This blog provides free general information for anyone who is seeking to understand more about the laparoscopic sleeve gastrectomy outcomes, not intended as a medical consult. Please seek proper medical advice for individual assessment and management.

Please read the other section on Bariatric Surgery Summary 2022 and Caveats of bariatric surgery for more information.

Laparoscopic sleeve gastrectomy

By 2014 the LSG has become the most widely performed bariatric procedure in the world. In 2016 LSG accounts for more than 50% of all bariatric interventions.

Worldwide LSG is the most popular primary bariatric surgical procedure because it is much safer than the RYGBP with comparable short/mid term outcomes.

LSG and OAGB are both technically easier than the RYGBP

• LSG has lower risk for peri-operative complications and re-operation than a RYGBP.
  • However staple line leak from LSG may be more serious than anastomotic leak from the RYGBP.
• Long term weight loss maintenance, resolution of medical co-morbidities, improvement in health related QOL may be superior with the OAGB and RYGBP compared to the LSG.

Advantage of LSG

• LSG avoid the side effects and complications of a gastric bypass, which may include anastomotic leak, marginal ulcers, internal hernia, small bowel obstruction, dumping syndrome, nutritional deficiencies and others.
• LSG is safer for young female population contemplating pregnancies in the future.
• The LSG can be recommended as a bridged stage 1 procedure for the super obese (BMI >50) and the super-super obese (BMI >60). The LSG is a very versatile procedure, which allows revision or conversion to another type of bypass or malabsorptive procedure in the future, as a planned procedure. Or as an unplanned procedure for reflux and weight regain.

Disadvantage of LSG

• Staple line leaks
• In the mid and long term there will be weight regain (as with any other bariatric procedures)
  • Revision surgery rates after LSG has been reported up to 20%, mostly for inadequate weight loss or weight regain after initial good success.

Unusual complications of LSG include:

Intra thoracic migration of the sleeve (? may occur in up to 7-30%) resulting in food intolerance (reflux, regurgitation, vomiting) and suboptimal weight loss (<25% TWL at 1 year)

• The patient may require surgery to repair the hiatus hernia

There are now reports of intra thoracic migration after RYGBP as well hence this complication may not be unique to the LSG as initially believed.

Long term results after laparoscopic sleeve gastrectomy

There have been a few studies reporting on the long term (>7 years) outcome after sleeve gastrectomy. Most reported 72.2% of patients attained >50% excess weight loss. Most report between 42 to 61% EWL in the long term.

One study with up to 15 years follow up reported a mean % EWL of 86.9 +/- 22.8%, resolution for HPT (51.7%), dyslipidaemia (58.1%) and T2DM (72.2%).

Some reported 1/5 to 1/3 of patients may have another procedure for reflux and/or weight regain after a 10 year period.

Banded sleeve gastrectomy

Currently the majority of surgeons do not routinely perform or recommend a silicone band to the sleeve gastrectomy

Banded weight loss has more weight loss result compare to non banded sleeve, reported 6.3 to 9% EWL difference and 1 study reported 14% EWL at 5 years

However it is unsure if there are any clinical relevance in the better weight loss group

Weight regain and revision surgeries may be similar in the two groups

There is increased post prandial regurgitation (in 37-44%) and a ring removal rate of 9.8% due to regurgitation

Ring slippage and potential gastric ischaemia requires the ring to be removed immediately

Side note:

In one European study RYGBP vs LSG, the gastric bypass has better weight loss with 10.1% more EWL at 7 years

If patients wish to have better weight loss, it is more likely that they will choose to have a gastric bypass rather than a banded sleeve gastrectomy.

Sleeve gastrectomy plus

The advantage of the sleeve is that it is a very versatile index operation that allows revision or conversion to another bariatric procedure, which includes re-sleeve, OAGB, RYGBP, SIPS, SADI-S, LSG plus duodeno-jejuno or jejuno-jejuno bypass or single anastomosis sleeve ileal bypass (SASI) and perhaps other innovations that may be develop in the future.

Currently in 2022 LSG conversion to OAGB and RYGBP are the two most common compared to the others mentioned above.

There are unique advantages and disadvantages for each of the above procedures and are not to be taken lightly.

Metabolic surgery

Apart from morbid obesity bariatric surgery is indicated for those with obesity related T2DM.

Obesity and T2DM are both a chronic and progressive disease where long term cure may not be possible. In the long term there will be weight regain and relapse of T2DM regardless of which type of bariatric procedures but after bariatric/metabolic surgery there is rapid normalization of glucose homeostasis and patients achieve better T2DM disease control.

Inadequate weight loss

With all types of bariatric surgical procedures, it has been reported that 15-35% of patients do not reach their weight loss goals in the 2 years after the initial procedure.

The reasons are multifactorial and may not be related to the technical aspects of the surgery.

Weight regain/recidivism

Post LSG weight regain after initial good success has been reported to be about 35% (after 5 years), range from 5.7% (after 2 years) and up to 75% (after 6 years).

In one study the weight regain rates are reported in 6 to 87% of patients after LSG and RYGBP (after 2 to 6 years of follow up).

Once again as already mentioned above

• Revision surgery rates after LSG has been reported up to 20%
• More than 80% of revision surgery is for inadequate weight loss or weight regain/recidivism

Revision surgery is usually performed on average after 5.6 years (range 1-17 years) after the initial procedure.

Conversion LSG to OAGB is more common in some centres for weight regain.

• LSG conversion to OAGB has better total weight loss (%TWL) result than RYGBP
• Conversion LSG to OAGB for reflux is controversial especially because of the incidence of bile reflux, erosive oesophagitis and GOJ adenocarcinoma

Conversion LSG to RYGBP is more common for weight regain and acid/bile reflux

• The risk for denovo reflux after LSG has been reported in up to 20-26% of cases
• However some or most patients did have reflux or at risk for reflux even before the sleeve as well (see below)

One study compared OAGB to SADI-S after LSG for weight regain (in those BMI>50)

• This study found 80% EWL (40% TWL) with both procedures
• Better results were in the SADI group but there were no statistical differences between the two

Acid reflux

After a sleeve gastrectomy there is 19% increase in GOR disease

The risk for denovo reflux has been reported in 20-26% and maybe up to 1/3 after LSG

• Risk factors include older patients, smokers, higher BMI

Some of the patients may already have reflux before the sleeve

• After weight loss the reflux symptoms improved in maybe in 1/5 of the patients
• After conversion to RYGBP there may be up to 75% resolution of reflux symptoms

• Hiatus hernia has been reported to occur in 23 to 40% of the obese population group before surgery. The risk of reflux may increase after LSG since the hernia is so common.
  • It is debatable whether the hiatus hernia should or should not be fixed at the time of the initial LSG operation. One report good results for reflux symptoms after both procedures but another study reported no improve of reflux symptoms as well as 41% of patients developing new reflux symptoms despite the hiatus hernia repair.
  • There may be new denovo reflux symptoms in 12% of patients and a recurrence hiatus hernia rate of 11% despite initial repair during the LSG. There were no difference found between suture vs mesh hiatus hernia repair.
  • Currently the common practice is to repair the hiatus hernia at the same time as the LSG, to prevent worsening of the reflux symptoms, quality of life, oesophagitis and maybe better weight loss results (but more likely there is no significant difference in weight loss between the two groups).
• Gastro-oesophageal reflux (GOR) symptoms may develop or worsen with time
  • New onset or denovo GOR has been reported to occur in 5-69% of cases. Most surgeons quote about 20 to 35% of patients develop denovo reflux symptoms.
  • Barrett’s oesophagus has been reported to occur in 2% of patients after 8 years (from a large study) and overall prevalence maybe up to 11%. The risk of oesophageal adenocarcinoma is reported to be 0.08%
  • Please note reflux also do occur after Roux Y gastric bypass as well in up to 21% and Barrett’s oesophagus in 1.4%

Acid reflux and sleeve gastrectomy short summary Gastro-oesophageal reflux disease: After a sleeve gastrectomy there may be GOR in about 60% of cases GOR may be pre-existing and worsen in 19-30% of cases GOR may be de novo in 23-30% of cases   Barrett’s oesophagus (BE) before sleeve gastrectomy: The main concern is that if GOR is not treated it may lead to erosive oesophagitis and BE   In the general population in  Western societies the prevalence of BE is 1.2 to 5.6% In severely obese patients the prevalence of BE is 11.6% (which may not correlate with the GOR symptoms) Around 5% of pre-op bariatric patients have BE Short segment BE <1cm has low risk to develop oesophageal adenocarcinoma The rate of oesophagitis in the obese is about 13% with increasing prevalence over time   BE after sleeve gastrectomy The SLEEVEPASS trial showed that 11.6% of LSG were converted to RYGBP for disabling GOR at 10 years   A systematic review and meta-analysis found that the incidence of BE after LSG was 4.6%. Another USA study reported BE incidence of 1.6% (at 2 years) and 6.4% (at 5 years) There is a low risk for BE after a conventional LSG and the rate is lower after a Nissen sleeve     Nissen sleeve gatsrectomy Nissen sleeve gastrectomy has been developed since 2016 Crural repair was performed if necessary with a 3cm Nissen fundoplication with 3 fixation points over a 37Fr calibration tube   Nissen sleeve gastrectomy was developed to prevent de novo GOR and for regression of pre-existing GOR disease   Nissen sleeve gastrectomy has been shown to significantly reduce post op GOR and oesophagitis compared to conventional sleeve gastrectomy in the medium term with similar weight loss results to a standard sleeve   Some studies have reported healing of the Barrett’s oesophagus in about 2/3 of the patients at 2 years follow up     Nissen LSG vs RYGBP One systematic review of patients with BE undergoing RYGBP reported BE regression rate of 56%   One study on Nissen sleeve gastrectomy study reported BE regression rates of 64% (at 1-2 years) and 71% (at 5 years), comparable to the RYGBP and superior to medical management

Sleeve gastrectomy and fundoplication

Some systematic review and meta analysis following fundoplication sleeve gastrectomy demonstrated a reduction in the proportion of post op GOR while maintaining a degree of weight loss similar to the standard sleeve

Earlier systematic review for sleeve + fundoplication reported GOR remission between 88-95% and % EWL ranging from 46.6 – 69% with a post op complication of 5.9-9.8% (chest pain, food bolus obstruction, bleeding, perforation, luminal narrowing, fluid collection, pancreatitis, DVT)

Without fundoplication

• After a sleeve gastrectomy there is 19% increase in GOR disease
• The risk for denovo reflux has been reported in 20-26% and maybe up to 1/3 after LSG

Sleeve gastrectomy + fundoplication

• Still have 9.2-11% post op GOR and estimated 59.1-68.7% EWL

However please note:

In general surgeons don’t recommend a sleeve gastrectomy for patients with reflux and Barrett’s oesophagus

Surgeons are more likely to recommend a Roux Y gastric bypass rather than a sleeve gastrectomy plus fundoplication

Also please note with both sleeve gastrectomy and gastric bypass there is a creation of a gastric tubular pouch

• Hence there is a risk for intra thoracic migration of the pouch and formation of a hiatus hernia
• The pouch volume and distensibility is reduced resulting in a rise in intra gastric pressure resulting in reflux
• In the long term there may be oesophageal dilatation and dysmotility

In the future investigational tool such as the EndoFLIP may help to assess oesophageal motility using real time high resolution impedance planimetry as well as measuring 3D oeosphageal diameter, cross sectional area, pressure and distensibility index (DI)

• High resolution manometry study primary peristalsis
• The EndoFLIP studies reactive or secondary peristalsis triggered by inflating a balloon in the distal lower oesophageal sphincter to measure the diameter and DI of the upper oeosphageal sphincter, lower oeosphageal sphincter and pylorus to help predict response to future endoscopic and operative intervention

Secondary peristalsis is categorized into 4 groups

• The normal motility pattern repetitive anterograde contraction (RAC)
• Abnormal motility patter which includes repetitive retrograde contraction (RRC), diminished or disorganized contractile response (DDCR) or absent contraction (AC)

Pregnancy after sleeve gastrectomy

Most surgeon recommendation patients wait 12-18 months after surgery before getting pregnant.

• This allows time for dietary/behaviour change and adequate weight loss to be achieved in this critical period of time.

However studies have found that 26 to 41% of women become pregnant within the first year after bariatric surgery.

However some studies showed that there are no differences in maternal and neonatal complications when pregnancy occurred less than 1 year after a sleeve gastrectomy.

• But obviously the post op window period to achieve significant total body weight loss is much shortened.

The sleeve is much safer than the OAGB or RYGBP when the patient become pregnant.

Special cautionary note for patients who became pregnant after a sleeve or bypass procedure. Please ask your GP to do the usual antenatal blood test and have the multivitamin supplements as recommended.

• During pregnancy fetal growth and immunity require vitamin A, D and zinc. Brain and neurological development require thiamine (B1), iodine and omega 3 fatty acids.
• Deficiencies in vitamin C, B9, B12, E, Zinc, Selenium and iron had been linked to preterm birth and deficiencies in vitamin B9 and B12 have a higher abortion rate.
• Also if a bowel obstruction (from gastric bypass surgeries) occurs during pregnancy, it is not possible to do a CT scan and very difficult to operate when the patient is pregnant. There is a risk for maternal and fetal mortality.

After multiple pregnancies weight regain often happen as well as reflux or hiatus hernia.

• Revision surgery is becoming more common for the younger female patients for weight regain and reflux years after initial sleeve gastrectomy.

Nutritional complications after sleeve gastrectomy

Micronutrient deficiencies can occur after LSG not just for the bypass patients.

After LSG it has been reported that there may be deficiencies in vitamin D (up to 89%), B12 (up to 26%0, iron (up to 43%) and PTH elevation (up to 39%) in the first year post op.

After LSG the causes of nutritional deficiencies are not related to the bypassed intestinal segments.

• The causes are multifactorial, which include reduced dietary intake, decreased gastric acid and intrinsic factor secretion, poor food choices and food intolerances.