Skip to main content

Racial disparities in reasons for mortality following bariatric surgery

Abstract

Background

Metabolic and bariatric surgery (MBS) remains a safe and effective treatment for patients with severe obesity. Recent studies have highlighted racial disparities in perioperative outcomes, including up to a twofold higher mortality rate in non-Hispanic black (NHB) (vs. non-Hispanic white (NHW)) patients. Causality for these disparate outcomes remains unclear and largely unexplored.

Objective

Our study aim was to determine reasons for mortality among racial and ethnic cohorts and MBS patients.

Setting

Academic Hospital.

Methods

Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) cases were identified using the 2015 to 2018 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Project (MBSAQIP) database using current procedural (CPT) codes 43,664, 43,645, and 43,775. Multivariate regression analyses were performed to determine independent predictors of overall and bariatric-related mortality. Reasons for mortality were identified and compared between racial and ethnic cohorts.

Results

Of 650,903 RYGB and SG cases, 512,041 were included in our analysis (73% SG). For the entire cohort, all-cause and bariatric-related mortality rates were 0.095% and 0.05%, respectively. Age, male gender, ASA 4, functional status, therapeutic anticoagulation, smoking, COPD, and RYGB were independently associated with both overall and bariatric-related mortality. NHB had increased odds (2.13, p < 0.001) of bariatric-related mortality. Compared to NHW patients (13.3%), venous thromboembolic (VTE) complication was the most common reason for overall mortality in NHB (27.8%) and Hispanic (25%) patients (p < 0.001). VTE-related mortality directly associated with the bariatric procedure was also higher in NHB (34.6%) and Hispanic (33.3%) (vs. NHW 21.0%) patients (p 0.05). When stratified by procedure, mortality causes in RYGB cases were similar between racial and ethnic cohorts. In the SG cohort, the proportion of VTE-related mortality varied significantly (p 0.043) between NHB (39.2%), Hispanic 40.0%, and NHW (20.5%) patients.

Conclusion

There are racial and ethnic differences in causes of mortality following bariatric surgery. The predominant cause of overall and bariatric-related mortality in NHB bariatric surgery patients is postoperative venous thromboembolism. More granular MBSAQIP data capture is needed to determine the role of patient risk versus practice patterns in these disparate outcomes.

This is a preview of subscription content, access via your institution.

Fig. 1

References

  1. Edwards MA, Bruff A, Mazzei M, Lu X, Zhao H. Racial disparities in perioperative outcomes after metabolic and bariatric surgery: a case-control matched study. Surg Obes Relat Dis. 2020;16(8):1111–23.

    Article  Google Scholar 

  2. Fouse T, Brethauer S. Resolution of comorbidities and impact on longevity following bariatric and metabolic surgery. Surg Clin North Am. 2016;96(4):717–32.

    Article  Google Scholar 

  3. Welsh LK, Luhrs AR, Davalos G, Diaz R, Narvaez A, Perez JE, Lerebours R, Kuchibhatla M, Portenier DD, Guerron AD. Racial Disparities in Bariatric Surgery Complications and Mortality Using the MBSAQIP Data Registry. Obes Surg. 2020;30(8):3099–110.

    Article  Google Scholar 

  4. Wiggins T, Guidozzi N, Welbourn R, Ahmed AR, Markar SR. Association of bariatric surgery with all-cause mortality and incidence of obesity-related disease at a population level: A systematic review and meta-analysis. PLoS Med. 2020;17(7):e1003206.

    Article  Google Scholar 

  5. Sjöström L. Review of the key results from the Swedish Obese Subjects (SOS) trial - a prospective controlled intervention study of bariatric surgery. J Intern Med. 2013;273(3):219–34.

    Article  Google Scholar 

  6. Sheka AC, Kizy S, Wirth K, Grams J, Leslie D, Ikramuddin S. Racial disparities in perioperative outcomes after bariatric surgery. Surg Obes Relat Dis. 2019;15(5):786–93.

    Article  Google Scholar 

  7. Wang Y, Beydoun MA, Liang L, Caballero B, Kumanyika SK. Will all Americans become overweight or obese? estimating the progression and cost of the US obesity epidemic. Obesity (Silver Spring). 2008;16(10):2323–30.

    Article  Google Scholar 

  8. Flegal KM, Kruszon-Moran D, Carroll MD, Fryar CD, Ogden CL. Trends in obesity among adults in the United States, 2005 to 2014. J Am Med Assoc. 2016;315(21):2284–91.

    CAS  Article  Google Scholar 

  9. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999–2004. JAMA. 2006;295(13):1549–55.

    CAS  Article  Google Scholar 

  10. Colquitt JL, Pickett K, Loveman E, Frampton GK. Surgery for weight loss in adults. Cochrane Database Syst Rev. 2014 Aug 8

  11. Yu J, Zhou X, Li L, Li S, Tan J, Li Y, Sun X. The long-term effects of bariatric surgery for type 2 diabetes: systematic review and meta-analysis of randomized and non-randomized evidence. Obes Surg. 2015;25(1):143–58.

    Article  Google Scholar 

  12. Schauer PR, Bhatt DL, Kirwan JP, for the STAMPEDE Investigators, et al. Bariatric surgery versus intensive medical therapy for diabetes—5-year outcome. N Engl J Med. 2017;376(7):641–51.

    Article  Google Scholar 

  13. Kashyap SR, Bhatt DL, Wolski K, Watanabe RM, Abdul-Ghani M, Abood B, Pothier CE, Brethauer S, Nissen S, Gupta M, Kirwan JP, Schauer PR. Metabolic effects of bariatric surgery in patients with moderate obesity and type 2 diabetes: analysis of a randomized control trial comparing surgery with intensive medical treatment. Diabetes Care. 2013;36(8):2175–82.

    CAS  Article  Google Scholar 

  14. Christou NV. Impact of obesity and bariatric surgery on survival. World J Surg. 2009;33(10):2022–7.

    Article  Google Scholar 

  15. Flum DR, Belle SH, King WC, et al. Longitudinal Assessment of Bariatric Surgery (LABS) Consortium Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med. 2009;361(5):445–54.

    Article  Google Scholar 

  16. Arterburn DE, Olsen MK, Smith VA, Livingston EH, Van Scoyoc L, Yancy WS Jr, Eid G, Weidenbacher H, Maciejewski ML. Association between bariatric surgery and long-term survival. JAMA. 2015;313(1):62–70.

    CAS  Article  Google Scholar 

  17. Chang SH, Stoll CR, Song J, Varela JE, Eagon CJ, Colditz GA. The effectiveness and risks of bariatric surgery: an updated systematic review and meta-analysis, 2003–2012. JAMA Surg. 2014;149(3):275–87.

    Article  Google Scholar 

  18. Hachem A, Brennan L. Quality of life outcomes of bariatric surgery: a systematic review. Obes Surg. 2016;26(2):395–409.

    Article  Google Scholar 

  19. Mazer LM, Azagury DE, Morton JM. Quality of life after bariatric surgery. Curr Obes Rep. 2017;6(2):204–10.

    Article  Google Scholar 

  20. Adams TD, Mehta TS, Davidson LE, Hunt SC. All-Cause and Cause-Specific Mortality Associated with Bariatric Surgery: A Review. Curr Atheroscler Rep. 2015;17(12):74.

    Article  Google Scholar 

  21. Nguyen GC, Patel AM. Racial disparities in mortality in patients undergoing bariatric surgery in the U.S.A. Obes Surg. 2013;23(10):1508–14.

    Article  Google Scholar 

  22. Omalu BI, Ives DG, Buhari AM, Lindner JL, Schauer PR, Wecht CH, Kuller LH. Death rates and causes of death after bariatric surgery for Pennsylvania residents 1995 to 2004. Arch Surg. 2007;142(10):923–8 (discussion 929).

    Article  Google Scholar 

  23. Maloney SR, Dugan N, Prasad T, Colavita PD, Mckillop IH, Gersin KS, Kuwada T, Barbat S, Roberts A, Nimeri A. Impact of age on morbidity and mortality following bariatric surgery. Surg Endosc. 2020;34(9):4185–92.

    Article  Google Scholar 

  24. Athanasiadis DI, Hernandez E, Monfared S, Kubicki N, Ninad N, Karim A, Selzer D, Stefanidis D, Banerjee A. Bariatric surgery outcomes: is age just a number? Surg Endosc. 2021;35(6):3139–46.

    Article  Google Scholar 

  25. Sakran N, Sherf-Dagan S, Blumenfeld O, Romano-Zelekha O, Raziel A, Keren D, Raz I, Hershko D, Gralnek IM, Shohat T, Goitein D. Incidence and Risk Factors for Mortality Following Bariatric Surgery: a Nationwide Registry Study. Obes Surg. 2018;28(9):2661–9.

    Article  Google Scholar 

  26. Modasi A, Dang JT, Afraz S, Hefler J, Switzer N, Birch DW, Karmali S. Bariatric Surgery Outcomes in Patients on Preoperative Therapeutic Anticoagulation: an Analysis of the 2015 to 2017 MBSAQIP. Obes Surg. 2019;29(11):3432–42.

    Article  Google Scholar 

  27. Nguyen NT, Masoomi H, Laugenour K, Sanaiha Y, Reavis KM, Mills SD, Stamos MJ. Predictive factors of mortality in bariatric surgery: Data from the Nationwide Inpatient Sample. Surgery. 2011;150(2):347–51.

    Article  Google Scholar 

  28. Edwards MA, Asbun D, Mazzei M. Comparison of eGFR formulas in determining chronic kidney disease stage in bariatric patients and the impact on perioperative outcomes. Surg Obes Rel Dis. 2021;17:1317–26.

    Article  Google Scholar 

  29. Mocanu V, Dang JT, Switzer N, Madsen K, Birch DW, Karmali S. Sex and Race Predict Adverse Outcomes Following Bariatric Surgery: an MBSAQIP Analysis. Obes Surg. 2020;30(3):0193–1101.

    Article  Google Scholar 

  30. Welsh LK, Luhrs A, Davalis G, Diaz R, et al. Racial Disparities in Bariatric Surgery Complications and Mortality Using the MBSAQIP Data Registry. Obes Surg. 2020;39(8):309903110.

    Google Scholar 

  31. Dang JT, Switzer N, Delisle M, et al. Predicting venous thromboembolism following laparoscopic bariatric surgery: development of the BariClot tool using the MBSAQIP database. Surg Endosc. 2019;33:821–31.

    Article  Google Scholar 

  32. Stein PD, Beemath A, Olson RE. Obesity as a risk factor in venous thromboembolism. Am J Med. 2005;118:978–80.

    Article  Google Scholar 

  33. Ageno W, Becattini C, Brighton T, Selby R, Kamphuisen PW. Cardiovascular risk factors and venous thromboembolism: A meta-analysis. Circulation. 2008;117(1):93–102.

    Article  Google Scholar 

  34. Pannacciulli N, De Mitrio V, Marino R, Giorgino R, De Pergola G. Effect of glucose tolerance status on PAI-1 plasma levels in overweight and obese subjects. Obes Res. 2002;10(8):717–25.

    CAS  Article  Google Scholar 

  35. Juhan-Vague I, Alessi MC, Mavri A, Morange PE. Plasminogen activator inhibitor-1, inflammation, obesity, insulin resistance and vascular risk. J Thromb Haemost. 2003;1(7):1575–9.

    CAS  Article  Google Scholar 

  36. Zakai NA, McClure LA. Racial differences in venous thromboembolism. J Thromb Haemost. 2011;9:1877–82.

    CAS  Article  Google Scholar 

  37. Zakia NA, McClure LA, Judd SE, et al. Racial and regional differences in venous thromboembolism in the United States in 3 cohorts. Circulation. 2014;129(14):1502–9.

    Article  Google Scholar 

  38. Javanainen MH, Scheinin T, Mustonen H, Leivonen M. Retrospective analysis of 3 different antithrombotic prophylaxis regimens in bariatric surgery. Surg Obes Relat Dis. 2016;12(3):675–80.

    Article  Google Scholar 

  39. Borkgren-Okonek MJ, Hart RW, Pantano JE, Rantis PC Jr, Guske PJ, Kane JM Jr, Gordon N, Sambol NC. Enoxaparin thromboprophylaxis in gastric bypass patients: extended duration, dose stratification and antifactor Xa activity. Surg Obes Relat Dis. 2008;4(5):625–31.

    Article  Google Scholar 

  40. Clark LN, Helm M and Could Practice patterns regarding post-discharge chemoprophylaxis for venous thromboembolism following bariatric surgery in the United States. Surg Obes Relat Dis. 2019;15(3):703–707.

  41. Fennern EB, Farjah F, Chen YY, et al. Use of post-discharge heparin prophylaxis and the risk of venous thromboembolism and bleeding following bariatric surgery. Surg Endosc. 2020. https://doi.org/10.1007/s00464-020-08049-7.

    Article  PubMed  Google Scholar 

  42. Edwards MA, Mazzei M, Zhoa H, Reddy S, Bashir R. Racial disparities in inferior vena cava filter use in metabolic and bariatric surgery patients: Nationwide insights from the MBSAQIP database. Am J Surg. 2021;221(4):749–58.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Contributions

Dr. Michael A. Edwards was involved in the study concept, Dr. Michael Edwards acquired the data, Dr. Aaron Spaulding and Dr. Michael Edwards analyzed and interpreted the data and critically reviewed the manuscript, and Divya Muraleedharan drafted the manuscript.

Corresponding author

Correspondence to Michael A. Edwards.

Ethics declarations

Ethics Approval

This is an observational study using deidentified data from a national database. The Mayo Clinic Research Ethics Committee has confirmed that no ethical approval is required.

Competing Interests

The authors have no relevant financial or non-financial interests to disclose.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Appendix

Appendix

Table 6 Categories of reasons for mortality after bariatric surgery

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Edwards, M.A., Muraleedharan, D. & Spaulding, A. Racial disparities in reasons for mortality following bariatric surgery. J. Racial and Ethnic Health Disparities (2022). https://doi.org/10.1007/s40615-022-01242-5

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s40615-022-01242-5

Keywords

  • Bariatric
  • Mortality
  • Racial disparity