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Bariatric operations: Perioperative morbidity and mortality

Robert B Lim, MD, FACS, COL, MC, USA
Section Editor
Daniel Jones, MD
Deputy Editor
Wenliang Chen, MD, PhD


Bariatric operations are performed as an effective method to reduce obesity and obesity-linked medical illnesses. Operating on obese patients is challenging because of anatomic and physiologic characteristics and comorbidities of obese patients. However, the risk of serious intraoperative and in-hospital complications and mortality rates are relatively low when the surgery is performed by experienced surgeons with an institutional investment in bariatric programs.

Adverse intraoperative events (AIE) are a risk factor for serious postoperative complications (eg, pulmonary embolus, myocardial infarction) [1,2]. In addition, postoperative complication rates vary with surgical approach, such as fewer complications with the laparoscopic approach than the open approach [3]. Complications also vary based upon type of procedure, such as fewer complications with the adjustable gastric band (AGB) than the laparoscopic Roux-en-Y gastric bypass (LRYGB) [3-5].

This topic will review the major perioperative (intraoperative and in-hospital postoperative) complications and mortality rates of the more common bariatric surgical procedures, including laparoscopic and open Roux-en-Y gastric bypass (RYGB), laparoscopic adjustable gastric band (LAGB), laparoscopic sleeve gastrectomy (LSG), and biliopancreatic diversion with duodenal switch (BPD-DS).

A description of bariatric procedures, indications and preoperative management, short-time medical outcomes, and long-term complications of laparoscopic operations are reviewed as separate topics.

(See "Bariatric procedures for the management of severe obesity: Descriptions".)


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Literature review current through: Sep 2016. | This topic last updated: Jun 1, 2015.
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  1. Greenstein AJ, Wahed AS, Adeniji A, et al. Prevalence of adverse intraoperative events during obesity surgery and their sequelae. J Am Coll Surg 2012; 215:271.
  2. Stenberg E, Szabo E, Agren G, et al. Early complications after laparoscopic gastric bypass surgery: results from the Scandinavian Obesity Surgery Registry. Ann Surg 2014; 260:1040.
  3. Lancaster RT, Hutter MM. Bands and bypasses: 30-day morbidity and mortality of bariatric surgical procedures as assessed by prospective, multi-center, risk-adjusted ACS-NSQIP data. Surg Endosc 2008; 22:2554.
  4. Encinosa WE, Bernard DM, Du D, Steiner CA. Recent improvements in bariatric surgery outcomes. Med Care 2009; 47:531.
  5. Longitudinal Assessment of Bariatric Surgery (LABS) Consortium, Flum DR, Belle SH, et al. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med 2009; 361:445.
  6. Brodsky JB, Lemmens HJ, Brock-Utne JG, et al. Morbid obesity and tracheal intubation. Anesth Analg 2002; 94:732.
  7. Langeron O, Masso E, Huraux C, et al. Prediction of difficult mask ventilation. Anesthesiology 2000; 92:1229.
  8. Kheterpal S, Han R, Tremper KK, et al. Incidence and predictors of difficult and impossible mask ventilation. Anesthesiology 2006; 105:885.
  9. DeMaria EJ, Murr M, Byrne TK, et al. Validation of the obesity surgery mortality risk score in a multicenter study proves it stratifies mortality risk in patients undergoing gastric bypass for morbid obesity. Ann Surg 2007; 246:578.
  10. Ogunnaike BO, Jones SB, Jones DB, et al. Anesthetic considerations for bariatric surgery. Anesth Analg 2002; 95:1793.
  11. Schumann R. Anaesthesia for bariatric surgery. Best Pract Res Clin Anaesthesiol 2011; 25:83.
  12. Owers CE, Abbas Y, Ackroyd R, et al. Perioperative optimization of patients undergoing bariatric surgery. J Obes 2012; 2012:781546.
  13. Buchwald H, Estok R, Fahrbach K, et al. Trends in mortality in bariatric surgery: a systematic review and meta-analysis. Surgery 2007; 142:621.
  14. Nelson DW, Blair KS, Martin MJ. Analysis of obesity-related outcomes and bariatric failure rates with the duodenal switch vs gastric bypass for morbid obesity. Arch Surg 2012; 147:847.
  15. Hutter MM, Schirmer BD, Jones DB, 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; 254:410.
  16. Schwartz ML, Drew RL, Andersen JN. Induction of pneumoperitoneum in morbidly obese patients. Obes Surg 2003; 13:601.
  17. Madan AK, Taddeucci RJ, Harper JL, Tichansky DS. Initial trocar placement and abdominal insufflation in laparoscopic bariatric surgery. J Surg Res 2008; 148:210.
  18. Jones, DB, Schneider, BE, Maithel ,SK. Atlas of Minimally Invasive Surgery. Cine-Med Inc, Woodbury 2006.
  19. Ahmad G, Duffy JM, Phillips K, Watson A. Laparoscopic entry techniques. Cochrane Database Syst Rev 2008; :CD006583.
  20. Peters TG, Steinmetz SR, Cowan GS Jr. Splenic injury and repair during bariatric surgical procedures. South Med J 1990; 83:166.
  21. Huerta S, Li Z, Livingston EH. Outcome of portal injuries following bariatric operations. Obes Surg 2006; 16:105.
  22. Al-Khyatt W, Thomas JD, Humes DJ, Lobo DN. Intestinal ischemia following laparoscopic surgery: a case series. J Med Case Rep 2013; 7:25.
  23. Schorr RT. Laparoscopic upper abdominal operations and mesenteric infarction. J Laparoendosc Surg 1995; 5:389.
  24. Mitchell PC, Jamieson GG. Coeliac axis and mesenteric arterial thrombosis following laparoscopic Nissen fundoplication. Aust N Z J Surg 1994; 64:728.
  25. Hasson HM, Galanopoulos C, Langerman A. Ischemic necrosis of small bowel following laparoscopic surgery. JSLS 2004; 8:159.
  26. Nguyen NT, Goldman C, Rosenquist CJ, et al. Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs. Ann Surg 2001; 234:279.
  27. Jamal MH, Corcelles R, Shimizu H, et al. Thromboembolic events in bariatric surgery: a large multi-institutional referral center experience. Surg Endosc 2015; 29:376.
  28. Mitchell MT, Gasparaitis AE, Alverdy JC. Imaging findings in Roux-en-O and other misconstructions: rare but serious complications of Roux-en-Y gastric bypass surgery. AJR Am J Roentgenol 2008; 190:367.
  29. Tiwari MM, Goede MR, Reynoso JF, et al. Differences in outcomes of laparoscopic gastric bypass. Surg Obes Relat Dis 2011; 7:277.
  30. Arterburn D, Livingston EH, Schifftner T, et al. Predictors of long-term mortality after bariatric surgery performed in Veterans Affairs medical centers. Arch Surg 2009; 144:914.
  31. Melinek J, Livingston E, Cortina G, Fishbein MC. Autopsy findings following gastric bypass surgery for morbid obesity. Arch Pathol Lab Med 2002; 126:1091.
  32. Schauer P, Ikramuddin S, Hamad G, Gourash W. The learning curve for laparoscopic Roux-en-Y gastric bypass is 100 cases. Surg Endosc 2003; 17:212.
  33. Wittgrove AC, Clark GW. Laparoscopic gastric bypass, Roux-en-Y- 500 patients: technique and results, with 3-60 month follow-up. Obes Surg 2000; 10:233.
  34. Schauer PR, Ikramuddin S, Gourash W, et al. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg 2000; 232:515.
  35. Westling A, Gustavsson S. Laparoscopic vs open Roux-en-Y gastric bypass: a prospective, randomized trial. Obes Surg 2001; 11:284.
  36. Nguyen NT, Ho HS, Palmer LS, Wolfe BM. A comparison study of laparoscopic versus open gastric bypass for morbid obesity. J Am Coll Surg 2000; 191:149.
  37. Higa KD, Boone KB, Ho T. Complications of the laparoscopic Roux-en-Y gastric bypass: 1,040 patients--what have we learned? Obes Surg 2000; 10:509.
  38. Papasavas PK, Hayetian FD, Caushaj PF, et al. Outcome analysis of laparoscopic Roux-en-Y gastric bypass for morbid obesity. The first 116 cases. Surg Endosc 2002; 16:1653.
  39. Luján JA, Hernandez Q, Frutos MD, et al. Laparoscopic gastric bypass in the treatment of morbid obesity. Preliminary results of a new technique. Surg Endosc 2002; 16:1658.
  40. Mehran A, Szomstein S, Zundel N, Rosenthal R. Management of acute bleeding after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2003; 13:842.
  41. Nguyen NT, Rivers R, Wolfe BM. Early gastrointestinal hemorrhage after laparoscopic gastric bypass. Obes Surg 2003; 13:62.
  42. Carlin AM, Zeni TM, English WJ, 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.
  43. Aurora AR, Khaitan L, Saber AA. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients. Surg Endosc 2012; 26:1509.
  44. Dick A, Byrne TK, Baker M, et al. Gastrointestinal bleeding after gastric bypass surgery: nuisance or catastrophe? Surg Obes Relat Dis 2010; 6:643.
  45. Stroh C, Köckerling F, Weiner R, et al. Are there gender-specific aspects of sleeve gastrectomy-data analysis from the quality assurance study of surgical treatment of obesity in Germany. Obes Surg 2012; 22:1214.
  46. Gentileschi P, Camperchioli I, D'Ugo S, et al. Staple-line reinforcement during laparoscopic sleeve gastrectomy using three different techniques: a randomized trial. Surg Endosc 2012; 26:2623.
  47. Dapri G, Cadière GB, Himpens J. Reinforcing the staple line during laparoscopic sleeve gastrectomy: prospective randomized clinical study comparing three different techniques. Obes Surg 2010; 20:462.
  48. Lim RB, Blackburn GL, Jones DB. Benchmarking best practices in weight loss surgery. Curr Probl Surg 2010; 47:79.
  49. Schneider BE, Villegas L, Blackburn GL, et al. Laparoscopic gastric bypass surgery: outcomes. J Laparoendosc Adv Surg Tech A 2003; 13:247.
  50. Gonzalez, R, Murr, MM. Anastomotic leaks following gastric bypass surgery. In: Weight Loss Surgery: A Multidisciplinary Approach, Jones, DB, Rosenthal, R (Eds), Matrix Medical Communications, Edgemont 2008. p.369.
  51. Smith MD, Adeniji A, Wahed AS, et al. Technical factors associated with anastomotic leak after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2015; 11:313.
  52. Hamilton EC, Sims TL, Hamilton TT, et al. Clinical predictors of leak after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Surg Endosc 2003; 17:679.
  53. Sims TL, Mullican MA, Hamilton EC, et al. Routine upper gastrointestinal Gastrografin swallow after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2003; 13:66.
  54. Madan AK, Stoecklein HH, Ternovits CA, et al. Predictive value of upper gastrointestinal studies versus clinical signs for gastrointestinal leaks after laparoscopic gastric bypass. Surg Endosc 2007; 21:194.
  55. Raman R, Raman B, Raman P, et al. Abnormal findings on routine upper GI series following laparoscopic Roux-en-Y gastric bypass. Obes Surg 2007; 17:311.
  56. Doraiswamy A, Rasmussen JJ, Pierce J, et al. The utility of routine postoperative upper GI series following laparoscopic gastric bypass. Surg Endosc 2007; 21:2159.
  57. White S, Han SH, Lewis C, et al. Selective approach to use of upper gastroesophageal imaging study after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2008; 4:122.
  58. Thodiyil PA, Yenumula P, Rogula T, et al. Selective nonoperative management of leaks after gastric bypass: lessons learned from 2675 consecutive patients. Ann Surg 2008; 248:782.
  59. Gonzalez R, Sarr MG, Smith CD, et al. Diagnosis and contemporary management of anastomotic leaks after gastric bypass for obesity. J Am Coll Surg 2007; 204:47.
  60. Marshall JS, Srivastava A, Gupta SK, et al. Roux-en-Y gastric bypass leak complications. Arch Surg 2003; 138:520.
  61. Durak E, Inabnet WB, Schrope B, et al. Incidence and management of enteric leaks after gastric bypass for morbid obesity during a 10-year period. Surg Obes Relat Dis 2008; 4:389.
  62. Merrifield BF, Lautz D, Thompson CC. Endoscopic repair of gastric leaks after Roux-en-Y gastric bypass: a less invasive approach. Gastrointest Endosc 2006; 63:710.
  63. Fukumoto R, Orlina J, McGinty J, Teixeira J. Use of Polyflex stents in treatment of acute esophageal and gastric leaks after bariatric surgery. Surg Obes Relat Dis 2007; 3:68.
  64. Mennigen R, Senninger N, Laukoetter MG. Novel treatment options for perforations of the upper gastrointestinal tract: endoscopic vacuum therapy and over-the-scope clips. World J Gastroenterol 2014; 20:7767.
  65. Shikora SA, Kim JJ, Tarnoff ME. Reinforcing gastric staple-lines with bovine pericardial strips may decrease the likelihood of gastric leak after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2003; 13:37.
  66. Liu CD, Glantz GJ, Livingston EH. Fibrin glue as a sealant for high-risk anastomosis in surgery for morbid obesity. Obes Surg 2003; 13:45.
  67. Shikora SA. The use of staple-line reinforcement during laparoscopic gastric bypass. Obes Surg 2004; 14:1313.
  68. Shikora SA, Kim JJ, Tarnoff ME. Comparison of permanent and nonpermanent staple line buttressing materials for linear gastric staple lines during laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2008; 4:729.
  69. Fullum TM, Aluka KJ, Turner PL. Decreasing anastomotic and staple line leaks after laparoscopic Roux-en-Y gastric bypass. Surg Endosc 2009; 23:1403.
  70. Miller KA, Pump A. Use of bioabsorbable staple reinforcement material in gastric bypass: a prospective randomized clinical trial. Surg Obes Relat Dis 2007; 3:417.
  71. Sapala JA, Wood MH, Schuhknecht MP. Anastomotic leak prophylaxis using a vapor-heated fibrin sealant: report on 738 gastric bypass patients. Obes Surg 2004; 14:35.
  72. Livingston EH, Liu CY, Glantz G, Li Z. Characteristics of bariatric surgery in an integrated VA Health Care System: follow-up and outcomes. J Surg Res 2003; 109:138.
  73. Lalor PF, Tucker ON, Szomstein S, Rosenthal RJ. Complications after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2008; 4:33.
  74. Baltasar A, Serra C, Pérez N, et al. Laparoscopic sleeve gastrectomy: a multi-purpose bariatric operation. Obes Surg 2005; 15:1124.
  75. Frezza EE, Reddy S, Gee LL, Wachtel MS. Complications after sleeve gastrectomy for morbid obesity. Obes Surg 2009; 19:684.
  76. Consten EC, Gagner M, Pomp A, Inabnet WB. Decreased bleeding after laparoscopic sleeve gastrectomy with or without duodenal switch for morbid obesity using a stapled buttressed absorbable polymer membrane. Obes Surg 2004; 14:1360.
  77. Gagner M, Deitel M, Kalberer TL, et al. The Second International Consensus Summit for Sleeve Gastrectomy, March 19-21, 2009. Surg Obes Relat Dis 2009; 5:476.
  78. Winegar DA, Sherif B, Pate V, DeMaria EJ. Venous thromboembolism after bariatric surgery performed by Bariatric Surgery Center of Excellence Participants: analysis of the Bariatric Outcomes Longitudinal Database. Surg Obes Relat Dis 2011; 7:181.
  79. Sapala JA, Wood MH, Schuhknecht MP, Sapala MA. Fatal pulmonary embolism after bariatric operations for morbid obesity: a 24-year retrospective analysis. Obes Surg 2003; 13:819.
  80. Masoomi H, Buchberg B, Reavis KM, et al. Factors predictive of venous thromboembolism in bariatric surgery. Am Surg 2011; 77:1403.
  81. Becattini C, Agnelli G, Manina G, et al. Venous thromboembolism after laparoscopic bariatric surgery for morbid obesity: clinical burden and prevention. Surg Obes Relat Dis 2012; 8:108.
  82. Wu EC, Barba CA. Current practices in the prophylaxis of venous thromboembolism in bariatric surgery. Obes Surg 2000; 10:7.
  83. American Society for Metabolic and Bariatric Surgery Clinical Issues Committee. ASMBS updated position statement on prophylactic measures to reduce the risk of venous thromboembolism in bariatric surgery patients. Surg Obes Relat Dis 2013; 9:493.
  84. Caruana JA, Anain PM, Pham DT. The pulmonary embolism risk score system reduces the incidence and mortality of pulmonary embolism after gastric bypass. Surgery 2009; 146:678.
  85. Birkmeyer NJ, Finks JF, English WJ, et al. Risks and benefits of prophylactic inferior vena cava filters in patients undergoing bariatric surgery. J Hosp Med 2013; 8:173.
  86. Masoomi H, Reavis KM, Smith BR, et al. Risk factors for acute respiratory failure in bariatric surgery: data from the Nationwide Inpatient Sample, 2006-2008. Surg Obes Relat Dis 2013; 9:277.
  87. Gupta PK, Gupta H, Kaushik M, et al. Predictors of pulmonary complications after bariatric surgery. Surg Obes Relat Dis 2012; 8:574.
  88. Huerta S, DeShields S, Shpiner R, et al. Safety and efficacy of postoperative continuous positive airway pressure to prevent pulmonary complications after Roux-en-Y gastric bypass. J Gastrointest Surg 2002; 6:354.
  89. Consensus paper on the surveillance of surgical wound infections. The Society for Hospital Epidemiology of America; The Association for Practitioners in Infection Control; The Centers for Disease Control; The Surgical Infection Society. Infect Control Hosp Epidemiol 1992; 13:599.
  90. Horan TC, Gaynes RP, Martone WJ, et al. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol 1992; 13:606.
  91. Lewis SS, Moehring RW, Chen LH, et al. It is time to change our focus: surgical site infections account for the greatest proportion of hospital-aquired infections. Infect Control Hosp Epidemiol 2013; In press.
  92. Boyce JM, Potter-Bynoe G, Dziobek L. Hospital reimbursement patterns among patients with surgical wound infections following open heart surgery. Infect Control Hosp Epidemiol 1990; 11:89.
  93. Poulsen KB, Bremmelgaard A, Sørensen AI, et al. Estimated costs of postoperative wound infections. A case-control study of marginal hospital and social security costs. Epidemiol Infect 1994; 113:283.
  94. Vegas AA, Jodra VM, García ML. Nosocomial infection in surgery wards: a controlled study of increased duration of hospital stays and direct cost of hospitalization. Eur J Epidemiol 1993; 9:504.
  95. Derzie AJ, Silvestri F, Liriano E, Benotti P. Wound closure technique and acute wound complications in gastric surgery for morbid obesity: a prospective randomized trial. J Am Coll Surg 2000; 191:238.
  96. Bohdjalian A, Langer FB, Kranner A, et al. Circular- vs. linear-stapled gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass. Obes Surg 2010; 20:440.
  97. Shang E, Hasenberg T, Magdeburg R, et al. First experiences with A circular stapled gastro-jejunostomy by a new transorally introducible stapler system in laparoscopic Roux-en-Y gastric bypass. Obes Surg 2009; 19:230.
  98. Pories WJ, van Rij AM, Burlingham BT, et al. Prophylactic cefazolin in gastric bypass surgery. Surgery 1981; 90:426.
  99. Chapman, A, Kiroff, G, Game, P et al. Systematic review of laparoscopic adjustable gastric banding in the treatment of obesity. (ASERNIP-S report no. 31). Adelaide: Australian Safety and Efficacy Register of New Interventional Procedures-Surgical; 2002.
  100. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004; 292:1724.
  101. Stephens DJ, Saunders JK, Belsley S, et al. Short-term outcomes for super-super obese (BMI > or =60 kg/m2) patients undergoing weight loss surgery at a high-volume bariatric surgery center: laparoscopic adjustable gastric banding, laparoscopic gastric bypass, and open tubular gastric bypass. Surg Obes Relat Dis 2008; 4:408.
  102. Jones KB Jr, Afram JD, Benotti PN, et al. Open versus laparoscopic Roux-en-Y gastric bypass: a comparative study of over 25,000 open cases and the major laparoscopic bariatric reported series. Obes Surg 2006; 16:721.
  103. Podnos YD, Jimenez JC, Wilson SE, et al. Complications after laparoscopic gastric bypass: a review of 3464 cases. Arch Surg 2003; 138:957.
  104. Janata K, Holzer M, Domanovits H, et al. Mortality of patients with pulmonary embolism. Wien Klin Wochenschr 2002; 114:766.
  105. Gagner M, Milone L, Yung E, et al. Causes of early mortality after laparoscopic adjustable gastric banding. J Am Coll Surg 2008; 206:664.
  106. Morino M, Toppino M, Forestieri P, et al. Mortality after bariatric surgery: analysis of 13,871 morbidly obese patients from a national registry. Ann Surg 2007; 246:1002.