Gastric Bypass Edges Out Sleeve Gastrectomy for 10-Year Outcomes

Roux-en-Y gastric bypass yielded slightly better weight loss at 10 years compared with laparoscopic sleeve gastrectomy, according to results from the randomized SLEEVEPASS study.

Among 240 patients with obesity, estimated mean percentage excess weight loss was 51.9% (95% CI 48.1-55.6) after gastric bypass versus 43.5% (95% CI 39.8-47.2) after sleeve gastrectomy, reported Paulina Salminen, MD, PhD, of Turku University Hospital in Finland, and colleagues in JAMA Surgery.

Neither surgery type was significantly better at putting type 2 diabetes into remission, which occurred in 26% of sleeve patients and 33% of gastric bypass patients at the 10-year mark. The biggest predictor of type 2 diabetes remission after either bariatric surgery was duration of disease prior to surgery:

• Under 2 years: 52% achieved remission
• 2-10 years: 25%
• Over 10 years: 0%

"As observed in multiple trials, longer preoperative type 2 diabetes duration was associated with lower remission rates, emphasizing the importance of early surgical treatment of patients with obesity and type 2 diabetes," the group noted.

Currently, laparoscopic sleeve gastrectomy is the most popular metabolic procedure, accounting for 60% of all bariatric surgeries in the U.S., Salminen and team pointed out.

Both surgeries have a relatively low rate of major complications, such as reoperations (15.7% for sleeve gastrectomy and 18.5% for gastric bypass), and minor complications, such as gastroesophageal reflux (GERD) and ulcers (34.7% and 24.4%, respectively). The majority of reoperations in the sleeve gastrectomy group were due to GERD, while internal herniation was the main driver in the gastric bypass group.

There were also no significant differences between the groups in dyslipidemia remission (19% for sleeve gastrectomy vs 35% for gastric bypass) or obstructive sleep apnea remission (16% and 31%, respectively). However, fewer sleeve patients were able to discontinue their medication for hypertension (8% vs 24%).

Median weight regain, measured as the percentage of maximum weight lost, was 24.7% for gastric bypass patients versus 35% for patients who underwent sleeve gastrectomy.

In addition, 49% of sleeve gastrectomy patients said GERD symptoms, as measured by the GERD Health-Related Quality of Life total score, worsened after surgery versus only 9% of gastric bypass patients. More sleeve patients also experienced postoperative esophagitis (31% vs 7%). At 10 years, 64% of sleeve patients were taking a proton pump inhibitor (PPI) versus 36% of gastric bypass patients.

"The cumulative incidence of Barrett esophagus was markedly lower than in previous trials and similar after both procedures, but endoscopic esophagitis, GERD symptoms, and PPI use were more prevalent after laparoscopic sleeve gastrectomy, underlining the importance of preoperative GERD assessment and patient selection," Salminen and colleagues wrote.

Despite some of these differences, both surgeries resulted in significant improvements in quality of life, as measured by the Moorehead-Ardelt QOL total score. At 10 years after surgery, the average quality-of-life total score was 0.64 after sleeve gastrectomy and 0.41 after gastric bypass.

For this 10-year follow-up, Salminen and team looked at 121 patients who underwent sleeve gastrectomy and 119 who underwent gastric bypass. Almost 70% of the cohort were women, mean age was 48.4, and mean baseline BMI was 45.9.

A total of 12 deaths occurred during follow-up, but none were related to bariatric surgery.

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