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Sleeve gastrectomy precludes need for subsequent bypass.

DALLAS -- Laparoscopic vertical sleeve gastrectomy is a safe first-stage procedure for high-risk, superobese patients whose weight and size complicate biliopancreatic diversion with duodenal switch, Dr. Chrystine M. Lee said at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

Originally conceived as the first stage of a two-stage duodenal switch procedure, laparoscopic vertical sleeve gastrectomy was meant to help high-risk superobese patients lose sufficient weight to make the subsequent procedure more technically feasible. However, vertical sleeve gastrectomy alone may produce enough weight loss in some patients to preclude the need for a second-stage operation, said Dr. Lee of the David Grant U.S. Air Force Medical Center at the Travis (California) AFB.

Vertical sleeve gastrectomy closes off and removes about 85% or more of the stomach and creates a thin, tubelike stomach, without bypassing the intestines.

In a study of 216 obese patients who underwent the procedure between November 2002 and August 2005, the surgery was associated with a mean excess weight loss of 58.5% at 1 year and 83.1% at 2 years, "which is on par with weight loss achieved with the duodenal switch and the Roux-en-Y gastric bypass procedures," Dr. Lee said. Of the 216 patients, only 9 experienced a weight loss plateau, defined as a loss of less than 10 pounds in a 6-month period, she said.

Patients in the study, 80% of whom were female, were aged 16-64 years (mean 44.7 years). The mean preoperative weight and body mass index (BMI) were 302 pounds and 42 kg/[m.sup.2], respectively. All operations were laparoscopic; no conversions to open procedures were required. Surgeons started 6 cm from the pylorus, and used 5-7 firings of a 45- to 60-mm linear stapler loaded with 3.5-mm staples along a 32F bougie. They performed a greater curvature gastrectomy to create a 100- to 120-mL gastric tube. The mean operating room time was 66 minutes, the mean excess blood loss was 29 cc, and the mean length of stay was 1.9 days, significantly less than that associated with the Roux-en-Y and switch procedures, Dr. Lee said.

No deaths were associated with the surgery, but 20 patients experienced mild complications, 3 had leaks, and 26 required reoperations--rates similar to those associated with gastric banding, Dr. Lee said.

"All six patients whose preoperative BMI was less than 50 achieved BMI less than 35," she said, eliminating the need for second-stage surgery. "The question with this type of procedure is weight loss durability. The gastroplasties in the past have not had durable weight loss--usually from 60% to 70% at 1 year, dropping down to 30%-40% at 5 years. The question is whether this procedure will follow those footsteps and be associated with rebound weight gain," she said.

Previous data from a procedure similar to vertical sleeve gastrectomy showed "good results and durable 5-year weight loss," Dr. Lee said. In that procedure, the stapled portion of the stomach was left instead of removed.

"We think our results will follow that lead," she said. The fact that vertical sleeve gastrectomy removes the part of the stomach that secretes ghrelin, the hormone associated with appetite, may contribute to long-term durability, she suggested.

"What we've observed is weight loss similar to that seen with the Roux-en-Y and switch procedures, and higher than that associated with gastric banding. Morbidity is lower than the Roux-en-Y bypass and the switch, but comparable to gastric banding, so it's the best of both without some of the disadvantages," she said.

Dr. Lee reported no conflict of interests with respect to her presentation.

BY DIANA MAHONEY

New England Bureau
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Title Annotation:Gastroenterology
Author:Mahoney, Diana
Publication:Internal Medicine News
Article Type:Clinical report
Geographic Code:1USA
Date:Aug 1, 2006
Words:604
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