Clinical Value of Routine Preoperative Ultrasonography in Bariatric Surgery Candidates: A Retrospective Analysis of 1119 Cases

<b>Background:</b> Preoperative evaluation in bariatric surgery aims to minimize perioperative risks and identify comorbid abdominal pathologies that may influence surgical planning. The role of routine abdominal ultrasonography (USG) remains debatable. <b>Methods:</b> This retrospective study included 1119 consecutive candidates for bariatric surgery who underwent routine preoperative ultrasonography (USG) between January 2022 and October 2024. Patients were stratified by BMI and categorized according to USG findings as normal, incidental, requiring follow-up/concomitant procedures, or necessitating cancellation. Baseline characteristics, USG findings, surgical outcomes, and predictors of cancellation were analyzed using univariate, multivariate, and Firth's penalized logistic regression analyses. Ultrasonographic findings were further stratified as clinically significant (requiring intervention) or non-clinically significant (not requiring intervention) to standardize interpretation. <b>Results:</b> Abnormal USG findings were present in 77.5% of patients, with hepatic steatosis (60.8% [n = 680]), hepatomegaly (21.5%), and gallstones (13.9%) being the most frequent. Higher BMI was significantly associated with hepatomegaly, steatosis, and gallstones (all <i>p</i> < 0.05), but not with surgical cancellation. Bariatric surgery was cancelled in 11 patients (1.0%) due to critical findings exclusively identified on USG, including large ovarian/uterine masses, choledochal cysts, and suspected malignancies. In multivariate and Firth-adjusted regression, large ovarian/uterine masses (adjusted OR 12.9, 95% CI 3.0-55.2, <i>p</i> = 0.001; Firth OR 11.4, 95% CI 2.5-51.4, <i>p</i> = 0.002) and choledochal cysts (Firth OR 29.7, 95% CI 1.8-489.5, <i>p</i> = 0.048) emerged as independent predictors of cancellation. <b>Conclusions:</b> Although the overall cancellation rate was low, the detection of critical USG findings in 1.0% of patients had major clinical implications, preventing inappropriate or unsafe surgery and enabling timely referral for specialist management. Routine preoperative ultrasonography thus offers a clinically meaningful safeguard in bariatric surgery, supporting its inclusion in preoperative assessment algorithms.