In Reply We thank Castillo-Castro et al for their comments and questions about our article.1 They are correct that the sleeve gastrectomy (SG) group at baseline was slightly younger (median age, 44 years in the SG group vs 46 years Roux-en-Y gastric bypass [RYGB]), with fewer comorbid conditions (26% patients with diabetes in the SG group vs 44% in the RYGB group), and a lower body mass index (calculated as weight in kilograms divided by height in meters squared; 46.8 SG vs 48.1 RYGB). In addition, the SG cases were performed later in the study, owing to time trends in procedure use, so the median follow-up was shorter for SG (2.2 years) than for RYGB (3.4 years). To account for these differences, our analyses adjusted for all baseline patient characteristics as well as the year of surgery, so the estimated comparison between RYGB and SG can be interpreted as the expected difference in outcome for a patient selecting SG vs RYGB, holding all other covariates constant. We did not include an interaction between year and procedure, so if the relative effect of RYGB vs SG changed over time, that would not be captured. While these approaches can address potential measured confounders in our study, there is still the potential for unobserved confounding owing to the nonrandomized study design. Finally, regarding follow-up time, we agree that additional comparative studies are needed with greater follow-up for both procedures to confirm our findings.
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Courcoulas AP, Coley RY, Arterburn D. Evidence-Based and Patient-Centered Decisions Regarding Bariatric Surgery—Reply. JAMA Surg. Published online July 01, 2020. doi:10.1001/jamasurg.2020.1530
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