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Changing tack

ASMBS update sleeve gastrectomy position statement

"Substantial changes to published literature" prompt shift of opinion on medical association
Sleeve gastrectomy associated with durable weight loss, improved comorbidities, long-term satisfaction, and improved QoL

The American Society for Metabolic and Bariatric Surgery (ASMBS) has published an updated position statement on the use of sleeve gastrectomy (SG).

The position statement update was published as the Clinical Issues Committee and Executive Council have determined that since the 2009 position statement on SG was issued, there have been substantial changes to the published literature regarding the procedure and that the number and quality of the publications evaluating SG warrant publication of an updated statement. 

Following a review of published literature, the ASMBS concluded that there is now substantial comparative and long-term data demonstrating durable weight loss, improved medical comorbidities, long-term patient satisfaction, and improved quality of life after SG.

The ASMBS therefore recognizes SG as an acceptable option as a primary bariatric procedure and as a first stage procedure in high risk patients as part of a planned staged approach. The position statement states that based on the current published literature, SG has a risk/benefit profile that lies between the laparoscopic adjustable gastric band and the laparoscopic Roux-en-Y gastric bypass. 

The recommendations of the 2009 position statement was based on a systematic literature review and reported overall mean percent excess weight loss (%EWL) after SG of 55% (average follow-up less than three years) and complication rates in large single centre series (n>100) ranged up to 15%. The reported leak, bleeding, and stricture rates in the systematic review (which included high risk patients) were 2.2%, 1.2%, and 0.63%, respectively, and the post-operative 30-day mortality rate was 0.19% in the published literature. 

An updated search of the literature revealed 69 studies published since the last position statement, which provides relevant outcome data to support updated recommendations. This new literature includes several randomised controlled trials that generally show equivalence or superiority of the laparoscopic SG to currently accepted procedures (Roux-en-Y gastric bypass, RYGB, and laparoscopic adjustable gastric banding, LAGB) with short and medium-term follow-up periods. 

In addition to the randomised trials, there are several matched cohort, prospective and case control studies that demonstrate weight loss outcomes, diabetes remission rates, improvements in inflammatory markers and cardiovascular risk, and improvements in a variety of obesity-related comorbidities after SG that are equivalent to or exceed RYGB and LAGB procedures.

Remission rates of type 2 diabetes after SG are typically reported between 60% and 80% depending on the patient population and length of follow-up. A systematic review of diabetes remission rates after SG included 27 studies and 673 patients. At a mean follow-up of 13 months, diabetes had resolved in 66% of patients and improved in 27%. 

There was a mean decrease in blood glucose of -88 mg/dL and a mean decrease in HbA1c of -1.7%. In addition to improvements in many clinical parameters, several studies have also demonstrated significant improvements in quality of life after SG.

While there are several case control and retrospective series that have demonstrated superiority of RYGB over SG with regards to weight loss, comorbidity reduction, or diabetes remission, 39 randomised studies have demonstrated superiority or equality to RYGB and superiority of LSG over LAGB in terms of weight loss (EWL 66% vs 48%), comorbidity reduction, or diabetes remission.

A review of published complications after SG demonstrates major complication rates that are equal to or less than those reported in the 2009 statement and no new safety concerns have emerged. Staple line leaks and bleeding after SG continue to be the most serious complications and occur in 1-3% of patients in large published series.

The development of gastroesophageal reflux (GERD) after sleeve gastrectomy is reported in several publications, but a recent systematic review evaluating the effect of SG on GERD reported inconsistent outcomes. The statement confirms that further studies of the long-term effects of SG on GERD symptoms and the role of SG for patients with hiatal hernia are necessary in order to draw more definitive conclusions.

There are also studies that report SG results in fewer nutritional deficiencies but the statement states that there is insufficient evidence to draw any definitive conclusions and more evidence is needed regarding the effect of SG on long-term vitamin, mineral, and nutritional deficiencies.

Several large registries have also reported weight loss and complication data after SG. The American College of Surgeons Bariatric Surgery Center Network longitudinal database (n=28,616) recently reported 30-day, six-month, and one-year outcomes of LSG, LAGB, and RYGB including morbidity and mortality, readmissions, and reoperations as well as reduction in body mass index (BMI) and weight-related comorbidities.

This study reported that the LSG has higher risk-adjusted morbidity, readmission and reoperation /intervention rates compared to the LAGB, but lower reoperation/intervention rates compared to the LRYGB and open RYGB. There were no differences in mortality between groups. However, LSG patients had a higher BMI and higher risk profile than LAGB patients. Reduction in BMI and most of the weight related comorbidities after the LSG also lies between those of the LAGB and the RYGB. 

The Michigan Bariatric Surgery Collaborative (MBSC) evaluated 30 day complication rates for 62 bariatric surgeons in 25 hospitals and reported the risk of serious complication after LSG to be 2.2% compared to 0.9% for LAGB and 3.6% for RYGB. Another publication from MBSC used a registry of 25,469 bariatric patients to develop a risk prediction model for serious complications after bariatric surgery and found the risk of SG to fall between LAGB and RYGB. 

A large prospective national registry in Spain reported outcomes of 540 SG patients from 17 centres. Morbidity rate was 5.2% and mortality rate 0.36%. Complications were more common in super obese patients, males, and patients >55 years old. Mean percent excess BMI loss (EBL) was 72.4 +/- 31% at 24 months and Bougie caliber was an inverse predictive factor of %EBL at 12 and 24 months. In this patient population, diabetes remitted in 81% of the patients and hypertension improved in 63.2%. A second-stage surgery was performed in 18 patients (3.2%).

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