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Sleeve gastrectomy

LSG - establishing consensus and current controversies

There are several preventable mistakes that occur during laparoscopic sleeve gastrectomy, including poorly dissected posterior fundus and poorly dissected gastro-oesophageal junction.
The Gore symposia will examine how the use of Staple Line Reinforcement can improve surgical technique and patient outcomes, as well as looking at the supporting clinical evidence for Staple Line Reinforcement

At the forthcoming IFSO World Congress in London, UK, Dr Michel Gagner (Professor of surgery, Herbert Wertheim School of Medicine, FIU Senior consultant, Hôpital du Sacre Coeur, Montreal, Canada) will be participating in two key events examining the current role of sleeve gastrectomy - 6th Annual International Consensus on Sleeve Gastrectomy and the GORE Sleeve Symposium. Bariatric News talked to Michel Gagner about the increasing popularity of the procedure, the importance of the IFSO events and understanding the mechanics of the sleeve gastrectomy.

“For several reasons, I always expected sleeve gastrectomy would be a popular procedure because on a technical level it is less complicated than performing an anastomosis, there a fewer nutritional risks and fewer long-term incidents of complications such as bowel obstructions or ulcers compared to other procedures.”

Michel Gagner

The rise in the number of sleeve gastrectomy procedures since the 1st International Conference on Sleeve Gastrectomy was held in New York in 2007 has been dramatic. This year, the Consensus meeting returns for its 6th instalment with more live cases, more analyses and more speakers than ever before.

“This year, we will look at how to recognise and manage common complications after sleeve gastrectomy, how to evaluate candidates for revisions and conversions, as well as how to prevent adverse events,” explained Michel Gagner. “The meeting is divided into two days, with the first dedicated to live surgical procedures from operators around the world. We hope to have approximately 20 live cases – three per hour – and the cases will not only include regular sleeve procedures done by masters but several conversions and revisions including the single anastomosis duodeno–ileal bypass with sleeve gastrectomy (SADI), rising in popularity, as well as reduced port sleeve gastrectomy, procedures for reflux during sleeve gastrectomy, endoscopic procedures and banded sleeve gastrectomy.”

The second day will focus on the prevention and management of complications, long term outcomes, weight regain, revisional procedures, management of leaks, buttressing, surgery in special patient groups and reflux after surgery. At the end of the second day attendees with be given a consensus questionnaire and the results will be published in a peer-reviewed journal in 2018.

"There is evidence that the smaller bougie size can increase the likelihood of complications such as strictures, Portal-Mesenteric vein thrombosis or a leak due to excessive pressure.”

“We want delegates to attend the consensus meeting because this procedure is evolving and the meeting is an excellent way to keep informed and up-to-date with all the latest data, hear tips and tricks, and learn about new techniques and devices.”

In addition to the 6th International Conference on Sleeve Gastrectomy, Michel Gagner will also be participating in two W.L. Gore & Associates lunch symposia at the IFSO. The symposia, to be held on Thursday 31st August and Friday 1st September, will examine how the use of Staple Line Reinforcement can improve surgical technique and patient outcomes, as well as looking at the supporting clinical evidence for Staple Line Reinforcement.

Delegates will hear from world renown sleeve gastrectomy experts from North America (Michel Gagner and Jamie Ponce), South America (Almino Ramos), Australia (Roy Brancatisano) and Europe (Ahmed Ahmed, David Nocca and Patrick Noël) who will focus on complications and how they can be reduced and prevented. There will also be an analysis of Staple Line Reinforcement results, videos on the operative technique of Staple Line Reinforcement, as well as a specific focus on reducing leeks and bleeding, with an emphasis on buttressing.

“The symposiums will be very different to the consensus meeting and will have an ‘Expert Panel Discussion’ format. Each expert will present their topic for five minutes and will then answer questions for 15 minutes giving delegates more time to have interactive discussions and to consider the many technical aspects of a sleeve gastrectomy such as bougie size and how to avoid complications and errors.”

Regarding bougie size, Michel Gagner said that there are several studies that have examined the association of bougie size and weight loss, although he is not convinced that it makes a huge difference if one considers weight loss over a few years.

He explained that there are some studies that have looked at the distance from the pylorus - and the MBSAQIP analysis (Berger et al, The Impact of Different Surgical Techniques on Outcomes in Laparoscopic Sleeve Gastrectomies: The First Report from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program) reported that the longer antrum had better weight loss than the shorter antrum - which is contrary to other analyses.

“We are still learning about the mechanisms of the sleeve gastrectomy and how to prevent complications such as stenosis. There is evidence that the smaller bougie size can increase the likelihood of complications such as strictures, Portal-Mesenteric vein thrombosis or a leak due to excessive pressure.”

"I have observed with some interest, and alarm, that the lower part of the stomach tends to be operated on very well, but the upper part not so well – perhaps this is part of the learning curve.”

In terms of weight loss, he said it was important not to leave any fundus, although that was not dependent on the bougie size. He clarified that bougie size is associated with how tight a surgeon staples close to the bougie, so it is important to remember that the bougie is there to avoid stricture and to avoid making the sleeve too narrow. Traction, pressure and tension should also be considered, he added, because when a surgeon removes the bougie, they do not want the tissue to spring back and create a stricture.

Michel Gagner explained that there are several preventable mistakes that occur during laparoscopic sleeve gastrectomy, including poorly dissected posterior fundus and poorly dissected gastro-oesophageal junction.

“Both can lead to significant complications that can require additional attention, such as a hiatal hernia and/or reflux,” he warned. “These are probably the most common problems I see and I have observed with some interest, and alarm, that the lower part of the stomach tends to be operated on very well, but the upper part not so well – perhaps this is part of the learning curve.”

He also noted that as revision and conversion procedures become more common there are important aspects that must be considered when performing these more challenging laparoscopic sleeve gastrectomy cases such as severe tissue scarring and identifying metal clips, staple lines, etc. It is also important that surgeons recognise the more difficult cases and learn to identify potential problems like portal hypertension or increased bleeding when dissecting between large veins.

Michel Gagner added that Staple Line Reinforcement and buttressing play a key role in the prevention of bleeding and leaks, and that there are multiple meta-analyses to support its use. He said that the MBSAQIP paper that concluded Staple Line Reinforcement was ‘associated with increased leak rate’ – lacked the sufficient data to support the conclusions that were reached. For example, he said that they seemed to imply that the use of reinforcement was not decreasing leaks, however, the problem with was that they did not know or could not identify what types of reinforcement were used.

“This paper contradicted several other meta-analyses that have concluded one type of reinforcement dramatically reduced leak rates and bleeding, whilst another type of reinforcement increased leak rates and bleeding. The fact the authors did not know the type of materials and/or were unware that the type of material can make a difference to leaks and bleeding rates surprised me,” he added. “In fact, two of the authors of the paper do not agree with their own paper’s conclusions as they regularly and consistently use staple line reinforcement, I take some of their conclusions with a grain of salt.”

He said large-scale, multi-centre randomised controlled trials are required to address such shortcomings, but unfortunately the cost of running such trials with the required substantial number of patients is prohibitive.

“I hope in the future that large societies such as the ASMBS and IFSO will be able to coordinate such studies and encourage their members to enter their patients in an electronic database so we can gather as much data as possible. I would also like to see the SADI procedure declared non-experimental as it is an established deconstructive operation and its experimental status is more to do with politics than science,” he concluded. “I have no doubt that sleeve gastrectomy will continue to grow and it is my hope that it will be used for the mass treatment of obesity in more and more countries, so that one day we could see the number of bariatric and metabolic procedure rise from 500,000 a year to five million.”

There will be a limited number of spaces at the Gore Symposia at IFSO. To register your interest in attending this event, please click here

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