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© Borgis - Postępy Nauk Medycznych 2/2018, s. 81-88 | DOI: 10.25121/PNM.2018.31.2.81
*Hady Razak Hady1, Pawel Wojciak1, Patrycja Pawluszewicz1, Inna Diemieszczyk1, Mikolaj Czerniawski1, Regina Sierzantowicz2, Lech Trochimowicz1, Safauldeen Salim Neamah3, Viktar Strapko4, Adam Kretowski5, Jacek Dadan1, Jerzy Robert Ladny1, 6
Laparoscopic sleeve gastrectomy (LSG) as a operative method of morbid obesity treatment and resolution of its comorbidities
Laparoskopowa rękawowa resekcja żołądka jako metoda operacyjnego leczenia otyłości patologicznej i chorób współistniejących
1Ist Department of General and Endocrine Surgery, University Clinical Hospital of Bialystok, Poland
2Department of Health Sciences, Medical University of Bialystok, Poland
3Department of General Surgery, College of Medicine, University of Kufa, Iraq
4Department of General Surgery, Grodno State Medical University, Belarus
5Department of Endocrinology, Diabetology and Internal Medicine, University Clinical Hospital in Bialystok, Poland
6Department of Emergency and Disaster Medicine, Medical University of Bialystok, Poland
Streszczenie
Wstęp. Globalna epidemia otyłości, jej szybko rosnące występowanie i zagrażające życiu powikłania są jednym z głównych wyzwań opieki zdrowotnej w XXI wieku. Badania nad współistniejącymi z otyłością zaburzeniami metabolizmu doprowadziły do opisania zespołu metabolicznego. Pilna potrzeba poszukiwania skutecznych metod leczenia otyłości patologicznej spowodowała rozwój wielu technik w chirurgii bariatrycznej, a wśród nich – stosunkowo nowej procedury nazywanej LSG, która okazała się bezpieczną i skuteczną metodą w leczeniu otyłości wraz z towarzyszącymi jej zaburzeniami metabolizmu i chorobami współistniejącymi.
Cel pracy. Celem niniejszej pracy była analiza przebiegu chorób towarzyszących otyłości oraz zmian BMI, ciśnienia krwi, poziomu glukozy, lipidów i innych parametrów metabolicznych u chorych otyłych poddanych operacji LSG i pooperacyjnej obserwacji jednorocznej.
Materiał i metody. Opracowanie bazowało na retrospektywnej analizie danych zebranych na materiale własnym podczas prospektywnego, jednorocznego badania 142 pacjentów otyłych, zoperowanych metodą LSG w naszej Klinice w latach 2012-2015. Uzyskano zgodę Komisji Bioetycznej Uniwersytetu Medycznego w Białymstoku oraz pisemne zgody pacjentów biorących udział w badaniu.
Wyniki. Analiza statystyczna danych zebranych w czasie jednorocznej obserwacji wykazała efektywną utratę masy ciała, poprawę parametrów metabolicznych glukozy i lipidów, a także częściowe lub nawet całkowite ustąpienie chorób współistniejących, w szczególności tych będących częścią zespołu metabolicznego, u większości pacjentów z otyłością patologiczną poddanych operacji LSG.
Wnioski. Laparoskopowa rękawowa resekcja żołądka (LSG) jest procedurą bezpieczną, skuteczną i leczącą także choroby współistniejące z otyłością, rekomendowaną jako pierwotne leczenie chirurgiczne pacjentów z otyłością patologiczną.
Summary
Introduction. Global pandemic of obesity, its quickly growing prevalence and life threatening comorbidities are one of the main healthcare issues of the 21st century. Research on metabolic disorders coexisting with obesity led to description of metabolic syndrome (MS). Urgent need to find effective methods of morbid obesity treatment provoked development of many bariatric surgery procedures, and among them, a relatively new procedure called LSG, that stands out to be safe and effective method in treating obesity and its comorbidities with their metabolic disorders.
Aim. Aim of the study was to analyze course of comorbidities and changes in BMI, blood pressure, glucose, lipids and other metabolism parameters in obese patients who undergone LSG procedure in 1-year follow-up.
Material and methods. The study is based on retrospective statistical analysis of own material acquired at 1-year prospective follow-up of 142 obese patients after LSG procedure, hospitalized and treated in our Clinic in years 2012 to 2015. The consent of the Bioethical Committee of Medical University of Bialystok, as well as written consent from all the subjected patients were obtained.
Results. Statistical analysis of data recorded at 1-year follow-up showed effective body weight loos, edification in glucose and lipid metabolism parameters and also total or partial remission on comorbidities, especially those forming metabolic syndrome, in majority of patients with morbid obesity subjected to LSG operation.
Conclusions. Laparoscopic sleeve gastrectomy (LSG) is safe, effective and comorbidity resolving procedure recommended as a primary surgical treatment method for patients with morbid obesity.



Introduction
Global pandemic of obesity is one of the main healthcare issues of the 21st century. It has a significant impression in socioeconomic and psychosocial areas of public health’s interests. According to the newest WHO report from year 2011, number of people with BMI exceeding 30 has increased above 500 million, that makes up to 10% of worldwide population. Especially worth emphasizing is fact, that in last 30 years obesity occurrence increased almost twice among World’s population (1). Quickly increasing number of obesity cases promotes development of many important comorbidities, such as: hypertension, non-insulin dependent diabetes (NIDDM), cardiovascular diseases, sleep apneas, osteoarticular system’s diseases, depression and other (2, 3). In the last decades, much research work, aimed on reduction of mortality caused by cardiovascular diseases, that are main cause of death in general, has been taken to find associations between many metabolic disorders. In effect, the metabolic syndrome (MS) was described, named also as syndrome X, insulin resistance syndrome or deadly quartet, compromising abdominal obesity, hypertension, glucose intolerance and dyslipidemia. Conception of metabolic syndrome exists since about 80 years (4). However, only in the last decade a few trials to define it’s uniform diagnostic criteria have been taken. The most well-known definition of the metabolic syndrome belonged to World Health Organization (WHO), stated in year 1998 (5), but nowadays it has become obsolete and has only historical importance. Actually, the most commonly used definition comes from American Heart Association (AHA) (6). According to variety of metabolic syndrome’s diagnostic criteria, that result in many interpretational difficulties, there was a joint consensus published in year 2009. It states that necessary for MS diagnosis is coexistence of 3 among 5 previous criteria, without preferring obesity as a main criterion (7). In Poland, according to AHA-NHLBI definition, 23% men and 20% of women meet metabolic syndrome’s diagnostic criteria (8-12). The results of epidemiological research prove, that the metabolic syndrome is also widespread in USA (13) and Europe (5, 12). Hitherto epidemiological researches asses, that among developed countries’ population about 20-25% people meet the metabolic syndrome’s diagnostic criteria (13, 14). Proved fact is also that patients with diagnosed MS undergo myocardial infarction or stroke 3 times more often and 5 times more often develop NIDDM than general population. According to proven relationship between metabolic syndrome and increased morbidity and mortality caused by cardiovascular diseases, in connection with obesity pandemic among World’s population, reducing or stopping of wide spreading metabolic disorders is one of the most important challenges for contemporary medicine (15-17). Thus it seems obvious, that besides urgent need for effective prophylaxis of obesity, also appropriate treatment of already existing obesity cases is necessary. Interesting fact is that to certain moment, obesity was treated as a result, not as a cause of metabolic disorders. Nowadays, with contribution to bariatric surgery’s development, comes possibility to observe how much normalization of patient’s weight influences and even cures disorders in glucose and lipids metabolism. Thus it is reasonable to research among all bariatric procedures those, which not only permanently reduce body mass, but also normalize lipid levels the most and bring the best therapeutic effects in diabetes treatment (18). Among all surgical methods of morbid obesity treatment used in last 5 years, a relatively new procedure called laparoscopic sleeve gastrectomy (LSG) stands out very promising results in long- and short-term postoperative observation. These results are continuously published in actual scientific literature (19-21). LSG was first described by Iless and Marceau in 1988, as a part of duodenal switch (DS) with biliopancreatic diversion (BPD) operation (22). Further development led Johnston and affiliates to describe this method in 1993 as an isolated operation (23), and in year 1999, Gagner performed the first primary LSG. Laparoscopic sleeve gastrectomy operation technique compromises sub-total resection of stomach with creating a long, tubular gastric conduit based on minor curvature of the stomach. Weight loss and alignment in metabolic parameters within metabolic syndrome is caused not only by gastric resection itself, but also by following neurohormonal changes. LSG, as a procedure with relatively low postoperative complications risk, was at first indicated especially for super-obese patients (BMI > 60 kg/m2), with high perioperative complication risk or as a procedure following laparoscopic Roux-en-Y gastric bypass (LGBP) operation. At present, it is also recommended as a isolated, definitive and effective bariatric operation (24), providing high therapeutic effectiveness in treatment of many metabolic syndrome’s elements (20, 25).
According to fact, that LSG is one of the newest bariatric operations for morbid obesity treatment, there is few reports in scientific literature referring to its influence on obesity comorbidities. Our study aims to enrich knowledge base in this area.
Aim
The aim of this study was to analyze the influence of laparoscopic sleeve gastrectomy (LSG) procedure on diseases accompanying obesity – their partial remission, total resolution or worsening and also to collect, measure and statistically asses changes in biometric and biochemical metabolic parameters in patients with morbid obesity, who undergone this operation during 1-year follow-up.
Material and methods
Our study bases on retrospective review of prospectively collected data derived form group of 142 patients with morbid obesity, qualified to bariatric surgery and operated using LSG procedure in the 1st Department of General and Endocrine Surgery of the University Hospital in Bialystok between years 2012 to 2015 (tab. 1). The consent of the Bioethical Committee of Medical University of Bialystok, as well as written consent from all the subjected patients were obtained. All operated patients were subsequently examined in 1-year follow-up. The patient follow up visits were scheduled at 1, 3, 6 and 12 months following the surgery at which the BMI and %EWL, %EBL (percentage of excess weight loos and excess BMI loos) was calculated and the resolution of comorbid illnesses was noted. %EWL and %EBL calculations was based on guidelines from year 2007, while resolution of comorbidities was based on cessation of medicine taken, symptoms’ severity reduction and normalization of laboratory values. The patients have had diagnosed comorbidities, namely: depression, hypertension, non-insulin dependent diabetes (NIDDM), sleep apnea, chronic obstructive pulmonary disease (COPD), coronary disease, cholecystolithiasis, varicose veins of inferior limbs, hemorrhoids, deep vein thrombosis of inferior limbs, leg ulcerations, gastric and duodenal ulcers, gastritis, duodenitis, gastroesophageal reflux disease (GERD), oesophagitis, osteoarthritis of hip and knee joints, spinal pain, undergone myocardial infarction, that coexisted with obesity. Incidence percentages and numbers of these comorbidities in study group are presented in table 2.
Tab. 1. Demographic data and mean preoperative biometric values of patients in study group with deviations
N = 142Females = 78Males = 64
Age (years)45.82 ± 9.246.44 ± 12.2
Body weight (kg)144.2 ± 21.14151.3 ± 22.43
BMI (kg/m2)48.18 ± 6.551.08 ± 8.2
Tab. 2. Preoperative comorbidity types. Numbers and percentages among analyzed group of patients
 
Comorbidities
Before surgical treatment
F 78M 64
n%n%
Depression3625.35%2114.78%
Type 2 diabetes2819.71%2316.20%
Hypertension3423.94%3826.76%
Sleep apnea1510.56%2114.78%
Chronic obstructive pulmonary disease (COPD)96.33%1711.97%
Coronary disease96.33%2215.49%
Cholecystolithiasis1812.67%74.92%
Varicose veins of inferior limbs1611.26%139.15%
Hemorrhoids53.52%117.74%
Deep vein thrombosis of inferior limbs32.11%21.4%
Trophic leg ulcerations64.22%85.63%
Peptic ulcer disease of stomach and duodenum117.74%149.85%
Gastritis and duodenitis2618.30%3222.32%
Gastro-esophageal reflux disease (GERD)85.63%64.22%
Oesophagitis128.45%1510.56%
Hip joint osteoarthritis85.63%42.81%
Knee joint osteoarthritis42.81%53.52%
Spinal pain1913.38%2618.30%
Undergone hearth infarct0053.52%
During follow-up, also laboratory values of certain metabolism-related parameters, such as insulin, glucose, total cholesterol with LDL and HDL factions, triglycerides, urea, uric acid serum levels, were measured, recorded and monitored for their variability over the observation time. Mean preoperative values and deviations of these lab tests are collected in table 3. Our study took into account also values and deviations of HOMA-IR (homeostatic model assessment insulin resistance index), calculated from the following formula:
HOMA-IR = {[fasting insulin [uU/ml] x fasting glucose [mmol/l]}/22.5.
Tab. 3. Mean preoperative values and deviations of laboratory tested metabolic parameters
Fasting insulin (uU/L)42.4 ± 21.62
Fasting glucose (mg/dl)146.2 ± 52.30
Total cholesterol (mg/dl)221.95 ± 19.40
Triglycerides (mg/dl)176.4 ± 45.70
LDL-cholesterol (mg/dl)152.40 ± 31.30
HDL-cholesterol (mg/dl)44.20 ± 12.10
Uric acid (mg/dl)5.81 ± 1.81
Urea (mg/dl)35.34 ± 7.40
HOMA-IR12.90 ± 10.60
Statistical analysis was done using the software Statistics 6.0 for Windows. The continuous variables were expressed as mean and standard deviation and compared using Students T-test. The p value < 0.05 was considered as statistically significant.
Results

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otrzymano: 2018-03-02
zaakceptowano do druku: 2018-03-26

Adres do korespondencji:
*Hady Razak Hady
I Klinika Chirurgii Ogólnej
i Endokrynologicznej
Uniwersytecki Szpital Kliniczny
w Białymstoku
ul. M. Skłodowskiej-Curie 24A
15-276 Białystok
tel. +48 (85) 831-86-72
hadyrazakh@wp.pl

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