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1 J.KyotoPref.Univ.Med.(9),69~66,03. Shortterm efectoflsginjapanesepatients 69 OriginalWorks PositiveShort-term OutcomesofLaparoscopicSleeve Gastrectomy(LSG)fortheTreatmentofObesityand ItsAssociatedComorbiditiesinJapanesePatients ChouheiSakakura *,YuhkiOzamoto,TakeshiTogawa,AkeoHagiwara,EigoOtsuji HitoshiFujiwara,KazumaOkamoto,DaisukeIchikawa,MasayoshiNakanishi TsuyoshiKubota,YoshiakiKuriu,HisashiIkoma,AtsushiShiozaki,ShuheiKomatsu YasutoshiMurayama,RyoMorimura andhirotakakonishi DepartmentofDigestiveSurgery,KyotoPrefecturalUniversityofMedicine GraduateSchoolofMedicalScience DoshishaUniversity,FacultyofLifeandMedicalSciences,GraduateSchoolofLifeandMedicalSciences Abstract:Background:Laparoscopicsleevegastrectomy(LSG)isanewtechnique forseverelyobesepatientsthatreportedlylowersratesofpostoperativecomplications anddeath. Thisstudywasdesignedtodetermineshort-term outcomesoflsg and associatedcomplicationsinourinstitute. Methods:From January009toJanuary03,4patientsunderwentLSGinour institution.operationtimeandcomplications,aswelasfolow-uppercentageofexcess weightloss(%ewl)andimprovementofcomorbidities,weredetermined. Results:Alprocedureswereperformedlaparoscopicaly.Themeanoperationtime was85.5±8.4minutes.nopatientrequiredreoperationduetoanearlycomplication. Oneyearaftersurgery,thesepatientshadamean55.0%±.8% EWL.Comorbidities, includingtypediabetes,sleepapnea,andhypertension,weremarkedlyimproved6 monthsaftersurgery,andtheefectswereprolongedformorethanmonths.however, aggravationofdiabeticrenalfailureaftermonthspostoperatively,andareboundof obesitywithpsychologicaldisorderswereobservedafter30months,respectively. Conclusions:LSGshowedgoodshort-term outcomesasarestrictiveprocedurefor weightlossandimprovementofcomorbidities. Longerfolow-upandprospective comparativetrialsareneededtoconfirm thelong-term outcomesofthisnovelprocedure andtoreachdefinitiveconclusions.lsgcanbesafelyperformed,andintensivefolow-up bymanyspecialistsmaybetermaintaingoodpostoperativecontrol. KeyWords:Bariatricsurgery,Obesity,LSG(Laparoscopicsleevegastrectomy). Received:July8,03.Accepted:August5,03 * CorrespondencetoChouheiSakakura465Kaji-cho,Kawaramachi-HirokoujiKamigyou-ku,Kyoto ,Japan sakakura@koto.kpu-m.ac.jp

2 60 Sakakuraetal. Introduction Obesityisamajorhealthproblem afectingover.7bilionpeopleworldwide.itisassociatedwith significantcomorbidconditionsandreducedlifeexpectancy 3).Whilethegeneraltreatmentforobesity injapanfocusesondietary,behavioral,andexercisetherapyaswelasdrugtreatment,surgical methods,caled metabolicsurgery,wererecentlyintroduced 4)5). BariatricsurgerywasfirstperformedinJapanin98 6).Althoughthisbariatricrestrictiveprocedure becameeligibleforinsurancereimbursement,itwasnotwidelyperformed.however,theincreased numberofobeseindividualinjapan,thegreatersocialneedsandexpensesinresponsetoobesity,and progressinlaparoscopicsurgicaltechniqueshaveresultedinmarkeddevelopmentsinthetreatment ofobesity. Laparoscopicsleevegastrectomy(LSG)wasapprovedinJapanfortreatmentofmorbid obesityin008,butfewreportshaveevaluateditsefectiveness.thisreportdescribestheexperience ofourinstitutewithmetabolicsurgeryinpatientswithmorbidobesity,andtheefectsoflsgonbody weightlossandimprovementofcomorbiditiesduringfolow-up. PatientsandMethods IndicationsforsurgerywereaccordingtotheguidelinesofTheJapaneseSocietyforTreatmentof Obesity(JSTO).Patientswereincludediftheywereaged3-49years,hadabodymassindex(BMI) >35kg/m or>3kg/m withcomorbidities,failednonoperativetreatmentafterafolow-upofyear, andparticipatedinregularphysicalactivity.patientswhomettheinclusioncriteriawereinvitedto atendpreoperativeseminarsconductedbyoursurgeons. Alpatientsunderwentmultidisciplinary evaluations performed by internists, psychiatrists, and surgeons. Blood tests, abdominal ultrasonography,upperendoscopy,andbodyfatsequencingwereperformedpreoperativelytoestablish abaseline.alpatientsprovidedwriteninformedconsentandacknowledgedthepurposeofthestudy, includingtherisksandbenefitsoftheprocedure. Fourteenpatientswereenroledthroughthe outpatientdepartmentofgeneralsurgeryfrom January0toJanuary03inarelatedhospitalofthe KyotoPrefecturalUniversityofMedicineandwereassignedtoundergoLSG.Patientcharacteristics areshownintable.onepatienthadahistoryofosteosisofposteriorlongitunalligament(opll). Thirteenpatientswerefolowedupat,3,6,andmonthspostoperatively.Onepatientwas foloweduponlyfor6months. Operativetimes,postoperativecomplications,percentageofexcess weightloss(%ewl),andchangesincomorbiditieswereanalyzed. Surgicalprocedure Thepatientwaspositionedinthemodifiedbeachchairpositionwithbotharmsplacedinabduction andthelowerextremitieskeptstraight.thesurgeonandscopiststoodtotherightofthepatient,and theassistanttotheleft.fig.showsanintraoperativepictureofapatientundergoinglsg.patients wereplacedinthemodifiedbeachchairposition,securingtheworkingspacearoundthestomachin morbidlyobesitypatients(fig.). A closedpneumoperitoneum ofmm Hgwasachieved. Thefirstportwasplacedwith Visiport TM 遺.One0mm trocarwasplacedabovetheumbilicusforthelaparoscope,andasecond0mm trocarwasplacedontheanteriorlineatthemidpointofthexiphoidandumbilicustopasstheneedle, forsuturingandforthesurgeon srighthand.a5mm trocarwasplacedbelowthexiphoidappendices

Shortterm efectoflsginjapanesepatients 6 Fig.. IntraoperativefindingofLSG. Thestumpofthesleevegastrectomyisobservedatthetimeof stapling. Fig.. Patientposition(modifiedbeachchairposition).

forliverretraction;asecond5mm trocarwasplacedontherightanterioraxilaryline,-3cm subcostalyforthesurgeon slefthand;andathird5mm trocarwasplacedontheleftmidclavicularline -3cm subcostaly forthe surgeon

3 Shortterm efectoflsginjapanesepatients 6 Fig.. IntraoperativefindingofLSG. Thestumpofthesleevegastrectomyisobservedatthetimeof stapling. Fig.. Patientposition(modifiedbeachchairposition). Morbidlyobesepatientsareplacedinthemodifiedbeachchair positiontosecuretheworkingspacearoundthestomach. forliverretraction;asecond5mm trocarwasplacedontherightanterioraxilaryline,-3cm subcostalyforthesurgeon slefthand;andathird5mm trocarwasplacedontheleftmidclavicularline -3cm subcostaly forthe surgeon s assistant.using an ultrasonic scalpel,the omentum and gastroepiploicvesselsweredissectedfrom thegreatercurvature,usualystarting5cm from thepylorus andcontinuinguptotheleftcrusofthediaphragm andtheangleofhis.theshortgastricvessels, posteriorgastricvein,andposteriorgastricatachmentswerecarefulydivided. Theendoscopist passeda3fnasogastrictubeorgastricfiberscopetowardthepylorus. Undertheguidanceof

4 6 Sakakuraetal. nasogastrictube,5to6timesofendo-gia60-mm staplerwereappliedalongthegreatercurvatureof thestomach.thevolumeoftheresidualstomachwasabout00mlwiththewidthof3to4cm.row of8-0extramucosalinterruptedstichesof3-0vicrylsutureswasplacedjustbelowtheangleofthehis andcontinueddistalyto4cm ofthepylorus. Results From January009toApril03,4patientswereenroledintothisstudy,includingwith hypertension and with type diabetes. Alcomorbidities were screened postoperatively. Clinicopathologicalfactorsofthese4patientsaresummarizedinTable.Theyrangedinagefrom 3to49yearsoldandhadaBMIof36.to7kg/m. Comorbiditiesincludedhypertension, hyperlipidemia,andtypediabetes,andjointdisease. Noneofthesepatientsexperiencedanysurgicalcomplications.Theirmean%EWLwas55.0%±.8% atmonths.nonerequiredconversionduetomassivebleeding.comorbiditiesimprovedor resolvedinmostpatients,includingarterialhypertension(00%)anddiabetesmelitus(9%)(table ). Sixmonthsaftersurgery,comorbidities,includingdiabetesandhypertension,improvedmarkedly inalpatients. However,onepatient,whohadpreoperativediabeticnephropathy,experiencedan exacerbationofthiscondition,resultinginacuterenalfailuremonthsafterlsg.anotherpatient Table. ClinicopathologicalfeaturesofthepatientswhounderwentLSG

5 Shortterm efectoflsginjapanesepatients 63 experiencedareboundofobesityafter30monthswhenregularvisitstothehospitalwereinterrupted bymentalstress. Table. SummaryofclinicaloutcomesafterLSG Fig.3. Folow-upresultsafterLSG. Chronologicalchangesofbodyweight,%EWL,andHbAcaftersurgery.

6 64 Sakakuraetal. Typicaldataofchangesovertimeinbodyweight,%EWL,andHbAcafterLSGareshowninFig. 3. Discussion LSGwasfirstreportedaspartofthedefectivebariatrictreatmentknownasduodenalswitch 7).LSG wasacceptedin008asanadvancedmedicaltechniqueinjapan,anditsuseisgradualyincreasing. Weintroducedthisprocedureformetabolicsurgeryandhaveperformeditsafelyandsuccessfulyin 4patients.Althoughthefolow-upperiodwasshort,wefoundthatLGScouldbeperformedsafely, resultingin efectivebodyweightlossandimprovementofcomorbidities,suggestingthatthis procedureisusefulinjapanesepatientsaswelaseuropeansandamericans. Many typesofmetabolicsurgery involve Roux-en-Y bypass,during which the stomach is interpositioned 4)5).AsgastriccancerisfrequentinJapan,screeningoftheresidualstomachisnecessary. Therefore,LSGmaybepreferable.Assessmentsofshort-term outcomesoflsgfoundthatthemean % EWLafterormoreyearsexceeded50%.Moreover,comorbidities,includingtypediabetes, hypertension,andjointdiseasewereimprovedinmorethan90% ofpatients.theseresultsaremostly inagreementwiththedataofanoldoverseas 3).Todate,fewpatientsinJapanhaveundergoneLSG; thustherearelitlefolow-updata ).Longterm folow-upisnecessarytoestimateitsefect. StaplelineleakageandinternalbleedingarereportedtobemajorcomplicationsofLSG ).Noneof thepatientsinourseries,however,experiencedanyintra-orpostoperativecomplications.however, duringfolow-up,onepatienteachexperienceddiabeticrenalfailureandobesityrebound.intensive folow-upbymanymedicalprofessionals,includingpsychiatrists,physicians,counselors,nurses,and dietitians,maybeneededtomaintaingoodpostoperativecontrolandtopreventthesecomplications. Todate,LSG methodshavegradualybeenstandardized 3 5),butthereisnogeneralconsensus aboutthetechniquestouse.thebeachchairpositionmaybeoptimalinensuringadequateworking spacearoundthestomachofthepatient.spaceissecuredwhenfatintheabdominalcavitymovestothe rearwithgravity;thus,thispositionmayalsobeusefulinoverweightpatientsundergoingothertypes ofupperabdominalsurgery. WeareunabletoidentifystudiesontheeconomicsofLSG,likelyduetovariationsinthe techniquesusedforbariatricsurgery.lsghasbeenshowntoimprovecomorbidities,contributingto decreasedmedicalcostsinmorbidlyobesepatients 6 ).Wefoundthatnoneofthe4patientsinthis studyrequiredanyofthemedicationsprescribedbeforelsg,includinginsulin,anti-hypertensive agents,statins,andotherlipidcontrolingagents.moreover,alpatientsshowedmarkedimprovements incomorbidities. Inconclusion,wefoundthatLSGresultedinanacceptable% EWLandgoodglobaloutcomesin morbidlyobesejapanesepatients.althoughlsgsignificantlyimprovedcomorbidities,itslong-term metabolicefectsarestilunclear,andfurtherstudiesinadditionalpatientsareneeded. Conflictofintereststatement:ChouheiSakakuraandotherco-authorshavenoconflictsofinterest. Theauthorsindicatednopotentialconflictofinterest.

7 Shortterm efectoflsginjapanesepatients 65 References )Chronicdiseaseinformationsheets[databaseon theinternet].htp:/ publications/facts/obesity/en/.accessed9june009. )The InternationalClassification ofadultunderweight,overweightandobesityaccordingtobmi. Globaldatabase004.Accessed8Apr009. 3)TjepkemaM.Adultobesity.HealthRep006;7:9-5. 4)BuchwaldH,AvidorY,BraunwaldE,JensenMD, PoriesW,FahrbachK,SchoelesK.Bariatricsurgery: asystematicreview andmeta-analysis.jama 004; 9: )BuchwaldH.Bariatricsurgeryformorbidobesity: healthimplicationsforpatients,healthprofessionals, andthird-partyplayers.jam ColSurg005;00: )KasamaK.Dr.IsaoKawamura,apioneerinmorbid obesitytreatmentinjapan.obessurg0;:43. 7)ReganJP,InabnetWB,GagnerM,PompA.Early experience with two-stage laparoscopicroux-en-y gastricbypassasanalternativeinthesuper-super obesepatient.obessurg003;3: )CurrentstatusofbariatricsurgeryinJapanand efectiveness in obesity and diabetes SasakiA, YakabayashiG,YoneiY.JGatroenterol03 DOI 0.007/s )A review oflaparoscopicsleevegastrectomy for morbidobesity.shix,karmalis,sharmaam,birch DW.ObesSurg00;0:7-7. 0)RoaPE,Kaidar-PersonO,PintoD.Laparoscopic sleevegastrectomyastreatmentformorbidobesity: techniqueandshort-term outcome.obessurg006; 6:33-6. )Cotam D, Qureshi FG, Matar SG, et al. Laparoscopicsleevegastrectomyasaninitialweightlossprocedure forhigh-risk patientswith morbid obesity.surgendosc006;0: )MognolP,Chosidow D,MarmuseJP.Laparoscopic sleevegastrectomyasaninitialbariatricoperationfor high-riskpatients:initialresultsin0patients.obes Surg005;5: )MingroneG,PanunziS,DeGaetanoA,GuidoneC, IaconeliA,LeccesiL,NanniG,PompA,Castagneto M,GhirlandaG,RubinoF.Bariatricsurgeryversus conventionalmedicaltherapyfortypediabetes.n EnglJMed0;366(7): )SchauerPR,KashyapSR,WolskiK,BrethauerSA, KirwanJP,PothierCE,ThomasS,AboodB,Nissen SE,BhatDL.Bariatricsurgery versusintensive medicaltherapyinobesepatientswithdiabetes.n EnglJMed0;366: )Long-term resultsoflaparoscopicsleevegastrectomyforobesity.himpensj,dobbeleirj,peetersg. AnnSurg00Aug;5(): )Harvey EJ,Arroyo K,KornerJ,InabnetWB. Hormonechangesafectingenergyhomeostasisafter metabolicsurgery.mtsinaijmed00;77: )Katzmarzyk PT,Janssen I.The economiccosts associated with physicalinactivity and obesity in Canada:anupdate.CanJApplPhysiol004;9: )Third InternationalSummit:Current status of sleevegastrectomy.deitelm,gagnerm,ericksonal, CrosbyRD.SurgObesRelatDis0;7: doi: 0.06/j.soard )Bariatric surgery for the treatmentofmorbid obesity:ameta-analysisofweightlossoutcomesfor laparoscopicadjustable gastricbanding and laparoscopicgastricbypass.garbj,welchg,zagarinss, KuhnJ,RomaneliJ.ObesSurg009;9: )Predicting risk for serious complications with bariatricsurgery:resultsfrom themichiganbariatric SurgeryColaborative.FinksJF,KoleKL,Yenumula PR,EnglishWJ,KrauseKR,CarlinAM,Genaw JA, BanerjeeM,BirkmeyerJD,BirkmeyerNJ;Michigan BariatricSurgeryColaborative,from thecenterfor HealthcareOutcomesandPolicy.AnnSurg0;54: )Gastricbandingorbypass?A systematicreview comparingthetwomostpopularbariatricprocedures. TiceJA,KarlinerL,WalshJ,PetersenAJ,Feldman MD.Am JMed008;:

8 66 Sakakuraetal. 和文抄録本邦における病的肥満及び併存疾患に対する腹腔鏡下スリーブ状胃切除術の短期成績阪倉長平, 小座本雄軌, 戸川剛, 萩原明於, 大辻英吾藤原窪田斉健, 岡本和真, 市川大輔, 中西正芳, 栗生宜明, 生駒久視, 塩崎敦小松周平, 村山康利, 森村玲, 小西博貴京都府立医科大学大学院医学研究科消化器外科学同志社大学生命医科学部 < 背景 > 腹腔鏡下スリーブ状胃切除術 (LSG) は, 欧米においては病的肥満患者に対する代謝手術として広く行われているが, 本邦では未だ一般化されていない. 本術式の日本人に対する有効性を検討した. < 対象と方法 > 009 年月から 03 年月までに, 肥満治療学会ステートメントの手術適応基準に準拠した 4 人に対して本術式を施行した. 超過体重減少率 (%EWL), 併発疾患の改善効果などについて経時的に経過観察した. < 結果 >いずれも腹腔鏡下手術にて施行しえた. 手術時間は 85.5±8.4 分, 術後合併症は認めなかった. 術後年後での %EWLは 55.0±.8% で, 型糖尿病や高血圧や高脂血症などの併存疾患の著明な改善効果を認めた. 内服薬やインシュリン皮下投与などは不要となり, その効果は術後か月間以上持続した. しかし術後フォロー中に術前からの糖尿病性腎障害の増悪による人工透析移行 ( 術後 30 ヶ月 ) を例, 神経症増悪による通院困難とリバウンド ( 術後ヶ月 ) を例に認めた. < 結論 > LSG は日本人の病的肥満患者に対しても安全に施行可能であり, 代謝手術として有効であると考えられた. また術後の合併症やリバウンドを予防するためには, 外科医のみならず精神科医や看護師やカウンセラーなどの多職種によるフォローアップが必要であると考えられた. キーワード : 減量手術, 肥満,LSG.

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untitled 1 日目 10 月 27 日木第 1 会場国際会議室開会の辞 12 15 12 20 ランチョンセミナー 1 12 20 13 10 共催大鵬薬品工業株式会社 LS- 1 座長齊藤博昭鳥取大学医学部病態制御外科学分野今度どうなる胃癌の術後補助化学療法小寺泰弘名古屋大学大学院医学系研究科消化器外科学主題 1 高齢者進行胃癌に対する治療戦略定型か縮小か 13 20 14