Sleeve gastrectomy vs. Roux-en-Y gastric bypass

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A recent study published JAMA Network Open evaluated differences in perioperative outcomes between laparoscopic sleeve gastrectomy (SG) and laparoscopic Roux-en-Y gastric bypass (RYGB).

Study: Comparison of sleeve gastrectomy versus Roux-en-Y gastric bypass: a randomized clinical trial.  Image credit: Donenko Oleksii / Shutterstock.comStudy: Comparison of sleeve gastrectomy versus Roux-en-Y gastric bypass: a randomized clinical trial.. Image credit: Donenko Oleksii / Shutterstock.com

Background

The prevalence of obesity has increased significantly worldwide, with many studies indicating that this metabolic disorder is associated with significant mortality. People with severe obesity may undergo metabolic and bariatric surgery for weight management, otherwise known as weight loss surgery.

Although SG and RYGB are the most commonly performed surgical bariatric procedures, no studies have compared their safety and efficacy. Until 2017, the most widely performed bariatric surgical procedure in Sweden was RYGB, until it was finally transferred to SG.

RYGB has been associated with sustained weight loss and improvement in overweight-related comorbidities; However, this procedure is associated with risk of abdominal pain, small bowel obstruction, nutritional deficiencies, alcohol use disorders, and post-bariatric hypoglycemia.

European randomized clinical trials compared SG and RYGB and revealed no significant differences in weight loss and resolution of comorbidities between the two procedures. Although diabetic patients who undergo RYGB demonstrate better glucose control than those who undergo SG, these findings are based on limited-sized clinical trials.

About the study

Current randomized and large-scale clinical trials are comparing the efficacy of SG and RYGB in weight loss and the risk of adverse events to determine which weight loss surgical technique is more effective. This study is of great importance because of the sudden growth of the SG system in Sweden and Norway.

Perioperative outcomes of SG and RYGB based on a large Swedish and Norwegian randomized clinical trial were presented. Methods were followed from a previously published Bypass Equip Sleeve Trial (BEST), which was a multicenter randomized clinical trial that evaluated five-year outcomes of SG and RYGB.

Perioperative outcomes were measured between zero and 30 days of SG and RYGB, including 90-day mortality. Individuals aged 18 years and older with a body mass index (BMI) between 35 and 50 were included in the study group.

All study participants were recommended bariatric surgery. Inflammatory bowel disease, uncontrolled psychiatric disorders, moderate to severe gastroesophageal reflux disease, low substance use, and those with a history of upper gastrointestinal tract surgery were excluded. Eligible participants were randomly selected for SG or RYGB.

Study results

A total of 878 and 857 patients underwent SG and RYGB, respectively, in 23 hospitals. The study cohort was 74% female and 26% male and had a mean age of 42.9 years, with a mean BMI of 40.8.

A low rate of perioperative complications was observed in both groups without statistical significance. Although aSG was associated with lower perioperative risk than RYGB, this was not considered clinically relevant due to the presence of other comorbid factors and differential long-term weight control efforts.

A higher number of serious adverse events were observed within 30 days of the procedure in the RYGB group than in the SG group. In randomized studies, a more significant risk difference between groups may be due to selection bias, as healthy patients are more likely to develop SG.

Conflicting study results are also influenced by the nature of the group. For example, the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) study included patients with higher BMI and comorbidities than the BEST. Therefore, MBSAQIP was associated with more complex surgical procedures than BEST.

The BEST data reflect the possibility that a surgical community with extensive experience in performing RYGB can rapidly transition to SG with lower complication rates. However, the possibility of a reversal must be reviewed.

Compared with previous evaluations on perioperative complications after RYGB, the present study found small bowel obstruction to be the most common perioperative complication. A higher incidence of small bowel obstruction after RYGB may be associated with the Lönroth surgical technique for RYGB.

Operating time was compared between RYGB and SG, where a longer operating time was associated with RYGB, which may be due to greater complications of this surgical procedure. In both SG and RYGB, the length of post-operative hospital stay was one day after surgery.

Conclusion

The current randomized and large-scale observational study evaluated the outcomes of SG and RYGB in individuals with a BMI of 35 to 50. Both surgical procedures were associated with low and nonsignificantly different perioperative morbidity. The study highlighted that perioperative risk should not be considered as a criterion for choosing between SG and RYGB procedures.



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