Benefits of Sleeve Gastrectomy Wane at 5 Years

Miriam E Tucker

August 06, 2015

The weight loss and diabetes remission achieved with laparoscopic sleeve gastrectomy (LSG) appear to wane by 5 years, a new cohort study suggests.

Sleeve gastrectomy has been growing in popularity as a bariatric technique, but data on its long-term effect on obesity-related comorbidities are scarce, with most findings reported so far limited to 2-year outcomes, explain Inbal Golomb, from Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel, and colleagues, in their paper published online August 5, 2015 in JAMA Surgery.

In their retrospective analysis of a prospective cohort study of 443 patients who underwent bariatric surgery at the university hospital between 2006 and 2013, the percentage of excess body weight lost had dropped from 77% in 241 patients with available data at 1 year to 56% among 39 at 5 years.

And of the 82 diagnosed with type 2 diabetes prior to surgery, the proportions achieving complete remission — defined as a fasting glucose level of less than 100 mg/dL and HbA1c below 6% — were 51% of 71 with available data at 1 year and 20% of 10 at the 5-year mark. Total cholesterol didn't change significantly at all, and decreases in LDL cholesterol were significant at 1 year but not at 5 years.

"Undergoing LSG induced a reduction in [percent of excess weight loss] and a major improvement in obesity-related comorbidities in the short term," Mr Golomb and colleagues note. But the longer follow-up data "revealed weight regain and a decrease in remission rates for [type 2 diabetes] and other obesity-related comorbidities. These data should be taken into consideration in the decision-making process for the most appropriate operation for a given obese patient," they conclude.

In an accompanying editorial, Anita P Courcoulas, MD, of the University of Pittsburgh department of surgery, Pennsylvania, observes that there are "critical gaps in knowledge in this area," resulting from the "paucity of comparative trials, incomplete follow-up, a lack of standardized definitions for changes in health status (eg, diabetes mellitus remission), and the tendency to a rush to judgment in favor of surgical-treatment options."

Gastric Bypass Appears Better for Diabetes and Heavier Patients

Asked to comment, Philip Schauer, MD, director of the Bariatric & Metabolic Institute at Cleveland Clinic, Ohio, told Medscape Medical News, "This is a 5-year study that adds to our understanding of the durability of the sleeve gastrectomy. These authors show, like the others do, that some of that weight loss and improvement in comorbidities does retard over time."

However, added Dr Schauer, who was one of the first surgeons to perform LSG over a decade ago, "Even at 5 years, there is still significant weight loss, and even though the remission rate of diabetes drops from 50% to 20%, that's still remarkable. That's not achievable with medical treatment."

He noted that LSG typically works better — and with more durable results — for patients with a shorter duration of diabetes and for those with lower levels of obesity (ie, 50–100 pounds overweight, as opposed >100 pounds). And it has some advantages over gastric bypass: it's a shorter procedure, with less short-term comorbidity.

But, he said, there is growing evidence from his data and those of others that "when we look at longer-term and more important outcomes, we're now seeing pretty consistent reporting in favor of the gastric bypass over the sleeve, at least for diabetes and the higher-weight people, too."

Large Randomized Trial Comparing Surgical Procedures Impractical

In her editorial, Dr Courcoulas says that cost and feasibility issues will make a large randomized comparative trial among surgical procedures relatively impractical.

Therefore, she said, data on long-term outcomes will need to come from sources such as large electronic databases and "also by thoughtful inference that will be made through pooled analyses of data like that from Golomb and colleagues and from many other disparate randomized and nonrandomized studies of bariatric surgery.

"It will take time, patience, and a willingness to avoid a rush to judgment," she adds.

Dr Schauer said, "I agree with her; we have to dampen our enthusiasm a little bit until we see the longer-term results."

In the meantime, Dr Courcoulas writes, "clinicians and prospective patients will need to discuss and weigh the evidence in a dynamic exchange driven not always by final conclusions but by the most current available data."

The study authors have no relevant financial relationships. Dr Courcoulas reports receiving grants from Nutrisystem, Ethicon, and Covidien and serving as a project consultant for Ethicon and Apollo Endosurgery. D. Schauer has received grants from Ethicon, Covidien, Novo Nordisk, the National Institutes of Health, and a travel grant from Nestle and is on advisory board for Surgiquest.

JAMA Surg.Published online August 5, 2015. Abstract, Editorial

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