The most important factors leading to obesity are irrational nutritional habits [12
]. Surgical management of obesity is currently the most effective in treating causes of obesity, its symptoms and systemic effects such as AHT, T2DM, cardiovascular disorders, dyslipidaemias, OSA, hepatic steatosis, gastroesophageal reflux disease (GERD), generalised oedema, depressive syndromes, osteoarthritis and neoplasms (including gastrointestinal neoplasms) [13
]. The results of surgery are especially noticeable because other treatment modalities with different pharmacological options do not satisfy the expectations of patients.
Obesity is a disorder that has been quite extensively examined in North America and Europe. However, with increasing frequency new studies indicate the rising rates of obesity in developing countries, and even in countries that were considered undeveloped economically so far. That trend is also visible in Poland, which accelerates the development of bariatric services in our country [3
]. Each bariatric procedure leads to some extent of weight loss [15
]. Although the sleeve gastrectomy is one of the most recently introduced bariatric procedures and the availability of published outcomes is modest, it does not seem to be inferior to other procedures and some authors claim its superiority in terms of BMI reduction [16
]. The weight loss after LSG is achieved due to two mechanisms of restriction and hormonal modulation. The presented results of LSG surgery are similar to published results of other bariatric centres worldwide. We proved that the BMI reduction continued for the whole 6-month observation period and was comparable to the results of Armstrong and O'Malley [17
] or Karamanakos et al
]. Short-term outcomes of LSG are comparable to other techniques, and to laparoscopic adjustable gastric banding (LAGB) outcomes. Nevertheless, the long-term (> 1 year) outcomes are in favour of LSG. These effects are visible at 1, 2, 3 years or even later, though the greatest effect was observed at 1 and 2 years after surgery [19
World literature supports the thesis of reduction of plasma levels of ghrelin using non-surgical management such as a low-energy diet, lifestyle modification or increased physical activity. The effects of bariatric procedures on ghrelin levels are diverse. Some of the procedures increase ghrelin levels, some decrease the levels and others do not influence levels. Laparoscopic sleeve gastrectomy significantly reduces the production of ghrelin in 90% of patients in a durable fashion [23
]. It is probably the result of resecting the gastric fundus where the majority of ghrelin production takes place [25
]. Age and gender are not proved to have an influence on the plasma levels of this orexigenic hormone. In turn, food intake plays a crucial role in ghrelin plasma secretion. The greatest reduction in plasma levels of ghrelin can be observed as a result of high-carbohydrate meal ingestion, and slightly less reduction is observed following a high-fat meal. Studies on the influence of high-protein meals are inconclusive and contradictory [26
]. The relationship between body mass reduction and the plasma levels of ghrelin are very complex as we can frequently observe weight loss despite a reduction in the peripheral levels of ghrelin. In the presented study we could observe the reduction of plasma levels of ghrelin after 7 days, and that continued to decrease after the 1st
postoperative months. At the end of the observation at 6 months we could observe a slight elevation of the mean ghrelin level reaching the level seen at the end of the first postoperative month.
An important effect of the weight loss is the improved metabolism of glucose and the reduction of insulin resistance and thus the clinical improvement of T2DM. Also other bariatric procedures influence T2DM. The co-existence of obesity with insulin resistance has been studied extensively and is well documented. Silecchia et al
. documented resolution of non-insulin-dependent DM (NIDDM) in 69.2% and 76.9% of patients, 12 and 18 months after LSG, and improvement of NIDDM in 15.4% and 15.4% in patients with super morbid obesity [28
]. It has been suggested that the patients with diagnosis of T2DM shorter than 5 years benefit more from the bariatric surgery than those who suffered from T2DM for more than 5 years [29
]. Rizzello et al
. demonstrated fast insulin tolerance and insulin resistance improvement following LSG that was independent of body mass reduction [30
]. In a study comparing outcomes of LAGB and LSG, Frezza et al
. noted that LSG provides better glucose control at 1 and 1.5 years after surgery than the LAGB, which seems to be suggestive of an important but not well understood influence of resection of the gastric fundus [31
In our study the symptoms of metabolic syndrome improved significantly following LSG. It allowed for the reduction of pharmacological treatment of co-morbidities. Laparoscopic sleeve gastrectomy is comparable to LAGB among other procedures in regards to the reduction of symptoms of T2DM and also to the majority of components of metabolic syndrome. It is particularly visible one year after surgery [32
]. Studies comparing LSG with other operative techniques are still rare due to the natural history of LSG. Nevertheless, the available literature indicates that the LSG procedure is comparable to laparoscopic Roux-en-Y gastric bypass (LRYGBP) [34
]. Hence, the authors conclude that the small intestine is not a significant part of the glucose homeostasis chain. It has been supported by the comparison of LAGB and LRYGBP, where there was a reduction of insulin resistance in both groups without a significant influence of duodenal and small intestine switch [35
]. Thus, it seems that the above improvement is a result of body mass reduction rather than the use of particular operative technique.
Available studies indicate that the greatest benefit of bariatric surgery with regards to the amelioration of components of the metabolic syndrome is seen in patients in the second and third class of obesity. Some of the studies show that the use of LSG provides a similar effect on metabolic syndrome to LRYGBP [36
], while some other studies favour LRYGBP [37
]. Some authors indicate the effect of weight loss, although the preoperative triglyceridaemia and diabetic status also matter [38
]. In some of the longitudinal studies investigators showed that the weight loss following LSG [28
] does not always cause significant improvement of metabolic syndrome and its lipid profile [39
We observed a significant reduction of insulin levels, particularly at the 7th postoperative day and 3 months after surgery. Glucose levels decreased as well. Insulin resistance (expressed as the HOMA IR) decreased significantly 7 days and 1 month after surgery. A smaller effect was seen 6 months after the procedure. The level of triglycerides decreased noticeably 7 days after surgery, decreasing systematically from the first postoperative day through the following 6 months. Total cholesterol level also decreased during the observation.
Chen et al
. tried to prove a synergistic correlation between obesity, insulin resistance and ALT levels. They suggest that such a correlation might be much more clinically significant in the diagnosis of insulin resistance than the metabolic syndrome itself [40
]. Bariatric surgery has become a treatment of choice in super morbid obesity and as such proved to be the only effective modality controlling weight loss for the long term. Moreover, the majority of patients with the aforementioned co-morbid conditions recovered or achieved an improvement in symptoms. We noted a greater effect of bariatric surgery in patients with a greater number of co-morbidities [41
]. Thanks to all above-mentioned effects, LSG is one of the most popular bariatric procedures in our centre [42
Bariatric techniques and standards are still being developed [43
]. But at this stage one can conclude that the evolution of both significantly reduces the risk of complications and patients’ postoperative discomfort [44
]. The possibility of applying SG as a stand-alone and definitive treatment with the option of a two-stage procedure constitutes significant progress [45
Adequate consideration should be paid to the recently published technique of LSG combined with simultaneous application of adjustable gastric banding (AGB), not only due to the metabolic benefits [48
]. We should think what benefits might come from adding restrictive and malabsorptive techniques. In theory, benefits of such a procedure might not be better than those of each procedure on its own, or there might be a synergistic effect of the procedure. However, it seems that this technique might be more effective because the band would prevent the stomach from dilating, and the sleeve resection and removal of the gastric fundus with cells producing ghrelin would reduce appetite. This however still requires further clinical evaluation. One of the first papers describing glucose homeostasis and body mass reduction in patients after combined procedures of LSG and LAGB was published recently [49
]. The outcomes seem very promising, but due to the small size of the study group and short follow-up time further studies are needed.