Short Term Outcomes of Laparoscopic Sleeve Gastrectomy for Obesity in Pakistan
Roger Christopher Gill1*, Fatima Mannan1,
Moaz Aslam2, Mohammad Hashim Jilani2, Muhammad
Muneeb Khan2, Ameer Hamza Khan2, Yousaf Bashir Hadi2,
Abdul Rehman Alvi1, Amir Shariff1
1Department of Surgery, The Aga Khan University Hospital Karachi,
Pakistan
2Department of Surgery, Aga Khan University Medical College
Karachi, Pakistan
*Corresponding author: Roger Christopher Gill, Department of Surgery, The Aga Khan
University Hospital Karachi, Pakistan. Tel: +923009234726; Email: christo214@gmail.com; roger.gill@aku.edu
Received Date: 02 September, 2018; Accepted Date: 17 September,
2018; Published Date: 24 September, 2018
Citation: Gill RC, Mannan F, Aslam M, Jilani MH, Khan MM,
et al. (2018) Short Term Outcomes of Laparoscopic Sleeve
Gastrectomy for Obesity in Pakistan. Emerg
Med Inves: 182. DOI: 10.29011/2475-5605.000082
Abstract
Introduction: Obesity
has been established as a major risk factor for a number of non-communicable
diseases and over the year’s multiple strategies have been directed at
addressing this issue including minimally invasive procedures like laparoscopic
sleeve Gastrectomy, specifically with an end goal of weight reduction for the
morbidly obese. This procedure has become the preferred choice for both
patients and physicians over the past few years. Laparoscopic sleeve
Gastrectomy was introduced at our center recently; we have carried out a
retrospective review of charts to evaluate this procedure short-term outcome at
our center in our local population.
Methods: A
retrospective Cohort study, based on a record review for the treatment outcome
of laparoscopic sleeve gastrectomy, was carried out at the department of
surgery, Aga khan University Hospital, Karachi over a three-year period since
its inception and analyzed in June 2015 using SPSS version 20.
Results: A
total of 17 patients fulfilled the inclusion criteria, out of which 12 were
females (70.6%). The mean age of study participants was 41.53 years. Only one
patient had undergone liposuction previously for weight loss. The most common
co-morbidities observed were diabetes mellitus (23.6%), hypertension (23.6%)
and polycystic ovarian syndrome (17.7%). A statistically significant mean
reduction in excess body weight of 28.9±14.90 Kg, CI 21.27-36.59 was
observed along with reduction in BMI at 1 year with a mean difference of 11.1±5.38 Kg/m2, CI 21.27-36.60. Results were further analyzed for reduction in
percentage excess body weight which showed a mean reduction of 43.6% for the
study participants. Co-morbidity improvement was seen as reduction in systolic
blood pressures in 9 patients (52%) though these were not found to be
significant.
Conclusion: Laparoscopic
Sleeve Gastrectomy shows great potential for the Indian sub-continent
population, especially for patients requiring rapid weight loss for better
health outcomes, although long term follow up and out comes will determine the
effectiveness of the procedure over extended periods and its role as a first
line intervention for obesity.
Keywords: BMI; Diabetes Mellitus; Hypertension; Poly cystic Ovarian
Syndrome; Sleeve Gastrectomy
1. Introduction
Obesity has been established as a major risk factor for a number
of non-communicable diseases including Diabetes, Ischemic heart disease,
Stroke, Obstructive sleep apnea and even some cancers [1]. Moreover, it has also
been linked to negative effects on different aspects of reproductive and
psychological health [2]. At the same time obesity is also one of the most reversible and
controllable of risk factors leading to significant improvement in prognosis
and management of diseases and their pathogenesis. These include improving
insulin resistance and decreasing morbidity and mortality from complex medical
issues such as metabolic syndrome [3].
A number of interventions are available for obesity including
life-style changes, dietary modifications, medical therapy and surgical
mediation [4].
Minimally invasive procedures such as laparoscopic sleeve Gastrectomy,
specifically with an end goal of weight reduction for the morbidly obese has
become the preferred choice for both patients and physicians over the past few
years. These interventions are less traumatic and offer a quicker
post-operative recovery with comparable outcomes to other bariatric
procedures [5]. As a relatively new procedure in the subcontinent, its results,
both short term and long term, are being assessed continuously to judge its
success in the local cohort. Prevalence of obesity in Pakistan and India is
significant enough to affect the health outcomes of the population, whereby its
importance becomes paramount as the region exhibits a high incidence of
cardiovascular diseases [6].
Laparoscopic sleeve Gastrectomy was introduced at our center
recently; we have carried out a retrospective review of charts to evaluate this
procedure short-term outcome at our center in our local population.
2. Methodology
A retrospective study, based on a record review for the
treatment outcome of laparoscopic sleeve gastrectomy, was carried out at the
department of surgery, Aga khan University Hospital, Karachi. Data was analyzed
in June 2015 and all those cases that had undergone this procedure over the
last 3 years were included, with the exception of those who had this procedure
for indications other than obesity i.e. cancer etc. Pregnant or lactating women
were excluded in order to have a uniform cohort.
Required approvals from the department and ethical review board
were taken. Files were called from the medical records department and every
possible measure was taken in order to protect the confidentiality and identity
of the patients that were included. Documented data included basic demographic
details (Table 1), pre-operative
weight and post-operative weight at 1 year after surgery, excess weight at the
time of procedure and excess weight loss or gain by 1 year of follow up. The
primary outcome was to see the difference in terms of reduction or gain in
excess body weight by 1 year after surgery expressed both as mean difference
and percentage.
Other comorbidities such as post-operative blood pressure
readings, HDL levels, HBA1C levels and fasting/random glucose levels were
documented at the time of follow up at 1 year. A change in post-operative blood
pressures was also analyzed and comorbidity resolution or improvement was
stated for hypertension. Excess weight loss/gain was calculated by attaining
the ideal body weight using Miller’s formula [7] and then
subtracting it from the weight at the time of the procedure at 1 year of follow
up. The data was entered and analyzed via SPSS IBM version 20. Paired sample
t-test was used to analyze differences between pre- and post-operative
continuous outcomes. A p-value of less than 0.05 was considered as
statistically significant.
3. Results
All patients who underwent laparoscopic sleeve Gastrectomy as a
primary procedure for obesity from 2012 till June 2014 at our Centre who also
followed up for at least one year with the department of surgery were included
in this study. Study participants’ demographics and co-morbidities are
presented in Table 1. A total of 17 patients fulfilled this criterion, out of whom
12 were females (70.6%). The mean age of study participants was 41.53 years.
Only one patient had undergone liposuction previously for weight loss. The most
common co-morbidities observed were diabetes mellitus (23.6%), hypertension
(23.6%) and polycystic ovarian syndrome (17.7%). The main study outcome
observed was change in the excess weight of the participants (as mean
difference and percentage), Body Mass Index and total body weight at 1 year of
follow-up as an indicator of short-term outcome of the intervention as shown
in Table 2. For this analysis
post-operative weight and the lowest weight achieved by the patients at the
completion of one year of surgery were taken.
A statistically significant (p-value<0.001) mean reduction in
excess body weight of 28.9±14.90
Kg, CI 21.27-36.59 was documented for the study participants. A similar
statistically significant result was obtained for reduction in BMI at 1 year
with a mean difference of 11.1±5.38
Kg/m2, CI 21.27-36.60.
Results were further analyzed for reduction in percentage excess body weight
which showed a mean reduction of 43.6% for the study participants. Co-morbidity
improvement was seen as reduction in systolic blood pressures in 9 patients
(52%) though no statistically significant mean difference was observed between
pre and post-operative blood pressures as listed in Table 3.
4. Discussion
Obesity is a well-established global health issue which is now
considered a possible drawback of urban and economic development. Changes in
life style coupled with the consumption of high caloric diet have largely led
to a positive energy balance of individuals causing weight gain [8]. Being a major yet
modifiable risk factor for potentially life-threatening conditions, such as
stroke and ischemic heart disease [1], investigations are being done to tackle the burden both
medically and surgically. New drugs such as liraglutide and its effects,
highlight the advances that have taken place to manage obesity medically [9] whereas
surgically, laparoscopic sleeve gastrectomy has gained immense popularity as a
minimally invasive intervention in the past decade.
Originally considered a part of a larger two step bariatric
intervention [10] it has now been converted to a single procedure [5]. This change makes it
important to report short term outcomes in order to add to the existing
literature and show its results in different regional and population cohorts
with diverse genetic, disease, life-style and dietary profiles. Furthermore,
the reporting of short-term findings assists care givers to assess long term
suitability of the procedure for their patients and if need be, the requirement
of a secondary intervention at an earlier stage. Specifically, the importance
of studying short term outcomes is vital in the case of bariatric procedures,
as stated previously by Han, sang Moon et al. 2005, due to a lack of standardization
of excess weight loss estimates for laparoscopic sleeve gastrectomy in the
current literature. Most of the previous research was focused in the west,
based on metropolitan life style populace, while Asians were prone to develop
obesity related complications at a much lower BMI [11-13]. Likewise,
post-operative dietary habits of different populations in dissimilar social
settings had a notable impact on short- and long-term outcomes for bariatric
procedures [14]. Our study, which to the best of our knowledge is the only one of
its kind from Pakistan, shows an excess weight loss of 43.6±16.59 % at one year
with a statistically significant mean difference (P<0.001) between pre and
post-operative weight for a mean BMI of 47.8±9.27.
These results are comparable to a study recently published from the neighboring
country of India, which has a similar genetic, disease and lifestyle profile,
which demonstrated an excess weight loss of 59.3 % at one year and had
overlapping pre-operative BMI profiles to our study [15]. These similar findings
complement both the studies and may point towards the effectiveness of
laparoscopic sleeve gastrectomy as a primary minimally invasive surgical
intervention for obesity in this region, which is inhabited by one seventh of
the world population.
Sleeve gastrectomy as a procedure for weight loss has been
described previously in literature, by Himpens, et al. 2006 in one of the first
randomized controlled trials. This study highlighted its potential as a sole
bariatric laparoscopic procedure with relatively better results as compared to
older interventions, such as gastric banding, showing an excess weight loss of
57.5 % [16]. Many other studies
have also evaluated the effectiveness of laparoscopic sleeve gastrectomy in
different stratifications of BMI. Han, et al. in 2005 showed the greatest and
highest reported percentage change in excess weight loss of 83.3 % at 12 months
with a mean pre-operative BMI of 37.2 [17]. Other studies with more comparable BMI profiles such as Baltasar,
et al. in 2005 and Cotem, et al. in 2006 have exhibited excess weight loss of
56.1 % and 45 % for mean BMI’s of 65 and 65.4 respectively [18,19]. Similarly, Langer, et
al. showed an excess weight loss of 56 % at 12 months for a post-operative mean
BMI of 48.5 [20]. These short term results may be explained by the restrictive
nature of the technique, a reduction in the functional capacity of the stomach
as well as the hormonal change that is caused by loss of the gastric
fundus [21]. The removal of the
fundus leads to a decrease in levels of the hunger-inducing enzyme gherlin.
While this effect may be short-term it is extremely helpful in producing
changes in weight loss in the initial period after surgery [22]. Many other
physiological factors such as increased gastric emptying and reduced
post-operative gastric compliance lead to a lack of proper digestion which may
also have a role in achieving this weight loss [23].
Laparoscopic Sleeve gastrectomy has many benefits including a
decreased risk of serious post-operative complications [24]. The continuity of
the gastro intestinal tract is preserved, and the laparoscopic nature of the
surgery provides a quicker post-operative recovery [5]. The chance of
acquiring mal-absorptive conditions is minimal and dietary supplementation for
essentials vitamins and minerals may not be required and the need to use
foreign objects such as band or intra gastric balloon is avoided. Alongside
this, the option to proceed to a second surgery, with a far more stable and healthier
patient, remains open if results are not satisfactory. While achieving weight
loss in the super obese and obese, the procedure also has a noticeable effect
on comorbidity resolution, though in our case there was no statistically
significant (P value>0.05) mean difference in the post-operative systolic
and diastolic pressures. However, a general reduction in pressures was noted in
some patients. Many other studies though have shown considerable comorbidity
resolution in terms of hypertension with a resolution in 13 out of 14 patients
by Han, sang Moon, et al. 2005 [17] while a recent study in the west bank Palestine showed
significant improvement in both hypertension and diabetes mellitus [25]. Similar findings were
demonstrated by the experience of the Spanish national registry which showed
improvement and remission of diabetes in 81% of its participants while
hypertension was improved in 63.2% of the cases [26].
Many consider surgery as a far better treatment option for
obesity with quicker and enhanced outcomes [7,28], but side effects such as gastro esophageal reflux should be kept
in mind, as they can cause some discomfort for the patient [16,23]. However, over time,
such effects resolve with a recovery of gastric compliance. While serious
complications such as gastric leaks may have adverse effects on patient safety,
they can be tackled by using a stapled buttressed absorbable polymer membrane,
drainage, total parental nutrition and most importantly proper antibiotic
coverage [29,30].
Laparoscopic Sleeve Gastrectomy shows great potential for the
Indian sub-continent population, especially for patients requiring rapid weight
loss for better health outcomes, although long term follow up and out comes
will determine the effectiveness of the procedure over extended periods and its
role as a first line intervention for obesity.
Variable |
N |
% |
Mean Age |
41.53±10.43 |
|
Mean Age Male |
43.60±12.7 |
|
Mean Age Female |
40.67±9.81 |
|
Gender |
|
|
Male |
5 |
29.4% |
Female |
12 |
70.6% |
Past History |
|
|
FH of Obesity |
0 |
0% |
History of previous surgery for weight loss |
1 |
5.9% |
Comorbid |
|
|
PCOS |
3 |
17.7 % |
Breast CA |
1 |
5.9 % |
DM |
4 |
23.6% |
HTN |
4 |
23.6% |
Gout |
1 |
5.9 % |
Dyslipidemia |
1 |
5.9% |
Table 1: Basic Demographic of study participants. N=number±Standard deviation, %=percentage.
Variable |
Mean±Standard deviation |
Mean Difference±Standard deviation |
95 % CI of the mean difference |
P value |
Weight Kg |
|
|
|
|
Pre-operative weight |
123.2±26.77 |
|
|
|
Post-operative weight at 1 year |
94.3±15.81 |
28.9±14.90 |
21.27-36.59 |
<0.001 |
BMI Kg/m2 |
|
|
|
|
Pre-operative BMI |
47.8±9.27 |
|
|
|
Post up BMI at 1 year |
36.7±5.89 |
11.1±5.38 |
8.33-13.87 |
<0.001 |
Excess weight loss |
|
|
|
|
Pre -operative Excess weight |
64.9±24.86 |
|
|
|
Post-operative Excess weight at 1 year |
35.9±14.82 |
28.9±14.90 |
21.27-36.60 |
<0.001 |
Post-operative %Excess weight loss at 1 year |
43.6±16.59 |
|
|
|
Table 2: Pre and post-Operative measurement of study outcomes and their paired sample T test for n=17.CI=confidence interval.
Variable |
Mean±Standard deviation |
Mean Difference±Standard deviation |
95 % CI of the mean difference |
P value |
Blood pressures systolic |
|
|
|
|
Pre -op blood pressure |
139±19.50 |
|
|
|
Post- op blood pressure |
128±24.60 |
10.71±21.78 |
-22.39 |
>0.05 |
Blood pressures diastolic |
|
|
|
|
Pre -op blood pressure |
79±9.01 |
|
|
|
Post- op blood pressure |
77±10.17 |
2.05±10.64 |
-3.41 - 7.53 |
>0.05 |
Table 3: Pre and post-Operative measurement of secondary study outcome and their paired sample T test for n=17.CI=confidence interval.
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