Long-term and midterm outcomes of laparoscopic sleeve gastrectomy versus Roux-en-Y gastric bypass: a systematic review and meta-analysis of comparative studies

doi:10.1016/j.soard.2016.08.011

Surgery for Obesity and Related Diseases

Volume 13, Issue 2, February 2017, Pages 170-180

https://doi.org/10.1016/j.soard.2016.08.011 Get rights and content

Abstract

Objective

This study aimed to compare midterm and long-term weight loss and resolution of co-morbidity with laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG).

Summary

LRYGB and LSG are the most common procedures performed in bariatric surgery. However, their weight loss efficacy in the midterm and long-term has not been well compared.

Methods

A meta-analysis was performed by systematically identifying comparative studies conducted until the end of June 2016 that investigated weight loss outcome and resolution of co-morbidities (type 2 diabetes mellitus, hypertension, hyperlipidemia, hypertriglyceridemia, and obstructive sleep apnea) with LRYGB and LSG in the midterm (3–5 years) and long term (≥5 years). The primary endpoint was weight loss after LRYGB versus LSG. The secondary endpoint was resolution of co-morbidities after these procedures.

Results

Fourteen studies comprising 5264 patients were eligible. Follow-up ranged from 36 months to 75.8±8.4 months. The pooled result for weight loss outcomes did not show any significant difference in midterm weight loss (standardized mean difference = -0.03; 95% confidence interval (CI), -0.38–.33; P = .88) but a significant difference in the long-term weight loss outcome favoring LRYGB (standardized mean difference = .17; 95% CI, .05–.28; P= .005). The pooled results demonstrated no significant difference for resolution of type 2 diabetes mellitus, hypertension, hyperlipidemia, and hypertriglyceridemia.

Conclusion

Despite the insignificant difference between LRYGB and LSG in midterm weight loss, LRYGB produced better weight loss in the long-term. There was no significant difference between the 2 procedures for co-morbidity resolution.

Section snippets

Methods

This study was designed using Cochrane handbook for systematic reviews of interventions [10] and was conducted according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines [11]. The protocol of this systematic review has been registered (CRD42016037669) and is available on the PROSPERO international prospective register of systematic reviews website (www.crd.york.ac.uk/PROSPERO/).

Results

The PRISMA flow diagram for our database search and study selection is shown in Fig. 1. Following identification of a total of 1887 records by database search, title and abstract of 1397 records were screened after removal of duplicates. Of these, full text of 37 articles was retrieved, of which 14 papers comprising 5264 patients were eligible for inclusion in our meta-analysis [6], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26]. Characteristics of included studies

Discussion

This systematic review and meta-analysis of comparative studies found similar weight loss and co-morbidity resolution in the midterm (3–5 years) and similar co-morbidity resolution in the long-term (≥5 years). However, this meta-analysis found a significantly better long-term weight loss outcome with LRYGB than with LSG. Fourteen studies were eligible, according to the systematic review quality requirements. Although 1 midterm study concluded superiority of the gastric bypass over sleeve

Conclusion

This systematic review and meta-analysis demonstrated that despite the insignificant difference between LRYGB and LSG in midterm weight loss, LRYGB produces better weight loss in the long term. However, no significant difference was observed between LRYGB and LSG regarding the resolution of co-morbidities. Considering its more demanding technique and higher complication rate, LRYGB indications should be reconsidered in morbidly obese patients with co-morbidity.

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Changes in eating behaviour including reductions in appetite and food intake, and healthier food cue reactivity, reward, hedonics and potentially also preference, contribute to weight loss and its health benefits after obesity surgery. Functional magnetic resonance imaging (fMRI) has been increasingly used to interrogate the neural correlates of eating behaviour in obesity, including brain reward-cognitive systems, changes after obesity surgery, and links with alterations in the gut-hormone-brain axis. Neural responses to food cues can be measured by changes in blood oxygen level dependent (BOLD) signal in brain regions involved in reward processing, including caudate, putamen, nucleus accumbens, insula, amygdala, orbitofrontal cortex, and top-down inhibitory control, including dorsolateral prefrontal cortex (dlPFC). This systematic review aimed to examine: (i) results of human fMRI studies involving obesity surgery, (ii) important methodological differences in study design across studies, and (iii) correlations and associations of fMRI findings with clinical outcomes, other eating behaviour measures and mechanistic measures.
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After RYGB surgery, food cue reactivity often decreased or was unchanged in brain reward systems, and there were inconsistent findings as to whether reductions in food cue reactivity was greater for high-energy than low-energy foods. There was minimal evidence from studies of VSG and LAGB surgeries for changes in food cue reactivity in brain reward systems, though effects of VSG surgery on food cue reactivity in the dlPFC were more consistently found. There was consistent evidence for post-operative increases in satiety gut hormones glucagon-like-peptide 1 (GLP-1) and peptide YY (PYY) mediating reduced food cue reactivity after RYGB surgery, including two interventional studies. Methodological heterogeneity across studies, including nutritional state, nature of food cues, post-operative timing, lack of control groups for order effects and weight loss or dietary/psychological advice, and often small sample sizes, limited the conclusions that could be drawn, especially for correlational analyses with clinical outcomes, other eating behaviour measures and potential mediators.
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A total of 3329 patients were identified in our institutional Metabolic and Bariatric Surgery Accreditation and Quality Improvement database using Current Procedural Terminology codes for either RYGB or SG. A general linear model was used for baseline characteristics. Logistic regression was used for factors favoring RYGB versus SG. A multivariable linear mixed model was used for weight-trajectory analysis. Cox regression was used for a cumulative hazard ratio of 10% weight regained from nadir.
Factors favoring RYGB were diagnoses of type 2 diabetes and gastroesophageal reflux disease, Hispanic ethnicity, and surgeon’s preference. SG was favored among Black patients and smokers. RYGB was associated with more weight loss at all time points. The risk of weight regain was significantly higher after SG versus RYGB.
The bariatric procedure choice is significantly influenced by race, medical history, and surgeon’s experience. RYGB results in a significantly more durable weight loss compared with SG regardless of race or other stratification factors.
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The objective of this study was to evaluate the long-term resolution (>5 years) of type 2 diabetes after BPD-DS.
Academic hospital.
This is a retrospective chart review of patients with diabetes who underwent primary BPD-DS at our institution from 2010 to 2015. Data for that cohort were collected until January 2021.
A total of 151 patients who had met the criteria were included in the final analysis. More than 1 year of follow-up data was available for 94% of patients, and more than 5 years of follow-up data was available for 51%. Most of the patients (98.1%) had either partial or complete resolution or improvement.
Patients with type 2 diabetes who underwent BPD-DS had profound improvement of their diabetes postoperatively. A significant percentage experienced complete resolution, with most of the remaining patients having demonstrated much improvement in their condition.
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Original articleLong-term and midterm outcomes of laparoscopic sleeve gastrectomy versus Roux-en-Y gastric bypass: a systematic review and meta-analysis of comparative studies

Abstract

Objective

Summary

Methods

Results

Conclusion

Section snippets

Methods

Results

Discussion

Conclusion

Surg Obes Relat Dis

Surg Obes Relat Dis

Surg Obes Relat Dis

Surg Obes Relat Dis

J Clin Epidemiol

Surg Obes Relat Dis

Surg Obes Relat Dis

J Acad Nutr Diet

BMC Surg

Meta-analysis: surgical treatment of obesity

Ann Intern Med

The effectiveness and risks of bariatric surgery: an updated systematic review and meta-analysis, 2003-2012

JAMA Surg

Metabolic/bariatric surgery worldwide 2011

Obes Surg

A randomized clinical trial of laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy for the treatment of morbid obesity in China: a 5-year outcome

Obes Surg

Laparoscopic conversion of sleeve gastrectomy to gastric bypass for super-obesity (BMI≥50 kg/m2) and incisional hernia: a video report

Obes Surg

Updated position statement on sleeve gastrectomy as a bariatric procedure

Surg Obes Relat Dis

Long-term effects of laparoscopic sleeve gastrectomy, gastric bypass, and adjustable gastric banding on type 2 diabetes

Surg Endosc

Original article
Long-term and midterm outcomes of laparoscopic sleeve gastrectomy versus Roux-en-Y gastric bypass: a systematic review and meta-analysis of comparative studies

Laparoscopic conversion of sleeve gastrectomy to gastric bypass for super-obesity (BMI≥50 kg/m²) and incisional hernia: a video report