Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio.
Surg Obes Relat Dis. 2020 Feb;16(2):332-339. doi: 10.1016/j.soard.2019.11.013. Epub 2019 Dec 2.
Guiding patients with type 2 diabetes (T2D) toward the most appropriate bariatric and metabolic procedure is crucial for improving outcomes. In recent years, Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) have been the most commonly performed bariatric procedures worldwide. Both are safe, effective, and durable metabolic procedures. The aim of this review was to critically examine the best available evidence derived from the randomized clinical trials (RCTs) to identify which bariatric procedure is superior in an individual with T2D to provide sustainable long-term remission. There are 4 RCTs in patients with T2D that directly compare RYGB with SG, report outcomes up to 5 years after randomization, and provide level I evidence for procedure selection. While the remission rate of T2D after RYGB versus SG is comparable in all 4 RCTs, all studies are underpowered to reveal differences in T2D-related endpoints between these 2 procedures. Combined analysis of RCTs (RYGB, n = 176 versus SG, n = 175) would indicate that 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. Prediction tools, such as the individualized metabolic surgery score, can identify patients who can benefit the most from the antidiabetic effects of RYGB. Nonetheless, the procedure selection should not be solely based on T2D-related outcomes. Diabetes is one outcome; one of many outcomes that needs to be considered in decision-making. Patient's conditions and clinical outcomes that are critical in choosing the most optimal bariatric and metabolic procedure will also be explained in this review.
指导 2 型糖尿病（T2D）患者选择最合适的减重和代谢手术对于改善结局至关重要。近年来，胃旁路术（RYGB）和袖状胃切除术（SG）已成为全球最常施行的减重手术。这两种手术均为安全、有效且持久的代谢手术。本综述旨在批判性地评估源自随机临床试验（RCT）的最佳可用证据，以确定哪种减重手术在 T2D 患者中更具优势，从而提供可持续的长期缓解。有 4 项 RCT 在 T2D 患者中直接比较了 RYGB 与 SG，报告了随机分组后长达 5 年的结局，并为手术选择提供了 I 级证据。虽然 4 项 RCT 中 RYGB 与 SG 后 T2D 的缓解率在所有患者中相当，但所有研究均未显示出这两种手术在 T2D 相关结局方面存在差异。对 RCT 进行联合分析（RYGB，n = 176 与 SG，n = 175）表明，在改善 T2D 方面，RYGB 与 SG 之间长期无显著差异，或者如果存在真正的差异（我们仍没有足够的统计学能力来揭示这种差异），这种差异<15%，有利于 RYGB。预测工具，如个体化代谢手术评分，可以识别出最能从 RYGB 的抗糖尿病作用中获益的患者。尽管如此，手术选择不应仅基于 T2D 相关结局。糖尿病是众多需要在决策中考虑的结局之一。在选择最佳减重和代谢手术时，还需要考虑患者的状况和临床结局。
