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Roux-en-Y gastric bypass or sleeve gastrectomy for type 2 diabetes: expanding role of individualized metabolic surgery score

      As recently summarized [
      • Aminian A.
      Bariatric procedure selection in patients with type 2 diabetes: choice between Roux-en-Y gastric bypass or sleeve gastrectomy.
      ], there are only 4 randomized clinical trials (RCTs) in patients with type 2 diabetes (T2D) comparing Roux-en-Y gastric bypass (RYGB) with sleeve gastrectomy (SG) and providing level 1 evidence up to 5 years after randomization [
      • Schauer P.R.
      • Bhatt D.L.
      • Kirwan J.P.
      • et al.
      for the STAMPEDE Investigators
      Bariatric surgery versus intensive medical therapy for diabetes - 5-year outcomes.
      ,
      • Salminen P.
      • Helmiö M.
      • Ovaska J.
      • et al.
      Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y gastric bypass on weight loss at 5 years among patients with morbid obesity: the SLEEVEPASS randomized clinical trial.
      ,
      • Peterli R.
      • Wölnerhanssen B.K.
      • Peters T.
      • et al.
      Effect of laparoscopic sleeve gastrectomy vs laparoscopic roux-en-y gastric bypass on weight loss in patients with morbid obesity: the SM-BOSS randomized clinical trial.
      ,
      • Ruiz-Tovar J.
      • Carbajo M.A.
      • Jimenez J.M.
      • et al.
      Long-term follow-up after sleeve gastrectomy versus Roux-en-Y gastric bypass versus one-anastomosis gastric bypass: a prospective randomized comparative study of weight loss and remission of comorbidities.
      ]. None of the individual studies were primarily designed and adequately powered to compare the effects of RYGB with SG on T2D. However, combined analysis of these RCTs (i.e., meta-analysis) to increase the sample size and statistical power (RYGB, n = 176 versus SG, n = 175) would indicate either there is no significant long-term difference between RYGB and SG in improving T2D, or in case of a true difference (and we still do not have enough statistical power to reveal the difference), that difference would be <15% favoring RYGB [
      • Aminian A.
      Bariatric procedure selection in patients with type 2 diabetes: choice between Roux-en-Y gastric bypass or sleeve gastrectomy.
      ].
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      References

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        Bariatric procedure selection in patients with type 2 diabetes: choice between Roux-en-Y gastric bypass or sleeve gastrectomy.
        Surg Obes Relat Dis. 2020; 16: 332-339
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        N Engl J Med. 2017; 376: 641-651
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        JAMA. 2018; 319: 241-254
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      Linked Article

      • Selecting surgical procedures for medically uncontrolled type 2 diabetes
        Surgery for Obesity and Related DiseasesVol. 16Issue 7
        • Preview
          Guiding patients with type 2 diabetes (T2D) toward the most appropriate bariatric and metabolic procedure is crucial for improving outcomes. Aminian [1] published an interesting review based on high-quality scientific data. However, some important issues must be raised. Among the 4 randomized control trials (RCTs) that back up his review, 2 were not powered to detect differences related to T2D outcomes, as weight loss was their primary outcome and STAMPEDE was not powered to detect differences among Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG), although indirectly shows that RYGB has better cardiovascular and glycemic outcomes than SG.
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