John R Montgomery, MD1, Seth A Waits, MD1, Justin B Dimick, MD, MPH2, Dana A Telem2. 1University of Michigan, Dept Transplant Surgery, 2University of Michigan, Center for Healthcare Outcomes & Policy
Objective: Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) have similar long-term weight-loss and comorbidity-improvement among obese patients with chronic kidney disease (CKD) or end-stage renal disease (ESRD). As such, the decision to proceed with RYGB versus LSG can be controversial and is often left to surgeon and/or patient preference. No published, generalizable data exists about the perioperative risks of these operations. To inform operative decision-making, we performed an analysis of perioperative safety of RYGB versus LSG in obese patients with CKD or ESRD using a national registry capturing >95% of bariatric operations.
Methods: Patients with CKD (creatinine ≥2 mg/dL, but not on dialysis) or dialysis-dependent ESRD who underwent primary, laparoscopic-RYGB or LSG between 2015-2016 were identified from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program participant use file. The primary outcome was a composite variable of death and severe, life-threatening complications within 30-days of operation. Logistic regression was used to compare adverse outcomes between patients who underwent RYGB versus LSG. Subgroup analyses were then performed among CKD and ESRD patients.
Results: During the study period, 2,357 primary, laparoscopic bariatric operations were performed on obese patients with CKD (n=1521, 64.5%) or ESRD (n=836, 35.5%); of these, 1,704 (72.3%) were LSG and 653 (27.7%) were RYGB. After adjusting for patient age, smoking status, hypertension, diabetes, and functional status, there was a trend towards RYGB association with the primary outcome of death or severe, life-threatening complications (6.7vs4.9%), but this was not statistically significant (aOR 1.41[0.96-2.07], p=0.078). Major contributors to the composite primary outcome between RYGB and LSG patients were reoperation (4.0vs3.1%, p=0.3), major infection (1.8vs0.6%, p=0.005), transfusion ≥3 units (1.2vs0.5%, p=0.046), and leak (0.9vs0.4%, p=0.084). In the CKD subgroup, RYGB was associated with progression to renal failure requiring dialysis (2.8vs0.8%, p=0.002), and major infection (2.0vs0.5%, p=0.006). In the ESRD subgroup, RYGB was associated with myocardial infarction (0.7vs0.0%, p=0.033).
Conclusion: In a contemporary cohort of bariatric surgeries, nearly one-third of obese CKD and ESRD patients undergo RYGB. Our analysis shows increased risk of major infection and transfusion ≥3 units among RYGB patients when compared to LSG. Furthermore, CKD patients undergoing RYGB are three times more likely to experience progressive renal failure requiring dialysis. Given the clinical similarity of LSG and RYGB in terms of weight-loss and comorbidity-improvement among CKD and ESRD populations, we strongly recommend LSG as the preferred bariatric surgery unless otherwise contraindicated.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 94562
Program Number: P084
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster