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++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ + + ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ SPECIAL SECTION: MINIMALLY INVASIVE PROCEDURES +++ +++ Laparoscopic SLEEVE GASTRECTOMY By John G. Zografakis, MD, FACS T HE INCREASING PREVALENCE of worldwide obesity poses a significant threat to public health. Bariatric surgery is widely recognized as the predominant treatment option for morbid obesity and its related co-morbidities. While patients and clinicians are aware of the benefits of laparoscopic gastric bypass (a combined restrictive and malabsorptive procedure), a newer procedure has emerged as the most effective restrictive procedure. Laparoscopic sleeve gastrectomy (LSG) is a restrictive weight loss procedure that limits the amount of food eaten and promotes early satiety. During this procedure, a narrow vertical sleeve of stomach is created and the rest of the stomach is removed. The remaining tubularized stomach is roughly 150 cubic centimeters (about the size of a banana). Since there is no malabsorptive component to this procedure, both normal digestion and absorption occurs. This allows for fewer vitamin and protein abnormalities. It also has advantages over hybrid restrictive/malabsorptive procedures (gastric bypass and duodenal switch), including less ulcerogenicity, malabsorption, hypoproteinemia, hypo- calcemia and dumping syndrome. While the mechanisms of action have not been completely evaluated, laparoscopic sleeve gastrectomy also induces an important reduction in plasma levels of ghrelin, an important mediator in the mechanism of satiety. After LSG, patients experience significant weight loss, often exceeding more than 60 percent of their excess body weight. Marked improvements in health co-morbidities have also been documented, including improvements in Type 2 Diabetes Mellitus (T2DM), hypertension, hyperlipidemia and obstructive sleep apnea. A recently published peer-reviewed clinical study showed significant health benefits were achieved by patients following sleeve gastrectomy: Co-Morbidity Type 2 Diabetes Mellitus Hypertension Hyperlipidemia Obstructive Sleep Apnea Remission Rate 81% 78% 73% 80% Remission/Improvement Rate 92% 85% 78% 87% The sleeve gastrectomy is an effective primary restrictive procedure, with a low conversion rate, and is technically feasible in both high-risk patients and super obese patients. It offers benefits over other available restrictive procedures now available, including the laparoscopic adjustable gastric band. Some of the advantages of LSG include: + No retained foreign body in the form of a band + No potential for erosion, slippage or prolapse + More effective weight loss over a 12-18 month period when compared to the band. This procedure is most frequently performed laparoscopically, using minimally invasive surgical techniques. With the recent implementation of Intuitive Surgical's da Vinci® Surgical System robotic platform for bariatric and general surgical procedures, the robotic-assisted laparoscopic sleeve gastrectomy is now possible and offers the advantages of excellent visualization for the surgeon, shorter hospital stay, faster recovery, smaller scars and less pain (compared to open surgical procedures). LSG patients are typically discharged on the first day after surgery. During the first year after surgery, they achieve a weight loss which is on par with that of gastric bypass patients. In addition, as with any weight-loss program, there is a need for a high-protein, low-calorie "diet for life," with an emphasis on vitamin and protein supplementation, along with incorporating a routine, dedicated exercise program. Surgery has become the most effective option in the management of morbid obesity and comorbid conditions. It provides excellent short- and long-term outcomes, a decrease in overall mortality and offers a marked survival advantage over more conservative efforts to lose weight. The sleeve gastrectomy is a safe surgical treatment option designed to effectively manage morbid obesity Dr. John Zografakis is board-certified in general surgery and fellowship-trained in advanced laparoscopic and bariatric surgery. He is affiliated with Summa Physicians Inc. and also is the director of the Bariatric Care Center at Summa Health System. ■ Reference Stacy A. Brethauer, MD, Jeffrey P. Hammel, MS. Philip R. Schauer, MD. Systematic review of sleeve gastrectomy as staging and primary bariatric procedure. Review article. Surgery for Obesity and Related Diseases, 5 (2009) 469 – 475. 42 | Cleveland-Akron-Canton MD NEWS n MDNEWS.COM n MARCH-APRIL 2012