|Year : 2015 | Volume
| Issue : 1 | Page : 5-10
Effect of laparoscopic sleeve gastrectomy on body mass index and metabolic parameters in morbid obese patients
Prabhdeep Singh Nain1, Vikas Garg2, Parminder Singh3, Ashish Ahuja2, Dipesh Batra2
1 Department of Surgery, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
2 Department of Medicine, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
3 Department of Endocrinology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
|Date of Web Publication||6-Jan-2015|
Prabhdeep Singh Nain
Department of Surgery, Dayanand Medical College and Hospital, Ludhiana, Punjab
Source of Support: None, Conflict of Interest: None
Aim: Existing evidence has suggested that bariatric surgery produces sustainable weight loss and remission or cure of type 2 diabetes mellitus; hypertension and dyslipidemia. Laparoscopic sleeve gastrectomy (LSG) has emerged as a low morbidity bariatric surgical procedure that leads to effective weight loss and control of co-morbid diseases. The objective of this study was to systematically review the effect of LSG on body mass index and metabolic profile. Materials and Methods: Thirty patients were studied retrospectively and prospectively. The effect of LSG was studied at 3 and 6 months after surgery on changes in body mass index (BMI) and metabolic parameters. Results: Totally 30 patients were included in the study. Sixteen patients were diabetic, which was resolved after 6 months in 13 patients and improvement was seen in other three patients. 16 patients were hypertensive, and complete resolution was seen in 10 and rest 6 showed improvement. Mean weight loss was 19.92 kg and 41.2 kg after 3 and 6 months, respectively. There were 31.21% and 64.05% of excessive weight loss after 3 and 6 months, respectively. 21 patients were dyslipidemic before surgery that resolved in all patients.
Keywords: Body mass index and dyslipidemia, diabetes mellitus, hypertension, laparoscopic sleeve gastrectomy
|How to cite this article:|
Nain PS, Garg V, Singh P, Ahuja A, Batra D. Effect of laparoscopic sleeve gastrectomy on body mass index and metabolic parameters in morbid obese patients. J Obes Metab Res 2015;2:5-10
|How to cite this URL:|
Nain PS, Garg V, Singh P, Ahuja A, Batra D. Effect of laparoscopic sleeve gastrectomy on body mass index and metabolic parameters in morbid obese patients. J Obes Metab Res [serial online] 2015 [cited 2018 Nov 20];2:5-10. Available from: http://www.jomrjournal.org/text.asp?2015/2/1/5/148598
| Introduction|| |
The epidemic of obesity has emerged as a major health problem in the world. It is one of the leading preventable causes of death world-wide with increasing prevalence in adults and children. Authorities view it as one of the most serious public health problems of the 21 st century. 
Obesity is calculated as Quetelet's body mass index (BMI) which is the ratio of weight (measured in kg) to a height (measured in meters square). Morbid obesity is the harbinger of many diseases that effect essentially every organ system, e.g., cardiovascular, respiratory, metabolic, musculoskeletal, endocrinal reproductive, dermatological, neurological and many more. 
The treatment for obesity includes diet, physical activity, behavior therapy, pharmacotherapy, and surgery. However, it is generally agreed that nonsurgical therapies do not solve the problem of morbid obesity.  The most effective treatment for obesity is bariatric surgery. The national institute of health in the United States has recommended bariatric surgery for people who have a BMI > 35 kg/m 2 with co-morbidity or BMI > 40 kg/m 2 .  Laparoscopic sleeve gastrectomy (LSG) have become a favored procedure for morbid obesity in the countries due to its cost, safety and effectiveness in weight reduction. Surgical weight loss functions by reducing caloric intake and depending upon the procedure, macronutrients absorption. 
| Materials And Methods|| |
The study was conducted on a total of 30 patients, including 15 prospectively and 15 retrospective patients for 6 months. The inclusion criteria followed was; morbid obese persons with BMI > 40 kg/m 2 /obesity related co-morbidities with BMI > 35 kg/m 2 and the failure with regimen of diet, physical activity and behavior therapy for at least 6 months. Following patients will be excluded, Patient for revision bariatric surgery, Obesity-related to endocrinological disorders, clinically significant coronary artery disease and stroke were excluded.
| Observations And Results|| |
This study was undertaken in the Department of Surgical Disciplines at DMCH Ludhiana between January 2009 and January 2012. A total of 30 patients, who underwent surgery for morbid obesity at DMCH and gave consent were included in the study.
Of 30, 19 (63.3%) patients were females and the male to female ratio was 2:3. Mean age of patients was 47.90 (23-66) years. Mean BMI was 51.04 (kg/m). As we can see in [Table 1], the mean duration of postoperative hospital stay in LSG was 3.20 days. No patient required blood postoperatively.
Effect on Mean Weight (Kilograms)
There was a progressive weight loss over a period after surgery. The mean weight loss after 3 and 6 months of surgery was 19.92 ± 4.37 and 41.20 ± 8.91 kg, respectively.
Mean percentage excess weight loss
This is the percent of excess weight (over the ideal body weight) lost after the surgery. EWL more than 50% is considered satisfactory. There was no case with a EWL < 25%. Ideal weight was calculated after multiplying 24.9 (ideal BMI) with height (m) 2 .
Excessive body weight loss (%) was calculated by using this formula:
| Morbidity And Mortality|| |
0There was no mortality in the study population. Regarding morbidity, one patient in LSG developed a late staple line leak. The patient was managed conservatively with percutaneous drainage, antibiotics, and NJ feeding. All procedures in LSG were completed laparoscopically. There were no reports of any bleeding in postoperative/intraoperative period, trocar site hernia or trocar site infections.
Impact on type 2 diabetes mellitus
Out of 30 patients in our study, 16 patients had type 2 diabetes mellitus (T2DM), 7 of them had duration of diabetes for more than 5 years, 4 patients had history of diabetes for <5 years and remaining patients were diagnosed preoperatively during the work-up for bariatric surgery. Out of the 16, 8 patients were on oral hypoglycemic agents and 3 of them were on insulin. Out of 16 patients, 8 became euglycemic within 3 months of surgery and were without any medication. The remaining 8 patients required reduced drug dosage for the control of diabetes and by 6 months 13 patients (81.2%) were off anti-diabetic medication.
At 6 months, all patients on preoperative diet therapy had normal fasting glucose values. 7 of 8 (87.5%) patients on oral hypoglycemic medication presented normal fasting glucose values without any medication, and one patient presented with improvement of the disease and needed less oral medications. The patients on insulin therapy had normal fasting glucose values at 6 months postoperatively. One patient still required insulin though the dose was reduced. One patient earlier on insulin was on oral medication at 6 months. The clinical and biochemical characteristics of study subjects with diabetes are shown in [Table 2].
|Table 2: Clinical and biochemical characteristics of study|
subjects with diabetes
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Fasting plasma glucose
The fasting plasma glucose levels of all patients were checked preoperatively as well at 3 rd and 6 th month after the bariatric procedure. There is a significant decrease in levels as compared to preoperative values. The fall in HbA1c varied from 0.6% to 1.8% at 3 months, with a further fall in HbA1c of 0.5-0.8% at 6 months.
The total decline in HbA1c varied from 1% to 3.8%. The maximum rate of decline was noted in first 3 months of follow-up. Maximum fall occurred in patients with high value of HbA1c.
Impact on hypertension
Sixteen patients were diagnosed as hypertensive in the preoperative period. Among them 10 patients were on more than one antihypertensive agent. Of 16 patients, 10 had completely discontinued their antihypertensive medications within 6 months of surgery and 6 patients were able to reduce the dose of antihypertensive agents.
Impact on lipid profile
Out of 30 patients, 21 patients had dyslipidemia. Improvement in lipid parameters was seen in 100% of them. No patient required any medication for dyslipidemia 6 months after surgery. The impact on serum lipid profile is shown in [Table 3].
Serum cholesterol decreased after surgery and by 6 months was in the normal range for all patients. Low-density lipoprotein (LDL) levels were significantly changed after surgery. High-density lipoprotein (HDL) cholesterol was increased after surgery.
The values of renal function test's (RFT's) (including serum electrolytes), Ca + , Mg + , Serum Uric acid, were within the normal range both pre and postoperatively at 3 and 6 months. In view of that, no further statistical data was calculated for above patient parameters.
The overview of weight parameters is shown in [Figure 1]. The impact on co-morbidities at 6 months is shown in [Figure 2].
| Discussion|| |
0Laparoscopic sleeve gastrectomy , was first described as a modification to the biliopancreatic diversion and combined with a duodenal switch in 1998, and was first performed laparoscopically in 1999. Patients experience excellent weight loss after LSG alone, and multiple recent reports have documented LSG as single therapy in the treatment of morbid obesity. Weight loss is the most important parameter of bariatric surgery operations, and it is the parameter by which success or failure of weight reducing techniques is measured. Success of treatment has been defined as weight loss > 50% of excess weight. In our study, 100% of patients lost > 50% of their excess weight 6 months after surgery. The mean weight loss at 3 and 6 months was 19.92 kg and 41.20 kg, the mean %EWL at 3 and 6 months was 31.21% and 64.05% respectively. LSG may induce weight loss by reducing food intake, but in accelerated gastric emptying, delivery of nutrients to the small intestine early in the eating cycle could activate small intestine satiety inducing chemoreceptors that could modify food ingestion periodicity. Increases in the response of gastrointestinal hormones, such as glucagon-like peptide-1, a meal-related satiation factor, have been reported after LSG. This type of response may be caused by the food quickly reaching the level of the small intestine due to accelerated gastric emptying.
D'Hondt et al.  retrospective reviewed 102 patients who underwent LSG as a sole bariatric operation. Their mean initial BMI was 39.3 kg/m 2 . No major complications occurred. At a median follow-up point of 49 months (range, 17-80 months), the mean %EWL was 72.3% ±29.3%. For the 23 patients who reached the 6-year follow-up point, the mean %EWL was 55.9% ±25.55%. They concluded that LSG is a safe and effective bariatric procedure, although the tendency for weight regain is noted after 5 years of follow-up evaluation.
Menenakos et al.  conducted a prospective single-center study of 261 patients with a median follow-up of 1-year. The median %EWL for the 1 st year of follow-up was 65.7. The median BMI for the patients that had completed at least 1-year of follow-up was 30.5 kg/m 2 . The overall success rate after the 1 st year was 74.3% when accounted for %EWL > 50 and 81.7% for BMI <3 5 kg/m 2 . They concluded that LSG is a safe and effective option as a bariatric surgery
Chowbey et al.  reported the Indian experience with 75 patients analyzed retrospectively with LSG they reported %EWL from 31.2% at 3 months to 52.3% at 6 months, 59.13% at 1-year, and 65% at 2 years.
In one of the biggest series, Lee et al.  reported an EWL of 59 ± 17% at 1-year in 216 patients who underwent LSG with a preoperative BMI of 49.2 ± 11 kg/m 2 . In 93 patients with a BMI of 46.9 ± 6.5 kg/m 2 , Skrekas et al.  reported an EWL of 67.2 ± 12.6% and 72.3 ± 10.3% at 1 and 2 years, respectively. Nocca et al.  reported an EWL of 61.5% at 2 years in 163 patients (LSG) with a preoperative BMI of 45.9 kg/m 2 . During the second LSG Summit,  the EWL after 1, 2, and 3 years was reported to be 60.7%, 64.7%, and 61.7%, respectively.
Boza et al.  presented data of 1000 patients who underwent LSG as a primary procedure for morbid obesity. Excess weight loss (EWL) was as follows: 1-year 86.6%, 2 years 84.1%, and 3 years 84.5%. Early and late complications occurred in 34 (3.4%) and 20 (2.0%) patients, respectively. There was no mortality during follow-up. They concluded that the LSG is a safe and effective surgical technique for morbid obesity as a stand-alone procedure.
Bariatric surgery and impact on glucose homeostasis
Nocca et al.  studied the impact of LSG on HbA1c blood level and pharmacological treatment of T2DM in morbidly obese patients. At 1-year after surgery, T2DM had resolved in 75.8% of the LSG group. Reduced use of pharmacological therapy was noted in 15.15% of the LSG patients. Percentage EWL and BMI lost were 60.11% and 29.80% in the LSG group, respectively. Chowbey et al.  reported type 2 diabetes was resolved in 81.2%, hypertension in 93.75%, and dyslipidemia in 85% at 1-year. Bariatric surgery has been shown to reduce co morbidities and mortality in patients with morbid obesity and most significantly to ameliorate or resolve T2DM. Much of the improvement has been related to the EWL after surgery. However, some effects appear to be independent from weight loss.
Rizzello et al.  emphasized the resolution of T2DM after LSG. They also presented the effect of LSG on T2DM in patients with a BMI < 35 kg/m 2 . They studied 9 patients with T2DM and a BMI of 30-35 kg/m 2 , who also had hypertension, dyslipidemia, and obstructive sleep apnea. A normal BMI and normal glycemia were achieved within 6 months, with a mean HbA1c of 6.0%. T2DM resolved in all but 1 of these patients (88% cured). The patient in whom T2DM did not resolve had been diabetic for > 20 years, but postoperatively had a decrease in the insulin requirement.
Eight of the 16 diabetic patients had resolution of diabetes at 3 months, and 13 patients had resolution after 6 months and improvement was seen in all the 16 patients. There was a reduction in the requirement of drugs in the remaining three patients. In the presence study out of 16 patients 14 had remission of diabetes; of the remaining two patients one was on metformin only and the other patient on half the dose of insulin.
Zhang et al.  retrospectively studied changes in lipid profiles in obese patients who underwent LSG from June 2004 to June 2008. One year after surgery mean BMI decreased from 57.5 to 39.9. They concluded that 1-year after LSG, significant weight loss and improvements in HDL and triglyceride (TG) levels, total cholesterol/HDL and TG/HDL ratios were observed.
Rubin et al.  conducted a prospective study assessment was made of 120 consecutive morbidly obese patients with body mass index (BMI) of 43, who underwent LSG. There were no postoperative complications or mortality. During a median follow-up of 11.7 months, percent of excess BMI lost reached 53% ± 24% and the BMI decreased from 43 ± 5 to 34 ± 5 kg/m 2 . Dyslipidemia is a recognized cardiovascular risk factor that could explain the excessive mortality rate in severely obese patients. It has been shown that bariatric procedures can improve the dyslipidemia associated with obesity; however the impact on the lipid profile varies with various series reporting different results.
In our study, the outcomes of LSG regarding resolution of dyslipidemia. At the end of 6 months, Total cholesterol levels were decreased from 268.44 to 175.76 after 6 months of surgery. LDL cholesterol levels were decreased from 106.64 to82.36 after 6 months of surgery. HDL levels were increased from 24.4 to 40.40 at 6 months after LSG. We conclude that the impact on lipid profile is significant after bariatric surgery, and the effects are similar after both surgeries and are related to weight loss.
Similar to our results, Chowbey et al.  reported an 80% resolution of dyslipidemia at 6 months after LSG in Indian setting. Boza et al.  reported an 85% resolution in dyslipidemia at 1-year after LSG.
Zhang et al.  reported the lipid profiles in morbidly obese patients 1-year after LSG. There was a significant decrease in weight and in elevated cholesterol and an increase in HDL cholesterol. There were no changes in LDL.
| Effect on Hypertension|| |
0All patients (100%) with preoperatively diagnosed hypertension (16 out of 30) showed improvement or resolution. At 6 months, 62.5% of LSG patients had resolution of hypertension. Similar results are found in the literature. Srinevasa  et al. reported a 29% resolution and 48% improvement in hypertension 1-year after LSG. Boza et al.  reported a 62.5% resolution of arterial hypertension at 1-year after LSG. Similarly D'Hondt et al.  reported a 95% resolution/improvement in hypertension status 1-year after Sleeve gastrectomy. Prasad et al.  reported a 75% resolution/improvement in hypertension 1-year after sleeve gastrectomy. Chowbey et al.  reported improvement in hypertension in 93.75% at 1-year.
| Effect on other Metabolic Parameters|| |
All the patients in the study population had normal values of RFT's including serum electrolytes, Ca + Mg + , serum uric acid both pre and postoperatively at 3 and 6 months. In view of that, those parameters were not calculated statistically. And no further data were analyzed.
| Complications Following Laparoscopic Sleeve Gastrectomy|| |
The most important and frequent major complication after sleeve gastrectomy is the appearance of a leak, which can result in death of a patient. We had leaked in one patient who underwent LSG. Chowbey et al.  one patient died at 2 weeks postoperatively due to pulmonary embolism.
The risk of postoperative hemorrhage is less than 1%. The source of bleeding can be the staple line, splenic trauma, a hepatic tear or the trocar site. Staple lines may bleed into the abdominal cavity as well as intraluminally. In the bleeding patient, we stop prophylactic anticoagulation agents such as clexane low-molecular-weight heparin as well as other medications (i.e. NSAIDs) that can potentially increase the risk of bleeding. We had no incidence of bleeding in both groups.
Arias et al.  performed a retrospective review 130 patients who underwent LSG as a final procedure for morbid obesity. Complications noted were one patient (0.7%) had leakage at the staple line, while four patients (2.8%) developed trocar site infection. Three patients (2.1%) complained of symptoms of gastroesophageal reflux disease, three patients (2.1%) developed symptomatic gallstones, and trocar site hernia was present in one (0.7%) patient. The mean weight loss was 21, 31.2, 37.4, 39.5, and 41.7 kg at 3, 6, 12, 18, and 24 months, respectively, whereas the mean BMI decreased to 36.9, 32.8, 29.5, 28, and 27.1 at 3, 6, 12 18, and 24 months, respectively. Percent of EWL (%EWL) was 33.1, 50.8, 62.2, 64.4, and 67.9 at 3, 6, 12, 18, and 24 months, respectively. They concluded that excess body weight loss is acceptable at 2 years after LSG.
| Summary and Conclusion|| |
0Laparoscopic sleeve gastrectomy has emerged as a low morbidity bariatric surgical procedure that leads to effective weight loss and control of co-morbid diseases. Most patients with DM, hypertension and dyslipidemia showed resolution or improvement after LSG.
Therefore, for morbidly obese patient in the short term, LSG is very safe and effective procedure without any significant morbidity or mortality.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]