Cohort studyindependent cross-checkfull text checked★ key study I-BAR-101 in-depth review
Israeli study: deaths after sleeve, bypass and banding vs usual care
Association of Bariatric Surgery Using Laparoscopic Banding, Roux-en-Y Gastric Bypass, or Laparoscopic Sleeve Gastrectomy vs Usual Care Obesity Management With All-Cause Mortality.
Overview
Reges et al.. JAMA 2018 · PMID 29340677 · DOI 10.1001/jama.2017.20513
People who had surgery, including sleeve, died less often over about 4 years than similar people with obesity who did not (sleeve 0.8% vs 1.3%).
Does the study support the specific claim? No · Methodological quality: moderate
Plain-language summary
Study explained simply
- What did the researchers want to find out?
Compare death rates after three operations with usual care
- How was the study done?
Matched cohort from health-fund records
- How many people, animals or samples were studied?
8,385 operated, 25,155 controls
- What was actually found?
Lower mortality with every operation, including sleeve
- How large was the observed effect?
Sleeve: HR about 0.62 (surgery vs control)
- What do the results mean in everyday life?
On average, sleeve did not shorten life in the first years
- What are the study's limitations?
Observational; short follow-up for sleeve
- What does it say about Elawady's specific claim?
Contradicts "sleeve is lethal"
- Do the results apply to Germany and Europe?
Health-system data from Israel; plausible for Europe
- What can explicitly not be concluded from this study?
Cannot prove causation or show very long-term effects
Scientific in-depth review
1. Full reference
- Authors
- Reges et al.
- Journal
- JAMA
- Year
- 2018
- Identifier
- PMID 29340677 DOI 10.1001/jama.2017.20513
- Verification
- verified – PubMed efetch 2026-10-26 + Crossref API
- Retracted
- no
- Corrections
- none
- Extent checked
- full text
- Conflicts of interest and funding
Full text: authors reported no conflicts of interest; no funding statement found in the PMC text.
2. Research question
Is bariatric surgery (banding, bypass, sleeve) associated with lower all-cause mortality than usual-care obesity management?
3. Study design and population
- Study design
- Cohort study – Retrospective matched cohort in an Israeli integrated health fund (Clalit; >50% of citizens), time-dependent sequential stratification matching 1:3
- Population
Adults >=24 y with obesity (median BMI 40.6) undergoing surgery 2005-2014 and matched nonsurgical patients
- Country
Israel
- Period
2005-2015
- Sample size
33,540 (8,385 surgical incl. 3,362 sleeve; 25,155 matched controls)
- Inclusion and exclusion criteria
Matched on age, sex, BMI group and diabetes; excluded active cancer, Crohn disease, ESRD, ascites, recent pregnancy
4. Methods and endpoints
- Exposure / intervention
Laparoscopic banding, Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy
- Comparator
Usual-care obesity management by primary care
- Endpoints
All-cause mortality (primary); BMI, diabetes, hypertension, complications (exploratory)
- Statistical methods
Cox regression adjusted for BMI, age, sex, SES, diabetes, hyperlipidaemia, hypertension, CVD, smoking; multiple imputation
5. Actual results
- Results
Deaths 105 (1.3%) surgical vs 583 (2.3%) nonsurgical over median ~4 y; sleeve 26/3362 (0.8%) vs 129/10086 (1.3%). Absolute difference 2.51 (1.86-3.15) fewer deaths/1000 person-years overall; 1.8 (0.6-3.0) for sleeve. Adjusted HR nonsurgical vs surgical 2.02 (1.63-2.52); banding 2.01 (1.50-2.69); bypass 2.65 (1.55-4.52); sleeve 1.60 (1.02-2.51). Follow-up for mortality 100%.
- Absolute risks
Sleeve: about 1.8 fewer deaths per 1000 person-years than matched usual care (median sleeve follow-up ~3 y).
- Authors' conclusion
Bariatric surgery, including sleeve gastrectomy, was associated with lower all-cause mortality than usual care over a median of about 4.5 years.
6. Strengths
- Complete mortality follow-up (low turnover health fund)
- Large sleeve stratum (3,362)
- Population covers >50% of a country, incl. ~20% Arab members
7. Weaknesses
- Observational; residual confounding (more low-SES patients among controls)
- Short sleeve follow-up (median ~3 y)
- Many surgical patients excluded for missing BMI or no match
- HRs reported inverted (control vs surgery)
8. Risk of bias
- Orienting tool
- ROBINS-E
- Type of assessment
- simplified assessment (abstract only)
- Full formal assessment
- no
- Overall risk of bias
- some concerns
- Rationale
Selection into surgery and residual confounding possible; outcome (death) objectively ascertained.
9. Assessment of the statistical interpretation
Inverted HRs give surgery vs control: overall 0.50 (0.40-0.61), sleeve 0.62 (0.40-0.98) (stats/I-BAR-101_reges_2018.py). CI log-symmetric. Sleeve upper limit close to 1.
10. Relevance to the specific claim
Direct sleeve-specific test of the claim that sleeve gastrectomy kills or shortens life; shows the opposite direction on average.
11. Independent contrary findings
Short follow-up; does not address late external-cause deaths.
12. Transferability to Germany and Europe
Israeli population with Middle Eastern/North African and Arab members; transferable to Egypt in biology, health-system quality differs.
13. Overall methodological judgement
Moderate-quality, direct evidence that sleeve gastrectomy is associated with lower, not higher, mortality in the medium term.
| Multidimensional assessment | |
|---|---|
| Authenticity of the source | verified |
| Methodological quality | moderate |
| Risk of bias | some concerns |
| Precision of results | moderate |
| Directness | direct |
| Reproducibility | replicated |
| Consistency with the overall evidence | consistent |
| Regional transferability | high |
| Adequacy of the interpretation (by the archive) | not applicable |
14. Open questions
Mortality beyond 10 years after sleeve.
15. Linked fact checks
- Sleeve gastrectomy (and bariatric surgery in general) is a lethal operation that kills patients / shortens life. – Studies contradicting or limiting the claim
- Sleeve gastrectomy is a physiologically wrong operation and a 'transgression against God's creation', because the stomach is not a bag but an endocrine, muscular and immune organ whose functions are lost. – Studies contradicting or limiting the claim