© Provided by Pittsburgh Post-Gazette It was not long ago — in the mid-2000s — that weight-loss surgeries were falling out of favor. Not only with surgeons and patients, but insurance companies too, who feared the complications and mortality data for some procedures was not worth the risk of paying for obese people to get the potentially life-saving surgery.
But a decade-and-a-half later, bariatric surgeons are now doing 250,000 weight-loss surgeries a year, more than double the number of a decade ago.
Experts say the dramatic increase is due to a combination of better and safer surgical options including the most popular: gastric sleeve surgery. Studies that increasingly show the leading surgical techniques have long-term health benefits, and also because most insurance — government and private — now regularly covers the leading techniques, making them available to more people.
A new study in the journal JAMA Surgery, led by University of Pittsburgh researcher Dr. Anita Courcoulas, that looked at more than 30,000 bariatric surgeries over 10 years at 10 different hospitals is adding to the growing body of evidence. The study showed that the two leading bariatric surgical techniques, gastric sleeve and gastric bypass surgery, not only have relatively few post-surgical interventions, but have mortality results that are in line with other long-established surgeries of less than 1% after five years.
But the study also found some differences between bypass and sleeve that had long been hypothesized but not analyzed on a long-term scale like the new study has done.
Patients who underwent gastric bypass surgery were found to require more abdominal operations or interventions than gastric sleeve surgery patients at all three time periods after the initial surgery (1 year, 3 years and 5 years). Bypass patients at 5 years required an operation or intervention 12.3% of the time, versus 8.9% for sleeve patients.
Bypass patients also were "more commonly associated" than sleeve patients with having to undergo endoscopy procedures and to be hospitalized in the years after the initial surgery.
© Provided by Pittsburgh Post-Gazette Longwall Mining Report locations The reason for that, said Dr. Courcoulas, a professor of surgery at Pitt, is because gastric bypass surgery "is a more complex operation to have than sleeve."
Gastric bypass surgery, which was first performed in 1953, helps patients lose weight by bypassing the stomach and creating a stomach-like pouch, which fills up faster and makes the person feel fuller sooner. Gastric sleeve surgery, which was first performed in 1988, pursues the same goal by removing a portion of the patient's stomach.
While bypass has been found to have more complications after surgery than sleeve, bypass also was found in a prior study, using the same data source, to result in more weight loss than sleeve.
Because of that, Dr. Courcoulas said, she hopes providers use this new study's findings of slightly more complications after surgery with bypass to advise patients considering both surgeries to make "shared decision making of the risks and rewards of both procedures."
For people whose health situation is dire — for example, with a higher body mass index count, or dealing with serious issues related to diabetes — it may make more sense, despite the post-surgical data, to undergo bypass rather than sleeve, she said.
"People are not always aware of the risk and benefits," she said. "And I think that's been because of a lack of available tools and data."
Sleeve more popular
In large part because sleeve is a less complicated surgery, it has rapidly become the most popular form of bariatric surgery, with 61% of patients choosing it in 2018, according to data from the American Society for Metabolic and Bariatric Surgery, up from 35% in 2011.
Bypass, by comparison, has fallen steadily in popularity with patients, from 36% of all bariatric surgeries in 2011, when it was the most popular technique, to 17% in 2018.
© Provided by Pittsburgh Post-Gazette bariatric As another example of how data informed patients' choice, gastric band surgery, in which a band was wrapped around a portion of the stomach to make it smaller, was found to cause significant problems for many patients a decade ago, and not have the weight loss of other techniques. It fell from 35% of all bariatric surgeries in 2011, to just 1% in 2018.
In her practice at UPMC Magee-Womens Hospital, where she is chief of minimally invasive and bariatric surgery, Dr. Courcoulas said the roughly 800 annual bariatric surgeries performed there are roughly split between sleeve and bypass.
That's because her department does use a "shared decision making" process with patients, and because many of Magee's patients are dealing with more serious health issues, she said.
Dr. George Eid, director of Allegheny Health Network's Bariatric and Metabolic Institute, who was not involved in the study, said the study's findings confirmed what many in the field have known for a long time about the differences between sleeve and bypass.
"This is why [sleeve surgery] is most attractive to patients, because it seems to be less invasive," he said.
But Dr. Eid said he hopes future studies can be "more specific" about the post-surgical interventions and operations and how, or if, they are directly related to the bariatric surgery.
"The study has a lot of limitations," he said, because of the data, which came from insurance codes and not actual patient charts, that researchers had to use.
He noted, as the study's authors acknowledged, that counting hospital readmissions after surgery could be for any reason, not just related to the bariatric surgery.
Still, he said, "any time you have a large set of data to analyze like this, it's good."
Dr. Shanu Kothari, president-elect of the American Society for Metabolic and Bariatric Surgery, who also was not involved in the study, said for him the study's main conclusion was "that the two most common surgeries performed for bariatric surgery are safe."
He hoped that patients and surgeons alike would not see the post-surgical differences between bypass and sleeve surgeries as the only data worth considering.
"Even though [bypass] has a higher need for interventions, most studies also show it has a higher benefit in regard to diabetes, acid reflux, high blood pressure and even sleep apnea," said Dr. Kothari, a bariatric surgeon with Prisma Health in Greenville, S.C. "In general, the chance of improvement or remissions [of disease] are better with [bypass] over sleeve."
Dr. Courcoulas said that one of her hopes is to redo the study with even longer-term outcomes at 10 years or more to see how patients are doing.
Dr. Kothari said the field is eager to see what that long-term data shows.
"We'd all like to repeat a study like this in five to seven years and see what it shows," he said.
Sean D. Hamill: shamill@post-gazette.com or 412-263-2579 or Twitter: @SeanDHamill
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