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Superobesity, Greater Chronic Disease Burden Linked to Higher Mortality After Bariatric Surgery

  • Authors: News Author: Laurie Barclay, MD
    CME Author: Désirée Lie, MD, MSEd
  • CME Released: 10/27/2009
  • Valid for credit through: 10/27/2010, 11:59 PM EST
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Target Audience and Goal Statement

This article is intended for primary care clinicians, surgeons, and other specialists who care for patients who undergo bariatric surgery.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  • Describe the risk for mortality after bariatric surgery in US veterans.
  • Identify predictors of mortality in veterans who undergo bariatric surgery for obesity.


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  • Laurie Barclay, MD

    Freelance writer and reviewer, MedscapeCME


    Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.


  • Brande Nicole Martin

    is the News CME editor for Medscape Medical News.


    Disclosure: Brande Nicole Martin has disclosed no relevant financial information.

CME Author(s)

  • Désirée Lie, MD, MSEd

    Clinical Professor, Family Medicine, University of California, Orange; Director, Division of Faculty Development, UCI Medical Center, Orange, California


    Disclosure: Désirée Lie, MD, MSEd, has disclosed no relevant financial relationships.

CME Reviewer(s)

  • Sarah Fleischman

    CME Program Manager, MedscapeCME


    Disclosure: Sarah Fleischman has disclosed no relevant financial relationships.

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Superobesity, Greater Chronic Disease Burden Linked to Higher Mortality After Bariatric Surgery

Authors: News Author: Laurie Barclay, MD CME Author: Désirée Lie, MD, MSEdFaculty and Disclosures

CME Released: 10/27/2009

Valid for credit through: 10/27/2010, 11:59 PM EST


October 27, 2009 — Superobesity and a greater burden of chronic disease are linked to higher mortality rates after bariatric surgery in veterans, according to the results of a prospective study reported in the October issue of Archives of Surgery.

"The risk of death related to bariatric surgery is generally thought to be low," write David Arterburn, MD, MPH, from Group Health Research Institute in Seattle, Washington, and colleagues. "Prior studies of bariatric surgery have primarily included younger female patients, so the mortality estimates from these studies might not apply to the older, predominantly male population that undergoes surgery at VA [Veterans Affairs] medical facilities."

The goal of the study was to determine patient-related factors predicting mortality among obese veterans treated with bariatric surgery, with use of data from the VA National Surgical Quality Improvement Program. From January 1, 2000, through December 31, 2006, a total of 856 veterans had undergone bariatric surgery in 1 of 12 VA bariatric centers of the Group Health Center for Health Studies, the VA North Texas Health Care System, the Denver VA Medical Center, and the Durham VA Medical Center. Cox proportional hazards allowed estimation of the risk for death.

Before surgery, mean body mass index (BMI) was 48.7 kg/m2, mean age was 54 years, and mean diagnostic cost group (DCG) score was 0.76. The study sample was 73.0% men, 83.9% white, and 7.0% American Society of Anesthesiologists class equal to 4. By the end of 2006, a total of 54 veterans (6.3%) had died.

The risk for death was increased in superobese patients (BMI > 50 kg/m2; hazard ratio [HR], 1.8; P = .04) or in those with a DCG score of 2 or greater (HR, 3.4; P < .001). There were 30 deaths in superobese patients (30-day, 90-day, and 1-year death rates of 2.0%, 3.6%, and 5.2%, respectively). Mortality rates in patients with a higher DCG score were 1.5%, 5.8%, and 10.1%, respectively.

"Superobese veterans and those with a greater burden of chronic disease had a greater risk of death after bariatric surgery from 2000 through 2006," the study authors write.

Limitations of this study include older, predominantly male population; limited number of deaths; and lack of access to data on cause of death or changes in weight after surgery.

"The results of this study should inform discussions with patients with regard to the potential risks and benefits of bariatric surgery," the study authors conclude. "These findings also suggest that the risks of bariatric surgery in patients with significant comorbidities, such as congestive heart failure, complicated diabetes and chronic obstructive pulmonary disease, should be carefully weighed against potential benefits in older male patients and those with superobesity."

In an invited critique, Clifford W. Deveney, MD, from Oregon Health and Sciences University in Portland, notes that these findings correlate with those of other series studying the risk for death during the first year after gastric bypass surgery.

"Despite seeing increased mortality up to 1 year, others have demonstrated a clear survival benefit of bariatric surgery during 5 to 10 years, with survival advantage (operated on vs not operated on) beginning at 6 months after surgery," Dr. Deveney writes. "Therefore, despite the fact that the mortality rate increases during the postoperative period up to 1 year, it is small and does not negate the several advantages for patients who undergo bariatric surgery. However, there seems to be a group of patients (male, older, high morbidity scores) in whom bariatric surgery may not offer a survival advantage."

The Office of Research and Development, Health Services Research and Development Service, Department of Veterans Affairs, supported this study. The study authors and Dr. Deveney have disclosed no relevant financial relationships.

Arch Surg. 2009;144:914-920.

Clinical Context

More than 10 million US adults, including 165,000 veterans who use the VA medical facilities, have type 3 obesity (≥ BMI 40 kg/m2). Bariatric surgery has been shown to improve outcomes and survival duration in those with obesity, with the number of bariatric surgeries increasing from 16,800 to more than 200,000 per year during the past decade. The risk for death at 30 days was recently estimated at 0.28% in a meta-analysis, and 1-year mortality rate is less than 1% in the United States, but it is unclear if this finding applies to older male veterans.

This is a retrospective study of 856 bariatric surgery patients at 12 US VA hospitals from 2000 to 2006 to determine the mortality rate and predictors of mortality.

Study Highlights

  • Data were obtained from the VA National Surgical Quality Improvement Program, which prospectively collects data on all surgeries performed in the VA system.
  • The investigators identified bariatric surgery patients in the National Surgical Quality Improvement Program database using Current Procedural Terminology 4 codes and International Classification of Diseases, Ninth Revision, diagnoses.
  • Variables examined were age, sex, ethnicity, BMI, ASA classification, smoking status, and DCG risk adjustment measure.
  • Patients with missing data were excluded.
  • The DCG reflected comorbidities by assigning International Classification of Diseases, Ninth Revision, codes during inpatient admissions and outpatient visits; past studies have shown that the DCG predicts cost of care for the cluster of conditions.
  • A DCG score of more than 1 denotes above-average cost of care, and a score less than 1 denotes lower-than-average cost of care.
  • The researchers extracted the ASA class from anesthesia records using a scale of 1 (healthy), 2 (mild), 3 (moderate), 4 (severe systemic disease), and 5 (moribund patient not expected to survive 24 hours).
  • Of 911 patients who had undergone bariatric surgery from 2000 to 2006, 856 were analyzed.
  • Number of procedures performed increased from 52 to 170 per year during the period studied.
  • Mean preoperative BMI was 48.7 kg/m2, mean age was 54 years, mean DCG score was 0.76, 83.9% were white, and 73.0% were men.
  • 93.0% had an ASA class of 2 or 3, and 7.0% had an ASA class of 4.
  • Roux-en-Y gastric bypass was performed on 96.9%, and 1.9% underwent gastric banding.
  • 25.0% had laparoscopic procedures, and 75.0% underwent open procedures.
  • Median follow-up duration was 984 days.
  • Overall, 30-day, 90-day, and 1-year mortality rates were 1.3%, 2.1%, and 3.4%, respectively.
  • Postoperative adverse outcomes were higher in those who died vs those who survived.
  • Adverse events included longer operative time; higher rates of return to the operating room; longer hospital stay; and higher rates of complications including cardiac arrest, sepsis, pneumonia, or intubation.
  • Patients who died were older; more likely to be men; and had a higher BMI, DCG score, and ASA classification.
  • They were more functionally impaired and had more comorbidities such as heart failure, dyspnea, dialysis, diabetes, and corticosteroid use.
  • Those who died were less likely to have undergone laparoscopic procedures (2% vs 26.4%) vs those who survived.
  • Patients who were superobese (≥ BMI 50 kg/m2) were more likely to have hypertension, heart failure, chronic obstructive pulmonary disease, higher ASA class, and open wounds.
  • 30-day, 90-day, and 1-year mortality rates for those who had a BMI of 50 kg/m2 or more were 2.0%, 3.6%, and 5.2%, respectively, higher than the other patients.
  • Superobese patients were less likely to have undergone laparoscopic procedures and had longer hospital stays and more complications.
  • Risk for death was associated with BMI of 50 kg/m2 or more (HR, 1.77; P = .04), DCG score of 2 or more (HR, 3.4; P < .001), and preoperative ASA classification of 4 (HR, 4.65; P = .06).
  • Those who had a laparoscopic procedure had a reduced risk for mortality (HR, 0.10; P = .02).
  • Sex, ethnicity, age, smoking, and diabetes treatment were not significant predictors of mortality.
  • One quarter of patients with both BMI of 50 kg/m2 or higher and DCG score of 2 or higher died within 3.5 years of follow-up, whereas those with BMI less than 50 kg/m2 and DCG score of less than 2 had the highest overall survival duration.
  • The authors concluded that mortality rates were higher in those with BMI of 50 kg/m2 or more and DCG score of 2 or more.

Clinical Implications

  • Overall mortality rates after bariatric surgery are 1.3%, 2.1%, and 3.4% at 30 days, 90 days, and 1 year, respectively, with higher mortality rate among those with a BMI of 50 kg/m2 or higher.
  • Predictors of mortality in VA patients after bariatric surgery are a BMI of 50 kg/m2 or higher, a preoperative DCG score of 2 or more, and an ASA classification of 4, whereas laparoscopic procedure reduces mortality rates.

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