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Original Investigation
May 15, 2019

Fracture Risk After Roux-en-Y Gastric Bypass vs Adjustable Gastric Banding Among Medicare Beneficiaries

Author Affiliations
  • 1Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
  • 2Division of Pharmacoepidemiology and Pharmacoeconomics; Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
  • 3Division of Rheumatology, Immunology and Allergy; Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
  • 4Center for Surgery and Public Health; Brigham and Women’s Hospital,Harvard Medical School, Boston, Massachusetts
JAMA Surg. 2019;154(8):746-753. doi:10.1001/jamasurg.2019.1157
Key Points

Question  How does the fracture risk associated with Roux-en-Y gastric bypass compare with that of adjustable gastric banding among older adults?

Findings  This cohort study analyzed claims data from 42 345 Medicare beneficiaries from 2006 to 2014 and found a 73% increased risk of nonvertebral fracture among adults who received Roux-en-Y gastric bypass compared with those who received adjustable gastric banding.

Meaning  Although bariatric surgery is associated with health benefits, increased fracture risk is an important factor to consider for patients seeking Roux-en-Y gastric bypass.

Abstract

Importance  Roux-en-Y gastric bypass (RYGB) is associated with significant bone loss and may increase fracture risk, whereas substantial bone loss and increased fracture risk have not been reported after adjustable gastric banding (AGB). Previous studies have had little representation of patients aged 65 years or older, and it is currently unknown how age modifies fracture risk.

Objective  To compare fracture risk after RYGB and AGB procedures in a large, nationally representative cohort enriched for older adults.

Design, Setting, and Participants  This population-based retrospective cohort analysis used Medicare claims data from January 1, 2006, to December 31, 2014, from 42 345 severely obese adults, of whom 29 624 received RYGB and 12 721 received AGB. Data analysis was performed from April 2017 to November 2018.

Main Outcomes and Measures  The primary outcome was incident nonvertebral (ie, wrist, humerus, pelvis, and hip) fractures after RYGB and AGB surgery defined using a combination of International Classification of Diseases, Ninth Edition and Current Procedural Terminology 4 codes.

Results  Of 42 345 participants, 33 254 (78.5%) were women. With a mean (SD) age of 51 (12) years, recipients of RYGB were younger than AGB recipients (55 [12] years). Both groups had similar comorbidities, medication use, and health care utilization in the 365 days before surgery. Over a mean (SD) follow-up of 3.5 (2.1) years, 658 nonvertebral fractures were documented. The fracture incidence rate was 6.6 (95% CI, 6.0-7.2) after RYGB and 4.6 (95% CI, 3.9-5.3) after AGB, which translated to a hazard ratio (HR) of 1.73 (95% CI, 1.45-2.08) after multivariable adjustment. Site-specific analyses demonstrated an increased fracture risk at the hip (HR, 2.81; 95% CI, 1.82-4.49), wrist (HR, 1.70; 95% CI, 1.33-2.14), and pelvis (HR, 1.48; 95% CI, 1.08-2.07) among RYGB recipients. No significant interactions of fracture risk with age, sex, diabetes status, or race were found. In particular, adults 65 years and older showed similar patterns of fracture risk to younger adults. Sensitivity analyses using propensity score matching showed similar results (nonvertebral fracture: HR 1.75; 95% CI, 1.22-2.52).

Conclusions and Relevance  This study of a large, US population–based cohort including a substantial population of older adults found a 73% increased risk of nonvertebral fracture after RYGB compared with AGB, including increased risk of hip, wrist, and pelvis fractures. Fracture risk was consistently increased among RYGB patients vs AGB across different subgroups, and to a similar degree among older and younger adults. Increased fracture risk appears to be an important unintended consequence of RYGB.

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