Obese patients with diabetes may fare better with gastric bypass surgery vs. other procedures

Issue: March 2011

Gastric bypass surgery appears to lead to better long-term results including greater weight loss, resolution of diabetes and improved quality of life compared with sleeve gastrectomy and laparoscopic adjustable gastric band surgery, according to two studies in the new issue of Archives of Surgery.

Laparoscopic Roux-en-Y gastric bypass is currently the most common surgical procedure for weight loss and type 2 diabetes in the United States. In 2001, the laparoscopic adjustable gastric band, commonly known as the Lap-Band, was approved as a less invasive alternative to gastric bypass; this month, it was approved by the FDA for use in people with less obese BMIs. Sleeve gastrectomy, which involves surgical removal of a large portion of the stomach, is another surgical weight-loss procedure.

To investigate the outcomes associated with different bariatric procedures, Guilherme M. Campos, MD, of the University of Wisconsin School of Medicine and Public Health, and colleagues examined 100 morbidly obese patients (BMI >40) who underwent laparoscopic adjustable band surgery. These patients were matched by age, sex, race and baseline BMI with 100 patients who underwent gastric bypass surgery.

According to the results, weight-loss outcomes were significantly greater for patients who underwent gastric bypass surgery. Average excess weight loss for this group was 64% vs. 36% for the laparoscopic adjustable band surgery group. In addition, 86% of patients in the gastric bypass group lost more than 40% of their excess weight compared with 31% in the other group.

Thirty-four patients in each group had type 2 diabetes at baseline. After surgery, diabetes resolution or improvement was significantly better after gastric bypass (76%) compared with laparoscopic adjustable band surgery (50%). One year after surgery, six of eight gastric bypass patients who were using insulin before the procedure had discontinued use; only one patient in the laparoscopic adjustable band group stopped using insulin.

Complications were similar between the groups: 12% with laparoscopic adjustable band surgery and 15% with gastric bypass. Early complications, within the first month after surgery, were higher in the gastric bypass group (11%) compared with the laparoscopic adjustable band group (2%); however, the reoperation rate was higher with band surgery (13%) as compared with gastric bypass (2%). No deaths were reported in either group.

“Our study shows that laparoscopic Roux-en-Y gastric bypass, when performed in high-volume centers by expert surgeons, has a similar rate of overall complications and lower rate of reoperations than laparoscopic adjustable gastric band,” Campos et al concluded. “Because it achieves greater weight loss, increased resolution of diabetes and better improvement in quality of life, we conclude that, in the setting we studied, laparoscopic Roux-en-Y gastric bypass has a better risk-benefit profile than laparoscopic adjustable gastric band.”

Examining diabetes resolution

Wei-Jei Lee, MD, PhD, of Min-Sheng General Hospital in Taiwan, China, and colleagues conducted a double blind, randomized, controlled trial of 60 moderately obese adults (BMI of 25 to 35) who had poorly controlled diabetes after conventional treatment. Half of the patients were randomly assigned to gastric bypass with duodenum exclusion, which bypasses the first 12 inches of the small intestine; the other half were randomly assigned to sleeve gastrectomy without duodenum exclusion.

At 1 year after surgery, 70% of the patients experienced remission of type 2 diabetes. However, the resolution was significantly greater among patients who underwent gastric bypass (93%) compared with sleeve gastrectomy (47%).

Overall weight loss was significant at 1 and 3 months’ follow-up in both groups, but was greater in the gastric bypass group at 6 and 12 months. Researchers reported greater improvements in waist circumference, HbA1c and lipid levels after gastric bypass.

When the researchers examined adverse events, they found late complications in two patients — one patient in each group. No major adverse events were observed, they said.

“Although more clinical trials are needed, this study and other previous studies have strongly recommended that laparoscopic gastric bypass as a metabolic surgery should be included in the armament of diabetes treatments in less obese populations (BMI of 25 to 35) and in the morbidly obese population (BMI greater than 35),” Lee and colleagues wrote.

Determining the ‘best’ procedure

According to Harry C. Sax, MD, “the question of what is ‘best’ for [an obese] patient remains.”

“With improvements in minimally invasive techniques and the certification of centers of excellence, the risk-benefit profile for all types of bariatric surgery has decreased,” Sax, from the department of surgery at Cedars Sinai Medical Center, wrote in an accompanying editorial.

Sax said the data from Campos et al comparing gastric bypass, sleeve gastrectomy and laparoscopic adjustable gastric banding should be interpreted with caution. He noted several limitations, including a small number of patients with diabetes at baseline, low insulin use and patient preference about which procedure to undergo. He said longer-term data to examine the weight loss beyond 1 year are needed to make clear conclusions.

“All bariatric surgeons must look honestly at their own results in the context of what they recommend to their patients,” Sax wrote. “The results of LABS 1, even with well-trained surgeons in certified centers, document clearly higher morbidity and mortality from open as opposed to laparoscopic Roux-en-Y gastric bypass. ‘More’ may be ‘better,’ but only if we can accomplish it without a significant cost to the patient.”

For more information:

Campos GM. Arch Surg. 2011;146:149-155.

Lee WJ. Arch Surg. 2011;146:143-148.

Sax HC. Arch Surg. 2011;146:155.

Disclosure: Drs. Campos, Lee and Sax report no relevant financial disclosures.

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