Sleeve gastrectomy, gastric bypass deliver low perioperative risk

Two weight-loss surgical procedures, namely laparoscopic sleeve gastrectomy (SG) and laparoscopic Roux-en-Y gastric bypass (RYGB), are both safe, with similarly low risk of complications during and immediately after the procedure, according to a study.

Data from the registry-based Bypass Equipoise Sleeve Trial (BEST) conducted in Scandinavia showed that the 30-day incidence of perioperative complications (any adverse event) was 4.6 percent in the SG arm and 6.3 percent in the RYGB arm. The difference was not significant (odds ratio [OR], 0.71, 95 percent confidence interval [CI], 0.47–1.08; p=0.11). [JAMA Netw Open 2024;7:e2353141]

Likewise, there was no significant difference in the incidence of serious adverse events (grade IIIb complications per Clavien-Dindo classification), being 1.7 percent in the SG arm and 2.7 percent in the RYGB arm (OR, 0.63, 95 percent CI, 0.33–1.22; p=0.19). The only notable distinction was small bowel obstruction, which occurred exclusively in the RYGB arm (0 percent vs 7 percent; p=0.01).

Such distinction, according to the investigators, may be related to the Lönroth surgical technique for RYGB, “in which closure of mesenteric defects have been demonstrated to be associated with an increased incidence of small bowel obstruction during the first year after surgery, although the long-term risk of [this complication] was markedly reduced.” [Surg Obes Relat Dis 2022;18:1151-1159; Lancet 2016;387:1397-1404]

Meanwhile, the 30-day rates of Clavien-Dindo grade IIIb complications in the SG and RYGB arms align with the proposed benchmark of <5.5 percent over <90 days for low-risk bariatric surgery, the investigators continued. [Ann Surg 2019;270:859-867]

“This finding is noteworthy considering that BEST was performed in a pragmatic multicentre setting, not restricted to low-risk patients or high-volume centres. However, similar complication rates have been reported previously,” they said. [Obes Surg 2018;28:3916-3922; https://www.ucr.uu.se/soreg/arsrapporter/arsrapporter]

BEST

In BEST, 1,735 adults (mean age 42.9 years, 73.9 percent women, mean body mass index [BMI] 40.8 kg/m²) from 23 hospitals across Sweden and Norway were randomly assigned to undergo either SG (n=878) or RYGB (n=857).

All surgical procedures were performed laparoscopically, except for a single case where a patient receiving SG had adhesions and the procedure was initially aborted. Open SG surgery was performed 4 months later. The mean operating time was 47.3 minutes in the SG arm and 67.7 minutes in the RYGB arm (p<0.001).

The median postoperative hospital stay after either SG or RYGB was 1 day, and all patients received antibiotic prophylaxis. Thrombosis prophylaxis with low-molecular-weight heparin were also administered in 1,711 patients.

None of the patients died in the SG and RYGB arms at the 30- and 90-day follow-up. Furthermore, the risk of complications within 30 days remained consistent across subgroups defined by sex, age, body mass index (BMI), diabetes status, or smoking history.

Between postoperative days 0 and 30, 3.1 percent of patients in the SG arm and 4.0 percent of those in the RYGB arm were readmitted (p=0.33) primarily for pain or dehydration. The median length of hospital stay during the second admission was 3 days in the SG arm and 2 days in the RYGB arm.

Navigating options

Compared with SG, RGYB has a higher degree of surgical complexity, as reflected by the numerically longer operating time. The relatively low complication rate with RGYB observed in BEST reflects the extensive experience with laparoscopic RYGB, with it being the standard procedure in Scandinavia for decades, according to the investigators.

“BEST indicate[s] that a surgical community with wide experience performing RYGB can change to performing SG with low complication rates. However, whether the opposite transition can be safely adopted remains to be demonstrated,” they added.

Taken together, the data demonstrate that both SG and RYGB can be performed with a low perioperative risk, the investigators said. “[T]herefore, among adult patients with obesity undergoing primary bariatric surgery, the perioperative risk should not be a main deciding factor in the choice of method.”