Original article
Abstract
Objective: This study aimed to compare midterm and long-term weight loss and resolution of comorbidity with laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve
gastrectomy (LSG).
Summary: LRYGB and LSG are the most common procedures performed in bariatric surgery.
However, their weight loss efcacy in the midterm and long-term has not been well compared.
Methods: A meta-analysis was performed by systematically identifying comparative studies conducted until the end of June 2016 that investigated weight loss outcome and resolution of comorbidities (type 2 diabetes mellitus, hypertension, hyperlipidemia, hypertriglyceridemia, and
obstructive sleep apnea) with LRYGB and LSG in the midterm (35 years) and long term (Z5
years). The primary endpoint was weight loss after LRYGB versus LSG. The secondary endpoint
was resolution of co-morbidities after these procedures.
Results: Fourteen studies comprising 5264 patients were eligible. Follow-up ranged from 36
months to 75.8 8.4 months. The pooled result for weight loss outcomes did not show any signicant difference in midterm weight loss (standardized mean difference -0.03; 95% condence
interval (CI), -0.38.33; P .88) but a signicant difference in the long-term weight loss outcome
favoring LRYGB (standardized mean difference .17; 95% CI, .05.28; P .005). The pooled
results demonstrated no signicant difference for resolution of type 2 diabetes mellitus, hypertension, hyperlipidemia, and hypertriglyceridemia.
Conclusion: Despite the insignicant difference between LRYGB and LSG in midterm weight
loss, LRYGB produced better weight loss in the long-term. There was no signicant difference
between the 2 procedures for co-morbidity resolution. (Surg Obes Relat Dis 2016;]:0000.) r 2016
American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Bariatric surgery; Laparoscopic Roux-en-Y gastric bypass; LRYGB; Laparoscopic sleeve gastrectomy; LSG;
Weight loss; Meta-analysis
http://dx.doi.org/10.1016/j.soard.2016.08.011
1550-7289/r 2016 American Society for Metabolic and Bariatric Surgery. All rights reserved.
S. Shoar et al. / Surgery for Obesity and Related Diseases ] (2016) 0000
Table 1
Inclusion/exclusion criteria for identied studies.
Inclusion criteria
Population
Exclusion criteria
resolution
Intervention
Outcome
Study design
None
Any
None
Follow-up
Follow-up o3years
Language
English language
Study sample
size
BMI body mass index; LRYGB laparoscopic Roux-en-Y gastric bypass; LSG laparoscopic sleeve gastrectomy; SD standard deviation.
Meta-analysis Comparing Long-term outcomes of LSG versus RYGB / Surgery for Obesity and Related Diseases ] (2016) 0000
Results
The PRISMA ow diagram for our database search and
study selection is shown in Fig. 1. Following identication
of a total of 1887 records by database search, title and
abstract of 1397 records were screened after removal of
duplicates. Of these, full text of 37 articles was retrieved, of
which 14 papers comprising 5264 patients were eligible for
inclusion in our meta-analysis [6,1426]. Characteristics of
included studies and their patient populations are presented
in Table 2. Publication time frame ranged from 2010 to
2016. Six studies were prospective cohorts [18,2024], 3
randomized controlled trials (RCTs) [6], 3 retrospective
ClinicalTrials.gov
PubMed
ISI
Scopus
Embase
Manual screening
n= 111
n= 1119
n= 231
n= 150
n= 271
n= 5
Studies identified
Duplicates removed
n= 1887
n= 485
Studies excluded
n= 1402
Full-texts article
screened
n= 37
Studies included in
meta-analysis
n= 1365
Studies excluded: n= 21
- No RYGB: n=1
- Including patients <18 yrs: n=1
- Not in English:n=8
- Unobtainable results: n=3
- Inadequate follow-up length: n = 4
- Review articles, editorials, or
commentaries: n= 6
n= 14
Fig. 1. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) ow diagram for literature search and study selection.
S. Shoar et al. / Surgery for Obesity and Related Diseases ] (2016) 0000
Patient characteristics
BMI body mass index; LRYGB laparoscopic Roux-en-Y gastric bypass; LSG laparoscopic sleeve gastrectomy; RCT randomized controlled trial.
47.4 (36.877.1)
47.4 4.2
37.5 6.1
45.8 6.0
35
31.8 3
41.1 4.9
38.5 4.2
51.5 7.2
51.6 6.7
37.9 4.6
49.8 7.2
44.9 3.4
51.6 15.9
49.2 (38.768.21)
46.8 3.6
37.5 6
47.2 5.8
42.5
32.3 2.4
42.1 4.7
39.3 3.8
49.1 6.1
47.4 6
38 3.4
44.8 4.6
45.8 3.7
47.4 8
49 (2467)
41.8 4.6
36 9.1
39.7 10.0
23
40.4 9.4
34.6 9.2
29.3 9.8
43.4 11.2
46.4 11.6
36.4 11.7
52.4 9.1
36 8.4
46.6 4.2
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Pekkarinen
Perrone
Lee
Dogan
Jammu
Yang
Leyba
Zhang
Alexandrou
Moize
Boza
Jimenez
Kehagias
Abbatini
(2016)
(2016)
(2015)
(2015)
(2015)
(2015)
(2014)
(2014)
(2014)
(2013)
(2012)
(2012)
(2011)
(2010)
[26]
[23]
[20]
[17]
[24]
[25]
[21]
[6]
[15]
[22]
[16]
[18]
[19]
[14]
Retrospective cohort
Prospective cohort
Prospective cohort
Retrospective cohort
Prospective cohort
RCT
Prospective cohort
RCT
Cross-sectional pilot
Prospective cohort
Case-control
Nonrandomized cohort
RCT
Retrospective cohort
163
142
519
245
295
32
75
32
55
294
786
98
30
16
94
162
519
245
339
32
42
32
40
61
811
55
30
20
47 (2463)
43.8 4.6
36.1 9.3
41.2 9.7
38
41.4 9.3
38 9.9
32.2 9.2
44.8 9.9
45.2 10.6
37 10.3
49.6 8.2
33.7 9.9
53 8.3
61/102
30/112
140/379
44/201
85/210
13/19
15/60
14/18
15/40
20/41
184/ 602
31/67
8/22
3/13
31/63
64/98
132/387
44/201
185/154
9/23
7/35
12/20
4/36
68/226
193/618
29/26
8/22
8/12
LSG
LRYGB
LSG
LSG
LRYGB
LSG
LRYGB
LRYGB
Table 2
Characteristics of included studies.
6.85 yr
75.8 8.4 mo
60 mo
3.1 1.2 yr
53.5 mo
36 mo
60 mo
60 mo
48 mo
60 mo
36 mo
35.4 13.5 mo
36 mo
36 mo
Maximum follow-up
Meta-analysis Comparing Long-term outcomes of LSG versus RYGB / Surgery for Obesity and Related Diseases ] (2016) 0000
HTN resolution
HTG resolution
HLP resolution
Five studies (798 patients) reported resolution rates for
HLP after 3 to 5 years [14,16,19,24,25] and 2 studies (67
patients) reported HLP resolution rates after 5 years [6,23].
The pooled results yielded no signicant difference in the
odds ratio of HLP resolution between LRYGB and LSG in
the midterm (OR = 1.21; 95% CI, 0.901.61; P = .2) and
LRYGB
Study or Subgroup
Mean
Abbatini2010
29.7
Alexandrou2014
Boza2012
LSG
SD Total Weight
3.4
7.2
36.3
60.8 18.8
55
97.2 24.3
786
Dogan2015
69.7 25.5
Jimenez2012
Kehagias2011
Yang2015
SD Total Mean
16
Sensitivity analysis
20
10.4%
57.4 15.5
40
14.4%
86.4 26.4
811
17.7%
245
69.7 25.1
245
17.2%
65.4 20.1
98
61.2 21.5
55
15.5%
14.5 0.55
30
15.3 0.75
30
12.4%
92.3 10.5
27
81.9
28
12.4%
1229 100.0%
14
1257
Control
37
43
29
32
22.2%
25
33
13
23
17.8%
Jimenez2012
78
98
38
55
47.6%
3.8%
28
30
27
31
8.5%
146 100.0%
50
100
209
172
111
Odds Ratio
Jammu-2015
Yang2015
Odds Ratio
Boza2012
Kehagias2011
-50
LRYGB LSG
Experimental
Events
-100
Study or Subgroup
0.01
0.1
10
100
LRYGB LSG
Fig. 2. Comparison of pooled midterm outcomes between laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy patients (from above to
below: weight loss outcome, resolution of type 2 diabetes mellitus, hyperlipidemia, hypertension, and hyper triglycerides).
S. Shoar et al. / Surgery for Obesity and Related Diseases ] (2016) 0000
Experimental
Study or Subgroup
Abbatini2010
Events
Control
Odds Ratio
1.0%
141
320
142
340
92.3%
Jammu-2015
37
50
11
21
4.8%
Kehagias2011
10
0.8%
17
18
18
21
1.1%
397 100.0%
Boza2012
Yang2015
401
206
0.01
Abbatini2010
Events
Control
Odds Ratio
12
3.6%
211
110
191
83.5%
Jammu-2015
34
47
14
30
8.2%
Kehagias2011
2.3%
Yang2015
12
10
2.4%
247 100.0%
Total events
286
177
Experimental
Abbatini2010
Boza2012
Total events
Control
Odds Ratio
10
100
2.0%
211
109
190
98.0%
196 100.0%
213
10
100
Odds Ratio
M-H, Fixed, 95% CI
124
0.1
LRYGB LSG
123
100
0.01
Events
10
140
Study or Subgroup
Odds Ratio
0.1
LRYGB LSG
123
Boza2012
181
Study or Subgroup
Odds Ratio
113
0.01
0.1
1
LRYGB LSG
Fig. 2. Continued.
requirements. Although 1 midterm study concluded superiority of the gastric bypass over sleeve gastrectomy in
weight reduction and co-morbidity resolution [24] and 2
long-term studies demonstrated higher weight loss outcome
for LRYGB compared with LSG [6,26], the remaining 11
studies found no signicant difference in the efcacy of the
2 procedures in the midterm or long-term [1423,25]. Metaanalyses were performed for all the mentioned outcomes
except for OSA. A meta-analysis by Li et al. reported a
better resolution rate for obesity-related co-morbidities with
LRYGB compared to LSG, but also a higher complication
and reoperation rate [27]. However, the main limitation of
this meta-analysis is its inclusion of studies with short-term
follow-up and combination of their data with midterm
studies. Moreover, the meta-analysis of Li et al. disregarded
the average follow-up of their included studies, as the
midterm studies included in their analysis have followed
their patients for an average of o3 years.
*
*
*
*
*
*
*
7
6
6
6
5
6
6
6
6
4
6
6
6
3
*
*
*
F/u length
**
**
**
**
**
**
**
**
F/u follow-up.
A maximum of 2 points can be devoted to this criterion.
*
Consistent with criteria (low risk of bias).
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
Selection
Representativeness
Study
Table 3
Methodological quality assessment of included studies.
Ascertainment
Comparability
Outcome assessment
F/u adequacy
Total score
Meta-analysis Comparing Long-term outcomes of LSG versus RYGB / Surgery for Obesity and Related Diseases ] (2016) 0000
Table 4
Outcomes reported by studies at end of follow-up.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
%Weight/BMI loss
T2D resolution
LRYGB
LRYGB
LSG
LSG
HTN resolution
HLP resolution
HTG
LRYGB
LRYGB
LRYGB
LSG
LSG
OSA resolution
LSG
LRYGB
LSG
N/A
N/A
N/A
N/A
N/A
N/A
4/6
N/A
69.7 25.5
69.7 25.1
72.3
53.6
92.3 10.5
81.9 14
60.8 18.8
57.4 15.5
65.4 20.1
61.2 21.5
97.2 24.3
86.4 26.4
14.5 0.55
15.3 0.75
29.7 3.4
36.3 7.2
-.3 (-.38.33)
P .88; I2 91%
N/A
N/A
25/33
13/23
28/30
27/31
N/A
N/A
78/98
38/55
37/43
29/32
4/5
4/5
N/A
N/A
1.62 (.952.75)
P .08; I2 0%
3-5 years
N/A
N/A
34/47
14/30
9/12
5/10
N/A
N/A
N/A
N/A
123/211
110/191
3/5
3/4
8/11
8/12
1.21 (.901.61)
P .2; I2 26%
N/A
N/A
37/50
11/21
17/18
18/21
N/A
N/A
N/A
N/A
141/320
142/340
9/10
6/8
2/3
4/7
1.24 (.871.75)
P .2; I2 0%
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
123/211
109/190
N/A
N/A
1/2
4/6
1.03 (.691.52)
P .89; I2 0%
N/A
N/A
N/A
N/A
N/A
N/A
2/3
N/A
57.5 22.61
45.79 32.3
81.6 21.4
78.8 23.5
28.5 9
28.3 8.9
69.8 18
67.3 21.75
76.2 21.7
63.2 24.5
68.3 75.6
67 72.3
.17 (.05.28)
P .005; I2 48%
N/A
N/A
N/A
N/A
N/A
N/A
2/3
1/1
7/8
8/9
N/A
N/A
.73 (.077.39)
P .79; I2 0%
Z 5 years
N/A
N/A
N/A
N/A
N/A
N/A
4/6
1/2
4/6
3/5
N/A
N/A
1.49 (.336.69)
P .6; I2 0%
N/A
N/A
23/26
13/15
N/A
N/A
N/A
N/A
12/13
11/13
N/A
N/A
1.54 (.2210.99)
P .67; I2 0%
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
5/5
N/A
N/A
N/A
N/A
N/A
N/A
N/A
NA
NA
N/A
N/A
N/A
N/A
7/7
N/A
NA
BMI body mass index; HLP hyperlipidemia; HTG hypertriglyceridemia; HTN hypertension; LRYGB laparoscopic Roux-en-Y gastric bypass; LSG laparoscopic sleeve gastrectomy; N/A
not available; OSA obstructive sleep apnea; T2D type 2 diabetes mellitus.
*
Pooled outcome is estimated as standardized mean difference for continuous variables and as odds ratio for categorical variables and expressed with the corresponding 95% condence interval; I2
Heterogeneity.
S. Shoar et al. / Surgery for Obesity and Related Diseases ] (2016) 0000
Study
Meta-analysis Comparing Long-term outcomes of LSG versus RYGB / Surgery for Obesity and Related Diseases ] (2016) 0000
LRYGB
Study or Subgroup
Mean
LSG
SD Total Mean
Lee-2015
28.5
218
Leyba2014
69.8
18
47
Moize2013
68.3
75.6
294
Pekkarinen/2016
SD Total Weight
8.9
116
26.0%
67.3 21.75
28.3
24
5.4%
67
72.3
61
17.3%
57.5 22.61
163 45.79
32.3
94
20.0%
Perrone2016
81.6
21.4
142
78.8
23.5
162
25.9%
Zhang2014
76.2
21.7
32
63.2
24.5
32
5.3%
489 100.0%
896
LSG
44.3%
Zhang2014
55.7%
10 100.0%
11
9
LRYGB
LSG
Odds Ratio
13
15
69.2%
Zhang2014
12
13
11
13
30.8%
28 100.0%
39
100
0.01
LSG
Odds Ratio
10
100
31.4%
68.6%
7 100.0%
12
10
100
Odds Ratio
Zhang2014
0.1
LRYGB LSG
Leyba2014
Total events
10
24
35
Odds Ratio
23
Study or Subgroup
0.1
LRYGB LSG
Perrone2016
Total events
100
0.01
50
Study or Subgroup
Odds Ratio
Leyba2014
Total events
-50
Odds Ratio
LRYGB LSG
LRYGB
Study or Subgroup
-100
0.01
0.1
1
LRYGB LSG
Fig. 3. Comparison of pooled long-term outcomes between laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy patients (from above
to below: weight loss outcome, resolution of type 2 diabetes mellitus, hyperlipidemia, hypertension).
10
S. Shoar et al. / Surgery for Obesity and Related Diseases ] (2016) 0000
Fig. 4. Funnel plot of all studies reporting on weight loss outcome after
laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve
gastrectomy.
Meta-analysis Comparing Long-term outcomes of LSG versus RYGB / Surgery for Obesity and Related Diseases ] (2016) 0000
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