Roux-en-Y bests sleeve gastrectomy in glycemic response, diabetes relapse rate
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Roux-en-Y gastric bypass is associated with larger and more persistent improvements in glycemic response and a 25% lower rate of type 2 diabetes relapse when compared with sleeve gastrectomy, according to findings published in JAMA Surgery.
“Studies focusing on the two most common bariatric procedures, sleeve gastrectomy and Roux-en-Y gastric bypass, show mixed evidence in terms of type 2 diabetes outcomes, especially in the longer term,” Kathleen McTigue, MD, MPH, MS, associate professor of medicine and epidemiology and director, clinical scientist track, internal medicine residency at the University of Pittsburgh, and colleagues wrote in the study background. “It is unclear how the choice between them is likely to affect type 2 diabetes. The comparison is particularly salient because sleeve gastrectomy has begun to supplant Roux-en-Y gastric bypass as the dominant bariatric procedure over the past decade, despite limited long-term comparative data.”
McTigue and colleagues analyzed data from 9,710 adults with type 2 diabetes who underwent Roux-en-Y or sleeve gastrectomy between 2005 and September 2015 at one of 35 health system sites participating in the National Patient-Centered Clinical Research Network Bariatric Study (mean age, 50 years; 72.6% women; 72.2% white; mean BMI, 49 kg/m²). Main outcomes were type 2 diabetes remission, type 2 diabetes relapse, percentage of total weight lost and change in HbA1c.
For the cohort, the mean presurgical HbA1c was 7.2%; adults were prescribed a mean 1.66 diabetes medications. Those who underwent Roux-en-Y had a higher prevalence of comorbidities such as sleep apnea, nonalcoholic fatty liver disease and reflux.
At 1 year after surgery, researchers found that weight loss was greater among adults who underwent Roux-en-Y gastric bypass compared with those who underwent sleeve gastrectomy (mean difference, 6.3 percentage points; 95% CI, 5.8-6.7). Results persisted at 5 years after surgery, with the mean difference widening to 8.1 percentage points (95% CI, 6.6-9.6).
The type 2 diabetes remission rate was approximately 10% higher among adults who underwent Roux-en-Y gastric bypass vs. adults who underwent sleeve gastrectomy (HR = 1.1; 95% CI, 1.04-1.16).
The estimated adjusted cumulative type 2 diabetes remission rates for the Roux-en-Y and sleeve gastrectomy groups were 59.2% (95% CI, 57.7-60.7) and 55.9% (95% CI, 53.9-57.9), respectively, at 1 year, and 86.1% (95% CI, 84.7-87.3) and 83.5% (95% CI, 81.6-85.1) at 5 years after surgery.
Among 6,141 adults with documented type 2 diabetes remission, the relapse rate was 25% lower among those who underwent Roux-en-Y gastric bypass vs. those who underwent sleeve gastrectomy (HR = 0.75, 95% CI, 0.67-0.84). Estimated relapse rates for adults who underwent gastric bypass and sleeve gastrectomy were 8.4% (95% CI, 7.4-9.3) and 11%(95% CI, 9.6-12.4) at 1 year and 33.1% (95% CI, 29.6-36.5) and 41.6% (95% CI, 36.8-46.1) at 5 years after surgery.
At 5 years, HbA1c levels were 0.8 percentage points and 0.35 percentage points below baseline levels among adults who underwent Roux-en-Y and sleeve gastrectomy, respectively, for a between-group difference of 0.45 percentage points (95% CI, 0.27-0.62).
The researchers noted that due to the observational nature of the study, procedure choice may have been influenced by unmeasured factors that affect the surgical effect on diabetes remission.
“Patients with more advanced type 2 diabetes at the time of surgery for whom remission is more difficult to achieve (eg, those with older age, insulin use, more complex type 2 diabetes medications, and/or poor glycemic control) may expect larger improvements in type 2 diabetes with Roux-en-Y gastric bypass compared with sleeve gastrectomy,” the researchers wrote. “On the other hand, for patients with higher likelihood of type 2 diabetes remission, Roux-en-Y gastric bypass and sleeve gastrectomy are likely to yield similar 5-year type 2 diabetes outcomes.” – by Regina Schaffer
Disclosures: McTigue reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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These data are very consistent with what we found in the STAMPEDE trial (Schauer PR, et al. N Engl J Med. 2017; doi:10.1056/NEJMoa1600869). This was a multicenter bariatric network, and the findings confirm that the best metabolic procedure for diabetes is gastric bypass. Part of the reason is related to greater weight loss with gastric bypass vs. the sleeve, and the durability of the effect is also greater with gastric bypass vs. the sleeve. Having said that, the trend, clinically, is patients and surgeons are preferring the sleeve, even though it is not the best, due to long-term consequences, such as nutritional deficiencies, metabolic bone disease and kidney stones.
Unfortunately, the researchers did not compare the sleeve to diet and exercise or medications; that is one of the study’s limitations. This compares two procedures and tells us what we already know. The sleeve is still a valid procedure. It results in 20% to 25% total body weight loss, and it reduces abdominal adipose tissue that causes CV risk and metabolic syndrome. We have to take these data in context with what we already know and long-term safety data. For people with severe diabetes — very medically refractive, with a very high BMI and a large insulin need with severe metabolic syndrome — the answer is clear that gastric bypass is the preferred procedure. For them, the risk/benefit ratio is certainly in their favor.
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