Laparoscopic gastric bypass vs sleeve gastrectomy in obese Korean patients

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1 Submit Mnuscript: Help Desk: DOI: /wjg.v21.i World J Gstroenterol 15 November 28; 21(44): ISSN (print) ISSN (online) 15 Bishideng Publishing Group Inc. All rights reserved. Retrospective Cohort Study ORIGINAL ARTICLE Lproscopic gstric bypss vs sleeve gstrectomy in obese Koren ptients Ji Yeon Prk, Yong Jin Kim Ji Yeon Prk, Yong Jin Kim, Deprtment of Surgery, Soonchunhyng University Seoul Hospitl, Seoul 1-743, South Kore Ji Yeon Prk, Deprtment of Surgery, Ntionl Cncer Center, Goyng-si, Gyeonggi-do , South Kore Author contributions: Kim YJ designed nd performed the reserch; Prk JY nlyzed the dt nd wrote the pper. Institutionl review bord sttement: The study ws reviewed nd pproved by the Soonchunhyng University Seoul Hospitl Institutionl Review Bord (SCHUH ). Conflict-of-interest sttement: Drs. Ji Yeon Prk nd Yong Jin Kim hve no finncil ties to disclose. Open-Access: This rticle is n open-ccess rticle which ws selected by n in-house editor nd fully peer-reviewed by externl reviewers. It is distributed in ccordnce with the Cretive Commons Attribution Non Commercil (CC BY-NC 4.0) license, which permits others to distribute, remix, dpt, build upon this work non-commercilly, nd license their derivtive works on different terms, provided the originl work is properly cited nd the use is non-commercil. See: licenses/by-nc/4.0/ Correspondence to: Yong Jin Kim, MD, PhD, Deprtment of Surgery, Soonchunhyng University Seoul Hospitl, 59, Desgwn-ro, Yongsn-gu, Seoul 1-743, South Kore. yjgs1997@gmil.com Telephone: Fx: Received: Mrch 16, 15 Peer-review strted: Mrch 17, 15 First decision: My 18, 15 Revised: My 26, 15 Accepted: August 29, 15 Article in press: August 31, 15 Published online: November 28, 15 Abstrct AIM: To compre the mid-term outcomes of lproscopic sleeve gstrectomy () nd lproscopic Roux-en-Y gstric bypss () in obese Koren ptients. METHODS: All consecutive ptients who underwent either or with primry to tret morbid obesity between Jnury 11 nd December 12 were retrospectively reviewed. Ptients with body mss index (BMI) 30 kg/m 2 with indequtely controlled obesity-relted comorbidities (e.g., dibetes, obstructive sleep pne, hypertension, or obesityrelted rthropthy) or BMI 35 kg/m 2 were considered for britric surgery ccording to the Interntionl Federtion for the Surgery of Obesity-Asi Pcific Chpter Consensus sttements in 11. The decision regrding the procedure type ws mde on n individul bsis following extensive discussion with the ptient bout the specific risks ssocited with ech procedure. All opertive procedures were performed lproscopiclly by single surgeon experienced in upper gstrointestinl surgeries. Bseline demogrphics, periopertive surgicl outcomes, nd postopertive nthropometric dt from prospectively estblished dtbse were thoroughly reviewed nd compred between the two surgicl pproches. RESULTS: One hundred four ptients underwent, nd 236 underwent. Preopertive BMI in the group ws significntly higher thn tht of the group (38.6 kg/m 2 vs 37.2 kg/m 2, P = 0.024). Ptients with dibetes were more prevlent in the group (18.3% vs 35.6%, P = 0.001). Operting time nd hospitl sty were significntly shorter in the group compred with the group (100 min vs 130 min, P < 0.001; 1 d vs 2 d, P = 0.003), but the incidence of periopertive complictions ws similr between the groups (P = 0.351). The men percentge of excess weight loss (%EWL) ws 71.2% for, while it ws 63.5% for, t men follow-up periods of 18.0 nd 21.0 mo, respectively (P = 0.073). The %EWL t 1, 3, 6, 12, 18, 24, nd 36 mo ws equivlent November 28, 15 Volume 21 Issue 44

2 between the groups. Four ptients required surgicl revision fter (4.8%), while revision ws only required in one cse following (0.4%; P = 0.011). CONCLUSION: Both nd re effective procedures tht induce comprble weight loss in the mid-term nd similr surgicl risks, except for the higher revision rte fter. Key words: Morbid obesity; Britric surgery; Rouxen-Y gstric bypss; Sleeve gstrectomy; Weight loss The Author(s) 15. Published by Bishideng Publishing Group Inc. All rights reserved. Core tip: Both lproscopic sleeve gstrectomy () nd lproscopic Roux-en-Y gstric bypss () re effective procedures tht result in comprble weight loss in the mid-term with similr surgicl risks in obese Koren ptients. However, lrger number of ptients required revisionl surgery following thn. The long-term complictions encountered fter ech procedure differed significntly, nd these complictions were not negligible. Surgeons should provide tilored surgicl option for ech ptient tht tkes into considertion the possible risks, s the longterm complictions my hve significnt influence on the qulity of life following the surgery. Prk JY, Kim YJ. Lproscopic gstric bypss vs sleeve gstrectomy in obese Koren ptients. World J Gstroenterol 15; 21(44): Avilble from: URL: wjgnet.com/ /full/v21/i44/12612.htm DOI: dx.doi.org/ /wjg.v21.i INTRODUCTION Obesity is one of the most concerning helth problems in the world tody, imposing considerble finncil burden on society [1]. Consistent effort hs been mde to enble individuls to chieve weight loss nd, concomitntly, to mnge vriety of obesity-relted comorbidities. However, none of the currently vilble conservtive mesures hs succeeded in relizing these gols, nd t the present time, britric surgery hs proven to be the most effective method for chieving sustined weight loss [2]. Among the vrious vilble options for britric surgery, Roux-en-Y gstric bypss hs been considered the gold stndrd for severl decdes. This procedure hs reltively long history compred to the other vilble procedures, qulified with sufficient dt involving stisfctory long-term outcomes in terms of durble weight loss nd resolution of comorbidities [3]. Recently, however, lproscopic sleeve gstrectomy () hs been rpidly gining populrity s stndlone tretment for morbid obesity [4]. It is thought to be techniclly less demnding nd to offer potentil benefit of reduced risk of long-term complictions compred to lproscopic Roux-en-Y gstric bypss (). The trend of exponentil increse in is even noticeble in Asin countries where britric surgery hs only recently been introduced [4], lthough results regrding the long-term efficcy of re still lcking. The present study imed to evlute the mid-term efficcy of nd nd to compre the results between the two procedures in obese Koren ptients t single center. MATERIALS AND METHODS All ptients who were operted on t Soonchunhyng University Seoul Hospitl, tertiry referrl medicl center, between Jnury 11 nd December 12 were retrospectively reviewed. Of those, the ptients who underwent either or with primry intent to tret morbid obesity were enrolled in the present study. Bseline, opertive, nd follow-up dt from prospectively estblished dtbse were thoroughly reviewed nd summrized. Approvl for this review of hospitl records ws obtined from the Institutionl Review Bord (SCHUH ); the need for ptient informed consent ws wived. Britric surgery cndidtes were selected ccording to the Interntionl Federtion for the Surgery of Obesity-Asi Pcific Chpter Consensus sttements in 11 [5]. As such, ptients with body mss index (BMI) 30 kg/m 2 with indequtely controlled obesityrelted comorbidities (e.g., dibetes, obstructive sleep pne, hypertension, or obesity-relted rthropthy) or with BMI 35 kg/m 2 were considered for britric surgery. The decision regrding the procedure type ws mde on n individul bsis following extensive discussion with the ptient bout the specific risks ssocited with ech procedure. Ptients received interdisciplinry eduction bout potentil surgicl nd nonsurgicl options, possible outcomes, possible complictions, nd necessry postopertive lifestyle chnges nd nutritionl supplementtion. Surgicl procedures All opertive procedures were performed lproscopiclly by single surgeon experienced in upper gstrointestinl surgeries. Six trocrs were used both in nd ; one 11-mm port for scope t the umbilicus, two 12-mm ports, nd three dditionl 5-mm ports. A 34 Fr bougie diltor ws used for guidnce during gstric resection in. The lengths of the limentry nd biliopncretic limbs were estimted t bout cm nd 50 cm, respectively, nd 15- mm sized liner stpled gstrojejunostomy ws estblished in. Detiled surgicl procedures were well described in our previously published study [6] November 28, 15 Volume 21 Issue 44

3 Tble 1 Preopertive demogrphics nd clinicl chrcteristics of the enrolled ptients Tble 2 Surgicl outcomes ccording to the surgicl procedures (n = 104) (n = 236) P vlue 1 Age (yr) 31 (25-38) 38 (29-46) < Sex Mle 41 (39.4) 37 (15.7) < Femle 63 (60.6) 199 (84.3) Body weight (kg) ( ) ( ) < BMI (kg/m 2 ) 38.6 ( ) 37.2 ( ) Excess weight (kg) ( ) 38.4 ( ) Comorbidities Dibetes 19 (18.3) 84 (35.6) Hypertension 28 (26.9) 88 (37.3) Dyslipidemi 64 (67.4) 116 (68.2) OSA Confirmed 10 (10.5) 24 (14.1) Suspicious 4 (4.2) 11 (6.5) Arthropthy 12 (12.6) 31 (18.2) GERD 14 (13.5) 19 (8.1) PCOS 3 12 (19.0) 30 (15.1) No. of comorbidities 1.5 (1-2) 2 (1-3) Dt re presented s n (%) or medin (interqurtile rnge). 1 Mnn- Whitney U test for continuous vribles nd Person s χ 2 test or Fisher s exct test for ctegoricl vribles were pplied; 2 The excess weight ws clculted from the idel weight using BMI of 23 kg/m 2 s the upper limit of norml ccording to the World Helth Orgniztion recommended definition of obesity for Asins; 3 The incidence mong femle ptients. : Lproscopic sleeve gstrectomy; : Lproscopic Roux-en-Y gstric bypss; BMI: Body mss index; OSA: Obstructive sleep pne; GERD: Gstro-esophgel reflux disese; PCOS: Polycystic ovrin syndrome. Postopertive dt collection nd follow-up dt nlysis Ptients returned to the outptient clinic 2 wk fter surgery nd then every 3 mo for the first postopertive yer to monitor weight loss, dysphgi or food intolernce, eting behvior, comorbidity sttus, nd the presence of ny complictions. Follow-up frequency ws then incresed to every 12 mo fter the first yer. Telephone interviews were lso used to monitor ptients who were unble to visit the outptient clinic. The degree of weight loss ws expressed s the percentge of totl weight loss (%TWL) nd the percentge of excess weight loss (%EWL), with the clcultion of idel body weight s tht equivlent to BMI of 23 kg/m 2 ccording to the World Helth Orgniztion (WHO)-recommended definition of obesity for Asins [7]. Sttisticl nlysis Sttisticl nlysis ws performed using SPSS version 18 for Windows (SPSS Inc., Chicgo, IL, United Sttes). Medins with interqurtile rnges of the vribles were clculted nd compred between the two different procedures. The χ 2 test or Fisher s exct test ws pplied to nlyze ctegoricl vribles, while Mnn-Whitney U test ws used for continuous vribles. All tests were two-tiled nd P vlues < 0.05 were considered significnt. RESULTS (n = 104) (n = 236) P vlue 1 Combined opertion 5 (4.8) 19 (8.1) Operting time (min) 100 (90-115) 130 ( ) < Intropertive blood loss 100 (50-150) 100 (50-0) Length of hospitl sty (d) 1 (1-2) 2 (1-2) Intropertive 1 (1.0) 4 (1.7) > compliction Postopertive compliction 2 No 95 (91.3) 2 (85.6) Yes Mild 7 (6.7) 25 (10.6) Moderte 0 (0) 5 (2.1) Severe 2 (1.9) 4 (1.7) Re-dmission 3 (2.9) 8 (3.4) > Dt re presented s n (%) or medin (interqurtile rnge). 1 Mnn- Whitney U test for continuous vribles, nd Person s χ 2 test or Fisher s exct test for ctegoricl vribles were pplied; 2 The severity of postopertive complictions were clssified ccording to the Accordion Severity Grding System. : Lproscopic sleeve gstrectomy; : Lproscopic Roux-en-Y gstric bypss. A totl of 3 consecutive ptients underwent either or for morbid obesity during the study period nd were included in the study. One hundred four ptients (30.6%) underwent, while 236 ptients (69.4%) underwent. The demogrphic chrcteristics re shown in detil in Tble 1. In the group, the ptients were younger, nd the proportion of mles ws greter (P < for both fctors) thn the group. Preopertive BMI ws 38.6 kg/m 2 [interqurtile rge (IQR), ] in the group, which ws significntly higher thn the BMI of 37.2 kg/m 2 (IQR, ) for the group (P = 0.024). Ptients with dibetes were more prevlent in the group (35.6% vs 18.3%, P = 0.001), while the incidence of other obesity-relted comorbidities ws similr between the two groups. The men operting time nd the length of hospitl sty were significntly shorter in the group thn in the group (100 min vs 130 min, P < 0.001; 1 d vs 2 d, P = 0.003; Tble 2). There ws one ptient in whom the scheduled ws converted to becuse of severe dhesions between smll bowel loops ssocited with previous history of pnperitonitis. The left gstroepiploic vessels were injured during in one ptient, but there ws no further evidence of ischemi. Technicl filure of gstrojejunostomy reconstruction ws encountered for four ptients in the group; successful lproscopic revision ws ccomplished for ll during the surgery. The incidence nd severity of postopertive complictions did not sttisticlly differ between the groups (P = 0.351). Most complictions in the group were minor, involving opertive wound or dietry problems; two severe complictions were November 28, 15 Volume 21 Issue 44

4 Tble 3 Anthropometric outcomes t lst follow-up (n = 104) (n = 236) P vlue 1 Men follow-up period 21.0 ( ) 18.0 ( ) (mo) At lst follow up Body weight (kg) 81.5 ( ) 72.0 ( ) < BMI (kg/m 2 ) 28.5 ( ) 27.3 ( ) %EWL (%) ( ) 71.2 ( ) %TWL (%) 25.0 ( ) 26.7 ( ) EWL < 50% t 1 yer 18 (21.2) 23 (13.6) Revision 5 (4.8) 1 (0.4) A BMI (kg/m 2 ) Dt re presented s n (%) or medin (interqurtile rnge). 1 Mnn- Whitney U test for continuous vribles nd Person s χ 2 test or Fisher s exct test for ctegoricl vribles were pplied; 2 A BMI of 23 kg/m 2 ws dopted s the upper limit of norml to clculte %EWL ccording to the World Helth Orgniztion recommended definition of obesity for Asins. : Lproscopic sleeve gstrectomy; : Lproscopic Roux-en-Y gstric bypss; BMI: Body mss index; EWL: Excess weight loss; TWL: Totl weight loss. relted to intr-bdominl bleeding in the immedite postopertive period tht required reopertion to chieve hemostsis. Menwhile, more thn hlf of the complictions (18/34, 52.9%) were ssocited with postopertive bleeding in the group; 12 of these were mild, four were moderte, nd two were severe complictions. The overll incidence of postopertive bleeding ws 7.6%, where two-thirds of the cses presented s luminl bleeding nd onethird presented s intr-bdominl bleeding. Cliniclly significnt hemorrhge requiring trnsfusion or invsive intervention occurred in 10 ptients (4.2%) undergoing. Other severe complictions included one cse of gstric pouch lekge nd one intestinl obstruction; both of these required surgicl intervention. Ptients were followed up for n verge of pproximtely 21.0 mo nd 18.0 mo in the nd groups, respectively (Tble 3). Although the postopertive BMI ws significntly higher in the group thn in the group (28.5 kg/m 2 vs 27.3 kg/m 2, P = 0.014) t the lst follow-up, the %EWL nd %TWL were similr between the groups (63.5% vs 71.2%, P = 0.073; 25.0% vs 26.7%, P = 0.394). The proportion of ptients who hd filed to chieve 50% of EWL 1 yer postopertively ws lrger in the group (21.2%) thn in the group (13.6%), but the difference ws not sttisticlly significnt (P = 0.148). Five ptients in the group (4.8%) required revisionl surgery following the initil procedure becuse of intolerble de novo reflux disese (n = 2) nd insufficient weight loss (n = 3). On the other hnd, only one ptient (0.4%) who hd undergone requested revision, RYGB reversl, due to mlnutrition, nd the rte of revision ws significntly lower thn in the group (P = 0.011). The chronologicl chnges in nthropometric dt during the follow-up period re shown in Figure 1. The body weight nd BMI of the group were generlly Preop 1M 3M 6M 9M 12M 18M 24M 36M Eligible ptients Ptients t follow-up B EWL (%) C TWL (%) M 3M 6M 9M 12M 18M 24M 36M 1M 3M 6M 9M 12M 18M 24M 36M Figure 1 Chronologicl chnges in nthropometric outcomes. A: Body mss index; B: Percentge of excess weight loss; C: Percentge of totl weight loss. Medins re used to depict the vlues, nd error brs indicte the interqurtile rnge. P < 0.05 between groups. : Lproscopic sleeve gstrectomy; : Lproscopic Roux-en-Y gstric bypss; BMI: Body mss index; EWL: Excess weight loss; TWL: Totl weight loss. higher thn those of the group throughout the study period. However, there were no significnt differences between the nd groups in %EWL nd %TWL, which plteued t round 80% nd 30%, respectively, in both groups November 28, 15 Volume 21 Issue 44

5 A 100 Tble 4 Long-term complictions (> 30 d) n (%) 80 (n = 104) (n = 236) % % 50.0% 57.4% 42.6% GERD 28 (26.9) Mrginl ulcer 64 (27.1) Anemi 4 (3.8) Confirmed by endoscopy 15 (6.4) Cliniclly suspicious 49 (.8) Anemi 53 (22.5) GERD 11 (4.7) Peterson herni 3 (1.3) Ventrl herni 3 (1.3) : Lproscopic sleeve gstrectomy; : Lproscopic Roux-en-Y gstric bypss; GERD: Gstro-esophgel reflux disese. B % C % 0 Resolved 7 39 Sustined % 77.3% 25.0% 22.7% 0 Resolved Sustined %.7% 66.0% 34.0% 0 Resolved Sustined Figure 2 Resolution of comorbidities. A: Dibetes; B: Hypertension; C: Dyslipidemi. P = 0.769, 0.801, nd 0.653, respectively. The obesity-relted comorbidities were resolved in considerble number of ptients in both groups. The overll resolution rtes of the obesity-relted comorbidities were 56.1% for type 2 dibetes, 76.7% for hypertension, nd 64.7% for dyslipidemi in the entire study popultion. No difference ws observed between the nd groups regrding comorbidity resolution (Figure 2). Differences were observed between the groups in the types of long-term complictions experienced (Tble 4). Twenty-eight ptients (26.9%) presented with gstroesophgel reflux symptoms following ; 24 of these suffered from de novo reflux symptoms fter the surgery, nd four showed ggrvtion of pre-existing gstroesophgel reflux disese (GERD). The most frequently encountered long-term compliction following ws mrginl ulcers. The clinicl symptom-bsed incidence reched 27.1%, but only one-fourth of the cses were confirmed with endoscopic evlution. Most of the symptoms ssocited with both reflux esophgitis nd mrginl ulcers were well mnged with proton pump inhibitors (PPIs). However, two ptients in the group were converted to due to intolerble reflux symptoms, nd one ptient in the group developed pnperitonitis owing to mrginl ulcer perfortion nd required emergent lprotomic explortion to redo the gstrojejunostomy. DISCUSSION In the present study, both nd were found to be effective britric procedures with similr surgicl risks leding to equivlent weight loss outcomes nd comorbidity resolution during the medium-term follow-up. To the best of our knowledge, this is the first report compring vs in obese Koren ptients, nd we believe tht this study will provide vluble informtion to better guide clinicl decisions for individul obese ptients in Kore. Britric surgery is reltively new in Est Asin countries, including Kore. There is mrked tendency in the region to prefer techniclly less demnding procedures, including lproscopic djustble gstric bnding or, over more complicted procedures such s or biliopncretic diversion [4]. This might be ttributble to the surgeons lck of experience s well s to the sufficient weight loss outcomes chieved by these reltively simple restrictive procedures. The surgeon in the current study first begn to perform the techniclly less demnding in 08, nd then, strting in 11, grdully begn to dopt the more November 28, 15 Volume 21 Issue 44

6 complicted, fter experience with 100 cses of. In the present study, we enrolled ptients who underwent surgery when the two surgicl options were evenly offered to prospective cndidtes. The selection of the procedure type lrgely depended on the ptient s decision fter thorough discussion regrding the outcomes nd potentil risks of ech procedure bsed on the historicl dt. However, ws prioritized in super obese ptients with BMI over 50 kg/m 2 to reduce surgicl risks with further stged opertion in mind. This tendency hs been reflected in the higher preopertive BMI of the group compred to tht of the group. hs been dvocted for its technicl simplicity nd reduced surgicl risks compred to [8,9]. According to recent met-nlysis by Zhng et l [10], ws shown to hve sttisticlly fewer mjor complictions thn. The periopertive surgicl outcomes in our series lso suggested tht ws techniclly less demnding thn, with shorter operting time nd hospitl sty. Although the incidence of overll nd severe complictions did not sttisticlly differ between nd, the incidence of both did trend higher for, nd cliniclly significnt bleeding requiring trnsfusion or reopertion developed more frequently following. Given the disprity in surgicl experience with nd in our series, however, there is chnce tht the compliction rte of cn be further lowered with sufficient experience on the prt of surgeons, nd the trend towrd higher complictions my presumbly recede. In the present study, both procedures chieved mximl %EWL of pproximtely 80% t between 12 nd 18 mo postopertively; this subsequently leveled off. These results re in line with the recently published literture reporting tht the %EWL following nd LRGYB rnged from 60.0%-76.5% nd 69.0%-76.6%, respectively, 1 yer postopertively, figures tht were mintined s 60.0%-75.4% nd 70.0%-73.0%, respectively, 2 yers postopertively [8,9,11,12]. The slightly higher %EWL in our study might be explined by the lower preopertive BMI of our study cohort, since %EWL is significntly influenced by initil BMI level [13]. The recent met-nlysis by Zhng et l found tht the excess weight loss ws similr between nd in the erly postopertive period, for up to 2 yers [10]. The present study lso reveled tht nd demonstrted lmost equl efficcy in terms of %EWL during the study s 3 yers of postopertive follow-up. Some studies with longer follow-up periods hve suggested tht weight regin is more prevlent in ptients who hve undergone [11,14], but the number of ptients who were followed up in the present study becme too smll fter 2 yers to llow definite conclusion. Longer follow-up with lrger number of ptients is necessry to determine whether the reduced weight would be mintined therefter. Interestingly, the ttrition rte ws higher in the group thn in the group throughout the follow-up period, with the exception of the third yer. This finding might be ttributble to the fct tht the surgeon trced the ptients undergoing more rigorously in order to evlute whether or not they required secondry opertions. A recent met-nlysis suggested tht nd showed equivlent efficcy in regrd to resolution of most of the obesity-relted comorbidities, except for dibetic control where ws superior to [10]. The current study showed similr resolution rtes of hypertension, dyslipidemi, nd dibetes following both procedures. As shown by the preopertive clinicl chrcteristics, the ptients with dibetes in our study initilly inclined towrd, expecting n dditionl metbolic effect from bypss. Therefore, there could be selection bis from the beginning. In ddition, the number of ptients with dibetes in the group ws too smll to llow comprehensive comprison of the efficcy of the two procedures in dibetic control. Nonetheless, the resolution rte of dibetes in the current study ws estimted to be less thn 60% even following, figure which is much lower thn the dibetes remission rte of 92%-95% reported in recently published met-nlysis [15]. Ethnic differences in the chrcteristics of type 2 dibetes, such s erly β-cell dysfunction, could be the reson for the decrese in effective dibetic control, despite equivlent %EWL, reltive to the Western popultion-bsed studies [16]. The potentil long-term complictions cn be n importnt issue when determining the type of surgicl procedure for given obese ptient. The present study showed tht ptients undergoing nd LRGYB encountered different kinds of long-term complictions following the surgery. led to fr less frequent nutritionl problems, such s nemi, thn ; but new onset GERD developed in bout 23% of the ptients. Although the mjority of ptients with pre-existing GERD (71.4% in the group vs 94.7% in the group) experienced symptom improvement long with weight loss following both procedures, the resolution rte ws considerbly lower in the group, nd some ptients experienced endoscopiclly proven disese ggrvtion following, similr to the results from previous rndomized tril [8]. On the other hnd, mrginl ulcer ws one of the representtive complictions following. The reported incidence vries significntly in the literture, rnging from 3.5% to 12.3%, depending on the definition nd evlution method [17-]. The incidence of endoscopiclly confirmed mrginl ulcers ws 6.4% in the present study, which is consistent with previous reports. However, the ctul incidence is expected to be higher, considering tht only bout hlf of the symptomtic ptients were evluted with endoscopy while the rest were mnged with PPIs bsed on their symptoms. The incidence of mrginl ulcer is reported to be s high s 27%-36% mong November 28, 15 Volume 21 Issue 44

7 symptomtic ptients [21,22]. Currently, plusible risk fctors for mrginl ulcer following LRGYB include technicl fctors, such s long gstric pouch or non-bsorbble suture mterils, smoking, nonsteroidl nti-inflmmtory drugs, dibetes mellitus, nd possibly Helicobcter pylori infection [19]. Although both post- GERD nd post- mrginl ulcers responded well to the PPI tretment, two ptients eventully required revisionl surgery, nd one ptient underwent emergent opertion due to mrginl ulcer perfortion in our series. It is difficult to sy which complictions would be esier to mnge. Nonetheless, surgeons should provide tilored surgicl option for ech ptient tht tkes into considertion the possible risks, s the long-term complictions my hve significnt influence on the qulity of life following the surgery. We believe tht would be better choice for the ptients with symptomtic GERD preopertively, while would be recommended for those with poor complince or for substnce busers, including hevy smokers. There re severl limittions to the present study. Above ll, this study is retrospective study bsed on prospectively collected dt, nd there could be selection bis for ech group, s shown in the preopertive demogrphics. Well-designed rndomized trils re necessry to truly elucidte the differences between nd. The ttrition rte in our series ws lso quite high, finding tht seems to be universl chllenge mong other institutions. Since britric surgery nd its relted exmintions re not reimbursed t ll in South Kore, the costs for the follow-up exmintions must come directly from the ptients. Ptients re reluctnt to cover ll of the expenses for regulr surveillnce unless they feel tht something is wrong, sitution which renders our follow-up dt less relible. In conclusion, both nd re effective procedures tht yield comprble weight loss in the mid-term with similr surgicl risks. However, lrger number of ptients required revisionl surgery following. The long-term complictions encountered fter ech procedure differ significntly, nd these complictions re not negligible. Longer follow-up periods re necessry to compre the longterm differences in weight loss nd complictions between nd. ACKNOWLEDGMENTS Min Ju Soh cordilly supported this study s reserch coordintor. COMMENTS Bckground Britric surgery is reltively new in Est Asin countries, including South Kore. There is mrked tendency in the region to prefer techniclly less demnding nd purely restrictive procedures, including lproscopic sleeve gstrectomy (), over more complicted procedures such s lproscopic Roux-en-Y gstric bypss (). Therefore, comprisons between nd re still lcking from Asin countries to demonstrte of the efficcy of ech procedure. Reserch frontiers The present study evluted the mid-term efficcy of nd nd compred the results between the two procedures in obese Koren ptients t single center. Innovtions nd brekthroughs Both nd were found to be effective britric procedures with similr surgicl risks leding to equivlent weight loss outcomes nd comorbidity resolution during the mid-term follow-up. To the best of our knowledge, this is the first report compring vs in obese Koren ptients. Applictions This study will provide vluble informtion to guide clinicl decisions for individul obese ptients in Asin countries. would be better choice for the ptients with symptomtic GERD preopertively, while would be recommended for those with poor complince or for substnce busers, including hevy smokers. Peer-review The uthors present hed-to-hed comprison of lproscopic sleeve gstrectomy nd lproscopic Roux-en-Y gstric bypss procedure s performed t single Koren center. They performed retrospective nlysis of prospectively collected dt. Overll the mnuscript is well orgnized nd very well written. The uthors re to be commended for their work. REFERENCES 1 Finkelstein EA. How big of problem is obesity? Surg Obes Relt Dis 14; 10: [PMID: DOI: / j.sord ] 2 Sjöström L. Review of the key results from the Swedish Obese Subjects (SOS) tril - prospective controlled intervention study of britric surgery. J Intern Med 13; 273: [PMID: DOI: /joim.112] 3 Buchwld H, Avidor Y, Brunwld E, Jensen MD, Pories W, Fhrbch K, Schoelles K. Britric surgery: systemtic review nd met-nlysis. JAMA 04; 292: [PMID: DOI: /jm ] 4 Buchwld H, Oien DM. Metbolic/britric surgery worldwide 11. Obes Surg 13; 23: [PMID: DOI: /s ] 5 Ksm K, Mui W, Lee WJ, Lkdwl M, Nitoh T, Seki Y, Sski A, Wkbyshi G, Sski I, Kwmur I, Kow L, Frydenberg H, Chen A, Nrwri M, Chowbey P. IFSO-APC consensus sttements 11. Obes Surg 12; 22: [PMID: DOI: /s ] 6 Prk JY, Song D, Kim YJ. Clinicl experience of weight loss surgery in morbidly obese Koren dolescents. Yonsei Med J 14; 55: [PMID: DOI: / ymj ] 7 The Asi-Pcific Perspective: redefining obesity nd its tretment. Helth Communictions, Sydney. Sidney: World Helth Orgniztion 8 Peterli R, Borbély Y, Kern B, Gss M, Peters T, Thurnheer M, Schultes B, Lederch K, Bueter M, Schiesser M. Erly results of the Swiss Multicentre Bypss or Sleeve Study (SM-BOSS): prospective rndomized tril compring lproscopic sleeve gstrectomy nd Roux-en-Y gstric bypss. Ann Surg 13; 258: ; discussion 695 [PMID: DOI: / SLA.0b013e ] 9 Crlin AM, Zeni TM, English WJ, Hwsli AA, Genw JA, Kruse KR, Schrm JL, Kole KL, Finks JF, Birkmeyer JD, Shre D, Birkmeyer NJ. The comprtive effectiveness of November 28, 15 Volume 21 Issue 44

8 sleeve gstrectomy, gstric bypss, nd djustble gstric bnding procedures for the tretment of morbid obesity. Ann Surg 13; 257: [PMID: DOI: / SLA.0b013e ded] 10 Zhng C, Yun Y, Qiu C, Zhng W. A met-nlysis of 2-yer effect fter surgery: lproscopic Roux-en-Y gstric bypss versus lproscopic sleeve gstrectomy for morbid obesity nd dibetes mellitus. Obes Surg 14; 24: [PMID: DOI: /s ] 11 Vidl P, Rmón JM, Gody A, Beniges D, Trillo L, Prri A, González S, Per M, Grnde L. Lproscopic gstric bypss versus lproscopic sleeve gstrectomy s definitive surgicl procedure for morbid obesity. Mid-term results. Obes Surg 13; 23: [PMID: DOI: /s ] 12 Dogn K, Gdiot RP, Arts EO, Betzel B, vn Lrhoven CJ, Biter LU, Mnnerts GH, Aufencker TJ, Jnssen IM, Berends FJ. Effectiveness nd Sfety of Sleeve Gstrectomy, Gstric Bypss, nd Adjustble Gstric Bnding in Morbidly Obese Ptients: Multicenter, Retrospective, Mtched Cohort Study. Obes Surg 15; 25: [PMID: DOI: / s ] 13 vn de Lr A, de Cluwé L, Dillemns B. Reltive outcome mesures for britric surgery. Evidence ginst excess weight loss nd excess body mss index loss from series of lproscopic Roux-en-Y gstric bypss ptients. Obes Surg 11; 21: [PMID: DOI: /s ] 14 Himpens J, Dobbeleir J, Peeters G. Long-term results of lproscopic sleeve gstrectomy for obesity. Ann Surg 10; 252: [PMID: DOI: /SLA.0b013e3181e90b31] 15 Chng SH, Stoll CR, Song J, Vrel JE, Egon CJ, Colditz GA. The effectiveness nd risks of britric surgery: n updted systemtic review nd met-nlysis, JAMA Surg 14; 149: [PMID: DOI: / jmsurg ] 16 M RC, Chn JC. Type 2 dibetes in Est Asins: similrities nd differences with popultions in Europe nd the United Sttes. Ann N Y Acd Sci 13; 1281: [PMID: DOI: / nys.198] 17 Dlll RM, Biley LA. Ulcer disese fter gstric bypss surgery. Surg Obes Relt Dis 06; 2: [PMID: DOI: /j.sord ] 18 El-Hyek K, Timrtn P, Shimizu H, Chnd B. Mrginl ulcer fter Roux-en-Y gstric bypss: wht hve we relly lerned? Surg Endosc 12; 26: [PMID: DOI: / s x] 19 Coblijn UK, Gouchm AB, Lgrde SM, Kuiken SD, vn Wgensveld BA. Development of ulcer disese fter Roux-en-Y gstric bypss, incidence, risk fctors, nd ptient presenttion: systemtic review. Obes Surg 14; 24: [PMID: DOI: /s ] Rsmussen JJ, Fuller W, Ali MR. Mrginl ulcertion fter lproscopic gstric bypss: n nlysis of predisposing fctors in 260 ptients. Surg Endosc 07; 21: [PMID: DOI: /s x] 21 Hung CS, Forse RA, Jcobson BC, Frrye FA. Endoscopic findings nd their clinicl correltions in ptients with symptoms fter gstric bypss surgery. Gstrointest Endosc 03; 58: [PMID: ] 22 Wilson JA, Romgnuolo J, Byrne TK, Morgn K, Wilson FA. Predictors of endoscopic findings fter Roux-en-Y gstric bypss. Am J Gstroenterol 06; 101: [PMID: DOI: /j x] P- Reviewer: Guidry CA, Pi SI S- Editor: Yu J L- Editor: Filipodi E- Editor: Zhng DN November 28, 15 Volume 21 Issue 44

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