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DS vs RYGB

DS results in greater weight loss and improved insulin sensitivity

RCTs are needed to determine whether there is a significant long-term effect of these variations

Compared to gastric bypass, duodenal switch results in greater weight loss and improves insulin sensitivity and glucose homeostasis without causing a hyperinsulinemic response, according to a study published in Surgical Endoscopy.

The study researchers, led by Dr Mitchell Roslin of Lenox Hill Hospital in New York, said that hyperinsulinemic hypoglycemia is common after Roux-en-Y gastric bypass (RYGB) and could be a cause in weight regain. Therefore, they decided to compare the effect of RYGB, vertical sleeve gastrectomy (VSG), and duodenal switch on insulin and glucose response to carbohydrate challenge.

For this prospective nonrandomized study, they gathered data from patients that met National Institutes of Health criteria for bariatric surgery, performed via a laparoscopic technique at a single institution. Preoperatively and at six, nine and 12 months’ follow-up, patients underwent blood draw to determine levels of fasting glucose, fasting insulin, glycated hemoglobin (HbA1c), C-peptide, and two hour oral glucose challenge test.

The researchers then calculated the homoeostatic model assessment (HOMA)-IR, fasting to one hour and one to two hour ratios of glucose and insulin.

Outcomes

Data from a total of 38 patients (13 RYGB, 12 VSG, 13 duodenal switch) were available for analysis. At baseline, all groups were similar; the only statistically significant difference was that duodenal switch patients had a higher preoperative weight and BMI. All operations caused weight loss (BMI 47.7 ± 10–30.7 ± 6.4 in RYGB; 45.7 ± 8.5–31.1 ± 5.5 in VSG; 55.9 ± 11.4–27.5 ± 5.6 in duodenal switch), reduction of fasting glucose, and improved insulin sensitivity.

The results also showed that RYGB patients had a rapid rise in glucose with an accompanying rise in one hour insulin to a level that exceeded preoperative levels. This was followed by a rapid decrease in glucose level. In comparison, DS patients had a lower increase in glucose and one hour insulin, and the lowest HbA1c. These differences were statistically significant at various data points. The researchers added that for VSG, the results were intermediary: “Because the response to challenge after VSG is intermediary, pyloric preservation alone cannot account for this difference.”

The wide fluctuations in glucose levels seen with gastric bypass could have an impact on hunger and weight control in the long run, the researchers concluded.

They stressed that randomised controlled trials are needed in order to determine whether there is a significant long-term effect of these variations.

This paper was presented at the SAGES 2013 Annual Meeting, in April 2013, in Baltimore.

The study was sponsored by Covidien.

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