The impact of laparoscopy on bariatric surgery

The rising popularity of bariatric surgery over the past several years is attributable in part to the development of laparoscopic bariatric surgery. Morbidly obese patients have associated comorbid conditions that may predispose them to postoperative morbidity. The laparoscopic approach to bariatric surgery offers a minimally invasive option that reduces the physiologic stress and provides clinical benefits, as compared with the open approach. This review summarizes the impact of laparoscopic surgery on bariatric surgery, the various risk factors that could potentially predispose morbidly obese patients to postoperative morbidity, the fundamental differences between laparoscopic and open bariatric surgery, and the physiology of reduced tissue injury associated with laparoscopic bariatric surgery.     

Comparison of laparoscopic radical renal surgery in morbidly obese and non-obese patients

BACKGROUND AND PURPOSE: Laparoscopic radical nephrectomy is rapidly becoming accepted as the preferred management of low-stage renal masses not amenable to partial nephrectomy. Minimally invasive surgery is advantageous to decrease perioperative and postoperative morbidity and allows patients to return to normal activities faster. Obesity has been a relative contraindication to this technique, and these patients have traditionally undergone open surgery. We present a review of 23 morbidly obese patients in comparison with patients who were not morbidly obese who underwent radical laparoscopic nephrectomy and nephroureterectomy at our institution. PATIENTS AND METHODS: Hospital charts between April 2001 and October 2003 were reviewed for morbidly obese patients undergoing transperitoneal laparoscopic renal surgery who were compared with age- and sex-matched control patients who underwent laparoscopic renal surgery in the same institution for similar indications. The data were collected at the time of the surgery. RESULTS: Twenty-three patients with a mean BMI of 42.2 kg/m2 underwent successful transperitoneal laparoscopic surgery. The mean specimen mass was 865 g, which was significantly larger than in the control group. The mean operative time was 200 minutes, which was around half an hour longer than in the matched group. The mean estimated blood loss was 243 mL, which was comparable to that of the controls. There were two perioperative complications, and the mean hospital stay was 4.5 days, 1 day longer than in the control group. CONCLUSIONS: Laparoscopic transperitoneal renal surgery is technically more difficult in morbidly obese patients but is a feasible, effective, minimally invasive method of removing renal malignancies. It offers decreased respiratory and cardiac morbidity in this higher-risk population. This study showed a complication profile similar to that in non-obese patients.     

Impact of gastric restrictive surgery on hypertension in the morbidly obese.

Hypertension is a major health risk factor in patients who are morbidly obese. Two hundred eighty-nine morbidly obese patients undergoing gastric restrictive surgery were evaluated for the presence of hypertension (blood pressure greater than or equal to 160/90 mm Hg or currently undergoing antihypertensive therapy) pre- and postoperatively. Of 74 (26%) preoperatively hypertensive patients, 67 (91%) were available for follow-up. Preoperative hypertension resolved in 66% (44 of 67) of patients following gastric restrictive surgery. Superobese and morbidly obese patients had similar reductions in hypertension after surgery (69% versus 63%). Patients not receiving antihypertensives preoperatively had a greater reduction of hypertension than those medically treated preoperatively (78% versus 58%). The amount of weight loss significantly predicted the reduction of hypertension, whereas follow-up weight achieved did not. The amounts of weight loss for patients with resolved and persistent hypertension were 89.3 +/- 5.6 lbs (mean +/- standard error of the mean +ADSEM+BD) and 66.0 +/- 8.3 lbs, respectively (p less than 0.02). For patients with resolved hypertension, follow-up weights for the morbidly obese and superobese were 162.0 +/- 10.8 lbs (133% +/- 4% ideal body weight +ADIBW+BD) and 220.4 +/- 9.5 lbs (170% +/- 7% IBW). Gastric restrictive surgery is effective therapy for hypertension in morbidly obese patients. Patients need not achieve weights approaching IBW to enjoy the benefits of gastric restrictive surgery on hypertension.     

Impact of bariatric surgery on cardiovascular and musculoskeletal morbidity

BACKGROUND: Obesity is currently recognized as a global epidemic. According to recent statistics, the prevalence of obesity increased from 13.8% of the Canadian population in 1978-1979 to 23.1% in 2004, and the prevalence of morbid obesity increased from .9% in 1978-1979 to 2.7% in 2004. Obesity is a known risk factor for highly prevalent chronic diseases, including cardiovascular and musculoskeletal disorders. The objective of the study was to assess the impact of bariatric surgery on cardiovascular and musculoskeletal morbidity. METHODS: This was an observational study that compared a cohort of 1035 morbidly obese patients treated with bariatric surgery at the Centre for Bariatric Surgery, McGill University Health Centre with a matched cohort of 5746 morbidly obese nonsurgically treated controls. Data were obtained from the Quebec provincial health insurance database (Régie de l'Assurance Maladie du Québec). Morbidity indicators included diagnoses or treatment for cardiovascular or musculoskeletal disorders. RESULTS: Patients who underwent bariatric surgery had a significant 62% mean reduction in excess weight and 32% mean reduction in body mass index (P < .001). Compared with the matched controls, patients who had undergone bariatric surgery had significantly lower rates of diagnoses and treatments related to cardiovascular and musculoskeletal conditions. CONCLUSIONS: These results indicate that bariatric surgery is effective in reducing weight and significantly reduces the risk of cardiovascular and musculoskeletal morbidity.     

Laparoscopic Ileogastrostomy

Laparoscopic ileogastrostomy was successfully performed on two of three morbidly obese persons. In our first case, access ports proved too short and the patient was converted to an open procedure. Aims were to carry out surgery for the morbidly obese patient through a laparoscope and, as a consequence, increase ambulation, while reducing pain, morbidity, and the chance of apnea (due to impaired breathing in the first 24 h following conventional surgery). Length of laparoscopic surgeries for the second and third patients were 5 and 4 h, respectively, while hospital stays were 10 days and 5 days. Pulmonary function tests at 24 h were carried out and showed a great advantage in favor of the laparoscopic approach. Response of the medical team to this procedure was that it was more time-consuming and demanding than open surgery. Although gastric banding and gastric stapling have been accomplished laparoscopically, we believe these to be the first procedures with anastomoses carried out on morbidly obese patients.     

Comorbidity among the morbidly obese: a comparative study of 2002 U.S. hospital patient discharges.

BACKGROUND: Increased morbidity is associated with increasing severity of obesity. However, among morbidly obese patients, comorbid prevalence has been reported primarily in the bariatric surgical literature. This study compares demographic characteristics and selected comorbid conditions of morbidly obese patients discharged after surgical obesity procedures and morbidly obese patients discharged after all other hospital procedures. METHODS: The 2002 National Hospital Discharge Survey (a nationally representative sample of hospital discharge records) and the International Classification of Diseases, 9th Revision, Clinical Modification were used to identify and describe all morbidly obese patient discharges (n = 3,473) and to quantify the prevalence of selected obesity-related comorbid conditions. RESULTS: Compared with all other morbidly obese patients, the obesity surgery patients (n = 833) were younger (median, 42 vs 48 years; range, 17 to 67) and more female (82.3% vs. 63.7%), with higher rates of sleep apnea (24.0% vs. 11.8%), osteoarthritis (22.9% vs. 11.8%), and gastroesophageal reflux disease (27.7% vs. 11.7%) (all P < .001). The prevalence of type 2 diabetes mellitus was lower in the obesity surgery patients (16.1% vs. 24.3%; P = .003), whereas the rates of hypertension (45.9% vs. 41.0%; P = .13) and asthma (9.6% vs. 12.0%; P = .26) were similar in the two groups. CONCLUSIONS: Demographic characteristics and comorbid prevalence of morbidly obese patients discharged after obesity surgery are consistent with reports in the bariatric surgical literature. Obesity surgery patients had a higher prevalence of some comorbid conditions. Possible explanations for this include preferential diagnosis, differential diagnostic coding, or increased severity of morbid obesity. Advancing surgical and insurance guidelines for bariatric surgery will require clinical data that accurately describe and quantify the demographic distribution of obesity and the associated burden of disease.     

Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients

OBJECTIVE: This study tested the hypothesis that weight-reduction (bariatric) surgery reduces long-term mortality in morbidly obese patients. BACKGROUND: Obesity is a significant cause of morbidity and mortality. The impact of surgically induced, long-term weight loss on this mortality is unknown. METHODS: We used an observational 2-cohort study. The treatment cohort (n = 1035) included patients having undergone bariatric surgery at the McGill University Health Centre between 1986 and 2002. The control group (n = 5746) included age- and gender-matched severely obese patients who had not undergone weight-reduction surgery identified from the Quebec provincial health insurance database. Subjects with medical conditions (other then morbid obesity) at cohort-inception into the study were excluded. The cohorts were followed for a maximum of 5 years from inception. RESULTS: The cohorts were well matched for age, gender, and duration of follow-up. Bariatric surgery resulted in significant reduction in mean percent excess weight loss (67.1%, P < 0.001). Bariatric surgery patients had significant risk reductions for developing cardiovascular, cancer, endocrine, infectious, psychiatric, and mental disorders compared with controls, with the exception of hematologic (no difference) and digestive diseases (increased rates in the bariatric cohort). The mortality rate in the bariatric surgery cohort was 0.68% compared with 6.17% in controls (relative risk 0.11, 95% confidence interval 0.04-0.27), which translates to a reduction in the relative risk of death by 89%. CONCLUSIONS: This study shows that weight-loss surgery significantly decreases overall mortality as well as the development of new health-related conditions in morbidly obese patients.     

The physiologic effects of pneumoperitoneum in the morbidly obese

OBJECTIVE: To review the physiologic effects of carbon dioxide (CO2) pneumoperitoneum in the morbidly obese. SUMMARY BACKGROUND DATA: The number of laparoscopic bariatric operations performed in the United States has increased dramatically over the past several years. Laparoscopic bariatric surgery requires abdominal insufflation with CO2 and an increase in the intraabdominal pressure up to 15 mm Hg. Many studies have demonstrated the adverse consequences of pneumoperitoneum; however, few studies have examined the physiologic effects of pneumoperitoneum in the morbidly obese. METHODS: A MEDLINE search from 1994 to 2003 was performed using the key words morbid obesity, laparoscopy, bariatric surgery, pneumoperitoneum, and gastric bypass. The authors reviewed papers evaluating the physiologic effects of pneumoperitoneum in morbidly obese subjects undergoing laparoscopy. The topics examined included alteration in acid-base balance, hemodynamics, femoral venous flow, and hepatic, renal, and cardiorespiratory function. RESULTS: Physiologically, morbidly obese patients have a higher intraabdominal pressure at 2 to 3 times that of nonobese patients. The adverse consequences of pneumoperitoneum in morbidly obese patients are similar to those observed in nonobese patients. Laparoscopy in the obese can lead to systemic absorption of CO2 and increased requirements for CO2 elimination. The increased intraabdominal pressure enhances venous stasis, reduces intraoperative portal venous blood flow, decreases intraoperative urinary output, lowers respiratory compliance, increases airway pressure, and impairs cardiac function. Intraoperative management to minimize the adverse changes include appropriate ventilatory adjustments to avoid hypercapnia and acidosis, the use of sequential compression devices to minimizes venous stasis, and optimize intravascular volume to minimize the effects of increased intraabdominal pressure on renal and cardiac function. CONCLUSIONS: Morbidly obese patients undergoing laparoscopic bariatric surgery are at risk for intraoperative complications relating to the use of CO2 pneumoperitoneum. Surgeons performing laparoscopic bariatric surgery should understand the physiologic effects of CO2 pneumoperitoneum in the morbidly obese and make appropriate intraoperative adjustments to minimize the adverse changes.     

Gastric Bypass Surgery in a Paraplegic Morbidly Obese Patient

The complications of spinal cord injury are exaggerated with obesity, and create complex medical and socioeconomic issues. Despite the well-documented advantages of bariatric surgery in reducing the morbidity of obesity, this option has not been routinely offered to obese patients with spinal cord injuries. We describe the first case of a morbidly obese male with a spinal cord injury who underwent a successful Roux-en-Y gastric bypass.     

Adenotonsillar surgery in morbidly obese children: routine elective admission of all patients to the intensive care unit is unnecessary

Morbidly obese children undergoing adenotonsillectomy, often with co-morbid obstructive sleep apnoea, may be considered at a higher risk of postoperative respiratory compromise. This retrospective study aimed to assess the frequency and severity of postoperative respiratory complications in these patients and to identify preoperative risks factors for such morbidity. Medical and nursing chart review of all consecutive elective post-adenotonsillectomy admissions of morbidly obese children (defined as >95th centile for body mass index adjusted for age and gender) to our intensive care unit over a 30-month period was performed. A total of 26 morbidly obese children were identified. The majority (14/26) had an uncomplicated recovery following surgery. Of those cases that required postoperative intervention, 10 patients required supplemental oxygen with or without suctioning and/or repositioning alone, whilst two required continuous positive airway pressure therapy. No patient required re-intubation. An oxygen saturation nadir of < 70% and the presence of more than one central apnoea, noted on preoperative overnight polysomnography, were associated with postoperative respiratory complications requiring intervention. Although the intervention group were younger, more obese and had a higher respiratory disturbance index, none of these factors were statistically significant. Routine admission to the paediatric intensive care unit of all morbidly obese children undergoing adenotonsillectomy may be unnecessary, once a suitable high level of nursing is available in an alternative setting, to administer simple positional and suctioning intervention and to perform regular patient observation. Special consideration should be given to the postoperative nursing environment for those patients with a SaO2 nadir < 70% noted preoperatively, indicating the presence of a significant central disease component.     

Antibiotic prophylaxis for surgery in morbidly obese patients

The rate of wound infections in morbidly obese patients who underwent gastroplasty surgery at our institution was 16.5% compared with a rate of 2.5% in normal-weight patients who underwent clean-contaminated surgery. Both groups received 1 gm of cefazolin intramuscularly before surgery was performed. We hypothesized that this regimen of prophylaxis did not provide adequate tissue levels in the morbidly obese. Morbidly obese patients who were undergoing gastroplasty were randomly selected to receive 1 gm cefazolin in the buttock fat, buttock muscle, or by intravenous injection. A fourth group of morbidly obese patients received 2 gm of cefazolin intravenously. Normal-weight patients who were undergoing upper abdominal surgery received 1 gm of cefazolin intravenously. At incision and closure, both blood and tissue levels of cefazolin were significantly (p less than 0.001) lower for all morbidly obese patients who received 1 gm cefazolin when compared with the blood and tissue levels of the drug found in normal-weight patients. The cefazolin levels obtained were below the minimal inhibitory concentrations of greater than 2 micrograms/ml for gram-positive cocci and of greater than 4 micrograms/ml for gram-negative rods. Only when the morbidly obese patient received 2 gm cefazolin were both the serum and adipose tissue levels adequate. For a 4-month period, all morbidly obese patients received 2 gm cefazolin prophylaxis, and the wound infection rate dropped to 5.6% compared with the previous rate of 16.5% (p less than 0.03). We conclude that antibiotic prophylaxis must be specially tailored to the needs of these obese patients.     

Treatment of Morbid Obesity with Adjustable Gastric Band: Preliminary Report

Background: The goal of surgery for morbid obesity is to achieve a good and durable loss of weight and improve health. Previous studies have demonstrated a significant weight loss for the Swedish adjustable gastric band (SAGB). Patients and Methods: Between November 1996 and April 1998, 18 morbidly obese patients underwent SAGB laparoscopically. Their mean age at surgery was 35 years. The mean preoperative weight was 128 kg (range 89-163), and the mean body mass index was 50.4 ± 9. Comorbidity was present in 13 patients. Results: One gastric perforation occurred, and in one patient it was not possible to create the pneumoperitoneum. Regarding late morbidity, one intragastric migration and one slippage of the band occurred. There was no mortality. Conclusion: The low morbidity, the good results with weight loss, and the improvement in comorbidity lead the authors to believe that Swedish adjustable gastric banding for the treatment of morbidly obese patients is a successful means of losing weight and improving general health.     

Changes in pulmonary mechanics during laparoscopic gastroplasty in morbidly obese patients

Background: Obesity is an important respiratory risk factor after abdominal surgery. Laparoscopic surgical techniques seem beneficial in obese patients in terms of respiratory morbidity, with a faster return to normal respiratory function. However, there is little information about intraoperative respiratory mechanics and about patient tolerance to abdominal insufflation in the morbidly obese.
Methods: We studied respiratory mechanics and arterial blood gases in 15 morbidly obese patients (mean BMI=45) undergoing laparoscopic gastroplasty under general anaesthesia and controlled ventilation. Respiratory mechanics were analysed using side-stream spirometry.
Results: When compared to preinsufflation values, servocon-trolled abdominal insufflation to 2.26 kPa caused a significant decrease in respiratory system compliance (31%), a significant increase in peak (17%) and plateau (32%) airway pressures at constant tidal volume with a significant hypercapnia but no change in arterial O₂ saturation. Respiratory system compliance and pulmonary insufflation pressures returned to baseline values after abdominal deflation.
Conclusion: These alterations in pulmonary mechanics are less than those observed with comparable degrees of abdominal inflation in non-obese patients, and were well tolerated. From the point of view of intraoperative respiratory mechanics, laparoscopic surgery is safe in morbidly obese patients.     

Bariatric Surgery Outcomes in Morbidly Obese with the Metabolic Syndrome at US Academic Centers

Background  The metabolic syndrome is associated with significant cardiovascular morbidity and mortality. We assessed the in-hospital outcomes of bariatric surgery in morbidly obese patients with the metabolic syndrome in comparison to a control group without the metabolic syndrome. Methods  Using ICD-9-CM diagnosis and procedure codes, clinical data for 20,242 patients with and without the metabolic syndrome who underwent bariatric surgery over a 5-year period were obtained from the University HealthSystem Consortium database. Results  The prevalence of the metabolic syndrome among bariatric surgery patients was 27.4%. Patients with the metabolic syndrome presented significantly higher overall morbidity as compared to morbidly obese patients without the metabolic syndrome (8.6% vs. 5.8%; p < 0.01), and similar mortality (0.04% vs. 0.01%; p = 0.2) after bariatric surgery. Hispanics with the metabolic syndrome had the highest morbidity rates, and men had the uppermost mortality. In-hospital bariatric surgery outcomes were significantly improved among patients who underwent laparoscopic adjustable gastric banding. Conclusions  The data suggest that the presence of the metabolic syndrome affects inter-ethnic and gender-specific short-term outcomes after bariatric surgery.     

Posterior cervical fusion failure in three morbidly obese patients following circumferential surgery

BACKGROUND: The stability of multilevel anterior corpectomy with fusion (ACF) is often enhanced by simultaneous posterior fusion (PF) which provides a "posterior tension band." Three morbidly obese patients undergoing circumferential surgery had posterior fusions performed without autogenous iliac crest graft to avoid donor site morbidity. METHODS: Three morbidly obese patients (300-350 lbs.), averaging 48 years of age, presented with rapidly progressive moderate/severe myelopathies. Magnetic resonance imaging (MRI) and computed tomography (CT) studies demonstrated severe ventral ossification of the posterior longitudinal ligament. Two to four level plated ACFs were performed utilizing fibula strut allograft and plates. Posterior spinous process wiring/fusion from C2-T1 were completed with braided titanium cables, fibula strut allografts, Inductive Conductive Matrix (a form of demineralized bone matrix), and allograft bone to avoid iliac crest donor site morbidity in such morbidly obese patients. Halo devices were utilized until fusion was documented on postoperative X-ray and 2D-CT studies subsequently obtained 3, 6, and up to 12 months postoperatively. Patients were followed an average of 3 years. RESULTS: Postoperatively, all 3 patients demonstrated mild residual myelopathy (Nurick Grade 0-I). Nevertheless, all 3 exhibited posterior pseudarthroses accompanied by anterior strut/plate extrusion (1 patient), partial anterior graft pseudarthrosis (1 patient), and a delayed strut fracture (1 patient). The first 2 patients required secondary posterior fusions performed with autogenous iliac crest graft, while the third fused with 6 months of additional bracing. CONCLUSIONS: Following circumferential cervical procedures, posterior fusions failed in 3 morbidly obese patients where iliac crest autograft was omitted in an attempt to avoid donor site morbidity.     

Hepatic Abnormalities in Obesity: comparison between mildly obese cases and morbidly obese cases

Hepatic morphology and clinical course of mildly obese subjects with abnormal liver tests were determined in comparison with those of surgically treated morbidly obese cases. Twenty mildly obese subjects (mean body mass index, 27.9) with elevated serum transaminase levels were followed up on a low-calorie diet. Nineteen morbidly obese patients (mean body mass index, 39.2) had a surgical biopsy at gastric restrictive surgery. In these two groups, the frequency and the severity of hepatic steatosis and fibrosis were comparable, whereas intralobular cell infiltration was somewhat greater in the mildly obese group. Follow-up studies of the two groups showed remarkable improvement of serum transaminase levels, the extent of which was greater in surgically treated cases. Thus, in mildly obese subjects with abnormal liver tests, (1) hepatic histological abnormalities are not milder than those in morbidly obese cases, and (2) improvement of serum transaminase levels upon diet therapy is less satisfactory than that in morbidly obese cases treated surgically. It is suggested these two groups may not be in the same spectrum of obesity-related hepatic disorders.     

Outcome Following Bariatric Surgery in Super versus Morbidly Obese Patients: Does Weight Matter?

Background: Numerous investigators have attempted to identify prognostic indicators for successful outcome following bariatric surgery. The purpose of this study was to determine whether degree of obesity affects outcome in super obese [>225% ideal body weight (IBW)] versus morbidly obese patients (160-225% IBW) undergoing gastric restrictive/bypass procedures. Methods: Since 1984, 157 patients underwent either gastric bypass or vertical banded gastroplasty. Super obese (78) and morbidly obese (79) patients were followed prospectively, documenting outcome and complications. Results: Super obese patients reached maximum weight loss 3 years following bariatric surgery, exhibiting a decrease in body mass index (BMI) from 61 to 39 kg/m² and an average loss of 42% excess body weight (EBW). Morbidly obese patients had a decrease in BMI from 44 to 31 kg/m² and carried 39% EBW at 1 year. After their respective nadirs, each group began to regain the lost weight with the super obese exhibiting a current BMI of 45 kg/m² (61% EBW) versus 34 kg/m² (52% EBW) in the morbidly obese at 72 months cumulative follow-up. Currently, loss of 50% or more of EBW occurred in 53% of super obese patients versus 72% of morbidly obese (P < 0.01). Twenty-six percent of super obese patients returned to within 50% of ideal body weight (IBW) while 71% of morbidly obese were able to reach this goal (P < 0.01). Co-morbidities and complications related to surgery were similar in each group. Conclusions: Super obese patients have a greater absolute weight loss after bariatric surgery than do morbidly obese patients. Using commonly utilized measures of success based on weight, morbidly obese patients tend to have better outcomes following bariatric surgery.     

Laparoscopic gastric bypass surgery: equipment and necessary tools

Advanced laparoscopy in the morbidly obese patient is technically challenging. Having the proper instrumentation and equipment available is a major component of technical success. Items routinely used during surgery performed on patients of normal size must often be modified or substituted when morbidly obese patients undergo surgery. In this article, we review the specific tools necessary for the safe and proper completion of laparoscopic Roux-en-Y gastric bypass, in addition to various alternatives that can be helpful when other procedures are performed on morbidly obese patients.     

Gastroplasty for Morbid Obesity after Cardiac and Renal Transplantation

The success of vertical banded gastroplasty (VBG) in the obese transplanted population is measured by a low operative morbidity and mortality in the context of a good record of permanent weight loss and an enhanced quality of life. Selection of transplanted patients for gastroplasty should be guided by the prevailing standards for the general population. VBG is the procedure of choice because of proven efficacy and has the benefit over gastric bypass of not producing malabsorption. The operation causes early satiety while allowing consistent absorption of immunosuppressive medication from the upper gastrointestinal tract, essential in these patients. The risk of hypertension, diabetes mellitus, hyperlipidemia, and immunosuppressive medication toxicity may be decreased by substantial long-term weight loss afforded morbidly obese transplant patients by gastric restrictive surgery. Cardiac risk factors associated with morbid obesity and immunosuppressive therapy are lessened with sustained weight reduction.     

Survival and changes in comorbidities after bariatric surgery

OBJECTIVE: To evaluate survival rates and changes in weight-related comorbid conditions after bariatric surgery in a high-risk patient population as compared with a similar cohort of morbidly obese patients who did not undergo surgery. SUMMARY BACKGROUND DATA: Morbid obesity is increasingly becoming a major public health issue. Existing studies are limited in their ability to assess the risks and benefits of bariatric surgery because few studies compare surgical patients to a similar, morbidly obese, nonsurgical cohort, especially in high-risk populations like the elderly and disabled. METHODS: A retrospective cohort analysis using Medicare fee-for-service patients from 2001 to 2004. Survival rates and diagnosed presence of 5 conditions commonly comorbid with morbid obesity were examined for morbidly obese patients who did and did not undergo bariatric surgery, with up to 2 years follow-up. RESULTS: Morbidly obese Medicare patients who underwent bariatric surgery had increased survival rates over the 2 years of this study when compared with a similar morbidly obese nonsurgical group (P < 0.001). For patients under the age of 65, this survival advantage started at 6 months postoperatively and for patients over age 65, at 11 months. The surgical group also experienced significant improvements in the diagnosed prevalence of 5 weight-related comorbid conditions (diabetes, sleep apnea, hypertension, hyperlipidemia, and coronary artery disease) relative to the nonsurgical cohort after 1 year postsurgery (P < 0.001). CONCLUSIONS: Bariatric surgery appears to increase survival even in the high-risk, Medicare population, both for individuals aged 65 and older and those disabled and under 65. In addition, the diagnosed prevalence of weight-related comorbid conditions declined after bariatric surgery relative to a control cohort of morbidly obese patients who did not undergo surgery.