袖状胃切除术与胃旁路术的安全性比较：工具变量法。
Comparative Safety of Sleeve Gastrectomy and Gastric Bypass: An Instrumental Variables Approach.
机构信息
National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan.
Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan.
出版信息
Ann Surg. 2022 Mar 1;275(3):539-545. doi: 10.1097/SLA.0000000000004297.
OBJECTIVE
To compare the safety of sleeve gastrectomy and gastric bypass in a large cohort of commercially insured bariatric surgery patients from the IBM MarketScan claims database, while accounting for measurable and unmeasurable sources of selection bias in who is chosen for each operation.
SUMMARY OF BACKGROUND DATA
Sleeve gastrectomy has rapidly become the most common bariatric operation performed in the United States, but its longer-term safety is poorly described, and the risk of worsening gastroesophageal reflux requiring revision may be higher than previously thought. Prior studies comparing sleeve gastrectomy to gastric bypass are limited by low sample size (in randomized trials) and selection bias (in observational studies).
METHODS
Instrumental variables analysis of commercially insured patients in the IBM MarketScan claims database from 2011 to 2018. We studied patients undergoing bariatric surgery from 2012 to 2016. We identified re-interventions and complications at 30 days and 2 years from surgery using Comprehensive Procedural Terminology and International Classification of Disease (ICD)-9/10 codes. To overcome unmeasured confounding, we use the prior year's sleeve gastrectomy utilization within each state as an instrumental variable-exploiting variation in the timing of payers' decisions to cover sleeve gastrectomy as a natural experiment.
RESULTS
Among 38,153 patients who underwent bariatric surgery between 2012 and 2016, the share of sleeve gastrectomy rose from 52.6% (2012) to 75% (2016). At 2 years from surgery, patients undergoing sleeve gastrectomy had fewer re-interventions (sleeve 9.9%, bypass 15.6%, P < 0.001) and complications (sleeve 6.6%, bypass 9.6%, P = 0.001), and lower overall healthcare spending ($47,891 vs $55,213, P = 0.003), than patients undergoing gastric bypass. However, at the 2-year mark, revisions were slightly more common in sleeve gastrectomy than in gastric bypass (sleeve 0.6%, bypass 0.4%, P = 0.009).
CONCLUSIONS AND RELEVANCE
In a large cohort of commercially insured patients, sleeve gastrectomy had a superior safety profile to gastric bypass up to 2 years from surgery, even when accounting for selection bias. However, the higher risk of revisions in sleeve gastrectomy merits further exploration.
目的
利用 IBM MarketScan 索赔数据库中大型商业保险减重手术患者队列，比较袖状胃切除术和胃旁路术的安全性，同时考虑到选择每种手术的患者存在可测量和不可测量的选择偏倚。
背景数据概要
袖状胃切除术在美国已迅速成为最常见的减重手术，但对其长期安全性的描述较差，并且需要再次手术以改善胃食管反流的风险可能高于先前认为的风险。先前比较袖状胃切除术和胃旁路术的研究受到样本量小（随机试验）和选择偏倚（观察性研究）的限制。
方法
利用 IBM MarketScan 索赔数据库中 2011 年至 2018 年商业保险患者的工具变量分析。我们研究了 2012 年至 2016 年接受减重手术的患者。我们使用综合程序术语和国际疾病分类（ICD）-9/10 代码在术后 30 天和 2 年时确定再干预和并发症。为了克服未测量的混杂因素，我们使用每个州前一年的袖状胃切除术使用率作为工具变量，利用支付者决定覆盖袖状胃切除术的时间的变化作为自然实验。
结果
在 2012 年至 2016 年间接受减重手术的 38153 名患者中，袖状胃切除术的比例从 52.6%（2012 年）上升至 75%（2016 年）。在术后 2 年时，接受袖状胃切除术的患者再干预（袖状 9.9%，旁路 15.6%，P<0.001）和并发症（袖状 6.6%，旁路 9.6%，P=0.001）更少，总医疗支出（47891 美元 vs 55213 美元，P=0.003）更低，低于接受胃旁路术的患者。然而，在 2 年时，袖状胃切除术的修订率略高于胃旁路术（袖状 0.6%，旁路 0.4%，P=0.009）。
结论和相关性
在一个大型商业保险患者队列中，与胃旁路术相比，袖状胃切除术在术后 2 年内的安全性更高，即使考虑到选择偏倚也是如此。然而，袖状胃切除术的再手术风险较高，值得进一步探讨。
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