|Year : 2019 | Volume
| Issue : 3 | Page : 687-692
Metabolic changes after laparoscopic sleeve gastrectomy
Samar R Elsayed Abo Elenin, Hoda A El-Azim Youssef, Amer H El-Barawey
Department of General Surgery, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
|Date of Submission||15-Oct-2019|
|Date of Decision||15-Oct-2000|
|Date of Acceptance||29-Oct-2019|
|Date of Web Publication||10-Feb-2020|
BSc Samar R Elsayed Abo Elenin
Department of General Surgery, Faculty of Medicine for Girls, Al-Azhar University, Cairo
Source of Support: None, Conflict of Interest: None
Introduction Obesity is a major cause of premature death, and its prevalence is increasing worldwide. Obesity is a major risk factor for the development of insulin-resistance type 2 diabetes mellitus (T2DM), hypertension, and dyslipidemia.
Aim The aim of this study was to evaluate the effects of laparoscopic sleeve gastrectomy (LSG) on metabolic diseases such as diabetes mellitus, hypertension, and dyslipidemia.
Patients and methods This is a prospective and retrospective study that included 30 patients. All patients underwent LSG as a primary one-stage bariatric procedure in Al Zahraa University Hospital during the period from 2018 till 2019. Preoperative evaluation followed the same standard protocol and included a thorough history, complete endocrinal workup, and counseling by a dietician. All patients underwent upper abdominal ultrasonography, to especially exclude gallstones. All comorbidities that increase perioperative risk were controlled before surgery as far as possible.
Results One of the main purposes of this study was to investigate further the effect of LSG on T2DM, hypertension, and hyperlipidemia. Our study shows that LSG resolved or improved lipid profile in most patients. After 12 months from surgery, significant changes in lipid profile included increased level of high-density lipoprotein and decreased level of cholesterol, triglycerides, and low-density lipoprotein level, and also improvement of T2DM and hypertension.
Conclusion According to our results, we have shown that at 12 months after surgery, SG is effective in inducing remission of obesity-associated metabolic comorbidities, such as T2DM, hypertension, and hyperlipidemia.
Keywords: bariatric surgery, laparoscopic sleeve gastrectomy, obesity
|How to cite this article:|
Elsayed Abo Elenin SR, El-Azim Youssef HA, El-Barawey AH. Metabolic changes after laparoscopic sleeve gastrectomy. Sci J Al-Azhar Med Fac Girls 2019;3:687-92
|How to cite this URL:|
Elsayed Abo Elenin SR, El-Azim Youssef HA, El-Barawey AH. Metabolic changes after laparoscopic sleeve gastrectomy. Sci J Al-Azhar Med Fac Girls [serial online] 2019 [cited 2020 Feb 29];3:687-92. Available from: http://www.sjamf.eg.net/text.asp?2019/3/3/687/278048
| Introduction|| |
Obesity is a major cause of premature death, and its prevalence is increasing worldwide . Obesity is a major risk factor for the development of insulin-resistant type 2 diabetes mellitus (T2DM), hypertension, and dyslipidemia .
Cardiovascular mortality is 50% greater in obese persons and 90% greater in severely obese persons. Because of the dramatically increased morbidity and mortality risk associated with extreme obesity, patients who do not achieve a significant weight reduction with therapeutic lifestyle changes or pharmacotherapy may benefit from surgical intervention .
Bariatric procedures are reportedly the most effective strategy to induce weight loss compared with nonsurgical interventions . Laparoscopic sleeve gastrectomy (LSG) is a common and efficient bariatric procedure with increasing popularity in the Western world during the past few years .
Both intermediate- and long-term data on LSG remain limited. Most of the earlier analyses had focused on weight loss and the remission of diabetes, even though hypertension and dyslipidemia are also comorbidities commonly related to obesity .
In this study, we aimed to determine the effect of LSG on diabetes, hypertension, hypercholesterolemia, and hypertriglyceridemia. The primary end points of this study were excess weight loss and partial and complete remission of obesity-related comorbidities (diabetes mellitus, hypertriglyceridemia, and hypertension).
| Aim|| |
The aim was to evaluate the effects of LSG on metabolic diseases such as diabetes mellitus, hypertension, and dyslipidemia.
| Patients and methods|| |
This is a prospective and retrospective study that included 30 patients. Ethical approval statement according committee of ethics. All patients underwent LSG as a primary one-stage bariatric procedure in Al Zahraa University Hospital during the period from 2018 till 2019. Ethical approval statement according committee of ethics. Informed written consent was obtained, and explanation of the possible complications that could occur in the perioperative period was specifically addressed.
Preoperative evaluation followed the same standard protocol and included a thorough history, complete endocrinal workup, and counseling by a dietician. All patients underwent upper abdominal ultrasonography, to especially exclude gallstones. All comorbidities that increase perioperative risk were controlled before surgery as far as possible.
The participants were considered appropriate candidates for the present study if they fulfilled the following criteria:
- Patients willing to give consent and comply with the evaluation and treatment schedule.
- Patients who were 20–50 years old (inclusive).
- Patients who have BMIs of 40 kg/m2 or more, or between 35 and 40 kg/m2 with other significant disease that could be improved if they lost weight.
- All appropriate nonsurgical measures have been tried but have failed to achieve or maintain adequate, clinically beneficial weight loss for at least 6 months.
- Patients are generally fit for anesthesia and surgery.
- Patients commit to the need for long-term follow-up.
- Patients needed to demonstrate the absence of significant psychopathology that could limit their ability to understand the procedure and comply with the medical, surgical, and/or behavioral recommendations.
The exclusion criteria included the following:
- Pregnancy or lactation at screening or surgery.
- A documented history of drug and/or or supplements within 30 days of the screening visit or during study participation.
- Alcohol abuse within 2 years of the screening visit.
- Previous malabsorptive or restrictive procedures performed for the treatment of obesity.
- Any condition that would preclude compliance with the study. Such conditions included the following:
- Inflammatory diseases of the gastrointestinal tract within the previous 10 years.
- Congenital or acquired anomalies of the gastrointestinal tract (e.g. atresia or stenosis).
- Severe cardiopulmonary disease or other serious organic disease making the participant a high-risk surgical candidate, uncontrolled hypertension, and portal hypertension.
- Additional exclusion criteria included chronic or acute upper gastrointestinal bleeding conditions (e.g. gastric or esophageal varices), cirrhosis, congenital or acquired intestinal telangiectasia, esophageal dysmotility, or Barrett’s esophagus, hiatal hernia, previous surgery of the foregut (i.e. hiatal hernia repair or previous gastric surgery), pancreatitis, an immunocompromised status, or autoimmune connective tissue disease.
All patients underwent a standard evaluation preoperatively. Blood tests were requested in the form of complete blood picture, fasting blood sugar, lipid profile [cholesterol, triglycerides, high-density lipoprotein (HDL), and high-density lipoprotein (LDL)], clinical chemistries (serum albumin, alanine transaminase, aspartate transaminase, urea, and creatinine), thyroid profile (FT3, FT4, thyroid-stimulating hormone), serum cortisol (a.m. and p.m.), and prothrombin time and concentration. Abdominal ultrasonography, chest radiography, and pulmonary function tests were performed preoperatively.
Thromboembolic prophylaxis with subcutaneous low-molecular weight heparin (clexan) was administered on the evening before surgery and continued daily from the first postoperative day until the patient was ambulant.
The occurrence of adverse events was carefully monitored throughout the entire study period and recorded.
Preoperative comorbidities were followed up postoperatively at 3, 6, and 12 months after surgery.
Recorded data were analyzed using the Statistical Package for the Social Sciences, version 20.0 (SPSS Inc., Chicago, Illinois, USA). Quantitative data were expressed as mean±SD. Qualitative data were expressed as frequency and percentage. So, the P value was considered significant as follows: P value less than or equal to 0.05 was considered significant, P value less than or equal to 0.001 was considered as highly significant, and P value greater than 0.05 was considered insignificant.
| Results|| |
[Table 1] shows statistically significant decreased mean weight (kg) and BMI after 6 months and after 12 months compared with preoperatively.
|Table 1 The extent of the difference over the periods through weight (kg) and BMI in the study group|
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[Table 2] shows statistically significant decreased fasting blood glucose and gycated hemoglobin over the periods.
|Table 2 The extent of the difference over the periods through fasting blood glucose and glycated hemoglobin in the study group|
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[Table 3] shows statistically significant decreased blood pressure over the periods in the study group.
|Table 3 The extent of the difference over the periods through blood pressure in the study group|
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[Table 4] shows statistically significant decreased total cholesterol, LDL, and TG, whereas increased HDL over the periods.
|Table 4 The extent of the difference over the periods through laboratory data in the study group|
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| Discussion|| |
Obesity is very serious issue in the world nowadays as it has become a global epidemic and a major problem in the 21st century, which influences many aspects of health. The WHO has declared obesity as the largest global chronic health problem in adults which is increasingly turning into a more serious problem than malnutrition .
Obesity is a risk factor for several of the leading causes of preventable death, including diabetes mellitus, hypertension, dyslipidemia, cardiovascular disease, and many types of cancer. Thus, successful treatment and control of obesity should be major imperatives .
Owing to its greater efficiency and low complication rate, LSG has become more widely accepted as a definitive treatment for morbidly obese patients .
LSG exerts its weight losing effect by reducing the capacity of the stomach to less than 100 ml, which induces early satiety sensation during eating, and another mechanism for weight loss is the decrease in serum levels of ghrelin and leptin .
LSG is categorized as a restrictive bariatric procedure; however, LSG is also a metabolic procedure owing to the changes in gut hormones induced by the operation in addition to the caloric restriction effect, thus leading to an important role in the field of bariatric surgery .
Previous studies have shown that bariatric surgery causes significant weight loss and is more effective than nonsurgical interventions. Not only does LSG achieve weight loss in the first few months after the operation but also this weight loss is sustained for a long time reaching up to 20 years, with far less mortality rate than that obtained with diet regimen, exercise programs, and medications .
In clinical practice, the body fatness is usually estimated by BMI. BMI is calculated as measured body weight (kg) divided by measured height squared (m2) .
In our study, 12 months postoperatively, we observed a significant decrease in BMI of all patients included in this study.
Similar results was obtained by the team of Hosam et al. ; this team found also a significant reduction in the BMI following LSG.
A growing number of clinical research studies suggest that LSG has a significant remission in T2DM in patients with BMI greater than or equal to 30 kg/m2; its remission rate is between 50 and 81% .
In our study, LSG resulted in a significant improvement for patients with T2DM. There was significant decrease of FBG after 6 months and after 12 months and significant decrease in gycated hemoglobin after 3, 6, and 12 months.
Our study results are maintained in accordance with the research results of Li Weijie et al. .
Many studies have shown improvement or resolution of hypertension following LSG , with up to 68% improvement or resolution of hypertension at 1-year follow up. Basso et al.  found that 62 out of 100 high-risk super obese patients with a mean BMI of 54.4 kg/m2 reported complete resolution of hypertension.
Regarding the short-term effects of LSG on hypertensive patients, many articles reported significant encouraging results. Samson et al.  concluded that LSG significantly reduced body weight, systolic blood pressure, and diastolic blood pressure as early as 1 month after the procedure in hypertensive morbidly obese patients. After 1 month, systolic blood pressure, and diastolic blood pressure did not decline further; they remained significantly lower than baseline levels despite a major reduction in antihypertensive therapy .
Xiaoqiang  observed that body weight and BMI were significantly reduced within a month after LSG, and the symptoms of hypertension were significantly improved within 10 days. A plateau of reduced blood pressure appeared at 1 month after the operation. At 1 year after operation, the systolic and diastolic pressures had decreased by 13 and 8 mmHg, respectively, although the reduction was small after the first month. These results suggest that there is a significant short-term effect on obese and hypertensive patients after surgical treatment, and decrease in blood pressure occurs before obtaining a significant loss of weight.
In our study, we observed a significant reduction in systolic and diastolic blood pressures 6 and 12 months after surgery, and this is agreed with the study performed by Grassi et al. , who found that at 12 months after operation, there was a reduction in mean systolic and diastolic pressures. These results suggest that there is a significant short-term effect on obesity and hypertension following surgical treatment. Moreover, there was greater reduction in systolic than diastolic blood pressure. For a long time, weight loss was considered as an effective treatment for hypertension, and bariatric surgery has become the most effective method.
Dyslipidemia is a major risk factor for cardiovascular disease and the main cause of mortality worldwide. Obesity is frequently associated with dyslipidemia, and bariatric surgery is most effective treatment for obesity, with high rate of prevention and remission of comorbid condition after surgery including dyslipidemia . With the development of bariatric and metabolic surgery, LSG is not confined to the treatment of obesity anymore and is applied to the treatment for T2DM and other obesity-associated diseases .
Overall, 80% of patients with obesity present with lipid abnormality and 15–20% of patients do not show classic metabolic lipid changes. Hyperlipidemia is widely recognized as a major co-morbidity in obese patients. So nowadays bariatric surgeries are increasingly focused on lipid profile in the drive to potentially reduce cardiovascular-related diseases .One of the main purposes of this study was to investigate further the effect of LSG on T2DM, hypertension, and hyperlipidemia. Our study shows that LSG resolved or improved lipid profile in most patients. After 12 months of surgery, significant changes in lipid profile included increased level of HDL and decreased levels of cholesterol, triglycerides (TG), and LDL.
Similar results were obtained by other authors . Feng et al.  also indicated that low level of HDL cholesterol and high TG and LDL levels are the main risk factor for cardiovascular disease in obese patient. Regarding the cardiovascular risk, the observed increased HDL and decreased TG and LDL levels are fairly positive prognostic factors.
Similar results were obtained by Vidal et al. , with a significant improvement of lipid profile parameters, including significant increase in HDL and significant decrease in TG and LDL levels following LSG.
In our study 12 months after LSG, we observed significant changes in lipid profile parameters including significant decrease in total cholesterol, TG, and LDL and significant increase in HDL.
The study has several limitations. They include the prospective and retrospective analysis of a single hospital experience and the absence of a control group. In addition, ambulatory BP was not measured, and the follow-up period was only 12 months. Without long-term follow-up, we cannot confirm the durability of metabolic comorbidities remission after surgery and the influence of possible weight change in the future. The strength of the present study is its large, homogenous population of morbidly obese patients who underwent LSG by experienced group of bariatric surgeons. Our findings are unbiased as most patients underwent surgery for cosmetic reasons and not for control of obesity-related morbid conditions.
No postoperative complications, morbidity, or mortality had occurred in any patient included in our study.
| Conclusion|| |
LSG can improve and resolve blood pressure in morbidly obese patients not only in the long term but also in the short term. It is a relatively safe and effective method not only for reduction of excessive body weight but also for improving and resolving many other comorbidities of morbid obesity. Diabetes remission, improvement of blood glucose control, and reduction of antidiabetic medications after bariatric surgery can be sustained for many years with a decrease in overall morbidity and mortality. According to our results, LSG is an effective method of obesity treatment.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]