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IMPORTANCE: Sleeve gastrectomy and gastric bypass are the most common bariatric surgical procedures in the world; however, their long-term medication discontinuation and comorbidity resolution remain unclear. OBJECTIVE: To compare the incidence of medication discontinuation and restart of diabetes, hypertension, and hyperlipidemia medications up to 5 years after sleeve gastrectomy or gastric bypass. DESIGN, SETTING, AND PARTICIPANTS: This comparative effectiveness research study of adult Medicare beneficiaries who underwent laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass between January 1, 2012, to December 31, 2018, and had a claim for diabetes, hypertension, or hyperlipidemia medication in the 6 months before surgery with a corresponding diagnosis used instrumental-variable survival analysis to estimate the cumulative incidence of medication discontinuation and restart. Data analyses were performed from February to June 2021. EXPOSURES: Laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass. MAIN OUTCOMES AND MEASURES: The primary outcome was discontinuation of diabetes, hypertension, and hyperlipidemia medication for any reason. Among patients who discontinued medication, the adjusted cumulative incidence of restarting medication was calculated up to 5 years after discontinuation. RESULTS: Of the 95 405 patients included, 71 348 (74.8%) were women and the mean (SD) age was 56.6 (11.8) years. Gastric bypass compared with sleeve gastrectomy was associated with a slightly higher 5-year cumulative incidence of medication discontinuation among 30 588 patients with diabetes medication use and diagnosis at the time of surgery (74.7% [95% CI, 74.6%-74.9%] vs 72.0% [95% CI, 71.8%-72.2%]), 52 081 patients with antihypertensive medication use and diagnosis at the time of surgery (53.3% [95% CI, 53.2%-53.4%] vs 49.4% [95% CI, 49.3%-49.5%]), and 35 055 patients with lipid-lowering medication use and diagnosis at the time of surgery (64.6% [95% CI, 64.5%-64.8%] vs 61.2% [95% CI, 61.1%-61.3%]). Among the subset of patients who discontinued medication, gastric bypass was also associated with a slightly lower incidence of medication restart up to 5 years after discontinuation. Specifically, the 5-year cumulative incidence of medication restart was lower after gastric bypass compared with sleeve gastrectomy among 19 599 patients who discontinued their diabetes medication after surgery (30.4% [95% CI, 30.2%-30.5%] vs 35.6% [95% CI, 35.4%-35.9%]), 21 611 patients who discontinued their antihypertensive medication after surgery (67.2% [95% CI, 66.9%-67.4%] vs 70.6% [95% CI, 70.3%-70.9%]), and 18 546 patients who discontinued their lipid-lowering medication after surgery (46.2% [95% CI, 46.2%-46.3%] vs 52.5% [95% CI, 52.2%-52.7%]). CONCLUSIONS AND RELEVANCE: Findings of this study suggest that, compared with sleeve gastrectomy, gastric bypass was associated with a slightly higher incidence of medication discontinuation and a slightly lower incidence of medication restart among patients who discontinued medication. Long-term trials are needed to explain the mechanisms and factors associated with differences in medication discontinuation and comorbidity resolution after bariatric surgery.

Sleeve gastrectomy is the most widely used bariatric operation; however, its long-term safety is largely unknown.To compare the risk of mortality, complications, reintervention, and health care use 5 years after sleeve gastrectomy and gastric bypass.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.Laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.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.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).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.

In any surgical procedure, various aspects of technique may affect patient outcomes. As new procedures enter practice, it is difficult to evaluate the association of each aspect of technique with patient outcomes.To examine the associations between technique and outcomes in laparoscopic sleeve gastrectomy.In this cohort study of bariatric surgery programs participating in a statewide surgical quality improvement collaborative, 30 surgeons submitted intraoperative videos from representative sleeve gastrectomies performed on 6915 patients with morbid obesity. These videos were reviewed by blinded peer surgeons on key technical elements, and 605 reviews were linked to sleeve gastrectomy outcomes of all of the surgeons' patients from January 1, 2015, to December 31, 2016.Surgeons' technical approaches to 5 controversial aspects of laparoscopic sleeve gastrectomy: dissection of the proximal stomach, sleeve caliber, sleeve anatomy, staple line reinforcement, and leak testing.The 30-day outcomes were rate of postoperative hemorrhage and staple line leak. The 1-year outcomes were percentage of total weight lost and reflux severity (Gastroesophageal Reflux Disease Health-Related Quality of Life instrument).A total of 30 surgeons submitted 46 videos of operations performed on 6915 patients (mean [SD] age, 45.4 [11.7] years; 5494 [79.5%] female; 4706 [68.1%] White). Complete dissection of the proximal stomach was associated with reduced hemorrhage rates (higher ratings for complete mobilization of fundus were associated with a decrease in hemorrhage rate from 2.1% [25th percentile] to 1.0% [75th percentile], P = .01; higher ratings for visualization of the left crus were associated with a decrease in hemorrhage rate from 1.5% to 0.94%, P = .006; and higher ratings for complete division of the short gastrics were associated with a decrease in hemorrhage rate from 2.8% to 1.2%, P = .03). The reduction in hemorrhage rates came at the expense of higher leak rates (higher ratings for complete mobilization of fundus were associated with an increase in leak rate from 0.05% [25th percentile] to 0.16% [75th percentile], P .001; higher ratings for visualization of the left crus were associated with an increase in leak rate from 0.1% to 0.2%, P = .003; and higher ratings for complete division of the short gastrics were associated with an increase in leak rate from 0.02% to 0.1%, P = .01). Surgeons who stapled more tightly to the bougie had smaller decreases in reflux than those who stapled less tightly (-2.0 to -1.3 on a 50-point scale, P = .002). Staple line reinforcement (buttressing and oversewing) was associated with a small (2 of 1000 cases) decrease in hemorrhage rates. Staple line buttressing was also associated with a similarly small increase in leak rates (1 of 1000 cases). Leak testing was associated with a statistically insignificant change in the staple line leak rate (0.16%-0.22%, P = .47).Variations in surgical technique can be measured by video review and are associated with differences in patient outcomes.

Following the US Food and Drug Administration approval for laparoscopic gastric band surgery in 2001, as many as 96 000 devices have been placed annually. The reported rates of reoperation range from 4% to 60% in short-term studies; however, to our knowledge, few long-term population-level data on outcomes or expenditures are known.To describe the rate of device-related reoperations occurring after laparoscopic gastric band surgery as well as the associated payments in a longitudinal national cohort.This retrospective review of 25 042 Medicare beneficiaries who underwent gastric band placement between 2006 and 2013 identifies gastric band-related reoperations, including device removal, device replacement, or revision to a different bariatric procedure (eg, a gastric bypass or sleeve gastrectomy). The rates of reoperation were risk adjusted using a multivariable logistic regression model that included patient age, sex, race/ethnicity, Elixhauser comorbidities, and the year that the operation was performed.Rate of device-related reoperation nationally and across individual hospital referral regions. Thirty-day total episode Medicare payments to hospitals for the index operation and any subsequent reoperations.Of the 25 042 patients who underwent gastric band placement, 20 687 (82.61%) were white, 18 143 (72.45%) were women, and the mean age was 57.56 years. Patients (mean age, 57.5; 76.2% women) requiring reoperation had lower rates of hypertension (64.9% vs 73.4%; P .001) and diabetes (40.4% vs 44.6%; P .001) and were more likely to have their index operation at a for-profit hospital (34.6% vs 22.0%; P .001). With an average of 4.5-year follow-up, 4636 patients (18.5%) underwent 17 539 reoperations (an average of 3.8 procedures/patient). Hospital referral regions demonstrated a 2.9-fold variation in risk- and reliability-adjusted rates of reoperation (lower quartile average, 13.3%; upper quartile average, 39.1%). During the study period, Medicare paid $470 million for laparoscopic gastric band associated procedures, of which $224 million (47.6%) of the payments were for reoperations. From 2006 to 2013, the proportion of payments from Medicare for reoperations increased from 16.4% to 77.3% of their annual spending on the gastric band device.Among Medicare beneficiaries undergoing gastric band surgery, device-related reoperation was common, costly, and varied widely across hospital referral regions. These findings suggest that payers should reconsider their coverage of the gastric band device.

Importance In the United States, reports about perioperative complications associated with bariatric surgery led to the establishment of accreditation criteria for bariatric centers of excellence and many bariatric centers obtaining accreditation. Currently, most bariatric procedures occur at these centers, but to what extent they uniformly provide high-quality care remains unknown. Objective To describe the variation in surgical outcomes across bariatric centers of excellence and the geographic availability of high-quality centers. Design, Setting, and Participants This retrospective review analyzed the claims data of 145 527 patients who underwent bariatric surgery at bariatric centers of excellence between January 1, 2010, and December 31, 2013. Data were obtained from the Healthcare Cost and Utilization Project’s State Inpatient Database. This database included unique hospital identification numbers in 12 states (Arkansas, Arizona, Florida, Iowa, Massachusetts, Maryland, North Carolina, Nebraska, New Jersey, New York, Washington, and Wisconsin), allowing comparisons among 165 centers of excellence located in those states. Participants were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Those included in the study cohort were patients with a primary diagnosis of morbid obesity and who underwent laparoscopic Roux-en-Y gastric bypass, open Roux-en-Y gastric bypass, laparoscopic gastric band placement, or laparoscopic sleeve gastrectomy. Excluded from the cohort were patients younger than 18 years or who had an abdominal malignant neoplasm. Data were analyzed July 1, 2016, through January 10, 2017. Main Outcomes and Measures Risk-adjusted and reliability-adjusted serious complication rates within 30 days of the index operation were calculated for each center. Centers were stratified by geographic location and operative volume. Results In this analysis of claims data from 145 527 patients, wide variation in quality was found across 165 bariatric centers of excellence, both nationwide and statewide. At the national level, the risk-adjusted and reliability-adjusted serious complication rates at each center varied 17-fold, ranging from 0.6% to 10.3%. At the state level, variation ranged from 2.1-fold (Wisconsin decile range, 1.5%-3.3%) to 9.5-fold (Nebraska decile range, 1.0%-10.3%). After dividing hospitals into quintiles of quality on the basis of their adjusted complication rates, 38 of 132 (28.8%) had a center in a higher quintile of quality located within the same hospital service area. Variation in rates of complications existed at centers with low volume (annual mean [SD] procedure volume, 156 [20] patients; complication range, 0.6%-6.4%; 9.8-fold variation), medium volume (annual mean [SD] procedure volume, 239 [27] patients; complication range, 0.6%-10.3%; 17.5-fold variation), and high volume (annual mean [SD] procedure volume, 448 [131] patients; complication range, 0.6%-4.9%; 7.5-fold variation). Conclusions and Relevance Even among accredited bariatric surgery centers, wide variation exists in rates of postoperative serious complications across geographic location and operative volumes. Given that a large proportion of centers are geographically located near higher-performing centers, opportunities for improvement through regional collaboratives or selective referral should be considered.