Shanu N. Kothari, MD, FACS
Harlan H. Stone Chairman of Surgery, Prisma Health, Greenville, South Carolina
EDITORIAL
Editor's note: This editorial was approved for publication by a vote of the MBS Digest editorial board (a majority of its voting editors). Dr. Kothari is the Editor-in-Chief of MBS Digest and did not vote. The views expressed are the author's.
Disclosure: Dr. Kothari reports consulting for Medtronic, an investor/advisor role with Minerra Health, and his role as Editor-in-Chief of MBS Digest (per the MBS Digest Disclosure Repository).
Despite decades of evidence supporting its effectiveness and safety, metabolic bariatric surgery continues to struggle against a persistent public perception that it is a high-risk operation. The reality is quite different. Modern metabolic bariatric surgery has become one of the safest major abdominal procedures performed today, with mortality rates that compare favorably with, and often outperform, many commonly accepted general surgical operations.
Contemporary data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), encompassing hundreds of thousands of patients annually, demonstrate 30-day mortality rates as low as 0.06% to 0.1% for the average bariatric surgery patient.[1] Even among higher-risk populations, mortality remains remarkably low.
By comparison, ventral hernia repair, a procedure generally viewed by patients and referring providers as routine and low risk, has reported mortality rates ranging from approximately 0.2% for elective repairs to 0.5% or higher in large national datasets, with substantially higher rates among complex and emergency cases.[2] In analyses of inpatient open ventral hernia repair, overall mortality has been reported at 1.34%, with high-risk patients experiencing mortality rates approaching 9% or greater.[3]
The paradox is striking. Many patients who would readily accept ventral hernia repair remain fearful of metabolic bariatric surgery, despite evidence suggesting that it often carries an equal or lower risk of death. The perception remains anchored in outcomes from decades ago, before the widespread adoption of minimally invasive techniques, accreditation standards, enhanced recovery pathways, and rigorous quality reporting.
This disconnect has real consequences. Obesity is associated with increased mortality, cardiovascular disease, diabetes, cancer, and diminished quality of life. When patients overestimate the risks of bariatric surgery, they may forgo one of the most effective treatments available for a chronic, progressive disease. Metabolic bariatric surgery not only improves comorbid conditions but has repeatedly been shown to extend life expectancy and reduce long-term mortality.
The challenge facing the bariatric community today is not proving the operation is safe. The data have already settled that debate. The challenge is communicating those results to patients, primary care providers, policymakers, and the public. We should leverage our relationships with our industry partners, as well as sponsoring societies to develop a unified message on this topic. Until we successfully bridge that gap, metabolic bariatric surgery will continue to be judged by outdated perceptions rather than contemporary evidence, and too many patients will miss the opportunity to benefit from one of the safest and most impactful operations in modern surgery.
Shanu N. Kothari, MD, FACS
References
1. Hampton L, Mocanu V, Verhoeff K, Birch DW, Karmali S, Switzer NJ. Asian race is not associated with increased 30-day serious complications or mortality: a MBSAQIP analysis of 594,837 patients. Surg Endosc. 2023;37(5):3893–3900. doi:10.1007/s00464-023-09898-8.
2. Lindmark M, Löwenmark T, Strigård K, Gunnarsson U. Major complications and mortality after ventral hernia repair: an eleven-year Swedish nationwide cohort study. BMC Surg. 2022;22(1):426. doi:10.1186/s12893-022-01873-9.
3. Basta MN, Fischer JP, Wink JD, Kovach SJ. Mortality after inpatient open ventral hernia repair: developing a risk stratification tool based on 55,760 operations. Am J Surg. 2015;211(6):1047–1057. doi:10.1016/j.amjsurg.2015.03.009.
