SLEEVE GASTRECTOMY
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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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Samuel szomstein m d facs

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


Samuel szomstein m d facs

Why a New Procedure ?


Samuel szomstein m d facs

The Mason Era

Gastric Bypass

Vertical Banded Gastroplasty

Mason and Ito, 1967

Mason et al, 1982

Mc Gregor A, ASBS Website, 1999


Samuel szomstein m d facs

  • “We need a bariatric procedure that does not cause as much morbidity and does not need as much follow up as the current ones “


Samuel szomstein m d facs

Potential Advantages If Effective ?

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


Samuel szomstein m d facs

Potential Advantages If Effective ?

When compared to RYGBP:

  • Completely removes Ghrelin cell mass

  • No dumping

  • Does not interfere with immunosuppressant

  • Can always be upgraded to RYGBP !?


Samuel szomstein m d facs

Potential Advantages If Effective ?

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 ?


Samuel szomstein m d facs

Brief History

Evolution of LSG


Samuel szomstein m d facs

Sleeve gastrectomy was first described in 1988

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.


Samuel szomstein m d facs

De Wind

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


Samuel szomstein m d facs

Laparoscopic Era

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

Obesity Surgery


Magenstrasse and mill1

Magenstrasse and Mill

Obesity Surgery


Samuel szomstein m d facs

Mechanism of Action

How does it work ?


How doest it work sleeve gastrectomy

How doest it work ?Sleeve gastrectomy

  • Creates restriction

  • Removes Ghrelin cells

  • Creates a natural band PYLORUS


Samuel szomstein m d facs

In review

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


Samuel szomstein m d facs

RESEARCH ARTICLE

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


Samuel szomstein m d facs

RESEARCH ARTICLE

Laparoscopic Sleeve Gastrectomy—Volume and Pressure Assessment

  • Closed pylorus and GE Junction

  • Inject Methylene blue

  • Measured Volume

Ronit Yeoshua et al. Obesity Surgery


Samuel szomstein m d facs

RESEARCH ARTICLE

Laparoscopic Sleeve Gastrectomy—Volume and Pressure Assessment

StomachSleeve

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

Appetite

- Pancreatic polypeptide (PP)

-Peptide tyrosine-tyrosine (PYY)

- Products of preproglucagon: Glucagon-like 1, oxyntomodulin

Appetite

- Ghrelin


Ghrelin plasma levels

Ghrelin plasma levels


Samuel szomstein m d facs

Regulation of energy balance at Brain

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 secretion

Negative energy balance

Starvation

Cachexia

Anorexia nervosa

Positive energy balance

Obesity ?

Hyperglycemia

Feeding

High

Low


Samuel szomstein m d facs

Sleeve gastrectomy:

Decreased plasma ghrelin levels


Preliminary results

Preliminary results

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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