Table of Contents  
ORIGINAL ARTICLE
Year : 2013  |  Volume : 6  |  Issue : 2  |  Page : 151-154  

Laparoscopic sleeve gastrectomy in remission of obesity and associated co-morbidities


1 Department of Surgery, Padmashree Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth Pimpri, Pune, India
2 Obesity Surgery Clinic, Prabhuta Villa, Hughes Road, Kemps Corner, Mumbai, India

Date of Web Publication10-Apr-2013

Correspondence Address:
Sangram Jadhav
Department of Surgery, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune - 400 703
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.110304

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  Abstract 

Background: There is a lot of discussion on bariatric surgery and its effect on weight loss as well as resolution of associated conditions such as diabetes, sleep apnea, and thyroid imbalance. Recent reports also indicate role of laparoscopic sleeve gastrectomy (LSG) in non-obese diabetics. Aims: This study was undertaken to assess medium-term effects of LSG on body weight and co-morbid factors such as diabetes, hypertension, and thyroid imbalance. Materials and Methods: A total of 42 obese subjects (19 males and 23 females; age: 23-65 years; body mass index [BMI]: 45 ± 5 kg/m¼) underwent evaluation of anthropometric/clinical parameters and blood sugar, hypertension and thyroid function tests before, 3 and 9-15 months after LSG. Results: Mean BMI decreased from 45 to 38 after 3 months and 30 at 9-15 months after surgery. Remission of type 2 diabetes mellitus and hypertension occurred in all patients except one. Sleep apnea and asthma was cured in all five patients. Out of the five patients with thyroid imbalance, all except one were off medication within 5 months. Conclusion: Our study showed that LSG is effective in producing a significant and sustained weight loss and improving diabetes mellitus, hypertension, and other co-morbid factors in obese patients.

Keywords: Diabetes mellitus, hypertension, laparoscopic sleeve gastrectomy, morbid obesity


How to cite this article:
Jadhav S, Borude S. Laparoscopic sleeve gastrectomy in remission of obesity and associated co-morbidities. Med J DY Patil Univ 2013;6:151-4

How to cite this URL:
Jadhav S, Borude S. Laparoscopic sleeve gastrectomy in remission of obesity and associated co-morbidities. Med J DY Patil Univ [serial online] 2013 [cited 2024 Mar 29];6:151-4. Available from: https://journals.lww.com/mjdy/pages/default.aspx/text.asp?2013/6/2/151/110304


  Introduction Top


Obesity is one of the most serious and urgent public health problems globally because of its metabolic and cardiovascular complications that negatively impact on life expectancy. [1] Equally alarming is the increase of morbid obesity (body mass index [BMI]: >40 kg/m½) that tripled in developing countries like India over the last 20 years and quadrupled globally over the last two decades, whereas extreme obesity (BMI >50 kg/m 2 ) increased five-fold. [2]

Bariatric surgery, also known as metabolic surgery, has emerged as a highly effective and long-lasting treatment in patients with morbid obesity and in those with BMI >35 kg/m 2 in the presence of co-morbidities such as type 2 diabetes mellitus (T2DM), hypertension, thyroid imbalance, and sleep apnea. [3] There is extensive evidence that bariatric procedures, including bilio-pancreatic diversion (BPD), gastric bypass (GBP), and gastric banding, can successfully control most of the obesity-related co-morbidities. [4] The rate of success is higher with the predominantly malabsorptive and mixed malabsorptive-restrictive procedures than purely restrictive operations. [5]

Laparoscopic sleeve gastrectomy (LSG) is emerging as a new promising therapy for the treatment of morbid obesity. [6] In fact, LSG has the advantage to be less invasive than GBP and BPD, and not inferior in terms of sustained weight loss, as demonstrated in some preliminary studies. [6] Few studies have examined the effects of LSG on co-morbidities in obese patients, and limited information is available on the long-term efficacy of this procedure. [7],[8],[9] Therefore, in this study, we assessed the medium-term (9-15 months) effects of LSG on body weight and co-morbid factors not adequately controlled by medical therapy.


  Materials and Methods Top


The study was conducted under the Department of Bariatric Surgery at hospitals in Mumbai, where subjects were enrolled through outpatient visits in our department between January 2010 and December 2010. All patients selected were given two fair and honest trials of diet and exercise which had failed. They were being treated with insulin for diabetes and anti-hypertensive medications for hypertension.

A total of 42 obese patients (19 males/23 females; age: 23-65 years; mean BMI: 45 kg/m 2 , standard deviation (SD): 5 kg/m 2 ), with co-morbidities such as diabetes mellitus, hypertension, thyroid imbalance, and sleep apnea underwent LSG surgery. All patients were examined by a multidisciplinary medical team consisting of a physician, bariatric surgeon, psychiatrist, endocrinologist, and dietician.

  • The inclusion criteria were:

    • Age: 25-65 years
    • BMI: >40 kg/m 2
    • Duration of diabetes/hypertension: >1 year.


  • Exclusion criteria were:

    • BMI: <35 kg/m 2
    • Fasting blood sugar: < 60 mg%.




Endocrine obesity

History of mental impairment, drug or alcohol addiction, recent major vascular event, and excessive surgical risks due to debilitating diseases that considerably impair life expectancy.

All patients underwent complete evaluation including nutritional status such as vitamin B-12, calcium, magnesium, iron, protein, fat, carbohydrate, body composition before and at 9-15 months after surgery. No nutritional supplements were given before and after surgery.

Post-operative patients were followed up after 1 month, 3 months, 6 months, 9 months, 1 year, and 15 months. All tests including weight loss, blood sugar, blood pressure, thyroid function test, and nutritional and clinical parameters were assessed regularly.

Dietary guidelines

Patients were kept on clear liquids 3 days before surgery.

After surgery, patient was nil by mouth for 48 h, followed by low-calorie clear liquids for 4 weeks, semisolids (low calorie) for 2-4 weeks followed by full diet.

Most of the patients lacked exercise and significant physical activity before surgery. After surgery, patients were asked to resume work from day 5, undertake gradual exercise and physical activity from day 10, with graded increase to walking upto 6 km in 1 h over the next 2-3 months. All patients provided written informed consent before undergoing surgery.

Operative technique

All operative procedures were performed laparoscopically. The first step consisted in opening the gastrocolic ligament attached to the stomach from the pyloric vein, usually 10 cm proximal to the pylorus toward the lower pole of the spleen. Then, the gastric greater curvature is freed upto the cardio-esophageal junction close to stomach sparing the gastroepiploic vessels. Meticulous dissection is performed at the angle of His with full mobilization of the gastric fundus. The stomach is mobilized downward toward the antrum upto 3-5 cm from pylorus. The stomach is resected with linear staplers parallel to the 40-French orogastric tube along the lesser curve starting 3-5 cm from the pylorus. The orogastric bougie was then replaced by a nasogastric tube positioned in the distal stomach. Hemostasis and staple line were checked. The resected stomach was then removed through the umbilical port. The residual gastric volume ranged from 60 to 80 ml.

Remission of Co-morbidities

Remission of T2DM was defined as fasting plasma glucose below 100 mg% in the absence of hypoglycemic treatment. Remission of hypertension was defined as blood pressure below 130/90 mmHg in the absence of anti-hypertensive treatment. Remission of thyroid imbalance was defined as normal thyroid profile in the absence of medical therapy. Remission of sleep apnea and asthma was defined as normal sleep and breathing without apneic/asthmatic spells devoid of treatment or Continuous Positive Airway Pressure CPAP.

Statistical analysis used

Results are expressed as mean ± SD or number. Analysis of variance with repeated measures was used to detect changes over time of the anthropometric and biochemical variables. Paired Student's t-tests were used to compare data before and after surgery. A P value of 0.05 was considered statistically significant. All statistical analyses were performed using Statistical Package for the Social Sciences (SPSS) version 13.0 (SPSS Inc., Chicago, IL, USA).


  Results Top


The main results are shown in [Table 1]. After surgery, there was significant reduction in feeling of hunger which was natural, not needing any forceful control and early satiety with limited food volume was achieved after surgery. There was no food intolerance post-operatively.
Table 1: Results of laparoscopic sleeve gastrectomy on body weight, BMI, and associated co-morbidities


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Following surgery, all patients discontinued their hypoglycemic medications, and full remission of T2DM was achieved in almost all patients. Hypertension was relieved in all but one patient and thyroid medication was continued in only one of five patients. Patients with Sleep apnea and asthma went off medications in five of the five operated patients. Most of the patients were off medications for co-morbid factors within 6-9 months following surgery in gradually reducing doses.

Average reduction of body weight was 28.7% in males and 44.6% in females. In terms of weight in kg, average weight loss was 29.59 kg in females and 25.43 kg in males and t value being 16.732.


  Discussion Top


Our study shows that LSG is effective in producing a significant and sustained weight loss [3] and improving the co-morbid conditions in obese patients. In fact, after 9-15 months from surgery, all patients achieved good glycemic control, thyroid function, and breathing status, all except one were cured of hypertension. This finding is in line with previous studies. [7],[8],[9],[10],[11] The results seem better in this study due to smaller sample size and measurement of clinical/anthropometric and blood sugar levels only. With inclusion of larger sample size, Hba1c levels, the results may match with world studies on more appropriate platforms.

Although the mechanisms underlying T2DM remission following LSG has yet to be fully determined, some human studies have reported favorable changes in insulin sensitivity. [12],[13] The improvement in insulin sensitivity is primarily due to weight loss, reduction in inflammatory mediators, and decreased calorie intake. Potential mechanisms include enhanced stimulation of gastrointestinal hormones secondary to rearrangement of gastrointestinal anatomy. For malabsorptive/mixed procedures (Roux-en-Y GBP and BDP), relevant and rapid changes in the enterohormonal axis have been demonstrated, consisting of complete recovery of meal-stimulated response of glucagon-like peptide-1 (GLP) and glucose-dependent insulinotropic polypeptide (GIP). [14] The recovery of incretin response is maintained over time, probably contributing to the recovery of beta-cell function. [7] This procedure is associated with a marked reduction of ghrelin secretion, an orexigenic peptide produced by the gastric fundus involved in mealtime hunger regulation. [14] Ghrelin is also known to exert several diabetogenic effects (increase in growth hormone, cortisol, and epinephrine); therefore, its suppression could contribute to improved glucose homeostasis. Interestingly, we observed an increased meal-stimulated GLP 1 and GIP response in our patients at 3 weeks post-operatively, which may have concurred to amelioration of glucose metabolism.

The reduction in sleep apnea relates directly to reduction in the mass of fat cells lining the alveoli, reduced pharyngeal adipose tissue as well as reduced external pressure of fatty tissue on the airways, fat being lost. The chest wall contractility improves with reduced weight.

Hypertension is reduced due to weight reduction with less total body mass to which blood needs to reach, reduced insulin resistance, reduced fat cells lining the endothelium of blood vessels, increased pliability of vessel wall (vascular compliance due to reduced sympathetic tone), and increased mobility or exercise improving cardiac reserve and stroke volume.

Reduction of weight and normalization of BMI helps maintain normal thyroid function as obesity and metabolic factors play an important role especially in hypothyroid obese patients.

None of the patients studied presented any sign of nutritional deficiencies at 9-15 month follow-up, confirming that LSG is a safe procedure in terms of nutritional status at odds with malabsorptive or mixed surgical procedures which often lead to multiple nutritional consequences due to the bypass of duodenum and jejunum. [15]


  Conclusion Top


LSG induces stable weight loss and resolution of co-morbid factors in large majority of patients. Controlled long-term comparisons between different bariatric interventions are needed to establish the optimal procedure in relation to patient's characteristics. Study could be improvised with a larger cohort size and measurement of Hba1c levels.

 
  References Top

1.Mensah GA, Mokdad AH, Ford E, Narayan KM, Giles WH, Vinicor F, et al. Obesity, metabolic syndrome, and type 2 diabetes: Emerging epidemics and their cardiovascular implications. Cardiol Clin 2004;22:485-504.  Back to cited text no. 1
    
2.Bessesen DH. Update on obesity. J Clin Endocrinol Metab 2008;93:2027-34.  Back to cited text no. 2
    
3.Schernthaner G, Morton JM. Bariatric surgery in patients with morbid obesity and type 2 diabetes. Diabetes Care 2008;31:S297-302.  Back to cited text no. 3
    
4.Buchwald H, Estok R, Fahrbach K, Banel D, Jensen MD, Pories WJ, et al. Weight and type 2 diabetes after bariatric surgery: Systematic review and meta-analysis. Am J Med 2009;122:248-56.  Back to cited text no. 4
    
5.Sjöström L, Lindroos AK, Peltonen M, Torgerson J, Bouchard C, Carlsson B, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004;351:2683-93.  Back to cited text no. 5
    
6.Daskalakis M, Weiner RA. Sleeve gastrectomy as a single-stage bariatric operation: Indications and limitations. Obes Facts 2009;2:8-10.  Back to cited text no. 6
    
7.Vidal J, Ibarzabal A, Romero F, Delgado S, Momblán D, Flores L, et al. Type 2 diabetes mellitus and the metabolic syndrome following sleeve gastrectomy in severely obese subjects. Obes Surg 2008;18:1077-82.  Back to cited text no. 7
    
8.Miguel GP, Azevedo JL, Gicovate Neto C, Moreira CL, Viana EC, Carvalho PS. Glucose homeostasis and weight loss in morbidly obese patients undergoing banded sleeve gastrectomy: A prospective clinical study. Clinics (Sao Paulo) 2009;64:1093-8.  Back to cited text no. 8
    
9.Shi X, Karmali S, Sharma AM, Birch DW. A review of laparoscopic sleeve gastrectomy for morbid obesity. Obes Surg 2010;20:1171-7.  Back to cited text no. 9
    
10.Rosenthal R, Li X, Samuel S, Martinez P, Zheng C. Effect of sleeve gastrectomy on patients with diabetes mellitus. Surg Obes Relat Dis 2009;5:429-34.  Back to cited text no. 10
    
11.Rizzello M, Abbatini F, Casella G, Alessandri G, Fantini A, Leonetti F, et al. Early postoperative insulin-resistance changes after sleeve gastrectomy. Obes Surg 2010;20:50-5.  Back to cited text no. 11
    
12.Abbatini F, Rizzello M, Casella G, Alessandri G, Capoccia D, Leonetti F, et al. Long-term effects of laparoscopic sleeve gastrectomy, gastric bypass, and adjustable gastric banding on type 2 diabetes. Surg Endosc 2010;24:1005-10.  Back to cited text no. 12
    
13.Thaler JP, Cummings DE. Minireview: Hormonal and metabolic mechanisms of diabetes remission after gastrointestinal surgery. Endocrinology 2009;150:2518-25.  Back to cited text no. 13
    
14.Peterli R, Wölnerhanssen B, Peters T, Devaux N, Kern B, Christoffel-Courtin C, et al. Improvement in glucose metabolism after bariatric surgery: Comparison of laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy: A prospective randomized trial. Ann Surg 2009;250:234-41.  Back to cited text no. 14
    
15.Koch TR, Finelli FC. Postoperative metabolic and nutritional complications of bariatric surgery. Gastroenterol Clin North Am 2010;39:109-24.  Back to cited text no. 15
    



 
 
    Tables

  [Table 1]


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