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ORIGINAL ARTICLE |
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Year : 2018 | Volume
: 31
| Issue : 4 | Page : 1181-1186 |
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Laparoscopic sleeve gastrectomy versus laparoscopic mini-gastric bypass in management of morbid obesity and its comorbidities
Elsayed A Mostafa1, Elsayed M Abdel Wahab1, Yehia G Abo Sayed2, Mohamed H Gafar2
1 Department of General Surgery, Faculty of Medicine (for Girls), Al-Azher University Cairo, Shebin Elkom, Menoufia, Egypt 2 Department of General Surgery, Shebin El-Kom Teaching Hospital, Shebin Elkom, Menoufia, Egypt
Date of Submission | 25-Jul-2018 |
Date of Acceptance | 28-Aug-2018 |
Date of Web Publication | 14-Feb-2019 |
Correspondence Address: Mohamed H Gafar Menoufia/Menouf/Manshat Sultan Egypt
Source of Support: None, Conflict of Interest: None | Check |
DOI: 10.4103/mmj.mmj_236_18
Background Laparoscopic mini-gastric bypass (MGBP) is gaining popularity among the bariatric procedures today, and laparoscopic sleeve gastrectomy (SG) as a single-stage procedure for the treatment of morbid obesity is becoming increasingly popular. Patients and methods Between October 2016 and July 2018, 50 obese patients were randomized, operated upon, and followed up for 12 months in Al Zahraa Hospital and Shebin El-Kom teaching Hospital. A total of 25 patients underwent SG, and 25 patients underwent MGBP. The mean BMI of all patients was 47.8 ± 5.5 kg/m2, their mean age was 30 ± 8.3 years, and 80% of them were female. Patients were followed up at 1, 3, 6, 9, and 12 months. Operative time, length of hospital stays, weight loss, comorbidity improvement or resolution, postoperative complications, reinterventions, and mortality were evaluated. Results Age, sex, BMI, and comorbidities were equal. The mean operative time for SG was 86.9 ± 51.6 min and that for MGBP was 108.4 ± 41.8 min; the percentage of 1-year excess weight loss was similar (76.2 ± 4.49% for SG and 80.3 ± 8.3% for MGBP). The comorbidities were significantly improved after both procedures, except for type 2 diabetes mellitus, which showed a higher resolution rate after MGBP. Conclusion Laparoscopic SG regarding excess weight loss is comparable to laparoscopic MGBP in short-term follow-up (1 year) with less metabolic effect. Further long-term studies are needed.
Keywords: comorbidities, diabetes mellitus, mini-gastric bypass, morbid obesity, sleeve gastrectomy
How to cite this article: Mostafa EA, Abdel Wahab EM, Abo Sayed YG, Gafar MH. Laparoscopic sleeve gastrectomy versus laparoscopic mini-gastric bypass in management of morbid obesity and its comorbidities. Menoufia Med J 2018;31:1181-6 |
How to cite this URL: Mostafa EA, Abdel Wahab EM, Abo Sayed YG, Gafar MH. Laparoscopic sleeve gastrectomy versus laparoscopic mini-gastric bypass in management of morbid obesity and its comorbidities. Menoufia Med J [serial online] 2018 [cited 2024 Mar 29];31:1181-6. Available from: http://www.mmj.eg.net/text.asp?2018/31/4/1181/252032 |
Introduction | | |
Obesity is a major health burden worldwide, and although it was considered a disease of the western world, it seems to have expanded to the developing world.[1] Severe obesity is one of the major problems in the world and is associated with several comorbidities [e.g. cardiovascular disease, metabolic syndrome, type 2 diabetes mellitus (T2DM), infertility, and increased mortality]. Significant obstructive sleep apnea (OSA) is present in 40% of obese persons and venous thromboembolism in 12%[2]. More than 70% of patients with sleep apnea present with obesity[3]. Conservative measures, such as dieting and physical exercise, have proven inadequate[4]. There is considerable evidence in the literature on the long-term positive effect of bariatric surgery as a primary therapy for the treatment of obesity and its comorbidities. Significant debate remains as to which patients are optimal candidates for which procedures. Depending on the type of operation, gastrointestinal surgery is also very effective in the resolution of diabetes[5]. Traditionally, the primary mechanisms through which bariatric surgery achieves its outcomes are believed to be the mechanical restriction of food intake, reduction in the absorption of ingested foods, or a combination of both[6]. A variety of surgical procedures are available, and currently, it is difficult to identify the most effective option based on patient characteristics and comorbidities. Furthermore, little is known regarding the effect of the various surgical procedures on glycemic control and T2DM remission[7]. Laparoscopic sleeve gastrectomy (LSG) is a restrictive approach used commonly in bariatric practice. SG was first described in 1999 as part of the biliopancreatic diversion duodenal switch procedure. Subsequently, LSG has been performed as a standalone procedure[8]. Although these procedures have proven to be good therapeutic options for some patients, it is not without significant complications, such as gastric leaks, which pose a particularly difficult challenge when they occur near the angle of His, potentially generating severe clinical conditions that require reoperation, and may even cause death[9]. Mini-gastric bypass (MGBP), first reported by Rutledge, was proposed as a simple and effective treatment of morbid obesity. MGBP is a modification of the Mason's loop gastric bypass, with weight loss results similar to laparoscopic Roux-en-Y gastric bypass (LRYGB)[10], which was the most favored bariatric procedure in America. This procedure has also been called one or single anastomosis gastric bypass[11]. However, controversies about the relative safety of this procedure remain, mainly the incidence of marginal ulcer and reflux esophagitis[12].
Objective
The objective was to compare SG with MGBP for the management of morbid obesity and its comorbidities.
Patients and Methods | | |
The study plan and the procedures followed were accepted by Al azhar University medical ethics committee. It was done from October 2016 to July 2018. All patients were evaluated preoperatively (full examination, obesity and its comorbidities). Patients were chosen and divided randomly into two groups in accordance to their admission to the study: the first group underwent LSG, whereas the second group underwent laparoscopic MGBP. All patients were evaluated regarding operative time, postoperative recovery, complications, resolution of comorbidities, and percent excess weight loss (%EWL). Results were recorded intraoperatively, early postoperatively, and at 1-month, 3-month, 6-month, and 12-month intervals. Written informed consent was obtained from all the patients to be included in this study.
Statistical analysis
Data were collected in tables and then analyzed with respect to χ2 and P value. Data were fed to the computer and analyzed using IBM SPSS software package version 20.0 (IBM Corp., Armonk, New York, USA). P values less than 0.05 were considered significant.
Results | | |
This prospective study included 50 obese patients who were blindly divided into two groups: the first group (SG) included 25 patients, with four (16%) males and 21 (84%) females, with initial BMI of 47.85 kg/m2. Of them eight (32%) had T2DM, six (24%) hypertension, seven (28%) osteoarthritis, three (12%) OSA, six (24%) dyslipidemia, and one (4%) polycystic ovary. The second group (MGB) included 25 patients, with six (24%) males and 19 (76%) females, having an initial BMI of 46.68 kg/m2. Of them, 11 (44%) had T2DM, eight (36%) had hypertension, six (24%) osteoarthritis, four (16%) OSA, eight (32%) dyslipidemia, and two (8%) polycystic ovary [Table 1]. The mean operative time was 68 min in SG whereas it was 73 min in MGB. The mean duration of hospital stay was 2.2 days in SG whereas it was 3 days in MGB. The mean starting oral intake was 1.23 days in SG, whereas it was 1 day in MGB. The mean return to daily activities was 4.04 days in SG, whereas it was 5.87 days in MGB. The mean return to work was 11.53 days in SG, whereas it was 13.07 days in MGB. The mean duration of analgesia was 5.27 in SG, whereas it was 5.67 days MGB [Table 2]. Mean %EWL was 32.05% at 1 month, 45.05% at 3 months, 67.6% at 6 months, and 76.22% at 12 months in SG and was 22.13% at 1 month, 39.75% at 3 months, 63.32% at 6 months, and 80.31% at 12 months in MGB [Table 3]. Overall, three patients with T2DM had complete and three had partial resolution in SG, whereas nine patients had complete and two partial resolution in MGB; three patients had complete and two partial resolution regarding hypertension in SG and five complete and three partial resolution in MGB; dyslipidemia remission was seen in four patients and improved in two patients in SG and seven patients had remission and one improved in MGB. There was resolution of osteoarthritis, OSA, and polycystic ovary in all patients in both groups [Table 4]. Bleeding was seen in three cases in SG, where two of them were managed conservatively and one needed exploration, and only one case in MGB, which was managed conservative. Wound infection was recorded in one case in SG and in two cases in MGB. Postoperative nausea and vomiting was seen in five cases in SG and in two cases in MGB; all were managed with antiemetics. Moreover, four cases had port site hernia in SG and two in MGB. Symptomatic cholelithiasis was obvious in both groups; in SG, eleven patients were managed conservative and three patients needed surgery, whereas in MGB, six patients were managed conservatively and one needed surgery. Overall, 16 patients had dumping symptoms and two patients had vitamin and mineral deficiencies only in MGB. No mortality, leak, or major organ injury was recorded in this study [Table 5]. | Table 1: Comparison between the two groups according to patient demographics
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| Table 2: Comparison between the two groups according to operative time and postoperative recovery (days)
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| Table 3: Comparison between the two groups according to percent excess weight loss
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| Table 4: Comparison between the two groups according to resolution of comorbidities
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| Table 5: Comparison between the two groups according to development of complications
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Discussion | | |
Obesity is notoriously difficult to manage. Diet, behavioral therapy, exercise, and pharmacologic intervention have traditionally been used but generally yield modest results. Additionally, weight regain is a common problem. In cases of failed medical therapy, bariatric surgery should be considered the treatment of choice for severe obesity[13].
A systematic analysis with pooled data from 19 prospective studies adjusted for age, study, physical activity, alcohol consumption, education, and marital status, over 160 000 deaths, showed that overall for men and women combined, for every five unit increase in BMI, a 31% increase in risk of death was observed[14].
There is strong published evidence that bariatric surgery is the only effective means to sustain long-term weight loss, and this weight loss is also associated with the resolution of obesity-related comorbid conditions, which increase the risk of mortality associated with obesity[15]. In our study, there were 19 (38%) patients with T2DM 8 in SG and 11 in MGB, 14 (28%) patients with hypertension six in SG and eight in MGB, and 14 (28%) patients with dyslipidemia, with six in SG and eight in MGB.
Plamper et al.[16] described in their study comparing SG with MGBP that both groups were comparable for age, preoperative weight, and BMI as well as the distribution of the associated comorbidities, which was similar to our study result.
Plamper et al.[16] reported in their study comparing SG with MGBP that duration of the operation showed to be significantly shorter for MGB as well as the time of the hospital stay. All operations were carried out in laparoscopic technique, and conversion rate was 0%, which was unlike our study, where there was significantly shorter hospital stay for the SG not for the MGB[16].
In our study, there were 19 (38%) patients with T2DM, eight in SG and 11 in MGB; 14 (28%) patients with hypertension, six in SG and eight in MGB; 14 (28%) patients with dyslipidemia, six in SG and eight in MGB; seven (28%) patients with OSA, three in SG and four in MGB; 13 (52%) patients with osteoarthritis, seven in SG and six in MGB; three (12%) patients with PCO, one in SG and two in MGB.
Weight loss is reported in many different ways. Sczepaniak et al. evaluated the different methods of reporting weight loss after bariatric procedures to find the best method of reporting weight loss. The best method should permit the closest comparisons between the broadest ranges of weight and population characteristics. Weight loss has been reported as absolute weight loss, percentage of total weight loss, %EWL, percentage of excess BMI loss, and percentage of patients with successful weight loss[17].
Sczepaniak et al.[17] compared SG with MGBP and found %EWL was 54.7 at 6 months and 69.4 at 12 months for gastric bypass and %EWL was 50.0% at 6 months and 60.2% at 12 months for sleeve gastrectomy.
Boza et al.[18] have reported excellent results of 1000 consecutive LSG procedures with a mean EWL of 84.5% at 3-year follow-up and with minimal weight regain after the first postoperative year. In our study, mean %EWL was 32.05% at 1 month, 45.05% at 3 months, 67.6% at 6 months, and 76.22% at 12 months in SG and was 22.13% at 1 month, 39.75% at 3 months, 63.32% at 6 months, and 80.31% at 12 months in MGB.
Laparoscopic MGBP in morbidly obese patients with T2DM has been proved to be effective in prospective randomized controlled trials[19], and in extensive reports in the literature[20], Lee et al.[21] have suggested that the efficacy of T2DM remission was similar regardless of BMI, and they recommend that more free use of gastric bypass should be considered in Asian patients with T2DM. We found three patients with T2DM had complete and three had partial resolution in SG whereas nine had complete and two had partial resolution in MGB; three patients had complete and two had partial resolution in hypertension in SG, whereas five had complete and three had partial resolution in MGB; dyslipidemia remission was seen in four patients and improvement in two patients in SG and seven patients with remission and one with improvement in MGB; and resolution of osteoarthritis, OSA, and polycystic ovary in all patients in both groups.
These data are correlated with a comparably steep increase in the prevalence of obesity. The primary risk factor for T2DM is obesity, and 90% of all patients with type 2 diabetes are either overweight or obese[22]. Gill et al.[23] found that SG results in T2DM resolution ranging from 80% to 96% in morbidly obese subjects. Laparoscopic MGBP in morbidly obese patients with T2DM has been shown to be effective[23]. Schauer et al.[24] recently demonstrated the superiority of the RYGB over a SG for the morbidly obese patients with remission of T2DM at 3 years.
Obesity is associated with an increased risk of GERD, with up to 50% of morbidly obese patients suffering from this condition. Prachand and Alverdy also concluded that the incidence of GERD seems to be more frequent after LSG[25]. There is no doubt that ∼0.5–1.0% of the patients develop malnutrition requiring surgical correction – reversal or shortening of biliopancreatic limb, or conversion to sleeve – after MGB[26].
Internal hernia is a major long-term problem after RYGB even in the hands of surgeons who close internal defects and a recognized cause of late mortality after surgery. In fact, the authors did not report any internal hernia in MGB patients. In the entire literature, there is only one reported case of Petersen's hernia after MGB[27]. No internal hernia was recorded in our study, and only four cases developed symptomatic acid reflux in SG and seven cases developed symptomatic (bile) reflux in MGB. It is believed that MGB results in less dumping and reactive hypoglycemia compared with RYGB. Carbajo et al.[28] did not see any dumping syndrome in their study. In our study, 16 (64%) developed dumping symptoms in MGB, and there was no leak or mortality or major organ injury in this study. Therefore, may be a larger study is needed.
Conclusion | | |
LSG regarding EWL is comparable to laparoscopic MGBP in short-term follow-up (1 year) with less metabolic effect. Further long-term studies are needed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References | | |
1. | Tsigos C, Hainer V, Basdevant A, Finer N, Fried M, Mathus-Vliegen E, et al. Management of obesity in adults: European clinical practice guidelines. Obes Facts 2008; 1:106–116. |
2. | Gruidah HSA, Eldsouky MS, Omran WM, Elhassan AEA. Risk factors for venous thromboembolism. Menoufia Med J. 2018; 31:169. |
3. | Toghaw P, Matone A, Lenbury Y, de Gaetano A. Bariatric surgery and T2DM improvement mechanisms: a mathematical model. Theor Biol Med Model 2012; 9:16. |
4. | Blackburn GL, Walker WA. Science-based solutions to obesity: what are the roles of academia, government, industry, and health care? Am J Clin Nutr 2005; 82:207s–210ss. |
5. | Rubino F, Kaplan LM, Schauer PR, Cummings DE. The Diabetes Surgery Summit consensus conference: recommendations for the evaluation and use of gastrointestinal surgery to treat type 2 diabetes mellitus. Ann Surg 2010; 251:399–405. |
6. | DeMaria EJ. Bariatric surgery for morbid obesity. N Engl J Med. 2007; 356:2176–2183. |
7. | Lee WJ, Chong K, Ser KH, Lee YC, Chen SC, Chen JC, et al. Gastric bypass vs sleeve gastrectomy for type 2 diabetes mellitus: a randomized controlled trial. Arch Surg 2011; 146:143–148. |
8. | Deitel M, Crosby RD, Gagner M. The first international consensus summit for sleeve gastrectomy (SG), New York City, October 25–27, 2007. Obes Surg 2008; 18:487–496. |
9. | Nocca D, Frering V, Gallix B, des Hons CD, Noël P, Foulonge MP, et al. Migration of adjustable gastric banding from a cohort study of 4236 patients. Surg Endosc 2005; 19:947–950. |
10. | Rutledge R. The mini-gastric bypass: experience with the first 1,274 cases. Obes Surg 2001; 11:276–280. |
11. | Carbajo M, Castro MJ, Kleinfinger S, Gómez-Arenas S, Ortiz-Solórzano J, Wellman R, et al. Effects of a balanced energy and high protein formula diet (Vegestart complet®) vs. low-calorie regular diet in morbid obese patients prior to bariatric surgery (laparoscopic single anastomosis gastric bypass): a prospective, double-blind randomized study. Nutr Hosp 2010; 25:939–948. |
12. | Fox SR, MacDonald KG, Greenville N, Mason EE, Lowa City I, Boyd E, et al. Mini-gastric bypass controversy. Obes Surg 2001; 11:773–777. |
13. | Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA 2005; 294:1909–1917. |
14. | Berrington de Gonzalez A, Hartge P, Cerhan JR, Flint AJ, Hannan L, MacInnis RJ, et al. Body-mass index and mortality among 1.46 million white adults. N Engl J Med. 2010; 363(23):2211-2219. |
15. | Carlsson LM, Peltonen M, Ahlin S, Anveden Š, Bouchard C, Carlsson B, et al. Bariatric surgery and prevention of type 2 diabetes in Swedish obese subjects. N Engl J Med 2012; 367:695–704. |
16. | Plamper A, Lingohr P, Nadal J, Rheinwalt KP. Comparison of mini-gastric bypass with sleeve gastrectomy in a mainly super-obese patient group: first results. Surg Endosc 2017; 31:1156–1162. |
17. | Sczepaniak JP, Owens ML, Shukla H, Perlegos J, Garner W Comparability of weight loss reporting after gastric bypass and sleeve gastrectomy using BOLD data 2008–2011. Obes Surg 2015; 25:788–795. |
18. | Boza C, Salinas J, Salgado N, Pérez G, Raddatz A, Funke R, et al. Laparoscopic sleeve gastrectomy as a stand-alone procedure for morbid obesity: report of 1,000 cases and 3-year follow-up. Obes Surg 2012; 22:866–871. |
19. | Lee WJ, Ser KH, Lee YC, Tsou JJ, Chen SC, Chen JC. Laparoscopic Roux-en-Y vs. mini-gastric bypass for the treatment of morbid obesity: a 10-year experience. Obes Surg 2012; 22:1827–1834. |
20. | Wang W, Wei PL, Lee YC, Huang MT, Chiu CC, Lee WJ. Short-term results of laparoscopic mini-gastric bypass. Obes Surg 2005; 15:648–654. |
21. | Lee WJ, Wang W, Lee YC, Huang MT, Ser KH, Chen JC Effect of laparoscopic mini-gastric bypass for type 2 diabetes mellitus: comparison of BMI>35 and<35 kg/m 2. J Gastrointest Surg 2008; 12:945–952. |
22. | Mokdad AH, Bowman BA, Ford ES, Vinicor F, Marks JS, Koplan JP The continuing epidemics of obesity and diabetes in the United States. JAMA 2001; 286:1195–1200. |
23. | Gill RS, Karmali S, Sharma AM. Treating type 2 diabetes mellitus with sleeve gastrectomy in obese patients. Obesity 2011; 19:701–702. |
24. | Schauer PR, Bhatt DL, Kirwan JP, Wolski K, Brethauer SA, Navaneethan SD, et al. Bariatric surgery versus intensive medical therapy for diabetes – 3-year outcomes. N Engl J Med. 2014; 370:2002–2013. |
25. | Prachand VN, Alverdy JC. Gastroesophageal reflux disease and severe obesity: fundoplication or bariatric surgery? World J Gastroenterol 2010; 16:3757. |
26. | Noun R, Skaff J, Riachi E, Daher R, Antoun NA, Nasr M. One thousand consecutive mini-gastric bypass: short-and long-term outcome. Obes Surg 2012; 22:697–703. |
27. | Genser L, Carandina S, Soprani A. Petersen's internal hernia complicating a laparoscopic omega loop gastric bypass. Surg Obes Relat Dis 2015; 11:e33–e34. |
28. | Carbajo M, García-Caballero M, Toledano M, Osorio D, García-Lanza C, Carmona JA One-anastomosis gastric bypass by laparoscopy: results of the first 209 patients. Obes Surg 2005; 15:398–404. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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