ArticlePDF Available

Long-term Metabolic Effects of Laparoscopic Sleeve Gastrectomy

Authors:

Abstract and Figures

The prevalence of laparoscopic sleeve gastrectomy (LSG) is increasing, but data on its long-term effect on obesity-related comorbidities are scarce. Because the population of bariatric patients is young, long-term results of those comorbidities are highly relevant. To investigate the long-term effects of LSG on weight loss, diabetes mellitus, hypertension, dyslipidemia, and hyperuricemia. Cohort study using a retrospective analysis of a prospective cohort at a university hospital. Data were collected from all patients undergoing LSGs performed by the same team between April 1, 2006, and February 28, 2013, including demographic details, weight follow-up, blood test results, and information on medications and comorbidities. Excess weight loss, obesity-related comorbidities, and partial and complete remission at 1, 3, and 5 years of follow-up. A total of 443 LSGs were performed. Complete data were available for 241 of the 443 patients (54.4%) at the 1-year follow-up, for 128 of 259 patients (49.4%) at the 3-year follow-up, and for 39 of 56 patients (69.6%) at the 5-year follow-up. The percentage of excess weight loss was 76.8%, 69.7%, and 56.1%, respectively. Complete remission of diabetes was maintained in 50.7%, 38.2%, and 20.0%, respectively, and remission of hypertension was maintained in 46.3%, 48.0%, and 45.5%, respectively. Changes in high-density lipoprotein cholesterol level (mean [SD] level preoperatively and at 1, 3, and 5 years, 46.7 [15.8], 52.8 [13.6], 56.8 [16.0], and 52.4 [13.8] mg/dL, respectively) and triglyceride level (mean [SD] level preoperatively and at 1, 3, and 5 years, 155.2 [86.1], 106.3 [45.3], 107.2 [53.4], and 126.4 [59.7] mg/dL, respectively) were significant compared with preoperative and postoperative measurements (P < .001). The decrease of low-density lipoprotein cholesterol level was significant only at 1 year (P = .04) and 3 years (P = .04) (mean [SD] level preoperatively and at 1, 3, and 5 years, 115.8 [33.2], 110.8 [32.0], 105.7 [25.9], and 110.6 [28.3] mg/dL, respectively). The changes in total cholesterol level did not reach statistical significance (mean [SD] level preoperatively and at 1, 3, and 5 years, 189.5 [38.2], 184.0 [35.4], 183.4 [31.2], and 188.1 [35.7] mg/dL, respectively). No changes in comorbidity status correlated with preoperative excess weight. Hypertriglyceridemia was the only comorbidity whose remission rates at 1 year of follow-up (partial/complete, 80.6%; complete, 72.2%) correlated with percentage of excess weight loss (76.8%) (P = .005). Undergoing LSG induced efficient weight loss and a major improvement in obesity-related comorbidities, with mostly no correlation to percentage of excess weight loss. There was a significant weight regain and a decrease in remission rates of diabetes and, to a lesser extent, other comorbidities over time.
Content may be subject to copyright.
Copyright 2015 American Medical Association. All rights reserved.
Long-term Metabolic Effects of Laparoscopic
Sleeve Gastrectomy
Inbal Golomb, BSc; Matan Ben David, MD; Adi Glass, BSc; Tamara Kolitz, MD; Andrei Keidar, MD
IMPORTANCE The prevalence of laparoscopic sleeve gastrectomy (LSG) is increasing, but data
on its long-term effect on obesity-related comorbidities are scarce. Because the population of
bariatric patients is young, long-term results of those comorbidities are highly relevant.
OBJECTIVE To investigate the long-term effects of LSG on weight loss, diabetes mellitus,
hypertension, dyslipidemia, and hyperuricemia.
DESIGN, SETTING, AND PARTICIPANTS Cohort study using a retrospective analysis of a
prospective cohort at a university hospital. Data were collected from all patients undergoing
LSGs performed by the same team between April 1, 2006, and February 28, 2013, including
demographic details, weight follow-up, blood test results, and information on medications
and comorbidities.
MAIN OUTCOMES AND MEASURES Excess weight loss, obesity-related comorbidities, and
partial and complete remission at 1, 3, and 5 years of follow-up.
RESULTS A total of 443 LSGs were performed. Complete data were available for 241 of the
443 patients (54.4%) at the 1-year follow-up, for 128 of 259 patients (49.4%) at the 3-year
follow-up, and for 39 of 56 patients (69.6%) at the 5-year follow-up. The percentage of
excess weight loss was 76.8%, 69.7%, and 56.1%, respectively. Complete remission
of diabetes was maintained in 50.7%, 38.2%, and 20.0%, respectively, and remission of
hypertension was maintained in 46.3%, 48.0%, and 45.5%, respectively. Changes in
high-density lipoprotein cholesterol level (mean [SD] level preoperatively and at 1, 3, and 5
years, 46.7 [15.8], 52.8 [13.6], 56.8 [16.0], and 52.4 [13.8] mg/dL, respectively) and
triglyceride level (mean [SD] level preoperatively and at 1, 3, and 5 years, 155.2 [86.1], 106.3
[45.3], 107.2 [53.4], and 126.4 [59.7] mg/dL, respectively) were significant compared with
preoperative and postoperative measurements (P< .001). The decrease of low-density
lipoprotein cholesterol level was significant only at 1 year (P= .04) and 3 years (P= .04)
(mean [SD] level preoperatively and at 1, 3, and 5 years, 115.8 [33.2], 110.8 [32.0], 105.7 [25.9],
and 110.6 [28.3] mg/dL, respectively). The changes in total cholesterol level did not reach
statistical significance (mean [SD] level preoperatively and at 1, 3, and 5 years, 189.5 [38.2],
184.0 [35.4], 183.4 [31.2], and 188.1 [35.7] mg/dL, respectively). No changes in comorbidity
status correlated with preoperative excess weight. Hypertriglyceridemia was the only
comorbidity whose remission rates at 1 year of follow-up (partial/complete, 80.6%; complete,
72.2%) correlated with percentage of excess weight loss (76.8%) (P= .005).
CONCLUSIONS AND RELEVANCE Undergoing LSG induced efficient weight loss and a major
improvement in obesity-related comorbidities, with mostly no correlation to percentage of
excess weight loss. There was a significant weight regain and a decrease in remission rates of
diabetes and, to a lesser extent, other comorbidities over time.
JAMA Surg. 2015;150(11):1051-1057. doi:10.1001/jamasurg.2015.2202
Published online August 5, 2015.
Invited Commentary
page 1057
Author Affiliations: Bariatric Clinic,
Rabin Medical Center, Beilinson
Hospital, Petah Tikva, Israel (Golomb,
Glass, Keidar); Department of
Surgery, Rabin Medical Center,
Beilinson Hospital, Petah Tikva, Israel
(Ben David, Keidar); Department of
Internal Medicine, Rabin Medical
Center, Beilinson Hospital, Petah
Tikva, Israel (Kolitz).
Corresponding Author: Andrei
Keidar,MD, Bariatric Clinic, Rabin
Medical Center, Beilinson Hospital,
Petah Tikva 4959208,Israel
(keidar66@yahoo.com).
Research
Original Investigation
(Reprinted) 1051
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: https://jamanetwork.com/ on 06/24/2020
Copyright 2015 American Medical Association. All rights reserved.
Obesity was recognized as a global epidemic by the World
Health Organization 15 years ago
1
and rates of obesity
have since been increasing. Obesity is currently con-
sidered a severe health hazard and a risk factor for diabetes melli-
tus, hypertension, dyslipidemia, heart failure, and many other
related comorbidities.
2
Obesity causes increased risk for car-
diovascular disease, even after eliminating other risk factors.
3
It is also a significant independent predictor of renal failure, in-
flammation, and many other comorbidities.
3-5
Bariatric procedures are reportedly the most effective strat-
egy to induce weight loss compared with nonsurgical
interventions.
6,7
Laparoscopic sleeve gastrectomy (LSG) is a
common and efficient bariatric procedure with increasing
popularity in the Westernworld during the last few years.
8
Both
intermediate and long-term data on LSGremain limited.
9
Most
of the earlier analyses had focused on weight loss and the re-
mission of diabetes,
6
even though hypertension, dyslipid-
emia, and hyperuricemia are also comorbidities commonly re-
lated to obesity. Moreover, most of the information on
dyslipidemia is based on records from follow-up of 2 years or
less,
10
and there are relatively few data on the long-term ef-
fects of LSG on these and other comorbidities.
In this study, we aimed to determine the effect of LSG on
diabetes, hypertension, hypercholesterolemia, hypertriglyc-
eridemia, and hyperuricemia after 1, 3, and 5 years. We also
sought to establish whether the remission of any of those obe-
sity-related comorbidities is correlated with weight loss and
which patients would be most likely to benefit from this pro-
cedure. The choice of bariatric procedure currently depends on
the surgeon’s preference, and there are few objective data to
compare the different approaches and their impact on spe-
cific comorbidities. This information is crucial to allow pa-
tients and physicians to choose the most appropriate proce-
dure according to the specific needs of each patient. The primary
end points of this study were excess weightloss and partial and
complete remission of obesity-related comorbidities.
Methods
This cohort study is a retrospective analysis of prospectively col-
lected data. Between April 1, 2006, and February 28, 2013, 1098
obese patients underwent bariatric surgery by the same surgical
team. Of these, 443 underwent LSG. All patientshad fulfilled the
criteria for undergoing bariatric surgery established by the
National Institutes of Health Consensus Conference.
11
They were
assigned to undergo an LSG based on clinical criteria, patient
choice, and the consensus of the bariatric clinic team. Potential
advantages, disadvantages, and risks of all procedures wereex-
plained in detail. The study was approved by the Rabin Medical
Center Institutional Review Board. Owing to the retrospective
nature of the study, a waiver of informed consent was granted.
Surgical Technique
All the LSGs were performed by the same surgical team. The gas-
tric tube was created using a 32Fr to 40Fr bougie. Stomach re-
section started 2 to 4 cm from the pylorus. Sleeve volume ranged
from 60 to 100 mL. Selective inversion of the staple line by se-
roserosal continuous suture (bougie in) was performed. Only the
areas of bleeding or staples crisscrossing or where the staples
seemed to not fit perfectly were oversutured.
The methylene blue dye leak test was used to ensure an
intact staple line. The percentage of excessweight loss (%EWL)
was calculated by assuming a normalized body weight at a body
mass index (BMI; calculated as weight in kilograms divided by
height in meters squared) of 25 and determined by dividing
the postoperative weightloss by the preoperative excess weight
and multiplying the result by 100.
Patient Care
Demographic data and the results of baseline blood tests were
collected. Type 2 diabetes mellitus (T2DM) was defined as a fast-
ing glucose level higher than 126 mg/dL (toconvert to millimoles
per liter, multiply by 0.0555) and glycated hemoglobin greater
than 6% of total hemoglobin (to convertto proportion of total he-
moglobin, multiply by 0.01), or any levelsin a patient receiving
antihyperglycemictreatment. Impaired fasting glucose (IFG) was
defined as a fasting glucose level higher than 100 mg/dL and
lower than 126 mg/dL in patientsw ith no use of antihyperglyce-
mic treatment. Hypercholesterolemiawas defined as a total cho-
lesterol level higher than 200 mg/dL (toconvert to millimoles per
liter, multiply by0.0259). Hypertriglyceridemia was defined as
a triglyceride level higher than 150 mg/dL (to convert to milli-
moles per liter, multiply by 0.0113). Hypertension was defined
as blood pressure higher than 140/90 mm Hgon more than 3 oc-
casions or the use of medications to treat hypertension. Hyper-
uricemia was defined as a plasma uric acid level higher than 6.8
mg/dL (to convert tomic romoles per liter, multiply by 59.485).
Preoperative and postoperativelaboratory assessments included
a complete blood cell count and ferritin, albumin, fasting glucose,
glycated hemoglobin, lipid profile, serum folate, vitamin B
12
,vi-
tamin D, and parathyroid hormone analyses. Information on
medication use was also collected prior to the surgery.
The postoperative follow-up was scheduled to take place
at 1, 3, 6, and 12 months and every year thereafter. Data were
gathered from hospital medical records, postoperative office
visit findings, and telephone interviews. Remissions of T2DM
and IFG were defined as a normal fasting glucose level (<100
mg/dL) and a normal glycated hemoglobin level (<6% of total
hemoglobin), respectively, with no use of insulin or oral medi-
cations. Partial remission for T2DM was defined as a reduc-
tion of medication dosage or cessation of medication use de-
spite abnormal laboratory results. No partial remission was
defined for IFG. Forarterial hypertension, normal blood pres-
sure without medication was considered remission and a de-
crease of medication dosage was considered partial remis-
sion. Remission of hyperlipidemia was defined as cessation of
medication use with normal laboratory results. Partial remis-
sion was defined as reduction of medication dosage or cessa-
tion of medication use despite abnormal laboratory results.
Statistical Analysis
The statistical analysis was performed using SAS version 9.4
statistical software (SAS Institute, Inc). Continuous variables
are presented as mean (standard deviation). Categorical vari-
ables are presented as number (percentage). The ttest was used
Research Original Investigation Metabolic Effects of Laparoscopic Sleeve Gastrectomy
1052 JAMA Surgery November 2015 Volume 150,Number 11 (Reprinted) jamasurgery.com
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: https://jamanetwork.com/ on 06/24/2020
Copyright 2015 American Medical Association. All rights reserved.
to compare the value of continuous variables between study
groups, and the χ
2
test was used to compare categorical vari-
ables between study groups. The paired ttest was used to as-
sess changes in clinical measures for patients at differenttimes.
Statistical significance was reached at P< .05.
Results
Of the total of 1098 patients who underwent bariatric surgery
between April 1, 2006, and February 28, 2013, 443 under-
went LSG. Complete data were available for 241 of the 443pa-
tients (54.4%) at the 1-year follow-up, for 128 of 259 patients
(49.4%) at the 3-year follow-up, and for 39 of 56 patients
(69.6%) at the 5-year follow-up. The study patients’ mean (SD)
age was 42.2 (12.4) years (range, 13-72 years), and their rel-
evant characteristics are listed in Table 1.
Prior to undergoing the surgery, 82 patients had been diag-
nosed as having T2DM, 65 as having IFG, 110 as having hyper-
tension, 155 as having hypercholesterolemia, 109 as having hy-
pertriglyceridemia, and 55 as having hyperuricemia. The rates
of patients who had partial or complete remission at 1, 3, and 5
years of follow-upare shown in Table 2. The rates of patients who
stopped using medications for T2DM were 64.5% at 1 year of
follow-up, 48.3% at 3 years, and 55.5% at 5 years. In patients with
preoperative insulin use, ratesof cessation of medic ationuse were
drastically lower than in the general T2DM population: 36.8%,
9.1%, and 0.0%at 1, 3, and 5 years, respectively.Complete remis-
sion of diabetes was maintained in 50.7%,38. 2%, and 20.0%, re-
spectively, and remission of hypertension was maintained in
46.3%, 48.0%, and 45.5%, respectively.
Effect on Weight Loss
The mean (SD) preoperative excessweight was 51.2 (18.4) kg, and
the mean (SD) preoperative BMI was 43.9 (6.6). At1 year of follow-
up, the mean (SD) body weight was 81.4 (16.7)kg, the mean (SD)
BMI was 29.9 (5.1),and the %EWL was 76.8%. At 3 years of follow-
up, the mean (SD) body weight was 84.1 (17.2) kg, the mean BMI
was 30.8 (5.3), and the %EWL was 69.7%. At 5 years of follow-
up, the mean (SD) weight was 88.6(15.7) kg, the mean (SD) BMI
was 32.3 (5.1), and the %EWL was 56.1%.There was a signific ant
decrease in %EWL between patients with 1 and 3 years of follow-
up or patients with 1 and 5 years of follow-up(−4.8%, P= .007;
and −16.3%, P< .001, respectively). The decrease in %EWL be-
tween 3 and 5 years was not statistically significant (P= .07). The
failure rates, determined as the percentage of patients with a
%EWL less than 50%, were 13.3%, 21.1%, and 38.5% at 1, 3, and
5 years, respectively. There was no mortality, and the leak rates
were 1.3% and 3.1% in the primary and conversion procedures,
respectively. Eighteen patients underwent conversionto another
bariatric procedure and were excluded from follow-up follow-
ing the conversion.
Postoperative Changes in Lipid Profiles
The changes in the high-density lipoprotein (HDL) choles-
terol and triglyceride levels were significant compared with the
Table 1. Baseline PatientCharacteristics for Patients at Each Follow-up Period
Characteristic
Follow-up, y
1
(n = 241)
3
(n = 128)
5
(n = 39)
Age, mean (SD), y 42.9 (12.5) 41.5 (13.4) 44.5 (12.5)
Female, No. (%) 172 (71.4) 95 (74.2) 24 (61.5)
Weight, mean (SD), kg 119.4 (21.4) 118.2 (20.0) 117.5 (22.6)
Excess weight, mean (SD), kg 51.2 (18.4) 49.9 (16.3) 48.6 (18.3)
BMI, mean (SD) 41.9 (6.7) 43.4 (5.8) 42.6 (6.5)
Patients with previous bariatric surgery, No. (%) 26 (10.8) 9 (7.0) 4 (10.3)
Type 2 diabetes mellitus, No. (%) 71 (29.5) 34 (26.6) 10 (25.6)
Impaired fasting glucose, No. (%) 52 (21.6) 27 (21.1) 7 (17.9)
Hypertension, No. (%) 108 (44.8) 50 (39.1) 10 (25.6)
Hypercholesterolemia, No. (%) 153 (63.5) 68 (53.1) 21 (53.8)
Hypertriglyceridemia, No. (%) 106 (44.0) 53 (41.4) 18 (46.2)
Hyperuricemia, No. (%) 52 (21.6) 23 (18.0) 8 (20.5)
Abbreviation: BMI, body mass index
(calculated as weight in kilograms
divided by height in meters squared).
Table 2. Remission Rates at 1,3, and 5 Years of Follow-up
Comorbidity
Remission, %
1y 3y 5y
Partial/Complete Complete Partial/Complete Complete Partial/Complete Complete
Type 2 diabetes mellitus 93.2 50.7 91.2 38.2 80.0 20.0
Hypertension 77.8 46.3 80.0 48.0 54.5 45.5
Hypercholesterolemia 56.8 40.0 57.4 45.6 52.2 26.1
Hypertriglyceridemia 80.6 72.2 73.6 66.0 83.3 72.2
Hyperuricemia 76.9 71.2 82.6 73.9 100.0 87.5
Metabolic Effects of Laparoscopic Sleeve Gastrectomy Original Investigation Research
jamasurgery.com (Reprinted) JAMA Surgery November 2015 Volume 150, Number 11 1053
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: https://jamanetwork.com/ on 06/24/2020
Copyright 2015 American Medical Association. All rights reserved.
preoperative and postoperativemeasurements (P< .001). The
decrease of low-density lipoprotein (LDL) cholesterol levelwas
also significant at 1 year (P= .04) and 3 years (P= .04), but the
effect at 5 years did not reach statistical significance (P= .33).
Changes in total cholesterol levels failed to reach statistical sig-
nificance for any of the follow-up groups (Table 3). There was
no significant difference between the change of total choles-
terol, LDL cholesterol, HDL cholesterol, and triglyceride lev-
els in patients with 1 and 3 years of follow-upor in patients with
1and5yearsoffollow-up.
Relationship Between Changes in Comorbid Conditions,
Preoperative Characteristics, and Weight Loss
Correlations of changes in obesity-related comorbid conditions
with age and preoperative excessweight, sex, other comorbidi-
ties, and postoperative %EWL were analyzed by the ttest. Par-
tial and complete remission of hypertension at 1 year of follow-
up correlated with age (youngerpatients had a higher chance of
partial or complete remission; P= .004) and with preoperative
T2DM (P= .02) and hypertriglyceridemia (P= .04). Hypercho-
lesterolemia, hyperuricemia, age, sex, preoperative excess
weight, and %EWL did not show any significant effect on the
change of hypertension. Partial and complete remission of hy-
pertriglyceridemia at 1 year of follow-upcorrelated with preop-
erative T2DM (P= .03) and %EWL (P= .005). Partial or complete
remission of T2DM, hypercholesterolemia, and hyperuricemia
showed no correlations with age; sex; preoperativehypertension,
hypercholesterolemia, hypertriglyceridemia,or hyperuricemia;
or %EWL. The %EWL was not significantly related to preopera-
tive obesity-related comorbidities, age, sex, or excess weight.
Discussion
The increasing prevalence of obesity and the consensus that
bariatric procedures are the most effective methods of weight
loss have led to the spiraling growth of these procedures. In-
deed, they are among the most commonly performed gastro-
intestinal operations worldwide.
8
Initially LSG had been de-
scribed as part of the duodenal switch, but its success led to
the suggestion that it could be used as a single and definitive
procedure for morbid obesity. In 2012, the American Society
for Metabolic and Bariatric Surgery noted that several matched-
cohort, prospective, and case-control studies demonstrated
that LSG was equivalent to or exceeded Roux-en-Y gastric by-
pass (RYGB) surgery as well as laparoscopic adjustable gastric
bypass surgery in terms of weight loss outcomes and improve-
ments in a variety of obesity-relatedcomorbidities after a short-
term follow-up.
12
Some of the advantages of LSG include tech-
nical cost efficiency and easy learnability, lack of an intestinal
anastomosis, normal intestinal absorption, and pylorus
preservation.
13
Long-term follow-up data on the statusof those
comorbidities following LSG, however, are sparse.
14
Reports on long-term results of LSG usually focused on
weight loss. In 2004, Sjöström et al
15
reported a significant re-
gain of body weight after 2 and 10 years following bariatric op-
erations. Long-term %EWL reportedly varied widely (46%-
86%), with a decline at longer follow-ups.
16-24
Our findings
agree with those results. The %EWL in our study groups de-
creased from 76.8% at 1 year to 69.7% at 3 years and 56.1% at
5 years of follow-up. The difference in %EWL between1 and 3
years as well as between 1 and 5 years were statistically sig-
nificant, but the difference in %EWL between 3 and 5 years was
not. This might imply that a major part of the weight regain
occurs in the first few years following the surgery. Further-
more, the failure rate, defined as the percentage of patientsw ith
a %EWL less than 50%, increased from 13.3% at 1 year of fol-
low-up to 21.1% at 3 years and 38.5% at 5 years.
The success of bariatric surgery is usually defined by long-
term weight loss, enduring improvement in comorbidities, and
low mortality and morbidity rates.
25
Rather than being consid-
ered a priority, the effect of those procedures on obesity-related
comorbidities is usually not taken into consideration when ana-
lyzing the results. Because the mean age of patients undergoing
bariatric surgery is usually 40 to 50 years, long-term results of
those comorbidities are both attainable and highly relevant.
Vest et al
26
performed a meta-analysis of different types
of bariatric surgery and cardiovascular outcomes. Ten of the
73 articles they reviewed included information on LSG, and the
length of follow-up rangedfrom 3 months to 14.5 years (mean,
4.8 years). The rates of partial or complete remission were73%
for diabetes, 63% for hypertension, and 73% for hyperlipid-
emia. Gill et al
27
systematically reviewed the effect of sleeve
gastrectomy on diabetes mellitus and reported that the com-
plete and partial remission rates at 13 months of follow-up were
66% and 27%, respectively. Sarkhosh et al
28
reviewed the ef-
fect of LSG on hypertension and found that 58% of patients
showed remission at a mean of 17 months. The effect of LSG
on hyperlipidemia was recently reviewed by Al Khalifa et al,
10
who reported that the partial and complete remission rate at
17 months was 83.5% and that the mean (SD) preoperative and
postoperative cholesterol levelswere 194.4 (12.3) mg/dL (range,
178-213 mg/dL) and 181 (16.3) mg/dL (range, 158-200 mg/dL),
respectively.
Table 3. Changesin Lipoprotein Prof ile
Measure
Mean (SD)
Preoperative
Follow-up, y
135
Cholesterol, mg/dL
Total 189.5 (38.2) 184.0 (35.4) 183.4 (31.2) 188.1 (35.7)
HDL 46.7 (15.8) 52.8 (13.6) 56.8 (16.0) 52.4 (13.8)
LDL 115.8 (33.2) 110.8 (32.0) 105.7 (25.9) 110.6 (28.3)
Triglycerides, mg/dL 155.2 (86.1) 106.3 (45.3) 107.2 (53.4) 126.4 (59.7)
Abbreviations: HDL, high-density
lipoprotein; LDL, low-density
lipoprotein.
SI conversion factors: Toconvert
total, HDL, and LDL cholesterol to
millimoles per liter, multiply by
0.0259; to convert triglycerides to
millimoles per liter, multiply by
0.0113.
Research Original Investigation Metabolic Effects of Laparoscopic Sleeve Gastrectomy
1054 JAMASurgery November 2015 Volume 150, Number 11 (Reprinted) jamasurgery.com
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: https://jamanetwork.com/ on 06/24/2020
Copyright 2015 American Medical Association. All rights reserved.
Reports on partial and complete remission of obesity-
related comorbidities after 3 or more yearsof follow-up after LSG
are scarce. In a systematic review by Brethauer et al,
29
only 1 of
the 10 studies on postoperative comorbidity statushad data from
follow-up longerthan 2 4 months.The range of partial and com-
plete remission is quite wide in the studies on the effect of sur-
gery on such comorbidities with a longer follow-up. In their
randomized trial, Schauer et al
30
compared the remission rates
of T2DM after LSG, RYGB, and medical therapy at 3 years of fol-
low-up and found that 24%of the patients who underwent LSG
had complete remission compared with 38% who underwent
RYBGand 5% who under wentmedic al therapy. Atkins et al
31
de-
scribed remission rates of 74.5%, 49.5%, and 26.5% for T2DM,
hypertension, and hyperlipidemia, respectively, at 4 years of fol-
low-up. Other studies with medium-term follow-up reported re-
mission rates of 67% to 86% for T2DM, hypertension, and
hyperlipidemia.
32-34
Our complete remission rates were lower:
38.2% for T2DM, 48.0% for hypertension, 45.6% for hypercho-
lesterolemia, and 66.0% for hypertriglyceridemia at 3 years of
follow-up. Lower remission ratescould be attributed to stricter
criteria, definition of remission, and interpretation of the labo-
ratory results. Studies also use different end points, making it
difficult to compare data. The definition of remission is espe-
cially important in the current context. A consensus statement
of the American Diabetes Association defined complete remis-
sion of diabetes as normal glycemic measures without the use
of pharmacologic therapy for 1 year or longer.
35
In this study,
however,we defined remission as normal postoperative glyce-
mic measures without medications, as reported in several other
studies.
36,37
One major additional drawback is the definition of
the term partial remission. Some studies define it as the reduc-
tion of medication, some as reduced severity of associated symp-
toms, and some as the normalization of laboratory results.
Clearly, different definitions cause vagueness of data. In this
study, we defined partial remission as the reduction of medi-
cation dosage or the cessation of medication use despite ab-
normal laboratory results. Moreover, our study showed that
64.5% of patients with preoperative use of antidiabetics stopped
using medications after 1 year of follow-up, with the rates at
3 and 5 years decreasing to 48.3% and 55.5%, respectively.
The majority of the patients with preoperative insulin use
did not require insulin treatment postoperatively: 63.2%
and 54.5% of patients stopped using insulin or were treatedw ith
oral diabetic agents only at 1 and 3 years of follow-up, respec-
tively. These results are lower than the rates of reduction of
insulin and oral diabetic agents reported by Schauer et al
38
fol-
lowing RYGB.
Complete remission rates in patients with preoperativein-
sulin use were much lower than complete remission rates in
the general T2DM population. This demonstrates the effect of
preoperative characteristics on remission rates. It is well known
that the severity of diabetes prior to surgery affects the remis-
sion rates. Therefore, diabetic patients with a long-standing
disease who are referred to the bariatric clinic as a last resort
cannot be compared with patients who undergo surgery shortly
after being diagnosed as having diabetes. As such, the differ-
ences between the reported remission rates may reflect the dif-
ferences in the levels of awareness of diabetologists.
The influence of LSG on hyperlipidemia warrants special
attention. Hyperlipidemia comprises 4 variables: total choles-
terol, LDL cholesterol, HDL cholesterol, and triglycerides. In
a recent analysis of changes in lipid profile in patientsafter LSG,
Zhang et al
39
noted that only HDL cholesterol and triglycer-
ide levels changed significantly. We also observed a signifi-
cant change in LDL cholesterol, HDL cholesterol, and triglyc-
eride levels, but the change in total cholesterol level did not
reach statistical significance. In addition, there was no signifi-
cant difference between the changes in the different fol-
low-up points, which means that the improvement in HDL cho-
lesterol and triglyceride levels did not deteriorate significantly
over time. A confounding factor of these results could be the
cessation of use of antihyperlipidemic agents.
Many authors have focused their studies on the compari-
son of different bariatric procedures. In a recent meta-
analysis, RYGB and LSG were found to have an equivalent ef-
fect on hypertension and dyslipidemia, although RYGB was
found to achieve better control of T2DM.
40
It should be noted
that most studies included in that meta-analysis reported data
that were retrieved after a follow-up of 2 years or less. Schauer
et al
30
also found RYGB to be superior to LSG in terms of the
likelihood of achieving a glycated hemoglobin level of 7% of
total hemoglobin or less with no use of diabetes medications
after 3 years of follow-up. Another study that compared the
improvement of the lipid profile followingLSG and RYGB found
that RYGB had a clear benefit in all lipid fractions.
41
Surprisingly, our results showed that none of the changes in
obesity-relatedcomorbidity status correlated with excess weight
prior to the surgery. Patients with preoperative T2DM were less
likely to show a remission of hypertension and hypertriglyceri-
demia. As described by others,
27
age was a negative predictive
factor for partial or complete remission of hypertension in our
study.Partial and complete remission of hypertension also cor-
related with preoperative hypertriglyceridemia.Hypertriglyceri-
demia was the only comorbidity whose remission rates correlated
with %EWL. Finally,there was a decline in the rates of remission
of diabetes at 1, 3, and 5 years of follow-up.
In our opinion, the presence of obesity-related comorbidi-
ties should play a major role when choosing the appropriatepro-
cedure for a specific patient. Forexample, performing an opera-
tion that yields a low resolution rate of hyperlipidemia translates
into lifelong medical treatment in a young patient with signifi-
cant hyperlipidemia. In that case, a malabsorptive procedure
might be more beneficial than an LSG procedure. If the recurrence
of obesity is known to be followed by the remittanceof an exist-
ing comorbidity in a specific procedure, an alternative procedure
should be considered. Forexample, the weight loss durability fail-
ure of almost 40% at 5 years of follow-up of the LSG should be
one of the deciding factors in such cases.
Our study has several limitations. First, patients lost to fol-
low-up may cause a bias because their characteristics and rea-
sons for not arriving at follow-up visits are unknown. How-
ever, the follow-up rates in this study are comparable to those
in other long-term studies
42
and our data included all pa-
tients’ relevant laboratory results. Another limitation is that
the follow-up was not continuous for all patientsand some fol-
low-up data were available for only 1 time. Also, the small
Metabolic Effects of Laparoscopic Sleeve Gastrectomy Original Investigation Research
jamasurgery.com (Reprinted) JAMA Surgery November 2015 Volume 150, Number 11 1055
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: https://jamanetwork.com/ on 06/24/2020
Copyright 2015 American Medical Association. All rights reserved.
sample size at 5 years of follow-up precludes arriving at firm
conclusions regarding the changes in their obesity-related co-
morbidities.
Conclusions
The results of this analysis demonstrated that %EWL
decreased with longer follow-up. Furthermore, partial and
complete remission rates of T2DM were significantly lower
when follow-up was longer. Undergoing LSG induced a
reduction in %EWL and a major improvement in obesity-
related comorbidities in the short-term. The longer follow-up
data revealed weight regain and a decrease in remission rates
for T2DM and other obesity-related comorbidities. These
data should be taken into consideration in the decision-
making process for the most appropriate operation for a
given obese patient.
ARTICLE INFORMATION
Accepted for Publication: April 16, 2015.
Published Online: August 5, 2015.
doi:10.1001/jamasurg.2015.2202.
Author Contributions: Dr Keidar had full access to
all of the data in the study and takes responsibility
for the integrity of the data and the accuracy of the
data analysis.
Study concept and design: Golomb, Ben David,
Keidar.
Acquisition, analysis, or interpretation of data: All
authors.
Drafting of the manuscript: Golomb, Glass, Kolitz,
Keidar.
Critical revision of the manuscript for important
intellectual content: Ben David, Kolitz,Keidar.
Statistical analysis: Golomb.
Administrative, technical, or material support: All
authors.
Study supervision: Ben David, Kolitz, Keidar.
Conflict of Interest Disclosures: None reported.
REFERENCES
1. Obesity: preventing and managing the global
epidemic: report of a WHO consultation. World
Health Organ TechRep Ser. 2000;894:i-xii, 1-253.
2. Haslam DW,James WP. Obesity. Lancet. 2005;366
(9492):1197-1209.
3. Hubert HB, Feinleib M, McNamara PM, Castelli
WP. Obesity as an independent risk factor for
cardiovascular disease: a 26-year follow-upof
participants in the Framingham Heart Study.
Circulation. 1983;67(5):968-977.
4. Ejerblad E, Fored CM, Lindblad P, Fryzek J,
McLaughlin JK, Nyrén O. Obesity and risk for
chronic renal failure. J Am Soc Nephrol. 2006;17(6):
1695-1702.
5. Myles TD, Gooch J, SantolayaJ. Obesity as an
independent risk factor for infectious morbidity in
patients who undergo cesarean delivery. Obstet
Gynecol. 2002;100(5,pt 1):959-964.
6. Colquitt JL, Pickett K, Loveman E, FramptonGK.
Surgery for weight loss in adults. Cochrane
Database Syst Rev. 2014;8:CD003641.
7. Gloy VL, Briel M, Bhatt DL, et al. Bariatric surgery
versus non-surgical treatment for obesity:
a systematic review and meta-analysis of
randomised controlled trials. BMJ. 2013;347:f5934.
8. Buchwald H, Oien DM. Metabolic/bariatric
surgery worldwide 2011. Obes Surg. 2013;23(4):
427-436.
9. Clinical Issues Committee of the American
Society for Metabolic and Bariatric Surgery.
Updated position statement on sleeve gastrectomy
as a bariatric procedure. Surg Obes Relat Dis.2010;
6(1):1-5.
10. Al Khalifa K, Al Ansari A, Alsayed AR, Violato C.
The impact of sleeve gastrectomy on
hyperlipidemia: a systematic review.J Obes.2013;
2013:643530.
11. Consensus Development Conference Panel. NIH
conference: gastrointestinal surgery for severe
obesity. Ann InternMed. 1991;115(12):956-961.
12. ASMBS Clinical Issues Committee. Updated
position statement on sleeve gastrectomy as a
bariatric procedure. Surg Obes Relat Dis. 2012;8(3):
e21-e26.
13. Iannelli A, Dainese R, Piche T,Facchiano E,
Gugenheim J. Laparoscopic sleeve gastrectomy for
morbid obesity. WorldJ Gastroenterol. 2008;14
(6):821-827.
14. Puzziferri N, Roshek TB III, Mayo HG, Gallagher
R, Belle SH, Livingston EH. Long-term follow-up
after bariatric surgery: a systematic review.JAMA.
2014;312(9):934-942.
15. Sjöström L, Lindroos AK, Peltonen M, et al;
Swedish Obese Subjects Study Scientific Group.
Lifestyle, diabetes, and cardiovascular risk factors
10 years after bariatric surgery. N Engl J Med. 2004;
351(26):2683-2693.
16. Shi X, Karmali S, Sharma AM, Birch DW.
A review of laparoscopic sleeve gastrectomy for
morbid obesity. Obes Surg.2010;20(8):1171-1177.
17. Abd Ellatif ME, Abdallah E, Askar W, et al. Long
term predictors of success after laparoscopic sleeve
gastrectomy.Int J Surg. 2014;12(5):504-508.
18. D’Hondt M, Vanneste S, PottelH, Devriendt D,
Van Rooy F, Vansteenkiste F. Laparoscopic sleeve
gastrectomy as a single-stage procedure for the
treatment of morbid obesity and the resulting
quality of life, resolution of comorbidities, food
tolerance, and 6-year weight loss. Surg Endosc.
2011;25(8):2498-2504.
19. Diamantis T,Apostolou KG, Alexandrou A,
Griniatsos J, FelekourasE , Tsigris C. Review of
long-term weight loss results after laparoscopic
sleeve gastrectomy.Surg Obes Relat Dis. 2014;10(1):
177-183.
20. Eid GM, Brethauer S, Mattar SG, Titchner RL,
Gourash W, Schauer PR. Laparoscopic sleeve
gastrectomy for super obese patients: forty-eight
percent excess weight loss after 6 to 8 years with
93% follow-up. Ann Surg. 2012;256(2):262-265.
21. Himpens J, Dobbeleir J, Peeters G. Long-term
results of laparoscopic sleeve gastrectomy for
obesity. Ann Surg.2010;252(2):319-324.
22. Rawlins L, Rawlins MP, Brown CC, Schumacher
DL. Sleeve gastrectomy: 5-year outcomes of a
single institution. Surg Obes Relat Dis. 2013;9(1):
21-25.
23. Sieber P, Gass M, Kern B, Peters T, Slawik M,
Peterli R. Five-year results of laparoscopic sleeve
gastrectomy.Surg Obes Relat Dis. 2014;10(2):
243-249.
24. van Rutte PW, Smulders JF, de Zoete JP,
Nienhuijs SW. Outcome of sleeve gastrectomy as a
primary bariatric procedure. Br J Surg. 2014;101(6):
661-668.
25. Reinhold RB. Critical analysis of long term
weight loss following gastric bypass. Surg Gynecol
Obstet. 1982;155(3):385-394.
26. Vest AR, Heneghan HM, Agarwal S, Schauer PR,
Young JB. Bariatric surgery and cardiovascular
outcomes: a systematic review.Heart. 2012;98(24):
1763-1777.
27. Gill RS, Birch DW, Shi X, Sharma AM, KarmaliS.
Sleeve gastrectomy and type 2 diabetes mellitus:
a systematic review.Surg Obes Relat Dis.2010;6
(6):707-713.
28. Sarkhosh K, Birch DW, Shi X, Gill RS,Karmali S.
The impact of sleeve gastrectomy on hypertension:
a systematic review.Obes Surg. 2012;22(5):832-837.
29. Brethauer SA, Hammel JP,Schauer PR.
Systematic review of sleeve gastrectomy as staging
and primary bariatric procedure. Surg Obes Relat Dis.
2009;5(4):469-475.
30. Schauer PR, Bhatt DL, Kashyap SR. Bariatric
surgery versus intensive medical therapy for
diabetes. N Engl J Med. 2014;371(7):682.
31. Atkins ER, Preen DB, Jarman C, Cohen LD.
Improved obesity reduction and co-morbidity
resolution in patients treated with 40-French
bougie versus 50-French bougie four years after
laparoscopic sleeve gastrectomy: analysis of 294
patients. Obes Surg. 2012;22(1):97-104.
32. Abbatini F, Rizzello M, Casella G, et al.
Long-term effects of laparoscopic sleeve
gastrectomy,gastric bypass, and adjustable gastric
banding on type 2 diabetes. Surg Endosc. 2010;24
(5):1005-1010.
33. Kehagias I, Karamanakos SN, Argentou M,
Kalfarentzos F. Randomized clinical trial of
laparoscopic Roux-en-Y gastric bypass versus
laparoscopic sleeve gastrectomy for the
management of patients with BMI < 50 kg/m2.
Obes Surg. 2011;21(11):1650-1656.
34. Prasad P, Tantia O,Patle N, Khanna S, Sen B.
An analysis of 1-3-year follow-upresults of
laparoscopic sleeve gastrectomy: an Indian
perspective. Obes Surg. 2012;22(3):507-514.
35. Buse JB, Caprio S, Cefalu WT, et al. How do we
define cure of diabetes? Diabetes Care. 2009;32
(11):2133-2135.
36. Chang SH, Stoll CR, Song J, Varela JE, EagonCJ,
Colditz GA. The effectiveness and risks of bariatric
Research Original Investigation Metabolic Effects of Laparoscopic Sleeve Gastrectomy
1056 JAMASurgery November 2015 Volume 150, Number 11 (Reprinted) jamasurgery.com
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: https://jamanetwork.com/ on 06/24/2020
Copyright 2015 American Medical Association. All rights reserved.
surgery: an updated systematic review and
meta-analysis, 2003-2012. JAMA Surg.2014;149(3):
275-287.
37. Schauer PR, Bhatt DL, Kirwan JP,et al;
STAMPEDE Investigators. Bariatric surgery versus
intensive medical therapy for diabetes: 3-year
outcomes. N Engl J Med. 2014;370(21):2002-2013.
38. Schauer PR, Burguera B, Ikramuddin S, et al.
Effect of laparoscopic Roux-en Y gastric bypasson
type 2 diabetes mellitus. Ann Surg. 2003;238(4):
467-484.
39. Zhang F, StrainGW, Lei W, Dakin GF, Gagner M,
Pomp A. Changes in lipid profiles in morbidly obese
patients after laparoscopic sleeve gastrectomy
(LSG). Obes Surg. 2011;21(3):305-309.
40. Zhang Y,Wang J, Sun X, et al. Laparoscopic
sleeve gastrectomy versus laparoscopic Roux-en-Y
gastric bypass for morbid obesity and related
comorbidities: a meta-analysis of 21 studies. Obes
Surg. 2015;25(1):19-26.
41. Benaiges D, Flores-Le-Roux JA, Pedro-Botet J,
et al; Obemar Group. Impact of restrictive (sleeve
gastrectomy) vs hybrid bariatric surgery (Roux-en-Y
gastric bypass) on lipid profile. Obes Surg. 2012;22
(8):1268-1275.
42. Higa K, Ho T,Tercero F, Yunus T, Boone KB.
Laparoscopic Roux-en-Y gastric bypass: 10-year
follow-up. Surg Obes Relat Dis. 2011;7(4):516-525.
Invited Commentary
No Rush to Judgment for Bariatric Surgery
Anita P. Courcoulas, MD, MPH
It is unclear whether current studies will address critical ques-
tions about the long-term outcomes of bariatric surgery, in-
cluding the sustainability of weight loss and comorbidity con-
trol and long-term complication rates.
1
These critical gaps in
knowledge pose a significant
problem for people consider-
ing a potential surgical op-
tion to treat severe obesity.
Contributing to these deficits are the paucity of comparative
trials, incomplete follow-up, a lack of standardized defini-
tions for changes in health status (eg, diabetes mellitus remis-
sion), and the tendency to a rush to judgment in favor of sur-
gical treatment options.
Laparoscopic sleeve gastrectomy is a good case in point,
evolving very quickly during the last several years into the
dominant procedure in use
2
despite a complete void of infor-
mation about the longer-term effects. Golomb et al
3
trytoad-
dress this by documenting 1-, 3-, and 5-year results in a co-
hort of 443 sleeve gastrectomy cases but clearly raise more
issues than they can answer. They show that both weight loss
and type 2 diabetes remission degrade substantially over time:
excess weight loss from 77% to 56% and complete remission
of diabetes from 51% to 20% between 1 and 5 years. Those re-
sults are from only 56 people available for 5-year followup and
with rates of loss to follow-up of 50%, on average, at 1 and 3
years. One must assume that people lost to follow-upmay dif-
fer in important ways. In addition, there are no standards to
report comorbid health changes following bariatric surgery,
which limits the ability to compare results across studies.
Golomb and colleagues do an excellent job of outlining the
study’s own specific definitions of prevalence, incidence, and
remission of type 2 diabetes and other health outcomes, but
these are neither standard nor shared between members of the
research community.
How can these problems be addressed? Large, prospec-
tive observational studies such as the Longitudinal Assess-
ment of Bariatric Surgery Consortium study report standard-
ized definitions and do better with long-term retention,
4
but
the burden of work and subsequent high cost are problematic
in a highly competitive funding environment.The issues of cost
and feasibility also make a large randomized trial that could
compare surgical procedures across heterogeneous popula-
tions impractical. There is hope for the use of large electronic
databases to contribute to these knowledge gaps, but the han-
dling of large amounts of missing data is a critical feature that
is often not well articulated by the authors or well under-
stood by the readers. The answers will likely be generated over
time not only by a few of these large-scale efforts but also by
thoughtful inference that will be made through pooled analy-
ses of data like that from Golomb and colleagues and from
many other disparate randomized and nonrandomized stud-
ies of bariatric surgery.
5
It will take time, patience, and a will-
ingness to avoid a rush to judgment. In the meantime, clini-
cians and prospective patients will need to discuss and weigh
the evidence in a dynamic exchange driven not always by
final conclusions but by the most current available data.
ARTICLE INFORMATION
Author Affiliation: Department of Surgery,
University of Pittsburgh Medical Center,Pittsburgh,
Pennsylvania.
Corresponding Author: Anita P. Courcoulas, MD,
MPH, Department of Surgery, University of
Pittsburgh Medical Center, 3380 Blvdof the Allie s,
Ste 390, Pittsburgh, PA 15213 (courcoulasap@upmc
.edu).
Published Online: August 5, 2015.
doi:10.1001/jamasurg.2015.2222.
Conflict of Interest Disclosures: Dr Courcoulas
reported receiving grants from Nutrisystem,
Ethicon, and Covidien and serving as a project
consultant for Ethicon and Apollo Endosurgery.
REFERENCES
1. Courcoulas AP, Yanovski SZ, Bonds D,et al.
Long-term outcomes of bariatric surgery: a National
Institutes of Health symposium. JAMA Surg.2014;
149(12):1323-1329.
2. Reames BN, Finks JF,Bacal D, Carlin AM, Dimick
JB. Changes in bariatric surgery procedure use in
Michigan, 2006-2013. JAMA. 2014;312(9):959-961.
3. Golomb I, Ben David M, Glass A, Kolitz T, Keidar
A. Long-term metabolic effects of laparoscopic
sleeve gastrectomy [published online August 5,
2015]. JAMA Surg. doi:10.1001/jamasurg.2015.2202.
4. Courcoulas AP, Christian NJ, Belle SH, et al;
Longitudinal Assessment of Bariatric Surgery
(LABS) Consortium. Weight change and health
outcomes at 3 years after bariatric surgery among
individuals with severe obesity.JAMA. 2013;310
(22):2416-2425.
5. Arterburn DE, Courcoulas AP.Bariatric surgery
for obesity and metabolic conditions in adults. BMJ.
2014;349:g3961.
Related article page 1051
Metabolic Effects of Laparoscopic Sleeve Gastrectomy Original Investigation Research
jamasurgery.com (Reprinted) JAMA Surgery November 2015 Volume 150, Number 11 1057
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: https://jamanetwork.com/ on 06/24/2020
... Among variable surgical options, sleeve gastrectomy (SG) has recently been adopted as one of the most common surgical procedures performed for bariatric purposes [4]. Despite SG being considered a safe and effective procedure, up to 30% of the patients who had undergone SG are nonresponders and necessitate further surgery due to insufficient (< 50%) excess weight loss (EWL) or weight regain [6]. ...
... The reasons why some patients do not respond to SG are not fully understood and are the subject of active research. It is likely due to a multifactorial process in which an abnormal function of the brain might be implicated [1][2][3][4][5][6]. ...
... Also, a larger sample size would have been preferable; noteworthy is that the population studied is truly homogeneous as all the surgical patients were treated with SG and were followed-up for at least 2 years. Third, there were a greater number of females in our sample limiting the generalizability of results for male patients; however, this gender distribution reflected the usual distribution of patients undergoing bariatric and metabolic surgery [1][2][3][4][5][6]. ...
Article
Full-text available
PurposeTo compare resting-state functional connectivity (RSFC) of obese patients responders or non-responders to sleeve gastrectomy (SG) with a group of obese patients with no past medical history of metabolic or bariatric surgery.MethodsMR images were acquired at 1.5 Tesla. Resting-state fMRI data were analyzed with statistical significance threshold set at p < 0.05, family-wise error (FWE) corrected.ResultsSixty-two subjects were enrolled: 20 controls (age range 25–64; 14 females), 24 responders (excess weight loss > 50%; age range 23–68; 17 females), and 18 non-responders to sleeve gastrectomy (SG) (excess weight loss < 50%; age range 23–67; 13 females). About within-network RSFC, responders showed significantly lower RSFC with respect to both controls and non-responders in the default mode and frontoparietal networks, positively correlating with psychological scores. Non-responders showed significantly higher (p < 0.05, family-wise error (few) corrected) RSFC in regions of the lateral visual network as compared to controls. Regarding between-network RSFC, responders showed significantly higher anti-correlation between executive control and salience networks (p < 0.05, FWE corrected) with respect to both controls and non-responders. Significant positive correlation (Spearman rho = 0.48, p = 0.0012) was found between % of excess weight loss and executive control-salience network RSFC.Conclusion There are differences in brain functional connectivity in either responders or non-responders patients to SG. The present results offer new insights into the neural correlates of outcome in patients who undergo SG and expand knowledge about neural mechanisms which may be related to surgical response.
... worldwide [9]), due to the efficacy in terms of weight loss results at least in the short-term period [10][11][12][13][14][15], even with significant costs [15][16][17]. Different surgical approaches have been developed, refined, or abandoned throughout the past twenty years [12,18], and, among them, the Laparoscopic Sleeve Gastrectomy (LSG) has seen a continuous growth, being considered relatively simple (compared to other metabolic ones) but effective [15,[18][19][20][21]. ...
... Different surgical approaches have been developed, refined, or abandoned throughout the past twenty years [12,18], and, among them, the Laparoscopic Sleeve Gastrectomy (LSG) has seen a continuous growth, being considered relatively simple (compared to other metabolic ones) but effective [15,[18][19][20][21]. However, additional concerns may arise for patients subjected to LSG, such as the gastroesophageal reflux disease (GERD) [22,23], weight regain [10], metabolic complications [11,13], and thus compromising the reputation in the long run. ...
Article
Full-text available
Background Obesity has become a global epidemic. Bariatric surgery is considered the most effective therapeutic weapon in terms of weight loss and improvement of quality of life and comorbidities. Laparoscopic sleeve gastrectomy (LSG) is one of the most performed procedures worldwide, although patients carry a nonnegligible risk of developing post-operative GERD and BE. Objectives The aim of this work is the development of computational patient-specific models to analyze the changes induced by bariatric surgery, i.e., the volumetric gastric reduction, the mechanical response of the stomach during an inflation process, and the related elongation strain (ES) distribution at different intragastric pressures. Methods Patient-specific pre- and post-surgical models were extracted from Magnetic Resonance Imaging (MRI) scans of patients with morbid obesity submitted to LSG. Twenty-three patients were analyzed, resulting in forty-six 3D-geometries and related computational analyses. Results A significant difference between the mechanical behavior of pre- and post-surgical stomach subjected to the same internal gastric pressure was observed, that can be correlated to a change in the global stomach stiffness and a minor gastric wall tension, resulting in unusual activations of mechanoreceptors following food intake and satiety variation after LSG. Conclusions Computational patient-specific models may contribute to improve the current knowledge about anatomical and physiological changes induced by LSG, aiming at reducing post-operative complications and improving quality of life in the long run.
... This trend was more evident in patients with a baseline BMI > 40 (Fig. 2). For comparative purposes, current LGP %EWL data are integrated into [12][13][14]. ...
Article
Full-text available
Background: Although laparoscopic gastric plication (LGP) has been mentioned in many studies, its practice has not yet been standardized. In addition, the outcomes remain conflicting, especially long-term ones. This study was conducted to elucidate the long-term consequences of LGP. Methods: Retrospective analysis of patients with obesity underwent LGP at our institution between March 2010 and September 2014. Data were prospectively collected from our database. Results: Of the 88 consecutive patients in the study period between 2010 and 2014, follow-up data out to 6 years was available in 60 LGP patients (68.18%). The mean age of the included patients was 41.3 ± 10 years. A total of 81.7% were females. We observed a significant BMI reduction out to 2 years (p < 0.001), a plateau at 3 and 4 years, and a significant BMI increase at 6 years (p < 0.01). %TWL at 2 years was 21.14% and 12.08% at 6 years. Weight regain was observed in 35 patients at 6 years to reach a rate of 58.3%. Predictors for weight regain at 6 years were disrupted plication fold, increased hunger, and non-adherence to regular exercise. The diabetes improvement rate was 66.6% at 6 years. There were 14 re-operations (23.3%): 1 emergency (1.6%) and 13 (21.6%) elective. There was no mortality. Conclusion: At the 6-year follow-up visit, LGP has a much less durable effect on weight loss with a % EWL of 32% and a weight regain of 58.3% resulting in a high rate of revisions.
... However, while this early weight loss pattern has been well-documented in most demographics, quality data describing postsurgical weight variations beyond 5 years are sparse, especially for younger patients undergoing newer procedures (e.g., LAGB and LSG) [6,27]. As a result, long-term insidious weight regain is still a concern with many newer surgeries and has already been observed in several studies analyzing LSG past the 5-year mark in adults [45][46][47], with similar trends seen in select LAGB and LRYGB cohorts as well [39,48,49]. This observation is particularly relevant for young patients, not only because LSG has become the most popular surgery in this age group but also because younger age at the time of surgery has been correlated with increased likelihood of long-term weight regain [40,50]. ...
Article
Full-text available
Background Obesity is a public health concern among adolescents and young adults. Bariatric surgery is the most effective treatment for morbid obesity and has been increasingly utilized in young patients. Long-term outcomes data for bariatric surgery in this age group are limited. Methods This is a single-institution, prospective analysis of 167 patients aged 15–24 years who underwent one of three laparoscopic bariatric procedures between 2001 and 2019: Roux-en-Y gastric bypass (LRYGB, n = 71), adjustable gastric banding (LAGB, n = 22), and sleeve gastrectomy (LSG, n = 74). Longitudinal weight and body mass index (BMI) measurements were compared to evaluate patterns of weight loss. Results All operations were completed laparoscopically using the same clinical pathways. Patients were predominantly female (82.6%), had a median age of 22.0 [Q1-Q3 20.0–23.0] years, and had a mean presurgical BMI of 48.5 ± 6.5 kg/m² (range 38.4–68.1 kg/m²). All procedures produced significant weight loss by 1 year, peak weight loss by 2 years, and modest weight regain after 5 years. Mean percent weight/BMI losses at 5 years for LRYGB, LAGB, and LSG were − 36.7 ± 10.8%, − 14.5 ± 15.3%, and − 25.1 ± 13.4%, respectively (p < 0.001). LRYGB patients were most likely to achieve ≥ 25% weight loss at 1, 3, and 5 years and maintained significant average weight loss for more than 15 years after surgery. Reoperations were procedure-specific, with LAGB, LRYGB, and LSG having the highest, middle, and lowest reoperation rates, respectively (40.9% vs. 16.9% vs. 5.4%, p < 0.001). Conclusion All procedures provided significant and durable weight loss. LRYGB patients achieved the best and most sustained weight loss. LSG patients experienced second-best weight loss between 1 and 5 years, with lowest chance of reoperation. LAGB patients had the least weight loss and the highest reoperation rate. Compared to other factors, type of bariatric procedure was independently predictive of successful weight loss over time. More studies with long-term follow-up are needed. Graphical abstract
... LSG is a volume-restrictive procedure, the volume of remaining gastric pouch after LSG and the volume of the resected stomach were studied as possible causes of inappropriate weight loss or weight regain after the procedure [17][18][19][20][21] (Fig. 2). ...
Article
Full-text available
Background The aim of this study is to evaluate the impact of the actual size and area of the remnant stomach, as measured by Upper gastrointestinal tract radiography, on weight loss after sleeve gastrectomy. Materials and methods From May 2017 to December 2019, 56 patients with morbid obesity were admitted to the Department of Medical and Surgical Sciences, University of Foggia and underwent laparoscopic sleeve gastrectomy. Results 56 patients underwent sleeve gastrectomy with a mean age of 43,5 ± 11 years of which 40 were female. The mean Excess Weight Loss (EWL) at 1 month was 24,09 ± 15,04%, at 6 months was 27,07 ± 19,55% and at 12 months was 69,9 ± 23,7%. The mean Excess Body Mass Index Loss (EBMIL) at 1 month was 23,1 ± 12,5%, at 6 months was 56,6 ± 19,7% and at 12 months was 69,7 ± 23,7%. The EWL % was correlated with the residual stomach area (RSA) at 1 month (r = −0,242 p = 0,072), at 6 months (r = −0,249 p = 0,064) and at 12 months (r = −0,451 p = 0,0005). The EBMIL % was correlated with the RSA at 1 month (r = −0,270; p = 0,043), at 6 months (r = −0,270; p = 0,043) andat 12 months (r = −0,46; p = 0,0004). Conclusion A greater postoperative EWL % was correlated with a smaller RSA and this resulted in a statistically significant change at 12 months after surgery.
... The issue of weight regain following bariatric procedures raises significant questions regarding their utilization, specifically in adolescents. Studies from several groups have demonstrated in adults that five years or more following SG, the most commonly performed procedure in adolescents, there is a substantial weight regain and significant reduction in remission rates of obesity related metabolic complications [41,42]. Moreover -on longer follow up of 7 years after SG -more than half of patients have regained weight substantially [43]. ...
Article
Background: Severe obesity among adolescent shows a worrisome trend in regard of its increasing prevalence and poses a great challenge for treatment. Conservative measures have modest effects on weight loss, usually fail in achieving a sustainable weight loss and resolution of comorbidities. This has led to greater utilization of bariatric surgery (BS) that offers a fast reduction in body mass index (BMI) with little perioperative complications. Despite the increasing utilization of BS, data is still insufficient, regarding their long-term outcome in adolescents. We review short and long-term effects of bariatric surgery and their implications on bone health and nutritional deficiencies in adolescents. In addition, we discuss possible pharmaceutical alternatives. Summary: BS results in a substantial weight loss of roughly 37% in the first-year post-operation and is superior to conservative measures in resolution of metabolic comorbidities. BS significantly improves health-related quality of life. Longer follow up, shows weight regain in 50% of patients. Furthermore, reduced bone mass and nutritional deficiencies were reported in up to 90% of patients. Most recently, alternative to BS became more relevant with approval of GLP-1 analogues use in adolescents. GLP-1 analogues are potent enough to induce moderate clinically meaningful weight loss and improvement of metabolic component. Key Messages: We conclude that obese adolescents without major obesity related complications may benefit from pharmacological interventions with lifestyle modification. We advise considering BS as treatment approach in adolescents with severe obesity and major obesity related complications with proper pre-operative preparation and post operative follow up in excellence centers.
Article
Full-text available
Sleeve gastrectomy, originally proposed as part of a two-stage operation, more than 15 years ago, is recognized as an independent, effective intervention for the treatment of obesity. The purpose of this review was to evaluate the effectiveness of sleeve gastrectomy based on data on long-term follow-up of patients. A search was performed in two databases, 33 literary sources were selected based on the results of the selection. In this review, the authors evaluated some parameters characterizing the effectiveness of sleeve gastrectomy in the long term after surgery. The percentage of follow-up of patients in the long-term period (follow up, %) varied from 5,6% to 97%, the expected decrease in % follow up over time did not occur. The authors have suggested similar results due to the heterogeneity of the data of the analyzed sources. By the five-year period, the detected average % of follow-up did not correspond to the optimal recommended level of follow-up for operated patients by this time. The most common criterion for assessing the return of weight is an increase in body weight by more than 10 kg from the lowest achieved. The prevalence of this phenomenon ranged from 26.3% to 44%. Among the reasons predisposing to weight loss are the initial high BMI, old age, dilatation of the formed stomach. In the absence of a universal definition of various terms (follow up, unsatisfactory result of surgery, weight loss, etc.), the results among the same patients when using different definitions will differ, there is a need to adopt standards when describing these phenomena. Despite the likelihood of weight loss after longitudinal resection, this operation is relatively simple from a technical point of view, safer, it can be used to improve the course of concomitant pathology (diabetes mellitus, hypertension), improve the quality and increase the life expectancy of patients.
Chapter
Using pharmacotherapy for weight management is consistent with treating obesity as a chronic and life-threatening disease that requires a multifactorial and long-term approach, encompassing behavioral intervention, dietary change, and appropriate medical treatment. Bariatric surgery is a very effective intervention for achieving weight loss and ameliorating obesity-related comorbidities, but is associated with risks and higher costs relative to nonsurgical interventions, and thus, it is not feasible or desirable for several individuals with obesity. Therefore, pharmacotherapy, with an efficacy level that falls between that of lifestyle and surgical interventions, can thus bridge the gap that exists. Current guidelines recommend that individuals who fail to respond to lifestyle interventions after 6 months of treatment and have a BMI of ≥30 kg/m² or a BMI of ≥27 kg/m² with an obesity-related comorbidity may be considered for weight loss medication treatment. The US Federal Drug Administration (US FDA) has approved several new medications for the treatment of obesity in the past 5 years. The objective of this chapter is to provide a profile of the effectiveness of currently anti-obesity medications and their side effects. The reviewed anti-obesity medications reported in this chapter include medicines approved for short-term use of weight management, drugs for chronic weight management, the off-label use medications for weight control, and future anti-obesity pharmacotherapeutics.
Article
Full-text available
Corresponding Author: Bradley N. Reames, MD, MS, Center for Healthcare Outcomes and Policy, University of Michigan, 2800 Plymouth Rd, Ann Arbor, MI 48109 (breames@umich.edu). Author Contributions: Dr Reames had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Finks, Bacal, Dimick. Acquisition, analysis, or interpretation of data: Reames, Carlin. Drafting of the manuscript: Reames, Bacal, Dimick. Critical revision of the manuscript for important intellectual content: Reames, Finks, Carlin, Dimick. Statistical analysis: Reames. Administrative, technical, or material support: Bacal. Study supervision: Finks, Bacal, Carlin, Dimick. Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Dimick reported serving as consultant and having an equity interest in ArborMetrix Inc, which provides software and analytics for measuring hospital quality and efficiency; however, the company had no role in the study. No other disclosures were reported. Funding/Support: Dr Reames is supported by grant 5T32CA009672-23 from the National Cancer Institute. Role of the Sponsor: The National Cancer Institute had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Disclaimer: The views expressed in this article do not necessarily represent those of the US government.
Article
Full-text available
Importance Bariatric surgery is an accepted treatment for obesity. Despite extensive literature, few studies report long-term follow-up in cohorts with adequate retention rates.Objective To assess the quality of evidence and treatment effectiveness 2 years after bariatric procedures for weight loss, type 2 diabetes, hypertension, and hyperlipidemia in severely obese adults.Evidence Review MEDLINE and Cochrane databases were searched from 1946 through May 15, 2014. Search terms included bariatric surgery, individual bariatric procedures, and obesity. Studies were included if they described outcomes for gastric bypass, gastric band, or sleeve gastrectomy performed on patients with a body mass index of 35 or greater, had more than 2 years of outcome information, and had follow-up measures for at least 80% of the initial cohort. Two investigators reviewed each study and a third resolved study inclusion disagreements.Findings Of 7371 clinical studies reviewed, 29 studies (0.4%, 7971 patients) met inclusion criteria. All gastric bypass studies (6 prospective cohorts, 5 retrospective cohorts) and sleeve gastrectomy studies (2 retrospective cohorts) had 95% confidence intervals for the reported mean, median, or both exceeding 50% excess weight loss. This amount of excess weight loss occurred in 31% of gastric band studies (9 prospective cohorts, 5 retrospective cohorts). The mean sample-size–weighted percentage of excess weight loss for gastric bypass was 65.7% (n = 3544) vs 45.0% (n = 4109) for gastric band. Nine studies measured comorbidity improvement. For type 2 diabetes (glycated hemoglobin <6.5% without medication), sample-size–weighted remission rates were 66.7% for gastric bypass (n = 428) and 28.6% for gastric band (n = 96). For hypertension (blood pressure <140/90 mm Hg without medication), remission rates were 38.2% for gastric bypass ( n = 808) and 17.4% for gastric band (n = 247). For hyperlipidemia (cholesterol <200 mg/dL, high-density lipoprotein >40 mg/dL, low-density lipoprotein <160 mg/dL, and triglycerides <200 mg/dL), remission rates were 60.4% for gastric bypass (n = 477) and 22.7% for gastric band (n = 97).Conclusions and Relevance Very few bariatric surgery studies report long-term results with sufficient patient follow-up to minimize biased results. Gastric bypass has better outcomes than gastric band procedures for long-term weight loss, type 2 diabetes control and remission, hypertension, and hyperlipidemia. Insufficient evidence exists regarding long-term outcomes for gastric sleeve resections.
Article
Full-text available
Importance: Severe obesity (body mass index [BMI] ≥35) is associated with a broad range of health risks. Bariatric surgery induces weight loss and short-term health improvements, but little is known about long-term outcomes of these operations. Objective: To report 3-year change in weight and select health parameters after common bariatric surgical procedures. Design and setting: The Longitudinal Assessment of Bariatric Surgery (LABS) Consortium is a multicenter observational cohort study at 10 US hospitals in 6 geographically diverse clinical centers. PARTICIPANTS AND EXPOSURE: Adults undergoing first-time bariatric surgical procedures as part of routine clinical care by participating surgeons were recruited between 2006 and 2009 and followed up until September 2012. Participants completed research assessments prior to surgery and 6 months, 12 months, and then annually after surgery. Main outcomes and measures: Three years after Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric banding (LAGB), we assessed percent weight change from baseline and the percentage of participants with diabetes achieving hemoglobin A1c levels less than 6.5% or fasting plasma glucose values less than 126 mg/dL without pharmacologic therapy. Dyslipidemia and hypertension resolution at 3 years was also assessed. Results: At baseline, participants (N = 2458) were 18 to 78 years old, 79% were women, median BMI was 45.9 (IQR, 41.7-51.5), and median weight was 129 kg (IQR, 115-147). For their first bariatric surgical procedure, 1738 participants underwent RYGB, 610 LAGB, and 110 other procedures. At baseline, 774 (33%) had diabetes, 1252 (63%) dyslipidemia, and 1601 (68%) hypertension. Three years after surgery, median actual weight loss for RYGB participants was 41 kg (IQR, 31-52), corresponding to a percentage of baseline weight lost of 31.5% (IQR, 24.6%-38.4%). For LAGB participants, actual weight loss was 20 kg (IQR, 10-29), corresponding to 15.9% (IQR, 7.9%-23.0%). The majority of weight loss was evident 1 year after surgery for both procedures. Five distinct weight change trajectory groups were identified for each procedure. Among participants who had diabetes at baseline, 216 RYGB participants (67.5%) and 28 LAGB participants (28.6%) experienced partial remission at 3 years. The incidence of diabetes was 0.9% after RYGB and 3.2% after LAGB. Dyslipidemia resolved in 237 RYGB participants (61.9%) and 39 LAGB participants (27.1%); remission of hypertension occurred in 269 RYGB participants (38.2%) and 43 LAGB participants (17.4%). Conclusions and relevance: Among participants with severe obesity, there was substantial weight loss 3 years after bariatric surgery, with the majority experiencing maximum weight change during the first year. However, there was variability in the amount and trajectories of weight loss and in diabetes, blood pressure, and lipid outcomes. Trial registration: clinicaltrials.gov Identifier: NCT00465829.
Article
Full-text available
Background: In short-term randomized trials (duration, 1 to 2 years), bariatric surgery has been associated with improvement in type 2 diabetes mellitus. Methods: We assessed outcomes 3 years after the randomization of 150 obese patients with uncontrolled type 2 diabetes to receive either intensive medical therapy alone or intensive medical therapy plus Roux-en-Y gastric bypass or sleeve gastrectomy. The primary end point was a glycated hemoglobin level of 6.0% or less. Results: The mean (±SD) age of the patients at baseline was 48±8 years, 68% were women, the mean baseline glycated hemoglobin level was 9.3±1.5%, and the mean baseline body-mass index (the weight in kilograms divided by the square of the height in meters) was 36.0±3.5. A total of 91% of the patients completed 36 months of follow-up. At 3 years, the criterion for the primary end point was met by 5% of the patients in the medical-therapy group, as compared with 38% of those in the gastric-bypass group (P<0.001) and 24% of those in the sleeve-gastrectomy group (P=0.01). The use of glucose-lowering medications, including insulin, was lower in the surgical groups than in the medical-therapy group. Patients in the surgical groups had greater mean percentage reductions in weight from baseline, with reductions of 24.5±9.1% in the gastric-bypass group and 21.1±8.9% in the sleeve-gastrectomy group, as compared with a reduction of 4.2±8.3% in the medical-therapy group (P<0.001 for both comparisons). Quality-of-life measures were significantly better in the two surgical groups than in the medical-therapy group. There were no major late surgical complications. Conclusions: Among obese patients with uncontrolled type 2 diabetes, 3 years of intensive medical therapy plus bariatric surgery resulted in glycemic control in significantly more patients than did medical therapy alone. Analyses of secondary end points, including body weight, use of glucose-lowering medications, and quality of life, also showed favorable results at 3 years in the surgical groups, as compared with the group receiving medical therapy alone. (Funded by Ethicon and others; STAMPEDE ClinicalTrials.gov number, NCT00432809.).
Article
Importance The clinical evidence base demonstrating bariatric surgery’s health benefits is much larger than it was when the National Institutes of Health last held a consensus panel in 1991. Still, it remains unclear whether ongoing studies will address critical questions about long-term complication rates and the sustainability of weight loss and comorbidity control.Objective To summarize findings from a multidisciplinary workshop convened in May 2013 by the National Institute of Diabetes and Digestive and Kidney Diseases and the National Heart, Lung, and Blood Institute. The workshop aimed to summarize the current state of knowledge of bariatric surgery, review research findings on the long-term outcomes of bariatric surgery, and establish priorities for future research directions.Evidence Review The evidence presented at the workshop was selected by the planning committee for both its quality and duration of follow-up. The data review emphasized randomized clinical trials and large observational studies with long-term follow-up, with or without a control group.Findings Several small randomized clinical trials showed greater weight loss and type 2 diabetes mellitus remission compared with nonsurgical treatments within the first 2 years of follow-up after bariatric surgery. Large, long-term observational studies have shown durable (>5 years) weight loss, diabetes, and lipid improvements with bariatric surgery. Still unclear are predictors of outcomes, long-term complications, long-term survival, microvascular and macrovascular events, mental health outcomes, and costs. The studies needed to address these knowledge gaps would be expensive and logistically difficult to perform.Conclusions and Relevance High-quality evidence shows that bariatric surgical procedures result in greater weight loss than nonsurgical treatments and are more effective at inducing initial type 2 diabetes mellitus remission in obese patients. More information is needed about the long-term durability of comorbidity control and complications after bariatric procedures and this evidence will most likely come from carefully designed observational studies.
Article
This review summarizes recent evidence related to the safety, efficacy, and metabolic outcomes of bariatric surgery to guide clinical decision making. Several short term randomized controlled trials have demonstrated the effectiveness of bariatric procedures for inducing weight loss and initial remission of type 2 diabetes. Observational studies have linked bariatric procedures with long term improvements in body weight, type 2 diabetes, survival, cardiovascular events, incident cancer, and quality of life. Perioperative mortality for the average patient is low but varies greatly across subgroups. The incidence of major complications after surgery also varies widely, and emerging data show that some procedures are associated with a greater risk of substance misuse disorders, suicide, and nutritional deficiencies. More research is needed to enable long term outcomes to be compared across various procedures and subpopulations, and to identify those most likely to benefit from surgical intervention. Given uncertainties about the balance between the risks and benefits of bariatric surgery in the long term, the decision to undergo surgery should be based on a high quality shared decision making process.
Article
Background: Bariatric (weight loss) surgery for obesity is considered when other treatments have failed. The effects of the available bariatric procedures compared with medical management and with each other are uncertain. This is an update of a Cochrane review first published in 2003 and most recently updated in 2009. Objectives: To assess the effects of bariatric surgery for overweight and obesity, including the control of comorbidities. Search methods: Studies were obtained from searches of numerous databases, supplemented with searches of reference lists and consultation with experts in obesity research. Date of last search was November 2013. Selection criteria: Randomised controlled trials (RCTs) comparing surgical interventions with non-surgical management of obesity or overweight or comparing different surgical procedures. Data collection and analysis: Data were extracted by one review author and checked by a second review author. Two review authors independently assessed risk of bias and evaluated overall study quality utilising the GRADE instrument. Main results: Twenty-two trials with 1798 participants were included; sample sizes ranged from 15 to 250. Most studies followed participants for 12, 24 or 36 months; the longest follow-up was 10 years. The risk of bias across all domains of most trials was uncertain; just one was judged to have adequate allocation concealment.All seven RCTs comparing surgery with non-surgical interventions found benefits of surgery on measures of weight change at one to two years follow-up. Improvements for some aspects of health-related quality of life (QoL) (two RCTs) and diabetes (five RCTs) were also found. The overall quality of the evidence was moderate. Five studies reported data on mortality, no deaths occurred. Serious adverse events (SAEs) were reported in four studies and ranged from 0% to 37% in the surgery groups and 0% to 25% in the no surgery groups. Between 2% and 13% of participants required reoperations in the five studies that reported these data.Three RCTs found that laparoscopic Roux-en-Y gastric bypass (L)(RYGB) achieved significantly greater weight loss and body mass index (BMI) reduction up to five years after surgery compared with laparoscopic adjustable gastric banding (LAGB). Mean end-of-study BMI was lower following LRYGB compared with LAGB: mean difference (MD) -5.2 kg/m² (95% confidence interval (CI) -6.4 to -4.0; P < 0.00001; 265 participants; 3 trials; moderate quality evidence). Evidence for QoL and comorbidities was very low quality. The LRGYB procedure resulted in greater duration of hospitalisation in two RCTs (4/3.1 versus 2/1.5 days) and a greater number of late major complications (26.1% versus 11.6%) in one RCT. In one RCT the LAGB required high rates of reoperation for band removal (9 patients, 40.9%).Open RYGB, LRYGB and laparoscopic sleeve gastrectomy (LSG) led to losses of weight and/or BMI but there was no consistent picture as to which procedure was better or worse in the seven included trials. MD was -0.2 kg/m² (95% CI -1.8 to 1.3); 353 participants; 6 trials; low quality evidence) in favour of LRYGB. No statistically significant differences in QoL were found (one RCT). Six RCTs reported mortality; one death occurred following LRYGB. SAEs were reported by one RCT and were higher in the LRYGB group (4.5%) than the LSG group (0.9%). Reoperations ranged from 6.7% to 24% in the LRYGB group and 3.3% to 34% in the LSG group. Effects on comorbidities, complications and additional surgical procedures were neutral, except gastro-oesophageal reflux disease improved following LRYGB (one RCT). One RCT of people with a BMI 25 to 35 and type 2 diabetes found laparoscopic mini-gastric bypass resulted in greater weight loss and improvement of diabetes compared with LSG, and had similar levels of complications.Two RCTs found that biliopancreatic diversion with duodenal switch (BDDS) resulted in greater weight loss than RYGB in morbidly obese patients. End-of-study mean BMI loss was greater following BDDS: MD -7.3 kg/m² (95% CI -9.3 to -5.4); P < 0.00001; 107 participants; 2 trials; moderate quality evidence). QoL was similar on most domains. In one study between 82% to 100% of participants with diabetes had a HbA1c of less than 5% three years after surgery. Reoperations were higher in the BDDS group (16.1% to 27.6%) than the LRYGB group (4.3% to 8.3%). One death occurred in the BDDS group.One RCT comparing laparoscopic duodenojejunal bypass with sleeve gastrectomy versus LRYGB found BMI, excess weight loss, and rates of remission of diabetes and hypertension were similar at 12 months follow-up (very low quality evidence). QoL, SAEs and reoperation rates were not reported. No deaths occurred in either group.One RCT comparing laparoscopic isolated sleeve gastrectomy (LISG) versus LAGB found greater improvement in weight-loss outcomes following LISG at three years follow-up (very low quality evidence). QoL, mortality and SAEs were not reported. Reoperations occurred in 20% of the LAGB group and in 10% of the LISG group.One RCT (unpublished) comparing laparoscopic gastric imbrication with LSG found no statistically significant difference in weight loss between groups (very low quality evidence). QoL and comorbidities were not reported. No deaths occurred. Two participants in the gastric imbrication group required reoperation. Authors' conclusions: Surgery results in greater improvement in weight loss outcomes and weight associated comorbidities compared with non-surgical interventions, regardless of the type of procedures used. When compared with each other, certain procedures resulted in greater weight loss and improvements in comorbidities than others. Outcomes were similar between RYGB and sleeve gastrectomy, and both of these procedures had better outcomes than adjustable gastric banding. For people with very high BMI, biliopancreatic diversion with duodenal switch resulted in greater weight loss than RYGB. Duodenojejunal bypass with sleeve gastrectomy and laparoscopic RYGB had similar outcomes, however this is based on one small trial. Isolated sleeve gastrectomy led to better weight-loss outcomes than adjustable gastric banding after three years follow-up. This was based on one trial only. Weight-related outcomes were similar between laparoscopic gastric imbrication and laparoscopic sleeve gastrectomy in one trial. Across all studies adverse event rates and reoperation rates were generally poorly reported. Most trials followed participants for only one or two years, therefore the long-term effects of surgery remain unclear.
Article
Background Sleeve gastrectomy is being performed increasingly in Europe. Data on long-term outcome would be helpful in defining the role of sleeve gastrectomy. The aim of this study was to evaluate the outcome of sleeve gastrectomy as a primary bariatric procedure.Methods Medical charts of all patients who underwent a primary sleeve gastrectomy at the authors' institution between August 2006 and December 2012 were reviewed retrospectively using a prospective online data registry. For evolution of weight loss and co-morbidity, only patients with follow-up of at least 1 year were included. A subgroup analysis was done to compare patients with an intended stand-alone procedure and those with an intended two-stage procedure.ResultsA total of 1041 primary sleeve gastrectomies were performed in the study period. Median duration of surgery was 47 min, and median hospital stay was 2 days. Intra-abdominal bleeding occurred in 27 patients (2·6 per cent) and staple-line leakage in 24 (2·3 per cent). Some 866 patients had at least 1 year of follow-up. Mean excess weight loss was 68·4 per cent after 1 year (P < 0·001) and 67·4 per cent after 2 years. Smaller groups of patients achieved a mean excess weight loss of 69·3 per cent (163 patients), 70·5 per cent (62) and 58·3 per cent (19) after 3, 4 and 5 years respectively. No difference in postoperative complications was found between the subgroups. Seventy-one (8·2 per cent) of 866 patients had a revision of the sleeve gastrectomy; reflux or dysphagia was the indication in 34 (48 per cent) of these patients.Conclusion Sleeve gastrectomy is a safe and effective bariatric procedure. Maximum weight loss was achieved after 4 years. Long-term results regarding weight loss and co-morbidities were satisfactory.
Article
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/m2. Operative time was 113+29 min. Reinforecement 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 6months, 1 , 2, 3, 4, 5, 6, 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.