Post-Op Path Smoother With Gastric Sleeve

Fewer interventions were needed after gastric sleeve surgery than with gastric bypass, a large study found.

In a comparison of over 18,000 patients who underwent Roux-en-Y gastric bypass to 15,500 patients who underwent sleeve gastrectomy, there was a 28% lower risk for operation or intervention after the sleeve procedure (hazard ratio 0.72, 95% CI 0.65-0.79), reported Anita Courcoulas, MD, of the University of Pittsburgh Medical Center, and colleagues.

Fewer gastric sleeve patients required hospitalization compared with gastric bypass (HR 0.82, 95% CI 0.78-0.87), they wrote in JAMA Surgery.

Also, the need for an endoscopy (diagnostic or therapeutic) was far less for sleeve patients than gastric bypass patients (HR 0.47, 95% CI 0.43-0.52).

All-cause morality rates were similar for both procedures, and there was a less than 1% cumulative risk for mortality 5 years out of surgery for either procedure. However, self-harm, substance and/or alcohol abuse, and unintentional injury all made the top 15 most common cases of death post-operative.

On the other hand, revision was slightly more common with the sleeve procedure, although this didn’t reach statistical significance (HR 1.17, 95% CI 0.98-1.39, P=0.09).

“In bariatric surgery, there has been an explosion of data, but most focuses on positive outcomes,” Courcoulas pointed out in a statement. “This study is important because it includes adverse events people might be concerned about.”

“What we advocate is high-quality shared decision making between providers and patients,” she highlighted, adding how this starts “with a conversation about what their preferences and values are. Some people value low risk, some value high weight loss. It’s important to have information on both sides of the risk-benefit equation.”

Drawing on data from the PCORnet Bariatric Surgery study cohort, the analysis included first-operation patients from 10 centers. Sleeve gastrectomy patients tended to be younger with lower rates of diabetes (26.4% vs 44.4%), and a slightly lower mean BMI (7.6 vs 8.1).

Operations after surgery were defined as any surgical procedure on the abdomen, including revisions and abdominal wall hernia repairs, but excluded biliary procedures such as cholecystectomy. Interventions were defined as a procedure involving enteral access, such as placing gastrostomy tubes, or involving a nonsurgical but invasive abdomen procedure like paracentesis or radiologically guided drainage procedures that do not involve incision.

Courcoulas suggested that the complexity of gastric bypass procedure and the need for more involved patient care after this surgery may play a role.

Study limitations included the fact that it was not randomized. Also, comorbidities and the score calculations were done using ICD-9-CM diagnosis codes, “which may have underestimated comorbidity prevalence rates and therefore disease severity,” the authors noted.

In an accompanying commentary, Anne Ehlers, MD, MPH, and Amir Ghaferi, MD, both of the University of Michigan in Ann Arbor, stated that the study addressed two major lingering questions in bariatric surgery.

First, these findings offer assurance that sleeve gastrectomy does not in fact lead to “unacceptably high rates of severe gastroesophageal reflux disease” leading to a disproportionate amount of reoperations. This was further reinforced by the lower rate of endoscopy versus gastric bypass, they said.

Second, Ehlers and Ghaferi noted that those with a lower BMI and less diabetes had arguably better postoperative outcomes.

“This adds to growing evidence suggesting that earlier intervention is optimal,” they stated, adding “It is time we stop questioning the safety or efficacy of surgery and begin advocating for comprehensive obesity care for patients.”

Last Updated January 15, 2020