D. DEL CASTILLO sleeve gastrectomy

Good morning, Roma.

Good morning, Tarragona. How are you?

Good. Very well.

Okay. As I said, Professor Palazzini,

thanks you for participating to this meeting.

There are many colleagues in the main hall

who are following you on the multi-screen

and can hear you on channel number eight.

My name is Michele.

I will be with you during the whole procedure, and I will ask you some questions, and please,

whenever you want to start illustrating the case, we are ready to follow you.

Okay.

Perfect.

Now we begin.

Again, when you say.

Any moment.

Whenever you feel like.

You can start if you want.

Thank you. Thank you very much.

Now, good morning from Reus.

We are located 100 kilometers south of Barcelona,

in the hometown of Antonio Gaudí.

Now I will present the surgical team.

the first sergeant is Professor del Castillo and the rest of team is Dr. Blanco, Dr. Hernandez and myself.

The anesthesiologist is Dr. Jordi Sánchez, Dr. Cuenca and the nursing staff we present is Maggie Blais, Mercedes Luzon and Rosa Sanguesa.

The surgery that we present in this session is laparoscopic sleeve gastrectomy.

The patient is a 39-year-old woman with a bone mass index of 44, and the preoperative

gastroscopy and gastric biopsy demonstrated a chronic gastritis with intestinal metaplasia.

That's the reason why we decided to make a sleeve gastrectomy, not a bypass.

The patient is now in the Davis position and in antithandelenburg.

The first surgeon is located between the legs of the patient habitually.

Here we present the side pods.

15 mm port will be useful for the removal of the stomach and there is no consensus about

the optimal distance from the pilaris in this case we start to 8 cm due to a slow gastric

emptying and finally the guide uses a 4-shape rope of 38 cranes and now let's go.

Thank you very much for this opportunity.

Hello Tarragona, we can hear you, good morning to all of you.

We already heard about the case.

So the procedure that you plan to perform is live gastrectomy, right?

Okay, yes.

In the hall, in the audience, there are also many young surgeons.

So please feel free to explain everything, even the simple things.

That would be very useful.

Thank you.

To start, we put five troccars. The first troccar is in the middle line. It's a 10 mm troccar.

We don't use the burst needle. We use the BC port system.

And we start.

This is the pass here, the posterior pass here.

Now we put the gas.

Yes, yes, it's coming in.

Probably we're inside now.

Yes.

Let's warm up a bit.

No, Andy.

This is a bit dirty.

Okay, we're inside.

Okay, the images are good.

We can see well.

We put a 12mm stroker on the left side and a 5mm stroker on the left side.

And then a 15mm stroker on the right side.

and 5mm stroker in the pigastric

so the total number of stroker is

5

to separate the left

the lever

on the right side

and that's the one that you this is the 15 millimeter yes which is the one that

you will use to take the piece of stomach out

It's a good lever for us, for the patient.

introduction you said that it's because this patient has a slow gastric emptying

it makes as a pump to the volume.

We cannot hear very well.

Can you try speaking with the microphone

a little closer to your mouth, please?

Yes, just a moment.

Now can you hear me?

Now it's better, thank you.

Now it's very disturbed.

We cannot understand what you say.

Okay, now it's better.

Better.

there was a noise yes now it's okay perfect I said that there is not a consensus about the

distance of the pillars when we start to cut in this case a patient has a slow gastric emptying

and we think that preserving part of ant room this ant room is like like a perm to to make

Take the bows, go down.

Okay, it's clear.

Thank you.

these are the short vessels

between stomach and spleen

if this lady

she's a lady, right?

yes

if this lady would have not had

the chronic gastritis with the intestinal metaplasia would you have

performed a different procedure yes the protocol said that there is a gastric

bypass because she's a 44 bond mass index and well is our protocol

Yes, I have a question.

If you don't have a study visa,

do you have a university visa?

Do you have a visa?

If you don't have a school visa,

you don't have a visa.

Yes, I have a visa.

I have to go home.

There are some other addresses between Stomach and Flynn.

That's very close.

And now we can see the end of the section very well here.

Can you see the left cross here?

This is very important to free the fundus and the fish angle in this place.

You have to mobilize the gastro-phrenic ligament, right?

How old is this lady?

39 years old.

This is the pancreas, yeah?

You see?

Okay.

Okay.

Okay.

We go to the pylorus now.

Cleaning.

Cleaning.

Cleaning the oxygen.

Look.

I'm sorry.

You see the pilots there?

Yes, we can see.

How large is it?

Thirty-eight.

Thirty-eight?

There are some adherences between

the gold platter and... Yes, yes, but

but we think it's now necessary to liberate it.

Free.

A little bit more.

The greater curvature now is completely free for you.

Now Dr. Sanchez put the emoji.

I see, okay.

Vale, entra un poquito.

Espera, retira, retira, que se está...

Se está volando.

Sí, se está volando.

De todas maneras, como vamos a empezar ahí...

Un poquito más, un poco más, un poco más.

Un poco más.

Sí, un poco más.

Un poco más.

Espera, vale, quédate ahí un momento.

Yes, now it's well positioned, along the lesser curvature.

How long is that suture?

Eight centimeters.

We start here.

okay is there a reason why you prepared also the distal part of the stomach the

one where you will not staple we try to do it the same possible in all patients

We usually use two green cartridges at the beginning of the division.

And then you would switch to the blue one, right?

Uh-huh.

We have some cleaning here.

We mobilize the tube for ensure the shot.

The next is the Blue Cartridge.

We have to clean here.

Ok, we have to clean it.

Now we use a 60mm blue cartridge until the end of the division.

Change the port. Until now we used the 15 port and now we will produce the cartridge in the 12mm port on the left side.

I'm sorry.

Ok. Dr. Sánchez.

Before firing always testing the correct position of the bullet.

For us it is very important to remove completely the posterior pouch.

Dr. Sánchez, please.

Probably this is the last file, probably, not always.

I don't know if you can see it, but the epitome is over there.

Ah, OK.

Testing the tube, please, Dr. Sanchez, please.

Buzzing.

Buzzing.

Ah, OK.

Still another one.

We are not sure, there is a stomach here, probably only the...

Yeah, yes.

No, no.

Yeah, there is no stomach.

This is the specimen and this is the tube.

Are you going to suture now or not?

No.

No.

I'm going to do a hepatic biopsy.

Can you tell us something about your results with this kind of procedure?

Well, here, the weight loss percent is about 60%, and we are studying these patients,

also making liver biopsies to study the evolution of osteotosis.

yes because it's there's no result so clarifying the evolution of a statuses

so you do it routinely yes always always right by signet

authority by the patient and also a blue samples were obtained to

to hormonal studies.

We are now studying the evolution of the cytosis

at the year of the surgery,

and these patients are so kindly.

We can do a second biopsy of the liver.

Percutanus.

Yes, guided by TAC.

Now we're going to remove the specimens.

Smoke from the...

The nasogastric tube is here and we check the blue methylene.

This is the methylene blue to check the stunted tube.

The next one I'll give you, you can carry it yourself, I don't see it.

Yes, yes, there's more, there's more.

Here?

Yes.

We have to clean here.

The test with the blue was negative, right?

Yes.

I hope.

What is the complication rate of this procedure?

Well, the main complication are the licks and hemorrhagic licks at level of his angle.

In what percentage?

Three or four percent.

Three or four percent.

The most licks are subclinical, are subclinical.

We have done to research again any lick.

how long do you leave the nose gastric tube just one day do you perform

radiologic testing for leaks before taking yes yes always always always yes

We remove the specimen.

In the 15mm port, we remove the stomach.

Okay.

Okay.

It came out faster even than the other one.

It's really good.

We always close this hole from the inside with a needle.

What are your indications for this kind of procedure?

Yes, in our center we perform the sleeve gastrectomy in patients with one mass index more than

50 or patients with comorbidities like diabetes or patients as a first step of the totally

is with duodenal. Patients with high risk or bone mass index of 60, 70, for example,

as a first step of duodenal switch. Until 50, we perform the gastric bypass. But in

this case, about intestinal metaplasia, we prefer to perform a sleeve gastrectomy.

When will this lady go home?

If it's all right, on Saturday.

I go to bed on Monday.

Two or three days.

Sunday, Monday.

Yes, on Sunday morning.

We don't see blue anywhere.

Yes.

Always we use a drain, a Jackson drain.

Jackson Pratt drain.

When do you remove it?

24, 48.

48 hours, more or less.

Okay, checking the fork sides.

What kind of laparoscope do you use, 90 degree, 30 degree?

30 degrees.

30 degrees.

Always use 30 degrees.

No bleeding.

Yes, we can see.

We are finished.

Do you have other procedures in your plan or is this the only one?

It's the only one. Today it's the only one.

Okay, so really congratulations for this very nice procedure.

It was very interesting, very kind.

Thank you to Professor del Castillo and the whole team.

We appreciate it very much.

Thank you by Professor Palazzini too.

Have a nice day.

Thank you very much.

Do you want to add something, say something about your experience, about your numbers?

you know only said that we are very great to be here with you and it's a good experience

for us for all of us thank you very much okay see you next year I hope thank you