Author’s Accepted Manuscript

American Society for Metabolic and Bariatric

Surgery Updated Position Statement on Sleeve
Gastrectomy as a Bariatric Procedure

Mohamed Ali, Maher El Chaar, Saber Ghiassi, Ann

M. Rogers, Shanu N. Kothari
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PII: S1550-7289(17)30377-5
DOI: http://dx.doi.org/10.1016/j.soard.2017.08.007
Reference: SOARD3097
To appear in: Surgery for Obesity and Related Diseases
Cite this article as: Mohamed Ali, Maher El Chaar, Saber Ghiassi, Ann M.
Rogers and Shanu N. Kothari, American Society for Metabolic and Bariatric
Surgery Updated Position Statement on Sleeve Gastrectomy as a Bariatric
P r o c e d u r e , Surgery for Obesity and Related Diseases,
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 ASMBS Guidelines/Statements

American Society for Metabolic and Bariatric Surgery Updated Position Statement on

Sleeve Gastrectomy as a Bariatric Procedure

Mohamed Ali MDa, Maher El Chaar MDb, Saber Ghiassi MDc, Ann M. Rogers MDd on behalf of

the American Society for Metabolic and Bariatric Surgery Clinical Issues Committee

a
Department of Surgery, University of California-Davis Medical Center, Sacramento, California;
b
Department of Surgery, Division of Bariatric and Minimally Invasive Surgery, the Medical

School of Temple University/St Luke's University Health Network, Allentown, Pennsylvania;

c
Department of Surgery, Yale University School of Medicine, New Haven, Connecticut;
d
Division of Minimally Invasive and Bariatric Surgery, Penn State Hershey Medical Center,

Hershey, Pennsylvania

Correspondence to:

Shanu N. Kothari, MD

Department of General Surgery

Gundersen Health System

La Crosse, WI 54601

Telephone: (608) 775-5187

Fax: (608) 775-7327

Email: [email protected]
 ASMBS Guidelines/Statements

American Society for Metabolic and Bariatric Surgery Updated Position Statement on

Sleeve Gastrectomy as a Bariatric Procedure

Preamble

The American Society for Metabolic and Bariatric Surgery (ASMBS) has previously

published 3 position statements on the use of sleeve gastrectomy (SG) as a bariatric procedure.1-3

These position statements were developed in response to inquiries made to the ASMBS by

patients, physicians, hospitals, health insurance payers, the media, and others regarding this

newer procedure that requires ongoing evaluation and evidence-based scrutiny. In 2012, the

ASMBS published a position statement recognizing SG as an acceptable primary bariatric

procedure option.3 Since that time there have been a number of high-quality publications that

support the use of SG by demonstrating durable weight loss, improved medical co-morbidities,

and relatively low surgical risk. The Clinical Issues Committee and Executive Council of

ASMBS have determined that the emergence of SG as the most commonly performed bariatric

procedure in the world today worldwide warrants an updated statement in order to compile

available data to facilitate sharing of the evidence which supports the value of sleeve

gastrectomy, as well as to review available evidence regarding issues that may limit application

of the procedure. Recommendations are made based on published, peer-reviewed scientific

evidence and expert opinion. This statement is not intended to be, and should not be construed
as, stating or establishing a local, regional, or national standard of care for any bariatric

procedure.

Comparative Studies of Weight Loss

Previous ASMBS statements confirmed that primary SG could effectively produce

significant weight loss. More recent studies have provided information comparing various

“accepted” ASMBS-approved surgical procedures to SG. Among these comparisons, Roux-en-

Y gastric bypass (RYGB) is felt by many to be the gold-standard procedure for weight loss and

therefore comparisons between SG and RYGB may be seen as useful.

Several studies demonstrate that SG and RYGB provide more comparable weight loss

than is seen following the adjustable gastric band (AGB) or non-surgical interventions.4-9 Leyba

et al. reported that SG and RYGB produced similar weight loss at one and five years of follow-

up.4,5 Peterli et al. reported early weight loss at 1 year after surgery to be comparable between

SG and RYGB in a randomized clinical trial.6 Vidal et al. reported no significant differences

between SG and RYGB in terms of excess weight loss (EWL) observed at 4 years of follow-up.7

Similarly, Lakdawala reported no significant early (1 year) difference in EWL between SG and

RYGB.8 Lim et al., although finding superior EWL after RYGB compared to SG at one year,

reported that the two procedures yielded similar weight loss results in the longer term of up to

five years.9 In a randomized trial of patients with a body mass index (BMI) <50 kg/m2, Kehagias

et al. found that SG yielded greater early weight loss, but this difference resolved over time

resulting in no weight loss difference between the two procedures by three years of follow-up.10

Karamanakos et al. also noted greater weight loss with SG than RYGB at one year, associated
with a statistically significant decrease in fasting ghrelin levels after SG but not after RYGB,

although the SG group was younger than the RYGB group which could be a confounding

factor.11

Other groups have reported that RYGB provides superior weight loss to that seen after

SG.12-16 In a meta-analysis of the 2-year outcomes of bariatric surgery, Zhang et al. reported that

patients undergoing RYGB achieved a lower BMI and greater %EWL compared to SG.12 A

retrospective cohort study of U.S. military veterans undergoing RYGB or SG compared with

matched patients treated without surgery demonstrated that patients undergoing RYGB lost a

mean of 27.5% of body weight, compared to 17.8% in the SG group.13 The surgical groups in

this study however were not well matched as the SG patients were older, more likely to be male,

and more likely to have diabetes, thus calling into question these results.

In a randomized trial conducted by Zhang et al in China, SG and RYGB led to similar

weight loss at one year, but RYGB was found to be superior at five years.14 El Chaar et al.

reported greater overall weight loss with RYGB at two years postoperatively. In this study, the

subset of patients with BMI<40 kg/m2 yielded similar weight loss with both procedures at one

year, but EWL was less 2 years after SG compared to RYGB.15 In studies of super obese

patients (BMI ≥50 kg/m2), several studies have demonstrated significantly greater weight loss

and percent total weight loss with RYGB than with SG.16,17

In summary, studies comparing weight loss after SG and after RYGB demonstrate

variable differences between the two procedures with no reliable conclusion as to which

operation produces the greatest weight loss early after surgery. However, the weight of current

evidence appears to support the conclusion that RYGB provides greater EWL compared to SG

beyond the first year.

Comparative studies regarding Comorbidity Improvements

Regarding improvement of weight-related conditions, previous randomized trials have

generally shown similarity between SG and RYGB, and superiority of both these procedures

compared to AGB.18 The results of two new randomized trials comparing SG to RYGB showed

similar weight loss outcomes and improvements in type 2 diabetes mellitus (T2D) and quality of

life (QOL) scores.6,19 In another randomized trial, the Surgical Treatment and Medications

Potentially Eradicate Diabetes Efficiently (STAMPEDE) trial, Schauer et al. reported 5-year

outcomes comparing the effectiveness of SG and RYGB combined with medical therapy versus

intensive medical therapy alone for the treatment of T2D.20 The results showed significant

superiority of both procedures over intensive medical therapy alone in terms of glycemic control;

weight loss; reduction of medication use for T2D, lipids and hypertension (HTN); renal function;

and QOL scores. There was no significant difference between SG and RYGB in terms of

improvement of glycemic control, HTN, or lipid profiles, but there was a significant difference

in 5-year weight loss, favoring RYGB. The outcomes and conclusions of these three RTs are

summarized in Table 1.

In a large case-control study matched for age, BMI and gender, Boza et al. compared 811

SG patients with 786 RYGB patients; the improvement of T2D, HTN and lipid profiles were

similar for both groups at 1 year after surgery.21 In a report from the Michigan Bariatric Surgery

Collaborative comparing outcomes of SG, RYGB and AGB, SG was associated with remission

rates of 66% for T2D and 40% for hyperlipidemia at one year postoperatively. These rates were

significantly greater than with AGB but less than with RYGB. Remission of HTN (40%) and
obstructive sleep apnea (OSA) (57%) after SG was similar to that with RYGB and superior to

that with AGB.22

Four meta-analyses comparing SG to RYGB have been published since 2012, two of

which reported similar remission of T2D,12,23 and two of which reported superior outcomes with

RYGB for several comorbidities.24,25 Yip et al. analyzed 33 studies (N=1375), including 3

randomized trials, 18 prospective and 12 retrospective studies, and concluded there was no

significant difference in T2D remission at 1 and 3 years (SG 68% and 80% vs. RYGB 76% and

81%).23 In a meta-analysis of 32 randomized and nonrandomized studies (N=6256) with up to 5-

year follow-up, Li et al. found that RYGB conferred significantly greater remission or

improvement of T2D, HTN, gastroesophageal reflux disease (GERD), arthritis, and

hypercholesterolemia but a higher risk for complications and reoperation than with SG.25

Several cohort studies of SG have reported mid- to long-term improvements in

comorbidities up to 7 years after surgery. Lemanu et al. reported a 42.9% remission of T2D at 5

years after SG and improvement in another 35.7%,26 while others have reported T2D remission

rates of 76.9% to 100% at five years27-30 and 83.8% at 7 years.31 The reduction in glycated

hemoglobin (HbA1c) after SG averages 1.7%-2.37% at one year, 1.8%-2.5% at three years, and

1.4% at five years after surgery.19,20,27

Comparative studies of surgical risk

A recent meta-analysis of 6 randomized controlled trials comprising 695 patients and

comparing complication rates after SG and RYGB found that SG was associated with

significantly fewer major complications within 30 days of surgery. There was a non-significant

trend toward fewer minor complications after SG compared to RYGB. Neither procedure was

found to have a higher readmission rate, reoperation rate, or 30-day mortality.32 The general

range of 30-day mortality and morbidity for SG in the current literature is 0-1.2% and 0-17.5%

respectively.33 Young et al analyzed 24,117 patients from the American College of Surgeons

National Surgical Quality Improvement Program (NSQIP) database in the years 2010-2011,

4945 of whom underwent SG and 19,172 of whom underwent RYGB. In this analysis, there was

a significantly greater number of RYGB patients with diabetes, chronic obstructive pulmonary

disease, HTN and smoking. However, the risk-adjusted complication rate was still significantly

lower overall among SG patients. The 30-day mortality rates of SG (0.1%) vs. RYGB (0.15%)

were both low and because of the small numbers, risk-adjusted mortality rates could not be

compared.34

Aminian et al. reported on 5871 SG cases from the NSQIP database over the period

2011-2012; the 30-day mortality rate was 0.5% and the overall rate of serious adverse events was

2.4%. Based on their analysis, they identified several factors that were predictive of adverse

events after SG, including a history of congestive heart failure, male gender, T2D, chronic

steroid use, increasing BMI, elevated preoperative total bilirubin level and low preoperative

hematocrit.35 A similar NSQIP study of 1005 bariatric patients > 65 years of age showed a 30-

day mortality rate of 0.6% for both SG and RYGB, and an overall 30-day morbidity rate of 9%
for SG and 9.1% for RYGB.36 The BariSurg multicenter randomized controlled trial in which

248 patients have been enrolled and blinded to undergo SG or RYGB will likely give us better

information as to the discreet differences in outcomes after these two procedures.33

One rare complication of laparoscopic surgery is portal venous thrombosis (PVT). In a

prospectively collected database comprising 6 bariatric centers and 5706 weight loss surgery

(WLS) patients, there were 17 patients (0.3%) with PVT, of whom 16 (94.1%) had undergone

SG.37 This particular complication requires heightened clinical suspicion on the part of

surgeons, as it will not be seen on CT scans without intravenous contrast. As PVT may prove to

be more common after SG than after other forms of WLS, this particular topic merits further

study. The mechanism of PVT after SG remains a matter of speculation at this time and no

recommendations are appropriate regarding anticoagulation for prevention of this rare

complication.

Current data – SG as a WLS Option for Adolescents

Given the growing prevalence of severe obesity among adolescents, and the fact that

adolescent obesity predicts adult obesity, WLS among teens is becoming more accepted.38 In

addition, based on safety and efficacy data, there is a trend toward SG as the procedure of choice

for adolescents, although both RYGB and SG are routinely performed in teen WLS programs.39

One multicenter, prospective study of WLS in adolescents included 161 RYGB patients and 67

SG patients. Among the RYGB patients there was a mean 28% total body weight loss at 3 years

after surgery, and among SG patients, 26%. There were no mortalities attributable to WLS and

the major complication rate was 8%. Nutritional deficiencies were seen as with adult
populations, so the need for long-term follow-up was emphasized.40 As there is almost no

literature on the outcomes of adults who underwent WLS as teens, this area merits further study.

Current data - SG and Gastroesophageal Reflux Disease

The effect of SG on GERD is controversial and, as a result, has been the subject of

extensive study. The existence and severity of preoperative GERD should be considered when

helping patients select the best surgical option. GERD is also an important postoperative

outcome variable after SG. In general, RYGB is considered an effective anti-reflux procedure in

patients with medically-complicated obesity and GERD. In contrast, early data suggested that

SG may worsen GERD and many recommended caution in offering SG to patients with GERD,

especially when it was severe.36 A growing body of literature, however, indicates that the rates

of development of de novo GERD and worsening of preoperative GERD after SG may be lower

than previously thought.28 While controversial, there is little evidence beyond expert opinion to

support the notion that pre-existing GERD should exclude patients from undergoing SG.

Numerous publications have addressed the persistence or development of GERD

following SG. At the time of the 2012 updated sleeve position statement, some studies had

reported a significant incidence of de novo GERD following SG,41-45 but more recent systematic

reviews of this topic are inconsistent.46,47 De novo GERD has been reported to occur in 8-11%

of patients following SG,28,48-50 although one study reported an incidence of 26.7%.30 One study

at 5 years after SG reported de novo GERD in only 7.4% of patients.48 Thereaux et al. found that

when patients before and six months after SG were assessed by pH measurement, two-thirds of
patients showed evidence of acid reflux following SG, including some who were asymptomatic.

However, in patients with pre-existing GERD, SG did not increase the measured abnormalities.50

In the presence of hiatal hernia, SG with simultaneous hiatal hernia repair improved

symptoms or reduced the need for medications in 1/3 of patients with pre-existing GERD, while

de novo reflux developed in 15.6 % of previously asymptomatic patients.51 One study of 110

SG patients undergoing routine pre- and post-operative upper endoscopy at a mean 58 months of

postsurgical follow-up reported a 17.2% rate of newly diagnosed Barrett esophagus and a

significant increase in erosive esophagitis, neither of which correlated with severity of

symptoms.52

Improvement in GERD symptoms has also been reported following SG. A large

retrospective review, the Bariatric Outcomes Longitudinal Database (BOLD) from 2007 to 2010

with 4832 patients found the prevalence of preoperative GERD to be 44.5%. After SG, 15.9% of

these patients reported resolution of symptoms.47 SG has been reported to lead to remission of

GERD symptoms in 53% of patients at 5 years28 and 64.7% of patients at 7 years.31 In

comparison to RYGB, however, patients are more likely to require acid reduction medications

after SG.53

Finally, while expert consensus appears to support the preferential use of RYGB as

superior to SG in the presence of Barrett esophagus, not all authors consider this metaplastic

change to be an absolute contraindication to the use of SG as a weight loss option.54 Given

significant ongoing controversy related to differences in reported outcomes of GERD in SG

patients, further study of this issue, including evaluation of long term endoscopic findings after

SG, is needed.
Summary and Recommendations

Substantial long-term outcome data published in the peer-reviewed literature, including

studies comparing outcomes of various surgical procedures, confirm SG provides significant and

durable weight loss, improvements in medical co-morbidities, improved QOL, and low

complication and mortality rates for obesity treatment. In terms of initial early weight loss and

improvement of most weight-related comorbid conditions, SG and RYGB appear similar. The

effect of SG on GERD, however, is less clear, as GERD improvement is less predictable and

GERD may worsen or develop de novo. Pre-operative counseling specific to GERD-related

outcomes is recommended for all patients undergoing SG.

The ASMBS recognizes SG as an acceptable option for a primary bariatric procedure or

as a first-stage procedure in high-risk patients as part of a planned, staged approach. As with any

bariatric procedure, long-term weight regain can occur after SG and may require one or more of

a variety of re-interventions. Informed consent for SG as a primary procedure should be

consistent with the consent provided for other bariatric procedures and, as such, should include

the risk of long-term weight regain. In addition, as with all currently recognized bariatric

procedures, surgeons performing SG are encouraged to prospectively collect, analyze and report

their outcome data in peer-reviewed scientific forums.

Sleeve gastrectomy position statement and standard of care

This position statement is not intended to provide inflexible rules or requirements of

practice and is not intended, nor should it be used, to state or establish a local, regional, or

national legal standard of care. Ultimately, there are various appropriate treatment modalities for

each patient, and surgeons must use their judgment in selecting from among the different feasible

treatment options.

The ASMBS cautions against the use of this position statement in litigation in which the

clinical decisions of a physician are called into question. The ultimate judgment regarding the

appropriateness of any specific procedure or course of action must be made by the physician in

light of all the circumstances presented. Thus, an approach that differs from the position

statement, standing alone, does not necessarily imply that the approach was below the standard

of care. A conscientious physician may responsibly adopt a course of action different from that

set forth in the position statement when, in the reasonable judgment of the physician, such a

course of action is indicated by the condition of the patient, limitations on available resources, or

advances in knowledge or technology. All that should be expected is that the physician will

follow a reasonable course of action according to current knowledge, the available resources, and

the needs of the patient to deliver effective and safe medical care. The sole purpose of the present

position statement is to assist practitioners in achieving this objective.

Conflict of Interest

The authors have no conflicts of interest to disclose.

References

1. Clinical Issues Committee of the American Society for Metabolic and Bariatric Surgery.

Updated position statement on sleeve gastrectomy as a bariatric procedure. Surg Obes

Relat Dis 2007;3(6):573-6.

2. Clinical Issues Committee of the American Society for Metabolic and Bariatric Surgery.

Updated position statement on sleeve gastrectomy as a bariatric procedure. Surg Obes

Relat Dis 2010;6(1):1-5.

3. ASMBS Clinical Issues Committee. ASMBS online statements/guidelines. Updated

position statement on sleeve gastrectomy as a bariatric procedure. Surg Obes Relat Dis

2012;8(3):e21-6.

4. Leyba JL, Aulestia SN, Llopis SN. Laparoscopic Roux-en-Y gastric bypass versus

laparoscopic sleeve gastrectomy for the treatment of morbid obesity. A prospective study

of 117 patients. Obes Surg 2011;21(2):212-6.

5. Leyba JL, Llopis SN, Aulestia SN. Laparoscopic Roux-en-Y gastric bypass versus

laparoscopic sleeve gastrectomy for the treatment of morbid obesity. A prospective study

with 5 years of follow-up. Obes Surg 2014;24(12):2094-8.

6. Peterli R, Borbely Y, Kern B et al. Early results of the Swiss Multicentre Bypass or

Sleeve Study (SM-BOSS): a prospective randomized trial comparing laparoscopic sleeve

gastrectomy and Roux-en-Y gastric bypass. Ann Surg 2013;258(5):690-4.

7. Vidal P, Ramón JM, Goday A, et al. Laparoscopic gastric bypass versus laparoscopic

sleeve gastrectomy as a definitive surgical procedure for morbid obesity. Mid-term

results. Obes Surg 2013;23(3):292-9.

8. Lakdawala MA, Bhasker A, Mulchandani D, Goel S, Jain S. Comparison between the

results of laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass in

the Indian population: a retrospective 1 year study. Obes Surg 2010;20(1):1-6.

9. Lim DM, Taller J, Bertucci W, Riffenburgh RH, O'Leary J, Wisbach G. Comparison of

laparoscopic sleeve gastrectomy to laparoscopic Roux-en-Y gastric bypass for morbid

obesity in a military institution. Surg Obes Relat Dis 2014;10(2):269-76.

10. Kehagias I, Karamanakos SN, Argentou M, Kalfarentzos F. Randomized clinical trial of

laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy for the

management of patients with BMI <50 kg/m2. Obes Surg 2011;21(11):1650-6.

11. Karamanakos SN, Vagenas K, Kalfarentzos F, Alexandrides TK. Weight loss, appetite

suppression, and changes in fasting and postprandial ghrelin and peptide-YY levels after

Roux-en-Y gastric bypass and sleeve gastrectomy: a prospective, double blind study. Ann

Surg 2008;247(3):401-7.

12. Zhang C, Yuan Y, Qiu C, Zhang W. A meta-analysis of 2-year effect after surgery:

laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy for

morbid obesity and diabetes mellitus. Obes Surg 2014;24(9):1528-35.

13. Maciejewski ML, Arterburn DE, Van Scoyoc L, et al. Bariatric surgery and long-term

durability of weight loss. JAMA Surg 2016;151(11):1046-55.

14. Zhang Y, Zhao H, Cao Z, et al. A randomized clinical trial of laparoscopic Roux-en-Y

gastric bypass and sleeve gastrectomy for the treatment of morbid obesity in China: a 5-

year outcome. Obes Surg 2014;24(10):1617-24.

15. El Chaar M, Hammoud N, Ezeji G, Claros L, Miletics M, Stoltzfus J. Laparoscopic

sleeve gastrectomy versus laparoscopic Roux-en-Y gastric bypass: a single center

experience with 2 years follow-up. Obes Surg 2015;25(2):254-62.

16. Thereaux J, Corigliano N, Poitou C, Oppert JM, Czernichow S, Bouillot JL. Comparison

of results after one year between sleeve gastrectomy and gastric bypass in patients with

BMI >/= 50 kg/m(2). Surg Obes Relat Dis 2015;11(4):785-90.

17. Celio AC, Wu Q, Kasten KR, Manwaring ML, Pories WJ, Spaniolas K. Comparative

effectiveness of Roux-en-Y gastric bypass and sleeve gastrectomy in super obese

patients. Surg Endosc 2017;31(1):317-23.

18. Jackson TD, Hutter MM. Morbidity and effectiveness of laparoscopic sleeve

gastrectomy, adjustable gastric band, and gastric bypass for morbid obesity. Adv Surg

2012;46:255-68.

19. Keidar A, Hershkop KJ, Marko L, et al. Roux-en-Y gastric bypass vs sleeve gastrectomy

for obese patients with type 2 diabetes: a randomised trial. Diabetologia

2013;56(9):1914-8.

20. Schauer PR, Bhatt DL, Kirwan JP, et al. Bariatric surgery versus intensive medical

therapy for diabetes - 3-year outcomes. N Engl J Med 2014;370(21):2002-13.

21. Boza C, Gamboa C, Salinas CJ, Achurra P, Vega A, Pérez G. Laparoscopic Roux-en-Y

gastric bypass versus laparoscopic sleeve gastrectomy: a case-control study and 3 years

of follow-up. Surg Obes Relat Dis 2012;8(3):243-9.

22. Carlin AM, Zeni TM, English WJ, et al; Michigan Bariatric Surgery Collaborative. The

comparative effectiveness of sleeve gastrectomy, gastric bypass, and adjustable gastric

banding procedures for the treatment of morbid obesity. Ann Surg 2013;257(5):791-7.

23. Yip S, Plank LD, Murphy R. Gastric bypass and sleeve gastrectomy for type 2 diabetes: a

systematic review and meta-analysis of outcomes. Obes Surg 2013;23(12):1994-2003.

24. Li JF, Lai DD, Ni B, Sun KX. Comparison of laparoscopic Roux-en-Y gastric bypass

with laparoscopic sleeve gastrectomy for morbid obesity or type 2 diabetes mellitus: a

meta-analysis of randomized controlled trials. Can J Surg 2013;56(6):E158-64.

25. Li JF, Lai DD, Lin ZH, Jiang TY, Zhang AM, Dai JF. Comparison of the long-term

results of Roux-en-Y gastric bypass and sleeve gastrectomy for morbid obesity: a

systematic review and meta-analysis of randomized and nonrandomized trials. Surg

Laparosc Endosc Percutan Tech 2014;24(1):1-11.

26. Lemanu DP, Singh PP, Rahman H, Hill AG, Babor R, MacCormick AD. Five-year

results after laparoscopic sleeve gastrectomy: a prospective study. Surg Obes Relat Dis

2015;11(3):518-24.

27. Abbatini F, Capoccia D, Casella G, Soricelli E, Leonetti F, Basso N. Long-term

remission of type 2 diabetes in morbidly obese patients after sleeve gastrectomy. Surg

Obes Relat Dis 2013;9(4):498-502.

28. Rawlins L, Rawlins MP, Brown CC, Schumacher DL. Sleeve gastrectomy: 5-year

outcomes of a single institution. Surg Obes Relat Dis 2013;9(1):21-5.

29. Angrisani L, Santonicola A, Hasani A, Nosso G, Capaldo B, Iovino P. Five-year results

of laparoscopic sleeve gastrectomy: effects on gastroesophageal reflux disease symptoms

and co-morbidities. Surg Obes Relat Dis 2016;12(15):960-8.

30. Boza C, Daroch D, Barros D, León F, Funke R, Crovari F. Long-term outcomes of

laparoscopic sleeve gastrectomy as a primary bariatric procedure. Surg Obes Relat Dis

2014;10(6):1129-33.

31. Casella G, Soricelli E, Giannotti D, et al. Long-term results after laparoscopic sleeve

gastrectomy in a large monocentric series. Surg Obes Relat Dis 2016;12(4):757-62.

32. Osland E, Yunus RM, Khan S, Alodat T, Memon B, Memon MA. Postoperative early

major and minor complications in laparoscopic vertical sleeve gastrectomy (LVSG)

versus laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures: a meta-analysis and

systematic review. Obes Surg 2016;26(10):2273-84.

33. Fischer L, Wekerle AL, Bruckner T, et al. BariSurg trial: sleeve gastrectomy versus

Roux-en-Y gastric bypass in obese patients with BMI 35-60 kg/m2 - a multi-centre

randomized patient and observer blind non-inferiority trial. BMC Surg 2015;15:87.

34. Young MT, Gebhart A, Phelan MJ, Nguyen NT. Use and outcomes of laparoscopic

sleeve gastrectomy vs laparoscopic gastric bypass: analysis of the American College of

Surgeons NSQIP. J Am Coll Surg 2015;220(5):880-5.

35. Aminian A, Brethauer SA, Sharafkhah M, Schauer PR. Development of a sleeve

gastrectomy risk calculator. Surg Obes Relat Dis 2015;11(4):758-64.

36. Spaniolas K, Trus TL, Adrales GL, Quigley MT, Pories WJ, Laycock WS. Early

morbidity and mortality of laparoscopic sleeve gastrectomy and gastric bypass in the

elderly: a NSQIP analysis. Surg Obes Relat Dis 2014;10(4):584-8.

37. Goitein D, Matter I, Raziel A, et al. Portomesenteric thrombosis following laparoscopic

bariatric surgery: Incidence, patterns of clinical presentation, and etiology in a bariatric

patient population. JAMA Surg 2013;148(4):340-6.

38. Linden BC, Barnett SJ. Adolescent bariatric surgery. In Agrawal S (ed), Obesity,

Bariatric and Metabolic Surgery: A Practical Guide, New York, Springer International

Publishing, 2015, pp 707-12.

39. Desai NK, Wulkan ML, Inge TH. Update on adolescent bariatric surgery. Endocrinol

Metab Clin North Am 2016;45(3):667-76.

40. Inge TH, Courcoulas AP, Jenkins TM, et al; Teen-LABS Consortium. Weight loss and

health status 3 years after bariatric surgery in adolescents. N Engl J Med

2016;374(2):113-23.

41. Himpens J, Dobbeleir J, Peeters G. Long-term results of laparoscopic sleeve gastrectomy

for obesity. Ann Surg 2010;252(2):319-24.

42. Hutter MM, Schirmer BD, Jones DB, et al. First report from the American College of

Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has

morbidity and effectiveness positioned between the band and the bypass. Ann Surg

2011;254(3):410-20.

43. Keren D, Matter I, Rainis T, Lavy A. Getting the most from the sleeve: the importance of

post-operative follow-up. Obes Surg 2011;21(12):1887-93.

44. Leivonen MK, Juuti A, Jaser N, Mustonen H. Laparoscopic sleeve gastrectomy in

patients over 59 years: early recovery and 12-month follow-up. Obes Surg

2011;21(8):1180-7.
45. Chiu S, Birch DW, Shi X, Sharma AM, Karmali S. Effect of sleeve gastrectomy on

gastroesophageal reflux disease: a systematic review. Surg Obes Relat Dis

2011;7(4):510-5.

46. Oor JE, Roks DJ, Ünlü Ç, Hazebroek EJ. Laparoscopic sleeve gastrectomy and

gastroesophageal reflux disease: a systematic review and meta-analysis. Am J Surg

2016;211(1):250-67.

47. DuPree CE, Blair K, Steele SR, Martin MJ. Laparoscopic sleeve gastrectomy in patients

with preexisting gastroesophageal reflux disease : a national analysis. JAMA Surg

2014;149(4):328-34.

48. Kehagias I, Spyropoulos C, Karamanakos S, Kalfarentzos F. Efficacy of sleeve

gastrectomy as sole procedure in patients with clinically severe obesity (BMI </=50

kg/m(2)). Surg Obes Relat Dis 2013;9(3):363-9.

49. van Rutte PW, Smulders JF, de Zoete JP, Nienhuijs SW. Outcome of sleeve gastrectomy

as a primary bariatric procedure. Br J Surg 2014;101(6):661-8.

50. Thereaux J, Barsamian C, Bretault M et al. pH monitoring of gastro-oesophageal reflux

before and after laparoscopic sleeve gastrectomy. Br J Surg 2016;103(4):399-406.

51. Samakar K, McKenzie TJ, Tavakkoli A, Vernon AH, Robinson MK, Shikora SA. The

effect of laparoscopic sleeve gastrectomy with concomitant hiatal hernia repair on

gastroesophageal reflux disease in the morbidly obese. Obes Surg 2016;26(1):61-6.

52. Genco A, Soricelli E, Casella G, et al. Gastroesophageal reflux disease and Barrett's

esophagus after laparoscopic sleeve gastrectomy; a possible, underestimated long-term

complication. Surg Obes Relat Dis 2017;13(4):568-74.

 53. Barr AC, Frelich MJ, Bosler ME, Goldblatt MI, Gould JC. GERD and acid reduction

medication use following gastric bypass and sleeve gastrectomy. Surg Endosc

2017;31(1):410-15.

54. Gagner M. Is sleeve gastrectomy always an absolute contraindication in patients with

Barrett's? Obes Surg. 2016;26(4):715-7.

Table 1. Randomized trials comparing SG and RYGB.

Investigators Procedures Preoperative Follow-up, Weight Conclusions

(n) BMI months loss

(kg/m2)

Peterli et al. SG (107) 43.6 36 months 63.3 SG: shorter operation

[6] RYGB 44.2 for weight %EBMIL time, fewer

(110) loss 72.8% complications.

12 months EBMIL RYGB: more effective

for for GERD

comorbidities Equivalent weight loss,

comorbidity response,

quality of life at 12

months.

Keidar et al. SG (18) 42.5 12 28.4% RYGB and SG are

[18] RYGB 42 TBW equivalent in weight

(19) 25.9% loss and HbA1c effect

TBW at 12 mos.
Schauer et SG (47) 36.1 60 18.6% Bariatric surgery is

al. [19] RYGB 37.1 TBW superior to intensive

(49) 36.4 23.2% medical therapy alone

Medication TBW in weight loss,

(38) 5.3% glycemic control,

TBW medication reduction,

and quality of life

improvement.

SG = sleeve gastrectomy; RYGB = Roux-en-Y gastric bypass; BMI = body mass index; EMBIL

= excess body mass index loss; TBW = total body weight; GERD = gastroesophageal reflux

disease; HBA1c = hemoglobin A1c.