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Samuel Szomstein, M.D., FACS Associate Director of The Bariatric and Metabolic Institute and Section of Minimally In

SLEEVE GASTRECTOMY “A new dimension in general and bariatric surgery”. Samuel Szomstein, M.D., FACS Associate Director of The Bariatric and Metabolic Institute and Section of Minimally Invasive Surgery Cleveland Clinic Florida Assistant Clinical Professor of Surgery

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Samuel Szomstein, M.D., FACS Associate Director of The Bariatric and Metabolic Institute and Section of Minimally In

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  1. SLEEVE GASTRECTOMY “A new dimension in general and bariatric surgery” Samuel Szomstein, M.D., FACS Associate Director of The Bariatric and Metabolic Institute and Section of Minimally Invasive Surgery Cleveland Clinic Florida Assistant Clinical Professor of Surgery Nova Southeastern University

  2. Why a New Procedure ?

  3. The Mason Era Gastric Bypass Vertical Banded Gastroplasty Mason and Ito, 1967 Mason et al, 1982 Mc Gregor A, ASBS Website, 1999

  4. “We need a bariatric procedure that does not cause as much morbidity and does not need as much follow up as the current ones “

  5. Potential Advantages If Effective ? When compared to RYGBP: • No long term complications ? • No Int. Hernias ? • No malabsorption – No micronutrient deficiency ? • No Strictures ? No Marginal Ulcerations ? • Maintains oral access to GI and Biliary tract

  6. Potential Advantages If Effective ? When compared to RYGBP: • Completely removes Ghrelin cell mass • No dumping • Does not interfere with immunosuppressant • Can always be upgraded to RYGBP !?

  7. Potential Advantages If Effective ? When compared to LAGB: • No need for adjustments. No needles !!! • Removes Ghrelin Cell mass. Loss of appetite !! • Creates restriction more than obstruction • No need to do yearly endoscopy • No/less follow up ?

  8. Brief History Evolution of LSG

  9. Sleeve gastrectomy was first described in 1988 when Scopinaro's technique of biliopancreatic diversion with distal gastrectomy and gastroileostomy was modified by Hess and simultaneously by Marceau Scopinaro, N., Adami, G. F., Marinari, G. M., Gianetta, E., Traverso, E., Friedman, D., Camerini, G., Baschieri, G., and Simonelli, A. Biliopancreatic Diversion. World J Surg. 1998;22(9):936-46. Hess, D. S. and Hess, D. W. Biliopancreatic Diversion With a Duodenal Switch. Obes.Surg. 1998;8(3):267-82. Marceau, P., Biron, S., St Georges, R., Duclos, M., Potvin, M., and Bourque, R. A. Biliopancreatic Diversion With Gastrectomy As Surgical Treatment of Morbid Obesity. Obes.Surg. 1991;1(4):381-7.

  10. De Wind Mason Scopinaro Mason Linnear VBG JIBP JCBP RYGBP BPD 1967 1954 1963 1978 1982 LSG Wittgrove De Meester Kuzmak Lap RYGBP Belachew Gagner Lap- Band Lap BPD / DS BPD-DS Banding 1994 1987 1990 1998 1999

  11. Gagner M, Rogula T. Laparoscopic reoperative sleeve gastrectomy for poor weight loss after biliopancreatic diversion with duodenal switch. Obes Surg. 2003 Aug;13(4):649-54 METHODS: Follow-up of 1 case of sleeve gastrectomy for Poor Weight loss after Biliopancreatic Diversion with Duodenal Switch. Review of the literature

  12. Laparoscopic Era Gagner described the first laparoscopic BPD-DS in 1999 Step procedure in super super morbidly obese patients to facilitate the laparoscopic approach Ren, C. J., Patterson, E., and Gagner, M. Early Results of Laparoscopic Biliopancreatic Diversion With Duodenal Switch: a Case Series of 40 Consecutive Patients. Obes.Surg. 2000;10(6):514-23.

  13. Magenstrasse and Mill Obesity Surgery

  14. Magenstrasse and Mill Obesity Surgery

  15. Mechanism of Action How does it work ?

  16. How doest it work ?Sleeve gastrectomy • Creates restriction • Removes Ghrelin cells • Creates a natural band PYLORUS

  17. In review Gastric Emptying is not affected by Sleeve Gastrectomy or the emptying function of the remnant stomach following sleeve gastrectomy assessed by gastric scintigraphy in morbidly obese patients. Hanna Bernstine2, Ronit Tzioni Yehoshua1, David Groshar2, Nahum Beglaibter4, Shikora Scott5, Raul J. Rosenthal 6, Moshe Rubin1,3

  18. RESEARCH ARTICLE Laparoscopic Sleeve Gastrectomy—Volume and Pressure Assessment Ronit T. Yehoshua & Leonid A. Eidelman & Michael Stein & Suzana Fichman & Amir Mazor & Jacopo Chen & Hanna Bernstine & Pierre Singer & Ram Dickman & Scott A. Shikora & Raul J. Rosenthal & Moshe Rubin Received: 11 May 2008 / Accepted: 15 May 2008 # Springer Science + Business Media, LLC 2008

  19. RESEARCH ARTICLE Laparoscopic Sleeve Gastrectomy—Volume and Pressure Assessment • Closed pylorus and GE Junction • Inject Methylene blue • Measured Volume Ronit Yeoshua et al. Obesity Surgery

  20. RESEARCH ARTICLE Laparoscopic Sleeve Gastrectomy—Volume and Pressure Assessment Stomach Sleeve Vol (mean) 1500 cc 130 cc Pressure 34 mmhg 43 mmhg Ronit Yeoshua et al. Obesity Surgery

  21. Gastrointestinal peptides involved in appetite control Appetite - Pancreatic polypeptide (PP) -Peptide tyrosine-tyrosine (PYY) - Products of preproglucagon: Glucagon-like 1, oxyntomodulin Appetite - Ghrelin

  22. Ghrelin plasma levels

  23. Regulation of energy balance at Brain Increases hunger: hypothal feeding centers. Humans injected with ghrelin: intense hunger. Suppresses fat utilization in adipose tissue Stimulates gastric emptying Increases cardiac output (possible GH effect) Fundus of Stomach is Primary Source GHRELIN

  24. Ghrelin secretion Negative energy balance Starvation Cachexia Anorexia nervosa Positive energy balance Obesity ? Hyperglycemia Feeding High Low

  25. Sleeve gastrectomy: Decreased plasma ghrelin levels

  26. Preliminary results 10 Sleeve gastrectomy patients 2 non-obese controls Quantification and distribution of ghrelin cells in the stomach Results: Mean number of ghrelin cells Sleeve gastrectomy Control 169 59 p=0.002

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