Author’s Accepted Manuscript
Long-term nutritional impact of sleeve gastrectomy
M. Caron, F.S. Hould, O. Lescelleur, S. Marceau,
S. Lebel, F. Julien, S. Simard, L. Biertho
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http://dx.doi.org/10.1016/j.soard.2017.07.019
SOARD3076
To appear in: Surgery for Obesity and Related Diseases
Cite this article as: M. Caron, F.S. Hould, O. Lescelleur, S. Marceau, S. Lebel,
F. Julien, S. Simard and L. Biertho, Long-term nutritional impact of sleeve
g a s t r e c t o my, Surgery
for
Obesity
and
Related
Diseases,
http://dx.doi.org/10.1016/j.soard.2017.07.019
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Long-term nutritional impact of sleeve gastrectomy.
M Caron, MD1; FS Hould, MD2; O Lescelleur, MD1; S Marceau, MD1; S Lebel, MD1; F
Julien, MD1; S Simard, MSc3; L Biertho, MD1
Quebec Heart and Lung Institute - Laval University, Quebec, QC, Canada
1. Department of Internal Medicine, Laval University
2. Department of Surgery, IUCPQ - Laval University
3. Department of Biostatistics, IUCPQ – Laval University
All authors have contributed to the study, including planning, execution, analysis of the data, and
redaction.
Correspondence:
Laurent Biertho, MD.
Institut Universitaire de Cardiologie et de Pneumologie de Québec
2725, Chemin Ste-Foy
Quebec, QC, Canada, G1V 4G5
Tel: 418.656.4810
Fax: 418.656.4825
Email: laurentbiertho@gmail.com
Keywords: Bariatric Surgery, Sleeve Gastrectomy, Nutrition
Running title: Nutritional Impact of SG
Long-term nutritional impact of sleeve gastrectomy.
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Running title: Nutritional Impact of SG
ABSTRACT
BACKGROUND: Sleeve gastrectomy (SG) has become a predominant bariatric procedure
throughout the world. The long-term nutritional impact of this procedure is however
unknown.
OBJECTIVES: To describe the nutritional deficiencies before and after SG, and analyse the
influence of baseline weight on nutritional status.
SETTING: University-affiliated tertiary care center.
METHODS: All patients who underwent a SG as a stand-alone procedure between 2008 and
2012 were included in this study. Patients were given multivitamin supplementation. Data
were obtained from our prospectively maintained electronic database and are reported as
means ± standard deviation and percentages. Bivariate analyses were conducted to evaluate
the influence of selected variables on outcomes.
RESULTS: The mean age of the 537 patients was 48.0±11.3 years, with an initial BMI of
48.1±8.7kg/m2. Excess weight loss and total weight loss were 56.2% and 28.0% at 1 year and
43.0% and 21.1% at five years, respectively (p<0.0001). Percentage of follow-up was 74% at
5 years (n=79). The mean follow-up time was 34.3±17.2 months. Hypoalbuminemia was
present in 1.1% pre-op and 4.2% at five years (p=0.0043), low ferritin levels in 8.6% and
37.8% (p<0.0001), low vitamin B12 in 30.3% and 16.4% (p<0.0001), low vitamin D 63.2%
and 24.3% (p<0.0001), and hyperparathyroidism in 23.4% and 20.8% (p<0.0001). There was
no significant difference in the prevalence of anemia over time (p=0.4301). The prevalence of
vitamin A insufficiency peaked from 7.9% pre-op to 28.7% at 3 months (p<0.0001), and
returned to baseline thereafter. Baseline weight was negatively correlated with vitamin B12
and vitamin D.
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CONCLUSION: Nutritional deficiencies are common in patients with morbid obesity, before
and after surgery. Pre-operative supplementation and long-term nutritional follow-up are
required to prevent nutritional deficiencies.
Keywords: Bariatric surgery, Sleeve Gastrectomy, Nutrition
Background
The prevalence of obesity has been increasing steadily over the last two decades. However,
the prevalence of severe obesity has increased in an exponential manner, with a 225%
increase in Canada between 1990 and 2003(1). Even though recent studies suggest that the
obesity epidemic has stabilized, obesity and obesity-related diseases represent a major
healthcare and economical burden in developed countries(2). Indeed, non-surgical
management of morbid obesity is usually ineffective on the long term and surgery remains
the only effective solution for these patients(3). A number of surgical procedures have thus
been described over the last 40 years. Sleeve gastrectomy (SG) was endorsed in 2011 by the
American Society for Metabolic and Bariatric Surgery as a stand-alone treatment for morbid
obesity(4). However, SG was described in 1991 in association with biliopancreatic diversion
by Hess and Marceau(5,6). This component of the surgery was designed originally as the
restrictive and acid suppressing part of a biliopancreatic diversion with duodenal switch
(BPD-DS). Indeed, our Centre started using sleeve gastrectomy with duodenal switch (SGDS) in the early 90’s, to decrease the risk of dumping syndrome and marginal ulcers
associated with standard BPD. To date, more than four thousand SG-DS have been
performed in our institution, but we started using routinely laparoscopic SG as a stand-alone
surgery in 2008.
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All our bariatric patients undergo a standardized follow-up, including blood work and
nutritional evaluation. We perceive that, even if the amount of weight loss and the risk for
nutritional deficiencies are somewhat lower after SG than other procedures, these patients
often require vitamin and mineral supplementation on a long-term basis. Considering these
observations, the aims of this study were to (i) report weight loss parameters in a series of SG
patients over a five year follow-up, (ii) describe nutritional deficiencies before and after
surgery, and (iii) analyze the relationship between baseline weight and pre-operative and
post-operative selected nutritional deficiencies.
Methods
All patients who underwent a primary SG between January 2008 and December 2012 were
included in this trial. Procedures were performed at a University-affiliated tertiary care center
by a team of five surgeons. Data were extracted from our prospectively maintained electronic
database and reviewed retrospectively. Follow-up ended when patients died or underwent
another bariatric surgery after SG. For each time point, the follow-up rate was calculated
from the number of patients for whom a weight was obtained, divided by the number of
operated patients still included in the study at that time.
Patients’ selection
Patient selection followed the standard NIH recommendations for bariatric surgery(7). All
patients were assessed by a bariatric surgeon, dietician, nurse specialized in bariatric surgery,
and social worker. All patients underwent an electrocardiogram, chest X-ray, complete
bloodwork, sleep apnea testing, and consultation in pneumology. Patients were screened for
nutritional deficiencies before surgery and supplementation was started at that time according
to standard supplementation protocols. A consultation with a psychiatrist was requested when
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a patient had a history of psychiatric disease. Standard pre-op education specific to SG was
given to all patients.
Surgical Technique
All patients followed our routine pre-op preparation including a low-residue diet for 2 days
before surgery, prophylactic antibiotics (cefazolin two to three grams at the time of surgery)
and venous thromboembolism prophylaxis (low-dose standard or low-molecular weight
subcutaneous heparin). A 15-mm Hg pneumo-peritoneum is first created. The greater
curvature of the stomach is mobilized using ultrasonic shears (Ace Ultrasonic, Ethicon
EndoSurgery, Cincinnati, OH, USA). A 48 Fr Bougie (used between 2008 and 2010) or a
34Fr Bougie (used after 2010) is used for the calibration of the SG. The stomach is then
transected along the Bougie using an articulating linear stapler-cutter (Echelon-Flex long 60,
Ethicon EndoSurgery, Cincinnati, OH, USA), starting 4-5cm from the pylorus. Standardized
post-operative orders were used including ulcer prevention, venous thromboembolism
prophylaxis (comprising post-op compression stockings and a low dose of either standard or
low-molecular weight heparin for three weeks post-op), and feeding protocols.
Nutritional management
Patients were discharged when tolerating a soft diet, with a multivitamin complex (Centrum
Forte®) once daily. Each Centrum Forte® caplet contains, among other elements, vitamin A
1000 IU, vitamin B12 20 µg, folic acid 0.4 mg, thiamin 2.25 mg, vitamin D 600 IU, calcium
200 mg, and iron 10 mg. In addition, patients with pre-op nutritional deficiencies were treated
for a minimum of 6 months after surgery. In the particular case of vitamin D deficiency,
patients received vitamin D3 10000 IU once daily for one month, followed by 1000 IU daily
before and after surgery, until blood levels normalized.
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Follow-up
Patients were followed at the clinic at 3, 6, 9, 12, 18 and 24 months post-operatively (postop), and then yearly thereafter. Similar blood analyses were performed before surgery and at
these times, including a complete blood count, electrolytes, urea and creatinine, albumin,
calcium, phosphate, PTH, vitamin D, serum iron, total iron binding capacity (TIBC), ferritin,
vitamin B12, and folic acid. Supplementations were adjusted over time according to these
analyses using standardized supplementation protocols. Patients were weighed at each visit.
The body mass index (BMI) was calculated with the formula: Mass (in kg)/[Height (in
meters)]2. The ideal weight was calculated as patient’s height (in meters)2 X 23, for an ideal
BMI of 23 kg/m2. Excess body weight (EBW) was calculated as: Current Weight – Ideal
Weight. Initial excess weight (IEW) was calculated as: Initial Weight – Ideal weight. Total
body weight loss (TBWL) was calculated as: (Initial Weight – Current Weight)/Initial
Weight X 100. The percentage of excess weight loss (EWL) was calculated as: (Initial
Weight – Current Weight)/(Initial Weight – KID) X 100.
Statistical analyses
Nominal variables were expressed using percentages. Continuous variables from subject’s
characteristics were expressed using the mean±SD or median with interquartile range (IQR)
according to the distribution. To analyze changes among different scheduled endpoints, a
mixed model with two experimental factors was used. The factors were defined as one linked
to the variability among patients, a random factor and the other associated to the comparison
among the different periods, fixed factors. The latter was analyzed as a repeated-measure
factor with the use of a heterogeneous autoregressive covariance structure. We used residual
maximum likelihood as the method of estimation and the Kenward–Roger method to estimate
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denominator degrees of freedom for time effect. Different distributions functions were
investigated (normal, lognormal, exponential and gamma) to best fit the continuous response
variables according to the Akaike information criteria. The binomial distribution was used for
binomial response variables. The model assumption was verified with the quantile-quantile
plot representation after a Cholesky factorization on residuals from the appropriate theoretical
distribution response variable. The same approach was used to validate the normality
distribution of the variability among patients (random effect). The Pearson correlation
coefficient (R) was reported to measure the relationship between variables. The results were
considered significant with p-values 0.05. All statistical analyses were performed with SAS
v9.4 (SAS Institute, Cary, NC, USA).
Results
Clinical characteristics and weight loss
A total of 537 patients underwent a SG. Their baseline characteristics are described in Table
1. There were two peri-operative deaths in the first 90 post-operative days (0.4%). The first
one occurred 33 days after surgery from portal thrombosis, and the second 67 days after
surgery from pulmonary embolism. There were fourteen long-term deaths (2.6%) from
cancer (n=5 at 105, 453, 779, 1175 and 1776 days), kidney failure (n=2 at 823 and 1293
days), cardiovascular disease (n=2 at 775 and 1190 days), cirrhosis (n=1 at 888 days), trauma
(n=1 at 1273 days) and of unknown cause (n=3 at 257, 1058 and 1434 days). The mean
follow-up was 34.3±17.2 months, with a follow-up rate of 74% at 5 years. Figure 1 and Table
2 summarize data regarding weight loss over time. Weight loss was maximal at 18 months
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after surgery, with a TBWL of 28.2% and an EWL of 57.0%. It was followed with weight
regain, up to 5 years when EWL reached 43.0%.
Vitamin and mineral supplementation
We used each patient’s last follow-up visit to evaluate the use of vitamins or minerals
supplements. At a mean 34±17 months, 89.6% of patients were taking a daily or twice daily
multivitamin complex, 24.4% iron, 38.5% calcium, 58.2% vitamin D, and 7.5% vitamin A.
Nutritional deficiencies
Figure 2 and Tables 3 and 4 show the evolution of lab values and prevalence of nutritional
deficiencies after surgery.
There was an increase in the prevalence of albumin deficiency after SG (1.1% pre-op vs 6.6%
one year post-op, p=0.0043). Baseline weight was negatively correlated with albumin levels
pre-operatively (R= –0.18, p<0.0001) and over time, i.e. patients with higher pre-operative
weight had lower albumin levels before and after surgery.
Anemia was present in 13.5% of women and 30.2% of men before surgery and its prevalence
decreased to 11.6% and 17.3% one year post-op, respectively. These rates remained stable at
five years of follow-up. New-onset anemia ranged from 34.6% at 3 months to 80.6% at four
years. However, severe anemia (hemoglobin level under 100 g/L) was infrequent (0.4 to
2.6% over 5 years). Baseline weight was positively correlated with pre-op (R=0.11,
p=0.0150) and post-op hemoglobin.
The prevalence of vitamin B12 possible (below 221 pmol/L) and definite (below 148 pmol/L)
deficiency decreased over time (30.3% and 5.0% pre-op versus 16.4% [p<0.0001] and 1.4%
at five years, respectively). Baseline weight was negatively correlated with pre-op (R= –0.12,
p=0.0064) and post-op vitamin B12 levels. True folic acid deficiency remained virtually
absent throughout the study. The prevalence of low ferritin levels (below 30.0 µg/L)
increased sustainably (8.6% vs 37.8%, p<0.0001) at five years. Furthermore, severe
-8-
deficiency (below 9.0 µg/L) became more prevalent (0.2% at baseline vs 10.8%) at five
years. Initial weight was positively correlated with ferritin levels pre-operatively (R=0.16,
p=0.0003) and over time.
High TIBC, which is a marker of iron deficiency, was noted in 3.6% of patients at baseline
and in 15.1% (p=0.0004) after four years.
Low vitamin D levels (below 70.0 nmol/L), which were highly prevalent before surgery,
decreased sustainably (63.2% pre-op and 24.3% at five years, p<0.0001). We found a
negative correlation between baseline weight and pre-op (R= –0.24, p<0.0001) and post-op
vitamin D levels over time.
Hyperparathyroidism was noted in 23.4% of patients at baseline, 12.5% at 18 months and
20.8% at five years (p<0.0001). There was a positive relationship between baseline weight
and PTH levels before (R=0.18, p<0.0001) and after SG.
The prevalence of vitamin A insufficiency (below 1.4 µmol/L) temporarily increased from
7.9% pre-op to 28.7% at three months and then decreased to pre-operative values at 2 years
(p<0.0001). Yet, vitamin A deficiency (below 0.7 µmol/L) was almost inexistent throughout
the study.
Discussion
To our knowledge, this is the largest study assessing nutritional deficiencies following SG.
Despite an excess in calories and refined carbohydrate intakes, poor dietary choices may lead
to unmet micronutrient needs in people with morbid obesity(8,9). Several studies have
investigated nutritional deficiencies in SG patients before and after surgery(10,11,12,13,14,15).
Results from previous work support routine use of nutrition monitoring and supplementations
to prevent such deficiencies(16,17). Current guidelines from the American Society for
Metabolic & Bariatric Surgery(18) recommend post-op routine preventative micronutrient
supplementation via multivitamin caplets and specific supplements. However, the optimal
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duration of supplementation is not specified, although experts have suggested time schedules
for nutritional follow-up(19).
Evolution of weight loss
At two years, the expected EWL is approximately 60% for SG. This is consistent with the
results from our study and from others, even though few studies were designed with such a
long follow-up duration(10,12,13,20). Weight regain is common after 2 years and this is what we
experienced between 2 and 5 years. In addition, we initially used a 48 Fr Bougie to calibrate
the SG, which could have potentially led to increased risk of weight regain. Also, patients
who had a second-stage surgery during the study period (n=90), typically between 18 and 24
months post-op, were excluded from the study thereafter. This might have led to a selection
bias of patients (i.e. patients who were good candidates for a second-stage duodenal switch
were excluded from the population).
Protein malnutrition
Sufficient protein amounts are mandatory to avoid post-op complications such as poor wound
healing and infections. In addition, protein depletion is associated with loss of lean tissue
mass including skeletal muscle(21), which may promote the development of insulin resistance.
In our case, we did not record energy and macronutrients consumption, but hypoalbuminemia
served as an indicator of protein depletion. Prevalence of hypoalbuminemia peaked at one
year post-op, and then decreased slightly. This observation correlates with reduced stomach
size and ensuing food intolerance, diminished overall food intake, and accelerated gastric
emptying, all of which improve with time. Results are heterogeneous, but most reports have
shown low prevalence or absence of hypoalbuminemia after SG(10,13,22). On the other hand, in
two studies, prealbumin concentrations below 200 mg/L were observed in 14 to 52% of
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patients one year after surgery(11,22), despite routine protein supplementation in the former
study. Thus, prealbumin might be more sensitive than albumin in detecting protein depletion.
Anemia and related disorders
Anemia was noticeably prevalent at baseline, mostly in men. However, changes in
hemoglobin were minor over time. This is consistent with previous results(11,12,23). Other
studies have observed decreased hemoglobin levels after SG(10,13,20).
In contrast, ferritin levels decreased sustainably throughout follow-up. Unlike ours, most
studies did not show a significant change in the prevalence of low ferritin levels after SG, but
their follow-up was shorter(11,12,13,20). In another long term follow-up SG study, low ferritin
levels were observed in 36.2% of patients at five years compared to 3.3% at baseline(14).
The prevalence of vitamin B12 deficiency is estimated to approximately five percent among
patients with obesity, depending on defined lower limit of normal(8), which is consistent with
our pre-operative data. To date, changes in vitamin B12 levels after SG have shown mixed
results. Some SG studies have described a worsening of vitamin B12 after one year of
follow-up(12,20,24). The underlying mechanism is that resection of the gastric fundus during SG
leads to a decreased production of intrinsic factor and, as a result, impaired absorption of
vitamin B12. Moreover, reduced stomach size puts patients at risk for insufficient food
intake. Other references, as in our study, report unchanged or improved vitamin B12 levels
after surgery(10,13). Supplementation with a multivitamin containing vitamin B12 seems
sufficient in maintaining normal levels for most patients. Additionally, in case of
discontinuation of medication and return to bad nutritional habits, it would take at least three
to four years for vitamin B12 stores to deplete. Therefore, our follow-up was not long enough
to assess this occurrence.
Unsurprisingly, folate levels were almost always normal in our population. Folate deficiency
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is a rarely encountered disorder in Western countries due to regulations concerning
fortification of grain products. In comparison, a recent Chinese study found high prevalence
(32.2%) of folate deficiency in patients presenting for bariatric surgery(25).
Phosphocalcium metabolism
Vitamin D deficiency is a common finding in people with obesity and its prevalence is higher
than in normal subjects. Multiple etiologies for this phenomenon have been hypothesized.
Insufficient sun exposure, low intake of food rich in vitamin D, and poor food fortification
may contribute to low serum levels of vitamin D. In addition, vitamin D deposition in adipose
tissue is thought to enhance the problem in patients with obesity(9). One study found vitamin
D insufficiency in up to 90% of patients awaiting bariatric surgery and therefore suggested
routine vitamin D repletion for this population, regardless of ethnicity. The mean BMI was
only slightly higher than in our study (52.6 vs 48.0)(26). Unsurprisingly, we found a high
prevalence of low vitamin D levels (63%) and vitamin D insufficiency (37%). Even though
improved, rates remained high after surgery, and tended to head back towards baseline after a
few years. This could be explained by a combination of weight gain, recurrence of bad
nutritional habits, and discontinuation of supplements after some time.
In the same way, high prevalence of hyperparathyroidism was observed prior to surgery. In
fact, total body fat and BMI are inversely associated with vitamin D levels and positively
associated with PTH. Additionally, PTH excess has been shown to promote weight gain(27,28).
PTH increases intracellular calcium, which enhances lipogenesis in the adipocytes. Thus,
vitamin D deficiency and hyperparathyroidism are clearly a consequence of, but might also
contribute to obesity.
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As expected, hypocalcemia was rare throughout the study. Serum calcium tends to be
preserved in the normal range even in presence of hyperparathyroidism, which confirms the
need for PTH dosage pre-operatively(29).
Rates of low phosphate levels followed the same pattern as those of low vitamin D levels, but
a normal value could not rule out a vitamin D insufficiency.
Vitamin A
Vitamin A is a fat soluble vitamin. Low vitamin A levels are reported in up to 12.5% of
patients undergoing bariatric surgery(9). Rates of new onset or worsening hypovitaminosis A
after SG alone are not clearly defined. In our study, there was a temporarily increased
prevalence of vitamin A insufficiency immediately after surgery. This might be explained by
reduced total food intake in the first months post-op. Routine dosage of vitamin A is
currently recommended within the first post-operative year(18), but our results show that it
might be beneficial to do so earlier, i.e. in the first months after SG.
Study limits
We used a prospective design with retrospective analysis. Thus, we could not isolate the
influence of each specific variable, such as weight loss, use of supplements, dietary intake,
and clinical characteristics of patients, among others. For that reason, nutritional deficiencies
observed in our study cannot be solely attributed to SG.
Although the current standard is to use a BMI of 25 kg/m2 to calculate ideal weights, our
center has been using a 23 kg/m2 BMI in all its databases and its other publications. Thus, we
retained this parameter for practical and historical purposes.
A number of patients were lost to follow-up after three years. Yet, the absolute number of
patients remained substantial. Nonetheless, this might have led to an underestimation of
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nutritional deficiencies among SG patients, supposing that the least engaged participants had
poorer medical adherence to supplements. Unfortunately, due to the design of our database,
we could not retrieve patients’ supplements intake at each time point, but only at the last
visit. Therefore, we could not determine the effect of this parameter on the occurrence of
nutritional deficiencies. In addition, we relied on patients’ word to assess their use of
supplements, so compliance might have been overestimated.
As outlined previously, our micronutrient routine supplementation protocol differed from
current guidelines(18), which generally suggest higher micronutrient doses post-op, especially
for calcium, vitamin D, vitamin B12, and thiamin. However, since 2016, our multivitamin
complex dose was increased to two caplets daily for all patients. Also, we did not monitor
thiamine levels. This lab test is seldom requested in our setting because the sample has to be
sent abroad, which results in high cost and significant delay in analysis.
Conclusions
Nutritional deficiencies are common in patients with morbid obesity, before and after SG. Pre
and post-operative supplementation with a multivitamin complex and other appropriate
micronutrients according to nutritional status, as well as a long-term nutritional follow-up,
are required to prevent and correct nutritional deficiencies. Further studies are needed to
define optimal supplement types and doses for these patients.
Acknowledgements
We wish to acknowledge the help of Mrs Paule Marceau, research assistant, for the
collection, verification of the data.
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Disclosures
The authors have no disclosures.
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- 17 -
28. McCarty MF, Thomas CA. PTH excess may promote weight gain by impeding
catecholamine-induced lipolysis-implications for the impact of calcium, vitamin D,
and alcohol on body weight. Med Hypotheses 2003;61(5-6):535-542.
29. Hamoui N, Anthone G, Crookes PF. Calcium Metabolism in the Morbidly Obese.
Obes Surg 2004;14(1):9-12.
Legends of figures
Figure 1. Evolution of weight over time.
EWL = excess weight loss; EBW = excess body weight; SE = standard error; N = number of
patients with available data.
Figure 2. Evolution of nutritional parameters over time.
This figure shows evolution of anemia (A), iron studies (B), phosphocalcium parameters (C),
and other nutritional parameters (D). Hb = hemoglobin; TSat = transferrin saturation; PTH =
parathyroid hormone.
Table 1. Anthropometry and clinical characteristics of patients preoperatively.
Total number of patients
N = 537
Female sex, N (%)
Mean age at operation, years±SD
Mean Weight, kg±SD
Mean BMI, kg/m2±SD
Mean IEW, kg±SD
%IEW±SD
Indication for sleeve gastrectomy alone instead of other
bariatric procedures, N (%)
Patient’s desire
Compliance issue
Surgical risk or comorbidities
Two-stage approach initially planned
Per-operative decision
341 (63.5)
48.0±11.3
132.9±28.0
48.1±8.7
69.2±25.2
109.0±37.7
- 18 -
211 (39.3)
169 (31.5)
98 (18.2)
21 (3.9)
38 (7.1)
CKD, N (%)
Stage 4 (GFR 15-29)
2 (0.4)
Stage 5 (GFR <15)
3 (0.6)
Type II diabetes, N (%)
302 (56.2)
OSA, N (%)
337 (62.8)
HTN, N (%)
337 (62.8)
CAD, N (%)
79 (14.7)
Dyslipidemia, N (%)
258 (48.0)
Cirrhosis, N (%)
18 (3.4)
Arthrosis, N (%)
111 (20.7)
GERD, N (%)
161 (30.0)
Depression, N (%)
110 (20.5)
Other, N (%)
267 (49.7)
N: number of patients; SD: standard deviation; IEW: initial excess weight; BMI: body mass index; CKD:
chronic kidney disease; GFR: glomerular filtration rate (mL/min/1.73m2); OSA: obstructive sleep apnea; HTN:
hypertension; CAD: coronary artery disease; GERD: gastroesophageal reflux disease. Other comorbidities
include heart failure, asthma, gout, venous stasis, polycystic ovary syndrome, migraines, thyroid disorders, and
fibromyalgia.
Table 2. Evolution of weight loss over 5 years of follow-up.
P
value
Baseline
3 mo
6 mo
1 year
18 mo
2 years
3 years
4 years
5 years
n/N
(%)
537/537
(100)
439/536
(98.7)
443/535
(97.4)
132.9±2
8.0
110.8±2
3.5
101.1±2
3.2
235/53
2
(44.2)
94.3±2
2.6
317/53
2
(59.6)
95.5±2
2.4
278/42
6
(65.3)
95.8±2
4.5
142/23
3
(60.9)
97.1±2
2.9
79/107
(73.8)
Weig
ht
(kg)
EBW
(kg)
BMI
425/53
4
(79.6)
95.2±2
1.2
104.4±2
9.6
<0.00
01
69.2±25
.2
48.1±8.
7
0
47.4±20
.7
40.3±7.
4
31.7±10
.6
15.5±4.
5
37.8±21
.2
36.8±7.
6
47.7±15
.3
23.5±6.
3
32.0±1
9.6
34.7±7.
1
56.2±1
8.3
28.0±8.
2
30.7±2
0.3
34.1±7.
2
57.0±2
0.1
28.2±9.
5
32.0±2
0.7
34.7±7.
6
55.2±2
1.6
27.6±1
0.4
32.8±2
2.6
35.0±8.
1
52.9±2
3.0
26.1±1
1.3
34.7±2
1.2
35.8±7.
9
50.0±2
2.7
24.7±1
0.8
42.7±27
.2
38.3±9.
8
43.0±22
.9
21.1±11
.5
<0.00
01
<0.00
01
<0.00
01
<0.00
01
EWL
(%)
TBW
0
L
(%)
Values are indicated as mean±SD. Many patients who underwent surgery later in the recruitment phase had not
reached a five-year cumulative follow-up period at time of analysis. n = number of patients for whom a weight
was obtained; N = number of patients available for follow-up; Mo = months; EBW = excess body weight; BMI
= body mass index; EWL = excess weight loss; TBWL = total body weight loss.
- 19 -
Table 3. Laboratory values over 5 years of follow-up.
Nor
mal
rang
e
Albu
min
Hb
MCV
Iron
Ferriti
n
TSat
TIBC
Vitam
in B12
Folic
Acid
Vitam
in D
PTH
Calciu
35.050.0
g/L
Fem
ale :
125165
g/L
Male
:
135185
g/L
80.096.0
FL
10.030.0
µmo
l/L
30.0200.
0
µg/L
0.200.50
45.075.0
mol/
L
145.
01000
.0
pmol
/L
9.555.0
nmol
/L
70.0125.
0
nmol
/L
9.065.0
ng/L
2.15-
Baselin
e
3 mo
6 mo
1 year
18 mo
2 years
3 years
4 years
5 years
P
value
42.1±2.
8 (526)
40.9±3.
6 (482)
40.7±3.
6 (459)
40.8±3.
7 (423)
40.8±3.
8 (265)
41.4±3.
6 (314)
40.7±3.
7 (269)
40.9±3.
7 (158)
40.5±3.
6 (71)
<0.0
001
134.0±1
2.5
(526)
135.5±1
2.3
(490)
135.7±1
2.3
(465)
135.6±1
2.2
(434)
135.0±1
2.9
(269)
135.5±1
2.2
(326)
135.2±1
3.1
(280)
132.8±1
4.7
(156)
135.5±1
4.5 (76)
0.00
06
88.8±4.
9 (525)
88.6±4.
5 (488)
89.8±4.
6 (466)
90.5±4.
3 (431)
90.0±6.
3 (267)
90.2±4.
3 (324)
90.2±4.
5 (280)
89.1±5.
7 (155)
89.7±5.
0 (75)
<0.0
001
13.2±4.
5 (521)
13.0±4.
6 (477)
15.0±5.
0 (456)
16.8±5.
9 (425)
17.4±5.
9 (257)
17.8±5.
6 (311)
17.3±6.
4 (267)
16.5±6.
7 (150)
17.3±5.
6 (73)
<0.0
001
137.6±1
34.7
(486)
123.5±1
21.9
(468)
111.0±1
02.9
(456)
109.0±1
08.9
(425)
100.0±9
8.9
(254)
96.3±98
.5 (314)
89.3±94
.3 (265)
79.3±14
6.4
(153)
99.1±18
5.4 (74)
<0.0
001
0.240±0
.094
(331)
57.5±8.
7 (333)
0.240±0
.097
(216)
54.9±10
.7 (187)
0.280±0
.110
(246)
56.2±9.
7 (211)
0.300±0
.115
(258)
56.7±10
.1 (225)
0.310±0
.113
(198)
57.8±10
.0 (165)
0.310±0
.117
(255)
58.0±9.
5 (217)
0.300±0
.122
(242)
59.0±9.
2 (205)
0.270±0
.121
(145)
62.0±11
.0 (119)
0.290±0
.126
(71)
62.7±11
.5 (58)
<0.0
001
293.9±1
22.1
(522)
322.4±1
30.9
(460)
308.0±1
36.3
(453)
325.5±1
51.7
(419)
352.1±1
56.0
(256)
360.5±1
64.4
(313)
367.1±1
67.4
(270)
361.4±1
63.9
(154)
336.9±1
19.8
(73)
<0.0
001
29.5±8.
4 (521)
32.7±11
.3 (452)
38.1±10
.8 (443)
39.1±10
.7 (412)
39.8±11
.2 (255)
39.6±10
.3 (305)
38.2±11
.5 (229)
38.0±11
.4 (117)
38.3±11
.6 (54)
<0.0
001
62.3±27
.8 (516)
82.6±32
.2 (435)
88.8±29
.6 (440)
94.2±39
.4 (403)
90.7±49
.3 (254)
96.4±35
.4 (309)
90.3±26
.8 (267)
87.9±27
.5 (151)
84.7±23
.9 (74)
<0.0
001
52.0±33
.1 (521)
50.9±22
.7 (440)
47.6±25
.0 (436)
47.6±33
.9 (408)
45.8±24
.6 (248)
47.4±19
.3 (305)
52.3±21
.9 (144)
55.0±31
.0 (72)
<0.0
001
2.34±0.
2.34±0.
2.34±0.
2.33±0.
2.32±0.
2.33±0.
59.2±11
8.6
(258)
2.33±0.
2.31±0.
2.32±0.
0.00
- 20 -
<0.0
001
m
2.55
09
10
11
10
11
11
10
10
10 (72)
77
mmo (518)
(474)
(454)
(422)
(262)
(313)
(270)
(156)
l/L
Phosp 0.87- 1.00±0. 1.08±0. 1.14±0. 1.17±0. 1.14±0. 1.12±0. 1.11±0. 1.12±0. 1.09±0. <0.0
hate
1.50
18
19
20
20
17
17
22
18
18 (72)
001
mmo (523)
(472)
(452)
(412)
(259)
(309)
(268)
(151)
l/L
Vitam 1.40- 2.14±0. 1.71±0. 1.83±0. 1.96±0. 2.01±0. 2.11±0. 2.08±0. 2.06±0. 2.10±0. <0.0
in A
3.40
60
55
60
61
56
55
58
55
64 (72)
001
µmo (518)
(436)
(436)
(400)
(250)
(303)
(259)
(141)
l/L
All values are indicated as mean±SD (number of data) unless otherwise specified. The number of data varies depending on
which variables were tested at each visit. Mo = months; Hb = hemoglobin; MCV = mean corpuscular volume; TSat =
transferrin saturation; TIBC = total iron binding capacity; PTH = parathyroid hormone.
Table 4. Prevalence of nutritional deficiencies preoperatively and over 5 years of follow-up.
Hypoalbuminemi
a
Definition of
deficiency
Baselin
e
<35.0 g/L
6 (1.1)
De novo
Anemia
Women : Hb
<120 g/L
45
(13.5)
Men : Hb
<135 g/L
58
(30.2)
Overall
Severe, Hb
<100 g/L
De novo
Iron
103
(19.6)
2 (0.4)
<10.0
µmol/L
104
(20.0)
Severe, <4.0
µmol/L
<30.0 µg/L
2 (0.4)
Severe, <9.0
µg/L
1 (0.2)
TSat
<0.20
117
(35.3)
TIBC
>75.0 mol/L
12 (3.6)
Ferritin
42 (8.6)
1
year
18
mo
2
years
3
years
4
years
5
years
28
(6.6)
24
(85.7
)
33
(11.6
)
26
(17.3
)
59
(13.6
)
0
12
(4.5)
11
(91.7
)
25
(13.7
)
17
(19.8
)
42
(15.6
)
3
(1.1)
25
(59.5
)
21
(8.2)
10
(3.2)
9
(90.0
)
24
(11.1
)
20
(18.2
)
44
(13.5
)
3
(0.9)
20
(45.5
)
19
(6.1)
11
(4.1)
10
(90.9
)
24
(12.6
)
18
(20.0
)
42
(15.0
)
1
(0.4)
20
(47.6
)
22
(8.2)
3
(4.2)
2
(66.7
)
5
(10.0
)
4
(15.4
)
9
(11.8
)
2
(2.6)
6
(66.7
)
6
(8.2)
0
0
69
(22.0
)
6
(1.9)
65
(24.5
)
6
(2.3)
77
(35.6
)
7
52
(21.1
)
7
43
(16.7
)
9
30
(15.2
)
10
50
(19.6
)
11
44
(18.2
)
8
41
(28.3
)
18
1
(1.4)
28
(37.8
)
8
(10.8
)
14
(19.7
)
8
----
81
(19.1
)
7
(1.6)
2
(0.8)
45
(17.7
)
5
(2.0)
6
(3.8)
4
(66.7
)
18
(15.5
)
13
(32.5
)
31
(19.9
)
3
(1.9)
25
(80.6
)
20
(13.3
)
4
(2.7)
55
(35.9
)
11
(7.2)
0.0043
51
(29.3
)
81
(16.5
)
2
(0.4)
28
(34.6
)
115
(24.1
)
2
(0.4)
68
(14.5
)
4
(0.9)
26
(5.7)
23
(88.5
)
31
(10.1
)
35
(22.0
)
66
(14.2
)
2
(0.4)
28
(42.4
)
66
(14.5
)
2
(0.4)
71
(15.6
)
5
(1.1)
3 mo
6 mo
19
(3.9)
16
(84.2
)
30
(9.5)
- 21 -
29
(49.2
)
38
(8.9)
0
P value
----
0.4301
0.0150
0.4301
-------
<0.000
1
<0.000
1
----
<0.000
1
0.0004
Vitamin B12
Folic Acid
Vitamin D
HyperPTH
Calcium
Phosphate
(3.7)
(3.3)
(4.0)
(6.1)
(5.1)
(3.9)
100
(21.7
)
16
(3.5)
124
(27.4
)
17
(3.8)
108
(25.8
)
20
(4.8)
44
(17.2
)
6
(2.3)
42
(13.4
)
9
(2.9)
42
(15.6
)
9
(3.3)
23
(23.0
)
5
(1.1)
153
(35.2
)
43
(9.9)
41
(33.1
)
6
(1.4)
105
(23.9
)
26
(5.9)
44
(40.7
)
2
(0.5)
77
(19.1
)
22
(5.5)
18
(40.9
)
0
15
(35.7
)
0
64
(25.2
)
17
(6.7)
11
(26.2
)
1
(0.3)
56
(18.1
)
6
(1.9)
0
1
(0.2)
0
0
0
25 (4.8)
13
(3.0)
91
(20.7
)
13
(2.7)
0
12
(2.8)
56
(12.8
)
14
(3.1)
0
14
(3.4)
55
(13.5
)
11
(2.6)
0
6
(2.4)
31
(12.5
)
13
(5.0)
0
Possible,
<221.0
pmol/L
Definite,
<148.0
pmol/L
De novo,
<221.0
pmol/L
<9.5 nmol/L
158
(30.3)
<70.0
nmol/L
326
(63.2)
Insufficienc
y, <50.0
nmol/L
Deficiency,
<12.5
nmol/L
Severe, PTH
>100.0 ng/L
PTH >65.0
ng/L
192
(37.2)
<2.15
mmol/L
Severe,
<2.00
mmol/L
<0.87
mmol/L
10 (1.9)
26 (5.0)
0
122
(23.4)
1 (0.2)
114
(21.8)
(15.1
)
23
(14.9
)
2
(1.3)
(13.8
)
12
(16.4
)
1
(1.4)
7
(58.3
)
0
----
52
(19.5
)
13
(4.9)
10
(43.5
)
2
(1.7)
32
(21.2
)
9
(6.0)
18
(24.3
)
3
(4.1)
<0.000
1
0
0
0
0
----
5
(1.6)
41
(13.4
)
7
(2.2)
1
(0.3)
8
(3.1)
54
(20.9
)
7
(2.6)
0
3
(2.1)
32
(22.2
)
6
(3.8)
0
4
(5.6)
15
(20.8
)
2
(2.8)
0
----
<0.000
1
----
----
<0.000
1
<0.000
1
0.5811
----
66
22
16
12
15
20
11
6
<0.000
(14.0 (4.9)
(3.9)
(4.6)
(4.9)
(7.5)
(7.3)
(8.3)
1
)
Vitamin A
Excess, >3.4 18 (3.5) 7
11
8
6
6
6
3
3
---µmol/L
(1.6)
(2.5)
(2.0)
(2.4)
(2.0)
(2.3)
(2.1)
(4.2)
Insufficienc
41 (7.9) 125
97
61
24
22
20
18
8
<0.000
y, <1.40
(28.7 (22.2 (15.3 (9.6)
(7.3)
(7.7)
(12.8 (11.1 1
µmol/L
)
)
)
)
)
Deficiency,
0
2
3
3
0
0
0
0
0
---<0.7 µmol/L
(0.5)
(0.7)
(0.8)
All values are indicated as number of affected patients (%). The number of data for each variable and time point is the same
as the matching cell in Table 3. Mo = months; Hb = hemoglobin; de novo = was not present at baseline; TSat = transferrin
saturation; TIBC = total iron binding capacity; HyperPTH = hyperparathyroidism; PTH = parathyroid hormone.
- 22 -
- 23 -