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Sleeve En Y Does Changing the Name Change the Perception?

Sleeve En Y Does Changing the Name Change the Perception?. Mitchell Roslin, MD FACS Chief of Bariatric Surgery Lenox Hill Hospital Northern Westchester Hospital Center. Disclosures. Consultant J&J, Covidien, CR Bard Research Grant Covidien Patent License J&J, CR Bard, Allergan

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Sleeve En Y Does Changing the Name Change the Perception?

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  1. Sleeve En YDoes Changing the Name Change the Perception? Mitchell Roslin, MD FACS Chief of Bariatric Surgery Lenox Hill Hospital Northern Westchester Hospital Center

  2. Disclosures • Consultant J&J, Covidien, CR Bard • Research Grant Covidien • Patent License J&J, CR Bard, Allergan • SAB ValenTx, Scientific Intake • Founder VentralFix

  3. Gastric bypass has been most popular stapling procedure • Best balance between outcome and complications? • Preferable for sweet eaters because of dumping? • Dumping is an important component for weight loss surgery as it deters carbohydrate intake? • Tremendous amount of long term data?

  4. “A person with a new idea is a crank until the idea succeeds.” Mark Twain • Described RYGB • Abandoned anemia, bone loss, micronutrient deficiencies • 1971 VBG • Lesser curvature • 2005 International Registry • RYGB 67 vs 59 %EBL • VBG 0 mortality vs .5% Edward E Mason MD, PHD

  5. Harvey SUGERman Ann Surg 1987 • Compared VBG to RYGB in sweet eaters • Big difference in outcome 37% EBL VBG • What is a sweet eater? • 69% vs 67% wt loss in sweet eaters vs non in rygb • Dumping caused sweet aversion?

  6. Ten and more years after vertical banded gastroplasty as primary operation for morbid obesity • 71 patients • BMI 49 – 39 • 26% 50% ebl • High amount of emesis • High re operation rate

  7. Weight gain after short- and long-limb gastric bypass in patients followed for longer than 10 years. • Lloyd MacLean • Isolated gastric bypass • 83% follow up • Progressive wt regain from nadir (2Yr) • No differences in short and long limb • 20% failure for MO • 35% failure for SMO

  8. Dumping? • Literature contains numerous articles about hyperinsulinemic hypoglycemia • None showing relationship between dumping and weight loss • Mallory et al: No relationship between wt loss and dumping

  9. OBESITY IS A CHRONIC DISEASE • 70% of excess weight loss after one year • Much higher rate of recidivism than noted

  10. RESTORE Trial

  11. Size does not Matter? • In cohort that had dgj>2cm, no difference with increasing size • Time matters • Will be difficult to identify clinical target that is reproducible

  12. Physiologic Cause • Lesser curvature • Restrictive anastomosis • No valve • Rapid emptying • Recidivism maybe based on anatomy, not return of old habits • Low glycemic index diet • Many eat refined carbs

  13. IMPLICATIONS:PRESERVATION OF PYLORUS VS SUPPORTED BYPSS

  14. RANDOMIZED TRIALLAP RYGB VS LAP DS • Mean BMI 54 RYGB • Mean BMI 55 DS • 1 Yr post RYGB = 38 • 1 Yr post DS = 32 • Similar complications • Will majority of super obese patients treated with RYGB be morbidly obese?

  15. The Duodenal Switch Operation for the Treatment of Morbid Obesity: A 10 Year Experience • 701 patients BMI 52 • 22% BMI >60 58% BMI >50 • 75% >50% excess wt at five years • 67% EBL maintained • 40 patients with revision for increased limb length • Similar data Hess and Marceau

  16. Pyloric Preservation? • Bypass with rapid emptying causing inter meal hunger • Instead of artificial fixed valve use biologic smart valve • Duodenal Switch has most weight loss • Sleeve preserves options

  17. Introducing the Sleeve En Y • Effectiveness of sleeve shows the value of long narrow pouch with pylorus intact • Combination of narrow pouch and pylorus limit intake and diarrhea • Intestinal bypass plays metabolic role • Can lengthen common channel to avoid oily stools and frequent bowel movements

  18. Responder Analysis • BMI > 50 Nadir response > 1 year • 50% EWL, BMI < 40, BMI < 35, BMI <30 • 13/120 Bands less than 40 • 270 of 346 RYGB less than 40 • 10 of 30 VSG • 22 of 23 lap DS (majority have not reached nadir • Lowest variability in response • Does treatment of super morbid obesity require intestinal bypass?

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