Benefits of Sleeve Gastrectomy Versus Gastric Bypass

More than 80 percent of patients had diabetes remission within 5 years of surgery

With David Arterburn MD

Feet wearing Chuck Taylors standing at the base of diverging arrows

There is plenty of data showing that traditional gastric bypass surgery can help those with type 2 diabetes lose weight and go into remission. But a new study finds that Sleeve Gastrectomy (SG) can have similar – even better – outcomes for initial diabetes remission, with 83.5% of SG patients experiencing a remission in 5 years compared with 80% of those who had Roux-en-Y Gastric Bypass (RYGB).

Over 50% of patients had diabetes remission within one year

The multicenter 10-year study reported interim outcomes in March for more than 9000 patients, 6200 who had traditional surgery, and 3400 who had the SG procedure. Outcomes studied included total weight loss, diabetes remission episodes, and diabetes relapse. The study found that 56-59% of patients had remission in the year after surgery, and 84-86% did within 5 years. A third of RYGB patients relapsed within 5 years of initial remission, and 42% of those with SG did. Patients with SG didn’t lose as much weight, nor maintain weight loss as well as the bypass patients – a finding which was echoed in another recent study.

The study authors noted, “Overall, these results indicate that RYGB is associated with better long-term type 2 diabetes and weight outcomes than SG in real world clinical settings. Patients with lower preoperative probability for remission (11%-33%) may be more likely to achieve remission with RYGB compared with SG. Estimating the likelihood of T2DM remission could help inform patients’ and clinicians’ discussions of procedure choice.”

Older patients, those who use insulin, had more complex medication regimens, and higher A1c levels are less likely to achieve remission, the paper continues.  

“I think what was interesting to see was how well the SG patients did in terms of diabetes remission,” said study author David Arterburn, MD, of the Kaiser Permanente Washington Health Research Institute in Seattle. “They lose less weight, so we figured remission rates would be lower than that.” The differences in relapse were less surprising.

The results of this study may add to ongoing debates on which procedure is better for patients, he says. However, Arterburn believes that physicians and patients need to take this and other data and make a decision together based on their individual concerns.

illustration diagramming a sleeve gastrectomySleeve gastrectomy was shown to be equivalent to traditional bypass for initial diabetes remission.

Sleeve gastrectomy has fewer complications

There is ample evidence that SG has fewer post-surgical adverse events, including a new study that found interventions, hospitalizations, and complications were more common with RYGB than SG. “There are clear tradeoffs between benefits and risks,” says Arterburn. “We have to approach this as a classic situation where you need to do good shared decision-making. People lose more weight and have better diabetes control long term with RYGB. But it is much safer to get a sleeve. Every patient has to weigh that. If a patient is really worried about safety, an informed patient might be more inclined to get a sleeve.”

However, if you are having major abdominal surgery anyway, and a sleeve is more likely to result in having another surgery down the line, perhaps the better option is traditional bypass and a procedure that “makes the most difference,” he notes.

Another factor in the decision is whether the patient has gastroesophogeal reflux (GERD). Patients with GERD who are so affected they take medications are more likely to see the condition worsen after a sleeve procedure, Arterburn notes. “They sometimes end up having to have further surgery to switch to a bypass, while the bypass itself can reduce reflux symptoms.”

The 10-year data from this patient cohort is being analyzed now, and Arterburn says it will help refine some of the discussions patients and physicians have around which procedure is best. “We want to know more about how durable the outcomes are for the sleeve compared to the bypass – weight loss, cancer risk, and survival are all known quantities for bypass. The data we have so far suggests that sleeve outcomes are also good, but we want to see more long term data on it. Surgeons want to know whether or not a patient is likely to need another surgery 10 years after the original SG.”

Age is a factor in the decision between SG and RYGB

Arterburn  says that bariatric patients are getting older – the average age has increased from 39 to 44 according to a new study, which means that patients who are at real risk of stroke and cardiovascular events can – and are – taking advantage of bariatric surgery. “The prevalence of obesity continues to increase, and it’s safer to perform this on older patients, even those over 65,” he says. “But the data suggests that if patients come to us earlier, we can prevent some problems from ever occurring.”

Arterburn and his colleagues are working on the development of prediction models where patients can input factors such as age and current health problems to determine the chances of diabetes remission, relapse, and reoperation for SG, RYGB, and not having surgery at all. “That’s the next big step. It would be great to be able to help patients understand tradeoffs. It would be easier to have these conversations.”

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