Post Laparoscopic Sleeve Gastrectomy Research Articles

A5310 - Short-Term Body Composition Changes and Hematobiochemical Response to Topical Vitamin Patch Supplementation as Compared to Oral Vitamin Supplementation Pre- and Post-Laparoscopic Sleeve Gastrectomy

A5310 - Short-Term Body Composition Changes and Hematobiochemical Response to Topical Vitamin Patch Supplementation as Compared to Oral Vitamin Supplementation Pre- and Post-Laparoscopic Sleeve Gastrectomy

Erosive Esophagitis Is Common in Obese Patients and Is Associated With the Need for Continued PPI Therapy Post-Laparoscopic Sleeve Gastrectomy

Erosive Esophagitis Is Common in Obese Patients and Is Associated With the Need for Continued PPI Therapy Post-Laparoscopic Sleeve Gastrectomy

Endoscopic management of post-laparoscopic sleeve gastrectomy stenosis.

Laparoscopic sleeve gastrectomy (LSG) is the most popular bariatric surgery worldwide. Gastric sleeve stenosis is the most common postoperative complication, occurring in up to 3.9% of the cases. Current treatment options include endoscopic treatments, such as dilatations and stent placement as well as surgical revisions such as laparoscopic Roux-en-Y gastric bypass (LRYGB), wedge gastrectomy or seromyotomy. A retrospective analysis of our prospectively collected therapeutical endoscopy database was performed between January 2014 and February 2017. We included all cases of axial deviation or stenosis post LSG, which were treated endoscopically. Patients with concomitant sleeve leaks were excluded. Endoscopic interventions were performed under general anaesthesia and fluoroscopic assistance when needed. Sequential treatment with CRE balloons, achalasia balloons (30-40mm) and fully covered stent placement for refractory cases was performed. A total of 1332 LSG were performed. Overall, 27/1332 patients (2%) developed a gastric stenosis. All patients presented an axial deviation at the incisura angularis and 26% had a concomitant proximal stenosis. Successful endoscopic treatments were performed in 56% (15/27) of patients, 73% of the successful patients underwent a single dilatation procedure. All successful cases had a maximum of 3 interventions. The unsuccessful cases (44%) underwent LRYGB. Mean time between the primary surgery and the diagnosis of the stenosis was 10.3months. Mean follow-up after the endoscopic treatment was 11.5months. A stent migration was the only complication (3.7%) recorded. Endoscopic treatment appears to be effective in 56% of patients with post-LSG stenosis. Only one session of achalasia balloon dilatation is necessary in 73% of successful cases. Pneumatic balloon dilatation seems to be a safe procedure in this patient population. Surgical revision into a LRYGB offers good outcomes in patients that have failed three consecutive endoscopic treatments.

Erratum to: Endoscopic management of post-laparoscopic sleeve gastrectomy stenosis

Erratum to: Endoscopic management of post-laparoscopic sleeve gastrectomy stenosis

An Algorithmic Approach to the Management of Gastric Stenosis Following Laparoscopic Sleeve Gastrectomy.

Gastric stenosis (GS) is a potential adverse event post-laparoscopic sleeve gastrectomy (LSG). Endoscopic management is preferred; however, there is significant variation in therapeutic strategies with no defined algorithm. This study aims to describe the safety and efficacy of a predefined step-wise algorithm for endoscopic management of GS post-LSG. Consecutive patients with symptomatic GS post-LSG, presenting between July 2015 and August 2016, were subjected to a predefined treatment algorithm of serial dilations using achalasia balloons, followed by a fully covered self-expanding metal stent (FCSEMS) if dilations were inadequate. Patients who did not respond or opted out of ongoing endoscopic therapy were offered revision Roux-en-Y gastric bypass (RYGB). Total of 17 patients underwent a median of 2 (range 1-4) balloon dilations. Twelve patients (70.6%) reported clinical improvement with balloon dilation alone, while 3 (17.6%) required subsequent FCSEMS placement. One patient suffered a tear to the muscularis propria with balloon dilation, which was managed conservatively. Overall, 15 (88.2%) reported clinical improvement with endoscopic management. PAGI-SYM scores revealed that the strongest response to therapy, based on mean reduction of score±SD, was in the following items: nausea (3±1.9, P<0.001), heartburn during day (2.8±1.5, P=0.003), heartburn on lying down (3.4±1.4, P<0.001), reflux during day (2.8±1.9, P<0.001), and reflux on lying down (3.0±1.9, P<0.001). Two (11.8%) patients failed endoscopic therapy and underwent RYGB. Endoscopic management of GS using the described algorithmic approach is safe and effective post-LSG. Patients with severe stenosis or helical stenosis are likely to require revision RYGB.

Phytobezoar: a rare late complication following laparoscopic sleeve gastrectomy surgery

Case reports of bezoar after bariatric surgery are available to date only following Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB), but not following laparoscopic sleeve gastrectomy (LSG). Presented here is the first case reports of phytobezoars occurrence post LSG. Two case reports are presented. The mechanisms involved and the therapeutic implications are discussed. Case 1: A 41-year-old woman with a body mass index (BMI) of 45 kg/m2 underwent LSG surgery. Seven months postoperatively she developed significant vomiting and an upper GI gastrografin swallow study revealed a gastric bezoar, confirmed by an esophagogastroduodenoscopy (EGD). The bezoar was broken up and removed with the endoscope. Case 2: A 34-year-old woman with initial BMI of 42.7 kg/m2 was readmitted 5 years post LSG due to reflux accompanied with epigastric pain, vomiting, dysphagia and constipation. An upper GI gastrografin swallow study revealed esophageal dilatation. EGD showed a gastric phytobezoar 3x4cm size, removed by the endoscope. The lack of reports on bezoar occurrence after LSG may be related to the higher rates of stricture reported for LRYGB procedure comparing to LSG. In addition, LSG is a relatively new bariatric procedure, and the interval between surgery and detection of bezoars may be many years later. Thus, even being a rare late complication, bezoars should be suspected in LSG patients presenting with obstructive symptoms during the late post-surgery period. We recommend prompt endoscopic intervention to relieve the obstruction before parts of the bezoar migrate to the small bowel, necessitating operative intervention

Obesogenic Drugs and their Effects on Post-Laparoscopic Sleeve Gastrectomy Outcomes

Obesogenic Drugs and their Effects on Post-Laparoscopic Sleeve Gastrectomy Outcomes

Intra-thoracic Sleeve Migration (ITSM): an Underreported Phenomenon After Laparoscopic Sleeve Gastrectomy.

Despite its technical simplicity, laparoscopic sleeve gastrectomy (LSG) complications are increasingly reported. Intra-thoracic sleeve migration (ITSM ) is a rare complication after LSG which has been inconsistently addressed in the literature. The purpose of this study was to emphasize ITSM occurrence after LSG and evaluate the perioperative factors associated with its development. Between January and July 2016, LSG patients diagnosed with ITSM at two bariatric surgery departments were identified. Perioperative factors were assessed for all the patients and compared between two groups, LSG alone and LSG with concomitant hiatal hernia (HH) repair (HHR). A total of 19 patients (6 males and 13 females) were included. Central obesity was present in 18 patients (94.7%). Nine patients (47.4%) had concomitant hiatal hernia repair during their original LSG. Post-LSG GERD (94.7%) (38.9% de novo and 61.1% recurrent) and post-LSG constipation (57.9%) were commonly associated with ITSM. Severe refractory GERD was the most common presentation for ITSM (94.7%), followed by epigastric pain (47.4%), persistent nausea/vomiting (36.8%), and dysphagia (21.1%). Time interval between primary LSG and ITSM diagnosis ranged from 1day to 3years. Patients with LSG and concomitant HHR presented with higher post-LSG BMI compared to the LSG patients (37±6.4kg/m2 vs. 30.1±6.3kg/m2, p=0.03). All the patients underwent successful reduction of ITSM and subsequent HHR. Central obesity, chronic constipation, post-LSG GERD, and concomitant HHR are commonly seen in post-laparoscopic sleeve gastrectomy intra-thoracic sleeve migration.

Endoscopic management of post-laparoscopic sleeve gastrectomy stenosis.

Laparoscopic sleeve gastrectomy (LSG) is becoming an increasingly popular form of bariatric surgery, accounting for more than 50% of these procedures performed in the USA. Given this popularity, more is being understood about the complications associated with LSG, which, though uncommon, include the formation of strictures and stenosis. The purpose of this study is to establish a safe and effective protocol for the treatment of stenosis post-LSG using endoscopic balloon dilatation. This is a prospective review of 26 patients who had undergone LSG in Kuwait, followed by sleeve gastrectomy stenosis (SGS) and were then referred to Amiri Hospital for endoscopic balloon dilatation from October 2008 up to June 2016. A total of 26 patients (four males; 22 females) presented with symptoms of stenosis post-LSG during the study period. The mean age of the patients was 34.6±10.8years. The mean body mass index at the time of surgery was 43±1.6kg/m2. The median interval from the initial LSG surgery was 95days. Nine patients had an early presentation (≤3months from surgery), while 17 presented late (>3months). The patients were followed for a mean duration of 156±20days from the last endoscopic balloon dilatation. A total of 23 (88.5%) patients had complete resolution of their symptoms. Adverse events were observed in one patients, who was removed from the study. Gastric stenosis is a rare but potentially serious complication of LSG. Serial dilatation of SGS employing endoscopic balloons is a safe method of treatment, with high efficacy rates. This new method may offer a less invasive alternative to surgical revision. However, if endoscopic treatment fails, surgery is necessary.

Endoscopic treatment of post-laparoscopic sleeve gastrectomy leaks using a specifically designed metal stent.

Background and study aim Leakage of the surgical suture is the main complication of laparoscopic sleeve gastrectomy (LSG) and is amenable to endoscopic therapy. The aim of this study was to evaluate the efficacy of a specifically designed self-expandable metal stent (SEMS) to seal the leakage. Patients and methods Over a 2-year period, patients referred for the treatment of post-LSG fistulas underwent placement of a fully covered esophagogastric SEMS with a specific design. Results A total of 10 patients were treated after a mean time of 50.9 days from the diagnosis of post-LSG leakage. A total of 11 SEMSs were placed. After stent removal, the leakage was seen to have healed in eight patients. Two patients who were treated with an SEMS with different mesh design, experienced stent migration, which required alternative endoscopic treatment such as the insertion of double-pigtail stents. After a mean follow-up period of 13.4 months, all patients were asymptomatic. Conclusions: Placement of a specifically designed SEMS for the treatment of post-LSG fistulas seems a promising first-line therapy according to this small series.

24-h Multichannel Intraluminal Impedance PH-metry 1Year After Laparocopic Sleeve Gastrectomy: an Objective Assessment of Gastroesophageal Reflux Disease.

It is not yet clear if laparoscopic sleeve gastrectomy (LSG) causes newly onset gastroesophageal reflux (GERD) or worsens already existing GERD. This is due to the absence of prospective studies using objective assessment measures of GERD such as pH monitoring. Our study aims at assessing GERD 1-year post-LSG procedure for obesity. Twelve asymptomatic obese patients were studied prospectively by using 24-h multichannel intraluminal impedance-pHmetry (MIIpH) pre- and 12months post-LSG. Of patients' 1-year post-LSG, 83.33% of patients' suffer from GERD (either newly onset or worsening of already existing) as indicated by abnormal DeMeester score. Mean DeMeester score 1-year post LSG was 47, almost 2.5 times higher than the preoperative score (p=0.072). The percentage of total time with pH lower than four was statistically significant higher postoperatively (13.27% vs 3.87%, p=0.048). This study is one of the few assessing GERD post-LSG by using 24-h MIIpH. The majority of patients suffer from GERD 12months postoperatively, implying that close postoperative monitor for GERD with the use of pH testing and upper gastrointestinal endoscopy in order to early diagnose GERD and identify possible mucosal injury and also a prophylactic proton pump inhibitor use may be of great importance.

A5209 - Management of Gastroesophageal Reflux Disease and Hiatal Hernia Post Sleeve Gastrectomy: Cardiopexy with Ligamentum Teres

This video demonstrates the management of Gastroesophageal Reflux Disease (GERD) post Laparoscopic Sleeve Gastrectomy (LSG). We present the case of a 26 year old female who underwent LSG 4 years ago. Her pre-operative weight was 116 kgs and her BMI was 44 kg/m2. Her post-operative weight was 59 kgs and her BMI was 22kg/m2. Post-operatively she had GERD and regurgitation and did not respond to medical treatment and dilatation. Endoscopy, barium swallow and CT scan revealed severe reflux, regurgitation with hiatal hernia. We discussed the treatment options as per our management of GERD protocol with the patient. She agreed to the ligamentum teres cardiopexy (LTC) technique which is currently being researched. In this video we demonstrate reproducible laparoscopic repair of hiatal hernia and cardiopexy utilizing ligamentum teres in 2 patients suffering from GERD and hiatal hernia. We discussed the option of gastric bypass with the patient as it is the standard of care in treating such complications, however after explaining both procedures the patient opted for LTC with the knowledge that if the procedure fails, she would require subsequently a gastric bypass.The video demonstrates step-by-step the technique of LTC repair which was successful in the short term follow up in both patients as evident in the post operative barium swallow which shows no hiatal hernia or reflex. At 6 months both patients had no symptoms of GERD.

Inadequate protein intake after laparoscopic sleeve gastrectomy surgery is associated with a greater fat free mass loss

BackgroundLow postoperative protein intake may represent a modifiable risk factor that leads to fat free mass (FFM) loss postlaparoscopic sleeve gastrectomy (LSG), but data concerning this phenomenon is scarce. ObjectivesTo evaluate the association between daily protein intake and relative FFM loss at 6 (M6) and 12 (M12) months after LSG surgery. SettingsPrivate hospital and university hospital. MethodsA prospective cohort study with 12 months follow-up of 77 patients who underwent LSG surgery. Anthropometrics including body composition analysis measured by multifrequency bioelectrical impedance analysis, 3-day food diaries, food intolerance, and habitual physical activity were evaluated at baseline and at M3, M6, and M12. ResultsRepeated body composition measurements and food diary were available for 77 patients (45 women) at M6 and for 68 patients at M12. Mean age was 42.7±9.4 years and mean preoperative body mass index was 42.2±4.8 kg/m2. A protein intake of≥60 g/d was achieved in 13.3%, 32.5% and 39.7% of the study participants at M3, M6 and M12, respectively. FFM significantly decreased at M6 and stabilized at M12. Protein intake of≥60 g/d was associated with a significantly lower relative FFM loss at M6 among women (8.9±6.5% versus 12.4±4.1%; P = .039) and this trend was also reported among men (9.5±5.5% versus 13.4±6.0%; P = .068). A logistic regression for the prediction of FFM loss of≥10% at M6, indicated that protein intake≥60 g/d is a strong protective factor (odds ratio = 0.29, 95% confidence interval .09–.96, P = .043). ConclusionOur study supports the currently recommended protein intake goal of≥60 g/d as an efficient strategy for better preservation of FFM post-LSG.

Sa1019 Endoscopic Treatment Post-Laparoscopic Sleeve Gastrectomy Leaks With a Specifically Designed Metal Stent

Sa1019 Endoscopic Treatment Post-Laparoscopic Sleeve Gastrectomy Leaks With a Specifically Designed Metal Stent

Endoscopic Therapy for Treatment of Staple Line Leaks Post-Laparoscopic Sleeve Gastrectomy (LSG): Experience from a Large Bariatric Surgery Centre in New Zealand.

Laparoscopic sleeve gastrectomy (LSG) is one of the most commonly performed bariatric procedures for treatment of morbid obesity. Despite its popularity, it is not without risks, the most serious of which is the staple line leak. Staple line leaks are difficult to manage and require significant resources in the form of surgical, radiological and endoscopic interventions; long hospital and intensive care stay and significant morbidity. International experience is slowly emerging, but there are still no clear guidelines regarding optimal management of leaks. This study aims to describe the experience of endoscopic management of these leaks by the authors and the development of a customised stent for this condition. Middlemore Hospital is the largest bariatric surgery centre in New Zealand. Since June 2007, a total of 21 patients have received endotherapy for post-LSG leak management. Treatment included the deployment of primary self-expanding metal stents (SEMS) across the leak site, combined with complementary endoscopic modalities. Persistent leaks were treated with follow-up stenting. This study aimed to evaluate the effectiveness of post-LSG staple line leak management at Middlemore Hospital. A total of 20/21 (95%) patients now have resolved leaks following a mean of 75days of treatment (median 47, range 9-187). The mean number of endoscopic procedures required was five. Inpatient stay and average duration till leak resolution has been notably reduced since the addition of customised stents. Clinically significant stent migration occurred in 19% of primary stents. The use of SEMS in conjunction with complementary endotherapy has shown to be both safe and effective in treating sleeve leaks; however, migration is the limiting factor for optimal management. Recent improvements in stent design, such as the one proposed in this paper, show promise in addressing this problem. Earlier use of SEMS seems to reduce the time till closure as well as the total hospital stay, as is apparent from our data.

Laparo-Endoscopic Gastrostomy (LEG) Decompression: a Novel One-Time Method of Management of Gastric Leaks Following Sleeve Gastrectomy

Leakage is the most feared and challenging complication following laparoscopic sleeve gastrectomy (LSG) as it can either be life-threatening or lead to major morbidity. Its management can be very complex. Endoscopic stents seem to be the mainstay of the current modality of treatment but are associated with a high rate of complications and also need supportive procedures for sepsis control and feeding. We aimed to approach this problem through a one-step intervention, achieving three objectives: a prolonged decompression of the gastric tube through a laparo-endoscopically placed gastrostomy, feeding jejunostomy and external drainage. Between 2014 January and March 2015, seven patients were managed for gastric leaks (post LSG) in our center by this novel approach. Their records were reviewed for details like prior operation, presence of comorbidities, if revisional surgery, day of presentation following surgery, intraoperative findings, post-op recovery, length of hospital stay, and time to heal. The results were tabulated and studied. Three were post primary LSG. Four were following revisional surgeries. Six out of seven (85.7 %) healed without alternative intervention. One patient with a large rent was managed by fistulojejunostomy. The average length of stay was 20.7 days. All patients were on postoperative enteral feeding through jejunostomy. There were no gastrostomy-related complications or mortality. Laparo-endoscopic gastrostomy (LEG) decompression is a feasible, single-step, successful procedure in managing post LSG leaks and may be a viable alternative to avoid stent-related morbidity.

Does weight loss due to bariatric surgery affect serum uric acid levels?

BackgroundIn the current scenario, bariatric surgery has become a popular modality for long-term weight loss among obese population. The available data mainly concentrated on its impact on diabetes, dyslipidemia, hypertension, and or metabolic syndrome. However, there is paucity in literature regarding effectiveness of laparoscopic sleeve gastrectomy on serum uric acid. Methods and materialsIn a prospective interventional study, 100 obese patients were studied for weight loss and change in serum uric acid levels postlaparoscopic sleeve gastrectomy. The subjects were enrolled for a period of 1 year. Three patients died during the study and nine were lost to follow-up. All subjects were classified according to WHO criteria of obesity, as mild, moderate, and severe obesity groups. Body weight, body mass index, and uric acid levels were determined at baseline, 3 months, and 6 months postsurgery. ResultsStatistically significant reduction in postoperative body weight and body mass index were noted in comparison to preoperative values. The preoperative mean uric acid levels for mild, moderate, and severe obese groups were 4.65, 5.91, and 6.06mg/dl, which decreased to 2.55, 5.04, and 4.46mg/dl at 6 months postsurgery, respectively. However, on comparison of the change in uric acid levels among the three obesity groups from 3 months to baseline (P=0.17) and from 6 months to baseline (P=0.08), no group was found superior in terms of reducing uric acid level after surgery. ConclusionsBariatric surgery reduces the body mass and leads to the significant reduction in serum uric acid levels. However, this reduction was comparable among obesity groups.

Impact of post-laparoscopic sleeve gastrectomy weight loss on C-reactive protein, lipid profile and CA-125 in morbidly obese women.

IntroductionObesity increases production of adipose tissue-derived proteins, such as tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6). Also there are elevated levels of C-reactive protein (CRP) and IL-6, CD8, and CD4, indicating chronic subclinical inflammation. Since obesity represents a serious risk factor in several metabolic diseases, identifying the status of carbohydrate antigen-125 (CA-125) would further link obesity and tumors.AimTo examine the effect of weight loss by laparoscopic sleeve gastrectomy (LSG) on plasma CRP, lipid profiles and CA-125 level in morbidly obese patients.Material and methodsThis prospective study was conducted in the Surgery Department, Fayoum University Hospital, between August 2013 and September 2015. To assess the effect of excess weight loss following this operation CRP, lipid profile and CA-125 were measured before and 12 months after the LSG operation for weight loss. The study included 30 cases of morbidly obese patients: 30 (100%) females aged 23–55 years who were considered clinically obese with a mean body mass index of 42.71 ±4.3 (38–46) kg/m2 and mean age of 40.3 ±8.5 (23–55) years. The National Institute of Health (NIH) inclusion criteria for bariatric surgery were used.ResultsA mean weight loss of 29.30% decreased plasma CRP, triglycerides, total cholesterol and low-density lipoprotein cholesterol (HDL cholesterol), CA-125 level and increased high-density lipoprotein cholesterol (HDL cholesterol) The percentage weight loss was significantly associated with changes in plasma CRP, triglycerides, total cholesterol, total HDL cholesterol and CA-125.ConclusionsWeight loss by LSG improves inflammation, dyslipidemia and CA-125 level.

Evolving endoscopic management options for symptomatic stenosis post-laparoscopic sleeve gastrectomy for morbid obesity: experience at a large bariatric surgery unit in New Zealand.

Symptomatic stenosis is an increasingly recognised complication following laparoscopic sleeve gastrectomy (LSG) to treat obesity with a reported prevalence between 0.1 and 3.9 %. This study aimed to determine the prevalence and management options for symptomatic stenosis (SS) after LSG. A total of 857 patients underwent LSG at Counties Health Auckland New Zealand between May 2008 and June 2013. All cases referred for management of symptomatic stenosis after LSG were recorded. Symptomatic stenosis developed in 26 (3.03 %) out of 857 receiving LSG confirmed by barium swallow. Three of these 26 patients developed a fixed stenosis in the proximal stomach. These were all successfully treated by one dilatation of controlled radial expansion (CRE) balloon of <20 mm. Of the 23 patients that showed a fixed stenosis at the incisura angularis, 16 were initially treated with dilatation by a CRE balloon. Seven of these patients were successfully dilated although one needed two dilatations. Of the nine failures, six were successfully treated using a 30-mm achalasia balloon dilator and the other three required temporary placement of a self-expandable metal stent (SEMS). Based on this experience, seven other patients who presented with strictures at the incisura >3 cm long were initially treated with the achalasia balloon. Five were successfully dilated, but two required temporary placement of a SEMS. None of the 26 patients required a surgical procedure to correct their stenosis. The use of a 30-mm achalasia balloon and a SEMS is an effective and safe treatment for patients with SS post-LSG who do not respond to dilatation. Achalasia balloon could be the first-line treatment in selected cases.

Lipid profile changes in the severely obese after laparoscopic sleeve gastrectomy (LSG), 1, 3, and 5 years after surgery.

Since there is an increasing acceptance of the laparoscopic sleeve gastrectomy (LSG) and limited information regarding its effect on cardiac risk factors, we assessed lipid profiles. A retrospective review of patient records pre and post LSG was performed. Analysis of variance evaluated group differences and paired t tests compared variable changes. Eighty two patients (67 % female, age 46.4 ± 13.9) had presurgery lipid profiles and follow-up (43 at 1 year, 28 at 3 years, and 26 at 5 years). Groups were not different in gender distribution. The presurgery mean body mass index (BMI) was 55.7 kg/m(2); 65.9 % of the subjects were super obese. After surgery, percentage of excess BMI loss was 58.1 % year (yr) 1, 61.3 % yr 3, and 39.0 % yr 5. Lipids were within the normal ranges for all parameters at all times; however, at baseline 77 % had at least one abnormality. At 1 year, triglycerides decreased significantly from baseline (adjusted p value (adj-p) = 0.004) and high-density lipoprotein (HDL) increased (adj-p = 0.025). Year 3 HDL was significantly different from baseline, adj-p = 0.0001. Yr 3 cholesterol increased from baseline, (adj-p = 0.027). Negative linear correlations with weight loss were present for low-density lipoprotein (LDL) at yr 3(r = 0.46, p = 0.02) and triglyceride change at year 5 (r = 0.48, p = 0.02). The percentage of patients with dyslipidemia or medicated did not change significantly during these 5 years. For this population electing LSG, mean lipid profiles were within normal ranges for all parameters before surgery. However, 77 % showed at least one abnormality presurgery. Weight change correlated with some changes of triglycerides, HDL, and LDL over time, but the impact was limited.