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Vertical Sleeve Gastrectomy Candidates PDF Print E-mail

The criteria for candidates for weight loss surgery were established by the National Institutes of Health in the early 1990s. These criteria were designed to allow surgery for patients who would be heavy enough and have enough medical problems to make the risks and consequences of surgery worthwhile. In other words, there is a cost benefit analysis that doctors and patients consider when choosing treatment alternatives. The NIH consensus panel felt that if the criteria listed below were met, then surgery should be considered.

The patient should be heavy enough. The patient’s BMI should be at least 40 if there are no severe medical problems,  or 35 if the patient suffers from diabetes mellitus, hypertension, obstructive sleep apnea, or severe heart disease that will benefit from weight loss. Secondly, the patient should be psychologically stable. Third, the patient should be in the best attainable medical condition before surgery. And fourth, the patient should have tried and failed reasonable non-operative approaches. The surgery should be performed in a multidisciplinary program where nutritional counseling and support are offered.

Vertical sleeve gastrectomy is contraindicated where a patient is not healthy enough for the surgery, where the patient is psychologically unstable or unreliable, or where there is alcohol or other substance abuse.

Outcomes

Vertical sleeve gastrectomy is a relatively new procedure. It has been performed more frequently in the last few years with insurance companies paying for it only since 2010. Hence there is relatively little long term information available at this time. The data that is emerging seem to indicate that in the early years, the weight loss from VSG falls somewhere between gastric banding and gastric bypass. How these results will hold up over time is of course yet to be determined.

Weight loss

There are so far only a few studies that report the long term weight loss results of vertical sleeve gastrectomy. Most bariatric surgeons consider five years to be a minimum length of time to be considered “long term”. Since vertical sleeve gastrectomy has only recently been approved by the insurance industry, it will take several more years before we have confirmation of the initial studies.

Author

Year

Percentage of excess weight lost

 

 

 

1 yr

3 yr

5yr

6 yr

 

Himpens

2010

 

73%

 

53%

 

Bohdjalian

2010

58%

60%

55%

 

 

Leyba

2010

79%

 

 

 

 

Gluck

2010

68%

62%

 

 

 

Pomerri

2010

61%

 

 

 

 

Nienhuijs

2010

50%

 

 

 

 

Fuks

2009

49%

 

 

 

 

Here are the summaries from two medical journal articles that discuss weight loss results.


Long-term results of laparoscopic sleeve gastrectomy for obesity.

Himpens J, Dobbeleir J, Peeters G.
Ann Surg. 2010 Aug;252(2):319-24.
Division of Bariatric Surgery, AZ St-Blasius, Kroonveldlaan, Dendermonde, Belgium.

Abstract

OBJECTIVE: To determine the mid- and long-term efficacy and possible side effects of laparoscopic sleeve gastrectomy as treatment for morbid obesity.

SUMMARY BACKGROUND DATA: Laparoscopic sleeve gastrectomy is still controversial as single and final treatment for morbid obesity. Some favorable short-term results have been published, however long-term results are still lacking.

METHODS: In the period between November 2001 and October 2002, 53 consecutive morbidly obese patients who, according to our personal algorithm, were qualified for restrictive surgery were selected for laparoscopic sleeve gastrectomy. Of the 53 patients, 11 received an additional malabsorptive procedure at a later stage because of weight regain. The percentage of excess weight loss (EWL) was assessed at 3 and 6 years postoperatively. A retrospective review of a prospectively collected database was performed for evaluation after 3 years. Recently, after the sixth postoperative year, patients were again contacted and invited to fill out a questionnaire.

RESULTS: Full cooperation was obtained in 41 patients, a response rate of 78%. Although after 3 years a mean EWL of 72.8% was documented, after 6 years EWL had dropped to 57.3%, which according to the Reinhold criteria is still satisfactory. These results included 11 patients who had benefited from an additional malabsorptive procedure (duodenal switch) and 2 patients who underwent a "resleeve" between the third and sixth postoperative year. Analyzing the results of the subgroup of 30 patients receiving only sleeve gastrectomy, we found a 3-year %EWL of 77.5% and 6+ year %EWL of 53.3%. The differences between the third and sixth postoperative year were statistically significant in both groups. Concerning long-term quality of life patient acceptance stayed good after 6 + years despite the fact that late, new gastro-esophageal reflux complaints appeared in 21% of patients.

CONCLUSIONS: In this long-term report of laparoscopic sleeve gastrectomy, it appears that after 6+ years the mean excess weight loss exceeds 50%. However, weight regain and de novo gastroesophageal reflux symptoms appear between the third and the sixth postoperative year. This unfavorable evolution might have been prevented in some patients by continued follow-up office visits beyond the third year. Patient acceptance remains good after 6+ years.
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Sleeve gastrectomy as sole and definitive bariatric procedure: 5-year results for weight loss and ghrelin.

Bohdjalian A, Langer FB, Shakeri-Leidenmühler S, Gfrerer L, Ludvik B, Zacherl J, Prager G.
Obes Surg. 2010 May;20(5):535-40. Epub 2010 Jan 22.
Department of Surgery, Division of General Surgery, Medical University of Vienna, General Hospital Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.

Abstract

BACKGROUND: Due to excellent efficacy for weight loss in the short-term follow-up, sleeve gastrectomy (SG) has gained enormous popularity as bariatric procedure, not only as first step in high-risk or super-obese patients but mainly as a sole and definitive operation in morbidly obese. In contrast to a large number of short and intermediate-term results, no series of SG with a follow-up of 5 years or more has been published so far.
METHODS: We report on the weight loss results of our first consecutive 26 patients with a complete follow-up of 5 years. Furthermore in a subgroup of 12 patients, plasma ghrelin levels were measured preoperatively, and up to 5 years following SG.

RESULTS: Weight loss defined as mean percent excess weight loss (%EWL) was found as 57.5 +/- 4.5, 60.3 +/- 5.0, 60.0 +/- 5.7, 58.4 +/- 5.4, and 55.0 +/- 6.8 (not converted, n = 21) for the first 5 years. Weight regain of more than 10 kg from nadir was observed in five (19.2%) of the [Type a quote from the document or the summary of an interesting point. You can position the text box anywhere in the document. Use the Text Box Tools tab to change the formatting of the pull quote text box.]

26 patients. Four of the patients (15.4%) were converted to gastric bypass due to severe reflux (n = 1, 3.8%) and weight loss failure (n = 3, 11.5%). A total of eight patients (30.8%) were at chronic need for proton pump inhibitor medication due to severe reflux. Plasma ghrelin levels were reduced from 593 +/- 52 to 219 +/- 23 pg/ml 12 months postoperatively, with a slightly, non-significant increase toward the 5-years values of mean 257 +/- 23 pg/ml.

CONCLUSIONS: At 5-year follow-up, a mean EWL of 55.0 +/- 6.8% was achieved, indicating that SG leads to stable weight loss. Beside significant weight regain, severe reflux might necessitate conversion to gastric bypass or duodenal switch. After an immediate reduction postoperatively, plasma ghrelin levels remained low for the first 5 years postoperatively.

Relief of comorbid medical problems

Diabetes

This report by Abbatini from Rome, Italy suggests that vertical sleeve gastrectomy and gastric bypass both offer early and effective resolution diabetes mellitus in 80% of patients. The antidiabetic effect of adjustable gastric band surgery was slower and only produced resolution of the diabetic state in 60% of patients.

Long-term effects of laparoscopic sleeve gastrectomy, gastric bypass, and adjustable gastric banding on type 2 diabetes.

Surg Endosc. 2010 May;24(5):1005-10. Epub 2009 Oct 29.
Abbatini F, Rizzello M, Casella G, Alessandri G, Capoccia D, Leonetti F, Basso N.
Department of Surgical-Medical Digestive Diseases, Policlinico Umberto I, University La Sapienza, Viale del Policlinico, 00161 Rome, Italy.

Abstract

BACKGROUND: This study aimed to compare the efficacy of laparoscopic sleeve gastrectomy (SG) with that of laparoscopic gastric bypass (GBP) and laparoscopic adjustable gastric banding (AGB) for glucose homeostasis in morbidly obese subjects with type 2 diabetes mellitus (T2DM) at a 3-year follow-up assessment and to elucidate the role of weight loss in the T2DM resolution after SG.


METHODS: For this study, 60 morbidly obese T2DM patients (44 females and 16 males) who underwent AGB (24 patients), GBP (16 patients), or SG (20 patients) between 1996 and 2008 were retrospectively analyzed. Age, sex, body mass index (BMI), estimated weight loss (EWL), fasting glycemia, HbA1c, euglycemic hyperinsulinemic clamp, discontinuation of diabetes treatment, and time until interruption of therapy were evaluated.


RESULTS: In the study, 54 patients received oral hypoglycemic agents for at least 12 months before surgery, and 6 patients received insulin. The mean follow-up period was 36 months. The resolution rate was 60.8% for the AGB patients, 81.2% for the GBP patients, and 80.9% for the SG patients. The postoperative time until interruption of therapy was 12.6 months for the AGB patients, 3.2 months for the GBP patients, and 3.3 months for the SG patients. The hyperinsulinemic euglycemic clamp test was performed 12 months after surgery for the cured patients. Insulin resistance was restored to normal values in all the patients. The greatest improvement from preoperative values occurred in the SG group. For the not-cured GBP and SG patients, an improvement of 120 mg/dl in fasting plasma glucose was observed 3 months after the surgery, suggesting an enhancement in insulin sensitivity, which determines better medical control. The resolution rate remained constant at the 36-month follow-up evaluation in both the GBP and SG groups.


CONCLUSIONS: All three bariatric procedures are effective in treating diabetes, with a 3-year follow-up evaluation showing an effect that lasts. The AGB procedure was the least effective. The antidiabetic effect was similarly precocious after GBP and SG compared with AGB. This difference may indicate that a hormonal mechanism may be involved, independent of weight loss.
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Lipid levels


This report evaluates lipid level before and one year after vertical sleeve gastrectomy. The authors found that along with significant weight loss, there was a significant drop in triglyceride levels and a significant raise if HDL (“good” cholesterol).

Changes in Lipid Profiles in Morbidly Obese Patients After Laparoscopic Sleeve Gastrectomy (LSG).

Zhang F, Strain GW, Lei W, Dakin GF, Gagner M, Pomp A.
Obes Surg. 2010 Sep 22. [Epub ahead of print]
Department of Surgery, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, 310006, China.

Abstract

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has evolved as a primary weight loss surgery. This study provides changes in lipid profiles in obese patients 1 year after LSG.


METHODS: A retrospective analysis of patients who underwent LSG from June 2004 to June 2008 provided data on demographics, body mass index (BMI) changes, co-morbidities, and medication changes. We compared lipid profiles, and the relationship between the lipid profiles and pre-operative weight, BMI, and weight loss. Proportion changes for all variables were also assessed. Lipid profiles for those taking lipid-lowering therapy and patients receiving no medication were evaluated.

RESULTS: Data is presented on 45 patients (58% women) ages 18 to 73 years. Co-morbidities included hypertension (19), hyperlipidemia (22), and diabetes (13). One year after LSG, weight decreased from 161.4 ± 34.3 to 112.9 ± 25.6 kg (p < 0.01). BMI decreased from 57.5 ± 9.6 to 39.9 ± 7.1 kg/m(2) (p < 0.01). Patients with elevated triglycerides decreased from 17 to 8 (p < 0.01) while patients with elevated cholesterol increased from 13 to 15. High-density lipoprotein cholesterol (HDL) increased from 48.4 to 54.5 mg/dl (p < 0.01) and triglycerides (TG) decreased from 141.7 to 109.3 mg/dl (p < 0.01). TC/HDL and TG/HDL ratios also, decreased significantly (p < 0.01). There were no changes for total cholesterol (TC) and low-density lipoprotein cholesterol (LDL). TG/HDL changes correlated with pre-op weight (r = 0.363, p < 0.05).
CONCLUSIONS: One year after LSG, significant weight loss and improvements in HDL and TG levels, TC/HDL and TG/HDL ratios were observed. TC and LDL levels were unchanged.

 

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