The Choice of Gastric Bypass or Sleeve Gastrectomy for Patients Stratified by Diabetes Duration and Body Mass Index (BMI) level: Results from a National Registry and Meta-analysis

Results of sleeve gastrectomy in obese patients with type 2 diabetes mellitus and impaired glucose tolerance: Retrospective cohort registry-based study

Background. In the available literature, the data on the positive effects of sleeve gastrectomy in treatment of type 2 diabetes mellitus (T2DM) and impaired glucose tolerance (IGT) become more common, however, they are heterogeneous and not always unambiguous.

The aim. To analyze our own results of treatment of patients with type 2 diabetes mellitus and impaired glucose tolerance, who underwent sleeve gastrectomy.

Materials and methods. Retrospective cohort registry-based study was carried out. From 2016 to April 2021, 29 (19 %) and 7 (4.6 %) patients with diagnosed T2DM and IGT respectively underwent surgery. Of these, sleeve gastrectomy was performed in 13  (44.8  %)  patients with type  2 diabetes mellitus and in 5  (71.4  %)  patients with IGT. The mean duration of follow-up for T2DM and IGT patients was 14.2 ± 12.3 and 11.2 ± 9.0 months respectively.

Results. The mean %EWL (% excess weight loss) in patients with T2DM and IGT was 44.1 ± 17.3 and 51.5 ± 16.9 respectively, and the mean %TWL (% total weight loss) was 25.0 ± 8.0 and 27.8 ± 6.0 respectively. At the moment of observation, all patients had normal level of fasting blood glucose. The level of HbA1c in patients with type 2 diabetes before the surgery was 8.2 ± 1.6, after surgery, at the time of observation – 5.8 ± 0.5 (U = 4; p ≤ 0.01). Targeted HbA1c values was recorded in all 13 patients with type 2 diabetes.

Conclusion. Our study shows the efficiency of sleeve gastrectomy both in terms of weight loss and of the remission for patients with T2DM and IGT. 

The effect of Roux-en-Y gastric bypass compared with omega-loop gastric bypass on weight loss, perioperative surgical events, and comorbidities

BACKGROUND

In comparison to conservative therapy, bariatric surgery has shown many reasonable results. The current study investigates whether Omega-loop-gastric-bypass (OAGB) or Roux-en-Y gastric-bypass (RYGB) improves weight loss, comorbidities, and perioperative complications.

METHODS

The study included 28,683 patients after RYGB and OAGB. Outcome criteria were perioperative morbidity, perioperative complications, and remission of comorbidities after one year of follow-up.

RESULTS

Of them 14,253 patients had completed a one-year follow-up (13,483 patients by RYGB and 770 by OAGB). BMI reduction was a significant difference in favor of OAGB (17.5±5.6 kg/m² for OAGB vs. 15.2±5.0 for RYGB; P<0.001). The %EWL was not significantly different between the two groups (P=0.073). There was also no significant difference in perioperative complications between the two groups (overall P>5%). Significant differences in favor of OAGB were observed in remission of insulin-dependent diabetes mellitus (IDDM) (P<0.001), and sleep apnea (P=0.002). Remission of reflux was more observed in RYGB than OAGB (P<0.001). Operating time was significantly higher in RYGB than OAGB (P<0.001).

CONCLUSIONS

Compared with RYGB, OAGB showed significant advantages in many respects. In particular, remission of comorbidities was significantly better after OAGB than in patients after RYGB during the one-year follow-up period. Nevertheless, many other factors such as medical history, long-term expected goals of bariatric surgery, and preexisting comorbidities should be taken into account when determining indications between the two procedures. Further studies with longer follow-up periods should be conducted to determine the efficacy of the two methods more accurately.

Obesity surgery: Which procedure should we choose and why?

In the 70years that bariatric surgery has existed, many different surgical procedures have been developed. Four procedures are officially accepted by all learned societies: adjustable gastric banding (AGB), sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB) and bilio-pancreatic diversion (BPD). Gastric banding has the lowest short-term surgical risk, but it has the highest re-operation rate. Compared to SG, RYGB presents about twice the risk of early complications. Late complications seem equivalent between the two procedures but studies with follow-up>10years are rarer for SG. SG has become the most commonly performed bariatric procedure worldwide, followed by RYGB, which is still the standard. BPD remains very marginal but the omega gastric bypass, an alternative technique that is still under evaluation, now competes with RYGB. The effectiveness of these different procedures on weight loss remains difficult to compare. SG and RYGB seem to be equivalent for weight loss results and remission of type-2 diabetes (T2DM). Their results are superior to AGB. Procedures that result in greater lengths of intestinal bypass (bilio-pancreatic diversion, omega bypass) seem to have a greater weight-loss effect but are burdened by more side effects. In conclusion, the choice of a procedure is conditioned firstly by the benefit-risk ratio and in relation to patient-related parameters, particularly the body mass index (BMI) and co-morbidities. Long-term results are also linked to factors other than surgery and in particular patient behavioral factors. Obesity is a chronic disease that indicates the need for real long-term medical and surgical management.

The influence of geometric algebra in surgical practice of sleeve gastrectomy-single center experience

Laparoscopic surgery could be considered as an art of geometric algebra. However, very little is studied in the context of bariatric surgery. The current study aims to explore the possible influence concept of geometric algebra on the surgical process in the overweight and obese patients in the setting of laparoscopic sleeve gastrectomy (LSG). During the study period, clinical data of subjects who underwent LSG was retrospectively analyzed. Parameters examined include body mass index (BMI), umbilical-xiphoidal interval (U-X) and umbilical-fundus (U-F) interval. In this study, LSG was performed via central view approach (C) and left view approach (L). In both groups, the body surface projection points of viewing hole (V), main and accessory operating holes (O1 and O2) and surface display of fundus (F) were connected to form a geometric figure. The accessibility of the surgical instrument into the fundus, the need for elongated instruments and related intra- and post-operative parameters were noted. The overweight and obese subjects showed a significant increased U-X and U-F interval compared to the non-obese subjects. The length of both U-X and U-F interval were correlated with the BMI. The geometric figure is quite different between L and C approach with significant increase of area of quadrangle. Significant longer O1-F, O2-F and V-F interval was calculated in C approach of patients and thus the elongated instruments were frequently required. The integration of the concept geometric algebra with the proper selection of troca may provide a better surgical experience and smooth surgical process.

Efficacy and safety of one anastomosis gastric bypass versus Roux-en-Y gastric bypass for type 2 diabetes remission (ORDER): protocol of a multicentre, randomised controlled, open-label, superiority trial

INTRODUCTION

Previous studies have demonstrated that one anastomosis gastric bypass (OAGB) is not inferior to Roux-en-Y gastric bypass (RYGB) in treating obesity. However, high level evidence comparing the efficacy and safety of both procedures in type 2 diabetes (T2D) treatment is still lacking, which is another main aim of bariatric surgery. The presented trial has been designed to aim at investigating the superiority of OAGB over the reference procedure RYGB in treating T2D as primary endpoint. And diabetes-related microvascular and macrovascular complications, cardiovascular comorbidities, weight loss, postoperative nutritional status, quality of life and overall complications will be followed up for 5 years as secondary endpoints.

METHODS AND ANALYSIS

This prospective, multicentre, randomised superiority open-label trial will be conducted in patients of Asian descent. A total of 248 patients (BMI≥27.5 kg/m²) who are diagnosed with T2D will be randomly assigned (1:1) to OAGB or RYGB with blocks of four. The primary endpoint is the complete diabetes remission rate defined as HbA1c≤6.0% and fasting plasma glucose≤5.6 mmol/L without any antidiabetic medications at 1 year after surgery. All secondary endpoints will be measured at different follow-up visit points, which will start at least 3 months after enrolment, with a continuous annual follow-up for five postoperative years in order to provide solid evidence on the efficacy and safety of OAGB in patients with T2D.

ETHICS AND DISSEMINATION

The study has been approved by the ethics committee of leading centre (Beijing Friendship Hospital, Capital Medical University, no. 2021-P2-037-03). The results generated from this work will be disseminated to academic audiences and the public via publications in international peer-reviewed journals and conferences. The data presented will be imported into a national data registry. Findings are expected to be available in 2025, which will facilitate clinical decision-making in the field.

TRIAL REGISTRATION NUMBER

NCT05015283.