BACKGROUND: Individuals who undergo metabolic and bariatric surgery (MBS) are often encouraged to prioritize moderate-to-vigorous physical activity (MVPA) to improve outcomes. However, this approach overlooks other impor...BACKGROUND: Individuals who undergo metabolic and bariatric surgery (MBS) are often encouraged to prioritize moderate-to-vigorous physical activity (MVPA) to improve outcomes. However, this approach overlooks other important daily movement behaviors, including light-intensity physical activity, sedentary behaviors, and sleep. The 24-hour paradigm, which recognizes these behaviors as interdependent, guides research and practice in type 2 diabetes and cancer and may offer similar uses and benefits in the context of MBS. OBJECTIVES: (1) Review studies examining movement behaviors, individually or combined, in the context of MBS and clinical outcomes and (2) present rationale and recommendations for integrating the 24-hour movement paradigm into MBS research and practice. SETTING: International collaboration of MBS researchers, clinicians, and stakeholders. METHODS: A narrative review examined how MBS patients engage in movement behaviors beyond MVPA, how these behaviors may be associated with MBS outcomes, and interventions targeting them. This evidence was used to shape the rationale and recommendations for integrating the 24-hour movement paradigm into MBS research and practice. RESULTS: Few studies have examined the 24-hour movement behaviors, and none have explored their interactions. Similarly, few research interventions have targeted behaviors beyond MVPA in MBS patients. There is a clear need to determine how to effectively integrate the 24-hour movement paradigm into MBS practice to improve weight and health outcomes. Several suggestions are offered to help integrate this approach to enhance healthier 24-hour movement patterns. CONCLUSION: Integrating the 24-hour movement paradigm into MBS research and clinical care can yield a more complete view of how daily movement patterns affect clinical outcomes and guide personalized interventions that address all behaviors collectively rather than each one in isolation.
Previous studies reported that the rate of complications after abdominoplasty is higher in patients with a history of metabolic and bariatric surgery (MBS). The current study aims to compare the rate of complications aft...Previous studies reported that the rate of complications after abdominoplasty is higher in patients with a history of metabolic and bariatric surgery (MBS). The current study aims to compare the rate of complications after abdominoplasty in patients with and without a history of MBS and their risk factors in patients with a history of MBS. A systematic search was conducted to identify observational studies that compare postoperative complication rates after abdominoplasty in patients with and without a history of MBS up to 15 April 2025. Pooled odds ratios were computed to compare complication rates between groups, and additional analyses evaluated complication rates and risk factors among MBS. A total of 26 retrospective studies and one prospective study, involving 6328 patients with a history of MBS, were included in the current study. There were no significant differences in the rate of wound dehiscence, surgical site infection, skin necrosis, fat necrosis, deep venous thrombosis, and reoperation after abdominoplasty in patients with and without a history of MBS. In meta-regression analysis, lower body mass index at the time of abdominoplasty is associated with a higher risk of wound dehiscence. Although body contouring surgery after MBS was associated with a higher risk of seroma and hematoma compared to non-MBS cases, the rate of other complications was not significantly different.
BACKGROUND: Metabolic and bariatric surgery (MBS) is the most effective treatment for severe obesity, producing durable weight loss and improvement in obesity-related comorbidities. However, a subset of patients experien...BACKGROUND: Metabolic and bariatric surgery (MBS) is the most effective treatment for severe obesity, producing durable weight loss and improvement in obesity-related comorbidities. However, a subset of patients experience inadequate weight loss (non-response, NR) or weight recurrence (WR), which can lead to persistence or recurrence of metabolic disease, diminished quality of life, and warrants for further treatment interventions. OBJECTIVES: This review summarizes current treatment options for NR and WR after MBS, including surgical revisions, endoscopic therapies, and obesity modifying medications (OMMs). METHODS: A comprehensive literature review was performed, incorporating recent systematic reviews, meta-analyses, and retrospective series evaluating outcomes of revisional procedures, endoscopic approaches, and pharmacotherapy for patients with NR and WR following MBS. RESULTS: Revisional surgical options after Roux-en-Y gastric bypass (RYGB) include pouch revision, banding, distalization, and conversion to biliopancreatic diversion-duodenal switch or single anastomosis duodeno-ileostomy with sleeve gastrectomy (SADI-S). After sleeve gastrectomy, revisional strategies include re-sleeve, conversion to RYGB, SADI-S, or one-anastomosis gastric bypass. Endoscopic therapies such as transoral outlet reduction and argon plasma coagulation offer modest but clinically meaningful weight loss with low complication rates. OMMs, particularly glucagon-like peptide-1 (GLP-1) receptor agonists (semaglutide) and dual gastrointestinal peptide/GLP-1 receptor agonists (tirzepatide), have demonstrated weight loss in post-MBS patients. Across all modalities, variability in outcomes and high loss to follow-up limit data quality. CONCLUSIONS: NR and WR after MBS require individualized, multidisciplinary management on a case-by-case basis. Surgical, endoscopic, and pharmacologic options all play important roles, and emerging OMMs represent a major advance. Standardized outcome reporting and prospective studies are needed to refine treatment algorithms.
BACKGROUND: Bariatric surgery produces substantial weight loss through metabolic and hormonal mechanisms, but how sleeve gastrectomy (SG) and one anastomosis gastric bypass (OAGB) differentially affect body composition r...BACKGROUND: Bariatric surgery produces substantial weight loss through metabolic and hormonal mechanisms, but how sleeve gastrectomy (SG) and one anastomosis gastric bypass (OAGB) differentially affect body composition remains unclear. Most studies rely on bioelectrical impedance analysis, which has recognized limitations in morbid obesity. The deuterium oxide (DO) dilution method provides more accurate assessment yet has rarely been applied in this population. OBJECTIVES: To compare 6-month body composition changes measured by the DO dilution method between adults undergoing SG and OAGB and to identify predictors of postoperative fat reduction. SETTING: A tertiary academic medical center, Taiwan. METHODS: This observational longitudinal study included adults with morbid obesity who received SG or OAGB. Of 79 patients enrolled, 68 completed 6-month follow-up, including 30 SGs and 38 OAGBs. Body composition was measured using the DO dilution method. RESULTS: At 6 months, body mass index decreased by 11.25 ± 4.04 kg/m, corresponding to total weight loss of 25.04 ± 6.83%, excess weight loss of 61.09 ± 19.10%, and a 22.82 ± 19.79% reduction in percent body fat. No significant difference in fat reduction was observed between procedures. Patients with diabetes had greater fat reduction. Diabetes history and body mass index change were independent predictors of fat reduction. CONCLUSIONS: Both SG and OAGB produced comparable weight loss and change in body composition at 6 months. Diabetes status was an important modifier of postoperative fat reduction, supporting the metabolic benefits of bariatric surgery.
BACKGROUND: Internal herniation is a serious complication after Roux-en-Y gastric bypass (RYGB). Diagnosis is challenging due to nonspecific clinical findings, heterogeneous computed tomography (CT)-based predictive mode...BACKGROUND: Internal herniation is a serious complication after Roux-en-Y gastric bypass (RYGB). Diagnosis is challenging due to nonspecific clinical findings, heterogeneous computed tomography (CT)-based predictive models, and lack of consensus on the optimal diagnostic strategy. Although diagnostic laparoscopic surgery (DLS) is considered the reference standard, it frequently results in negative explorations. OBJECTIVES: To identify predictive clinical parameters and CT signs for internal herniation in post-RYGB patients presenting with abdominal pain, and to evaluate the clinical decision-making process leading to DLS. SETTING: Emergency department of a high-volume nonacademic teaching hospital with a dedicated bariatric center in the Netherlands. METHODS: This prospective diagnostic accuracy study included all adults presenting with acute abdominal pain more than 30 days post-RYGB between March 2023 and June 2024. Standardized clinical, laboratory, and CT assessments were performed. A bariatric surgeon assigned a clinical suspicion score (CSS) and a dedicated radiologist a radiological suspicion score (RSS). Patient management followed a predefined protocol. Predictors were analyzed using Least Absolute Shrinkage and Selection Operator regression. RESULTS: In total, 125 patients were included. DLS was performed in 84 patients (67%), confirming internal herniation in 30 (36%). CSS was not associated with internal herniation, whereas a higher RSS was strongly associated with its presence (P < .001). Venous congestion, swirl sign, and mushroom sign were identified as independent predictors. CONCLUSION: Clinical assessment alone has limited reliability in guiding decision-making regarding DLS in post-RYGB patients with abdominal pain. Structured CT assessment by a dedicated abdominal radiologist is the most accurate diagnostic tool and should be performed in all such patients.
BACKGROUND: Bariatric surgery is an effective treatment for obesity. However, the degree of postoperative weight loss can vary greatly between patients, and the rationale behind such disparity remains unclear. Recent stu...BACKGROUND: Bariatric surgery is an effective treatment for obesity. However, the degree of postoperative weight loss can vary greatly between patients, and the rationale behind such disparity remains unclear. Recent studies have suggested that genetics can influence the response to bariatric surgery, but little is known about the role of microRNAs (miRNAs) in this setting. OBJECTIVES: To identify miRNA candidates that predict weight loss after bariatric surgery. SETTING: Academic medical center. METHODS: RNA was isolated from patients' blood collected at initial preoperative consult visits for bariatric surgery (laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy). Percentage of excess body mass index loss at 1-year follow-up was calculated to separate patients into 2 groups: high weight loss (HWL) and low weight loss (LWL). Twenty samples from each group were subjected to small RNA sequencing on an Illumina platform. Differential expression and downstream analyses were performed. RESULTS: HWL and LWL groups had similar baseline demographics and makeup of operative procedures. In total, 5666 unique miRNAs were detected, of which only 3 exhibited significant differential expression: miR-1914-3p (P = 4.9 × 10), miR-664b-5p (P = 1.7 × 10), and miR-370-3p (P = 1.7 × 10). Downstream analyses revealed several potential genetic targets and enrichment for cellular metabolism and adipocyte differentiation pathways. CONCLUSIONS: Small RNA sequencing revealed 3 candidate miRNAs with differential expression between weight loss groups that may be predictive of outcomes in patients after bariatric surgery. These findings contribute to the development of preoperative algorithms that further personalize obesity treatment decisions.
BACKGROUND: One-anastomosis gastric bypass (OAGB) has been proposed as a viable alternative to standard bariatric surgical interventions such as sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). Due to one few...BACKGROUND: One-anastomosis gastric bypass (OAGB) has been proposed as a viable alternative to standard bariatric surgical interventions such as sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). Due to one fewer anastomosis, OAGB is perceived to reduce risk and require less operative time compared to RYGB. OBJECTIVE: We aimed to evaluate the 30-day outcomes of OAGB compared to SG and RYGB. SETTING: 2020-2023 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. METHODS: We analyzed patients who underwent primary SG, RYBG, and OAGB. Using propensity score matching (PSM) analysis, the cohorts were matched for 23 preoperative characteristics. We then compared 30-day postoperative outcomes between OAGB versus SG and OAGB versus RYGB. RESULTS: We analyzed 500,477 SG; 190,813 RYGB; and 3607 OAGB. The matched cohorts comparing SG versus OAGB and RYGB versus OAGB had similar preoperative characteristics. PSM outcomes of OAGB versus SG showed OAGB was associated with higher rates of interventions (.9% vs. .4%), reoperations (1.2% vs. .5%), and emergency visits (10.6% vs. 7.4%) (all P < .050). PSM outcomes comparing OAGB versus RYGB showed that OAGB patients had shorter length of stay (1.29 ± .93 vs. 1.49 ± 1.18), as well as lower rates of unplanned intensive care unit admissions (.3% vs .7%), readmissions (2.4% vs. 4.9%), blood transfusions (.2% vs. .8%), interventions (.9% vs 1.5%), nonhome discharge (.1% vs .3%), postoperative bleeding (.2% vs .8%), and intestinal obstruction (.2% vs 1.0%), compared to RYGB (all P < .050). CONCLUSION: While OAGB is a more complex surgery than SG and requires more emergency visits, reoperations, and interventions, it is a safe and feasible alternative to RYGB, with fewer adverse short-term outcomes than RYGB.
BACKGROUND: Preoperative weight loss is often recommended before metabolic and bariatric surgery, although its impact on postoperative outcomes, particularly in high body mass index (BMI) patients (e.g., 50.0-59.9, ≥60),...BACKGROUND: Preoperative weight loss is often recommended before metabolic and bariatric surgery, although its impact on postoperative outcomes, particularly in high body mass index (BMI) patients (e.g., 50.0-59.9, ≥60), is not fully established. OBJECTIVE: To test the hypothesis that preoperative body mass index reduction (PBR) is associated with improved postoperative outcomes. SETTING: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, 2015-2023. METHODS: A total of 1,795,127 records were examined, and primary cases were selected while excluding emergencies, revisions, conversions, cases with incomplete data, and preoperative BMI <30 kg/m. PBR was expressed as a percentage of the highest preoperative BMI. No BMI loss, <10% loss, and ≥10% loss categories were arbitrarily analyzed. Regression analysis was used to analyze outcomes, including prolonged length of stay (>5 days), serious complications, and readmissions. RESULTS: Among 1,316,050 cases, close to 83% achieved PBR and 6.5% achieved ≥10% PBR. Across all starting BMI, PBR was associated with a lower risk of prolonged length of stay (>5 days). Additionally, for BMI ≥60, there was a significant reduction in serious complications with <10% PBR. Similar trends persisted for >10% PBR for serious complications and readmissions. CONCLUSIONS: PBR has selective benefits for high-BMI metabolic and bariatric surgery patients. Although complications overall are uncommon, PBR's effect on the risk of these outcomes varies. Focused studies examining well-controlled groups are needed to better understand the potential differences in PBR across the BMI spectrum.
BACKGROUND: Refractory late and chronic leaks or fistulas after sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) represent a major therapeutic challenge, particularly after failure of conventional endoscopic o...BACKGROUND: Refractory late and chronic leaks or fistulas after sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) represent a major therapeutic challenge, particularly after failure of conventional endoscopic or combined approaches. Endoscopic septotomy with argon plasma coagulation (ES-APC) restores internal drainage by eliminating the septum separating the perigastric cavity or fistulous tract from the gastric lumen. OBJECTIVES: This study evaluated the efficacy and safety of a standardized ES-APC technique. SETTING: Unité d'Endoscopie Interventionnelle, Hôpital Privé des Peupliers, Paris, France. METHODS: This retrospective analysis of prospectively collected data included consecutive adult patients with refractory late or chronic postbariatric leaks or fistulas treated with ES-APC between September 2019 and August 2025 at a tertiary referral center. ES-APC consisted of stepwise septal ablation using standardized APC settings to achieve wide cavity-lumen communication, followed by systematic placement of a through-the-scope metallic clip to promote ischemic completion and reduce bleeding or perforation risk. The primary outcomes were technical success (TS) and clinical success (CS); the secondary outcomes included recurrence, adverse events (AEs), and long-term durability. RESULTS: Sixty-four patients were included (76.6% female; mean age 40.8 6 11.2 years), predominantly after SG (95.3%). At septotomy, 25% of defects were classified as late and 75% as chronic according to the Rosenthal classification. Patients had undergone a median of 4 prior treatments (interquartile range [IQR]: 3-5). A median of one ES-APC session (IQR: 1-2) was required, with a median procedural time of 15 minutes (IQR: 12-22). TS was achieved in all cases (100%). CS was obtained in 93.7% (60/64), with one recurrence (1.7%) successfully managed endoscopically. CS was significantly lower in patients with gastrocutaneous fistula (86.7% versus 100%, P = .04). No major endoscopy-related AEs were observed. Durable clinical resolution was confirmed after a median follow-up of 44 months. CONCLUSIONS: ES-APC is a safe, standardized, and highly effective minimally invasive technique for refractory late and chronic postbariatric leaks and fistulas, offering durable healing while limiting the need for high-risk surgical revision.
BACKGROUND: Roux-en-Y gastric bypass (RYGB) is the preferred revisional procedure for the resolution of gastroesophageal reflux disease (GERD) following sleeve gastrectomy (SG). Although several studies have demonstrated...BACKGROUND: Roux-en-Y gastric bypass (RYGB) is the preferred revisional procedure for the resolution of gastroesophageal reflux disease (GERD) following sleeve gastrectomy (SG). Although several studies have demonstrated effective reflux resolution after conversion to RYGB, a subset of patients continues to experience persistent symptoms. Data specifically addressing factors associated with refractory reflux after conversion remain limited. OBJECTIVES: The primary aim of this study is to identify factors associated with persistent reflux symptoms following conversion from SG to RYGB. SETTING: University hospital. METHODS: A retrospective review was conducted of patients who underwent conversion from SG to RYGB at our institution between 2013 and 2024. Patient records were reviewed to assess reflux-related symptoms, proton pump inhibitor (PPI) use, and weight-related outcomes. Univariate and multivariate regression analyses were performed to identify factors associated with persistent postoperative reflux. RESULTS: A total of 109 patients were included. Preoperative endoscopy identified esophagitis in 45.9% and sleeve anatomical abnormalities (angulation or stricture) in 17.4%. At baseline, 80% of patients used daily PPI therapy, including 43.5% on twice-daily dosing. After conversion, reflux symptoms resolved and PPI therapy was discontinued in 75.5% of patients, whereas 24.5% had persistent symptoms requiring maximum-dose PPI at last follow-up. On univariate analysis, sleeve angulation (odds ratio [OR] = 7.7), pre-SG GERD (OR = 2.7), preoperative dysphagia (OR = 3.9), and twice-daily PPI use (OR = 2.6) were associated with persistent reflux, whereas conversion for weight regain (OR = .27) was protective. Sleeve angulation remained independently associated with persistent reflux on multivariate analysis (adjusted OR = 6.2). CONCLUSION: Persistent reflux following conversion from SG to RYGB remains clinically significant. Comprehensive preoperative assessment is essential to identify patients at increased risk for persistent symptoms and to optimize patient selection and counseling.
Pelvic floor dysfunction (PFD), including urinary incontinence (UI), pelvic organ prolapse (POP), and fecal incontinence (FI), is highly prevalent among women and strongly linked to obesity. Given the mechanical and phys...Pelvic floor dysfunction (PFD), including urinary incontinence (UI), pelvic organ prolapse (POP), and fecal incontinence (FI), is highly prevalent among women and strongly linked to obesity. Given the mechanical and physiological effects of excess weight on pelvic floor support, weight loss via bariatric surgery may improve PFD symptoms. This systematic review and meta-analysis aimed to evaluate the impact of bariatric surgery on PFD outcomes, based on 32 prospective studies encompassing 5299 patients. Following surgery, the mean body mass index decreased by 12.26 kg/m. UI prevalence declined by 50%, with significant improvements in both stress and urge UI. POP symptoms also significantly improved, while FI outcomes remained unchanged. Quality of life measures such as Pelvic Floor Distress Inventory-20, Incontinence Questionnaire-Short Form, and Pelvic Floor Impact Questionnaire-7 showed notable improvement, though no significant change was observed in PISQ-12 scores. These findings underscore the beneficial effects of bariatric surgery on urinary and prolapse symptoms, supporting its role in the multidisciplinary management of obesity-related PFD.
BACKGROUND: Factors influencing fetal growth after metabolic bariatric surgery remain to be clarified. OBJECTIVES: To evaluate the relationships between birth weight (BW) and maternal nutritional and metabolic parameters...BACKGROUND: Factors influencing fetal growth after metabolic bariatric surgery remain to be clarified. OBJECTIVES: To evaluate the relationships between birth weight (BW) and maternal nutritional and metabolic parameters after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). SETTING: University Hospital, France. METHODS: Women with a singleton pregnancy who underwent at least one second-trimester nutritional assessment at our institution between 2006 and 2022 were included. Associations between maternal parameters and BW adjusted for sex and gestational age (Z-score) were studied. RESULTS: A total of 155 pregnancies were studied, 71 after RYGB and 84 after SG. Although postoperative weight loss was greater after RYGB, maternal characteristics before pregnancy were comparable. The number of nutritional deficiencies was similar but women after RYGB took more nutritional supplements, while gestational weight gain was greater after SG. Mean BW (3095 ± 628 g versus 3184 ± 516 g) and the proportion of small-for-gestational-age (SGA) newborns (24% versus 21%) were similar between procedures. No association was observed between nutritional deficits and BW. After RYGB, serum iron parameters were negatively correlated with BW Z-score, while fasting glucose and insulin concentrations were positively correlated (P < .01). No significant associations were identified after SG. CONCLUSIONS: Despite a similar risk of SGA, the maternal determinants of BW differ between RYGB and SG. Metabolic parameters appear to be involved after RYGB but not after SG, whereas nutritional deficiencies do not seem to be associated with BW. Additional maternal factors, particularly after SG, should be investigated to explain the increased risk of SGA.
Metabolic dysfunction-associated fatty liver disease (MAFLD) is increasingly common among candidates for metabolic and bariatric surgery, yet clinical thresholds defining when surgery is beneficial or contraindicated rem...Metabolic dysfunction-associated fatty liver disease (MAFLD) is increasingly common among candidates for metabolic and bariatric surgery, yet clinical thresholds defining when surgery is beneficial or contraindicated remain unclear. This systematic review and meta-analysis synthesized evidence from 29 studies including 71,904 patients with biopsy-confirmed or elastography-confirmed MAFLD undergoing sleeve gastrectomy, Roux-en-Y gastric bypass, or other metabolic procedures. Bariatric surgery was associated with marked hepatic and endocrine improvement, with pooled remission rates of 70% for steatohepatitis, 57% for fibrosis, and 59% for type 2 diabetes. Both sleeve gastrectomy and Roux-en-Y gastric bypass achieved comparable metabolic and hepatic benefits, supporting the role of weight-independent mechanisms such as enhanced incretin signaling and improved insulin sensitivity. Postoperative complications occurred in 15% of patients, including 4% major complications, indicating an overall acceptable safety profile. Across studies, patients with compensated cirrhosis experienced meaningful hepatic improvement, whereas those with decompensated cirrhosis, clinically significant portal hypertension, or impaired hepatic reserve had higher morbidity and limited benefit. Endocrine instability-particularly poorly controlled endocrine disease (e.g., uncontrolled diabetes or untreated thyroid dysfunction)-also emerged as a relative contraindication due to impaired healing and unpredictable metabolic responses. These findings underscore the need for careful preoperative evaluation integrating liver staging, endocrine profiling, and metabolic capacity. Overall, bariatric surgery provides substantial hepatic and endocrine benefits for appropriately selected MAFLD patients, while advanced cirrhosis and uncontrolled endocrine disease represent key thresholds at which surgical risk may outweigh benefit. A multidisciplinary liver-endocrine approach is essential for optimal candidate selection and postoperative outcomes.
BACKGROUND: The implementation of robotic Roux-en-Y gastric bypass (R-RYGB) has been met with tremendous enthusiasm over the last decade. Yet, despite the rapidly increasing adoption of robotic delivery, remarkably littl...BACKGROUND: The implementation of robotic Roux-en-Y gastric bypass (R-RYGB) has been met with tremendous enthusiasm over the last decade. Yet, despite the rapidly increasing adoption of robotic delivery, remarkably little is known about the impact of modern R-RYGB on short-term morbidity and mortality. OBJECTIVES: The objective of this study was to characterize and evaluate differences in 30-day morbidity and mortality between patients receiving elective RYGB cases through either laparoscopic or robotic approaches in 2023. SETTING: All participating Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) centers entering data in the most recent 2023 operative year. METHODS: A retrospective analysis of the 2023 MBSAQIP database was performed by identifying all elective primary laparoscopic (L-RYGB) and robotic RYGB cases. Bivariate analysis was conducted using either χ tests or Wilcoxon rank sum tests as appropriate. Multivariable logistic regression analysis was then used to identify independent predictors of morbidity and mortality. RESULTS: A total of 50,365 patients underwent RYGB, of whom 19,553 (38.8%) received R-RYGB. There were no clinically relevant differences with respect to age (44.6 ± 11.6 R-RYGB versus 44.4 ± 11.5 L-RYGB; P = .05), body mass index (45.6 ± 7.8 R-RYGB versus 45.3 ± 7.5 L-RYGB; P < .0001), or female sex (83.1% R-RYGB versus 83.3% L-RYGB; P = .6) between cohorts. R-RYGB patients were more likely to have reflux (46.4% versus 41.6%; P < .0001), undergo concurrent paraesophageal hernia repair (19.4% versus 15.8%; P < .0001), and have increased operative length (139.7 ± 55.5 min versus 115.2 ± 53.7 min; P < .0001). L-RYGB patients had higher rates of bleeding (1.5% versus 1.2%; P = .001), whereas R-RYGB patients had higher 30-day rates of readmission (5.3% versus 4.3%; P < .0001), cardiac events (.2% versus .1%; P = .005), and mortality (.14% versus .07%; P = .02%). After adjusting for patient and technical factors, robotic delivery was independently associated with increased mortality (odds ratio: 2.10; 95% confidence interval: 1.11-3.96; P = .02). CONCLUSION: In 2023, robotic RYGB comprised only 39% of elective cases yet over one half of all deaths occurring within 30 days. Multivariable regression demonstrated a 2-fold increased mortality associated with robotic delivery. Caution should be employed as robotic approaches become increasingly adopted with emphasis made on training standardization and center accreditation.