Changes in Obesity-Related Diseases and Biochemical Variables After Laparoscopic Sleeve Gastrectomy

A Two-Year Follow-up Study

Villy Våge; Vetle Aaberge Sande; Gunnar Mellgren; Camilla Laukeland; Jan Behme; John Roger Andersen

Disclosures

BMC Surg. 2014;14(8) 

In This Article

Methods

After having obtained written informed consent from the patients, data was prospectively collected and stored in our database from the first LSG in May 2007 when LSG was introduced as a part of our standard bariatric program. The database is part of our continuous surveillance-program and approved by the Norwegian Data Inspectorate. This present study is a prospective cohort study with data extracted from the database. By December 2011 we had 117 patients eligible for a two year follow-up. Indications for LSG were either a BMI ≥ 40 kg/m2 or a BMI ≥ 35 kg/m2 with obesity-related diseases. Contraindications for operation were alcohol or drug abuse and active psychosis.

Preoperative evaluation and care included a one day seminar with information about morbid obesity, bariatric surgery and its risks, and estimated results as well as projected possibilities about life changes after surgery. This was followed by an individual consultation with the bariatric surgeon and other health-personnel if needed. Preoperative advice included smoking cessation, increased physical activity and weight loss.

On the evening before the operation all patients received low molecular weight heparin subcutaneously (enoxaparin), 40 mg if < 160 kg or 60 mg if ≥ 160 kg, and an H2 blocker (cimetidine 300 mg) orally. Intravenous antibiotic prophylaxis (400 mg doxycycline, 1.5 g metronidazole) was started just prior to the operation. The operation was performed through six ports. Pneumoperitoneum was established through the upper part of the left rectal sheet using a 10 mm port containing the camera and the CO2-insufflator. A 15 mm port was introduced at the same level through the right rectal sheet. Four 5 mm ports were used: One at the right subcostal area, one just below the xiphoid process and two towards the left subcostal area. All ports were reusable (Karl Storz™) except for the 15 mm port which was non-reusable (Ethicon™).

The greater curvature was freed from the pylorus to the cardia, dividing all vessels by Ligasure (Covidien™). To ensure a good overview of the left crus and the gastro esophageal junction the periesophageal fat-pad was generally freed from both the diaphragm and the cardia. The stomach was divided along a 32 Fr bougie by the Tri-Stapler (Covidien™) from 1–2 cm proximal to the pylorus to the cardia. Over-sewing of the staple line was performed for visible bleeding. Attention was paid to avoid twisting or otherwise disrupting the gastric tube. The resected part of the stomach was removed without a bag through the incision for the 15 mm port. The abdominal fascia at this point was closed by two Polydioxanon (PDS) number 1 sutures. All skin-incisions were closed by intracutaneous reabsorbable sutures. Patients were allowed to drink freely from the first postoperative day, and discharged when tolerating a liquid diet. The enoxaparin was continued for ten days after discharge.

Postoperative advice included a low carbohydrate - high protein diet, intake of one multivitamin tablet daily, high frequency of water intake and physical activity. The first 61 patients were also routinely recommended to take Calcigran Forte (NycoMed Pharma™) containing one gram of calcium carbonate and 800IE 25-hydroxyvitamin D (25(OH)D) daily. Controls and data collection took place at the outpatient clinic 3, 12 and 24 months postoperatively. In addition, the patients were advised to see their general practitioner at 6 and 18 months. Pregnancy was strongly discouraged during the first 12 months after the operation.

Surgical complications were defined as complications occurring within 90 days after the surgical procedure. Obesity-related diseases were defined as diseases that were under medical care, and considered resolved when the patient no longer needed medical care for the actual disease (dichotomous variables). Diseases evaluated were type 2 diabetes mellitus (T2DM), hypertension, hyperlipidemia, sleep apnea, obstructive lung disease, musculoskeletal pain, anxiety, depression and gastroesophageal reflux. In addition, obesity-related problems as snoring, urinary leakage, amenorrhea and infertility were included independently of whether the patient received treatment or not. Infertility was defined as attempting to get pregnant over a period of two years without success.

Biochemical variables were selected according to our empirical experience, and were all analyzed by the Department of Clinical Biochemistry at our hospital except for the vitamin D-analyses (Hormone Laboratory, Haukeland University Hospital). The biochemical variables were converted into dichotomous variables, as either within the reference range or outside the reference range.

Statistical Package for the Social Sciences (SPSS) version 19.0 was used to perform the statistical analysis. Paired t- test was used in comparing paired means for change in BMI, and the McNemar's test was used for categorical variables. Statistical significance was set conventionally at p < 0.05.

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