RYGB in severe obesity leads to weight loss, hypertension remission

In patients with severe obesity, undergoing either laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (RYGB) resulted in weight loss, according to long-term follow-up of the SLEEVEPASS* trial. However, remission of hypertension was more likely in patients who underwent RYGB compared with LSG.

The multicentre, multi-surgeon, open-label SLEEVEPASS trial was conducted in Finland between April 2008 and June 2010 and involved 240 patients aged 18–60 years (mean age 48.4 years, 69.6 percent female) with severe obesity** (mean BMI 45.9 kg/m²) who had failed prior sufficient conservative treatment. They were randomized 1:1 to undergo either LSG or RYGB. Two patients did not undergo surgery and 10 patients died of unrelated causes over the 10-year follow-up period. Eighty-five percent of the remaining patients completed follow-up and 77 percent underwent gastroscopy.

At baseline, 42 percent of patients had type 2 diabetes (T2D), 35 percent had dyslipidaemia, 27.1 percent had obstructive sleep apnoea (OSA), and 70.8 percent were receiving medication for hypertension.

At 10 years, the mean estimated percentage excess weight loss was 8.4 percent greater with RYGB than LSG (mean 51.9 percent vs 43.5 percent). Median percentage excess weight loss was 43.5 and 50.7 percent following LSG and RYGB, respectively. [JAMA Surg 2022;doi:10.1001/jamasurg.2022.2229]

“However, based on the study design and the prespecified equivalence margins, the superiority of RYGB could not be shown,” the authors noted.

Percentage of total weight loss <5 percent at 10 years was documented in 5.1 and 3.2 percent of patients who underwent LSG and RYGB, respectively (p=0.72). Median weight regain (percentage of maximum weight lost) was also comparable between the two groups (35.0 percent vs 24.7 percent; p=0.16).

At 10 years, the rate of T2D remission did not significantly differ between patients who underwent LSG and RYGB (26 percent vs 33 percent; p=0.63), nor did mean fasting plasma glucose levels (6.9 vs 6.8 mmol/L; p=0.42) or HbA_1c levels (6.9 percent vs 7.0 percent; p=0.64). Remission rates of dyslipidaemia (19 percent vs 35 percent; p=0.23) or OSA (discontinued use of continuous positive airway pressure device; 16 percent vs 31 percent; p=0.30) were also not significantly different between groups.

However, more patients who underwent RYGB than LSG had discontinued their hypertension medication at 10 years (24 percent vs 8 percent; p=0.04), while 32 and 24 percent, respectively, had reduced their medications, and 60 and 53 percent, respectively, had no change in hypertension medications.

Patients who underwent LSG were more likely to experience esophagitis after surgery than those who underwent RYGB (31 percent vs 7 percent; p<0.001). Those who underwent LSG also had a higher intake of proton pump inhibitors (PPIs; 64 percent vs 36 percent) and a higher gastroesophageal reflux disease (GERD)-related health-related quality of life (QoL) score (10.5 vs 0; p<0.001 for both) at 10 years compared with patients who underwent RYGB. However, rates of post-surgery Barrett’s oesophagus did not significantly differ between groups (4 percent each; p=0.29).

QoL did not differ between groups at 10 years (p=0.91) but was significantly better than that at baseline (mean estimate of total QoL, 0.49 vs 0.11; p=0.001). Minor complication rate at 10 years was not significantly different between patients who underwent LSG and RYGB (34.7 percent vs 24.4 percent; p=0.08), nor was re-operation rate (15.7 percent vs 18.5 percent; p=0.57).

Take-home message

“[B]oth LSG and RYGB resulted in good and sustainable weight loss [at 10 years],” said the authors. “[While] there was no statistically significant difference [between groups] in [remission of] T2D, dyslipidaemia, and OSA … RYGB resulted in superior remission of hypertension,” they added.

“[T]he significantly higher rate of endoscopic esophagitis, GERD symptoms, and PPI use after LSG compared with RYGB underline the importance of systematic pre-operative assessment of GERD and the associated endoscopic findings. For patients with clinical GERD, LSG may not be the optimal procedure of choice,” the authors said.