Greater weight loss, less CV risk after Roux-en-Y gastric bypass vs. sleeve gastrectomy
Roux-en-Y gastric bypass surgery may be associated with greater weight loss, diabetes control and lower risk for major adverse cardiovascular events compared with sleeve gastrectomy, according to findings published in Diabetes Care.
“Guiding patients toward the most appropriate surgical procedure is crucial for improving outcomes,” Ali Aminian, MD, associate professor of surgery and director of Cleveland Clinic’s Bariatric and Metabolic Institute, told Healio. “Several factors should be considered when the patient and medical team make a shared decision about the most appropriate metabolic surgical procedure. The surgical risk, impact of each procedure on body weight and comorbidities, coexistence of other medical and mental problems, patient’s behavioral factors, values and goals are important considerations in choosing the most appropriate surgical procedure. One factor that may help in decision-making would be understanding the differential impact of each surgical procedure on the future risk of CV events.”
In a retrospective study, Aminian and colleagues analyzed data from 13,490 patients with obesity and type 2 diabetes who underwent Roux-en-Y gastric bypass (n = 1,362) or sleeve gastrectomy (n = 693) at Cleveland Clinic between 1998 and 2017. Each patient was matched via propensity scoring to five nonsurgical patients (n = 11,435) based on index date, age, sex, BMI, location, insulin use and presence of diabetes end-organ complications. Researchers used Cox regression analysis to estimate time to incidence extended major adverse CV events, defined as first occurrence of coronary artery events, cerebrovascular events, heart failure, nephropathy, atrial fibrillation and all-cause mortality.
The cumulative incidence of the primary endpoint at 5 years was 13.7% (95% CI, 11.4-15.9) in the gastric bypass group and 24.7% (95% CI, 19-30) in the sleeve gastrectomy group, with an adjusted HR of 0.77 (95% CI, 0.6-0.98; P = .04). Both surgical procedures were associated with lower cumulative incidence of the primary endpoint at 5 years compared with usual care, with HRs of 0.53 for gastric bypass (95% CI, 0.46-0.61) and 0.69 for sleeve gastrectomy (95% CI, 0.56-0.85).
Gastric bypass was also associated with a lower cumulative incidence of nephropathy at 5 years compared with sleeve gastrectomy (2.8% vs. 8.3%), with an HR of 0.47 (95% CI, 0.28-0.79). Gastric bypass was also associated with a greater reduction in body weight, HbA1c and use of medications to treat diabetes and CVD.
Compared with sleeve gastrectomy, patients who underwent gastric bypass were more likely to require upper endoscopy at 5 years (45.8% vs. 35.6%; P < .001), as well as abdominal surgical procedures (10.8% vs. 5.4%; P = .001).
“We observed larger and more sustained weight loss after gastric bypass compared with sleeve gastrectomy — a 10% difference in total weight loss at 5 years — and subsequent greater improvement in cardiometabolic risk factors,” Aminian told Healio. “The study shows a dose-response effect in weight loss, diabetes control, change in diabetes and CV medications, and risk for major adverse CV events in patients with obesity and type 2 diabetes, showing gastric bypass is superior to sleeve gastrectomy, which is superior to usual care.”
Aminian noted a small percentage of nonsurgical patients received newer diabetes medications — GLP-1 receptor agonists and SGLT2 inhibitors — and comparison of surgical procedures with new diabetes and obesity medications in the setting of clinical trials would be necessary.