1. Sleeve Gastrectomy in Patients with BMI < 35. It Makes Sense! Samer G. Mattar, MD, FRCS, FACS Associate Professor of Surgery Indiana University

2. Outline Evolution of Sleeve Gastrectomy Safety profile of SG Outcomes of SG SG in BMI <35

3. Sleeve Gastrectomy Tubular stomach Two thirds of stomach removed Stomach capacity ≈ 100 mL Based upon Magenstrasse and Mill Procedure Initially used in 2 stage procedure for super morbidly obese Weight loss proved promising with some pts electing not to proceed with second portion of procedure Braghetto et al. Obes Surg. November/December 2007 Regan et al. Obes Surg. December 2003

4. EvolutionMagenstrasse & Mill2003 Developed by Johnston in UK 100 patients No deaths Major complication rate = 4% EWL% at 1 yr. = 61% Johnston D et al. Obes Surg 2003 (13)1: 10

5. EvolutionDuodenal Switch Developed by Marceau and Hess as a derivative of BPD Sleeve performed over a 60F bougie

6. 2 Staged LBPD-DS in High Risk Patients – Mount Sinai2003 First reported by Gagner in 2003 Reserved for patients BMI >60 Attempt to reduce morbidity and mortality Interval time was 1 yr EWL% = 33% (about 100 pound weight loss) Regan JP et al. Obes Surg 2003 (13)6:861

7. BPD-DS for Super-Super Morbidly Obese Patients 23% 17% 6.5% 3.5% 0% 2.8%

8. 118 Patients Median BMI 55, Median age 47 41% male 31 patients intra-operative decision: 5 anatomy (adhesions, short mesentery) 16 prolonged OR time/intraop complications 11 unexpected operative findings 47% EWL at 24 months

10. 23 patients had LRYGB

12. Results of LRYGB = -One death Morbidity 8% EWL% = an extra 20% Cottam et al Surg Endosc 2006 (20)6:859

13. 126 Patients, 47% male Mean age 49.5 years Mean BMI 65.3 kg/m2 42% ASA III, 52% ASA IV No perioperative mortality 46% EWL at one year * P < 0.05

14. Sleeve Gastrectomy as a Definitive Operation Staged patients were not returning for 2nd stage. Bougie size gradually decreased from 60F to 34F Resection initiated 5-6 cm from pylorus

15. Expected Weight Loss Outcomes %EWL is about 50% at 1 year. In an Austrian study of 126 patients, 64% lost > 50% excess weight within a mean of 20 months. In a French study of 137 patients, median 2 y %EWL was 55%. (Felberbauer et al, Obes Surg 2008) (Chazelet, Topart, Verhaege. In press)

16. Current EvidenceMetanalysis – 5 year Follow Up 35 Studies between 1/03 and 1/09 2,410 patients Pre-op BMI 35 – 69 kg/m2 (50) Post-op BMI 26 – 53 kg/m2 (36) Follow-up 3 months to 5 years EWL%: 33 – 83% (55%) Complication rate 0 – 24% 3 postoperative mortalities (0.12%) Brethauer et al. SOARD 2009 (4): 469-475

17. Primary Procedure / Lower Risk Patients 21 studies reported detailed complication rates (1,491 patients) 36 leaks (2.4%) 13 postoperative bleeding (0.9%) 1 mortality in 1,597 patients (0.06%) Brethauer et al. SOARD 2009 (4): 469-475

18. F.D.A. Approves Band Device for Less Obese By ANDREW POLLACK Published: February 16, 2011 People no longer need to be quite as obese as before to qualify for weight loss surgery. The Food and Drug Administration on Wednesday approved the wider use of Allergan’s Lap-Band stomach-restricting device to some people who are just barely obese. Allergan estimated that more than 26 million Americans would be newly eligible for the surgery, more than doubling the 15 million to 18 million eligible under the old standard.

20. More loss of hunger in Sleeve Gastrectomy group80% 70% Sleeve Gastrectomy 60% EWL (BMI(25)) Adjustable Gastric Band 50% 40% 30% 20% 10% 0% 0 10 20 30 40 50 60 Time (Mo) Himpens et al. A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years. Obes Surg 2006;16:1450–6.

21. Ghrelin Wang and Liu; Obes Surg:2009

22. Gastric Emptying: Accelerated 67 patients 3 groups: lean control, mo with DM2 no LSG, mo with Dm2 with LSG All patients had GE half time and SBTT Shah et al: SOARD 2010;4(6):152-7

23. Body Composition Changes 30 SG patients at 16 + 5 months FU

24. Ileal interposition with SG in BMI < 35 454 patients in Goiania, Brazil Mean BMI = 29 +/- 3 All were diabetic > 3 years Mean duration of DM2 was 10 years Mean HgA1C = 8.8% DePaula AL, et al. World J Surg 2011;35(1):102-8

25. Ileal interposition with SG in BMI < 35 Mortality = 0.4% Major complications = 6.4% Re-admission rate = 4.4% DePaula AL, et al. World J Surg 2011;35(1):102-8

26. Ileal interposition with SG in BMI < 35 DePaula AL, et al. World J Surg 2011;35(1):102-8

27. Conclusion The incidence of obesity continues to rise. Prior studies have shown that early treatment of obesity results in better resolution of comorbidities. FDA has approved gastric band in BMI < 35. SG is more effective than the band. Therefore, it makes sense to offer it to patients with BMI <35!