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D. AlTarrah370
Moreover, to ensure that patients are well prepared for lifelong dietary and lifestyle changes, RD’s and a nutrition education team work closely with patients to
ensure that they are taught how to prepare meals to suit their tolerance at each
dietary progression stage, and eat mindfully, chew food adequately, and ensure
that patients recognize their sense of satiety. Keeping hydrated is likewise important and a nutrition priority to prevent dehydration and constipation. As such,
patients are advised to sip small quantities of water throughout the day, avoid
drinking fluids with meals, and ideally wait 30 min between meals [13].
3 Conclusion
Nutritional management during the postoperative period is imperative to ensure
bariatric patients adhere to dietary progression guidelines, maintain their nutritional status and maximize weight loss [4, 14]. However, taking into consideration that no evidence-based nutrition guidelines for LSG have been developed, it is
evident that more research is needed to better understand the nutritional needs of
LSG patients in order to tailor an appropriate postoperative diet [10].
References
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cess of bariatric surgery. Surg Obes Relat Dis. 2013;9(6):963–8.
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371
Potential Benefits of the LSG
How Laparoscopic Sleeve Gastrectomy May Cause Weight Loss
Michel Gagner
Comprendre, ce n'est pas tout comprendre, c'est aussi reconnaître qu'il y a de
l'incompréhensible. Edgar Morin, in La méthode, Éthique (2004).
Increased restriction, diminished acid output, and intensified gastric emptying.
At first, sleeve gastrectomy which evolved as a two stage procedure from laparoscopic duodenal switch, then to a stand-alone procedure for non super-obese
patients, was recognized to be mostly, purely restrictive, in the early 2000’s [1,
2]. In fact Marceau et al., when conversing about the open duodenal switch opera-
tion, was insinuating a parietal cell gastrectomy with modest restriction [3]. It
also involved at that time a decrease in acid output from the stomach, as shown
by the dramatic reduction in ulcer rate, witnessed after classical BPD from when
a greater curvature gastrectomy was executed with, as Hess mentioned, one or two
fingers breath from a regular bougie [4].
Sleeve size has been shown to have an effect on weight loss over time, a
smaller bougie causes more weight loss in the long-term, however a smaller tube
seem to cause significantly more GERD and morbi-mortality, so the right balance
much be chosen [5–12]. Decreased gastric volume, initially, in the first months
causes a decrease of caloric intake, 500 too 700 kcal per day are not unusual.
Comparable analogies have been achieved by looking at volume of gastric resection and correlate with weight loss [13–15]. Similarly, larger gastric resection, correlates with diminish levels of serum ghrelin and higher GLP-1 [14]. This is best
exemplified with re-sleeve gastrectomy, in which re-resection of the left stretched
parts of the sleeve, causes more weight loss, on average 10 points of BMI [16, 17].
The antrum size is another variable that has been studied recently. It appears that
M. Gagner (*)
Department of Surgery, Sacré-Coeur Hospital, Montréal, QC, Canada
e-mail: Gagner.Michel@cliniqueMichelGagner.com
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer
Nature Switzerland AG 2021
S. Al-Sabah et al. (eds.), Laparoscopic Sleeve Gastrectomy,
https://doi.org/10.1007/978-3-030-57373-7_36
375
M. Gagner376
smaller antrum may cause more weight loss later, and resolution of type-2 diabetes, and faster gastric emptying [18, 19].
1 Ghrelin Effect
Ghrelin is an orexigenic (i.e. appetite-stimulating) hormone chiefly secreted from
gastric cells [20]. Flowing ghrelin increases rapidly prior to meals in humans and
was assumed to be decisive for eating. Cummings et al. from the University of
Washington have observed that patients post-RYGB appeared to have cessation
of diurnal or pre-meal variation in circulating ghrelin [21]. Clinical observations
reveals that patients often, in the initial postoperative period, feels lessened hunger sensation, sometimes seems to disregard to eat or have to force themselves to
ingest proteins and calories.
Furthermore, sleeve gastrectomy eliminates a majority of ghrelin-producing
gastric matter from the fundus and body, and it has been postulated that the
absence of ghrelin, may be fundamental to weight loss witnessed following this
intervention [22]. This proposition is reinforced by the observation that circulating ghrelin levels are decreased immediately postoperatively and maintained at
1 to 5 years in sleeve gastrectomy patients [23, 24]. Some authors have made a
clear correlation between the amount of Ghrelin-Secreting Cells in the gastric
fundus and Excess Weight Loss after Sleeve Gastrectomy [25]. Resection is very
important, as two recent observations seem to confirm this hypothesis, firstly
when ghrelin levels and hunger sensation are measured after Laparoscopic
Sleeve Gastrectomy and compared with Laparoscopic Greater Curvature
Plication in obese patients, ghrelin is dramatically less and correlates with
healthier weight loss, as when a simple tube is created without resected gastric
tissue. This may explains why plication fails more repeatedly [26]. Secondly,
analogous findings are detected following metabolic hormones measurements
after Endoscopic Sleeve Gastroplasty (ESG), an endoscopic greater curvature
plication [27].
It has also been observed that ghrelin reduction is more profound and durable
after sleeve gastrectomy than after Roux-en-Y gastric bypass, making it an important mechanism of weight loss after sleeves, it also seems to potentiate GLP-1
effect [28, 29]. Interestingly, some levels of ghrelin production remains after near
total gastrectomy, and it seems to come from the pancreas, de novo pancreatic production of ghrelin is stimulated [30]. Ghrelin reductions following bariatric surgery were associated with decreased resting state activity in the hippocampus [31].
But, this is still controversial as some papers seem to indicate that Ghrelin
is not necessarily related with weight loss in bariatric surgery, certainly after
Roux-en-Y gastric bypass, and in animal models at least, the data’s are not completely connected. For example, short-term results suggest that sleeved stomach
without resection is as effective as sleeve gastrectomy in improving glucose control in type 2 diabetes mellitus Sprague–Dawley Rat model [32].
How Laparoscopic Sleeve Gastrectomy May Cause Weight Loss
377
1.1 Other Gastrointestinal Hormone Secretion
A recent structured systematic review and meta-analysis was performed to evaluate changes in ghrelin, glucagon-like peptide-1 (GLP-1), peptide YY (PYY), and
gastric inhibitory peptide (GIP) gut hormone levels in patients after sleeve gastrectomy, especially using randomized controlled trials and prospective observational
studies evaluating pre and post-procedure hormones fasting ghrelin, postprandial
GLP-1, postprandial PYY, and fasting GIP levels were comprised. A total of 28
studies (n = 653; 29.56% male) were counted in, with a mean age was 42 years,
and an average follow-up of 12 months. Pre-sleeve BMI) was 46 kg/m2, with a
post sleeve gastrectomy BMI of 34 representing an excess weight loss of 57%
(P < 0.001). Fasting ghrelin levels decreased, whereas postprandial GLP-1 and
PYY increased after sleeve gastrectomy. Fasting GIP levels remained unchanged
[36].
Some studies imply that these postoperative changes are driven by the
increased rate of nutrient delivery in the gut after sleeve gastrectomy. Gastric emptying and intestinal nutrient delivery are augmented following sleeve gastrectomy
patients, and as stated before is associated with increased secretion of the more
distal intestinal hormones GLP-1 and peptide YY (PYY) [37-41]. Postprandial
GLP-1 secretion is greatly heightened in rats and humans after some bariatric techniques, including sleeve gastrectomy, and has been widely hypothesized to promote reduced consumption, weight loss, and the restitutions in
glucose homeostasis after sleeve. Wilson-Perez and colleagues found that sleeve
gastrectomy-operated GLP-1 receptor-deficient rodents responded comparably to
wild-type controls in terms of body weight and body fat loss, improved glucose
tolerance, food intake reduction, and altered food choice. This study explain that
GLP-1 receptor activity is not necessary for the metabolic improvements induced
by sleeve gastrectmy [42]. Further, post-bariatric surgery hypoglycaemia (PBH)
is more frequently observed in sleeve gastrectomy patients than previously recognized. In rats it was shown to have increased glycemic variability and hypoglycaemia after sleeve gastrectomy. Postprandial hypoglycaemia was specifically
detected after liquid versus solid meals. Further, the blockade of GLP-1R signalling raises the glucose nadir but does not affect glycemic variability [43].
1.2 Other Molecular Changes
Growth hormone (GH) (12.32 vs. 50.97 pg/mL, p < 0.001) and insulin-like
growth factor IGFBP-2 levels (51.86 vs. 68.81 pg/mL, p < 0.001) were significantly elevated after sleeve gastrectomy. BMI (52.2 vs. 40.1, p = 0.001), insu-
lin (19.4 vs. 8.8 mIU/L, p < 0.001) and HOMA-IR index (6.5 to 2.5, p < 0.001)
were reduced after surgery. Lipid profile analysis revealed that total cholesterol
(4.26 vs. 5.12 mmol/L, p < 0.001) and high-density lipoprotein (HDL) (0.90 to
1.55 mmol/L, p < 0.001) were increased, while triglycerides were decreased, after
M. Gagner378
surgery (1.62 vs. 1.05 mmol/L p < 0.001). GH, IGF-1, and IGFBP-2 were not correlated with insulin or lipid parameters [44].
Cytokine behaviour after sleeve gastrectomy as been studied, and as showed
two prototype patterns: a concordant type, where cytokines behave the same way
for all patients (notably IL-0 and TNFα), and a variable type, where different patterns of expression are seen for different patients (notably IL-8, IL-6 and IL-1RA).
Analysis of the cytokines at the individual patient-level showed a strong four-way
correlation between IL-1RA, GCSF, MIP-1β and MCP-1. As it holds for most
patients and not just on average, this suggests that they form a network, which
may play a central role in the response to gastro-intestinal injuries in humans [45].
1.3 Bile Acid Metabolism
Bile acids and their receptors like farnesoid X receptor (FXR) and G-protein coupled bile acid receptor (TGR5)) are significant mediators of metabolism. Bile
acids have metabolic effects, and in mice deficient in the bile acid receptor FXR,
effects of sleeve gastrectomy on body weight are annulled [46]. Hence, sleeve
is associated with increased plasma bile acid concentrations in patients [47, 48].
TGR5 has also been in the associated with rodents studies of sleeve gastrectomy,
such like Cummings et al. revealed that TGR5, the G-protein coupled bile acid
receptor, is required for improved glucose regulation phenotype of sleeve in the
mouse [49]. Sleeve gastrectmy in TGR5 knockout mice is related with changed
bile acid pool configuration, which may have additional metabolic significances.
Captivatingly, the TGR5 knockout animals following sleeve reacted similar to
wild type animals with respect to glucose-stimulated insulin secretion. Therefore,
this experiment deduces that some beneficial effects of sleeve related to glucose
homeostasis are mediated through TGR5 [49]. Another study investigated the
acute and short-term effects of bypass and sleeve on bile acid compositions and
fibroblast growth factor 19 (FGF19) in obese individuals with T2DM and to evaluate any correlations between changes in these measures with glucose metabolic
improvements. At 3 days post-operation, FGF19 levels increased significantly in
both surgery groups. Fasting and postprandial increases from pre-operative values in secondary, conjugated, glycine-conjugated and secondary-conjugated bile
acids correlated with decreases in the postprandial states of glucose (defined by
area under the curve (AUC) over 120 min (AUC0-120 min)). Increases in postprandial primary-conjugated bile acids were found to be associated with decreases
in HOMA-IR). However, increases in fasting and postprandial taurine-conjugated
bile acids correlated with decreases in both basal insulin secretion rate and
C-peptide level. After 3 months, fasting and postprandial increases in secondary, secondary-conjugated and non-12α-OH bile acids were found to correlate
with increases in Stumvoll Insulin Sensitivity Index. Increases in both fasting and
How Laparoscopic Sleeve Gastrectomy May Cause Weight Loss
379
postprandial 12α-OH BAs were correlated with the decreases in glucose AUC (P
= 0.04). Both bypass and sleeve gastrectomy attain increases in many bile acids
species as early as 3 days post-procedure, which are sustained at 3 months postoperation. Rises in secondary bile acids and conjugated forms are correlated
with early upgrades in glucose metabolism at 3 days post-operation. These along
with 12α-OH BA correlated with improved glucose metabolism at 3 months
post-operation, evoking they may contribute to the observed T2DM remission
after sleeve gastrectomy [50].
1.4 Microbiome
Laparoscopic sleeve gastrectomy (LSG) causes a change in gut microbiota and is
linked to the efficacy of the operation. In fact severely obese subjects subjected
to sleeve gastrectomy had the composition and abundance of the microbiota and
bile acids in faeces assessed by 16S ribosomal RNA sequencing, quantitative PCR
and liquid chromatography-mass spectrometry. The increase in α-diversity and
abundance of specific taxa, such as Rikenellaceae and Christensenellaceae, was
strongly associated with reduced faecal bile acid levels. These changes had a significant association with excess weight loss and metabolic improvements. Sleeve
gastrectomy is related with a reduction in faecal bile acids and superior richness
of specific bacterial taxa and α-diversity that may promote the metabolic changes
observed [51].
1.5 Central Nervous System Changes
Authors have compared whole brain activation in response to high-energy dense
versus low-energy dense visual and auditory food cues before and approximately
4 months after Roux-en-Y Gastric Bypass and Sleeve Gastrectomy. In this study,
they included two control groups: a low-calorie diet weight loss group and a
non-treatment group. Relative to the control groups, the surgery groups showed
increased dorsolateral prefrontal cortex and decreased parahippocampal/fusiform
gyrus activation in response to high enery dense visual cues, suggesting greater
cognitive dietary inhibition and decreased rewarding effects and attention related
to high energy dense foods. Dorsolateral prefrontal cortex activation was significantly more increased in bypass than in sleeve. They found that postprandial
rises in GLP-1 correlated with postsurgical decreases in bypass brain activity in
the inferior temporal gyrus and the right middle occipital gyrus in addition to
increases in the right medial prefrontal gyrus/paracingulate for high energy stimuli, suggesting involvement of these attention and inhibitory regions in satiety signalling post surgery [52].
M. Gagner380
1.6 Conclusion
Sleeve gastrectomy causes multiple hormonal, physiological alterations that
decreases appetite, causes a reduction and change in foods, and brings cerebral
differences that leads to weight loss [53].
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