Skip to main navigation menu Skip to main content Skip to site footer
##common.pageHeaderLogo.altText##

Systematic review

Vol. 148 No. 2728 (2018)

Comparison of metabolic outcomes in patients undergoing laparoscopic roux-en-Y gastric bypass versus sleeve gastrectomy – a systematic review and meta-analysis of randomised controlled trials

  • Christelle Hayoz
  • Thierry Hermann
  • Dimitri Aristotle Raptis
  • Alain Brönnimann
  • Ralph Peterli
  • Markus Zuber
DOI
https://doi.org/10.57187/smw.2018.14633
Cite this as:
Swiss Med Wkly. 2018;148:w14633
Published
05.07.2018

Summary

BACKGROUND AND OBJECTIVES

Bariatric surgery is the most effective treatment for morbid obesity and is known to have beneficial effects on glycaemic control in patients with type 2 diabetes mellitus (T2DM) and in diabetes prevention. The preferred type of surgery and mechanism of action is, however, unclear. We performed a systematic review and meta-analysis of randomised controlled trials (RCTs) comparing the effects of laparoscopic roux-en-Y gastric bypass (RYGB) with those of sleeve gastrectomy (SG) on metabolic outcome, with a special focus on glycaemic control.

METHODS

A literature search of the Medline, Pubmed, Cochrane, Embase and SCOPUS databases was performed in November 2014 for RCTs comparing RYGB with SG in overweight and obese patients with or without T2DM. The primary outcome was improvement in postoperative glycaemic control. Secondary outcomes included weight-related and lipid metabolism parameters. Synthesis of these data followed established statistical procedures for meta-analysis.

RESULTS

Sixteen RCTs with a total of 1132 patients with overweight or obesity were included in the analysis. When compared with patients who underwent SG, those who underwent RYGB showed no difference after 12 months in mean fasting blood glucose (mean difference [MD] −6.22 mg/dl, 95% confidence interval [CI] −17.27 to 4.83; p <0.001). However, there was a better outcome with RYGB, with lower mean fasting glucose levels at 24 months (MD −16.92 mg/dl, 95% CI −21.67 to −12.18), 36 months (MD −5.97mg/dl, 95% CI −9.32 to −2.62) and at 52 months (MD −15.20 mg/dl, 95% CI −27.35 to −3.05) mg/dl; p = 0.010) and lower mean glycated haemoglobin (HbA1 at 12 months (MD −0.47%, 95% CI −0.73 to −0.20%; p <0.001) and at 36 months postoperatively compared to SG. Fasting insulin levels and HOMA indices showed no difference at any stage of follow-up. In the subgroup including only diabetic patients HbA1c showed lower levels at 12 months (MD −0.46%, 95% CI−0.73 to −0.20%). No difference was found for the fasting insulin at baseline and after 12 months. Similarly, when compared to SG, patients that underwent RYGB had lower low-density lipoproteins at 12 months. This effect was lost at 36 months. Patients undergoing RYGB also had lower triglycerides at 12 months and at 52 months, lower cholesterol at 60 months and an improvement of BMI at 52 months postoperatively. BMI values at 12 months and low-density lipoprotein levels at 12 and 36 months were lower for diabetic patients only, as in the overall analysis.

CONCLUSION

Based on this meta-analysis, RYGB is more effective than SG in improving weight loss and short- and mid-term glycaemic and lipid metabolism control in patients with and without T2DM. Therefore, unless contraindicated, RYGB should be the first choice to treat patients with obesity and T2DM and/or dyslipidaemia.

References

  1. Colquitt J, Clegg A, Sidhu M, Royle P. Surgery for morbid obesity. Cochrane Database Syst Rev. 2003;(2):CD003641. DOI: https://doi.org/10.1002/14651858.CD003641
  2. Angrisani L, Santonicola A, Iovino P, Formisano G, Buchwald H, Scopinaro N. Bariatric Surgery Worldwide 2013. Obes Surg. 2015;25(10):1822–32. doi:.https://doi.org/10.1007/s11695-015-1657-z DOI: https://doi.org/10.1007/s11695-015-1657-z
  3. Mingrone G, Panunzi S, De Gaetano A, Guidone C, Iaconelli A, Nanni G, et al. Bariatric-metabolic surgery versus conventional medical treatment in obese patients with type 2 diabetes: 5 year follow-up of an open-label, single-centre, randomised controlled trial. Lancet. 2015;386(9997):964–73. doi:.https://doi.org/10.1016/S0140-6736(15)00075-6 DOI: https://doi.org/10.1016/S0140-6736(15)00075-6
  4. Lee WJ, Chong K, Ser KH, Lee YC, Chen SC, Chen JC, et al. Gastric bypass vs sleeve gastrectomy for type 2 diabetes mellitus: a randomized controlled trial. Arch Surg. 2011;146(2):143–8. doi:.https://doi.org/10.1001/archsurg.2010.326 DOI: https://doi.org/10.1001/archsurg.2010.326
  5. Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol. 2005;5(1):13. doi:.https://doi.org/10.1186/1471-2288-5-13 DOI: https://doi.org/10.1186/1471-2288-5-13
  6. Raptis DA, Mettler T, Fischer MA, Patak M, Lesurtel M, Eshmuminov D, et al. Managing multicentre clinical trials with open source. Inform Health Soc Care. 2014;39(2):67–80. doi:.https://doi.org/10.3109/17538157.2013.812647 DOI: https://doi.org/10.3109/17538157.2013.812647
  7. Woelnerhanssen B, Peterli R, Steinert RE, Peters T, Borbély Y, Beglinger C. Effects of postbariatric surgery weight loss on adipokines and metabolic parameters: comparison of laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy--a prospective randomized trial. Surg Obes Relat Dis. 2011;7(5):561–8. doi:.https://doi.org/10.1016/j.soard.2011.01.044 DOI: https://doi.org/10.1016/j.soard.2011.01.044
  8. Peterli R, Steinert RE, Woelnerhanssen B, Peters T, Christoffel-Courtin C, Gass M, et al. Metabolic and hormonal changes after laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy: a randomized, prospective trial. Obes Surg. 2012;22(5):740–8. doi:.https://doi.org/10.1007/s11695-012-0622-3 DOI: https://doi.org/10.1007/s11695-012-0622-3
  9. Peterli R, Borbély Y, Kern B, Gass M, Peters T, Thurnheer M, et al. Early results of the Swiss Multicentre Bypass or Sleeve Study (SM-BOSS): a prospective randomized trial comparing laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass. Ann Surg. 2013;258(5):690–4, discussion 695. doi:.https://doi.org/10.1097/SLA.0b013e3182a67426 DOI: https://doi.org/10.1097/SLA.0b013e3182a67426
  10. Lee WJ, Chen CY, Chong K, Lee YC, Chen SC, Lee SD. Changes in postprandial gut hormones after metabolic surgery: a comparison of gastric bypass and sleeve gastrectomy. Surg Obes Relat Dis. 2011;7(6):683–90. doi:.https://doi.org/10.1016/j.soard.2011.07.009 DOI: https://doi.org/10.1016/j.soard.2011.07.009
  11. Lee WJ, Chong K, Lin YH, Wei JH, Chen SC. Laparoscopic sleeve gastrectomy versus single anastomosis (mini-) gastric bypass for the treatment of type 2 diabetes mellitus: 5-year results of a randomized trial and study of incretin effect. Obes Surg. 2014;24(9):1552–62. doi:.https://doi.org/10.1007/s11695-014-1344-5 DOI: https://doi.org/10.1007/s11695-014-1344-5
  12. Schauer PR, Kashyap SR, Wolski K, Brethauer SA, Kirwan JP, Pothier CE, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med. 2012;366(17):1567–76. doi:.https://doi.org/10.1056/NEJMoa1200225 DOI: https://doi.org/10.1056/NEJMoa1200225
  13. Schauer PR, Bhatt DL, Kirwan JP, Wolski K, Brethauer SA, Navaneethan SD, et al.; STAMPEDE Investigators. Bariatric surgery versus intensive medical therapy for diabetes--3-year outcomes. N Engl J Med. 2014;370(21):2002–13. doi:.https://doi.org/10.1056/NEJMoa1401329 DOI: https://doi.org/10.1056/NEJMoa1401329
  14. Kashyap SR, Bhatt DL, Wolski K, Watanabe RM, Abdul-Ghani M, Abood B, et al. Metabolic effects of bariatric surgery in patients with moderate obesity and type 2 diabetes: analysis of a randomized control trial comparing surgery with intensive medical treatment. Diabetes Care. 2013;36(8):2175–82. doi:.https://doi.org/10.2337/dc12-1596 DOI: https://doi.org/10.2337/dc12-1596
  15. Karamanakos SN, Vagenas K, Kalfarentzos F, Alexandrides TK. Weight loss, appetite suppression, and changes in fasting and postprandial ghrelin and peptide-YY levels after Roux-en-Y gastric bypass and sleeve gastrectomy: a prospective, double blind study. Ann Surg. 2008;247(3):401–7. doi:.https://doi.org/10.1097/SLA.0b013e318156f012 DOI: https://doi.org/10.1097/SLA.0b013e318156f012
  16. Peterli R, Wölnerhanssen B, Peters T, Devaux N, Kern B, Christoffel-Courtin C, et al. Improvement in glucose metabolism after bariatric surgery: comparison of laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy: a prospective randomized trial. Ann Surg. 2009;250(2):234–41. doi:.https://doi.org/10.1097/SLA.0b013e3181ae32e3 DOI: https://doi.org/10.1097/SLA.0b013e3181ae32e3
  17. Kehagias I, Karamanakos SN, Argentou M, Kalfarentzos F. Randomized clinical trial of laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy for the management of patients with BMI < 50 kg/m2. Obes Surg. 2011;21(11):1650–6. doi:.https://doi.org/10.1007/s11695-011-0479-x DOI: https://doi.org/10.1007/s11695-011-0479-x
  18. Paluszkiewicz R, Kalinowski P, Wróblewski T, Bartoszewicz Z, Białobrzeska-Paluszkiewicz J, Ziarkiewicz-Wróblewska B, et al. Prospective randomized clinical trial of laparoscopic sleeve gastrectomy versus open Roux-en-Y gastric bypass for the management of patients with morbid obesity. Wideochir Inne Tech Malo Inwazyjne. 2012;7(4):225–32. doi:.https://doi.org/10.5114/wiitm.2012.32384 DOI: https://doi.org/10.5114/wiitm.2012.32384
  19. Ramón JM, Salvans S, Crous X, Puig S, Goday A, Benaiges D, et al. Effect of Roux-en-Y gastric bypass vs sleeve gastrectomy on glucose and gut hormones: a prospective randomised trial. J Gastrointest Surg. 2012;16(6):1116–22. doi:.https://doi.org/10.1007/s11605-012-1855-0 DOI: https://doi.org/10.1007/s11605-012-1855-0
  20. Keidar A, Hershkop KJ, Marko L, Schweiger C, Hecht L, Bartov N, et al. Roux-en-Y gastric bypass vs sleeve gastrectomy for obese patients with type 2 diabetes: a randomised trial. Diabetologia. 2013;56(9):1914–8. doi:.https://doi.org/10.1007/s00125-013-2965-2 DOI: https://doi.org/10.1007/s00125-013-2965-2
  21. Helmiö M, Victorzon M, Ovaska J, Leivonen M, Juuti A, Peromaa-Haavisto P, et al. Comparison of short-term outcome of laparoscopic sleeve gastrectomy and gastric bypass in the treatment of morbid obesity: A prospective randomized controlled multicenter SLEEVEPASS study with 6-month follow-up. Scand J Surg. 2014;103(3):175–81. doi:.https://doi.org/10.1177/1457496913509984 DOI: https://doi.org/10.1177/1457496913509984
  22. Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al.; Cochrane Bias Methods Group; Cochrane Statistical Methods Group. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343(oct18 2):d5928. doi:.https://doi.org/10.1136/bmj.d5928 DOI: https://doi.org/10.1136/bmj.d5928
  23. Li JF, Lai DD, Lin ZH, Jiang TY, Zhang AM, Dai JF. Comparison of the long-term results of Roux-en-Y gastric bypass and sleeve gastrectomy for morbid obesity: a systematic review and meta-analysis of randomized and nonrandomized trials. Surg Laparosc Endosc Percutan Tech. 2014;24(1):1–11. doi:.https://doi.org/10.1097/SLE.0000000000000041 DOI: https://doi.org/10.1097/SLE.0000000000000041
  24. Yip S, Plank LD, Murphy R. Gastric bypass and sleeve gastrectomy for type 2 diabetes: a systematic review and meta-analysis of outcomes. Obes Surg. 2013;23(12):1994–2003. doi:.https://doi.org/10.1007/s11695-013-1030-z DOI: https://doi.org/10.1007/s11695-013-1030-z
  25. Li JF, Lai DD, Ni B, Sun KX. Comparison of laparoscopic Roux-en-Y gastric bypass with laparoscopic sleeve gastrectomy for morbid obesity or type 2 diabetes mellitus: a meta-analysis of randomized controlled trials. Can J Surg. 2013;56(6):E158–64. doi:.https://doi.org/10.1503/cjs.026912 DOI: https://doi.org/10.1503/cjs.026912
  26. Benaiges D, Flores Le-Roux JA, Pedro-Botet J, Chillarón JJ, Renard M, Parri A, et al. Sleeve gastrectomy and Roux-en-Y gastric bypass are equally effective in correcting insulin resistance. Int J Surg. 2013;11(4):309–13. doi:.https://doi.org/10.1016/j.ijsu.2013.02.007 DOI: https://doi.org/10.1016/j.ijsu.2013.02.007
  27. Milone M, Lupoli R, Maietta P, Di Minno A, Bianco P, Ambrosino P, et al. Lipid profile changes in patients undergoing bariatric surgery: a comparative study between sleeve gastrectomy and mini-gastric bypass. Int J Surg. 2015;14:28–32. doi:.https://doi.org/10.1016/j.ijsu.2014.12.025 DOI: https://doi.org/10.1016/j.ijsu.2014.12.025
  28. Lutz TA, Bueter M. The physiology underlying Roux-en-Y gastric bypass: a status report. Am J Physiol Regul Integr Comp Physiol. 2014;307(11):R1275–91. doi:.https://doi.org/10.1152/ajpregu.00185.2014 DOI: https://doi.org/10.1152/ajpregu.00185.2014
  29. le Roux CW, Aylwin SJ, Batterham RL, Borg CM, Coyle F, Prasad V, et al. Gut hormone profiles following bariatric surgery favor an anorectic state, facilitate weight loss, and improve metabolic parameters. Ann Surg. 2006;243(1):108–14. doi:.https://doi.org/10.1097/01.sla.0000183349.16877.84 DOI: https://doi.org/10.1097/01.sla.0000183349.16877.84