Standardized Assessment of Metabolic Bariatric Surgery Outcomes: Secondary Analysis of 2 Randomized Clinical Trials

Comparison of SADI-S Versus SG in Chinese with Diabetes and BMI < 35 kg/m2:a Retrospective Study with Medium-Term Outcomes

BACKGROUND

As a modification of the duodenal switch (DS), the single-anastomotic ileo-ileal bypass combined with sleeve gastrectomy (SADI-S) has recently gained popularity and has been successfully employed for weight loss and the remission of type 2 diabetes mellitus (T2DM). However, current studies predominantly focus on patients with severe obesity.

OBJECTIVES

In this study, we present the first comparison of single-anastomotic duodenoileal bypass combined with sleeve gastrectomy (SADI-S) and sleeve gastrectomy (SG) for the mid-term treatment of Chinese diabetic patients with a BMI < 35 kg/m2. This research provides comparative reports on the efficacy of these two surgical approaches.

PATIENTS AND METHODS

We included 53 diabetic patients with BMI < 35 kg/m2 who underwent either SADI-S or SG and were followed for 2 years postoperatively. Demographic characteristics, weight loss, and nutritional and metabolic outcomes were analyzed at 3-month, 6-month, 1-year, and 2-year follow-up intervals. All surgeries were performed by the same surgeon at a single weight loss center in China between July 2015 and November 2022.

RESULTS

A total of 24 patients who underwent Single Anastomosis Duodenal-Ileal Bypass with Sleeve Gastrectomy (SADI-S) and 29 patients who underwent Sleeve Gastrectomy (SG) were included in our analysis. Comparative analysis of the baseline indicators between the two groups revealed no statistically significant differences (P > 0.05).Both patient groups completed a 2-year follow-up. In terms of weight loss, the SADI-S group demonstrated superior outcomes compared to the SG group, with better results in weight, BMI, and total weight loss percentage (%TWL) at the 2-year follow-up, and these differences were statistically significant (66.9 ± 7.9 vs. 61.2 ± 6.6, p = 0.007; 23.8 ± 2.0 vs. 21.7 ± 1.6, p = 0.000; 31.1% ± 6.3% vs. 24.4% ± 6.4%, p = 0.000). Regarding diabetes remission, the SADI-S group also outperformed the SG group (p = 0.000). Specifically, 91.8% of patients in the SADI-S group achieved complete remission of T2DM, compared to 41.4% in the SG group (p = 0.000). Furthermore, the SADI-S group showed significantly better results in the remission of hyperlipidemia compared to the SG group.However, there was no significant difference in hypertension relief between the SADI-S group and the SG group. Additionally, the incidence of postoperative hypozincemia was significantly higher in the SADI-S group compared to the SG group (p = 0.038). No significant differences were observed in other postoperative nutritional outcomes between the two groups.

CONCLUSION

In Chinese diabetic patients with a BMI < 35 kg/m2, both SADI-S and SG were effective in treating obese T2DM.However, compared with SG, primary SADI-S can achieve better weight loss and remission of obesity-related metabolic diseases.Additionally, the rates of postoperative nutritional deficiencies were found to be acceptable. Nonetheless, multicenter studies with larger sample sizes and longer follow-up periods are necessary to draw definitive conclusions.

Long-Term Outcomes of Laparoscopic Roux-en-Y Gastric Bypass vs Laparoscopic Sleeve Gastrectomy for Obesity: The SM-BOSS Randomized Clinical Trial

Importance

Reports on long-term outcomes from randomized clinical trials comparing laparoscopic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) are scarce.

Objective

To compare long-term weight and metabolic outcomes, reoperation rates, and quality of life for patients undergoing SG vs RYGB at 10 years and beyond.

Design, Setting, and Participants

The SM-BOSS (Swiss Multicenter Bypass or Sleeve Study) randomized clinical trial was conducted from January 2007 to November 2011 at 4 bariatric centers in Switzerland. (The last follow-up was obtained in July 2023.) A total of 3971 patients with severe obesity were assessed, and 217 patients were enrolled and randomized to undergo SG or RYGB.

Interventions

Laparoscopic SG or RYGB.

Main Outcomes and Measures

The primary outcome of the SM-BOSS trial was the percentage excess body mass index loss (%EBMIL) at 5 years. The present study reports on the long-term weight and metabolic outcomes at 10 years and beyond, including changes in weight and obesity-related diseases, reoperation rates, and quality of life.

Results

Of 217 patients randomized to undergo SG or RYGB, mean (SD) age was 42.5 (11.1) years, mean (SD) baseline BMI was 43.9 (5.3), and 156 patients (71.9%) were female. Of 217 patients, 110 patients were randomized to RYGB and 107 to SG. Complete 10-year follow-up is available for 65.4% of patients. In the intention-to-treat population, mean (SD) %EBMIL was 60.6% (25.9) after SG and 65.2% (26.0) after RYGB (P = .29). Patients who underwent SG had significantly higher conversion rates because of insufficient weight reduction or reflux compared to RYGB (29.9% vs 5.5%; P < .001). Patients undergoing RYGB had significantly higher mean (SD) %EBMIL compared to SG after 10 years in the per-protocol (PP) population (65.9% [26.3] vs 56.1% [25.2]; P = .048). However, mean (SD) percentage total weight loss was not significantly different between groups (RYGB: 27.7% [10.8]; SG: 25.5% [15.1]; P = .37). SG patients had significantly more de novo gastroesophageal reflux (GERD) compared with RYGB (P = .02).

Conclusions and Relevance

In the SM-BOSS randomized clinical trial, RYGB led to significantly higher %EBMIL in the PP population compared with SG beyond 10 years of follow-up, with better results for GERD. Patients undergoing SG experienced a significantly higher number of conversions to different anatomy compared with RYGB.

Trial Registration

ClinicalTrials.gov Identifier NCT00356213.

Metabolic disease remission after Roux-en-Y gastric bypass depends on preoperative disease severity: use of a new objective metabolic scoring system

BACKGROUND

Severity stratification and longitudinal evaluation of metabolic conditions in response to Roux-en-Y gastric bypass (RYGB) are not standardized. Our Assessment of Obesity-related Metabolic Comorbidities (AOMC) scoring tool combines pharmacotherapy and biochemical data to objectively define type 2 diabetes (T2D), hypertension (HTN), and dyslipidemia (DYS) severity. We previously showed that AOMC more accurately describes disease severity than clinical history alone.

OBJECTIVES

We aimed to show that AOMC more precisely and reproducibly measures metabolic disease response to RYGB and preoperative disease severity influences remission rates.

SETTING

University hospital, United States.

METHODS

AOMC scores for T2D, DYS, and HTN were calculated preoperatively and postoperatively (1-, 2-, and 5-years) for patients who underwent RYGB over 14 years. Generalized linear mixed-effect models were used to evaluate AOMC score trends and remission over time.

RESULTS

Of 351 patients, 214, 188, and 303, presented with any T2D, DYS, or HTN respectively. One-year remission rates were: T2D 57.1%, DYS 59.7%, and HTN 29.3%. Over 5 years post-RYGB, remission rates declined for T2D (P < .05) and DYS (P < .05) but remained steady for HTN (P > .05). Remission was associated with preoperative disease severity: those with premetabolic disease had the highest remission rates (i.e., 1-year: pre-T2D 81.4%, pre-DYS 91.4%, pre-HTN 53.5%, all P < .05), while those with most severe scores preoperatively (untreated/uncontrolled) had the lowest remission rates.

CONCLUSIONS

AOMC allows precise assessment of comorbidity severity and disease-specific postoperative quantification of comorbidity responses and remission rates. These findings can guide preoperative metabolic disease optimization and postoperative metabolic recovery expectations and standardize communication regarding comorbidity severity.

Evaluating the impact and costs of conversional or revisional metabolic bariatric surgery on obstructive sleep apnea: Insights from a French nationwide cohort

BACKGROUND

This study assesses the effectiveness of 5 main conversional or revisional metabolic bariatric surgery sequences after sleeve gastrectomy, adjustable gastric banding and gastric bypass on reimbursement and cost of continuous positive airway pressure therapy, the first line treatment for obstructive sleep apnea, in France.

METHODS

This nationwide observational population-based cohort study analyzed data from the French National Health Insurance database. It included all patients who had undergone primary metabolic bariatric surgery in France between January 1, 2012, and December 31, 2014, and followed until December 31, 2020. The study assessed continuous positive airway pressure therapy reimbursement discontinuation and costs of reimbursed continuous positive airway pressure therapy across 5 different conversional or revisional metabolic bariatric surgery sequences.

RESULTS

During follow-up, 6,396 patients underwent the following sequences: sleeve gastrectomy-gastric bypass (n = 2,400), adjustable gastric banding-sleeve gastrectomy (n = 2,277), adjustable gastric banding-gastric bypass (n = 1,173), sleeve gastrectomy-sleeve gastrectomy (n = 546), and gastric bypass-others (n =332), with a rate of obstructive sleep apnea of 15.2%, 12.4%, 15.5% 12.8%, and 9.9% in the year before conversional or revisional metabolic bariatric surgery. The rates of patients who had a discontinuation of continuous positive airway pressure were at 2 and 4 years: 41.1%, 41.9%, 46.4%, 29.3%, and 33.3%; 62.3%, 57.0%, 78.2%; 57.5%, and 44.4%, respectively. At 4 years, the mean annual costs (euros) of obstructive sleep apnea treatment per patient were significantly lower (P < .01) than the costs in the year before conversional or revisional metabolic bariatric surgery for each sequence: 526.9 ± 414.4 vs 257.4 ± 349.7; 368.0 ± 247.5 vs 230.9 ± 288.4; 433.7 ± 326.0 vs 116.8 ± 238.3; 540.7 ± 275.3 vs 248.0 ± 308.4 and 501.2 ± 254.0 vs 281.1 ± 287.0, respectively.

CONCLUSIONS

Our study underscore the effectiveness of conversional or revisional metabolic bariatric surgery in significantly reducing the need and associated costs of continuous positive airway pressure therapy for patients with obstructive sleep apnea postprimary metabolic bariatric surgery over a 4-year period.

Fat Mass Index Predicts the Effect of Weight Loss and Quality of Life Early After Laparoscopic Sleeve Gastrectomy

BACKGROUND

Fat mass index (FMI) is a body composition indicator that reflects body fat content. Laparoscopic sleeve gastrectomy (LSG) is widely performed in patients with obesity.

OBJECTIVE

This study aimed to evaluate the value of the FMI in predicting weight loss effect and quality of life early after LSG.

MATERIAL AND METHODS

From January 2014 to July 2022, the clinical data and computed tomography (CT) images of patients who underwent LSG at a tertiary referral teaching hospital were analyzed. Body composition indicators were calculated using the SliceOmatic software. Achieving initial body mass index within 6 months postoperatively was defined as early eligible weight loss (EEWL). The relationship between body composition and EEWL was analyzed.

RESULTS

A total of 243 patients were included. Receiver operating characteristic (ROC) curve analysis showed that the predictive value of the FMI for EEWL in patients after LSG was higher than that of other indicators (all P < 0.05; area under the curve = 0.813). The best FMI cut-off point was 13.662. Accordingly, the patients were divided into the high-FMI group and low-FMI group. The %EWL and BMI of patients in the low-FMI group at 1, 3, 6, 9, 12, and 24 months after surgery were better than those in the high-FMI group (all P < 0.001). Patients in the low-FMI group had higher BAROS (Bariatric Analysis and Reporting Outcome System) scores than those in the high-FMI group (P < 0.001).

CONCLUSION

Compared with other body composition indicators, FMI can effectively predict the early effect of weight loss and quality of life after LSG.