Long-Term Outcomes of Laparoscopic Sleeve Gastrectomy—a Single-Center, Retrospective Study

Abstract

Introduction Sleeve gastrectomy (LSG) is one of the most popular bariatric procedures. We present our long-term results regarding weight loss, comorbidities, and gastric reflux disease.

Material and Methods We identified patients who underwent LSG in our institution between 2006 and 2009. We revised the data, and the patients with outdated contact details were tracked with the national health insurance database and social media (facebook). Each of the identified patients was asked to complete an online or telephone survey covering, among others, their weight and comorbidities. On that basis, we calculated the percent total weight loss (%TWL) and percent excess weight loss (%EWL), along with changes in body mass index (ΔBMI). Satisfactory weight loss was set at >50% EWL (for BMI = 25 kg/m2 ). We evaluated type 2 diabetes (T2DM) and arterial hypertension (AHT) based on the pharmacological therapy. GERD presence was evaluated by the typical symptoms and/or proton pump inhibitor (PPI) therapy. Results One hundred twenty-seven patients underwent LSG between 2006 and 2009. One hundred twenty patients were qualified for this study. Follow-up data was available for 100 participants (47 female, 53 male). Median follow-up period reached 8.0 years (from 7.1 to 10.7). Median BMI upon qualification for LSG was 51.6 kg/m2 . Sixteen percent of patients required revisional surgery over the years (RS group), mainly because of insufficient weight loss (14 Roux-Y gastric bypass—LRYGB; one mini gastric bypass, one gastric banding). For the LSG (LSG group n = 84), the mean %EWL was 51.1% (±22.3), median %TWL was 23.5% (IQR 17.7– 33.3%), and median ΔBMI was 12.1 kg/m2 (IQR 8.2–17.2). Fifty percent (n = 42) of patients achieved the satisfactory %EWL of 50%. For RS group, the mean %EWL was 57.8% (±18.2%) and median %TWL reached 33% (IQR 27.7– 37.9%). Sixty-two percent (n = 10) achieved the satisfactory weight loss. Fifty-nine percent of patients reported improvement in AHT therapy, 58% in T2DM. After LSG, 60% (n = 60) of patients reported recurring GERD symptoms and 44% were treated with proton pomp inhibitors (PPI). In 93% of these cases, GERD has developed de novo. Conclusions Isolated LSG provides fairly good effects in a long-term follow-up with mean %EWL at 51.1%. Sixteen percent of patients require additional surgery due to insufficient weight loss. More than half of the subjects observe improvement in AHT and T2DM. Over half of the patients complain of GERD symptoms, which in most of the cases is a de novo complaint.


Introduction
Laparoscopic sleeve gastrectomy (LSG) was introduced as preliminary bariatric procedure for superobese patients, whose BMI exceeded 50 kg/m2 [1]. Its purpose was to achieve substantial weight loss, therefore lowering the rate of possible complications during the second, more extensive procedure, such as Duodenal Switch or Laparoscopic Roux-en-Y Gastric Bypass [2]. Yet the results of LSG concerning excessive weight-loss, co-morbidities, and postoperative shift in the American Society of Anesthesiologists (ASA) physical classification score have changed bariatric surgeons’ approach to LSG as a sole bariatric procedure [3–5]. The worldwide popularity of LSG increased from 4.5% of all bariatric procedures in 2008 to 37% in 2013, and it became the most popular operation in the USA in 2015 [6–8]. First results regarding the long-term outcomes of LSG are being published, yet there is still a need for longer follow-up (exceeding 5 years) with smaller lost-to-follow up ratio [9, 10]. Since our institution is the leading center for bariatric surgery in the country, with over 300 operations performed each year [11], we would like to present our results regarding long-term outcomes of LSG.


Aim
The aim of this study was to evaluate long-term clinical outcomes of laparoscopic sleeve gastrectomy regarding weight loss, comorbidities, physical activity, and complaints of gastroesophageal reflux disease (GERD).


Materials and Methods
The study was approved by our Institution’s Review Board.


Participants
Our institution database was revised for the records of patients who underwent LSG as a one-stage procedure between 2006 (when we started our sleeve gastrectomy program) and 2009. We gathered the data on their weight, body mass index (BMI), and co-morbidities. The patients who did not fulfill their check-ins and whose personal data was outdated were tracked using the national health insurance database, or found and contacted privately using social media (Facebook) and its support groups. The rest of the patients were contacted by phone. Every participant filled out a questionnaire regarding their current weight, medical history, physical activity habits— expressed by regular (minimum three times-a-week), over 30-min exercise routine, and sedentary behavior, assessed by hours spent siting down on a daily basis.


Evaluation of the Outcomes
To measure the effectiveness of the procedure, we calculated the percentage total weight loss (%TWL), percentage excess weight loss (%EWL), and change in body mass index (ΔBMI).

To obtain the excess weight (EW), we subtracted ideal body weight (IBW) for BMI of 25 kg/m2 from the weight before surgery. Satisfactory weight loss after the surgery was defined by the %EWL greater than 50%. GERD presence was evaluated by the typical symptoms and/or proton pump inhibitor (PPI) therapy, according to the latest guidelines [12]. The questions regarding typical symptoms (such as postprandial heartburn, regurgitation, chronic cough) were included in the survey. We evaluated type 2 diabetes (T2DM) and arterial hypertension (AHT), the two major obesity related comorbidities, based on the pharmacological therapy—whether it was ceased after the surgery, the doses or number of drugs administered changed, or no changes were observed.


Conclusions
Based on our results, LSG may be considered a fairly effective bariatric procedure, with mean %EWL of 51.1% at an 8-year, long-term follow-up. Forty-two percent of patients achieved the satisfactory weight loss of over 50% EWL only after LSG (rev. 2 note 3) and 16% of the patients required conversion to other procedure due to insufficient weight loss. This fact may urge on a more thorough and meticulous follow up. Fifty-nine percent of patients reported improvement in AHT therapy, 58% in T2DM. We conclude that there is a high rate of GERD symptoms after LSG, which requires further studies and may alter our perspective on patient selection and the procedure itself.