GHRELIN


Ghrelin secretion
Ghrelin gastrectomy for poor weight loss after biliopancreatic diversion with duodenal switch. Obes Surg. secretion

Negative energy balance

Starvation

Cachexia

Anorexia nervosa

Positive energy balance

Obesity ?

Hyperglycemia

Feeding

High

Low


Sleeve gastrectomy: gastrectomy for poor weight loss after biliopancreatic diversion with duodenal switch. Obes Surg.

Decreased plasma ghrelin levels


Preliminary results
Preliminary results gastrectomy for poor weight loss after biliopancreatic diversion with duodenal switch. Obes Surg.

10 Sleeve gastrectomy patients

2 non-obese controls

Quantification and distribution of ghrelin cells in the stomach

Results: Mean number of ghrelin cells

Sleeve gastrectomy Control

169 59

p=0.002


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