Less Abdominal Surgery Post Sleeve Gastrectomy vs Gastric Bypass

Marlene Busko

December 24, 2019

Compared with Roux-en-Y gastric bypass, sleeve gastrectomy was associated with a lower risk for subsequent abdominal surgery or endoscopy in a new study that examined the two bariatric procedures.

In up to 4 years of follow-up, compared to patients who underwent gastric bypass, those who underwent sleeve gastrectomy were 20% less likely to have a further abdominal operation (18.7% vs 21.9%) — mainly gallbladder removal or hernia repair — or to undergo endoscopy (for diagnosis or treatment of the upper GI tract) or require a feeding tube.

The study was based on national insurance claims data from more than 13,000 patients in the United States and was published online in JAMA Network Open on December 18.

"Although bypass surgery is more effective for weight loss and diabetes remission, patients should be aware that it may be associated with a slightly higher risk of undergoing additional procedures later," said lead author Kristina H. Lewis, MD, MPH, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, in a statement issued by her institution.

"We already have strong evidence that bariatric surgery is the most effective weight loss intervention for patients with severe obesity, and surgery is definitely much safer than it used to be," she continued.

"But patients still have to balance the pros of having surgery against potential complications," she said, "and this may be especially important when choosing between bariatric surgery types."

The decision to have either sleeve gastrectomy or gastric bypass, Lewis noted, "will depend on a patient's goals for surgery and his or her particular health concerns."

The current study findings, the researchers write, "add to the complex and emerging picture regarding procedure choice for patients considering bariatric surgery.

"It is crucial for clinicians to clearly communicate these potential risks to patients considering bariatric surgery as they weigh the potential benefits and complications of these two procedures," they stress.

Unclear Risk for Subsequent Abdominal Procedures

Previous studies have estimated that 1% to 15% of patients who undergo sleeve gastrectomy and 6% to 22% of patients who undergo gastric bypass will have another abdominal operation within 1 to 5 years.

Researchers have also reported wide variations in subsequent nonsurgical abdominal procedures after these two types of bariatric surgery.

To clarify these risks, Lewis and colleagues analyzed national insurance claims from the Bariatric CHOICE (Comparative Health Outcomes Using Insurance Claims to Study Effectiveness) project.

They matched 4476 patients who underwent laparoscopic gastric bypass with 8851 patients who underwent laparoscopic sleeve gastrectomy during 2010 to 2017. Patients were matched on the basis of their body mass index (BMI) range, year of surgery, geographic region, and diabetes status.

The mean age of the patients was 44 years, and 74% were women.

About half (46%) had an initial BMI of 40 to 49.9 kg/m2; the others had a BMI of 50 to >60 kg/m2 (24%) or 30 to 39.9 kg/m2 (14%).

Sixty percent had gastroesophageal reflux disease (GERD); 42% had type 2 diabetes; and about 47% had hypertension.

Patients' postoperative data were available for a median of 1.6 years. Only 42% were still enrolled in the insurance plan at 2 years, and only 16% were still enrolled at 4 years.

During up to 4 years of follow-up, patients who underwent sleeve gastrectomy had a lower risk of undergoing a biliary procedure (adjusted hazard ratio, 0.77), an abdominal wall hernia repair (0.60), endoscopy (0.54), or requiring a feeding tube (0.58). All calculations were adjusted for the matched variables and age range, sex, comorbidity score, hypertension, GERD, and mental illness.

Rare Repeat Bariatric Surgery, but Higher Risk in Sleeve Group

In contrast, the patients who underwent sleeve gastrectomy had a higher risk of undergoing a subsequent bariatric surgery procedure during follow-up, although the rate was low (2.4% vs 1.1%; adjusted hazard ratio, 1.83).

Some patients may have undergone a planned gastric bypass after a gastrectomy because they were initially too overweight for gastric bypass, and others may have undergone a repeat gastrectomy because of regaining weight, the researchers speculate.

They acknowledge that study limitations include the high number of patients who were lost to follow-up and the lack of information about surgeon case volume.

Nevertheless, the research highlights the importance of considering "not only the clinical effectiveness of these [two] procedures but also the risk for subsequent operative and nonoperative interventions," they reiterate.

The Bariatric CHOICE project was supported by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases.

JAMA Network Open. Published online December 18, 2019. Full text

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