Sleeve En YDoes Changing the Name Change the Perception?

Mitchell Roslin, MD FACS

Chief of Bariatric Surgery

Lenox Hill Hospital

Northern Westchester Hospital Center

Disclosures

• Consultant J&J, Covidien, CR Bard• Research Grant Covidien• Patent License J&J, CR Bard, Allergan• SAB ValenTx, Scientific Intake• Founder VentralFix

• Gastric bypass has been most popular stapling procedure

• Best balance between outcome and complications?

• Preferable for sweet eaters because of dumping?• Dumping is an important component for weight

loss surgery as it deters carbohydrate intake?• Tremendous amount of long term data?

“A person with a new idea is a crank until the idea succeeds.”

Mark Twain • Described RYGB• Abandoned anemia, bone

loss, micronutrient deficiencies

• 1971 VBG• Lesser curvature• 2005 International

Registry• RYGB 67 vs 59 %EBL• VBG 0 mortality vs .5%

Edward E Mason MD, PHD

Harvey SUGERman• Compared VBG to

RYGB in sweet eaters• Big difference in

outcome 37% EBL VBG• What is a sweet eater?• 69% vs 67% wt loss in

sweet eaters vs non in rygb

• Dumping caused sweet aversion?

Ann Surg 1987

Ten and more years after vertical banded gastroplasty as primary operation for

morbid obesity

• 71 patients• BMI 49 – 39• 26% 50% ebl• High amount of

emesis• High re operation rate

Weight gain after short- and long-limb gastric bypass in

patients followed for longer than 10 years.• Lloyd MacLean

• Isolated gastric bypass

• 83% follow up

• Progressive wt regain from nadir (2Yr)

• No differences in short and long limb

• 20% failure for MO

• 35% failure for SMO

Dumping?

• Literature contains numerous articles about hyperinsulinemic hypoglycemia

• None showing relationship between dumping and weight loss

• Mallory et al: No relationship between wt loss and dumping

OBESITY IS A CHRONIC DISEASE

• 70% of excess weight loss after one year• Much higher rate of recidivism than noted

Size does not Matter?

• In cohort that had dgj>2cm, no difference with increasing size

• Time matters• Will be difficult to

identify clinical target that is reproducible

Physiologic Cause

• Lesser curvature• Restrictive anastomosis• No valve• Rapid emptying• Recidivism maybe based

on anatomy, not return of old habits

• Low glycemic index diet• Many eat refined carbs

IMPLICATIONS:PRESERVATION OF PYLORUS

VS SUPPORTED BYPSS

RANDOMIZED TRIALLAP RYGB VS LAP DS

• Mean BMI 54 RYGB• Mean BMI 55 DS• 1 Yr post RYGB = 38• 1 Yr post DS = 32• Similar complications• Will majority of super

obese patients treated with RYGB be morbidly obese?

The Duodenal Switch Operation for the Treatment of Morbid Obesity: A

10 Year Experience• 701 patients BMI 52• 22% BMI >60 58% BMI >50• 75% >50% excess wt at five

years• 67% EBL maintained• 40 patients with revision for

increased limb length• Similar data Hess and

Marceau

Pyloric Preservation?

• Bypass with rapid emptying causing inter meal hunger

• Instead of artificial fixed valve use biologic smart valve

• Duodenal Switch has most weight loss

• Sleeve preserves options

Introducing the Sleeve En Y

• Effectiveness of sleeve shows the value of long narrow pouch with pylorus intact

• Combination of narrow pouch and pylorus limit intake and diarrhea

• Intestinal bypass plays metabolic role

• Can lengthen common channel to avoid oily stools and frequent bowel movements

Responder Analysis• BMI > 50 Nadir response > 1 year

• 50% EWL, BMI < 40, BMI < 35, BMI <30

• 13/120 Bands less than 40

• 270 of 346 RYGB less than 40

• 10 of 30 VSG

• 22 of 23 lap DS (majority have not reached nadir

• Lowest variability in response

• Does treatment of super morbid obesity require intestinal bypass?