Surgery for Obesity and Related Diseases 11 (2015) 732
Letter to the Editor
Is excision of the gastric mucosa responsible for the superior outcomes of sleeve gastrectomy compared with gastric plication? Dear Editor, We read with interest the recently published study comparing laparoscopic gastric greater curvature plication (LGGCP) with laparoscopic sleeve gastrectomy (LSG) [1]. Abdelbaki et al. report a higher percentage of excess weight loss in the LSG group compared with the LGGCP group at 12 months, which is consistent with that reported by a similar comparative study by Shen et al. [2]. Although the study by Abdelbaki et al. compares the 2 surgical techniques with regards to efficacy and safety, the authors do not speculate as to what the underlying mechanistic processes are that likely resulted in the superior weight loss reported in the LSG cohort. The study design was such that the volume of the stomach (measured using a 32F bougie) postoperation was identical between both groups. Consequently, the fundamental difference between the 2 surgeries is that, in LSG, approximately 80% of the gastric mucosa is excised from the patient. Therefore, one hypothesis may be that the mechanisms by which LSG elicits weight reduction and improvement in metabolic profile are due to removal of the gastric mucosa. Basso et al. alluded to the fact that the importance of the gastric mucosa in LSG has been largely overlooked [3]. The gastric mucosa secretes orexigenic (ghrelin) and anorexigenic (leptin, obestatin, and nesfatin-1) hormones, making it a complex regulator of food intake and metabolism [4]. Additionally, increased insulin secretion and improved insulin sensitivity in diabetic obese patients immediately after sleeve gastrectomy, before any weight loss, supports the hypothesis that the benefits are a result of hormonal changes of gastric origin and are independent of gastric restriction and/or weight loss [3,5]. Disappointingly, the mechanisms contributing to the benefits of bariatric surgery remain uncertain, despite offering potential to reveal new methods of managing the obesity epidemic. No single gut hormone has emerged as
the critical conductor for the metabolic success of LSG and therefore, in the immediate future, no drug is likely to emerge as the panacea for obesity. If excision of the gastric mucosa is responsible for the neurohormal changes and weight loss that occur in LSG, then minimally invasive technologies can be developed to target the gastric mucosa. Disclosures The authors have no disclosures.
Vivek Kumbhari, M.D. Division of Gastroenterology and Hepatology Johns Hopkins Hospital 1800 Orleans St, Suite 2058 B Baltimore, MD 21205 Andreas Oberbach, M.D., Ph.D. Department of Cardiac Surgery University of Leipzig Leipzig Germany References [1] Abdelbaki TN, Sharaan M, Abdel-Baki NA, Katri K. Laparoscopic gastric greater curvature plication versus laparoscopic sleeve gastrectomy: early outcome in 140 patients. Surg Obes Relat Dis 2014;10 (6):1141–6. [2] Shen D, Ye H, Wang Y, et al. Comparison of short-term outcomes between laparoscopic greater curvature plication and laparoscopic sleeve gastrectomy. Surg Endosc 2013;27(8):2768–74. [3] Basso N, Capoccia D, Rizzello M, et al. First-phase insulin secretion, insulin sensitivity, ghrelin, GLP-1, and PYY changes 72 h after sleeve gastrectomy in obese diabetic patients: the gastric hypothesis. Surg Endosc 2011;25(11):3540–50. [4] Stengel A, Tache Y. Gastric peptides and their regulation of hunger and satiety. Curr Gastroenterol Rep 2012;14(6):480–8. [5] Rizzello M, Abbatini F, Casella G, et al. Early postoperative insulinresistance changes after sleeve gastrectomy. Obes Surg 2010;20(1):50–5.
http://dx.doi.org/10.1016/j.soard.2015.01.023
http://dx.doi.org/10.1016/j.soard.2015.01.023 1550-7289/r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Letter to the Editor
Is excision of the gastric mucosa responsible for the superior outcomes of sleeve gastrectomy compared with gastric plication? Dear Editor, We read with interest the recently published study comparing laparoscopic gastric greater curvature plication (LGGCP) with laparoscopic sleeve gastrectomy (LSG) [1]. Abdelbaki et al. report a higher percentage of excess weight loss in the LSG group compared with the LGGCP group at 12 months, which is consistent with that reported by a similar comparative study by Shen et al. [2]. Although the study by Abdelbaki et al. compares the 2 surgical techniques with regards to efficacy and safety, the authors do not speculate as to what the underlying mechanistic processes are that likely resulted in the superior weight loss reported in the LSG cohort. The study design was such that the volume of the stomach (measured using a 32F bougie) postoperation was identical between both groups. Consequently, the fundamental difference between the 2 surgeries is that, in LSG, approximately 80% of the gastric mucosa is excised from the patient. Therefore, one hypothesis may be that the mechanisms by which LSG elicits weight reduction and improvement in metabolic profile are due to removal of the gastric mucosa. Basso et al. alluded to the fact that the importance of the gastric mucosa in LSG has been largely overlooked [3]. The gastric mucosa secretes orexigenic (ghrelin) and anorexigenic (leptin, obestatin, and nesfatin-1) hormones, making it a complex regulator of food intake and metabolism [4]. Additionally, increased insulin secretion and improved insulin sensitivity in diabetic obese patients immediately after sleeve gastrectomy, before any weight loss, supports the hypothesis that the benefits are a result of hormonal changes of gastric origin and are independent of gastric restriction and/or weight loss [3,5]. Disappointingly, the mechanisms contributing to the benefits of bariatric surgery remain uncertain, despite offering potential to reveal new methods of managing the obesity epidemic. No single gut hormone has emerged as
the critical conductor for the metabolic success of LSG and therefore, in the immediate future, no drug is likely to emerge as the panacea for obesity. If excision of the gastric mucosa is responsible for the neurohormal changes and weight loss that occur in LSG, then minimally invasive technologies can be developed to target the gastric mucosa. Disclosures The authors have no disclosures.
Vivek Kumbhari, M.D. Division of Gastroenterology and Hepatology Johns Hopkins Hospital 1800 Orleans St, Suite 2058 B Baltimore, MD 21205 Andreas Oberbach, M.D., Ph.D. Department of Cardiac Surgery University of Leipzig Leipzig Germany References [1] Abdelbaki TN, Sharaan M, Abdel-Baki NA, Katri K. Laparoscopic gastric greater curvature plication versus laparoscopic sleeve gastrectomy: early outcome in 140 patients. Surg Obes Relat Dis 2014;10 (6):1141–6. [2] Shen D, Ye H, Wang Y, et al. Comparison of short-term outcomes between laparoscopic greater curvature plication and laparoscopic sleeve gastrectomy. Surg Endosc 2013;27(8):2768–74. [3] Basso N, Capoccia D, Rizzello M, et al. First-phase insulin secretion, insulin sensitivity, ghrelin, GLP-1, and PYY changes 72 h after sleeve gastrectomy in obese diabetic patients: the gastric hypothesis. Surg Endosc 2011;25(11):3540–50. [4] Stengel A, Tache Y. Gastric peptides and their regulation of hunger and satiety. Curr Gastroenterol Rep 2012;14(6):480–8. [5] Rizzello M, Abbatini F, Casella G, et al. Early postoperative insulinresistance changes after sleeve gastrectomy. Obes Surg 2010;20(1):50–5.
http://dx.doi.org/10.1016/j.soard.2015.01.023
http://dx.doi.org/10.1016/j.soard.2015.01.023 1550-7289/r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
