Obesity Surgery

, Volume 23, Issue 11, pp 1842–1851 | Cite as

Sleep-Disordered Breathing and Postoperative Outcomes After Bariatric Surgery: Analysis of the Nationwide Inpatient Sample

  • Babak MokhlesiEmail author
  • Margaret D. Hovda
  • Benjamin Vekhter
  • Vineet M. Arora
  • Frances Chung
  • David O. Meltzer
Original Contributions



Sleep-disordered breathing (SDB), also known as obstructive sleep apnea (OSA), has been increasingly recognized as a possible risk factor for adverse perioperative outcomes in non-bariatric surgeries. However, the impact of SDB on postoperative outcomes in patients undergoing bariatric surgery remains less clearly defined. We hypothesized that SDB would be independently associated with worse postoperative outcomes.


Data were obtained from the Nationwide Inpatient Sample database and included a total of 91,028 adult patients undergoing bariatric surgeries from 2004 to 2008. The primary outcomes were in-hospital death, total charges, and length of stay. There were two secondary outcomes of interest: respiratory and cardiac complications. Regression models were fitted to assess the independent association between SDB and the outcomes of interest.


SDB was independently associated with decreased mortality (OR = 0.34, 95% CI = 0.23–0.50, p < 0.001), total charges (−$869, p < 0.001), and length of stay (−0.25 days, p < 0.001). SDB was independently associated with significantly increased odds ratio of emergent endotracheal intubation (OR = 4.35, 95% CI = 3.97–4.77, p < 0.001), noninvasive ventilation (OR = 14.12, 95% CI = 12.09–16.51, p < 0.001), and atrial fibrillation (OR = 1.25, 95% CI = 1.11–1.41, p < 0.001). Emergent intubation occurred significantly earlier in the postoperative course in patients with SDB. Although non-SDB patients had an overall lower risk of emergent intubation compared to SDB patients, their outcomes were significantly worse when they did get emergently intubated.


In this large nationally representative sample, despite the increased association of SDB/OSA with postoperative cardiopulmonary complications, the diagnosis of SDB/OSA was negatively, rather than positively, associated with in-hospital mortality and resource use.


Sleep-disordered breathing Bariatric surgery Obstructive sleep apnea Postoperative complications Intubation Respiratory failure Death Length of stay Cost 



Charlson comorbidity index


Confidence interval


Continuous positive airway pressure/noninvasive ventilation


International Classification of Diseases, 9th Revision, Clinical Modification


Length of stay


Nationwide inpatient sample


Odds ratio


Sleep-disordered breathing



This study was supported by the University of Chicago Institute for Translational Medicine and the Clinical and Translational Science Awards (CTSA) program (UL1 RR024999). Dr. Arora is supported by the National Institutes on Aging (K23 AG033763). Dr. Meltzer is supported by a Midcareer Career Development Award from the National Institutes of Health (1 K24 AG031326-01).

Conflict of Interest Statement

Babak Mokhlesi has served as a consultant for Philips/Respironics, but has no conflicts of interest relevant to the present study. Margaret D. Hovda, Benjamin Vekhter, Vineet M. Arora, Frances Chung, and David O. Meltzer have no conflicts of interest relevant to the present study to declare.

Role of the Sponsor

The sponsor had no role in the design and conduct of the study, in the collection, analysis, and interpretation of the data, or in the preparation, review, or approval of the manuscript.


  1. 1.
    Chung F, Yegneswaran B, Liao P, et al. STOP Questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108(5):812–21.PubMedCrossRefGoogle Scholar
  2. 2.
    Gupta RM, Parvizi J, Hanssen AD, Gay PC. Postoperative complications in patients with obstructive sleep apnea syndrome undergoing hip or knee replacement: a case–control study. Mayo Clin Proc. 2001;76(9):897–905.PubMedGoogle Scholar
  3. 3.
    Hwang D, Shakir N, Limann B, et al. Association of sleep-disordered breathing with postoperative complications. Chest. 2008;133(5):1128–34.PubMedCrossRefGoogle Scholar
  4. 4.
    Kaw R, Chung F, Pasupuleti V, et al. Meta-analysis of the association between obstructive sleep apnoea and postoperative outcome. Br J Anaesth. 2012;109:897–906.PubMedCrossRefGoogle Scholar
  5. 5.
    Kaw R, Pasupuleti V, Walker E, et al. Postoperative complications in patients with obstructive sleep apnea. Chest. 2012;141(2):436–41.PubMedCrossRefGoogle Scholar
  6. 6.
    Mador MJ, Goplani S, Gottumukkala VA, et al. Postoperative complications in obstructive sleep apnea. Sleep Breath. 2013;17(2):727–34.Google Scholar
  7. 7.
    Liao P, Yegneswaran B, Vairavanathan S, et al. Postoperative complications in patients with obstructive sleep apnea: a retrospective matched cohort study. Can J Anaesth. 2009;56(11):819–28.PubMedCrossRefGoogle Scholar
  8. 8.
    Flink BJ, Rivelli SK, Cox EA, et al. Obstructive sleep apnea and incidence of postoperative delirium after elective knee replacement in the nondemented elderly. Anesthesiology. 2012;116(4):788–96.PubMedCrossRefGoogle Scholar
  9. 9.
    Memtsoudis S, Liu SS, Ma Y, et al. Perioperative pulmonary outcomes in patients with sleep apnea after noncardiac surgery. Anesth Analg. 2011;112(1):113–21.PubMedCrossRefGoogle Scholar
  10. 10.
    Memtsoudis SG, Bombardieri AM, Ma Y, et al. Mortality of patients with respiratory insufficiency and adult respiratory distress syndrome after surgery: the obesity paradox. J Intensive Care Med. 2012;27(5):306–11.PubMedCrossRefGoogle Scholar
  11. 11.
    Chandra D, Stamm JA, Taylor B, et al. Outcomes of noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease in the United States, 1998–2008. Am J Respir Crit Care Med. 2012;185(2):152–9.PubMedCrossRefGoogle Scholar
  12. 12.
    HCUP (Healthcare Cost and Utilization Project). June 2012. Accessed 10 November 2012.
  13. 13.
    Charlson ME, Pompei P, Ales KL, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–83.PubMedCrossRefGoogle Scholar
  14. 14.
    Nielsen demographic services. Accessed July 2012.
  15. 15.
    HCUP C (Healthcare Cost and Utilization Project). August 2012. Accessed 10 November 2012.
  16. 16.
    Manning WG, Mullahy J. Estimating log models: to transform or not to transform? J Health Econ. 2001;20(4):461–94.PubMedCrossRefGoogle Scholar
  17. 17.
    Nelder J, Wedderburn R. Generalized linear models. J Royal Stat Soc. 1972;135:370–84.CrossRefGoogle Scholar
  18. 18.
    Flum DR, Belle SH, King WC, et al. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med. 2009;361(5):445–54.PubMedCrossRefGoogle Scholar
  19. 19.
    Jensen C, Tejirian T, Lewis C, et al. Postoperative CPAP and BiPAP use can be safely omitted after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2008;4(4):512–4.PubMedCrossRefGoogle Scholar
  20. 20.
    Weingarten TN, Flores AS, McKenzie JA, et al. Obstructive sleep apnoea and perioperative complications in bariatric patients. Br J Anaesth. 2011;106(1):131–9.PubMedCrossRefGoogle Scholar
  21. 21.
    Fernandez Jr AZ, Demaria EJ, Tichansky DS, et al. Multivariate analysis of risk factors for death following gastric bypass for treatment of morbid obesity. Ann Surg. 2004;239(5):698–702. discussion 702–3.PubMedCrossRefGoogle Scholar
  22. 22.
    Nguyen NT, Masoomi H, Laugenour K, et al. Predictive factors of mortality in bariatric surgery: data from the Nationwide Inpatient Sample. Surgery. 2011;150(2):347–51.PubMedCrossRefGoogle Scholar
  23. 23.
    Berger S, Aronson D, Lavie P, et al. Endothelial progenitor cells in acute myocardial infarction and sleep-disordered breathing. Am J Respir Crit Care Med. 2013;187(1):90–8.PubMedCrossRefGoogle Scholar
  24. 24.
    Lavie L, Lavie P. Ischemic preconditioning as a possible explanation for the age decline relative mortality in sleep apnea. Med Hypotheses. 2006;66(6):1069–73.PubMedCrossRefGoogle Scholar
  25. 25.
    Lavie L, Lavie P. Coronary collateral circulation in sleep apnea: a cardioprotective mechanism? Chest. 2010;137(3):511–2.PubMedCrossRefGoogle Scholar
  26. 26.
    Shah N, Redline S, Yaggi HK, et al. Obstructive sleep apnea and acute myocardial infarction severity: ischemic preconditioning? Sleep Breath. 2013;17(2):819–26.Google Scholar
  27. 27.
    Campos-Rodriguez F, Martinez-Garcia MA, de la Cruz-Moron I, et al. Cardiovascular mortality in women with obstructive sleep apnea with or without continuous positive airway pressure treatment: a cohort study. Ann Intern Med. 2012;156(2):115–22.PubMedCrossRefGoogle Scholar
  28. 28.
    Marin JM, Carrizo SJ, Vicente E, et al. Long-term cardiovascular outcomes in men with obstructive sleep apnoea–hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005;365(9464):1046–53.PubMedGoogle Scholar
  29. 29.
    Punjabi NM, Caffo BS, Goodwin JL, et al. Sleep-disordered breathing and mortality: a prospective cohort study. PLoS Med. 2009;6(8):e1000132.PubMedCrossRefGoogle Scholar
  30. 30.
    Young T, Finn L, Peppard PE, et al. Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin sleep cohort. Sleep. 2008;31(8):1071–8.PubMedGoogle Scholar
  31. 31.
    Vasquez TL, Hoddinott K. A potential complication of bi-level positive airway pressure after gastric bypass surgery. Obes Surg. 2004;14(2):282–4.PubMedCrossRefGoogle Scholar
  32. 32.
    Yamada S, Nishimiya J, Kurokawa K, et al. Bilevel nasal positive airway pressure and ballooning of the stomach. Chest. 2001;119(6):1965–6.PubMedCrossRefGoogle Scholar
  33. 33.
    Frangos SG, Schwartz DR. Continuous positive airway pressure and postoperative hypoxemia. JAMA. 2005;293(22):2714. author reply 2714–5.PubMedGoogle Scholar
  34. 34.
    Weingarten TN, Kendrick ML, Swain JM, et al. Effects of CPAP on gastric pouch pressure after bariatric surgery. Obes Surg. 2011;21(12):1900–5.PubMedCrossRefGoogle Scholar
  35. 35.
    Lockhart EM, Willingham MD, Abdallah AB, et al. Obstructive sleep apnea screening and postoperative mortality in a large surgical cohort. Sleep Med. 2013;14:407–15.Google Scholar
  36. 36.
    Isono S, Remmers JE, Tanaka A, et al. Anatomy of pharynx in patients with obstructive sleep apnea and in normal subjects. J Appl Physiol. 1997;82(4):1319–26.PubMedGoogle Scholar
  37. 37.
    Isono S. Obstructive sleep apnea of obese adults: pathophysiology and perioperative airway management. Anesthesiology. 2009;110(4):908–21.PubMedCrossRefGoogle Scholar
  38. 38.
    Sareli AE, Cantor CR, Williams NN, et al. Obstructive sleep apnea in patients undergoing bariatric surgery—a tertiary center experience. Obes Surg. 2011;21(3):316–27.PubMedCrossRefGoogle Scholar
  39. 39.
    Ravesloot MJ, van Maanen JP, Hilgevoord AA, et al. Obstructive sleep apnea is underrecognized and underdiagnosed in patients undergoing bariatric surgery. Eur Arch Otorhinolaryngol. 2012;269(7):1865–71.PubMedGoogle Scholar
  40. 40.
    Carneiro G, Florio RT, Zanella MT, et al. Is mandatory screening for obstructive sleep apnea with polysomnography in all severely obese patients indicated? Sleep Breath. 2012;16(1):163–8.PubMedCrossRefGoogle Scholar
  41. 41.
    Dempsey JA, Skatrud JB, Jacques AJ, et al. Anatomic determinants of sleep-disordered breathing across the spectrum of clinical and nonclinical male subjects. Chest. 2002;122(3):840–51.PubMedCrossRefGoogle Scholar
  42. 42.
    Hoffstein V, Szalai JP. Predictive value of clinical features in diagnosing obstructive sleep apnea. Sleep. 1993;16(2):118–22.PubMedGoogle Scholar
  43. 43.
    Katz I, Stradling J, Slutsky AS, et al. Do patients with obstructive sleep apnea have thick necks? Am Rev Respir Dis. 1990;141(5 Pt 1):1228–31.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Babak Mokhlesi
    • 1
    Email author
  • Margaret D. Hovda
    • 1
  • Benjamin Vekhter
    • 2
  • Vineet M. Arora
    • 2
    • 3
  • Frances Chung
    • 4
  • David O. Meltzer
    • 2
    • 5
  1. 1.Sleep Disorders Center and the Section of Pulmonary and Critical Care, Department of MedicineThe University of ChicagoChicagoUSA
  2. 2.Center for Health and Social SciencesThe University of ChicagoChicagoUSA
  3. 3.Section of General Internal Medicine, Department of MedicineThe University of ChicagoChicagoUSA
  4. 4.Department of AnesthesiaUniversity Health Network, University of TorontoTorontoCanada
  5. 5.Section of Hospital Medicine, Department of MedicineThe University of ChicagoChicagoUSA

Personalised recommendations