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SLEEVE GASTRECTOMY: ANATOMIA DI UN DILEMMA TERAPEUTICO.

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Presentation on theme: "SLEEVE GASTRECTOMY: ANATOMIA DI UN DILEMMA TERAPEUTICO."— Presentation transcript:

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2 SLEEVE GASTRECTOMY: ANATOMIA DI UN DILEMMA TERAPEUTICO

3 Introduction Laparoscopy achieves the same anatomic objectives as open bariatric surgery but avoids a large abdominal incision Bariatric surgery is the most effective method for achieving sustained weight loss of considerable degree in individuals with morbid obesity Surgeons should have a clear understanding of the four most commonly discussed operations for morbid obesity at this time: 1)Laparoscopic Roux-en-Y gastric bypass (LRYGB) 2)Laparoscopic adjustable gastric banding (LAGB) 3)Duodenal switch (DS) 4)Laparoscopic sleeve gastrectomy (LSG)

4 General overview of the various laparoscopic procedures for morbid obesity

5 “La chirurgia dell obesita e accetabile solamente se e efficace e sicura”

6 EFFICACITA Perdita di al meno 50% del eccesso ponderale a 1 anno e a 3 anni

7 SLEEVE GASTRECTOMY 2000 come “ first step” nelle “ two stages” procedure Cauto ottimismo entusiasmo

8 Esistono “ tendenze” : la scelta del intervento nel ambito della chirurgia dell obesita, e arbitraria (Necessita di guidelines )

9 VANTAGGI DELLA TECNICA  Riduzione dela capacita gastrica senza perdita funzionale  Assenza di dumping a causa della preservazione pylorica  Meccanismo “ ormonale”

10 DIFETTI  Rischi legati alla linea di sutura  Irreversibilita

11 Laparoscopic sleeve gastrectomy. A bariatric procedure with multiple indications. Baltasar A: Cir Esp 2006 May;79 (5): patienti 63,1 % BMI (76 % nei vari sottogruppi nei due anni)

12 “Reduction of the ghrelin – production stomach mass may account for its sureriority to other gasric restrictive procedures…long – term studies are necessary to see if it is a durable procedure.” Gumbs AA, Gagner M. Sleeve gastrectomy for morbid obesity Obes.Surg 2007 Jul;17(7):962-9

13 RISULTATI I A prospective multicenter study of 163 sleeve gastrectomies: results at 1 and 2 years. Nocca D et al Obes Surg May2008; 18(5):560-5 EWL 48,9% 6 mesi 59,45% 1 anno 62,02% 18 mesi 61,5% 2 anni

14 RISULTATI II Results of laparoscopic sleeve gastrectomy: a prospective study in 135 patients with morbid obesity. Fuks D et al. Surgery 2009 Jan; 145(1) EWL 38,6 6 mesi 49,4 1 anno

15 RISULTATI III Feasibility and technique of laparoscopic conversion of adjustable gastric banding to sleeve gastrectomy Dapri G, Cadiere GB, Himpens J. Surg Obes. Relat Dis.2009 EWL 16,7% adizionale 34,8 % totale(!!)

16 Laparoscopic sleeve gastrectomy: does bougie size affect mean %EWL? Short – term outcomes. Parikh M, Gagner M e altri. Surg Obes Relat Dis Jul-Aug; 4(4): ( 40 F vs 60 F) !!!???

17 MORBIDITA Complicanze per operatorie Complicanze post operatorie precoci Complicanze tardive

18 COMPLICANZE PER OPERATORIE  Transezione gastrica  Emorragia  Ischemia splenica  Traumatismo hepatico

19 MORTALITA  0 – 3,2% Aggarwal et al. Surgery Obes Rel Dis ;

20 COMPLICANZE POST OPERATORIE PRECOCI  Fistola  Emorragia  Ascesso

21 COMPLICANZE POST OPERATORIE TARDIVE  Riflusso  Stenosi

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24 COMPLICANZE The First International Consensus Summit for Sleeve Gastrectomy (SG), New York City, October 25-27, 2007

25 SERIE PERSONALE (SLEEVE)

26 TECNICA  French position Trocar ( 4+1)

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28 TECNICA  Infiltrazione anestesia locale  Ultracision  32 fr  Echelon  2 verdi  4-6 gold Tissue thickness of human stomach measured on excised gastric speciments from obese patients Elariny H, Gonzalez H, Wang B. Surg Technol Int 2005;14:  Buscopan  Drenagio

29 SG Technical considerations

30 RISULTATI (SLEEVE)

31 EVOLUZIONE BMI (SLEEVE)

32 EVOLUZIONE EWL (SLEEVE)

33 COMPLICANZE I (SLEEVE)

34 COMPLICANZE II (SLEEVE) 1 anno GERD = 11%

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36 The mechanism of weight loss and resultant comorbidity improvement seen after sleeve gastrectomy may be related to gastric restriction or neurohumoral changes due to the gastric resection, or some other unidentified factor(s) Published complication rates range from 0% to 24%, with an overall reported mortality rate of 0.39% Sleeve gastrectomy is probably at least as effective and durable as adjustable gastric banding at 1 and 3 years after surgery Long-term (5 yr) weight loss and comorbidity resolution data for sleeve gastrectomy have not been reported at this time SG-1

37 SG-2 Weight regain or a desire for further weight loss in a super-super-obese patient may require the procedure to be revised to a gastric bypass or BPD with duodenal switch. Sleeve gastrectomy appears to be a technically easier and/or faster laparoscopic procedure than Roux-en-Y GB or malabsorptive procedures in complex or high- risk patients, including the super-super-obese patient (BMI 60 kg/m2) Sufficient as a “stand alone” procedure ? From a technical standpoint, there appears to be no consensus regarding the optimal dilator size that should be used to create the lesser curve conduit (32F- 60F !!!)

38 Complications and outcome of SG Position Statement ASMBS 2007, Surgery for Obesity and Related Diseases 2007;3:573-6`

39 AGB vs SG Kueper M A et al. World J Surg 2008;32:1462-5

40 AGB vs SG Kueper M A et al. World J Surg 2008;32:1462-5

41 AGB vs SG Wong S KH et al. Hong Kong Med J 2009; 15:100-9

42 AGB vs SG Wong S KH et al. Hong Kong Med J 2009; 15:100-9

43 In a randomized study comparing gastric banding with sleeve gastrectomy (n = 80), was found that the median percentage of excess weight loss at 3 years was 48% for gastric banding and 66% for sleeve gastrectomy Himpens J et al. Obes Surg 2006;16: AGB vs SG

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