Roux-en-Y gastric bypass, gastric banding, or sleeve gastrectomy for severe obesity: Baseline data from the By-Band-Sleeve randomized controlled trial

Roux-en-Y gastric bypass, adjustable gastric banding, or sleeve gastrectomy for severe obesity (By-Band-Sleeve): a multicentre, open label, three-group, randomised controlled trial

BACKGROUND

The health risks of severe obesity can be reduced with metabolic and bariatric surgery, but it is uncertain which operation is most effective or cost-effective. We aimed to compare Roux-en-Y gastric bypass, adjustable gastric banding, and sleeve gastrectomy in patients with severe obesity.

METHODS

By-Band-Sleeve is a pragmatic, multi-centre, open-label, randomised controlled trial conducted in 12 hospitals in the UK. Eligible participants were adults (aged ≥18 years) meeting national criteria for metabolic and bariatric surgery. Initially, a 2-group trial (Roux-en-Y gastric bypass versus adjustable gastric banding) became a 3-group trial to include sleeve gastrectomy at 2·6 years from study opening, when it became widely used in the UK. Co-primary endpoints were weight (proportion achieving ≥50% excess weight loss) and quality-of-life (EQ-5D utility score) at 3 years. If the proportion achieving at least 50% excess weight loss was non-inferior (<12% difference between groups) and quality-of-life was superior, sleeve gastrectomy and Roux-en-Y gastric bypass were considered more effective than adjustable gastric banding, and sleeve gastrectomy more effective than Roux-en-Y gastric bypass. Cost-effectiveness of the procedures was compared. This trial is registered with ClinicalTrials.gov, NCT02841527, and ISRCTN, 00786323.

RESULTS

Between Jan 16, 2013, and Sept 27, 2019, 1351 participants were randomly assigned; five withdrew consent and 1346 (mean age 47·3 [SD 10·6] years, 1020 [76%] women, 324 (24%) men, and two with missing data, mean weight of 129·7 kg [23·6] and mean BMI of 46·4 [6·9] kg/m2) were included in this report. Of 1346 participants, 462 (34%) were in the Roux-en-Y gastric bypass group, 464 (34%) in the adjustable gastric banding group, and 420 (31%) in the sleeve gastrectomy group. 1183 (88%) participants underwent surgery. 276 (68%) of 405 participants in the Roux-en-Y gastric bypass group, 97 (25%) of 383 participants in the adjustable gastric banding group and 141 (41%) of 342 participants in the sleeve gastrectomy group achieved at least 50% excess weight loss (adjusted risk difference: Roux-en-Y gastric bypass vs adjustable gastric banding 41% [98% CI 34 to 48]; sleeve gastrectomy vs adjustable gastric banding 15% [5 to 24]; sleeve gastrectomy vs Roux-en-Y gastric bypass, -26% [-36 to -16%]). Mean EQ-5D scores were 0·72 for Roux-en-Y gastric bypass, 0·62 for adjustable gastric banding, and 0·68 for sleeve gastrectomy (adjusted mean difference: Roux-en-Y gastric bypass vs adjustable gastric banding 0·08 [0·04 to 0·12], sleeve gastrectomy vs adjustable gastric banding 0·05 [0·01 to 0·09], and sleeve gastrectomy vs Roux-en-Y gastric bypass -0·03 [-0·07 to 0·01]). 1651 adverse events were reported following surgery (5·7 per year after sleeve gastrectomy, 6·0 per year after Roux-en-Y gastric bypass, and 4·6 per year after adjustable gastric banding). There were 11 deaths from randomisation to 3 years: one attributable to surgery (in the adjustable gastric bypass group, during the surgical admission) and ten not attributable to surgery (four each in the Roux-en-Y gastric bypass and adjustable gastric banding groups and two in the sleeve gastrectomy group). Roux-en-Y gastric bypass was most cost-effective.

INTERPRETATION

Roux-en-Y gastric bypass and sleeve gastrectomy are more effective than adjustable gastric banding. Sleeve gastrectomy has inferior weight loss and lower mean quality of life score compared with Roux-en-Y gastric bypass. Based on this evidence, it is recommended that patients electing to have metabolic and bariatric surgery are advised to have Roux-en-Y gastric bypass. Where contraindicated or unfeasible, sleeve gastrectomy should be offered. This evidence does not support adjustable gastric band as standard treatment for severe obesity.

FUNDING

National Institute for Health and Care Research Health Technology Assessment Programme.

Weight management during pregnancy, what is new?

PURPOSE OF REVIEW

The prevalence of women entering pregnancy with overweight or obesity is increasing which raises concerns for adverse outcomes for mothers and their infants. Evidence suggests that appropriate gestational weight gain is important, irrespective of maternal BMI. The aim of this present article is to review the evidence on weight management during pregnancy and evaluate the evidence on current interventions.

RECENT FINDINGS

There is currently no standardized definition of 'excessive' gestational weight gain or a unified approach to manage gestational weight, despite the rising prevalence of maternal overweight and obesity globally. Recently, the Dietary Intervention in Gestational Diabetes (DiGest) trial showed promising results for energy restriction as a potential strategy to reduce gestational weight gain and improve maternal and infant outcomes. Pharmacological treatments, including GLP-1 receptor agonists, also show promise, but safety concerns remain requiring further research. More studies are needed to assess the effectiveness of both lifestyle and pharmacological interventions to guide future clinical recommendations.

SUMMARY

There is a need for individualized guidelines that consider maternal characteristics including ethnicity, preexisting conditions and emerging health risks, to tackle weight management during pregnancy and improve pregnancy outcomes. Further research is needed on optimal weight management strategies during pregnancy.

The latest evidence and guidance in lifestyle and surgical interventions to achieve weight loss in people with overweight or obesity

BACKGROUND

The prevalence of obesity and related co-morbidities has reached epidemic proportions. Effective evidence-based treatment approaches are therefore important. Lifestyle intervention remains the mainstay of the treatment strategy to manage obesity. Increased evidence has also emerged regarding the efficacy of metabolic bariatric surgery (MBS) to induce significant and sustained weight loss while also reducing the progression of obesity-related co-morbidities for people living with obesity.

AIMS & METHODS

This article aims to bring together current evidence, guidance and best practice for the prevention and management of people living with overweight or obesity by means of lifestyle and behavioural intervention, as well as by MBS.

RESULT

Lifestyle intervention encompasses dietary strategies, physical activity and behavioural intervention. Discussion on MBS will focus on current indications, comparison between different MBS procedures, novel endoscopic techniques, potential complications and pre-operative management.

PLAIN LANGUAGE SUMMARY

The number of people living with excess weight and complications associated with being overweight is alarmingly quite high. Effective treatment approaches that are supported by clinical studies are therefore important. Lifestyle changes remain very important to manage excess weight. Increased evidence has also shown the benefits of weight loss surgery to produce significant weight loss which could be sustained, while also reducing the risk of developing medical conditions associated with excess weight. This article aims to bring together current evidence, guidance and best practice for the prevention and management of people living with excess weight by means of lifestyle and behavioural changes, as well as by weight loss surgery. Lifestyle intervention encompasses dietary strategies, physical activity and behavioural intervention. Discussion on weight loss surgery will focus on current criteria for suitability, comparison between different weight loss surgery procedures, new techniques, possible complications and appropriate management prior to weight loss surgery.

Actual weight loss trajectories after bariatric surgery compared with the SOPHIA prediction tool: An observational comparison study

AIMS

Estimation of post-bariatric surgery weight loss is important for informed clinical decisions, yet existing predictive models lack accuracy and reliability. We assessed the effectiveness of the validated Stratification of Obesity Phenotypes to Optimize Future Therapy (SOPHIA) bariatric weight trajectory prediction tool in our patient population.

MATERIALS AND METHODS

We conducted a retrospective study of 178 adults who underwent bariatric surgery over a 3-year period. Actual weights at baseline and annually over 5 years of follow-up were compared with predicted weights to calculate mean difference and median absolute deviation (MAD).

RESULTS

The study comprised 157 women (88.2%) and 21 men (11.8%) with mean (standard deviation) age of 46.9 (10.6) years and baseline weight of 138.4 (23.5) kg. The bariatric surgical procedures included 148 (83.1%) gastric bypass, 19 (10.7%) sleeve gastrectomy and 11 (6.2%) gastric band operations. The proportion of patients with actual weights within the prediction interquartile range (IQR) was 50.7%, 43.2% and 38.8% at 12, 24 and 60 months, respectively. The mean difference between actual and predicted weight at 60 months was 0.6 (16.7) kg, p = 0.654 (paired t test). The mean MAD at 60 months was 12.9 (95% CI, 11.3-14.4) kg, indicating moderate predictive utility. The predictive accuracy was highest for gastric bypass. Subgroup analysis revealed greater accuracy in patients without diabetes/pre-diabetes, and in nonsmokers.

CONCLUSIONS

The SOPHIA study tool provides accurate postoperative weight forecasts for some subgroups of patients, but its precision diminishes with time. This study reiterates the necessity for better personalized weight prediction tools to inform bariatric surgery decision-making.

The approach to a pregnancy after bariatric surgery

With a rising worldwide incidence of obesity, particularly in the young, bariatric surgery offers an effective method of meaningful and sustained weight loss. At present, most bariatric procedures are carried out in women and increasingly in younger age groups. In line with the fertility benefits associated with weight loss, pregnancy after bariatric surgery is now a very common scenario. Although there is limited evidence to support optimal care in this group, most women appear to have good pregnancy outcomes, with reduced rates of pre-eclampsia and gestational diabetes (GDM). However, rates of stillbirth and small-for-gestational-age (SGA) babies are increased, suggesting that screening and supplementation of micronutrients is likely to be very important in this cohort. The risks and benefits that bariatric surgery may pose to pregnancy outcomes, both maternal and fetal, are largely dependent upon the degree of weight loss, weight stability upon entering pregnancy, surgical complications and the time interval between bariatric surgery and pregnancy. Ideally, preconception care would be more widely available, helping to assess and address micronutrient deficiencies and support preparation for pregnancy.

Long-term effect of sleeve gastrectomy vs Roux-en-Y gastric bypass in people living with severe obesity: a phase III multicentre randomised controlled trial (SleeveBypass)

Background

Sleeve gastrectomy is the most performed metabolic surgical procedure worldwide. However, conflicting results offer no clear evidence about its long-term clinical comparability to Roux-en-Y gastric bypass. This study aims to determine their equivalent long-term weight loss effects.

Methods

This randomised open-label controlled trial was conducted from 2012 until 2017 in two Dutch bariatric hospitals with a 5-year follow-up (last follow-up July 29th, 2022). Out of 4045 patients, 628 were eligible for metabolic surgery and were randomly assigned to sleeve gastrectomy or Roux-en-Y gastric bypass (intention-to-treat). The primary endpoint was weight loss, expressed by percentage excess body mass index (BMI) loss. The predefined clinically relevant equivalence margin was -13% to 13%. Secondary endpoints included percentage total kilograms weight loss, obesity-related comorbidities, quality of life, morbidity, and mortality. This trial is registered with Dutch Trial Register NTR4741: https://onderzoekmetmensen.nl/nl/trial/25900.

Findings

628 patients were randomised between sleeve gastrectomy (n = 312) and Roux-en-Y gastric bypass (n = 316) (mean age 43 [standard deviation (SD), 11] years; mean BMI 43.5 [SD, 4.7]; 81.8% women). Excess BMI loss at 5 years was 58.8% [95% CI, 55%-63%] after sleeve gastrectomy and 67.1% [95% CI, 63%-71%] after Roux-en-Y gastric bypass (difference 8.3% [95% CI, -12.5% to -4.0%]). This was within the predefined margin (P < 0.001). Total weight loss at 5 years was 22.5% [95% CI, 20.7%-24.3%] after sleeve gastrectomy and 26.0% [95% CI, 24.3%-27.8%] after Roux-en-Y gastric bypass (difference 3.5% [95% CI, -5.2% to -1.7%]). In both groups, obesity-related comorbidities significantly improved after 5 years. Dyslipidaemia improved more frequently after Roux-en-Y gastric bypass (83%, 54/65) compared to sleeve gastrectomy (62%, 44/71) (P = 0.006). De novo gastro-oesophageal reflux disease occurred more frequently after sleeve gastrectomy (16%, 46/288) vs Roux-en-Y gastric bypass (4%, 10/280) (P < 0.001). Minor complications were more frequent after Roux-en-Y gastric bypass (5%, 15/316) compared to sleeve gastrectomy (2%, 5/312). No statistically significant differences in major complications and health-related quality of life were encountered.

Interpretation

In people living with obesity grades 2 and 3, sleeve gastrectomy and Roux-en-Y gastric bypass had clinically comparable excess BMI loss according to the predefined definition for equivalence. However, Roux-en-Y gastric bypass showed significantly higher total weight loss and significant advantages in secondary outcomes, including dyslipidaemia and GERD, yet at a higher rate of minor complications. Major complications, other comorbidities, and overall HRQoL did not significantly differ between the groups.

Funding

Not applicable.

Bariatric Surgery in Women with Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is the most common endocrine condition in premenopausal women and is a common cause of anovulatory subfertility. Although obesity does not form part of the diagnostic criteria, it affects a significant proportion of women with PCOS and is strongly implicated in the pathophysiology of the disease. Both PCOS and obesity are known to impact fertility in women; obesity also reduces the success of assisted reproductive technology (ART). With or without pharmacotherapy, lifestyle intervention remains the first-line treatment in women with PCOS and obesity. Bariatric surgery is still an experimental treatment in women with PCOS and subfertility. This review will present an overview of the pathophysiology of PCOS and obesity and the role of bariatric surgery. Although data are sparse regarding the impact of bariatric surgery on subfertility in women with PCOS and obesity, existing studies point to a beneficial role in treating metabolic and reproductive dysfunction.

Comparing Safety and Efficacy Outcomes of Gastric Bypass and Sleeve Gastrectomy in Patients With Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis

Sleeve Gastrectomy (SG) could be done by the removal of a big portion of the stomach, leading to reduced amounts of food taken as a result of the smaller stomach size. In contrast, Roux-en-Y Gastric Bypass (RYGB) can be done by creating a small stomach pouch and rerouting a part of the small intestine, employing combined mechanisms of restriction and malabsorption to limit food intake and modify nutrient absorption. Our aim is to identify the most effective and safest surgical intervention for individuals with both Type 2 Diabetes Mellitus (T2DM) and obesity, considering both short and long-term outcomes. We will assess participants undergoing either SG or RYGB to determine the optimal surgical approach. We made a thorough search of PubMed, Cochrane Library, Scopus, and Web of Science databases up to November 2023. Our focus was on randomized controlled trials (RCTs) comparing the safety and efficacy of RYGB and SG in T2DM regarding any extractable data. We excluded studies of other designs, such as cohorts, case reports, case series, reviews, in vitro studies, postmortem analyses, and conference abstracts. Utilizing Review Manager 5.4, we performed a meta-analysis, combining risk ratios (RR) with a 95% confidence interval (CI) conducted for binary outcomes, while mean with SD and 95% CI are pooled for the continuous ones. The total number of participants in our study is 4,148 patients. Our analysis indicates superior outcomes in the group undergoing RYGB surgery compared to the SG group (RR = 0.76, 95% (CI) (0.66 to 0.88), P = 0.0002). The pooled data exhibited homogeneity (P = 0.51, I2 = 0%) after employing the leave-one-out method. For the 1-3 year period, six studies involving 332 patients with T2DM yielded non-significant results (RR = 0.83, 95% CI (0.66 to 1.06), P = 0.14) with homogeneity (P = 0.24, I2 = 28%). Conversely, the 5-10 year period, with six studies comprising 728 DM patients, demonstrated significant results (RR = 0.69, 95% CI (0.56 to 0.85), P = 0.14) and homogeneity (P = 0.84, I2 = 0%). In terms of total body weight loss, our findings indicate significantly higher weight loss with RYGB (mean difference (MD) = -6.13, 95% CI (-8.65 to -3.6), P > 0.00001). However, pooled data exhibited considerable heterogeneity (P > 0.00001, I2 = 93%). Subgroup analyses for the 1-3 year period (five studies, 364 DM patients) and 5-10 year period (six studies, 985 DM patients) also revealed significant differences favoring RYGB, with heterogeneity observed in both periods (1-3 years: P > 0.00001, I2 = 95%; 5-10 years: P = 0.001, I2 = 75%). RYGB demonstrated significant long-term improvement in diabetes remission and superior total body weight loss compared to SG. While no notable differences were observed in other efficacy outcomes, safety parameters require further investigation. no significant distinctions were found in any of the safety outcomes: hypertension (HTN), high-density lipoprotein (HDL), hyperlipidemia, fasting blood glucose, vomiting, low-density lipoprotein (LDL), and total cholesterol. Further research is essential to comprehensively assess safety outcomes for both surgical approaches.

Using trials of caloric restriction and bariatric surgery to explore the effects of body mass index on the circulating proteome

Thousands of proteins circulate in the bloodstream; identifying those which associate with weight and intervention-induced weight loss may help explain mechanisms of diseases associated with adiposity. We aimed to identify consistent protein signatures of weight loss across independent studies capturing changes in body mass index (BMI). We analysed proteomic data from studies implementing caloric restriction (Diabetes Remission Clinical trial) and bariatric surgery (By-Band-Sleeve), using SomaLogic and Olink Explore1536 technologies, respectively. Linear mixed models were used to estimate the effect of the interventions on circulating proteins. Twenty-three proteins were altered in a consistent direction after both bariatric surgery and caloric restriction, suggesting that these proteins are modulated by weight change, independent of intervention type. We also integrated Mendelian randomisation (MR) estimates of the effect of BMI on proteins measured by SomaLogic from a UK blood donor cohort as a third line of causal evidence. These MR estimates provided further corroborative evidence for a role of BMI in regulating the levels of six proteins including alcohol dehydrogenase-4, nogo receptor and interleukin-1 receptor antagonist protein. These results indicate the importance of triangulation in interrogating causal relationships; further study into the role of proteins modulated by weight in disease is now warranted.