Sleeve, bypass, or something new – which surgery really dominates the day?  This Bariatric Surgery Journal Club dives into the debate over which bariatric operation is best. We compare the outcomes of the gastric bypass, sleeve gastrectomy, and the newer Sadie procedure, exploring how bypass may have an edge in long-term diabetes remission and weight loss.  We also discuss revisional options for failed sleeves and the importance of matching the patient to the right operation for their specific needs.

Hosts:

- Matthew Martin, trauma and bariatric surgeon at the University of Southern California/Los Angeles General Medical Center (Los Angeles, California) 
- Adrian Dan, bariatric and MIS surgeon, program director for the advanced MIS bariatric and foregut fellowship at Summa Health System (Akron, Ohio)
- Crystal Johnson Mann, bariatric and foregut surgeon at the University of Florida (Gainesville, Florida)
- Katherine Cironi, general surgery resident at the University of Southern California/Los Angeles General Medical Center (Los Angeles, California)

Learning objectives:

- Contrast the outcomes of Roux-en-Y gastric bypass, sleeve gastrectomy, and revisional options such as the single-anastomosis duodeno-ileal bypass (SADI)
- Article #1: Hauge 2025, Effect of gastric bypass versus sleeve gastrectomy on the remission of type 2 diabetes, weight loss, and cardiovascular risk factors at 5 years (Oseberg): secondary outcomes of a single-centre, triple blind, randomized controlled trial https://pubmed.ncbi.nlm.nih.gov/40185112/
- Describe the design and unique triple-blind methodology of a single-center randomized trial comparing bypass and sleeve in patients with obesity and type 2 diabetes. 
- Interpret the clinical relevance of the 5-year outcomes, including 63% diabetes remission with bypass vs 30% with sleeve. 
- Examine secondary outcomes such as weight loss and cholesterol reduction, which favored bypass over the sleeve
- Formulate patient-centered strategies for selecting bypass versus sleeve in populations with advanced metabolic disease, balancing efficacy with patient preference 
- Article #2: The By-Band-Sleeve Collaborative Group 2025, Roux-en-Y gastric bypass, adjustable gastric banding, or sleeve gastrectomy for severe obesity (By-Band-Sleeve): a multicenter, open-label, three-group, randomized controlled trial https://pubmed.ncbi.nlm.nih.gov/40179925/
- Summarize the findings of this multi-center, open-label randomized controlled trial of over 1,300 patients comparing bypass, sleeve, and gastric banding at 5 years
- Discuss the relative weight loss outcomes: 67% excess weight loss for bypass, 63% for sleeve, and 28% for adjustable gastric band
- Evaluate the improvements in diabetes remission, hypertension control, and lipid management with bypass and sleeve compared to banding.
- Analyze the declining role of gastric banding in modern bariatric surgery, while acknowledging its benefits compared to no weight loss treatment
- Article #3: Thomopoulos 2024, Long-term results of Roux-en-Y gastric bypass (RYGB) versus single anastomosis duodeno-ileal bypass (SADI) as revisional procedures after failed sleeve gastrectomy: a systematic literature review and pooled analysis https://pubmed.ncbi.nlm.nih.gov/39579238/
- Compare long-term outcomes of bypass versus SADI after failed sleeve gastrectomy, based on pooled analysis of over 1,000 patients 
- Interpret the trade-offs: SADI provides greater weight loss and metabolic improvements, but carries a higher risk for malnutrition and fat-soluble vitamin deficiencies 
-  Develop strategies for preoperative counseling, nutritional supplementation, and close long-term monitoring, particularly for patients undergoing SADI
- Individualize decision-making for revisional surgery, considering factors such as patient goals, comorbidity burden, prior anatomy, BMI, and reliability with follow-up
- Evolving revisional strategies will influence the next decade of bariatric surgical innovation  
- Overall, bariatric surgery consistently improves weight, diabetes control, and cardiovascular risk.
- The procedure of choice should be tailored to the patient through detailed discussion between surgeon and patient, aligning clinical evidence with patient goals and risks.
 
References

1.     Wågen Hauge J, Borgeraas H, Birkeland KI, Johnson LK, Hertel JK, Hagen M, Gulseth HL, Lindberg M, Lorentzen J, Seip B, Kolotkin RL, Svanevik M, Valderhaug TG, Sandbu R, Hjelmesæth J, Hofsø D. Effect of gastric bypass versus sleeve gastrectomy on the remission of type 2 diabetes, weight loss, and cardiovascular risk factors at 5 years (Oseberg): secondary outcomes of a single-centre, triple-blind, randomised controlled trial. Lancet Diabetes Endocrinol. 2025 May;13(5):397-409. doi: 10.1016/S2213-8587(24)00396-6. Epub 2025 Apr 1. PMID: 40185112. https://pubmed.ncbi.nlm.nih.gov/40185112/

2.     By-Band-Sleeve Collaborative Group. Roux-en-Y gastric bypass, adjustable gastric banding, or sleeve gastrectomy for severe obesity (By-Band-Sleeve): a multicentre, open label, three-group, randomised controlled trial. Lancet Diabetes Endocrinol. 2025 May;13(5):410-426. doi: 10.1016/S2213-8587(25)00025-7. Epub 2025 Mar 31. PMID: 40179925.
https://pubmed.ncbi.nlm.nih.gov/40179925/

3.     Thomopoulos T, Mantziari S, Joliat GR. Long-term results of Roux-en-Y gastric bypass (RYGB) versus single anastomosis duodeno-ileal bypass (SADI) as revisional procedures after failed sleeve gastrectomy: a systematic literature review and pooled analysis. Langenbecks Arch Surg. 2024 Nov 23;409(1):354. doi: 10.1007/s00423-024-03557-9. PMID: 39579238; PMCID: PMC11585492.
https://pubmed.ncbi.nlm.nih.gov/39579238/

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