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Laparoscopic Sleeve Gastrectomy

An Online Continuing Education ActivitySponsored By

Grant Funds Provided By

Welcome to

Laparoscopic Sleeve Gastrectomy

(An Online Continuing Education Activity)

CONTINUING EDUCATION INSTRUCTIONSThis educational activity is being offered online and may be completed at any time. Steps for Successful Course CompletionTo earn continuing education credit, the participant must complete the following steps:

1. Read the overview and objectives to ensure consistency with your own learning needs and objectives. At the end of the activity, you will be assessed on the attainment of each objective.

2. Review the content of the activity, paying particular attention to those areas that reflect the objectives.

3. Complete the Test Questions. Missed questions will offer the opportunity to re-read the question and answer choices. You may also revisit relevant content.

4. For additional information on an issue or topic, consult the references.5. To receive credit for this activity complete the evaluation and registration form. 6. A certificate of completion will be available for you to print at the conclusion.

Pfiedler Enterprises will maintain a record of your continuing education credits and provide verification, if necessary, for 7 years. Requests for certificates must be submitted in writing by the learner.

If you have any questions, please call: 720-748-6144.

CONTACT INFORMATION:

© 2015All rights reserved

Pfiedler Enterprises, 2101 S. Blackhawk Street, Suite 220, Aurora, Colorado 80014www.pfiedlerenterprises.com Phone: 720-748-6144 Fax: 720-748-6196

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OVERVIEWIn the United States, nearly one third of the adult population is obese. Worldwide, 13% of the adult population was obese in 2014 and 39% of adults aged 18 years and older were overweight.1 Being overweight is also a major risk factor for a multitude of non-communicable diseases such as cardiovascular disease, type 2 diabetes, joint pain, and some types of cancer as well as many others. The number of people who are affected by obesity continues to escalate although obesity is preventable. While there are many ways for a person to achieve safe and effective weight loss, surgical intervention has proven over the years to be the best hope for weight loss in the extremely obese that is both substantial and sustainable and also offers increased co-morbidity resolution. In this study guide we will learn about Laparoscopic Sleeve Gastrectomy (LSG) and its recent emergence as the procedure of choice in bariatric surgery. In order to fully understand the importance and relevance of LSG, we will review gastric anatomy and bariatric surgery; review recommended ASMBS guidelines; and discuss the background of LSG and studies validating the procedure including the risks and benefits.

OBJECTIVESUpon completion of this self-study activity, the participant should be able to:

1. Review Gastric Anatomy.2. Discuss recommended guidelines from the ASMBS (American Society for Metabolic

and Bariatric Surgery).3. Describe the background of Laparoscopic Sleeve Gastrectomy (LSG) and studies

validating the procedure. 4. Discuss the LSG procedure and instrumentation used in the procedure.5. Identify the patient risks and benefits associated with LSG.

INTENDED AUDIENCEThis self-study activity is intended for the perioperative nurse and surgical technologists who are interested in learning more about laparoscopic sleeve gastrectomy procedures and the benefits for the surgical patient.

CREDIT/CREDIT INFORMATION State Board Approval for Nurses Pfiedler Enterprises is a provider approved by the California Board of Registered Nursing, Provider Number CEP14944, for 1.0 contact hours.

Obtaining full credit for this offering depends upon attendance, regardless of circumstances, from beginning to end. Licensees must provide their license numbers for record keeping purposes.

The certificate of course completion issued at the conclusion of this course must be retained in the participant’s records for at least four (4) years as proof of attendance.

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IACETPfiedler Enterprises has been accredited as an Authorized Provider by the International Association for Continuing Education and Training (IACET).

CEU Statements• As an IACET Authorized Provider, Pfiedler Enterprises offers CEUs for its programs

that qualify under the ANSI/IACET Standard. • Pfiedler Enterprises is authorized by IACET to offer 0.1 CEUs for this program.

RELEASE AND ExPIRATION DATE:This continuing education activity was planned and provided in accordance with accreditation criteria. This material was originally produced in May, 2015 and renewed in July, 2016; therefore, this continuing education activity expires July, 2017.

DISCLAIMERPfiedler Enterprises does not endorse or promote any commercial product that may be discussed in this activity

SUPPORTFunds to support this activity have been provided by Ethicon

AUThORS/PLANNING COMMITTEE/REVIEWERMarilyn M. Burns, RN, BS, CNOR Tullahoma, TNClinical Consultant/ Planning Committee/AuthorMMBG Consulting Judith I. Pfister, RN, BSN, MBA Aurora, COProgram Manager/Planning CommitteePfiedler Enterprises

Julia A. Kneedler, RN, MS, EdD Aurora, COProgram Manager/ReviewerPfiedler Enterprises

DISCLOSURE OF RELATIONShIPS WITh COMMERCIAL ENTITIES FOR ThOSE IN A POSITION TO CONTROL CONTENT FOR ThIS ACTIVITy Pfiedler Enterprises has a policy in place for identifying and resolving conflicts of interest for individuals who control content for an educational activity. Information below is provided to the learner, so that a determination can be made if identified external interests or influences pose potential bias in content, recommendations or conclusions. The intent is full disclosure of those in a position to control content, with a goal of objectivity, balance and scientific rigor

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in the activity. For additional information regarding Pfiedler Enterprises’ disclosure process, visit our website at: http://www. pfiedlerenterprises.com/disclosure

Disclosure includes relevant financial relationships with commercial interests related to the subject matter that may be presented in this continuing education activity. “Relevant financial relationships” are those in any amount, occurring within the past 12 months that create a conflict of interest. A commercial interest is any entity producing, marketing, reselling, or distributing health care goods or services consumed by, or used on, patients.

Activity Authors/ Planning Committee/Reviewer

Marilyn Burns, RN, BS, CNOR No conflict of interest

Judith I. Pfister, RN, MBA Co-owner of company that receives grant funds from commercial entities Julia A. Kneedler, RN, EdD Co-owner of company that receives grant funds from commercial entities

PRIVACy AND CONFIDENTIALITy POLICyPfiedler Enterprises is committed to protecting your privacy and following industry best practices and regulations regarding continuing education. The information we collect is never shared for commercial purposes with any other organization. Our privacy and confidentiality policy is covered at our website, www.pfiedlerenterprises.com, and is effective on March 27, 2008.

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Phone: 720-748-6144

Email: registrar@pfiedlerenterprises.com

Postal Address: 2101 S. Blackhawk Street, Suite 220 Aurora, Colorado 80014

Website URL: http://www.pfiedlerenterprises.com

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INTRODUCTIONObesity is a serious health issue that affects approximately one in three Americans. Traditionally, a person has been considered obese if they are more than 20% over their ideal weight. Ideal weight takes into account the person’s height, age, sex, and build. Obesity has been more precisely defined by the National Institutes of Health (the NIH) as a BMI (Body Mass Index) of 30 kg/m2 and above. The problem of obesity is becoming an epidemic. The World Health Organization (WHO) published the following facts about obesity in January 2015:

• “Worldwide obesity has more than doubled since 1980. • In 2014, more than 1.9 billion adults, 18 years and older, were overweight. Of

these over 600 million were obese.• Overall, about 13% of the world’s adult population (11% of men and 15% of

women) was obese in 2014. • In 2014, 39% of adults aged 18 years and over (38% of men and 40% of women)

were overweight.• Most of the world’s population lives in countries where mortality is higher in the

overweight and obese segments than those that are underweight.• 42 million children under the age of 5 were overweight or obese in 2013. • Obesity is preventable.”2

Overweight and obesity have also been defined as abnormal or excessive fat accumulation that may impair health.

Body mass index (BMI) is a simple index of weight-for-height that is commonly used to classify overweight and obesity in adults. It is defined as a person’s weight in kilograms divided by the square of his height in meters (kg/m2).

WHO definitions:• Overweight: BMI greater than or equal to 25 kg/m2.• Obesity: BMI greater than or equal to 30 kg/m2.

BMI provides the most useful population-level measure of overweight and obesity as it is the same for both sexes and for all ages of adults. Childhood obesity is also on the rise. According to the World Health Organization (WHO) in 2013, 42 million children under the age of 5 were overweight or obese. Previously considered a high-income country problem, the prevalence of being overweight and obese is now on the rise in low- and middle-income countries, particularly in urban settings. In developing countries with emerging economies (classified by the World Bank as lower- and middle-income countries) the rate of increase in children being overweight and obese has been more than 30% higher than that of developed countries.3 Obesity and being overweight is linked to more deaths worldwide than being underweight. Raised BMI is a major risk factor for non-communicable diseases such as:

• cardiovascular diseases;• type 2 diabetes;

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• hypoventilation syndrome;• asthma;• sleep apnea;• stroke;• arthritis;• musculoskeletal disorders (especially osteoarthritis - a highly disabling degenerative

disease of the joints); • urinary incontinence;• gall bladder disease;• depression; and• several types of cancers (such as endometrial, breast, and colon).

The risk for these non-communicable diseases increases, with an increase in BMI. According to Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), there is current evidence that suggests that surgical therapies offer the best hope for weight loss in the extremely obese that is substantial and sustainable and also offers reduction in mortality. Because of all of these facts surrounding obesity and the risks associated with it, the rate of bariatric surgery has increased dramatically in recent years.

GASTRIC ANATOMyAn understanding of the gastric anatomy is important when learning about Laparoscopic Sleeve Gastrectomy ( LSG) and other bariatric procedures. The normal pathway of food through the gastric system begins at ingestion through the mouth and proceeds through the esophagus to the stomach; from there it travels through the small intestine then the large intestine before it enters the rectum and exits the body via the anus.

The stomach itself has several parts that are labeled below and will become more significant in the discussions of specific bariatric procedures.

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CLINICAL PRACTICE GUIDELINES FOR ThE SURGICAL WEIGhT LOSS PATIENTIn 2013, ASMBS along with AACE (American Association of Clinical Endocrinologists) and TOS (The Obesity Society) published, Clinical Practice Guidelines for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient, an update to their guidelines for the selection of patients for bariatric surgery. These guidelines offer clinical practice guidance that adheres to various professional organizations standards and is the result of the re-evaluation of previous recommendations that were then updated based on the evidence and subjective factors per protocol. Examples of expanded topics in this update include: the roles of sleeve gastrectomy, bariatric surgery in patients with type-2 diabetes, bariatric surgery for patients with mild obesity, copper deficiency, informed consent, and behavioral issues. This document contains 74 recommendations including 56 revised recommendations and 2 new recommendations (See the 2008 ASMBS document for original recommendations). In summary, the AACE/TOS/ASMBS 2013 update includes evidence based guidance on the following topics:

• Patients who should receive bariatric surgery;• Type of bariatric procedure that should be offered;• How potential bariatric surgical candidates should be managed preoperatively;• Preoperative Checklist for Bariatric Surgery (see Table 5);• Postoperative Checklist for Bariatric Surgery (see Table 6);• Elements of medical clearance for bariatric surgery;• Optimizing early postoperative care;• Achieving optimal follow-up of bariatric surgery; and• Criteria for hospital admission after bariatric surgery.

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*Source: AACE/TOS/ASMBS Guidelines: Clinical Practice Guidelines for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient-2013 Update

*Source: AACE/TOS/ASMBS Guidelines: Clinical Practice Guidelines for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient-2013 Update

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BARIATRIC SURGERy OVERVIEWBariatric surgery is the most effective therapy available for significant and sustainable weight loss in patients with morbid obesity, and its use has increased during the last decade.4 “Weight-loss surgery is the most effective treatment for morbid obesity, producing durable weight loss, improvement or remission of comorbid conditions and longer life (level I, grade A).”5There are many different types of bariatric surgery, although the types vary they all involve techniques to reduce the quantity of food that can be ingested.

Bariatric procedures are classified as: • Restrictive, • Malabsorptive, • Combination, and • Revision.

Restrictive procedures: the size of the stomach is significantly reduced which ensures early satiety or full feeling. Gastric banding is an example of a restrictive procedure. The advantages of restrictive procedures include:

• Weight loss, and• Improvement of comorbidities such as:

◦ Diabetes mellitus, ◦ Hypertension, ◦ Sleep Apnea, ◦ Gastro-esophageal reflux disease, ◦ Joint pain, ◦ High cholesterol, ◦ Stress incontinence, and ◦ Low back pain.

Malabsorptive-only procedures: bypass a large part of the small intestine and have become obsolete due to the significant adverse health effects caused by the intentional malabsorption. Combination procedures: restrictive and malabsorptive techniques are combined to produce an optimal outcome; most of the commonly performed procedures today are combination procedures. Revision procedures: for people who have had a primary bariatric procedure and need revisions to a primary procedure due to:

• Inadequate weight loss, • Regaining of weight lost after primary procedure, and• Comorbidities associated with obesity not resolved after primary surgery.

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Recently, research has shown that there is more to bariatric surgery than just restriction and malabsorption and that the physiologic and metabolic changes after surgery are a critical factor in the reason that bariatric surgery continues to be the most effective long-term treatment of obesity. Metabolic procedures affect both weight loss and have the ability to improve other conditions by causing a cascading effect on hormones and metabolic set points that are proven to shift after a stapling bariatric procedure is performed. The Metabolic Applied Research Strategy (MARS) Initiative, Bariatric Surgery: Beyond Restriction and Absorption; provides amazing insight into the evidence based approach to bariatric surgery that demonstrates through research on both animals and humans that these physiologic and metabolic changes can lead to not only sustained weight loss; but also can improve conditions such as Type 2 diabetes and other obesity related disorders. In a series of articles published in Bariatric Times in 2012, not only is bariatric surgery and how it works explained; 5 Myths associated with obesity and bariatric surgery are “debunked” and the facts are explained leaving the reader with new insights into the value of bariatric surgery and the future possibilities of treatment for obesity. Adjustable gastric band(AGB) is NOT a metabolic procedure and therefore does not offer the benefit of an outcome that will include the powerful beneficial effects such as successful control or resolution of Type 2 diabetes as will metabolic procedures Roux-en-Y Gastric Bypass (RYGB), Laparoscopic (vertical) sleeve gastrectomy (LSG), and Biliopancreatic Diversion with Duodenal Switch (BPD/DS).

Bariatric surgery has evolved over the years as technology has improved and enabled physicians to provide better outcomes to patients with less risk. Ten years ago, bypass surgery was the primary procedure; today LSG is becoming the procedure of choice. Both of these methods rely on certain common techniques, such as transection and stapling to ensure success.

The current types of bariatric procedures The American Society of Metabolic and Bariatric Surgery (ASMBS)-approved surgeries that are performed most commonly in the U.S. include:

• Roux-en-Y Gastric Bypass (RYGB),• Laparoscopic adjustable gastric banding (AGB), • Biliopancreatic Diversion with Duodenal Switch (BPD/DS) • Laparoscopic (vertical) sleeve gastrectomy (LSG)

The Roux-en-Y gastric bypass (RYGB) “is considered the ‘gold standard’ of weight loss surgery and is the most commonly performed bariatric procedure worldwide”6. In this procedure, the surgeon cuts the stomach in two to create a small gastric pouch out of the smaller proximal (near) portion of the stomach, attaches it to the small intestine, bypasses a large part of the stomach and the entire duodenum.

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Advantages• Produces significant long-term weight loss (60 to 80 percent excess weight loss);• Restricts the amount of food that can be consumed;• May lead to conditions that increase energy expenditure;• Produces favorable changes in gut hormones that reduce appetite and enhance

satiety; and• Typical maintenance of >50% excess weight loss;

Disadvantages and Complications• Technically more complex surgery than the AGB or LSG and potential for greater

complication rates;• Can lead to long-term vitamin/mineral deficiencies particularly deficits in vitamin

B12, iron, calcium, and folate;• Generally has a longer hospital stay;• Requires adherence to dietary recommendations, life-long vitamin/mineral

supplementation, and follow-up compliance; and• Surgical complications:

◦ Fistula, ◦ Leaking at the staple line/infection, ◦ Pouch and/or anastomotic dilatation, and ◦ Poor metabolism that leads to weight gain.

Revisions of the procedure to close the fistula, re-trim the pouch or perform a more metabolically active procedure may be necessary if surgical complications occur. Laparoscopic adjustable gastric banding (AGB) is another type of restrictive bariatric surgery. It is much less invasive than the RYGB technique and is also reversible. This minimally invasive approach takes a silicone band with an inflatable collar and places the band around the upper stomach. The placement of the band creates a small

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stomach pouch above the band, and the rest of the stomach below the band. The band is connected to a port which can be adjusted to make more restriction.

Advantages:• Reduces the amount of food the stomach can hold;• Induces excess weight loss of approximately 40 – 50 percent;• No cutting of the stomach or rerouting of the intestines;• Requires a shorter hospital stay, usually less than 24 hours, sometimes same day

discharge;• Reversible and adjustable;• Lowest rate of early postoperative complications and mortality among the

approved bariatric procedures7; and• Lowest risk for vitamin and/or mineral deficiencies.

Disadvantages and complications:• Slower and less early weight loss than other bariatric procedures;• Higher percentage of patients failing to lose at least 50 percent of excess body

weight compared to the other bariatric procedures;• A foreign device must remain in the body;• Band can potentially slop or erode into the stomach;• Possible mechanical problems with the band, tube or port in a small percentage

of patients;• Dilation of the esophagus can occur if the patient overeats;• Strict adherence to the postoperative diet and to postoperative follow-up visits is

required;• Highest rate of re-operation; and • Surgical complications:

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◦ Tubing and port problems: twisting, flipping or leaking of port so that no restriction occurs;

◦ Poor weight loss or weight regain; and ◦ Band leakage.

Biliopancreatic Diversion with Duodenal Switch (BPD/DS) : A smaller, tubular stomach pouch is created by removing a portion of the stomach, very similar to the sleeve gastrectomy. Next, a large portion, almost three-fourths, of the small intestine is by-passed. Because the food does not mix with bile and pancreatic enzymes until way down the small intestine, a significant decrease in the absorption of calories and nutrients (particularly protein and fat) as well as nutrients and vitamins dependent on fat for absorption (fat soluble vitamins and nutrients) occurs. Basically, this procedure has high weight loss potential, but also high complication rates and serious potential for long-term nutritional deficiency related issues.

Advantages• Results in greater weight loss than RYGB, LSG, or AGB, i.e. 60 – 70% percent

excess weight loss or greater, at 5 year follow up;• Allows patients to eventually eat near “normal” meals;• Reduces the absorption of fat by 70 percent or more; • Causes favorable changes in gut hormones to reduce appetite and improve

satiety; and• Is the most effective against diabetes compared to RYGB, LSG, and AGB.

Disadvantages• Has higher complication rates and risk for mortality than the AGB, LSG, and

RYGB;• Requires a longer hospital stay than the AGB or LSG;• Has a greater potential to cause protein deficiencies and long-term deficiencies

in a number of vitamin and minerals, i.e. iron, calcium, zinc, fat-soluble vitamins such as vitamin D; and

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• Compliance with follow-up visits and care and strict adherence to dietary and vitamin supplementation guidelines are critical to avoiding serious complications from protein and certain vitamin deficiencies.

LAPAROSCOPIC SLEEVE GASTRECTOMyThe Laparoscopic sleeve gastrectomy (LSG) has emerged recently as the current forerunner in bariatric surgery success. This procedure is performed by removing approximately 80 percent of the stomach. The remaining stomach is a tubular pouch that resembles a banana. This procedure works by several mechanisms. First, the new stomach pouch holds a much smaller volume than prior to the surgery and helps to significantly reduce the amount of food (calories) that can be consumed. “The greater impact, however, seems to be the effect the surgery has on gut hormones that impact a number of factors including hunger, satiety, and blood sugar control.”8

Advantages• Stomach volume is reduced/Restricts the food holding capacity of the stomach;• Rapid and significant weight loss similar to that of the RYGB;• Requires no foreign objects (AGB);• Does not bypass or re-route the food stream (RYGB);• Short hospital stay; • Causes favorable changes in gut hormones that suppress hunger, reduce

appetite and improve satiety; ◦ Patient experiences decreased hunger anger and appetite; ◦ No dumping syndrome; and ◦ Can be converted to other weight loss procedures (staged).

Disadvantages• A non-reversible procedure;• Potential for long-term vitamin deficiencies;

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• Higher early complication rate than the AGB; and ◦ Potential for sleeve dilatation; ◦ Potential for weight gain, poor weight loss;

• Surgical complications: ◦ Leaks: Leaks are a very significant complication of LSG. An unstable

patient with a contained or uncontained symptomatic leak typically requires immediate reoperation according to most literature on the subject. Leaks can be classified according to observation periods.

▪ Acute-stent is valid treatment option for acute proximal leak in which conservative therapy has failed.

▪ Early, ▪ Late, and ▪ Chronic;

◦ Strictures; ◦ Bleeding; ◦ Gastro-esophageal reflux disease; ◦ Nutritional problems: excessive weight loss, vitamin and mineral

deficiencies, hair loss, bone weakening, gallstones or kidney stones; and ◦ Wound infection.

LSG ProcedureThe procedure itself is an important factor in the overall success of the LSG. Surgical technique and the technical aspects of the procedure are paramount in achieving the desired clinical and patient outcomes. The main technical aspects of the performance of LSG are summarized below:

• Sizing of the sleeve: The optimal bougie size is 32F-36F. One study published in 2012 produced a consensus paper published by an international panel of 25 leading bariatric surgeons that stated “The panel believed that using a bougie <32F might increase complications significantly and that using a bougie > 36F could lead to lack of long-term restriction and possible dilation of the sleeve, resulting in failure of weight loss or long-term weight regain.”9

• Stapling: The staple line in LSG is the most critical point for the success of the procedure. Tissue thickness and density present unique challenges during laparoscopic stapling. Leaks at the staple line can lead to severe complications including the need for emergent reoperation or infection. In a recent study, it was noted that there is increased tissue thickness in patients with BMI greater than 50, especially in male patients. This produces greater stapling challenges. The Rawlins paper stated that “choice of an incorrect staple height load could lead to an increased rate of malformed staples and thereby increasing the rate of bleeding or staple line leakage”10

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• Mobilization of fundus: It is important to completely mobilize the fundus prior to the transection. If complete mobilization does not occur, the surgeon could miss a hiatal hernia and leave behind too much stomach which would decrease the restrictive component of the procedure.

A basic description of the LSG procedure includes:

ACCESS:• Insert Trocars, (typically 3 x 5 mm, 1 x 12 mm, 1 x 14 mm)• Insert camera for viewing and instrumentation for grasping and manipulating

stomach,• Place a liver retractor to support the liver,• Identify pylorus,• Mobilize greater curvature, • Mobilize posterior attachments to stomach, • Ligate short gastric vessels,• Check for hiatal hernia,• If hiatal hernia present repair at this time or after gastric sleeve is created,• A 32F-36F Bougie is passed by anesthesia and positioned in the distal antrum,• Create gastric sleeve,

◦ Typically, resectioning of the antrum begins using the green load then resectioning of the body and fundus of the stomach is achieved using blue loads. However, as we will discuss in detail later; tissue thickness determines stapling technique and choices in order to provide proper staple formation, minimize tissue slippage, enhance performance and staple line integrity.

◦ Buttress material is sometimes used, but is surgeon preference. Another surgeon preference at this point in the procedure may be to over-sew/reinforce staple line.

REPAIR:• Repair hiatal hernia if not repaired previously,• Perform a leak test/ensure staple line is secure along the sleeve, and• Remove the remnant stomach, and• Remove all instruments, camera and trocars.• CLOSURE:• Close trocar sites.

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Surgical Instrumentation typically used in LSG includes (not limited to): • Trocars,• Laparoscope,• Tissue sealing device,• Stapling device and variety of reloads,• Gastroscope,• Bougie dilator set,• Laparoscopic instrumentation,• General instrumentation,• Liver retractor,• Tissue closure devices,• Specimen retrieval bag,• Sutures,• Drain, and• Dressings.

Short term studies show that the LSG is:• As effective as the RYGB in terms of weight loss and improvement or remission

of diabetes. • Effective in improving type 2 diabetes independent of the weight loss. • Has complication rates that fall between those of the AGB and the RYGB.

“Bradley N. Reames, M.D., M.S., of the University of Michigan, Ann Arbor, and colleagues analyzed data on 43,732 adults who underwent primary inpatient and outpatient bariatric surgery within the 39-hospital Michigan Bariatric Surgery Collaborative between June 2006 and December 2013.

The researchers found that relative use of LSG increased from 6.0 percent of all procedures in 2008 to 67.3 percent of all procedures in 2013, an increase of 61 percent. During the same period, use of RYGB decreased from 58.0 percent to 27.4 percent, and use of laparoscopic adjustable gastric banding (AGB) decreased from 34.5 percent to 4.6 percent.”11 Please note that these results were specific for the Michigan Bariatric Surgery Collaborative.

Effective June 27, 2012, the Centers for Medicare and Medicaid Services (CMS) removed the Non-coverage designation for the Laparoscopic sleeve gastrectomy (LSG) which allowed coverage for this procedure as a stand-alone procedure. This was in response to submission of a strong evidence base for LSG and the response from patients, surgeons, health care providers and team members, medical societies and others. This determination allowed more patients to receive the benefits of LSG than

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ever before and allowed the utilization of the procedure to increase. The conditions that must be satisfied:

• The beneficiary has a body mass index (BMI) ≥ 35kg/m2;• The beneficiary has at least one co-morbidity related to obesity; and• The beneficiary has been previously unsuccessful with medical treatment for

obesity. 12

With clearance from CMS and the increasing amounts of data providing evidence of successful outcomes, improved co-morbidities and high patient satisfaction; LSG has experienced growth in both quantities of procedures and in popularity.Current statistics from the ASBMS highlight and reinforce the trends in the growth of LSG. The total bariatric surgeries for 2013 as reported to ASBMS were 179,000 in 2013 up from 158,000. The total use of LSG in 2013 as reported to ASBMS was 42.1% and large increase from 17.8% in 2011. During the same period, use of RYGB decreased from 36.7% in 2011 to 34.2% in 2013. Use of AGB decreased from 35.4% in 2011 to 14% in 2013.13

Not only does the volume of cases performed support the trend toward LSG as the “new gold standard”. ASBMS has recently issued an Updated position statement on sleeve gastrectomy as a bariatric procedure in which research studies support the summary and recommendations: “Substantial and long-term data have now been published in peer-reviewed studies demonstrating durable weight loss, improved medical co-morbidities, long-term patient satisfaction, and improved quality of life after SG.”14

In addition to the data we have already mentioned regarding the LSG, there are also studies available that address the technical aspects of the procedure as well. In one study, the surgeon performed 529 cases without a leak. This study revealed a documented low complication rate for this procedure. “Follow-up data was collected on 490 of the 529 (92.6%) patients at 6 weeks. A total complication rate of 3.2% and a 1.7% readmission rate were observed. No leaks occurred in any of the 529 patients, and one death (0.19%) was observed. The most common complications were nausea and vomiting with dehydration and venous thrombosis. The percentages of excess weight loss were 42.36, 65.92, 66.11, and 64.42 with a follow-up of 71%, 68%, 63% and 49% at 6 months, 1 year,2, and 3 years respectively.”15 The surgeon indicated that a number of factors contributed to the success of the procedures including staple cartridge selection for his technique (green for antrum, blue for body), use of 34F bougie without the use of buttressing material or over-sewing of the staple line, and the belief in two main tenets to adopt in order to minimize leaks. “First, and of utmost importance is to avoid creating a physiologic stricture at the incisura angularis and second, avoid stapling too close to the esophagus in the area of the cardia”16 Allowing time for compression of the gastric tissue with the stapling device to promote proper staple formation and reduce both serosal trauma and bleeding was also recommended.

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SUMMARyWith more than one third of the adults in the United States considered obese, this major public health problem is becoming a nationwide concern. Being overweight is a major risk factor for a multitude of non-communicable diseases such as cardiovascular disease, type 2 diabetes, joint pain, and some types of cancer as well as many others. Although obesity is preventable and there are many proven ways to lose weight, surgical intervention has proven over the years to be the best hope for weight loss in the extremely obese that is both substantial and sustainable and also offers reduction in mortality. The current trends and guidelines supported by evidence based research data and endorsed by multiple clinical professional organizations have shown LSG to be an excellent procedure for achieving substantial and sustainable weight loss, improved medical co-morbidities, long-term patient satisfaction, and improved quality of life with minimal complications.

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GLOSSARyAntrum A portion of the stomach before the outlet, which

is lined by mucosa and does not produce acid.Bariatric Relating to or specializing in the treatment of

obesity.Bariatric Surgery A surgical procedure performed for the purpose of

producing weight loss.Basal Metabolic Rate (BMR) Basal metabolic rate or BMR is the amount

of heat or energy produced by an individual in a resting state when the digestive system is inactive.

Base Mass Index (BMI) The measure of a person’s body fat based upon height and weight. This is applicable for both male and female adults.

Gastrectomy Excision of the stomach or part of the stomach.Malabsorption Incomplete digestion or absorption of food intake.Obese A person has traditionally been considered to be

obese if they are more than 20% over their ideal weight. That ideal weight must take into account the person’s height, age, sex, and build. Obesity has been more precisely defined by the National Institutes of Health (the NIH) as a BMI (Body Mass Index) of 30 and above.

Ideal Body Weight A weight that is believed to be maximally healthful for a person, based chiefly on height but modified by factors such as gender, age, build, and degree of muscular development. The weight statistically determined on actuarial tables to be associated with the lowest mortality for an average individual, adjusting for some combination of height, age, frame size, and gender. Which factors should be included and how it should be determined remain controversial.

Jejunum A type of surgical technique that uses a lighted Laparoscopy scope inserted into a tiny incision in the abdomen.MIS Minimally Invasive Surgery. Procedures that use

small incisions or openings to gain access to the body’s internal organs or tissues, endoscopic instruments, computer assisted devices, robotics, or other emerging technologies.

Morbidly Obese A person with a BMI greater than 40kg/m2.

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Pouch A surgically created portion of the stomach that serves as a reservoir for food immediately after food exits the esophagus.

Small Intestine A row of staples placed in the bowel or stomach Staple Line by a surgical stapling device. Staples can be used to create an anastomosis, create a partition, or secure the end of a segment of bowel when a side anastomosis is performed.Stomach Trocar A surgical instrument that consists of a sheath

with a sharp or blunt obturator used to puncture or penetrate multiple layers of tissue. The sheath stays in place and the obturator is removed. The laparoscopic instruments and scopes, cameras etc, are passed through the sheath.

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BIBLIOGRAPhy1. Obesity and overweight. Fact sheet N°311. Updated January 2015. World Health

Organization. http://www.who.int/mediacentre/factsheets/fs311/en/. Accessed March 3, 2015.

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4. JAMA - Journal of the American Medical Association. Change in type of procedure most commonly used for bariatric surgery. http://www.sciencedaily.com/releases/2014/09/140902171152.htm . Accessed February 27, 2015.

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9. Haskins, O. Clinical guidelines Sleeve gastrectomy best practices published. Bariatric News. http://www.bariatricnews.net/?q=news/1197/sleeve-gastrectomy-best-practices-published . Accessed March 3, 2015.

10. Rawlins, L., Rawlins, M., Teel II, D. Human Tissue thickness measurements from excised sleeve gastrectomy specimens. PLEASE COMPLETE FULL ARTICLE INFO!

11. JAMA - Journal of the American Medical Association. Change in type of procedure most commonly used for bariatric surgery. http://www.sciencedaily.com/releases/2014/09/140902171152.htm. Accessed February 27, 2015.

12. MLN Matters® Number: MM8028. Bariatric Surgery for the Treatment of Morbid Obesity National Coverage Determination, Addition of Laparoscopic Sleeve Gastrectomy (LSG). http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8028.pdf . Accessed March 5, 2015.

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14. ASBMS Clinical Issues Committee, Updated position statement on sleeve gastrectomy as a bariatric procedure. Revised March 14, 2012. https://asmbs.org/wp/uploads/2012/03/UpdatedPositionSleeveGastrectomyMar142012.pdf. Accessed March, 1, 2015.

15. Bellinger, D. Greenway, F. Laparoscopic Sleeve Gastrectomy, 529 Cases Without a Leak: Short-Term Results and Technical Considerations. http://www.vcu.edu/lesspainsurgery/obesity/pdfs/Sleeve_ClinResearch_Bellanger.pdf . Accessed February 27, 2015.

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