Third International Summit: current status of sleeve gastrectomy

this is only the abstract of the article but it still looks bad for vsg results... im just shocked people still using 60f??

Mervyn Deitel M.D., F.A.S.M.B.S., C.R.C.S.C.^{a, ,} , Michel Gagner M.D., F.A.S.M.B.S., F.A.C.S., F.R.C.S.C.^b, Ann L. Erickson B.A.^c and Ross D. Crosby Ph.D.^d

^a Editor-in-Chief Emeritus and Founding Editor, Obesity Surgery

^b Department of Surgery, Florida International University Herbert Wertheim College of Medicine, Miami, Florida, and Clinique Michel Gagner MD Inc., Montreal, Quebec, Canada

^c Neuropsychiatric Research Institute, Fargo, North Dakota

^d Department of Biomedical Statistics Neuropsychiatric Research Institute, Fargo, North Dakota

Received 2 June 2011;  accepted 26 July 2011.  Available online 10 August 2011.

Abstract

Background

Laparoscopic sleeve gastrectomy (LSG) has been performed for morbid obesity in the past 10 years. LSG was originally intended as a first-stage procedure in high-risk patients but has become a stand-alone operation for many bariatric surgeons. Ongoing review is necessary regarding the durability of the weight loss, complications, and need for second-stage operations.

Methods

The first International Summit for LSG was held in October 2007, the second in March 2009, and this third in December 2010. There were presentations by experts, and, to provide a consensus, a questionnaire was completed by 88 attendees who had >1 year (mean 3.6 ± 1.5, range 1–8) of experience with LSG.

Results

The results of the questionnaire were based on 19,605 LSGs performed within 3.6 ± 1.5 years (228.8 ± 275.0 LSGs/surgeon). LSG had been intended as the sole operation in 86.4% of the cases; in these, a second-second stage became necessary in 2.2%. LSG was completed laparoscopically in 99.7% of the cases. The mean percentage of excess weight loss at 1, 2, 3, 4, and 5 years was 62.7%, 64.7%, 64.0%, 57.3%, and 60.0%, respectively. The bougie size was 28–60F (mean 36F, 70% blunt tip). Resection began 1.5–7.0 cm (mean 4.8) proximal to the pylorus. Of the surgeons, 67.1% reinforced the staple line, 57% with buttress material and 43% with oversewing. The respondents excised an estimated 92.9% ± 8.0% (median 95.0%) of fundus (i.e., a tiny portion is maintained lateral to the angle of His). A drain is left by 57.6%, usually closed suction. High leaks occurred in 1.3% of cases (range 0–10%); lower leaks occurred in .5%. Intraluminal bleeding occurred in 2.0% of cases. The mortality rate was .1% ± .3%.

Conclusion

According to the questionnaire, presentations, and debates, the weight loss and improvement in diabetes appear to be better than with laparoscopic adjustable gastric banding and on par with Roux-en-Y gastric bypass. High leaks are infrequent but problematic

Those percentages  of excess weight lost are right about where RnY is. (Which it even says in the conclusion.) 

Of course, average excess weight loss is a problematic measure of success because it's not an independent variable but is dependent on starting BMI. But it's what everyone uses and it does give some idea of relative effectiveness of various WLS types.

Thanks Linda,

Wow I admit I am surprised and disappointed, but I think it will get better over time as the standard becomes smaller, we rarely see anyone over a 45 F here...  and I think we will see the higher numbers less and less.  So hopefully these numbers imporove overall...

I love my Sleeve and plan to keep my weight off and do better than the numbers above.

Cindy

I know that I was an early Kaiser "Sleever" and they were all using 40f in N. California when I had it done.  Several months after me, they all went to a 34F.    The results in the support group meeting are apparent as those people are losing at a much faster rate.  That said, I had buttress material and I know I wasn't pulled tight because of fear of leaks.  They may have also started pulling tighter on the bougie or oversewing as they became less fearfull and realized it would produce better results.  I can eat way more than people only a few months behind me in surgery dates *****ceived smaller sleeves.

The results are par with what I found out, while researching for the sleeve. Weight regain is a complicated issue, since there are so many psychological and behavioral factors at play. Bougie size is important, but in the long run, it is up to the individual to use their tool to their greatest advantage and to adopt a healthier lifestyle, so that weight loss can be maintained. The sleeve is only a tool to help us to get to a healthier BMI and to hopefully, resolve our co-morbidities. It is up to us, to adopt exercise and making better food choices as part of our new lifestyle.

ANY WLS can be eaten around, no matter what your sleeve size. We see this on a daily basis on OH. People get into trouble, when they return to eating carbs and other high caloric foods. The sleeve is most effective, when the rules are followed; protein first. Portions should be measured. Eating to fullness is what led us to become morbidly obese in the first place.

JMHO.

Gail

I see this as GOOD news in a way--the fact that 5 years out average weight loss is still at 60% (as opposed to 62.7% at 1 year) probably means that most people are not significantly regaining. You can't read too much into the data, of course. It would be nice to see underlying numbers, like of those who lost 100%, where were they at 5 years? Or if initial weight loss was 60%, did those people regain or maintain? I also think it's interesting that 57.6% of doctors use a drain--that seems high compared to what we see here, doesn't it? It just goes to show that it's not a standardized surgery!

Lizanne

Lizanne, I agree, those are the most important questions.  From the start when I compared myself to everyone around me and felt bad about my progress, I decided that the way I'd think about it all is... let's all get together in five years and see where we're at.   I had to realize that my fast or slow progress isn't necessarily any factor in how I'll do in keeping it off.  Mz. Brandi always reminds me that it's been such a chore to get it off that it may actually be my greatest asset in keeping it off.

I love seeing the experiences of all of you who are further out than me and I appreciate each of you!

Where we are at in five years will be "proof of the pudding" as they say. When I had my pre-op, my surgeon said that is the telling factor. In the beginning, just about everyone loses weight and it is a very exciting time, but life happens, and the real proof is 5 years down the line. In the WLS world, maintaining a 50% weight loss, is considered a success, but by my standards and probably everyone else on this board, that would be considered a failure. I would be devastated, if I regained 50% of my lost weight, but would still be considered a "success" by WLS success standards.

Lee, your tenaciousness, I have always said, may be your greatest asset in keeping the weight off. You have had to work very, very hard for every pound and your appreciation may be much higher than someone who had an easier time of things. I think you have learned alot during your journey and this will help you to keep the weight off.  You have always been an inspiration for me, to keeping at it, and the weight will come off. JMHO.

Gail

A couple of things this study ignores that I'm seeing have a huge impact: Surgeon technique and patient education.

Surgeon technique: regardless of bougie size, there are still surgeons out there that are starting the staple lines several centimeters from the valve at the esophagus at the top and the pylorus at the bottom. One patient who saw her sleeve in a scan described it as "barbell shaped" - it had a large pouch at the top and bottom, then went down to just the size of the bougie between. This has a huge impact on restriction and involves very stretchable tissue.

Also, how tight to the bougie is the surgeon stapling? A loosely stapled 32 is probably the equivalent of a tightly stapled, oversewn 40.

Patient education: Many, many, many patients are not going into this with good eating plans that have been explained to them in depth. Either that or there's no follow up to make sure they "get" it.

I believe these things can have a much bigger impact on results than just bougie size.

 I have to agree with Thin Lizzy here.  If the average wt loss at one year was 62.7% and at 5 years was 60%, I'd say that shows good things as far as regaining goes.  Many of us have lost 100% of the weight, and if we average a regain of only 2.7%, that would be fantastic.  Of course, We can't read too much into this.  It's up to the individual, after all.  I know I have a 32f that was over-sown. Time will tell.  But the bottom line is up to me.