A recent study published in JAMA Network Open evaluated the differences in perioperative outcomes between laparoscopic sleeve gastrectomy (SG) and laparoscopic Roux-en-Y gastric bypass (RYGB).
Study: Comparing Sleeve Gastrectomy with Roux-en-Y Gastric Bypass: A Randomized Clinical Trial. Image credit: Donenko Oleksii / Shutterstock.com
The global prevalence of obesity has increased significantly, and many studies indicate that this metabolic disorder is associated with substantial mortality. Individuals with severe obesity may undergo metabolic and bariatric surgery, also known as weight loss surgery, for weight control.
Although SG and RYGB are the most commonly performed surgical bariatric procedures, their safety and effectiveness have not been compared in any study. Until 2017, RYGB was the most commonly performed bariatric surgical procedure in Sweden, until it eventually shifted to SG.
While RYGB has been associated with sustained weight loss and improvements in obesity-related comorbidities, this procedure is, however, associated with an increased risk of abdominal pain, small bowel obstruction, malnutrition, alcohol abuse, and post-bariatric hypoglycemia.
In European randomized clinical trials, SG and RYGB were compared, and no significant differences in weight loss and resolution of comorbidities between the two procedures were found. Although diabetics undergoing RYGB showed better glucose control than those undergoing SG, these findings were based on clinical trials of limited size.
About the Study
The current randomized, large-scale clinical trial compared the efficacy of SG and RYGB in weight loss and the risk of adverse events to determine which surgical technique for weight reduction 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 were presented based on a large Swedish and Norwegian randomized clinical trial. It followed a previously published BEST methodology (Bypass Equipoise Sleeve Trial), a multicenter, randomized clinical trial that evaluated the five-year outcomes of SG and RYGB.
The perioperative outcomes were measured between zero and 30 days for SG and RYGB, as well as the 90-day mortality. The study cohort included individuals aged 18 and over with a body mass index (BMI) between 35 and 50.
All study participants were recommended for bariatric surgery. Participants with inflammatory bowel disease, uncontrolled psychiatric conditions, moderate to severe gastroesophageal reflux disease, substance abuse, and those with a history of major upper gastrointestinal tract surgeries were excluded. Eligible participants were randomly assigned to SG or RYGB.
A total of 878 and 857 patients in 23 hospitals underwent SG and RYGB, respectively. The study cohort consisted of 74% women and 26% men, with an average age of 42.9 years and an average BMI of 40.8.
Both groups showed a low rate of perioperative complications without statistical significance. Although SG was associated with a lower perioperative risk than RYGB, this was not considered clinically relevant due to the existence of other comorbid factors and different efforts for long-term weight control.
A higher number of serious adverse events within 30 days after the procedure was observed in the RYGB group compared to the SG group. In randomized studies, a larger difference in risk between the groups could be due to selection bias, as healthier patients are more likely to undergo SG.
Conflicting study results are also influenced by the nature of the cohort. For example, the study from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) 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 broader experience in performing RYGB can quickly transition to SG with low complication rates. However, the possibility of a reverse transition should be explored.
Compared to previous investigations of perioperative complications after RYGB, the current study found that small bowel obstruction was the most common perioperative complication. A higher incidence of small bowel obstructions after RYGB could be related to the Lönroth surgical technique for RYGB.
The operative time was compared between RYGB and SG, with RYGB being associated with a longer operative time, which could be attributed to the greater complexity of this surgical procedure. Both in SG and RYGB, the length of postoperative hospital stay was one day after the operation.
The current randomized, large-scale observational study examined 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 emphasized that perioperative risk should not be considered as a criterion for choosing between SG and RYGB procedures.