Gastric Bypass Vs. Sleeve Gastrectomy For Severe Obesity

In the 2018 special issue of JAMA on obesity, two research articles compare long-term outcomes (5 years) after laparoscopic roux-en-Y gastric bypass (RYG) to sleeve gastrectomy (SG).

In the first study by Ralph Peterli and colleagues from Switzerland, the authors report on the findings from the  Swiss Multicenter Bypass or Sleeve Study (SM-BOSS), a 2-group randomized trial, that included 217 patients at 4 bariatric centres, who were enrolled and randomly assigned to SG or RYG.

At 5 years, weight loss was slightly greater in the RYG group but this difference was not statistically significantly.

Gastric reflux improved more after RYG and was more likely to worsen with SG. Reoperation rates were marginally higher in the RYG group (seven reoperations after sleeve gastrectomy were for severe GERD, and 17 reoperations after bypass were for internal hernias) .

In the second study Paulina Salminen and colleagues from Finland report on the  Sleeve vs Bypass (SLEEVEPASS) multicenter, multisurgeon, open-label, randomized clinical equivalence trial which randomly assigned patients with severe obesity to SG (n=121) or RYG (n=119)  with a 5-year follow-up period.

At 5 years, weight loss, remission of diabetes, as well as improvements in dyslipidemia and hypertension were slightly higher in the RYG group than in the SG group.

Overall, there was no difference in improvement in quality of life or in morbidity rates between the two groups. There was no treatment-related mortality in either group.

In an accompanying editorial, David Arterburn and Arniban Gupta from the University of Washington, Seattle, note that,

“Collectively, these studies provide reassuring data to suggest that the rapid switch from Roux-en-Y gastric bypass to sleeve gastrectomy in the last decade has not been a therapeutic misadventure similar to the rise and fall of the adjustable gastric band,⁵ which has been all but abandoned.”

They also point to five important learnings from these studies:

1. Patients should be informed that deciding between sleeve gastrectomy and bypass is complex and requires patients to simultaneously consider information about many factors, including weight loss, control of different comorbidities, and short- and long-term risks.
2. Weight loss between the two procedures are more or less on par.
3. GS may be a reasonable choice even for patients with diabetes.
4. Patients with GERD deserve careful consideration, because their outcomes are differentially affected by sleeve gastrectomy and gastric bypass.
5. Given the relative parity between these procedures in weight loss and comorbidity resolution, shared decision making conversations should prioritize discussion of individual risk tolerance and preferences, ie, which potential risk or consequence is more acceptable to the patient—the risk of reoperation for GERD with sleeve gastrectomy vs the risk of reoperation for a small bowel obstruction or internal hernia with bypass.

Ultimately, deciding between the two procedures is not easy and warrants an in-depth discussion between patients and their surgeons.

@DrSharma
Edmonton, AB