Sign in to follow this  
Followers 0
North Star

Does bougie size matter? Slow weight loss.

2 posts in this topic

Hi Dr. Callery,

I'm  having a slow weight loss. I had gastric sleeve in October 2015. My surgeon used 38 size bougie. Does bougie size matter ?

Share this post


Link to post
Share on other sites

Dear North Star,

As you know a bougie is a flexible tube that is place in the stomach by the anesthesiologist. The surgeon uses the bougie to guide the stomach transection (cut/stapling). Bougie sizes are expressed in French (Fr.) units. Divide the Fr. by 3 to get mm. So 42 Fr. is the same as 13 mm. If the sleeve is too tight, people can't eat thicker foods. If the stomach is too large, there is less restriction. There may also be an increased risk of staple line leak if the stomach is too narrow.

Here's were it gets tricky. Many surgeons use the bougie as a guide, but don't cut exactly on the bougie. To do so would leave the stomach too narrow near the top of the stomach and near the bend in the stomach (angula incisura). So surgeons often cut wide of the bouie as needed. There is no absolute agreement on bougie size, and there is little objective research that can be used to inform a surgeon's choice.

To make matters even trickier, there is a lot of variation from stomach to stomach. Some are thicker or thinner and some are more or less elastic. These differences can make getting an exact diameter of the sleeve difficult. In addition the stomach isn't flat. It bends toward the back near the top. So getting a nice clean staple line going around a bend while not getting too close to the esophagus is a challenge.

Bougie size choices range from 36 to 50. The "consensus" among surgeons who have done large numbers of cases is that about 40 Fr. best. However, as we all know consensus is a good starting point. There is no substitute for carefully done research.  "The great tragedy of science - the slaying of beautiful hypothesis by and ugly fact." - Thomas Huxley.

Bariatric surgeries including the sleeve are "tools" to help with weight loss. The sleeve works partially by restriction, partially by changes in internal hormone signalling, and to a great extent by patient behavior. As you know behavior is a matter of choice. But choice is a tricky issue. Our choices are a matter of immediate will power, but are influenced by environment, social factors, and genetics. The sleeve is definitely more restrictive early on, and like the bypass, becomes looser as time passes. Hormonal effects of surgery may be more profound early one and less so later. Finally, people are often more highly motivated at first, and lose resolve with time.

So as you can see there are a lot of trade-offs. Larger diameter sleeves may be safer, but may not give quite as much resistance to eating. Sleeve diameter is probably not related to hormonal effect. Sleeve diameter doesn't affect a patient's social setting, genetics, or activity level.

Before surgery each patient should have a discussion with her/his surgeon about technical aspects of the surgery and expectations for weight loss and relief of medical problems.

From a practical standpoint, after surgery, each person should make the best of the situation. If you are not losing weight as quickly as you expect,discuss it with your surgeon. Are your expectations realistic given your preop weight and medical condition? How many calories are you taking in each day. It's easy to over eat after any operation by nibbling or snacking. What is the quality of the food that you are eating? Are you getting in as much physical activity as possible? Are you getting a good night's sleep? Who are your hanging out with, and what are their eating habits? Are you taking medications that tend to make you hungrier? Can you do anything to reduce your stress level?

In summary, bougie size matters, but it's only one of many things that matter. Patients can see a real improvement in their health and weight regardless of which size bougie the surgeon uses.

Choose healthy, be active, and have a Happy New Year,

Dr. Callery

 

Surg Endosc. 2015 Jul 21. [Epub ahead of print]

Laparoscopic sleeve gastrectomy with 27 versus 39 Fr bougie calibration: a randomized controlled trial.

BACKGROUND:

Laparoscopic sleeve gastrectomy (LSG) has become a widely used primary bariatric surgery. As this is a restrictive procedure, calibrating bougie size is assumed to impact on both morbidity and weight loss. However, no prospective studies have confirmed this hypothesis. The objective of this trial was to compare LSG outcomes using different calibrating bougie diameters.

MATERIALS AND METHODS:

A randomized controlled trial: 126 patients undergoing LSG were randomized to either a 27-Fr (group A) or a 39-Fr (group B) calibrating bougie. Inclusion criteria were BMI 40-50 kg/m2, aged 20-70 and absence of prior gastric surgery. All surgeries were performed by the same surgeon. Sample size was calculated to detect a six-point difference in percentage of excess weight loss (%EWL) at 1 year after surgery, considering an α error = 0.05 and a β error = 0.2. The volume of resected stomach, morbidity and weight loss at 6 months and at 1 year after surgery were analyzed.

RESULTS:

Groups (group A n = 62, group B n = 64) were similar in BMI (44.3 vs. 43.5), aged (41.9 vs. 42.2) and female percentage (87.1 vs. 84.3 %). A 1-year follow-up was achieved in 90.1 and 87.1 %, respectively. Two major complications occurred, one leak in each group (1.6 %). The volume of resected stomach was similar (426 vs. 402 ml, P = 0.71), as well as 6 months %EWL (66.3 vs. 66.6 %; P = 0.91) and 1 year %EWL (75.6 vs. 71.3 %, P = 0.21). A 1-year %EWL higher than 50 was achieved in 96.5 % of patients in group A versus 85.2 % in group B (P = 0.11).

CONCLUSIONS:

The use of different bougie diameters had no impact on the volume of resected stomach, morbidity or short-term weight loss after LSG, although a trend was seen toward better weight loss with the smaller bougie. A longer-lasting follow-up will be necessary to further assess differences.

______________________________________________________________________________________________________________________________________________

Obes Surg. 2014 Jul;24(7):1090-3. doi: 10.1007/s11695-014-1199-9.

Laparoscopic sleeve gastrectomy using 42-French versus 32-French bougie: the first-year outcome.

BACKGROUND:

The optimal size of bougie in laparoscopic sleeve gastrectomy (LSG) remains controversial. The aim of this study was to evaluate the first-year outcome of LSG using two different sizes of bougies.

METHODS:

This study used a single institute retrospective case-control study of two groups of patients. Group A (N = 66) underwent LSG using 42-Fr and group B (N = 54) using 32-Fr bougies. A medication score was applied to assess the change in comorbid conditions.

RESULTS:

Groups A and B's age (39.5 ± 12 vs. 43.6 ± 12.3 years), weight (119 ± 17 vs. 120 ± 20), and BMI (42.8 ± 3.8 vs. 43.6 ± 6.9 kg/m(2)), respectively, were comparable (p = NS). Comorbid conditions were type 2 diabetes (T2DM) in 19 (29%) vs. 23 (43%) patients, hypertension in 22 (33%) vs. 18 (33%) patients, and gastroesophageal reflux (GERD) in 28 (42%) vs. 10 (19%) patients, respectively. At 1 year, group A vs. B BMI was (29.4 ± 5 vs. 30 ± 5 kg/m(2)) and excess weight loss was 67 vs. 65%, respectively (p = NS). Postoperatively, T2DM (79 vs. 83%), hypertension (82 vs. 61%), and GERD (82 vs. 60%) (p = NS), respectively, in groups A vs. B did not require previous medications anymore. Complications were comparable.

CONCLUSIONS:

Our data suggest that using a 42-Fr or 32-Fr bougie does not influence LSG first-year weight loss or resolution of comorbid conditions. Long-term data is needed to conclude this issue.

_________________________________________________________________________________________________________________________

 

Int J Surg. 2014;12(5):504-8. doi: 10.1016/j.ijsu.2014.02.008. Epub 2014 Feb 18.

Long term predictors of success after laparoscopic sleeve gastrectomy.

BACKGROUND:

To evaluate early, mid and long term efficacy of laparoscopic sleeve gastrectomy as a definitive management of morbid obesity and to study factors that may predict its success.

MATERIALS AND METHODS:

A retrospective study was conducted by reviewing the database of patients who underwent LSG as a definitive bariatric procedure, from April 2005 to March 2013. Univariate and multivariate analysis were performed.

RESULTS:

1395 patients were included in this study. Mean age was 33 years and women:men ratio was 74:26. The mean preoperative BMI was 46 kg/m(2). Operative time was 113 ± 29 min. Reinforcement of staple line was done only in 447 (32%) cases. 11 (0.79%) cases developed postoperative leak, with total number of complications 72 (5.1%) and 0% mortality. Percentage of excess weight loss (%EWL) was 42%, 53%, 61%, 73%, 67%, 61%, 59% and 57% at 6 months, 1-7 years. Remission of diabetes (DM), hypertension (HTN) and hyperlipidaemia (HLP) occurred 69%, 54% and 43% respectively. 56 (4%) patients underwent revision surgery, for insufficient weight loss (n = 37) and severe reflux symptoms (n = 19). Mean follow up was 76 ± 19 (range: 6-103) months. Smaller bougie size and leaving smaller antrum were associated with significant %EWL. Bougie ≤36F remained significant in multivariate analysis.

CONCLUSION:

This study supports safety, effectiveness and durability of LSG as a sole definitive bariatric procedure. Smaller bougie size and shorter distance from pylorus were associated with significant %EWL.

Copyright © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

__________________________________________________________________________________________________________________
 
 
Obes Surg. 2013 Oct;23(10):1685-91. doi: 10.1007/s11695-013-1047-3.

The effects of bougie caliber on leaks and excess weight loss following laparoscopic sleeve gastrectomy. Is there an ideal bougie size?

Laparoscopic sleeve gastrectomy (LSG) has become a common surgical procedure, yet there is no consensus on what bougie size is best for LSG. We reviewed the literature and assessed the relationship between the size of bougie used and the incidence of leak as well as weight loss parameters. We wanted to determine if there is an ideal bougie size for LSG. A search of the medical literature was undertaken. We limited the search to articles published in the last 5 years written in English and investigating humans. We analyzed 32 publications comprising 4,999 patients. We determined the frequency of staple line leaks as well as weight loss parameters in relation to bougie size. This study was exempt from our institutional review board. The use of bougies of 40 French (F) and larger was associated with a leak rate of 0.92% as opposed to 2.67% for smaller bougies (p < 0.05). Weight loss in percent of extra weight loss (%EWL) was 69.2% when a bougie of 40 F and larger was used, as opposed to 60.7% of EWL when smaller bougies were used (p = 0.29). LSG is becoming an important and common procedure. Larger sizing bougies are associated with a significant decrease in incidence of leak with no change in weight loss. Further studies are needed before an unequivocal decision on the optimal bougie size is made. A recommendation to use the smallest bougie possible should be avoided because the risks may outweigh the benefits.

 
__________________________________________________________________________________________________________________
 
 
Surg Endosc. 2012 Jun;26(6):1509-15. doi: 10.1007/s00464-011-2085-3. Epub 2011 Dec 17.

Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients.

INTRODUCTION:

Sleeve gastrectomy has become a popular stand-alone bariatric procedure with comparable weight loss and resolution of comorbidities to that of laparoscopic gastric bypass. The simplicity of the procedure and the decreased long-term risk profile make this surgery more appealing. Nonetheless, the ever present risk of a staple-line leak is still of great concern and needs further investigation.

METHODS:

An electronic literature search of MEDLINE database plus manual reference checks of articles published on laparoscopic sleeve gastrectomy for morbid obesity and its complications was completed. Keywords used in the search were "sleeve gastrectomy" OR "gastric sleeve" AND "leak." We analyzed 29 publications, including 4,888 patients. We analyzed the frequency of leak after sleeve gastrectomy and its associated risks of causation.

RESULTS:

The risk of leak after sleeve gastrectomy in all comers was 2.4%. This risk was 2.9% in the super-obese [body mass index (BMI) > 50 kg/m(2)] and 2.2% for BMI < 50 kg/m(2). Staple height and use of buttressing material did not affect leak rate. The use of a size 40-Fr or greater bougie was associated with a leak rate of 0.6% compared with those who used smaller sizes whose leak rate was 2.8%. Leaks were found at the proximal third of the stomach in 89% of cases. Most leaks were diagnosed after discharge. Endoscopic management is a viable option for leaks and was documented in 11% of cases as successful.

CONCLUSIONS:

Sleeve gastrectomy has become an important surgical option for the treatment of the ever growing morbidly obese population. The risk of leak is low at 2.4%. Attention to detail specifically at the esophagogastric junction cannot be stressed enough. Careful patient selection (BMI < 50 kg/m(2)) and adopting the use of a 40-Fr or larger bougie may decrease the risk of leak. Vigilant follow-up during the first 30 days is critical to avoid catastrophe, because most leaks will happen after patient discharge.

 
___________________________________________________________________________________________________________________
 

Surg Obes Relat Dis. 2008 Jul-Aug;4(4):528-33. doi: 10.1016/j.soard.2008.03.245.


Laparoscopic sleeve gastrectomy: does bougie size affect mean %EWL? Short-term outcomes.

BACKGROUND:

Laparoscopic sleeve gastrectomy (LSG) has been increasingly offered to high-risk bariatric patients as the first-stage procedure before gastric bypass or biliopancreatic diversion or as the primary weight loss procedure. The bougie size has varied by surgeon during LSG. The aim of this study was to determine whether short-term weight loss correlates with the bougie size used during creation of the sleeve.

METHODS:

We retrospectively reviewed the data from all patients who had undergone LSG at our institution between 2003 and 2006. Revision LSG for failed bariatric procedures was excluded. The data analyzed included preoperative age, body mass index (BMI), bougie size, and percentage of excess weight loss (%EWL).

RESULTS:

A total of 135 patients underwent LSG during the 4-year period. Most of these patients (79%) underwent LSG as part of a 2-stage operation (either gastric bypass or duodenal switch within a mean of 11 months). The mean preoperative age and BMI was 43.5 years and 60.1 kg/m(2), respectively. The mean BMI and %EWL at 6 months was 47.1 kg/m(2) and 37.9%, respectively. The mean BMI and %EWL at 12 months was 44.3 kg/m(2) and 47.3%, respectively. When stratifying the %EWL by bougie size (40F versus 60F), we did not find a significant difference at 6 months (38.8% versus 40.6%, P = NS) or 12 months (51.9% versus 45.4%, P = NS).

CONCLUSION:

LSG results in significant weight loss in the short term. When stratifying outcomes by bougie size, our results suggested that a bougie size of 40F compared with 60F does not result in significantly greater weight loss in the short term. However, longer follow-up of the primary LSG group is required to determine whether a difference becomes evident over time.

Edited by Dr. Callery
MarktheNerd and 17May16 like this

Share this post


Link to post
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!


Register a new account

Sign in

Already have an account? Sign in here.


Sign In Now
Sign in to follow this  
Followers 0