Laparoscopic sleeve gastrectomy in Asia: Long term outcome and revisional surgery.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is a popular stand-alone bariatric surgery, despite a paucity of long-term data. Hence, this study is to report the long-term outcome of LSG as primary bariatric procedure and the result of revisional surgery. METHODS: With retrospective analysis of a prospective bariatric database, participants who defaulted clinic follow-up were interviewed by telephone. A total of 667 LSG was performed as primary bariatric procedure (2006-2012) with mean age of 34.5 ± 9.7 years old, female 74.7%, mean body mass index (BMI) 37.3 ± 8.1 kg/m(2). A 36-F bougie was used for all cases. RESULTS: There were 61 patients available with long-term data. The weight loss outcome at 1 year, 2 years, 3 years, 4 years, and 5 years showed a mean BMI 26.3, 25.2, 25.3, 27.1, and 26.2 with mean excess weight loss (EWL) 76.0%, 79.6%, 77.3%, 73.4%, and 72.6% respectively. However, 17% patients developed de novo gastro-esophageal reflux disease (GERD). Eighteen patients (2.2%) needed surgical revisions due to weight regain (n = 6), persistent type 2 diabetes mellitus (T2DM; n = 2), stricture (n = 2), and GERD (n = 8). The revision resulted in an additional mean excess weight loss of 23.8% with mean BMI 24.9 kg/m(2) at 6 months postoperatively. There was a 23.7% mean reduction of HbA1c with one patient who was in complete diabetic remission at 1 year. CONCLUSION: Our results showed LSG is a durable bariatric procedure with > 70% EWL at 5 years despite a high incidence of GERD. The need for revision of LSG is low and mainly for GERD.

Bariatric versus diabetes surgery after five years of follow up.

BACKGROUND: Bariatric surgery (BS) is totally different from diabetes surgery (DS) in the patient characters, goals of surgery, and management although similar in surgical procedure. Comparison of BS and DS with long-term data is lacking. MATERIALS AND METHODS: A retrospective review of patients who received BS and patients who received DS at Min-Sheng General Hospital from 2007 to 2013 was designed. All inpatient and outpatient follow-up data were analyzed. Patients undergoing BS for the treatment of morbid obesity were compared with patients undergoing metabolic surgery for the treatment of type 2 diabetes mellitus (T2DM). Patients who received revision surgeries were excluded. The main outcome measures were: (1) operation risk; (2) weight loss; and (3) diabetes remission. RESULTS: Between 2007 and 2013, 2073 patients who received BS and 741 patients who received DS were recruited from both centers. DS patients were older (41.1 ± 10.9 years vs. 33.1 ± 9.3 years, p < 0.05) and were more likely to be male (40.2% vs. 28.2%, p < 0.05) and to have diabetes (100% vs. 6.0%, p < 0.05), however, they had similar body mass index (BMI) (37.9 ± 8.0 vs. 38.5 ± 9.7, p = 0.78) compared to the BS patients. Surgical procedures are significantly different between the two groups (73.3% of the DS surgeries were gastric bypass procedure, whereas this procedure made up only 47.1% of BS surgeries). Although the major complication rates were similar (2.0% vs. 2.4%), the DS program had a significant higher mortality rate than the BS program (0.54% vs. 0.1%; p < 0.05). At the 5-year follow-up time point, 58.0% of the BS patients had achieved successful results (weight loss > 30%) and 80% of the DS patients had complete remission of their diabetes [hemoglobin A1c (HbA1c) < 6.0%]. Both the DS and the BS group had good results in up to 85% of the patients at the 5-year follow-up time point. CONCLUSION: The clinical profiles were very different between the BS and the DS programs. Both programs achieved the desired outcomes equally well, however, the DS program had a higher risk than the BS program.

Laparoscopic sleeve gastrectomy for type 2 diabetes mellitus: predicting the success by ABCD score.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is becoming a primary bariatric surgery for obesity and related diseases. This study presents the outcome of LSG with regard to the remission of type 2 diabetes mellitus (T2 DM) and the usefulness of a grading system to categorize and predict outcome of T2 DM remission. METHODS: A total of 157 patients with T2 DM (82 women and 75 men) with morbid obesity (mean body mass index 39.0±7.4 kg/m(2)) who underwent LSG from 2006 to 2013 were selected for the present study. The ABCD score is composed of the patient's age, body mass index, C-peptide level, and duration of T2 DM (yr). The remission of T2 DM after LSG was evaluated using the ABCD score. RESULTS: At 12 months after surgery, 85 of the patients had complete follow-up data. The weight loss was 26.5% and the mean HbA1c decreased from 8.1% to 6.1%. A significant number of patients had improvement in their glycemic control, including 45 (52.9%) patients who had complete remission (HbA1c<6.0%), another 18 (21.2%) who had partial remission (HbA1c<6.5%), and 9 (10.6%) who improved (HbA1c<7%). Patients who had T2 DM remission after surgery had a higher ABCD score than those who did not (7.3±1.7 versus 5.2±2.1, P<.05). Patients with a higher ABCD score were also at a higher rate of success in T2 DM remission (from 0% in score 0 to 100% in score 10). CONCLUSION: LSG is an effective and well-tolerated procedure for achieving weight loss and T2 DM remission. The ABCD score, a simple multidimensional grading system, can predict the success of T2 DM treatment by LSG.

Medium-Term Results of Laparoscopic Sleeve Gastrectomy: a Matched Comparison with Gastric Bypass.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is considered a primary bariatric surgery and is increasingly being performed worldwide; however, long-term data regarding the durability of this procedure are inadequate. Here, we report the long-term results of LSGs in comparison to those of gastric bypass surgeries. METHODS: A prospectively collected bariatric database from Ming-Shen General Hospital was retrospectively studied. Five hundred nineteen morbidly obese patients (mean age 36.0 ± 9.1 years old (14-71), 74.6 % female, mean body mass index (BMI) 37.5 ± 6.1 kg/m(2)) underwent LSG as a primary bariatric procedure from 2006 to 2012 at our institute. The operative parameters, weight loss, laboratory data, and quality of life were followed. Another two matched groups of laparoscopic Roux-en-Y gastric bypass (RYGB) and laparoscopic single anastomosis (mini-) gastric bypass (SAGB) patients who were matched in terms of age, sex, and BMI were recruited for comparisons. RESULTS: The mean surgical time for LSG was 113.5 ± 31.3 min, and the mean blood loss was 49.1 + 100.9 ml. The rate of major complications was 1.6 %, and the average length of the postoperative stay was 3.0 ± 1.7 days. The operation times of the RYGB patients were longer than those of both the LSG and SAGB patients. The RYGB and SAGB patients experienced higher major complication rate than the LSG patients. The weight loss of the LSG patient at 5 years was 28.3 + 8.9 %, and the mean BMI was 27.1 + 4.3. The RYGB patients exhibited a 5-year weight loss similar to the LSG patients, and the SAGB patients exhibited greater weight loss than both of the other groups. Both the RYGB and SAGB patients exhibited significantly better glycemic control and lower blood lipids than the LSG patients, but the LSG patients exhibited a lesser micronutrient deficiency than the RYGB and SAGB groups. All three of the groups exhibited improved quality of life at 5 years after surgery, and there was no significant between-group difference in this measure. CONCLUSIONS: LSG appears to be an ideal bariatric surgery, and the efficacy of this surgery is not inferior to that of gastric bypass.

Laparoscopic adjustable gastric banding (LAGB) with gastric plication: short-term results and comparison with LAGB alone and sleeve gastrectomy.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) is the safest type of bariatric surgery but is less effective than other bariatric surgeries. Combining LAGB with gastric plication (LAGB-P) may increase weight loss compared to LAGB alone. METHODS: In this study, we report our short-term experience with this novel technique and compare the data for the first 42 consecutive patients with the data for LAGB alone and LSG. Forty-two morbidly obese patients underwent LAGB-P and were followed for 12 months. Operative complications, weight loss, and late complications were followed and compared with matched groups of LAGB alone and laparoscopic sleeve gastrectomy (LSG). The setting was a university hospital in Taiwan. RESULTS: The study consisted of 42 patients, specifically 21 males and 21 females with an average age of 32.6±9.7 years (range 18 to 58) and a mean body mass index of 40.7±6.1 kg/m2 (range 31.5 to 56.4). The mean operation time was 141.9±24.8 minutes (range 105 to 190), and the mean hospital stay was 2.3±1.9 days. Two (4.8%) major complications were encountered and resolved by laparoscopic revision surgery. There was 1 (2.4%) major complication in the LSG group and none in the LAGB group. The operation time for LAGB-P was longer than for LAGB and LSG (75.6±17.9 and 110.5±22.3 minutes; P<.001). The mean body mass index of the LAGB-P group decreased from 40.7 to 29.4 kg/m2 at 1 year after surgery, with an excess weight loss of 62.6%. This result is similar to the 67.2% excess weight loss in the LSG group, but is higher than the 31.7% excess weight loss of the LAGB group. At follow-up, revision surgery was required in 2 (4.8%) patients in the LAGBP group, none (0%) in the LAGB group, and 1 (2.4%) in the LSG group. More patients in the LSG group still required proton pump inhibitor treatment at 1 year after surgery than the other 2 groups CONCLUSION: By combining LAGB with gastric plication, LAGB-P can augment the weight loss of LAGB and is similar to LSG but may increase risk.

Impairment of gastrointestinal quality of life in severely obese patients.

AIM: To investigate the common gastro-intestinal symptoms and quality of life in severely obese subjects. METHODS: We prospectively recruited 340 severely obese patients [mean age 30.5 ± 7.8 years; mean body mass index (BMI) 42.9 ± 6.1 kg/m(2)] and 340 healthy persons (mean BMI 23.1 ± 3.8 kg/m(2)) matched in sex, age, marriage and education. The quality of life was studied using a specific gastrointestinal quality of life index (GIQLI) questionnaire. The 36 items and four functional domains of the GIQLI were compared and analyzed between the groups. The possible correlation of GIQLI scores with specific clinical variables in severely obese patients was assessed by measuring Pearson's coefficient of correlation. RESULTS: The mean GIQLI score of severely obese patients was lower than the normal control group (108.5 ± 17.1 vs 123.2 ± 14.8, P < 0.01). Severely obese patients had decreased scores in the domains of general health, including physical (17.3 ± 6.0 vs 22.4 ± 3.1, P < 0.01), emotional (12.6 ± 4.3 vs 16.6 ± 3.1, P < 0.01) and social function (14.7 ± 3.9 vs 17.9 ± 2.5, P < 0.01), and in the domain of gastrointestinal symptoms (63.9 ± 6.7 vs 66.3 ± 7.2, P < 0.05). A significantly decreased score was found in nine items, and there was an increased score in one out of the 19 items in the domain of symptoms of the GIQLI questionnaire. The decreased score in the domain of symptoms was correlated with increasing glycosylated hemoglobin (HbA1c) levels. CONCLUSION: Severe obesity resulted in a significant impairment of the quality of life and caused specific gastrointestinal symptoms compared with normal controls. The development of gastrointestinal symptoms is correlated increasing HbA1c, suggesting that a poor control of hyperglycemia might be the etiology.

Laparoscopic Nissen fundoplication with gastric plication as a potential treatment of morbidly obese patients with GERD, first experience and results.

BACKGROUND: Laparoscopic Nissen fundoplication is an effective treatment for gastroesophageal reflux disease (GERD). However, there is no consensus for the surgical treatment of GERD in morbidly obese patients. METHODS: Twenty-five morbidly obese patients with GERD underwent our novel procedure, laparoscopic Nissen fundoplication with gastric plication (LNFGP), and were monitored for 6 to 18 months. Operative complication, weight loss, and GERD symptoms were monitored. RESULTS: The study subjects consisted seven males and 18 females. The average age was 38.2 years (from 18 to 58), and the mean BMI was 37.9 kg/m(2) (from 31.5 to 56.4). The mean operative time was 145.6 min (from 105 to 190). All procedures were performed via laparoscopic surgery. Two patients (8%) displayed a major 30-day perioperative complication. The first patient had an acute leak on the second postoperative day. The patient received a laparoscopic revision sleeve gastrectomy and was discharged 5 days later after an uneventful recovery. Another patient developed an intra-abdominal abscess 3 weeks after surgery and received laparoscopic drainage and a revision sleeve gastrectomy. Upon follow-up, only four (16%) patients experienced occasional acid regurgitation symptoms; however, no anti-acid medication was required. A significant decrease in the prevalence of erosive esophagitis (80 vs. 17%) after LNFGP was observed. The mean weight loss was 9.7, 14.1, 17.9, and 18.1% at 1, 3, 6 and 12 months, respectively. The mean BMI decreased to 30.8 kg/m(2) 1 year post surgery with a mean body weight loss of 25 kg. CONCLUSIONS: LNFGP appears to be an acceptable treatment option for treating GERD in morbidly obese patients who refuse Roux-en-Y gastric bypass. However, further study is indicated to verify this novel procedure.

Laparoscopic sleeve gastrectomy for diabetes treatment in nonmorbidly obese patients: efficacy and change of insulin secretion.

BACKGROUND: Sleeve gastrectomy is a new bariatric surgery, and many reports have showed that patients who have undergone sleeve gastrectomy have experienced rapid resolution of type 2 diabetes. The mechanisms accounting for the beneficial effects of sleeve gastrectomy on glucose homeostasis are not well understood and remain speculative. This trial assessed prospectively the effect of sleeve gastrectomy on type 2 diabetes and the serial changes of insulin secretion to oral glucose loads. METHODS: Prospective study on the response of insulin secretion to oral glucose loads in 20 severe diabetic patients (body mass index [BMI] >25 and <35, HbA1C >7.5%) before and at 1, 4, 12, 26, and 52 weeks after sleeve gastrectomy. The insulin secretion was measured by insulinogenic index and area under the curve (AUC) during a standard oral glucose tolerance test (OGTT). Remission of type 2 diabetes was defined as fasting glucose level <126 mg/dL and HbA1C <6.5% without any glycemic therapy. RESULTS: Of the 20 patients enrolled, the mean age was 46.3 + or - 8.0 years, mean BMI was 31.0 + or - 2.9 kg/m(2), and mean HbA1C was 10.1 + or - 2.2. The mean BMI and excess body weight loss at 1, 4, 12, 26, and 52 weeks after operation were 28.9 (22.1%), 27.4 (43.0%), 25.7 (55.1%), 24.9 (71.9%), and 24.6 (69.1%), respectively. The mean HbA1C at 1, 4, 12, 26, and 52 weeks after operation were 9.2, 8.4, 7.7, 7.3, and 7.1, respectively. Resolution of type 2 diabetes was achieved in 2 (20%) patients at 4 weeks, 6 (30%) at 12 weeks, 8 (40%) at 26 weeks, and 10 (50%) at 52 weeks after sleeve gastrectomy. Before operation, the mean fasting plasma glucose and insulin levels were 240.1 + 80.9 mg/dL and 16.8 + or - 15.4 uIU/mL, respectively. The OGTT test showed a blunted insulin secretion pattern with an AUC of 3,135 uIU x min/mL. At 1 week after operation, the fasting plasma glucose and insulin levels significantly decreased to 158 + or - 52 mg/dL and 5.6 + or - 3.2 uIU/mL, respectively. The AUC decreased to 2,988.7 uIU x min/mL. The AUC at 4, 12, 26, and 52 weeks after operation was 2,211, 1,584, 3,621, and 3,351 uIU x min/mL, respectively. The diabetes resolution rates for those with pre-operative C-peptide <3, 3-6, and >6 ng/mL were 1/7 (14.3%), 7/11 (63.6%), and 2/2 (100%), respectively (P < .05). CONCLUSION: Laparosopic gastric sleeve gastrectomy resulted in remission of poorly controlled nonmorbidly obese T2DM patients up to 50% at 1 year after operation. The effect is related more to the decreasing of insulin resistance because of calorie restriction and weight loss rather than to the increasing of insulin secretion. C-peptide >3 ng/mL is the most important predictor for a successful treatment.