Low overall mortality during 10 years of bariatric surgery: nationwide study on 63,469 procedures from the Scandinavian Obesity Registry

BackgroundBariatric surgery results in an improvement in quality of life, co-morbid diseases, and an increased life expectancy. However, to obtain these benefits perioperative mortality rates need to be low.ObjectivesEvaluate 90-day and 1-year mortality after bariatric surgery in Sweden from 2008 to 2017.SettingNational quality register.MethodsData on applicable patients from the Scandinavian Obesity Surgery Registry, including 63,469 patients (85.1% gastric bypass, 12.5% sleeve gastrectomy, .8% duodenal switch, .5% minor revisions, and 1.1% other procedures), were retrieved and matched to the Cause of Death registry.ResultsDuring the 10-year period, 36 patients died within 90 days, resulting in a .06% overall mortality. The 1-year mortality rate was .19% (n = 111). Both mortality rates decreased over the study period. In a multivariate analysis, depression (odds ratio [OR] 2.38, [95% confidence interval 1.48–3.84]), leakage (OR 9.32 [4.85–17.94]), and thromboembolic events (OR 7.60 [1.63–35.37]) increased mortality risks at both 90 days and 1 year, whereas age (OR 1.03 [1.01–1.06] per increased year of age) and abdominal circumference (OR 1.03 [1.01–1.05] per cm) were also associated with increased mortality at 1 year. The predictive value of the Obesity Surgery Mortality Risk Score was confirmed.ConclusionsThe low 90-day and 1-year mortality, .06% and .19%, respectively, demonstrates that bariatric surgery in Sweden is safe. The use of antidepressants and 2 serious postoperative complications were the most significant risk factors for early deaths, while increased age and preoperative abdominal circumference also contributed at 1 year.     

Guideline compliance in bariatric surgery: a French nationwide study

BackgroundStrict adherence to guidelines with a comprehensive preoperative assessment and rigorous follow-up are essential to improve postoperative and long-term outcomes of bariatric surgery (BS).ObjectivesTo investigate the trends in BS in France and to assess the compliance to guidelines in people with obesity before and after BS.SettingUniversity Hospital of Bordeaux, France.MethodsData on patients who were admitted for a primary BS procedure in France between January 1 and April 1, 2014, were extracted from the French national health insurance system database. Data on patients’ characteristics, preoperative assessment, hospitalization, and postoperative follow-up, including medical consultations, laboratory tests, and drug consumption, during the year preceding and the 2 years after BS were collected.ResultsMost of the 11,824 patients (60.4%) had sleeve gastrectomy. Rates of reimbursement for preoperative consultations with general practitioners, digestive surgeons, and endocrinologists or internists were 94.5%, 89.2%, and 63%, respectively. Laboratory tests for nutritional and obesity-related co-morbidity evaluations were performed in 94.3% and 91.4%, respectively. Rates of consultation with general practitioners, digestive surgeons, and endocrinologists or internists dropped from 93.1%, 91.2%, and 29.2%, respectively, the first year to 88.4%, 50.3%, and 20%, respectively, the second year after BS (P < .001). Reimbursements for vitamin, iron, and calcium supplementation dropped from 66.6%, 24.9%, and 21%, respectively, the first year to 52.1%, 19.3%, and 11.7%, respectively, the second year after BS (P < .001).ConclusionOverall compliance with guidelines is improving. While preoperative medical assessment is nearly optimal, efforts still should be made in order to improve long-term follow-up in general and patient adherence to micronutrient supplementation in particular.     

Incidence of and risk factors associated with care fragmentation following bariatric surgery

BackgroundCurrent readmission rates do not account for readmissions to nonindex hospitals and may underestimate the actual burden of readmissions.ObjectiveUsing a nationally representative database, we sought to characterize nonindex readmissions following bariatric surgery and identify risk factors associated with readmission to a nonindex hospital.SettingPatients in the United States undergoing elective bariatric surgery.MethodsThe Nationwide Readmissions Database was used to identify a weighted sample of 545,377 patients undergoing elective bariatric surgery between 2010 and 2014. Multivariable logistic regression analysis was used to identify factors associated with readmission to a nonindex hospital.ResultsAmong all patients, 5.6% were readmitted at least once within 30 days. Within the subgroup of patients who were readmitted, 17.6% were readmitted to a different hospital than the index admission hospital. Factors independently associated with higher odds of readmission to a nonindex hospital were primary payor (Medicare: odds ratio [OR] = 1.48, 95% confidence interval [CI]: 1.24–1.75; Medicaid: OR = 1.56, 95% CI: 1.26–1.95), All Patients Refined Diagnosis Related Group severity of illness score (extreme versus minor: OR = 1.48; 95% CI: 1.04–2.09), primary procedure (laparoscopic sleeve gastrectomy versus laparoscopic gastric bypass: OR = 1.23; 95% CI: 1.05–1.44), hospital bed size (reference: small hospital, medium: OR = .52, 95% CI: .39–.70; large: OR = .47, 95% CI: .35–.63), hospital ownership (reference: private, nonprofit hospital, government: OR = 1.77, 95% CI: 1.32–2.37; private, investor-owned: OR = 1.33, 95% CI: 1.07–1.64), and hospital location (reference: metropolitan area >1 million population, metropolitan <1 million population: OR = .44, 95% CI: .34–.56; micropolitan/rural: OR = .44, 95% CI: .27–.73).ConclusionFailure to account for readmissions to different hospitals may underestimate readmission rates by approximately 18%.     

Racial disparity in causes for readmission following bariatric surgery

BackgroundReadmission after bariatric surgery is not cost-effective and is a preventable quality metric within standardized practices. However, reasons for readmission among racial/ethnic bariatric cohorts are less explored and understood.ObjectiveOur study objective was designed to compare reasons for readmission among racial/ethnic cohorts of bariatric patients.SettingAcademic hospital.MethodsWe performed a retrospective analysis of the 2015–2018 MBSAQIP databases to identify Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) cases. Regression analyses determined predictors of all-cause and bariatric-related readmissions. Reasons for readmission were compared between racial/ethnic cohorts using propensity score matching.ResultsMore than 550 000 RYGB and SG cases were analyzed. The readmission rate was 3%–4%. Black race, RYGB, robot-assisted approach, and numerous co-morbidities were independently associated with readmission (P <.05). In RYGB cases, black (versus white) patients were at decreased odds of leak-related (P < .001) and cardiovascular-related (P < .001) readmissions but at increased odds of readmissions related to renal complications (P < .001). Hispanic (versus white) patients had a higher likelihood of venous thromboembolism–related readmissions (P < .001). In SG cases, black (versus white) patients had a similar lower likelihood of readmission related to leaks or cardiovascular complications but higher odds of readmission related to renal complications (P < .001). Hispanic (versus black) patients had a higher likelihood of leak-related readmissions (P < .001).ConclusionReadmission reasons after bariatric surgery vary by race/ethnicity. Perioperative pathways to mitigate complications, including readmissions, should consider these disparate findings.     

Plastic surgery in bariatric patients: a nationwide study of 17,000 patients on the national administrative database

Background

Bariatric patients are often candidates for plastic surgery. However, the rate of postbariatric procedures is not known.

Prior bariatric surgery is associated with lower complications,in-hospital mortality,and healthcare utilization after elective spine fusion surgery

BackgroundGrade 3 obesity could potentially increase postoperative complications after spinal fusion surgery. However, the relationship between prior bariatric surgery (BS) and postoperative complications after spinal fusion surgery is not well-established.SettingInpatient hospital admissions from the Nationwide Inpatient Sample.MethodsPatients with a primary procedure of spinal fusion surgery discharged between 2006 and 2014 were identified. In-hospital outcomes included postoperative complications, mortality, cost, and length of stay were compared between patients with prior BS and grade 3 obesity.ResultsA total of 3,132,192 patients who underwent elective spinal fusion surgery were identified. There were 33,936 (1.1%) patients with a diagnosis of prior BS. The prevalence of prior BS increased significantly from .1% in 2006 to 1.5% in 2014. Compared with patients with grade 3 obesity, patients with prior BS were younger, more likely to be female, had less co-morbidities, and higher proportion of cervical surgery. Multivariable analysis indicated that patients with prior BS had lower risk of overall complications (odds ratio [OR]: .44; 95% confidence interval [CI]: .38–.49), neurologic (OR: .55; 95%CI: .35–.84), respiratory (OR: .30; 95%CI: .23–.37), cardiac (OR: .38; 95%CI: .24–.60), gastrointestinal (OR: .61; 95%CI: .44–.84), urinary and renal (OR: .34; 95%CI: .26–.44), venous thromboembolism (OR: .35; 95%CI: .19–.63), wound-related complications (OR: .67; 95%CI: .53–.85), and in-hospital mortality (OR: .12; 95%CI: .02–.88). Prior BS was also related to 13% shorter length of stay and 2% lower cost.ConclusionsAmong patients undergoing spinal fusion surgery, prior BS is associated with lower complications, in-hospital mortality, and healthcare utilization. BS might mitigate risk of worse outcomes associated with grade 3 obesity after spine fusion surgery.     

POSSUM and p-POSSUM overestimate morbidity and mortality in laparoscopic bariatric surgery

BackgroundDespite their wide use in surgical audit, the application of the Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) and the Portsmouth predictor of mortality (p-POSSUM) in bariatric surgery has been limited. The aim of this study was to evaluate the usefulness of POSSUM and p-POSSUM in bariatric comparative audit.MethodsData were retrospectively collected on consecutive patients who underwent laparoscopic gastric by-pass (LRYGB) and sleeve gastrectomy (SG) at a teaching institute. POSSUM and p-POSSUM equations were applied. The observed to expected ratios for morbidity and mortality were calculated. A Student’s t test was performed to assess if a relationship could be found between the observed and the predicted outcomes.ResultsBetween 2008 and 2013, 504 patients (370 female) with a mean (range) age of 46 (17–69) years underwent LRYGB (n = 383) and SG (n = 121). The operative morbidity was 10.9% and mortality was .2%. POSSUM overpredicted morbidity (30.56%), and no relationship between morbidity risk and the development of complications was found (P = .152). There was a grouping of patients in the low-risk mortality groups for both POSSUM and p-POSSUM. Both equations overpredicted mortality (5.95% and 1.62%, respectively).ConclusionBoth POSSUM and p-POSSUM equations overpredicted morbidity and mortality in this only study in the literature of modern bariatric practice that employed a large representative patient sample receiving the commonest procedures. A multicenter study is needed to address the low incidence of events and enable modification of those equations for use in bariatric surgical audit.     

Predicting 90-day mortality after bariatric surgery: an independent,external validation of the OS-MRS prognostic risk score

BackgroundThe Obesity Surgery Mortality Risk Score (OS-MRS) was developed using data from 1995 to 2004; it has yet to be validated for more recent patients in integrated delivery system settings. The objective of this study was to validate the OS-MRS using data from electronic health records in a distributed data network.MethodsWe conducted a retrospective cohort study of 3,817 adults who underwent an open (21.4%) or laparoscopic (78.6%) gastric bypass surgery between 2005 and 2007 in the Scalable Partnering Network. Our main outcome was all-cause mortality during the 90 days after surgery. We scored patients’ risk of mortality by adding characteristics according to the OS-MRS (i.e., 1 point for each predictor).ResultsSixteen of 3,817 (0.42/100; 95% CI, .24–.68) patients died within 90 days. The OS-MRS discriminated low-risk and high-risk patients effectively: low-risk (2 of 1,654 patients; .12 deaths/100 patients), intermediate-risk (10 of 2,008 patients; .50 deaths/100 patients), and high-risk (4 of 155 patients; 2.58 deaths/100 patients). High-risk patients were 21.3 times more likely to die in the first 90 days after surgery than low-risk patients (risk ratio = 21.3; 95% CI, 3.9–115.6).ConclusionIn these 10 U.S. healthcare delivery systems, the OS-MRS appears valid—albeit with the caveat that we observed a small number of deaths. The OS-MRS appears useful for identifying the small fraction of patients at high risk for 90-day mortality after open and laparoscopic RYGB.     

Cost analysis and risk factors for interval cholecystectomy after bariatric surgery: a national study

Background

Besides rate and extent of weight loss, little is known regarding demographic factors predicting interval cholecystectomy (IC) after bariatric surgery and its incremental costs.

Trends in metabolic bariatric surgery in adolescents in France: a nationwide analysis on an 11- year period

BackgroundAs the prevalence of obesity in adolescents has reached an alarming level of 16%, the rate of metabolic bariatric surgery (MBS) in this population is also rising in several countries.ObjectivesThis study aimed to compare the trends in types of MBS, short-term safety, and revisional rates, in younger adolescents aged < 18 years, compared with older adolescents (aged 18–19 yr) and adults aged >20 years.SettingClinical research center, general hospital in France.MethodsUsing a national administrative database (Programme de Médicalisation des Systèmes d’Information [PMSI]), data regarding all patients undergoing MBS between 2008 and 2018 in France were examined. Demographic parameters, body mass index (BMI), co-morbidities, types of surgery, early complications, and long-term revisional rates were analyzed, comparing younger adolescents (<18 yr), older adolescents (18–19 yr), and adults (≥20 yr).ResultsThe number of bariatric procedures in adolescents initially increased from 59 in 2008 to 135 in 2014, and then progressively declined to 56 procedures in 2018. Adjustable gastric banding (AGB) decreased from 83.1% (n = 49) of procedures to 32.1% (n = 18) of procedures during the study period, while sleeve gastrectomy (SG) increased from 6.8% (n = 4) to 46.4% (n = 26). In the early postoperative period, younger adolescents undergoing MBS experienced fewer episodes of reoperation (1.0% versus 1.3% in older adolescents and 2.6% in adults, P < .001) and intensive care unit (ICU) stays (.2% versus .2% in older adolescents and .6% in adults, P < .001), and no deaths were observed in younger adolescents (.02% in older adolescents and .1% in adults, P = .18). At 10 years, the AGB removal rate was lower in younger adolescents (24.8%) compared with that in older adolescents (29.6%) and adults (50.3%, P < .001). Similarly, rates of revisional surgery after SG were different in the 3 groups: 2.9%, 4.6% and 12.2% in younger adolescents, older adolescents, and adults, respectively.ConclusionDespite significantly lower early complication rates and long-term revisional rates in young adolescents (<18 yr), we observed a progressive decrease in the utilization of MBS in this population in France, compared with adults (≥20 yr) and older adolescents (18–19 yr).     

Validation of the cumulative deficit theory in bariatric surgery: new bariatric frailty score is associated with non-home discharge,prolonged hospital stay and mortality in the era of fast-track bariatric surgery

BackgroundFrailty is a wasting disorder that can coexist with obesity, thus, the term “obese frailty syndrome”. Frailty can be measured using the cumulative deficit model demonstrated in the Canadian Study of Health and Aging-Frailty Index (CSHA-FI).ObjectivesTo develop a Bariatric Frailty Score (BFS) to predict 30-day adverse postoperative outcomes.SettingUniversity hospital.MethodsPatients (aged 18–80 yr) who underwent sleeve gastrectomy (SG) and Roux-en-Y-gastric bypass (RYGB) were included using the 2015–2018 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. Fourteen variables of the CSHA-FI were mapped onto 10 variables of MBSAQIP (each component equal 1 point). Correlations and multivariate logistical regression analysis were performed between BFS and 4 postoperative outcomes (non-home discharge, mortality, prolonged hospital stay, and ICU admissions). Finally, a propensity matching score (PSM) between low BFS (0–4) and high BFS (5–10) was performed.ResultsIn 650,882 patients (72% SG, 28% RYGB), the increasing BFS was strongly correlated on linear regression. In the multivariate analysis, scores of 5, 6, and 7 strongly predicted the 4 postoperative outcomes of interest. After the PSM, high BFS (5–10) was associated with an increased rate of postoperative complications in SG and RYGB groups.ConclusionOur BFS is a better predictor of non-home discharge, prolonged hospital stay, mortality, and unplanned ICU admission compared with age >60 years or American Society of Anesthesiologists (ASA) score of IV–V. Our study validated the cumulative deficit theory in bariatric surgery, implying that the cumulative effects of the existing co-morbidities are higher than if these co-morbidities were simply added.     

Postoperative nausea and vomiting after bariatric surgery and dexmedetomidine anesthetic: a propensity-weighted analysis

BackgroundPatients undergoing laparoscopic bariatric surgery have high rates of postoperative nausea and vomiting (PONV). Dexmedetomidine based anesthetic could reduce PONV rates.ObjectivesTo determine if PONV rates differ in patients undergoing laparoscopic bariatric surgery with anesthesia primarily based on dexmedetomidine or standard anesthetic management with inhalational agents and opioids.SettingUniversity hospital.MethodsFrom January 2014 to April 2018, 487 patients underwent laparoscopic bariatric surgery and met inclusion criteria (dexmedetomidine, n = 174 and standard anesthetic, n = 313 patients). In both groups, patients received preoperative PONV prophylaxis. We analyzed rates of PONV and moderate-to-deep sedation. A propensity score was calculated and outcomes were assessed using generalized estimating equations with inverse probability of treatment weighting.ResultsPerioperative opioids and volatile anesthetics were reduced in dexmedetomidine patients. During anesthesia recovery the incidence of PONV was similar between dexmedetomidine and standard anesthetic patients (n = 37 [21.3%] versus n = 61 [19.5%], respectively; inverse probability of treatment weighting odds ratio = 1.35; 95% confidence interval .78–2.32, P = .281), and the incidence of sedation higher in dexmedetomidine patients (n = 86 [49.4%] versus n = 75 [24.0%]; inverse probability of treatment weighting odds ratio = 2.43; 95% confidence interval 1.47–4.03, P < 0.001). Rates of PONV and sedation were similar during the remainder of the hospital stay. A secondary sensitivity analysis was performed limited to dexmedetomidine patients who did not receive volatile and results were similar.ConclusionsWhile dexmedetomidine-based anesthesia was associated with reduced opioid and volatile agents use, it was not associated with a reduction of PONV. The higher rates of moderate-to-deep sedation during anesthesia recovery observed with dexmedetomidine may be undesirable in morbidly obese patients.     

The association between bariatric surgery and cataract: a propensity score-matched cohort study

BackgroundObesity is considered a risk factor for cataracts. The association between weight loss and a cataract among patients with obesity has not been assessed to date.ObjectivesTo assess the association between weight loss following bariatric surgery and cataracts.SettingNationwide Swedish healthcare registries between 2006 and 2019.MethodsWe performed a population-based cohort study. Patients aged 40–79 years who underwent bariatric surgery were matched on their propensity score (PS) to up to 2 patients with obesity (“unexposed patients”). Cox proportional hazard regression analyses calculated hazard ratios (HRs) and 95% confidence intervals (CIs) of developing cataracts following bariatric surgery, compared with unexposed patients. Subgroup analyses by age, sex, bariatric surgery type, and duration of follow-up were conducted.ResultsIn total, 22,560 bariatric surgery patients were PS-matched to 35,523 unexposed patients. The risk of cataracts was decreased in bariatric surgery patients compared with unexposed patients (HR .71, 95% CI .66–.76). We observed the lowest risk of cataracts among bariatric surgery patients aged 40–49 years (HR .52, 95% CI .44–.75) but a null result for patients aged ≥60 years. Gastric bypass or duodenal switch were associated with decreased risks of cataracts, whereas sleeve gastrectomy yielded a null result. Subgroups of sex and duration of follow-up showed no evidence of effect modification (hazards were proportional throughout follow-up).ConclusionOur results suggest that substantial weight loss following bariatric surgery is associated with a decreased risk of cataracts, especially if bariatric surgery was performed before age 60.     

Outcome expectation and risk tolerance in patients seeking bariatric surgery

BackgroundAverage long-term outcome after laparoscopic Roux-en-Y gastric bypass is 25% total weight loss. The risk of short-term complications (leakage and bleeding), acute internal herniation, and mortality are 4.0%, 2.5%, and .2%, respectively. There is a paucity of evidence on what patients expect in terms of weight loss and to what extent surgical risks are tolerated.ObjectiveTo examine the patient’s weight loss expectations and acceptance of the morbidity and mortality risk after primary laparoscopic Roux-en-Y gastric bypass.SettingTeaching hospital, Amsterdam, the Netherlands.MethodsTwo-hundred patients participated in a standardized survey after completion of an extensive multidisciplinary screening, before surgery. Weight loss expectations, naive assessment, and acceptation of risks of morbidity and mortality were addressed with standard gamble methods.ResultsThe 200 participants (156 female, 78%) had a mean age of 45.1 years and a mean body mass index of 42.3 kg/m². Weight loss was overestimated by 151 patients (75.5%), and 79 participants (39.5%) were disappointed with the predicted weight loss. Median accepted risks on short-term complications, acute internal herniation, and mortality were 35.8% (interquartile range, 21.0%–58.0%), 25.1% (interquartile range, 15.9%–50.8%), and 4.5% (interquartile range, 1.0%–10.0%), respectively.ConclusionPatients seeking bariatric surgery seem to have unrealistic weight loss objectives and are willing to accept substantial risks to achieve these goals.     

Postoperative sepsis after primary bariatric surgery: an analysis of MBSAQIP

BackgroundIdentifying patients at higher risk of postoperative sepsis (PS) may help to prevent this life-threatening complication.ObjectivesThis study aimed to identify the rate and predictors of PS after primary bariatric surgery.SettingAn analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) 2015-2017.MethodsPatients undergoing elective sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) were included. Exclusion criteria were revisional, endoscopic, and uncommon, or investigational procedures. Patients were stratified by the presence or absence of organ/space surgical site infection (OS-SSI), and patients who developed sepsis were compared with patients who did not develop sepsis in each cohort. Logistic regression was used to identify independent predictors of PS.ResultsIn total, 438,752 patients were included (79.4% female, mean age 44.6±12 years). Of those, 661 patients (.2%) developed PS of which 245 (37.1%) developed septic shock. Out of 892 patients with organ/space surgical site infections (OS-SSI), 298 (45.1%) developed sepsis (P <.001). Patients who developed PS had higher mortality (8.8% versus .1%, P < .001), and this was highest in patients without OS-SSI (11.8% versus 5%, P = .002). The main infectious complications associated with PS in patients without OS-SSI were pneumonia and urinary tract infection. Independent predictors of PS in OS-SSI included RYGB versus SG (OR, 1.8), and age ≥50 years (OR, 1.4). Independent predictors of PS in patients without OS-SSI were conversion to other approaches (OR, 6), operation length >2 hours (OR, 5.7), preoperative dialysis (OR, 4.1), preoperative therapeutic anticoagulation (OR, 2.8), limited ambulation most or all of the time (OR, 2.4), preoperative venous stasis (OR, 2.4), previous nonbariatric foregut surgery (OR, 2), RYGB versus SG (OR, 2), hypertension on medication (OR, 1.5), body mass index ≥50 kg/m²(OR, 1.4), age ≥50 years (OR, 1.3), obstructive sleep apnea (OR, 1.3).ConclusionDevelopment of OS-SSI after primary bariatric surgery is associated with sepsis and increased 30-day mortality. Patients without OS-SSI who develop PS have a significantly higher mortality rate compared with patients with OS-SSI who develop PS. Early identification and intervention in patients with PS, including those without OS-SSI, may improve survival in this high-risk group.     

Quality indicators in bariatric surgery: improving quality of care

OBJECTIVES: Bariatric surgery is one of the most common complex intraabdominal operations, and there are reports of variations in outcome among providers. There is a need to standardize the processes of care in this specialty, and, as an attempt to do so, quality indicators were developed. METHODS: Candidate indicators, covering preoperative to follow-up care (5 domains), were developed based on evidence in the literature. Indicators were formally rated as valid by use of the RAND/UCLA Validity and Appropriateness method, which quantitatively assesses the expert judgment of a group using a 9-point scale (1 = not valid; 9 = definitely valid). Fourteen individuals participated in the expert panel, including bariatric surgeons and obesity experts. The method is iterative with 2 rounds of ratings and a group discussion. Indicators with a median rating > or =7 were valid. This method has been shown to have content, construct, and predictive validity. RESULTS: Of 63 candidate indicators, 51 were rated as valid measures of good quality of care covering the spectrum of perioperative care for bariatric surgery. Of the 51 indicators rated as valid (> or =7), all had sufficient "agreement" scores among panelists. Indicators included structural measures (e.g., procedural volume requirements) as well as processes of care (e.g., receipt of preoperative antibiotics, use of clinical pathway). CONCLUSIONS: This is the first formal attempt at development of quality indicators for bariatric surgery. Adherence to the indicators should equate with better quality of care, and their implementation will allow for quantitative assessment of quality of care.