Bariatric surgery is currently considered the most effective form of treatment in patients with grade III obesity (BMI greater than 40 kg/m²) and in patients with grade II obesity (BMI greater than 35 kg/m²) who have associated comorbidities. Currently, the indication for surgery resides in these situations, after proven failure in clinical treatment, with specialized follow-up by an endocrinologist for one year. There are several studies proving the benefits in controlling and even remitting diabetes, as well as reducing all-cause mortality, as seen in the SOS study, the most classic on the subject.
In the literature, however, there is a paucity of long-term data comparing different surgical techniques. Studies such as STAMPEDE have demonstrated a sustained benefit in diabetes (DM) control at five years after surgery compared to non-operated controls maintained on clinical treatment. Based on the scarcity of studies and with the objective of evaluating outcomes comparing the most commonly used techniques, it was published in the journal JAMA the SLEEVEPASS, a follow up ten-year study based on a randomized clinical trial (RCT) evaluating the effect of sleeve compared to gastric bypass on weight loss and comorbidities.
The study involved 240 patients between 18 and 60 years (mean age 48.4 years), with a mean BMI of 44.6 kg/m², 69.6% of whom were women, randomized in Finland. O trial The initial study was conducted between 2008 and 2010, with follow-up until January 2021. The objectives of the study were to assess the percentage of excess weight loss and to assess the impact of weight loss on comorbidities, as well as the emergence of reflux and consequences in ten years. . Of these, 228 participants completed the follow-up (85%).
One of the objectives of the study was to assess the percentage of excess weight loss. This is one of the measures commonly used in studies to define the success or failure of a bariatric surgery procedure, generally aiming at a 50% loss of excess weight. Excess weight is defined as weight in excess of that calculated for a BMI of 25 kg/m² (Ex: if a patient is 1.70 m and weighs 122.25 kg, their weight for a BMI of 25 would be 72.25 kg Therefore, your excess weight would be 50 kg (122.25 – 72.25). If the patient loses 25 kg, he will have lost 50% of the excess weight).
After ten years, study patients undergoing sleeve achieved an excess weight loss of 43.5% and 50.7% after the bypass, with an advantage for the latter – difference of 8.4% (3.1 – 13.6; 95% CI). Quality of life improved in both groups, with no difference between them. As for comorbidities:
- Diabetes remission: 26% on Sleeve vs. 33% in bypass (no difference between groups; p = 0.063)
*It is worth noting that both groups presented a considerable result, comparable to STAMPEDE, where the remission of diabetes after five years of surgery reached 23% in the sleeve and 29% in the Bypass – despite being a different population, this data may suggest that there is a trend towards sustained remission of diabetes in some patients.
- Hypertension remission (SAH): higher in the bypass group – 24% vs 8% (p = 0.04);
- Dyslipidemia remission (DLP): 35% in bypass and 19% in sleeve, with no statistical difference (p = 0.23);
- Sleep Apnea Remission (OSAS): 31% on bypass and 16% (p = 0.30) on sleeve.
In addition to the greater benefit in SAH and the difference in excess weight loss in the bypass group, there was also a lower incidence of esophagitis compared to the Sleeve group (31% in the bypass group vs 7% in the sleeve group; P < 0.001), but no difference in the prevalence of Barrett's esophagus (4% in both groups).
Bariatric surgery: Long-term effects of sleeve and bypass on diabetes remission
Results and considerations
As mentioned, there are few comparative data between the long-term techniques. This study, despite including only a Finnish population, shows that despite the benefits being a little more evident in the bypass, both techniques provided benefits in weight loss, impact on diabetes remission and improvement of control, remission of hypertension and reached a percentage of adequate excess weight loss. The decision on the surgical technique to be used must be individualized according to the patient’s characteristics (eg, a sleeve may be a good choice in patients with a lower BMI and therefore, need for less weight loss), as well as the technique with greater expertise on the part of the surgical team (bypass is the most used technique in Brazil, for example).
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