Indications and Operative Outcomes of Gastric Bypass Reversal.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) is one of the best-known and most commonly performed bariatric procedures. However, this procedure carries infrequent but serious long-term complications, which may require revisional procedures. This study reports the indications and outcomes of gastric bypass reversal that have not been described well in the literature. METHODS: A multicenter retrospective study of 50 patients who underwent reversal of RYGB conducted between 2006 and 2015 was reviewed to describe the usual indications and outcomes of gastric bypass reversal surgeries. RESULTS: Of 50 patients, 7 (14 %) were males and 43 (86 %) were females. The mean age of the patient population was 40.4 ± 11.6 years (range 19-66). Reasons for reversal included anastomotic ulcers (n = 27), anastomotic complications (n = 9), malnutrition (n = 2), and functional disorder (n = 12). The mean BMI before the reversal was 29 ± 9.4 kg/m(2) (range 16-60). The mean time between the primary procedure and reversal was 60 ± 65.5 months (range 2-300). Fourteen of the reversals were done via laparotomy. Mean hospital stay was 8.4 ± 7.3 days (range 3-34 days). There was no peri-operative death 30 days after reversal. Following gastric bypass reversal, 92.6 % (n = 25) of the patient population had resolution from ulcers, 77.8 % (n = 7) of the patient population had resolution from anatomic complications, 100 % (n = 2) of the patient population had resolution from malnutrition, and 66.7 % (n = 8) of the patient population had resolution from functional disorders. CONCLUSIONS: Gastric bypass reversal is a reasonable and safe treatment for complications arising from the GBP surgery. A laparoscopic approach is feasible in select patients.

Bariatric-related medical malpractice experience: survey results among ASMBS members.

BACKGROUND: The medicolegal aspects of bariatric surgery are very difficult to analyze scientifically because there is no central, searchable database of closed case claims and little incentive for malpractice insurers to divulge data. Examining medicolegal data may provide insight into the financial and psychological burden on physicians. Detailed data also may be used to improve patient safety and determine common causes of negligence. METHODS: All U.S.-based members of the American Society of Metabolic and Bariatric Surgeons were asked to complete a survey regarding their bariatric-related medical malpractice experience. RESULTS: Of the 1672 eligible members that received the survey, 330 responded (19.7%). Mean years in practice was 15.3 ± 9. Mean annual cost of malpractice insurance was $59,200 ± $52,000 (N = 197). The respondent surgeons experienced 1.5 ± 3.2 lawsuits on average over the course of their practice. Of the 330 respondents, 144 (48%) did not report a bariatric-related lawsuit filed against them. Of the 464 lawsuits reported by 156 surgeons, 126 were settled out of court (27%), 249 were dropped (54%), and 54 (18%) went to trial. Seventy-two percent of cases that went to trial were found to be in favor of the defense. The mean lifetime amount paid for suits was $250,000±$660,000. The probability of a bariatric surgeon experiencing a lawsuit was independently associated with the years in practice (P = .03) and number of total cases the surgeon has performed (P = .01). The annual cost of malpractice insurance was independently predicted by the amount paid in previous claims (P = .01). CONCLUSIONS: The probability of a medical malpractice lawsuit correlates positively to the number of procedures performed and the number of years the surgeon has been in practice.

Ethnic differences in weight loss and diabetes remission after bariatric surgery: a meta-analysis.

OBJECTIVE: It has been postulated that the effectiveness of bariatric surgery varies between ethnic groups. However, data regarding this topic are inconclusive, as most studies included few patients from minority groups. We conducted a meta-analysis to determine the difference in percentage of excess weight loss (%EWL) 1-2 years after bariatric surgery in people of African and Caucasian descent. We also studied differences in diabetes mellitus (DM) remission. RESEARCH DESIGN AND METHODS: We performed a MEDLINE and EMBASE search for studies reporting %EWL and/or DM remission after bariatric surgery and including both African Americans and Caucasians. The 613 publications obtained were reviewed. We included 14 studies (1,087 African Americans and 2,714 Caucasians); all provided data on %EWL and 3 on DM remission. We extracted surgery type, %EWL, and DM remission 1-2 years after surgery. After analyzing %EWL for any surgery type, we performed subanalyses for malabsorptive and restrictive surgery. RESULTS: The overall absolute mean %EWL difference between African Americans and Caucasians was -8.36% (95% CI -10.79 to -5.93) significantly in favor of Caucasians. Results were similar for malabsorptive (-8.39% [-11.38 to -5.40]) and restrictive (-8.46% [-12.95 to -3.97]) surgery. The remission of DM was somewhat more frequent in African American patients than in Caucasian patients (1.41 [0.56-3.52]). However, this was not statistically significant. CONCLUSIONS: In %EWL terms, bariatric surgery is more effective in Caucasians than in African Americans, regardless of procedure type. Further studies are needed to investigate the exact mechanisms behind these disparities and to determine whether ethnic differences exist in the remission of comorbidities after bariatric surgery.

Analysis of perioperative outcomes, length of hospital stay, and readmission rate after gastric bypass.

BACKGROUND: Hospital lengths of stay (LOS) and readmission rates often are used by third parties to measure quality of outcomes despite only a few published series that analyze risk-adjusted data and predictors of these events. METHODS: Single-institution retrospective multivariable analysis of consecutive Roux-en-Y gastric bypass (RYGB) patients was performed to determine variables that may influence LOS and the readmission rate. RESULTS: Between 2006 and 2010, 1,065 consecutive RYGB procedures were analyzed. The mean initial body mass index (BMI) of the patients was 48.4 kg/m(2) (range 35-108 kg/m(2)), and their mean age was 42 years (range 15-75 years). Of these patients, 42% were black and 31% were either Medicare or Medicaid beneficiaries. The average LOS was 1.8 days (range 1-59 days; median, 2 days). The hospital discharged 48% of these patients on postoperative day (POD) 1, 85% on POD 2, and 96% on POD 3. According to multivariable Poisson regression, the independent predictors of a longer LOS included longer procedure time, surgeon, BMI, black race, older age, and status as a Medicare/Medicaid beneficiary (all P < 0.01). Gender and measured comorbidities were not associated with LOS. However, this model was poorly predictive of LOS due to substantial unexplained variance (R (2) = 0.10). Complications were significantly associated with Medicare/Medicare status (odds ratio [OR] 2.0), older age (OR 1.03), and longer procedure time (OR 1.02) (P < 0.05). According to logistic regression, a 30-day readmission rate was predicted only by a LOS longer than 3 days for the primary procedure (P < 0.0005). CONCLUSIONS: Early discharge on postoperative day 1 is possible but nonmodifiable, and random patient factors challenge predictable discharge planning. Reliable discharge on postoperative day 1 is not likely with current technologies.

Longitudinal analysis of cardiovascular parameters after gastric bypass surgery.

BACKGROUND: Identifying the predictors of co-morbidity improvement after gastric bypass surgery (Roux-en-Y gastric bypass) might give insight into disease pathophysiology. METHODS: We performed an observational study of 949 patients undergoing primary RYGB from 2005 to 2010. Multivariate mixed models were used to determine the predictors of change in hemoglobin A1c (HbA1c), lipids, systemic blood pressure, and C-reactive protein. RESULTS: Greater weight loss, decreased severity of initial disease, and a greater initial body mass index predicted a significantly greater likelihood of improvement in nearly all measured parameters. Male gender predicted greater improvement in diastolic blood pressure and low-density lipoprotein and triglyceride levels. Younger patients had a greater improvement in blood pressure. Improvement in the lipid profile was independent of weight loss, and improved glycemic control was strongly dependent on weight loss. Of the 949 patients, 33% had diabetes before RYGB. A mean of 388 days after RYGB, 66% of these patients had an HbA1c of <6.5, with their mean HbA1c decreasing from 8.0 to 5.9. A greater decrease in HbA1c was also seen in patients who initially were only treated with oral hypoglycemic agents compared with those receiving insulin. The low-density lipoprotein cholesterol levels decreased significantly from a mean of 108 to 87 mg/dL. High-density lipoprotein increased by a mean of 10 mg/dL in both men and women. Also, 15% of the patients had a triglyceride level of ≥ 200 mg/dL before RYGB and only 1.1% did so afterward. The mean C-reactive protein level decreased from 5.0 to 1.6 mg/dL. We measured a 20% reduction in patients with measured hypertension after RYGB. CONCLUSION: RYGB resulted in dramatic improvement in cardiovascular risk factors, with several significant predictors of outcome.

Analysis of leukopenia and anemia after gastric bypass surgery.

BACKGROUND: Although anemia is a well-described complication after Roux-en-Y gastric bypass (RYGB) in association with iron deficiency, no studies have been published regarding changes in the white blood cell count. METHODS: Mixed longitudinal models were used to follow the changes in white blood cell count, platelet count, and hematocrit over time after RYGB. RESULTS: A total of 590 patients, who had undergone RYGB from 2006 to 2010, inclusively, had laboratory studies available. The mean follow-up was 398 days (range 30-1484). The incidence of leukopenia (white blood cell count ≤4000 cm(3)) increased significantly from 2.0% (12 of 590) before surgery to 14.6% (86 of 590) afterward (P < .0005). A lower white blood cell count was independently predicted by greater weight loss, longer time after surgery, a lower hematocrit, and a lower platelet count (P < .0005). No patient developed neutropenia. The incidence of pre-existing anemia was ∼17% for both men and women. After surgery, the incidence of anemia substantially increased only in premenopausal women (from 16% to 33%). Anemia occurred independently of the degree of weight loss. The platelet counts decreased by a clinically insubstantial, although statistically significant, amount (281,000-250,000; P < .0005). CONCLUSION: RYGB is associated with a generalized decrease in the white blood cell and platelet counts. These decreases do not seem clinically important, unlike the substantial decrease in red blood cell mass in premenopausal women. A generalized suppression of hematopoiesis might occur after RYGB.

Analysis of weight loss after bariatric surgery using mixed-effects linear modeling.

BACKGROUND: The standard analysis of bariatric surgery weight outcomes data (using t tests) is well known. However, these uncontrolled comparisons may yield misleading results and limit the range of research questions. The aim of the study was to develop a valid approach to the longitudinal analysis of weight loss outcomes after bariatric surgery using multivariable mixed models. This study has a multi-institutional setting. METHODS: We developed a mixed-effects model to examine weight after gastric bypass surgery while controlling for several independent variables: gender, anastomotic technique, age, race, initial weight, height, and institution. We contrasted this approach with traditional uncontrolled analyses using percent excess weight loss (%EWL). RESULTS: One thousand one hundred sixty-eight gastric bypass procedures were performed between 2000 and 2006. The average %EWL at 1, 2, and 3 years was 71%, 79%, and 76%, respectively. Using weight as the outcome variable, initial weight and gender were the only independent predictors of outcome (p<0.001). %EWL was substantially less accurate than weight as an outcome measure in multivariable modeling. Including initial weight and height as separate independent variables yielded a more accurate model than using initial body mass index. In a traditional uncontrolled analysis, average %EWL was higher in women than men. However, average weight loss was lower, not higher, in women (p<0.001) in our multivariable mixed model. Height, surgical technique, race and age did not independently predict weight loss. CONCLUSIONS: Multivariable mixed models provide more accurate analyses of weight loss surgery than traditional methods and should be used in studies that examine repeated measurements.

Management of ventral hernias during laparoscopic gastric bypass.

BACKGROUND: Despite the relatively high incidence of ventral hernias in the morbidly obese, their management in bariatric surgery patients remains difficult and controversial. We sought to define a rational approach to ventral hernia management in the gastric bypass patient in a university hospital setting. METHODS: We performed a retrospective, single-institution analysis of all patients who had undergone concomitant ventral hernia repair (VHR) during antecolic gastric bypass. RESULTS: A total of 325 consecutive patients underwent laparoscopic gastric bypass, and 26 (8%) had a ventral hernia found at laparoscopic gastric bypass. In 8 select patients, the incarcerated omental hernia contents were left in situ, and their VHR was successfully deferred. Of the remaining 15 patients, 8 underwent primary VHR and 10 underwent VHR with prosthetic mesh (Proceed). The average length of hospital stay for the VHR versus non-VHR repair groups was 1.6 and 2.7 days, respectively. The only predictor for an increased length of hospital stay was hernia repair with mesh (odds ratio 9.2, P = .002). The average follow-up was 14 months (range 4-30 months). Of the 8 patients who had undergone primary repair, 2 presented with a postoperative small bowel obstruction at the site of their VHR. None of the patients who underwent VHR with prosthetic mesh developed an obstruction or clinical evidence of recurrence or infection. CONCLUSION: In this small study, primary VHR was associated with a high incidence of small bowel obstruction. Prosthetic mesh repair of ventral hernias during LGB did not result in any infection, although the length of hospital stay was increased. In select patients, deferral might be safe.

Outcomes with the adjustable gastric band.

BACKGROUND: The laparoscopic adjustable gastric band (LAGB) has been offered as a safe, effective, and reversible alternative to more invasive weight loss procedures. METHODS: All LAGB procedures performed from May 2001 to July 2005 were reviewed retrospectively with respect to complications and weight loss. RESULTS: During this time period, 186 LAGBs were placed. Average body mass index (BMI) was 43.5 kg/m2 (range, 32 to 62 kg/m2). Average age was 47.8 years (range, 18 to 76 years). Females constituted 76% of patients. Average duration of follow-up was 26.1 months, with follow-up at 1, 2, and 3 years of 96%, 76%, and 62% of patients, respectively. Average number of postoperative office visits was 11. At 1, 2, and 3 years, excess weight loss was 36%, 42%, and 42%, respectively. Of the patients, 30% did not lose more than 25% of their excess weight, and 54% did not achieve a BMI less than 35 kg/m2. The only measured predictor of improved weight loss was lower initial weight (P < .0005). The independent variables, surgeon, surgeon experience, patient age, height and sex were not predictive. Mortality rate was zero. 113 complications developed in 87 patients (47%). The 30-day re-operation rate was 2% and the overall re-operation rate was 33%. However, eliminating patients who had the older Taper I port and only examining patients with the newer Taper II port, overall complication and re-operation rates decreased to 32% and 17%, respectively. Persistent esophageal complications occurred in 16 patients (8.6%); 5 patients developed pouch dilation, and 4 developed prolapse. A total of 13 (7%) LAGBs were explanted, and 9 patients were converted to a gastric bypass. CONCLUSION: The LAGB procedure resulted in variable weight loss and a substantial number of complications.

Sexual dysfunction is common in the morbidly obese male and improves after gastric bypass surgery.

BACKGROUND: There has been limited research examining the mechanisms and epidemiology of sexual dysfunction in the morbidly obese. Our objectives were to measure sexual function in the morbidly obese man before and after substantial weight loss induced by gastric bypass surgery. STUDY DESIGN: All male patients in undergoing gastric bypass completed the Brief Male Sexual Function Inventory (BSFI) before and after operation. BSFI scores were also compared with published normative controls and analyzed for predictors of change. Mixed models were created to control for age, diabetes, and hypertension. RESULTS: Ninety-seven men with a mean age of 48 years (range 19 to 75 years) and mean body mass index of 51 kg/m(2) (range 36 to 89 kg/m(2)) underwent gastric bypass surgery. On average, preoperative morbidly obese patients reported a substantially greater degree of sexual dysfunction than did published reference controls in all domains, p < 0.001. Increasing weight independently predicted lower domain scores. Mean postoperative followup length was 19 months (range 6 to 45 months). On average, BSFI scores improved from preoperative levels by bivariate analysis in all categories (means+/-SE): sexual drive (range 0 to 8), 3.9+/-0.3 to 5.3+/-0.3; erectile function (range 0 to 12), 6.4+/-0.5 to 8.9+/-0.5; ejaculatory function (range 0 to 8), 4.9+/-0.4 to 6.3+/-0.4; problem assessment (range 0 to 12), 7.4+/-0.5 to 9.6+/-0.5; and sexual satisfaction (range 0 to 4), 1.6+/-0.2 to 2.3+/-0.2; all p < 0.01. On multivariable analysis, the amount of weight loss independently predicted the degree of improvement in all BSFI domains, p < 0.05. After an average 67% excess weight loss, BSFI scores in postoperative gastric bypass patients approached those of the reference controls. CONCLUSIONS: Men with morbid obesity commonly suffer from profound, but reversible sexual dysfunction.

Comparative analysis of short-term outcomes after bariatric surgery between two disparate populations.

BACKGROUND: Risk adjustment is a critically important aspect of outcomes research. Racial, geographic, cultural, and socioeconomic differences are nonclinical parameters that can affect clinical outcomes measurement after gastric bypass surgery. METHODS: A single surgeon's experience with 217 consecutive laparoscopic gastric bypass patients in private practice in Southern California was compared with the same surgeon's experience with 124 consecutive patients in an academic institution in Philadelphia. RESULTS: Of the Southern California and Philadelphia groups, 89%, 1%, 9%, and 1% and 55%, 38%, 6%, and 0% were white, black, Hispanic, and Asian, respectively. The average number of co-morbidities was 7.8 in the Southern California group versus 14.4 in the Philadelphia group (P <.001). The 60-day readmission to the hospital rate and emergency room admission rate was 1.4% versus 10.4% and 1.4% versus 18.5%. The insurer mix of private pay, private insurer, and federally funded insurer was 20%, 80%, and 0% in the Southern California group and 0.8%, 71%, and 28% in the Philadelphia group, respectively. Multivariate logistic regression analysis found Medicaid status and practice location independently predicted for the 60-day readmission rate (odds ratio [OR] 3.7, P = .04 and OR 5.6, P = .04, respectively) and a return to the emergency room (OR 3.2, P = .03 and OR 16.3, P <.001). Race, income, and the presence of diabetes were not independent predictors. Variables with nonsignificant differences between the Southern California and Philadelphia cohorts included average age, average body mass index, and major complications (return to surgery and intensive care unit admissions). CONCLUSION: The results of this study have shown that in comparing and predicting the outcomes after bariatric surgery, adjustment for demographic and insurance variables might be necessary to improve accuracy.

Gouty attacks occur frequently in postoperative gastric bypass patients.

BACKGROUND: Both obesity and surgery are known risk factors for instigating gouty attacks. We describe the incidence and management of postoperative gouty attacks after bariatric surgery. METHODS: We performed a retrospective, multi-institutional review of 411 consecutive laparoscopic gastric bypass patients and identified all patients with postoperative gouty attacks. RESULTS: Of the 411 patients reviewed, 21 (5.1%) had had a previous diagnosis of gout. Of these 21 patients, 7 (33.3%) had had an acute attack postoperatively. No patient who had never had a preoperative episode developed gout. In 4 of the 7 (57.1%) patients, the attack was severe enough to require treatment with corticosteroids. Monoarticular attacks occurred in 5 (71.4%) of the 7 patients, and polyarticular attacks occurred in 2 (28.6%). The joints involved included the toes, ankles, and wrists. One patient presented with cervical gout and developed polyarticular gout that required a significant rehabilitation stay. CONCLUSION: The morbidity of postoperative gouty attacks in bariatric surgery patients is significant. Patients with a history of gout should given prophylactic treatment and closely monitored.

Medicare and Medicaid status predicts prolonged length of stay after bariatric surgery.

BACKGROUND: The outcomes of Medicare patients undergoing bariatric surgery have been particularly scrutinized, especially with the Center of Medicare and Medicaid Services' decision to offer bariatric surgery benefits. METHODS: The length-of-stay (LOS) data were analyzed from the National Hospital Discharge Survey from 2002 to 2004. To test the hypothesis that Medicare and Medicaid beneficiaries were more likely to have a prolonged length of stay (PLOS), we used a multivariate logistic regression model controlling for age, gender, hospital size, and year of procedure. RESULTS: An estimated 312,000 bariatric procedures were performed nationally from 2002 to 2004. The average patient age was 41.5 years (range 14-75) and 83.6% were women. The in-hospital mortality rate was reported to be .17%. A PLOS occurred in 3.7% of the population. The Medicare and Medicaid beneficiaries represented 5.7% and 6.2% of the population, respectively. The Medicare beneficiaries were 6.0 times (95% confidence interval 2.5-14; P <.001) as likely to have a PLOS, and Medicaid beneficiaries were 3.2 times (95% confidence interval 1.2-8.9; P = .02) as likely to have a PLOS as others after controlling for age, gender, hospital size, and year of procedure. For every 10-year increase in age, the risk of a PLOS increased by 30% (P <.012). CONCLUSION: Medicare and Medicaid beneficiaries are both at an increased risk of a PLOS. This study was not designed to identify the potential causes of a PLOS. Data from prospectively collected bariatric registries might aid surgeons in assessing the risk/benefit ratio of surgical interventions in groups regarded as high risk.

"Candy cane" Roux syndrome--a possible complication after gastric bypass surgery.

BACKGROUND: An excessive length of nonfunctional Roux limb proximal to the gastrojejunostomy can cause abnormal upper gastrointestinal symptoms after gastric bypass surgery. The purpose of this study was to characterize the syndrome and provide the practitioner with diagnosis and management options. METHODS: We performed a retrospective descriptive review of patients who had undergone revisional surgery for "candy cane" Roux syndrome. RESULTS: From 2004 to 2006, 3 patients underwent revision because of a redundant proximal Roux limb. These 3 revisions were performed at 3, 12, and 36 months after the original Roux-en-Y gastric bypass procedure. The symptoms included regurgitation of food in 2 patients, reflux in 2, significant weight regain in 1, postprandial pain that was relieved after vomiting in 2, persistent nausea in 2, and epigastric fullness in 2 patients. The symptoms were progressive in all 3 patients. The resected length of bowel ranged from 8 to 15 cm. Three different surgeons had performed the initial gastric bypass, and a circular stapler had been used for the construction of the original gastrojejunostomy in all 3 patients. Resection of the excess Roux limb was performed laparoscopically in all cases, and all patients reported complete and immediate resolution of their symptoms. CONCLUSION: A long, nonfunctional Roux limb tip may cause persistent nausea, postprandial epigastric pain, and, even, a lack of satiety. Surgeons should attempt to minimize redundancy in the Roux limb during the primary procedure. Additional studies may better characterize this possible complication.

Back to basics--clinical diagnosis in bariatric surgery. Routine drains and upper GI series are unnecessary.

BACKGROUND: The routine use of closed suction drains and upper GI (UGI) series has been used to aid in the diagnosis and management of gastrojejunal leak after gastric bypass as well as diagnose intra-abdominal bleeding. MATERIALS AND METHODS: 352 consecutive laparoscopic gastric bypass procedures were performed without the use of routine drains or post-operative UGI series. RESULTS: There were no adverse events related the lack of routine drains or UGI studies. Five patients (1.4%) did have a drain placed at the time of surgery, at the surgeon's discretion, due to a particularly difficult gastrojejunal anastomosis although none developed an anastomotic leak. UGI series were ordered post-operatively in seven patients all for unexplained tachycardia, none of who had abnormal radiographic findings. Two patients with tachycardia and normal UGIs had a negative diagnostic laparoscopy to rule out a leak. No UGI series demonstrated a leak although one tachycardic patient with a normal UGI did have a leak diagnosed at laparoscopy. Five patients had clinical signs of a severe gastrojejunal obstruction. Three resolved completely within 48 hours, and two patients required endoscopic intervention without the need for UGI. Six patients (1.7%) required a blood transfusion; all developed tachycardia and five were from bleeding in the GI tract. CONCLUSIONS: Routine use of drains and UGI series were not necessary for the safe management of gastric bypass patient in our series. In this small series, clinical indicators for leak, obstruction or bleeding were obvious without the additional data from a drain or UGI.

Medicolegal analysis of 100 malpractice claims against bariatric surgeons.

BACKGROUND: Very few studies have addressed malpractice litigation specific to bariatric surgery. This study was designed to analyze litigation trends in bariatric surgery to prevent further lawsuits and improve patient care. METHODS: A total of 100 consecutive bariatric lawsuits were reviewed by a consortium of experienced bariatric surgeons and an attorney specializing in medical malpractice. RESULTS: Of the 100 lawsuits, 45% were reviewed for defense attorneys. The mean patient age was 40 years (range 18-65), 75% were women, 81% had a body mass index of <60, 31% were diabetic, and 38% had sleep apnea. Of the surgeons, 42% had <1 year of experience, and 26% had done <100 cases. Although 69% of the physicians were members of the American Society of Bariatric Surgery, only 22% had detailed consent forms. The surgical procedures were performed between 1997 and 2005 and included Roux-en-Y gastric bypass (78% total, 33% open, and 45% laparoscopic), vertical banded gastroplasty (3%), minigastric bypass (6%), biliopancreatic diversion/duodenal switch (4%), and revision (9%). Of the 100 cases, 32% involved an intraoperative complication and 72% required additional surgery. The most common adverse events initiating litigation were leaks (53%), intra-abdominal abscess (33%), bowel obstruction (18%), major airway events (10%), organ injury (10%), and pulmonary embolism (8%). From these injuries, 53 patients died, 28% had a full recovery, 12% had a minor disability, and 7% had major disabilities. Evidence of potential negligence was found in 28% of cases. Of these cases, 82% resulted from a delay in diagnosis and 64% from misinterpreted vital signs. CONCLUSIONS: This study found that leaks and delayed diagnosis were the most common cause of litigation. Even experienced bariatric surgeons should understand the most common errors made by others to prevent complications and avoid litigation.