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A long-term observational study examining cumulative costs and clinical outcomes for sleeve gastrectomy and Roux-en-Y gastric bypass (RYGB) found more similarities than differences between the two procedures.

The study, which included approximately 7,000 patients, found no significant differences in 4-year cumulative healthcare costs associated with the surgeries ($33,682 for sleeve gastrectomy, $33,948 for RYGB, P=0.86), reported Jean-Eric Tarride, PhD, of McMaster University in Hamilton, Ontario, and colleagues.

As shown in the study online in , there were also no significant differences at 4 years in all-cause mortality (1.5% for RYGB, 2.2% for sleeve gastrectomy, P=0.26). For both procedures, approximately half of all postoperative expenditures were for hospitalizations, but the total number did not differ significantly during the study period (754 hospitalizations for RYGB, 669 for sleeve gastrectomy, P=0.11).

The researchers did find, however, that non-elective hospitalizations occurred more often with RYGB (472 vs 339 for sleeve gastrectomy, P=0.002), and that a greater proportion of patients underwent a second bariatric procedure after a sleeve gastrectomy compared with RYGB (4.6% vs 1%, P <0.001).

"To our knowledge, this is the first study comparing long-term healthcare expenditures among patients undergoing RYGB vs sleeve gastrectomy," the team wrote. "In contrast to the growing clinical literature comparing RYGB and sleeve gastrectomy, only a few comparative studies have evaluated healthcare expenditures associated with RYGB and sleeve gastrectomy, but their analyses were limited to 30 days after the index procedure."

The study included residents of Ontario province who underwent publicly funded surgery with RYGB (n=6,301) or sleeve gastrectomy (n=926) from March 1, 2010, to March 31, 2015, and consented to participate in the database. Mean age was 48, the majority (76.5%) were women, and mean body-mass index (BMI) was 51.9.

The researchers noted that the study was unique in that it did not use the standard Cox proportional hazard models for statistical analysis. The team instead used propensity scoring matching methods to create matched cohorts of patients who underwent RYGB or sleeve gastrectomy.

In an , David Arterburn, MD, of the Kaiser Permanente Washington Health Research Institute in Seattle, and Kristina Lewis, MD, of Wake Forest University in Winston-Salem, North Carolina, offered potential explanations for the similarities in cost.

The lack of a difference could be partly due to the eligibility criteria for gastric bypass in Canada during the study period, Arterburn and Lewis speculated. Sleeve gastrectomy was only publicly reimbursed when RYGB was not possible due to small bowel disease or other conditions, or when performed as part of a planned two-stage bariatric surgery in patients with a BMI greater than 60, the editorialists noted.

"As a result, the sleeve cohort in this study was likely very different from (and potentially higher risk than) the average contemporary sleeve gastrectomy cohort in the U.S., where this procedure is considered first-line and accounts for roughly 60% of bariatric operations," Arterburn and Lewis explained. "Indeed, prior large U.S.-based cohorts have estimated that overall rates of reoperation are 20% to 30% lower with sleeve gastrectomy than with RYGB."

Another potential explanation for the cost similarity was the study's lack of data on the price of prescription drugs, the editorialists said. "Pharmaceutical costs for chronic comorbidities are significantly reduced after bariatric surgery, but there are likely to be differences between sleeve gastrectomy and RYGB, with greater and more durable decreases among patients undergoing RYGB, owing to more durable chronic disease remission and control."

Tarride and colleagues mentioned this limitation as well, noting that they didn't have access to medication costs because prescription drugs for people younger than 65, the vast majority of the study participants, are not covered by public insurance.

Another limitation, the team said, was the small number of sleeve gastrectomy procedures in the study, which did not allow for analysis of potentially important subgroups such as patients with diabetes or coronary artery disease. In addition, the study did not include gastric banding because that procedure is not publicly reimbursed.

Finally, "although we separated elective vs nonelective hospitalizations in our analyses, we did not examine the underlying reasons for healthcare use and associated expenditures (e.g., surgical complications vs elective joint replacement, which is now possible owing to weight loss after the bariatric procedure). This is an important avenue for future research," Tarride and co-authors wrote.

Arterburn and Lewis concluded that the study's finding of similar costs "may disappoint payers and other stakeholders hoping for cost savings resulting from the shift toward more sleeve operations, but it has potentially important implications for patients, who would likely view healthcare dollars spent on elective care much more favorably than those spent on urgent interventions for complications."

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