Surgery for Obesity and Related Diseases 11 (2015) 987–990
Original article
Laparoscopic sleeve gastrectomy leads the U.S. utilization of bariatric surgery at academic medical centers J. Esteban Varela, M.D., F.A.C.S., F.A.S.M.B.S., Ninh T. Nguyen, M.D., F.A.C.S., F.A.S.M.B.S.* Department of Surgery, Irvine Medical Center of University of California, Orange, California Received October 9, 2014; accepted February 8, 2015
Abstract
Background: Analysis of a recent single state bariatric surgery registry revealed that laparoscopic sleeve gastrectomy was the most common bariatric procedure starting in 2012. The objective of this study was to examine the trend in utilization of laparoscopic sleeve gastrectomy performed at academic medical centers in the United States. Methods: Using ICD-9 diagnosis and procedure codes, clinical data obtained from the University HealthSystem Consortium database for all bariatric procedures performed for the treatment of severe obesity between October 1, 2011, and June 30, 2014. Quarterly trends in utilization for the 4 most commonly performed bariatric operations were examined, and comparisons between procedures were performed. Results: A total of 54,953 bariatric procedures were performed. Utilization of laparoscopic sleeve gastrectomy increased from 23.7% of all bariatric procedures during the fourth quarter of 2011 to 60.7% during the second quarter of 2014 while laparoscopic gastric bypass decreased from 62.2% to 37.0%, respectively. Utilization of laparoscopic sleeve gastrectomy surpassed that of laparoscopic gastric bypass in the second quarter of 2013 (50.6% versus 45.8%). During the same time period, utilization of open gastric bypass fell from 6.6% to 1.5%, and the use of laparoscopic adjustable gastric banding decreased from 7.5% to .8%. Conclusions: Within the context of U.S. academic medical centers, there has been a significant increase in the utilization of laparoscopic sleeve gastrectomy, which has surpassed laparoscopic gastric bypass utilization since 2013. Laparoscopic sleeve gastrectomy is now the most commonly performed bariatric procedure at the national level within academic centers. (Surg Obes Relat Dis 2015;11:987–990.) r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Bariatric surgery; Severe obesity; Laparoscopic sleeve gastrectomy; Laparascopic gastric bypass; Laparoscopic adjustable gastric banding
Introduction A recent analysis of bariatric surgery practices in the state of Michigan revealed that laparoscopic sleeve gastrectomy was the most commonly performed bariatric procedure [1]. Laparoscopic Roux-en-Y gastric bypass The information contained in this article was based on the clinical database provided by the University HealthSystem Consortium. * Correspondence: Ninh T. Nguyen, M.D., Department of Surgery, 333 City Building West, Suite 850, Orange, CA 92868, USA. E-mail: [email protected]
(LRYGB) had been the most commonly performed bariatric operation in the U.S. over the last decade [2,3]. Using the University HealthSystem Consortium (UHC) database, we previously reported a change in the bariatric surgery makeup within academic medical centers with a rapid increase in the utilization of laparoscopic sleeve gastrectomy in 2012 [4]. This increase primarily affected the utilization of laparoscopic adjustable gastric banding. Before the development of the sleeve gastrectomy, we previously reported an increase in utilization of laparoscopic adjustable gastric banding from 2004 to 2007 [5].
http://dx.doi.org/10.1016/j.soard.2015.02.008 1550-7289/r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
988
J. E. Varela and N. T. Nguyen / Surgery for Obesity and Related Diseases 11 (2015) 987–990
Laparoscopic gastric banding has been associated with lower perioperative morbidity but a modest weight loss at both short- and medium-term follow-up compared to laparoscopic gastric bypass [6–8]. Laparoscopic sleeve gastrectomy was first reported as a 2-stage procedure for high-risk patients undergoing laparoscopic gastric bypass [9,10]. Recent studies have shown that laparoscopic sleeve gastrectomy is an effective stand-alone procedure, resulting in weight loss somewhere between that of gastric banding and gastric bypass [11–13]. Furthermore, a recent meta-analysis revealed that the weight loss achieved with laparoscopic sleeve gastrectomy was comparable to that of laparoscopic gastric bypass at 5 years [14]. The American Society for Metabolic and Bariatric Surgery (ASMBS) has also recognized sleeve gastrectomy as an acceptable primary bariatric procedure [15]. The purpose of this study was to provide an update on the national trends in utilization of laparoscopic sleeve gastrectomy compared to other commonly performed bariatric procedures within U.S. academic medical centers. Methods
procedure code for laparoscopic adjustable gastric banding was 44.95; laparoscopic gastric bypass was 44.38; open gastric bypass was 44.31 and 44.39, respectively; and laparoscopic sleeve gastrectomy was 43.82. The procedures for obesity MS-DRG code (201) and risk-adjustment models were also used. Of note, the ICD-9 code for laparoscopic sleeve gastrectomy became available in the fourth quarter (Q4) of 2011. Statistical analysis Between Q4-2011 and Q2-2014, we analyzed the quarterly distribution of laparoscopic sleeve gastrectomy, laparoscopic and open gastric bypass, and laparoscopic adjustable gastric banding. We also compared patient characteristics (age, gender, race, and severity class) between patients who underwent laparoscopic sleeve gastrectomy versus laparoscopic and open gastric bypass and adjustable gastric banding. Proportional differences were analyzed by χ2 tests. Statistical analysis was performed using SPSS statistical software, version 12.0 (SPSS Inc., Chicago, IL). A P value of o.05 was considered significant.
Database The UHC database is an administrative, clinical, and financial database that provides benchmark measures on the utilization of healthcare resources for comparative data analysis between academic institutions. The UHC database is a collection of patient-level discharge abstract data from academic health centers and affiliate community hospitals. It contains discharge information on inpatient hospital stays. Approval for the use of the UHC patient-level data in this study was obtained from our Institutional Review Board and the UHC. One of the benefits of the UHC clinical database is the risk-adjusted data for comparing institutions. In addition, the Refined Diagnosis Related Group (RDRG) methodology is used to assign a level of severity of illness by grouping patients based on the severity and complexity of their secondary diagnoses (co-morbidities and complications). The severity classes for grouping patients are minor, moderate, major, or extreme severity. Data analysis We analyzed the UHC database for discharge data on all patients who underwent laparoscopic sleeve gastrectomy, laparoscopic and open Roux-en-Y gastric bypass, and laparoscopic adjustable gastric banding for the treatment of severe obesity. These procedures were identified using the appropriate diagnosis and procedural codes as specified by the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). The principal ICD-9 diagnosis codes for obesity and severe obesity were utilized (278.01 and 278.00, respectively). The principal ICD-9
Results A total of 54,953 patients underwent bariatric surgery for the treatment of severe obesity at U.S. academic medical centers between October 1, 2011, and June 30, 2014. Quarterly distribution of bariatric procedures performed during the study period is shown in Fig. 1. Utilization of laparoscopic sleeve gastrectomy increased from 23.7% of all bariatric procedures in Q4-2011 to 60.7% in Q2-2014. Laparoscopic gastric bypass use reduced from 62.2% to 37.0% in that time period. Utilization of laparoscopic sleeve gastrectomy surpassed that of laparoscopic gastric bypass during Q2-2013 (50.6% versus 45.8%). During the study period, the use of open gastric bypass decreased from 6.6% to 1.5%, and laparoscopic adjustable gastric banding mirrored that of open gastric bypass and decreased from 7.5% to .8%. During the last 5 quarters (Q2-2013 to Q2-2014), laparoscopic sleeve gastrectomy utilization exceeded that of laparoscopic gastric bypass (60.7% for sleeve versus 37.0% for bypass in Q2-2014). Demographic data for patients who underwent bariatric surgery in this time period is presented in Table 1. A higher proportion of patients 450 years of age who underwent laparoscopic adjustable gastric banding had a minor severity of illness compared to patients who underwent laparoscopic sleeve gastrectomy. Discussion This study examined the procedural trends of bariatric surgery at the national level using a large administrative database of academic medical centers. The main findings of
Sleeve Gastrectomy Lead U.S. Bariatric Makeup / Surgery for Obesity and Related Diseases 11 (2015) 987–990
989
Fig. 1. Quarterly utilization of laparoscopic sleeve gastrectomy (LSG), laparoscopic and open Roux-en-Y gastric bypass (LRYGB), and laparoscopic adjustable gastric banding (LAGB) at U.S. academic medical centers between Q4-2011 and Q2-2014. Laparoscopic and open Roux-en- Y gastric bypass are shown together.
this study were an increase in the utilization of laparoscopic sleeve gastrectomy that surpassed that of laparoscopic gastric bypass in 2013, accompanied by a moderate decline in utilization of laparoscopic and gastric bypass as well as a decline in utilization of laparoscopic adjustable gastric banding. Sleeve gastrectomy is part of the duodenal switch operation. Laparoscopic sleeve gastrectomy was originally reported as a staged procedure in high-risk patients undergoing laparoscopic gastric bypass [9]. Subsequently, sleeve gastrectomy was
performed as a standalone or primary bariatric operation with some technical modifications that have included a smaller bougie size [11]. As a stand-alone procedure, laparoscopic sleeve gastrectomy resulted in 55% of excess weight loss at 3 years and a 15% complication rate. Leaks, bleeding, and stricture rates in the systematic review were 2.2%, 1.2%, and .63%, respectively, with a 30-day mortality rate of .19% [16]. Long-term follow-ups of more than 5 years after sleeve gastrectomy were reported by 6 different studies with an excess weight loss ranging between 53% and 69% [15].
Table 1 Demographic characteristics of patients undergoing laparoscopic sleeve gastrectomy (LSG), laparoscopic gastric bypass (LGB), and laparoscopic adjustable gastric banding (LAGB) at U.S. academic medical centers between Q4-2011 and Q2-2014 (N ¼ 53,009)
No. Patients Age, years; n (%) 18-30 31-50 51-65 4 65 Female, n (%) Race, n (%) White Black Others Severity of illness, N (%) Minor Moderate to Extreme
LSG
LGB
LAGB
24,276
27,062
1,671
3,226 (13.3%) 13,347 (55.0%) 6,813 (28.0%) 801 (3.3%) 18,625 (76.7%)
3,245 (12.0%) 14,239 (52.6%)* 8,407 (31.1%)* 1,120 (4.1%)* 21,305 (78.7%)*
212 (12.7%) 807 (48.3%)* 488 (29.2%) 156 (9.3%)* 1,286 (77.0%)
15,559 (63.2%) 5,549 (22.9%) 3,368 (13.9%)
18,928 (69.9%)* 4,988 (18.5%)* 3,146 (11.6%)*
1,150 (68.8%)* 341 (20.4%)* 180 (10.8%)*
15,401 (63.5%) 8,866 (36.5%)
15,778 (58.3%)* 11,280 (41.7%)*
1,158 (69.3%)* 513 (30.7%)*
LSG ¼ Laparoscopic sleeve gastrectomy; LGB ¼ Laparoscopic gastric bypass; LAGB ¼ Laparoscopic adjustable gastric banding * P o .05 compared to LSG, χ2 test.
990
J. E. Varela and N. T. Nguyen / Surgery for Obesity and Related Diseases 11 (2015) 987–990
In 2012, the ASMBS recognized sleeve gastrectomy as an acceptable primary bariatric procedure [17]. We have previously reported a change in the makeup of bariatric surgery with an early utilization of laparoscopic gastric bypass, which became the most commonly performed bariatric operation at U.S. academic medical centers in 2004-2005, with 72% of all bariatric operations were performed using the laparoscopic technique [4,18]. In this study, we report a new and important change in the composition of bariatric surgery at U.S. academic centers. We found a dramatic 3-fold increase in utilization of laparoscopic sleeve gastrectomy over the past 3 years, which has now superseded that of laparoscopic gastric bypass and become the most commonly performed bariatric procedure at U.S. academic medical centers. This increase may be attributed to the technical simplicity of laparoscopic sleeve gastrectomy compared to laparoscopic gastric bypass; its demonstrated safety profile; its ability to be converted, revised, or used as a stage to a second bariatric procedure (i.e., gastric bypass or duodenal switch); its recognition as a primary bariatric operation by the ASMBS; its good long-term weight loss and remission of co-morbidities, comparable to that of gastric bypass; its improved third-party payors’ coverage; and its superior long-term weight loss compared with the gastric banding and the high rate of explantation at long-term follow-up for gastric banding [9,11,12]. The perioperative morbidity and mortality for sleeve gastrectomy has been reported to be somewhere between laparoscopic gastric banding and laparoscopic gastric bypass [13]. This study has several limitations. The data utilized in this study were obtained from an administrative database that included only U.S. academic medical centers; the results from this study may not be representative of utilization of bariatric surgery in private practice. There was a 1-year overlap in analysis of the UHC database performed between October 1, 2011, and September 10, 2012, between our previous and the current publication on this topic [4]. This overlap was important to show the trends in utilization of bariatric procedure. Lastly, many adjustable gastric banding procedures have been transitioned to an outpatient procedure. The UHC is an inpatient database, and therefore, the utilization data presented for laparoscopic gastric banding may not be a good representation of the true number of banding procedure being performed.
Conclusion An increase in the utilization of laparoscopic sleeve gastrectomy was found that exceeded that of laparoscopic gastric bypass in 2013. Within the context of U.S. academic medical centers, laparoscopic sleeve gastrectomy is now the most commonly performed bariatric operation for the treatment of severe obesity.
Disclosure The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] Reames BN, Finks JF, Bacal D, Carlin AM, Dimick JB. Changes in bariatric surgery procedure use in Michigan, 2006-2013. JAMA 2014;312(9):959–61. [2] Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic Gastric Bypass, Roux-en-Y: Preliminary Report of Five Cases. Obes Surg 1994;4(4):353–7. [3] Nguyen NT, Root J, Zainabadi K, et al. Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery. Arch Surg 2005;140(12):1198–202; discussion 1203. [4] Nguyen NT, Nguyen B, Gebhart A, Hohmann S. Changes in the makeup of bariatric surgery: a national increase in use of laparoscopic sleeve gastrectomy. J Am Coll Surg 2013;216(2):252–7. [5] Hinojosa MW, Varela JE, Parikh D, Smith BR, Nguyen XM, Nguyen NT. National trends in use and outcome of laparoscopic adjustable gastric banding. Surg Obes Relat Dis 2009;5(2):150–5. [6] Nguyen NT, Slone JA, Nguyen XM, Hartman JS, Hoyt DB. A prospective randomized trial of laparoscopic gastric bypass versus laparoscopic adjustable gastric banding for the treatment of morbid obesity: outcomes, quality of life, and costs. Ann Surg 2009;250(4):631–41. [7] Angrisani L, Lorenzo M, Borrelli V. Laparoscopic adjustable gastric banding versus Roux-en-Y gastric bypass: 5-year results of a prospective randomized trial. Surg Obes Relat Dis 2007;3(2):127– 132; discussion 132–3. [8] Biertho L, Steffen R, Ricklin T, et al. Laparoscopic gastric bypass versus laparoscopic adjustable gastric banding: a comparative study of 1,200 cases. J Am Coll Surg 2003;197(4):536–44; discussion 544–5. [9] Regan JP, Inabnet WB, Gagner M, Pomp A. Early experience with two-stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient. Obes Surg 2003;13(6):861–4. [10] Varela JE. Laparoscopic sleeve gastrectomy versus laparoscopic adjustable gastric banding for the treatment severe obesity in high risk patients. JSLS 2011;15(4):486–91. [11] Boza C, Salinas J, Salgado N, et al. Laparoscopic sleeve gastrectomy as a stand-alone procedure for morbid obesity: report of 1,000 cases and 3-year follow-up. Obes Surg 2012;22(6):866–71. [12] Himpens J, Dapri G, Cadiere GB. A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years. Obes Surg 2006;16(11):1450–6. [13] 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):410–20; discussion 420–2. [14] Chang SH, Stoll CR, Song J, Varela JE, Eagon CJ, Colditz GA. The effectiveness and risks of bariatric surgery: an updated systematic review and meta-analysis, 2003-2012. JAMA 2014;149(3):275–87. [15] ASMBS Clinical Issues Committee. Updated position statement on sleeve gastrectomy as a bariatric procedure. Surg Obes Relat Dis 2012;8(3):e21–6. [16] Clinical Issues Committee of American Society for Metabolic and Bariatric Surgery. Sleeve gastrectomy as a bariatric procedure. Surg Obes Relat Dis 2007;3(6):573–6. [17] Clinical Issues Committee of the American Society for Metabolic and Bariatric Surgery. Updated position statement on sleeve gastrectomy as a bariatric procedure. Surg Obes Relat Dis 2010;6(1):1–5. [18] Nguyen NT, Hinojosa M, Fayad C, Varela E, Wilson SE. Use and outcomes of laparoscopic versus open gastric bypass at academic medical centers. J Am Coll Surg 2007;205(2):248–55.
Original article
Laparoscopic sleeve gastrectomy leads the U.S. utilization of bariatric surgery at academic medical centers J. Esteban Varela, M.D., F.A.C.S., F.A.S.M.B.S., Ninh T. Nguyen, M.D., F.A.C.S., F.A.S.M.B.S.* Department of Surgery, Irvine Medical Center of University of California, Orange, California Received October 9, 2014; accepted February 8, 2015
Abstract
Background: Analysis of a recent single state bariatric surgery registry revealed that laparoscopic sleeve gastrectomy was the most common bariatric procedure starting in 2012. The objective of this study was to examine the trend in utilization of laparoscopic sleeve gastrectomy performed at academic medical centers in the United States. Methods: Using ICD-9 diagnosis and procedure codes, clinical data obtained from the University HealthSystem Consortium database for all bariatric procedures performed for the treatment of severe obesity between October 1, 2011, and June 30, 2014. Quarterly trends in utilization for the 4 most commonly performed bariatric operations were examined, and comparisons between procedures were performed. Results: A total of 54,953 bariatric procedures were performed. Utilization of laparoscopic sleeve gastrectomy increased from 23.7% of all bariatric procedures during the fourth quarter of 2011 to 60.7% during the second quarter of 2014 while laparoscopic gastric bypass decreased from 62.2% to 37.0%, respectively. Utilization of laparoscopic sleeve gastrectomy surpassed that of laparoscopic gastric bypass in the second quarter of 2013 (50.6% versus 45.8%). During the same time period, utilization of open gastric bypass fell from 6.6% to 1.5%, and the use of laparoscopic adjustable gastric banding decreased from 7.5% to .8%. Conclusions: Within the context of U.S. academic medical centers, there has been a significant increase in the utilization of laparoscopic sleeve gastrectomy, which has surpassed laparoscopic gastric bypass utilization since 2013. Laparoscopic sleeve gastrectomy is now the most commonly performed bariatric procedure at the national level within academic centers. (Surg Obes Relat Dis 2015;11:987–990.) r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Bariatric surgery; Severe obesity; Laparoscopic sleeve gastrectomy; Laparascopic gastric bypass; Laparoscopic adjustable gastric banding
Introduction A recent analysis of bariatric surgery practices in the state of Michigan revealed that laparoscopic sleeve gastrectomy was the most commonly performed bariatric procedure [1]. Laparoscopic Roux-en-Y gastric bypass The information contained in this article was based on the clinical database provided by the University HealthSystem Consortium. * Correspondence: Ninh T. Nguyen, M.D., Department of Surgery, 333 City Building West, Suite 850, Orange, CA 92868, USA. E-mail: [email protected]
(LRYGB) had been the most commonly performed bariatric operation in the U.S. over the last decade [2,3]. Using the University HealthSystem Consortium (UHC) database, we previously reported a change in the bariatric surgery makeup within academic medical centers with a rapid increase in the utilization of laparoscopic sleeve gastrectomy in 2012 [4]. This increase primarily affected the utilization of laparoscopic adjustable gastric banding. Before the development of the sleeve gastrectomy, we previously reported an increase in utilization of laparoscopic adjustable gastric banding from 2004 to 2007 [5].
http://dx.doi.org/10.1016/j.soard.2015.02.008 1550-7289/r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
988
J. E. Varela and N. T. Nguyen / Surgery for Obesity and Related Diseases 11 (2015) 987–990
Laparoscopic gastric banding has been associated with lower perioperative morbidity but a modest weight loss at both short- and medium-term follow-up compared to laparoscopic gastric bypass [6–8]. Laparoscopic sleeve gastrectomy was first reported as a 2-stage procedure for high-risk patients undergoing laparoscopic gastric bypass [9,10]. Recent studies have shown that laparoscopic sleeve gastrectomy is an effective stand-alone procedure, resulting in weight loss somewhere between that of gastric banding and gastric bypass [11–13]. Furthermore, a recent meta-analysis revealed that the weight loss achieved with laparoscopic sleeve gastrectomy was comparable to that of laparoscopic gastric bypass at 5 years [14]. The American Society for Metabolic and Bariatric Surgery (ASMBS) has also recognized sleeve gastrectomy as an acceptable primary bariatric procedure [15]. The purpose of this study was to provide an update on the national trends in utilization of laparoscopic sleeve gastrectomy compared to other commonly performed bariatric procedures within U.S. academic medical centers. Methods
procedure code for laparoscopic adjustable gastric banding was 44.95; laparoscopic gastric bypass was 44.38; open gastric bypass was 44.31 and 44.39, respectively; and laparoscopic sleeve gastrectomy was 43.82. The procedures for obesity MS-DRG code (201) and risk-adjustment models were also used. Of note, the ICD-9 code for laparoscopic sleeve gastrectomy became available in the fourth quarter (Q4) of 2011. Statistical analysis Between Q4-2011 and Q2-2014, we analyzed the quarterly distribution of laparoscopic sleeve gastrectomy, laparoscopic and open gastric bypass, and laparoscopic adjustable gastric banding. We also compared patient characteristics (age, gender, race, and severity class) between patients who underwent laparoscopic sleeve gastrectomy versus laparoscopic and open gastric bypass and adjustable gastric banding. Proportional differences were analyzed by χ2 tests. Statistical analysis was performed using SPSS statistical software, version 12.0 (SPSS Inc., Chicago, IL). A P value of o.05 was considered significant.
Database The UHC database is an administrative, clinical, and financial database that provides benchmark measures on the utilization of healthcare resources for comparative data analysis between academic institutions. The UHC database is a collection of patient-level discharge abstract data from academic health centers and affiliate community hospitals. It contains discharge information on inpatient hospital stays. Approval for the use of the UHC patient-level data in this study was obtained from our Institutional Review Board and the UHC. One of the benefits of the UHC clinical database is the risk-adjusted data for comparing institutions. In addition, the Refined Diagnosis Related Group (RDRG) methodology is used to assign a level of severity of illness by grouping patients based on the severity and complexity of their secondary diagnoses (co-morbidities and complications). The severity classes for grouping patients are minor, moderate, major, or extreme severity. Data analysis We analyzed the UHC database for discharge data on all patients who underwent laparoscopic sleeve gastrectomy, laparoscopic and open Roux-en-Y gastric bypass, and laparoscopic adjustable gastric banding for the treatment of severe obesity. These procedures were identified using the appropriate diagnosis and procedural codes as specified by the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). The principal ICD-9 diagnosis codes for obesity and severe obesity were utilized (278.01 and 278.00, respectively). The principal ICD-9
Results A total of 54,953 patients underwent bariatric surgery for the treatment of severe obesity at U.S. academic medical centers between October 1, 2011, and June 30, 2014. Quarterly distribution of bariatric procedures performed during the study period is shown in Fig. 1. Utilization of laparoscopic sleeve gastrectomy increased from 23.7% of all bariatric procedures in Q4-2011 to 60.7% in Q2-2014. Laparoscopic gastric bypass use reduced from 62.2% to 37.0% in that time period. Utilization of laparoscopic sleeve gastrectomy surpassed that of laparoscopic gastric bypass during Q2-2013 (50.6% versus 45.8%). During the study period, the use of open gastric bypass decreased from 6.6% to 1.5%, and laparoscopic adjustable gastric banding mirrored that of open gastric bypass and decreased from 7.5% to .8%. During the last 5 quarters (Q2-2013 to Q2-2014), laparoscopic sleeve gastrectomy utilization exceeded that of laparoscopic gastric bypass (60.7% for sleeve versus 37.0% for bypass in Q2-2014). Demographic data for patients who underwent bariatric surgery in this time period is presented in Table 1. A higher proportion of patients 450 years of age who underwent laparoscopic adjustable gastric banding had a minor severity of illness compared to patients who underwent laparoscopic sleeve gastrectomy. Discussion This study examined the procedural trends of bariatric surgery at the national level using a large administrative database of academic medical centers. The main findings of
Sleeve Gastrectomy Lead U.S. Bariatric Makeup / Surgery for Obesity and Related Diseases 11 (2015) 987–990
989
Fig. 1. Quarterly utilization of laparoscopic sleeve gastrectomy (LSG), laparoscopic and open Roux-en-Y gastric bypass (LRYGB), and laparoscopic adjustable gastric banding (LAGB) at U.S. academic medical centers between Q4-2011 and Q2-2014. Laparoscopic and open Roux-en- Y gastric bypass are shown together.
this study were an increase in the utilization of laparoscopic sleeve gastrectomy that surpassed that of laparoscopic gastric bypass in 2013, accompanied by a moderate decline in utilization of laparoscopic and gastric bypass as well as a decline in utilization of laparoscopic adjustable gastric banding. Sleeve gastrectomy is part of the duodenal switch operation. Laparoscopic sleeve gastrectomy was originally reported as a staged procedure in high-risk patients undergoing laparoscopic gastric bypass [9]. Subsequently, sleeve gastrectomy was
performed as a standalone or primary bariatric operation with some technical modifications that have included a smaller bougie size [11]. As a stand-alone procedure, laparoscopic sleeve gastrectomy resulted in 55% of excess weight loss at 3 years and a 15% complication rate. Leaks, bleeding, and stricture rates in the systematic review were 2.2%, 1.2%, and .63%, respectively, with a 30-day mortality rate of .19% [16]. Long-term follow-ups of more than 5 years after sleeve gastrectomy were reported by 6 different studies with an excess weight loss ranging between 53% and 69% [15].
Table 1 Demographic characteristics of patients undergoing laparoscopic sleeve gastrectomy (LSG), laparoscopic gastric bypass (LGB), and laparoscopic adjustable gastric banding (LAGB) at U.S. academic medical centers between Q4-2011 and Q2-2014 (N ¼ 53,009)
No. Patients Age, years; n (%) 18-30 31-50 51-65 4 65 Female, n (%) Race, n (%) White Black Others Severity of illness, N (%) Minor Moderate to Extreme
LSG
LGB
LAGB
24,276
27,062
1,671
3,226 (13.3%) 13,347 (55.0%) 6,813 (28.0%) 801 (3.3%) 18,625 (76.7%)
3,245 (12.0%) 14,239 (52.6%)* 8,407 (31.1%)* 1,120 (4.1%)* 21,305 (78.7%)*
212 (12.7%) 807 (48.3%)* 488 (29.2%) 156 (9.3%)* 1,286 (77.0%)
15,559 (63.2%) 5,549 (22.9%) 3,368 (13.9%)
18,928 (69.9%)* 4,988 (18.5%)* 3,146 (11.6%)*
1,150 (68.8%)* 341 (20.4%)* 180 (10.8%)*
15,401 (63.5%) 8,866 (36.5%)
15,778 (58.3%)* 11,280 (41.7%)*
1,158 (69.3%)* 513 (30.7%)*
LSG ¼ Laparoscopic sleeve gastrectomy; LGB ¼ Laparoscopic gastric bypass; LAGB ¼ Laparoscopic adjustable gastric banding * P o .05 compared to LSG, χ2 test.
990
J. E. Varela and N. T. Nguyen / Surgery for Obesity and Related Diseases 11 (2015) 987–990
In 2012, the ASMBS recognized sleeve gastrectomy as an acceptable primary bariatric procedure [17]. We have previously reported a change in the makeup of bariatric surgery with an early utilization of laparoscopic gastric bypass, which became the most commonly performed bariatric operation at U.S. academic medical centers in 2004-2005, with 72% of all bariatric operations were performed using the laparoscopic technique [4,18]. In this study, we report a new and important change in the composition of bariatric surgery at U.S. academic centers. We found a dramatic 3-fold increase in utilization of laparoscopic sleeve gastrectomy over the past 3 years, which has now superseded that of laparoscopic gastric bypass and become the most commonly performed bariatric procedure at U.S. academic medical centers. This increase may be attributed to the technical simplicity of laparoscopic sleeve gastrectomy compared to laparoscopic gastric bypass; its demonstrated safety profile; its ability to be converted, revised, or used as a stage to a second bariatric procedure (i.e., gastric bypass or duodenal switch); its recognition as a primary bariatric operation by the ASMBS; its good long-term weight loss and remission of co-morbidities, comparable to that of gastric bypass; its improved third-party payors’ coverage; and its superior long-term weight loss compared with the gastric banding and the high rate of explantation at long-term follow-up for gastric banding [9,11,12]. The perioperative morbidity and mortality for sleeve gastrectomy has been reported to be somewhere between laparoscopic gastric banding and laparoscopic gastric bypass [13]. This study has several limitations. The data utilized in this study were obtained from an administrative database that included only U.S. academic medical centers; the results from this study may not be representative of utilization of bariatric surgery in private practice. There was a 1-year overlap in analysis of the UHC database performed between October 1, 2011, and September 10, 2012, between our previous and the current publication on this topic [4]. This overlap was important to show the trends in utilization of bariatric procedure. Lastly, many adjustable gastric banding procedures have been transitioned to an outpatient procedure. The UHC is an inpatient database, and therefore, the utilization data presented for laparoscopic gastric banding may not be a good representation of the true number of banding procedure being performed.
Conclusion An increase in the utilization of laparoscopic sleeve gastrectomy was found that exceeded that of laparoscopic gastric bypass in 2013. Within the context of U.S. academic medical centers, laparoscopic sleeve gastrectomy is now the most commonly performed bariatric operation for the treatment of severe obesity.
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