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Tag: Gastrectomy

  • Bariatric surgery outperforms traditional treatments for long-term diabetes control

    Bariatric surgery outperforms traditional treatments for long-term diabetes control

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    In a recent study published in the Journal of American Medical Association (JAMA), researchers from the United States of America (US) compared the safety, efficacy, and long-term outcomes of bariatric surgery and medical and lifestyle management in patients with type 2 diabetes mellitus (T2DM). They found that patients undergoing bariatric surgery had better glycemic control and higher remission rates at 7–12 years compared to medical management.

    Study: Long-Term Outcomes of Medical Management vs Bariatric Surgery in Type 2 Diabetes. Image Credit: Terelyuk / ShutterstockStudy: Long-Term Outcomes of Medical Management vs Bariatric Surgery in Type 2 Diabetes. Image Credit: Terelyuk / Shutterstock

    Background

    T2DM affects over 500 million adults globally, presenting significant economic burdens. Although bariatric surgery has shown superiority over medical and lifestyle therapies in treating the condition, limited randomized controlled trials (RCTs) with constraints in sample size and follow-up duration have hindered widespread recommendations. This has led to less than 1% of individuals with a body mass index (BMI) of 35 kg/m2 or higher considering surgical treatment. Despite advances in weight loss medications, their cost, uncertain long-term efficacy, and the need for prolonged use pose challenges.

    The Alliance of Randomized Trials of Medicine vs. Metabolic Surgery in Type 2 Diabetes (ARMMS-T2D) consortium conducted the most extensive pooled analysis to date, combining long-term observational data from four US single-center randomized trials. It aimed to assess bariatric surgery’s safety, durability, and efficacy compared to medical/lifestyle treatment for T2DM. At three years, the study revealed the superior and sustained effectiveness of bariatric surgery over medical/lifestyle intervention, even in individuals with a BMI of 25–35 kg/m2. In the present study, researchers report the extended follow-up results at 7–12 years after randomization.

    About the study

    The study included 262 T2DM patients with a BMI of 27–45 kg/m2. The mean age was 49.9 years, and 68.3% of them were female. Patients were randomized to undergo intensive medical and lifestyle management (n = 96), or bariatric surgery (Roux-en-Y gastric bypass, sleeve gastrectomy, or adjustable gastric banding), and postoperative care (n =166). Based on self-reported racial information, about 31% of patients were Black, and 67.2% were White. While the study was conducted between 2007 and 2013, the observational follow-up was conducted until 2022.

    The study’s primary outcome was a between-group difference in the change (%) in glycated hemoglobin (HbA1c) from baseline to seven years, with extended data up to 12 years. The secondary outcomes were changes in HbA1c, changes in various metabolic and cardiovascular parameters, and diabetes remission, with a hypothesis favoring bariatric surgery over medical/lifestyle treatment. Adverse events were systematically collected, covering serious events and complications up to 12 years. The statistical methods involved the use of a linear mixed-effect model, inverse probability weighting, sensitivity analysis, and exploratory analyses.

    Results and discussion

    In spite of higher baseline values, the bariatric surgery group consistently maintained significantly lower HbA1c levels than the medical group, with a difference of -1.4% and -1.1% at seven years and 12 years, respectively. At seven years, HbA1c improvements were similar between Roux-en-Y gastric bypass and sleeve gastrectomy, while adjustable gastric banding showed less improvement than sleeve gastrectomy (P = .007) and Roux-en-Y gastric bypass (P = .03). As 25% of patients switched from medical management to surgery during the study, a per-protocol sensitivity analysis was conducted, which confirmed the main results.

    At one year, diabetes remission was achieved by 0.5% of patients in the medical group as compared to 50.8% in the surgery group. At seven years, remission rates were 6.2% vs. 18.2% in the medical group and surgery group, respectively, and the difference persisted at 12 years. HbA1c was found to be < 7% in 26.7% of patients in the medical group vs. 54.1% of those in the surgery group. Additionally, bariatric surgery resulted in significantly higher weight loss and rates of non-obesity at 7 and 12 years. The surgery group also experienced significantly reduced medication and insulin use as compared to the medical group. Further, the bariatric group showed significantly higher high-density lipoprotein (HDL) and lower triglycerides. No significant differences were observed for systolic blood pressure, low-density lipoprotein (LDL), serum creatinine, or urine albumin-to-creatinine ratio in the two groups at seven years. Adverse events were found to be similar between the groups, with increased gastrointestinal events in the surgery group.

    The study is strengthened by its larger sample size, diversity in sampling, inclusion of data on the most common surgical procedures, and longer follow-up compared to previous studies. However, the study is limited by its open-label design, heterogeneous treatments, missing data, lack of power for procedure-specific outcomes, and changes in surgical procedures and medication use during follow-up.

    Conclusion

    In conclusion, after 7 to 12 years, patients assigned to bariatric surgery demonstrated better glycemic control, reduced diabetes medication usage, and higher rates of diabetes remission compared to those on medical/lifestyle intervention. The findings endorse the employment of bariatric surgery as a viable treatment option for T2DM in individuals with obesity.

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  • Sleeve gastrectomy vs. Roux-en-Y gastric bypass

    Sleeve gastrectomy vs. Roux-en-Y gastric bypass

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    A recent study published in JAMA Network Open evaluates the differences in perioperative outcomes between laparoscopic sleeve gastrectomy (SG) and laparoscopic Roux-en-Y gastric bypass (RYGB).

    Study: Comparison of Sleeve Gastrectomy vs Roux-en-Y Gastric Bypass: A Randomized Clinical Trial. Image Credit: Donenko Oleksii / Shutterstock.comStudy: Comparison of Sleeve Gastrectomy vs Roux-en-Y Gastric Bypass: A Randomized Clinical Trial. Image Credit: Donenko Oleksii / Shutterstock.com

    Background

    The worldwide prevalence of obesity has increased substantially, with many studies indicating that this metabolic disorder is associated with significant mortality. Individuals with severe obesity may undergo metabolic and bariatric surgery, which is otherwise known as weight loss surgery, for weight management.

    Although SG and RYGB are the most commonly performed surgical bariatric procedures, no studies have compared their safety and effectiveness. Until 2017, the most widely performed bariatric surgical procedure was RYGB in Sweden, until it ultimately shifted to SG.  

    RYGB has been associated with providing sustained weight loss and improvements in overweight-related comorbidities; however, this procedure is associated with an increased risk of abdominal pain, small bowel obstruction, nutritional deficiencies, alcohol use disorder, and post-bariatric hypoglycemia 

    European randomized clinical trials have compared SG and RYGB and revealed no significant differences in weight loss and resolution of comorbidities between the two procedures. Although diabetic patients who underwent RYGB exhibited better glucose control than those subjected to SG, these findings are based on limited-size clinical trials. 

    About the study

    The current randomized and large-scale clinical trial compared the effectiveness of SG and RYGB in weight loss and risk to adverse events to determine which weight reduction surgical technique is more efficient. This study is extremely important due to the sudden increase in SG procedures in Sweden and Norway.

    Perioperative outcomes of SG and RYGB, based on a large Swedish and Norwegian randomized clinical trial, were presented. A previously published Bypass Equipoise Sleeve Trial (BEST) methodology was followed, which was a multicenter randomized clinical trial that assessed the five-year outcomes of SG and RYGB.

    Perioperative outcomes were measured between zero and 30 days of SG and RYGB, along with 90-day mortality. The study cohort included individuals 18 and older with a body mass index (BMI) between 35 and 50.

    All study participants were recommended bariatric surgery. Participants with inflammatory bowel disease, uncontrolled psychiatric disease, moderate to severe gastroesophageal reflux disease, under-substance use, and those with a history of major upper gastrointestinal tract surgery were excluded. Eligible participants were randomly selected for SG or RYGB.

    Study findings

    A total of 878 and 857 patients underwent SG and RYGB, respectively, in twenty-three hospitals. The study cohort consisted of 74% females and 26% males, and their average age was 42.9 years, with a mean BMI of 40.8. 

    A low rate of perioperative complications was observed in both groups without statistical significance. Although aSG was associated with  lower perioperative risk than RYGB, this was not considered clinically relevant due to the existence of other comorbid factors and differential long-term weight control efforts.

    A higher number of serious adverse events within 30 days of the procedure was observed in the RYGB group in comparison to the SG group. In randomized studies, a more significant risk difference between groups could be due to selection bias, as healthier patients are more likely to undergo SG. 

    Contradictory study outcomes are also affected by the nature of the cohort. For example, the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) study included patients with higher BMI and comorbidities than BEST. Therefore, MBSAQIP was associated with more complicated surgical procedures than BEST. 

    The BEST data reflects the possibility that a surgical community with a wider experience of performing RYGB can swiftly shift to SG with low complication rates. However, the possibility of an opposite transition must be reviewed.

    As compared to previous assessments on perioperative complications after RYGB, the current study observed small bowel obstruction to be the most common perioperative complication. A higher incidence of small bowel obstruction after RYGB could be linked with the Lönroth surgical technique for RYGB.

    The operating time between RYGB and SG was compared, in which a greater operating time was associated with RYGB, which could be due to the greater complexity of this surgical procedure. In both SG and RYGB, the length of post-operative hospitalization was one day after surgery.

    Conclusions

    The current randomized and large-scale observational study assessed the outcomes of SG and RYGB in individuals with a BMI of 35 to 50. Both surgical procedures were associated with low and insignificantly different perioperative morbidity. The study highlighted that perioperative risk should not be considered a criterion for selecting between SG and RYGB procedures.

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