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Fewer interventions after sleeve gastrectomy vs. Roux-en-Y, real-world data show

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Stop questioning bariatric surgery safety

This study by Courcoulas and colleagues adds to an established body of data showing that bariatric surgery is safe, according to authors of an invited commentary on the study.

More specifically, the study provides data that sleeve gastrectomy – which has become the most common bariatric procedure in the United States – is safe in the long term, said Anne P. Ehlers, MD, MPH, and Amir A. Ghaferi, MD, MS.

Barriers to surgery need to come down in response to the worsening public health crisis that these procedures address, according to Dr. Ehlers and Dr. Ghaferi.

“It is time we stop questioning the safety or efficacy of surgery and begin advocating for comprehensive obesity care for patients,” they said in their invited commentary.

Less than 1% of patients eligible for bariatric surgery undergo this “life-saving” treatment, they said, adding that obesity bias delays surgical referrals, while some “continue to fear” surgical risks, and decades-old guidelines restrict procedures to patients with higher body mass index.

The present study shows that sleeve gastrectomy is at least as safe, if not safer, than the Roux-en-Y gastric bypass procedure, said Dr. Ehlers and Dr. Ghaferi.

The study also answers the question of whether sleeve gastrectomy has an “unacceptably high” rate of gastroesophageal reflux disease (GERD) prompting revision surgeries, they said.

On the contrary, sleeve gastrectomy was associated with lower rates of reoperation, and lower rates of endoscopies, which almost always come before reoperations related to GERD, they explained.

Anne P. Ehlers, MD, MPH, and Amir A. Ghaferi, MD, MS, are with the department of surgery at the University of Michigan in Ann Arbor. They reported no conflicts of interests related to their invited commentary, which appears in JAMA Surgery .



Sleeve gastrectomy was associated with significantly fewer postsurgical interventions and operations than was Roux-en-Y gastric bypass over longer-term follow-up in a recent cohort study based on real-world clinical data, according to investigators.

Interventions, operations, and hospitalizations were “relatively common” for both procedures over the 5-year follow-up, though significantly less so with sleeve gastrectomy, which has become the most common bariatric operation, the investigators said in a recent report on the study.

The benefit of sleeve gastrectomy seemed to be most pronounced in patients with lower body mass index and those with fewer comorbidities, according to the authors of the report, led by bariatric and general surgeon Anita Courcoulas, MD, of the University of Pittsburgh Medical Center.

That finding is counterintuitive, since in clinical practice, sleeve gastrectomy is frequently thought of as the preferred procedure for individuals with higher BMI or more comorbidities, though Dr. Courcoulas and colleagues cautioned that the findings were “exploratory” and require further investigation. Historically, Roux-en-Y gastric bypass provided more weight loss.

Safety results from this study, balanced by weight loss and health outcomes data, will “help inform procedure-specific decision making for prospective patients and physicians,” said Dr. Courcoulas and coauthors of the report, which appears in JAMA Surgery.

The study included 33,560 adults who had undergone the Roux-en-Y procedure or sleeve gastrectomy, making it one of the largest bariatric cohort studies ever to be done, according to the investigators.

The majority of patients in the study (54%) underwent Roux-en-Y gastric bypass, though the number of sleeve gastrectomy procedures increased each year in the study, which included patients who underwent a primary bariatric surgery procedure between January 2005 and September 2015 at 1 of 10 sites in the National Patient-Centered Clinical Research Network.

Most of the patients were female (80%) and white (66%), and 26% were Hispanic, according to the researchers, who said their study was more racially diverse than other bariatric studies, and therefore potentially more generalizable to real-world clinical practice.

Over the 5-year follow-up period, patients who underwent sleeve gastrectomy were less likely to subsequently undergo operations involving the abdomen, or interventions for enteral access, such as placement of gastrostomy tubes, according to the investigators, who reported a hazard ratio (HR) of 0.72 (95% confidence interval [CI], 0.65-0.79; P less than .001).

The estimated cumulative rate of operations or interventions at 5 years was 8.94% (95% CI, 8.23%-9.65%) for the patients who underwent sleeve gastrectomy, compared with 12.27% (95% CI, 11.49%-13.05%) for those who underwent the Roux-en-Y procedure, according to the report.

Hospitalization was also less likely for sleeve gastrectomy versus Roux-en-Y gastric bypass, with a hazard ratio of 0.82 and estimated cumulative incidence rates of 32.79% and 38.33%, respectively. Likewise, endoscopy was less likely in the sleeve gastrectomy group.

All-cause mortality did not differ between the groups at this 5-year follow-up, the investigators said.

“The present data were gathered from clinical care in the real world, yet the results are comparable to controlled studies and therefore lend additional support to the findings of these other types of studies that operation and intervention occur less commonly after sleeve gastrectomy than after Roux-en-Y gastric bypass for up to 5 years,” Dr. Courcoulas and coauthors noted in a discussion of their results.

This work was funded by the Patient-Centered Outcomes Research Institute. Dr. Courcoulas reported receiving a grant from Allurion. Coauthors provided disclosures related to the National Institutes of Health, IFSO Latin America Chapter, and the Food and Drug Administration.

*This story was updated on January 16, 2020.

SOURCE: Courcoulas A et al. JAMA Surg. 2020 Jan 15. doi: 10.1001/jamasurg.2019.5470.

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