What is the clinical evidence from this study?

Study design: Observational. Population: Obesity undergoing metabolic surgery (n=75871). Intervention: BMI ≥ 40 kg/m2 without severe systemic disease vs. BMI < 40 kg/m2 with severe systemic disease. Primary outcome: Complicated course (any complication) (OR 1.72, 95% CI 1.43-2.08, p=<0.001).

July 29, 2025Obesity Surgery2 citationsOpen Access

The Role of the BMI ≥ 40 kg/m2 Criterium in ASA-PS Classification for Metabolic Surgery

Q: What are the key findings of this study?

Patients with a BMI ≥ 40 kg/m2 without severe systemic disease were significantly less likely to experience complications after metabolic surgery compared to those with a BMI < 40 kg/m2 and severe systemic disease (OR 1.72).

EEElisabeth S. van Ede SNSimon W. Nienhuijs MBMarc P. Buise

Key Result

Patients with a BMI ≥ 40 kg/m2 without severe systemic disease were significantly less likely to experience complications after metabolic surgery compared to those with a BMI < 40 kg/m2 and severe systemic disease (OR 1.72).

Study Design

Type

Observational (n=75,871)

Multicenter

Yes

Structured PICO

Does an ASA-PS III classification based solely on BMI ≥ 40 kg/m2 accurately reflect peri-operative risk compared to severe systemic disease in patients undergoing metabolic surgery?

Population

28,597 adult patients undergoing primary or first of two-stage metabolic surgery (Roux-en-Y gastric bypass or sleeve gastrectomy) in the Netherlands between 2018 and 2023, assigned an ASA-PS III score.

Intervention

ASA-PS III classification based solely on BMI ≥ 40 kg/m2 without severe systemic disease

Comparator

ASA-PS III classification based on BMI < 40 kg/m2 with the presence of severe systemic comorbid conditions

Outcome

Complication prevalence (peri-operative, ≤ 30 days and > 30 days), Clavien-Dindo score, hospital stay (> 2 days), ICU admission, readmission, and mortality ratessafety

Patients assigned ASA-PS III solely due to a BMI ≥ 40 kg/m2 have significantly fewer peri-operative complications than those assigned ASA-PS III due to severe systemic disease, suggesting the BMI criterion overestimates surgical risk in metabolic surgery.

Main Result

Effect estimate: OR 1.72 (95% CI 1.43-2.08)

Absolute Event Rate: 5.45% vs 8.74%

p-value: p=<0.001

Limitations

Retrospective data collection dependent on diagnosis codes that were not always distinctive in severity
Lack of data regarding smoking status or alcohol use
Possibility of missing data, inconsistencies between centers, and potential coding errors
Opt-out nature of the registry could introduce selection bias
Lack of multilevel analysis for cases with multiple complication registrations

Abstract

BACKGROUND: effectively contributes to peri-operative risk stratification for patients undergoing metabolic surgery. METHODS: Adult patients (January 2015-January 2023) were included from the Dutch Audit for the Treatment of Obesity registry. Logistic regression adjusted for confounders compared groups stratified by BMI and presence of systemic disease. OUTCOME MEASURES: complication prevalence (peri-operative, ≤ 30 days and > 30 days), Clavien-Dindo score, hospital stay (> 2 days), ICU admission, readmission, and mortality rates. RESULTS: ) (OR: 1.72, 95% CI: 1.43-2.08, p < 0.001). CONCLUSIONS: and severe systemic disease. This suggests that adhering to the BMI criterion may undermine the ASA-PS classification's effectiveness in risk stratifying these patients.

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