Objective evidence that bariatric surgery improves obesity-related obstructive sleep apnea

doi:10.1016/j.surg.2006.08.012

Surgery

Volume 141, Issue 3, March 2007, Pages 354-358

https://doi.org/10.1016/j.surg.2006.08.012 Get rights and content

Background

Obstructive sleep apnea (OSA) is associated with obesity. Our aim in this study is to report objective improvement of obesity-related OSA and sleep quality after bariatric surgery.

Methods

Prospective bariatric patients were referred for polysomnography if they scored ≥6 on the Epworth Sleepiness Scale. The severity of OSA was categorized by the respiratory disturbance index (RDI) as follows: absent, 0 to 5; mild, 6 to 20; moderate, 21 to 40; and severe, <40. Patients were referred for repeat polysomnography 6 to 12 months after bariatric surgery or when weight loss exceeded 75 lbs. Means were compared using paired t tests. Chi-square tests and linear regression models were used to assess associations between clinical parameters and RDI; P < .05 was considered statistically significant.

Results

Of 349 patients referred for polysomnography, 289 patients had severe (33%), moderate (18%), and mild (32%) OSA; 17% had no OSA. At a median of 11 months (6 to 42 months) after bariatric surgery, mean body mass index (BMI) was 38 ± 1 kg/m² (P < .01 vs 56 ± 1 kg/m² preoperatively) and the mean RDI decreased to 15 ± 2 (P < .01 vs 51 ± 4 preoperatively) in 101 patients who underwent postoperative polysomnography. In addition, minimum oxygen saturation, sleep efficiency, and rapid eye movement latency improved, and the requirement for continuous positive airway pressure was reduced (P ≤ .025). Male gender and increasing BMI correlated with increasing RDI (P < .01) by chi-square analysis. In a multivariate linear regression model adjusted for age and gender, preoperative BMI correlated with preoperative RDI (r = 0.27; P < .01).

Conclusions

OSA is prevalent in at least 45% of bariatric surgery patients. Preoperative BMI correlates with the severity of OSA. Surgically induced weight loss significantly improves obesity-related OSA and parameters of sleep quality.

Section snippets

Methods

This study was approved by the Institutional Review Board at the University of South Florida Health Science Center and was conducted in compliance with HIPAA guidelines and regulations.

Prevalence of OSA in bariatric patients

A total of 597 consecutive bariatric surgery patients completed the ESS during the study period (Figure); 447 patients who scored ≥6 on the ESS were referred for consultation with a pulmonologist. On further consultation with the pulmonologist, 98 of the 447 patients did not undergo polysomnography, because their symptoms were mild and not attributed to airway obstruction. The remaining 349 patients underwent polysomnography for evaluation and documentation of OSA. This group was composed of

Discussion

This study confirms that surgically induced weight loss results in significant improvement of obesity-related OSA in bariatric patients. Moreover, this is the largest series that documents objective improvement of obesity-related OSA as measured by polysomnography after bariatric surgery.

OSA is prevalent in obese patients and in patients seeking bariatric surgery.1, 2, 3, 4 This study confirms our earlier reports,1, 2 that at least 45% of bariatric patients who were screened for OSA were

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The efficacy of bariatric surgery on pulmonary function and sleep architecture of patients with obstructive sleep apnea and co-morbid obesity: a systematic review and meta-analysis
2023, Surgery for Obesity and Related Diseases
Obstructive sleep apnea (OSA) is highly prevalent in patients with morbid obesity. There is a growing interest in the role of bariatric surgery in OSA management. This study aims to evaluate the therapeutic efficacy of bariatric surgery on changes in pulmonary function and sleep architecture. Studies of patients with OSA that underwent bariatric surgery were searched in 4 different databases (PubMed, Cochrane, Web of Science, and Embase) until October 31, 2022. We identified studies evaluating the efficacy of surgical intervention on primary outcomes (body mass index [BMI] and apnea-hypopnea index [AHI]) and secondary outcomes such as forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), FEV1/FVC, oxygen desaturation index (ODI), T90, mean oxygen saturation (SpO₂), nadirSpO₂, sleep efficiency (SE), N1%, N2%, N3%, rapid eye movement (REM%), arousal index, Epworth sleepiness scale (ESS), neck circumference, waist circumference, and weight. A total of 24 eligible studies were finally chosen. Risk of bias assessed through funnel plots was collected and analyzed via random effects meta-analyses. There were significant reductions in BMI and AHI after bariatric surgery induced weight loss. Accordingly, improvement in FVC, meanSpO₂, nadirSpO₂, SE, N3%, REM%, and ESS were observed compared with baseline. Patients with OSA also exhibit lower ODI, T90, arousal index, neck circumference, waist circumference, and weight after treatment. Bariatric surgery has beneficial effects on patients with OSA and obesity, particularly with morbid obesity. Surgical weight loss significantly eliminates apnea-hypopnea events, reduces weight, increases oxygen saturation, N3 and REM sleep stage, reduces sleep fragmentation, and improves pulmonary functions with augmented FVC.
Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures – 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists
2020, Surgery for Obesity and Related Diseases
The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, algorithms, and checklists.
Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.
New or updated topics in this CPG include contextualization in an adiposity-based, chronic disease complications–centric model, nuance-based, and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current healthcare arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).
Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision–making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.
The effects of weight loss, tracheostomy, and medication on obesity hypoventilation syndrome
2020, Obesity Hypoventilation Syndrome: From Physiologic Principles to Clinical Practice
Beyond noninvasive ventilation, the treatment options for patients with obesity hypoventilation syndrome (OHS) are very limited. Weight loss probably cures OHS. But the extent of weight loss needed for cure is severe and can only be reliably achieved with bariatric surgery. Our understanding of the role of surgery and its safety in patients with OHS remains limited. Tracheostomy is also effective in improving ventilation, but it is rarely performed. Ventilation can be increased or decreased with medication. This chapter summarizes our current knowledge of these interventions.
Clinical Practice Guidelines For The Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures – 2019 Update: Cosponsored By American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society For Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists
2019, Endocrine Practice
The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society, American Society of Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists.
Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.
New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health-care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).
Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues. (Endocr Pract. 2019;25:1-75)
The effect of surgical weight loss on obstructive sleep apnoea: A systematic review and meta-analysis
2018, Sleep Medicine Reviews
This review aimed to examine the relationship between surgical weight loss and obstructive sleep apnoea (OSA) severity (i.e., apnoea-hypopnoea index [AHI]), and how this relationship is altered by the various respiratory events scoring (RES) criteria used to derive the AHI. A systematic search of the literature was performed up to December 2017. Before-and-after studies were considered due to a paucity of randomised controlled trials (RCTs) available to be reviewed in isolation. Primary outcomes included pre- and post-surgery AHI and body mass index (BMI). Secondary outcomes included sleep study type and RES criteria. Meta-analysis was undertaken where possible. Overall, surgical weight loss resulted in reduction of BMI and AHI, however, OSA persisted at follow-up in the majority of subjects. There was high between-study heterogeneity which was largely attributable to baseline AHI and duration of follow-up when analysed using meta-regression. There was insufficient data to evaluate the impact of different RES criteria on OSA severity. Therefore, more RCTs are needed to verify these findings given the high degree of heterogeneity and future studies are strongly encouraged to report the RES criteria used to enable fair and uniform comparisons of the impact of any intervention on OSA severity.
Is bariatric surgery effective for co-morbidity resolution in the super-obese patients?
2018, Surgery for Obesity and Related Diseases
Citation Excerpt :
Additionally, both groups reached a similar %TBWL at the 6-month and 1-year follow-ups (Fig. 4). Many studies have discussed how weight reduction—even at modest levels—has been associated with significant improvements in T2D, OSA, HTN, and HLD [9–13]. To the best of our knowledge, however, there are only a few studies that focus on the remission of these co-morbidities in super-obese patients, and more importantly, that compare the resolution of these co-morbidities in the super-obese with other obese groups.
Type 2 diabetes (T2D), obstructive sleep apnea (OSA), hypertension (HTN), and hyperlipidemia (HLD) are common co-morbidities that are strongly associated with obesity.
The purpose of this study was to compare the rate of obesity-related co-morbidity remission and percent total body weight loss of super-obese patients with a body mass index (BMI) ≥50 kg/m² with bariatric patients who have a BMI of 30 to 49.9 kg/m².
Academic hospital, United States.
A retrospective analysis of outcomes of a prospectively maintained database was done on obese patients with a diagnosis of ≥1 co-morbidity (T2D, OSA, HTN, or HLD) who at the time of initial visit had undergone either a sleeve gastrectomy or a Roux-en-Y gastric bypass at our hospital between 2011 and 2015. The patients were stratified based on their preoperative BMI class, BMI of 30 to 49.9 kg/m² versus BMI ≥50 kg/m².
Of the 930 patients, 732 underwent sleeve gastrectomy and 198 underwent Roux-en-Y gastric bypass. The 6-month follow-up co-morbidity remission rates for patients with a BMI of 30 to 49.9 kg/m² (n = 759) versus super-obese patients (n = 171) were 46.0% and 36.7% (P = .348) for T2D; 75.0% and 73.2% (P = .772) for OSA; 35.0% and 22.0% (P = .142) for HTN; and 37.0% and 21.0% (P = .081) for HLD, respectively. The 1-year follow-up co-morbidity remission rates for patients with a BMI of 30 to 49.9 kg/m² versus super-obese patients were 54.2% and 45.5% (P = .460) for T2D; 87.0% and 89.7% (P = .649) for OSA; 37.4% and 23.9% (P = .081) for HTN; and 43.2% and 34.6% (P = .422) for HLD, respectively. Furthermore, there was no difference in the mean percent total weight loss for patients with a preoperative BMI of 30 to 49.9 kg/m² versus the super-obese at the 6-month (21.4%, 20.9%, P = .612) and 1-year (28.0%, 30.7%, P = .107) follow-ups.
In our study, preoperative BMI did not have an impact on postoperative co-morbidity remission rates or percent total body weight loss. Future studies should investigate the effect of other factors, such as disease severity and duration.

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Original communicationObjective evidence that bariatric surgery improves obesity-related obstructive sleep apnea

Background

Methods

Results

Conclusions

Section snippets

Methods

Prevalence of OSA in bariatric patients

Discussion

Am J Clin Nutr

Chest

Chest

J Gastrointest Surg

Otolaryngol Head Neck Surg

Clinical predictors of sleep apnea in patients undergoing bariatric surgery

Obes Surg

Gastric bypass is an effective treatment for obstructive sleep apnea in patients with clinically significant obesity

Obes Surg

Evidence supporting routine polysomnography before bariatric surgery

Obes Surg

Original communication
Objective evidence that bariatric surgery improves obesity-related obstructive sleep apnea