Major Finding: Weight loss at 2 years in patients undergoing sleeve gastrectomy was similar to that achieved by gastric bypass surgery.
Data Source: A review of 446 consecutive cases.
Disclosures: Dr. Topart disclosed that he has received travel support and research grants from Ethicon Endo-Surgery and W.L. Gore, and research grants from Santinov.
NATIONAL HARBOR, MD. — Although sleeve gastrectomy has a higher rate of complications compared with other bariatric procedures, 2-year weight loss was similar to that seen after gastric bypass in a study of 446 patients.
“Gastric staple line leaks are the main concern in this procedure,” Dr. Philippe Topart said at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons. “Twenty-three of the major complications were gastric leaks.”
But at 2 years, his patients had lost a mean of 55% of their excess body weight, said Dr. Topart of the Clinique D'Anjou, Angers, France.
His series included procedures in 14 facilities in France and Switzerland. The patients' mean age was 43 years; 25% had failed a prior gastric banding. Most (83%) were female. Body mass index was more than 50 kg/m
Most patients (65%) had at least one comorbid condition, including metabolic syndrome (52%) hypertension (38%), dyslipidemia (24%), diabetes (23%), and nonalcoholic steatohepatitis (1%).
The majority of cases (99%) were performed laparoscopically. Mean length of hospital stay was 7 days. There were no postoperative deaths. The overall complication rate of 17% was attributable to dysphagia in 23 patents, postoperative bleeding in 1, and obstruction in 1, along with minor complications in 23 patients.
Gastric leaks occurred in 23 patients (5%). The leak rate was reduced in patients with staple line reinforcement (0% vs. 4.5% in nonreinforced staple lines) and in patients with oversewing (35% vs. 6%), Dr. Topart said.
“However, this was not a significant difference and the only prognostic factor was the operation duration,” he said.
Patients with a lower BMI (35–49 kg/m
Males and patients with multiple comorbidities lost significantly less weight than did women or patients with no comorbidities. Prior gastric banding did not significantly affect weight loss.
“Sleeve gastrectomy appears to be a reasonable option as a primary bariatric surgical treatment, although the complication rate—especially gastric leaks—is far from being negligible,” Dr. Topart said in an interview.
Since 2008, 150 sleeve gastrectomies have been performed in his practice, with a complication rate slightly higher than that seen in the 400 Roux-en-Y gastric bypasses performed.
“However, as reported in the multicenter retrospective study, there were no postoperative deaths, while with our gastric bypass we had a 0.25% 90-day death rate.”
Evidence in favor of sleeve gastrectomy has mounted to the point that two major U.S. insurance companies—Aetna Inc. and UnitedHealthcare—announced that they will cover the procedure. Aetna began coverage in April. UnitedHealthcare began coverage in October 2009 when sleeve gastrectomy was was done as part of other related procedures, but now covers it as a stand-alone procedure, according to spokeswoman Cheryl Randolph.
The major concern is still the long-term weight-loss outcomes, Dr. Topart said. But a 2009 position statement by the American Society for Metabolic and Bariatric Surgery (ASMBS) appeared to be the tipping point for Aetna to decide to cover the surgery. “ASMBS determined that sleeve gastrectomy is an 'approved bariatric surgical procedure,' despite finding only 'limited' intermediate-term data and a lack of long-term data on the effectiveness of the procedure,” the Aetna policy states.
ASMBS accepted sleeve gastrectomy as an approved procedure because of its potential value for high-risk patients, primarily those with an average BMI of 60 kg/m
“Although the published intermediate-term 3- to 5-year follow-up data after sleeve gastrectomy are increasing, the data remain limited. The ASMBS has accepted sleeve gastrectomy as an approved bariatric surgical procedure primarily because of its potential value as a first-stage operation for high-risk patients, with the full realization that successful long-term weight reduction in an individual patient after the procedure would obviate the need for a second-stage procedure,” the statement said.
It is unclear how often sleeve gastrectomy patients will require a different bariatric procedure.
The ASMBS paper noted that long-term data “might or might not ultimately confirm that the procedure should remain in the category of a staged treatment intervention.” Sleeve gastrectomy can cause long-term nutritional deficits because the resected stomach absorbs some vitamins and nutrients less readily than it did before surgery, the paper stated.