Dig Surg 2014;31:48–54 DOI: 10.1159/000354313
Published online: May 8, 2014
Laparoscopic Sleeve Gastrectomy: With or without Duodenal Switch? A Consecutive Series of 800 Cases L. Biertho S. Lebel S. Marceau F.S. Hould O. Lescelleur P. Marceau S. Biron Division of Bariatric and Metabolic Surgery, Department of Surgery, Quebec Heart and Lung Institute, Quebec, Que., Canada
Key Words Bariatric surgery · Duodenal switch · Sleeve gastrectomy · Metabolic surgery
Abstract Background: Sleeve gastrectomy (SG) was originally performed as the restrictive and acid-reducing part of a biliopancreatic diversion with duodenal switch (BPD-DS). It is now recognized as a stand-alone procedure, but direct comparison between the two procedures is still lacking. The goal of this study is to compare the outcomes of the two procedures and their respective impact on obesity-related comorbidities. Methods: All patients who had a laparoscopic SG (n = 378) or a laparoscopic BPD-DS (n = 422) before 10/2011 were included in this study (n = 800). Data were obtained from our prospectively maintained electronic database and are reported as mean ± standard deviation comparing SG with BPD-DS patients. Results: SG patients were older (48 ± 11 vs. 40 ± 10 years, p < 0.001) with a higher prevalence of comorbidities (type 2 diabetes mellitus in 51 vs. 37%; hypertension 62 vs. 49%; sleep apnea 63 vs. 51%; all p < 0.001). Initial BMI was 48 ± 9 vs. 48 ± 6 (p = 0.8). There was one 30day mortality in the BPD-DS group, from a pulmonary embo-
© 2014 S. Karger AG, Basel 0253–4886/14/0311–0048$39.50/0 E-Mail [email protected] www.karger.com/dsu
lism, for an overall mortality rate of 0.13%. Thirty-day complications occurred in 6 vs. 8% of patients (p = 0.2), including gastric leaks in 4 (1%) vs. 0 patients (p = 0.049). Mean followup was 29 ± 10 months. Excess weight loss was 45 ± 14 vs. 62 ± 15% at 6 months, 53 ± 18 vs. 81 ± 14% at 12 months, 53 ± 23 vs. 87 ± 15% at 18 months, 50 ± 19 vs. 86 ± 15% at 24 months and 51 ± 24 vs. 83 ± 16% at 36 months (p < 0.05 for all time points). The surgery induced the remission of type 2 diabetes mellitus in 56 vs. 90% of patients, hypertension in 54 vs. 76% and sleep apnea in 43 vs. 74% (all p < 0.05). In type 2 diabetic patients, fasting plasma glucose decreased by –1.9 mmol/l after SG vs. –2.9 mmol/l after BPD-DS (p < 0.05) and hemoglobin A1C by –1.1 vs. –1.9% (p < 0.05). Conclusion: SG results in a significant 3-year weight loss and remission of comorbidities. BPD-DS provides further improvement of associated comorbidities and can be an option for the management of insufficient weight loss or residual comorbidities following SG. © 2014 S. Karger AG, Basel
This study was presented at the Third Meeting of the International Consensus Summit on Sleeve Gastrectomy, New York, N.Y., USA, December 2012.
Laurent Biertho, MD Institut Universitaire de Cardiologie et de Pneumologie de Québec 2725, Chemin Ste-Foy Quebec, QC G1V 4G5 (Canada) E-Mail laurentbiertho @ gmail.com
Introduction
The prevalence of obesity has been increasing steadily over the last two decades. However, the prevalence of severe obesity has increased in an exponential manner, with a 225% increase in Canada between 1990 and 2003 [1]. Even though recent studies suggest that the obesity epidemic has stabilized, this medical condition still represents a major healthcare and economical problem worldwide [2]. Indeed, nonsurgical management of morbid obesity is usually ineffective in the long term, and surgery remains the only long-term solution for these patients [3]. Numerous surgical techniques have thus emerged over the years, and some have been endorsed by international medical societies. The most recent bariatric surgery is known as sleeve gastrectomy (SG). It is also one of the oldest bariatric procedures, since it was first described in 1989 by Hess and Hess [4] and Marceau et al. [5] as the restrictive and acid-suppressing part of a biliopancreatic diversion with duodenal switch (BPD-DS). Indeed, our Center started using SG in the early 1990s to decrease the dumping syndrome and rate of marginal ulcers associated with Scopinaro type biliopancreatic diversion. To date, more than 3,000 sleeve gastrectomies with duodenal switches have been performed in our Institution since 1991; but laparoscopic SG without a duodenal switch has only been introduced in 2008. The goal of this study was to compare the results of these two techniques, with a special emphasis on the risk/ benefit ratio for each procedure and their impact on associated comorbidities. We assessed the 30-day complications, long-term readmission rate and analyzed the effect of these two procedures on weight loss, comorbidities and some biochemical parameters associated with the metabolic syndrome.
surgeon, dietician, nurse specialized in bariatric surgery and social worker. Patients had an electrocardiogram, chest X-ray, blood work, sleep apnea testing and consultation in pneumology. Vitamin or mineral supplementation was started when deficiencies were discovered before the surgery. Consultation with a psychiatrist was requested when the patient had a history of psychiatric disease. Standard preoperative education specific to BPD-DS or SG was given to all patients. Surgical Technique All patients followed our routine preoperative preparation including a low-residue diet for 2 days before surgery, antibioprophylaxis (cefazolin 2 g at the time of surgery) and thromboprophylaxis (standard or low-molecular-weight subcutaneous heparin). A 15-mm Hg pneumoperitoneum is first created. The greater curvature of the stomach is mobilized using ultrasonic shears (Ace Ultrasonic, Ethicon EndoSurgery, Cincinnati, Ohio, USA). A 34- to 44-Fr bougie is used for the calibration of an SG as a stand-alone procedure. The stomach is then transected along that bougie using an articulating linear stapler-cutter (Echelon-Flex long 60; Ethicon EndoSurgery, Cincinnati, Ohio, USA), starting 4–5 cm from the pylorus. For BPD-DS, the gastrectomy is started 7–8 cm from the pylorus, to create a larger gastric reservoir, with an estimated volume of 250 cm3. The first duodenum is then transected 3–4 cm from the pylorus, using a blue cartridge. The ileocecal valve is then identified, and the small bowel is transected 250 cm proximal, using a white cartridge. The duodeno-ileal anastomosis is then created. At the beginning of our experience, a 21-mm circular stapler was used to create that anastomosis. Since 2010, we transitioned to a hand-sewn anastomosis, using 2 posterior layers and one anterior layer of 3-0 absorbable sutures. The mesenteric window is closed using a 2-0 Prolene suture. Routine cholecystectomy was also performed. Standard postoperative orders have been used in both groups including ulcer prevention, thromboprophylaxis and feeding protocol. Patients were discharged when tolerating a soft diet, with daily supplementations of vitamins and minerals. A multivitamin complex (Centrum Forte) was given to all patients. In addition, BPD-DS patients received daily vitamin A 20,000 IU, vitamin D 50,000 IU, calcium carbonate 1,000 mg and ferrous sulfate 300 mg.
All patients who had a laparoscopic BPD-DS or a laparoscopic SG at the Quebec Heart and Lung Institute, a University-affiliated tertiary care center, were included in this study. Laparoscopic BPD-DS was introduced in November 2006, the date of the beginning of this study. Laparoscopic SG was introduced in 2008. To obtain a minimal follow-up of one year, patients were included up to November 2011. Data were extracted from a prospectively maintained electronic database and reviewed retrospectively.
Follow-Up Patients were followed at the clinics at 3, 6, 9, 12, 18 and 24 months after operation and yearly thereafter. Blood analysis was performed at these times, including a complete blood count, electrolytes, urea and creatinine, calcium, parathormone, vitamin D, vitamin A, serum iron, total iron binding capacity and ferritin. Supplementations were adjusted over time according to these analyses. The percentage of excess weight loss (EWL) was calculated as follows: (initial weight – current weight)/(initial weight – ideal weight). The ideal weight was calculated by multiplying the square of the patient’s height in meters by 23. The BMI was calculated by dividing the patient’s weight in kilograms by the square of the height in meters.
Patient Selection Patient selection followed the standard NIH recommendations for bariatric surgery [6]. All patients were assessed by a bariatric
Statistical Methods The data are reported as mean ± standard deviation for continuous data or as percentages for categorical variables. Statistical
Sleeve versus Duodenal Switch
Dig Surg 2014;31:48–54 DOI: 10.1159/000354313
Methods
49
Table 1. Demographic data
Patients Age, years Sex ratio, % F/M BMI Weight, kg T2DM, % Hypertension, % Sleep apnea, % Mean number of comorbidities
SG
BPD-DS
378 48 ± 11 66 48 ± 9 134 ± 29 51 62 63 5.3 ± 1.6
422 40 ± 10 82 48 ± 6 131 ± 23 37 49 51 4.1 ± 1.6
p – 0.001 0.001 NS NS
Published online: May 8, 2014
Laparoscopic Sleeve Gastrectomy: With or without Duodenal Switch? A Consecutive Series of 800 Cases L. Biertho S. Lebel S. Marceau F.S. Hould O. Lescelleur P. Marceau S. Biron Division of Bariatric and Metabolic Surgery, Department of Surgery, Quebec Heart and Lung Institute, Quebec, Que., Canada
Key Words Bariatric surgery · Duodenal switch · Sleeve gastrectomy · Metabolic surgery
Abstract Background: Sleeve gastrectomy (SG) was originally performed as the restrictive and acid-reducing part of a biliopancreatic diversion with duodenal switch (BPD-DS). It is now recognized as a stand-alone procedure, but direct comparison between the two procedures is still lacking. The goal of this study is to compare the outcomes of the two procedures and their respective impact on obesity-related comorbidities. Methods: All patients who had a laparoscopic SG (n = 378) or a laparoscopic BPD-DS (n = 422) before 10/2011 were included in this study (n = 800). Data were obtained from our prospectively maintained electronic database and are reported as mean ± standard deviation comparing SG with BPD-DS patients. Results: SG patients were older (48 ± 11 vs. 40 ± 10 years, p < 0.001) with a higher prevalence of comorbidities (type 2 diabetes mellitus in 51 vs. 37%; hypertension 62 vs. 49%; sleep apnea 63 vs. 51%; all p < 0.001). Initial BMI was 48 ± 9 vs. 48 ± 6 (p = 0.8). There was one 30day mortality in the BPD-DS group, from a pulmonary embo-
© 2014 S. Karger AG, Basel 0253–4886/14/0311–0048$39.50/0 E-Mail [email protected] www.karger.com/dsu
lism, for an overall mortality rate of 0.13%. Thirty-day complications occurred in 6 vs. 8% of patients (p = 0.2), including gastric leaks in 4 (1%) vs. 0 patients (p = 0.049). Mean followup was 29 ± 10 months. Excess weight loss was 45 ± 14 vs. 62 ± 15% at 6 months, 53 ± 18 vs. 81 ± 14% at 12 months, 53 ± 23 vs. 87 ± 15% at 18 months, 50 ± 19 vs. 86 ± 15% at 24 months and 51 ± 24 vs. 83 ± 16% at 36 months (p < 0.05 for all time points). The surgery induced the remission of type 2 diabetes mellitus in 56 vs. 90% of patients, hypertension in 54 vs. 76% and sleep apnea in 43 vs. 74% (all p < 0.05). In type 2 diabetic patients, fasting plasma glucose decreased by –1.9 mmol/l after SG vs. –2.9 mmol/l after BPD-DS (p < 0.05) and hemoglobin A1C by –1.1 vs. –1.9% (p < 0.05). Conclusion: SG results in a significant 3-year weight loss and remission of comorbidities. BPD-DS provides further improvement of associated comorbidities and can be an option for the management of insufficient weight loss or residual comorbidities following SG. © 2014 S. Karger AG, Basel
This study was presented at the Third Meeting of the International Consensus Summit on Sleeve Gastrectomy, New York, N.Y., USA, December 2012.
Laurent Biertho, MD Institut Universitaire de Cardiologie et de Pneumologie de Québec 2725, Chemin Ste-Foy Quebec, QC G1V 4G5 (Canada) E-Mail laurentbiertho @ gmail.com
Introduction
The prevalence of obesity has been increasing steadily over the last two decades. However, the prevalence of severe obesity has increased in an exponential manner, with a 225% increase in Canada between 1990 and 2003 [1]. Even though recent studies suggest that the obesity epidemic has stabilized, this medical condition still represents a major healthcare and economical problem worldwide [2]. Indeed, nonsurgical management of morbid obesity is usually ineffective in the long term, and surgery remains the only long-term solution for these patients [3]. Numerous surgical techniques have thus emerged over the years, and some have been endorsed by international medical societies. The most recent bariatric surgery is known as sleeve gastrectomy (SG). It is also one of the oldest bariatric procedures, since it was first described in 1989 by Hess and Hess [4] and Marceau et al. [5] as the restrictive and acid-suppressing part of a biliopancreatic diversion with duodenal switch (BPD-DS). Indeed, our Center started using SG in the early 1990s to decrease the dumping syndrome and rate of marginal ulcers associated with Scopinaro type biliopancreatic diversion. To date, more than 3,000 sleeve gastrectomies with duodenal switches have been performed in our Institution since 1991; but laparoscopic SG without a duodenal switch has only been introduced in 2008. The goal of this study was to compare the results of these two techniques, with a special emphasis on the risk/ benefit ratio for each procedure and their impact on associated comorbidities. We assessed the 30-day complications, long-term readmission rate and analyzed the effect of these two procedures on weight loss, comorbidities and some biochemical parameters associated with the metabolic syndrome.
surgeon, dietician, nurse specialized in bariatric surgery and social worker. Patients had an electrocardiogram, chest X-ray, blood work, sleep apnea testing and consultation in pneumology. Vitamin or mineral supplementation was started when deficiencies were discovered before the surgery. Consultation with a psychiatrist was requested when the patient had a history of psychiatric disease. Standard preoperative education specific to BPD-DS or SG was given to all patients. Surgical Technique All patients followed our routine preoperative preparation including a low-residue diet for 2 days before surgery, antibioprophylaxis (cefazolin 2 g at the time of surgery) and thromboprophylaxis (standard or low-molecular-weight subcutaneous heparin). A 15-mm Hg pneumoperitoneum is first created. The greater curvature of the stomach is mobilized using ultrasonic shears (Ace Ultrasonic, Ethicon EndoSurgery, Cincinnati, Ohio, USA). A 34- to 44-Fr bougie is used for the calibration of an SG as a stand-alone procedure. The stomach is then transected along that bougie using an articulating linear stapler-cutter (Echelon-Flex long 60; Ethicon EndoSurgery, Cincinnati, Ohio, USA), starting 4–5 cm from the pylorus. For BPD-DS, the gastrectomy is started 7–8 cm from the pylorus, to create a larger gastric reservoir, with an estimated volume of 250 cm3. The first duodenum is then transected 3–4 cm from the pylorus, using a blue cartridge. The ileocecal valve is then identified, and the small bowel is transected 250 cm proximal, using a white cartridge. The duodeno-ileal anastomosis is then created. At the beginning of our experience, a 21-mm circular stapler was used to create that anastomosis. Since 2010, we transitioned to a hand-sewn anastomosis, using 2 posterior layers and one anterior layer of 3-0 absorbable sutures. The mesenteric window is closed using a 2-0 Prolene suture. Routine cholecystectomy was also performed. Standard postoperative orders have been used in both groups including ulcer prevention, thromboprophylaxis and feeding protocol. Patients were discharged when tolerating a soft diet, with daily supplementations of vitamins and minerals. A multivitamin complex (Centrum Forte) was given to all patients. In addition, BPD-DS patients received daily vitamin A 20,000 IU, vitamin D 50,000 IU, calcium carbonate 1,000 mg and ferrous sulfate 300 mg.
All patients who had a laparoscopic BPD-DS or a laparoscopic SG at the Quebec Heart and Lung Institute, a University-affiliated tertiary care center, were included in this study. Laparoscopic BPD-DS was introduced in November 2006, the date of the beginning of this study. Laparoscopic SG was introduced in 2008. To obtain a minimal follow-up of one year, patients were included up to November 2011. Data were extracted from a prospectively maintained electronic database and reviewed retrospectively.
Follow-Up Patients were followed at the clinics at 3, 6, 9, 12, 18 and 24 months after operation and yearly thereafter. Blood analysis was performed at these times, including a complete blood count, electrolytes, urea and creatinine, calcium, parathormone, vitamin D, vitamin A, serum iron, total iron binding capacity and ferritin. Supplementations were adjusted over time according to these analyses. The percentage of excess weight loss (EWL) was calculated as follows: (initial weight – current weight)/(initial weight – ideal weight). The ideal weight was calculated by multiplying the square of the patient’s height in meters by 23. The BMI was calculated by dividing the patient’s weight in kilograms by the square of the height in meters.
Patient Selection Patient selection followed the standard NIH recommendations for bariatric surgery [6]. All patients were assessed by a bariatric
Statistical Methods The data are reported as mean ± standard deviation for continuous data or as percentages for categorical variables. Statistical
Sleeve versus Duodenal Switch
Dig Surg 2014;31:48–54 DOI: 10.1159/000354313
Methods
49
Table 1. Demographic data
Patients Age, years Sex ratio, % F/M BMI Weight, kg T2DM, % Hypertension, % Sleep apnea, % Mean number of comorbidities
SG
BPD-DS
378 48 ± 11 66 48 ± 9 134 ± 29 51 62 63 5.3 ± 1.6
422 40 ± 10 82 48 ± 6 131 ± 23 37 49 51 4.1 ± 1.6
p – 0.001 0.001 NS NS
