Single anastomosis sleeve ileal (SASI) bypass versus sleeve gastrectomy: a case-matched multicenter study
01 Feb 2021-Surgical Endoscopy and Other Interventional Techniques (Surg Endosc)-Vol. 35, Iss: 2, pp 652-660
TL;DR: Both procedures had similar weight loss at 6 months postoperatively and comparable complication rates and SASI bypass conferred better improvement in T2DM and GERD than SG.
Abstract: The present study aimed to compare the outcome of single anastomosis sleeve ileal (SASI) bypass and sleeve gastrectomy (SG) in regards weight loss, improvement in comorbidities at 12 months of follow-up, and postoperative complications. This was a case-matched, multicenter analysis of the outcome of patients who underwent SG or SASI bypass. Patients who underwent SASI bypass were matched with an equal number of patients who underwent SG in terms of age, sex, BMI, and comorbidities. The main outcome measures were excess weight loss (EWL) at 6 and 12 months after surgery, improvement in medical comorbidities, and complications. A total of 116 patients (97 female) of a mean age of 35.8 years were included. Fifty-eight patients underwent SASI bypass and an equal number underwent SG. %EWL at 6 months postoperatively was similar between the two groups. SASI bypass conferred significantly higher %EWL at 12 months than SG (72.6 Vs 60.4, p < 0.0001). Improvement in type 2 diabetes mellitus (T2DM) and gastroesophageal reflux disease (GERD) after SASI bypass was better than SG (95.8% Vs 70% and 85.7% Vs 18.2%, respectively). SASI bypass required longer operation time than SG (108.7 Vs 92.8 min, p < 0.0001). Complications occurred in 12 (20.7%) patients after SG and 4 (6.9%) patients after SASI bypass (p = 0.056). The %EWL at 12 months after SASI bypass was significantly higher than after SG. SASI bypass conferred better improvement in T2DM and GERD than SG. Both procedures had similar weight loss at 6 months postoperatively and comparable complication rates.
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TL;DR: SASI bypass is a newly introduced investigational procedure for improving weight loss and comorbidities; however, it may result in EWL and protein malnutrition and should only be performed for select patients and by well-experienced bariatric surgeons.
Abstract: Single anastomosis sleeve ileal (SASI) bypass is a new bariatric and metabolic procedure that has both restrictive and malabsorptive effects. This study was conducted to assess both the efficacy and safety of this procedure in a short-term follow-up. This retrospective cohort study examined weight loss- and obesity-related comorbidities and complications in patients who had undergone SASI bypass from October 2017 to March 2018 at a center of excellence for bariatric/metabolic surgery. Twenty-four patients had undergone SASI bypass due to some existing risk factors of gastric cancer or premalignant lesions in the esophagogastroduodenoscopy. The mean BMI of the patients was 44.2 (median 43.7, range 37.0–54.8) kg/m2. Six and 12 months after surgery, the mean (median) excessive weight loss (EWL) was 67.8% (63.3) and 86.2% (82.9) and total weight loss (TWL) was 28.5% (27.6) and 36.46% (35.8), respectively. Most patients had complete remission in type 2 diabetes mellitus (89%), arterial hypertension (86%), dyslipidemia (100%), obstructive sleep apnea (100%), and non-alcoholic fatty liver disease (73%) during the 1 year after surgery. One case of extra-luminal bleeding and one case of trocar site hernia occurred after surgery. Moreover, two patients converted to sleeve gastrectomy because of hypoalbuminemia and EWL about 1 year after SASI. SASI bypass is a newly introduced investigational procedure for improving weight loss and comorbidities; however, it may result in EWL and protein malnutrition and should only be performed for select patients and by well-experienced bariatric surgeons.
24 citations
Cites background or result from "Single anastomosis sleeve ileal (SA..."
...[5] and better than similar studies, which had reported 36–57% rates [7, 13]....
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...The first mechanism is the decrease in Ghrelin after sleeve gastrectomy, and the second is hindgut stimulation by the rapid transition of food to the terminal part of the small bowel, which can stimulate the satiety hormones and also decrease the proximal bowel movement and delay gastric emptying [4, 7, 8]....
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...6 6 and 12 months after SASI bypass, respectively [7]....
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...[5], but better than those of two other studies (65–88%) [7, 13]....
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TL;DR: In this paper, the authors conducted a systematic literature search, querying electronic databases and Google Scholar, for studies that reported the outcome of the SASI bypass, and the main outcome measures of the review were change in body mass index (BMI), % of excess weight loss (%EWL), improvement in comorbidities, and complications.
16 citations
TL;DR: The authors based their recommendation to use SASI bypass selectively on the fact that two of their patients required conversion to sleeve gastrectomy due to excessive weight loss or severe protein malnutrition, and concur that these consequences can follow SASi bypass, certain points need to be highlighted.
Abstract: Dear Editor We read with great interest the article titled “1-Year Follow-up of Single Anastomosis Sleeve Ileal (SASI) Bypass in Morbid Obese Patients: Efficacy and Concerns” by Kermansaravi et al. [1]. Firstly, we would like to congratulate the authors on this important study and want to clarify a few issues with regard to the study and its conclusions. We think the conclusions of the study need to be restated as the authors started their conclusions in the abstract by describing SASI bypass as an investigational procedure which is not entirely true. Since it was first described, SASI bypass has been assessed in several studies, including a large multicenter study entailing 551 patients from seven countries [2] and a bicenter cohort study comparing SASI bypass with sleeve gastrectomy [3]. Hence, we could better describe the procedure as newly introduced, rather than an investigational procedure. The authors then recommended “to use SASI bypass only as a conversional surgery after sleeve failure or as a de novo procedure in carefully selected patients” [1]. We think this recommendation is not based on data of their study since none of the 24 patients in their series underwent SASI bypass as a revision after failed sleeve gastrectomy or other procedures. Moreover, the term “carefully selected patients” is not precisely defined for the readers. The patients selected for their series had either focal intestinal metaplasia and/or gastric atrophy, unresectable antral polyps, or family history of gastric cancer which are not the usual patient population on whom bariatric surgery is performed. The authors based their recommendation to use SASI bypass selectively on the fact that two of their patients required conversion to sleeve gastrectomy due to excessive weight loss or severe protein malnutrition. While we concur that these consequences can follow SASI bypass, certain points need to be highlighted. Although the previous studies that assessed the nutritional changes after SASI bypass reported a reduction of serum albumin levels postoperatively, the albumin levels remained within normal range and none of the patients required conversional surgery. The first published study by Mahdy et al. [4] reported that serum albumin levels showed insignificant changes from 3.8 ± 0.7 g/dl before surgery to 4.3 ± 0.4 g/dl at 6 months then was reduced to 4.1 ± 0.9 g/dl at 12 months postoperatively. Although the largest multicenter series on SASI bypass [2] and another study by Salama et al. [5] recorded a significant decrease in serum albumin levels at 12months after SASI bypass, the mean postoperative serum albumin level was 3.9 g/dl, within normal range, in both studies. Another randomized trial [6] that compared SASI bypass with sleeve gastrectomy did not observe any significant difference in the incidence of hypoalbuminemia between the two procedures (11% versus 8%). One important limitation of the study by Kermansaravi et al. [1] is the small number of patients included which can lead to type II error when analyzing the outcomes. This was readily apparent when assessing the improvement in comorbidities. Although the remission of diabetes mellitus and hypertension was recorded in about 89% and 86% of patients, this result was not statistically significant. However, we still concur that excessive weight loss and hypoalbuminemia, despite being infrequently recorded, are still possible after SASI bypass. To decipher the mechanism of these consequences after SASI bypass, one must comprehend the basic physiologic aspects of the procedure. As the procedure depends on the bipartition principle, certain technical aspects should be respected in order not to end with a complete diversion of food instead of bipartition. * Sameh Hany Emile sameh200@hotmail.com
8 citations
Cites result from "Single anastomosis sleeve ileal (SA..."
...Since it was first described, SASI bypass has been assessed in several studies, including a large multicenter study entailing 551 patients from seven countries [2] and a bicenter cohort study comparing SASI bypass with sleeve gastrectomy [3]....
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TL;DR: The SASI bypass is an effective bariatric surgery that achieved sequential weight loss and improvement in medical comorbidities three years after the surgery; however, standardization of SASI procedure technique is needed to ameliorate nutritional deficiencies.
5 citations
TL;DR: SASI bypass is an effective and safe bariatric surgical procedure that achieves satisfactory weight loss with significantly improvement in obesity-related complications, such as T2DM and GERD, and minimal postoperative nutritional complications.
4 citations
References
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TL;DR: Five‐year outcome data showed that, among patients with type 2 diabetes and a BMI of 27 to 43, bariatric surgery plus intensive medical therapy was more effective thanintensive medical therapy alone in decreasing, or in some cases resolving, hyperglycemia.
Abstract: BackgroundLong-term results from randomized, controlled trials that compare medical therapy with surgical therapy in patients with type 2 diabetes are limited. MethodsWe assessed outcomes 5 years after 150 patients who had type 2 diabetes and a body-mass index (BMI; the weight in kilograms divided by the square of the height in meters) of 27 to 43 were randomly assigned to receive intensive medical therapy alone or intensive medical therapy plus Roux-en-Y gastric bypass or sleeve gastrectomy. The primary outcome was a glycated hemoglobin level of 6.0% or less with or without the use of diabetes medications. ResultsOf the 150 patients who underwent randomization, 1 patient died during the 5-year follow-up period; 134 of the remaining 149 patients (90%) completed 5 years of follow-up. At baseline, the mean (±SD) age of the 134 patients was 49±8 years, 66% were women, the mean glycated hemoglobin level was 9.2±1.5%, and the mean BMI was 37±3.5. At 5 years, the criterion for the primary end point was met by 2...
1,905 citations
TL;DR: In obese patients with uncontrolled type 2 diabetes, 12 months of medical therapy plus bariatric surgery achieved glycemic control in significantly more patients than medical therapy alone.
Abstract: Of the 150 patients, 93% completed 12 months of follow-up. The proportion of patients with the primary end point was 12% (5 of 41 patients) in the medicaltherapy group versus 42% (21 of 50 patients) in the gastric-bypass group (P = 0.002) and 37% (18 of 49 patients) in the sleeve-gastrectomy group (P = 0.008). Glycemic control improved in all three groups, with a mean glycated hemoglobin level of 7.5±1.8% in the medical-therapy group, 6.4±0.9% in the gastric-bypass group (P<0.001), and 6.6±1.0% in the sleeve-gastrectomy group (P = 0.003). Weight loss was greater in the gastric-bypass group and sleeve-gastrectomy group (−29.4±9.0 kg and −25.1±8.5 kg, respectively) than in the medical-therapy group (−5.4±8.0 kg) (P<0.001 for both com parisons). The use of drugs to lower glucose, lipid, and blood-pressure levels decreased significantly after both surgical procedures but increased in patients receiving medical therapy only. The index for homeostasis model assessment of insulin resistance (HOMA-IR) improved significantly after bariatric surgery. Four patients underwent reoperation. There were no deaths or life-threatening complications. Conclusions In obese patients with uncontrolled type 2 diabetes, 12 months of medical therapy plus bariatric surgery achieved glycemic control in significantly more patients than medical therapy alone. Further study will be necessary to assess the durability of these results. (Funded by Ethicon Endo-Surgery and others; ClinicalTrials.gov number, NCT00432809.)
1,542 citations
TL;DR: Information is provided on the percentage of patients comprising the original study group who complete each follow-up period reported for the study and the reasons for patient attrition from the study should be reported when possible.
Abstract: ASMBS, SOARD, outcome reporting standards Standardized outcomes reporting in metabolic and bariatric surgery Stacy A Brethauer, MD*, Julie Kim, MD, Maher el Chaar, MD, Pavlos Papasavas, MD, Dan Eisenberg, MD, Ann Rogers, MD, Naveen Ballem, MD, Mark Kligman, MD, Shanu Kothari, MD for the ASMBS Clinical Issues Committee Bariatric and Metabolic Center, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio Department of Surgery, Tufts University, Boston, Massachusetts Department of Surgery, St Luke’s Hospital, Allentown, Pennsylvania Department of Surgery, Hartford Hospital, Hartford, Connecticut Department of Surgery, Stanford University and Palo Alto VA Health Care Center, Palo Alto, California Department of Surgery, Penn State University, Hershey, Pennsylvania Center for Advanced Surgical Weight Loss, Montclair, New Jersey Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland Department of Surgery, Gundersen Health System, La Crosse, Wisconsin Received February 2, 2015; accepted February 2, 2015
292 citations
TL;DR: The mechanisms responsible for GERD in obese subjects as well as the results after a SG with respect to GERD are reviewed, along with the current surgical options for morbidly obese patients with GERD and undergoing bariatric surgery.
Abstract: Bariatric surgery is the only effective procedure that provides long-term sustained weight loss. Sleeve gastrectomy (SG) has emerged over the last few years to be an ideal bariatric procedure because it has several advantages compared to more complex bariatric procedures, including avoiding an intestinal bypass. However, several published follow-up studies report an increased rate of gastroesophageal reflux (GERD) after a SG. GERD is described as either de novo or as being caused by aggravation of preexisting symptoms. However, the literature on this topic is ambivalent despite the potentially increased rate of GERDs that may occur after this common bariatric procedure. This article reviews the mechanisms responsible for GERD in obese subjects as well as the results after a SG with respect to GERD. Future directions for clinical research are discussed along with the current surgical options for morbidly obese patients with GERD and undergoing bariatric surgery.
189 citations
TL;DR: The postoperative prevalence of GERD, esophagitis, and BE following SG is significant and the long-term outcomes of this commonly performed bariatric procedure should be considered alongside its weight loss and metabolic effects.
Abstract: Objective The aim of this study was to appraise the prevalence of gastroesophageal reflux disease (GERD), esophagitis, and Barrett's esophagus (BE) after sleeve gastrectomy (SG) through a systematic review and meta-analysis. Background The precise prevalence of new-onset or worsening GERD after SG is controversial. Subsequent esophagitis and BE can be a serious unintended sequalae. Their postoperative prevalence remains unclear. Methods A systematic literature search was performed to identify studies evaluating postoperative outcomes in primary SG for morbid obesity. The primary outcome was prevalence of GERD, esophagitis, and BE after SG. Meta-analysis was performed to calculate combined prevalence. Results A total of 46 studies totaling 10,718 patients were included. Meta-analysis found that the increase of postoperative GERD after sleeve (POGAS) was 19% and de novo reflux was 23%. The long-term prevalence of esophagitis was 28% and BE was 8%. Four percent of all patients required conversion to RYGB for severe reflux. Conclusions The postoperative prevalence of GERD, esophagitis, and BE following SG is significant. Symptoms do not always correlate with the presence of pathology. As the surgical uptake of SG continues to increase, there is a need to ensure that surgical decision-making and the consent process for this procedure consider these long-term complications while also ensuring their postoperative surveillance through endoscopic and physiological approaches. The long-term outcomes of this commonly performed bariatric procedure should be considered alongside its weight loss and metabolic effects.
177 citations