laparoscopic sleeve gastrectomy


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1 : ICCSSG NEW YORK 2007 SLEEVE GASTRECTOMY IN HIGH RISK PATIENTS P Mognol, D Chosidow, JP Marmuse HOPITAL BICHAT PARIS FRANCE
2 : ICCSSG NEW YORK 2007 Is the sleeve effective ?
3 : ICCSSG NEW YORK 2007 Definitively YES
4 : ICCSSG NEW YORK 2007 SLEEVE GASTRECTOMY - Patients Demographics - PATIENTS 35 (17 Males , 18 females ) Age ( years ) 46 ? 11 extrêmes ( 25 – 71 ) Weight ( Kg ) 181 ? 45 extrêmes ( 90 – 252 ) BMI 66 ? 13 extrêmes ( 40 – 89 ) BMI < 50 = 7 BMI 50 – 60 = 3 BMI 60 – 70 = 14 BMI > 70 = 11 6 patients had a previous lap band
5 : ICCSSG NEW YORK 2007 SLEEVE GASTRECTOMY - WEIGHT LOSS -
6 : ICCSSG NEW YORK 2007 SLEEVE GASTRECTOMY our results Perte de poids
7 : ICCSSG NEW YORK 2007 SLEEVE GASTRECTOMY compared results in our experience
8 : ICCSSG NEW YORK 2007 SLEEVE GASTRECTOMY - Individual results at 1 year -
9 : ICCSSG NEW YORK 2007 SLEEVE GASTRECTOMY - Individual results at 1 year - Single stage procedure Second stage procedure will be needed
10 : ICCSSG NEW YORK 2007
11 : ICCSSG NEW YORK 2007 SLEEVE GASTRECTOMY Results at 1 year Cottam & all ; Surg Endosc 2006 : 859-863
12 : ICCSSG NEW YORK 2007 Himpens & all ; Obes Surg 2006, 16 , 1450-1456 Sleeve gastrectomy offers better results than other restrictive procedure
13 : ICCSSG NEW YORK 2007 Why is the sleeve effective ?
14 : ICCSSG NEW YORK 2007 SLEEVE GASTRECTOMY Mechanism ? Restriction Volume 100 à 150 ml Hormonal Ghrelin
15 : ICCSSG NEW YORK 2007 Is the sleeve an easy procedure ?
16 : ICCSSG NEW YORK 2007 Definitively not
17 : ICCSSG NEW YORK 2007 SLEEVE GASTRECTOMY Dangerous zones 1 - Gastric antrum Thick gastric wall Use green staples 2 - Gastric angle ° Stenosis 3 - Angle of hiss LEAK Thin gastric wall Use blue staples Angle of hiss liberation Left crus Short gastric vessels 2 1 3
18 : ICCSSG NEW YORK 2007 Intraoperative complications Staple line disruption (revision procedure..) Bougie stapling Bleeding from the staple line Bleeding from gastric or short gastric vessels Bleeding from the spleen Exposure difficulty in supersuper obese patients
19 : ICCSSG NEW YORK 2007 Is the sleeve safe ?
20 : ICCSSG NEW YORK 2007 YES AND NO
21 : ICCSSG NEW YORK 2007 MORBIDITY AND MORTALITY RELATED TO THE SURGICAL PROCEDURE
22 : ICCSSG NEW YORK 2007 SLEEVE GASTRECTOMY complications Postoperatives complications Staple line leakage Bleeding from the staple line Gastric stenosis Late complications Marginal ulcer GERD ++ Gastric dilatation and weight regain
23 : ICCSSG NEW YORK 2007
24 : ICCSSG NEW YORK 2007 MORBIDITY AND MORTALITY RELATED TO THE HIGH RISK PATIENT
25 : ICCSSG NEW YORK 2007 Man 220 Kg ( diabetes mellitus , sleep apnea , HTA )) Hypoxic cardiac arrest J2 Sacral pressure ulcer J5 without rhabdomyolysis extensive cellulitisJ8 Multiorgan failure IN OUR EXPERIENCE ONE THIRD OF THE PATIENTS HAD A PREOPERATIVE BMI > 70 kg/m2 Conversion : 0 Morbidity : 0 Mortality : 1 ( 2.8%)
26 : ICCSSG NEW YORK 2007 SLEEVE AND GERD
27 : ICCSSG NEW YORK 2007 SLEEVE GASTRECTOMY Published studies Himpens & all ; Obes Surg 2006, 16 , 1450-1456
28 : ICCSSG NEW YORK 2007 No important problem of reflux in our experience What should we do in case of important hiatal hernia ? Nothing Closing the crus
29 : ICCSSG NEW YORK 2007 SLEEVE GASTRECTOMY Long-term results ???? Durability ? Not enough data in our small experience Second Stage ? Is it allways necessary ? Timing of the second stage Effectiveness of the second stage ? Which procedure for the second stage ? BPD + Duodenal switch R en Y GBP
30 : ICCSSG NEW YORK 2007 When should we performe the second stage?
31 : ICCSSG NEW YORK 2007 When reaching the plateau with insuffisent weight loss and in case of weight regain
32 : ICCSSG NEW YORK 2007 SLEEVE GASTRECTOMY
33 : ICCSSG NEW YORK 2007 Is the second stage effective in term of weight loss?
34 : ICCSSG NEW YORK 2007 SLEEVE GASTRECTOMY Two stage procedure : 3 patients = BP
35 : ICCSSG NEW YORK 2007 SLEEVE GASTRECTOMY Two stage procedure in supersuper obese patients One stage BPD/ DS 26 patients Initial BMI : 68.9 kg/m² Two stage BPD/DS 18 patients Initial BMI : 65.8 Kgm² Gagner M :Surg Clin North Am 2005
36 : ICCSSG NEW YORK 2007 Conclusion Sleeve gastrectomy is safe and effective even in high risk patients Sleeve gastrectomy shouldn’t be considered as an easy to perform procedure The results are good as a single procedure for patients with BMI<60 A second stage procedure will be needed in patients with BMI >60

 

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