Surgery for Obesity and Related Diseases 10 (2014) 177–183

Review article

Review of long-term weight loss results after laparoscopic sleeve gastrectomy Theodoros Diamantis, M.D., F.A.C.S., Konstantinos G. Apostolou, M.D., M.Sc.*, Andreas Alexandrou, M.D., John Griniatsos, M.D., Evangelos Felekouras, M.D., Christos Tsigris, M.D., Ph.D., F.A.C.S First Surgical Department of the University of Athens, Laiko General Hospital, 17 Agiou Thoma St, 11527, Athens, Greece Received July 8, 2013; accepted November 12, 2013

Abstract

Sleeve gastrectomy (SG) has gained enormous popularity both as a first-stage procedure in high-risk super-obese patients and as a stand-alone procedure. The objective of this study was to evaluate the longterm weight loss results after SG published in the literature and compare them with the well-documented short-term and mid-term weight loss results. A detailed search in PubMed using the keywords “sleeve gastrectomy” and “long-term results” found 16 studies fulfilling the criteria of this study. A total of 492 patients were analyzed, with a follow-up of at least 5 years after laparoscopic sleeve gastrectomy (LSG) (373 at 5 years, 72 at 6 years, 13 at 7 years, and 34 at 8 or more years). Of the total number of patients, 71.1% were women (15 studies, n ¼ 432 patients). Mean patient age was 45.1 years (15 studies, n ¼ 432 patients). Mean preoperative body mass index in all 16 studies was 49.2 kg/m2. The mean percentage excess weight loss (%EWL) was 62.3%, 53.8%, 43%, and 54.8% at 5, 6, 7, and 8 or more years after LSG, respectively. The overall mean %EWL (defined as the average %EWL at 5 or more years after LSG) was 59.3% (12 studies, n ¼ 377 patients). The overall attrition rate was 31.2% (13 studies). LSG seems to maintain its well-documented weight loss outcome at 5 or more years postoperatively, with the overall mean %EWL at 5 or more years after LSG still remaining 450%. The existing data support the role of LSG in the treatment of morbid obesity. (Surg Obes Relat Dis 2014;10:177–183.) r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.

Keywords:

Bariatric procedure; Laparoscopic sleeve gastrectomy; Long-term outcomes

Sleeve gastrectomy for weight loss was first described by Marceau in 1991 as a component of biliopancreatic diversion [1]. Laparoscopic sleeve gastrectomy (LSG) was performed as a component of biliopancreatic diversion with duodenal switch (BPD/DS) in 2000 by Ren et al. [2] and was subsequently used as the initial stage of a 2-staged approach for super-morbidly obese patients. Over time, LSG has gained popularity and is now often used as a stand-alone procedure because of its *Correspondence: Konstantinos G. Apostolou, M.D., M.Sc., First Surgical Department of the University of Athens, Laiko General Hospital, Charilaou Trikoupi 25 B, 17 Agiou Thoma St, 11527, Athens 16675, Greece. E-mail: [email protected]

demonstrated safety and effectiveness, which has been established in 3 international consensus summits [3–5]. A recent meta-analysis of 2570 patients who were included in 36 studies [6] also showed a resolution of common co-morbid conditions, apart from a good excess weight loss (EWL). Although the significant data concerning short-term and mid-term results is more than convincing, the number of published studies regarding the long-term weight loss effectiveness of LSG is rather small. Thus, a systematic review of the existing data concerning the long-term weight loss outcomes after LSG is necessary and would serve as a helpful tool when trying to evaluate and compare the effectiveness of this procedure with the other well-established bariatric

1550-7289/14/$ – see front matter r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved. http://dx.doi.org/10.1016/j.soard.2013.11.007

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procedures, such as Roux-en-Y gastric bypass, which serve as a gold standard. Materials and methods A detailed search in PubMed for citations that included sleeve gastrectomy, using the keywords “sleeve gastrectomy 5-year weight loss results” found 4100 studies. After an initial review of these studies, only 16 reports seemed to match our criteria; a review of these reports was conducted and the full text was reviewed. Prospective and retrospective series reporting on LSG as a primary or as a staged procedure for the treatment of severe obesity were included if they reported weight loss results at 5 or more years after LSG. Case reports

(o5 patients) and studies reporting on technique only were not included. Substudies of larger series by the same group were not included in our analysis of the total procedures performed, to avoid duplication of data. Statistical analyses were performed only on the extracted data from the selected studies, in patients who had not undergone another bariatric operation. Basic descriptive statistics (simple counts and means) were used to summarize the patient, study, and weight loss data. Data regarding the weight loss outcome after LSG were expressed as percentage of excess weight loss (%EWL) in 12 of the 16 studies; in the remaining 4 studies, data were expressed as percentage of excess body mass index loss (% EBMIL). As listed in Table 1, no uniformity was present across studies for the method of reporting weight loss data.

Table 1 Long-term outcomes of laparoscopic sleeve gastrectomy for obesity Author

Patients (n)

Mean preoperative BMI (kg/m2)

Bougie size (F)

Months of follow-up (follow-up rate)

Mean %EWL

Complication rate, %

Postoperative mortality (30-days), %

Weiner et al., 2007 [7]

8

61.6

60 (NR)

0

21

48.2 ⫾ 1.3

60 (96.15%)

40% EBMIL 55%

17.5

Bohdjalian et al., 2010 [8] Himpens et al., 2010 [9] D'Hondt et al., 2011 [10] Sarela et al., 2011 [11] Strain et al., 2011 [12] Eid et al., 2012 [13]

No calibration tube, 44, 32 48

NR

NR

30 39 27 pts and 23 pts 39.3

34 30

0 0

45.9 56.1 ⫾ 14.0 66 ⫾ 7

32 40 or 60 50

53.30% 71.3% and 55.9% 69% 48% EBMIL 52%, 43%, and 46%

12.2 0

13 23 19 pts, 13 pts, and 21 pts. (total 53 pts) 49

72 (78%) 60 and 72 (26.50%) Z96 (65%) 60 (NR) 72, 84, and 96 (93%)

5 NR 15

0 NR 0

65

26.4

60 (100%)

86%

1.9

0

14

40.2

32

60 (93.3%)

57.4%

NR

NR

13

52.1 ⫾ 8.5

48

60 (54.1%)

56%

NR

NR

30

52.2 ⫾ 10.2

NR

60 (NR)

NR

NR

60

38.4 ⫾ 5.1

32 or 40

60 (11%)

48% EBMIL 57.3%

5.7

0

6

37.4 ⫾ 4.75

36

60 (30%)

63.7%

4.4

0.43

45

49.1 ⫾ 8.5

34

60 (82%)

50.7%

5.7

0

23

50.7 ⫾ 10.6

NR

60 (79%)

49.5%

NR

0

54

43 ⫾ 8

35

60 (91%)

Rawlins et al., 2012 [14] Lim et al., 2012 [15] Abbatini et al., 2012 [16] Saif et al., 2012 [17] Braghetto et al., 2012 [18] Zachariah et al., 2013 [19] Catheline et al., 2013 [20] Brethauer et al., 2013 [21] Sieber et al., 2013 [22] Total:

Average %EWL (excluding the studies by Weiner et al., Strain et al., Saif et al., and Sieber et al., which report %EBMIL instead of % EWL)

57.4% 4.4 0 EBMIL 492 patients followed up for at least 5 years; average mean preoperative BMI ¼ 49.2 kg/m2, and average follow-up rate ¼ 68.8% 59.3

BMI ¼ body mass index; EBMIL ¼ excess BMI loss [(Preoperative BMI – Postoperative BMI) / (Preoperative BMI – BMI Goal)]; pt(s) ¼ patient(s); %EWL ¼ percentage excess weight loss [average %EWL ¼ (Number of patients  Percentage of EWL) / Total Number of Patients]; F ¼ French; NR ¼ not reported.

LSG and Long-Term Weight Loss Results / Surgery for Obesity and Related Diseases 10 (2014) 177–183 Table 2 Percentage EWL 5 years after sleeve gastrectomy

179

Table 4 Percentage EWL 7 years after sleeve gastrectomy

Investigator

Patients (n/d)

5-year %EWL

Investigator

Patients (n)

7-year %EWL

Bohdjalian et al., 2010 [8] D'Hondt et al., 2011 [10] Rawlins et al., 2012 [14] Lim et al., 2012 [15] Abbatini et al., 2012 [16] Braghetto et al., 2012 [18] Zachariah et al., 2013 [19] Catheline et al., 2013 [20] Brethauer et al., 2013 [21] Summary – 9 studies

21/26 27/102 49/55 14/15 13/33 60/560 6/20 45/65 23/297 258/1173

55 71.3 86 57.4 56 57.3 63.7 50.7 49.5 62.3

Eid et al., 2012 [13]

13/74

43

d ¼ original number of patients; EWL ¼ excess weight loss.

EWL ¼ excess weight loss.

of the patients were women. The mean patient age was 45.1 years (15 studies, n ¼ 432 patients). The mean preoperative body mass index (BMI) in all 16 studies was 49.2 kg/m2 (Table 1). Weight loss

A total of 16 studies [7–22] were extracted for the present review. Of the 16 studies, 8 were from Europe, 6 were from the United States, 1 was from Asia, and the remaining originated in Latin America. All studies, except for one [20], were from a single institution. Of the 16 studies, 4 stated clearly that SG was used as part of a staged therapeutic procedure or as a management strategy for a high-risk patient population, and 11 studies reported the results of SG used as a stand-alone procedure with no intent of a second-stage procedure (1 study had clearly defined patients in both groups). The remaining study stated that SG was used either as part of a 2-stage procedure in some patients or as a stand-alone procedure in patients with lower BMI. All studies reported on the laparoscopic technique of sleeve gastrectomy (LSG). The follow-up rate at 5 or more years after LSG was reported in 13 of 16 studies and ranged from 11% to 100%. The size of the bougie used for calibration of the gastric sleeve was reported in 13 of 16 studies and ranged from 26.4 F to 60 F (Table 1). The beginning of the gastric resection was reported in 12 studies and ranged from 2 cm to 8 cm from the pylorus, with staple line reinforcement used in 7 studies.

The mean percentage of excess weight loss (%EWL) ranged from 43% at 84 months after surgery in the study by Eid et al. [13] to 86% at 60 months after surgery in the study from Rawlins et al. [14]. Excluding the studies by Weiner et al. [7], Strain et al. [12], Saif et al. [17], and Sieber et al. [22] from the calculating process of the %EWL, which report the weight loss outcome as percentage of excess BMI loss (%EBMIL) and not as %EWL, a total of 377 patients were followed-up for a period of 60 months or more (range ¼ 60 to Z96 months) with the %EWL ranging from 43% to 86%. In more detail, the 60 months follow-up group consisted of 9 studies that enrolled 258 patients. The mean %EWL for this group was estimated to be 62.3%. The 72-months follow-up group consisted of 3 studies, with a total of 72 patients. The mean %EWL for this group was estimated to be 53.8%. The 84-months follow-up group included only 1 study, with only 13 patients followed-up. The %EWL for this follow-up group was 43%. Finally, the Z96-months follow-up group consisted of 2 studies, with 34 patients enrolled. The mean %EWL for this follow-up group was estimated to be 54.8%. More details about the follow-up groups at 60, 72, 84, and Z96 months after LSG are depicted in Table 2, 3, 4, and 5, respectively, and are summarized in Fig. 1. The calculated long-term (Z60 months after surgery) mean % EWL is 59.3% (Table 1).

Patient characteristics

Effect on co-morbidities

The total number of patients enrolled in these studies was 492. Fifteen studies reported the patient gender, and 71.1%

Only 7 [14,16,18–22] of the 16 studies contained data about the long-term effect of LSG on the co-morbidities, which are usually present in these patients. There was

Results Study characteristics

Table 3 Percentage EWL 6 years after sleeve gastrectomy Investigator

Patients (n/d)

6-year %EWL

Himpens et al., 2010 [9] D'Hondt et al., 2011 [10] Eid et al., 2012 [13] Summary – 3 studies

30/53 23/102 19/74 72/229

53.3 55.9 52 53.8

d ¼ original number of patients; EWL ¼ excess weight loss.

Table 5 Percentage EWL 8 or more years after sleeve gastrectomy Investigator

Patients (n)

Z8-years %EWL

Sarela et al., 2011 [11] Eid et al., 2012 [13] Summary – 2 studies

13/20 21/74 34/94

69 46 54.8

EWL ¼ excess weight loss.

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Fig. 1. Mean % EWL at different follow-up intervals. (summarizes the average % EWL of the published series to date) (The vertical axis indicates the mean % EWL, while the horizontal axis indicates the years after LSG)

complete or near-complete resolution of arterial hypertension in 72.4% of patients (n = 122) [14,18–20], in 61.5% of patients with hyperlipidemia (n = 98) [14,18–20] and in 87% of patients with obstructive sleep apnea (n = 47) [14,20]. Type 2 diabetes mellitus was resolved in 70.9% of patients (n = 143) (range = 46%–100%) [14,16,18–22]. The resolution of gastroesophageal reflux symptoms was not in the scope of this study. Complications and operative mortality The postoperative complication rate ranged from 0% to 17.5%. The leak rate was available in 10 of the 16 studies and ranged from 0% to 5%, with a mean value of 2.4% (10 studies, n = 1321 patients). A single death was reported for the first 30 postoperative days [19], so the percentage of 30day postoperative mortality was .2%. Discussion “Durable” weight loss is one important benefit of bariatric surgery, and this is a standard by which success or failure of weight-reducing procedures is measured. One of the most important issues regarding LSG is the durability of the weight loss result several years after the operation and, especially, at 5 or more years postoperatively. Most of the published studies agree that weight regain might be observed in patients after LSG at various time intervals after the operation and can be classified as early [7,23] or late, without a distinct borderline between them. This issue has also been reported in the past with the use of other restrictive procedures, especially adjustable gastric banding [24–26]. Regarding the short-term and mid-term results after LSG, the systematic review of LSG as a staging and a primary

bariatric procedure, published by Brethauer et al. [6] in 2009, summarized all patients who underwent LSG as a primary procedure from surgery through a predefined follow-up interval. This review included 24 studies that enrolled a total of 1749 patients. The preoperative BMI ranged from 37.2 to 54.5 kg/m2, with a mean value of 46.6 kg/m2. The predefined for each study follow-up period ranged from 3 to 36 months after LSG. The mean %EWL ranged from 36% to 85%, with the %EWL being 58.8%, 77%, and 63% at 1, 2, and 3 years postoperatively, respectively, and the overall mean %EWL was 60.7%. The long-term results after LSG are defined as the results at 5 or more years postoperatively, when LSG is performed without the addition of any other bariatric procedure. The long-term results after LSG published in the literature are depicted and summarized in Table 1. At this point, it should be considered that the weight loss outcome at the fifth postoperative year published by Rawlins et al. [14] far exceeds the average percentage of excess weight loss at the fifth postoperative year derived by the remaining studies published by Bohdjalian et al. [8], D’Hondt et al. [10], Lim et al. [15], Abbatini et al. [16], Braghetto et al. [18], Zachariah et al. [19], Catheline et al. [20], and Brethauer et al. [21], which is estimated to be 56.7% and, because of the significant number of patients included in their study, affects significantly the average percentage of excess weight loss at the fifth postoperative year, which finally is 62.3% (Table 2). According to the authors, the reason for this is multifactorial, with the more important reasons for this phenomenon being the beginning of the gastric transection 3 cm from the pylorus, the use of a 26.4 F endoscope as a bougie, thus creating a very tight sleeve, and finally, the use of other selection and management factors. However, more studies with the special characteristics of the study published by Rawlins et al. [14] should be performed and published to confirm this promising outcome. Considering the studies published by Braghetto et al. [18] and Zachariah et al. [19], it is noteworthy that the lower preoperative BMI was 33.3 kg/m2 and 32.7 kg/m2 in these 2 studies, respectively. This fact is controversial with the published eligibility criteria for bariatric surgery, published by the National Institutes of Health. Moreover, the study published by Zachariah et al. [19] states that the inclusion criteria was not based on the National Institutes of Health criteria but on the Asian Pacific Bariatric Surgery Society Guidelines for Bariatric Surgery in 2005 [27]. The study published by Sieber et al. [22] consisted of 2 groups of patients that underwent LSG as a definitive treatment. The difference between the 2 groups was that the patients belonging to group 1 had never undergone any other bariatric procedure, while the patients in group 2 had already undergone a failed laparoscopic adjustable gastric banding operation in terms of band intolerance (16 patients, 59.3%), insufficient weight loss (11 patients, 40.7%), band

LSG and Long-Term Weight Loss Results / Surgery for Obesity and Related Diseases 10 (2014) 177–183

slippage (10 patients, 37%), concentric pouch dilation (4 patients, 14.8%), or acute food intolerance (3 patients, 11.1%). Comparing the 2 groups of patients, it is noteworthy that patients belonging to group 2 had worse weight loss results during the entire follow-up period, although the difference between them is not statistically significant. Moreover, group 2 is characterized by a statistically significant higher number of reoperations due to insufficient weight loss. Regarding the complication rate, a single sleeve leak occurred in only 1 patient belonging to group 2 (1 patient, 1.5%), which is in accordance with the average leak rate of 1.06% ⫾ 1.13% reported in the International Sleeve Gastrectomy Expert Panel Consensus Statement [28]. Regarding the leak rate after LSG, it is obvious that leakage occurs more often when LSG is performed after another previous bariatric operation or after a previously performed LSG [29]. Nowadays, LSG is being used more often than in the past as a definitive treatment for obesity. Thus, it is more helpful trying to evaluate the long-term weight loss outcomes of LSG as a definitive treatment and compare them with the weight loss results, when LSG is being used as part of a staged approach. In more detail, 12 of 16 studies report their weight loss outcome, when LSG is used as a definitive operation. In this group of studies, the mean preoperative BMI was 43.9 kg/m2 and the average mean %EWL was 56.3% at 5 years postoperatively (Table 6). On the other hand, in all the studies reporting long-term weight loss results after LSG, the mean preoperative BMI was 49.2 kg/ m2 and the average mean %EWL was 62.3% at 5 years postoperatively (Table 2). Considering these results, it is reasonable that the mean preoperative BMI in the “definitive operation group” was lower than in the other group, because the patients of the latter group had higher BMI and underwent LSG in an attempt to lose weight before the second step operation. However, the %EWL at 5 years

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postoperatively is lower in the “definitive operation group” than in the other group, although the size of the sleeve is usually smaller in this group of patients than in patients undergoing LSG as part of a staged approach. A possible explanation for this phenomenon may be the fact that the patients undergoing LSG as part of a staged approach lose more easily part of their excess weight because of their higher preoperative BMI, thus resulting in the higher % EWL in this group of patients. One contribution to the weight loss outcome after SG might be the changes in the plasma levels of ghrelin, the only known peripheral hormone so far, inducing food uptake and increasing appetite. As the gastric fundus, known as the main localization of the ghrelin-producing cells is completely resected in SG, less hunger is expected to favor the restrictive effect of the sleeve on food intake. A thorough search in the published literature found only 3 studies comparing the plasma levels of ghrelin preoperatively and postoperatively at different follow-up points [8,30,31]. All these studies confirmed the hypothesis that SG leads to a significant reduction in plasma ghrelin levels during the postoperative period. The attrition rate phenomenon is the Achilles' heel that plagues most long-term outcomes studies. In the present study, the percentage of the original patients followed up for 5 years or more postoperatively ranges from 11% in the study by Braghetto et al. [18] to 100% in the study by Rawlins et al. [14], with an average of 68.8% (Table 1). This fact could be attributed to various factors and may influence the long-term weight loss outcomes. Despite the great differences in the follow-up rate between the studies included, it is obvious that no difference in the weight loss outcomes at predefined follow-up points could be identified between studies with higher and lower follow-up rates. As a result, we cannot distinguish whether the weight loss outcome of patients included in studies with a higher

Table 6 Long-term outcomes of laparoscopic sleeve gastrectomy as definitive operation Author

Patients (n)

Mean preoperative BMI (kg/m2) 5-year %EWL

Bohdjalian et al., 2010 [8] 21 48.2 ⫾ 1.3 Himpens et al., 2010 [9] 30 39 D'Hondt et al., 2011 [10] 27 patients (5 years follow-up) and 39.3 23 patients (6 years follow-up) Sarela et al., 2011 [11] 13 45.9 Lim et al., 2012 [15] 14 40.2 Abbatini et al., 2012 [16] 13 52.1 ⫾ 8.5 Saif et al., 2012 [17] 30 52.2 ⫾ 10.2 Braghetto et al., 2012 [18] 60 38.4 ⫾ 5.1 Zachariah et al., 2013 [19] 6 37.4 ⫾ 4.75 Catheline et al., 2013 [20] 45 49.1 ⫾ 8.5 Brethauer et al., 2013 [21] 23 50.7 ⫾ 10.6 Sieber et al., 2013 [22] 54 43 ⫾ 8 Summary: 12 studies 359 patients 43.9

6-year %EWL 8-year %EWL

55% 53.30% 71.3%

— — 55.9%

— — —

— 57.4% 56% 48% EBMIL 57.3% 63.7% 50.7% 49.5% 57.4% EBMIL 56.3% (239 patients)*

— — — — — — — — — 55.9%

69% — — — — — — — — 69%

Data excludes from the calculating process the study by Saif et al. [17] and Sieber et al. [22], which reported the weight loss outcome as %EBMIL. BMI ¼ body mass index; %EWL ¼ percentage excess weight loss; %EBMIL ¼ percentage excess body mass index loss.

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follow-up rate is due to the patients’ compliance to the predefined guidelines or if their weight loss outcome was not as satisfactory as expected and thus the patients sought follow-up to improve their weight loss outcome. Considering Fig. 1, it is obvious that LSG leads to a weight loss result that is at least stable for the first 5 postoperative years, while there is a tendency for the %EWL to increase during the first 5 years. At 6 or more years postoperatively, the %EWL is lower compared with that at 5 years, but remains stable and still 450%, with the exception of the weight loss data at 7 years after surgery published by Eid et al. [13], which is 43%EWL, but because of the very small number of patients, reaching this follow-up interval cannot be assumed to be statistically significant. This reduction in the %EWL at 6 or more years postoperatively cannot arbitrarily be attributed to a possible weight regain, because of the interfering very high attrition rates associated with remote data, as well as the small number of patients followed-up for 6 or more years postoperatively, compared with the number of patients at 5 or less years after LSG. In case of weight regain after LSG, this can be effectively managed with reintervention [32]. At this point, it should be emphasized that LSG is recognized as an acceptable option, both as a primary bariatric procedure and as part of a staged approach in highrisk patients, with a risk–to-benefit profile being between the laparoscopic adjustable gastric banding and the laparoscopic Roux-en-Y gastric bypass [32]. However, it should also be emphasized that the increase in the performance of LSG seen during the past years takes place without having any evidence of its weight loss results at 10 or more years postoperatively, because to date, only 492 patients have reached at least the follow-up point of 5 years postoperatively, with the published results suggesting that the weight loss result is more than satisfactory in most cases. Hence, more studies need to be performed and published and more time must pass before a larger and more detailed cohort of patients can confirm the effectiveness of LSG at 10 or more years postoperatively. Conclusion LSG may be performed either as part of a staged approach in high-risk patients or as a primary bariatric procedure. The results of the present study show that LSG seems to maintain its well-documented weight loss outcome at 5 or more years postoperatively, with the overall mean % EWL at 5 or more years after LSG still remaining 4 50%. The existing data support the role of LSG in the treatment of morbid obesity. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article.

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Review of long-term weight loss results after laparoscopic sleeve gastrectomy.

Sleeve gastrectomy (SG) has gained enormous popularity both as a first-stage procedure in high-risk super-obese patients and as a stand-alone procedur...
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