Stable Weight Loss 12 Years After RYGB; 50% Had Diabetes Remission

More than 400 severely obese patients who had Roux-en-Y gastric bypass (RYGB) at a Utah center had largely sustained weight loss and better HbA_1c, blood pressure, and lipid levels 12 years later, compared with more than 700 similar control patients who did not undergo this surgery.

"This study showed long-term durability of weight loss and effective remission and prevention of type 2 diabetes, hypertension, and dyslipidemia after Roux-en-Y gastric bypass," Ted D Adams, MD, Intermountain Live Well Center, Salt Lake City, Utah, and colleagues report in a paper published in the September 21 issue of the New England Journal of Medicine.

On average, the patients in the surgery group initially weighed 133.9 kg (295.2 pounds), and they had lost 45 kg (35% of body weight) 2 years later, 28 kg (28%) 6 years later, and 26.9 kg (27%) 12 years later.

Half of the 84 patients with type 2 diabetes prior to surgery no longer had it 12 years later, but remission was less likely in patients who had been receiving insulin.

"Thus, it is intuitive to suggest that the more advanced the type 2 diabetes, the less the glycemic benefit from Roux-en-Y gastric bypass," Dr Adams and colleagues note.

Patients in the surgery group also had lower incidence rates of hypertension and dyslipidemia.

There were however, seven suicides in patients who underwent bariatric surgery but none in the other patients.

Thus, "on the basis of the results of the current study and of other reports of increased self-harm after bariatric surgery, there is an apparent pressing, unmet need to better predict and prevent this uncommon but very serious sequela of bariatric surgery," the researchers urge.

Six-Year Outcomes Previously Reported

Prior work from the Swedish Obese Subjects (SOS) study of bariatric surgery, which enrolled patients starting in 1987 who mainly had vertical banded gastroplasty (which is no longer performed), showed that, at 10 years, the 34 patients who had RYGB pass surgery had lost 25% of their initial weight.

Previously, Dr Adams and colleagues have reported 6-year changes in weight and metabolic parameters in patients who had bariatric surgery and control patients, in a large, contemporary US cohort (JAMA. 2012;308:1122-1131; Obesity. 2010;18:121-130). The current analysis extends the findings to 12 years.

They identified 418 severely obese patients who had RYGB surgery at their center from July 2000 through March 2016.

The nonsurgery controls included 417 severely obese patients who had wanted the procedure but their insurance didn't cover it and 321 adults with severe obesity who did not seek bariatric surgery.

Roughly a third (35%) of those who had wanted the surgery and 12% of the other nonsurgery patients did end up having bariatric surgery.

Diabetes Remission Much Rarer in Those Initially on Insulin

On average, patients in the nonsurgery group had an initial weight of 123 kg, and those who had wanted the surgery had lost 2.9 kg (2%) and the others had lost less than 1 kg (0.9%) at 12 years (excluding patients in these groups who went on to have bariatric surgery).

Compared with the other study participants, fewer patients in the surgery group developed type 2 diabetes (3% vs 26%), and surgery patients had an approximately 90% lower risk of developing type 2 diabetes (P < .001).

Of patients who had type 2 diabetes when they had bariatric surgery, 73% of those who were on antidiabetic medications — 56% of patients receiving oral antiglycemic agents but only 16% of patients on insulin — had diabetes remission.

At 12 years, 36% of patients in the surgery group vs 10% and 14% of patients in the nonsurgery groups had remission of hypertension.

Patients with hyperlipidemia who had bariatric surgery also had significant, 3.3-fold to 18.6-fold higher odds of having their levels of HDL cholesterol, LDL cholesterol, or triglycerides return to normal.

Suicide: An "Uncommon But Very Serious Sequela"

During follow-up, 6% of patients who had surgery died (including five deaths by suicide), and 6% and 9% of patients in the nonsurgery groups died (including two deaths by suicide in patients who had later had bariatric surgery).

A review of 28 studies reported that "potential risk factors for suicide after bariatric surgery included age younger than 35 years; hormonal changes; persistence of coexisting conditions; preexisting depression and other mood disorders; worsening or lack of improvement in health-related quality of life; social, sexual, and relationship issues; poor body image; and a history of maltreatment during childhood," Dr Adams and colleagues note.

And others have reported that "reduced bioavailability of some serotonin-reuptake inhibitors 1 month after gastric bypass,...binge-eating disorder before bariatric surgery, and the use of psychiatric related medications" may be implicated.

Whether "bariatric surgery itself or whether any large, sustained weight loss would also be associated with an increased risk of suicide is unknown," but this highlights the need to better predict and prevent this rare outcome after bariatric surgery, the authors warn.

The study was supported by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health; a US Public Health Service research grant from the National Center for Research Resources; Biomedical Research Program funds from Weill Cornell Medicine; and Intermountain Healthcare. Adams had no relevant financial relationships. Disclosures for the coauthors are listed on the journal website.

N Engl J Med. 2017;377:1143-1155. Article

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