Latest / Behind The Knife: The Surgery Podcast / Journal Review in Bariatric Surgery: Sleeve vs Bypass and Revisional Strategies
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- btk JC sleeve vs rygb vs revision === [00:00:00] Hi everyone. Welcome back to another episode of our Bariatric Surgery Journal Club series. Today we are comparing the outcomes between the gastric bypass sleeve gastrectomy, and the CD procedures. We are welcome by the incredible panel of bariatric surgeons. Hi, this is Matt Martin, bariatric surgeon at the University of Southern California. I'm a Adrian Medical Director of the Bariatric Care Center and Program Director for the advanced G-I-M-I-S Forgotten Bariatric Surgery Fellowship at a place called Summa Health. Northeast Ohio Medical University in Akron, Ohio. And hey, I am Crystal Johnson Mann. I am a big surgeon at the University of Florida where I'm also our interim medical director for bariatric metabolic surgery. And I am Katie Serone. I'm one of the general surgery residents at the University of Southern California. Alright, well let's jump right in. Today is a journal club episode, so we've certainly all seen how bariatric surgery has transformed the landscape for obesity. Diabetes treatment and other metabolic comorbidity [00:01:00] treatments over the past two decades. But we still have a big question remaining which operation is best amongst an ever increasing number of operation options? How do the outcomes hold up long term? And what do we do when our most common option, the sleeve gastrectomy, gives a suboptimal result? That is quite a lot to cover. Dr. To start, let's explore the Oberg trial. This was a single center, triple blind, randomized controlled trial out of Norway that compared the RU and y gastric bypass with the sleeve gastrectomy in patients with obesity and type two diabetes looking at five year outcomes. Yeah, this was a randomized controlled study. Interestingly, triple blind. That's not something you hear very often in surgical trials. You know, both the surgeries were done minimally invasive fashion laparoscopically. And they even standardized the incision sites, so patients couldn't tell which operation they had done. The methodology was quite impressive, I thought. [00:02:00] Truly a feat. In this study, they randomized about 109 patients of whom 93 patients completed the five year follow-up. The primary endpoint was diabetes remission at that mark, which was defined as a hemoglobin A1C, less than 6.5% without glucose lowering medications. Patients who underwent a bypass had a 63% remission rate compared to a sleeve who had a 30% remission rate. I mean, that's really impressive, right? So quite the difference. And when they looked at secondary outcomes like weight loss and cardiovascular risk factors, the bypass via the sleeve, again, with significantly decreased body weight after gastric bypass and significantly decreased total cholesterol and LDL after gastric bypass. But I think it's important to also, to recognize though the, the sleeve wasn't far behind the bypass and both of these operations technically worked. They both induced sustained weight loss. They both had improvements in [00:03:00] diabetes control from baseline. It's also important to note that there was a higher incidence of postprandial hypoglycemia in the gastric bypass patients. Yeah. Looking at the amount of GERD and the potential risk for esophagitis in the future. The sleeve did have a slightly higher chance of that, but I think we can all agree that over the years, our sleeves have gotten a lot better, and there's been a lot of technical adjustments to the sleeve procedure that have decreased the amount of gerd. It's something that I don't see very often, at least not clinically significant enough to require a conversion anymore in my practice. Matt, for the, the two of us that are a little more gray haired on this, on this panel, I think you'd agree that our sleeve from 2010 and our sleeve from 2025 are very different procedures, so the sleeve's not that far behind. It's a great operation and there have been some other trials that have needed [00:04:00] five years and 10 year follow ups to show the difference between the two. And if you need that many patients to pull studies and to take that long. What that tells me is that the, the difference, even though it's there, may not be that big and that clinically significant. Good point. Dr. Dan, now in your practice, do you see these differences play out? Do you favor bypass when diabetes remission is the main goal? That's a great question, Katie. So. The answer is yes and no. And that's why it's a great question because when I do have a patient that needs more metabolic impact, whether it's severe obesity or whether it's longstanding type two diabetes, I do favor a hypo ERP procedure. But in my practice at least the gastric bypass is not a procedure that I do much anymore. It's been replaced on one end by a better sleeve, as I mentioned, and it's been replaced on the other side. By a more [00:05:00] potent hypo absorptive operation. That being the single osmosis duo, no ileostomy, which we'll touch on later. But I do favor a hypo absorptive procedure over a sleeve when people have severe diabetes or when they need that, that additional impact. Okay. Let's put this into practice. Say you have a 52-year-old male with poorly controlled type two diabetes on insulin. BMI is 42, has a history of hypertension and hyperlipidemia. He is a candidate for surgery, but which surgery are you kind of steering him towards? Dr. Johnson Mann. Yeah, so great question. In my practice with the patients that we have in our Catchme area of 2 billion people. With a lot of rurality in my practice. This is a bypass patient. Barring that there are any other medical issues to be concerned about, like advanced liver disease cirrhosis in which that might be a different [00:06:00] conversation, but this patient has advanced metabolic disease and a bypass honestly gives him the best chance of diabetes remission. Does it give it the best chance? Is is my question? And are you burning bridges to that operation? You know, so I think. There's not a lot of duty switch Mercedes done in my part of Florida, honestly, just because of how highly rural it is in the distance that patients have to travel to receive care. There's a lot of access to care issues, and we can go on a different conversation about the sort of metabolic derangement and more hyper abortive operations and kind of what that does. But I think for our catchment area, the bypass is the best option by large. And, and I'd agree in general, this patient is older, he has more comorbidities. He's a diabetic already on insulin. So I think just based on the weight loss and diabetes, you can say bypass has a metabolic edge. We also have to really factor in how long they've had diabetes, that that's probably the strongest predictor. Is someone going [00:07:00] to respond or have remission with the cooperation? If this were a younger patient or even pediatric as we're we're doing now here in Los Angeles, I think I would still steer them towards a sleeve because they have a higher remission of diabetes and it's a safer long-term operation or a sad operation here, but, but we will get to that in a little bit. Alright, let's move on to our next paper. It is on the by band sleeve trial. This study is from the UK and it is a multi-centered, randomized control trial. One of the largest we've ever seen in bariatric surgery with almost 1200 patients who underwent surgery with gastric bypass sleeve gastrectomy, or an adjustable gastric band, and then measured the follow up. At three years, all surgeries were done laparoscopically, and unlike the Oberg trial, this was all an open label trial, so everyone knew which surgery they were getting. And that makes sense. And [00:08:00] particularly, there's really no way to blind patients or the surgeons as to whether they have a gastric band port, you know, on their abdomen sitting in the subacute position. I also feel for the surgeons who had to do all these band fills and adjustments in this study. That's a great point, Matt. You know, this day and age would be difficult. Some people find it ethically. Difficult to place a band, somebody. When we have the data from the last 20 years, which shows that the band, although it does have a role in a very few select patients, may not be the best operation for the large majority of patients. I think it's important to point out that even though we compare one operation to another, including the bypass and the sleeve and the band, as this article did. All of these operations are beneficial compared to untreated obesity. So all of these operations, although some of us may be very quick to point out, some of their flaws have saved [00:09:00] more lives than any trouble that they've caused. But again, to randomize a third of the people to the gastric band, we have seen the gastric band dwindle down to a couple percent of all the operations done in the us. So at three years, it looks like the bypass and the sleeve are far superior to the gastric band in terms of weight loss and comorbidity resolution. But I would say that there's still a role in a very, very few patients for this operation. Exactly. And the results of this trial showed that about 60% of patients in the bypass cohort achieved at least 50% of their excess weight loss. Compared with 41% in the sleeve group and 25% in the gastric band cohort. The study also measured a mental health component, analyzing disease specific quality of life, which also favored the bypass over the sleeve and the gastric band. Interestingly, you know, I think what Dr. Dan had to say is, you know, really kind of true, so, you know. [00:10:00] The results of this trial kind of just really confirms what we know to be true about the band long term, and that it's just less efficacious in terms of weight loss compared to stapling procedures. But again, there are patients who do benefit from it. And again, to that point that was raised earlier, some benefit is better than zero benefit. We look at things in the long term. Are either of you doing any bands in your current brac? I'm not. Absolutely not. No. I take a lot of bands out and then end up converting people to other things. That's the main benefit is practice for our residents and fellows in removing them. You know what? What was really interesting in this study? What was the head-to-head comparison to the bypass versus the sleeve? As you know, other studies have suggested they're almost virtually equivalent, which obviously is different than this study. The bypass group here again, like the last study, had increased rates of remission of type two diabetes, hypertension, and dyslipidemia at three years compared to the sleeve. So similar [00:11:00] to the other study appeared to be a better and more durable metabolic operation. Yeah. And the gastric sleeve remains the most commonly performed operational worldwide. And that's what I like to refer to in terms of that, the Lean six Sigma. Language, the voice of the customer. They figured out what works, what's most beneficial, and that's why we're doing close to 70% plus sleeps in the United States. And the, the gastric bypass has decreased to, to about 15%. And we have new numbers on that coming up at our national meeting in, in November here, that'll be released. So it's interesting to see where that's gonna go with some of the switch procedures increasing. But I find it hard to look at these studies because now what we really need to study is in settings where you have a failed sleeve, how the bypass compares to the other operations, such as one Stenosis gastric bypass, or Sadie. That's what's being [00:12:00] done right now in terms of research, and that's what we'll be seeing in the coming years with regards to which operation is most beneficial in severe obesity and diabetes remission. The other thing I wanna point out is I think it's been mentioned by Crystal that we already know some of this data on the gastric band, but we also know the data on remission of type two diabetes from the Stampede trial. And it's almost identical. It's about 40% remain diabetes free in the bypass group, and about 25% remain diabetes free in the sleeve group. So some of this we already know. It's just a matter of studying the newer operations to determine what our patients, when appropriate for those operations can benefit from the most. Great. Let's go through a few patient discussions. Let's consider a 55-year-old female. Now BMI is 45 with diabetes, hypertension, and hyperlipidemia. Which surgery would you [00:13:00] guys kind of steer her towards? I think in the current discussion here, I would strongly favor a bypass for this patient. You know, I think, again, as we kind of discussed sort of the outcomes in terms of diabetes remission, and this is a diabetic patient with some other metabolic associated, I think this kind of gives her the most bang for her. Of the options we're currently discussing. I'm gonna make a couple teaching points here for our listeners. The most important thing here to Matt's point, is how long has this patient been a diabetic? Okay? Five years is kind of the threshold. If you've been a diabetic for over five years, the chances of remission become slimmer and slimmer. If you've been a diabetic for less than five years, preferably a couple, or even pre-diabetes. The likelihood of not progressing to diabetes or having remission of your diabetes is huge. That's why it's so important. We don't wait until these patients have been a diabetic for five or 10 years before we offer 'em this treatment, so I would want to know that if my only options were sleeve and bypass, then bypass would be the way to go. [00:14:00] However, as Crystal mentioned, not everybody is suited for a Sadie procedure, and in that situation a sleeve may be better. To determine if the patient remains compliant, and if they are, then we can convert to a Sadie. Yeah, and I think we often talk in terms of what operation would you do rather than how would you come to a shared decision with the patient, right? So we never tell patients you need to have this operation. We present them options and we can certainly steer them, but it's also, you know, their decision at the end of the day. And we certainly see a lot of patients that I think. If it were me, I would have a bypass, but they want to have a sleeve, you know, simpler, lower complication risk. So we have to factor in patient preference here. Typically, a sleeve is considered superior for young women who are considering pregnancy as the nutritional deficiencies are more common after the bypass. However, there have been several excellent series looking at obstetrical outcomes and in general, obstetrical outcomes are significantly improved after bariatric [00:15:00] surgery, including either the sleeve or the bypass compared to obese patients who don't undergo a bariatric surgery. So I wouldn't have a problem doing a bypass in a young female patient just based on a featured pregnancy. And not just that, but not to guilt a mom about their obesity and how it can impact their fetus. Even the, the likelihood of the fetus being overweight, obese, or diabetic in adulthood is affected by the insulin resistance that a patient may have during her pregnancy and the glucose control during pregnancy. Yeah, absolutely. I think what it kind of comes down to is like a complete discussion. Of things regarding procedures, follow up complications, what sits right with the patient. 'cause again, they can be the perfect patient for a specific operation, but if in their soul they absolutely can reconcile with what they think are acceptable risks, I think that's fine. There's very few areas where there's really hard and fast contraindications to various [00:16:00] procedures. There are some that require some in-depth conversations, right? Like I'm not gonna have the. Sleep anatomy conversation with someone with longstanding Barretts esophagus, for instance. We're just not gonna do that. And I explained to them why. But all sudden that there's, there's lots of open area for discussion. And interestingly enough about the whole pregnancy thing, I have a lot of young women who have either had children and want future children who come to me specifically for a bypass. That is what they want. They don't even wanna entertain a sleeve 'cause they're like, I want this specifically. And they come with a list. They're like, I've researched it, I've talked to my friends, I've had family members, coworkers, family members, dah, dah, dah. And they're just like, this is whatever they want. I'm like, okay, all right. We'll proceed. You know, from these two papers specifically. 'cause we're, we're not bringing in Sadie Anatomy currently, but from these two papers it kind of really hits home that the bypass. Really has the advantage in sort of treating not only the weights, but also helping with the long-term issues with their metabolic comorbidities. But I know y'all are itching to get to [00:17:00] Sadie discussions so well, and I will mention that Adrian was the first one to use the F word and they used their, definitely wherever the old failure is, obsessed weight loss, less than 50%. One thing we've gone away from, I think the term failure, you know, weight regain or weight remission. But what do you guys think of that definition? I mean, it's probably the most common one, but do you think that's a reasonable definition of success of your bariatric operation? Not necessarily. Right. You know, so I think people get so caught up on just scale victories. There's also non-scale victories, and I think we have to really understand that what the set point is for one person is a different set point for someone else. So at this certain weight set point, this person's gonna develop type two diabetes, hypertension, hyperlipidemia, so on and so forth, right? And so they may need to swing the path, you know, to 70% x of weight loss to put those diseases into remission. Someone else [00:18:00] may not need to do that, to have a similar metabolic effect. So I think. It's always nice to look at numbers, and I think numbers are important, but you cannot hold true and facet to numbers for all members of our population. And you need to look at remission of metabolic associated comorbidities and just quality of life, like if the patients are happy with our progress. Okay, let's keep it going. I, I couldn't agree with you more. Crystal. You know, a percentage is not a good definition for success. And Matt, thank you for correcting that. You know the word, the F word, we can bleep over that. I think the proper terminology is inadequate weight loss, and I think 50% is a good, but it shouldn't be the definition of success for the patient. It only takes about 10, 15% of your excess weight loss to actually get the cardiometabolic benefits, the decrease in sleep apnea, the improved insulin homeostasis, and decreased insulin resistance that can occur with metabolic surgery. Great. Thank you guys. Now it's [00:19:00] time. Let's talk about the Sadie. One paper that discussed, this is the Theopolis paper that came out about a year ago in 2024. This was a systemic review and pooled analysis that compared two revisional options after the sleeve gastrectomy failed. These two options were the Ruin y gastric bypass, and the Sadie, or the Single Anastomosis Denal Ileal bypass. So for anyone who is not familiar with the Anatomy of a Sadie. It's essentially a single osmosis version of the Al Switch operation. But if you want more details, you can listen to our 2024 episode behind the knife where we discuss the Sadie in detail. But to circle back to this particular study, it was a relatively modest analysis in terms of sample size. Had about 400 patients across seven studies over a five year period in the main indications were inadequate weight loss or weight routine after patients had had prior sleeve gastrectomy. So I think this is actually a very timely discussion for us, for our group here. [00:20:00] I think the overarching finding was that Sadie showed improved weight loss when compared to gastric bypass in a situation where a sleeve gastrectomy did not provide that weight loss. You know, and this paper looked at a lot of papers that were individual papers that looked at one of the two operations when all put together. It showed that the Sadie was by no means inferior to the gastric bypass. But one of the papers within this systematic review. The dish horse study from Holland was the only one to directly compare Sadie and gastric bypass head to head. And I think what's striking to me is in situations where the obesity was so severe and so refractory that patients were not able to reach their goals with a sleeve gastrectomy. At one year, there was a 22% total weight loss with a Sadie versus 10% with a sleeve, obviously more than double. At five years, the [00:21:00] residual total weight loss was 15% with a Sadie versus just 2% with a sleeve. So the question becomes, by doing a gastric bypass in this population, are you giving an operation where they will eventually gain their, their weight back? That is actually inferior to obesity management medications at this point. And are you burning the bridges? Conversion of a gastric bypass back to a sleeve and then back to a denal switch is feasible, but it's fraught with long-term complications. So those are the things to think about. That's where I think the Sadie really has a role, and that's where I think that when sleeve has not worked out and the patient has shown and proven themselves to be a good candidate by showing their compliance and their willingness to comply with postoperative recommendations. Safety really makes sense. Yeah, and, and obviously it's very clear we're moving [00:22:00] from the clear waters of primary bariatric surgery data to the murky swamp of revisional bariatric surgery data. And for the sleeve, you'll notice a lot of studies do this. You really gotta be cognizant of it. They'll lump together patients who got revised for some complication of the sleeve, like reflux. Patients who are getting revised for weight, regain, or failure to lose initial desired weight, and those are two completely different patient populations and they'll merge them together. But I do think it's important to remember that gastric bypass and generalist appreciation of choice for sleeve patients that are getting revised for reflux or esophagitis or Barretts or dysphagia symptoms after their sleeve. And definitely on your board exams for all the residents listening. Fellows, the, the sleeve patient who has refractory reflux, the board answer is convert to a gastric bypass. Don't, don't leave 'em with that same sleeve and just add malabsorption to it. [00:23:00] And Matt, I couldn't agree more that that's the setting where a gastric bypass still makes sense and it remains the very best operation. It can provide further weight loss, although a little bit less. It can provide the best anti-reflux operation and anatomy that we can bestow on a patient with those types of problems, or erosive esophagitis, bare esophagus, severe reflux. It still remains about 5% of my practice for that reason. Just before we jump to the next thing, I think that that is really important point to kinda drill home to the trainees on that are listening to this podcast, but also, you know, just motility of the esophagus. That's another one. Because the sleeve can exacerbate underlying issues with peristalsis that can become very, very significant and can drive these other issues. And the only way to address that is to change the pressure change that is to convert them to a gastric bypass. That's an excellent point. And the other thing to [00:24:00] mentions proponents of the CD is going to the benefits in terms of long-term complications. There are fewer anastomotic leaks as there's less. Attention on the on the anastomosis. Fewer strictures, marginal ulcerations, a very much decreased risk of internal hernia, although still a possible risk of internal hernia. But you have to take a look at the potential for increased nutritional deficiencies, and you surely don't wanna hurt anybody. You truly want to make sure the patients are suitable for such a hypo absorptive procedure. What that means is to evaluate their willingness to comply, their likelihood to comply their support systems, and also the professional opinion of a bariatric psychologist. And just one more plug, because I think all bear to surgeons tend to be very much wear our public health advocacy hats. This is where really paying attention to social determinants of health is really important to [00:25:00] help our patients be their best version of themselves. Absolutely. Now, let's say a patient comes to you after weight regain after a sleeve gastrectomy, Dr. Dan, what would you pick between and why a gastric bypass versus Sadie? So I just wanna reiterate what Dr. Martin already said is that this is a shared decision. I present them with the best evidence that exists. Including the potential long-term complications of gastric bypass. The success of bariatric surgery, again, I'm gonna quote Matt, is measured in decades, not in months or years. So we're not looking at the 30 day morbidity, we're looking at the potential for long-term complications, and then once I present them with the likelihood of success based on the various operations in terms of. Excess weight loss that's expected, total weight loss expected, and potential complications. We tend to make that decision together when a patient is likely to not have the support and the abilities due [00:26:00] to certain social determinants. As Dr. Johnson Mann mentioned. Then Sadie may not be the better operation for them. You want to make sure you're hurting someone first, do no harm, right? So in that situation, a gastric bypass may be the appropriate procedure and. Patients with severe obesity who started out or BMIs in the seventies, eighties, or people with such severe diabetes that it has led to an organ damage, then the Sadie may be the better operation where you can truly have the most powerful impact up on that metabolic dysfunction. Yeah, and, and remember, not only do you have to think about what's best for the patient, think about what's best for me. Right. A Sadie is such a nicer option after a sleeve than going up there and digging that sleeve out and transecting it and trying to do a new anastomosis. So just, just emotionally converting it to a Sadie is a [00:27:00] much less stressing option and I think a more enjoyable procedure. This study, I think is a good first step comparing these two options. It is certainly not randomized controlled data. In fact, they couldn't even do a true meta-analysis because the outcomes were so drastically different. This is a pooled analysis, so we certainly don't have level one evidence to direct these decisions. Plus we certainly need longer term follow-up data to look at if there's any incidence of nutritional deficiency are different between these. Completely agree with that. The only level one randomized control study that. Compares sleeve to bypass to duodenal switch, not to Sadie, but to duo switches. The Rome study written by Jill Truman and Francesco Rubino came out about four years ago, and that's a great study where they randomized, I believe it was about 25 patients in each arm, and that does show a benefit for Al Switch compared to [00:28:00] the other two, but better, larger. Studies are necessary in order for us to make a, a really good judgment. Yeah, I mean, I think this paper just brings up the question, and I think as we've kind of elucidated from this conversation that honestly we just need more data. We need to really understand what are the best options for these patients after sleep gastrectomy. And it's not an uncommon problem. Right. And it's increasing every year. 'cause we're doing more sleeves and the percent that go on to either get a revision, need a revision, or it is so variable between studies. I mean, I've seen anywhere from 5% to 40% in these samples of sleeves are getting revised. And then you still have to drill down on, well, what's the reason? Is it reflux? Mm-hmm. Is it dysphagia? Is it, you know, weight regain like. The the options are many. Is it 'cause of [00:29:00] strictures? Because that definitely changes the pathway and I think, you know, this is an opportunity for a multicenter study. Guys, let's do it. Let's do it. I'm very down. All right. Let's recap the big takeaways just from these three papers from the Osberg trial. Patients who underwent a gastric bypass are more than twice as likely to have remission of their type two diabetes at that five year mark. Compared to those after a sleeve gastrectomy, and then from the bi band sleeve, trial banding is a much less preferred option for surgery. While bypass patients had greater excess weight loss and improved quality of life compared to sleeve gastrectomy patients, this was at three years. Then from the Theopolis group for patients after a failed sleeve gastrectomy, the Sadie and the ruin wide gastric bypass are both very suitable options, although I think we can all agree that a lot more research needs to be done in the future to truly delineate. Yeah, [00:30:00] and I think we have to remember the overarching theme here is that in general, bariatric surgery is highly effective. The exact operation does matter. Tailored to the right patient, but all of these operations sleeve bypass, Sadie lead to durable, significant improvements in weight loss that clearly outpaces dietary interventions and even the GLP one data and reduction in diabetes and other cardiovascular risk factors. I completely agree. I think at the end of the day when we're sitting in front of our patients and we're. Mulling over all the things that we know about what we do surgically. We just have to be able to match it, match the patient to the operation, but also ensure everything about the patient is ideal for that particular operation and that they're set up for success and that follow up is consistent and that we're keeping close tabs on them. Exactly. Crystal. You know, I think it's important to look at all these [00:31:00] operations and understand that they each are better than untreated obesity and even the, mm-hmm. You know, the gastric band, if you think of the folks that are putting the gastric bands together and selling the gastric bands, they only have one thing in mind, and that's to help our patient population. And if somebody's looking for an option where there is no. Stapling for whatever reason, whether a patient's not comfortable with it or whether there's some kind of condition that is not suitable for that. Well, there's the option. They provide that. So all of these operations, the gastric bypass, we've done a lot of them over the years, and yeah, we've seen some complications from them, but again, they've saved more lives and added more quality of life and life years than any trouble they've caused. So now with the Sadie procedure, that's something that. Has its own Achilles heel, potentially nutritional deficiencies. It's about finding the right balance where the patient can have the right risk to benefit ratio that fits [00:32:00] them. And with that, I'll say that, you know, obesity medicine are coming in and more frequently being used now, so we gotta find that right balance for everybody. And despite these great operations that we have, and despite these great medications that keep getting better. I still have not seen the headline that obesity rates are on the decline. Right? So despite all that, there's a lot of need for all of these modalities. So it's nice to be able to compare 'em all rather than leaving obesity untreated. And those are my final thoughts. I 100% co-sign that. Absolutely. And thank you all today. Thank you for the great discussion. And thank you to our listeners. One, two. Three. Dominate, dominate, dominate the day.