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Invited Critique
December 21, 2009

Slimming Down for Safer Surgery: Comment on “Preoperative Weight Loss Before Bariatric Surgery”

Arch Surg. 2009;144(12):1155-1156. doi:10.1001/archsurg.2009.214

Morbid obesity is a significant health problem for which bariatric surgery has been demonstrated to be the most effective and durable treatment. This surgery reduces excess body weight and improves comorbidities, satisfaction, and quality of life. The number of weight-loss operations performed yearly continues to escalate, and previously held limitations on patient selection—age, BMI, and presence of preoperative disease—are now being reconsidered because of the significant health benefits conferred by successful weight loss and treatment of the metabolic syndrome. Strategies to further improve outcomes after bariatric surgery are, therefore, of significant interest, because there is often less room for adverse events with morbidly obese patients than in patients with fewer comorbidities or those of healthy weight. Postoperative complications in the former population can be particularly difficult to manage and deadly. The authors retrospectively review data from hundreds of consecutive patients who had undergone an open or laparoscopic weight-loss procedure and demonstrate that complications can be reduced with aggressive preoperative weight loss.

While we try to provide accurate risk stratification information to patients, identification of the factors that do not portend poor outcomes is also important. In this article, neither age nor sex was an independent predictor of postoperative complications, although both previously have been identified as risk factors. That no correlation was demonstrated certainly could be the result of an underpowered study. One interesting interpretation of the finding advanced by the authors, however, is that preoperative weight loss attenuates previously identified risk factors. The question raised is ripe for a subsequent study in which it also can be determined whether ultimate resolution of comorbidities varies based on the demographic characteristics of age and sex. A future prospective study could also further define the factors that impact the abilities of patients to achieve preoperative weight loss.

Losing weight is a challenging proposition under most circumstances, and it is partly this difficulty itself that accounts for the popularity of bariatric surgical procedures. This manuscript demonstrates clearly that, when other factors are held constant, the odds ratio for any complication decreases with weight loss. If modest preoperative weight loss confers a safety advantage to the patient, emphasis on an aggressive preoperative regimen would then seem appropriate, irony notwithstanding.

Another finding in this study, one not emphasized as firmly by the authors but that is certainly of note, is that patients who underwent open procedures had a significantly higher risk of experiencing any complication compared with those in the laparoscopic arm of the study and had a significantly higher risk of experiencing respiratory, cardiac, wound, or urinary complications specifically. Also for consideration, however, is the finding that patients who underwent the open approach were more likely to be male, older, and to have a higher BMI.

Overall, this article presents the largest study thus far, to our knowledge, which may demonstrate a significant advantage to preoperative weight loss. Moreover, the authors did not experience the attrition feared by some surgeons should they require preoperative weight loss of their patients. These findings suggest that consideration be given to incorporating either a suggestion of or the requirement for modest weight loss prior to bariatric surgery as a means of decreasing postoperative complications.

Correspondence: Dr Turner, University of Maryland Medical Center, Division of General Surgery, 22 S Greene St, Rm S4B19, Baltimore, MD 21201 (pturner@smail.umaryland.edu).