Sleeve Gastrectomy The Metabolic
Choice
Why Sleeve Gastrectomy?

“We need a bariatric procedure that
does not cause as much morbidity
and does not need as much follow
up as the current ones”
 E.E. Mason Presidential Address 2007
ASMBS
Mechanism of action
1. Restriction
2. Natural Band
Formation
3. Hormonal
1. Restriction
LSG reduces the size
of the gastric
reservoir to 60-100
ml
permitting intake of
only small amounts
of food and
imparting a feeling
of satiety earlier
during a meal
2. Natural Band
The pylorus
functions as a
natural band in
this procedure
facilitating
further restriction
3. Ghrelin
• hormone
produced mainly
by P/D1 cells lining the fundus
of the human stomach and
epsilon cells of the pancreas
that stimulates hunger
•Ghrelin levels
increase before
meals and decrease after
meals.
•the counterpart of the
hormone leptin, produced by
adipose tissue, which induces
satiation when present at
higher levels
3. Ghrelin
•By resecting the fundus
in a LSG, the majority of
ghrelin producing cells
are removed
•reducing plasma ghrelin
levels and subsequently
hunger.
Current Weight loss Evidence
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35 Studies between 1/03 and 1/09
2,570 patients
Pre-op BMI 35 – 69 kg/m2 (mean 50)
Post-op BMI 26 – 53 kg/m2 ( mean 37)
Follow-up 3 months to 5 years
33 – 83% EWL (mean 55%)
Complication rate 0 – 24%
0 – 15% in 11 studies with n> 100
5 postoperative mortalities (0.19%)
Sleeve Gastrectomy
 Good Excess Weight loss
 Technically feasible
 Safe
Sleeve Gastrectomy and Diabetic
Control
Resolution, Remission or Cure

It is generally accepted that effective medical
or surgical diabetes therapy results in
remission of the disease and not cure

This generally means that the patient is off
all hypoglycemic medications and/or insulin
and that they have normal fasting plasma
glucose, normal post prandial glucose
excursions and normal HbA1c
Bariatric Surgery Efficacy
Procedure
% EWL
T2DM
(Remission)
Gastric Banding
47% (n=1848)
48%
Gastric Bypass
62% (n=4204)
84%
BPD
70% (n=2480)
98%
Buchwald H. JAMA, 2004
|
Bariatric Surgery is Effective,
But Not Equal-Where does sleeve fit in?
Benefit
Excess Weight Loss
Diabetes Resolution Rate
100%
Switch
Roux-en-Y
50%
Banding
10%
0.001
Risk
0.01
0.1
1
10
30 Day Mortality
Adapted from Buckwald H, et al, Bariatric surgery, a systematic review and metaanalysis, JAMA. 2004;292:1724-1737 and Maggard M, et al, Meta-Analysis: Surgical
Treatment of Obesity, Ann Intern Med. 2005;142:547-559.
|
Medium
Low
Efficacy
High
Diabetes Surgical Interventions (DSI)
Low
Medium
High
Technical Complexity
14 |
How does a Sleeve Gastrectomy
impart its Diabetic Remission?
1. Hormonal Changes
2. Hindgut theory
1. Hormonal Changes-Ghrelin Effect
Marked Reduction of fasting ghrelin levels postoperatively
Karamkos et al. 2008

Ghrelin is a hormone produced primarily by the gastric
fundus

Ghrelin :
 suppress the insulin sensitizing hormone
adiponectin
 Blocks hepatic insulin signaling
 Inhibits insulin secretion
 By gastric fundus removal, the reduced circulating
ghrelin level and its insulinostatic effect will increase
the maximal captacity of glucose induced insulin
release and enable the islet to secrete more insulin
Abbatini et al. 2009
2. The Hindgut Theory
 The more rapid delivery
of undigested nutrients
to the distal bowel
upregulates the
production of L-cell
derivatives like GLP-1,
Peptide YY
Mason E. Obes Surg 2005 15, 459-461
Rubino et.al, Ann Surg, 2006
|
The But we are not making any new anastamosis like
a BPD or a RNYGB so how does this happen with a
SG???


Melissas et al. Obes Surg 2007
• gastric emptying half-time (T1/2) accelerated (47.6
+/- 23.2 vs 94.3 +/- 15.4, P<0.01) post-operatively.
•
The percentage of the meal emptied from the
stomach 90 min after consumption increased
significantly after SG (75.4 +/- 14.9% vs 49.2 +/8.7%, P<0.01).
• study indicates that following SG, the stomach
empties its contents rapidly into the small intestine
Thus despite preservation of the pylorus, the stomach
emptying of solid foods into the small intestine is
increased
Hindgut theory: Peptide YY
 Secreted from entire GI tract –
“L” cells
▪ Mainly distal (ileum, colon and
rectum)
▪ Food intake stimulates its
release – fasting reduces it
 Effects
▪ May ameliorate insulin
resistance (in mice)
▪ Delays pancreatic/gastric
secretions/gastric
emptying/intestinal transit
Bloom SR. et.al. Nature 2006
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Hindgut theory-Glucagon Like Peptide– 1

GLP-1 “Enteroglucagon”
 Secreted by ileal “L-cells” in
(rapid) response to a meal
 Animal study Li et al.
demonstrated an increased in
GLP 1 levels in SG group
 Actions
▪ Potent stimulator of insulin /
supresses glucagon
▪ Slows gastric emptying
▪ Reduces appetite
▪ Increases beta cell mass
Wynne K. J Clin Endo Met, 2004
The Evidence-Diabetes
Remission post LSG
Systematic Review Remission of
Diabetes post Sleeve
Gastrectomy
Karmali S, Shi X, Sharma A.M., Birch D.W.
Methodology

Search strategy: Medline, Pubmed, Embase, Scopus, Dare,
Cochrane library, Clinical evidence, TRIP, HTA database;
meanwhile, conference abstracts, registered clinical trials
were also searched. Google was also used for grey or other
literature, such as clinical practice guidelines, government
documents.

Search terms: sleeve gastrectomy, or vertical gastrectomy, or
bariatric surgery, or metabolic surgery and diabetes, or
T2DM, or DM or comorbidities.

All human studies, not limited to English language, reported
from 2000 to April 2010 were included in our searching.
3,621 Citations Identified for Screening
3,332 Rejected (Met Exclusion Criteria)
289 Abstracts Reviewed
261 Rejected (Did Not Meet Inclusion Criteria
230 Wrong Publication Type (case report, <5 patients,
technique only, no outcomes measured, experts
opinions, animal models)
5 Wrong Population (not adult)
20 Wrong Intervention (sleeve gastrectomy combined
with other procedures)
6 Kin Relationship (substudies, duplicate patients)
28 Primary Studies Included
4 Nonrandomized Prospective
Controlled Trials
3 Retrospective Controlled
Trials
15 Prospective Case Series
6 Retrospective Case Series
Year
2010
2010
2010
2010
2010
2010
2009
2009
2009
2009
2009
2009
2009
2009
2009
2009
2009
2008
2008
2008
2008
2008
2008
2007
2007
2006
2005
2005
Nation
Netherlands
India
India
UK
Brazil
New Zealand
USA
USA
Italy
France
Isreal
UK
France
Chile
USA
India
India
Spain
Taiwan(rct)
USA
Australia
Czech
Japan
USA
Australia
USA
Italy
Korea
study
prospective
prospective
retrospective
prospective
non-R CT
prospective
retrospective
retrospective CT
retrospective CT
non-R CT
retrospective
prospective
prospective
prospective
prospective
retrospective
retrospective CT
non-R CT
prospective
prospective
prospective
prospective
prospective
retrospective
non-R CT
prospective
prospective
retrospective
pt#
20
53
23
34
32
25
30
53
20
33
18
18
14
39
23
7
39
20
13
33
17
6
14
21
75
17
8
Results-Demographics
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Total number of patients: 705
Mean BMI: 46.3 +/- 7.9 (31-53.5)
Mean Age: 47.3 +/- 3.8 (42-53)
Mean Follow-up: 13.0 +/- 8.1 months (3-36)
%EWL: 47.3 +/-19.1 (6.3-74.6)
Post-surgical BMI: 35.9 +/-6.6 (24.6-44.7)
Type 2 Diabetes Mellitus
Glucose Levels
HbA1C change
Bariatric Surgery Efficacy
3
1
|
Procedure
% EWL
T2DM
(Remission)
Gastric Banding
47% (n=1848)
48%
Sleeve Gastrectomy
47.3% (n=705)
66.5%
Gastric Bypass
62% (n=4204)
84%
BPD
70% (n=2480)
98%
Buchwald H. JAMA, 2004
Medium
Low
Efficacy
High
Diabetes Surgical Interventions (DSI)
Low
Medium
High
Technical Complexity
32 |
So Why choose Sleeve?
Sleeve vs. LAGB
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%EWL, Diabetes remission better with sleeve
No need for adjustments. No needles !!!
Removes Ghrelin Cell mass. Loss of appetite
Creates restriction more than obstruction
less follow up ?
SLEEVE VS. RYGB and BPD-DS
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%EWL and T2DM remission may not be as strong
BUT..
LSG is much technically less complex-wider
applicability to general surgeons
No risk of Internal Hernias
No/Less malabsorption – No/Less micronutrient
deficiency ?
Maintains oral access to GI and Biliary tract
Completely removes Ghrelin cell mass
No dumping
Does not interfere with immunosuppressant
Can always be upgraded to RYGBP or BPD-DS
SLEEVE WINS!!!!
Questions? Questions?