New Guidelines for Weight-Loss Surgery Upgrade Sleeve Procedure
Sleeve gastrectomy is an effective form of bariatric surgery and should no longer be considered investigational, according to updated guidelines cosponsored by the American Association of Clinical Endocrinologists, The Obesity Society, and the American Society for Metabolic & Bariatric Surgery.
Since the last update in 2008, studies have shown sleeve gastrectomy to be comparable to other bariatric procedures, with similar weight loss as is achieved with gastric banding and gastric bypass, Adrienne Youdim, MD, of Cedars-Sinai Weight Loss Center in Los Angeles, and colleagues wrote in the updated guideline, which was published in the March issue of Obesity.
Sleeve gastrectomy has "historically been used in patients who are too high risk for gastric bypass, but as more data have been collected on outcomes with sleeve gastrectomy, it has become clear that this surgery is effective in its own right," Youdim told MedPage Today.
Jeffrey Mechanick, MD, of Mount Sinai in New York City, a co-author of the guidelines and president-elect of AACE, said the guidelines were in need of an update because "there's a lot of new information that's relevant to clinical practice."
But the guidelines still steer away from recommending one procedure over another.
"We were reluctant to give clear-cut recommendations on which procedure to use, because it depends on regional expertise," Mechanick told MedPage Today.
The writers did note, however, that clinicians should use more caution with the more aggressive biliopancreatic diversion with duodenal switch, and although they "don't dissuade people from using the band, it's clear in the discussion that the results one sees with the band might be shorter-lived and of lesser dimension in terms of weight loss."
The recommendations pin the gastric sleeve procedure between banding and bypass in terms of weight loss, Mechanick said.
What makes a good candidate for any of the procedures is another area covered in the guidelines, and Youdim said there's more evidence for using bariatric surgery as "metabolic" surgery to treat cardiometabolic complications such as type 2 diabetes, although, she noted, questions remain, particularly about long-term outcomes for safety and diabetes remission rates.
The new guidelines suggest that patients with a BMI of 30 to just under 35 who have type 2 diabetes may be offered bariatric surgery, Youdim said, with the caveat that the evidence is limited.
The FDA approved gastric banding for this patient population in 2011.
Other controversial candidates include patients with mild or moderate obesity, as well as those at "extremes of age" -- typically adolescents at one end and much older patients at the other.
Research has been done in these groups but there aren't sufficient data to make recommendations on these populations, the researchers wrote.
The two groups of patients for whom there is the strongest evidence that bariatric surgery is safe and effective are still patients with a BMI of 40 and above, and those with a BMI of 35 and above plus comorbidities.
Overall mortality has also improved since the 2008 guideline was issued, the researchers said, with one large Swedish study showing about a 30% reduced risk of death over the 10 years following bariatric surgery, along with a cohort study showing about a 50% reduced risk of death over 20 years.
Youdim added that the guideline addresses a broad range of perioperative factors such as pre- and postoperative nutrient screening, assessment of comorbidities such as sleep apnea, and the need for psychosocial and behavioral evaluations before and after surgery.
For instance, since 2008, more studies have looked at alcohol use before and after surgery, with some finding an increased prevalence of problem drinking after weight loss.
The new guideline also includes updated evidence for counseling women of reproductive age about an increased risk of pregnancy after surgery, and it's recommended that they refrain from trying to get pregnant for one year after surgery, Youdim said.
Many of the recommendations from 2008 are "now backed by a higher level of evidence," she said. "The current document has level I or level II evidence for up to 40% of the recommendations, compared with only 16% in the prior document."
Mechanick added that the guidelines emphasize a team approach to bariatric surgery in order to prevent and treat complications such as metabolic disease that may arise.