OBES SURG (2015) 25:452456

DOI 10.1007/s11695-014-1415-7

ORIGINAL CONTRIBUTIONS

Effect of Sleeve Gastrectomy on Thyroid Hormone Levels

Yasmin Abu-Ghanem & Roy Inbar & Vitaly Tyomkin &
Ilan Kent & Liron Berkovich & Ronen Ghinea &
Shmuel Avital

Published online: 31 August 2014

# Springer Science+Business Media New York 2014

Abstract
Background Weight loss in morbidly obese patients is associated with changes in thyroid function. Studies have demonstrated equivalent changes following bariatric surgery. Changes in thyroid function were reported following laparoscopic
Roux-en-Y gastric bypass (LRYGB), biliopancreatic diversion (BPD), and laparoscopic adjustable gastric banding
(LAGB). No data exists on changes in thyroid function following laparoscopic sleeve gastrectomy (LSG). The aim of
the current study is to evaluate changes in thyroid function
following LSG in patients with normal thyroid function.
Methods Data were retrieved from a prospectively collected
database of patients who underwent LSG for morbid obesity.
Euthyroid patients were evaluated for changes in TSH and
free thyroxine (FT4), 612 months after surgery. Correlation
between changes in thyroid hormone levels, excess weight
loss (EWL), and baseline TSH were evaluated.
Results Thirty-eight patients were included in the study. Mean
BMI decreased from 42.4 to 32.5 kg/m2 (P<0.0001). Mean
TSH levels decreased from 2.450.17 mU/L at baseline to
1.820.18 mU/L (P<0.0001), whereas mean FT4 levels
remained the same after surgery (13.270.45 pmol/L compared to 12.960.42 pmol/L, P=NS). TSH decrease was
directly related to baseline TSH but did not correlate with
EWL.
Conclusions This is the first study to evaluate changes in
thyroid hormone levels following LSG for morbid obesity.
TSH decrease and steady levels of FT4 are expected following
LSG. These findings are comparable to reported changes
following LRYGB. TSH decrease was not associated with
Yasmin Abu-Ghanem and Roy Inbar contributed equally to this work.
Y. Abu-Ghanem : R. Inbar : V. Tyomkin : I. Kent : L. Berkovich :
R. Ghinea : S. Avital (*)
Department of Surgery B, Meir Medical Center, Kfar Saba, Israel
e-mail: avitalshmuel@gmail.com

EWL. Further studies are required to elucidate the exact

mechanism of this effect.
Keywords Bariatric surgery . Thyroid hormone levels .
Thyroid function . Sleeve gastrectomy . Excess weight loss

Introduction
Morbid obesity and its association with abnormal thyroid
function have been described in the medical literature for
many years [1]. Clinical studies have demonstrated a positive
correlation between obesity and plasma TSH levels. Furthermore, weight loss in these patients is associated with changes
in serum TSH and thyroid hormone levels [26]. The relationship between the adipose tissue and thyroid function is not
completely understood. There are different adipokines that
may have an impact on thyroid function, and a potential
existence of a hypothalamic-pituitary-adipose axis was suggested [6, 7]. Specifically, changes in thyroid hormone levels
following weight loss may be partly explained by a decrease
in serum leptin levels, as often seen after weight loss [8, 9].
Leptin has been described to have a stimulatory effect on
thyroid activity; hence, its decrease may lead to a decrease
in serum TSH, T3, and T4 levels [10, 11].
In the recent decade, bariatric surgery became very prevalent, as it was proven to be an effective method to obtain a
substantial weight loss with significant improvement of associated co-morbidities [12].
There has been an increasing interest in evaluating the
effect of weight loss after bariatric surgery on various hormones including thyroid hormone levels. Clinical studies
focusing on the impact of surgical weight loss following
different bariatric procedures as laparoscopic Roux-en-Y gastric bypass (LRYGB), biliopancreatic diversion (BPD), and

OBES SURG (2015) 25:452456

laparoscopic adjustable gastric banding (LAGB) on thyroid

hormone levels have yielded inconsistent results.
While some of these studies demonstrated a decrease in
TSH level with no change in free thyroxine (FT4) levels [13,
14], others revealed an increase in FT4 but no change in TSH
level [15, 16].
In recent years, LSG has gained much popularity throughout the world and was recently approved as a valid alternative
bariatric procedure to LRYGB [17].
To the best of our knowledge, no data regarding thyroid
hormone changes following weight loss after LSG has been
reported. The aim of this study was to evaluate changes in
thyroid function in euthyroid obese patients undergoing LSG
and compare it to reported changes following other bariatric
procedures.

Materials and Methods

Data were retrieved from a prospectively collected database of
patients who underwent laparoscopic sleeve gastrectomy for
morbid obesity between March 2012 and April 2013. All
operations were performed by a dedicated bariatric team that
consisted of two surgeons. In all cases, a standardized surgical
approach, using a 36-French bougie, was employed.
We identified 38 patients with no prior history of thyroid
disease, with normal thyroid hormone levels prior to surgery,
and with no history of thyroid hormone replacement therapy.
Baseline TSH and FT4 were defined prior to surgery, as part
of the initial preoperative evaluation.
Data recorded included age, gender, previous comorbidities (hypertension, diabetes, hyperlipidemia, and degenerative arthritis), body weight, and TSH and FT4 levels at
baseline and 612 months after surgery. Weight loss was
expressed in terms of percentage of excess body weight loss
(EWL). Correlations were computed by Spearman rank order
correlation.
Thyroid hormone levels were not taken at the same time
intervals in every patient. Thus, we have decided to evaluate
changes in thyroid hormones at 612 months after surgery in
view of the fact that a significant weight loss is generally
achieved by that time. Obviously, the correlation between
changes in thyroid hormone levels and the level of EWL
was evaluated at the same time point after surgery in each
individual patient.
Statistical analysis was performed using Statistical Package
for the Social Sciences (SPSS, Version 17.0, Chicago, IL,
USA). Students paired-samples t test was used for comparisons between paired measurements. The linear regression
model was used to study the relationship between outcome
variables. A P value of less than 0.05 was considered statistically significant.

453

Results
The study included 38 patients who underwent LSG, of whom
28 were women (74 %) and 10 were men (26 %). Mean
standard error (SE) age at the time of sleeve gastrectomy was
39.71.97 years (range 2060 years). None of the patients
had a history of thyroid disease. All patients had grade III
(BMI 40 kg/m2) or grade II obesity (BMI 35 and <40 kg/
m2) with co-morbidities (Table 1). Patients had a meanSE
preoperative weight of 117.922.81 kg and BMI of 42.6
0.58 kg/m2 (Table 2). Mean EWL of 612 months was 63 %.
Mean BMI was reduced from 42.4 to 32.5 kg/m2 (P<0.0001;
Table 2). TSH was 2.450.17 mU/L at baseline and decreased
significantly to 1.820.18 mU/L at 612 months after bariatric surgery (P<0.0001; Fig. 1). FT4 was 13.270.45 pmol/L
at baseline and 12.960.42 pmol/L at 612 months following
the operation (non-significant; Fig. 1). Changes in TSH levels
were significantly correlated with baseline TSH (Fig. 2). Yet,
the decrease in TSH following surgery did not correlate with
EWL (Fig. 3).

Discussion
Changes in thyroid hormone levels succeeding weight loss are
a well-known phenomenon. Variations in thyroid function
following a weight reduction surgery are also reported. However, the reported changes were not always similar in the
different studies and may depend on the type of surgery
performed.
A summary of the significant results of published reports to
date, including the present study, on the effect of the different
types of weight reduction surgeries on thyroid hormones is
presented in Table 3. Four studies evaluated thyroid function
changes following RYGB [1315, 18]. Three of them showed
a decrease in TSH levels following the operation while only
one failed to show it.
Fazylov et al. [18] evaluated the impact of LRYGB in 20
morbidly obese female patients with hypothyroidism and on
thyroid replacement therapy. The authors did not specify
changes in TSH or thyroid hormones; however, they have
shown a decrease in postoperative L-thyroxine dosage as an
indication of improvement in thyroid gland function. Hypothyroidism resolved in 25 % of patients, improved in 10 % of
patients, was unchanged in 40 % of patients, and worsened in
Table 1 Co-morbidities
of the study population

Values in parentheses are

percentages

Co-morbidities

Number (%)

Diabetes
Hyperlipidemia
Hypertension
Arthritis

10 (26.3)
12 (31.6)
8 (21.1)
8 (21.1)

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OBES SURG (2015) 25:452456

Table 2 Variables before and after laparoscopic sleeve gastrectomy

(LSG)
Variable

Baseline

612 months

P value

Weight (kg)
Body mass index (kg/m2)
TSH (mU/L)
Free thyroxine (pmol/L)

117.9
42.4
2.45
13.27

87.3
31.5
1.82
12.96

0.0001
0.0001
0.001
0.272

5 (25 %) of patients. However, most of the patients whose

hypothyroidism worsened had thyroid autoimmune disease.
The author concluded that hypothyroidism appears to improve
in the vast majority of morbidly obese patients who undergo
LRYGB, except for those whose thyroid disease is autoimmune in nature.
Another study by Moulin et al. [13] demonstrated the effect
of LRYGB on thyroid function tests in obese patients with
subclinical hypothyroidism and in euthyroid patients. Twelve
months following the operation, Moulin and colleagues have
documented a significant decrease in TSH and T3 levels with
no change in FT4 in both groups. TSH concentrations reached
normal values in all SH patients after RYGB. Interestingly, the
decrease in TSH was not correlated with EWL.
Similar results with a decrease in TSH and steady levels of
FT4 in euthyroid patients as well as a complete resolution of

Fig. 1 TSH (a) and FT4 (b) changes 612 months following LSG

Fig. 2 Correlation between absolute changes in TSH levels and baseline

TSH

subclinical hypothyroidism were reported by Chikunguwo

et al. [14]. However, in this study, which included 86 patients,
they have incorporated patients that underwent open (5) and
laparoscopic (65) RYGB with patients that underwent LAGB
(16), with no differentiation of the results between the groups.
In contrast to the results of the previous three studies, a
more recent study by MacCuish et al. did not reveal a significant decrease in TSH levels in euthyroid patients undergoing
LRYGB. However, FT4 levels were found to increase following this surgery [15]. Two other papers evaluated the impact of
BPD on thyroid function with contradictive results. Alagna
et al. [19] found no change in TSH and FT4 12 months after
BPD in 38 euthyroid patients. However, a decrease in T3 was
noted. In contrast, Camastra et al. [20] found that TSH significantly decreased in 16 patients undergoing BPD.
To date, only one study by DallAsta et al. [16] concentrated solely in patients undergoing LAGB. In this study that
included 258 patients, TSH levels did not change 624 months

Fig. 3 Correlation between absolute changes in TSH levels and changes

in excess weight loss (EWL)

OBES SURG (2015) 25:452456

455

Table 3 Published results on changes in thyroid function following different types of bariatric procedures
FT4 T3/FT4 EWL/ TSH Comments
correlationa

Ref.

No. of Time from

Population
pts.
surgery (months)

Surgery

TSH

Fazylov et al. [18]

Moulin de Moraes
et al. [13]
Chikunguwo et al. [14]
MacCuish et al. [15]
Camastra et al. [20]

20
72

124
12

Hypothyroid
(Euo and sub)

RYGBP
RYGBP

Hypo-improved

86
55
16

612
424
6

(Euo and sub)

Euthyroid
Euthyroid

RYGBP/band
RYGBP
BPD

38
258
38

12
624
612

Euthyroid
Euthyroid
Euthyroid

BPD
Band
Sleeve

~
~

Alagna et al. [19]

DallAsta et al. [16]
Abu-Ghanem et al.
[present report]

No
No

T3

Yes

Yes
No

T3
T3

euo euthyroid, sub subclinical hypothyroidism

a

Correlation between the percentage of excess body weight loss (EWL) and TSH decrease following the operation

following the operation despite a significant increase in FT4

levels.
To our knowledge, our study is the first to evaluate changes
in thyroid hormone levels following LSG. We believe that our
study results contribute significantly to the reported observed
hormonal changes following the different types of bariatric
operations. Our study focused on euthyroid patients. However, it is important to note that high TSH concentrations
(>2 mIU/L) were reported to be associated with an increased
risk of future hypothyroidism [21]. In our study, the average
TSH level prior to surgery was above 2 mIU/L (2.450.17)
and decreased to a level below 2 mIU/L (1.820.18). Nevertheless, our further plans are to evaluate changes in a specific
group of hypothyroid patients undergoing sleeve gastrectomy
as was evaluated by Fazylov et al. in a small group of hypothyroid patients undergoing LRYGB [18]. Our results (i.e., a
significant decrease in TSH with no change in FT4) are more
consistent with most of the reports on patients following
LRYGB.
The exact mechanism leading to a decrease in TSH following sleeve gastrectomy and LRYGB is not clear and still
remains to be elucidated. The main explanation, suggested
by several studies, is related to a decrease in leptin levels
following surgery. Leptin is produced by adipocytes and was
shown to influence the secretion of several hypothalamic
hormones, including thyrotropin-releasing hormone [22]. A
reduction in leptin levels following the weight loss induced by
bariatric surgery would lead to a reduction in this effect with
lower TSH secretion.
However, the surgery itself may have an additional effect
besides the expected changes anticipated due to weight reduction. This can be learned from the fact that the level of TSH
reduction was not directly correlated to the EWL in our study
and in other reports [13, 18]. We believe that this effect is
similar to other effects of weight reduction surgery such as
seen in diabetes, where improvement is associated not only

with the weight loss but also with the surgery itself through
hormonal mediation [23]. Moreover, the specific type of surgery may have a different effect on thyroid function changes.
This can be concluded from observing that different types of
surgeries lead to different hormonal profile changes.
A recently published paper has shown that circulating
ghrelin levels significantly correlated with TSH levels among
other hormones [24]. Since ghrelin levels were shown to be
suppressed following LRYGB and LSG but not after LAGB
[25], we postulate in here that the reduction in ghrelin following LRYGB and LSG may have an added effect on the
reduction in TSH levels.
Our hypothesis is that like in other co-morbidities of obesity (e.g., diabetes), which improve after bariatric surgery, this
effect is achieved by a combination of weight loss and hormonal changes. Thus, bariatric surgery, specifically procedures associated with transaction of the gastric fundus leading
to a reduction in ghrelin levels, may have an added effect in
improving thyroid function over weight loss alone.

Conclusions
In conclusion, this is the first study to evaluate changes in
thyroid function following LSG. The reduction in TSH found
in our study was parallel to most of the reported changes
following LRYGB. The mechanism responsible for these
changes is not well understood and should be further
investigated.

Conflict of Interest Dr. Yasmin Abu-Ghanem, Dr. Roy Inbar, Dr.

Vitaly Tyomkin, Dr. Ilan Kent, Dr. Liron Berkovich, Dr. Ronen Ghinea,
and Dr. Shmuel Avital declare that they have no conflict of interest.
Statement of Human and Animal Rights This study has been approved by the appropriate institutional research committee and has been

456
performed in accordance with the ethical standards as laid down in the
1964 Declaration of Helsinki and its later amendments or comparable
ethical standards.

OBES SURG (2015) 25:452456

12.

Statement of Informed Consent For this type of study (retrospective

in nature), formal consent is not required. (An exemption from informed
consent for this study was given by the institutional research committee as
the data were retrospectively retrieved from an existing prospectively and
routinely collected database.)

13.

Funding Source None.

14.

15.

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