Importance Sleeve gastrectomy is the most widely used bariatric operation; however, its long-term safety is largely unknown.

Objective To compare the risk of mortality, complications, reintervention, and health care use 5 years after sleeve gastrectomy and gastric bypass.

Design, Setting, and Participants This retrospective cohort study included adult patients in a national Medicare claims database who underwent sleeve gastrectomy or gastric bypass from January 1, 2012, to December 31, 2018. Instrumental variables survival analysis was used to estimate the cumulative incidence of outcomes up to 5 years after surgery.

Exposures Laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.

Main Outcomes and Measures The main outcome was risk of mortality, complications, and reinterventions up to 5 years after surgery. Secondary outcomes were health care use after surgery, including hospitalization, emergency department (ED) use, and total spending.

Results Of 95 405 patients undergoing bariatric surgery, 57 003 (60%) underwent sleeve gastrectomy (mean [SD] age, 57.1 [11.8] years), of whom 42 299 (74.2%) were women; 124 (0.2%) were Asian; 10 101 (17.7%), Black; 1951 (3.4%), Hispanic; 314 (0.6%), North American Native; 43 194 (75.8%), White; 534 (0.9%), of other race or ethnicity; and 785 (1.4%), of unknown race or ethnicity. A total of 38 402 patients (40%) underwent gastric bypass (mean [SD] age, 55.9 [11.7] years), of whom 29 050 (75.7%) were women; 109 (0.3%), Asian; 6038 (15.7%), Black; 1215 (3.2%), Hispanic; 278 (0.7%), North American Native; 29 986 (78.1%), White; 373 (1.0%), of other race or ethnicity; and 404 (1.1%), of unknown race or ethnicity. Compared with patients undergoing gastric bypass, at 5 years after surgery, patients undergoing sleeve gastrectomy had a lower cumulative incidence of mortality (4.27%; 95% CI, 4.25%-4.30% vs 5.67%; 95% CI, 5.63%-5.69%), complications (22.10%; 95% CI, 22.06%-22.13% vs 29.03%; 95% CI, 28.99%-29.08%), and reintervention (25.23%; 95% CI, 25.19%-25.27% vs 33.57%; 95% CI, 33.52%-33.63%). Conversely, patients undergoing sleeve gastrectomy had a higher cumulative incidence of surgical revision at 5 years (2.91%; 95% CI, 2.90%-2.93% vs 1.46%; 95% CI, 1.45%-1.47%). The adjusted hazard ratio (aHR) of all-cause hospitalization and ED use was lower for patients undergoing sleeve gastrectomy at 1 year (hospitalization, aHR, 0.83; 95% CI, 0.80-0.86; ED use, aHR, 0.87; 95% CI, 0.84-0.90) and 3 years (hospitalization, aHR, 0.94; 95% CI, 0.90-0.98; ED use, aHR, 0.93; 95% CI, 0.90-0.97) after surgery but similar between groups at 5 years (hospitalization, aHR, 0.99; 95% CI, 0.94-1.04; ED use, aHR, 0.97; 95% CI, 0.92-1.01). Total health care spending among patients undergoing sleeve gastrectomy was lower at 1 year after surgery ($28 706; 95% CI, $27 866-$29 545 vs $30 663; 95% CI, $29 739-$31 587), but similar between groups at 3 ($57 411; 95% CI, $55 239-$59 584 vs $58 581; 95% CI, $56 551-$60 611) and 5 years ($86 584; 95% CI, $80 183-$92 984 vs $85 762; 95% CI, $82 600-$88 924).

Conclusions and Relevance In a large cohort of patients undergoing bariatric surgery, sleeve gastrectomy was associated with a lower long-term risk of mortality, complications, and reinterventions but a higher long-term risk of surgical revision. Understanding the comparative safety of these operations may better inform patients and surgeons in their decision-making.

重要性 袖状胃切除术是应用最广泛的减肥手术；然而，它的长期安全性在很大程度上是未知的。

目的 比较袖状胃切除术和胃绕道手术后5年的死亡率、并发症、再干预和医疗保健使用的风险。

设计、设置和参与者 这项回顾性队列研究纳入了国家医疗保险索赔数据库中于 2012 年 1 月 1 日至 2018 年 12 月 31 日期间接受袖状胃切除术或胃绕道手术的成年患者。使用工具变量生存分析来估计手术后长达 5 年的结果。

暴露 腹腔镜袖状胃切除术和腹腔镜 Roux-en-Y 胃旁路术。

主要结果和措施 主要结果是术后 5 年的死亡率、并发症和再次干预风险。次要结果是手术后的医疗保健使用，包括住院、急诊科 (ED) 使用和总支出。

结果 在接受减肥手术的 95 405 名患者中，57 003 名（60%）接受了袖状胃切除术（平均 [SD] 年龄，57.1 [11.8] 岁），其中 42 299 名（74.2%）为女性；124 (0.2%) 人是亚洲人；10 101 (17.7%)，黑色；1951 (3.4%)，西班牙裔；314 (0.6%)，北美原住民；43 194 (75.8%)，怀特；534 (0.9%)，其他种族或民族；785 (1.4%)，种族或民族不明。共有 38 402 名患者（40%）接受了胃旁路术（平均 [SD] 年龄，55.9 [11.7] 岁），其中 29 050 名（75.7%）为女性；109 (0.3%)，亚洲人；6038 (15.7%)，黑色；1215 (3.2%)，西班牙裔；278 (0.7%)，北美原住民；29 986 (78.1%)，怀特；373 (1.0%)，其他种族或民族；404 (1.1%)，种族或民族不明。与接受胃旁路术的患者相比，术后 5 年，接受袖状胃切除术的患者累积死亡率较低（4.27%；95% CI，4.25%-4.30% vs 5.67%；95% CI，5.63%-5.69%），并发症（22.10%；95% CI，22.06%） -22.13% vs 29.03%；95% CI，28.99%-29.08%）和再干预（25.23%；95% CI，25.19%-25.27% vs 33.57%；95% CI，33.52%-33.63%）。相反，接受袖状胃切除术的患者在 5 年时手术翻修的累积发生率更高（2.91%；95% CI，2.90%-2.93% vs 1.46%；95% CI，1.45%-1.47%）。接受袖状胃切除术的患者在 1 年时全因住院和 ED 使用的调整后风险比 (aHR) 较低（住院，aHR，0.83；95% CI，0.80-0.86；ED 使用，aHR，0.87；95% CI , 0.84-0.90) 和 3 年（住院，aHR，0.94；95% CI，0.90-0.98；ED 使用，aHR，0.93；95% CI，0.90-0。97）手术后，但 5 年时各组之间相似（住院，aHR，0.99；95% CI，0.94-1.04；ED 使用，aHR，0.97；95% CI，0.92-1.01）。接受袖状胃切除术的患者在术后 1 年的总医疗保健支出较低（28 706 美元；95% CI，27 866 美元至 29 545 美元 vs 30 663 美元；95% 可信区间，29 739 美元至 31 587 美元），但在 3 （$57 411；95% CI，$55 239-$59 584 对比 $58 581；95% CI，$56 551-$60 611）和 5 年（$86 584；95% CI，$80 183-$92 984 对比 $85 762；95% CI ，82 600 美元至 88 924 美元）。

结论和相关性 在接受减肥手术的大型患者队列中，袖状胃切除术与较低的长期死亡率、并发症和再干预风险相关，但与较高的手术翻修的长期风险相关。了解这些手术的相对安全性可能会更好地为患者和外科医生的决策提供信息。