Comparative Safety of Sleeve Gastrectomy and Gastric Bypass Up to 5 Years After Surgery in Patients With Severe Obesity

Importance: Sleeve gastrectomy is the most widely used bariatric operation; however, its long-term safety is largely unknown. Objective: To compare the risk of mortality, complications, reintervention, and health care use 5 years after sleeve gastrectomy and gastric bypass. Design, Setting, and Participants: This retrospective cohort study included adult patients in a national Medicare claims database who underwent sleeve gastrectomy or gastric bypass from January 1, 2012, to December 31, 2018. Instrumental variables survival analysis was used to estimate the cumulative incidence of outcomes up to 5 years after surgery. Exposures: Laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass. Main Outcomes and Measures: The main outcome was risk of mortality, complications, and reinterventions up to 5 years after surgery. Secondary outcomes were health care use after surgery, including hospitalization, emergency department (ED) use, and total spending. Results: Of 95 405 patients undergoing bariatric surgery, 57 003 (60%) underwent sleeve gastrectomy (mean SD age, 57. 1 11. 8 years), of whom 42 299 (74. 2%) were women; 124 (0. 2%) were Asian; 10 101 (17. 7%), Black; 1951 (3. 4%), Hispanic; 314 (0. 6%), North American Native; 43 194 (75. 8%), White; 534 (0. 9%), of other race or ethnicity; and 785 (1. 4%), of unknown race or ethnicity. A total of 38 402 patients (40%) underwent gastric bypass (mean SD age, 55. 9 11. 7 years), of whom 29 050 (75. 7%) were women; 109 (0. 3%), Asian; 6038 (15. 7%), Black; 1215 (3. 2%), Hispanic; 278 (0. 7%), North American Native; 29 986 (78. 1%), White; 373 (1. 0%), of other race or ethnicity; and 404 (1. 1%), of unknown race or ethnicity. Compared with patients undergoing gastric bypass, at 5 years after surgery, patients undergoing sleeve gastrectomy had a lower cumulative incidence of mortality (4. 27%; 95% CI, 4. 25%-4. 30% vs 5. 67%; 95% CI, 5. 63%-5. 69%), complications (22. 10%; 95% CI, 22. 06%-22. 13% vs 29. 03%; 95% CI, 28. 99%-29. 08%), and reintervention (25. 23%; 95% CI, 25. 19%-25. 27% vs 33. 57%; 95% CI, 33. 52%-33. 63%). Conversely, patients undergoing sleeve gastrectomy had a higher cumulative incidence of surgical revision at 5 years (2. 91%; 95% CI, 2. 90%-2. 93% vs 1. 46%; 95% CI, 1. 45%-1. 47%). The adjusted hazard ratio (aHR) of all-cause hospitalization and ED use was lower for patients undergoing sleeve gastrectomy at 1 year (hospitalization, aHR, 0. 83; 95% CI, 0. 80-0. 86; ED use, aHR, 0. 87; 95% CI, 0. 84-0. 90) and 3 years (hospitalization, aHR, 0. 94; 95% CI, 0. 90-0. 98; ED use, aHR, 0. 93; 95% CI, 0. 90-0. 97) after surgery but similar between groups at 5 years (hospitalization, aHR, 0. 99; 95% CI, 0. 94-1. 04; ED use, aHR, 0. 97; 95% CI, 0. 92-1. 01). Total health care spending among patients undergoing sleeve gastrectomy was lower at 1 year after surgery (28 706; 95% CI, 27 866-29 545 vs 30 663; 95% CI, 29 739-31 587), but similar between groups at 3 (57 411; 95% CI, 55 239-59 584 vs 58 581; 95% CI, 56 551-60 611) and 5 years (86 584; 95% CI, 80 183-92 984 vs 85 762; 95% CI, 82 600-88 924). Conclusions and Relevance: In a large cohort of patients undergoing bariatric surgery, sleeve gastrectomy was associated with a lower long-term risk of mortality, complications, and reinterventions but a higher long-term risk of surgical revision. Understanding the comparative safety of these operations may better inform patients and surgeons in their decision-making.