The current study presents the long-term weight loss outcomes and progression of comorbidities in a series of 104 patients who underwent SG as a stand-alone bariatric procedure at our institution between 2005 and 2009. The last follow-up was at least 11 years after SG. As mentioned in the results, %EBWL and %TBWL at a mean follow-up of 13.4 years were 59 and 29, respectively. Our results are consistent with data from previously published studies presenting long-term (≥ 10 years) weight loss after SG,,,,,. According to these studies, %EBWL during long-term follow-up after SG ranges between 50−70.5, while %TBWL ranges between 21−31.5. However, it should be noted that the weight loss outcomes in these studies are usually overestimated, as they do not include patients undergoing conversion or revision surgery. The conversion or revision surgery rate during long-term follow-up after SG is estimated to be 6–49%. The most common indication for conversion or revision surgery is inadequate weight loss or weight regain5. In contrast, only one patient in our study was converted to RYGB, and this was due to GERD. The low conversion/revision surgery rate in our study was mainly due to patients' unwillingness to undergo re-operation, or because many patients were lost from follow-up. In this respect, our results should be considered more representative of long-term weight loss after SG. On the other hand, patient selection and surgical technique in our study were designed to improve long-term outcomes after SG. For instance, BMI has been shown to be a negative predictor of weight loss after SG. However, patients with a BMI ≥ 52 kg/m2 were not eligible for SG at our institution. In this regard, weight loss outcomes may have been overestimated in our study as well.
It has been shown that during the medium-term follow-up (5–7 years) after SG up to 40% of patients exhibit an increase in body weight of > 10 kg from weight nadir,, while up to 30% of patients exhibit > 25% EBW regain with respect to weight nadir,. Weight regain during long-term follow-up after SG cannot be precisely estimated, as some patients undergo conversion or revision surgery. Our study showed that 61% of patients experienced an increase in body weight of > 10 kg from weight nadir and 47% of patients experienced > 25% EBW regain with respect to weight nadir at a mean follow-up of 13.4 years. In line with previous observations, this indicates an increasing trend in the proportion of patients experiencing weight regain after SG as the time after surgery increases. Although, weight regain may be a major late complication of SG, it s a common phenomenon after all types of bariatric surgery and it does not necessarily imply weight loss failure or need for re-operation. The mean annual increase in body weight and decrease in % EBWL in our study group during 10 + years after the first postoperative year were only 1,2% and 2,5%, respectively. This suggests acceptable to good long-term weight loss maintenance for the majority of patients. Patient selection and surgical technique are crucial for long-term weight loss maintenance after SG, as large residual gastric volume, large bougie size, removed gastric volume of < 500 cc, limited antral resection, stress, anxiety, high serotonin levels, eating disorders, pregnancy, lack of exercise, and poor nutrition habits (such as high fat intake and increased consumption of sweets) have been identified as predictors for weight regain. Surgical options for the treatment of weight regain after SG include repeat sleeve gastrectomy (re-sleeve), endoscopic sleeve gastroplasty (ESG), and conversion to RYGB, BPD-DS, one anastomosis gastric bypass (OAGB) / mini gastric bypass (MGB), or single anastomosis duodeno-ileal bypass (SADI-S).
According to the results of our study, SG resulted in an extremely high rate of remission or improvement in T2DM and OSA, in a fairly high rate of remission or improvement in DLP, and in a modest remission or improvement in HTN and DJD. Comparison with other studies was not possible due to the heterogeneity of the definitions used in the literature. Nevertheless, most published studies with long-term follow-up agree that SG is more effective in remission or improvement of T2DM and OSA rather than HTN and DLP13,15,17. Preoperative duration of T2DM has been shown to be a predictor of remission or improvement after SG. A preoperative duration of T2DM > 10 years has been associated with lower postoperative remission rate21. Therefore, SG is a reasonable option for patients with morbid obesity, recent onset of T2DM and good preservation of β-cells. In other cases, bariatric surgery with duodenal exclusion may be more appropriate. Preoperative weight has also been shown to be a negative predictor of remission of T2DM after SG. In particular, higher preoperative weight has been associated with lower postoperative remission rates of T2DM17. Therefore, even in this case, patient selection seems to play an important role in the remission or improvement of T2DM after SG. The rate of new onset of HTN, T2DM, DLP, OSA, and DJD was very low. This indicates a possible role for SG in preventing the onset of these comorbidities. In summary, despite high weight regain rates, SG resulted in acceptable to high rates of remission or improvement and low rates of new onset of HTN, T2DM, DLP, OSA, and DJD during long-term follow-up.
Due to patient selection criteria, the remission or improvement of preexisting GERD after SG cannot be reliably evaluated by the present study. The new onset of GERD symptoms during long-term follow-up was 43%. The incidence of de novo GERD during long-term follow-up after SG in the literature is as high as 58.4%13,14,15,17,18 and this may be the Achilles’ heel of the procedure. The pathogenesis of GERD after SG is attributed to a complex interaction of anatomical, physiological, and physical factors. The shape of the sleeve, the extent of injury to the lower esophageal sphincter, and the presence of hiatal hernia are factors of particular importance for the postoperative occurrence of GERD. So, pitfalls of surgical technique may increase the incidence of GERD after SG. SG is now considered a low compliance, high-pressure system, responsible for the development of symptoms of GERD, and/or endoscopic findings GERD, erosive esophagitis and Barret’s esophagus,. Although the symptoms of GERD are effectively treated with proton pump inhibitors (PPIs) in most patients, the occurrence of Barrett's esophagus is a potentially threatening condition. The incidence of Barrett's esophagus during medium- and long-term follow-up after SG has been estimated at 14−17.2%15,31. It is worth noting that several studies have shown no correlation between clinical and endoscopic findings after SG31,. Taking into account the relatively high incidence of Barrett's esophagus and the mismatch of clinical and endoscopic findings, endoscopic surveillance is indicated for all patients after SG32,. The only proven surgical option for treating intractable GERD after SG is conversion to a RYGB. Hiatal hernia repair with gastropexy and the LINX® Reflux Management System (Torax Medical, St. Paul MN) has also been used in some cases14,34. Interestingly, our study did not show an association between GERD symptoms and long-term weight regain after SG, suggesting different pathophysiological mechanisms.