Laparoscopic Sleeve Gastrectomy Versus Banded Roux-en-Y Gastric Bypass for Diabetes and Obesity: a Prospective Randomised Double-Blind Trial

Background

There are very few randomised, blinded trials comparing laparoscopic sleeve gastrectomy (LSG) versus laparoscopic Roux-en-Y gastric bypass (LRYGB) in achieving remission of type 2 diabetes (T2D), particularly silastic ring (SR)-LRYGB. We compared the effectiveness of (LSG) versus SR-LRYGB among patients with T2D and morbid obesity.

Methods

Prospective, randomised, parallel, 2-arm, blinded clinical trial conducted in a single Auckland (New Zealand) centre. Eligible patients aged 20–55 years, T2D of at least 6 months duration and BMI 35–65 kg/m² were randomised 1:1 to LSG (n = 58) or SR-LRYGB (n = 56) using random number codes disclosed after anaesthesia induction. Primary outcome was T2D remission defined by different HbA1c thresholds at 1 year. Secondary outcomes included weight loss, quality of life, anxiety and depressive symptoms, post-operative complications and mortality.

Results

Mean ± standard deviation (SD) pre-operative BMI was 42.5 ± 6.2 kg/m², HbA1c 63 ± 16 mmol/mol (30% insulin-treated, 28% had diabetes duration over 10 years). Proportions achieving HbA1c ≤ 38 mmol/mol, < 42 mmol/mol, < 48 mmol/mol and < 53 mmol/mol without diabetes medication at 1 year in SR-LRYGB vs LSG were 38 vs 43% (p = 0.56), 52 vs 49% (p = 0.85), 75 vs 72% (p = 0.83) and 80 vs 77% (p = 0.82), respectively. Mean ± SD % total weight loss at 1 year was greater after SR-LRYGB than LSG: 32.2 ± 7.7 vs 27.1 ± 7.5%, respectively (p < 0.001). Gastrointestinal complications were more frequent after SR-LRYGB (including 3 ulcers, 1 anastomotic leak, 1 abdominal bleeding). Quality of life and depression symptoms improved significantly in both groups.

Conclusion

Despite significantly greater weight loss after SR-LRYGB, there was similar T2D remission and psychosocial improvement after LSG and SR-LRYGB at 1 year.

Trial Registration

Prospectively registered at Australia and New Zealand Clinical Trials Register (ACTRN 12611000751976) and retrospectively registered at Clinical Trials (NCT1486680).

     

A Meta-analysis of 2-Year Effect After Surgery: Laparoscopic Roux-en-Y Gastric Bypass Versus Laparoscopic Sleeve Gastrectomy for Morbid Obesity and Diabetes Mellitus

Literature search was performed for bariatric surgery from inception to September 2013, in which the effects of laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) on body mass index (BMI), percentage of excess weight loss (EWL%), and diabetes mellitus (DM) were compared 2 years post-surgery. A total of 9,756 cases of bariatric surgery from 16 studies were analyzed. Patients receiving LRYGB had significantly lower BMI and higher EWL% compared with those receiving LSG (BMI mean difference (MD)?=??1.38, 95 % confidence interval (CI)?=??1.72 to ?1.03; EWL% MD?=?5.06, 95 % CI?=?0.24 to 9.89). Improvement rate of DM was of no difference between the two types of bariatric surgeries (RR?=?1.05, 95 % CI?=?0.90 to 1.23). LRYGB had better long-term effect on body weight, while both LRYGB and LSG showed similar effects on DM.     

Laparoscopic Gastric Bypass Versus Laparoscopic Sleeve Gastrectomy as a Definitive Surgical Procedure for Morbid Obesity. Mid-Term Results

Background

Laparoscopic sleeve gastrectomy (LSG) has been gaining acceptance because it has shown good short- and mid-term results as a single procedure for morbid obesity. The aim of this study was to compare short- and mid-term results between laparoscopic Roux-en-Y gastric bypass (LRYGB) and LSG.

Methods

Observational retrospective study from a prospective database of patients undergoing LRYGB and LSG between 2004 and 2011, where 249 patients (mean age 44.7 years) were included. Patients were followed at 1, 3, 6, 12, and 18 months, and annually thereafter. Short- and mid-term weight loss, comorbidity improvement or resolution, postoperative complications, re-interventions, and mortality were evaluated.

Results

One hundred thirty-five LRYGB and 114 LSG were included. Significant statistical differences between LRYGB and LSG were found in operative time (153 vs. 93 min. p?<?0.001), minor postoperative complications (21.5 % vs. 4.4 %, p?=?0.005), blood transfusions (8.8 % vs. 1.7 %, p?=?0.015), and length of hospital stay (4 vs. 3 days, p?<?0.001). There were no differences regarding major complications and re-interventions. There was no surgery-related mortality. The percentage of excess weight loss up to 4 years was similar in both groups (66?±?13.7 vs. 65?±?14.9 %). Both techniques showed similar results in comorbidities improvement or resolution at 1 year.

Conclusions

There is a similar short- and mid-term weight loss and 1-year comorbidity improvement or resolution between LRYGB and LSG, although minor complication rate is higher for LRYGB. Results of LSG as a single procedure need to be confirmed after a long-term follow-up.     

Improvement in Cardiovascular Indices After Roux-en-Y Gastric Bypass or Sleeve Gastrectomy for Morbid Obesity

Background

Morbidly obese patients display cardiac abnormalities which are partially reversed after weight loss. The aim of the present study was to assess the potential difference in cardiovascular disease indices between patients who underwent either gastric bypass surgery or sleeve gastrectomy.

Methods

Thirty-seven morbidly obese patients who underwent either Roux-en-Y gastric bypass (RYGB) (n?=?14) or SG (n?=?23) were examined before, 3 and 6 months after surgery. Indices of cardiac autonomic nervous system activity were evaluated, namely baroreflex sensitivity (BRS) and heart rate variability (HRV). A complete echocardiographic study was performed in a subgroup of 17 patients (RYGB 8, SG 9) preoperatively and 6 months after surgery, evaluating epicardial fat thickness, aortic distensibility, left ventricular (LV) Tei index, left atrium diameter, ejection fraction, and LV mass.

Results

All subjects experienced significant (p?<?0.001) and similar weight loss independently of the type of operation. BRS and HRV indices improved significantly and to the same degree after surgery in both groups. In the echocardiographic study, all parameters improved significantly at 6 months in comparison with the baseline values. In addition, the RYGB group displayed significantly greater reduction in epicardial fat thickness (p?=?0.007) and also tended to have a better LV performance as expressed by the lower values of the Tei index (p?=?0.06) compared to the SG group 6 months after surgery.

Conclusions

Both RYGB and SG exert comparable effects on weight loss and improvement of cardiovascular parameters. RYGB displays a more beneficial influence on epicardial fat thickness and left ventricular performance than SG.     

Experience with Laparoscopic Sleeve Gastrectomy for Morbid Versus Super Morbid Obesity

Background  

We evaluated the safety and efficacy of laparoscopic sleeve gastrectomy (LSG) for super morbid obesity in patients with an initial body mass index (BMI) of <50 or ≥50.     

A Randomized Clinical Trial of Laparoscopic Roux-en-Y Gastric Bypass and Sleeve Gastrectomy for the Treatment of Morbid Obesity in China: a 5-Year Outcome

Background

No randomized comparative trials have presented long-term outcomes for laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). The present study was designed to compare the efficacy and safety of these two procedures.

Methods

From January 2007 to July 2008, 64 eligible patients were randomly assigned to LSG or LRYGB. During the 5-year follow-up, we compared morbidity rate, body mass index (BMI), percent of excess weight loss (%EWL), Moorehead-Ardelt (M-A) II quality of life, and resolution or improvement rate of obesity-related comorbidities between the groups.

Results

Both groups were matched with respect to age, gender, and BMI. Slightly more major complications were observed in patients undergoing LRYGB (P?>?0.05). Weight loss was significantly better with LRYGB except during the first postoperative year. At 5 years, %EWL for LSG and LRYGB was 63.2?±?24.5 % and 76.2?±?21.7 % (P?=?0.02), respectively. No statistical difference was observed in quality of life between the groups at all intervals (P?>?0.05). At the last follow-up, most comorbidities in both groups were resolved or improved, with no difference between the groups (P?>?0.05).

Conclusion

LRYGB and LSG are equally safe and effective in quality of life and improvement or resolution of comorbidities, and LRYGB possesses the superiority in terms of weight loss. Further studies are needed to evaluate micronutrient deficiencies of these procedures.     

Internal Hernia after Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is associated with a relatively high incidence of internal hernias (IH) when compared to the open operation. Methods: A search in PubMed MEDLINE from January 1994 through January 2006 was performed (keywords: obesity, laparoscopy, gastric bypass and internal hernia). Results: 26 studies with a total of 11,918 patients were considered. 300 cases of IH occurred (rate 2.51%). IH occurred 116 times at the level of the transverse colon mesentery (69%), 30 at the Petersen's space (18%), and 22 at the entero-enterostomy site (13%). 142 re-operations were performed laparoscopically (85.6%), and 24 by laparotomy (14.4%). Bowel resection was done in 5 cases (4.7%). Mortality was 1.17%. Conclusions: IH after LRYGBP has an incidence of 2.51%. Closure of mesenteric defects with non-absorbable running suture and antecolic Roux limb are recommended. Surgical exploration for suspicion of IH after LRYGBP should be first done by laparoscopy.     

A Review of Laparoscopic Sleeve Gastrectomy for Morbid Obesity

Laparoscopic sleeve gastrectomy (LSG) is an innovative approach to the surgical management of morbid obesity. Weight loss may be achieved by restrictive and endocrine mechanisms. Early data suggest LSG is efficacious in the management of morbid obesity and may have an important role either as a staged or definitive procedure. A systematic review of the literature analyzing the clinical and operational outcomes of LSG was completed to further define the status of LSG as an emerging treatment modality for morbid obesity. Data from LSG were compared to benchmark clinical data and local operational data from laparoscopic adjustable gastric band (LAGB) and laparoscopic gastric bypass (LRYGB). Fifteen studies (940 patients) were identified following systematic review. The percent excessive weight loss (%EWL) for LSG varied from 33% to 90% and appeared to be sustained up to 3 years. The mortality rate was 0-3.3% and major complications ranged from 0% to 29% (average 12.1%). Operative time ranged from 49 to 143 min (average 100.4 min). Hospital stay varied from 1.9 to 8 days (average 4.4 days). The operational impact of LSG has not been described in the literature. According to data from the Royal Alexandra Hospital, the estimated total cost of LSG was 10,317 CAD as compared to LAGB (10,317 CAD as compared to LAGB (7,536 CAD) and LRYGB ($11,666 CAD). These costs did not include further surgical interventions which may be required for an undefined group of patients after LSG. Early, non-randomized data suggest that LSG is efficacious in the surgical management of morbid obesity. However, it is not clear if weight loss following LSG is sustainable in the long term and therefore it is not possible to determine what percent of patients may require further revisional surgery following LSG. The operational impact of LSG as a staged or definitive procedure is poorly defined and must be analyzed further in order to establish its overall health care costs and operational impact. Although LSG is a promising treatment option for patients with morbid obesity, its role remains undefined and it should be considered an investigational procedure that may require revision in a subset of patients.     

Improvement of Hypothyroidism after Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been very effective in managing a broad range of morbid obesity-related co-morbidities. We report a beneficial effect of LRYGBP that has not been previously observed. Methods: Between December 1999 and September 2002, 224 patients underwent LRYGBP. Preoperative assessment for hypothyroidism and follow-up data were prospectively collected in our database. Improved thyroid function (ITF) or unchanged thyroid function (UTF) was determined by comparison of preoperative and postoperative thyroxine requirements. Results: 23 of 224 patients (10.3%) were treated preoperatively for hypothyroidism. During a median follow-up of 17 months, hypothyroidism was improved in 10/23 patients (43.5%). 2 patients had complete resolution, and the remaining 8 had reduction (14%-50%) of their thyroxine requirements. ITF occurred at a mean follow-up of 8.9 months and at a mean excess weight loss (EWL) of 57%. 6 of the 8 patients (75%) with ITF ≥ 25% had EWL >90% at last follow-up, compared to 1 out of 15 patients (6.6%) with UTF or <25% improvement (P =0.001). Comparison of patients with ITF and UTF over time during a 20-month follow-up, showed no significant difference in mean body mass index (BMI) and mean percentage of EWL. Conclusion: Improvement of hypothyroidism may be an additional benefit of bariatric surgery that has not been previously reported. Reduction of thyroxine requirements is most likely the result of the decrease in the BMI.     

Mid-term Results of Laparoscopic Sleeve Gastrectomy and Roux-en-Y Gastric Bypass in Adolescent Patients

The prevalence and severity of obesity in children and adolescents has been increasing in recent years at an unprecedented rate. Morbidly obese children will almost certainly develop severe comorbidities as they progress to adulthood, and bariatric surgery may provide the only alternative for achieving a healthy weight. The aim of this study was to assess the long-term outcomes and safety of laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB) as new treatment modalities for morbidly obese adolescents. We conducted a retrospective review of a prospectively collected database of all adolescent patients who underwent LSG and RYGB under IRB protocol at the Bariatric and Metabolic Institute in Cleveland Clinic Florida between 2002 and 2011. Patients were also contacted by phone, adhering to HIPAA regulations, and were asked to answer a survey. Eighteen adolescents had a bariatric procedure performed at this institution. The mean age was 17.5 years, the average weight was 293.1 lbs, and the average BMI was 47.2 kg/m². The mean follow-up period consisted of 55.2 months. The postoperative weight at 55 months follow-up was 188.4 lbs and average BMI was 30.1 kg/m². Fifteen of the patients were available for follow-up. Thirteen out of 16 (81 %) comorbidities in patients available for follow-up were in remission following rapid weight loss. The long-term follow-up and perioperative morbidity shown in this study suggest that LSG and LRYGB appear to be safe and effective operations in morbidly obese adolescents.     

腹腔镜袖状胃切除术治疗重度肥胖症的临床疗效

目的探讨腹腔镜下袖状胃切除术对重度肥胖症(体重指数BMI>35)的临床疗效。方法 2008年8月～2011年5月,对30例重度肥胖症患者实施腹腔镜袖状胃切除术,全身麻醉,腹腔镜下超声刀离断胃周韧带,术中电子胃镜指引下,使用Endo-GIA紧贴胃大弯侧行袖状胃切除。术后随访1年,观察BMI及超重体重下降百分比(excess weight loss,EWL%)的变化情况。结果 30例手术顺利,无术中并发症及中转开腹。术后1年体重指数(28.7±5.3)较术前(35.2±7.2)降低(t=3.98,P<0.001)。术后1年随访EWL%,根据Reinhold等制定的标准,效果极佳24例(80%)(EWL%76%～90%),良好6例(20%)(EWL%55%～73%)。结论腹腔镜袖状胃切除术治疗重度肥胖症近期疗效明显,长期疗效有待进一步观察。     

Superior Mesenteric Artery Syndrome after Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity

Gastrointestinal obstructive complications after laparoscopic Roux-en-Y gastric bypass (LRYGBP) are not uncommon. Their usual causes are strictures, internal hernias and adhesions. Superior mesenteric artery (SMA) syndrome is a rare disorder caused by compression of the third portion of the duodenum by the SMA that can occur after rapid weight loss. This has been reported in patients with scoliosis, burns, immobilization in body casts, and idiopathic weight loss. SMA syndrome following bariatric surgery has not been reported. We present 3 cases of SMA syndrome after LRYGBP and extensive weight loss. Two patients underwent laparoscopic duodenojejunostomy and the third patient was treated with intravenous hyperalimentation. All three are symptom free at 4-18 months follow-up. The diagnosis of SMA syndrome should be considered in bariatric surgery patients with rapid weight loss who develop atypical, recurrent obstructive symptoms not attributable to other common causes.     

Diagnosis and Management of Gastric Leaks After Laparoscopic Sleeve Gastrectomy for Morbid Obesity

Background  

Laparoscopic sleeve gastrectomy (LSG) is increasingly being recognised as a valid stand-alone procedure for the surgical management of morbid obesity. The leak rate from the gastric staple line ranges from 1.4% to 20%. From our experience of management of LSG leaks, we have been able to formulate an algorithm-based approach to the management of these patients.     

Sleeve Gastrectomy for Morbid Obesity

The rising prevalence of morbid obesity and the increased incidence of super-obese patients (BMI >50 kg/m2) seeking surgical treatments has led to the search for surgical techniques that provide adequate EWL with the least possible morbidity. Sleeve gastrectomy (SG) was initially added as a modification to the biliopancreatic diversion (BPD) and then combined with a duodenal switch (DS) in 1988. It was first performed laparoscopically in 1999 as part of a DS and subsequently done alone as a staged procedure in 2000. With the revelation that patients experienced weight loss after SG, interest in using this procedure as a bridge to more definitive surgical treatment has risen. Benefits of SG include the low rate of complications, the avoidance of foreign material, the maintenance of normal gastro-intestinal continuity, the absence of malabsorption and the ability to convert to multiple other operations. Reduction of the ghrelin-producing stomach mass may account for its superiority to other gastric restrictive procedures. SG should be in the armamentarium of all bariatric surgeons. Nonetheless, long-term studies are necessary to see if it is a durable procedure in the treatment of morbid obesity.     

Single-Incision Laparoscopic Gastric Bypass for Morbid Obesity

Background  

Single-incision laparoscopic surgery (SILS) has been developed with the aim of reducing the invasiveness of traditional laparoscopy.     

Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass

Introduction

A subset of patients undergoing laparoscopic sleeve gastrectomy (SG) require eventual conversion to Roux-en-Y gastric bypass (RYGB) due to complications from SG or to enhance weight loss. The aim of this study is to characterize the indications for conversion and perioperative outcomes in a large cohort of these patients at a single institution.

Methods

Patients who underwent revisional surgery to convert SG to RYGB at our institution from January 2008 through January 2017 were retrospectively reviewed.

Results

Eighty-nine patients with previous SG underwent conversion to RYGB as part of a planned two-stage approach to gastric bypass (n?=?36), for weight recidivism (n?=?11), or for complications related to SG (n?=?42). Complications from SG that warranted conversion included refractory GERD (40.5%), sleeve stenosis (31.0%), gastrocutaneous (16.7%), or gastropleural (7.1%) fistula, and gastric torsion (4.1%). The mean (SD) age was 47.2 years (11.4 years) and median BMI at the time of revision was 43.2 kg/m². A laparoscopic approach was successfully completed in 76 patients (85.4%), with an additional of four completed robotically (4.5%). The median length of stay was 3 days. Twenty-eight patients (31.5%) had complications which included surgical site infection (20.2%), re-operation (6.7%), anastomotic stricture (3.4%), and one pulmonary embolism. There were no mortalities with a median follow-up of 15 months.

Conclusions

Conversion of SG to RYGB is safe and technically feasible when performed for complications of SG or to enhance weight loss. This operation can be successfully performed laparoscopically with a low rate of conversion and reasonable complication profile.

     

Anastomotic Leak following Antecolic versus Retrocolic Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity

Background Laparoscopic Roux-en-Y gastric bypass(LRYGBP) is the most commonly performed operation for the treatment of morbid obesity in the United States. Previous reports suggest that postoperative complications may be influenced by Roux limb orientation (antecolic versus retrocolic), although thisremains controversial. The aim of this study was toanalyze our experience with anastomotic leaks following LRYGBP with an antecolic- versus retrocolicrouted Roux limb. Methods During the 2-year period of June 2003 to June 2005, 353 patients underwent a LRYGBP. 135 were antecolic and 218 retrocolic. All cases were performedby one of three bariatric surgeons. The decisionto perform antecolic versus retrocolic LRYGBP was left to the surgeon’s preference. The primary outcome measure was anastomotic leak. Results Mean follow-up was 28 weeks. There wereno perioperative deaths. Overall complication rate was 16.9%. 17 gastrojejunal leaks (4.8%) were identified, consisting of 12 intraoperative leaks (3.4%) and 5 postoperative leaks (1.4%). Postoperative gastrojejunal leak rate was higher in the antecolic group (P = 0.04). Conclusion Mortality and complication rates were consistent with reported benchmarks on the efficacy and safety of LRYGBP. Our review suggests that anastomotic leak may be more common after antecolic than after retrocolic LRYGBP for morbid obesity. A prospective randomized study is needed to determine whether antecolically-routed Roux limb is an independent predictor for anastomotic leak following LRYGBP.     

Staged Laparoscopic Sleeve Gastrectomy Followed by Roux-en-Y Gastric Bypass for Morbidly Obese Patients: A Risk Reduction Strategy

Background  In our centre laparoscopic Roux-en-Y gastric bypass (LRYGBP) is the most effective weight loss surgical procedure performed. However, LRYGBP may be associated with higher risk of peri- and postoperative complications in contrast to a purely restrictive procedure to justify this procedure on all comers. Laparoscopic sleeve gastrectomy (LSG) as a staged procedure may be an alternate risk reduction strategy. The aim of this study is to report on the short-term outcomes of LSG, the effect on operative risk reduction and resolution of comorbidities. Methods  A prospective review of 138 patients who underwent consecutive LSG from November 2004 to November 2006 was performed. Data were collected on all patients who attended the three to six monthly clinical follow-up and/or the patient questionnaire. Data collection included demographics, degree of weight reduction, postoperative complications, and changes in comorbidities. Results  Median BMI was 50.60 kg/m² (33–82). Of the patients, 46.38% had a BMI ≥50 kg/m². The overall median postoperative excess weight loss (EWL) was 43.26%, 31.08% at 6 months, 54.50% at 12 months, 51.47% at 18 months and 46.05% at 24 months. Of the patients, 39% had resolution of type 2 diabetes mellitus, 48% had resolution of dyslipidemia, 29% in hypertension, 52% in obstructive sleep apnea. Complication rate was 5.07% and four patients needed further surgical intervention. The mortality rate was zero. Conclusion  LSG does minimize postoperative complication rates significantly on high-risk patients and achieves effective short-term weight loss with resolutions in comorbidities. Additional studies are required to evaluate LSG as a stand-lone procedure.