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ORIGINAL
The Effect of Laparoscopic Sleeve Gastrectomy on Obesity
and Obesity-related Disease : the Results of 10 Initial Cases
Hideya Kashihara1, Mitsuo Shimada1, Kozo Yoshikawa1, Jun Higashijima1, Tomohiko Miyatani1,Takuya Tokunaga1, Masaaki Nishi1, Chie Takasu1, and Yasuhiro Hamada2
Department of Surgery, Tokushima University, Tokushima, Japan, 2Department of Therapeutic nutrition, Tokushima University, Tokushima,
Japan1

Abstract : Introduction : The number of patients who undergo laparoscopic sleeve gastrectomy (LSG) has been increasing. Department of Surgery, Tokushima University performed the first LSG in 2013. The aim of this study wasto report the results of the initial ten cases who underwent a LSG. Patients and methods : Ten obese patients : fivemales and five females ; age range from thirty-three years to fifty-six years (mean age 42.2 years) ; mean bodymass index (BMI) 50.3 ; five with diabetes ; nine with hypertension (HT) ; four with hyperlipidemia (HL) ; eightwith sleep apnea syndrome (SAS) who underwent LSG were enrolled in this study. The data was analyzed retrospectively and included short- and long-term outcomes. Results : There were no post-operative complications inthis study. The %EWL at three and six months and one year post-operative were 44.2%, 50.2% and 48.6% respectively. In three months post-operative the non-alcoholic fatty liver (NAFLD) and non-alcoholic steatohepatitis(NASH) had improved transaminase (AST/ALT), liver to spleen ratio in plain CT value. Improvements were also
evident in the obesity-related diseases : diabetes 80% (4/5) ; HT 67% (6/9) ; HL 75% (3/4) ; and SAS 88% (7/8). Conclusion : LSG is a promising option for the treatment of morbid obesity and obesity-related diseases. J. Med. Invest.
66 : 289-292, August, 2019
Keywords : LSG, HT, HL, SAS, NASH

INTRODUCTION
Metabolic syndrome (MS) is a disease characterized by obesity, diabetes, hypertension, and dyslipidemia. The incidence ofMS has increased along with rapid economic development andan associated change in diet (1). Consequently, increased attention has been paid to the prevention of MS.
There is strong published evidence that bariatric surgery isan effective means to sustain long-term weight loss (2-4). Some
reports have shown that bariatric surgery is superior to internal
medicine in the treatment of MS (5). Especially, bariatric surgery is reported to achieve complete remission in obese patientswith type 2 diabetes mellitus (T2DM) (6).
The authors previously reported that duodenal-jejunal bypass
improved T2DM and liver steatosis by enhancing glucagon like
peptide-1 (GLP-1) secretion through increasing serum bile acids
and the proliferation of L cells in the ileum in vivo (7).
Three (3) main bariatric surgeries are performed worldwide : gastric banding ; Roux-en-Y gastric bypass (RYGB) ; andsleeve gastrectomy (SG).
The laparoscopic sleeve gastrectomy (LSG), initially used as
the first stage of a more complex procedure (duodenal switch orgastric bypass) in patients with high surgical risk, has gained
popularity in recent years due to reported good short-term results and its relatively lower technical difficulties (8, 9).
Key words and acronyms
laparoscopic sleeve gastrectomy (LSG) ; Body Mass Index (BMI) ; type2
diabetes mellitus (T2DM) ; hypertension (HT) ; hyperlipidemia (HL) ;sleep apnea syndrome (SAS) ; percent excess weight loss (%EWL) ; nonalcoholic fatty liver (NAFLD) ; non-alcoholic steatohepatitis(NASH) ; Roux-en-Y gastric bypass (RYGB) ; glucagon-like peptide 1 (GLP1) ; metabolic syndrome (MS) ; sleeve gastrectomy (SG) ; transaminase(AST/ALT) ; computed tomography (CT) ; bariatric surgery ; bodyweight (BW) ; vertical sleeve gastrectomy (VSG) ; hemoglobin A1c(HbA1c) ; farnesoid X receptor (FXR) ; duodenal-jejunal bypass (DJB)

In Japan, the number of patients who have undergone aLSG has been increasing (10) since the Department of Surgery,
Tokushima University performed the first LSGs in 2013. These
initial ten (10) LSG cases are the focus of this study.

MATERIALS AND METHODSPatient selection and data collection

Patients were included in this study based on the following
indicators : a LSG at the Tokushima University Hospital ; aged
between 18 years and 60 years ; a body mass index (BMI)of > 35 kg/m2-- ; internal therapy of > 6 months ; and co-morbidity
with : T2DM ; hypertension (HT) ; hyperlipidemia (HL) ; or sleep
apnea syndrome (SAS).
The exclusion criteria were : known malignancies ; pregnancy ; and conditions associated with poor compliance (psychiatricillness).
The protocol for this research project was approved by a suitably constituted Ethics Committee of the Tokushima University
Hospital.
From 2013 to 2017, ten (10) patients (5 males and 5 females ; age range from 33 years to 56 years (mean age 42.2years) ; and a mean BMI of 50.3) were referred to the Tokushima
University for treatment of morbid obesity. Co-morbidity included
Received for publication March 20, 2019 ; accepted June 12, 2019.
Address correspondence and reprint requests to Hideya Kashihara,
M.D., PhD., Department of Surgery, Tokushima University, 3-18-15
Kuramoto-cho, Tokushima, 770-8503, Japan, and Fax : +81-88-631-9698.

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H. Kashihara, et al. The effect of sleeve gastrectomy290

the following : five (5) patients with T2DM ; nine (9) patientswith HT ; four (4) patients with HL ; and eight (8) patients withSAS (Table 1).
Data were collected retrospectively from medical records andsupplemented with data and laboratory results.
Table 1. Patients’ characteristics before LSG.
Factors
Age (y.o.)Gender : male/female
BW (kg)n = 10

Table 2. Short-term outcome after LSG.
Factorsn = 10Operation time (min.)

233 ± 20.7

Blood loss (ml)11.7 ± 13.1

Postoperative complication (%)

0Hospital stay after LSG (days)

30.8 ± 8.0

Weight loss during hospital stay (kg)16.2 ± 5.8

42.2 (33 – 56)
5/5
138.8 (100.9 – 165.9)

BMI (kg/m2)

50.3 (42.5 – 60.1)

Comorbidity

T2DM 5, HT 9, HL 4, SAS 8

HbA1c (%)

6.2 (4.9 – 8.4)

Technical description of a LSG
All surgical procedures were started laparoscopically. First,
the greater curvature and the angle of His were dissected to staple the gastric fundus and greater curvature parallel to a gastricfiber, which was inserted in the stomach through the esophagus.
Stapling (total five (5) to eight (8) times) was started from a distance of 5 cm to 8 cm from the pylorus on the greater curvatureside toward the angle of His. This resulted in a tube-like stomach
with a volume of approximately 100 mls made from the lesser
curvature only. The staple line was reinforced by 3-0 PDS andvicryl continuous sutures.

Post-operative management

Table 3. Long-term outcome after LSG.
Factorsn = 10%EWL in postoperative 3 months

44.2 (20.6 – 56.9)%EWL in potoperative 6 months

50.2 (32.0 – 61.6)%EWL in postoperative 1 year

48.6 (35.5 – 62.6)

Improvement of obesity-related diseaseT2DM 80% (4/5)
Hypertension 67% (6/9)
Hyperlipidemia 75% (3/4)
SAS 88% (7/8)

HbA1c (%) in postoperative 3 months

5.4 (4.8 – 6.5)

At three (3) months post-operative the LSGs had decreased
the value of transaminase (AST/ALT) and increase the ratio ofliver to spleen in plain CT value. Therefore, the LSGs contributed to the improvement of non-alcoholic fatty liver (NAFLD)/
non-alcoholic steatohepatitis (NASH) (Figures 1a ; 1b ; 1c and1d).

After the LSGs, the patients were started with water on dayone (1) post-operative and a liquid diet on days four (4) and five(5) post-operative. A thrombosis prophylaxis was administered
twice a day for a week.
After discharge, the patients were followed up once a monthfor two (2) months. At outpatient’s clinic, the body weight (BW),blood test and plain CT of the patients were evaluated. For thepurpose of the evaluation for fatty liver, the ratio of liver to spleenin plain CT was used. The ratio of liver to spleen in plain CTvalue > 1.0 indicated fatty liver.

Statistical analysisThe t-test was used for statistical analysis of the continuousvariables. For all tests, p < 0.05 was interpreted as significant.
The values for each continuous variable were expressed as amean ± the standard deviation (SD).

RESULTS
An overview of the short-term outcomes after the LSGs isgiven in Table 2. The operation time was 233 ± 20.7 minutes
and the blood loss was 11.7 ± 13.1 ml. The hospital stay after theLSGs was 30.8 ± 8.0 days and the weight loss during the hospital
stay after the LSGs was 16.2 ± 5.8 kg. There were no post-operative complications after the LSGs.
Percent excess weight loss (%EWL) in three (3) months, six(6) months and one (1) year post-operative were : 44.2% (20.6 –56.9) ; 50.2% (32.0 – 61.6) ; and 48.6% (35.5 – 62.6) respectively.
Obesity related diseases were also improved at one (1) year
post-operative : diabetes 80% (4/5) ; hypertension 67% (6/9) ; hyperlipidemia 75% (3/4) ; and SAS ; 88% (7/8). HbA1c at three (3)months post-operative was significantly lower than that recorded pre-operation (5.4 vs 6.2) (Table 3).

Figures 1a and 1b : The comparison between the pre-operation andthree (3) months post-operation levels of AST and ALT. The values foreach continuous variable were expressed as a mean ± the standard deviation (SD). The t-test was used for statistical analysis of the continuous variables. For all tests, p < 0.05 was interpreted as significant.

The Journal of Medical Investigation Vol. 66 August 2019

Figures 1c : The comparison between the pre-operation and three(3) months post-operation in the value of liver to spleen in plain CT.
The ratio of liver to spleen in plain CT value > 1.0 showed fatty liver.
Values for each continuous variable were expressed as a mean ± thestandard deviation (SD). The t-test was used for statistical analysisof the continuous variables. For all tests, p < 0.05 was interpreted assignificant.

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gaining in popularity. A LSG is considered a definitive procedure
for the treatment of morbid obesity and T2DM. A LSG is increasingly used world-wide and represents the bariatric procedure inmany countries (11-13). SG is successfully performed by laparoscopy in 99.7% of cases, with a high leak rate of 1.3%, a low leakrate of 0.5% and a mortality rate of 0.1% (14).
Zhang N, et al. reported that the remission rates of co-morbidity were observed in LSG for : sleep apnea (91.2) ; hyperlipidemia(63%) ; hypertension (38.8%) ; diabetes (58.6%) ; and musculoskeletal disease (66.7%) (15). Obesity is associated with NAFLD(16), and the resolution of NAFLD following bariatric surgery
has been proven (17).
Regarding the resolution of diabetes and NASH following aLSG, a vertical sleeve gastrectomy (VSG) was reported to be aseffective as RYGB for increasing secretion of GLP-1 and insulin
as well as improving hepatic sensitivity to insulin. As well, theseeffects are independent of weight loss (18).
In the author’s previous report, duodenal-jejunal bypass (DJB)
improved T2DM and liver steatosis by enhancing GLP-1 secretion through increasing serum bile acids and the proliferation ofL cells in the ileum in vivo (7). In addition, the authors have also
reported that a DJB changed the composition of gut microbiota
and these changes might be the factors that contributed to theeffects of DJB (19). Ryan KK, et al. reported that bile acids andbile acid receptor, known as the farnesoid X receptor (FXR) was
an important molecular underpinning for the beneficial effects ofbariatric surgery (20). In this report, FXR in SG was associatedwith the change of gut microbiota. So, the important roles in SG
might be the correlation among bile acids, GLP-1, FXR and gut
microbiota.
In this study, the initial ten (10) cases who underwent LSGs
were reported. LSG is a promising option for the treatment ofmorbid obesity and obesity-related disease.

ACKNOWLEDGMENTS
The authors of this study are grateful to the staff at theDepartment of Surgery, Tokushima University, for important
contributions.

DISCLOSURES
Hideya Kashihara and the co-authors have no conflict of interest regarding this report.
All investigations on human subjects must include a statement that the subject gave informed consent and patient anonymity should be preserved.

Figures 1d : The representative CT image in the pre-operation andthree (3) months post-operation.

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This study was designed to investigate the effect of a LSG onobesity and obesity-related disease in the Department of Surgery’s initial ten (10) cases. The results showed not only BW loss
but also improvements in T2DM, HT, HL, SAS and NAFLD/NASH.
SG surgery, in which 80% of the stomach is removed along
the greater curvature but the intestinal anatomy is unaltered, is3.

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