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Clinical guidelines

Sleeve gastrectomy best practices published

Consensus paper created to avoid problems often experienced in the learning curve
Based on experience from almost 13,000 operations in 24 centres
90% agree: LSG is a valid procedure both stand-alone and for successful, but complicated, gastric bands
Recommendations include using a bougie above 32F to size sleeve, and to completely mobilise the fundus, to avoid complications

An international panel of 25 leading bariatric surgeons has published a consensus paper on the best practices for performing laparoscopic sleeve gastrectomy. The panel's recommendations on patient selection, proper surgical technique and prevention, and the management of complications represents the experiences from 24 centres in 11 countries with more than 12,000 sleeve gastrectomy cases.

“There is a misleading perception amongst surgeons and patients that this procedure is an easy one,” said lead author and panel chairman Dr Raul J Rosenthal, Bariatric and Metabolic Institute and the Cleveland Clinic, FL. “Despite its simplicity, laparoscopic sleeve gastrectomy requires a meticulous technique in order to avoid complications and maximize procedure outcomes. We felt the need to create guidelines to help surgeons prevent complications that are related, in most cases, to the learning curve.”

“When so many new surgical technologies, techniques and procedures are being developed, it is crucial to provide resources for surgeons to learn best practices in a shorter period of time to achieve the optimal procedure results while minimising complications.” Dr Raul Rosenthal, guideline lead author

According to the authors, this is the first time an international panel of experts has reached consensus on the best practices for performing laparoscopic sleeve gastrectomy. It is hoped that the consensus statement will help the surgical community continue to improve patient outcomes, minimise complications and move toward adoption of standardised techniques. The consensus paper was recently published in the January 2012 issue of Surgery for Obesity and Related Diseases, the official journal of the American Society for Metabolic and Bariatric Surgery.

Although laparoscopic sleeve gastrectomy (LSG) is a relatively new surgical approach has been readily adopted by surgeons who have embraced the ‘simplicity’ of the surgical technique, resolution of co-morbidities and excellent weight loss outcomes. As a result, an international expert panel was convened on March 25 and 26 2011 in Coral Gables, FL, to achieve consensus regarding various predetermined aspects of LSG and: (1) conduct discussion and evaluation of various procedural aspects of LSG (inclusive of indications/contraindications, surgical technique, and prevention and management of complications) that included and considered the collective experience of participants and current published data; (2) achieve consensus on topics in LSG from the discussion and evaluation; and (3) aid the surgical community and improve the safety of performance with minimal morbidity and high efficacy using the resulting best practice guidelines.

Panel data

A questionnaire was sent to all panellists before the consensus meeting to compile various data on the total number of LSG cases performed by the group.  The total number of LSG cases was 12,799, with mean patient age 42 years of whom 26% were male and 73% female. The mean body mass index of the patients was 44±4.47kg/m2. The mean bougie size was 37F± 5.92F. The average length of hospital stay was 2.5± 93 days and the conversion rate was 1.05%±1.85%. On average, patients experienced a 1.06% leak rate and 0.35% stricture rate, with a postoperative gastroesophageal reflux rate reported as 12.11%±8.97%.

Patient selection

In addition to reaching consensus on LSG as a valid stand-alone procedure (90%), the panellists identified LSG as a valid treatment option for the following categories of patients: patients considered high risk (96%); transplant candidates (kidney and liver) (96%); morbidly obese patients with the metabolic syndrome (91%); patients with a body mass index of 30–35kg/m2 with associated co-morbidities (95%); patients with inflammatory bowel disease (86%); morbidly obese patients in adolescence (77%); morbidly obese patients who are elderly (100%); and patients with Child's A or B liver cirrhosis (78%). As the first stage of a two-step approach, LSG is only appropriate for the super morbidly obese patient (75%) and that the presence of Barrett's oesophagus is an absolute contraindication for LSG (81%).

Revisions

In regards to revision procedures, the panellists agreed that LSG is an acceptable option to convert a successful, but complicated, gastric band (95%). However, it was acknowledged that Roux-en-Y gastric bypass, not LSG, is the best option to convert a failed gastric band (71%). When a patient undergoes conversion from gastric banding to LSG, the operation can be done in one step, which is a valid approach (72%). The two-step approach is also valid (79%). Even assuming that ≤30% of LSG patients will need a second procedure, the panel agreed that it is still an excellent procedure (90%). With regards to staple firings, the last firings (across the thickened site of the previous intervention) should be green or larger (71%). The transection should begin 2–6cm from the pylorus (92%); and it is important to be cautious and maintain a reasonable distance from the gastroesophageal junction on the last firings (96%).

Surgical technique

The panel achieved consensus on the technical aspects of the performance of LSG, which were summarised as:

Sizing the sleeve - in addition to it being important when performing LSG to use a bougie to size the sleeve (100%), the optimal bougie size is 32F–36F (87%). The panel believed that using a bougie <32F might increase complications significantly and that using a bougie >36F could lead to the lack of long-term restriction and possible dilation of the sleeve, resulting in failure of weight loss or long-term weight regain. In addition, invaginating the staple line with sutures might result in temporary or permanent reduction of the lumen size (83%), depending on the suture type used (absorbable versus nonabsorbable).

Staple heights and firings - consensus was achieved for some points including that it is not appropriate to use staples with a closed height less than that of a blue load (1.5mm) on any part of a sleeve gastrectomy (81%). Although panellists voted against this as they did not agree that anything less than a green load should be used. When using buttressing materials (79%) and when resecting the antrum, the surgeon should never use any staple with a closed height less than that of a green load (2.0mm) (87%), because the gastric antrum wall is the thickest part of the stomach.

Mobilisation – it is important to completely mobilise the fundus before transection (96%), otherwise the surgeon could miss a hiatal hernia and leave behind too much stomach, decreasing the restrictive component of the operation.

Complications

The panel agreed that leaks, strictures, bleeding, and gastro-oesophageal reflux disease were the most prevalent complications observed after LSG. Consensus was reached on several points regarding leaks, including defining leak classifications according to observation periods and can be classified into acute, early, late, and chronic (73%). Additional points of consensus included that the use of a stent is a valid treatment option for an acute proximal leak for which conservative therapy has failed (95%). The use of a stent is a valid treatment option for an acute proximal leak (93%) and an unstable patient with a contained or uncontained symptomatic leak requires immediate reoperation (86%).

The panel also made some general observations regarding staple line reinforcement, stating that the use of staple line reinforcement will reduce bleeding along the staple line (100%). Interestingly, they could not agree  whether to buttress or on whether buttressing reduces leaks. The general points of consensus outside the specific areas of LSG indications, technique, and complications included hiatal hernias and gastro-oesophageal reflux disease.

Interestingly, the panel stated that sleeve gastrectomies should only be performed by bariatric surgeons (85%) and that endoscopy should routinely be performed in patients undergoing sleeve gastrectomy (70%).

The paper states that the panel reached consensus on almost all topics, providing a basis for current technical and clinical approaches and the development of future guidelines. However, those topics that did not reach consensus (emphasize the need for additional studies and long-term data, especially within the specific areas of staple line reinforcement, patient selection, and specific points about the management of complications.

Conclusions

The paper concludes by stating that it is not meant to establish a standard of practice merely to support and encourage surgeons and surgical societies to develop standardised guidelines, as well as highlight the areas needing additional study and long-term experience and data.

“This type of consensus meeting is, to our knowledge, one of the first aimed at standardizing a surgical technique,” explained Rosenthal. “In these times, when so many new surgical technologies, techniques and procedures are being developed, it is crucial to provide resources for surgeons to learn best practices in a shorter period of time to achieve the optimal procedure results while minimising complications.”

The assembly and work of the expert surgeon panel that developed the consensus was supported by an educational grant from Ethicon Endo-Surgery. 

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