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Review paper

The hundred most frequently cited studies on sleeve gastrectomy

Tomasz Stefura
1
,
Artur Kacprzyk
1
,
Jakub Droś
1
,
Katarzyna Chłopaś
1
,
Michał Wysocki
1, 2
,
Anna Rzepa
1
,
Magdalena Pisarska
1, 2
,
Piotr Małczak
1, 2
,
Michał Pędziwiatr
1, 2
,
Michał Nowakowski
1
,
Andrzej Budzyński
1, 2
,
Piotr Major
1, 2

1.
2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
2.
Centre for Research, Training, and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
Videosurgery Miniinv 2020; 15 (2): 249–267
Online publish date: 2019/10/29
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Introduction

Sleeve gastrectomy (SG) has recently become one of the most common bariatric procedures worldwide. Some authors consider SG to be an ideal bariatric procedure [1–3]. In 2013, there was a significant increase in the utilisation of laparoscopic SG in the largest academic centres of the United States; as a result, the popularity of SG surpassed that of laparoscopic Roux-en-Y gastric bypass [4]. SG allows the patient to achieve satisfactory loss of excess body weight and resolution of obesity-related comorbidities, including type 2 diabetes mellitus, hypertension, and dyslipidaemia [5]. Staged approaches to the surgical treatment of morbid obesity often include SG as an initial procedure, but SG is also implemented as a singular and primary bariatric operation [6, 7]. Moreover, SG seems to be a more cost-effective choice of treatment compared with laparoscopic Roux-en-Y gastric bypass [8, 9].
Despite the high effectiveness of SG in both the short and long term, thorough scientific investigation is required to correctly understand the mechanisms underlying this bariatric procedure. These mechanisms should be the main focus of current research, in contrast to the development of new operations and techniques [10]. At present, SG is one of the most frequently and thoroughly studied areas in bariatric surgery.
Many recent publications have focused on the 100 most frequently cited papers investigating various surgical topics. The role of this type of research is to underline which authors, bariatric centres, countries, or journals have most strongly influenced advances in surgery [11–13]. Previous studies conducting bibliometric analyses in the field of bariatric and metabolic surgery focused on this subject as a whole and had several methodological shortcomings [14]. We believe that bibliometric analysis of a specific bariatric operation, which has rapidly gained popularity in recent years, would provide valuable insight into the current development of trends in the surgical treatment of obesity.

Aim

Our objective was to analyse and summarise the characteristics of the most frequently cited studies focusing on SG.

Material and methods

Study design

We used the Web of Science database (Thomson Reuters, Philadelphia, PA, USA) to identify all studies focused on SG as a bariatric procedure, published from 2000 to 2018. The terms “sleeve gastrectomy”, “vertical gastrectomy”, “parietal gastrectomy”, and “reduction gastrectomy” were used to conduct the search on 31 December 2018. The search strategy did not include any limitations on language and abstract availability. The inclusion criterion was an original study or secondary source (review or meta-analysis) with the primary focus on SG as a bariatric operation. The search strategy was limited to the period 2000–2018. We excluded publications that did not consider SG as a separate procedure, studies focusing on open surgeries, and animal studies. Articles were ranked based on the number of citations; if two or more articles had the same number of citations, they were then ranked based on the year of publication. We excluded studies with fewer than 50 citations. Two independent reviewers assessed the list and selected the 100 most frequently cited studies with a focus on SG by reviewing the titles and abstracts of all identified records. A third reviewer compared the two lists, discussed the differences, and resolved any conflicts. All articles included in the list of 100 were retrieved.

Outcomes of interest

Data were extracted independently by the two reviewers. When a disagreement was encountered, a consensus was reached by discussion with a third reviewer. During the full-text screening, the reviewers extracted the following data: title, primary and senior authors’ names, total number of authors and their department of origin (academic/non-academic, surgical/non-surgical, and single-centre/multi-centre), year of publication, number of citations, citations per year, continent, country, journal, focus of the journal (bariatric surgery, general surgery, general medicine), journal origin, impact factor in 2017, immediacy index, study type (clinical experience, basic science, review), article type (case series, observational study, randomised clinical trial, basic science, review/expert opinion, systematic review, meta-analysis), funding source, and level of evidence (I–V) assessed in accordance with publication by Wright et al. [15] and the subject of the study.

Statistical analysis

Statistical analysis was performed using Statistica 12 Software (StatSoft Inc., Tulsa, OK, USA). The Shapiro-Wilk test was used to assess the data distribution. Continuous variables are presented as arithmetical means with standard deviations. Correlations were assessed using Spearman’s test. The Mann-Kendall trend test was used to determine time-dependent trends. A p-value of < 0.05 was considered statistically significant.

Results

Our search strategy revealed 6845 records related to SG. Overall, 180 publications were focused on SG and contained a total of ≥ 50 citations. The 100 most frequently cited publications were included in the final list (Table I) [15–117]. A flowchart of the study is presented in Figure 1.
The most frequently cited publication was a study by Karamanakos et al. [16] (493 citations). The article by Ryan et al. [118] had the highest mean number of citations per year (73.00 citations) (Table II). Studies were most frequently published in the years 2010 (15 studies) and 2012 (13 studies) (Figure 2). Articles were most frequently cited in the years 2014 to 2016 (Figure 3). We observed a positive correlation between the citation density and time (r = 0.314, p < 0.05) (Figure 4). The number of citations per year increased with time (r = 0.852, p < 0.05). The number of articles also rose in subsequent years (r = 0.581, p < 0.05).
Overall, 64 of the included articles were observational studies, 11 were randomised clinical trials, and eight were systematic reviews. Most of the included publications reported neither commercial nor public funding (79 publications). Public foundations financed 19 studies, and commercial companies financed three studies (Table III).
The included articles were most commonly published in Obesity Surgery (49 articles), followed by Surgery for Obesity and Related Diseases (14 articles) and Annals of Surgery (11 articles). The scope of the journals that published the included studies was mostly focused on bariatric surgery (63 journals) or general surgery (28 journals). Most journals originated from the United States (96 journals) (Table IV).
The most frequent country of origin among the included studies was the United States (38 studies). Eight studies were conducted by institutions from Spain, six by institutions from Italy, and six from Chile (Table V). Most articles were written by authors from academic departments (51 articles). Most articles were published by authors working in a surgical institution (89 articles). They were predominantly conducted in multiple centres (65 studies). The mean number of authors in the included articles was 6.56 ±3.36. Four people were listed as the first author of three articles in our list: Italo Braghetto, Michel Gagner, Wei-Jei Lee, and Ralph Peterli (Table VI). Raul Rosenthal was a senior author in five articles, and Michel Gagner and Nicola Basso were senior authors in four publications (Table VII).
The most common level of evidence among the studies was III (50 studies), followed by II (29 studies) and I (10 studies) (Figure 5). The mean number of citations per year was highest among articles with a level of evidence of V (26 citations) (Figure 6). The mean number of citations per article was highest among articles with a level of evidence of I (215.4 citations) (Figure 7).
Most of the included studies focused on the short- and long-term clinical outcomes of SG (36 studies). Metabolic and hormonal changes were investigated by one-fourth (22) of the included articles. Overall, 18 of the included publications were reviews investigating the subject of SG in its entirety (Table VIII).

Discussion

The present report summarises the characteristics of the 100 most frequently cited publications focused on SG published up to date. These results may be useful in the process of designing further studies, and they provide a new understanding of the increased popularity of SG. Our study gives new insight into which articles, authors, countries, and journals have played a key role in understanding the advantages of SG and in promoting its use. Ahmad et al. [119] suggested the constant need to update bibliometric articles because of their limited life span. Conducting updates could help to identify changes in research trends [119]. We believe that further studies concentrating on bariatric surgery should also investigate the most popular procedures separately because of the vastness of the currently published literature devoted to bariatric surgery and the multiplicity of bariatric operations that are now performed.
Some of the most frequently cited studies were reviews that considered the subject of bariatric surgery in its entirety. Such reviews allow for a new understanding of the evolution of bariatric surgery as a field of study, which has undergone considerable change during recent years [14, 119]. Academic interest in bariatric surgery has been rapidly growing since the beginning of the 21st century, although surgical treatment of obesity has been performed for more than six decades [120, 121]. Additionally, bibliometric analyses have helped to outline which publications should be included in educational programs as mandatory reading material for surgeons, surgical trainees, and allied health professionals working in the field of bariatric surgery [121].
SG (parietal gastrectomy) was first introduced in 1988 as a restrictive component of biliopancreatic diversion with duodenal switch [121, 122]. Bariatric surgeons started to consider SG as an independent bariatric operation in the 21st century. Therefore, most research investigating SG is relatively recent [123]. Most of the studies included in our list were published after 2006. Our results indicate growing scientific interest in SG both in terms of the number of publications and the number of citations.
Although the receipt of external commercial funding, if clearly described, should not decrease the value of presented data, the vast majority of the most influential studies on SG were not funded commercially [124, 125].
During submission of a manuscript, it is critical to choose a journal with a scope matching the subject of the article [126]. Authors often desire to submit their work to prestigious journals. Unfortunately, there is no ideal parameter with which to measure the value of a journal. Currently, the most commonly used measure of a journal’s scientific influence is the impact factor, although this parameter has multiple imperfections [127]. Previously published bibliometric analyses of bariatric surgery, as well as most of the articles included in our list, were published in the most influential journals devoted to bariatric surgery: Surgery for Obesity and Related Diseases (established in 2005, the official journal of the American Society for Metabolic and Bariatric Surgery) and Obesity Surgery (established in 1999, the official journal of the International Federation for the Surgery of Obesity and Metabolic Disorders) [14, 109].
First authorship is often vigorously pursued by researchers as confirmation of a substantial contribution to the study and a crucial role during the research [128]. Senior authorship (last author) is usually associated with the role of supervisor or overseer of the study. According to Zbar and Frank, the senior author often has a minor or no contribution to the study; instead, he or she may have provided funding or is a laboratory head or mentor. The last author is often chosen based on seniority in the field [129]. We analysed the first and senior authorship among the included papers. Several authors repeatedly appeared in multiple publications included in our list, proving that they have played a substantial role in investigating SG and promoting advancements in bariatric surgery and recognition of SG.
Most of the included articles were published by authors from the United States. In accordance with the study by Angrisani et al. [1], the United States/Canada was also the region with the highest number of bariatric procedures. A recent analysis of bariatric practice in the United States demonstrated that laparoscopic SG has become the most common bariatric procedure performed in this country [130]. Moreover, it seems that academic institutions in the United States play a leading role in various fields of medical research other than bariatric surgery [131–133].
In 2003, The Journal of Bone & Joint Surgery introduced level of evidence ratings that have been extensively used in further publications and bibliometric analyses [15]. Most of the articles included in our list had a level of evidence of III. In contrast, most of the articles in the study by Ahmad et al. [119], who investigated bariatric surgery in general, had a level of evidence of IV. These results indicate the need to conduct further trials in bariatric surgery, preferably randomised clinical trials, because they are associated with the highest levels of evidence according to the current principles of evidence-based medicine [134].
Most of the literature included in our list comprised clinical experience/observational studies that presented outcomes of bariatric treatment in the clinical environment or metabolic and hormonal changes following the operation. Consistent with a previous publication by Carlson [10], we believe that further research should explain the mechanisms associated with SG, which would advance our current understanding of the physiological changes that occur after the procedure. Additionally, further improvement of techniques used in bariatric treatment should be encouraged [18, 19, 135].
The present study has several limitations. First, the number of citations provided by the Web of Science might not be extensive. In contrast to some previous articles, we decided not to verify the number of citations using Google Scholar. This is a database that does not standardise authors’ names, that includes every citation whether scholarly or not, and includes every version of an article, resulting in multiple duplicate entries and thus a duplicated number of citations [20]. Nevertheless, a similar search strategy conducted in a different database would probably result in a different outcome. Second, the number of citations is a limited measure of the relevance of a study. Finally, recently published studies that will significantly influence the development of bariatric surgery in the future might have been omitted.

Conclusions

Our study indicates an increase in medical researchers’ interest in the subject of SG since the year 2000 (especially since 2006). Crucial scientific papers investigating SG are usually observational clinical studies conducted in academic surgical centres. Influential scientific evidence seems to be authored mostly by scientists from the United States and published in bariatric surgery-oriented journals. Our study underlines the need to perform studies with a high level of evidence, preferably randomised clinical trials, to further analyse the outcomes of SG and basic science research to properly investigate the mechanism underlying metabolic changes after SG.

Conflict of interest

The authors declare no conflict of interest.

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Received: 1.07.2019, accepted: 21.08.2019.
Copyright: © 2019 Fundacja Videochirurgii This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0) License (http://creativecommons.org/licenses/by-nc-sa/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, provided the original work is properly cited and states its license.
  
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