Weight Loss Higher After Roux-en-Y Surgery vs. Gastric Banding

View on the News

Still a Few Caveats

"I personally agree" with Romy et al. that Roux-en-Y gastric bypass is the better procedure, but "before we make from this conclusion a paradigm, a few caveats remain," said Dr. Jacques Himpens.

A case-control study such as this one may be biased. Even though a prospective randomized trial comparing the two surgeries isn’t feasible, a prospective rather than retrospective comparison of matched patients would yield better evidence, as would a multicenter rather than a single-center study.

In addition, a growing number of Roux-en-Y patients are showing neuroglycopenia and diabetes recurrence several years after surgery, which is concerning.

Dr. Himpens is at the European School of Laparoscopy at Saint Pierre University Hospital, Brussels. He reported being a consultant for Ethicon Endo-Surgery, Covidien, and Gore. These remarks were taken from his invited critique that accompanied Dr. Romy’s article (Arch. Surg. 2012 Jan. 16 [doi:10.1001/archsurg.2011.1855]).



Roux-en-Y gastric bypass surgery resulted in greater, more rapid, and more sustained weight loss compared with gastric banding, but also a higher number of complications in a matched-pair study published online Jan. 16 in Archives of Surgery.

The weight loss advantage achieved with Roux-en-Y leads to better correction of the comorbidities that accompany obesity, such as adverse lipid profiles and high fasting glucose levels, said Dr. Sébastein Romy of the department of visceral surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland, and his associates.

Although there are more early complications with the Roux-en-Y procedure, they are outweighed by "the much higher long-term major morbidity seen after gastric bypass, leading to a large number of major reoperations and their risks," the investigators noted.

The sharp rise in bariatric surgeries performed in recent years in the United States has occurred predominantly in gastric banding procedures. "This is probably because gastric banding is perceived both by doctors and patients as a simple, safe, and reversible operation but also because of a huge industry-driven marketing campaign," they said.

Which surgery is "better" has been contested. To date, among the 17 published studies comparing the two procedures, many have had important methodologic flaws such as small numbers of patients and very limited follow-up.

Dr. Romy and his colleagues performed a matched-pair analysis of patients who underwent the two procedures in 1998-2005. The study subjects, who had failed to lose weight with more conservative approaches, all had a body mass index of 40 or more, or a BMI of 35 plus at least one severe comorbidity. A total of 221 patients who underwent Roux-en-Y gastric bypass were matched for age, sex, and BMI with 221 who underwent gastric banding. Follow-up rates after 6 years were approximately 92% in both groups. The same team performed the operations at the same two hospitals.

Maximal weight loss was achieved at a mean of 18 months after Roux-en-Y gastric bypass, compared with 36 months after gastric banding. The percentage of excess weight lost was significantly higher after Roux-en-Y (78.5%) than after gastric banding (64.8%), and the mean nadir in BMI was significantly lower (26.7 vs. 29.4, respectively). After 6 years, only 5 patients (2.4%) in the Roux-en-Y group had a BMI greater than 40, compared with 21 patients (13.8%) in the gastric banding group.

As a result, significantly more patients who had Roux-en-Y surgery were rated as having excellent or acceptable results at all time points during follow-up, Dr. Romy and his associates said (Arch. Surg. 2012 Jan. 16 [doi:10.1001/archsurg.2011.1708]).

Treatment failures were defined as a weight loss of less than 25% of baseline weight or the need to reverse the surgery or convert to a different bariatric procedure. At the 3-year mark, there were no treatment failures among Roux-en-Y patients, compared with 39 treatment failures (18.2%) among gastric banding patients. After 6 years, failure rates were 2.5% and 38.9%, respectively, in Roux-en-Y and gastric banding patients.

Improvement in lipid profiles was significantly greater after Roux-en-Y than after gastric banding. Total cholesterol, LDL cholesterol, and triglyceride levels decreased after Roux-en-Y but not after gastric banding. Fasting glucose levels also were lower after Roux-en-Y (89.55 mg/dL vs. 92.79 mg/dL).

Quality of life improved in both groups, but the improvement was significantly faster and persisted for a longer time after Roux-en-Y surgery. In particular, Roux-en-Y patients had much better food tolerance, with no worsening after surgery, whereas food tolerance tended to worsen over time after gastric banding.

There were significantly more early complications after Roux-en-Y (17.2%) than after gastric banding (5.4%), which is not surprising given that Roux-en-Y is a more complex operation and requires a longer operative time and longer hospitalization. However, most of these early complications required only conservative treatment, and there was no significant difference between the two groups in early major complications, the researchers said.

In contrast, gastric banding was associated with significantly more long-term complications than was Roux-en-Y (41.6% vs. 19%) and required more than twice as many reoperations (26.7% vs. 12.7%).

"After gastric banding, functional problems like esophageal dilatation (10.4%), impairing reflux requiring (or resistant to) daily high-dose proton-pump inhibitor therapy (6.8%), or severe food intolerance (6.3%) accounted for the majority of long-term complications, together with band erosions (7.7%). Overall, band removal was necessary in 47 patients (21.3%)," they said.

"Long-term complications after Roux-en-Y gastric bypass are essentially limited to anastomotic strictures and bowel obstructions and symptomatic internal hernia." Most strictures were not considered major complications, requiring only endoscopic dilatation. Although bowel obstruction is potentially life threatening, in most cases it doesn’t jeopardize the bypass or require reversal, Dr. Romy and his colleagues said.


Recommended Reading

Diabetes: Calorie Restriction Yields Lasting Cardiac Benefit
MDedge Cardiology