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.

Socioeconomically Distressed Communities Associated With Long-term Mortality After Bariatric Surgery.

BACKGROUND: Surgical outcomes are affected by socioeconomic status, yet these factors are poorly accounted for in clinical databases. We sought to determine if the Distressed Communities Index (DCI), a composite ranking by zip code that quantifies socioeconomic risk, was associated with long-term survival after bariatric surgery. METHODS: All patients undergoing Roux-en-Y gastric bypass (1985-2004) at a single institution were paired with DCI. Scores range from 0 (no distress) to 100 (severe distress) and account for unemployment, education, poverty, median income, housing vacancies, job growth, and business establishment growth. Distressed communities, defined as DCI ≥75, were compared with all other patients. Regression modeling was used to evaluate the effect of DCI on 10-year bariatric outcomes, whereas Cox Proportional Hazards and Kaplan-Meier analysis examined long-term survival. RESULTS: Gastric bypass patients (n = 681) come from more distressed communities compared with the general public (DCI 60.5 ± 23.8 versus 50 ± 10; P < 0.0001). A total of 221 (32.3%) patients came from distressed communities (DCI ≥75). These patients had similar preoperative characteristics, including BMI (51.5 versus 51.7 kg/m2; P = 0.63). Socioeconomic status did not affect 10-year bariatric outcomes, including percent reduction in excess body mass index (57% versus 58%; P = 0.93). However, patients from distressed communities had decreased risk-adjusted long-term survival (hazard ratio, 1.38; P = 0.043). CONCLUSIONS: Patients with low socioeconomic status, as determined by the DCI, have equivalent outcomes after bariatric surgery despite worse long-term survival. Future quality improvement efforts should focus on these persistent disparities in health care.

Roux-en-Y gastric bypass is safe in elderly patients: a propensity-score matched analysis.

BACKGROUND: Numerous studies have established the effectiveness of Roux-en-Y gastric bypass (RYGB) for weight loss and co-morbidity amelioration. However, its safety and efficacy in elderly patients remains controversial. OBJECTIVES: To evaluate outcomes in patients aged ≥60 years who underwent RYGB compared with nonsurgical controls with the hypothesis that RYGB provides weight loss benefits without differences in survival. SETTING: University-affiliated tertiary center. METHODS: All patients who underwent RYGB from 1985 to 2015 were identified and divided into elderly (age ≥60) and nonelderly (age <60) groups. A nonsurgical elderly control population was identified using a clinical data repository of outpatient visits to propensity match elderly patients 4:1 on demographic characteristics, co-morbidities, and relevant preoperative substance/medication use. Unpaired appropriate univariate analyses compared each stratified group. Kaplan-Meier survival curves were fitted based on social security death data. RESULTS: A total of 2306 patients underwent RYGB. The 107 elderly patients had lower median body mass index (47.0 versus 49.9; P = .007) and higher rates of co-morbidities. Rates of complications did not differ between elderly and nonelderly patients. Elderly surgical patients were propensity matched 4:1 (10,044 controls) yielding 428 well-matched nonsurgical controls. The elderly group demonstrated significant percent reduction in excess body mass index compared with the control group (81.8% versus 10.3%; P < .001). Kaplan-Meier survival analysis with log-rank test demonstrated no difference in midterm survival (P = .63). CONCLUSIONS: A significant weight reduction benefit was identified after RYGB in elderly patients without a difference in midterm survival compared with propensity-matched controls, suggesting RYGB is a safe and efficacious weight loss strategy in the elderly.

Comparison of Early Morbidity and Mortality Between Sleeve Gastrectomy and Gastric Bypass in High-Risk Patients for Liver Disease: Analysis of American College of Surgeons National Surgical Quality Improvement Program.

INTRODUCTION: Chronic liver disease is prevalent in obese patients presenting for bariatric surgery and is associated with increased postoperative morbidity and mortality (M&M). There are no comparative studies on the safety of different types of bariatric operations in this subset of patients. OBJECTIVE: The aim of this study is to compare the 30-day postoperative M&M between laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-Y-gastric bypass (LRYGB) in the subset of patients with a model of end-stage liver disease (MELD) score ≥ 8. METHODS: Data for LSG and LRYGB were extracted from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from years 2012 and 2013. MELD score was calculated using serum creatinine, bilirubin, INR, and sodium. Postoperative M&M were assessed in patients with a score ≥ 8 and compared for the type of operation. This was followed by analysis for MELD subcategories. Multiple logistic regression was performed to adjust for confounders. RESULTS: Out of 34,169, 9.8% of cases had MELD ≥ 8 and were included. Primary endpoint, 30-day M&M, was significantly lower post-LSG (9.5%) compared to LRYGB (14.7%); [AOR = 0.66(0.53, 0.83)]. Superficial wound infection, prolonged hospital stay, and unplanned readmission were more common in LRYGB. M&M post-LRYGB (30.6%) was significantly higher than LSG (15.7%) among MELD15-19 subgroup analysis. CONCLUSION: LRYGB is associated with a higher postoperative risk than LSG in patients with MELD ≥ 8. The difference in postoperative complications between procedures was magnified with higher MELD. This suggests that LSG might be a safer option in morbidly obese patients with higher MELD scores, especially above 15.

Increasing the Value of Healthcare: Improving Mortality While Reducing Cost in Bariatric Surgery.

BACKGROUND: Healthcare costs in the United States (U.S.) are rising. As outcomes improve, such as decreased length of stay and decreased mortality, it is expected that costs should go down. The aim of this study is to analyze hospital charges, cost of care, and mortality in bariatric surgery over time. METHODS: A retrospective analysis of the Nationwide Inpatient Sample (NIS) database was performed. Adults with morbid obesity who underwent gastric bypass or sleeve gastrectomy were identified by ICD-9 codes. Multivariate analyses identified independent predictors of changes in hospital charges and in-hospital mortality. Results were adjusted for age, race, gender, Charlson comorbidity index, surgical approach (open versus laparoscopic), hospital volume, and insurance status. In order to estimate baseline surgical inflation, changes in hospital charges over time were also calculated for appendectomy. RESULTS: From 1998 to 2011, 209,106 patients were identified who underwent bariatric surgery. Adjusted in-hospital mortality for bariatric surgery decreased significantly by 2003 compared to 1998 (p < 0.001, OR 0.47, 95 % CI 0.22-0.92) and remained significantly decreased for the remainder of the study period. As such, a 60-80 % decrease in mortality was maintained from 2003 to 2010 compared to 1998. After adjusting for inflation, the cumulative increase in hospital charges per day of a bariatric surgery admission was 130 % from 1998 to 2011. Charges per stay increased by 2.1 % annually for bariatric surgery compared to 5.5 % for appendectomy. CONCLUSION: In-hospital mortality rate following bariatric surgery underwent a ninefold decrease since 1998 while maintaining surgical inflation costs less than appendectomy. Innovation in bariatric surgical technique and technology has resulted in improvement of outcomes while providing overall cost savings.

Roux-en-Y gastric bypass compared with aggressive diet and exercise therapy for morbidly obese patients awaiting renal transplant: a decision analysis.

BACKGROUND: The optimal management of morbidly obese patients awaiting renal transplant is controversial and unknown. The objective of this study was to compare the impact of Roux-en-Y gastric bypass (RYGB) versus diet and exercise on the survival of morbidly obese patients with end-stage renal disease awaiting renal transplant. METHODS: A decision analytic Markov state transition model was designed to simulate the life of morbidly obese patients with end-stage renal disease awaiting transplant. Life expectancy after RYGB and after 1 and 2 years of diet and exercise was estimated and compared in the framework of 2 clinical scenarios in which patients above a body mass index (BMI) of 35 kg/m(2) or above a BMI of 40 kg/m(2) were ineligible for transplantation, reflecting the BMI restrictions of many transplant centers. In addition to base case analysis (45 kg/m(2) BMI preintervention), sensitivity analysis of initial BMI was completed. Markov model parameters were extracted from the literature. RESULTS: RYGB improved survival compared with diet and exercise. Patients who underwent RYGB received transplants sooner and in higher frequency. Using 40 kg/m(2) as the upper limit for transplant eligibility, base case patients who underwent RYGB gained 5.4 years of life, whereas patients who underwent 1 and 2 years of diet and exercise gained 1.5 and 2.8 years of life, respectively. Using 35 kg/m(2) as the upper limit, RYGB base case patients gained 5.3 years of life, whereas patients who underwent 1 and 2 years of diet and exercise gained .7 and 1.5 years of life, respectively. CONCLUSIONS: In morbidly obese patients with end-stage renal disease, RYGB may be more effective than optimistic weight loss outcomes after diet and exercise, thereby improving access to renal transplantation.

Comparing 20 years of national general surgery malpractice claims data: obesity versus morbid obesity.

BACKGROUND: We hypothesized that the increasing body mass index of the population has affected general surgery malpractice claims. METHODS: We queried the Physician Insurers Association of America database from 1990 to 1999 (ie, period 1) and 2000 to 2009 (ie, period 2) for claims associated with obesity and morbid obesity. We analyzed the error involved, injury severity, procedure, and outcome. RESULTS: Five hundred seventy-five claims were identified. The percentage of paid claims did not differ by body mass index. Improper performance was the most common alleged error, gastric bypass was the most common procedure, and death was the most common injury. For obesity claims, the case was more likely to be settled in period 1 and withdrawn/dismissed in period 2 (P < .001). The number of morbid obesity claims rose from 9 in period 1 to 249 in period 2. CONCLUSIONS: The significant rise in morbid obesity claims between periods is likely caused by the substantial increase in the number of bariatric procedures performed.

Reducing cost of surgery by avoiding complications: the model of robotic Roux-en-Y gastric bypass.

BACKGROUND: Robotic surgery is a complex technology offering technical advantages over conventional methods. Still, clinical outcomes and financial issues have been subjects of debate. Several studies have demonstrated higher costs for robotic surgery when compared to laparoscopy or open surgery. However, other studies showed fewer costly anastomotic complications after robotic Roux-en-Y gastric bypass (RYGBP) when compared to laparoscopy. METHODS: We collected data for our gastric bypass patients who underwent open, laparoscopic, or robotic surgery from June 1997 to July 2010. Demographic data, BMI, complications, mortality, intensive care unit stay, hospitalization, and operating room (OR) costs were analyzed and a cost projection completed. Sensitivity analyses were performed for varied leak rates during laparoscopy, number of robotic cases per month, number of additional staplers during robotic surgery, and varied OR times for robotic cases. RESULTS: Nine-hundred ninety patients underwent gastric bypass surgery at the University Hospital Geneva from June 1997 to July 2010. There were 524 open, 323 laparoscopic, and 143 robotic cases. Significantly fewer anastomotic complications occurred after open and robotic RYGBP when compared to laparoscopy. OR material costs were slightly less for robotic surgery (USD 5,427) than for laparoscopy (USD 5,494), but more than for the open procedure (USD 2,251). Overall, robotic gastric bypass (USD 19,363) was cheaper when compared to laparoscopy (USD 21,697) and open surgery (USD 23,000). CONCLUSIONS: Robotic RYGBP can be cost effective due to balancing greater robotic overhead costs with the savings associated with avoiding stapler use and costly anastomotic complications.

Roux en Y gastric bypass by single-incision mini-laparotomy: outcomes in 3,300 consecutive patients.

BACKGROUND: Although the laparoscopic technique of Roux en Y gastric bypass (LRYGB) has popularized this weight loss procedure, the costs are justifiable if outcomes are superior to the open technique. We report our results with single-incision mini-laparotomy. METHODS: From June 2000 through November 2009, RYGB was performed in 3,300 consecutive patients using a 10-15-cm single-abdominal incision. Established guidelines for patient selection were followed and protocols were developed for patient education and for the prevention of perioperative complications. Weight loss (WL) over time and complications were recorded prospectively. Actual 90-day mortality was compared to that predicted by the Obesity Surgery Mortality Risk Score (OS-MRS). RESULTS: Eighty-four percent of patients were females with a mean body mass index (BMI) of 50 ± 13. BMI of males was 54 ± 9. There was a normal distribution of the WL response over 2,000 days. Complications included bleeding (1.4%), leak (1%), pulmonary embolism (0.7%), internal hernia (2.5%), and incisional hernia (5.6%). There were 1,793 Class A, 1,288 Class B, and 219 Class C patients. Eleven patients (0.3%) died within 90 days (one Class A, seven Class B, and three Class C), with mortality rates in all classes less than expected by the OS-MRS. Average hospital charges were $13,000. CONCLUSIONS: Our protocols and operative technique should be reproducible in other centers and may have a special appeal, if the costs of LRYGB limit access to bariatric surgery in qualified patients.

Decision modeling to estimate the impact of gastric bypass surgery on life expectancy for the treatment of morbid obesity.

OBJECTIVE: To create a decision analytic model to estimate the balance between treatment risks and benefits for patients with morbid obesity. DESIGN: Decision analytic Markov state transition model with multiple logistic regression models as inputs. Data from the 2005 National Inpatient Survey were used to calculate in-hospital mortality risk associated with bariatric surgery and then adjusted for 30-day mortality. To calculate excess mortality associated with obesity, we used the 1991-1996 National Health Interview Survey linked to the National Death Index. Bariatric surgery was assumed to influence mortality only through its impact on the excess mortality associated with obesity, and the efficacy of surgery was estimated from a recent large observational trial. INTERVENTION: Gastric bypass surgery. Main Outcome Measure Life expectancy. RESULTS: Our base case, a 42-year-old woman with a body mass index of 45, gained an additional 2.95 years of life expectancy with bariatric surgery. No surgical treatment was favored in our base case when the 30-day surgical mortality exceeded 9.5% (baseline 30-day mortality, 0.2%) or when the efficacy of bariatric surgery for reducing mortality decreased to 2% or less (baseline efficacy, 53%). CONCLUSIONS: The optimal decision for individual patients varies based on the balance of risk between perioperative mortality, excess annual mortality risk associated with increasing body mass index, and the efficacy of surgery; however, for the average morbidly obese patient, gastric bypass improves life expectancy.

Mortality and hospital stay after bariatric surgery in 2,167 patients: influence of the surgeon expertise.

BACKGROUND: Postoperative mortality is a rare event after bariatric surgery. The main goal of this study was to calculate the 30-day mortality rate postbariatric "open" surgery and the length of hospital stay of patients assisted by a health maintenance organization in Brazil. We also investigate their association with sex, age, BMI, preexisting comorbidities, and volume of procedures performed by surgeons. METHODS: A total of 2,167 patients who underwent RYGB between 01/2004 and 12/2007 were analyzed. The deaths and hospital stay were identified in the healthcare transactional database and the morbidity data in the preoperative medical audit records. Factors contributing to adverse outcomes were determined by multiple logistic regression analysis. RESULTS: The overall mortality rate was 0.64%, with a decreasing trend over the years. The median hospital stay was 3.1 days. In the multivariate analysis, both mortality and longer hospital stay were positively and significantly associated with age > 50 years, BMI > 50 kg/m(2), and surgeon volume of less than 20 bariatric surgeries/year. Presence of hypertension also increased the risk of longer hospital stay. Multivariate analysis showed that the 30-day mortality was six times higher in patients operated by professionals who performed less surgeries/year and longer hospital stay, four times more frequent. CONCLUSIONS: The 30-day mortality post-RYGB is similar to the rates found in developed countries and much lower than the rates found for patients assisted by the public health system in Brazil. In addition to age and clinical factors, the results suggest that mortality and longer hospital stay are strong and inversely related to surgeon's experience.

Avoidance of complications in older patients and Medicare recipients undergoing gastric bypass.

HYPOTHESIS: Perioperative morbidity and mortality do not increase in carefully evaluated and managed Medicare and elderly patients undergoing gastric bypass. DESIGN: Retrospective review of a prospectively maintained bariatric database. SETTING: Academic tertiary care medical center. PATIENTS: We reviewed our database of 928 consecutive patients who underwent gastric bypass from March 24, 1998, through May 31, 2006. Of these patients, 36 underwent revision surgery and were excluded. The remaining 892 patients were separated into 4 groups by age and Medicare status. Group 1 consisted of 46 patients 60 years or older at the time of gastric bypass (range, 60-66 years). Group 2 consisted of 846 patients 59 years or younger at the time of gastric bypass (range, 18-59 years). Group 3 consisted of 31 Medicare recipients (age range, 31-66 years). Group 4 consisted of 861 non-Medicare recipients (age range, 18-64 years). MAIN OUTCOME MEASURES: Groups were compared in terms of demographics, morbidity, and mortality. RESULTS: No differences were found in outcomes between older vs younger and Medicare vs non-Medicare patients for any postoperative complication or mortality. CONCLUSIONS: Bariatric surgery can be performed in carefully selected Medicare recipients and patients 60 years or older with acceptable morbidity and mortality. No difference was found in the occurrence of complications in Medicare patients, patients younger than 60 years, or patients 60 years and older. We believe that these results reflect careful patient selection, intensive preoperative education, and expert operative and perioperative management. Our results indicate that bariatric surgery should not be denied solely based on age or Medicare status.

A comparison of open and laparoscopic Roux-en-Y gastric bypass surgery for morbid and super obesity: a decision-analysis model.

BACKGROUND: The aim of this study was to compare laparoscopic Roux-en-Y gastric bypass (LGBP) with open Roux-en-Y gastric bypass (OGBP) to determine which approach resulted in better clinical outcomes and cost effectiveness in patients with morbid obesity. METHODS: A decision-analysis model was constructed to evaluate outcomes of LGBP versus OGBP in patients with body mass index (BMI) ranges of 35 to 49, 50 to 60, and greater than 60. Baseline assumptions for the model were derived from published reports. Sensitivity and cost-effectiveness analyses were performed to determine the optimal strategy. Success was defined as no major procedure-related complications and no long-term complications over a 1-year period after surgery. Failure of therapy was defined as either recurrent symptoms or death attributed to a surgical complication. RESULTS: In patients with a BMI of 35 to 49, LGBP failed in 14% and OGBP failed in 18% of patients, favoring LGBP alone as the dominant strategy. Mortality in the OGBP group was 1.3 times that of the LGBP group. For a BMI of 50 to 60, LGBP was dominant with an overall success rate of 82% as compared with OGBP (77%). Mortality in the OGBP group was 1.3 times that of the LGBP group. For a BMI of greater than 60, LGBP was the dominant strategy with an overall success rate of 67% compared with OGBP (63%). Sensitivity and cost-effective analysis showed that LGBP was the dominant strategy in terms of greater success and less overall morbidity and mortality for all 3 groups. CONCLUSIONS: This analysis suggests that for all BMI ranges evaluated, LGBP is preferable to OGBP. These conclusions are limited by potential selection and publication bias in the trials assessed for this analysis. These limitations can be resolved only by randomized control trials.

[Factors associated with morbidity and mortality after gastric bypass. Alternatives for risk reduction: sleeve gastrectomy]. / Factores asociados a morbimortalidad tras el bypass gástrico. Alternativas para disminuir riesgos: gastroplastia tubular.

INTRODUCTION: The aim of this study was to analyze factors related to morbidity and mortality after gastric bypass and to evaluate lower-risk alternatives in selected patients. PATIENTS AND METHODS: A prospective cohort of 761 patients who underwent gastric bypass was included. Prognostic factors were studied using a logistic regression model with SPSS 11.0. Independent variables were age, sex, body mass index (BMI), comorbidities, and the laparoscopic approach. Dependent variables consisted of medical complications, surgical complications, and mortality. We performed a preliminary descriptive study of morbidity and weight loss at 3 months after sleeve gastrectomy. RESULTS: In the postoperative period, 2.8% of patients presented medical complications and 5.4% presented surgical complications. Mortality was 0.52%. Surgical complications were significantly associated with age > 45 years (P = .04; OR = 2.00 [1.03-3.8]) and male sex (P = .041; OR = 2.40 [1.12-5.14]). Medical complications were significantly associated with a BMI of > 50 kg/m2 (P = .012; OR = 3.32 [1.23-8.98]), and mortality was significantly associated with a BMI of > 50 kg/m2 (P = .006) and male sex (P = .006). Sleeve gastrectomy was performed in eight patients with a BMI of > 60 kg/m2, in three patients with a BMI of > 50 kg/m2, cardiopulmonary disease and android fat distribution, and in four patients with a BMI of between 35 and 40 kg/m2 and major comorbidity. Morbidity consisted of self-limited febrile syndrome in one patient. There was no mortality. Weight loss at 3 months was 39.8 +/- 5.36% of excess BMI in superobese patients (n = 4) and was 50.2 +/- 11.05% of excess BMI in morbidly obese patients (n = 4). CONCLUSIONS: Postoperative morbidity and mortality was significantly higher in male patients, in patients aged more than 45 years, and in those with a BMI of > 50 kg/m2. Sleeve gastrectomy in selected patients could be a lower-risk alternative.

Early mortality among Medicare beneficiaries undergoing bariatric surgical procedures.

CONTEXT: Case series demonstrate that bariatric surgery can be performed with a low rate of perioperative mortality (0.5%), but the rate among high-risk patients and the community at large is unknown. OBJECTIVES: To evaluate the risk of early mortality among Medicare beneficiaries and to determine the relative risk of death among older patients. DESIGN: Retrospective cohort study. SETTING AND PATIENTS: All fee-for-service Medicare beneficiaries, 1997-2002. MAIN OUTCOME MEASURES: Thirty-day, 90-day, and 1-year postsurgical all-cause mortality among patients undergoing bariatric procedures. RESULTS: A total of 16 155 patients underwent bariatric procedures (mean age, 47.7 years [SD, 11.3 years]; 75.8% women). The rates of 30-day, 90-day, and 1-year mortality were 2.0%, 2.8%, and 4.6%, respectively. Men had higher rates of early death than women (3.7% vs 1.5%, 4.8% vs 2.1%, and 7.5% vs 3.7% at 30 days, 90 days, and 1 year, respectively; P<.001). Mortality rates were greater for those aged 65 years or older compared with younger patients (4.8% vs 1.7% at 30 days, 6.9% vs 2.3% at 90 days, and 11.1% vs 3.9% at 1 year; P<.001). After adjustment for sex and comorbidity index, the odds of death within 90 days were 5-fold greater for older Medicare beneficiaries (aged > or =75 years; n = 136) than for those aged 65 to 74 years (n = 1381; odds ratio, 5.0; 95% confidence interval, 3.1-8.0). The odds of death at 90 days were 1.6 times higher (95% confidence interval, 1.3-2.0) for patients of surgeons with less than the median surgical volume of bariatric procedures (among Medicare beneficiaries during the study period) after adjusting for age, sex, and comorbidity index. CONCLUSIONS: Among Medicare beneficiaries, the risk of early death after bariatric surgery is considerably higher than previously suggested and associated with advancing age, male sex, and lower surgeon volume of bariatric procedures. Patients aged 65 years or older had a substantially higher risk of death within the early postoperative period than younger patients.

The cost effectiveness of laparoscopic versus open gastric bypass surgery.

BACKGROUND: Over the last decade, laparoscopic gastric bypass (LGBP) has been proven to be a safe and well-tolerated approach to the Roux-en-Y gastric bypass, despite its increased cost when compared to the open approach (OGBP). This increased expense has led many to question whether LGBP is a cost effective alternative to OGBP. The aim of this study is to determine which approach is most cost effective, considering costs associated with the operation itself, perioperative complications, and income lost during convalescence. METHODS: A PubMed search of the National Library of Medicine online journal database was conducted. Studies that met predetermined criteria for selection were included in the analyses of patient demographics, perioperative complications, length of hospital stay, excess weight loss, and time to recovery. Data on 6,425 OGBP and 5,867 LGBP patients were used to compare the outcomes associated with each approach. RESULTS: Significant differences were found in the perioperative complication profiles, time to recovery, and overall expense of the two approaches. OGBP was associated with an increased incidence of major perioperative complications, especially extraintestinal complications, and greater perioperative mortality. LGBP was associated with shorter hospital stays, increased incidence of intestinal complications, and a 2.25% incidence of conversion to OGBP. Patient demographics and percent excess weight loss (%EWL) at 3 years follow-up were found to be similar with both OGBP and LGBP. CONCLUSION: LGBP is a cost effective alternative to OGBP for surgical weight loss. Despite the increased cost of LGBP, patients suffer fewer expensive and lifethreatening perioperative complications.