Surgery for Obesity and Related Diseases ] (2014) 00–00
Original article
Comparison of results after one year between sleeve gastrectomy and gastric bypass in patients with BMI Z 50 kg/m² Jérémie Thereaux, M.D.a, Nicola Corigliano, M.D., Ph.D.a, Christine Poitou, M.D, Ph.D.c, Jean-Michel Oppert, M.D., Ph.D.c, Sebastien Czernichow, M.D., Ph.D.a,b, Jean-Luc Bouillot, M.D.a,* a
Department of General, Digestive and Metabolic Surgery, the Department of Nutrition. Ambroise Paré University Hospital, Versailles Saint-Quentin University, Assistance Publique-Hôpitaux de Paris, Boulogne-Billancourt, France b Centre for Epidemiologic Cohort in Population (INSERM UMS 011), Villejuif, France. c Department of Nutrition, Pitié-Salpêtrière Hospital, Assistance Publique- Hôpitaux de Paris, Pierre-et-Marie-Curie-Paris 6 University, Human Nutrition Research Centre Île-de-France (CRNH IdF), Institute of Cardiometabolism and Nutrition (ICAN), Paris, France Received September 15, 2014; accepted November 23, 2014
Abstract
Background: Although laparoscopic sleeve gastrectomy (LSG) was initially described as the first step of a 2-stage procedure for high-risk patients requiring laparoscopic Roux-en-Y gastric bypass (LRYGB), it is now being used as a single-stage procedure. Experience with laparoscopic bariatric surgery is growing, such that LRYGB is increasingly feasible for patients with body mass index (BMI) Z 50 kg/m². Nevertheless, outcomes for such category of patients following LSG and LRYGB are lacking. Objective: To compare weight loss and changes in obesity related comorbidities at one year following LSG with LRYGB in patients with BMI Z 50 kg/m². Settings: The prospective database of a single surgery university center was queried for clinical and other relevant data. Methods: From January 2004 to January 2013, 74 and 285 patients underwent LSG or LRYGB with a BMI Z 50 kg/m². At one year, rate of follow-up was 92.8%. Success of surgery was defined as % of excess weight loss (%EWL) Z 50% at one year. Logistic regression was used to compute odds ratio (OR) to evaluate the success at one year of surgery. Results: LSG (N ¼ 74) and LGBP (N ¼ 285) groups did not differ for initial BMI (57.2 ⫾ 7.1 versus 56.7 ⫾ 5.5 kg/m²; P ¼ .52), % of female (64.6% versus 73.7%, P ¼ .13) or major adverse postoperative events (5.7% versus 6.7%; P ¼ .85). At one year, the mean percentage of weight loss (%) (22.0 ⫾ 7.6 versus 30.3 ⫾ 7.4; P o .0001) and percentage of excess weight loss (%) (40.2 ⫾ 15.2 versus 55.0 ⫾ 14.6; P o .0001) and rates of remission of diabetes (47.5% versus 70.7%; P ¼ .01) were greater in the LGBP than LSG group. In multivariate analyses (OR), LSG was an independent factor of failure of weight loss (.12; P o .0001) Conclusion: After 1 year of follow-up in patients with a BMI Z 50 kg/m², LRYGB provides better weight loss and resolution in diabetes than LSG with similar postoperative morbidity. Further longterm studies are needed to confirm these results. (Surg Obes Relat Dis 2014;]:00–00.) r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Bariatric surgery; Gastric bypass; Sleeve gastrectomy; Super obesity; Super-super obesity
*
Correspondence: Prof. Jean-Luc Bouillot, Department of General, Digestive and Metabolic Surgery, Ambroise Paré University Hospital, Versailles Saint-Quentin University, Assistance Publique-Hôpitaux de Paris, 9, Avenue Charles de Gaulle, 92100 Boulogne-Billancourt, France. E-mail: [email protected]
With the increasing prevalence of obesity worldwide [1], bariatric surgery has gained in popularity as the treatment of choice for morbid obesity [2]. Laparoscopic gastric bypass
http://dx.doi.org/10.1016/j.soard.2014.11.022 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
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J. Thereaux et al. / Surgery for Obesity and Related Diseases ] (2014) 00–00
(LRYGB) was first described several decades ago, and is currently viewed as the gold standard surgical treatment, as it provides excellent long-term weight loss and high rates of remission of coexisting conditions [3]. However, LRYGB is a technically challenging procedure, requiring great skill, especially in cases of super obesity (body mass index [BMI] Z 50 kg/m²) and super-super obesity (BMI Z 60 kg/m²). The risk of major postoperative adverse events is higher in such cases than for patients with BMI o50 kg/m2 [4,5]. Laparoscopic Sleeve Gastrectomy (LSG) was first described in the nineties as a new type of gastrectomy for bilio-pancreatic diversion [6]. Regan et al. reported the first LSG as the initial step of a 2-stage LRYGB for high-risk patients [7]. Because of substantial long-term weight loss [8–11] and remission of diabetes [11,12], LSG is increasingly used as a stand-alone procedure. This is partly because the morbidity associated with LSG, although worse than with laparoscopic adjustable gastric banding, is less than that associated with LRYGB [13]. In France, the number of LSG performed has risen by 100% during the years 2011–2013: there are now more than 20,000 LSG per year, such that this bariatric procedure is now the most frequently performed [14]. Several studies have compared outcomes between LRYGB and LSG, but very few were randomized trials [15–18]. Furthermore, no large studies have focused on patients with BMI Z 50 kg/m² although LSG was first used for this type of high-risk patient. We report the first large monocentric study assessing one year weight loss and co-morbidity outcomes in obese patients with BMI Z 50 kg/m² undergoing LSG or LRYGB. Methods Patients Since January 2004, all of our patients undergoing LSG or LRYGB have been prospectively included in an electronic database. All procedures performed due to failure of sleeve gastrectomy, vertical banded gastroplasty or loop gastric bypass (mini gastric bypass) were excluded. We retrospectively reviewed this database and identified 359 patients (74 LSG and 285 LRYGB) with a preoperative BMI Z 50 kg/m² undergoing bariatric surgery from January 2004 to January 2013. At one year, the rate of follow-up was 92.8%. Our prospectively collected database has been registered with the French National Data Protection Agency (Commission Nationale Informatique et Libertés, CNIL, #1689730). Bariatric surgery was offered to patients in accordance with French guidelines for bariatric surgery, which are similar to those of the National Institutes of Health [19]. Each patient was evaluated and followed for at least 6 months in a University Nutrition department before surgery and the indication for bariatric surgery was endorsed by a
multidisciplinary team. Preoperatively, LSG was systematically preferred to LRYGB in cases of expected small bowel adhesion, or of disease either needing long-term medication (such as acquired immunodeficiency syndrome) or needing upper tract endoscopic follow-up. Hypertension was defined as a blood pressure above 140 mm Hg (systolic) and/or 90 mm Hg (diastolic) or use of antihypertensive medication. Diabetes was defined as fasting glycemia above 7 mmol/L on at least 2 different occasions or use of antidiabetic medication. Dyslipidemia was defined as a total cholesterol concentration above 5.7 mmol/L and/or a serum HDL-c (High Density Lipoproteincholesterol) level below 1.0 mmol/L and/or a triglyceride level above 1.7 mmol/L, or use of lipid-lowering medication. All patients had a nocturnal polygraphy and were considered to have obstructive sleep apnea syndrome if the apnea–hypopnea index was 45 events/hour, or if they were already being treated with nocturnal continuous positiveairway pressure. Surgery We have been using a standardized surgical technique for each LRYGB and LSG since 2004. At the beginning of our experience, LRYGB was our gold standard procedure. Then, with progressive published results of SG, progressively, both procedures became our gold standards for morbid obesity treatment. For LRYGB procedure, we have used a standardized surgical technique and postoperative management system since 2004 as described previously [20]. For LSG, mobilization of the greater curve begins 6cm proximal to the pylorus, and continues to the angle of His with importance accorded to the total exposure of the left crural pillar. Gastric resection involves using a 36 French bougie. The staple line is reinforced with a 2-0 absorbable running suture. The absence of gastric leak is verified by introducing methylene blue through a naso-gastric tube at the end of the operation. On day 2, patients routinely undergo standard upper gastrointestinal tract imaging. Patients are allowed to drink if no complication is observed. Patients are usually discharged on day 4 or 5. Outcomes All patients were evaluated 1, 3, 6, and 12 months after surgery. No patients underwent any other bariatric surgery during follow-up. Remission of hypertension, dyslipidemia, and obstructive sleep apnea syndrome were defined as normalization of the corresponding baseline characteristics without any drugs or use of a continuous positive-pressure airway machine. Remission of diabetes was defined as a glycated hemoglobin a1 c (HbA1 c) o6.5% without any treatment for at least one year. Improvements in diabetes, hypertension, dyslipidemia, and obstructive sleep apnea
Better Outcomes of Gastric Bypass in Super-Obese / Surgery for Obesity and Related Diseases ] (2014) 00–00
syndrome were defined as the improvement of the corresponding baseline characteristics with the same or lower doses of therapy [21]. Weight loss (in kg) was defined as [weight at baseline – weight at follow-up]. Percentage of initial weight loss (%IWL) was calculated as: 100*[weight loss/weight at baseline]. Baseline excess weight (kg) was calculated, according to the theoretical weight (1983 Metropolitan Life Insurance tables), as [weight at baseline – theoretical weight]. The % of excess weight loss (%EWL) was assessed as 100*[weight loss/baseline excess weight]. According to Reinhold criteria [22], success of weight loss was defined as %EWL Z50%. Postoperative morbimortalities were compared using a composite endpoint of major adverse outcomes at 30 days (30-day MAO) previously described [4]. This endpoint includes death, percutaneous or endoscopic interventions or repeat surgery, venous thromboembolism and a failure to be discharged from the hospital at day 30 [4,20].
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Table 1 Demographic characteristics and baseline health status characteristics of the patients at the time of the bariatric procedure* Characteristics
Laparoscopic sleeve gastrectomy (n ¼ 74)
Laparoscopic gastric P bypass (n ¼ 285) value†
Age (years) Female (%) Weight (kg) BMI (kg/m²)‡ Maximal BMI (kg/ m²)‡ Hypertension Diabetes Obstructive sleep apnea syndrome Dyslipidemia Joint pain Ischemic cardiopathy
45.5 ⫾ 13.7 64.9% 157.9 ⫾ 25.1 57.2 ⫾ 7.1 59.4 ⫾ 9.6
40.9 ⫾ 12.2 73.7% 155.4 ⫾ 21.0 56.7 ⫾ 5.5 58.7 ⫾ 7.2
.005 .13 .36 .52 .48
64.9% 55.4% 87.8%
51.9% 34.1% 70.2%
.05 .001 .002
33.8% 60.8% 6.8%
32.6% 74.0% 5.3%
.85 .025 .62
BMI ¼ Body mass index. Plus-minus values are means ⫾ SD or %, as appropriate. † P values are for the comparison between the 2 groups. Values were calculated with student-t tests or Chi-squared tests as appropriate. ‡ Body mass index is the weight in kilograms divided by the square of the height in meters. *
Categorical data are presented as percentages. Continuous variables are presented as means and standard deviations or median (InterQuartile Range) as appropriate. We used χ² or Fisher’s exact tests for categorical variables as appropriate. For numerical variables, we used Student’s t tests or MannWhitney tests as appropriate. Univariate and multivariate analyses were carried out by logistic regression models and 95% confidence intervals (95% CI) were calculated for the risk of failure of weight loss (%EWL o50%) at one year. All factors with a P o .15 in univariate analyses were kept for the multivariate models. All analyses were performed with SAS software version 9.3 (SAS Institute, Cary, NC). The significance threshold was set at P = .05. Results Baseline characteristics A total of 359 patients with BMI Z 50 kg/m² underwent bariatric surgery between January 2004 and January 2013 in our tertiary care unit. They were 74 LSG (group 1) and 285 LRYGB (group 2). Group 1 and group 2 were similar for initial BMI (57.2 ⫾ 7.1 versus 56.7 ⫾ 5.5 kg/m²; P = .52) and rate of female (64.6% versus 73.7%, P = .13). Patients in group 1 were older (45.5 ⫾ 13.7 versus 40.9 ⫾ 12.2; P = .005) and had more diabetes (55.4% versus 34.1%; P = .001) (Table 1). Surgery and 30-day morbid-mortality
respectively. One (1.4%) gastric fistula after LSG was reported and was managed endoscopically. The median length of hospital stay (days) was longer for group 2 (5.0 versus 4.5; P ¼ .001). One year outcomes At one year, rate of follow-up was 92.8%. Fig. 1 shows the percentage weight change during the one-year follow-up for the 2 groups. At one year, patients undergoing LRYGB showed greater %weight loss (30.3 ⫾ 7.4 versus 22.0 ⫾ 7.6; P o .0001) and greater %EWL (40.2 ⫾ 15.2 versus 55.0 ⫾ 14.6; P o .0001). BMI (kg/m²) at one year was significantly lower for the LRYGB group (39.8 ⫾ 6.5 versus 44.4 ⫾ 7.4; P o .0001). Rates of remission of coexisting conditions were greater in group 2 (Table 2). 0 -5 -10
Weight Change (%)
Statistical Analysis
-15
Sleeve gastrectomy Gastric bypass
-20 -25 -30 -35
The operative time (in minutes) was longer for LRYGB than for LSG (213 ⫾ 39 versus 65 ⫾ 13; P o .0001) with similar rates of conversion (1.0% versus 1.4%; P ¼ .99), of 30 days major adverse outcomes (6.7% versus 5.7%; P ¼ .85) and of mortality (1.0% versus 0%; P ¼ .99),
-40 0
1 mth
3 mths
6 mths
12 mths
Months of Follow-up
Fig. 1. Weight Change over one Year Follow-up according to Procedure. Bars denote Standart-deviation
J. Thereaux et al. / Surgery for Obesity and Related Diseases ] (2014) 00–00
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Table 2 Weight status characteristics, weight loss, resolution and improvement of coexisting conditions of the patients one year after procedure* Characteristics
Laparoscopic sleeve gastrectomy (n ¼ 70/74)
Laparoscopic gastric bypass (n ¼ 263/285)
P value†
BMI (kg/m²)‡ % Weight loss (%) % Excess weight loss (%) Patients with %excess weight lossZ50 Hypertension§ Diabetes§ Obstructive sleep apnea§ Dyslipidemia§ Joint pain§
44.4 ⫾ 7.4 22.0 ⫾ 7.6 40.2 ⫾ 15.2 21.4% 13.3% / 82.2% 47.5% / 87.5% 33.3% / 80.0% 24.0% / 56.0% 29.3% / 70.7%
39.8 ⫾ 6.5 30.3 ⫾ 7.4 55.0 ⫾ 14.6 63.5% 47.2% / 83.1% 70.7% / 95.6% 61.8% / 86.0% 69.4% / 89.4% 49.5% / 82.0%
o .0001 o .0001 o .0001 o .0001 o .0001 / .90 .01 / .09 o .0001 / .26 o .0001 / o .0001 .02 / .10
BMI ¼ Body mass index. Plus-minus values are means ⫾ SD or %, as appropriate. † P values are for the comparison between the 2 groups. Values were calculated with student-t tests or Chi-squared tests as appropriate. ‡ Body-mass index is the weight in kilograms divided by the square of the height in meters. § Rates of Resolution / Improvement. *
Preoperatively, 29.3% (LSG) and 33.0% (LRYGB) of diabetic patients had insulin. At one year, respectively, 50.0% and 31.2% were still under insulin treatment (P ¼ .76) In multivariate analyses, regardless of age, sex and diabetes status, LSG was found as an independent negative predictive factor (OR ¼ .12) for success of weight loss (95% CI .06-0.25; P o .0001). Table 3 Discussion We provide, here, the first large study assessing one year outcomes between LSG and LRYGB in patients with preoperative BMI Z50 kg/m². Our results clearly indicate that LRYGB provides better weight loss and resolution of coexisting conditions with an insignificant trend for higher
postoperative morbi-mortality. Several studies have compared outcomes between LRYGB and LSG, and these studies included patients with lower BMI than those in our study. Most show similar results for the 2 procedures. Of the 4 published randomized studies, only 2 show similar weight loss at one year [15,18], Kehagias et al. [16] reported a greater weight loss at one year after LSG, but similar %EWL at 3 years and Zhang et al. provide better weight loss for LRYGB group [17]. Two case control studies have been reported, and describe similar weight loss. The %EWL (%) at 3 years reported by Boza et al. for patients with a mean baseline BMI of 38 kg/m² were 86.8% ⫾ 27.1 after LSG versus 93.1% ⫾ 25.0 after LRYGB (P ¼ .082) [23,24]. In the report by Chouillard et al., the maximal mean BMI is indicated, but not baseline BMI [23]. Other relevant studies are comparative
Table 3 Univariate and multivariate analyses of success at one year %EWL Z 50%) after bariatric surgery as a function of patient (N ¼ 333/359) characteristics and of bariatric procedure Univariate analyses OR (95% CI) Female Age (yr) Hypertension Diabetes Dyslipidemia Obstructive sleep apnea syndrome Joint pain Surgical experience categories (distribution by quartile) 1st quartile 2nd quartile 3rd quartile 4th quartile BMI (kg/m²)* Sleeve gastrectomy
Multivariate analyses P value
OR (95% CI)
P value
.92 (.521.62) .99 (.971.01)
.76 .39
.85 (.501.45)
.55
1.20 .99 .91 .69 .83 1.21 1.25
(.731.97) (.971.005) (.591.41) (.451.08) (.531.30) (.751.96) (.782.01)
.47 .17 .66 .10 .43 .44 .35
1.00 1.54 1.53 1.60 .88 .16
() (0.842.8) (0.832.7) (0.882.9) (0.840.92) (0.090.30)
.16 .16 .16 o .0001 o .0001
0.86 (0.810.90) 0.12 (0.060.25)
BMI ¼ Body mass index; OR ¼ odds ratio; CI ¼ Confidence interval; %EWL ¼ Percentage of excess weight loss. * Body-mass index is the weight in kilograms divided by the square of the height in meters.
o .0001 o .0001
Better Outcomes of Gastric Bypass in Super-Obese / Surgery for Obesity and Related Diseases ] (2014) 00–00
retrospective studies reporting similar results for LRYGB and LSG with various follow-ups [25–27]. Furthermore, most of studies included patients with a mean BMI o40 kg/m² [17,24], or with a BMI at baseline o45 kg/m² [15,23,26,27], and some excluded patients with a BMI 450 kg/m² [16,17]. Hence, we think that because of expected difficulties to perform LRYGB in patients with BMI Z 50 kg/m², randomized studies would be difficult to perform in such category of patients. Our mean %EWL is under 50% for the LSG group and it needs to be compared to other previous studies. Hence, at one year, %EWL in patients with BMI Z50 kg/m² is slightly higher than in our study, with outcomes varying from 55.5% [28] to 43.9% [29]. Furthermore, only Zerrweck et al. had compared LSG and LRYGB for patients with BMI Z 50 kg/m² [29]. In accordance with our results, they provided better outcomes for LRYGB at one year but this study suffer from limitation since it has small samples [29]. Although LSG was described (as the first step of gastric bypass or duodenal switch procedures) twenty years ago, there have been few non-comparative studies assessing long-term outcomes. After 6 years, the %EWL varies from 53.3% [8] to 68% [10] for cases with low baseline BMI. For super-obese patients, Eid et al. reported a %EWL of 46% at 8 years, which is compatible with our early results, but 40.5% of the patients required revisional surgery for weight loss failure, suggesting disappointing results of LSG for many super-obese patients [11]. LSG was initially described as the first step of a 2-stage procedure for high-risk patients requiring LRYGB [7], but it is increasingly used worldwide as a stand-alone treatment. The LSG procedure offers many advantages compared to LRYGB. It is easier to perform, especially for super-obese patients, and is associated with fewer short- and long-term complications and with a lower incidence of malabsorption, denutrition and vitamin deficiency. We found an insignificant trend for higher morbi-mortality in patients undergoing LRYGB. These results are in accordance with previous studies. Hence, LSG is considered to be an intermediate-risk bariatric procedure, positioned between adjustable gastric banding and LRYGB, with a 30-day mortality of .11% [13]. The choice of the best procedure for an individual patient seeking bariatric surgery is still a matter for debate. For patients with BMI o50 kg/m², results after LSG and LRYGB are similar, and the literature indicates that LSG can be used as an alternative to LRYGB for morbid obesity with BMI o50 kg/m² [15,16,18,23–27]. For patients with BMI Z 50 kg/m², bilio-pancreatic diversion with duodenal switch (BPD-DS) in one or 2 steps has been shown to be more effective than LRYGB [30]. However, several bariatric teams have expressed concerns about the risks associated with this procedure. Malnutrition, protein denutrition, intractable diarrhea, vitamin A and D deficiencies,
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and higher risk of reversal surgery have been documented [31,32]. Our study has some limitations. First, baseline characteristics are different for age, diabetes and obstructive sleep apnea. These characteristics are known to be leading factors of postoperative morbi-mortality [4,5] showing that our LSG group is more prone to have complications. But this hypothesis is not confirmed in our study, confirming that both LSG and LRYGB are safe procedure in such category of high risk patients in an expert centre. Furthermore, age and diabetes status could negatively influence weight loss [33]. Our multivariate analyses clearly indicate that LSG is an independent factor for failure of weight loss regardless of age, sex and diabetes status, at one year. However, multivariate analyses cannot completely reduce this potential bias. Furthermore, because we began our surgical experience with LRYGB, we assessed relation between our learning curves and outcomes. However, we did not find any relation between our learning curve and weight loss at one year. Another shortcoming is the short-term follow-up (only one year), and long-term prospective studies are required to confirm our results. Conclusions This study indicates that LRYGB allows better weight loss at one year than LSG in patients with BMI Z 50 kg/m² with higher resolution of diabetes. LRYGB should be considered as the first choice for patients with BMI Z 50 kg/m² or when it is the choice of the patient. However, our data show that LSG is a valuable alternative, and allows substantial weight loss, providing the opportunity for a subsequent, second-stage procedure, especially in the highest risk patients when perioperative difficulties are expected. Further studies with more patients and longer-term followup are needed to confirm our results. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] Shields M, Carroll MD, Ogden CL. Adult obesity prevalence in Canada and the United States. NCHS Data Brief 2011;56:1–8. [2] Sjostrom L, Peltonen M, Jacobson P, et al. Bariatric surgery and longterm cardiovascular events. JAMA 2012;307:56–65. [3] Adams TD, Davidson LE, Litwin SE, et al. Health benefits of gastric bypass surgery after 6 years. JAMA 2012;308:1122–31. [4] Flum DR, Belle SH, King WC, et al. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med 2009;361: 445–54. [5] Benotti P, Wood GC, Winegar DA, et al. Risk factors associated with mortality after Roux-en-Y gastric bypass surgery. Ann Surg 2014; 259:123–30.
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[6] Lagace M, Marceau P, Marceau S, et al. Biliopancreatic Diversion with a New Type of Gastrectomy: Some Previous Conclusions Revisited. Obes Surg 1995;5:411–8. [7] Regan JP, Inabnet WB, Gagner M, Pomp A. Early experience with two-stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient. Obes Surg 2003;13:861–4. [8] Himpens J, Dobbeleir J, Peeters G. Long-term results of laparoscopic sleeve gastrectomy for obesity. Ann Surg 2010;252:319–24. [9] Rawlins L, Rawlins MP, Brown CC, Schumacher DL. Sleeve gastrectomy: 5-year outcomes of a single institution. Surg Obes Relat Dis 2013;9:21–5. [10] Sarela AI, Dexter SP, OʼKane M, Menon A, McMahon MJ. Longterm follow-up after laparoscopic sleeve gastrectomy: 8–9-year results. Surg Obes Relat Dis 2012;8:679–84. [11] Eid GM, Brethauer S, Mattar SG, Titchner RL, Gourash W, Schauer PR. Laparoscopic sleeve gastrectomy for super obese patients: fortyeight percent excess weight loss after 6 to 8 years with 93% followup. Ann Surg 2012;256:262–5. [12] Dorman RB, Serrot FJ, Miller CJ, et al. Case-matched outcomes in bariatric surgery for treatment of type 2 diabetes in the morbidly obese patient. Ann Surg 2012;255:287–93. [13] Hutter MM, Schirmer BD, Jones DB, et al. First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann Surg 2011;254: 410–20; discussion 420–2. [14] Agence Technique de l’Information sur l’Hospitalisation (ATIH). [Page on the internet]. French medicare database source. Available from: http://www.atih.sante.fr/. Accessed May, 2014. [15] Peterli R, Borbely Y, Kern B, et al. Early Results of the Swiss Multicentre Bypass Or Sleeve Study (SM-BOSS): A Prospective Randomized Trial Comparing Laparoscopic Sleeve Gastrectomy and Roux-en-Y Gastric Bypass. Ann Surg 2013;258:690–4; discussion 695. [16] Kehagias I, Karamanakos SN, Argentou M, Kalfarentzos F. Randomized clinical trial of laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy for the management of patients with BMI o50 kg/m2. Obes Surg 2011;21:1650–6. [17] Zhang N, Maffei A, Cerabona T, et al. Reduction in obesity-related comorbidities: is gastric bypass better than sleeve gastrectomy? Surg Endosc 2013;27:1273–80. [18] Keidar A, Hershkop KJ, Marko L, et al. Roux-en-Y gastric bypass vs sleeve gastrectomy for obese patients with type 2 diabetes: a randomised trial. Diabetologia 2013;56:1914–8. [19] Haute Autorité de Santé: Obésité: prise en charge chirurgicale chez l’adulte. Recommandations de bonnes pratiques professionnelles. http://www.has-sante.fr/portail/jcms/c_765529/obesite-prise-en-chargechirurgicale-chez-l-adulte. Accessed May, 2014.
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Original article
Comparison of results after one year between sleeve gastrectomy and gastric bypass in patients with BMI Z 50 kg/m² Jérémie Thereaux, M.D.a, Nicola Corigliano, M.D., Ph.D.a, Christine Poitou, M.D, Ph.D.c, Jean-Michel Oppert, M.D., Ph.D.c, Sebastien Czernichow, M.D., Ph.D.a,b, Jean-Luc Bouillot, M.D.a,* a
Department of General, Digestive and Metabolic Surgery, the Department of Nutrition. Ambroise Paré University Hospital, Versailles Saint-Quentin University, Assistance Publique-Hôpitaux de Paris, Boulogne-Billancourt, France b Centre for Epidemiologic Cohort in Population (INSERM UMS 011), Villejuif, France. c Department of Nutrition, Pitié-Salpêtrière Hospital, Assistance Publique- Hôpitaux de Paris, Pierre-et-Marie-Curie-Paris 6 University, Human Nutrition Research Centre Île-de-France (CRNH IdF), Institute of Cardiometabolism and Nutrition (ICAN), Paris, France Received September 15, 2014; accepted November 23, 2014
Abstract
Background: Although laparoscopic sleeve gastrectomy (LSG) was initially described as the first step of a 2-stage procedure for high-risk patients requiring laparoscopic Roux-en-Y gastric bypass (LRYGB), it is now being used as a single-stage procedure. Experience with laparoscopic bariatric surgery is growing, such that LRYGB is increasingly feasible for patients with body mass index (BMI) Z 50 kg/m². Nevertheless, outcomes for such category of patients following LSG and LRYGB are lacking. Objective: To compare weight loss and changes in obesity related comorbidities at one year following LSG with LRYGB in patients with BMI Z 50 kg/m². Settings: The prospective database of a single surgery university center was queried for clinical and other relevant data. Methods: From January 2004 to January 2013, 74 and 285 patients underwent LSG or LRYGB with a BMI Z 50 kg/m². At one year, rate of follow-up was 92.8%. Success of surgery was defined as % of excess weight loss (%EWL) Z 50% at one year. Logistic regression was used to compute odds ratio (OR) to evaluate the success at one year of surgery. Results: LSG (N ¼ 74) and LGBP (N ¼ 285) groups did not differ for initial BMI (57.2 ⫾ 7.1 versus 56.7 ⫾ 5.5 kg/m²; P ¼ .52), % of female (64.6% versus 73.7%, P ¼ .13) or major adverse postoperative events (5.7% versus 6.7%; P ¼ .85). At one year, the mean percentage of weight loss (%) (22.0 ⫾ 7.6 versus 30.3 ⫾ 7.4; P o .0001) and percentage of excess weight loss (%) (40.2 ⫾ 15.2 versus 55.0 ⫾ 14.6; P o .0001) and rates of remission of diabetes (47.5% versus 70.7%; P ¼ .01) were greater in the LGBP than LSG group. In multivariate analyses (OR), LSG was an independent factor of failure of weight loss (.12; P o .0001) Conclusion: After 1 year of follow-up in patients with a BMI Z 50 kg/m², LRYGB provides better weight loss and resolution in diabetes than LSG with similar postoperative morbidity. Further longterm studies are needed to confirm these results. (Surg Obes Relat Dis 2014;]:00–00.) r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Bariatric surgery; Gastric bypass; Sleeve gastrectomy; Super obesity; Super-super obesity
*
Correspondence: Prof. Jean-Luc Bouillot, Department of General, Digestive and Metabolic Surgery, Ambroise Paré University Hospital, Versailles Saint-Quentin University, Assistance Publique-Hôpitaux de Paris, 9, Avenue Charles de Gaulle, 92100 Boulogne-Billancourt, France. E-mail: [email protected]
With the increasing prevalence of obesity worldwide [1], bariatric surgery has gained in popularity as the treatment of choice for morbid obesity [2]. Laparoscopic gastric bypass
http://dx.doi.org/10.1016/j.soard.2014.11.022 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
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(LRYGB) was first described several decades ago, and is currently viewed as the gold standard surgical treatment, as it provides excellent long-term weight loss and high rates of remission of coexisting conditions [3]. However, LRYGB is a technically challenging procedure, requiring great skill, especially in cases of super obesity (body mass index [BMI] Z 50 kg/m²) and super-super obesity (BMI Z 60 kg/m²). The risk of major postoperative adverse events is higher in such cases than for patients with BMI o50 kg/m2 [4,5]. Laparoscopic Sleeve Gastrectomy (LSG) was first described in the nineties as a new type of gastrectomy for bilio-pancreatic diversion [6]. Regan et al. reported the first LSG as the initial step of a 2-stage LRYGB for high-risk patients [7]. Because of substantial long-term weight loss [8–11] and remission of diabetes [11,12], LSG is increasingly used as a stand-alone procedure. This is partly because the morbidity associated with LSG, although worse than with laparoscopic adjustable gastric banding, is less than that associated with LRYGB [13]. In France, the number of LSG performed has risen by 100% during the years 2011–2013: there are now more than 20,000 LSG per year, such that this bariatric procedure is now the most frequently performed [14]. Several studies have compared outcomes between LRYGB and LSG, but very few were randomized trials [15–18]. Furthermore, no large studies have focused on patients with BMI Z 50 kg/m² although LSG was first used for this type of high-risk patient. We report the first large monocentric study assessing one year weight loss and co-morbidity outcomes in obese patients with BMI Z 50 kg/m² undergoing LSG or LRYGB. Methods Patients Since January 2004, all of our patients undergoing LSG or LRYGB have been prospectively included in an electronic database. All procedures performed due to failure of sleeve gastrectomy, vertical banded gastroplasty or loop gastric bypass (mini gastric bypass) were excluded. We retrospectively reviewed this database and identified 359 patients (74 LSG and 285 LRYGB) with a preoperative BMI Z 50 kg/m² undergoing bariatric surgery from January 2004 to January 2013. At one year, the rate of follow-up was 92.8%. Our prospectively collected database has been registered with the French National Data Protection Agency (Commission Nationale Informatique et Libertés, CNIL, #1689730). Bariatric surgery was offered to patients in accordance with French guidelines for bariatric surgery, which are similar to those of the National Institutes of Health [19]. Each patient was evaluated and followed for at least 6 months in a University Nutrition department before surgery and the indication for bariatric surgery was endorsed by a
multidisciplinary team. Preoperatively, LSG was systematically preferred to LRYGB in cases of expected small bowel adhesion, or of disease either needing long-term medication (such as acquired immunodeficiency syndrome) or needing upper tract endoscopic follow-up. Hypertension was defined as a blood pressure above 140 mm Hg (systolic) and/or 90 mm Hg (diastolic) or use of antihypertensive medication. Diabetes was defined as fasting glycemia above 7 mmol/L on at least 2 different occasions or use of antidiabetic medication. Dyslipidemia was defined as a total cholesterol concentration above 5.7 mmol/L and/or a serum HDL-c (High Density Lipoproteincholesterol) level below 1.0 mmol/L and/or a triglyceride level above 1.7 mmol/L, or use of lipid-lowering medication. All patients had a nocturnal polygraphy and were considered to have obstructive sleep apnea syndrome if the apnea–hypopnea index was 45 events/hour, or if they were already being treated with nocturnal continuous positiveairway pressure. Surgery We have been using a standardized surgical technique for each LRYGB and LSG since 2004. At the beginning of our experience, LRYGB was our gold standard procedure. Then, with progressive published results of SG, progressively, both procedures became our gold standards for morbid obesity treatment. For LRYGB procedure, we have used a standardized surgical technique and postoperative management system since 2004 as described previously [20]. For LSG, mobilization of the greater curve begins 6cm proximal to the pylorus, and continues to the angle of His with importance accorded to the total exposure of the left crural pillar. Gastric resection involves using a 36 French bougie. The staple line is reinforced with a 2-0 absorbable running suture. The absence of gastric leak is verified by introducing methylene blue through a naso-gastric tube at the end of the operation. On day 2, patients routinely undergo standard upper gastrointestinal tract imaging. Patients are allowed to drink if no complication is observed. Patients are usually discharged on day 4 or 5. Outcomes All patients were evaluated 1, 3, 6, and 12 months after surgery. No patients underwent any other bariatric surgery during follow-up. Remission of hypertension, dyslipidemia, and obstructive sleep apnea syndrome were defined as normalization of the corresponding baseline characteristics without any drugs or use of a continuous positive-pressure airway machine. Remission of diabetes was defined as a glycated hemoglobin a1 c (HbA1 c) o6.5% without any treatment for at least one year. Improvements in diabetes, hypertension, dyslipidemia, and obstructive sleep apnea
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syndrome were defined as the improvement of the corresponding baseline characteristics with the same or lower doses of therapy [21]. Weight loss (in kg) was defined as [weight at baseline – weight at follow-up]. Percentage of initial weight loss (%IWL) was calculated as: 100*[weight loss/weight at baseline]. Baseline excess weight (kg) was calculated, according to the theoretical weight (1983 Metropolitan Life Insurance tables), as [weight at baseline – theoretical weight]. The % of excess weight loss (%EWL) was assessed as 100*[weight loss/baseline excess weight]. According to Reinhold criteria [22], success of weight loss was defined as %EWL Z50%. Postoperative morbimortalities were compared using a composite endpoint of major adverse outcomes at 30 days (30-day MAO) previously described [4]. This endpoint includes death, percutaneous or endoscopic interventions or repeat surgery, venous thromboembolism and a failure to be discharged from the hospital at day 30 [4,20].
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Table 1 Demographic characteristics and baseline health status characteristics of the patients at the time of the bariatric procedure* Characteristics
Laparoscopic sleeve gastrectomy (n ¼ 74)
Laparoscopic gastric P bypass (n ¼ 285) value†
Age (years) Female (%) Weight (kg) BMI (kg/m²)‡ Maximal BMI (kg/ m²)‡ Hypertension Diabetes Obstructive sleep apnea syndrome Dyslipidemia Joint pain Ischemic cardiopathy
45.5 ⫾ 13.7 64.9% 157.9 ⫾ 25.1 57.2 ⫾ 7.1 59.4 ⫾ 9.6
40.9 ⫾ 12.2 73.7% 155.4 ⫾ 21.0 56.7 ⫾ 5.5 58.7 ⫾ 7.2
.005 .13 .36 .52 .48
64.9% 55.4% 87.8%
51.9% 34.1% 70.2%
.05 .001 .002
33.8% 60.8% 6.8%
32.6% 74.0% 5.3%
.85 .025 .62
BMI ¼ Body mass index. Plus-minus values are means ⫾ SD or %, as appropriate. † P values are for the comparison between the 2 groups. Values were calculated with student-t tests or Chi-squared tests as appropriate. ‡ Body mass index is the weight in kilograms divided by the square of the height in meters. *
Categorical data are presented as percentages. Continuous variables are presented as means and standard deviations or median (InterQuartile Range) as appropriate. We used χ² or Fisher’s exact tests for categorical variables as appropriate. For numerical variables, we used Student’s t tests or MannWhitney tests as appropriate. Univariate and multivariate analyses were carried out by logistic regression models and 95% confidence intervals (95% CI) were calculated for the risk of failure of weight loss (%EWL o50%) at one year. All factors with a P o .15 in univariate analyses were kept for the multivariate models. All analyses were performed with SAS software version 9.3 (SAS Institute, Cary, NC). The significance threshold was set at P = .05. Results Baseline characteristics A total of 359 patients with BMI Z 50 kg/m² underwent bariatric surgery between January 2004 and January 2013 in our tertiary care unit. They were 74 LSG (group 1) and 285 LRYGB (group 2). Group 1 and group 2 were similar for initial BMI (57.2 ⫾ 7.1 versus 56.7 ⫾ 5.5 kg/m²; P = .52) and rate of female (64.6% versus 73.7%, P = .13). Patients in group 1 were older (45.5 ⫾ 13.7 versus 40.9 ⫾ 12.2; P = .005) and had more diabetes (55.4% versus 34.1%; P = .001) (Table 1). Surgery and 30-day morbid-mortality
respectively. One (1.4%) gastric fistula after LSG was reported and was managed endoscopically. The median length of hospital stay (days) was longer for group 2 (5.0 versus 4.5; P ¼ .001). One year outcomes At one year, rate of follow-up was 92.8%. Fig. 1 shows the percentage weight change during the one-year follow-up for the 2 groups. At one year, patients undergoing LRYGB showed greater %weight loss (30.3 ⫾ 7.4 versus 22.0 ⫾ 7.6; P o .0001) and greater %EWL (40.2 ⫾ 15.2 versus 55.0 ⫾ 14.6; P o .0001). BMI (kg/m²) at one year was significantly lower for the LRYGB group (39.8 ⫾ 6.5 versus 44.4 ⫾ 7.4; P o .0001). Rates of remission of coexisting conditions were greater in group 2 (Table 2). 0 -5 -10
Weight Change (%)
Statistical Analysis
-15
Sleeve gastrectomy Gastric bypass
-20 -25 -30 -35
The operative time (in minutes) was longer for LRYGB than for LSG (213 ⫾ 39 versus 65 ⫾ 13; P o .0001) with similar rates of conversion (1.0% versus 1.4%; P ¼ .99), of 30 days major adverse outcomes (6.7% versus 5.7%; P ¼ .85) and of mortality (1.0% versus 0%; P ¼ .99),
-40 0
1 mth
3 mths
6 mths
12 mths
Months of Follow-up
Fig. 1. Weight Change over one Year Follow-up according to Procedure. Bars denote Standart-deviation
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Table 2 Weight status characteristics, weight loss, resolution and improvement of coexisting conditions of the patients one year after procedure* Characteristics
Laparoscopic sleeve gastrectomy (n ¼ 70/74)
Laparoscopic gastric bypass (n ¼ 263/285)
P value†
BMI (kg/m²)‡ % Weight loss (%) % Excess weight loss (%) Patients with %excess weight lossZ50 Hypertension§ Diabetes§ Obstructive sleep apnea§ Dyslipidemia§ Joint pain§
44.4 ⫾ 7.4 22.0 ⫾ 7.6 40.2 ⫾ 15.2 21.4% 13.3% / 82.2% 47.5% / 87.5% 33.3% / 80.0% 24.0% / 56.0% 29.3% / 70.7%
39.8 ⫾ 6.5 30.3 ⫾ 7.4 55.0 ⫾ 14.6 63.5% 47.2% / 83.1% 70.7% / 95.6% 61.8% / 86.0% 69.4% / 89.4% 49.5% / 82.0%
o .0001 o .0001 o .0001 o .0001 o .0001 / .90 .01 / .09 o .0001 / .26 o .0001 / o .0001 .02 / .10
BMI ¼ Body mass index. Plus-minus values are means ⫾ SD or %, as appropriate. † P values are for the comparison between the 2 groups. Values were calculated with student-t tests or Chi-squared tests as appropriate. ‡ Body-mass index is the weight in kilograms divided by the square of the height in meters. § Rates of Resolution / Improvement. *
Preoperatively, 29.3% (LSG) and 33.0% (LRYGB) of diabetic patients had insulin. At one year, respectively, 50.0% and 31.2% were still under insulin treatment (P ¼ .76) In multivariate analyses, regardless of age, sex and diabetes status, LSG was found as an independent negative predictive factor (OR ¼ .12) for success of weight loss (95% CI .06-0.25; P o .0001). Table 3 Discussion We provide, here, the first large study assessing one year outcomes between LSG and LRYGB in patients with preoperative BMI Z50 kg/m². Our results clearly indicate that LRYGB provides better weight loss and resolution of coexisting conditions with an insignificant trend for higher
postoperative morbi-mortality. Several studies have compared outcomes between LRYGB and LSG, and these studies included patients with lower BMI than those in our study. Most show similar results for the 2 procedures. Of the 4 published randomized studies, only 2 show similar weight loss at one year [15,18], Kehagias et al. [16] reported a greater weight loss at one year after LSG, but similar %EWL at 3 years and Zhang et al. provide better weight loss for LRYGB group [17]. Two case control studies have been reported, and describe similar weight loss. The %EWL (%) at 3 years reported by Boza et al. for patients with a mean baseline BMI of 38 kg/m² were 86.8% ⫾ 27.1 after LSG versus 93.1% ⫾ 25.0 after LRYGB (P ¼ .082) [23,24]. In the report by Chouillard et al., the maximal mean BMI is indicated, but not baseline BMI [23]. Other relevant studies are comparative
Table 3 Univariate and multivariate analyses of success at one year %EWL Z 50%) after bariatric surgery as a function of patient (N ¼ 333/359) characteristics and of bariatric procedure Univariate analyses OR (95% CI) Female Age (yr) Hypertension Diabetes Dyslipidemia Obstructive sleep apnea syndrome Joint pain Surgical experience categories (distribution by quartile) 1st quartile 2nd quartile 3rd quartile 4th quartile BMI (kg/m²)* Sleeve gastrectomy
Multivariate analyses P value
OR (95% CI)
P value
.92 (.521.62) .99 (.971.01)
.76 .39
.85 (.501.45)
.55
1.20 .99 .91 .69 .83 1.21 1.25
(.731.97) (.971.005) (.591.41) (.451.08) (.531.30) (.751.96) (.782.01)
.47 .17 .66 .10 .43 .44 .35
1.00 1.54 1.53 1.60 .88 .16
() (0.842.8) (0.832.7) (0.882.9) (0.840.92) (0.090.30)
.16 .16 .16 o .0001 o .0001
0.86 (0.810.90) 0.12 (0.060.25)
BMI ¼ Body mass index; OR ¼ odds ratio; CI ¼ Confidence interval; %EWL ¼ Percentage of excess weight loss. * Body-mass index is the weight in kilograms divided by the square of the height in meters.
o .0001 o .0001
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retrospective studies reporting similar results for LRYGB and LSG with various follow-ups [25–27]. Furthermore, most of studies included patients with a mean BMI o40 kg/m² [17,24], or with a BMI at baseline o45 kg/m² [15,23,26,27], and some excluded patients with a BMI 450 kg/m² [16,17]. Hence, we think that because of expected difficulties to perform LRYGB in patients with BMI Z 50 kg/m², randomized studies would be difficult to perform in such category of patients. Our mean %EWL is under 50% for the LSG group and it needs to be compared to other previous studies. Hence, at one year, %EWL in patients with BMI Z50 kg/m² is slightly higher than in our study, with outcomes varying from 55.5% [28] to 43.9% [29]. Furthermore, only Zerrweck et al. had compared LSG and LRYGB for patients with BMI Z 50 kg/m² [29]. In accordance with our results, they provided better outcomes for LRYGB at one year but this study suffer from limitation since it has small samples [29]. Although LSG was described (as the first step of gastric bypass or duodenal switch procedures) twenty years ago, there have been few non-comparative studies assessing long-term outcomes. After 6 years, the %EWL varies from 53.3% [8] to 68% [10] for cases with low baseline BMI. For super-obese patients, Eid et al. reported a %EWL of 46% at 8 years, which is compatible with our early results, but 40.5% of the patients required revisional surgery for weight loss failure, suggesting disappointing results of LSG for many super-obese patients [11]. LSG was initially described as the first step of a 2-stage procedure for high-risk patients requiring LRYGB [7], but it is increasingly used worldwide as a stand-alone treatment. The LSG procedure offers many advantages compared to LRYGB. It is easier to perform, especially for super-obese patients, and is associated with fewer short- and long-term complications and with a lower incidence of malabsorption, denutrition and vitamin deficiency. We found an insignificant trend for higher morbi-mortality in patients undergoing LRYGB. These results are in accordance with previous studies. Hence, LSG is considered to be an intermediate-risk bariatric procedure, positioned between adjustable gastric banding and LRYGB, with a 30-day mortality of .11% [13]. The choice of the best procedure for an individual patient seeking bariatric surgery is still a matter for debate. For patients with BMI o50 kg/m², results after LSG and LRYGB are similar, and the literature indicates that LSG can be used as an alternative to LRYGB for morbid obesity with BMI o50 kg/m² [15,16,18,23–27]. For patients with BMI Z 50 kg/m², bilio-pancreatic diversion with duodenal switch (BPD-DS) in one or 2 steps has been shown to be more effective than LRYGB [30]. However, several bariatric teams have expressed concerns about the risks associated with this procedure. Malnutrition, protein denutrition, intractable diarrhea, vitamin A and D deficiencies,
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and higher risk of reversal surgery have been documented [31,32]. Our study has some limitations. First, baseline characteristics are different for age, diabetes and obstructive sleep apnea. These characteristics are known to be leading factors of postoperative morbi-mortality [4,5] showing that our LSG group is more prone to have complications. But this hypothesis is not confirmed in our study, confirming that both LSG and LRYGB are safe procedure in such category of high risk patients in an expert centre. Furthermore, age and diabetes status could negatively influence weight loss [33]. Our multivariate analyses clearly indicate that LSG is an independent factor for failure of weight loss regardless of age, sex and diabetes status, at one year. However, multivariate analyses cannot completely reduce this potential bias. Furthermore, because we began our surgical experience with LRYGB, we assessed relation between our learning curves and outcomes. However, we did not find any relation between our learning curve and weight loss at one year. Another shortcoming is the short-term follow-up (only one year), and long-term prospective studies are required to confirm our results. Conclusions This study indicates that LRYGB allows better weight loss at one year than LSG in patients with BMI Z 50 kg/m² with higher resolution of diabetes. LRYGB should be considered as the first choice for patients with BMI Z 50 kg/m² or when it is the choice of the patient. However, our data show that LSG is a valuable alternative, and allows substantial weight loss, providing the opportunity for a subsequent, second-stage procedure, especially in the highest risk patients when perioperative difficulties are expected. Further studies with more patients and longer-term followup are needed to confirm our results. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] Shields M, Carroll MD, Ogden CL. Adult obesity prevalence in Canada and the United States. NCHS Data Brief 2011;56:1–8. [2] Sjostrom L, Peltonen M, Jacobson P, et al. Bariatric surgery and longterm cardiovascular events. JAMA 2012;307:56–65. [3] Adams TD, Davidson LE, Litwin SE, et al. Health benefits of gastric bypass surgery after 6 years. JAMA 2012;308:1122–31. [4] Flum DR, Belle SH, King WC, et al. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med 2009;361: 445–54. [5] Benotti P, Wood GC, Winegar DA, et al. Risk factors associated with mortality after Roux-en-Y gastric bypass surgery. Ann Surg 2014; 259:123–30.
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[6] Lagace M, Marceau P, Marceau S, et al. Biliopancreatic Diversion with a New Type of Gastrectomy: Some Previous Conclusions Revisited. Obes Surg 1995;5:411–8. [7] Regan JP, Inabnet WB, Gagner M, Pomp A. Early experience with two-stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient. Obes Surg 2003;13:861–4. [8] Himpens J, Dobbeleir J, Peeters G. Long-term results of laparoscopic sleeve gastrectomy for obesity. Ann Surg 2010;252:319–24. [9] Rawlins L, Rawlins MP, Brown CC, Schumacher DL. Sleeve gastrectomy: 5-year outcomes of a single institution. Surg Obes Relat Dis 2013;9:21–5. [10] Sarela AI, Dexter SP, OʼKane M, Menon A, McMahon MJ. Longterm follow-up after laparoscopic sleeve gastrectomy: 8–9-year results. Surg Obes Relat Dis 2012;8:679–84. [11] Eid GM, Brethauer S, Mattar SG, Titchner RL, Gourash W, Schauer PR. Laparoscopic sleeve gastrectomy for super obese patients: fortyeight percent excess weight loss after 6 to 8 years with 93% followup. Ann Surg 2012;256:262–5. [12] Dorman RB, Serrot FJ, Miller CJ, et al. Case-matched outcomes in bariatric surgery for treatment of type 2 diabetes in the morbidly obese patient. Ann Surg 2012;255:287–93. [13] Hutter MM, Schirmer BD, Jones DB, et al. First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann Surg 2011;254: 410–20; discussion 420–2. [14] Agence Technique de l’Information sur l’Hospitalisation (ATIH). [Page on the internet]. French medicare database source. Available from: http://www.atih.sante.fr/. Accessed May, 2014. [15] Peterli R, Borbely Y, Kern B, et al. Early Results of the Swiss Multicentre Bypass Or Sleeve Study (SM-BOSS): A Prospective Randomized Trial Comparing Laparoscopic Sleeve Gastrectomy and Roux-en-Y Gastric Bypass. Ann Surg 2013;258:690–4; discussion 695. [16] Kehagias I, Karamanakos SN, Argentou M, Kalfarentzos F. Randomized clinical trial of laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy for the management of patients with BMI o50 kg/m2. Obes Surg 2011;21:1650–6. [17] Zhang N, Maffei A, Cerabona T, et al. Reduction in obesity-related comorbidities: is gastric bypass better than sleeve gastrectomy? Surg Endosc 2013;27:1273–80. [18] Keidar A, Hershkop KJ, Marko L, et al. Roux-en-Y gastric bypass vs sleeve gastrectomy for obese patients with type 2 diabetes: a randomised trial. Diabetologia 2013;56:1914–8. [19] Haute Autorité de Santé: Obésité: prise en charge chirurgicale chez l’adulte. Recommandations de bonnes pratiques professionnelles. http://www.has-sante.fr/portail/jcms/c_765529/obesite-prise-en-chargechirurgicale-chez-l-adulte. Accessed May, 2014.
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