Laparoscopic sleeve gastrectomy: More than a restrictive bariatric surgery procedure?

Table 1 Randomized trials of bariatric surgery studies including laparoscopic sleeve gastrectomy

Ref.	Country	Follow-up(mo)	Intervention groups	Preoperative BMI (kg/m2)	Weight loss	T2DM	T2DM remission	T2DM remision criteria
Langer et al[53]	Austria	6	SG (10)	48.3	61.4%EWL	10%	NR
			LAGB (10)	46.7	28.7%EWL	30%
Himpens et al[54]	Belgium	36	SG (40)	39.0	66%EWL	NR
			LAGB (40)	37.0	48%EWL
Lee et al[55]	Taiwan	12	SG (30)	30.3	76.3%EWL	100%	93%	FG < 126 mg/dL and A1c < 6.5% without hypoglycemic therapy
			RYGB (30)		94.4%EWL		47%
Karamanakos et al[56]	Greece	12	SG (16)	45.1	69.7%EWL
			RYG (16)	46.6	60.5%EWL
Kehagias et al[57]	Greece	36	SG (30)	44.9	68.5%EWL	16.7%	80%	FG < 126 mg/dL without hypoglycemic therapy
			RYGB (30)	45.8	62.1%EWL	16.7%	80%
Peterli et al[58]	Switzerland	12	SG (11)	44.7	65.6%EWL	0%
			RYGB (12)	46.7	77.0%EWL	0%
Schauer et al[59]	USA	36	SG (50)	36.2	81%EWL	100%	26.5%	A1c < 6.0% without hypoglycemic therapy
			RYGB (50)	37.0	88%EWL		42%
			Medical therapy (50)	36.8	13%EWL
Schauer et al[60]	USA	12	SG (50)	36.2	21.1%TWL	100%	29%	A1c < 6.0% without hypoglycemic therapy
			RYGB (50)	37.0	24.5%TWL		46%
			Medical therapy (50)	36.8	4.2%TWL		0%
Paluszkiewicz et al[61]	Poland	12	SG (36)	46.1	67.6%EWL	27.8%	40%	FG < 100 mg/dL and A1c < 6.0% without hypoglycemic therapy
			RYGB (36)	48.6	64.2%EWL	38.9%	64.3%
Ramón et al[28]	Spain	12	SG (8)	43.5	NR	25.0%	100%	NR
			RYGB (7)	44.2		28.6%	100%
Vix et al[62]	USA	12	SG (45)	45.5	82.9%EWL	8.9%	NR
			RYGB (45)	47.0	80.3%EWL	8.9%

BMI: Body mass index; T2DM: Type 2 diabetes mellitus; EWL: Excess weight loss; LABG: Laparoscopic adjustable gastric banding; FG: Fassting glucose; SG: Sleeve gastrectomy; RYGB: Roux-en-Y gastric bypass; %EWL: Percentage excess weight loss; %TWL: Percentage total weight loss; NR: Not reported; LAGB: Laparoscopic adjustable gastric banding.

Table 2 Complication and mortality rates of the different bariatric surgery techniques according to the American College of Surgeons - Bariatric Surgery Center Network

	LSG	LAGB	LRYGB
30-d mortality	0.11	0.05	0.14
1-yr mortality	0.21	0.08	0.34
30-d morbidity	5.61	1.441	5.91
30-d readmission	5.40	1.711	6.47
30-d reoperation	2.97	0.921	5.021

¹Statistically-significant differences compared with LSG. LSG: Laparoscopic sleeve gastrectomy; LAGB: Laparoscopic adjustable gastric banding; LRYGB: Laparoscopic Roux-Y-gastric bypass.

Table 3 Sleeve gastrectomy may be preferable to other procedures in the following situations

Extreme obesity (BMI > 50 kg/m2): first-step procedure

ASA IV morbidly-obese patient

Absence of hypercholesterolemia

To avoid drug malabsorption

Extreme ages

BMI of 35-40 kg/m2 with comorbidity

Class I obesity

Crohn’s disease

Prevent potential consequences of hypoglycemia in specific occupations

BMI: Body mass index.

Table 4 Clinical outcomes of sleeve gastrectomy and Roux-en-Y gastric bypass

	SG	RYGB
Weight loss	No differences with RYGB	No differences with SG
	67.1 %EWL at 12 mo[63]	68.9% EWL at 12 mo[63]
Type 2 diabetes mellitus remission	Early improvement before significant weight loss	Slightly more effective than SG. HR 1.49, 95%CI: 1.04-2.12 for type 2 diabetes mellitus remission in favor of RYGB[63]
	More effective than other restrictive techniques
Hypertension remission	Greater efficacy than other restrictive techniques	More effective than SG
	69% (55-82) Hypertension remission for SG and 45% (27-56) for LAGB[72]	HR of 1.47, 95%CI: 1.115-1.86 for Hypertension remission in favor of RYGB[63]
Dyslipidemia remission	Same as other malabsorptive techniques, no hypercholesterolemia improvement	Clearly more effective than SG. HR = 2.41, 95%CI: 1.87-3.11 for Dyslipidemia remission in favor of RYGB[63]
Mortality	No differences (detailed in table 2)	No differences
Surgical complications	Less surgical time, lowest 30-d morbidity, 30-d readmission and 30-d reoperation. (detailed in table 2)	Increased risk of nutritional deficiencies
	Characteristic complications: staple line leaks (2.7%[86]; < 1% in expert hands[87])	Characteristic complications: severe hypoglycemia
Long-term results	Limited evidence	Effective and safe in the long term
Other advantages	Possibility of conversion to a malabsorptive surgery

SG: Sleeve gastrectomy; RYGB: Roux-en-Y gastric bypass; %EWL: Percentage excess weight loss; HR: Hazard ratio; LABG: Laparoscopic adjustable gastric banding.