surgery

1. Surgery Presentation
Gastric band and Sleeve gastrectomy
Yunghang Chan, MS3

2. Clinical Presentation
CC: 60 y/o F presents in the ER with abdominal pain, nausea
HPI: 2d abdominal pain that is getting progressive worse (10/10) and causing her to
feel nauseous. Last BM was 2 days ago and obstipated
ROS: negative other than HPI
PMH: HTN
PSH: lap band that has not been accessed or manipulated for years

3. PE
Vital: Afebrile BP: 175/106 HR: 90 RR: 17
SpO2: 98% at RA
GENERAL: NAD, AAO
SKIN: Warm, dry
HEENT: no pallor, no icterus, mucous membranes moist.
RESPIRATORY: normal breath sounds equal bilaterally.
CARDIOVASCULAR: normal RR, S1S2
ABDOMEN: Soft, ND, RLQ tenderness and tenderness to umbilicus, port palpable on right side of abdomen
MUSCULOSKELETAL/EXTREMITIES: palpable pulses,
NEURO AND PSYCH: Alert, oriented, normal strength. Sensation grossly intact. Moving all extremities.

4. Image

5. Background info
- Bariatrics surgery numbers
are on the rise due to
increasing obesity prevalence
- Sleeve Gastrectomy is the
most common

6. Bariatric Surgery Indication
- BMI > 40
- BMI between 35 and 39.9 with at least one obesity-related comorbidity
- BMI from 30 to 34.9 with
- Inadequate glycemic control
- Inability to achieve a sustained healthy weight loss

7. Gastric band vs. Sleeve Gastrectomy
- Both Restriction
- Gastric band - reversible
- Sleeve Gastrectomy - irreversible
- SG has additional hormonal effects
- Decreased Ghrelin
- Small intestine absorption intact
- Expected 2 year weight loss: 50% vs. 60%

8. Technique
1. Trochar placement
2. Dissection
3. Orogastric tube (Bougie) placement
4. Stapling
5. Leak Test
Image Courtesy: : UCLA
Department of Surgery

9. Dissection
1. Liver retraction
2. Dissection of greater omentum
3. Divide vessels along greater
curvature and towards fundus
4. Dissect posterior wall from the
lesser sac

10. Dissection
1. Liver retraction
2. Dissection of greater omentum
3. Divide vessels along greater
curvature and towards fundus
4. Dissect posterior wall from the
lesser sac

11. Bougie
- 32-40 Fr bougie are used as a guide for
stapling
- Size of bougie
- weight loss vs. leak risk
Image Courtesy: : UCLA Department of Surgery

12. Stapling
1. Start about 3-6 cm proximal to pylorus
parallel to lesser curvature to avoid stricture
a. Starting point doesn’t affect weight loss outcome
2. Reinforcement of staple line
a. Absorbable polymer membrane is shown to have
decrease leak & other complication
3. Leak check
a. Methylene blue
Image Courtesy: : UCLA Department of Surgery

13. Post operation
- Overall mortality of 0.05%
- Benefits
- Weight loss
- Remission of diabetes
- Complications
- Early: Leak, Hemorrhage, ileus
- Late: strictures, GERD, nutritional deficits
- Long term management
- Diet monitoring
- nutritional deficits screening (esp. micronutrients, vitamins)

14. Reference
1. Mechanick JI, et al. CLINICAL PRACTICE GUIDELINES FOR THE PERIOPERATIVE NUTRITION, METABOLIC, AND
NONSURGICAL SUPPORT OF PATIENTS UNDERGOING BARIATRIC PROCEDURES - 2019 Endocr Pract. 2019
Dec;25(12):1346-1359.
2. Seeras K, Sankararaman S, Lopez PP. Sleeve Gastrectomy. 2022 Feb 1. In: StatPearls [Internet]. Treasure Island
(FL): StatPearls Publishing; 2022 Jan–. PMID: 30085577.
3. Yuval JB, Mintz Y, Cohen MJ, Rivkind AI, Elazary R. The effects of bougie caliber on leaks and excess weight loss
following laparoscopic sleeve gastrectomy. Is there an ideal bougie size? Obes Surg. 2013 Oct;23(10):1685-91. doi:
10.1007/s11695-013-1047-3. PMID: 23912264.
4. Wang Y, Yi XY, Gong LL, Li QF, Zhang J, Wang ZH. The effectiveness and safety of laparoscopic sleeve gastrectomy
with different sizes of bougie calibration: A systematic review and meta-analysis. Int J Surg. 2018 Jan;49:32-38. doi:
10.1016/j.ijsu.2017.12.005. Epub 2017 Dec 12. PMID: 29246457.
5. Garay M, Balagué C, Rodríguez-Otero C, Gonzalo B, Domenech A, Pernas JC, Gich IJ, Miñambres I, Fernández-Ananín
S, Targarona EM. Influence of antrum size on gastric emptying and weight-loss outcomes after laparoscopic sleeve
gastrectomy (preliminary analysis of a randomized trial). Surg Endosc. 2018 Jun;32(6):2739-2745. doi:
10.1007/s00464-017-5972-4. Epub 2018 Jan 8. PMID: 29313122.
6. Gagner M, Kemmeter P. Comparison of laparoscopic sleeve gastrectomy leak rates in five staple-line reinforcement
options: a systematic review. Surg Endosc. 2020 Jan;34(1):396-407. doi: 10.1007/s00464-019-06782-2. Epub 2019
Apr 16. PMID: 30993513; PMCID: PMC6946737.
7. Robertson AGN, Wiggins T, Robertson FP, Huppler L, Doleman B, Harrison EM, Hollyman M, Welbourn R.
Perioperative mortality in bariatric surgery: meta-analysis. Br J Surg. 2021 Aug 19;108(8):892-897. doi:
10.1093/bjs/znab245. PMID: 34297806.
8. Lim, R., Beekley, A., Johnson, D. C., & Davis, K. A. . Early and late complications of bariatric operation. Trauma
Surgery & Acute Care Open. 2018, October 1. Retrieved March 20, 2022

15. Questions?