Type 2 diabetes remission more likely with gastric bypass vs. sleeve gastrectomy
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Key takeaways:
- Type 2 diabetes remission was achieved by 75% of adults who had gastric bypass.
- Diabetes recurrence was more likely for adults who underwent sleeve gastrectomy.
Most adults with type 2 diabetes and obesity who undergo gastric bypass achieve continued diabetes remission, even after weight regain, according to study findings published in the Journal of the American College of Surgeons.
“Our findings have significant clinical implications, suggesting that gastric bypass might be a superior surgical option over sleeve gastrectomy for adults with type 2 diabetes in terms of achieving sustained diabetes remission, independent of and despite weight recurrence,” Omar M. Ghanem, MD, FACS, chair of the division of metabolic and abdominal wall reconstructive surgery at Mayo Clinic in Rochester, Minnesota, told Healio. “The study reports a significantly higher overall rate of continued diabetes remission in the gastric bypass group (75%) compared with the sleeve gastrectomy group (34.8%). It underscores the importance of considering the long-term metabolic outcomes when selecting the type of bariatric surgery for patients with diabetes.”
Ghanem and colleagues conducted a retrospective single-center study of adults with type 2 diabetes and a BMI of 35 kg/m2 or higher who underwent gastric bypass or sleeve gastrectomy from January 2008 to February 2017. Demographics, type 2 diabetes duration, HbA1c, diabetes medication and insulin use before surgery were collected from medical records. Researchers obtained HbA1c, fasting glucose, diabetes medication use, insulin use and annual body weight for at least 5 years of follow-up after surgery. Type 2 diabetes remission was defined as an HbA1c of less than 6.5% for at least 3 months without the use of diabetes medications. Adults who achieved remission and had their HbA1c increase to 6.5% or higher or restarted use of diabetes medication were considered to have type 2 diabetes recurrence.
There were 224 adults who underwent gastric bypass and 46 adults who underwent sleeve gastrectomy included in the study. A higher percentage of adults in the gastric bypass group achieved diabetes remission compared with the sleeve gastrectomy group (75% vs. 34.8%; P < .001). Adults who underwent sleeve gastrectomy were more likely to have type 2 diabetes recurrence after achieving diabetes remission than those who underwent gastric bypass (adjusted OR = 5.5; 95% CI, 2.38-12.71; P < .001).
Among adults who underwent gastric bypass, 50% had continued diabetes remission at a median 10 years of follow-up in Kaplan-Meier survival analysis. Participants who had insulin-dependent type 2 diabetes (aOR = 2.63; 95% CI, 1.17-5.91; P = .02), had a higher HbA1c before surgery (aOR = 1.5; 95% CI, 1.1-2.06; P = .01) and had a longer duration of type 2 diabetes before surgery (aOR = 1.06; 95% CI, 1.02-1.1; P = .04) had greater odds for type 2 diabetes recurrence.
“Notably, weight recurrence itself was not independently associated with type 2 diabetes recurrence, suggesting that the metabolic benefits of gastric bypass might involve mechanisms beyond mere weight loss,” Ghanem said. “Nevertheless, weight remains a key factor and cannot be entirely overlooked, as it is also related to the worsening and recurrence of other comorbidities and overall quality of life.”
In a subgroup analysis, adults who underwent gastric bypass were divided into quartiles based on weight regain after surgery. In all four quartiles, more than half of adults maintained diabetes remission. During a median follow-up of 9 years, 10 adults who underwent gastric bypass regained more than 100% of their presurgical body weight. Among that group, six adults had continued diabetes remission.
“The study suggests the need for further research to explore the exact mechanisms through which gastric bypass surgery exerts its long-term metabolic benefits, especially those independent of weight loss,” Ghanem said. “Additionally, there is a need for research focusing on optimizing patient selection for bariatric surgery based on individual metabolic profiles and risk factors for diabetes recurrence.”
For more information:
Omar M. Ghanem, MD, FACS, can be reached at ghanem.omar@mayo.edu.
Perspective
Back to TopVance L. Albaugh, MD, PhD, FACS, FASMBS; Philip R. Schauer, MD, FACS, FASMBS
The work by Ghanem and colleagues is yet another important study focusing on the metabolic effects of bariatric surgery, namely long-term diabetes remission and the effect of weight recurrence. The findings of the current single-center, retrospective study confirmed that Roux-en-Y gastric bypass has a significantly higher frequency of diabetes remission postoperatively compared to sleeve gastrectomy. These findings are consistent with prior randomized controlled trials (such as STAMPEDE, SM-BOSS, SLEEVEPASS) that also demonstrate diabetes remission benefits of Roux-en-Y gastric bypass compared with sleeve gastrectomy.
Interestingly, this more effective diabetes remission is also persistent despite varying degrees of weight recurrence, suggesting that some mechanisms of diabetes remission after Roux-en-Y gastric bypass may be more weight independent than sleeve gastrectomy. If remission is entirely the result of weight loss and resultant adipose mass reduction, then weight gain should reverse remission. This study and others demonstrate that remission may persist despite weight recurrence following Roux-en-Y gastric bypass.
Overall, this study highlights findings similar to others that there appear to be weight-independent effects of Roux-en-Y gastric bypass relative to sleeve gastrectomy. Despite both these operations increasing nutrient delivery to the small intestine, the mechanisms of these weight-independent effects may be due to bypassing the endocrine rich proximal small intestine of the Roux-en-Y gastric bypass.
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