WASHINGTON – Fifteen years after having a Roux-en-Y gastric bypass, patients who had laparoscopic surgery were more likely to still be alive, without long-term complications and with a much smaller surgery-related medical bill than those who had open surgery.
Laparoscopic surgery conferred a 44% decrease in the chance of death from any cause, and a 20% decrease in the risk of having a long-term complication related to bariatric surgery, Dr. Anna Weiss reported at the annual clinical congress of the American College of Surgeons.
Her population-based study of 135,000 patients is one of the largest and longest of its kind, allowing it to pick up long-term outcomes trends that have not been detailed before, said Dr. Weiss of the University of California, San Diego.
Michele G. Sullivan/IMNG Medical Media
Dr Anna Weiss
The study used data from the California Office of Statewide Health Planning and Development. The database assigns every patient a unique identification number and tracks every hospital admission for that patient. Dr. Weiss looked at health outcomes for patients who underwent an open or laparoscopic Roux-en-Y gastric bypass anytime from 1995 to 2009.
The study’s primary outcome was all-cause mortality. Secondary outcomes included the incidence of gallbladder disease, cholecystectomy, marginal ulcer, and reoperation. It also examined the cost of the index surgery and subsequent costs related to the surgery.
She found a significant, time-bound association with the frequency of laparoscopic bypass. In 1995, less than 5% of the procedures were performed laparoscopically. By 2000, that had risen to about 20%. Thereafter, the frequency rose sharply. By 2009, just over 90% of Roux-en-Y procedures were minimally invasive.
About 80% of the patients were women; about 72% were white. They ranged widely in age, with more than 2,000 being 80 years or older at the time of surgery. But, Dr. Weiss said, the majority, about 70%, were aged 30-60 years.
Comorbidities were common and included prior gallbladder disease (20%), hypertension (51%), hyperlipidemia (31%), and diabetes (28%).
Most patients (67%) stayed in the hospital no more than 3 days. However, significantly more patients with laparoscopic surgery had these short stays (90% vs. 44% of the open-surgery group). Significantly more patients in the open-surgery group stayed 4-6 days (33% vs. 8%) and 7 or more days (22% vs. 2%).
Most of the patients had private insurance (80%). Medicare insured 10% and Medi-Cal, 6%. The remainder were self-pay. Significantly more laparoscopic procedures were performed at Centers of Excellence (76% vs. 59% of open procedures).
Overall, the rates of marginal ulcer and reoperations were low (1% each). However, Dr. Weiss noted, other outcomes were much more common, including gallbladder complications (22%) and cholecystectomies (13%). Long-term complications were significantly more common in the open group (10% vs. less than 5%).
By the end of the follow-up period, overall all-cause mortality was 11%. It was significantly less in the laparoscopic group than in the open group (about 5% vs. 20%).
Laparoscopic surgery carried a significantly smaller price tag than open surgery. The mean cost of the index operation was $56,170 for laparoscopic surgery, compared with a mean of $87,026 for open surgery. Over the entire follow-up period, patients who had open surgery racked up about $31,000 more in costs related directly to the procedure. However, Dr. Weiss noted, the standard deviation of lifetime costs ranged from $208,153 for an open procedure vs. $84,299 for a laparoscopic procedure.
Despite these differences, publicly insured patients were much more likely to have had open surgery. Patients with Medicare were significantly more likely to have an open than a laparoscopic procedure (15% vs. 6%), as were patients with Medi-Cal (7% vs. 4%). Patients with private insurance were significantly more likely to have laparoscopic surgery (86% vs. 74%).
In a multivariate analysis, several factors were significantly associated with outcome. Female gender reduced the risk of death by more than 30%. Younger age also portended better outcomes. Compared with patients in their 20s, those in their 50s were three times as likely to have died; those in their 60s, six times as likely, and those in their 70s, almost nine times as likely. The few patients who had surgery in their 80s were 10 times as likely to die as the youngest. However, several commentators pointed out during discussion that age-related all-cause mortality is not a surprising finding in a longitudinal study.
Insurance was also significantly related to outcome. Dr. Weiss used the self-pay group as her reference group. Compared with these patients, Medicare and Medi-Cal patients were twice as likely to have died by the study’s end. "Interestingly, they were no more likely to have long-term complications. However, when they did, these were more serious complications, possibly indicating that overall those with public insurance could have been a sicker group" at baseline.