Sunday, May 10, 2009

The Sleeve

I have attended a Master Course of Laparoscopic Sleeve Gastrectomy held in Boston on May 8, 2009. Dr. Raul Rosenthal (Cleveland Clinic, Weston, Florida) directed the course. My goal was to interact with colleagues who perform the same, and to get a sense of what’s new.

Sleeve gastrectomy is a weight loss (bariatric) procedure that removes 60-80% of the stomach (that bag-like part), leaving behind a tube-like stomach.

A Short History: Sleeve gastrectomy has been the first part of the more extensive bariatric surgical operation named “Biliopancreatic bypass with Duodenal Switch”, or, in short, the Duodenal Switch. Sometimes, in super super obese patients, the sleeve was performed as a first step, allowing patients to lose weight and be under less risk to perform the second step, that is, the switch. As a matter of principle, a second surgery is not as easy as a first operation. An exception is when the first operation is not easy, either, because of severe obesity, in which case, weight reduction may actually make a second stage relatively easier, but not exactly a piece of cake. Well, some patients did not follow through, and stayed content with the first step. Noticing that a good number of those patients achieved health benefits from the sleeve alone , the concept of accepting the “sleeve gastrectomy” as a stand-alone, or a “final” operation arose. Even though it is now an accepted “final” procedure, it can be later followed by a gastric bypass, for example, to achieve more weight loss, or stop weight regain.

Technical points: These were presented by Dr. Rosenthal and Dr. Nathan Zundel of Florida International University School of Medicine. The technique of “sleeve gastrectomy” as a “final” procedure evolved from its predecessor, the “step” procedure aiming at achieving more weight loss, and, hopefully, more durable, weight loss. The following technical points remain today, as they have been in the past, controversial.

Distance of starting dividing the stomach, as measured from the pylorus: There is a tendency to accept 5-6 cm among surgeons in the meeting. There is, however, a school that goes as little as 2 cm.

Size of the bougie: The tube (sleeve) is fashioned by dividing the stomach while a bougie is in place. Smaller-diameter bougies replaced the large ones used for the step procedure. The course surgeons used sizes 34-38. There is a school of surgeons that goes as tight as size 32. Notice that one point in that system equals only 0.3 mm. It is quite possible that, due to other fine differences in the technique of dividing the stomach, the actual final product of the surgeons who use 32 is not too different from those who use size 34. In other words, the size of the bougie is not the only determining factor of the final size, when we are talking in terms of less than a millimeter difference.

To buttress or not to buttress: Reinforcing the staple line has been performed by the presenters. The presenters used over-sewing (suturing), rather than buttressing strips. This is a matter of a surgeon’s preference, though.

Outcomes of Sleeve Gastrectomy as a final step: The quoted weight loss was 67-68% of the excess weight in 2 years. This is more than the average for an adjustable laparoscopic gastric band (example: Lap Band), but a little bit less than a gastric bypass. Resolution or improvement of comorbidities was comparable to gastric bypass in the short term. Again, we do not have long-term results.

Complications: No surgery is free from complications. The quoted incidences were leak, abscess, hemorrhage, and stricture in 0.3% each. This compares favorably to other weight loss surgical procedures.

Notice that the risks include a leak, which is rare, but can cause a long stay in the hospital. A leak is also a risk with gastric bypass. How about Lap Bands? The risk is less, but not zero. A leak can arise when a Band causes erosion (that is, cuts through or erodes through the stomach wall), and therefore needs to be removed, which potentially leaves a hole in the stomach that needs to be repaired.

For Prospective Patients: Dr. Matthew Hutter of Massachusetts General Hospital highlighted the importance of informing prospective patients that the Sleeve Gastrectomy as a final procedure is a newer approach and that we are still learning about it. We have limited experience, and there is very limited information as to the long term results. He also stressed that right now, experience is greater than what is published in the literature.

Insurance coverage: Unfortunately, access to this operation is very limited because most insurance companies still consider this as an investigational procedure. It is becoming more and more a favorite among cash paying patients, though. Insurance may pay, after a time-consuming process, if a convincing case can be made, that the other options are contraindicated or are bad choices for a particular patient who needs bariatric surgery.

Cash-paying patients are to be reminded, though, that, if an insurance company does not approve their procedure, it is very unlikely to cover for complications, and the costs of complications from any type of surgery can be staggering. Discuss that with your doctor and see what arrangements may exist, if any. This is sad, because most insurance companies would pay for treating diseases and injuries that may be caused by certain choices (for example, smoking, ovreating, etc.), but not when a patient does the responsible thing and takes charge of their health and chooses the best available treatment for obesity, and pay for it out of -pocket. Oh, I guess I deviated from the main topic.