http://www.gastroendonews.com/ViewA...ews&d_id=187&i=July+2015&i_id=1207&a_id=32937
ISSUE: JULY 2015 | VOLUME: 66:7
On the Spot: The State of Bariatrics in 2015
by Colleen Hutchinson
Although technology is offering new options to bariatric surgeons and their patients by way of new procedures and devices, it is a good time to take the pulse of these contributors on some general aspects of bariatrics that are still up for debate. Also, as we see more and more advances in genomics and genetic testing, the question arises: What do these advances potentially mean for the obese population? Although genetic testing is now being integrated into oncologic and other areas of patient care, it has not developed to the point where we can use it for personalized intervention for the obese patient. But when we can—and that time is coming—the possibilities are endless. Read on for some insights from this group of experts about genomics in bariatrics.
Don’t miss the new section on page 16 in which I take the contributors’ temperatures on some existing and forthcoming new techniques and procedures. There is quite a bit of variation among the responses.
P A R T I C I P A N T S
Robin Blackstone, MD, is medical director of Scottsdale Healthcare Bariatric Center, in Scottsdale, Ariz.
Wayne English, MD, is associate professor at Vanderbilt University Medical Center, in Nashville, Tenn. Disclosure: Research support from Obalon and Reshape Medical.
Michel Gagner, MD, is president of the Clinique de Michel Gagner, and professor of surgery at Hôpital du Sacre Coeur, in Montreal, Canada. Disclosure: Speaking honoraria from Boehringer Ingelheim, Covidien, Ethicon, Gore and Olympus; equity ownership in TransEnterix.
Shanu N. Kothari, MD, is director of minimally invasive bariatric surgery at Gundersen Health System, in La Crosse, Wisc. Disclosure: Serves as a preceptor for Torax Medical.
Marina Kurian, MD, is medical director of New York Minimally Invasive Surgery, and associate clinical professor of Surgery at NYU Langone Medical Center, in New York City. Disclosure: Receives honoraria as a speaker and proctor for Apollo Endosurgery.
Jaime Ponce, MD, is bariatric surgery medical director at Hamilton Medical Center, in Dalton, Ga., and Memorial Hospital, in Chattanooga, Tenn. Disclosure: Consultant for Apollo Endosurgery; receives research support from and is a consultant for Gore and Reshape Medical; receives research support from Obalon and USGI Medical; and serves as a speaker and consultant for ConMed and Olympus.
Raul Rosenthal, MD, is chief of staff and chairman of the Department of General Surgery; director of the Bariatric and Metabolic Institute at Cleveland Clinic Florida, in Weston; and professor of surgery at the Herbert Wertheim College of Medicine at Florida International University, in Miami.
Flavia C. Soto, MD, is a bariatric surgeon at the Weight Loss Center at Banner Health Gateway and Banner Estrella Medical Center, in Phoenix.
Natan Zundel, MD, is clinical professor of surgery and vice chairman, Department of Surgery at Herbert Wertheim College of Medicine, Florida International University, and medical director, Bariatric and Metabolic Institute at Jackson North Medical Center, in Miami. He is president of the International Federation for Obesity Surgery, Latin American chapter, for 2013-2015.
Statement:Single-anastomosis duodenal switch (DS) is a better surgical option for the bariatric surgery patient than classic DS.
Dr. Gagner: On the fence.
We need a randomized study comparing SADI [single-anastomosis duodeno-ileal bypass] and the classic DS, with a five-year follow-up. However, even if there is less weight loss, if there are fewer nutritional deficiencies and side effects, I think most surgeons and patients would go for it.
Dr. Blackstone: Disagree.
Our specialty has always been at the forefront of investigational techniques. The single-anastomosis DS may prove to be safe and effective, but there is very little data. Performing this procedure with institutional review board oversight and close and careful data collection (for instance, within the MBSAQIP [Metabolic and Bariatric Surgical Accreditation and Quality Improvement Program] registry) is essential to establish the safety record and begin to judge the effectiveness of the procedure. In addition, animal models need to be developed and studied so that the physiologic basis of the procedure can be ascertained.
Dr. English: On the fence.
I need more data to be convinced further, but I’m impressed with what little data are available to us at this time. As the data matures, single-anastomosis DS may very well emerge as a better option as patients experience similar weight loss with fewer side effects (decreased risk for malnutrition and electrolyte abnormalities, fewer bowel movements and fewer complaints of foul-smelling flatulence) compared with classic DS patients. Decreased incidence of bowel obstructions and internal hernia may be seen in single-anastomosis DS as well.
Dr. Soto: Disagree.
A combination of gastric reduction, sleeve simile, with a malabsorptive component, loop of ileum anastomosed to the sleeve, and transection of the duodenum preserving the pylorus attached to the sleeve—sounds charming based on the fact that there is only “one anastomosis” involved. But there are not enough data yet to sustain how successful this procedure can be in terms of morbidity and mortality and long-term weight loss. Time will tell!
Dr. Ponce: Agree.
At least [based] on the few studies available, maybe fewer complications with similar weight loss. We need more studies.
Dr. Kothari: Disagree—partly depends on the definition of “better.”
If “better” means less technically complex, then yes. But efficacy in a head-to-head comparison based on a high-level study, to my knowledge, has yet to be performed. With all bariatric operations, we must weigh the risks versus benefits. In general, the higher the perioperative risk of the bariatric procedure, the better the weight loss and percentage chance of comorbidity reduction. Currently, DS provides the most weight loss and reduction of diabetes, but at the added risk for severe protein malnutrition in a small percentage of patients, requiring limb lengthening. Where single-anastomosis DS falls in this spectrum of risk–benefit remains to be seen. I look forward to prospective studies currently being performed on this topic.
Dr. Rosenthal: Disagree.
Although the concept of a single-anastomosis malabsorptive procedure is attractive, there is no literature that compares both approaches to determine that this statement is valid.
Dr. Kurian: Agree.
So far, the data presented shows fewer perioperative complications and fewer long-term malnutrition complications compared with the DS. The improvements in comorbidities and excess weight loss also make it an attractive surgical option for selected patients.
Dr. Zundel: Disagree.
It seems that stomach intestinal pylorus-sparing surgery is a safe option. Overall results are not as good as the results of the classic DS, but has it been shown to be simpler? Fewer complications? It’s only been around for five years. We need more numbers and longer-term data to understand it better. Even some of the proponents of it still call it investigational.
Statement:Reflux is a contraindication for sleeve gastrectomy.
Dr. Gagner: Disagree—not at all, and in fact, it is the reverse.
This has been well demonstrated by the study of Morino et al published in Annals of Surgery (2014;260:909-914), where the GERD [gastroesophageal reflux disease] is greatly improved, de novo GERD is only 5% and the LES [lower esophageal sphincter] is unchanged. The study looked at a group of LSG [laparoscopic sleeve gastrectomy] with preoperative nanometry, 24-hour pH studies, endoscopy and questionnaire, all repeated two years later.
Dr. English: Agree!
Reflux should be considered a relative contraindication for LSG. Although data demonstrate low reflux rates after LSG, there are data showing reflux rates are indeed significant. I’m in favor of minimizing the risk of subjecting a patient to a potentially unnecessary second operation to correct severe intractable acid reflux after sleeve. You should consider a different surgical option in the symptomatic patient with reflux and documented reflux esophagitis, as I feel these patients have the highest risk for developing worsening symptoms after surgery. I recommend using pH testing liberally in patients who report reflux.
Dr. Zundel: Disagree.
A fair amount of morbidly obese patients have GERD (up to 35%-40%). But most have GERD related to the mechanical and physiologic changes related to obesity, so those patients will do well if they lose weight. My concern is the patients that have significant GERD. In my practice, if a patient wants LSG, but has a history of using proton pump inhibitors (PPIs) for long periods of time, and the need for upper endoscopy in the past, we order pH studies and manometry. If the reflux is really significant, we offer him or her LRYGB [laparoscopic Roux-en-Y gastric bypass] instead.
Dr. Kothari: On the fence.
Currently, I consider reflux a relative contraindication to sleeve. We still have much to learn about the impact of LSG on GERD. There is a percentage of patients who develop clinically significant GERD post-LSG who did not have it preoperatively. There is a percentage of patients with preoperative GERD who have symptomatic resolution post-LSG, and, perhaps most worrisome, there is a percentage who develop asymptomatic esophagitis post-LSG. The patient variables and technical factors that go into sleeve construction that result in varying percentage rates of these three categories warrant further study.
Statement:There is a standard sleeve gastrectomy technique.
Dr. Rosenthal: Disagree.
Obesity is a reason for GERD and increased prevalence of hiatal hernias. Weight loss and repair of hiatal hernias should resolve GERD. Depending on the DeMeester score of the patient, and the age and the degree of esophagitis, sleeve becomes a contraindication. Young patients with high DeMeester score and/or Barrett’s are certainly contraindications. In the elderly or critically ill, the aforementioned contraindications become relative. We should study patients before making decisions. The great majority of these patients complain of GERD and take PPIs, but [this] was never studied properly.
Dr. Kurian: On the fence.
I think patients with severe GERD should have a gastric bypass, whereas patients with mild GERD and small hiatal hernias can do well with sleeve. I always counsel my patients that the Achilles heel of the sleeve is GERD, and I find this helps stratify the patients who are symptomatically at greater risk. I obtain routine endoscopy and selective pH and manometry tests in prospective sleeve patients.
Dr. Ponce: Disagree.
Reflux can improve, especially if crural repair is done. Severe reflux with complications might be a contraindication for sleeve.
Dr. Soto: Agree!
A good assessment and diagnosis not only of GERD, but also of other hypomotility and dysmotility conditions prior to surgery, is key for a successful outcome after LSG. The sleeve gastrectomy is a high-pressure system that can exacerbate reflux. If there is a questionable diagnosis, a pH/manometry would obtain the answer (DeMeester score). For morbidly obese patients with reflux disease, the best option is the gastric bypass.
Dr. Blackstone: Disagree.
GERD spans a continuum of severity seemingly unrelated to the incidence of hiatal hernia. There is little data on how weight loss by itself affects GERD, but we all believe that it improves just from the decrease in intraabdominal pressure. Certainly GERD is a risk, but with the current technique, [it is] less than 25%. By the time GERD surfaces a patient has lost a substantial amount of weight and it can be controlled with a PPI [proton pump inhibitor]. This is a critical point of education for the patient and the primary care physicians to understand. If GERD develops, the patient will need endoscopic surveillance to detect development of Barrett’s. The incidence of Barrett’s after sleeve is not known.
Dr. Rosenthal: Agree.
In reality, no surgery can be reproduced identically regardless of the surgical field being considered. When it comes to bariatric surgery, LAGB [laparoscopic adjustable gastric banding] and LSG are the most reproducible or standardized.
Dr. Gagner: Agree.
We have done five consensus conferences defining how sleeve should be performed, and we have more standards than in gastric bypass, which has been around for more than 40 years.
Dr. Kurian: Disagree.
Everyone does it slightly different. There are new devices coming to market that may help standardize the sleeve, such as the Covidien GastriSail, ViSiGi 3D [Boehringer Ingelheim] or the Standard Clamp from Standard Bariatrics. These may help achieve standardization.
Dr. Soto: Agree.
There are several steps we need to respect and follow to achieve best outcomes, some of which are a bougie size not smaller than 32 Fr, first fire 2 to 6 cm from the pylorus, complete mobilization of the fundus, staple-line reinforcement to decrease bleeding, avoidance of the [gastroesophageal] junction in the last fire and use of the appropriate staple height.
Dr. English: Disagree!
While surgeons follow the same basic tenets for performing LSG, there are too many variables of the procedure to say there is a standard technique. Variation in any one of these may result in different outcomes. These variables include bougie size, exploration for hiatal hernia or not, fat pad dissection or not, distance from pylorus, hugging the bougie or not, staple height used, staple-line reinforcement (buttressing, oversewing, imbrication) or not, degree of lateral traction during transection, distance from gastroesophageal junction, leak test or not; if so, endoscopy or not, omentoplasty or not, specimen bag or not.
Dr. Blackstone: Disagree.
There is little or no standardization of any bariatric procedure. This is in part due to the surgeon’s individual technique (we practice an experiential “art”), but also because every patient has variations in the “material” of the tissue. So even using a standard scope or bougie may result in significant volume differences within the tube of the sleeve on distention due to patient variation.
Dr. Zundel: Totally disagree.
For the past two decades, I have been waiting for the standardization of gastric bypass. The question is do we know what a standard LSG looks like? Is it the one I do? (It is for me.) There is variation in technique among even the most experienced LSG surgeons today. Which is the variation that shows superior results and fewer complications, and is cost-effective and reproducible? That one we can call standard.
Dr. Ponce: Agree.
In my hands, there is now.
Dr. Kothari: Disagree.
Gastric bypass has been around decades longer than sleeve and we certainly don’t have a standard gastric bypass technique with regard to limb lengths, limb route or optimal choice of anastomotic construction to reduce complications and maximize results. That being said, there is pooled data showing a lower leak rate with sleeve gastrectomy when a bougie size of 40 or greater is used compared with less than 40 (Surg Endosc 2012;26:1509-1515). Use of buttress material has shown mixed results with regard to decreased bleeding from staple lines and staple-line leaks. Some have shown a reduction in these complications, and others have shown no effect.
Like or Dislike?
Contributor
Question 1:
Air-Filled Balloon
Dr. Rosenthal ‘Dislike’
Dr. Gagner ‘Like’
Dr. Zundel ‘On the fence’
Dr. Soto ‘Dislike’
Dr. Ponce ‘Like’
Dr. Blackstone ‘Like’
Dr. Kurian ‘Dislike’
Dr. English ‘Like’
Dr. Kothari ‘Dislike’
Gut Reaction: Clinical Bariatric
Contributor
Question 1:
Role of Gastric Banding: Obsolete
Dr. Rosenthal ‘Not true’
Dr. Zundel ‘Today it’s the only approved procedure for low BMI.’
Dr. Gagner ‘Yes’
Dr. Soto ‘No, still an option for the right candidates’
Dr. Ponce ‘Still an option for some patients’
Dr. Blackstone ‘I have not done this as a primary procedure since 2011.’
Dr. Kurian ‘Suitable for certain patients’
Dr. English ‘Perhaps soon, but should remain a treatment option’
Dr. Kothari ‘The defense rests.’
BMI, body mass index; DS, duodenal switch; IBD, inflammatory bowel disease; LSG, laparoscopic sleeve gastrectomy; STAMPEDE, Surgical Therapy and Medications Potentially Eradicate Diabetes Efficiently
ISSUE: JULY 2015 | VOLUME: 66:7
On the Spot: The State of Bariatrics in 2015
by Colleen Hutchinson
Although technology is offering new options to bariatric surgeons and their patients by way of new procedures and devices, it is a good time to take the pulse of these contributors on some general aspects of bariatrics that are still up for debate. Also, as we see more and more advances in genomics and genetic testing, the question arises: What do these advances potentially mean for the obese population? Although genetic testing is now being integrated into oncologic and other areas of patient care, it has not developed to the point where we can use it for personalized intervention for the obese patient. But when we can—and that time is coming—the possibilities are endless. Read on for some insights from this group of experts about genomics in bariatrics.
Don’t miss the new section on page 16 in which I take the contributors’ temperatures on some existing and forthcoming new techniques and procedures. There is quite a bit of variation among the responses.
P A R T I C I P A N T S
Statement:Single-anastomosis duodenal switch (DS) is a better surgical option for the bariatric surgery patient than classic DS.
Dr. Gagner: On the fence.
We need a randomized study comparing SADI [single-anastomosis duodeno-ileal bypass] and the classic DS, with a five-year follow-up. However, even if there is less weight loss, if there are fewer nutritional deficiencies and side effects, I think most surgeons and patients would go for it.
Dr. Blackstone: Disagree.
Our specialty has always been at the forefront of investigational techniques. The single-anastomosis DS may prove to be safe and effective, but there is very little data. Performing this procedure with institutional review board oversight and close and careful data collection (for instance, within the MBSAQIP [Metabolic and Bariatric Surgical Accreditation and Quality Improvement Program] registry) is essential to establish the safety record and begin to judge the effectiveness of the procedure. In addition, animal models need to be developed and studied so that the physiologic basis of the procedure can be ascertained.
Dr. English: On the fence.
I need more data to be convinced further, but I’m impressed with what little data are available to us at this time. As the data matures, single-anastomosis DS may very well emerge as a better option as patients experience similar weight loss with fewer side effects (decreased risk for malnutrition and electrolyte abnormalities, fewer bowel movements and fewer complaints of foul-smelling flatulence) compared with classic DS patients. Decreased incidence of bowel obstructions and internal hernia may be seen in single-anastomosis DS as well.
Dr. Soto: Disagree.
A combination of gastric reduction, sleeve simile, with a malabsorptive component, loop of ileum anastomosed to the sleeve, and transection of the duodenum preserving the pylorus attached to the sleeve—sounds charming based on the fact that there is only “one anastomosis” involved. But there are not enough data yet to sustain how successful this procedure can be in terms of morbidity and mortality and long-term weight loss. Time will tell!
Dr. Ponce: Agree.
At least [based] on the few studies available, maybe fewer complications with similar weight loss. We need more studies.
Dr. Kothari: Disagree—partly depends on the definition of “better.”
If “better” means less technically complex, then yes. But efficacy in a head-to-head comparison based on a high-level study, to my knowledge, has yet to be performed. With all bariatric operations, we must weigh the risks versus benefits. In general, the higher the perioperative risk of the bariatric procedure, the better the weight loss and percentage chance of comorbidity reduction. Currently, DS provides the most weight loss and reduction of diabetes, but at the added risk for severe protein malnutrition in a small percentage of patients, requiring limb lengthening. Where single-anastomosis DS falls in this spectrum of risk–benefit remains to be seen. I look forward to prospective studies currently being performed on this topic.
Dr. Rosenthal: Disagree.
Although the concept of a single-anastomosis malabsorptive procedure is attractive, there is no literature that compares both approaches to determine that this statement is valid.
Dr. Kurian: Agree.
So far, the data presented shows fewer perioperative complications and fewer long-term malnutrition complications compared with the DS. The improvements in comorbidities and excess weight loss also make it an attractive surgical option for selected patients.
Dr. Zundel: Disagree.
It seems that stomach intestinal pylorus-sparing surgery is a safe option. Overall results are not as good as the results of the classic DS, but has it been shown to be simpler? Fewer complications? It’s only been around for five years. We need more numbers and longer-term data to understand it better. Even some of the proponents of it still call it investigational.
Statement:Reflux is a contraindication for sleeve gastrectomy.
Dr. Gagner: Disagree—not at all, and in fact, it is the reverse.
This has been well demonstrated by the study of Morino et al published in Annals of Surgery (2014;260:909-914), where the GERD [gastroesophageal reflux disease] is greatly improved, de novo GERD is only 5% and the LES [lower esophageal sphincter] is unchanged. The study looked at a group of LSG [laparoscopic sleeve gastrectomy] with preoperative nanometry, 24-hour pH studies, endoscopy and questionnaire, all repeated two years later.
Dr. English: Agree!
Reflux should be considered a relative contraindication for LSG. Although data demonstrate low reflux rates after LSG, there are data showing reflux rates are indeed significant. I’m in favor of minimizing the risk of subjecting a patient to a potentially unnecessary second operation to correct severe intractable acid reflux after sleeve. You should consider a different surgical option in the symptomatic patient with reflux and documented reflux esophagitis, as I feel these patients have the highest risk for developing worsening symptoms after surgery. I recommend using pH testing liberally in patients who report reflux.
Dr. Zundel: Disagree.
A fair amount of morbidly obese patients have GERD (up to 35%-40%). But most have GERD related to the mechanical and physiologic changes related to obesity, so those patients will do well if they lose weight. My concern is the patients that have significant GERD. In my practice, if a patient wants LSG, but has a history of using proton pump inhibitors (PPIs) for long periods of time, and the need for upper endoscopy in the past, we order pH studies and manometry. If the reflux is really significant, we offer him or her LRYGB [laparoscopic Roux-en-Y gastric bypass] instead.
Dr. Kothari: On the fence.
Currently, I consider reflux a relative contraindication to sleeve. We still have much to learn about the impact of LSG on GERD. There is a percentage of patients who develop clinically significant GERD post-LSG who did not have it preoperatively. There is a percentage of patients with preoperative GERD who have symptomatic resolution post-LSG, and, perhaps most worrisome, there is a percentage who develop asymptomatic esophagitis post-LSG. The patient variables and technical factors that go into sleeve construction that result in varying percentage rates of these three categories warrant further study.
Statement:There is a standard sleeve gastrectomy technique.
Dr. Rosenthal: Disagree.
Obesity is a reason for GERD and increased prevalence of hiatal hernias. Weight loss and repair of hiatal hernias should resolve GERD. Depending on the DeMeester score of the patient, and the age and the degree of esophagitis, sleeve becomes a contraindication. Young patients with high DeMeester score and/or Barrett’s are certainly contraindications. In the elderly or critically ill, the aforementioned contraindications become relative. We should study patients before making decisions. The great majority of these patients complain of GERD and take PPIs, but [this] was never studied properly.
Dr. Kurian: On the fence.
I think patients with severe GERD should have a gastric bypass, whereas patients with mild GERD and small hiatal hernias can do well with sleeve. I always counsel my patients that the Achilles heel of the sleeve is GERD, and I find this helps stratify the patients who are symptomatically at greater risk. I obtain routine endoscopy and selective pH and manometry tests in prospective sleeve patients.
Dr. Ponce: Disagree.
Reflux can improve, especially if crural repair is done. Severe reflux with complications might be a contraindication for sleeve.
Dr. Soto: Agree!
A good assessment and diagnosis not only of GERD, but also of other hypomotility and dysmotility conditions prior to surgery, is key for a successful outcome after LSG. The sleeve gastrectomy is a high-pressure system that can exacerbate reflux. If there is a questionable diagnosis, a pH/manometry would obtain the answer (DeMeester score). For morbidly obese patients with reflux disease, the best option is the gastric bypass.
Dr. Blackstone: Disagree.
GERD spans a continuum of severity seemingly unrelated to the incidence of hiatal hernia. There is little data on how weight loss by itself affects GERD, but we all believe that it improves just from the decrease in intraabdominal pressure. Certainly GERD is a risk, but with the current technique, [it is] less than 25%. By the time GERD surfaces a patient has lost a substantial amount of weight and it can be controlled with a PPI [proton pump inhibitor]. This is a critical point of education for the patient and the primary care physicians to understand. If GERD develops, the patient will need endoscopic surveillance to detect development of Barrett’s. The incidence of Barrett’s after sleeve is not known.
Dr. Rosenthal: Agree.
In reality, no surgery can be reproduced identically regardless of the surgical field being considered. When it comes to bariatric surgery, LAGB [laparoscopic adjustable gastric banding] and LSG are the most reproducible or standardized.
Dr. Gagner: Agree.
We have done five consensus conferences defining how sleeve should be performed, and we have more standards than in gastric bypass, which has been around for more than 40 years.
Dr. Kurian: Disagree.
Everyone does it slightly different. There are new devices coming to market that may help standardize the sleeve, such as the Covidien GastriSail, ViSiGi 3D [Boehringer Ingelheim] or the Standard Clamp from Standard Bariatrics. These may help achieve standardization.
Dr. Soto: Agree.
There are several steps we need to respect and follow to achieve best outcomes, some of which are a bougie size not smaller than 32 Fr, first fire 2 to 6 cm from the pylorus, complete mobilization of the fundus, staple-line reinforcement to decrease bleeding, avoidance of the [gastroesophageal] junction in the last fire and use of the appropriate staple height.
Dr. English: Disagree!
While surgeons follow the same basic tenets for performing LSG, there are too many variables of the procedure to say there is a standard technique. Variation in any one of these may result in different outcomes. These variables include bougie size, exploration for hiatal hernia or not, fat pad dissection or not, distance from pylorus, hugging the bougie or not, staple height used, staple-line reinforcement (buttressing, oversewing, imbrication) or not, degree of lateral traction during transection, distance from gastroesophageal junction, leak test or not; if so, endoscopy or not, omentoplasty or not, specimen bag or not.
Dr. Blackstone: Disagree.
There is little or no standardization of any bariatric procedure. This is in part due to the surgeon’s individual technique (we practice an experiential “art”), but also because every patient has variations in the “material” of the tissue. So even using a standard scope or bougie may result in significant volume differences within the tube of the sleeve on distention due to patient variation.
Dr. Zundel: Totally disagree.
For the past two decades, I have been waiting for the standardization of gastric bypass. The question is do we know what a standard LSG looks like? Is it the one I do? (It is for me.) There is variation in technique among even the most experienced LSG surgeons today. Which is the variation that shows superior results and fewer complications, and is cost-effective and reproducible? That one we can call standard.
Dr. Ponce: Agree.
In my hands, there is now.
Dr. Kothari: Disagree.
Gastric bypass has been around decades longer than sleeve and we certainly don’t have a standard gastric bypass technique with regard to limb lengths, limb route or optimal choice of anastomotic construction to reduce complications and maximize results. That being said, there is pooled data showing a lower leak rate with sleeve gastrectomy when a bougie size of 40 or greater is used compared with less than 40 (Surg Endosc 2012;26:1509-1515). Use of buttress material has shown mixed results with regard to decreased bleeding from staple lines and staple-line leaks. Some have shown a reduction in these complications, and others have shown no effect.
Like or Dislike?
Contributor
Question 1:
Air-Filled Balloon
Dr. Rosenthal ‘Dislike’
Dr. Gagner ‘Like’
Dr. Zundel ‘On the fence’
Dr. Soto ‘Dislike’
Dr. Ponce ‘Like’
Dr. Blackstone ‘Like’
Dr. Kurian ‘Dislike’
Dr. English ‘Like’
Dr. Kothari ‘Dislike’
Gut Reaction: Clinical Bariatric
Contributor
Question 1:
Role of Gastric Banding: Obsolete
Dr. Rosenthal ‘Not true’
Dr. Zundel ‘Today it’s the only approved procedure for low BMI.’
Dr. Gagner ‘Yes’
Dr. Soto ‘No, still an option for the right candidates’
Dr. Ponce ‘Still an option for some patients’
Dr. Blackstone ‘I have not done this as a primary procedure since 2011.’
Dr. Kurian ‘Suitable for certain patients’
Dr. English ‘Perhaps soon, but should remain a treatment option’
Dr. Kothari ‘The defense rests.’
BMI, body mass index; DS, duodenal switch; IBD, inflammatory bowel disease; LSG, laparoscopic sleeve gastrectomy; STAMPEDE, Surgical Therapy and Medications Potentially Eradicate Diabetes Efficiently
