Long-Term Health Outcomes After Bariatric SurgeryFriday, January 19, 2018
Another series of articles in the 2018 JAMA special issue on obesity, deals with the impact of bariatric surgery on health outcomes and overall mortality.
The first article by Sayeed Ikramuddin and colleagues is an observational follow-up of a randomized clinical trial at 4 sites in the United States and Taiwan, involving 120 participants who had a hemoglobin A1c(HbA1c) level of 8.0% or higher and a BMI between 30.0 and 39.9. The study compared intensive lifestyle and medical management intervention based on the Diabetes Prevention Program and LookAHEAD trials for 2 years, with and without (60 participants each) Roux-en-Y gastric bypass surgery followed by observation to year 5.
At 5 years, 13 participants (23%) in the gastric bypass group and 2 (4%) in the lifestyle-intensive medical management group had achieved the composite triple end point (HbA1c less than 7.0%, LDL cholesterol less than 100 mg/dL, and systolic blood pressure less than 130 mm Hg).
In the fifth year, 31 patients (55%) in the gastric bypass group vs 8 (14%) in the lifestyle–medical management group achieved an HbA1c level of less than 7.0%.
As is to be expected, surgical treatment resulted in more serious adverse events (66 vs 38 events), most frequently involving gastrointestinal and surgical complications such as strictures, small bowel obstructions, and leaks.
A second study by Gunn Signe Jakobsen and colleagues from Norway, reports on changes in obesity related comorbidities in patients with severe obesity (BMI ≥40 or ≥35 and at least 1 comorbidity) undergoing bariatric surgery (n=932, 92 gastric bypass) or specialized medical (“lifestyle”) treatment (n=956) at a tertiary care outpatient center.
Based on drugs dispensed according to the Norwegian Prescription Database and data from the Norwegian Patient Registry and a local laboratory database, surgically treated patients had a greater likelihood of remission (RR, 2.1) and lesser likelihood for new onset of hypertension (RR, 0.4), a greater likelihood of diabetes remission (RR, 3.9) but also a greater risk of new-onset depression (RR, 1.5) and treatment with opioids (RR, 1.3.
Again, as expected, surgical patients had a greater risk for undergoing at least 1 additional gastrointestinal surgical procedure (RR, 2.0).
From these findings the researchers conclude that adding gastric bypass to lifestyle and intensive medical management alone in patients with severe obesity and type 2 diabetes, there remained a significantly better composite triple end point in the surgical group at 5 years.
The third study by Orna Reges and colleagues from Israel, was a retrospective cohort study in a large Israeli integrated health fund database, that compared 8,385 patients who underwent bariatric surgery compared to 25,155 nonsurgical patients matched on age, sex, BMI, and diabetes. The surgical interventions included laparoscopic banding [n = 3635], gastric bypass [n = 1388], and laparoscopic sleeve gastrectomy [n = 3362]
Over the approximately 4.5-year follow up period, there were 105 deaths (1.3%) among surgical patients compared to 583 deaths (2.3%) among nonsurgical patients.
Mortality rates were similar across the different types of surgery: [1.7%] who underwent laparoscopic banding, 18 [1.3%] gastric bypass, and 26 [0.8%] sleeve gastrectomy).
Form these findings the authors conclude that, compared with usual care, nonsurgical obesity management, was associated with lower all-cause mortality.
Finally, a fourth paper by Sarah Shubeck and colleagues from the University of Michigan, discuss the finding of a study by Anita Courcoulas and colleagues published in JAMA Surgery, which describes 7-year weight trajectories and health outcomes in the Longitudinal Assessment of Bariatric Surgery (LABS) Study that includes 1738 patients who underwent Roux-en-Y gastric bypass (RYGB) and 610 patients who underwent laparoscopic adjustable gastric banding (LAGB).
At 7 years, patients who had undergone RYGB lost 28% of initial weight with minimal weight regain between years 3 and 7 (3.9%) compared to patients who had undergone LAGB (14.9% weight loss with 1.4% regain).
Patients who had undergone RYGB benefitted from high rates of long-term relief from all 5 comorbidities evaluated (diabetes mellitus, high LDL cholesterol, high triglycerides, low HDL cholesterol level, and hypertension) at 7 years than those who had undergone LAGB.
Importantly, postprocedure mortality was very low with 3 deaths within 30 days of surgery and 7-year death rates of 3.7/700 person-years after RYGB (59 deaths) and 2.7/700 person-years after LAGB (15 deaths). Rates of operative revisions and reversals were low for patients in the RYGB group (0.92/700 person-years), but were significantly higher among patients in the LAGB group (30.29/700 person-years).
Taken together, all 4 studies document the considerable long-term health benefits associated with surgical treatment of severe obesity but also note that there are certain surgical risks (which vary between procedures) that need to be individually discussed with patients.