Roux-en-Y gastric bypass versus sleeve gastrectomy: nationwide data from the Danish quality registry for treatment of severe obesity

BackgroundBariatric surgery as treatment of obesity is increasing worldwide. No guidelines exist on which type of bariatric procedure to choose for the individual patient.ObjectivesThis study aims to compare Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) with respect to weight loss, complications, comorbidities, and quality of life.SettingA nationwide multi-center register-based cohort study.MethodsWe identified 16,053 patients treated by bariatric surgery from 2008 to 2021 (RYGB, n = 13,075; SG, n = 2978) from the Danish quality registry for treatment of severe obesity (DBSO). We calculated risk ratios (RRs) and prevalence ratios (PRs) comparing surgical complications, weight loss, and medical comorbidities by type of procedure up to 2 years after surgery.ResultsPatients treated with RYGB experienced a greater weight loss than patients treated by SG both after 1 year (PR, .53; 95% confidence interval [CI], .48–.58) and 2 years (PR, .46; 95% CI, .39–.54). Compared with RYGB, SG yielded a lower risk of readmission (RR, .71; 95% CI, .60–.85). Likewise, the risk of reoperation between 30 days and 1 year (RR, .40; 95% CI, .30–.53) and 1 and 5 years (RR, .15; 95% CI, .12–.20]) were lower following SG. At 1-year follow-up, 76% of patients treated with RYGB and 63% of patients treated with SG experienced diabetes remission. Ten percent and 61% of patients were lost to follow-up after 1 and 2 years, respectively.ConclusionThe DBSO is an important resource in studying treatment of severe obesity. Weight loss is slightly greater after RYGB than after SG, but RYGB is associated with more frequent readmissions and reoperations.     

Hospital utilization 4 years after bariatric surgery: sleeve gastrectomy versus Roux-en-Y gastric bypass

BackgroundWhile sleeve gastrectomy (SG) has lower perioperative risk compared with Roux-en-Y gastric bypass (RYGB), long-term data about their differential impact on overall health are unclear. Hospital use after bariatric surgery is an important parameter for improving peri- and postoperative care.ObjectiveThis present study was aimed to compare SG and RYGB in terms of their effect on long-term hospital-based healthcare utilization.SettingMulticenter, statewide database.MethodsA retrospective cohort study of adult patients who underwent SG and RYGB between 2009 and 2011, with follow-up until 2015 and 2-year presurgery information. Propensity score–matched SG and RYGB groups were created using preoperative demographic characteristics, co-morbidities, and presurgery hospital use, measured by cumulative length of stay (LOS) and frequency of emergency department visits. Postsurgery yearly LOS, incidence of hospital visits, and the reason for the visit were compared. Primary outcomes included postoperative hospital visits during years 1 to 4 after bariatric surgery and cumulative LOS. Secondary outcomes included specific reasons for hospital use.ResultsThere were 3540 SG and 13,587 RYGB patients, whose mean (95% confidence interval [CI]) LOS was 1.3 (1.3–1.4), .9 (.8–1), 1 (.9–1.1), and 1.2 (1–1.3) days at years 1 through 4, respectively. Postoperative yearly LOS was similar between the 2 propensity-matched groups. The risk of hospitalizations (odd ratio .73, 95% CI .64–.84, P < .0001) and emergency department visits (odds ratio .84, 95% CI .75–.95, P = .005) was significantly lower for SG, during the first postoperative year. The reverse was seen at the fourth postoperative year, with higher risk of emergency department use after SG (odds ratio 1.16, 95% CI 1.01–1.33, P = .035).ConclusionPostoperative 4-year hospital utilization remains low for both SG and RYGB. The previously established lower early perioperative risk of SG was not appreciated for longer-term hospital use compared with RYGB.     

Safety of bariatric surgery in patients older than 65 years

BackgroundThe increase in life expectancy along with the obesity epidemic has led to an increase in the number of older patients undergoing bariatric surgery. There is conflicting evidence regarding the safety of performing bariatric procedures on older patients.ObjectiveThe purpose of this study was to compare the safety of laparoscopic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) for older patients (>65 yr).SettingNationwide analysis of accredited centers.MethodsThe Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2015 to 2017 database was used to identify nonrevisional laparoscopic RYGB and SG procedures. Comparisons were made based on patient age. Clinical outcomes included postoperative events and mortality.ResultsThere was a total 13,422 and 5395 matched pairs for SG and RYGB in comparing patients aged 18 years to those aged 65 and >65 years, respectively, and 5395 matched RYGB and SG procedures performed in patients >65 years. The complication rate was higher in older patients undergoing RYGB compared with SG (risk difference = 2.39%, 95% confidence interval: 1.57%–3.21%, P < .0001). When comparing older to younger patients, the older group had a higher complication rate for SG but not for RYGB (SG: risk difference = 1.01%, 95% confidence interval: .59%–1.43%, P < .0001, RYGB: risk difference = .59%, 95% confidence interval: ?.29% to 1.47%, P = .2003).ConclusionsOverall complication rates of bariatric surgery are low in patients >65 years. SG appears to have a favorable safety profile in this patient population compared with RYGB. The overall complication rate for RYGB is not significantly different between the older and younger groups.     

Comparison of the incidence of cholelithiasis after sleeve gastrectomy and Roux-en-Y gastric bypass: a meta-analysis

BackgroundBariatric surgery could increase the risk of cholelithiasis, although it is unclear whether the incidence rates of cholelithiasis are similar after different bariatric procedures.ObjectivesTo compare the incidence rates of cholelithiasis after sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) in people with obesity.SettingMeta-analysis of cohort studies.MethodsWe searched the PubMed and Web of Science databases for relevant studies before December 2020, and estimated the summary odds ratios (OR) and 95% confidence intervals (CI) using a random-effects model or fixed-effects model, according to the heterogeneity.ResultsIn total, 8 cohort studies were included in this meta-analysis, and 94,855 and 106,844 participants received SG and RYGB, respectively. Compared with those receiving RYGB, the summary results showed that participants receiving SG had a 35% lower rate of cholelithiasis (OR, .65; 95% CI, .49–.86). Also, the participants receiving SG had a significantly lower incidence of cholecystectomy than those receiving RYGB (OR, .54; 95% CI, .30–.99). In a subgroup analysis, SG was associated with a significantly lower incidence of subsequent cholelithiasis than RYGB in both Western and non-Western countries. SG led to a significantly lower incidence of cholelithiasis than RYGB only when the follow-up was <2 years instead of over 2 years.ConclusionParticipants receiving SG had a significantly lower incidence of cholelithiasis than those receiving RYGB, particularly within the first 2 years after the bariatric surgery.     

Metabolic effects of bariatric surgery on patients with type 2 diabetes: a population-based study

BackgroundBariatric surgery among patients with obesity and type 2 diabetes (T2D) can induce complete remission. However, it remains unclear whether sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) has better T2D remission within a population-based daily practice.ObjectivesTo compare patients undergoing RYGB and SG on the extent of T2D remission at the 1-year follow-up.SettingNationwide, population-based study including all 18 hospitals in the Netherlands providing metabolic and bariatric surgery.MethodsPatients undergoing RYGB and SG between October 2015 and October 2018 with 1 year of complete follow-up data were selected from the mandatory nationwide Dutch Audit for Treatment of Obesity (DATO). The primary outcome is T2D remission within 1 year. Secondary outcomes include ≥20% total weight loss (TWL), obesity-related co-morbidity reduction, and postoperative complications with a Clavien-Dindo (CD) grade ≥III within 30 days. We compared T2D remission between RYGB and SG groups using propensity score matching to adjust for confounding by indication.ResultsA total of 5015 patients were identified from the DATO, and 4132 (82.4%) had completed a 1-year follow-up visit. There were 3350 (66.8%) patients with a valid T2D status who were included in the analysis (RYGB = 2623; SG = 727). RYGB patients had a lower body mass index than SG patients, but were more often female, with higher gastroesophageal reflux disease and dyslipidemia rates. After adjusting for these confounders, RYGB patients had increased odds of achieving T2D remission (odds ratio [OR], 1.54; 95% confidence interval [CI], 1.14–2.1; P < .01). Groups were balanced after matching 695 patients in each group. After matching, RYGB patients still had better odds of T2D remission (OR, 1.91; 95% CI, 1.27–2.88; P < .01). Also, significantly more RYGB patients had ≥20%TWL (OR, 2.71; 95% CI, 1.96–3.75; P < .01) and RYGB patients had higher dyslipidemia remission rates (OR, 1.96; 95% CI, 1.39–2.76; P < .01). There were no significant differences in CD ≥III complications.ConclusionUsing population-based data from the Netherlands, this study shows that RYGB leads to better T2D remission rates at the 1-year follow-up and better metabolic outcomes for patients with obesity and T2D undergoing bariatric surgery in daily practice.     

Early morbidity and mortality of laparoscopic sleeve gastrectomy and gastric bypass in the elderly: a NSQIP analysis

BackgroundEven though the U.S. population is aging, outcomes of bariatric surgery in the elderly are not well defined. Current literature mostly evaluates the effects of gastric bypass (RYGB), with paucity of data on sleeve gastrectomy (SG). The objective of this study was to assess 30-day morbidity and mortality associated with laparoscopic SG in patients aged 65 years and over, in comparison to RYGB.MethodsThe National Surgical Quality Improvement Program (NSQIP) database was queried for all patients aged 65 and over who underwent laparoscopic RYGB and SG between 2010 and 2011. Baseline characteristics and outcomes were compared. P value<.05 was considered significant. Odds ratios (OR) with 95% confidence interval (CI) were reported when applicable.ResultsWe identified 1005 patients. Mean body mass index was 44±7. SG was performed in 155 patients (15.4%). The American Society of Anesthesiology physical classification of 3 or 4 was similar between the 2 groups (82.6% versus 86.7%, P = .173). Diabetes was more frequent in the RYGB group (43.2% versus 55.6%, P = .004). 30-day mortality (0.6% versus 0.6%, OR 1.1, 95% CI .11–9.49), serious morbidity (5.2% versus 5.6%, OR .91, 95% CI .42–0.96), and overall morbidity (9% versus 9.1%, OR 1.0, 95% CI .55–1.81) were similar.ConclusionIn elderly patients undergoing laparoscopic bariatric surgery, SG is not associated with significantly different 30-day outcomes compared to RYGB. Both procedures are followed by acceptably low morbidity and mortality.     

Metabolic bone disease and fracture risk after gastric bypass and sleeve gastrectomy: comparative analysis of a multi-institutional research network

BackgroundRoux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are the two most performed bariatric procedures. Multiple studies have investigated the metabolic bone complications after bariatric surgery, but there is a paucity of data comparing bone health after RYGB and SG.ObjectivesTo compare the rates of major fractures and osteoporosis after Roux-en-Y gastric bypass and sleeve gastrectomy.SettingData from TriNetX multi-institutional research network that includes data from multiple health care organizations in the USA was analyzed at West Virginia University.MethodsWe conducted a retrospective cohort study using TriNetX, a federated multi-institutional research network. We identified patients who underwent RYGB or SG. Primary outcome was the rate of major fractures at 3 years after the procedure. Other outcomes included the rate of spine fracture, femur fracture, osteoporosis, and vitamin D deficiency at follow-up.ResultsIn unmatched analysis, patients with SG were less likely to have major fractures or an osteoporosis diagnosis than RYGB patients at 3 years after the procedure (P < .05). After propensity-score matching, similar results were noted; patients with SG were less likely to have major fractures than RYGB patients at 3 years after procedure (2.85% versus 3.66%, risk ratio [RR]: .78, 95% confidence interval [CI]: .71–.85), and a lower rate of osteoporosis diagnosis was noted in the SG group. High rates of vitamin D deficiency were noted in both cohorts. The incidence of spine fractures was significantly lower in the SG group than in the RYGB group (.76% versus 1.18%, RR: .65, 95% CI: .54–.77). Similarly, the incidence of femur fracture was significantly lower after SG (RR: .62, 95% CI: .44–.88). Female sex, higher age, smoking history, and diabetes were independently associated with osteoporosis diagnosis during follow-up (all P values <.05).ConclusionOur analyses showed that RYGB is associated with a higher risk of osteoporosis, vitamin D deficiency, and osteoporotic fractures. Thus, in patients with a higher baseline osteoporotic risk, SG may be preferred option; however, further studies are needed.     

The risk of kidney stones following bariatric surgery: a systematic review and meta-analysis

Background With rising prevalence of morbid obesity, the number of bariatric surgeries performed each year has been increasing worldwide. The objective of this meta-analysis was to assess the risk of kidney stones following bariatric surgery. Methods A literature search was performed using MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews from inception through July 2015. Only studies reporting relative risks, odd ratios or hazard ratios (HRs) to compare risk of kidney stones in patients who underwent bariatric surgery versus no surgery were included. Pooled risk ratios (RR) and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method. Results Four studies (One randomized controlled trial and three cohort studies) with 11,348 patients were included in analysis to assess the risk of kidney stones following bariatric surgery. The pooled RR of kidney stones in patients undergoing bariatric surgery was 1.22 (95% CI, 0.63–2.35). The type of bariatric surgery subgroup analysis demonstrated an increased risk of kidney stones in patients following Roux-en-Y gastric bypass (RYGB) with the pooled RR of 1.73 (95% CI, 1.30–2.30) and a decreased risk of kidney stones in patients following restrictive procedures including laparoscopic banding or sleeve gastrectomy with the pooled RR of 0.37 (95% CI, 0.16–0.85). Conclusions Our meta-analysis demonstrates an association between RYGB and increased risk of kidney stones. Restrictive bariatric surgery, on the other hand, may decrease kidney stone risk. Future study with long-term follow-up data is needed to confirm this potential benefit of restrictive bariatric surgery.     

Esophageal cancer after sleeve gastrectomy: a population-based comparative cohort study

BackgroundSleeve gastrectomy (SG) is the most common bariatric surgery; however, this approach may induce gastroesophageal reflux disease (GERD). Both obesity and GERD are independent risk factors for esophageal cancer, however the impact of SG on risk of esophageal cancer remains unknown.ObjectiveTo evaluate the risk of esophageal cancer after reflux-prone bariatric surgery.SettingPopulation-level, provincial administrative healthcare database, Quebec, Canada.MethodsWe identified a population-based cohort of all patients with obesity who underwent reflux-prone surgery (SG and duodenal switch [DS]) or reflux-protective Roux-en-Y gastric bypass (RYGB) during 01/2006–12/2012 in Quebec, Canada. For every surgical patient, 2-3 nonsurgical controls with obesity matched for age, sex, and geography were also identified. Crude incidence rate ratios (IRRs) for esophageal cancer were calculated using person-time analysis. Hazard ratios (HRs) were obtained using multivariate cox regression.ResultsA total of 4121 patients had reflux-prone procedures and 852 underwent RYGB. At a mean follow-up of 7.6 years, 8 cases of esophageal cancer were identified after bariatric surgery. Compared with RYGB, IRR for esophageal cancer in reflux-prone group was 1.45 (95%CI: .19–65.5) and HR = .83 (95%CI: .10–7.27). The crude incidence rate of esophageal cancer in the reflux-prone group was higher than that of nonsurgical controls (n = 12,159; IRR = 3.46, 95%CI: 1.00–12.5), but after adjustment the difference disappeared (HR = 2.47, 95%CI: .82–7.45).ConclusionsLong-term incidence of esophageal cancer after reflux-prone bariatric surgery is not greater than RYGB. While crude incidence of esophageal cancer after reflux-prone surgery is higher than in nonsurgical patients with obesity, such difference disappears after accounting for confounders. Given the low incidence of esophageal cancer and slow progression of dysplastic Barrett esophagus, studies with longer follow-up are needed.     

The relationship between kidney function and body mass index before and after bariatric surgery in patients with chronic kidney disease

BackgroundImprovements in kidney function post–bariatric surgery may be related to weight loss–independent effects.ObjectivesTo characterize the dynamic relationship between body mass index (BMI) and estimated glomerular filtration rate (eGFR) before and after bariatric surgery in patients with chronic kidney disease (CKD).SettingKaiser Permanente Southern California (KPSC) health system.MethodsWe conducted an observational, retrospective cohort study of patients with CKD stage 3 or higher who received bariatric surgery at the KPSC health system between 2007–2015. Bariatric surgery procedures included primary Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) procedures. Outcomes consisted of mean trajectory estimates and correlations of BMI and eGFR taken between 2 years before and 3 years after surgery. Multivariate functional mixed models were used to estimate how BMI and eGFR trajectories evolved jointly.ResultsA total of 619 RYGB and 474 SG patients were included in the final analytic sample. The measurements were available before surgery for a median time of 1.9 years for SG and 1.8 years for RYGB patients. Median follow-up times after surgery were 2.8 years for both SG and RYGB patients. The mean age at the time of surgery was 58 years; 77% of patients were women; 56% of patients were non-Hispanic White; the mean BMI was 44 kg/m²; 60% of patients had diabetes mellitus; and 84% of patients had hypertension. Compared to the presurgery eGFR declines, the postsurgery declines in eGFR were 57% slower (95% credible interval [CrI], 33%–81%) for RYGB patients and 55% slower (95% CrI, 25%–75%) for SG patients. The mean correlation between BMI and eGFR was negligible at all time points.ConclusionThough bariatric surgery slowed declines in eGFR up to 3 years after surgery, changes in eGFR tracked poorly with changes in BMI. This study provides evidence that the kidney-related benefits of bariatric surgery may be at least partly independent of weight loss. Confirming this hypothesis could lead to mechanistic insights and new treatment options for CKD.     

Analysis of vitamin levels and deficiencies in bariatric surgery patients: a single-institutional analysis

BackgroundBariatric surgery patients are at risk for vitamin deficiencies.ObjectivesInvestigate the prevalence of deficiencies of vitamins A, B1, B12, D, and folate in sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) patients in a single institution.SettingAn academic medical center.MethodsRetrospective chart reviews of 468 bariatric surgery patients (358 SG and 110 RYGB) were analyzed for vitamin levels, calcium, and parathyroid hormone. Both preoperative and postoperative measurements were obtained.ResultsDeficiency of vitamin D was the most common, seen in 27% preoperatively. Postoperatively, RYGB patients had a higher prevalence of vitamin D deficiency than SG patients (11.5% RYGB versus 5.2% SG within the first postoperative year, and 20.3% RYGB versus 13.4% SG after 1 year). Elevated parathyroid hormone was observed in 45% of RYGB patients after 1 year postoperatively. Vitamin A deficiency was uncommon preoperatively (2.7% SG versus 1.7% RYGB), but increased after surgery (9.4% SG versus 15.9% RYGB within 1 year postoperatively, and 5.2% SG versus 7.7% RYGB after 1 year). Vitamin B1 deficiency was observed in 8.1% SG versus 1.7% RYGB patients preoperatively and increased during the first year postoperatively (SG 10.5% and RYGB 13.7%), but improved after 1 year (7.2% SG versus 5.9% RYGB). Less than 2% of Vitamin B12 deficiencies and no folate deficiencies occurred in both SG and RYGB patients.ConclusionsThe highest prevalence of vitamin B1 and A deficiencies were seen in the first year postoperatively. Vitamin B12 and folate deficiency were uncommon in our patients. Vitamin D deficiency improved after surgery, but elevated parathyroid hormone was common after RYGB.     

Bariatric surgery in patients with obesity and end-stage renal disease

BackgroundBariatric surgery has been suggested as a treatment for obesity and end-stage renal disease (ESRD). Although the number of bariatric surgeries in patients with ESRD is increasing, its safety and effectiveness in these patients are still controversial and the surgical method of choice in these patients is under debate.ObjectivesTo compare the outcomes of bariatric surgery between patients with and without ESRD and to assess different methods of bariatric surgery in patients with ESRD.SettingMeta-analysis.MethodsA comprehensive search was conducted in Web of Science and Medline (via Pubmed) until May 2022. Tow meta-analyses were performed: A) to compare bariatric surgery outcomes among patients with and without ESRD, and B) to compare outcomes of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) in patients with ESRD. Using a random-effect model, odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were computed for surgical and weight loss outcomes.ResultsOf 5895 articles, 6 studies were included in meta-analysis A and 8 studies in meta-analysis B. The risk of bias was moderate to serious among studies. Major postoperative complications (OR = 2.82; 95% CI = 1.66–4.77; P = .0001), reoperation (OR = 2.66; 95% CI = 1.99–3.56; P < .00001), readmission (OR = 2.37; 95% CI = 1.55–3.64; P < .0001), and in-hospital/90-d mortality (OR = 4.03; 95% CI = 1.80–9.03; P = .0007) were higher in patients with ESRD. Patients with ESRD also had a longer hospital stay (MD = 1.23; 95% CI = .32–2.14; P = .008). Bleeding, leakage, and total weight loss were comparable among groups. SG showed a 10% lower rate of overall complications and significantly shorter hospital stay than RYGB did. The quality of evidence was very low for the outcomesConclusionsBariatric surgery in patients with ESRD seems to have higher rates of major complications and perioperative mortality than in patients without ESRD, but a comparable rate of overall complications. SG has fewer postoperative complications and could be the method of choice in these patients. These findings should be interpreted cautiously in light of the moderate to high risk of bias in most included studies.     

Health disparity in access to bariatric surgery

BackgroundSociodemographic disparities in terms of access to bariatric surgery are ongoing.ObjectivesThis study aimed to examine the trends for bariatric interventions based on patient characteristics from 2011 to 2018 in the state of New York.SettingAdministrative statewide database.MethodsThis study used the New York Statewide Planning and Research Cooperative System database to identify all patients with obesity who underwent Roux-en-Y gastric bypass (RYGB), laparoscopic sleeve gastrectomy (SG), and laparoscopic adjustable gastric banding (LAGB) between 2011 and 2018. The trends were studied for the types of bariatric procedures performed across different patient characteristics, including median household income as determined based on ZIP code. A multivariable logistic regression analysis was performed to compare the yearly trends.ResultsWe identified 111,793 patients who underwent bariatric surgery. The number of bariatric procedures increased from 9304 in 2011 to 16,946 in 2018. RYGB was the most performed bariatric operation in 2011, but was replaced by SG from 2013 to 2018. Patients living in the highest decile median household income ZIP code areas had the highest increase in SG (odds ratio [OR], 1.51; 95% confidence interval [CI], 1.46–1.55; P < .0001) and the largest decrease in LAGB (OR, .53; 95% CI, .51–.56; P = .0007).ConclusionsThe use of bariatric surgery increased significantly from 2011 to 2018. However, the disproportionately and substantially increased use of SG and the decreased use of LAGB in patients living in wealthier areas suggest that disparity in the use of bariatric interventions still exists. Public health efforts should be made to equalize access to bariatric surgery.     

Analysis of the risk factors for perioperative morbidity after laparoscopic revisional bariatric procedures: results from the multicenter Polish Revision Obesity Surgery Study

BackgroundThe growing number of primary bariatric operations has led to an increase in demand for revision surgeries. Higher numbers of revisional operations are also observed in Poland, yet their safety and efficacy remain controversial because of a lack of current recommendations and guidelines.ObjectiveTo review risk factors influencing perioperative morbidity.MethodsA retrospective study was conducted to analyze the results of surgical treatment among 12 Polish bariatric centers. Inclusion criteria were laparoscopic revisional bariatric surgeries and patients ≥18 years of age. The study included 795 patients, of whom 621 were female; the mean age was 47 years (range: 40–55 years).ResultsPerioperative morbidity occurred in 92 patients (11.6%) enrolled in the study, including 76 women (82.6%). The median age was 45 years (range: 39–54 years). Statistically significant risk factors in univariate logistic regression models for perioperative complications were the duration of obesity, revisional surgery after Roux-en-Y gastric bypass (RYGB) or adjustable gastric band (AGB), difference in body mass index before revisional surgery and the lowest achieved after primary surgery, and postoperative morbidity of the primary surgery as the cause for revisional bariatric surgery. These factors were included in the multivariate regression model. Revisional surgery after AGB (odds ratio [OR] = 2.18; 95% confidence interval [CI]: 1.28–3.69; P = .004), revisional surgery performed after RYGB (OR = 6.52; 95% CI: 1.98–21.49; P = .002), and revisions due to complication of the primary surgery (OR = 1.89; 95% CI: 1.06–3.34; P = .030) remained independent risk factors for perioperative morbidity.ConclusionRevisional operations after RYGB or AGB and those performed because of postoperative morbidity after primary surgery as the main cause for revisional surgery were associated with a significantly increased risk of postoperative morbidity.     

Fracture Risk After Bariatric Surgery: Roux‐en‐Y Gastric Bypass Versus Adjustable Gastric Banding

The long‐term consequences of bariatric surgery on fracture risk are unclear but are likely to vary by procedure type. In physiologic studies, Roux‐en‐Y gastric bypass (RYGB) and adjustable gastric banding (AGB) have differential effects on rates of bone loss. Therefore, our objective was to compare fracture risk in obese adults after RYGB and AGB procedures. Using claims data from a US commercial health plan, we analyzed rates of nonvertebral fractures within a propensity score–matched cohort (n = 15,032) of morbidly obese adults who received either RYGB or AGB surgery between 2005 and 2013. A total of 281 nonvertebral fractures occurred during a mean follow‐up time of 2.3 ± 1.9 years. RYGB patients had an increased risk of nonvertebral fracture (hazard ratio [HR] = 1.43, 95% confidence interval [CI] 1.13–1.81) compared with AGB patients. In fracture site–specific analyses, RYGB patients had increased risk of fracture at the hip (HR = 1.54, 95% CI 1.03–2.30) and wrist (HR = 1.45, 95% CI 1.01–2.07). Nonvertebral fracture risk associated with RYGB manifested >2 years after surgery and increased in subsequent years, with the highest risk in the fifth year after surgery (HR = 3.91, 95% CI 1.58–9.64). In summary, RYGB is associated with a 43% increased risk of nonvertebral fracture compared with AGB, with risk increasing >2 years after surgery. Fracture risk should be considered in risk/benefit discussions of bariatric surgery, particularly among patients with high baseline risk of osteoporosis who are deciding between RYGB and AGB procedures. © 2017 American Society for Bone and Mineral Research.     

Diagnoses related to abuse of alcohol and addictive substances after gastric bypass and sleeve gastrectomy: a nation-wide registry study from Norway

BackgroundAfter Roux-en-Y gastric bypass (RYGB) patients are at higher risk of alcohol problems. In recent years, sleeve gastrectomy (SG) has become a common procedure, but the incidence rates (IRs) of alcohol abuse after SG are unexplored.ObjectivesTo compare IRs of diagnoses indicating problems with alcohol or other substances between patients having undergone SG or RYGB with a minimum of 6-month follow-up.SettingAll government funded hospitals in Norway providing bariatric surgery.MethodsA retrospective population-based cohort study based on data from the Norwegian Patient Registry. The outcomes were ICD-10 of Diseases and Related Health Problems diagnoses relating to alcohol (F10) and other substances (F11–F19).ResultsThe registry provided data on 10,208 patients who underwent either RYGB or SG during the years 2008 to 2014 with a total postoperative observation time of 33,352 person-years. This corresponds to 8196 patients with RYGB (27,846 person-yr, average 3.4 yr) and 2012 patients with SG (5506 person-yr; average 2.7 yr). The IR for the diagnoses related to alcohol problems after RYGB was 6.36 (95% confidence interval: 5.45–7.36) per 1000 person-years and 4.54 (2.94–6.70) after SG. When controlling for age and sex, adjusted hazard ratio was .75 (.49–1.14) for SG compared with RYGB. When combining both bariatric procedures, women <26 years were more likely to have alcohol-related diagnoses (3.2%, 2.1–4.4) than women of 26 to 40 years (1.6%, 1.1–2.1) or women >40 (1.3%, .9–1.7). The IR after RYGB for the diagnoses related to problems with substances other than alcohol was 3.48 (95% confidence interval: 2.82–4.25) compared with 3.27 (1.94–5.17) per 1000 person-years after SG. Controlling for age and sex, the hazard ratio was .99 (.60–1.64) for SG compared with RYGB.ConclusionsIn our study, procedure-specific differences were not found in the risks (RYGB versus SG) for postoperative diagnoses related to problems with alcohol and other substances within the available observation time. A longer observation period seems required to explore these findings further.     

Retrospective comparative study of the effectiveness of bariatric surgery on 3-year outcomes in the real-world clinical setting

BackgroundBariatric surgery has shown an improvement in obesity and obesity-related disease in many clinical trials and single center studies. However, real-world data, including data from non-centers of excellence, is sparse.ObjectivesTo provide clinical outcomes of patients who underwent bariatric surgery in real-world clinical setting.SettingAcademic Institution.MethodsAdults with obesity undergoing Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and a control group (CG) between 2007 and 2019 were identified. The CG represented patients with a previous visit to a bariatric surgeon without a subsequent surgery. Cohorts were matched on age, gender, ethnicity, baseline body mass index (BMI), and presence of diabetes and hypertension. Groups were compared in terms of co-morbidities, weight loss, and chronic conditions for three years.ResultsA total of 61 313 patients were identified. From these, 14 916 RYGB and 20 867 SG patients were matched to the CG (n = 16 562). The median BMI loss three years after surgery was 28.7% (interquartile range [IQR] 20.8%–36.2%) and 20.5% (IQR 13.5%–28.6%) for RYGB and SG groups, respectively. The CG had a median BMI loss of 6.7% with IQR of 20.4% decrease to 1.78% gain. At three years postoperatively, HbA1C decreased by 13% for RYGB and 5.9% for the SG group. The probabilities of remission from diabetes, hypertension, and low high-density lipoprotein cholesterol were significantly higher among patients who had surgery compared to the CG. For both RYGB and SG, the estimated probabilities of remission were similar.ConclusionThis study shows that bariatric surgery performed in the real-world clinical setting is an effective therapy for various expressions of the metabolic syndrome with results that are comparable to randomized control trials.     

Nonsteroid anti-inflammatory drugs and the risk of peptic ulcers after gastric bypass and sleeve gastrectomy

BackgroundPharmacologic pain treatment is common among bariatric patients. Nonsteroid anti-inflammatory drugs (NSAID) are not recommended after Roux-en-Y gastric bypass (RYGB) because of the increased risk of marginal ulceration, but the connection with NSAID is not unambiguous.ObjectivesExamine the association between NSAID exposure and peptic ulcers after primary laparoscopic RYGB and sleeve gastrectomy (SG) respectively.SettingUniversity Hospital, Sweden.MethodsCross-matched data from 3 national registers were used in this retrospective, population-based cohort study of all primary laparoscopic RYGB and SG in Sweden within the period from 2010–2015. NSAID exposure was analyzed with individual data of dispensed daily defined doses (DDD) of NSAID after surgery. Multivariate logistic regression estimated the association between NSAID exposure and peptic ulcers, expressed as odds ratios with 95% confidence intervals adjusted for confounding.ResultsOf the 41,380 patients (37,913 RYGB, 3467 SG), 1.8% were diagnosed with peptic ulcers after surgery (RYGB 1.9%, SG .2%). In total, 60% of the patients had been prescribed NSAID during a follow-up period of 4.1 (1.0–7.0) years in median. The adjusted risk odds ratios for NSAID exposure were 1.10 (.88–1.38), 1.43 (1.16–1.76), and 1.52 (1.25–1.84) for >0–30 DDD, >30–100 DDD, and >100 DDD, respectively. In subanalysis, the association was similar for RYGB alone, whereas no association was found for SG.ConclusionThe results of the present study support the notion that continuous NSAID use of ≥30 days is a significant risk factor for the development of peptic ulcers after RYGB, whereas temporary use (<30 days) is not. No association between NSAID exposure and the development of peptic ulcers after SG was identified.     

Perioperative and 1-year outcomes of bariatric surgery in septuagenarians: implications for patient selection

BackgroundAlthough bariatric surgery is an effective treatment for obesity, utilization of bariatric procedures in older adults remains low. Previous work reported higher morbidity in older patients undergoing bariatric surgery. However, the generalizability of these data to contemporary septuagenarians is unclear.ObjectivesWe sought to evaluate differences in 30-day outcomes, 1-year weight loss, and co-morbidity remission after bariatric surgery among 3 age groups as follows: <45 years, 45–69 years, and ≥70 years.SettingStatewide quality improvement collaborative.MethodsUsing a large quality improvement collaborative, we identified patients undergoing sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) between 2006 and 2018. We used multivariable logistic regression models to evaluate the association between age cohorts and 30-day outcomes, 1-year weight loss, and co-morbidity remission.ResultsWe identified 641 septuagenarians who underwent SG (68.5%) or RYGB (31.5%). Compared with 45–69 year olds, septuagenarians had higher rates of hemorrhage (5.1% versus 3.1%; P = .045) after RYGB and higher rates of leak/perforation (.9% versus .3%; P = .044) after SG. Compared with younger patients, septuagenarians lost less of their excess weight, losing 64.8% after RYGB and 53.8% after SG. Remission rates for diabetes and obstructive sleep were similar for patients aged ≥70 years and 45–69 years.ConclusionsBariatric surgery in septuagenarians results in substantial weight loss and co-morbidity remission with an acceptable safety profile. Surgeons with self-imposed age limits should consider broadening their selection criteria to include patients ≥70 years old.     

Racial disparities in bariatric perioperative outcomes among the elderly

BackgroundBariatric surgery outcomes in elderly patients have been shown to be safe, but with a higher rate of adverse outcomes compared with nonelderly patients. The impact of race on bariatric surgery outcomes continues to be explored, with recent studies showing higher rates of adverse outcomes in black patients. Perioperative outcomes in racial cohorts of elderly bariatric patients are largely unexplored.ObjectiveThe goal of this study was to compare outcomes between elderly non-Hispanic black (NHB) and non-Hispanic white (NHW) bariatric surgery patients to determine whether outcomes are mediated by race.SettingAcademic hospital.MethodsPatients who had a primary Roux-en-Y (RYGB) and sleeve gastrectomy (SG) in the period 2015–2018 and were at least 65 years of age were identified from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant Use Data File (MBSAQIP PUF). Selected cases were stratified by race. Outcomes were compared between matched racial cohorts. Multivariate regression analyses were performed to determine whether race independently predicted morbidity.ResultsFrom 2015 to 2018, 29,394 elderly NHW (90.8%) and NHB (9.2%) patients underwent an RYGB or SG. At baseline, NHB elderly patients had a higher burden of co-morbid conditions, resulting in higher rates of overall (7.7% versus 6.4%, P = .009) and bariatric-related (5.4% versus 4.1%, P = .001) morbidity. All outcome measures were similar between propensity-score-matched racial elderly bariatric patient cohorts. On regression analysis, NHB race remained independently correlated with morbidity (odds ratio [OR] 1.3, 95% CI 1.08–1.47, P = .003).ConclusionRYGB and SG are safe in elderly patient cohorts, with no differences in adverse outcomes between NHB and NHW patients, accounting for confounding factors. While race does not appear to impact outcomes in the elderly cohorts, NHB race may play a role in access.