Association of Bariatric Surgery Using Laparoscopic Banding, Roux-en-Y Gastric Bypass, or Laparoscopic Sleeve Gastrectomy vs Usual Care Obesity Management With All-Cause Mortality

Abstract

<div class="section"> <a class="named-anchor" id="ab-joi170157-1"> <!-- named anchor --> </a> <h5 class="section-title" id="d10219380e323">Question</h5> <p id="d10219380e325">Is there an association between undergoing bariatric surgery with laparoscopic banding, Roux-en-Y gastric bypass, or laparoscopic sleeve gastrectomy vs nonsurgical usual care management and all-cause mortality among patients with obesity? </p> </div><div class="section"> <a class="named-anchor" id="ab-joi170157-2"> <!-- named anchor --> </a> <h5 class="section-title" id="d10219380e328">Findings</h5> <p id="d10219380e330">In this retrospective cohort study of 8385 patients who underwent bariatric surgery and 25 155 matched patients who received usual care, the mortality rate over approximately 4.5 years was 1.3% among surgical patients compared with 2.3% among nonsurgical patients, a significant difference. </p> </div><div class="section"> <a class="named-anchor" id="ab-joi170157-3"> <!-- named anchor --> </a> <h5 class="section-title" id="d10219380e333">Meaning</h5> <p id="d10219380e335">Bariatric surgery was associated with reduced all-cause mortality.</p> </div><div class="section"> <a class="named-anchor" id="ab-joi170157-4"> <!-- named anchor --> </a> <h5 class="section-title" id="d10219380e339">Importance</h5> <p id="d10219380e341">Bariatric surgery is an effective and safe approach for weight loss and short-term improvement in metabolic disorders such as diabetes. However, studies have been limited in most settings by lack of a nonsurgical group, losses to follow-up, missing data, and small sample sizes in clinical trials and observational studies. </p> </div><div class="section"> <a class="named-anchor" id="ab-joi170157-5"> <!-- named anchor --> </a> <h5 class="section-title" id="d10219380e344">Objective</h5> <p id="d10219380e346">To assess the association of 3 common types of bariatric surgery compared with nonsurgical treatment with mortality and other clinical outcomes among obese patients. </p> </div><div class="section"> <a class="named-anchor" id="ab-joi170157-6"> <!-- named anchor --> </a> <h5 class="section-title" id="d10219380e349">Design, Setting, and Participants</h5> <p id="d10219380e351">Retrospective cohort study in a large Israeli integrated health fund covering 54% of Israeli citizens with less than 1% turnover of members annually. Obese adult patients who underwent bariatric surgery between January 1, 2005, and December 31, 2014, were selected and compared with obese nonsurgical patients matched on age, sex, body mass index (BMI), and diabetes, with a final follow-up date of December 31, 2015. A total of 33 540 patients were included in this study. </p> </div><div class="section"> <a class="named-anchor" id="ab-joi170157-7"> <!-- named anchor --> </a> <h5 class="section-title" id="d10219380e354">Exposures</h5> <p id="d10219380e356">Bariatric surgery (laparoscopic banding, Roux-en-Y gastric bypass, or laparoscopic sleeve gastrectomy) or usual care obesity management only (provided by a primary care physician and which may include dietary counseling and behavior modification). </p> </div><div class="section"> <a class="named-anchor" id="ab-joi170157-8"> <!-- named anchor --> </a> <h5 class="section-title" id="d10219380e359">Main Outcomes and Measures</h5> <p id="d10219380e361">The primary outcome, all-cause mortality, matched and adjusted for BMI prior to surgery, age, sex, socioeconomic status, diabetes, hyperlipidemia, hypertension, cardiovascular disease, and smoking. </p> </div><div class="section"> <a class="named-anchor" id="ab-joi170157-9"> <!-- named anchor --> </a> <h5 class="section-title" id="d10219380e364">Results</h5> <p id="d10219380e366">The study population included 8385 patients who underwent bariatric surgery (median age, 46 [IQR, 37-54] years; 5490 [65.5%] women; baseline median BMI, 40.6 [IQR, 38.5-43.7]; laparoscopic banding [n = 3635], gastric bypass [n = 1388], laparoscopic sleeve gastrectomy [n = 3362], and 25 155 nonsurgical matched patients (median age, 46 [IQR, 37-54] years; 16 470 [65.5%] women; baseline median BMI, 40.5 [IQR, 37.0-43.5]). The availability of follow-up data was 100% for all-cause mortality. There were 105 deaths (1.3%) among surgical patients during a median follow-up of 4.3 (IQR, 2.8-6.6) years (including 61 [1.7%] who underwent laparoscopic banding, 18 [1.3%] gastric bypass, and 26 [0.8%] sleeve gastrectomy), and 583 deaths (2.3%) among nonsurgical patients during a median follow-up of 4.0 (IQR, 2.6-6.2) years. The absolute difference was 2.51 (95% CI, 1.86-3.15) fewer deaths/1000 person-years in the surgical vs nonsurgical group. Adjusted hazard ratios (HRs) for mortality among nonsurgical vs surgical patients were 2.02 (95% CI, 1.63-2.52) for the entire study population; by surgical type, HRs were 2.01 (95% CI, 1.50-2.69) for laparoscopic banding, 2.65 (95% CI, 1.55-4.52) for gastric bypass, and 1.60 (95% CI, 1.02-2.51) for laparoscopic sleeve gastrectomy. </p> </div><div class="section"> <a class="named-anchor" id="ab-joi170157-10"> <!-- named anchor --> </a> <h5 class="section-title" id="d10219380e369">Conclusions and Relevance</h5> <p id="d10219380e371">Among obese patients in a large integrated health fund in Israel, bariatric surgery using laparoscopic banding, gastric bypass, or laparoscopic sleeve gastrectomy, compared with usual care nonsurgical obesity management, was associated with lower all-cause mortality over a median follow-up of approximately 4.5 years. The evidence of this association adds to the limited literature describing beneficial outcomes of these 3 types of bariatric surgery compared with usual care obesity management alone. </p> </div><p class="first" id="d10219380e374">This cohort study uses Israeli electronic health record data to compare mortality of obese adult patients who underwent bariatric surgery (laparoscopic banding, Roux-en-Y gastric bypass, or laparoscopic sleeve gastrectomy) vs obese adults receiving nonsurgical usual care management. </p>