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Mal Fobi’s Corner

Sleeve gastrectomy: A simple operation that is not that simple

...creation of this vertical gastroplasty component of the Biliopancreatic diversion with the switch (BPD-DS) was the easy component of the operation

Vertical resection of the stomach to reduce the gastric reservoir in the biliopancreatic diversion operation (BPD) was introduced by Hess in order to decrease the incidence of marginal ulcers in that operation and by maintaining the pylorus to also enhance the restrictive effects of the operation and also decrease the incidence of dumping. The volume of the gastric pouch created by Hess was 250-400cc akin to the size of the transverse fundal pouch in the Scopinaro procedure. This pouch size was to reduce the caloric intake that resulted in the initial weight loss of the BPD as studied and well documented by Scopinaro. This was the thinking before the discovery of the role of ghrelin.

Since the BPD was rarely done because of its complexity, the problems of malabsorption (protein caloric malnutrition), the incidence of frequent stools and the foul body odor and flatus after the operation, similarly the BPD-DS modification by Hess was rarely done or done and abandoned because of the same issues. However, the reports from surgeons who did either the BPD or BPD-DS established that these operations are the most effective for weight loss, weight loss maintenance and control of T2DM.

Creation of this vertical gastroplasty component of the Biliopancreatic diversion with the switch (BPD-DS) was the easy component of the operation. The duodenectomy and duodeno-ileostomy was the difficult component. With the introduction of laparoscopic approach into the field of bariatric surgery, the difficult component of the operation forced surgeons to do the operation in two stages: the vertical gastric transection as stage 1 followed by the stage 2 duodenectomy and the Roux-Y- duodeno-ileostomy. The thinking was that the vertical gastrectomy will induce a certain quantity of weight loss that will make the second stage operation easier particularly in super obese patients.

The serendipitous observation that some of the patients lost significant weight and in the short to midterm maintained the weight loss after the stage one vertical gastrectomy gave birth to the sleeve gastrectomy as a standalone operation. Unfortunately, this operation received the endorsement of the ASMBS with minimal studies and scrutiny.

"I foresee a time in the not too far future when we will see the demise of the sleeve gastrectomy if we do not objectively address the shortcomings of this operation."

It was not long after many surgeons started doing the sleeve as a standalone operation using the large pouch of the BPD-DS that it became apparent that there was a high incidence of weight regain after an initial weight loss. Dilation of the sleeve pouch was the most common cause for this weight regain. Intuitively and guided by La Place law, surgeons started reducing the sleeve size to minimize the sleeve dilation. Some blamed the fundus (retained fundus or dilated fundus) and others the antrum (retained large antrum) for the dilation. There have been few if any studies to guide the optimal size of the sleeve created in the standalone sleeve. The use of a bougie in the stomach to guide the transection of the sleeve does not standardize the sleeve pouch. It mainly tells the surgeon the possible lower limit of the sleeve volume. In practice, the volume of the sleeve depends on the surgeon. That is why there are so many variations with the outcome from the standalone sleeve. However, cumulative reports indicate that the smaller the size of the sleeve the more the weight loss. As more data has become available and with longer term experience it is becoming obvious that making the smaller sleeve only delays the time for significant dilation.

The benefit from reducing the pouch size in the sleeve gastrectomy is the increased and slightly protracted weight loss after the standalone sleeve. However, the risk and price are just becoming very evident. Leaks, particularly intractable leaks with fistulas are not un common. The cost to treat these leaks are high. The incidence of gastrectomy in some of the patients with complicated fistulas from these leaks is not insignificant. The incidence of strictures and torsion of the sleeve are not uncommon. The neo-GERD after these tight sleeves with resultant severe esophagitis and some with early transition to Barrett’s esophagitis are becoming a concern. Finally, the weight gain in the long term because dilation is part of the natural history of the sleeve will result in revisional operations. It is amazing that surgeons are quick to revise a failed sleeve to a BPD-DS or SADI, procedures that are rarely performed as primary procedures for the reasons already stated above.  These issues bring into vogue the question: “If the sleeve gastrectomy was a drug or a device would it have been recalled by regulatory agencies?” Unfortunately, in spite of all these short comings the sleeve is gaining more and more popularity. Can the sleeve gastrectomy be modified and standardized to avoid the complications from reducing the size of the sleeve pouch?

Unfortunately, the ease of being able to separate the omentum from the greater curvature of the stomach and to resect 60% to 95% of the greater curvature of the stomach to perform the sleeve gastrectomy make it an operation that can be performed by any laparoscopic surgeon. That is why the sleeve is the most common bariatric metabolic operation worldwide. More unfortunate for the patients is that there is a honeymoon period when no matter what the surgeon does the patient will lose a certain amount of weight. This is relevant because obesity is a lifelong disease but the follow up rate after bariatric metabolic procedures beyond two years is very poor. I foresee a time in the not too far future when we will see the demise of the sleeve gastrectomy if we do not objectively address the shortcomings of this operation.

It is not too late for randomized multi-center prospective studies on the sleeve gastrectomy like the French multi-center study by Robert Maud and her team on the OAGB. All patients will have preoperative endoscopies and the size of the sleeve standardized. Oliak and Bhandari and many others have published You-Tube videos on standardizing the size of the sleeve so it is not made so narrow. All patients will have routine surveillance postsurgical endoscopies. With this protocol we can give the sleeve gastrectomy its rightful place in the armamentarium of bariatric metabolic procedures. “Sleeve gastrectomy is a simple operation that is not that simple”.

References

Scopinaro N, Gianetta E, Civalleri D, et al. Biliopancreatic bypass for obesity: II. Initial experience in man. Br J Surg 1979; 66:618-20.
Scopinaro N, Gianetta E, Civalleri D, et al. Long-term clinical and functional impact of biliopancreatic diversion on type 2 diabetes in morbidly and non–morbidly obese patients. Surg Obes Relat Dis 2016 May;12(4):822-7.
DeMeester TR, Fuchs KH, Ball CS, et al. Experimental and clinical results with proximal end-to-end duodenjejunostomy for pathologic duodenogastric reflux. Ann Surg 1987; 206:414-24.
Hess DS, Hess DW. Biliopancreatic diversion with a duodenal switch. Obes Surg 1998; 8:267-82.
Marceau P, Hould FS, Simard S, et al. Biliopancreatic diversion with duodenal switch. World J Surg 1998 Sep;22(9):947-54.
Gagner M, Hutchinson C, Rosenthal R. Fifth International Consensus Conference: current status of sleeve gastrectomy. Surg Obes Relat Dis 2016 May;12(4):750-6.
Angrisani L, Santonicola A, Iovino A, et al. Bariatric surgery and endoluminal procedures: IFSO worldwide survey 2014. Obes Surg 2017 Sep;27(9):2279-89.

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