laparoscopic sleeve gastrectomy

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Slide 1 : ICCSSG NEW YORK 2007 SLEEVE GASTRECTOMY IN HIGH RISK PATIENTS P Mognol, D Chosidow, JP Marmuse HOPITAL BICHAT PARIS FRANCE
Slide 2 : ICCSSG NEW YORK 2007 Is the sleeve effective ?
Slide 3 : ICCSSG NEW YORK 2007 Definitively YES
Slide 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
Slide 5 : ICCSSG NEW YORK 2007 SLEEVE GASTRECTOMY - WEIGHT LOSS -
Slide 6 : ICCSSG NEW YORK 2007 SLEEVE GASTRECTOMY our results Perte de poids
Slide 7 : ICCSSG NEW YORK 2007 SLEEVE GASTRECTOMY compared results in our experience
Slide 8 : ICCSSG NEW YORK 2007 SLEEVE GASTRECTOMY - Individual results at 1 year -
Slide 9 : ICCSSG NEW YORK 2007 SLEEVE GASTRECTOMY - Individual results at 1 year - Single stage procedure Second stage procedure will be needed
Slide 10 : ICCSSG NEW YORK 2007
Slide 11 : ICCSSG NEW YORK 2007 SLEEVE GASTRECTOMY Results at 1 year Cottam & all ; Surg Endosc 2006 : 859-863
Slide 12 : ICCSSG NEW YORK 2007 Himpens & all ; Obes Surg 2006, 16 , 1450-1456 Sleeve gastrectomy offers better results than other restrictive procedure
Slide 13 : ICCSSG NEW YORK 2007 Why is the sleeve effective ?
Slide 14 : ICCSSG NEW YORK 2007 SLEEVE GASTRECTOMY Mechanism ? Restriction Volume 100 à 150 ml Hormonal Ghrelin
Slide 15 : ICCSSG NEW YORK 2007 Is the sleeve an easy procedure ?
Slide 16 : ICCSSG NEW YORK 2007 Definitively not
Slide 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
Slide 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
Slide 19 : ICCSSG NEW YORK 2007 Is the sleeve safe ?
Slide 20 : ICCSSG NEW YORK 2007 YES AND NO
Slide 21 : ICCSSG NEW YORK 2007 MORBIDITY AND MORTALITY RELATED TO THE SURGICAL PROCEDURE
Slide 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
Slide 23 : ICCSSG NEW YORK 2007
Slide 24 : ICCSSG NEW YORK 2007 MORBIDITY AND MORTALITY RELATED TO THE HIGH RISK PATIENT
Slide 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%)
Slide 26 : ICCSSG NEW YORK 2007 SLEEVE AND GERD
Slide 27 : ICCSSG NEW YORK 2007 SLEEVE GASTRECTOMY Published studies Himpens & all ; Obes Surg 2006, 16 , 1450-1456
Slide 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
Slide 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
Slide 30 : ICCSSG NEW YORK 2007 When should we performe the second stage?
Slide 31 : ICCSSG NEW YORK 2007 When reaching the plateau with insuffisent weight loss and in case of weight regain
Slide 32 : ICCSSG NEW YORK 2007 SLEEVE GASTRECTOMY
Slide 33 : ICCSSG NEW YORK 2007 Is the second stage effective in term of weight loss?
Slide 34 : ICCSSG NEW YORK 2007 SLEEVE GASTRECTOMY Two stage procedure : 3 patients = BP
Slide 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
Slide 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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