Sleeve Gastrectomy Associated with Higher Revision Rate But Better Long-Term Outcomes than Gastric Bypass

Ryan Howard, MD

A Michigan Medicine study comparing 5-year outcomes of sleeve gastrectomy versus gastric bypass suggests one approach may be more effective for reducing risk of death and complications but is also associated with greater risk of requiring follow-up surgery.

Results of the study, which assessed data from a national sample of nearly 100,000 Medicare beneficiaries, indicate laparoscopic sleeve gastrectomy was associated with lower incidence of mortality, complications, and reintervention but an increased incidence of surgical revision at 5 years among patients with severe obesity.

“It’s really important for patients to understand the risk of significant issues like death, complications, and hospitalization after these two procedures because that helps inform the decision about which type of bariatric surgery to choose,” said study investigator Ryan Howard, MD, a general surgery resident at Michigan Medicine, in a statement.

As the popularity of bariatric surgery continues to grow in the US and abroad, interest in long-term research, specifically outcomes, has grown with it. Using data from fee-for-service Medicare claims, Howard and colleagues designed a retrospective cohort study aimed at assessing long-term risks associated with laparoscopic sleeve gastrectomy or laparoscopic Roux-en-Y gastric bypass.

To do so, Howard and fellow investigators designed their study using data from a national Medicare claims database from January 1, 2012, to December 31, 2018. For inclusion in the study, individuals needed to be continuously enrolled for at least 3 months prior to undergoing bariatric surgery and for 1, 3, and 5 years after surgery. The primary outcomes of interest for the study were the cumulative incidence of mortality, complications, and reinterventions upon to 5 years after undergoing bariatric surgery.

For the purpose of analysis, complications were categorized as splenic, hemorrhagic, anastomotic, wound-related, obstruction-related, pulmonary, cardiac, neurologic, genitourinary, thromboembolic, shock, and unexpected reoperations. Additionally, reinterventions were group into categories defined as revision, reoperation, enteral access, vascular access, and other interventions. The primary analysis of the study used a Cox proportional hazards model to estimate the adjusted hazards ratio for outcomes of interest between those who underwent sleeve gastrectomy versus gastric bypass.

A total of 95,405 patients were identified for inclusion in the study, including 57,003 who underwent sleeve gastrectomy and 38,402 who underwent gastric bypass. Patients undergoing sleeve gastrectomy had a mean age of 57.1 (SD, 11.8) years, 74.2% were women, and 75.8% were White. Patients undergoing gastric bypass had a mean age of 55.9 (SD, 11.7) years, 75.7% were women, and 78.1% were White.

Upon analysis of 5-year data, results indicated those 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%]) compared to those who underwent gastric bypass. However, those who underwent sleeve gastrectomy had a higher cumulative incidence of surgical revision at 5 years than their counterparts who underwent gastric bypass (2.91% [95% CI, 2.90%-2.93%] vs 1.46% [95% CI, 1.45%-1.47%]).

In adjusted analyses, risk of all-cause hospitalization and emergency department (ED) use were lower among those who underwent sleeve gastrectomy at both 1 (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. However, rates were 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]). Further analysis suggested total health care spending was lower among those who underwent sleeve gastrectomy at 1 year after surgery, but similar rates were observed between the groups at years 3 and 5 ($86,584 [95% CI, $80,183-$92,984] vs $85,762 [95% CI, $82,600-$88,924]).

“You could envision a scenario where a patient is averse to that risk, and so even if a sleeve gastrectomy doesn’t confer as much weight loss, they may want it because it’s the safer surgery,” Howard said. “On the other hand, if a patient has a lot of comorbidities, and a bypass is going to afford a better clinical benefit, maybe that risk is worth it.”

This study, “Comparative Safety of Sleeve Gastrectomy and Gastric Bypass Up to 5 Years After Surgery in Patients With Severe Obesity,” was published in JAMA Surgery.