Adam Celio, MD1, Qiang Wu, PhD2, Kevin Kasten, MD1, Mark Manwaring, MD1, William Chapman, MD1, Walter Pories, MD1, Konstantinos Spaniolas, MD1. 1Department of Surgery, Brody School of Medicine at East Carolina University, 2Department of Biostatistics, College of Allied Health Sciences at East Carolina University
The disproportionate increase of the super-obese (SO) patient is a hidden component of the current obesity pandemic. SO is associated with a greater burden of obesity related comorbidities, with BMI itself a strong predictor of mortality. The best bariatric operation for this group should be based on safety and efficacy in this specific patient population. The aim of this study is to assess the comparative effectiveness of the two most common bariatric procedures in the SO.
Methods and Procedures:
The Bariatric Outcomes Longitudinal Database (Surgical Review Corporation; Raleigh, NC) from 2005-2012 was used for this study. We compared SO patients (BMI >50) undergoing laparoscopic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). A stepwise logistic regression model was used to calculate a propensity score and adjust for patient demographics and comorbidities. Data is presented as mean (standard deviation) or weighted percentage where the weight is defined as the inverse of the propensity score of the group assigned.
We identified 50,987 SO patients who underwent RYGB (N=42,119, 82.6%) or SG (N=8,868, 17.4%). RYGB patients had higher adjusted rates of 30 day mortality (0.3% vs 0.2% p=0.042), reoperation (4.0% vs 2.4%, p<0.001), and readmission (6.9% vs 5.5% p<0.001) compared to SG patients but no difference in overall complications (11.5% vs 11.1% p=0.250). Similar differences were seen with 90 day outcomes, including higher overall complications (16.0% vs 13.7% p<0.001), reoperation (6.7% vs 3.2% p<0.001), readmission (9.2% vs 6.6% p<0.001), strictures (2.4% vs 0.6% p<0.001), and ulcers (0.9% vs 0.1% p<0.001). Percent of total weight loss (TWL) was significantly higher for SO patients who underwent RYGB compared to SG at 3 months (14.1% vs 13.1% p<0.001), 6 months (25.2% vs 22.4% p<0.001), and 12 months (34.5% (6.7) vs 29.7% (1.8), p<0.001). The comorbidity resolution and improvement at 3 months, 6 months, and 12 months is shown in figures 1 and 2; all differences are statistically significant (p<0.001) except OSA resolution at 12 months follow-up.
Figure1. Comorbidity Resolution.
Figure 2. Comorbidity Improvement.
There are significant differences in comorbidity resolution and postoperative safety between RYGB and SG in the SO population. Significantly more RYGB patients developed complications and required readmission. However, RYGB is considerably more effective in controlling obesity related comorbidities within the first year after surgery. TWL differences were statistically significant but clinically small. Our results favor performance of RYGB in SO patients of appropriate risk.