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Original Investigation
October 6, 2021

Comparative Safety of Sleeve Gastrectomy and Gastric Bypass Up to 5 Years After Surgery in Patients With Severe Obesity

Author Affiliations
  • 1Department of Surgery, University of Michigan, Ann Arbor
  • 2Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
  • 3National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
  • 4Veterans Affairs Ann Arbor, Ann Arbor, Michigan
  • 5Department of Surgery, Yale School of Medicine, New Haven, Connecticut
  • 6Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
  • 7Kaiser Permanente Washington Health Research Institute, Seattle
  • 8Center for Evaluating Health Reform, University of Michigan, Ann Arbor
  • 9University of Michigan School of Public Health, Ann Arbor
  • 10Division of Minimally Invasive Surgery, Department of Surgery, University of Michigan, Ann Arbor
JAMA Surg. 2021;156(12):1160-1169. doi:10.1001/jamasurg.2021.4981
Key Points

Question  What is the long-term comparative safety of sleeve gastrectomy vs gastric bypass?

Findings  This cohort study of a national sample of 95 405 Medicare beneficiaries found that sleeve gastrectomy was associated with a lower risk of mortality, complications, and overall reintervention 5 years after surgery. However, the risk of surgical revision was higher among patients undergoing sleeve gastrectomy.

Meaning  Results suggest that the safety benefits of sleeve gastrectomy persist up to 5 years after surgery; this information may help patients and surgeons make informed treatment decisions.

Abstract

Importance  Sleeve gastrectomy is the most widely used bariatric operation; however, its long-term safety is largely unknown.

Objective  To compare the risk of mortality, complications, reintervention, and health care use 5 years after sleeve gastrectomy and gastric bypass.

Design, Setting, and Participants  This retrospective cohort study included adult patients in a national Medicare claims database who underwent sleeve gastrectomy or gastric bypass from January 1, 2012, to December 31, 2018. Instrumental variables survival analysis was used to estimate the cumulative incidence of outcomes up to 5 years after surgery.

Exposures  Laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.

Main Outcomes and Measures  The main outcome was risk of mortality, complications, and reinterventions up to 5 years after surgery. Secondary outcomes were health care use after surgery, including hospitalization, emergency department (ED) use, and total spending.

Results  Of 95 405 patients undergoing bariatric surgery, 57 003 (60%) underwent sleeve gastrectomy (mean [SD] age, 57.1 [11.8] years), of whom 42 299 (74.2%) were women; 124 (0.2%) were Asian; 10 101 (17.7%), Black; 1951 (3.4%), Hispanic; 314 (0.6%), North American Native; 43 194 (75.8%), White; 534 (0.9%), of other race or ethnicity; and 785 (1.4%), of unknown race or ethnicity. A total of 38 402 patients (40%) underwent gastric bypass (mean [SD] age, 55.9 [11.7] years), of whom 29 050 (75.7%) were women; 109 (0.3%), Asian; 6038 (15.7%), Black; 1215 (3.2%), Hispanic; 278 (0.7%), North American Native; 29 986 (78.1%), White; 373 (1.0%), of other race or ethnicity; and 404 (1.1%), of unknown race or ethnicity. Compared with patients undergoing gastric bypass, at 5 years after surgery, patients undergoing sleeve gastrectomy had a lower cumulative incidence of mortality (4.27%; 95% CI, 4.25%-4.30% vs 5.67%; 95% CI, 5.63%-5.69%), complications (22.10%; 95% CI, 22.06%-22.13% vs 29.03%; 95% CI, 28.99%-29.08%), and reintervention (25.23%; 95% CI, 25.19%-25.27% vs 33.57%; 95% CI, 33.52%-33.63%). Conversely, patients undergoing sleeve gastrectomy had a higher cumulative incidence of surgical revision at 5 years (2.91%; 95% CI, 2.90%-2.93% vs 1.46%; 95% CI, 1.45%-1.47%). The adjusted hazard ratio (aHR) of all-cause hospitalization and ED use was lower for patients undergoing sleeve gastrectomy at 1 year (hospitalization, aHR, 0.83; 95% CI, 0.80-0.86; ED use, aHR, 0.87; 95% CI, 0.84-0.90) and 3 years (hospitalization, aHR, 0.94; 95% CI, 0.90-0.98; ED use, aHR, 0.93; 95% CI, 0.90-0.97) after surgery but similar between groups at 5 years (hospitalization, aHR, 0.99; 95% CI, 0.94-1.04; ED use, aHR, 0.97; 95% CI, 0.92-1.01). Total health care spending among patients undergoing sleeve gastrectomy was lower at 1 year after surgery ($28 706; 95% CI, $27 866-$29 545 vs $30 663; 95% CI, $29 739-$31 587), but similar between groups at 3 ($57 411; 95% CI, $55 239-$59 584 vs $58 581; 95% CI, $56 551-$60 611) and 5 years ($86 584; 95% CI, $80 183-$92 984 vs $85 762; 95% CI, $82 600-$88 924).

Conclusions and Relevance  In a large cohort of patients undergoing bariatric surgery, sleeve gastrectomy was associated with a lower long-term risk of mortality, complications, and reinterventions but a higher long-term risk of surgical revision. Understanding the comparative safety of these operations may better inform patients and surgeons in their decision-making.

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