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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1116_Библиотеки_им_академика_М_И_Перельмана.pdf
Banded Sleeves
Fig. 4 Banded sleeve
253
that include a bariatric physician, bariatric surgeon, pulmonologist, cardiologist,
anaesthesiologist, and as indicated by other consultants. Bariatric Physician sees
the patient initially and obtains a detailed history and does an examination with
emphasis on determining any risk factors and comorbid conditions usually associated with obesity such as diabetes, hypertension, sleep apnea, osteoarthritis,
liver disorders, bleeding disorders, polycystic ovarian disease, Gastroesophageal
reflux disease (GERD) and other social, physical, psychological and economic
problems. Preoperative laboratory investigations include but are not limited to
complete blood count, blood tests that include electrolytes, urea, glucose, and calcium levels. Liver function tests, including Bilirubin, protein, Albumin is routinely
determined. Lipid Profile, thyroid profile, HbA-1c, C-peptide, serology-HIV, and
Hepatitis B and C tests are done. Radiological investigations include chest x-rays,
abdominal CT scan, and Ultrasound. Electrocardiography, echocardiography, pulmonary function tests and arterial blood gas are routinely done. All the investigations are reviewed by the surgeon and/or a member of the multi-disciplinary team
to make sure the patient is a safe and good candidate for surgery.
Once the patient and the surgeon have decided on the operation to be done,
the patient consents for surgery. Consent is also obtained from all patients to use
their redacted information for analysis, presentation, and publications as needed.
Patients are admitted the day before surgery and are kept on a clear liquid diet
and then NPO for at least six hours before the operation. All patients get a dose
of prophylactic antibiotics preoperatively. Compression devices are used during the
operation. Ambulation is initiated within four hours of return of the patient from
surgery. All patients get low molecular weight heparin prophylaxis for 24 hour or
until the patient is ambulating frequently. In high risks patients, this prophylaxis
is continued for six weeks. Patients are started on sips of water 4 hours after the
M. Bhandari254
surgery and advanced to a liquid diet the following day if vital parameters are normal. Patients are usually discharged on the third postoperative day with instructions
on how to advance their diet. All patients are placed on proton pump inhibitors for
six months. Vitamins and other mineral supplements are prescribed for life long
use. Patients are seen at three months, six months, twelve months, and yearly thereafter. Nutritional counseling is done and evaluation of the quality of life and blood
chemistries are monitored at six months, 12 months, and yearly thereafter.
4 Results
We have performed a total of 1121 BSG. We have six-year follow up comparative data of BSG v LSG for 68 and 152 patients respectively [14]. The groups
were extremely well-matched at baseline for all relevant characteristics. Both
groups experienced major, durable weight loss throughout 6 years, with significant
changes from baseline. While in BSG nadir weight was achieved at 3 years, in
LSG nadir it was at 1 year and patients have gradually started gaining weight from
thereafter (Table 1). Maximum %EWL achieved was 90% at 3 years in BSG from
there on plateaued and %EWL at the end of 6 years in 82.25% whereas in LSG
maximum % EWL was at 1 year, plateaued for a year and from 2nd-year patients
started regaining weight and at the end of 6 years, %EWL was 50.25%. There is
a total of 32% difference in %EWL in BSG v LSG at 6 years (Table 2). Follow
up was 70.5% and 64.4% IN BSG AND LSG respectively (Table 3). Failure rate
which is defined as % EWL less than 50% at 3 years is 11.1% and 0% and at
6 years is 46.9% and 0% in LSG and BSG respectively (Table 4). Resolution of
diabetes was 75.7 and 58%, Hypertension was 64% and 49.1%, OSA was 80%
and 55% respectively in BSG and LSG.
Resolution of type 2 diabetes, defined as normal fasting blood glucose levels
(≤110 mg/dL), HbA1C levels below 6.5 mmol/L and no longer taking type 2 diabetes medications [18].
Remission of hypertension can be defined as systolic and diastolic blood pressure <140 mm Hg and 90 mm Hg, respectively, without any medications based on
blood pressure monitoring unit [19].
There is no major difference in nutrient deficiencies in both groups. During our
5-year follow-up, no BSG patient underwent any additional operations, whereas
19 SG patients had elective revisional bariatric procedures (3 at 3 yr, 16 at 4 yr),
for inadequate weight loss or weight regain. These failed SG operations were converted to 11 banded gastric bypasses, 6 one-anastomosis gastric bypasses, and 2
repeat SGs.
5 Band Complications
Of the total 1121 BSG performed at our center band complications were seen in
26(2.3%) patients.
Banded Sleeves
255
yr
06 M 1 yr 2 yr 3 yr 4 yr 5 yr
Weight loss outcome
BSG 95.24 ± 12.71 4.84 ± 11.27 76.88 ± 10.28 75.15 ± 10.26 8.3 ± 10.14 79.5 ± 11.01 80.48 ± 10.85
Table 1 Weight loss outcome in BSG vs LSG at 6 years
LSG 89.49 ± 14.14 81.75 ± 12.70 82.12 ± 13.05 4.15 ± 13.89 8.58 ± 14.75 92.22 ± 16.17 95.23 ± 15.87
M. Bhandari256
yr
06 M 1 yr 2 yr 3 yr 4 yr 5 yr
% EBWL loss outcome
Table 2 % EBWL loss outcome in BSG vs LSG at 6 years
BSG 5.47 ± 5.64 4.17 ± 7.21 88.09 ± 8.06 90.57 ± 8.11 5.33 ± 7.38 3.20 ± 8.57 2.25 ± 8.49
LSG 57.46 ± 5.152 3.68 ± 9.43 3.18 ± 15.64 8.48 ± 20.07 8.58 ± 16.36 52.98 ± 16.59 50.25 ± 18.92
Banded Sleeves
Table 3 Follow up data (BSG vs LSG)
Follow up data # and % F/U
06 M 1 yr yr yr yr 5 yr
BSG (68) 68 (100%) 66
SG (152) 152
(100%)
Table 4 Failure rate at 3 and 6 years (BSG vs LSG)
Three years Six years
Less than
50%
BSG (0) 0% (2) 3.5% (56) 96.5% (0) 0% (4) 8.3% (44) 91.7%
SG (15)11.1% (66)47.4% (53)39.5% (46)46.9% (46)46.9% (9)9.1%
(97.0%)
48
(97.3%)
50–75% Above75% Less than
3 (92.6%) 8 (85.2%) 54
142
(93.4%)
34 (88.1) 111
(79.4%)0 (73.5%)
(73.0%)
50%
102
(67.1%)
50–75%
yr
46
(70.5%)
98
(64.4%)
Above75%
These are grouped as.
1. Band erosion—5 (19.23%)
2. Band slippage—4 (15.38)
3. Stricture—16 (61.5%)
4. Food intolerance—1 (3.8%).
257
Of the 5 people with band erosion all of them were removed endoscopically and
in four patients with band slippage laparoscopic band removal was done. Of sixteen patients with stricture in six band removal was done and converted to gastric
bypass, in eight patients laparoscopic band removal was done and in two patients
laparoscopic band removal with endoscopic dilatation was done. One patient who
had food intolerance issues had the band removed laparoscopically.
6 Weight Loss and Complications After Banded Sleeve
in Other Studied and Comparative Analysis
We have compared this data in terms of excess weight loss and a total percentage
of weight loss with other existent studies. At 6 years, the cohort of patients operated at our centre had percentage excess weight loss. The total percentage weight
loss at 6 years for the banded group was 82.25 and 50.25% for the non-banded
group.
Failure rate which is defined as % EWL less than 50% at 3 years is 11.1% and
0% and at 6 years is 46.9% and 0% in LSG and BSG respectively.
The banded sleeve group maintained much better weight loss which increased
progressively from 3 until 5 years.
M. Bhandari258
In the series on banded sleeve published by Luc Lemmens et al., %EWL at
5 years was 57.8 ± 25 and 86.7 ± 11.9 in the non-banded group and BLSG, respec-
tively [13].
These results show that in the non-banded group, 35.2% of the patients
have < 50%EWL at the 5 years follow-up, whereas none of the banded sleeves
treated patients had < 50%EWL.
In a series published by Jodok Fink et al., he has reported better weight loss by
Banded sleeve [20].
Total weight loss in their series was equal in the early follow-up but significantly better in BSG, 3 and 5 years after surgery (BSG versus SG at 3 yr
38.7% ± 7.8, n = 33 versus 31.9 ± 10.7, n = 33, P = 0.002; BSG versus SG at 5 yr
37.6% ± 8.5, n = 27 versus 29.5 ± 12.9, n = 23, P = 0.008).
We have reported band complications of 2.3%, whereas Lemmens et al.
reported band-related complications of 4.1% which required band removal or
readjusting.
7 Conclusions
The banded sleeve is a safe and feasible procedure. Considering the excellent
weight loss maintenance results seen after the banded sleeve procedure, banding
of the sleeve makes sense. We need long term data from multiple institutions on
complications from the banded sleeve and its efficacy.
A randomised control trial between banded and non-banded sleeves with long
term results will be the key to answers we sought regarding the efficacy and complications of banded sleeve.
References
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259
Buttressing the Sleeve
Safwan Taha
1 Introduction
Ever since staplers were introduced to the gastrointestinal tract surgery arsenal,
a vigilant search was started for techniques and\or gadgets that increased their
safety [1, 2]. Buttressing the staple line was one of those techniques that drew
particular attention from bariatric surgeons who implemented it late in the last
century and published data about it in the early 2000s, starting with laparoscopic
Roux-en-Y gastric Bypass (RYGB) [3, 4] and, eventually, laparoscopic sleeve gastrectomy (LSG) [5–7] with special emphasis on its two most feared inherent complications; bleeding [8, 9] and leak [10–12].
Staple line leak post LSG is a potentially serious complication that has been
reported in 1.5–3% of cases [13]. It can result in grave morbidities, and even mortality, if not promptly recognized and properly managed [14].
The main cause of staple line leak following LSG is the markedly increased
intraluminal pressure in the sleeve tube beyond the ability of the staples to hold the
integrity of the staple line (also known as burst pressure), resulting in disruption
of the staple line and, consequently, leak. This phenomenon was clearly described
in several publications that also tested it under controlled environments on animal
models both with and without buttressing materials. Most of those studies reported
a significantly higher burst pressure for tissues that were reinforced with buttressing material [15–17], (Fig. 1). It is believed that buttressing achieves this result
through distributing the tension across a wider surface area of the gastric edge,
S. Taha (*)
Consultant Metabolic and Bariatric Surgeon, Mediclinic Airport Road Hospital,
Abu Dhabi, UAE
e-mail: Safwan.Taha@Mediclinic.ae
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer
Nature Switzerland AG 2021
S. Al-Sabah et al. (eds.), Laparoscopic Sleeve Gastrectomy,
https://doi.org/10.1007/978-3-030-57373-7_28
261
Fig. 1 Burst pressure increases significantly with buttressing
S. Taha262
Fig. 2 The ideal “B” configuration of the staple
Buttressing the Sleeve
263
increasing the burst pressure of the staple line beyond that of the gastric body
itself in the process [18].
2 Technical Aspects
Technical aspects of the procedure also play a decisive role to its outcome especially when it comes to post-operative leak. Of particular relevance of all those
factors is choosing the appropriate staple height that corresponds to the thickness
of the part of stomach to be stapled (Table 1), which is why all manufacturers provide their recommendations for the staple height that is most suitable for deployment on the specific parts of stomach in relation to its tissue thickness [17]. More
attention should be paid to this point when the surgeon chooses to use a buttressing material, since the latter increases the thickness of the tissue to be buttressed,
adding twice the thickness of the buttressing layer to the original tissue thickness, with a possible upgrade of the staple height, to make sure that the staples
will go through all the four layers, 2 tissue and 2 buttressing, and deploy properly forming the ideal, complete “B” configuration [18–21] (Fig. 2). As examples, the bovine pericardial strip (Peri-Strips, Synovis Surgical Innovations) adds
a total thickness of 0.8 mm, the absorbable synthetic Polyglycolide/Trimethylene
Table 1 Summary statistics for gastric tissue thickness
Antrum thickness
(mm)
Female (N = 15)
Mean + SU 3.09 ± 062 2.64 ± 0.60 I.72 ± 0.59
MeantSD (Elariny) 3.09 ± 0.553 2.34 ± 0349 1.61 ± 0279
Min 2.00 2.00 1.05
Max 407 4 00 2.83
Quartile 1–25th % 2.63 2.23 1.32
Quartile 2–50th % 3.10 2,50 1.50
Quartile 2–75th % 3.53 2.88 2.03
Male (N = 11)
MeantSD 3.I2 ± 0.8I 2.57 ± 0.42 I.67 ± 0.32
MeantSD (Elanny) 3.17 ± 0.324 2.6 ± 0.391 1 81 ± 0453
Min 2.45 2.12 1.24
Max 5.39 3.46 2.28
Quartile 1–25th % 2.72 2.29 1.37
Quartile 2–50th % 2.92 2.45 1.65
Quartile 2–75th % 3.21 2.82 1.85
SD standard deviation
Midbudy tluckness
(mm)
Fundus thickness
(mm)