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<a href=Surgery for Obesity and Related Diseases ] (2016) 00 00 Original article Long-term and midterm outcomes of laparoscopic sleeve gastrectomy versus Roux-en-Y gastric bypass: a systematic review and meta-analysis of comparative studies Saeed Shoar, M.D. , Alan A. Saber, M.D., F.A.C.S. Department of Metabolic and Bariatric Surgery, The Brooklyn Hospital Center, Icahn School of Medicine at Mount Sinai, Brooklyn, NY Received July 14, 2016; accepted August 8, 2016 Abstract Objective: This study aimed to compare midterm and long-term weight loss and resolution of co- morbidity 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 ef fi cacy in the midterm and long-term has not been well compared. Methods: A meta-analysis was performed by systematically identifying comparative studies con- ducted until the end of June 2016 that investigated weight loss outcome and resolution of co- morbidities (type 2 diabetes mellitus, hypertension, hyperlipidemia, hypertriglyceridemia, and obstructive sleep apnea) with LRYGB and LSG in the midterm (3 – 5 years) and long term ( Z 5 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 sig- ni fi cant difference in midterm weight loss (standardized mean difference ¼ -0.03; 95% con fi dence interval (CI), -0.38 – .33; P ¼ .88) but a signi fi cant difference in the long-term weight loss outcome favoring LRYGB (standardized mean difference ¼ .17; 95% CI, .05 – .28; P ¼ .005). The pooled results demonstrated no signi fi cant difference for resolution of type 2 diabetes mellitus, hyper- tension, hyperlipidemia, and hypertriglyceridemia. Conclusion: Despite the insigni fi cant difference between LRYGB and LSG in midterm weight loss, LRYGB produced better weight loss in the long-term. There was no signi fi cant difference between the 2 procedures for co-morbidity resolution. (Surg Obes Relat Dis 2016; ] :00 – 00.) 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 Bariatric surgery has been established as the stand-alone treatment for morbid obesity [1] . Currently, it is the only therapeutic option that results in substantial and durable weight loss [1 – 3] . Laparoscopic Roux-en-Y gastric bypass Correspondence: Alan A. Saber, M.D., F.A.C.S., Weight Loss Center, The Brooklyn Hospital, 121 DeKalb Ave, Brooklyn, NY 11201. E-mail: saber6231@gmail.com http://dx.doi.org/10.1016/j.soard.2016.08.011 (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are the 2 most popular bariatric procedures performed in the United States [1 , 4 , 5] . However, their long-term effective- ness for weight loss and co-morbidity resolution has not been suf fi ciently compared [6] . Documentation of long-term weight loss is a hassle in bariatric surgery, since a substantial proportion of patients are lost to follow-up several years after enrollment into the 1550-7289/ r 2016 American Society for Metabolic and Bariatric Surgery. All rights reserved. " id="pdf-obj-0-4" src="pdf-obj-0-4.jpg">
<a href=Surgery for Obesity and Related Diseases ] (2016) 00 00 Original article Long-term and midterm outcomes of laparoscopic sleeve gastrectomy versus Roux-en-Y gastric bypass: a systematic review and meta-analysis of comparative studies Saeed Shoar, M.D. , Alan A. Saber, M.D., F.A.C.S. Department of Metabolic and Bariatric Surgery, The Brooklyn Hospital Center, Icahn School of Medicine at Mount Sinai, Brooklyn, NY Received July 14, 2016; accepted August 8, 2016 Abstract Objective: This study aimed to compare midterm and long-term weight loss and resolution of co- morbidity 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 ef fi cacy in the midterm and long-term has not been well compared. Methods: A meta-analysis was performed by systematically identifying comparative studies con- ducted until the end of June 2016 that investigated weight loss outcome and resolution of co- morbidities (type 2 diabetes mellitus, hypertension, hyperlipidemia, hypertriglyceridemia, and obstructive sleep apnea) with LRYGB and LSG in the midterm (3 – 5 years) and long term ( Z 5 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 sig- ni fi cant difference in midterm weight loss (standardized mean difference ¼ -0.03; 95% con fi dence interval (CI), -0.38 – .33; P ¼ .88) but a signi fi cant difference in the long-term weight loss outcome favoring LRYGB (standardized mean difference ¼ .17; 95% CI, .05 – .28; P ¼ .005). The pooled results demonstrated no signi fi cant difference for resolution of type 2 diabetes mellitus, hyper- tension, hyperlipidemia, and hypertriglyceridemia. Conclusion: Despite the insigni fi cant difference between LRYGB and LSG in midterm weight loss, LRYGB produced better weight loss in the long-term. There was no signi fi cant difference between the 2 procedures for co-morbidity resolution. (Surg Obes Relat Dis 2016; ] :00 – 00.) 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 Bariatric surgery has been established as the stand-alone treatment for morbid obesity [1] . Currently, it is the only therapeutic option that results in substantial and durable weight loss [1 – 3] . Laparoscopic Roux-en-Y gastric bypass Correspondence: Alan A. Saber, M.D., F.A.C.S., Weight Loss Center, The Brooklyn Hospital, 121 DeKalb Ave, Brooklyn, NY 11201. E-mail: saber6231@gmail.com http://dx.doi.org/10.1016/j.soard.2016.08.011 (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are the 2 most popular bariatric procedures performed in the United States [1 , 4 , 5] . However, their long-term effective- ness for weight loss and co-morbidity resolution has not been suf fi ciently compared [6] . Documentation of long-term weight loss is a hassle in bariatric surgery, since a substantial proportion of patients are lost to follow-up several years after enrollment into the 1550-7289/ r 2016 American Society for Metabolic and Bariatric Surgery. All rights reserved. " id="pdf-obj-0-6" src="pdf-obj-0-6.jpg">

Original article

<a href=Surgery for Obesity and Related Diseases ] (2016) 00 00 Original article Long-term and midterm outcomes of laparoscopic sleeve gastrectomy versus Roux-en-Y gastric bypass: a systematic review and meta-analysis of comparative studies Saeed Shoar, M.D. , Alan A. Saber, M.D., F.A.C.S. Department of Metabolic and Bariatric Surgery, The Brooklyn Hospital Center, Icahn School of Medicine at Mount Sinai, Brooklyn, NY Received July 14, 2016; accepted August 8, 2016 Abstract Objective: This study aimed to compare midterm and long-term weight loss and resolution of co- morbidity 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 ef fi cacy in the midterm and long-term has not been well compared. Methods: A meta-analysis was performed by systematically identifying comparative studies con- ducted until the end of June 2016 that investigated weight loss outcome and resolution of co- morbidities (type 2 diabetes mellitus, hypertension, hyperlipidemia, hypertriglyceridemia, and obstructive sleep apnea) with LRYGB and LSG in the midterm (3 – 5 years) and long term ( Z 5 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 sig- ni fi cant difference in midterm weight loss (standardized mean difference ¼ -0.03; 95% con fi dence interval (CI), -0.38 – .33; P ¼ .88) but a signi fi cant difference in the long-term weight loss outcome favoring LRYGB (standardized mean difference ¼ .17; 95% CI, .05 – .28; P ¼ .005). The pooled results demonstrated no signi fi cant difference for resolution of type 2 diabetes mellitus, hyper- tension, hyperlipidemia, and hypertriglyceridemia. Conclusion: Despite the insigni fi cant difference between LRYGB and LSG in midterm weight loss, LRYGB produced better weight loss in the long-term. There was no signi fi cant difference between the 2 procedures for co-morbidity resolution. (Surg Obes Relat Dis 2016; ] :00 – 00.) 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 Bariatric surgery has been established as the stand-alone treatment for morbid obesity [1] . Currently, it is the only therapeutic option that results in substantial and durable weight loss [1 – 3] . Laparoscopic Roux-en-Y gastric bypass Correspondence: Alan A. Saber, M.D., F.A.C.S., Weight Loss Center, The Brooklyn Hospital, 121 DeKalb Ave, Brooklyn, NY 11201. E-mail: saber6231@gmail.com http://dx.doi.org/10.1016/j.soard.2016.08.011 (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are the 2 most popular bariatric procedures performed in the United States [1 , 4 , 5] . However, their long-term effective- ness for weight loss and co-morbidity resolution has not been suf fi ciently compared [6] . Documentation of long-term weight loss is a hassle in bariatric surgery, since a substantial proportion of patients are lost to follow-up several years after enrollment into the 1550-7289/ r 2016 American Society for Metabolic and Bariatric Surgery. All rights reserved. " id="pdf-obj-0-18" src="pdf-obj-0-18.jpg">

Long-term and midterm outcomes of laparoscopic sleeve gastrectomy versus Roux-en-Y gastric bypass: a systematic review and meta-analysis of comparative studies

Saeed Shoar, M.D. * , Alan A. Saber, M.D., F.A.C.S.

Department of Metabolic and Bariatric Surgery, The Brooklyn Hospital Center, Icahn School of Medicine at Mount Sinai, Brooklyn, NY

Received July 14, 2016; accepted August 8, 2016

Abstract Objective: This study aimed to compare midterm and long-term weight loss and resolution of co- morbidity 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 con- ducted until the end of June 2016 that investigated weight loss outcome and resolution of co- morbidities (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 sig- nicant difference in midterm weight loss (standardized mean difference ¼ -0.03; 95% condence interval (CI), -0.38.33; P ¼ .88) but a signicant difference in the long-term weight loss outcome favoring LRYGB (standardized mean difference ¼ .17; 95% CI, .05.28; P¼ .005). The pooled results demonstrated no signicant difference for resolution of type 2 diabetes mellitus, hyper- tension, 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;]:00 00.) 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

Bariatric surgery has been established as the stand-alone treatment for morbid obesity [1]. Currently, it is the only therapeutic option that results in substantial and durable weight loss [13]. Laparoscopic Roux-en-Y gastric bypass

* Correspondence: Alan A. Saber, M.D., F.A.C.S., Weight Loss Center, The Brooklyn Hospital, 121 DeKalb Ave, Brooklyn, NY 11201. E-mail: saber6231@gmail.com

(LRYGB) and laparoscopic sleeve gastrectomy (LSG) are the 2 most popular bariatric procedures performed in the United States [1,4,5]. However, their long-term effective- ness for weight loss and co-morbidity resolution has not been sufciently compared [6]. Documentation of long-term weight loss is a hassle in bariatric surgery, since a substantial proportion of patients are lost to follow-up several years after enrollment into the

1550-7289/ r 2016 American Society for Metabolic and Bariatric Surgery. All rights reserved.

2 S. Shoar et al. / Surgery for Obesity and Related Diseases ] (2016) 00 –www.crd.york.ac.uk/PROSPERO/ ). Search strategy A comprehensive literature search was performed in the PubMed, ISI Web of Science, Scopus, Embase, and ClinicalTrials.gov databases as well as major journals in the fi elds of obesity, metabolic and bariatric surgery, and gastroenterology until the end of June 2016. A combination of the following search terms was applied: (sleeve gastrec- tomy, LSG, or SG) and (gastric bypass, RYGB, Roux-en-Y Table 1 Inclusion/exclusion criteria for identi fi ed studies. gastric bypass, or LRYGB). A manual screening of the reference lists of relevant studies and systematic reviews was also performed to supplement our literature search. Two independent reviewers performed the literature review, screening, and retrieval of the full texts of eligible papers and extracted data on study endpoints. Any con fl ict was resolved by a third researcher. Eligibility and study selection We screened the identi fi ed records for studies comparing weight loss outcomes or co-morbidity resolution of primary LSG versus laparoscopic LRYGB at least 3 years after weight loss surgery. Inclusion criteria were comparative human study in English language reporting weight loss outcomes or co-morbidity resolution after primary LRYGB versus primary LSG with at least 3 years of follow-up. The minimum follow-up point was determined according to the American Society for Metabolic and Bariatric Surgery position statements on bariatric procedures [12] . Studies with unobtainable outcomes of interest as mean standard deviation (SD) (for continuous outcome) or number/% (for dichotomous outcome) or an average follow-up o 3 years; studies that recruited patients with a body mass index (BMI) o 27 kg/m or aged o 18 or 4 65 years old; studies that combined data of revision or conversion surgeries; and review articles, editorial comments, or case reports were excluded ( Table 1 ). De fi nition of endpoints The primary endpoint was weight loss outcome after bariatric surgery at the end of follow-up. The secondary outcome was co-morbidity resolution at the last follow-up. Inclusion criteria Exclusion criteria Population BMI 4 27 kg/m Age 4 18 years Undergoing bariatric surgery for weight loss or co-morbidity resolution Primary LRYGB and LSG Weight loss, or Co-morbidity resolution rate Comparative cohorts comparing LRYGB versus LSG Study sample size Any Postoperative follow-up Z 3 years None Other bariatric procedures Revision or conversion procedures Unobtainable outcome as mean SD Unobtainable outcome as number (%) Noncomparative Review articles, protocol descriptions, case report, or commentaries None Follow-up o 3years Non-English full text BMI ¼ body mass index; LRYGB ¼ laparoscopic Roux-en-Y gastric bypass; LSG ¼ laparoscopic sleeve gastrectomy; SD ¼ standard deviation. " id="pdf-obj-1-4" src="pdf-obj-1-4.jpg">
  • 2 S. Shoar et al. / Surgery for Obesity and Related Diseases ] (2016) 00 00

weight loss program. Additionally, some LSG patients later undergo revisional surgery due to inadequate weight loss or weight regain [79]. For this reason, it has not been adequately determined which bariatric procedure, LRYGB or LSG, results in more weight loss or better co-morbidity resolution. There has been no meta-analysis to pool available data on midterm (35 years) and long-term (Z5 years) outcomes of LRYGB and LSG. The aim of this systematic review is to compare midterm and long-term weight loss outcomes (primary endpoint) and co-morbidity resolution (secondary endpoint) of LRYGB and LSG through a meta-analysis of comparative studies.

Methods

This study was designed using Cochrane handbook for systematic reviews of interventions [10] and was conducted according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines [11]. The protocol of this systematic review has been registered (CRD42016037669) and is available on the PROSPERO international prospective register of systematic reviews website (www.crd.york.ac.uk/PROSPERO/).

Search strategy

A comprehensive literature search was performed in the PubMed, ISI Web of Science, Scopus, Embase, and ClinicalTrials.gov databases as well as major journals in the elds of obesity, metabolic and bariatric surgery, and gastroenterology until the end of June 2016. A combination of the following search terms was applied: (sleeve gastrec- tomy, LSG, or SG) and (gastric bypass, RYGB, Roux-en-Y

Table 1 Inclusion/exclusion criteria for identied studies.

gastric bypass, or LRYGB). A manual screening of the reference lists of relevant studies and systematic reviews was also performed to supplement our literature search. Two independent reviewers performed the literature review, screening, and retrieval of the full texts of eligible papers and extracted data on study endpoints. Any conict was resolved by a third researcher.

Eligibility and study selection

We screened the identied records for studies comparing weight loss outcomes or co-morbidity resolution of primary LSG versus laparoscopic LRYGB at least 3 years after weight loss surgery. Inclusion criteria were comparative human study in English language reporting weight loss outcomes or co-morbidity resolution after primary LRYGB versus primary LSG with at least 3 years of follow-up. The minimum follow-up point was determined according to the American Society for Metabolic and Bariatric Surgery position statements on bariatric procedures [12]. Studies with unobtainable outcomes of interest as mean standard deviation (SD) (for continuous outcome) or number/% (for dichotomous outcome) or an average follow-up o3 years; studies that recruited patients with a body mass index (BMI) o27 kg/m 2 or aged o18 or 465 years old; studies that combined data of revision or conversion surgeries; and review articles, editorial comments, or case reports were excluded (Table 1).

Denition of endpoints

The primary endpoint was weight loss outcome after bariatric surgery at the end of follow-up. The secondary outcome was co-morbidity resolution at the last follow-up.

Inclusion criteria

Exclusion criteria

Population

Intervention

Outcome

Study design

BMI 427 kg/m 2 Age 418 years Undergoing bariatric surgery for weight loss or co-morbidity resolution Primary LRYGB and LSG

Weight loss, or Co-morbidity resolution rate Comparative cohorts comparing LRYGB versus LSG

Study sample

size

Follow-up

Language

Any

Postoperative follow-up Z3 years

English language

None

Other bariatric procedures Revision or conversion procedures

Unobtainable outcome as mean SD Unobtainable outcome as number (%) Noncomparative Review articles, protocol descriptions, case report, or commentaries

None

Follow-up o3years

Non-English full text

BMI ¼ body mass index; LRYGB ¼ laparoscopic Roux-en-Y gastric bypass; LSG ¼ laparoscopic sleeve gastrectomy; SD ¼ standard deviation.

Meta-analysis Comparing Long-term outcomes of LSG versus RYGB / Surgery for Obesity and Related Diseases ]

Meta-analysis Comparing Long-term outcomes of LSG versus RYGB / Surgery for Obesity and Related Diseases ] (2016) 00 00

3

The included studies were divided into 2 groups according to the average postoperative length of follow-up: midterm (3-5 years) and long term (Z5 years). The endpoints were separately analyzed for each group.

Data extraction

Extracted data included study characteristics (author, publication year, country of study, study type, sample size, and maximum follow-up), patient characteristics (average age and preoperative BMI and gender distribution in each group), and postsurgery outcome, including weight loss results (expressed as BMI loss, percent of excess weight loss (%EWL), weight loss, or excess weight loss) or co- morbidity resolution (hypertension [HTN], type 2 diabetes mellitus [T2D], hyperlipidemia [HLP], hypertriglyceridemia [HTG], and obstructive sleep apnea [OSA]).

Quality assessment

Methodological quality assessment of included studies was performed by 2 authors (S.S. and A.A.S.) independ- ently according to the NewcastleOttawa Scale (NOS) on nonrandomized comparative studies [13]. Included studies were assessed on 7 items, including representativeness, patient selection, ascertainment, mention of conict of interest, comparability, outcome assessment, follow-up length, and follow-up adequacy, with a maximum score of 9. Comparative studies with a score Z6 were considered of high quality (low risk of bias) while studies with a score o6 were considered of moderate or low quality (high risk of bias).

Data analysis

Data was analyzed using Review Manager for Windows version 5.3 (The Nordic Cochrane Centre, Copenhagen,

Denmark). Continuous data were presented as mean SD and analyzed using the inverse variance. Categorical data were presented as frequency (percentages) and analyzed using the Mantel-Haenszel method. To quantify heteroge- neity between studies, I 2 was calculated and considered representative of low heterogeneity at values o30%, of moderate heterogeneity at values between 30% and o50%, and of considerable heterogeneity at values 450%. The random-effects model was used for analysis of studies with considerable heterogeneity, and the xed-effects model was used for studies with low or moderate heterogeneity. Because weight loss was reported variably by studies, data was synthesized using standardized mean difference (SMD). For categorical data, odds ratio (OR) was used as the presentation method. All values are reported with their corresponding 95% condence intervals (CIs). A subgroup analysis was performed to identify the difference between midterm (Fig. 2) and long-term (Fig. 3) pooled outcomes. Publication bias was assessed by visual inspection of the funnel plot obtained from all included studies. A P value o .05 was considered statistically signicant for both the pooled data and heterogeneity estimation.

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=
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
Titles and abstracts
screened
Studies excluded
n= 1365
n= 1402
Full-texts article
Studies excluded: n= 21
screened
-
No RYGB: n=1
n= 37
-
Including patients <18 yrs: n=1
-
Not in English:n=8
-
Unobtainable results: n=3
-
Inadequate follow-up length: n = 4
Studies included in
meta-analysis
-
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.

Maximum follow-up 6.85 yr 75.8 8.4 mo 60 mo 3.1 1.2 yr 53.5 mo 36 mo

Maximum follow-up

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

49.2 (38.768.21) 47.4 (36.877.1)

49.8 7.2 44.9 3.4 51.6 15.9

47.4 4.2 37.5 6.1 45.8 6.0

31.8 3 41.1 4.9 38.5 4.2 51.5 7.2 51.6 6.7 37.9 4.6

LSG

35

Average preop BMI LRYGB

BMI ¼ body mass index; LRYGB ¼ laparoscopic Roux-en-Y gastric bypass; LSG ¼ laparoscopic sleeve gastrectomy; RCT ¼ randomized controlled trial.

32.3 2.4 42.1 4.7 39.3 3.8

46.8 3.6 37.5 6 47.2 5.8

49.1 6.1 47.4 6 38 3.4 44.8 4.6 45.8 3.7 47.4 8

42.5

185/154

132/387

193/618

68/226

44/201

12/20

29/26

64/98

31/63

LRYGB LSG

8/22

8/12

4/36

7/35

9/23

Gender (M/F)

184/ 602

140/379

85/210

30/112

61/102

44/201

15/60

15/40

13/19

31/67

14/18

20/41

8/22

3/13

49 (2467) 41.8 4.6 36 9.1 39.7 10.0

43.4 11.2 46.4 11.6 36.4 11.7 52.4 9.1 36 8.4 46.6 4.2

40.4 9.4 34.6 9.2 29.3 9.8

LSG

23

Average age

44.8 9.9 45.2 10.6 37 10.3 49.6 8.2 33.7 9.9 53 8.3

47 (2463) 43.8 4.6 36.1 9.3 41.2 9.7

41.4 9.3 38 9.9 32.2 9.2

LRYGB

38

LSG

162

20

40

30

42

32

32

94

519

339

245

55

811

61

Sample size

LRYGB

142

294

786

519

245

295

163

30

32

32

16

98

75

55

Jimenez (2012) [18] Nonrandomized cohort

Pekkarinen (2016) [26] Retrospective cohort Perrone (2016) [23] Prospective cohort Lee (2015) [20] Prospective cohort Dogan (2015) [17] Retrospective cohort Jammu (2015) [24] Prospective cohort

Abbatini (2010) [14] Retrospective cohort

Alexandrou (2014) [15] Cross-sectional pilot Moize (2013) [22] Prospective cohort Boza (2012) [16] Case-control

Leyba (2014) [21] Prospective cohort

Study type

RCT

RCT

RCT

Table 2 Characteristics of included studies.

Yang (2015) [25]

Kehagias (2011) [19]

Zhang (2014) [6]

Author

  • 9
    10

    • 11
      12

    • 13
      14

  • 1
    2

  • 3
    4

  • 5
    6

7

8

  • 4 S. Shoar et al. / Surgery for Obesity and Related Diseases ] (2016) 00 00

cohorts [14,17,26], 1 a cross-sectional pilot [15], and a 1 case-control study [16].

Patient characteristics

Patient characteristics were inserted in the meta-analysis. Patients undergoing LRYGB and LSG did not signicantly differ in age (weighted mean difference = .90 years; 95% CI, -0.101.91), male sex (OR = .82; 95% CI, 0.571.17), and BMI (weighted mean difference = -0.5 kg/m 2 ; 95% CI, -1.33.33). Patient follow-up ranged from 36 months [14,16,19,25] and 75.8 8.4 months [23]. Studies were divided, based on the reported average of follow-up, into midterm (35 years) and long-term (Z5 years) categories. Eight studies (3129 patients) followed their patients for an average of 3 to 5 years [1419,24,25] and 6 studies (2135 patients) followed their patients Z5 years [6,2023,26]. Table 3 and 4

Methodological quality assessment (Table 3)

With the exception of 3 studies [14,22,24], all the included studies were of high quality (NOS score Z6). Complete outcome assessment was satisfactory in 5 studies [6,16,2426]. No studies reported conict of interest. Follow-up length was satisfactory in 9 studies [6,15,17,2024,26]. Follow-up adequacy (percent of patients present at the last follow-up) was met in 6 studies

[6,15,18,19,23,25,26].

Weight loss outcome

Of 14 studies with an obtainable mean SD on weight loss outcome [6,1423,25,26], 7 studies (2486 patients) compared weight loss between LRYGB and LSG after 3 to 5 years [1419,25], while 6 studies (1642 patients) com- pared the outcome between the 2 procedures after 5 years (Table 4) [6,2023,26]. The pooled result for weight loss outcome did not show any signicant difference between LRYGB and LSG in midterm weight loss (SMD = -0.03; 95% CI, -0.38.33; P = .88) but revealed a signicant difference in long-term weight loss between LRYGB and LSG favoring LRYGB (SMD = .17; 95% CI, 0.05, .28; P = .005). There was a high heterogeneity between studies in the midterm subgroup (I 2 = 91%, P o .0001) and a moderate heterogeneity between studies in the long-term subgroup (I 2 = 48%, P = .09).

T2D resolution

Five studies (355 patients) reported resolution rates for T2D after 3 to 5 years [16,18,19,24,25] and 2 studies (21 patients) reported T2D resolution rates after 5 years [6,21]. The pooled results demonstrated no signicant difference in the odds ratio of T2D resolution between LRYGB and LSG

in the midterm (OR = 1.62; 95% CI, .952.75; P = .08) or

Meta-analysis Comparing Long-term outcomes of LSG versus RYGB / Surgery for Obesity and Related Diseases ]

Meta-analysis Comparing Long-term outcomes of LSG versus RYGB / Surgery for Obesity and Related Diseases ] (2016) 00 00

5

long-term (OR = .73; 95% CI, 0.077.39; P = .79). There was a nonsignicant low heterogeneity between studies of both subgroups (I 2 o30%, P 4 .05).

HTN resolution

Five studies (533 patients) reported resolution rates for HTN after 3 to 5 years [14,16,19,24,25] and 2 studies (19 patients) reported HTN resolution rates after 5 years [6,21]. The pooled results demonstrated no signicant difference in the odds ratio of HTN resolution between LRYGB and LSG in the midterm (OR = 1.24; 95% CI, 0.871.75; P = .23) and long-term (OR = 1.54; 95% CI, 0.2210.99; P = .67). There was a nonsignicant low heterogeneity between studies of both sub-groups (I 2 o 30%, P 4 .05).

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

long-term (OR = 1.49; 95% CI, 0.336.69; P = .79). There was an insignicant low heterogeneity within studies of both subgroups (I 2 = 0%, P 4 .05).

HTG resolution

Only 2 studies reported (409 patients) resolution rates for HTG after 3 to 5 years. The pooled results demonstrated no signicant difference in the odds ratio of HTG resolution between LRYGB and LSG in the midterm (OR = 1.03; 95% CI, 0.691.52; p = .89). There was an insignicant low heterogeneity within studies of this group (I 2 = 0%, P 4 .05).

OSA resolution

Only 2 studies, 1 midterm (7 patients) [19] and 1 long- term (12 patients) [6], reported OSA resolution rates. Since there was only 1 study in each subgroup, no pooled result could be obtained for resolution of this co-morbidity.

Sensitivity analysis

Excluding low-to-moderate studies with a NOS o6 [14,22,24] yielded similar results concerning weight loss

 

LRYGB

LSG

Mean

SD

Total

Mean

SD

Total

Weight

Std. Mean Difference

 

Std. Mean Difference

 

Study or Subgroup

IV, Random, 95% CI

IV, Random, 95% CI

     

Abbatini2010

  • 29.7 10.4%

3.4

16 -1.11 [-1.82, -0.39]

36.3

7.2

20

   

Alexandrou2014

  • 60.8 57.4

    • 18.8 15.5

      • 55 14.4%

40

0.19

[-0.22, 0.60]

 

Boza2012

  • 97.2 86.4

    • 24.3 26.4

786

  • 811 17.7%

0.43

[0.33, 0.52]

 

Dogan2015

  • 69.7 69.7

245

  • 25.5 25.1

    • 245 17.2%

0.00

[-0.18, 0.18]

 

Jimenez2012

  • 65.4 61.2

    • 20.1 21.5

98

  • 55 15.5%

0.20

[-0.13, 0.53]

 

Kehagias2011

  • 14.5 15.3

    • 0.55 12.4%

30

0.75

  • 30 -1.20 [-1.75, -0.65]

   

Yang2015

  • 92.3 81.9

    • 10.5 27

14

28 12.4%

0.83

[0.27, 1.38]

 

Total (95% CI)

1257

1229

100.0%

-0.03 [-0.38, 0.33]

 

Heterogeneity: Tau² = 0.18; Chi² = 64.10, df = 6 (P < 0.00001); I² = 91%

-100

-50

0

50

100

Test for overall effect: Z = 0.15 (P = 0.88)

 

LRYGB

LSG

Experimental Control Study or Subgroup Events Total Events Total Weight Odds Ratio M-H, Fixed, 95% CI
Experimental
Control
Study or Subgroup
Events
Total
Events
Total
Weight
Odds Ratio
M-H, Fixed, 95% CI
Odds Ratio
M-H, Fixed, 95% CI
Boza2012
37
43
29
32
22.2%
0.64
[0.15, 2.77]
Jammu-2015
25
33
13
23
17.8%
2.40
[0.76, 7.56]
Jimenez2012
78
98
38
55
47.6%
1.74
[0.82, 3.71]
Kehagias2011
4
5
4
5
3.8%
1.00
[0.05, 22.18]
Yang2015
28
30
27
31
8.5%
2.07
[0.35, 12.27]
Total (95% CI)
209
146
100.0%
1.62 [0.95, 2.75]
Total events
172
111
Heterogeneity: Chi² = 2.21, df = 4 (P = 0.70); I² = 0%
0.01
0.1
1
10
100
Test for overall effect: Z = 1.76 (P = 0.08)
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).

6 S. Shoar et al. / Surgery for Obesity and Related Diseases ] (2016) 00 –
  • 6 S. Shoar et al. / Surgery for Obesity and Related Diseases ] (2016) 00 00

Experimental Control Study or Subgroup Events Total Events Total Weight Odds Ratio M-H, Fixed, 95% CI
Experimental
Control
Study or Subgroup
Events
Total
Events
Total
Weight
Odds Ratio
M-H, Fixed, 95% CI
Odds Ratio
M-H, Fixed, 95% CI
Abbatini2010
2
3
4
7
1.0%
1.50
[0.09, 25.39]
Boza2012
141
320
142
340
92.3%
1.10
[0.81, 1.50]
Jammu-2015
37
50
11
21
4.8%
2.59
[0.89, 7.50]
Kehagias2011
9
10
6
8
0.8%
3.00
[0.22, 40.93]
Yang2015
17
18
18
21
1.1%
2.83
[0.27, 29.96]
Total (95% CI)
401
397
100.0%
1.21
[0.90, 1.61]
Total events
206
181
Heterogeneity: Chi² = 3.32, df = 4 (P = 0.51); I² = 0%
0.01
0.1
1
10
100
Test for overall effect: Z = 1.28 (P = 0.20)
LRYGB
LSG
Experimental
Control
Study or Subgroup
Events
Total
Events
Total
Weight
Odds Ratio
M-H, Fixed, 95% CI
Odds Ratio
M-H, Fixed, 95% CI
Abbatini2010
8
11
8
12
3.6%
1.33
[0.22, 7.98]
Boza2012
123
211
110
191
83.5%
1.03
[0.69, 1.53]
Jammu-2015
34
47
14
30
8.2%
2.99
[1.14, 7.81]
Kehagias2011
3
5
3
4
2.3%
0.50
[0.03, 8.95]
Yang2015
9
12
5
10
2.4%
3.00
[0.50, 18.17]
Total (95% CI)
286
247
100.0%
1.24
[0.87, 1.75]
Total events
177
140
Heterogeneity: Chi² = 5.38, df = 4 (P = 0.25); I² = 26%
0.01
0.1
1
10
100
Test for overall effect: Z = 1.20 (P = 0.23)
LRYGB
LSG
Experimental
Control
Study or Subgroup
Events
Total
Events Total
Weight
Odds Ratio
M-H, Fixed, 95% CI
Odds Ratio
M-H, Fixed, 95% CI
Abbatini2010
1
2
4
6
2.0%
0.50
[0.02, 12.90]
Boza2012
123
211
109
190
98.0%
1.04
[0.70, 1.54]
Total (95% CI)
213
196
100.0%
1.03
[0.69, 1.52]
Total events
124
113
Heterogeneity: Chi² = 0.19, df = 1 (P = 0.66); I² = 0%
0.01
0.1
1
10
100
Test for overall effect: Z = 0.14 (P = 0.89)
LRYGB
LSG

Fig. 2. Continued.

outcome at 3 to 5 years (SMD) = .10; 95% CI, -0.23.44; P = .55) and Z5 years (SMD = .17; 95% CI, 0.07.32; P = .002). Due to small number of studies within each co-morbidity subgroup, sensitivity analysis was not performed.

Publication bias

Visual inspection of the funnel plot did not reveal any asymmetry of studies reporting weight loss outcomes difference between LRYGB and LSG patients (Fig. 4). However, this does not exclude publication bias, and, as

mentioned above, interstudies heterogeneity was calculated for each subgroup meta-analysis.

Discussion

This systematic review and meta-analysis of comparative studies found similar weight loss and co-morbidity reso- lution in the midterm (35 years) and similar co-morbidity resolution in the long-term (Z5 years). However, this meta- analysis found a signicantly better long-term weight loss outcome with LRYGB than with LSG. Fourteen studies were eligible, according to the systematic review quality

Total score 4 6 6 6 6 6 6 6 6 6 6 7 5 3

Total score

4

6

6

6

6

6

6

6

6

6

6

7

5

3

F/u adequacy

*

* *

*

*

*

**

**

º

º

º

º

º

º

ºº

F/u length

*

*

*

*

*

*

º

º

º

º

Outcome assessment

*

*

*

*

*

º

ºº

º

º

º

º

º

º

º

Representativeness Selection Ascertainment Conicted results mentioned Comparability

**

**

**

**

**

**

**

**

*

*

*

º

º

º

º

º

º

º

º

º

º

º

º

º

º

º

º

**

**

**

**

**

**

**

**

**

**

**

**

**

**

F/u ¼ follow-up. A maximum of 2 points can be devoted to this criterion.

Table 3 Methodological quality assessment of included studies.

Not consistent with criteria (high risk of bias).

* Consistent with criteria (low risk of bias).

*

*

*

*

*

*

*

*

*

*

*

*

*

*

Dogan (2015) [17] Jammu (2015) [24] Yang (2015) [25] Leyba (2014) [21] Zhang (2014) [6] Alexandrou (2014) [15] Moize (2013) [22] Boza (2012) [16] Jimenez (2012) [18] Kehagias (2011) [19] Abbatini (2010) [14]

Pekkarinen (2016) [26] Perrone (2016) [23] Lee (2015) [20]

Study

º

Meta-analysis Comparing Long-term outcomes of LSG versus RYGB / Surgery for Obesity and Related Diseases ] (2016) 00 00

7

requirements. Although 1 midterm study concluded superi- ority 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]. Meta- analyses 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.

Publication bias and heterogeneity

Due to the strict inclusion criteria of our systematic review in terms of study design and follow-up length, there were few studies available in each subgroup. Hence, a low heterogeneity was observed between studies included in most of the subgroups. The exception was the weight loss subgroup, in which a high heterogeneity was detected, probably due to the larger number of included studies. Moreover, as determine by visual inspection, a low risk of publication bias was observed among all the included studies. However, this does not exclude other risks of bias among the studies in this systematic review.

Weight loss outcome

LRYGB has shown a good long-term outcome in weight loss and co-morbidity resolution, with 64.9% of patients achieving a %EWL of at least 50% after 7 years [28]. Similarly for LSG, it has been shown that 78% of patients sustained a %EWL of at least 50% after 7 years [29]. In the longest follow-up found in the literature, an average percent excess BMI loss of 52.2% and 62.5% was shown for LRYGB after 12 years [30] and LSG after 11 years [31], respectively. No meta-analysis has pooled the comparative data on LRYGB and LSG in the long-term. The only available meta-analysis of long-term comparisons of LRYGB versus LSG revealed an insignicantly greater weight loss and a superior co-morbidity resolution rate for LRYGB compared with LSG [27]. However, this study suffers a major limitation, which is that it the included short-term studies in the pooled analysis of midterm studies but claimed to be a long-term meta-analysis. In contrast with the study of Li et al. [27], our meta-analysis showed an insignicant weight loss difference in the midterm, but a signicantly better weight loss outcome in the long-term with LRYGB than with LSG. Although these

8

S. Shoar et al. / Surgery for Obesity and Related Diseases ] (2016) 00 00

Table 4 Outcomes reported by studies at end of follow-up.

Study

%Weight/BMI loss

T2D resolution

HTN resolution

HLP resolution

HTG

OSA resolution

LRYGB

LSG

LRYGB

LSG

LRYGB

LSG

LRYGB

LSG

LRYGB

LSG

LRYGB

LSG

 

3-5 years

  • 1 Dogan (2015) [17] 69.7 25.5

69.7 25.1

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

  • 2 Jammu (2015) [24] 72.3

53.6

25/33

13/23

34/47

14/30

37/50

11/21

N/A

N/A

N/A

N/A

  • 3 92.3 10.5

Yang (2015) [25]

81.9 14

28/30

27/31

9/12

5/10

17/18

18/21

N/A

N/A

N/A

N/A

Alexandrou (2014) [15]

  • 4 60.8 18.8

57.4 15.5

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

  • 5 65.4 20.1

Jimenez (2012) [18]

61.2 21.5

78/98

38/55

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

  • 6 97.2 24.3

Boza (2012) [16]

86.4 26.4

37/43

29/32

123/211

110/191

141/320

142/340

123/211

109/190

N/A

N/A

  • 7 14.5 0.55

Kehagias (2011) [19]

15.3 0.75

4/5

4/5

3/5

3/4

9/10

6/8

N/A

N/A

2/3

4/6

  • 8 29.7 3.4

36.3 7.2

N/A

N/A

8/11

8/12

2/3

4/7

1/2

4/6

N/A

N/A

Abbatini (2010) [14] Pooled outcome *

-.3 (-.38.33) P ¼ .88; I 2 ¼ 91%

1.62 (.952.75) P ¼ .08; I 2 ¼ 0%

1.21 (.901.61) P ¼ .2; I 2 ¼ 26%

1.24 (.871.75) P ¼ .2; I 2 ¼ 0%

1.03 (.691.52) P ¼ .89; I 2 ¼ 0%

NA

  • 9 57.5 22.61

Pekkarinen (2016) [26]

45.79 32.3

N/A

N/A

Z 5 years N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

  • 10 81.6 21.4

Perrone (2016) [23]

78.8 23.5

N/A

N/A

N/A

N/A

23/26

13/15

N/A

N/A

N/A

N/A

  • 11 28.5 9

Lee (2015) [20]

28.3 8.9

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

  • 12 69.8 18

Leyba

(2014)

[21]

67.3 21.75

2/3

1/1

4/6

1/2

N/A

N/A

N/A

N/A

N/A

N/A

  • 13 76.2 21.7

Zhang

(2014)

[6]

63.2 24.5

7/8

8/9

4/6

3/5

12/13

11/13

N/A

N/A

5/5

7/7

  • 14 68.3 75.6

Moize

(2013)

[22]

67 72.3

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Pooled outcome *

.17 (.05.28) P ¼ .005; I 2 ¼ 48%

.73 (.077.39) P ¼ .79; I 2 ¼ 0%

1.49 (.336.69) P ¼ .6; I 2 ¼ 0%

1.54 (.2210.99) P ¼ .67; I 2 ¼ 0%

 

NA

NA

BMI ¼ body mass index; HLP ¼ hyperlipidemia; HTG ¼ hypertriglyceridemia; HTN ¼ hypertension; LRYGB ¼ laparoscopic Roux-en-Y gastric bypass; LSG ¼ laparoscopic sleeve gastrectomy; N/A ¼ not available; OSA ¼ obstructive sleep apnea; T2D ¼ 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; I 2 ¼ Heterogeneity.

8 S. Shoar et al. / Surgery for Obesity and Related Diseases ] (2016) 00 –
Meta-analysis Comparing Long-term outcomes of LSG versus RYGB / Surgery for Obesity and Related Diseases ]

Meta-analysis Comparing Long-term outcomes of LSG versus RYGB / Surgery for Obesity and Related Diseases ] (2016) 00 00

9

LRYGB LSG Study or Subgroup Mean SD Total Mean SD Total Weight Std. Mean Difference IV,
LRYGB
LSG
Study or Subgroup
Mean
SD
Total
Mean
SD
Total
Weight
Std. Mean Difference
IV, Fixed, 95% CI
Std. Mean Difference
IV, Fixed, 95% CI
Lee-2015
28.5
9
218
28.3
8.9
116
26.0%
0.02
[-0.20, 0.25]
Leyba2014
69.8
18
47
67.3
21.75
24
5.4%
0.13
[-0.36, 0.62]
Moize2013
68.3
75.6
294
67
72.3
61
17.3%
0.02
[-0.26, 0.29]
Pekkarinen/2016
57.5
22.61
163
45.79
32.3
94
20.0%
0.44
[0.18, 0.70]
Perrone2016
81.6
21.4
142
78.8
23.5
162
25.9%
0.12
[-0.10, 0.35]
Zhang2014
76.2
21.7
32
63.2
24.5
32
5.3%
0.55
[0.05, 1.05]
Total (95% CI)
896
489
100.0%
0.17
[0.05, 0.28]
Heterogeneity: Chi² = 9.53, df = 5 (P = 0.09); I² = 48%
Test for overall effect: Z = 2.82 (P = 0.005)
-100
-50
0
50
100
LRYGB
LSG
LRYGB
LSG
Study or Subgroup
Events
Total
Events
Total
Weight
Odds Ratio
M-H, Fixed, 95% CI
Odds Ratio
M-H, Fixed, 95% CI
Leyba2014
2
3
1
1
44.3%
0.56
[0.01, 24.51]
Zhang2014
7
8
8
9
55.7%
0.88
[0.05, 16.74]
Total (95% CI)
11
10
100.0%
0.73 [0.07, 7.39]
Total events
9
9
Heterogeneity: Chi² = 0.03, df = 1 (P = 0.85); I² = 0%
0.01
0.1
1
10
100
Test for overall effect: Z = 0.26 (P = 0.79)
LRYGB
LSG
LRYGB
LSG
Events
Total
Events
Total
26
13

Study or Subgroup

Weight

Odds Ratio M-H, Fixed, 95% CI

 

Odds Ratio M-H, Fixed, 95% CI

 
     

Perrone2016

  • 23 69.2%

13

  • 15 1.18 [0.17, 8.00]

     
   

Zhang2014

  • 12 11

  • 13 30.8%

2.18

[0.17, 27.56]

   

Total (95% CI)

39

100.0%

  • 28 1.49 [0.33, 6.69]

 
Total (95% CI) 39 100.0% 28 1.49 [0.33, 6.69]
 

Total events

  • 35 24

 

Heterogeneity: Chi² = 0.14, df = 1 (P = 0.70); I² = 0%

 
  • 0.01 0.1

 

1

10

100

Test for overall effect: Z = 0.52 (P = 0.60)

 

LRYGB

LSG

 
 

LRYGB

LSG

Odds Ratio

 

Odds Ratio

 

Study or Subgroup

Events

Total

Events

Total

Weight

M-H, Fixed, 95% CI

M-H, Fixed, 95% CI

Leyba2014

  • 4 1

6

  • 2 31.4%

2.00

[0.08, 51.59]

Zhang2014

  • 4 3

6

  • 5 68.6%

1.33

[0.11, 15.70]

Total (95% CI)

12

  • 7 100.0%

1.54 [0.22, 10.99]

 
Total events 8 4 Heterogeneity: Chi² = 0.04, df = 1 (P = 0.85); I² =
Total events
8
4
Heterogeneity: Chi² = 0.04, df = 1 (P = 0.85); I² = 0%

0.01

0.1

1

10

100

Test for overall effect: Z = 0.43 (P = 0.67)

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).

ndings could result from the separate subgroup analyses of midterm and long-term studies, the large weight granted to the Pekkarinen study could affect the result of the meta-analysis in the long-term group [26]. Excluding the Pekkarinen study from the meta-analysis led to an insignicant difference in long-term weight loss between LRYGB and LSG. Moreover, this largely weighted study did not report long-term resolution of

co-morbidities and hence did not impose such an effect on long-term subgroup of this meta-analysis.

Co-morbidity resolution

Both LRYGB and LSG have proven efcacy in terms of substantial resolution of obesity-related co-morbidities

10 S. Shoar et al. / Surgery for Obesity and Related Diseases ] (2016) 00 –
  • 10 S. Shoar et al. / Surgery for Obesity and Related Diseases ] (2016) 00 00

10 S. Shoar et al. / Surgery for Obesity and Related Diseases ] (2016) 00 –

Fig. 4. Funnel plot of all studies reporting on weight loss outcome after laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy.

[29,32,33]. Additionally, it has been shown that co-morbidity resolution is sustained to some extent despite weight regain in some patients in the long term [32]. Our systematic review did not reveal any signicant difference between the 2 procedures in terms of co-morbidity reso- lution, though subgroup analysis for each co-morbidity included few studies in the midterm and long-term arms of the meta-analysis. Moreover, there were not sufcient studies to perform a pooled analysis for HTG in the long term and OSA in both the midterm and the long term. Unlike our ndings, the meta-analysis of Li et al. showed LRYGB to be more effective than LSG in co-morbidities resolution [27]. However, their results could be related to the fact that data from short-term and midterm studies were combined with long-term studies. Although it has been stated that metabolic benets of LRYGB are seen before a substantial weight loss occurs [34,35], co-morbidity reso- lution in mainly restrictive procedures such as LSG may occur after a signicant weight loss has been achieved [35]. This may explain the dilution of the difference in co- morbidity resolution between LRYGB and LSG after 3 years, when a signicant weight loss has been achieved with both procedures [36].

Strength of this systematic review

This is the rst meta-analysis of comparative studies on the long-term weight loss outcome and co-morbidity resolution of LRYGB and LSG. Our restrictive eligibility requirement of exclusively selecting studies with sufcient length of follow-up is another strength of this study, assuring the inclusion in the pooled analysis of comparative studies with the highest possible quality. Moreover, our systematic review focused on the most clinically relevant

outcomes in metabolic and bariatric surgery, weight loss and resolution of the 5 most common obesity-related co- morbidities.

Limitation of this study

The main limitation of this study is related to a lack of data in available studies on co-morbidity resolution (the secondary endpoint) and inconsistencies in reporting weight loss outcomes. There is a substantial lack of RCTs in the literature investigating long-term outcomes of LRYGB versus LSG. Due to the restrictive inclusion criteria set for this systematic review, the number of included studies in each subgroup was relatively low. Although this led to the inclusion of high-quality comparative studies (with NOS score Z6, low heterogeneity, and acceptable publication bias), a large body of literature was excluded from pooled analysis. Although we acknowledge the difculty of design- ing and performing a RCT with long-term patient follow- up, our systematic review revealed the need for future comparative analysis of the available registry database on long-term outcomes after LRYGB and LSG.

Conclusion

This systematic review and meta-analysis demonstrated that despite the insignicant difference between LRYGB and LSG in midterm weight loss, LRYGB produces better weight loss in the long term. However, no signicant difference was observed between LRYGB and LSG regard- ing the resolution of co-morbidities. Considering its more demanding technique and higher complication rate, LRYGB indications should be reconsidered in morbidly obese patients with co-morbidity.

References

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