Original article| Volume 18, ISSUE 8, P1033-1041, August 2022

Long-term comparative effectiveness of gastric bypass and sleeve gastrectomy on use of antireflux medication: a difference-in-differences analysis



      Gastroesophageal reflux (GERD) is common among patients with obesity who undergo bariatric surgery. Although gastric bypass and sleeve gastrectomy are the most common bariatric operations performed in the United States, their long-term comparative effectiveness on GERD medication use is unknown.


      To compare the long-term effectiveness of gastric bypass and sleeve gastrectomy on use of antireflux medication.
      Setting: National cohort undergoing inpatient bariatric surgery.


      This is a retrospective study of Medicare beneficiaries undergoing gastric bypass and sleeve gastrectomy between January 1, 2012, and December 31, 2017. A difference-in-differences analysis was conducted to evaluate the differential change in antireflux medication use between groups before and after surgery.


      A total of 16,640 patients underwent gastric bypass, and 26,724 patients underwent sleeve gastrectomy. Before surgery, GERD medication use was higher among patients who underwent gastric bypass (62.4%; 95% confidence interval [CI]: 62.0%–63.7%) compared with patients who underwent sleeve gastrectomy (60.1%; 95% CI: 59.3%–60.9%). Five years after surgery, GERD medication use was lower in patients who underwent gastric bypass (47.8%; 95% CI: 46.3%–49.3%) compared with patients who underwent sleeve gastrectomy (53.7%; 95% CI: 50.5%–56.9%). The differential decrease from baseline GERD medication use was greater for patients who underwent gastric bypass at 2 years (–4.1 percentage points [pp]; 95% CI: –1.7 to –6.5 pp), 3 years (–4.3 pp; 95% CI: –1.6 to –7.0 pp), 4 years (–6.9 pp; 95% CI: –4.1 to –9.6 pp), and 5 years (–8.3 pp; 95% CI: –3.7 to 12.8 pp) after surgery.


      Though use of antireflux medication decreased following both procedures, gastric bypass was associated with a greater reduction in antireflux medication use 5 years after surgery compared with sleeve gastrectomy. Understanding the long-term comparative effectiveness of these common bariatric operations may better inform treatment decisions among patients and surgeons.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Surgery for Obesity and Related Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Gu L.
        • Chen B.
        • Du N.
        • et al.
        Relationship between bariatric surgery and gastroesophageal reflux disease: a systematic review and meta-analysis.
        Obes Surg. 2019; 29: 4105-4113
        • Campos G.M.
        • Khoraki J.
        • Browning M.G.
        • Pessoa B.M.
        • Mazzini G.S.
        • Wolfe L.
        Changes in utilization of bariatric surgery in the United States from 1993 to 2016.
        Ann Surg. 2020; 271: 201-209
        • Hutter M.M.
        • Schirmer B.D.
        • Jones D.B.
        • et al.
        First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass.
        Ann Surg. 2011; 254 (discussion 420–1): 410-420
        • DuPree C.E.
        • Blair K.
        • Steele S.R.
        • Martin M.J.
        Laparoscopic sleeve gastrectomy in patients with preexisting gastroesophageal reflux disease : a national analysis.
        JAMA Surg. 2014; 149: 328-334
        • Brethauer S.A.
        • Kim J.
        • El Chaar M.
        • et al.
        Standardized outcomes reporting in metabolic and bariatric surgery.
        Obes Surg. 2015; 25: 587-606
        • Carter P.R.
        • LeBlanc K.A.
        • Hausmann M.G.
        • Kleinpeter K.P.
        • deBarros S.N.
        • Jones S.M.
        Association between gastroesophageal reflux disease and laparoscopic sleeve gastrectomy.
        Surg Obes Relat Dis. 2011; 7: 569-572
        • Howard D.D.
        • Caban A.M.
        • Cendan J.C.
        • Ben-David K.
        Gastroesophageal reflux after sleeve gastrectomy in morbidly obese patients.
        Surg Obes Relat Dis. 2011; 7: 709-713
        • Peterli R.
        • Wolnerhanssen B.K.
        • Peters T.
        • et al.
        Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y gastric bypass on weight loss in patients with morbid obesity: the SM-BOSS randomized clinical trial.
        JAMA. 2018; 319: 255-265
        • Courcoulas A.
        • Coley R.Y.
        • Clark J.M.
        • et al.
        Interventions and operations 5 years after bariatric surgery in a cohort from the US National Patient-Centered Clinical Research Network Bariatric Study.
        JAMA Surg. 2020; 155: 194-204
        • Chhabra K.R.
        • Telem D.A.
        • Chao G.F.
        • et al.
        Comparative safety of sleeve gastrectomy and gastric bypass: an instrumental variables approach.
        Ann Surg. 2022; 275: 539-545
        • Weiss A.C.
        • Parina R.
        • Horgan S.
        • Talamini M.
        • Chang D.C.
        • Sandler B.
        Quality and safety in obesity surgery-15 years of Roux-en-Y gastric bypass outcomes from a longitudinal database.
        Surg Obes Relat Dis. 2016; 12: 33-40
        • McTigue K.M.
        • Wellman R.
        • Nauman E.
        • et al.
        Comparing the 5-year diabetes outcomes of sleeve gastrectomy and gastric bypass: the National Patient-Centered Clinical Research Network (PCORNet) bariatric study.
        JAMA Surg. 2020; 155e200087
        • Arterburn D.
        • Wellman R.
        • Emiliano A.
        • et al.
        Comparative effectiveness and safety of bariatric procedures for weight loss: a PCORNet cohort study.
        Ann Intern Med. 2018; 169: 741-750
        • Birkmeyer N.J.
        • Dimick J.B.
        • Share D.
        • et al.
        Hospital complication rates with bariatric surgery in Michigan.
        JAMA. 2010; 304: 435-442
        • Courcoulas A.P.
        • Yanovski S.Z.
        • Bonds D.
        • et al.
        Long-term outcomes of bariatric surgery: a National Institutes of Health symposium.
        JAMA Surg. 2014; 149: 1323-1329
        • Ryan A.M.
        • Burgess Jr., J.F.
        • Dimick J.B.
        Why we should not be indifferent to specification choices for difference-in-differences.
        Health Serv Res. 2015; 50: 1211-1235
        • Alalwan A.A.
        • Friedman J.
        • Park H.
        • Segal R.
        • Brumback B.A.
        • Hartzema A.G.
        US national trends in bariatric surgery: a decade of study.
        Surgery. 2021; 170: 13-17
        • Carlin A.M.
        • Zeni T.M.
        • English W.J.
        • et al.
        The comparative effectiveness of sleeve gastrectomy, gastric bypass, and adjustable gastric banding procedures for the treatment of morbid obesity.
        Ann Surg. 2013; 257: 791-797
        • El-Hadi M.
        • Birch D.W.
        • Gill R.S.
        • Karmali S.
        The effect of bariatric surgery on gastroesophageal reflux disease.
        Can J Surg. 2014; 57: 139-144
        • Chiu S.
        • Birch D.W.
        • Shi X.
        • Sharma A.M.
        • Karmali S.
        Effect of sleeve gastrectomy on gastroesophageal reflux disease: a systematic review.
        Surg Obes Relat Dis. 2011; 7: 510-515
        • Cottam D.
        • Qureshi F.G.
        • Mattar S.G.
        • et al.
        Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity.
        Surg Endosc. 2006; 20: 859-863
        • Rawlins L.
        • Rawlins M.P.
        • Brown C.C.
        • Schumacher D.L.
        Sleeve gastrectomy: 5-year outcomes of a single institution.
        Surg Obes Relat Dis. 2013; 9: 21-25
      1. Ehlers AP, Thumma JR, Finks JF, Carlin AM, Ghaferi AA, Varban OA. Evaluation of patient reported gastroesophageal reflux severity at baseline and at one-year after bariatric surgery. Ann Surg. Epub 2020 Nov 17.

        • Ali M.
        • El Chaar M.
        • Ghiassi S.
        • Rogers A.M.
        American Society for Metabolic and Bariatric Surgery Clinical Issues Committee. American Society for Metabolic and Bariatric Surgery updated position statement on sleeve gastrectomy as a bariatric procedure.
        Surg Obes Relat Dis. 2017; 13: 1652-1657
        • Coblijn U.K.
        • Lagarde S.M.
        • de Castro S.M.
        • Kuiken S.D.
        • van Wagensveld B.A.
        Symptomatic marginal ulcer disease after Roux-en-Y gastric bypass: incidence, risk factors and management.
        Obes Surg. 2015; 25: 805-811
        • Goldberg I.
        • Yang J.
        • Nie L.
        • et al.
        Safety of bariatric surgery in patients older than 65 years.
        Surg Obes Relat Dis. 2019; 15: 1380-1387
      2. Medicare Coverage Database [database on the Internet]. U.S. Centers for Medicare & Medicaid Services; 2013.
        ([cited 2022 Feb 7]. Bariatric surgery for treatment of co-morbid conditions related to morbid obesity; [about 5 p.]. Available from:)
      3. Medicare Coverage Database [database on the Internet]. U.S. Centers for Medicare & Medicaid Services; 2013.
        ([cited 2021 Jan 30]. Health outcomes after bariatric surgical therapies in the medicare population; [about 8 p.]. Available from:)
        • Fass O.Z.
        • Poels K.E.
        National trends for medicare prescriptions of antireflux medications.
        Gastroenterology. 2020; 159: 378-380.e373
        • Hungin A.P.
        • Hill C.
        • Molloy-Bland M.
        • Raghunath A.
        Systematic review: patterns of proton pump inhibitor use and adherence in gastroesophageal reflux disease.
        Clin Gastroenterol Hepatol. 2012; 10: 109-116
        • Steiner J.F.
        • Prochazka A.V.
        The assessment of refill compliance using pharmacy records: methods, validity, and applications.
        J Clin Epidemiol. 1997; 50: 105-116
        • Boules M.
        • Corcelles R.
        • Guerron A.D.
        • et al.
        The incidence of hiatal hernia and technical feasibility of repair during bariatric surgery.
        Surgery. 2015; 158 (discussion 916–18): 911-916
        • Dewender L.
        • Kaul A.
        The practice of bariatric coding and reimbursement.
        in: Nguyen N.T. Brethauer S.A. Morton J.M. Ponce J. Rosenthal R.J. The ASMBS textbook of bariatric surgery. Springer International, Cham, Switzerland2020: 577-583