Trends in Bariatric Surgery: The Rise of

the Gastric Sleeve

Sohaib M. Khan
General Surgery Resident
Department of Surgical Education and General Surgery
University of Toledo
 OBESITY

Worldwide
• According to WHO, obesity has more than doubled since 1980
• In 2014, more than 1.9 billion adults were overweight, of these over
600 million were obese1
United States
• According to National Health and Nutrition Examination Survey
(NHANES) the prevalence of morbidly obese adults has gone up from
2.9% in 1994 to 5.9% in 20062
• After smoking, obesity is the second leading cause of preventable
death and increase in health care cost3,4
 BARIATRIC SURGERY

Bariatric Surgery is superior to medical

management for a sustained weight loss
and alleviation of associated medical
conditions5
 TYPES OF BARIATRIC
PROCEDURES
Restrictive Procedures
• Laparoscopic Adjustable
Banding
• Laparoscopic Sleeve
Gastrectomy

Malabsorbtive Procedures
• Open Gastric Bypass
• Laparoscopic Gastric Bypass
• Duodenal Switch/ Bilio-Pancreatic
Diversion
 OBJECTIVES

• To determine the recent trend of utilization of different bariatric

procedures

• To analyze the short term outcomes of bariatric surgery from the year
2008 to 2012
 METHODS
Sample Population
• Nationwide Inpatient Sample of Health Care Cost and Utilization Project
from year 2008 through 2012
• US Census Population of 2010 was used as reference to calculate the
number of procedures per 100,000 adult population
Inclusion Criteria  Exclusion Criteria
• Age>18 years • Procedures having a
• Primary bariatric procedures diagnosis code of abdominal
 Laparoscopic Adjustable
neoplasms
Banding • Procedure not having a
 Open Gastric Bypass
diagnosis code of obesity
 Laparoscopic Gastric Bypass

 Laparoscopic Sleeve

Gastrectomy
 Duodenal Switch
 OUTCOMES
• To compute the trends of the bariatric procedures
• To compute the complications of individual procedure and their trends across
five years
• Venous Thromboembolism

• Respiratory Complications

• Renal Complications
• Bleeding

• Postoperative infection
• Visceral Injury

• Reoperation
• Composite In-hospital Morbidity

• In-hospital Mortality

• To compute the trends of length of stay and hospital charges

 STATISTICAL ANALYSIS
• Chi-square test was used to evaluate the trend of categorical variables
• Kruskal-Wallis test was used to compare the trend of numerical variables
• IBM’S Statistical Package for Social Sciences Version 21 was used for
statistical analysis (IBM Corporation, Armonk, NY, USA)
 RESULTS
Table 1: Trends in Bariatric Surgical Procedures

Type of Procedure 2008 2009 2010 2011 2012

Total No. of Bariatric 125347 128812 122891 100586 121120

Procedures
Procedures per 100,000 adult 53 55 52 43 51
population
Lap. Gastric Banding % 28.8* 22.8* 20.4* 14.4* 5.6*

Open Gastric Bypass % 8.1* 5.1* 6.3* 4.4* 3.2*

Lap. Gastric Bypass % 58.2* 63.2* 56.8 53.9* 49.4*

Lap. Sleeve Gastrectomy % 0.0 0.0 0.0 8.2* 39.6*

Duodenal Switch % 5.7* 10.1* 17.1* 19.5* 2.6*

 Total Number of Bariatric Procedures per
100,000 adult population
60

50

40

30

20

10

0
2008 2009 2010 2011 2012
70

60

50
Lap. Gastric Banding
Open Gastric Bypass
40
Laparoscopic Gastric
Bypass
30 Laparoscopic Sleeve
Gastrectomy
20 Duodenal Switch

10

0
2008 2009 2010 2011 2012
Table 2: Trends in Demographic Variables

Demographic 2008 2009 2010 2011 2012

Variables

Age (Mean±SD) 44.99±11.68 45.37±12.01* 44.80±11.86 44.83±12.35 44.84±12.06

Females % 79.0* 77.5* 78.5 77.6 77.9

Whites % 73.7* 70.7* 70.5 69.5 66.2*

African American % 12.4* 12.9* 16.0* 15.3* 15.3*

Hispanic % 7.8* 10.9 9.2* 12.4* 12.8*

Asian % 0.9 0.8 0.5* 0.4* 1.4*

Native American % 0.6* 0.8* 0.4 0.2* 0.5

Other % 4.7* 3.8 3.3* 2.2* 4.0*

 RACIAL DISTRIBUTION
Whites Blacks Hispanics Asians Native Americans Others

1% 0%
4%

11%

14%

70%
GENDER DISTRIBUTION
Female Male

22%

78%
Table 3: Trends in Comorbidities

Comorbidities 2008 2009 2010 2011 2012

ECI (Mean±SD) 1.76±1.2* 1.88±1.3* 1.90±1.3* 2.0±1.4* 1.83±1.4*

Diabetes % 33.3 35.2 33.1* 33.4 33.3

Hypertension % 56.3* 59.5* 58.4 57.8 57.7

CCF % 1.3* 2.0* 1.8 1.8 1.7

CLD % 10.1* 9.5* 10.8* 10.2 11.8*

Chronic Pulmonary 18.0* 18.6 18.8 19.9* 19.7

Disease %

OSA % 28.0* 30.5* 33.1* 36.3* 35.8*

70

60

50 Diabetes Mellitus
Hypertension
40
Congestive Cardiac Failure
Chronic Liver Disease
30
Chronic Pulmonary
Disease
20 Obstructive Sleep Apnea
10

0
2008 2009 2010 2011 2012
Table 5: Comparison of Complications between Different Procedures
Complication LGB OB LGB LSG DS

VTE % 0.048* 0.738* 0.124* 0.061* 0.278*

Respiratory 4.5* 7.7* 5.7* 3.3* 5.7*

Complications
%

Renal 0.7* 5.6* 1.6 0.8* 2.7*

Complications
%

Visceral Injury 0.4* 2.2* 0.6* 0.3* 0.9*

%
Bleeding % 0.3* 1.8* 1.4* 0.3* 1.3*

Infections % 0.1* 2.6* 0.3* 0.1* 1.1*

Reoperation 0.02* 0.5 0.6* 0.4 0.8*

%
In-Hospital 5.8* 15.5* 9.4* 5.3* 10.6*
Morbidity %
In-hospital 0.049* 0.9* 0.082* 0.035* 0.332*
Mortality %
Table 4: Trends in Outcome Complications

Complication 2008 2009 2010 2011 2012

VTE % 0.081* 0.141 0.142 0.190 0.215*

Respiratory 6.1* 5.7* 6.6* 4.3* 3.9*
Complications %

Renal 1.4* 1.6 1.7 2.1* 1.7

Complications %

Visceral Injury % 0.8* 0.7 0.8 0.6 0.5*

Bleeding % 1.1 1.3* 1.3* 1.0* 1.0*

Infections % 0.4 0.4 0.5 0.6* 0.4*

Reoperation % 0.2* 0.6* 0.4* 0.5 0.6*

In-Hospital 9.1* 9.5* 10.2* 7.9* 7.1*

Morbidity %

In-hospital 0.101 0.122 0.137 0.176 0.144

Mortality %
Table 4: Length of Stay (LOS) and Hospital Charge of Different Procedures

LGB OB LB LSG DS

LOS (Days) 1.13±1.23* 4.62±7.3* 2.34±2.842* 1.93±1.43* 2.85±4.293*

Hospital 33140± 57105± 45711± 44458± 53937±

Charge $ 22604* 89534* 32701* 25308* 51714*
Table 4: Trends in the Length of Stay (LOS) and Hospital Charge
2008 2009 2010 2011 2012 P Value
LOS (Days) 2.21±3.2 2.25±3.1 2.18±3.5* 2.31±3.4 2.26±2.7 <0.01

Hospital 38978± 42431± 46729± 46124± 48735± <0.01

Charge $ 32552* 35759* 37361* 46581* 39424*
 CONCLUSIONS

Number of bariatric procedures have observed a plateau from 2004

onwards. The same plateau has been observed in our study

Laparoscopic sleeve gastrectomy is the fastest rising procedure

Laparoscopic Gastric Bypass and Laparoscopic Gastric Banding are the two
most common procedures but there use has significantly trended down
 The gender distribution of bariatric patients reported in our study (77 to
79% females) is close to the national average of 80%6

 The racial distribution of bariatric patients shows that there is an increasing

demand and acceptance of bariatric surgery in other races and hence the
overall percentage of white bariatric patients shows a downward trend

 Most common comorbid condition among bariatric patients was

hypertension followed by diabetes
 Complications, morbidity and mortality are lower in laparoscopic
adjustable gastric banding and laparoscopic sleeve gastrectomy and higher
in open gastric bypass and duodenal switch procedure

 Over 5 years venous thromboembolism showed a mild upward trend,

though this can be a better recognition of the complication

 Respiratory complications increased from 2008 to 2010 and then

decreased parallel to the in-hospital morbidity

 Renal complications, bleeding, infection, visceral injuries and reoperations

didn’t show clear trend

 In-hospital mortality in bariatric patients remained stable from 0.10% to

0.14%
 Laparoscopic adjustable gastric banding has the shortest length of stay and
the lowest hospital charges, followed by laparoscopic sleeve gastrectomy
and laparoscopic gastric bypass

 Over 5 years the length of stay has remained constant and hospital charges
have significantly increased every year
 LIMITATIONS
• Administrative study

• The ICD-9 code for Laparoscopic Sleeve Gastrectomy wasn’t available late
until 2011

• Nationwide Inpatient Sample information is restricted to single hospital

encounter leading to underestimation of the morbidity and mortality

• There was no data on BMI and no weight loss tracking

 REFERENCES

 1. Obesity and Overweight. 2014; http://www.who.int/mediacentre/factsheets/fs311/en/. Accessed

August 10, 2015.

 2. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and
obesity in the United States, 1999-2004. Jama. Apr 5 2006;295(13):1549-1555.

 3. Fontaine KR, Redden DT, Wang C, Westfall AO, Allison DB. Years of life lost due to obesity. JAMA.
Jan 8 2003;289(2):187-193.

 4. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000.
Jama. Mar 10 2004;291(10):1238-1245.

 5. Gastrointestinal surgery for severe obesity: National Institutes of Health Consensus Development
Conference Statement. The American journal of clinical nutrition. Feb 1992;55(2 Suppl):615s-619s.

 Fuchs HF, Broderick RC, Harnsberger CR, et al. Benefits of bariatric surgery do not reach obese
men. J Laparoendosc Adv Surg Tech A. Mar 2015;25(3):196-201.
THANK YOU
Type of Procedures  
Laparoscopic Gastric Adjustable Banding 44.95
Laparoscopic Sleeve Gastrectomy 43.82
Open Gastric Bypass 44.31, 44.39
Laparoscopic Gastric Bypass 44.38
Laparoscopic Gastroplasty (VBG) 44.68
Biliopancreatic Diversion (Duodenal Switch) 43.89
Comorbidities  
OSA 327.23
Hypertension Already in NIS data
Diabetes Mellitus w and w/o complications Already in NIS data
Liver Disease Already in NIS data
Chronic Pulmonary Disease Already in NIS data
Congestive Heart Failure Already in NIS data
Outcomes  
Infection  
Postoperative Infection 998.59
Peritoneal Abscess 567.22
Bacteremia 790.7
Septic Shock 785.52
Visceral Injury  
Intestinal Perforation 589.63
Accidental Laceration of any organ during a procedure 998.2

Reoperation 54.11, 54.12, 54.19

For Dehiscence 54.61
Bleeding  
Hemorrhage complicating a procedure 998.11

Hematoma complicating a procedure 998.12

Seroma Complicating a procedure 998.13

Renal Complications  
Postoperative Urinary Complication (Unspecified) 997.5

Acute Renal Failure 584.5, 584.6, 584.7, 584.8, 584.9

Urinary Tract Infection (Unspecified Site) 599.0

Respiratory Complications  
Ventilator Associated Pneumonia 997.31
Postprocedural Pneumonia 997.32
Other respiratory complications (procedural) NEC 997.39

Prolonged Mechical Ventilation (>4 hours) 96.72

Respiratory Arrest 799.1

Respiratory Failure 518.5, 518.81, 518.82, 518.84
VTE  
Iatrogenic PE 415.11
DVT