Endoluminal Anatomy of the Gastric Sleeve: Are we all created equal?

Abel E Bello, MD, Leena Khaitan, MD. University Hospitals Case Surgery

INTRODUCTION: Laparoscopic Sleeve Gastrectomy (SG) has been rapidly evolving as one of the most commonly performed bariatric surgical procedures. Although the technique has been fairly standardized, little is known about the final SG luminal size, volume and shape. We present a series of SG patients who underwent intraoperative endoscopy; luminal diameter and volume measurement followed by post-operative contrast study (UGI), aiming at identification of similarities and disparities.

METHODS: Ten patients underwent SG between 2012-2014. Volume and diameter was measured distal to Z-line with EndoFLIP EF-620 catheter (160mm, Crospon, Ireland). All Patients had SG created with 34F sizing tube and had endoscopic evaluation of sleeve with identification of Z-line. Data on demographics, symptoms, weight loss, UGI and catheter measurements were collected. 3 volume measurements were used with catheter (20, 25 and 30mL). Total Sleeve volume was measured at 30mL distention. Area of smallest diameter with its Cross-sectional area (CSA) was recorded and largest diameter position and measurement described. All patients had UGI post-operative day 1 for evaluation of shape, reflux and area of largest diameter for comparison. All data were kept in secure database. Statistical analysis was performed using SPSS V22.

RESULTS: All procedures completed laparoscopically, no immediate post-operative complication. Mean preop BMI 45.69 ± 7.45; follow up 11.20 ± 6.3 months, and excess weight loss (EWL) 51.97% ± 10.82%. On intraoperative endoscopy no gross abnormalities were seen on all patients and scope advanced to pylorus without difficulties. On catheter measurement, SG volume was 22.8-38.4mL (Mean 32.8±4.1mL). Smallest diameter at 30mL distention ranged from 21F–38F (Mean 28.50±5.6) and CSA 41–126mm2 (Mean 73.5±27.1); while largest diameter ranged from 53F–67F (Mean 62.6±3.8). The area of smallest diameter was found between 8-14 cms below Z-line in 70% of patients with a Mean of 11cms; while the area of largest diameter was seen at the top in 6/10 and bottom in 4/10. Of those patients with large diameter at the top, 67% had the smallest diameter at roughly 9.5cms below Z-line with average size of 27F. The remaining 33% had a more distal smaller diameter of 27F at 15cms. The length of the smallest diameter segment and hence higher-pressure zone was on average 4±2 cms and correlated with just above the incisura. On UGI, 3/10 had an hourglass shape, 4/10 Top, and 3/10 Bottom contrast distribution. The area of largest diameter as measured by catheter was concordant with contrast distribution seen on UGI (p=0.027). Reflux was seen in 3 patients of whom 100% had mid-portion narrowing with the area of largest diameter at the top. Two of these patients were on PPI therapy post-operatively and the other 1 was lost at follow up. None of these patients had previous reflux.

CONCLUSION: Bougie size does not accurately predict luminal size, total volume and final shape of the newly created gastric sleeve. Although the sample size is small, there appears to be a relationship between mid-portion small diameter by the incisura and proximal sleeve dilation with immediate post-operative reflux seen after SG.

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