Prof. C.M. HUANG Totally Laparoscopic Gleeve Gastrectomy

Hello, Dr. Dong. I'm Lu Jun.

Our surgery is about to start.

Okay.

Hey, did you say bye-bye, bye-bye?

Are the Italian experts gone?

They're still here.

Bye-bye, but it's Mr. Fan and Mr. Lujan.

Can you hear me?

Hello?

Yeah, yeah, we can hear you.

This is your second operation, I think.

Yeah, this is our second operation.

So you started to do this kind of operation in your center.

董教授好

Hello, 盧教授好

你好 你好

Hello, Dr. Lu

董教授好

Hi Professor Zheng, there are two professors online.

Hello friend from Italy, I think it's Dr. Massimo, Dr.

Yeah, I'm Dr. Desiderio and also Dr. Barbieri that is connected with you.

Nice meeting you guys online.

the line yeah welcome in rome

yes

I'll start now.

You can introduce Jacobo.

Professor Jacobo, can you hear me?

How are you?

Fine, long time no see.

How are you doing?

Can you explain the indication for your surgery?

I will indicate our second case patient information to you.

The second operation will do the total laparoscopic sleeve gastrectomy.

This is a 32 years old female patient with BMI 38.7 and no special disease history and

the vital signs are normal and the abdominal CT scan showed the moderate fatty liver and

and with uric acid higher, about 583.

And the patient also has diabetes,

and fasting blood glucose is more than nine.

So today we are prepared to do the sleeve gastrectomy

for this patient.

And our surgeon is Professor Chaohui Zheng from our center.

And also, we welcome two experts in our country, Dr. Dong, Professor Dong from Guangzhou, and Professor Zhang from Beijing.

Thank you.

It's out. Okay.

How many cases do you report each year?

Dr. Jackbo.

Thank you, Professor Lu. I'm very glad to have this opportunity to join this webinar and very look forward to the surgery demo by Professor Jun's team.

and also welcome everybody from the surgeons from italy and also from china

together to deliver a very proactive discussion and hopefully we can

exchange our idea and our techniques in the deep gastrectomy so i'm a i'm a

Dr. Charles Zhang from Beijing Friendship Hospital and is the Chief of Metabolic and Barrier Surgery.

All right, so here we also have Professor Dong Zhiyong Dong from Guangzhou. Can you introduce

yourself, Professor Dong? Yes, hello Professor Zhang. I'm Dr. Dong and I'm from Guangzhou,

So, first of all, at the hospital of Jinan University, I'm Nathan Farrell from CC1.

And I'm so very honored to be here with you, Jacopo, and the professor from Italy,

to join in this webinar, Live Surgery, from Dr. Chen.

So, thank you.

All right.

So, we also online, we have a professor.

Professor, we have, let's say, Professor Dosimo, he is a professor, president of Italy Society of Surgery, have Professor Di Ugo, he's a director of Agostino Gemmelti Polyclinic Hospital, Rome,

and also Professor Desiderio from St. Mary's Hospital of Terni, Italy, and also have Professor

Papieri. He's from the hospital of Reggio Emilia. Very nice to meet you, everybody.

Okay, so let's move forward. So I just heard the case report that this patient is

is a 30-year-old young person with a BMI of 38.7 with type 2 diabetes, and the fasting

plasma glucose is about 9 mmol per liter. So what's the HB-A1C level, and also how

how long is the duration of this type 2d how many years of duration

okay

So let's discuss this case.

So why do you guys do a stiff gastrectomy on this patient?

If you were the surgeon,

what kind of procedure are you going to do

to recommend to the patient?

Oh, I think you can answer.

All right.

I think this case is maybe suitable

for Dr. Professor Dong, because their centers are more...

So the question we asked, so how many years of type 2 diabetes does this patient have?

How many years of type 2 diabetes? One and more years, yes.

One and more years. One and more years.

One year, just one year? One year, just one year, yes.

Yes.

Okay.

Okay.

And then did you, did you had like endoscopy or upper GI or whatever to diagnose whether

a patient have the esophageal reflux or not?

Yes.

We do endoscopy for every patient.

So this patient.

I think it is this patient got a reflex.

No.

No.

There's no esophagitis, right?

Okay.

so so the question for dr uh dosimo like for this kind of patient what kind of procedure

do you recommend to the patient you cannot hear it

yeah i mean i mean for for this patient if he he's young and his bmi just 38 and type 2 diabetes just

just one year and looks like if there's no acid reflux, probably Steve is the best choice for

this patient. That's my opinion. I think it's probably the same here for every of us.

Like you say, this patient's BMI is not too high, and diabetes is just one year,

and not to do high sugar.

I think for me, I would choose sleeve, the same,

and then no reflex.

So if the patient got reflex, like level B,

so what do you recommend about the procedure,

the type of procedure?

yeah for patients they have if they have ra to uh lab uh like uh kind of esophagitis and also

there's a solid evidence of girl right now you're i i prefer more to someone that's your bypass

so how about how about the oagb do you uh choose the oagb sometimes no i i i don't i don't have

have too much experience about oegb because i just started that half a year ago because we're running

a trial compare oegb versus ygb that's the reason why i i start to practice oegb i i really i don't

have too much experience by oegb how about our our folks from italy for uh for this patient

what kind of procedure you really uh recommend to the to the i would like i would like i i agree

with the indication for a sleeve gastrectomy we are more bypass oriented but the bmi of this

patient allows to a choice if she has no reflux as i understand i think you're right

hello

did you hear me yes way to hear you okay thank you yes it's a distinct for our center

we perform in this case even as the gastrectomy also we started a trial for obesity patients

with the early diabetes onset of diabetes so less than one year

because we think that in some patients

can be a good indication also for the metabolic syndrome.

Okay.

Okay.

So, yeah, it looks like Professor Zheng is dissecting the funders.

So when you guys do the stiff gastrectomy,

how far do you usually dissect the funders?

Any anatomic mark?

For me, it's one to two centimeters.

Okay, so do you guys usually clearly expose the left crua?

Yes, usually we do.

Yeah, usually I do it.

Yes, yes, I agree.

So how about, let's say, how about a routine dissection of the hiatal, do sleeve gastrectomy,

do you really routinely dissect the hiatal, or if you don't do that, so what's your indication

when to dissect the hiatal and do the chloroplasty?

Okay. I'll go first. Okay. Usually, when I'm doing sleeve, I will detect the hiatal hernia.

If the deflection is too big or they have some deflection, I'll conduct sleeve plus

hiatal hernia repair. And sometimes, if the deflection is more than four centimeters,

meter i performed sleeve and the plus uh hyaluronic repair with mesh okay so professor i think

professor zhang is going going fast yeah he's going he's doing very fast

yeah very skilled so when when and also i'll ask uh our folks in italy so uh when when do you uh

dissect the hiatus when you do the stiff gastrectomy.

I mean, there are some surgeons now,

they dissect the hiatus for every patient.

I'd say never.

Me too.

Okay.

How many teachers do you perform at Fujian in Fuzhou?

Yes, yes, yes, in our hospital.

Yeah, but how many teachers per year?

Around, this year we have performed around 200.

200?

Yeah.

So, I think Professor Zhang is that with Deborah from Pinelaw is one, two centimeter, right?

It's kind of two centimeter.

Yeah, two centimeter.

Two to three centimeter.

So how, what size are the bougie?

36, 36, 36, yes.

Yes.

So what do you guys think of the EIDL budget size?

It looks nice.

So do you guys prefer to the electronic stapler, a power stapler, or just manual?

Thank you very much.

Professor Tong?

yeah i think when you do a sleeve procedure do you use the ultrasonic knife or like ligature

energy devices ultrasonic knife only use yeah okay sonic knife yeah maybe maybe i i think

i think professor zhang sometimes use the yeah you know i i like both i like both but

uh for for steve gastrectomy i think the uh ligature give you more power

when i do uh one gas bypass are your preferred to the uh harmonic but for the for the uh steve i

I prefer more to ligature.

Ligature.

Ligature sometimes is good for stop breathing,

and especially for short, yeah, arteries.

So how do you guide to prevent the stenosis

when doing the second stablet?

How to avoid stenosis, right?

Yes, stenosis is important, I think,

in the second step yeah so uh you're you're when i when i do first cutting i uh i don't have uh

fuji inside and uh and all i do for first stapler i uh without puji so it all depends on the

anatomic marks so i the end of the black vessel from the uh from a small curvature which is uh

which is an atomic mark i use so don't expect that in the first from second stapler i use the

budgie and once you put inside usually you uh you you you won't cause if there's no tricky

you won't cause any stenosis but the thing that so the budgie must be more floppy if you use a

very rigid bulging and can affect your judgment i know uh yeah you know a lot of surgeons use

like a poly pu tube it's not actually a bulge you use pure tube you you re-sterilize that and it

gets uh that uh bulges the tube more rigid so that's uh sometimes if you uh just affect your

judgment and cause the stenosis so what kind of uh uh booty size uh do you usually use are you 34

are you 34 french 34 yes oh yeah it's from uh uh tele uh whatever that's not everything from

yeah they have some evidence from uh paper they think the idol size of the boujee is kind of 33 to

36 is the best for sleeve so what do you think i agree so our you know there's uh no we we don't

have no we don't have something like a seam guard for the for when we do the stippling stippling how

how how's our uh how's your prep the practice in italy that's certainly usually uh they use

like a seam guard with a stapler or not the singer okay yeah we think it's useful and fast

fast do you think that that really helps uh yes it seems in our experience uh we we don't perform

a suturing we prefer to use the the singer usually it's give us a good

they most assist you can tell me so how I don't know how we go so okay okay okay

I mean I can't I think he's got another you can add a part of it you go so we

bunch you need I don't you know we're gonna hold on okay so the super last

cutting the professor to me you really do like one point five centimeter to the

piece angle so yeah this is the his angle over here and more than one

which percentage of fistulas do you have post-operative

hello well can you hear me you know the percentage of fistulas in china

After this procedure, we just use suture, the stabilizer, reinforce the stabilizer.

Most people reinforce the stabilizer, only use the suture.

Okay.

意大利部分吗?

很多部分。他们有点膜。

So, they have some, a few directions in China, they didn't reinforce the stable line.

What is your leakage rate?

The data from our database is kind of about 1% leakage of the sleeve, but I think in most

the most big bacteria center, the leakage rate is only 0.1%.

I think it's the same in Professor Zhang's center.

You said 0.1?

0.1.

0.1.

Okay.

Like in our department, we almost done actually more than 4,000, but only three people get

like leaking.

Okay.

And in total, China, the debt is 1%, 2%.

So how about the debt in your center or in your country?

but like like i said we are more bypass gastric bypass yes we are more we are most lived

without kevin we don't have such an extensive experience in a sleeve gastrectomy but in in

In world literature, the percentage of leakage is 1.7, 1.7, 1.7, 2, 3, 4, yes.

You have a nice, very nice data.

Yeah.

Yeah.

And our center is 2% now, 2% Oh, okay.

That's good.

Yeah.

possibly we also got uh got some leakage from bypass like in our department we got one patient

uh got uh leakage from by after the bypass uh from one thousand patients so it is less

leakage in bypass right yes even in our experience yeah

uh i think the uh reinforcement is uh maybe is the reason why the leakage rate is so low

we are so worried about the leakage a lot of pressure from patients patient family and

the surgeon's team in the hospital if one patient got

leaky and you leave a nasogastric tube

i think i think dr zhang leave the

Boogie inside, right?

Boogie inside, okay.

Professor Zheng, is the boogie tube in there?

No.

I put the boogie out.

Remove the boogie.

Okay.

Remove the boogie.

For some surgeons, they like to put the boogie inside before the suture.

Reinforce.

Okay.

But after you finished, you left, you leave a nasogastric tube or not?

Yes.

No?

Nothing?

Nothing.

No tube, no gastric tube, no.

And no drain energy tube.

And you give a liquid diet when?

Tomorrow.

Tomorrow we get a liquid diet.

Tomorrow?

Yeah.

Ah, okay.

The first day after surgery.

The first, okay.

Okay.

Clear liquid.

Clear liquid.

Okay.

Before the clear water, maybe we'll give a person like the water, some water to

text and then later clear liquid.

Okay.

So I think you're saying in Italian, right?

Yes.

Yes.

Yes.

Even for the gastric bypass.

So, how much value our liquid per day, in the first day?

Yes, in the first day, yes.

How much?

How much?

How much?

500?

100?

No, 500.

500?

Yes.

Usually we do like 100 in the morning, 200 in the afternoon, and 300 in the evening.

in the evening okay yes okay it is easy to remember for the patient one two three

one two three yes and and even in gastric bypass you don't leave any nasogastric tube no no no okay

i think you're saying uh for professor zhang then professor zhang no yes same yeah thank you yeah

how many hospitals stay after operation in italian usually it depends of course

without the deliver problem the patient can be discharged after three days three days yes

In our center, four days discharge after operation.

It's quite the same, but it depends on the most operative course.

So, Giacomo, what's your opinion for the child surgery for obesity treatment?

What do you mean?

What's your opinion for the children surgery for obesity surgery?

How many, what's the age limitation for child in your center?

For our center is 65 years.

65 years.

Yeah, 65.

For your center?

Yeah, 16. Yes, same.

How about Dong? 16 or 14?

Eight.

Eight?

Eight? Eight, you mean?

maybe okay yes now it is some patient is very young but uh he got with serious obesity and

the metabolic disease uh disease okay like we have a patient he would perform innate

before we performed like bending but now there is no bending

i can't see it no no i mean silicon bending lagb laparoscopic adjustable gastric bending

no band anymore no bond anymore okay okay okay so do you still do bending no no no no no we have an

extensive experience here removing the bandings but i think you may say they also steal the

several thousand children do bending right yes yes but now it's not popular now

it's also for us

too high like regain yeah a lot of complications yes even even severe complication

Yes.

Right.

So, you guys never reinforce the stable line?

Never?

Or it depends?

No, we do.

No, we do.

We do.

Yes.

So, what kind of reinforce?

Like this.

Like this?

Like this.

Like this?

Yes.

Yeah, it's true, next year.

Yeah, it's a big conference in Italy in the next year, probably May or November.

November, yeah.

November.

Will you come?

Yes, I may be welcome. I never went to Italy. So, I think Italy is famous for back surgery

and also the headquarters of IFSO, right?

I mean the headquarters of IFSO.

The office is in Italy.

Headquarters.

You're almost done in this leaf.

A little bit.

A little bit, right?

Yeah.

I was still learning your seven steps yesterday.

What is the reason? They think that the reduction effect of the sleeve is not as good as the bypass.

So in Italy, the bypass is much more than the sleeve, right? In the whole country?

It depends on the center. We perform more sleeve gastrectomy.

It depends on every center. It's different, right? So how about the OHEV and ascites?

No, usually we perform sleeve S, the main procedure, not other procedures, or the bypass,

but in selective patients.

So do you like suture the omental to the stable line, like Professor Zheng just doing, no,

just leave it?

I think it doesn't make sense, right?

We can hear you. Professor, did you turn on your voice?

We never perform this…

This…

Aumentum to the storyline.

Dr. Tong, do you fix the Aumentum?

Yeah, I always do that.

There are some differences.

but they have as a paper i just they have a paper report that if you know

or mental to separate level uh got honey got hernia but just one case from the pubmed

so it does it doesn't matter

and do you leave a drain do leave a drain leave one drain one drain okay

oh so no no no drain no drain no drain no drain yeah finish

This professor's name, I don't know.

This older professor.

Professor Dugo.

Professor Dugo is not here.

Oh, sorry.

So, do you drink?

I'll put the sand tube.

Yes.

Yes.

Every sleeve, right?

Yes.

So far, international sleeve consensus, they're about 60, 70, don't put like a tube, any tube,

drainage tube.

tube so maybe it's dependent on the situation on the sleeve when doing the sleeve if you

worry about leaking you can put the tube or drape tuber yes it's for that and we we we do a check

in the second post-operative day and then we do text yeah after sleep do you do any

text gastrography Dr. Giacobbo in your center do you always give the patients a medication

for gallbladder prevention after surgery?

Always, routinely, yes, okay.

No, we, sorry, I just have some emergencies, sorry.

So when you give a patient like for UDC for three months,

gallstone is, the prevalence of gallstone

is pretty high after stiff gastrectomy.

So I routinely give patients UDC for three months.

You are like 250 milligram BID.

okay how about you guys yeah yeah i get it it's the same how about ppi uh dr professor zhang

so how long uh will a patient take a ppi after surgery sleeve or first leave i give two months

two months so why two months not one month no one month two months and for if we do bypass

give three month three month so okay depend on some evidence or experience

no we minimally minimally we give two months use after sleep and a three months

after gastric bypass if if a patient have some symptoms then probably the PPR

can be extended. Thank you. Thank you, Professor Do and Professor Zhang Peng. Thank you. Thank you.

I finished my operation. Thank you so much. Thanks to you. Thanks to you. Thanks to you.

Thank you.

Amazing.

Thank you.

See you.

Bye bye.

Have a good weekend.

Bye bye.

Happy Thanksgiving!