Background: Bariatric surgery can improve health outcomes but high-quality comparative evidence about different procedures is limited. Objective: To compare the effectiveness and cost-effectiveness of Roux-en-Y gastric bypass (Bypass), adjustable gastric banding (Band) and sleeve gastrectomy (Sleeve) for people living with severe obesity. Design, setting and participants: Multicentre, parallel-group, randomised controlled trial conducted in 12 National Health Service hospitals. Adults with a body mass index >= 35 kg/m2 with comorbidity or body mass index >= 40 kg/m2 without comorbidity were eligible. Participants were initially randomised 1 : 1 to Bypass or Band. After 32 months of recruitment, the trial was adapted to include Sleeve, and participants were randomised to Bypass, Band or Sleeve thereafter. Participants were followed up for 3 years. Interventions: Bypass, Band and Sleeve surgery. Main outcome measures: Primary outcomes were self-reported quality of life (EQ-5D-5L utility score) and weight (at least 50% excess weight lost) at 3 years. Sleeve and Bypass were each considered superior to Band if there was non-inferior excess weight loss (< 12% difference between groups) and superior quality of life. Sleeve was considered superior to Bypass by the same criteria. Secondary outcomes included comorbidities, adverse health events, generic and disease-specific quality of life at 6, 12, 24 and 36 months post randomisation, dietary intake, binge eating behaviour and cost-effectiveness. Results: One thousand three hundred and fifty-one participants were randomised between December 2012 and September 2019. Five participants withdrew consent to use their data, leaving 1346 (462 Bypass, 464 Band, 420 Sleeve). The mean age was 47.3 years, 1020 (75.9%) were women and the mean weight and body mass index was 129.7 kg and 46.4 kg/m(2), respectively. Overall, 1183 (87.5%) of participants underwent surgery within 3 years, with a median waiting time of 5 months (interquartile range 2.5-10.1 months). At least 50% excess weight loss at 3 years was achieved for 276/405 (68.1%) participants randomised to Bypass, 97/383 (25.3%) randomised to Band and 142/342 (41.5%) randomised to Sleeve [adjusted risk difference (Bypass-Band) + 40.7%, 98% confidence interval (+ 33.9% to + 47.5%); (Sleeve-Band) + 14.7% (+ 5.2% to + 24.2%), (Sleeve-Bypass)-26.0% (-35.8% to-16.3%)]. Mean EQ-5D scores at 3 years were 0.72 (standard deviation 0.29), 0.62 (0.33) and 0.68 (0.30) for participants randomised to Bypass, Band and Sleeve, respectively [adjusted mean difference (Bypass-Band) + 0.079 (+ 0.040 to + 0.117), (Sleeve-Band) + 0.045 (+ 0.006 to + 0.085), (Sleeve-Bypass)-0.033 (-0.072 to + 0.006)]. Secondary outcomes showed similar trends. The adverse event rate was highest in the Band group and lowest with Sleeve. Bypass was the most cost-effective procedure, with probabilities < 0.3 that Sleeve or Band was the most cost-effective. Limitations: The study was impacted by the COVID-19 pandemic which prevented some participants having surgery and/or attending hospital for study follow-up appointments, which impacted on the completeness of data for these visits. Conclusions: Bypass and Sleeve are more effective than Band. Sleeve has inferior excess weight loss and lower mean quality-of-life score than Bypass.

The prevalence of revision and conversion metabolic bariatric surgery (MBS) has increased alongside the growing number of primary Roux-en-Y gastric bypass (RYGB) procedures performed worldwide. Common indications for revision or conversion after RYGB include weight recurrence (WR), suboptimal clinical response (SoCR), and late postoperative complications such as internal hernia, marginal ulcers, malnutrition, dumping syndrome, and post-bariatric hypoglycemia. However, high-quality comparative evidence remains limited, and no international consensus exists regarding optimal management strategies. This study aimed to evaluate current international practices and expert opinions on revision and conversion surgery after RYGB through a global expert survey. This international online binary survey comprised 61 questions and was conducted via SurveyMonkey™ between November 14 and December 10, 2025. A total of 188 specialists participated (75.2% of invitees), with 184 completing the questionnaire (98% completion rate). Item-specific response rates ranged from 177 to 187. The survey demonstrated broad international agreement that WR and SoCR are multifactorial conditions requiring individualized, multidisciplinary management. Endoscopic approaches were generally favored as first-line options in selected patients with anatomical dilation, whereas hypoabsorptive procedures (distal RYGB, SADI-S, BPD-DS) were considered more effective for long-term weight loss and metabolic outcomes. High agreement (> 90%) was observed for multidisciplinary follow-up, individualized procedure selection, lifelong nutritional surveillance, and management of several late complications. Important areas of controversy remain. These findings provide preliminary insights that may support future standardized definitions, clinical pathways, and evidence-based guidelines.

Endoscopic bariatric therapies, including endoscopic sleeve gastroplasty (ESG) and intragastric balloon (IGB), are emerging as less invasive alternatives to bariatric surgery. However, their economic value relative to established treatments such as bariatric surgery and pharmacotherapy remains uncertain. This study evaluated the cost-effectiveness of endoscopic bariatric therapies compared with surgery and semaglutide from a UK health system perspective. Three state-transition Markov models compared: (1) ESG versus laparoscopic sleeve gastrectomy (LSG), (2) ESG versus semaglutide, and (3) IGB versus semaglutide. The models simulated transitions between body mass index (BMI)-defined health states over a 5-year time horizon using treatment effectiveness data derived from published studies and expert input. Outcomes were expressed as quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) from the UK National Health Service perspective. Deterministic and probabilistic sensitivity analyses explored uncertainty. For patients with class II-III obesity, LSG was cost-effective compared with ESG (£10,593/QALY). For class I and II obesity, ESG generated modestly greater QALYs than semaglutide at slightly higher cost (ICER £7,267/QALY). Semaglutide was dominant compared with IGB, producing greater health gains at lower cost. Results were most sensitive to intervention costs and assumptions regarding long-term recurrent weight gain. Endoscopic bariatric therapies may represent a cost-effective option for obesity management depending on patient characteristics and comparator treatments. LSG remains the most cost-effective intervention for severe obesity, whereas ESG may offer a cost-effective alternative to pharmacotherapy for patients with lower BMI. LSG was cost-effective compared with ESG for class II-III obesity. ESG was cost-effective vs. semaglutide for class I-II obesity. Semaglutide dominated intragastric balloon therapy. Endoscopic therapies may bridge drugs and bariatric surgery.

Data on multinational 90-day mortality and morbidity rates after surgery for gastric cancer is limited in the literature. This study aimed to understand the 90-day mortality and morbidity outcomes among patients undergoing elective gastric cancer surgery, as in the GASTRODATA Registry, and to identify associated risk factors. We conducted an international prospective study on patients aged ≥ 18 years undergoing elective surgery for gastric cancer with curative intent from January 4 to September 30, 2022. Known metastatic disease, concurrent secondary cancers, gastrointestinal stromal tumour (GIST) and Siewert type I/II oesophagogastric junction malignancies were excluded. Univariate and multivariate logistic regression were used to identify variables associated with the 90-day outcome. 380 collaborators from 47 countries submitted data on 1538 patients. Median age was 65 years (IQR: 19–94), and 58.5

Metabolic and bariatric surgery (MBS) has been an established treatment option for patients with Type 2 diabetes mellitus (T2DM), but there is a relative paucity of evidence-based guidelines on preoperative, operative, and postoperative considerations concerning metabolic surgery for T2DM patients. To address this gap, we initiated a Delphi consensus process with a diverse group of international multidisciplinary experts. We embarked on a Delphi consensus-building exercise to propose an evidence-based expert consensus covering various aspects of MBS in patients with T2DM. We defined the scope of the exercise and proposed statements and surveyed the literature through electronic databases. The literature summary and voting process were conducted by 52 experts, who evaluated 44 statements. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Consensus, defined as > 80

Bariatric surgery is associated with low but definite early and late mortality. This study aims to further understand early (≤ 90 days) and delayed (> 90 days) mortality related to bariatric surgery. This is a retrospective collaborative audit of patients who had undergone bariatric surgery and developed complications that ultimately led to death. Individuals who were 18 years or older and had undergone bariatric surgery (primary, revisional, and endoscopic procedures) and subsequently died within 90 days or after 90 days following the surgery between 1 January 2022, and 31 December 2022. A descriptive analysis was conducted. About 30 centres from 21 countries submitted data on 82 patients where patient death was deemed to be related to bariatric surgery. Mortality within 90 days post-surgery was observed in 58 individuals (70.7%), while 24 patients (29.3%) died after this period. Causes of mortality after SG include GI leak, PE, respiratory infection, and malnutrition. Causes of mortality after RYGB include GI leak, coronary heart disease, and bleeding. Reported common causes of early mortality in this study were gastrointestinal leaks, bleeding, coronary heart disease, and pulmonary embolism. Reported common causes of delayed mortality were gastrointestinal leaks and malnutrition. This study characterises patients where death was attributed to a bariatric procedure and identifies common causes of death in these patients. This could aid development of strategies for preventing and managing these complications in the future.

BackgroundWith over 1 billion individuals affected globally, obesity and obesity related diseases is now a leading cause of death. Metabolic and bariatric surgery (MBS) has emerged as a cornerstone intervention for severe obesity and its associated comorbidities. Despite its efficacy, postoperative care and follow-up after MBS remains highly variable worldwide.ObjectiveThe PARTNER study aimed to evaluate global clinical practices in the postoperative management following MBS by surveying multidisciplinary healthcare professionals.MethodsThis study was an international online survey conducted between October 2024 and January 2025. A multidisciplinary team developed the questionnaire based on existing literature and international guidelines. The survey assessed five domains: follow-up care, postoperative treatment, dietary management, patient support, and measurement of surgical outcomes. Responses were analysed descriptively.ResultsA total of 262 responses were received from 62 countries. Most respondents were bariatric surgeons (72.1%) working in public healthcare systems (73.3%). While 78.7% reported conducting three-month postoperative reviews, only 23.7% offered indefinite follow-up. Hybrid models of care (virtual and in-person) were common (56.9%). VTE prophylaxis and postoperative PPI use were recommended by 64.1% and 84.3% respectively. Nearly all respondents (98.1%) provided dietary advice, with protein and micronutrient supplementation widely endorsed. Only 56.1% routinely referred patients for psychological follow-up. Definitions of surgical success and failure varied widely, with inconsistent objective outcome measures.ConclusionThe PARTNER study reveals significant international variation in postoperative management practices following MBS. These findings underscore the need for more standardized, evidence-based guidelines to improve long-term outcomes and equity of care worldwide.

Objective:This study aimed to assess 30-day morbidity and mortality rates following cholecystectomy for benign gallbladder disease and identify the factors associated with complications.Background:Although cholecystectomy is common for benign gallbladder disease, there is a gap in the knowledge of the current practice and variations on a global level.Methods:A prospective, international, observational collaborative cohort study of consecutive patients undergoing cholecystectomy for benign gallbladder disease from participating hospitals in 57 countries between January 1 and June 30, 2022, was performed. Univariate and multivariate logistic regression models were used to identify preoperative and operative variables associated with 30-day postoperative outcomes.Results:Data of 21,706 surgical patients from 57 countries were included in the analysis. A total of 10,821 (49.9%), 4263 (19.7%), and 6622 (30.5%) cholecystectomies were performed in the elective, emergency, and delayed settings, respectively. Thirty-day postoperative complications were observed in 1738 patients (8.0%), including mortality in 83 patients (0.4%). Bile leaks (Strasberg grade A) were reported in 278 (1.3%) patients, and severe bile duct injuries (Strasberg grades B-E) were reported in 48 (0.2%) patients. Patient age, American Society of Anesthesiologists physical status class, surgical setting, operative approach, and Nassar operative difficulty grade were identified as the 5 predictors demonstrating the highest relative importance in predicting postoperative complications.Conclusions:This multinational observational collaborative cohort study presents a comprehensive report of the current practices and outcomes of cholecystectomy for benign gallbladder disease. Ongoing global collaborative evaluations and initiatives are needed to promote quality assurance and improvement in cholecystectomy.

Background:Bariatric surgery is the most effective treatment for obesity, but access is limited. Endoscopic obesity treatments are potentially cheaper and less invasive options, which may be similarly effective. There is currently a lack of evidence to inform decisions on whether such treatments should be considered for people living with obesity. Objective(s):What is the current evidence for the clinical and cost-effectiveness of endoscopic treatments compared to alternative weight management interventions for obesity? Methods:Comprehensive searches were undertaken to January 2023 and a searchable evidence map of all quantitative studies (n > 2) on endoscopic treatments was constructed. The map was used where possible to inform the economic models. Indirect comparisons were undertaken where relevant direct evidence for the model was not available. A systematic review of cost-effectiveness studies was undertaken. Targeted searches were undertaken to identify additional evidence to inform model parameters. Three economic (Markov) models were designed to estimate the cost-effectiveness of endoscopic therapies compared to alternative weight management interventions from a United Kingdom National Health Service and Personal Social Services perspective. Results:The evidence map included over 1500 records of studies of endoscopic therapies, most of which related to intragastric balloons and endoscopic sleeve gastrectomy. Three cost-utility analyses were identified, one of which was set in the United Kingdom and was used to inform the models. Laparoscopic sleeve gastrectomy is likely cost-effective compared with endoscopic sleeve gastroplasty for patients' obesity class II and III (£10,593 per quality-adjusted life-year-gained). Endoscopic sleeve gastroplasty is likely cost-effective compared with semaglutide for patients' obesity class I and II (£7267 per quality-adjusted life-year-gained). Semaglutide is dominant (cheaper and more effective) than intragastric balloon in patients' obesity class I and II. Probabilistic sensitivity analysis found a degree of confidence in the estimates. The 5-year time horizon may not capture longer-term benefits from endoscopic sleeve gastroplasty or laparoscopic sleeve gastrectomy. Limitations and conclusions:The effectiveness evidence base was greater and more wide-ranging than anticipated. However, for the interventions compared within the economic models, there were no randomised controlled trials and either limited, or an absence of, direct comparative evidence. There was also limited long-term data on interventions. These limitations necessitated the use of assumptions in modelling. Future work:Future research should focus on longer-term effectiveness of endoscopic treatments, studies directly comparing endoscopic therapies against semaglutide or other emerging weight loss drugs and studies which better reflect the complex treatment pathways of obesity and different obesity classes. Such studies could provide more robust evidence for informing future cost-effectiveness models beyond a 5-year time horizon. Study registration:This study is registered as PROSPERO CRD42022302942. Funding:This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR133099) and is published in full in Health Technology Assessment; Vol. 29, No. 68. See the NIHR Funding and Awards website for further award information.

Aldo-keto reductase 1C3 (AKR1C3) is a key enzyme in the activation of both classic and 11-oxygenated androgens. In adipose tissue, AKR1C3 is co-expressed with 11β-hydroxysteroid dehydrogenase type 1 (HSD11B1), which catalyses the local activation of glucocorticoids but also the inactivation of 11-oxygenated androgens, and thus has the potential to counteract AKR1C3. Using a combination of in vitro assays and in silico modelling we show that HSD11B1 attenuates the biosynthesis of the potent 11-oxygenated androgen, 11-ketotestosterone, by AKR1C3. Employing ex vivo incubations of human female adipose tissue samples we show that inhibition of HSD11B1 results in the increased peripheral biosynthesis of 11-ketotestosterone. Moreover, circulating 11KT increased 2-3 fold in individuals with type 2 diabetes after receiving the selective oral HSD11B1 inhibitor AZD4017 for 35 days, thus confirming that HSD11B1 inhibition results in systemic increases in 11KT concentrations. Our findings show that HSD11B1 protects against excess 11KT production by adipose tissue, a finding of particular significance when considering the evidence for adverse metabolic effects of androgens in women. Therefore, when targeting glucocorticoid activation by HSD11B1 inhibitor treatment in women, the consequently increased generation of 11-ketotestosterone may offset beneficial effects of decreased glucocorticoid activation. Graphical Abstract

Abstract Background Textbook outcome (TO) is a composite measure of surgical outcomes that, when collectively achieved, depict the optimal result for the patient. Multidimensional parameters, like TO offer a in depth picture of hospital performance, by combining multiple indicators. While an increasing number of studies are evaluating TO in cancer, its application for gastric cancer is still a recent advance. Since surgical reality differs worldwide, a common language is essential when setting outcome goals. This study aims to assess TO accomplishment in several hospital typologies that offer curative-intent resections for gastric cancer. Method A prospective observational multi-institutional audit and 90 day follow-up included data from 138 institutions, in 47 countries. This is a preliminary analysis with focus on TO. Adult patients who underwent elective gastric cancer resection with curative intent, between April 1st and September 30th, 2022, were included. Textbook Outcome (TO) was achieved when all the following seven criteria were met: complete resection (R0), more than 15 lymph nodes sampled, discharge before 21 days, no mortality, no severe morbidity (Clavien–Dindo over 2), no reintervention and no readmission within 90 days post-operative. Results A total of 380 collaborators submitted data on 1538 patients. The mean age was 64.2 years and 58.5% were males. A total of 734 (48%) from the included 1538 patients, achieved TO. “No reintervention in 90 days” was registered in 92% of patients. “No morbidity in 90 days” was observed in 71%. “More than 15 lymph nodes sampled" was achieved in only 79%. The 90-day morbidity and mortality rates were 38.2% (n=587) and 2.9% (n=45), respectively. Conclusion This study demonstrates that achieving Textbook Outcome in gastric cancer resection is seldom attainable. A significant variability across the different outcome parameters within the participating centres was expected. The high rates of mortality-free and reintervention-free outcomes express an effective postoperative care. The lower rates of adequate lymph node sampling and morbidity-free outcomes indicate areas for improvement. Further research should focus on standardizing protocols and improving specific surgical practices to enhance overall TO rates in gastric cancer patients, among the hospital typologies and geographic locations, included in this study.

There is little international data on morbidity and mortality of surgery for perforated peptic ulcer (PPU). This study aimed to understand the global 30-day morbidity and mortality of patients undergoing surgery for PPU and to identify variables associated with these. We performed an international study of adults (≥ 18 years) who underwent surgery for PPU from 1st January 2022 to 30th June 2022. Patients who were treated conservatively or had an underlying gastric cancer were excluded. Patients were divided into subgroups according to age (≤ 50 and > 50 years) and time from onset of symptoms to hospital presentation (≤ 24 and > 24 h). Univariate and Multivariate analyses were carried out to identify factors associated with higher 30-day morbidity and mortality. 1874 patients from 159 centres across 52 countries were included. 78.3

Introduction Revisional bariatric surgery (RBS) for insufficient weight loss/weight regain or metabolic relapse is increasing worldwide. There is currently no large multinational, prospective data on 30-day morbidity and mortality of RBS. In this study, we aimed to evaluate the 30-day morbidity and mortality of RBS at participating centres. Methods An international steering group was formed to oversee the study. The steering group members invited bariatric surgeons worldwide to participate in this study. Ethical approval was obtained at the lead centre. Data were collected prospectively on all consecutive RBS patients operated between 15th May 2021 to 31st December 2021. Revisions for complications were excluded. Results A total of 65 global centres submitted data on 750 patients. Sleeve gastrectomy (n = 369, 49.2 %) was the most common primary surgery for which revision was performed. Revisional procedures performed included Roux-en-Y gastric bypass (RYGB) in 41.1 % (n = 308) patients, One anastomosis gastric bypass (OAGB) in 19.3 % (n = 145), Sleeve Gastrectomy (SG) in 16.7 % (n = 125) and other procedures in 22.9 % (n = 172) patients. Indications for revision included weight regain in 615(81.8 %) patients, inadequate weight loss in 127(16.9 %), inadequate diabetes control in 47(6.3 %) and diabetes relapse in 27(3.6 %). 30-day complications were seen in 80(10.7 %) patients. Forty-nine (6.5 %) complications were Clavien Dindo grade 3 or higher. Two patients (0.3 %) died within 30 days of RBS. Conclusion RBS for insufficient weight loss/weight regain or metabolic relapse is associated with 10.7 % morbidity and 0.3 % mortality. Sleeve gastrectomy is the most common primary procedure to undergo revisional bariatric surgery, while Roux-en-Y gastric bypass is the most commonly performed revision.

The health benefits of bariatric surgery are well documented; however, the occurrence of weight-regain after surgery, along with the development of mental health difficulties poses a question of how contemporary psychology could assist to prepare people living with obesity prior to undergoing bariatric surgery. This research explored individuals' (in the immediate pre-operative and post-operative population) attitudes, beliefs and experiences towards obesity and their journey to bariatric surgery. Seventeen adult participants (males n = 4; age range: 26-64 years) were recruited and participated in a semi-structured interview. Twelve individuals participated prior to undergoing bariatric surgery. Five individuals participated in the early post-operative period (<3 months post-surgery). People living with obesity displayed high optimism for positive outcomes, with participants hoping that bariatric surgery would be different to previous attempts at weight regulation, with there being a clear shift in the locus of control for weight management from self to healthcare professionals. Whilst this is adaptive, there was the presence of seemingly unrealistic optimism, with many pre-surgery participants not relaying the realistic possibility of post-surgery weight-regain. Despite the optimism individuals feel about bariatric surgery, participants felt that the psychological factors influencing eating behaviours are not being addressed by healthcare. These findings suggest that mindfulness, mindful eating, and self-compassion approaches should be incorporated into clinical practice to support weight regulation and adaption to physiological changes after bariatric surgery.

Abstract Background Data on multinational 90-day mortality and morbidity rates after surgery for gastric cancer is limited in the literature. This study aimed to understand the 90-day mortality and morbidity outcomes according to GASTRODATA Registry for elective gastric cancer surgery patients and identify risk factors. Method We conducted an international prospective study on ≥18 years patients undergoing elective surgery for gastric cancer with curative intent from 01 April 2022 to 30 September 2022. Known metastatic disease, concurrent secondary cancers, gastrointestinal stromal tumour (GIST) and Siewert type I/II oesophagogastric junction malignancies were excluded. Univariate and multivariate logistic regression was used to identify variables associated to 90-day outcome. Results 380 collaborators from 47 countries submitted data on 1538 patients. Mean age was 64.2 years and 58.5% were males. 90-day morbidity rate was 38.2% (n=587) and mortality rate was 2.9% (n=45). Pre-operative higher CCI or ASA score, pre-operative weight loss >10%, and surgical determinants such as type of gastric resection, positive specimen margin, number of harvested lymph nodes, longer surgery duration and post operative pathological IV staging (p value<0.05) were identified as predictors of postoperative severe complications and mortality. Conclusion Elective gastric cancer surgery has a 90-day morbidity of 38.2% and 90-day mortality of 2.9%, globally. This study identified several factors associated with higher morbidity and exemplified the importance of a unified language on surgical morbidity, pre-habilitation and ongoing audits to enhance patient outcomes.

BackgroundNo robust data are available on the safety of primary bariatric and metabolic surgery (BMS) alone compared to primary BMS combined with other procedures.ObjectivesThe objective of this study is to collect a 30-day mortality and morbidity of primary BMS combined with cholecystectomy, ventral hernia repair, or hiatal hernia repair.SettingThis is as an international, multicenter, prospective, and observational audit of patients undergoing primary BMS combined with one or more additional procedures.MethodsThe audit took place from January 1 to June 30, 2022. A descriptive analysis was conducted. A propensity score matching analysis compared the BLEND study patients with those from the GENEVA cohort to obtain objective evaluation between combined procedures and primary BMS alone.ResultsA total of 75 centers submitted data on 1036 patients. Sleeve gastrectomy was the most commonly primary BMS (N = 653, 63%), and hiatal hernia repair was the most commonly concomitant procedure (N = 447, 43.1%). RYGB accounted for the highest percentage (20.6%) of a 30-day morbidity, followed by SG (10.5%). More than one combined procedures had the highest morbidities among all combinations (17.1%). Out of overall 134 complications, 129 (96.2%) were Clavien-Dindo I-III, and 4 were CD V. Patients who underwent a primary bariatric surgery combined with another procedure had a pronounced increase in a 30-day complication rate compared with patients who underwent only BMS (12.7% vs. 7.1%).ConclusionCombining BMS with another procedure increases the risk of complications, but most are minor and require no further treatment. Combined procedures with primary BMS is a viable option to consider in selected patients following multi-disciplinary discussion.

Introduction:Increasing numbers of patients with advanced organ disease are being considered for bariatric and metabolic surgery (BMS). There is no prospective study on the safety of BMS in these patients. This study aimed to capture outcomes for patients with advanced cardiac, renal, or liver disease undergoing BMS.Materials and methods:This was a multinational, prospective cohort study on the safety of elective BMS in adults (>= 18 years) with advanced disease of the heart, liver, or kidney.Results:Data on 177 patients with advanced diseases of heart, liver, or kidney were submitted by 75 centres in 33 countries. Mean age and BMI was 48.56 +/- 11.23 years and 45.55 +/- 7.35 kg/m2, respectively. Laparoscopic sleeve gastrectomy was performed in 124 patients (70%). The 30-day morbidity and mortality were 15.9% (n=28) and 1.1% (n=2), respectively. Thirty-day morbidity was 16.4%, 11.7%, 20.5%, and 50.0% in patients with advanced heart (n=11/61), liver (n=8/68), kidney (n=9/44), and multi-organ disease (n=2/4), respectively. Cardiac patients with left ventricular ejection fraction less than or equal to 35% and New York Heart Association classification 3 or 4, liver patients with model for end-stage liver disease score greater than or equal to 12, and patients with advanced renal disease not on dialysis were at increased risk of complications. Comparison with a propensity score-matched cohort found advanced disease of the heart, liver, or kidney to be significantly associated with higher 30-day morbidity.Conclusion:Patients with advanced organ disease are at increased risk of 30-day morbidity following BMS. This prospective study quantifies that risk and identifies patients at the highest risk.