Fewer Deaths After Sleeve Gastrectomy Versus Gastric Bypass

Bariatric surgery patients who opted for sleeve gastrectomy saw a lower risk of death, a new study found.

In a retrospective cohort study of nearly 100,000 Medicare patients with severe obesity, those who underwent laparoscopic sleeve gastrectomy had a lower cumulative mortality incidence over 5 years compared with patients who underwent laparoscopic Roux-en-Y gastric bypass (4.27% vs 5.67%), reported Ryan Howard, MD, of the University of Michigan in Ann Arbor, and colleagues.

This equated to a 32%, 22%, and 16% lower adjusted risk for death at postoperative years 1, 3, and 5, respectively.

“This absolute difference in 5-year mortality of 1.4 percentage points translates to a 32.8% relative difference in mortality between the two procedures and a number needed to harm of 71,” the group wrote in JAMA Surgery. “Consequently, had all patients in the current study undergone sleeve gastrectomy, we can estimate that roughly 540 fewer deaths would have occurred at the 5-year time point.”

Sleeve patients also experienced significantly fewer complications compared with gastric bypass patients (22.10% vs 29.03%), which likely contributed to the lower risk of death, as well as lower rates of reintervention — a composite of revision, reoperation, enteral access and vascular access procedures, and other interventions — over 5 years (25.23% vs 33.57%, respectively).

However, when surgical revision was looked at separately, sleeve patients actually did have a higher cumulative incidence of revision at 5 years (2.91% vs 1.46%).

Sleeve gastrectomy patients did have lower risks of all types of reoperations — abdominal wall hernia repair, biliary procedures, and internal hernia repair — but the risk of paraesophageal hernia repair was more than two-fold higher 1 year after sleeve gastrectomy and continued to rise in the years thereafter (at 5 years: adjusted HR [aHR] 3.16, 95% CI 2.16-4.63).

At the 1-year postoperative mark, sleeve gastrectomy patients saw a lower risk of hospitalization (aHR 0.83, 95% CI 0.80-0.86), as well as emergency department use (aHR 0.87, 95% CI 0.84-0.90). This remained significantly lower 3 years after surgery (hospitalization: aHR 0.94, 95% CI 0.90-0.98; ED use: aHR 0.93, 95% CI 0.90-0.97), but leveled out and was comparable between sleeve and gastric bypass patients 5 years after surgery.

As for total healthcare spending, sleeve gastrectomy was less costly at 1 year ($28,706 vs $30,663 for bypass). But, following a similar trend as hospitalization rates, total healthcare spending among sleeve and bypass patients was similar at year 3 ($57,411 vs $58,581) and at year 5 ($86,584 vs $85,762).

“Sleeve gastrectomy is the most common bariatric procedure performed in the U.S.,” Howard’s group wrote. “Composing less than 10% of bariatric procedures in 2010, it now accounts for over 60% of all bariatric procedures.”

“Its popularity is owed largely to its excellent short-term safety profile, efficacious weight loss and comorbidity resolution, and technical ease compared with gastric bypass, which is the second most common bariatric operation,” they pointed out. “Sleeve gastrectomy is also recognized as a safe surgical option for high-risk patient groups, such as older patients with multiple comorbidities.”

For the analysis, the researchers gathered data on 95,405 Medicare patients who underwent sleeve gastrectomy or gastric bypass from January 2012 through December 2018. This included a total of 57,003 patients in the sleeve gastrectomy group and 38,402 patients in the gastric bypass group, with mean ages of 57 and 56, respectively. As expected, about 75% of both surgery groups were comprised of women.

Comorbidities were comparable between the two surgical groups, though patients with diabetes more often opted for gastric bypass, accounting for 45% of this group, while 36% of sleeve patients had diabetes.

This was a difference highlighted by Anita P. Courcoulas, MD, MPH, and Bestoun Ahmed, MD, both of the University of Pittsburgh Medical Center in Pennsylvania, in an accompanying commentary, who noted that diabetes resolution has been known to be better with gastric bypass than sleeve gastrectomy.

“The mortality difference is a new finding,” they noted. “Also, the rate of surgical revisional procedures … was higher for those who had sleeve gastrectomy, which is new and important confirmatory evidence of what is currently observed in clinical practice, with revisions likely driven mostly by refractory gastroesophageal reflux and/or weight loss failure.”