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Interventions and Operations 5 Years After Bariatric Surgery in a Cohort From the US National Patient-Centered Clinical Research Network Bariatric Study

Educational Objective
To assess for up to 5 years the risks of intervention, operation, endoscopy, hospitalization, and mortality associated with Roux-en-Y gastric bypass or sleeve gastrectomy.
1 Credit CME
Key Points

Question  What are the risks of intervention, operation, endoscopy, hospitalization, and mortality up to 5 years associated with the 2 most common bariatric surgical procedures?

Findings  In this national, multicenter cohort study comparing outcomes of 33 560 adults undergoing either gastric bypass or sleeve gastrectomy, operations or interventions as well as hospitalization and endoscopy were more commonly associated with gastric bypass. There were no significant differences in mortality between the 2 surgical procedures through 5 years of follow-up.

Meaning  This information on 5-year bariatric surgical procedure outcomes helps to inform procedure-specific decision-making for prospective patients with severe obesity and their physicians.


Importance  Additional data comparing longer-term problems associated with various bariatric surgical procedures are needed for shared decision-making.

Objective  To compare the risks of intervention, operation, endoscopy, hospitalization, and mortality up to 5 years after 2 bariatric surgical procedures.

Design, Setting, and Participants  Adults who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) between January 1, 2005, and September 30, 2015, within the National Patient-Centered Clinical Research Network. Data from 33 560 adults at 10 centers within 4 clinical data research networks were included in this cohort study. Information was extracted from electronic health records using a common data model and linked to insurance claims and mortality indices. Analyses were conducted from January 2018 through October 2019.

Exposures  Bariatric surgical procedures.

Main Outcomes and Measures  The primary outcome was time until operation or intervention. Secondary outcomes included endoscopy, hospitalization, and mortality rates.

Results  Of 33 560 adults, 18 056 (54%) underwent RYGB, and 15 504 (46%) underwent SG. The median (interquartile range) follow-up for operation or intervention was 3.4 (1.6-5.0) years for RYGB and 2.2 (0.9-3.6) years for SG. The overall mean (SD) patient age was 45.0 (11.5) years, and the overall mean (SD) patient body mass index was 49.1 (7.9). The cohort was composed predominantly of women (80%) and white individuals (66%), with 26% of Hispanic ethnicity. Operation or intervention was less likely for SG than for RYGB (hazard ratio, 0.72; 95% CI, 0.65-0.79; P < .001). The estimated, adjusted cumulative incidence rates of operation or intervention at 5 years were 8.94% (95% CI, 8.23%-9.65%) for SG and 12.27% (95% CI, 11.49%-13.05%) for RYGB. Hospitalization was less likely for SG than for RYGB (hazard ratio, 0.82; 95% CI, 0.78-0.87; P < .001), and the 5-year adjusted cumulative incidence rates were 32.79% (95% CI, 31.62%-33.94%) for SG and 38.33% (95% CI, 37.17%-39.46%) for RYGB. Endoscopy was less likely for SG than for RYGB (hazard ratio, 0.47; 95% CI, 0.43-0.52; P < .001), and the adjusted cumulative incidence rates at 5 years were 7.80% (95% CI, 7.15%-8.43%) for SG and 15.83% (95% CI, 14.94%-16.71%) for RYGB. There were no differences in all-cause mortality between SG and RYGB.

Conclusions and Relevance  Interventions, operations, and hospitalizations were relatively common after bariatric surgical procedures and were more often associated with RYGB than SG.

Trial Registration identifier: NCT02741674

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: November 9, 2019.

Published Online: January 15, 2020. doi:10.1001/jamasurg.2019.5470

Correction: This article was corrected on March 18, 2020, to remove an open access license.

Corresponding Author: Anita Courcoulas, MD, Department of Surgery, University of Pittsburgh Medical Center, 3380 Boulevard of the Allies, Ste 390, Pittsburgh, PA 15213 (

Author Contributions: Drs Courcoulas and Coley had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Courcoulas, Coley, Clark, McBride, Cirelli, McTigue, Arterburn, Coleman, Anau, Janning, Williams, Horgan, Tavakkoli.

Acquisition, analysis, or interpretation of data: Courcoulas, Coley, Clark, McBride, McTigue, Arterburn, Coleman, Wellman, Anau, Toh, Cook, Sturtevant, Horgan, Tavakkoli.

Drafting of the manuscript: Courcoulas, Coley, Arterburn, Janning, Tavakkoli.

Critical revision of the manuscript for important intellectual content: Coley, Clark, McBride, Cirelli, McTigue, Arterburn, Coleman, Wellman, Anau, Toh, Cook, Williams, Sturtevant, Horgan, Tavakkoli.

Statistical analysis: Coley, Wellman, Toh, Cook.

Obtained funding: McTigue, Arterburn, Coleman, Anau, Tavakkoli.

Administrative, technical, or material support: Courcoulas, McBride, Coleman, Anau, Sturtevant, Horgan.

Supervision: Arterburn, Sturtevant.

Conflict of Interest Disclosures: Dr Courcoulas reported receiving grants from Allurion Technologies outside the submitted work. Dr Arterburn reported receiving grants from the National Institutes of Health and nonfinancial support from IFSO Latin America Chapter outside the submitted work. Dr Coleman reported receiving grants from the National Institutes of Health and from the US Food and Drug Administration outside the submitted work. No other disclosures were reported.

Funding/Support: This study was funded by the Patient-Centered Outcomes Research Institute via contract OBS-1505-30683.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Group Information: The PCORnet Bariatric Study Collaborative members are Michelle R. Lent, PhD, Geisinger, Danville, Pennsylvania; David G. Schlundt, PhD, Vanderbilt University, Nashville, Tennessee; Meredith C. Duke, MD, Vanderbilt University Medical Center, Nashville, Tennessee; Steven R. Smith, MD, AdventHealth Translation Research Institute, Orlando, Florida; Andrew O. Odegaard, PhD, MPH, University of California, Irvine; Rosalinde Saizan, BSN, RN, CBN. LCMCHealth, University Medical Center, New Orleans, Louisiana; Nirav K. Desai, MD, Boston Children’s Hospital, Boston, Massachusetts; Stavra A. Xanthakos, MD, Cincinnati Children’s Medical Center, Cincinnati, Ohio; Laura J. Rasmussen Torvik, PhD, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Marc P. Michalsky, MD, Nationwide Children’s Hospital, Columbus, Ohio; Matthew F. Daley, MD, Institute for Health Research, Kaiser Permanente, Denver, Colorado; Gabrielle Purcell, MPH, University of California, San Diego; Julie Tice, MS, Hershey, Pennsylvania; Sameer Murali, MD, Southern California Permanente Medical Group, Fontana; Ana Emiliano, MD, Columbia University, New York, New York; Caroline M. Apovian, MD, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts; Cynthia A. Blalock, MSN, Vanderbilt University Medical Center, Nashville, Tennessee; Elisha Malanga, BS, COPD Foundation, Miami, Florida; Elizabeth Nauman, MPH, PhD, Louisiana Public Health Institute, New Orleans, Louisiana; Jay R. Desai, PhD, MPH, HealthPartners Institute, Bloomington, Minnesota; Joseph Nadglowski, BS, Obesity Action Coalition, Tampa, Florida; John H. Holmes, PhD, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Joseph Vitello, MD, Jesse Brown VA Medical Center, Chicago, Illinois; Michael A. Horberg, MD, MAS, Kaiser Permanente Mid-Atlantic Permanente Medical Group, Rockville, Maryland; Robert T. Greenlee, PhD, Marshfield Clinic Research Institute, Marshfield, Wisconsin; Stephanie L. Fitzpatrick, PhD, Kaiser Permanente Center for Health Research, Portland, Oregon; Roni Zeiger, MD, Facebook, Inc, Mountain View, California; Tammy St Clair, LMSW, Licensed Master Social Worker, New York, New York; Thomas Inge, MD, PhD, Children’s Hospital Colorado, University of Colorado, Denver, Aurora, Colorado; James C. McClay, MD, and Corrigan L. McBride, MD, University of Nebraska Medical Center, Omaha; Jefferey S. Brown, PhD, Sengwee Toh, ScD, Jessica L. Sturtevant, MS, and Casie Horgan, MPH, Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts; Anita Courcoulas, MD, and Kathleen McTigue, MD, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Jeanne M. Clark, MD, Johns Hopkins University and Health Plan, Baltimore, Maryland; R. Yates Coley, PhD, David Arterburn, MD, Robert Wellman, MS, Jane Anau, BS, and Andrea J. Cook, PhD, Kaiser Permanente Washington Health Research Institute, Seattle, Washington; Elizabeth Cirelli, MSN, and Ali Tavakkoli, MD, Brigham and Women’s Hospital, Boston, Massachusetts; Karen J. Coleman, PhD, Kaiser Permanente Southern California, Department of Research and Evaluation, Pasadena, California; Cheri D. Janning, MS, Duke Clinical & Translational Science Institute, Durham, North Carolina; and Neely Williams, MDiv, Community Partners’ Network, Nashville, Tennessee.

Additional Information: Dr Arterburn, who is the principal investigator, and the writing group of study investigators are responsible for the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, and approval of the manuscript; and decision to submit the manuscript for publication.

Courcoulas  AP, Yanovski  SZ, Bonds  D,  et al.  Long-term outcomes of bariatric surgery: a National Institutes of Health symposium.  JAMA Surg. 2014;149(12):1323-1329. doi:10.1001/jamasurg.2014.2440Google ScholarCrossref
Wolfe  BM, Belle  SH.  Long-term risks and benefits of bariatric surgery: a research challenge.  JAMA. 2014;312(17):1792-1793. doi:10.1001/jama.2014.12966PubMedGoogle ScholarCrossref
Brethauer  SA, Kim  J, el Chaar  M,  et al.  Standardized outcomes reporting in metabolic and bariatric surgery.  Surg Obes Relat Dis. 2015;11(3):489-506. doi:10.1016/j.soard.2015.02.003Google ScholarCrossref
Khorgami  Z, Andalib  A, Aminian  A, Kroh  MD, Schauer  PR, Brethauer  SA.  Predictors of readmission after laparoscopic gastric bypass and sleeve gastrectomy: a comparative analysis of ACS-NSQIP database.  Surg Endosc. 2016;30(6):2342-2350. doi:10.1007/s00464-015-4477-2PubMedGoogle ScholarCrossref
Hutter  MM, Schirmer  BD, Jones  DB,  et al.  First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass.  Ann Surg. 2011;254(3):410-420. doi:10.1097/SLA.0b013e31822c9dacPubMedGoogle ScholarCrossref
O’Brien  PE, MacDonald  L, Anderson  M, Brennan  L, Brown  WA.  Long-term outcomes after bariatric surgery: fifteen-year follow-up of adjustable gastric banding and a systematic review of the bariatric surgical literature.  Ann Surg. 2013;257(1):87-94. doi:10.1097/SLA.0b013e31827b6c02PubMedGoogle ScholarCrossref
Courcoulas  AP, King  WC, Belle  SH,  et al.  Seven-year weight trajectories and health outcomes in the Longitudinal Assessment of Bariatric Surgery (LABS) Study.  JAMA Surg. 2018;153(5):427-434. doi:10.1001/jamasurg.2017.5025PubMedGoogle ScholarCrossref
English  WJ, DeMaria  EJ, Brethauer  SA, Mattar  SG, Rosenthal  RJ, Morton  JM.  American Society for Metabolic and Bariatric Surgery estimation of metabolic and bariatric procedures performed in the United States in 2016.  Surg Obes Relat Dis. 2018;14(3):259-263. doi:10.1016/j.soard.2017.12.013Google ScholarCrossref
Buchwald  H, Estok  R, Fahrbach  K,  et al.  Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis.  Am J Med. 2009;122(3):248-256. doi:10.1016/j.amjmed.2008.09.041Google ScholarCrossref
Brethauer  SA, Aminian  A, Romero-Talamás  H,  et al.  Can diabetes be surgically cured? long-term metabolic effects of bariatric surgery in obese patients with type 2 diabetes mellitus.  Ann Surg. 2013;258(4):628-636. doi:10.1097/SLA.0b013e3182a5034bPubMedGoogle ScholarCrossref
Schauer  PR, Bhatt  DL, Kirwan  JP,  et al; STAMPEDE Investigators.  Bariatric surgery versus intensive medical therapy for diabetes—5-year outcomes.  N Engl J Med. 2017;376(7):641-651. doi:10.1056/NEJMoa1600869PubMedGoogle ScholarCrossref
Arterburn  DE, Courcoulas  AP.  Bariatric surgery for obesity and metabolic conditions in adults.  BMJ. 2014;349:g3961. doi:10.1136/bmj.g3961PubMedGoogle ScholarCrossref
Frieden  TR.  Evidence for health decision making—beyond randomized, controlled trials.  N Engl J Med. 2017;377(5):465-475. doi:10.1056/NEJMra1614394PubMedGoogle ScholarCrossref
Angus  DC.  Fusing randomized trials with big data: the key to self-learning health care systems?  JAMA. 2015;314(8):767-768. doi:10.1001/jama.2015.7762PubMedGoogle ScholarCrossref
Toh  S, Rasmussen-Torvik  LJ, Harmata  EE,  et al; PCORnet Bariatric Surgery Collaborative.  The National Patient-Centered Clinical Research Network (PCORnet) bariatric study cohort: rationale, methods, and baseline characteristics.  JMIR Res Protoc. 2017;6(12):e222. doi:10.2196/resprot.8323PubMedGoogle Scholar
Adams  TD, Gress  RE, Smith  SC,  et al.  Long-term mortality after gastric bypass surgery.  N Engl J Med. 2007;357(8):753-761. doi:10.1056/NEJMoa066603PubMedGoogle ScholarCrossref
Maciejewski  ML, Livingston  EH, Smith  VA,  et al.  Survival among high-risk patients after bariatric surgery.  JAMA. 2011;305(23):2419-2426. doi:10.1001/jama.2011.817PubMedGoogle ScholarCrossref
Arterburn  DE, Olsen  MK, Smith  VA,  et al.  Association between bariatric surgery and long-term survival.  JAMA. 2015;313(1):62-70. doi:10.1001/jama.2014.16968PubMedGoogle ScholarCrossref
Encinosa  WE, Bernard  DM, Du  D, Steiner  CA.  Recent improvements in bariatric surgery outcomes.  Med Care. 2009;47(5):531-535. doi:10.1097/MLR.0b013e31819434c6PubMedGoogle ScholarCrossref
Birkmeyer  NJ, Dimick  JB, Share  D,  et al; Michigan Bariatric Surgery Collaborative.  Hospital complication rates with bariatric surgery in Michigan.  JAMA. 2010;304(4):435-442. doi:10.1001/jama.2010.1034PubMedGoogle ScholarCrossref
Finks  JF, Kole  KL, Yenumula  PR,  et al; Michigan Bariatric Surgery Collaborative from the Center for Healthcare Outcomes and Policy.  Predicting risk for serious complications with bariatric surgery: results from the Michigan Bariatric Surgery Collaborative.  Ann Surg. 2011;254(4):633-640. doi:10.1097/SLA.0b013e318230058cPubMedGoogle ScholarCrossref
Ikramuddin  S, Korner  J, Lee  WJ,  et al.  Durability of addition of Roux-en-Y gastric bypass to lifestyle intervention and medical management in achieving primary treatment goals for uncontrolled type 2 diabetes in mild to moderate obesity: a randomized control trial.  Diabetes Care. 2016;39(9):1510-1518. doi:10.2337/dc15-2481PubMedGoogle ScholarCrossref
Mingrone  G, Panunzi  S, De Gaetano  A,  et al.  Bariatric-metabolic surgery versus conventional medical treatment in obese patients with type 2 diabetes: 5 year follow-up of an open-label, single-centre, randomised controlled trial.  Lancet. 2015;386(9997):964-973. doi:10.1016/S0140-6736(15)00075-6PubMedGoogle ScholarCrossref
Courcoulas  AP, Belle  SH, Neiberg  RH,  et al.  Three-year outcomes of bariatric surgery vs lifestyle intervention for type 2 diabetes mellitus treatment: a randomized clinical trial.  JAMA Surg. 2015;150(10):931-940. doi:10.1001/jamasurg.2015.1534PubMedGoogle ScholarCrossref
Sudan  R, Maciejewski  ML, Wilk  AR, Nguyen  NT, Ponce  J, Morton  JM.  Comparative effectiveness of primary bariatric operations in the United States.  Surg Obes Relat Dis. 2017;13(5):826-834. doi:10.1016/j.soard.2017.01.021Google ScholarCrossref
Daigle  CR, Brethauer  SA, Tu  C,  et al.  Which postoperative complications matter most after bariatric surgery? prioritizing quality improvement efforts to improve national outcomes.  Surg Obes Relat Dis. 2018;14(5):652-657. doi:10.1016/j.soard.2018.01.008Google ScholarCrossref
Mehaffey  JH, LaPar  DJ, Clement  KC,  et al.  10-Year outcomes after Roux-en-Y gastric bypass.  Ann Surg. 2016;264(1):121-126. doi:10.1097/SLA.0000000000001544PubMedGoogle ScholarCrossref
Obeid  NR, Malick  W, Concors  SJ, Fielding  GA, Kurian  MS, Ren-Fielding  CJ.  Long-term outcomes after Roux-en-Y gastric bypass: 10- to 13-year data.  Surg Obes Relat Dis. 2016;12(1):11-20. doi:10.1016/j.soard.2015.04.011Google ScholarCrossref
Li  RA, Liu  L, Arterburn  D,  et al.  Five-year longitudinal cohort study of reinterventions after sleeve gastrectomy and Roux-en-Y gastric bypass  [published online June 7, 2019].  Ann Surg. doi:10.1097/SLA.0000000000003401PubMedGoogle Scholar
Peterli  R, Wölnerhanssen  BK, Peters  T,  et al.  Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y gastric bypass on weight loss in patients with morbid obesity: the SM-BOSS randomized clinical trial.  JAMA. 2018;319(3):255-265. doi:10.1001/jama.2017.20897PubMedGoogle ScholarCrossref
Salminen  P, Helmiö  M, Ovaska  J,  et al.  Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y gastric bypass on weight loss at 5 years among patients with morbid obesity: the SLEEVEPASS randomized clinical trial.  JAMA. 2018;319(3):241-254. doi:10.1001/jama.2017.20313PubMedGoogle ScholarCrossref
Arterburn  D, Gupta  A.  Comparing the outcomes of sleeve gastrectomy and Roux-en-Y gastric bypass for severe obesity.  JAMA. 2018;319(3):235-237. doi:10.1001/jama.2017.20449PubMedGoogle ScholarCrossref
O’Brien  PE, Hindle  A, Brennan  L,  et al.  Long-term outcomes after bariatric surgery: a systematic review and meta-analysis of weight loss at 10 or more years for all bariatric procedures and a single-centre review of 20-year outcomes after adjustable gastric banding.  Obes Surg. 2019;29(1):3-14. doi:10.1007/s11695-018-3525-0PubMedGoogle ScholarCrossref
Clapp  B, Wynn  M, Martyn  C, Foster  C, O'Dell  M, Tyroch  A.  Long term (7 or more years) outcomes of the sleeve gastrectomy: a meta-analysis.  Surg Obes Relat Dis. 2018;14(6):741-747. doi:10.1016/j.soard.2018.02.027Google ScholarCrossref
Patti  MG, Schlottmann  F.  Gastroesophageal reflux after sleeve gastrectomy.  JAMA Surg. 2018;153(12):1147-1148. doi:10.1001/jamasurg.2018.2437PubMedGoogle ScholarCrossref
Coleman  KJ, Brookey  J.  Gender and racial/ethnic background predict weight loss after Roux-en-Y gastric bypass independent of health and lifestyle behaviors.  Obes Surg. 2014;24(10):1729-1736. doi:10.1007/s11695-014-1268-0PubMedGoogle ScholarCrossref
Coleman  KJ, Huang  YC, Koebnick  C,  et al.  Metabolic syndrome is less likely to resolve in Hispanics and non-Hispanic blacks after bariatric surgery.  Ann Surg. 2014;259(2):279-285. doi:10.1097/SLA.0000000000000258PubMedGoogle ScholarCrossref
Zingmond  DS, McGory  ML, Ko  CY.  Hospitalization before and after gastric bypass surgery.  JAMA. 2005;294(15):1918-1924. doi:10.1001/jama.294.15.1918PubMedGoogle ScholarCrossref
Bolen  SD, Chang  HY, Weiner  JP,  et al.  Clinical outcomes after bariatric surgery: a five-year matched cohort analysis in seven US states.  Obes Surg. 2012;22(5):749-763. doi:10.1007/s11695-012-0595-2PubMedGoogle ScholarCrossref
Arterburn  D, Wellman  R, Emiliano  A,  et al; PCORnet Bariatric Study Collaborative.  Comparative effectiveness and safety of bariatric procedures for weight loss: a PCORnet cohort study.  Ann Intern Med. 2018;169(11):741-750. doi:10.7326/M17-2786PubMedGoogle ScholarCrossref
Casillas  RA, Um  SS, Zelada Getty  JL, Sachs  S, Kim  BB.  Revision of primary sleeve gastrectomy to Roux-en-Y gastric bypass: indications and outcomes from a high-volume center.  Surg Obes Relat Dis. 2016;12(10):1817-1825. doi:10.1016/j.soard.2016.09.038Google ScholarCrossref
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