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Introduction: Sleeve Gastrectomy (SG) has surpassed Roux-en-Y Gastric Bypass (RYGB) as the most commonly performed bariatric operation. Though the beneficial effect of SG on Type 2 Diabetes Mellitus is less than that of RYGB, it is perceived to have a lower complication rate. The purpose of this study was to quantify the complication rates between of SG and RYGB in a severely obese diabetic population. Methods: This was a retrospective cohort study that included all diabetic patients undergoing RYGB and SG at an academic medical center from January 1, 2011 to July 1, 2015. Patients were followed at 6 week, 6 month, 1 year, 2 year, and 3 year postoperatively. Outpatient and emergency visits were identified in the EMR system. Continuous data was analyzed using Student T tests and discrete data was analyzed using Fisher’s Exact Test. We defined early complications as those occurring within 30 days postoperatively, and late complications as those after 30 days. Results: A total of 96 patients underwent RYGB and 89 underwent SG. The groups were concurrent and similar with regards to preoperative demographic factors such as age, gender, Hgb-A1c, HOMA2 parameters, excess body weight, BMI, and diabetic medication use. In terms of early complications, the rate of hemorrhage requiring transfusion was higher in the SG group compared to RYGB (10.1% vs. 3.1%, p=0.073). Postoperative length of stay was lower in the SG group (m=1.7 d vs. m=2 d, p=0.02), but the early readmission rate was also higher in the SG group (7.9% vs. 2.1%, p=0.09). For late postoperative complications, there were 4 anastomotic ulcer perforations and one case of internal hernia in the RYGB group. There were 6 late postoperative reoperations in the RYGB group (6% vs. 0%, p=0.03). In addition, 13 patients underwent 16 total upper endoscopies in the RYGB group (13.5% vs. 0%, p=0.0002). The cumulative rate of early and late interventions was higher in the RYGB group (20% vs. 3.4%, p=0.0005). Conclusions: While the rate of early postoperative complication is similar between SG and RYGB, the need for late intervention is higher after RYGB. The cumulative need for reintervention (early and late) is higher after RYGB. This may explain the shift from Roux-en-Y Gastric Bypass to Sleeve Gastrectomy as the most commonly performed bariatric intervention.

Introduction: Bariatric surgery is being increasingly investigated as treatment for Type II Diabetes Mellitus (T2DM). As Sleeve Gastrectomy (SG) surpasses Roux-en-Y Gastric Bypass (RYGB) as the new standard in bariatric surgery, it is still unknown if its efficacy in achieving remission is comparable to RYGB. This study compared diabetic remission rates between SG and RYGB in order to identify the predictive factors for remission and the mechanisms of achieving remission. Methods: This was a retrospective cohort study comparing all diabetic patients undergoing RYGB and SG at an academic medical center from 1/1/11-7/1/15. Patients were followed preoperatively and at 6 week, 6 month, and 1, 2, and 3 year intervals. We defined diabetic remission as HbA1c under 7 without insulin or hypoglycemic use and excess body weight (EBW) as percent over ideal body weight. Data were analyzed using Cox analysis, Fisher’s Exact Tests, and Student T Tests. Results: During the study, 96 patients underwent RYGB and 89 underwent SG. Preoperatively, patients from both groups had similar age, weight, gender, preoperative weight loss, HbA1c at onset and at surgery, oral hypoglycemic use, insulin use, and HOMA2 parameters. At one year postoperatively, patients who underwent RYGB showed a statistically greater postoperative EBW loss (62% vs. 36% p < 0.0001). Kaplan Meier analysis showed a significantly higher rate of remission, (83% vs. 66%) in patients who underwent SG (p=0.02). After using Cox analysis to account for differences in delta BMI (p=0.04), EBW loss (p=0.04), preoperative HOMA2 parameters (p=0.008-0.011), and preoperative factors such as HbA1c and insulin use (p=0.001 for both), there was no change in RYGB’s impact on diabetic remission compared to SG. Conclusion: Our results confirm that RYGB achieves a significantly greater rate of diabetic remission and a significantly higher weight loss than SG. Additionally, the difference in rate of diabetic remission is not explained by weight loss or preoperative predictors of less reversible diabetes (HOMA2 parameters, use of insulin). Identification of the factor(s) responsible for this differential effect on diabetes may afford opportunity for therapeutic intervention.

Obesity is a strong risk factor for resistance to insulin-mediated glucose disposal, a precursor of type 2 diabetes and other disorders. However, not all obese individuals are insulin resistant. We sought to identify the molecular pathways that might cause obesity-associated insulin resistance in humans by studying the morbidly obese who were insulin sensitive versus insulin resistant, thereby eliminating obesity as a variable.Combining gene expression profiling with computational approaches, we determined the global gene expression signatures of omental and subcutaneous adipose tissue samples obtained from similarly obese patients undergoing gastric bypass surgery.Gene sets related to chemokine activity and chemokine receptor binding were identified as most highly expressed in the omental tissue from insulin-resistant compared with insulin-sensitive subjects, independent of the body mass index. These upregulated genes included chemokines (C-C motif) ligand 2, 3, 4, and 18 and interleukin-8/(CC-X motif) ligand 8 and were not differentially expressed in the subcutaneous adipose tissues between the 2 groups of subjects. Insulin resistance, but not the body mass index, was associated with increased macrophage infiltration in the omental adipose tissue, as was adipocyte size, in these morbidly obese subjects.Our findings have demonstrated that inflammation of the omental adipose tissue is strongly associated with insulin resistance in human obesity even in subjects with similar body mass index values.