1. Sleeve Gastrectomy The Metabolic Choice
Shahzeer Karmali MD, FRCSC Assistant Professor Surgery Centre for the Advancement of Minimally Invasive Surgery, University Of Alberta, Edmonton, Alberta, Canada

2. Why Sleeve Gastrectomy?
“We need a bariatric procedure that does not cause as much morbidity and does not need as much follow up as the current ones”
E.E. Mason Presidential Address 2007 ASMBS

3. Mechanism of action
Restriction
Natural Band Formation
Hormonal

4. 1. Restriction LSG reduces the size of the gastric reservoir to 60-100ml
permitting intake of
only small amounts
of food and
imparting a feeling
of satiety earlier
during a meal

5. 2. Natural Band The pylorus functions as a natural band in
this procedure
facilitating
further restriction

6. 3. Ghrelin
hormone produced mainly by P/D1 cells lining the fundus of the human stomach and epsilon cells of the pancreas that stimulates hunger
Ghrelin levels increase before meals and decrease after meals.
the counterpart of the hormone leptin, produced by adipose tissue, which induces satiation when present at higher levels

7. 3. Ghrelin By resecting the fundus in a LSG, the majority of
ghrelin producing cells
are removed
reducing plasma ghrelin
levels and subsequently
hunger.

8. Current Weight loss Evidence
35 Studies between 1/03 and 1/09
2,570 patients
Pre-op BMI 35 – 69 kg/m2 (mean 50)
Post-op BMI 26 – 53 kg/m2 ( mean 37)
Follow-up 3 months to 5 years
33 – 83% EWL (mean 55%)
Complication rate 0 – 24%
0 – 15% in 11 studies with n> 100
5 postoperative mortalities (0.19%)

9. Sleeve Gastrectomy
Good Excess Weight loss
Technically feasible
Safe

10. Sleeve Gastrectomy and Diabetic Control

11. Resolution, Remission or Cure
It is generally accepted that effective medical or surgical diabetes therapy results in remission of the disease and not cure
This generally means that the patient is off all hypoglycemic medications and/or insulin and that they have normal fasting plasma glucose, normal post prandial glucose excursions and normal HbA1c

12. Bariatric Surgery Efficacy
Procedure
% EWL
T2DM
(Remission)
Gastric Banding
47% (n=1848)
48%
Gastric Bypass
62% (n=4204)
84%
BPD
70% (n=2480)
98%
Buchwald H. JAMA, 2004

13. Bariatric Surgery is Effective, But Not Equal-Where does sleeve fit in?
Benefit
100%
Switch
Roux-en-Y
Excess Weight Loss
Diabetes Resolution Rate
50%
Banding
10%
0.001
0.01
0.1 1 10
Risk
30 Day Mortality
Adapted from Buckwald H, et al, Bariatric surgery, a systematic review and meta-analysis, JAMA. 2004;292: and Maggard M, et al, Meta-Analysis: Surgical Treatment of Obesity, Ann Intern Med. 2005;142:

14. Diabetes Surgical Interventions (DSI)
High
Efficacy
Medium
Low
Low
Medium
High
Technical Complexity

15. How does a Sleeve Gastrectomy impart its Diabetic Remission?

16. 1. Hormonal Changes 2. Hindgut theory

17. 1. Hormonal Changes-Ghrelin Effect
Marked Reduction of fasting ghrelin levels post-operatively Karamkos et al. 2008
Ghrelin is a hormone produced primarily by the gastric fundus
Ghrelin :
suppress the insulin sensitizing hormone adiponectin
Blocks hepatic insulin signaling
Inhibits insulin secretion
By gastric fundus removal, the reduced circulating ghrelin level and its insulinostatic effect will increase the maximal captacity of glucose induced insulin release and enable the islet to secrete more insulin
Abbatini et al. 2009

18. 2. The Hindgut Theory
The more rapid delivery of undigested nutrients to the distal bowel upregulates the production of L-cell derivatives like GLP-1, Peptide YY
Mason E. Obes Surg ,
Rubino et.al, Ann Surg, 2006

19. The But we are not making any new anastamosis like a BPD or a RNYGB so how does this happen with a SG???
Melissas et al. Obes Surg 2007
gastric emptying half-time (T1/2) accelerated (47.6 +/ vs /- 15.4, P<0.01) post-operatively.
The percentage of the meal emptied from the stomach 90 min after consumption increased significantly after SG (75.4 +/- 14.9% vs /- 8.7%, P<0.01).
study indicates that following SG, the stomach empties its contents rapidly into the small intestine
Thus despite preservation of the pylorus, the stomach emptying of solid foods into the small intestine is increased

20. Hindgut theory: Peptide YY
Secreted from entire GI tract – “L” cells
Mainly distal (ileum, colon and rectum)
Food intake stimulates its release – fasting reduces it
Effects
May ameliorate insulin resistance (in mice)
Delays pancreatic/gastric secretions/gastric emptying/intestinal transit
Bloom SR. et.al. Nature 2006

21. Hindgut theory-Glucagon Like Peptide– 1
GLP-1 “Enteroglucagon”
Secreted by ileal “L-cells” in (rapid) response to a meal
Animal study Li et al. demonstrated an increased in GLP 1 levels in SG group
Actions
Potent stimulator of insulin / supresses glucagon
Slows gastric emptying
Reduces appetite
Increases beta cell mass
Wynne K. J Clin Endo Met, 2004

22. The Evidence-Diabetes Remission post LSG

23. Systematic Review Remission of Diabetes post Sleeve Gastrectomy
Karmali S, Shi X, Sharma A.M., Birch D.W.

24. Methodology
Search strategy: Medline, Pubmed, Embase, Scopus, Dare, Cochrane library, Clinical evidence, TRIP, HTA database; meanwhile, conference abstracts, registered clinical trials were also searched. Google was also used for grey or other literature, such as clinical practice guidelines, government documents.
Search terms: sleeve gastrectomy, or vertical gastrectomy, or bariatric surgery, or metabolic surgery and diabetes, or T2DM, or DM or comorbidities.
All human studies, not limited to English language, reported from 2000 to April 2010 were included in our searching.

25. 3,621 Citations Identified for Screening
261 Rejected (Did Not Meet Inclusion Criteria
230 Wrong Publication Type (case report, <5 patients, technique only, no outcomes measured, experts opinions, animal models)
5 Wrong Population (not adult)
20 Wrong Intervention (sleeve gastrectomy combined with other procedures)
6 Kin Relationship (substudies, duplicate patients)
3,332 Rejected (Met Exclusion Criteria)
289 Abstracts Reviewed
28 Primary Studies Included
4 Nonrandomized Prospective Controlled Trials
3 Retrospective Controlled Trials
15 Prospective Case Series
6 Retrospective Case Series

26. Year
Nation
study
pt#
2010
Netherlands
prospective 20
India 53
retrospective 23 UK 34
Brazil
non-R CT 32
New Zealand 25
2009
USA 30
retrospective CT
Italy
France 33
Isreal 18
Chile 14 39 7
2008
Spain
Taiwan(rct) 13
Australia
Czech 17
Japan 6
2007 21
2006 75
2005
Korea 8

27. Results-Demographics
Total number of patients: 705
Mean BMI: /- 7.9 ( )
Mean Age: /- 3.8 (42-53)
Mean Follow-up: /- 8.1 months (3-36)
%EWL: /-19.1 ( )
Post-surgical BMI: /-6.6 ( )

28. Type 2 Diabetes Mellitus
Resolution: /- 24.5
Improvement /- 25.1
Stable /

29. Glucose Levels
181.1 to 119.2

30. HbA1C change
7.9 to 6.2

31. Bariatric Surgery Efficacy
Procedure
% EWL
T2DM
(Remission)
Gastric Banding
47% (n=1848)
48%
Sleeve Gastrectomy
47.3% (n=705)
66.5%
Gastric Bypass
62% (n=4204)
84%
BPD
70% (n=2480)
98%
Buchwald H. JAMA, 2004

32. Diabetes Surgical Interventions (DSI)
High
Efficacy
Medium
Low
Low
Medium
High
Technical Complexity

33. So Why choose Sleeve?

34. Sleeve vs. LAGB %EWL, Diabetes remission better with sleeve
No need for adjustments. No needles !!!
Removes Ghrelin Cell mass. Loss of appetite
Creates restriction more than obstruction
less follow up ?

35. SLEEVE VS. RYGB and BPD-DS
%EWL and T2DM remission may not be as strong BUT..
LSG is much technically less complex-wider applicability to general surgeons
No risk of Internal Hernias
No/Less malabsorption – No/Less micronutrient deficiency ?
Maintains oral access to GI and Biliary tract
Completely removes Ghrelin cell mass
No dumping
Does not interfere with immunosuppressant
Can always be upgraded to RYGBP or BPD-DS

36. SLEEVE WINS!!!!

37. Questions?
Questions?