Cardiovascular Outcomes in Patients With Type 2 Diabetes and Obesity: Comparison of Gastric Bypass, Sleeve Gastrectomy, and Usual Care

Objective: To determine which one of the two most common metabolic surgical procedures is associated with greater reduction in risk of major adverse cardiovascular events (MACE) in patients with type 2 diabetes (T2DM) and obesity.

Research Design and Methods: A total of 13,490 patients including 1,362 Roux-en-Y gastric bypass (RYGB), 693 sleeve gastrectomy (SG), and 11,435 matched non-surgical patients with T2DM and obesity who received their care at the Cleveland Clinic (1998-2017) were analyzed with follow-up through December 2018. Multivariable Cox regression analysis estimated time to incident extended MACE, defined as first occurrence of coronary artery events, cerebrovascular events, heart failure, nephropathy, atrial fibrillation, and all-cause mortality.

Results: The cumulative incidence of the primary endpoint at 5 years was 13.7% [95%CI 11.4-15.9] in the RYGB groups and 24.7% [95%CI 19.0-30.0] in the SG group with an adjusted HR of 0.77 [95%CI 0.60 to 0.98], p=0.04. Of the 6 individual endpoints, RYGB was associated with a significantly lower cumulative incidence of nephropathy at 5 years compared with SG (2.8% vs 8.3%, respectively); HR 0.47 [95%CI 0.28-0.79], p=0.005. Furthermore, RYGB was associated with a greater reduction in body weight, glycated hemoglobin, and use of medications to treat diabetes and cardiovascular diseases. Five years after RYGB, patients required more upper endoscopy (45.8% vs 35.6%, p<0.001) and abdominal surgical procedures (10.8% vs 5.4%, p=0.001) compared with SG.

Conclusion: In patients with obesity and T2DM, RYGB may be associated with greater weight loss, better diabetes control, and lower risk of MACE and nephropathy compared with SG.