Weight Regain After The Sleeve Gastrectomy
Referred to as the new operation on the block the laparoscopic sleeve gastrectomy has seen a rapid rise globally with patients choosing this over the gastric bypass and gastric band as a first choice treatment option. Currently there isn’t enough long term data on the sleeve compared to the other operations and the most recent long term study showed significant weight regain with a return of the comorbidities.
The study led by Andrei Keidar, MD, at the Beilinson Hospital in Israel and his researchers reviewed 443 cases of LSG from 2006 to 2013 by the same surgery team and found that within 5 years, the percentage of excess weight loss declined from 77% to 56%, and “complete remission of diabetes was maintained in only 20% of patients.”
They also found that remission of hypertension was only maintained in 45.5% of patients and there were significant differences in levels of high-density lipoprotein cholesterol levels and triglyceride levels. The results of the study were published in JAMA Surgery in August 2015.
Anita P Courcoulas MD, MPH from the University Of Pittsburgh School Of Medicine wrote in an accompanying editorial that caution should be urged in interpreting the findings stating that answers about the effectiveness of bariatric surgery will not be easy to come by.
“It will take time, patience, and a willingness to avoid a rush to judgment,” she wrote. “In the meantime, clinicians 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.”
In the beginning the laparoscopic sleeve gastrectomy was performed as an intervention for high risk patients before they underwent a gastric bypass or performed as the first step of a biliopancreatic diversion duodenal switch. However Dr’s soon realised that the sleeve could be done as stand-alone procedure and since then it has grown in popularity. However, according to Keidar and his colleagues there are still relatively few studies on the long term effects of the sleeve.
Obesity specialist; Craig Primack MD from the Scottsdale Weight Loss Centre in Arizona, wrote in an email that doctors may be surprised at the lack of quality, long-term data for LSG.
“If I am going to let a surgeon cut out my stomach (especially as many now consider this procedure the procedure of choice) I would sure like to know what will happen to my weight and other comorbidities down the road,” he wrote.”
In the latest study, Keidar and colleagues looked at how patients fared at one, three, and five years after surgery. More than 1,000 patients underwent bariatric surgery during the time frame that the researchers looked at, and less than half underwent LSG.
The definition of remission of diabetes was defined as a normal fasting glucose level (<100mg/dL) with no use of insulin or oral medications. The definition of partial remission was defined as a reduction of medication dosage or cessation of medication use despite abnormal laboratory results. Complete data were not available for a relatively high number of patients: at one year, complete data were available for 241 of the patients (54.4%), at three years for 128 of 259 patients (49.4%), and at five years for 39 of 56 patients (69.6%).
The mean preoperative body mass index was 43.9, noted the authors. At one year, the percent of excess weight loss was 76.8%. It was 69.7% at year three and 56.1% at year five.
Before undergoing surgery, 82 of the patients had been diagnosed with type 2 diabetes, 65 with impaired fasting glucose, 110 with hypertension, 155 with hypercholesterolemia, 109 with hypertriglyceridemia, and 55 with hyperuricemia. At one year, 64.5% of the patients stopped taking medications for type 2 diabetes, at three years 48.3% stopped, and at five years 55.5% stopped.
Courcoulas wrote that there are gaps in the knowledge about how effective LSG is. “These critical gaps in knowledge pose a significant problem for people considering a potential surgical option to treat severe obesity,” she wrote. “Contributing to these deficits are the paucity of comparative trials, incomplete follow-up, a lack of standardized definitions for changes in health status (e.g., diabetes mellitus remission), and the tendency to a rush to judgment in favour of surgical treatment options.”
Many of the studies done on LSG use different end points, wrote the authors, making it difficult to compare. In addition, the term “partial remission” is used to mean different things in the studies.
“In our opinion, the presence of obesity-related comorbidities should play a major role when choosing the appropriate procedure for a specific patient,” wrote the authors. “For example, performing an operation that yields a low resolution rate of hyperlipidaemia translates into lifelong medical treatment in a young patient with significant hyperlipidaemia. In that case, a malabsorptive procedure might be more beneficial than an LSG procedure.”
The study was done at a single site and the results may not be generalizable. Also, many of the patients were lost to follow-up, which may have led to a bias, noted the authors. The small sample size at five years precluded conclusions about the changes in comorbidities, and the follow-up was not continuous for all of the patients.
Anita P Courcoulas, MD MPH No Rush to Judgment for Bariatric Surgery JAMA Surgery August 2015 DOI: 10.1001/jamasurg.2015.2222
Andrei Keidar, MD et al. Long-term Metabolic Effects of Laparoscopic Sleeve Gastrectomy. JAMA Surgery, August 2015 DOI:10.1001/jamasurg.2015.2202