Annals of Surgery Journal Club

Interactive resource for surgery residents and surgeons to discuss and critically evaluate articles published in Annals of Surgery selected by a monthly guest expert who will review an article each month, offer questions and respond to reader's comments.

Saturday, December 28, 2013

January, 2014 Journal Club
Moderator: Dr. Bruce Schirmer
Article: Early Results of the Swiss Multicentre Bypass or Sleeve Study (SM-BOSS): A Prospective Randomized Trial Comparing Laparoscopic Sleeve Gastrectomy and Roux-en-Y Gastric Bypass. Peterli, Ralph MD*; Borbély, Yves MD*,†; Kern, Beatrice MD*; Gass, Markus MD*; Peters, Thomas MD*; Thurnheer, Martin MD; Schultes, Bernd MD; Laederach, Kurt MD; Bueter, Marco MD, PhD§; Schiesser, Marc MD§.  Ann Surg 258:  690–695.
Summary: This is a prospective randomized trial conducted at four centers in Switzerland over a four year period.  Laparoscopic sleeve gastrectomy (LSG) was compared to laparoscopic  Roux-en-Y gastric bypass (LRYGB) for weight loss, morbidity and mortality, improvement of comorbid medical conditions, and patient satisfaction.  The follow-up at one year is 100% with a 2 year follow-up under 50% and 3 year at 33%.  Some patients have not been enrolled long enough to meet the latter parameters.  The data show that the operations are very comparable in most ways: patient satisfaction, resolution of comorbidities (except GERD), weight loss, and severe complications.  The differences are that LSG is a shorter operation to perform, and has less overall complications (17.2 vs. 8.4%).  The data are very comparable to those presented at the American Surgical Association meeting in 2011, the first major report from the ACS BSCN database, published in the Annals of Surgery (Hutter MM, et al 2011; 254:410-22).  The authors of this article do not cite that article for some reason.  That data, gathered in the same fashion as NSQIP data, represented a large national sample of U.S. bariatric centers of excellence and their outcomes with LSG versus LRYGB and lap band.  The Swiss study concludes that LSG is an appropriate and effective operation for metabolic and bariatric surgeons to use, is associated with less operative time and lower complications, and should be further tested with long term data.

1.       Given the low complication rates of LSG, should it be approved  by all major insurance carriers in the U.S. for use in all medical centers, not just those who have achieved a center of excellence designation?

2.       The LSG has gained popularity in a rapid fashion, going from almost never performed in 2006 to rarely done in 2008 to common in 2010 to likely now the most popular procedure done in the U.S. in the last part of 2013.  Why don’t we recommend it for everyone?

3.       The LRYGB has been shown to have metabolic effects beyond just pure weight loss to improve the condition of type 2 diabetes in the severely obese.  Theories involve the fact that the lower stomach and duodenum is bypassed.  How can the LSG be just as effective against diabetes if weight loss is the same but the stomach and duodenum are not bypassed?

4.       Are there any patient populations in the world for whom the LSG is a much preferable operation to the LRYGB?

Please feel free to comment on any or all of the questions above. We look forward to hearing from you, the Annals readers. This article can be accessed for free.