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Sleeve Gastrectomy, a Review European Review for Medical and Pharmacological Sciences 2016; 20: 4930-4942 Sleeve gastrectomy: have we finally found the holy grail of bariatric surgery? A review of the literature I. KEHAGIAS¹, A. ZYGOMALAS¹, D. KARAVIAS¹, S. KARAMANAKOS² ¹Department of General Surgery, Nutrition Support and Morbid Obesity Unit, University Hospital of Patras, Greece ²Department of General Surgery, Basildon and Thurrock University Hospitals, Essex, UK Abstract. – OBJECTIVE: Laparoscopic sleeve fully classified as a disease by WHO. Bariatric gastrectomy has become one of the most com- surgery can effectively treat obesity and also monly performed bariatric operations. It is es- improve or even resolve a number of related co- sentially a restrictive bariatric operation; how- morbidities, offering patients a better life. Based ever, a series of hormonal changes occurring on recent studies, LSG is not only a safe, but also postoperatively contribute to decreased appe- tite and reduced food intake. an effective bariatric procedure with long-lasting 2 PATIENTS AND METHODS: This is a literature results . The aim of this report is to approach the review of recent articles published on Pubmed, role of sleeve gastrectomy as a contemporary Medline and Google Scholar databases in English. bariatric procedure through a comprehensive and RESULTS: Although, laparoscopic sleeve gas- concise review regarding various aspects of this trectomy is commonly performed worldwide, promising technique. Articles on sleeve gastrec- there is still a lack of standardization regarding the surgical technique. Standardizing the surgi- tomy, published on Pubmed, Medline and Google cal technique is essential in order to minimize Scholar databases in English were thoroughly postoperative complications and offer patients revised and included in the discussion. the best long-term weight loss. CONCLUSIONS: Laparoscopic sleeve gas- trectomy appears to be an effective bariatric op- Historical evolution eration. It is relatively easy to perform, well tol- erated by the patients and very effective regard- ing long-term excessive weight loss and reso- Sleeve gastrectomy was first performed by lution of the comorbidities, with minimum nutri- Hess in 1988 as part of his biliopancreatic diver- tional deficiencies. sion with the duodenal switch (BPD-DS) pro- cedure, adapted from Scopinaro’s biliopancre- Key Words atic diversion (BPD) and DeMeester’s duodenal Bariatric surgery, Sleeve gastrectomy, Laparoscopy- switch (DS) procedures3-5. Later in 1991 and ic surgery, Morbid obesity, Gastric sleeve. 1993 Marceau also proposed his modifications on Scopinaro’s biliopancreatic diversion that effec- tively included early forms of sleeve gastrectomy Introduction variations6,7. With the evolution of laparoscopic surgery during the 1990s, Gagner performed es- Laparoscopic sleeve gastrectomy (LSG) has sentially the first laparoscopic sleeve gastrectomy become one of the most commonly performed as part of BPD-DS in 19998. As a less demand- bariatric operations over the last years1. With ing technique, sleeve gastrectomy quickly gained more than 94.000 procedures performed in 2011, popularity early in the 21st century. Initially, it LSG has not only gained popularity, but also be- was performed as a first step intervention for came the second most commonly bariatric oper- super-obese patients (BMI > 60 kg/m2), before ation performed after gastric bypass1. With more definite intervention was undertaken with either than 1.9 billion overweight and over 600 million gastric bypass or biliopancreatic diversion proce- obese people worldwide in 2014, obesity is right- dures9,10. Nowadays laparoscopic sleeve gastrec- 4930 Corresponding Author: Ioannis Kehagias, MD, Ph.D; e-mail: [email protected] Sleeve gastrectomy, a review tomy (LSG) is considered a principal laparoscop- offering patients considerable excess weight loss ic bariatric procedure, mainly due to the many (%EWL)17-19. Boza et al20 reported, after 1000 advantages it possesses. consecutive cases, that the %EWL at 1, 2 and 3 years had been 86.6%, 84.1% and 84.5% respec- tively. Similarly, Rawlins et al21 found a %EWL Mechanisms of action of 86% at 5 years. In contrast to these very promising results, most publications agree that The LSG is essentially a restrictive bariatric patients undergoing LSG achieve a 60%EWL at operation. Weight loss is achieved by drastically 5 years22-27. After an initial high %EWL, most reducing the gastric volume, which in turn leads series report some weight regain after the second to reduced food intake. In addition, a series of year19. Respectively, Himpens et al25 and D’Hondt hormonal changes occurring postoperatively in et al28 observed that patients regain weight after bariatric patients, contribute to decreased appe- 5 years, with the % EWL dropping below 60%. tite, reduced food intake and long-term weight However, Sarela et al29 reported a %EWL of 69% loss (Figure 1)11, 12. Ghrelin, a hormone produced at 9 years, the longest follow-up to date. primarily by the oxyntic cells of the fundus of the stomach during fasting, stimulates appetite by increasing the expression of the orexigenic hypo- Nutrient deficiencies thalamic neuropeptide Y (NPY)11. By removing the gastric fundus, patients undergoing sleeve It is well documented that obese patients are gastrectomy have markedly decreased levels of generally malnourished, mainly due to a non-var- ghrelin and suppressed appetite respectively13. ied diet high in fats and carbohydrates and low Peptide YY (PYY), a hormone produced post- in quality protein products, dairy and vegetables. prandially from the gut, inhibits the release of Most nutrient and micronutrient deficiencies per- NPY and has an anorectic effect14. PYY is nota- sist postoperatively in patients undergoing bar- bly increased after sleeve gastrectomy, leading iatric surgery and as a result multivitamin sup- to prolonged satiety and reduced food intake13. plementation is necessary for these patients30,31. Glucagon-like peptide-1 (GLP-1) is secreted from However, nutritional deficiencies vary greatly the enteroendocrine L-cells in the intestine as a between different bariatric operations, with LSG response to food indigestion. GLP-1 stimulates having only a minimal impact on the nutrient insulin release, inhibits glucagon secretion and status22,32,33. Similarly to other types of bariatric has a satiating effect. Both rapid gastric emptying procedures, most commonly observed nutrient and postprandial hyperglucagonemia observed deficiencies like iron, folate and thiamine persist after sleeve gastrectomy lead to increased GLP-1 postoperatively, but can be easily resolved with levels15, 16. a daily multivitamin supplementation22,32-35. Iron deficiency and anemia in particular, commonly seen in bariatric patients, are also present after Weight loss after LSG LSG. However, the risk for anemia after LSG is lower compared to the other type of procedures, A major advantage of LSG is that despite when the iron supplement is administered post- being an easy, quick and safe bariatric proce- operatively33,36. Vitamin D deficiency is common dure, it is also an effective surgical technique, among obese patients due to malnutrition and limited sun exposure. Postoperative hypovita- minosis D, however, is not common after LSG due to loss of adipose tissue and adequate supple- mentation22,32. Respectively vitamin B12 deficien- cy is also not common after LSG as compared to gastric bypass and BPD22,32,34,36,37. Vitamin B12 is absorbed in the terminal ileum when banded to intrinsic factor, which is produced from the pari- etal cells in the antrum and duodenum. As com- pared to other malabsorptive bariatric operations, Figure 1. Hormonal changes occurring postoperatively af- where the duodenum is bypassed, the uptake of ter LSG. vitamin B12 is not disturbed in LSG32,36. 4931 I. Kehagias, A. Zygomalas, D. Karavias, S. Karamanakos Improvement in metabolic changes faction postoperatively and a significant number (diabetes) of them change their eating habits to a healthier diet over time56. Furthermore, due to the quick Besides excess weight loss (%EWL), LSG rehabilitation and the adequate weight loss, phys- has a positive effect on diabetes. Several stud- ical activity, sexual life and self-esteem are also ies report that type 2 diabetes mellitus (T2DM) improved postoperatively52. Additionally, in con- resolves in a significant percentage of patients trast to laparoscopic adjustable gastric banding undergoing LSG19,38,39. Improvement and resolu- (LAGB) procedure, which is also considered to tion rates as high as 86% of patients are reported, be safe and one of the least invasive bariatric which are similar to those seen after RYGB and operations, no foreign bodies are used during superior to LAGB22,40-44. Control of T2DM after LSG57. As a result, long-term complications like LSG is achieved, as in other bariatric opera- gastric erosion and infections are not seen after tions, with the rapid excess weight loss. However, LSG57. However, the extended gastric resection glycemic control without diabetic medication, performed during LSG has a significant impact normalization of hemoglobin A1c and improve- on gastric acid secretion and motility. Many pa- ment or even resolution of T2DM are seen early tients experience a series of gastrointestinal (GI) after LSG45. A reason for the early improvement symptoms postprandial, like heartburn, epigas- of T2DM after LSG is the notable low levels of tric pain, distress and dysphagia. Nevertheless,
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