Characteristics of patients undergoing bariatric surgery in an underserved minority population - Does OSA affect postoperative weight loss?

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Abhishrut Jog, Jorge Mosquera, Luis Rodriguez Piedra, Ajit Singh, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4414267/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Obese patients are at increased risk of Obstructive Sleep Apnea (OSA). Bariatric surgery is an important therapeutic measure in obese patients for management of weight and management of comorbidities. There is a scarcity of data on OSA, in inner city Hispanic and Black patients who undergo bariatric surgery. Differences between patients with and without OSA have not been assessed in this population. The study aims to answer these questions. Health sciences/Diseases/Endocrine system and metabolic diseases/Obesity Health sciences/Medical research/Outcomes research Sleep apnea Obstructive Bariatric Surgery Health Disparity Population Weight Loss Figures Figure 1 Introduction In a study of the National Health and Nutrition Examination Survey (NHANES) database, Ogden et al, showed that over the last two decades, the prevalence of obesity has increased among men and women in the U.S. The study also showed that there was a greater increase in obesity in Mexican American men that non-Hispanic White men [ 1 ]. Obesity remains the strongest risk factor for development of Obstructive Sleep Apnea and both diseases increase cardiovascular risk [ 2 ]. Bariatric surgery is now recognized as an important option for permanent and sustainable weight loss [ 3 ]. There is scarcity of data available on Hispanic patients undergoing bariatric surgery. Zhao et al, in their meta-analysis, found a total of 52 studies on the topic of post-operative weight loss comparing at least two races. Out of these 52 studies, only 20 studies included Hispanic patients. Some of these studies have less than 10% Hispanic representation, going as low as 4.7%. In addition, many studies have less than a year of follow up [ 4 ]. To address this data vacuum, the following study was undertaken. In New York City, the Burrough with the highest prevalence of obesity is the Bronx (30.5%) [ 5 ]. The Burrough with the highest number of Hispanic and Black people is also the Bronx. As a result, the hospital where the study was conducted has a large pool of inner-city patients Hispanic or Black patients. This allowed analysis of outcomes and characteristics in this underserved and understudied population. Objectives: The study aimed at finding out the various characteristics of patients qualifying for bariatric surgery, including, anthropometric measures and lab tests. It also aimed to find out if there existed any significant difference between bariatric candidates with OSA and without OSA based on these findings. Finally, the study aimed to analyze the post operative outcome of the bariatric surgery in these patients at 6 months and 1 year, with regards to weight loss. Methods Data collection This was a single center, multi- surgeon study, retrospective study. The study protocol was approved by the Institutional Review Board (IRB 04132305). All research was conducted in accordance with guidelines set forth by the Belmont Report and the Common Rule (the federal policy for the protection of human subjects). No identifiable information of the study population has been provided in the manuscript. No intervention was performed on any subjects for the purpose of the study. Data were collected retrospectively, by electronic medical record review. Human Ethics and Consent to Participate declaration is not applicable. All the patients over the age of 18 years, that underwent bariatric surgery from January 2021 to February 2023 at BronxCare Hospital System, Icahn School of Medicine at Mount Sinai, New York, were considered in the study. Pre-operative data- Pertinent information collected included demographics, sleep study findings (Apnea-Hypopnea Index, minimum oxygen saturation, duration of desaturation), type of bariatric procedure, comorbidities such as hypertension (HTN), Type 2 Diabetes Mellitus ( T2DM), Coronary Artery Disease (CAD) Cerebrovascular accident (CVA), atrial fibrillation (Afib), Major Depressive Disorder (MDD), pre-operative anthropometric measurements – weight (measured in kilograms – kg), and body mass index (BMI). Pre-operatively, certain laboratory parameters were collected- HbA1C, Serum cortisol, serum Thyroid Stimulating Hormone (TSH), Serum Vitamin D. Included patients underwent pre-operative Echocardiography and data on the Ejection Fraction (EF) and Pulmonary Artery Systolic Pressure (PASP), were collected. Included patients also underwent pre-operative Esophagogastroduodenoscopy (EGD). Data were collected on the EGD findings and Helicobacter pylori testing using Rapid Urease Test (CLO test- Campylobacter Like Organism test). Post-operative data- Post-operative anthropometric measurements of weight and BMI were noted at 6 months and 12 months. Calculations- Six values were calculated based on the pre- and post-operative anthropometric measurements - Excess Weight Loss % at 6 months (EWL6), Excess Weight Loss % at 12 months (EWL12) as per Eq. (1), Total Weight Loss % at 6 months (TWL6), Total Weight Loss % at 12 months (TWL12) as per Eq. (2), Change in BMI % at 6 months (Delta BMI 6) and change in BMI % at 12 months (Delta BMI 12) as per Eq. (3). 1) Excess Weight Loss: 2) Total Weight Loss: 3) Change in BMI: Statistical analysis Data were analyzed using the STATA software. Mean values were calculated for all the numerical data. Chi square testing was applied to categorical variables. T test was applied for continuous variable. A p value of less than 0.05 was considered significant. Results A total of 122 bariatric surgeries were performed at the hospital in the study period. 108 patients out of the screened patients had a pre-operative sleep study. Preoperative weight data was not available for one patient in the OSA group. 6-month postoperative weight data was not available for 5 patients in the OSA group. 12-month postoperative weight data was not available for 21 patients in the OSA group and 7 patients in the non-OSA group. Analysis of anthropometric measures was accordingly done on the available data. 69.4% had OSA (75/108) and 30.6% (33/108) patients had no OSA. 45.3% (34/75) had mild OSA, 26.7% (20/75) had moderate OSA and 28% (21/75) had severe OSA. 88% of the participants were female (99/ 108). Mean age in the cohort was 41.9 +/- 10.8. 85.2% (92/108) of the total patients were Hispanic, 14% (15/108) were Black. There were no active smokers (15.7% former smokers and 84.3% never smokers). Mean pre-operative weight was 111.2 +/- 20 kg in those without OSA and 115.9 +/- 22.6 kg in those with OSA. Mean preoperative BMI was 42.3 +/- 6.6 in the group without OSA and 44.5 +/- 15 in the group with OSA. In the group without OSA, the respective TWL6 and TWL12 were 26.7 +/- 8.5 and 28.3 +/- 9.2 and in the group with OSA the respective values of TWL6 and TWL 12 were 26.8 +/- 13.6 and 31.1 +/- 16.2 (p value for TWL6 was 0.9 and for TWL12 was 0.4) . In the group without OSA, the respective EWL6 and EWL12 were 49.4 +/- 14.3 and 54.7 +/- 18.4 and in the group with OSA the respective values of EWL6 and EWL 12 were 44.9 +/- 13.9 and 51.7 +/- 15.7 (p value for EWL6 was 0.1 and for EWL12 was 0.5). In the group without OSA, the respective Delta BMI 6 and Delta BMI 12 were 10.11 +/- 3.7 and 10.8 +/- 4.4 and in the group with OSA the respective values of Delta BMI 6 and Delta BMI 12 were 11.2 +/-15.3 and 13.1 +/- 17.3 (p value for Delta BMI 6 was 0.7 and for Delta BMI 12 was 0.5). Between the group without OSA and with OSA, no statistically significant difference was noted in the mean HbA1C ( 6.2 +/- 1.1 vs 6.1 +/- 1.1, p = 0.9), TSH ( 1.85 +/- 1 vs 2.3 +/- 2.3), serum cortisol (1.4 +/- 2.3 vs. 1.1 +/- 2.3, p = 0.7) Vitamin D ( 18.1 +/- 6.5 vs 21.4 +/- 9.2, p = 0.07), EF ( 65% +/- 5.9 vs 65% +/- 6, p = 0.8), PASP ( 36.8 +/- 9 vs. 40.2 +/- 8.3, p = 0.1), CLO test ( 45.5% vs. 43%, p = 0.8). Abnormal EGD findings were seen in 54.6% (59/ 108) patient. In descending frequencies, the abnormal EGD findings were mucosal erythema in 29.6% (32/ 108), gastritis in 11.1% (12/108), hiatal hernia in 4.6% (5/108), gastric ulcer in 3.7% (4/108), gastric polyp in 2.7% (3/108), and esophagitis in 2.7% (3/108). Active MDD requiring medication was seen in 7.4% (8/108) patients. The results are presented below in Table 1 . The types of surgeries performed are given in Table 2 . Table 1 Results. The mean values with the standard errors are provided in the table. Chi square testing was applied to categorical variables. T test was applied for continuous variable. A p value of less than 0.05 was considered significant. The test used to generate the p value is shown in parentheses next to each p value. c = Chi square test. t = T test. No OSA (33) OSA (75) Total (108) P value Age (years) 39 +/- 11.5 43.3 +/- 10.3 41.9 +/- 10.8 0.05 (t) Sex Male Female 1 (3%) 32 (97%) 12 (16%) 63 (84%) 13 (12%) 95 (88%) 0.06 (c) Ethnicity Hispanic Black White 29 (88%) 3 (9%) 1 (3%) 63 (84%) 12 (16%) 0 92 (85.2%) 15 (14%) 1 (0.8%) - Smoking status Former smoker Never smoker 6 (18%) 27 (82%) 12 (16%) 63 (84%) 18 (16.7%) 90 (83.3%) - Preop weight 111.2 +/-_ 20 115.9 +/- 22.6 (n = 74) 114.7 +/-_ 21.6 (n = 107) 0.3 (t) Preop BMI 42.3 +/- 6.6 44.5 +/- 15 (n = 74) 43.9 +/- 13 (n = 107) 0.4 (t) TWL 6 26.7 +/- 8.5 26.8 +/-13.6 (n = 70) 26.8 +/- 12.2 (n = 103) 0.9 (t) TWL 12 28.3 +/- 9.2 (n = 26) 31.1 +/- 16.2 (n = 54) 30.2 +/- 14.3 (n = 80) 0.4 (t) EWL 6 49.4 +/- 14.3 44.9 +/- 13.9 (n = 70) 46.4 +/- 14.1 (n = 103) 0.1 (t) EWL 12 54.7 +/- 18.4 (n = 26) 51.7 +/- 15.7 (n = 54) 52.6 +/- 16.6 (n = 80) 0.5 (t) Delta BMI 6 10.11 +/- 3.7 11.2 +/- 15.3 (n = 70) 10.8 +/-12.8 (n = 103) 0.7 (t) Delta BMI 12 10.8 +/- 4.4 (n = 26) 13.1 +/- 17.3 (n = 54) 12.3 +/- 14.5 (n = 80) 0.5 (t) HbA1c 6.2 +/- 1.1 6.1 +/- 1.1 6.1 +/- 1.1 0.9 (t) TSH 1.85 +/-_ 1 2.3 +/- 2.3 2.2 +/- 2 0.3 (t) Cortisol 1.4 +/- 2.3 1.1 +/- 2.3 1.2 +/- 2.3 0.7 (t) Vitamin D 18.1 +/- 6.5 21.4 +/- 9.2 20.4 +/- 8.6 0.07 (t) HTN 11 (33.3%) 26 (34.6%) 37 (34.3%) 0.9 (c) T2DM 8 (24.24%) 16 (21.3%) 24 (22.2%) 0.7 (c) CVA 0 0 0 - CAD 1 (3%) 1 (1.3%) 2 (1.8%) - Afib 0 0 0 - Depression 3 (9.1%) 5 (6.7%) 8 (7.4%) 0.7 (c) EF 64.98 +/- 5.9 65.2 +/- 6 65.1 +/- 5.97 0.8 (t) RVSP 36.8 +/- 9 40.2 +/- 8.3 39.1 +/- 8.6 0.11 (t) Clo test 15 (45.5%) 32 (42.6%) 47 (43.5%) 0.8 (c) EGD Abnormal Normal 22 (66.6%) 11 (33.3%) 38 (50.7%) 37 (49.3%) 59 (54. 6%) 49 (45.4%) 0.4 (c) Table 2 Types of Surgery. Type of Surgery Percentage Robotic gastric sleeve resection 91/ 108 (84.26%) Robotic Roux en Y gastric bypass 8/ 108 (7.41%) Laparoscopic sleeve gastrectomy 6/ 108 (5.56%) Revision 2/108 (1.85%) Laparoscopic Roux en Y gastric bypass 1/108 (0.93%) Discussion In eligible patients, bariatric surgery results in substantial weight loss. In a study on individuals between age 20 and 64 in NHANES comparing individuals who had bariatric surgery with those who were eligible for it, but did not get surgery, it was found that post- bariatric surgery, there is five times more likelihood of achieving at least 20% weight loss. Participants who had surgery had a reduction of 15.5 BMI units and a 31% weight loss compared to 4.4 BMI units and 9.9% weight loss in the eligible but not operated group. 86.2% of the operated patients achieved 20% weight loss compared to 15.3% of the non- operated group [ 6 ]. Most patients in our study (84.26%) underwent robotic gastric sleeve resection. Factors that have been implicated as being impactful in post-operative weight loss include age, race, socioeconomic status, gender, marital status, behavioral disorders, pre-operative weight status, comorbidities such as diabetes mellitus, psychiatric illness, and sexual abuse, and institutional differences etc. Only a few are consistently supported in literature [ 7 ]. In our review, we found a few studies that looked at OSA as a predictor of post-bariatric surgery weight loss. In the larger of the studies by de Raaff et al, 816 patients were analyzed retrospectively. Out of these, 522 (64%) had OSA and 294 (36%) did not have OSA. The study was aimed at evaluating the impact of OSA on % EWL at 12 months and BMI changes at 12 months after bariatric surgery. No information about ethnicity was available in the article. After adjustment for waist circumference, BMI, and age, no effect of OSA was seen on either the %EWL or BMI change at the end of 12 months [ 8 ]. In another study on a similar topic, Guggino et al analyzed 371 patients included in a prospective cohort, the Severe Obesity Outcome Network cohort. 210 out of these had moderate – severe OSA, and 161 had no OSA. Multivariable analysis of the data showed that age, initial BMI, and surgery type were associated with differences in % EWL. OSA independently, was not shows to be associated with % EWL [ 9 ]. In a similar study by Mihalache et al. The authors analyzed a bariatric population that underwent laparoscopic sleeve gastrectomy. The primary outcome was % body fat change at 6 months and 12 months. The study revealed that patients with OSA had lesser loss of body fat as compared to patients without OSA. The weight loss experienced by both group of patients was the same. All participants in this study were Caucasian [ 10 ]. In our study, we noted a similar lack of difference in the weight loss attained between patients with and without OSA at the end of 6 and 12 months. Prevalence of DM ranges from 6.6% in patients without OSA to 28.9% in patients with severe OSA, thus showing an increase with severity [ 11 ]. OSA results in sleep fragmentation and intermittent hypoxemia, which in turn lead to increased sympathetic neural activity, oxidative stress, systemic inflammation, activation of hypothalamic pituitary axis and alternation of circulating adipokines. These result in insulin resistance and beta cell dysfunction culminating to diabetes. Even in patients without T2DM, severity of OSA has been shown to be independently associated with insulin resistance. In reverse, the neuropathy that DM induces, can affect the central control of respiration and upper airway neural reflexes. This can lead to emergence of sleep apnea. Hence, the relationship between OSA and DM has been cited as being bi-directional [ 12 ]. Bariatric surgery results in improvement in obesity and drop in AHI. This is thought to be beneficial in the control of DM [ 12 ]. The American Society of Metabolic and Bariatric Surgery (ASMBS) now recommends bariatric surgery for individuals with BMI of 30-34.9 with metabolic disease including hyperglycemia that does not respond to non-surgical options [ 13 ]. In our study, no significant difference was noted in the A1C levels or the prevalence of diabetes mellitus in the two groups. Hypothyroidism is associated with OSA. Deposition of muco-proteins in the upper airway resulting in upper airway obstruction, neuropathy induced disruption of the regulatory control of pharyngeal dilator muscles and respiratory center depression have been cited as possible causes of OSA in hypothyroidism. Prevalence of hypothyroidism in OSA is low (0.4%), but subclinical hypothyroidism seems to be more common in OSA (11.1%) [ 14 ]. TSH levels are positively correlated with BMI [ 15 ]. In our study we noted that the mean TSH level in the OSA group was higher than the non-OSA group, although the difference did not reach statistical significance (2.3 +/- 2.3 vs 1.85 +/- 1) A meta-analysis from 2023 including 5592 individuals from 18 observational studies found a lower levels of Vitamin D in patients with OSA compared to those without (18.2 +/- 5.6 ng/ml vs. 23.2 +/- 4.3 ng/ml). The effect was significant only in people with moderate to severe OSA, and not in mild OSA [ 16 ].Similarly, another meta-analysis, reveals a 35% higher prevalence of vitamin D deficiency in obese subjects [ 17 ]. Perception of low social acceptance leading to decreased outdoor activities and increased use of clothes to cover more body is one theory cited to explain vitamin D deficiency in the obese. Sequestration of cholecalciferol by excess fat, and greater local use of 25 (OH)D are other theories in obese individuals [ 17 ]. Hypoxia induced in OSA is related to vitamin D deficiency via HIF 1 alpha (Hypoxia inducible factor 1 alpha) [ 16 ]. There was no significant difference in the vitamin D levels between the 2 groups in our study. One of the possibilities for this, could be the smaller number of severe OSA patients in our study. In many centers esophagogastroduodenoscopy is routinely performed before bariatric surgery, the rationale behind this being that the bariatric procedure might alter the foregut anatomy. Gomez et al analyzed 232 patients cleared to undergo bariatric surgery, and noted abnormal findings in 61.6% patients, with 15.1% requiring medical management alterations and 1.7% requiring alterations in surgical management. The commonest finding on EGD was a small hiatal hernia (23.7%) [ 18 ]. In our study, the commonest EGD finding was erythematous mucosa. A few studies have demonstrated association between OSA and H pylori, whereas others have not [ 19 ] [ 20 ] [ 21 ].In our study the prevalence of H pylori infection was found to be 43% in the total cohort, with no statistically significant difference between the two groups. However, this is higher than the average H pylori prevalence of 36% in the country [ 22 ]. OSA is linked with pulmonary hypertension [ 23 ]. The mean Pulmonary Artery Pressure increases during OSA. The OSA patient performs a series of inspiratory efforts against a completely obstructed upper airway. These can last from 10 seconds to 2 minutes with negative pleural pressures that can go up to -60 mmH2O before resumption of ventilation. Such sleep related events result in hypoxemia, hypercapnia, variations in intrathoracic pressure and arousals associated with sympathetic upswings. The consequent changes in vascular tone and cardiac output modify the pulmonary artery pressure. Pulmonary Hypertension (PH) due to lung diseases is classified as group 3 PH [ 24 ]. Independent of OSA, obesity has been linked with pulmonary hypertension as well [ 25 ]. Two parameters were recorded on echocardiography in our bariatric population- Ejection Fraction (EF) and PASP (Pulmonary Artery Systolic Pressure), both showing no significant difference. OSA is a known risk factor for HTN [ 26 ], T2DM [ 11 ], CAD [ 27 ], CVA [ 28 ], Atrial fibrillation [ 29 ] and MDD [ 30 ]. Difference was not noted in any of these diseases. The study has certain limitations. The behavioral changes such as increased sedentary lifestyle and reduced physical exertion as a result of the coronavirus pandemic, might have affected the findings in the study. This was a single center study. Post-operative data was available only for weight and BMI, and not for other metabolic parameters such as A1C, TSH, cortisol, Vitamin D etc. We noted the following major strengths of this study. Majority of the patients in this study were Hispanic. The population was predominantly from the inner-city area. This population is underserved and has traditionally not been well studied. Conclusions No significant differences exist between patients with or without OSA, who qualify for bariatric surgery, either in pre-operative anthropometric or lab characteristics. Post-operatively, there exists no difference in the amount of weight loss achieved between patients with or without OSA. Abbreviations Afib- Atrial Fibrillation BMI- Body Mass Index CAD- Coronary Artery Disease Campylobacter Like Organism test - CLO test CVA- Cerebrovascular accident EF- Ejection Fraction EGD- Esophagogastroduodenoscopy EWL 6 %- Excess Weight Loss % at 6 months EWL 12 %- Excess Weight Loss % at 12 months HTN- Hypertension Kg - kilograms MDD- Major Depressive Disorder OSA- Obstructive Sleep Apnea PASP- Pulmonary Artery Systolic Pressure T2DM -Type 2 Diabetes Mellitus TSH- Thyroid Stimulating Hormone TWL 6 % - Total Weight Loss % at 6 months TWL 12 %- Total Weight Loss % at 12 months Declarations Competing interests: The authors declare no competing interests. Author Contribution Preparation of manuscript was done by A.J. Figures and tables were prepared by A.J. Data collection and tabulation was done by A.J, J.M, L.R.P. All authors were involved in the review of manuscript. Acknowledgement Dr Gilda Diaz-Fuentes for valuable inputs. Pravash Budhathoki and Siddarth Hanumanthu for tabulation and statistical analysis. Data Availability The datasets generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request. References Ogden, CL. et al. Trends in obesity prevalence by race and hispanic origin—1999–2000 to 2017–2018. JAMA.;324(12):1208. Sep 22 2020 Gami, AS. Caples, SM. Somers, VK. Obesity and obstructive sleep apnea. Endocrinol Metab Clin North Am;32(4):869–94. Dec 2003 Al Oweidat, K. Toubasi, AA. Tawileh, RBA. Tawileh, HBA. Hasuneh, MM. Bariatric surgery and obstructive sleep apnea: a systematic review and meta-analysis. Sleep Breath . 1;27(6):2283–94. Dec 2023 Zhao, J. Samaan, JS. Abboud, Y. Samakar, K. Racial disparities in bariatric surgery postoperative weight loss and co-morbidity resolution: a systematic review. Surg Obes Relat Dis;17(10):1799–823. Oct 2021 Prevalence of obesity among New York State adults by county. https://www.health.ny.gov/statistics/prevention/injury_prevention/information_for_action/docs/2021-02_ifa_report.pdf 2021 Xie, W. Johnston, SS. Waggoner, JR. Doshi, ID. Stokes, AC. Bariatric surgery and weight loss in the short- and long‐term: Evidence from NHANES 2015–2018. Clin Obes.;13(1):e12563. Feb 2023 Adams, ST. Salhab, M. Hussain, ZI. Miller, GV. Leveson, SH. Roux-en-Y gastric bypass for morbid obesity: what are the preoperative predictors of weight loss? Postgrad Med J. 1;89(1053):411–6. Jul 2013 De Raaff, CAL. et al. Predictive factors for insufficient weight loss after bariatric surgery: does obstructive sleep apnea influence weight loss? Obes Surg;26(5):1048–56. May 2016 Guggino, J. et al. Bariatric surgery short-term outcomes in patients with obstructive sleep apnoea: the severe obesity outcome network prospective cohort. Int J Obes;45(11):2388–95. Nov 2021 Mihalache L, et al. The influence of obstructive sleep apnea syndrome on anthropometric parameters at 12 months after laparoscopic sleeve gastrectomy. Sci Rep . 11;11(1):5781. Mar 2021 Kent. BD, et al. Diabetes mellitus prevalence and control in sleep-disordered breathing. CHEST ;146(4):982–90. Oct 2014 Reutrakul. S, Mokhlesi, B. Obstructive sleep apnea and diabetes. Chest;152(5):1070–86. Nov 2017 Eisenberg. D, et al. 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): Indications for metabolic and bariatric surgery. Surg Obes Relat Dis;18(12):1345–56. Dec 2022 Bahammam, SA. Sharif, MM. Jammah, AA. BaHammam, AS. Prevalence of thyroid disease in patients with obstructive sleep apnea. Respir Med.;105(11):1755–60. Nov 2011 Sanyal, D. Raychaudhuri, M. Hypothyroidism and obesity: an intriguing link. Indian J Endocrinol Metab.;20(4):554. 2016 Loh, HH. et al. Obstructive sleep apnea and vitamin D: an updated systematic review and meta-analysis. Hormones. 22(4):563–80. Dec 2023 Pereira-Santos, M. Costa, PRF. Assis, AMO. Santos, CAST. Santos, DB. Obesity and vitamin D deficiency a systematic review and meta-analysis. Obesity Reviews, 16 (4), 2015. Gómez, V. et al. Routine screening endoscopy before bariatric surgery: is it necessary? Bariatr Surg Pract Patient Care.;9(4):143–9. Dec 2014 Khazaie, H. Sharafkhaneh, A. Maroufi, A. Khazaie, S. Ghadami, MR. Obstructive sleep apnea and helicobacter pylori infection: is there a link? Scandinavian Journal of Sleep Medicine. 1(1): 21–26. 2021 Gultepe, B., Günbatar, H., & Dülger, A. C. Helicobacter pylori seroprevalance in patients with obstructive sleep apnea syndrome. Eastern Journal of Medicine, 19(1), 13–15. 2014 Unal, M. Ozturk, L. Ozturk, C. Kabal, A. The seroprevalence of helicobacter pylori infection in patients with obstructive sleep apnoea: a preliminary study. Clin Otolaryngol Allied Sci;28(2):100–2. Apr 2003 Shah, S. et al. Diagnosis and treatment patterns among patients with newly diagnosed helicobacter pylori infection in the United States 2016–2019. Sci Rep;13(1):1375. Jan 25 2023 Adir, Y. Humbert, M. Chaouat, A. Sleep-related breathing disorders and pulmonary hypertension. Eur Respir J ;57(1):2002258. Jan 2021 Humbert, M. et al. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J;43(38):3618–731. Oct 11, 2022 Frank, RC. et al. Obesity is associated with pulmonary hypertension and modifies outcomes. J Am Heart Assoc;9(5):e014195. Mar 3, 2020 Carlson, JT. Hedner, JA. Ejnell, H. Peterson, LE. High prevalence of hypertension in sleep apnea patients independent of obesity. Am J Respir Crit Care Med;150(1):72–7. Jul 1994 Peker, Y. Carlson, J. Hedner, J. Increased incidence of coronary artery disease in sleep apnoea: a long-term follow-up. Eur Respir J;28(3):596–602. Sep 1, 2006 Wu, Z. Chen, F. Yu, F. Wang, Y. Guo, Z. A meta-analysis of obstructive sleep apnea in patients with cerebrovascular disease. Sleep Breath. 22(3):729–742. Sep 2018 Gami, AS. et al. Association of atrial fibrillation and obstructive sleep apnea. Circulation;110(4):364–7. Jul 27, 2004 Stubbs, B. et al. The prevalence and predictors of obstructive sleep apnea in major depressive disorder, bipolar disorder and schizophrenia: A systematic review and meta-analysis. J Affect Disord;197:259–67. Jun 2016 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4414267","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":308393761,"identity":"6368a818-7897-44f0-805d-c14572ce7061","order_by":0,"name":"Abhishrut Jog","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIie3SsYrCMBjA8e8jUBera2/QvkKlIBzeca9iEZx08gUKQl2is3KDbyG3XUrAqTgLERdHl3Sr4mBK0THtKJj/kGTIjyQQAJPpFXPqwDDMVwxAqsmqVSVqAlzmhFQgUBAAkg9QRpq/8zi+/B2Df+T8/HXduA0CKNOR5pDDrs/tZBJQ2A5744XoRATIx2qjOWY/8jhGfUWSrj+mAhWxiK0hriLx5UE+qfgpJZ4izC6If4JMBKWkc0g8rohP2XaI81AMIoJT7VvagvqpulhrtuRcZjfxvZ5NY5nqnv/MYZaDUb4qPkOFmiGRcKu42WQymd6qO2hqWg2qeOHYAAAAAElFTkSuQmCC","orcid":"","institution":"BronxCare Hospital","correspondingAuthor":true,"prefix":"","firstName":"Abhishrut","middleName":"","lastName":"Jog","suffix":""},{"id":308393762,"identity":"079b69ec-9218-4fc0-a7e9-e00941e70765","order_by":1,"name":"Jorge Mosquera","email":"","orcid":"","institution":"BronxCare Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jorge","middleName":"","lastName":"Mosquera","suffix":""},{"id":308393763,"identity":"b567086f-4245-409d-a7e8-4b0ae9763c8b","order_by":2,"name":"Luis Rodriguez Piedra","email":"","orcid":"","institution":"BronxCare Hospital","correspondingAuthor":false,"prefix":"","firstName":"Luis","middleName":"Rodriguez","lastName":"Piedra","suffix":""},{"id":308393764,"identity":"505a9bdc-26bb-4aff-ba3b-938272fc91ba","order_by":3,"name":"Ajit Singh","email":"","orcid":"","institution":"BronxCare Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ajit","middleName":"","lastName":"Singh","suffix":""},{"id":308393765,"identity":"a2a1eadb-6993-491a-87fa-6098155bcc82","order_by":4,"name":"David Fan","email":"","orcid":"","institution":"BronxCare Hospital","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"","lastName":"Fan","suffix":""},{"id":308393766,"identity":"bd458b6c-c883-4d66-94d8-19193cb1145e","order_by":5,"name":"Vincent Grbach","email":"","orcid":"","institution":"Mount Sinai Hospital","correspondingAuthor":false,"prefix":"","firstName":"Vincent","middleName":"","lastName":"Grbach","suffix":""},{"id":308393767,"identity":"ba22f619-5c1a-4c1a-931f-bc07fba95c9a","order_by":6,"name":"Dmitry Lvovsky","email":"","orcid":"","institution":"BronxCare Hospital","correspondingAuthor":false,"prefix":"","firstName":"Dmitry","middleName":"","lastName":"Lvovsky","suffix":""}],"badges":[],"createdAt":"2024-05-13 15:40:34","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4414267/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4414267/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":57722287,"identity":"37529297-9a69-4b9c-abc5-b8d517c714e7","added_by":"auto","created_at":"2024-06-04 19:02:04","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":48488,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of patients. OSA = Obstructive Sleep Apnea. Out of 122 patients who underwent bariatric surgery, 14 patients had no sleep study. 108 patients were included in the final analysis, of which 75 had OSA and 33 did not. Severe, moderate and mild OSA were seen in 34, 20 and 21 patients respectively.\u003c/p\u003e","description":"","filename":"Figure1manuscript.png","url":"https://assets-eu.researchsquare.com/files/rs-4414267/v1/ac5f20b991092092a826bbdd.png"},{"id":57751884,"identity":"5a1bd8be-c48a-437c-be2a-3d801409783a","added_by":"auto","created_at":"2024-06-05 07:19:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":540080,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4414267/v1/adcf3ba9-e70b-4fd5-a4a3-15ae037d64d7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Characteristics of patients undergoing bariatric surgery in an underserved minority population - Does OSA affect postoperative weight loss?","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn a study of the National Health and Nutrition Examination Survey (NHANES) database, Ogden et al, showed that over the last two decades, the prevalence of obesity has increased among men and women in the U.S. The study also showed that there was a greater increase in obesity in Mexican American men that non-Hispanic White men [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Obesity remains the strongest risk factor for development of Obstructive Sleep Apnea and both diseases increase cardiovascular risk [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Bariatric surgery is now recognized as an important option for permanent and sustainable weight loss [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere is scarcity of data available on Hispanic patients undergoing bariatric surgery. Zhao et al, in their meta-analysis, found a total of 52 studies on the topic of post-operative weight loss comparing at least two races. Out of these 52 studies, only 20 studies included Hispanic patients. Some of these studies have less than 10% Hispanic representation, going as low as 4.7%. In addition, many studies have less than a year of follow up [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo address this data vacuum, the following study was undertaken. In New York City, the Burrough with the highest prevalence of obesity is the Bronx (30.5%) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The Burrough with the highest number of Hispanic and Black people is also the Bronx. As a result, the hospital where the study was conducted has a large pool of inner-city patients Hispanic or Black patients. This allowed analysis of outcomes and characteristics in this underserved and understudied population.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eObjectives:\u003c/h2\u003e \u003cp\u003eThe study aimed at finding out the various characteristics of patients qualifying for bariatric surgery, including, anthropometric measures and lab tests. It also aimed to find out if there existed any significant difference between bariatric candidates with OSA and without OSA based on these findings. Finally, the study aimed to analyze the post operative outcome of the bariatric surgery in these patients at 6 months and 1 year, with regards to weight loss.\u003c/p\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eThis was a single center, multi- surgeon study, retrospective study. The study protocol was approved by the Institutional Review Board (IRB 04132305). All research was conducted in accordance with guidelines set forth by the Belmont Report and the Common Rule (the federal policy for the protection of human subjects). No identifiable information of the study population has been provided in the manuscript. No intervention was performed on any subjects for the purpose of the study. Data were collected retrospectively, by electronic medical record review. Human Ethics and Consent to Participate declaration is not applicable.\u003c/p\u003e \u003cp\u003eAll the patients over the age of 18 years, that underwent bariatric surgery from January 2021 to February 2023 at BronxCare Hospital System, Icahn School of Medicine at Mount Sinai, New York, were considered in the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003ePre-operative data-\u003c/h2\u003e \u003cp\u003ePertinent information collected included demographics, sleep study findings (Apnea-Hypopnea Index, minimum oxygen saturation, duration of desaturation), type of bariatric procedure, comorbidities such as hypertension (HTN), Type 2 Diabetes Mellitus ( T2DM), Coronary Artery Disease (CAD) Cerebrovascular accident (CVA), atrial fibrillation (Afib), Major Depressive Disorder (MDD), pre-operative anthropometric measurements \u0026ndash; weight (measured in kilograms \u0026ndash; kg), and body mass index (BMI). Pre-operatively, certain laboratory parameters were collected- HbA1C, Serum cortisol, serum Thyroid Stimulating Hormone (TSH), Serum Vitamin D. Included patients underwent pre-operative Echocardiography and data on the Ejection Fraction (EF) and Pulmonary Artery Systolic Pressure (PASP), were collected. Included patients also underwent pre-operative Esophagogastroduodenoscopy (EGD). Data were collected on the EGD findings and Helicobacter pylori testing using Rapid Urease Test (CLO test- Campylobacter Like Organism test).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003ePost-operative data-\u003c/h2\u003e \u003cp\u003ePost-operative anthropometric measurements of weight and BMI were noted at 6 months and 12 months.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eCalculations-\u003c/h2\u003e \u003cp\u003eSix values were calculated based on the pre- and post-operative anthropometric measurements - Excess Weight Loss % at 6 months (EWL6), Excess Weight Loss % at 12 months (EWL12) as per Eq.\u0026nbsp;(1), Total Weight Loss % at 6 months (TWL6), Total Weight Loss % at 12 months (TWL12) as per Eq.\u0026nbsp;(2), Change in BMI % at 6 months (Delta BMI 6) and change in BMI % at 12 months (Delta BMI 12) as per Eq.\u0026nbsp;(3).\u003c/p\u003e \u003cp\u003e1) \u0026nbsp; Excess Weight Loss:\u003c/p\u003e\n\u003cp\u003e\u003cimg 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\" width=\"524\" height=\"74\"\u003e\u003c/p\u003e\n\u003cp\u003e2) \u0026nbsp; Total Weight Loss:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cimg src=\"data:image/png;base64,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\" height=\"70\" width=\"531\"\u003e\u003c/p\u003e\n\u003cp\u003e3) \u0026nbsp; Change in BMI:\u003c/p\u003e\n\u003cp\u003e\u003cimg src=\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAgQAAABICAYAAACJB+2oAAASZElEQVR4Ae2dC5ITORZF2QuLYS0shZWwENbBWmriMH2ay2sp7XLZ4EquItzKlN7nviPZEnRPzIeXthIogRIogRIogb+ewIe/nkABlEAJlEAJlEAJvPRC0E1QAiVQAiVQAiXQC0H3QAmUQAmUQAmUwEsvBN0EJVACJVACJVACvRB0D5RACZRACZRACbz0QtBNUAIlUAIlUAIl0AtB90AJlEAJlEAJlAAE+r8y6D4ogRIogRIogRLohaB7oARKoARKoARKoH9D0D1QAiVQAiVQAiXQf2XQPVACJVACJVACJQCB/jcE3QclUAIlUAIlUAK9EHQPlEAJlEAJlEAJvOJvCD5+/Pjy4cOH/3y+fPnyKo7fvn37EeP79+//+n39+vXf59c+kH+l69OnT7+E4p0adg09xFHLSufO99pxNKy0Mka+Mzbqcq1Zq6M1eEv972kfvKXOa3zdw9fY/kmb1JnfvXtruuY75/c9NU0dnz9//mX/8n1m7FLD7iju9L9kq1brumQ/47/1nbx+p401NVHzs7V7/hatGNyrXs+iGc9x13119uY5fcsaXP2vDEi0EoC4a74UFufGcUNd+6XSf/a7Qwa9qYs8cyxjMU8tfrmmzrS99XlXKzkfucFu1ftWv0cw3Gl6T/tgV8M9xt1L94j1yBi778Ijcub32vhy8nfIvcpvhGPa0mPPHB/bNTWwL/N3SN9dfymmutFLU7fvu7j3Gofl/K1aaYATtTxLU6Nru/u9uFYv8XIvXOt3yQ59Mp62uY+1Yz/Y5t5B32v2HnHefCFQ2LUbci7MLMLiru13C+sX2DjmWS0imgCXwKdO47ylV8MqBrqo5UztEQx3fN7TPtjVcI9xD4x7xHpkjKPvwr3z5vc6Y/Od8wfVvco+Wn0P1Zu/H45lzPlMbg+hObd6vxRz9TvBb9drf/hXuY/G3FfUM2uCF7qzyfM1taf/vZ+nnt3vxWvyUrP75zV+O1s0yZc+20pvcp/14etYxrn0/GvWA+vVRtR8bmIvCRaXm0WR2DCuTX7RHLNPf3Par0Axx0JlTDXyxZmLyJi6nPN9t6FTuzrtjaFGezX4nr18ZYcm42nnO33W5jxjaeM4PXPoyvmpc27InEdPasLWuBlTXfJzjli5VowbQ53q8z3zYU/MXcvYaUNMNTHuGhA762OOMXU75/tuH2Sua56NZ63ymb5Hazl90U2b4/Iyp7m014dc8HM+eanLOfqc3+3XqQU/xmj53TGW8+owr70aeTenmoh31Iw9bYipJhnRq0l78pFj7jH3knazJ/bUZh610xOXhq3jUwPz1k2M17S5FuYjBnPkMvfUax5syKt+tBy1IzvrmLoYZ2/KIPcpuXIOm+SAbuatg3n91WJc8rqWGXMyzzl88cvG+46XvlMjcXbsnJNL5iIen2zWxRg+Uz/jxEwN6b96vsuFALiCycU2IYUo1iKE4kJqi11uWO3nYmjvwvpuT5wEYR7G1Kot0Gj05jGvOrV9S6+GGYMa3AzyW2lMLvoYi3pzw/BsXdgwv6rPemc8fLA3p/FWTNWgdn0mQ8bRQctn/ZNP7hnmja1efexX8Zh7tn0gk1wb2VrL0Vrqn/sy1xU+GVt7ehvz5KRp77owxjrkO/auKfM8m8N1yf1qztQ4a8y1JibxXNt8Zi7jmU9b5udeYSzbjMcc/jvNjCcv6vWTXGYNmZNn5pOb2mds9MnqKGZywMdPspgamMv4alCX875P//meGuZcvh+tiRomS3RaizaymvHU7Tzc8Pddf+NN3dSLPXFt6PGd+dQ3/fExB/2qEYscNPXubNNf2xybe4m5zI9ebGajBhnMudX73S8EQBBqJnSxJtj5BVgBw3dXlAuLzfykT+YBknmwUW/mmTqzlluf0TA1+q4eFzm1X1psbIkzG3XiS+PZOrXj3U2EPzVnIy5+NGx91kbNvtNnzskQLcawTnPmu88z/o4DeZmT5eyT5Z/eBzKxbtmhGZ2X1lL/ycY40z/r1SZjaJ/x5I/djjnriK+2PNsylmPm8X3qsn7mc1/Od+b4zIb/ZKrN3A++uxexm0wyB3bUlPsXn1mD+eyzJsZWXDLvpZjarnQnf/PTY4vubLkWPq+0pY/PajiyNya2q4bvXK/JFj+0E2tlz3zuE9aCTzberX3qZhwN2RgzxkpP2vo819hxe+aJSa8W53a9/HJ+tY7JJVlc8sv5+fwrkTkb7ytBTidIiwfA/FDoXBjs88tnzBlnB3O3cIyT342bechnPMbduNijkTZ1qustfWrYxclF1ga9k6Xv1LFjkPlW60etjJvTmLNHx27DOZc+rudkOHWmvpzTL2P6jN5VS/+cZxzfZ9kH1qYetcICrbs6khXP8uA52/wxWa27642WaW8s/Ji7tPcylr72zql1tw7YM0c+2mSUc1l7xk0b89vv5hhf7VV1q0XGc20Y199c2ROfWlaNufxodxRzcjHu1OU4PTnk6njG2a2/trNP3znHu/HQtGvytWbsVjW4d3c502fFLcdmjPRV5xzL9WFu1fyerOYYMy9arm0yTHv8pwY50jO3ynFJX+bg+S4XggS/Ep5JBUQRtPT1nYXI4nifMIzJOEWvWn4ZMg8aeBeovmk/dWpjjz/2q8/8AqbP0Q8Idmoivw2fI78dg6zZL5cx6dHJuDldk7TxmfzEy8YY9Sd/ntU6GU6d5idm6tMvc116nrHTPtc1mZCHd+vXJ+3VsmJDztX6O5ZcjL2Lhw7i7epI3cbyh4N8MndMm+TqmPWiZdprgx9zxDW2c9lnLMcdS47mkeOsJ22JY379jC0n36/pZ2x9kvVcF/IwRu3Y0dKe91mDce3JS4xsjPExpnm1O4qpbcbjGUarvcbcqnbjsBaT74w939N3zhmL/qi5P6wZ28mWMffuLmf6rLjl2IyRvmpdjTHHHnDdZm3uU2PMnpj6zrnduxxzfvU9tCbs8FntAXIn54y5en7zhWAuLsJZiF2ziNUPw5wjhvEBu2q7RcQ2YeTmcG5Cxt4FX2lZ5X/N2NSw8rXeXMSjGomx2kCM+4XymXqz5Vpl7Wnjc9oyttLJOHHMMxmu6sCecXr3xC62Wlb9KrZ2xJbnXAP1qtkaHrUPZKKe1EjOa9ZSH3t8/DGY/rNefNQAZ+1lz3zyP+I6bdUz9wrjc42nLtYBLTbssZl2q9j67PoZWztz8J5MeGeOXPjKhjE5YzO1Gdd+5p3+2Mnf/XBNTG3Nk3U4Zp+/AY6Zk/d8dv6on5y0RcOs17nZ5/5ybsVG7St7/HIvrLjl2NS9yrcaU5/5yJntqGZ1w5hapm/GyefVmqy05disj3irscyzen7zhQAgWagQEGuzQAROkblo+mJjAyQ5Mp5z9AnlaDzzYIfmuZj5PnVm7Fufp4ZVnBUD7CZn9cGWBifi26zPdznKVn/f4UgO8tuIhx+NeBmfseTFO/Op0xzGXK2VOmdsx38k/+cfs8acW8Vmfo6Th9g288iR8axr1qDfrb3x5EocNOT7rFON2Ppdkilj1CQ/59VnvlmfDLTXf8bjPdeU94y52q+TufbEUfdch2RODuMyjr/NcXLYrCHtnKOfsZ3LcTWqzzy5LrOuWYNx7Zlf6XTeHFnjpZjEw96m7lxf5+gnG3Oqy/n0OXo2n5xWOY78mVNDrtdkix3s1ZnfgVXOFbccm7pX+XJsfifJCXf1ZB3JgnFbfo/Nv1snfeh3a5L5ZZjxqJePjfx+zx271P/cWRcsCY6g+UlAhlBs2gpNML5bPLY04qUf87NQ86zs0zftcnMwro60wVfAzqsz7W59nhpWcWRH/tmyNp6nzVyj9HdzZIzpP9nn5mJj5Tuxc+2Ii//8IqmJOT68Z5Oz3HOOWKn3aHNP7emXMecamD9t8FWP8/faB8bL2iYTtMjNOlLfrHWuiz6zBseTo2uYemY8cutrTx203X6d+rVTk3mJZ3znfgz8c9FZsTGWWuiP1ift8hmONtcl48AhbXhOPXMvGcueetKecXxSg7WYZ3IxVvZpQ6zJLW15nvbmyrnps3vfccqa8tl9kvGsOecmW+xhl1pzj5Ij/VdrMceIhx8xV/nm2Fyr1II+3rFZNX1zDvupO+d9dr18t5ebfKce7KwRm5024636qy8EK+eOvR8C88v1fpSfS+nqB/VPVrj78fmTms6Umx/mvGScqba/vRYO3EuXsffGqBeC97ZiN+rtheBGcHd264XgzkCfPBx/isu/kXlyuZV3JQG+x/ymnq31QvCbVtS/5mn/33/tVCZl0j3QPfCe98BvOkYenqYXgocjboISKIESKIESeH4CvRA8/xpVYQmUQAmUQAk8nEAvBA9H3AQlUAIlUAIl8PwEeiF4/jWqwhIogRIogRJ4OIFeCB6OuAlKoARKoARK4PkJ9ELw/GtUhSVQAiVQAiXwcAK9EDwccROUQAmUQAmUwPMT6IXg+deoCkugBEqgBErg4QR6IXg44iYogRIogRIogecn0AvB869RFZZACZRACZTAwwn0QvBwxE1QAiVQAiVQAs9PoBeC51+jKiyBEiiBEiiBhxPoheDhiJugBEqgBEqgBJ6fQC8Ez79GVVgCJVACJVACDyfQC8HDETdBCZRACZRACTw/gV4Inn+NqvDBBL58+fKy+/9iZ+5vad+/f3/59u3bj3K/fv36g8kjajf2ZP7x48df0n3+/PmiBmK4Rujn3Rp+CdaXEiiBiwR6IbiIqAZnJ8CBMg8javaA4QA7e7PW33GYeiGYTD99+vTCx8aFgHXJMefoGWe+F4Kk0ucSuJ1ALwS3s6vnSQjsLgSUx6G0O5BOUv6PMp7hQsBlhD/h22QPf/Rl470XgiTS5xJ4O4Gf3763x2qEEniXBK69EPCnUf8aO/9qmoOJdz/z8FpByTgZC1viqcmY/inYWP4pezWPrYcl8+Qyrvb2jHsZcAx/4zNv3T+C/PMPD29rxUd/+qO/VcnYq5iOeSEgNp9sauzfECSVPpfA2wj0QvA2fvU+AQEOFw6W2Tz0PNyw4bDLxsHLx6YP/a5x0GU+D0h9iEceD0EPbN+19zAmD/E8+LGbh7KHa2rCRh9zqMEc2Oez/hnPfM7Rp/4c53kVj3HqZs5mDrQlL+Z5d1wuswbjtC+BEriOwK+/btf51KoETkXAA41DbH7ygMpDFwAe/hMGB5kH7ZzbHVoeftjPSwZjaPRQpE9dzKcW68nc5J2NPOqcuuahDZfMme88e5EwB7bqdcze2JM17x7u2E4m5qBHO40c+swazNe+BErgOgK9EFzHqVYnJpCH7VGZefhgd3SweWDNeB7c84BODXlQ668f76uD1DHiZiz97ZnTll6d8zC1Nv3ycM45/TJmPuufffqvxj34Mye6vbzQE4OWa6IW/TN2n0ugBC4T6IXgMqNanJzA0QGapefhwziHEmO75iHuAYmtYxxe2VLDNReCo0MvY5mDMXU4Rp5rLwTqxjf1eQjPesyx6ncXAmyTcV4IiC9r6jBf2qvliM1KT8dKoAT+T6AXgu6Ev57A6gBdQcnDh3kPSQ+nlc8c2x1aefjlQa1/apw6tLFPW8c4RP1TtWPEufZCgI95iZWH7iq2OVb9pQuBOpOJ+Vdj1EvbsV1p6FgJlMB/CfRC8F8mHfnLCKwO0BUCD8Sc40BlPBsHJAfXrjGHjc0D0kOWmHnIetB5UE574mTMVT1Tu/avuRAQF12zXsfzYrTiMuv13d66fEej+hgzD70t65KTHLVpXwIlcB2Bn79K19nXqgROR4ADZh5yqyLz8Ml5D3AOSz55YKVdPnsg65OHGPHmvJcBY3h46p/6V/UQX1t64mPHs806mDO+c/QeuKv6jGWOPMgzBs/G1jb7vFSgI+OYP21yTZxPljN330ugBPYEfv4a7G06UwIl8BsJeCH4jSmbqgRKoAReeiHoJiiBJyPQC8GTLUjllMBfQqAXgr9koVvm+yHQC8H7WasqLYEzEeiF4Eyr2VpKoARKoARK4EYCvRDcCK5uJVACJVACJXAmAr0QnGk1W0sJlEAJlEAJ3EigF4IbwdWtBEqgBEqgBM5EoBeCM61maymBEiiBEiiBGwn0QnAjuLqVQAmUQAmUwJkI9EJwptVsLSVQAiVQAiVwI4FeCG4EV7cSKIESKIESOBOBXgjOtJqtpQRKoARKoARuJNALwY3g6lYCJVACJVACZyLQC8GZVrO1lEAJlEAJlMCNBHohuBFc3UqgBEqgBErgTAR6ITjTaraWEiiBEiiBEriRQC8EN4KrWwmUQAmUQAmciUAvBGdazdZSAiVQAiVQAjcS+B+zBV8gvB6RPwAAAABJRU5ErkJggg==\" height=\"72\" width=\"516\"\u003e\u003c/p\u003e\u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData were analyzed using the STATA software. Mean values were calculated for all the numerical data. Chi square testing was applied to categorical variables. T test was applied for continuous variable. A p value of less than 0.05 was considered significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":" \u003cp\u003eA total of 122 bariatric surgeries were performed at the hospital in the study period. 108 patients out of the screened patients had a pre-operative sleep study. Preoperative weight data was not available for one patient in the OSA group. 6-month postoperative weight data was not available for 5 patients in the OSA group. 12-month postoperative weight data was not available for 21 patients in the OSA group and 7 patients in the non-OSA group. Analysis of anthropometric measures was accordingly done on the available data.\u003c/p\u003e \u003cp\u003e69.4% had OSA (75/108) and 30.6% (33/108) patients had no OSA. 45.3% (34/75) had mild OSA, 26.7% (20/75) had moderate OSA and 28% (21/75) had severe OSA. 88% of the participants were female (99/ 108). Mean age in the cohort was 41.9 +/- 10.8. 85.2% (92/108) of the total patients were Hispanic, 14% (15/108) were Black. There were no active smokers (15.7% former smokers and 84.3% never smokers).\u003c/p\u003e \u003cp\u003eMean pre-operative weight was 111.2 +/- 20 kg in those without OSA and 115.9 +/- 22.6 kg in those with OSA. Mean preoperative BMI was 42.3 +/- 6.6 in the group without OSA and 44.5 +/- 15 in the group with OSA.\u003c/p\u003e \u003cp\u003eIn the group without OSA, the respective TWL6 and TWL12 were 26.7 +/- 8.5 and 28.3 +/- 9.2 and in the group with OSA the respective values of TWL6 and TWL 12 were 26.8 +/- 13.6 and 31.1 +/- 16.2 (p value for TWL6 was 0.9 and for TWL12 was 0.4) .\u003c/p\u003e \u003cp\u003eIn the group without OSA, the respective EWL6 and EWL12 were 49.4 +/- 14.3 and 54.7 +/- 18.4 and in the group with OSA the respective values of EWL6 and EWL 12 were 44.9 +/- 13.9 and 51.7 +/- 15.7 (p value for EWL6 was 0.1 and for EWL12 was 0.5).\u003c/p\u003e \u003cp\u003eIn the group without OSA, the respective Delta BMI 6 and Delta BMI 12 were 10.11 +/- 3.7 and 10.8 +/- 4.4 and in the group with OSA the respective values of Delta BMI 6 and Delta BMI 12 were 11.2 +/-15.3 and 13.1 +/- 17.3 (p value for Delta BMI 6 was 0.7 and for Delta BMI 12 was 0.5).\u003c/p\u003e \u003cp\u003eBetween the group without OSA and with OSA, no statistically significant difference was noted in the mean HbA1C ( 6.2 +/- 1.1 vs 6.1 +/- 1.1, p\u0026thinsp;=\u0026thinsp;0.9), TSH ( 1.85 +/- 1 vs 2.3 +/- 2.3), serum cortisol (1.4 +/- 2.3 vs. 1.1 +/- 2.3, p\u0026thinsp;=\u0026thinsp;0.7) Vitamin D ( 18.1 +/- 6.5 vs 21.4 +/- 9.2, p\u0026thinsp;=\u0026thinsp;0.07), EF ( 65% +/- 5.9 vs 65% +/- 6, p\u0026thinsp;=\u0026thinsp;0.8), PASP ( 36.8 +/- 9 vs. 40.2 +/- 8.3, p\u0026thinsp;=\u0026thinsp;0.1), CLO test ( 45.5% vs. 43%, p\u0026thinsp;=\u0026thinsp;0.8).\u003c/p\u003e \u003cp\u003eAbnormal EGD findings were seen in 54.6% (59/ 108) patient. In descending frequencies, the abnormal EGD findings were mucosal erythema in 29.6% (32/ 108), gastritis in 11.1% (12/108), hiatal hernia in 4.6% (5/108), gastric ulcer in 3.7% (4/108), gastric polyp in 2.7% (3/108), and esophagitis in 2.7% (3/108).\u003c/p\u003e \u003cp\u003eActive MDD requiring medication was seen in 7.4% (8/108) patients.\u003c/p\u003e \u003cp\u003eThe results are presented below in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The types of surgeries performed are given in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResults. The mean values with the standard errors are provided in the table. Chi square testing was applied to categorical variables. T test was applied for continuous variable. A p value of less than 0.05 was considered significant. The test used to generate the p value is shown in parentheses next to each p value. c\u0026thinsp;=\u0026thinsp;Chi square test. t\u0026thinsp;=\u0026thinsp;T test.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo OSA (33)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOSA (75)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal (108)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 +/- 11.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.3 +/- 10.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41.9 +/- 10.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.05 (t)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (3%)\u003c/p\u003e \u003cp\u003e32 (97%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (16%)\u003c/p\u003e \u003cp\u003e63 (84%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (12%)\u003c/p\u003e \u003cp\u003e95 (88%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.06 (c)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eHispanic\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eBlack\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eWhite\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (88%)\u003c/p\u003e \u003cp\u003e3 (9%)\u003c/p\u003e \u003cp\u003e1 (3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63 (84%)\u003c/p\u003e \u003cp\u003e12 (16%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e92 (85.2%)\u003c/p\u003e \u003cp\u003e15 (14%)\u003c/p\u003e \u003cp\u003e1 (0.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSmoking status\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eFormer smoker\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eNever smoker\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (18%)\u003c/p\u003e \u003cp\u003e27 (82%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (16%)\u003c/p\u003e \u003cp\u003e63 (84%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (16.7%)\u003c/p\u003e \u003cp\u003e90 (83.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreop weight\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e111.2 +/-_ 20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e115.9 +/- 22.6\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e114.7 +/-_ 21.6\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;107)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.3 (t)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreop BMI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42.3 +/- 6.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.5 +/- 15\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43.9 +/- 13\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;107)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.4 (t)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTWL 6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.7 +/- 8.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.8 +/-13.6\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.8 +/- 12.2\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;103)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.9 (t)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTWL 12\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.3 +/- 9.2\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.1 +/- 16.2\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.2 +/- 14.3\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.4 (t)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEWL 6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49.4 +/- 14.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.9 +/- 13.9\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46.4 +/- 14.1\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;103)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.1 (t)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEWL 12\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54.7 +/- 18.4\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.7 +/- 15.7\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52.6 +/- 16.6\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.5 (t)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDelta BMI 6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.11 +/- 3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.2 +/- 15.3\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.8 +/-12.8\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;103)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.7 (t)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDelta BMI 12\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.8 +/- 4.4\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.1 +/- 17.3\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.3 +/- 14.5\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.5 (t)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHbA1c\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.2 +/- 1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.1 +/- 1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.1 +/- 1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.9 (t)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTSH\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.85 +/-_ 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.3 +/- 2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.2 +/- 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.3 (t)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCortisol\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.4 +/- 2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.1 +/- 2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.2 +/- 2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.7 (t)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVitamin D\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.1 +/- 6.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.4 +/- 9.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.4 +/- 8.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.07 (t)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHTN\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (34.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37 (34.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.9 (c)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eT2DM\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (24.24%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (21.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (22.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.7 (c)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCVA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCAD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (1.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAfib\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDepression\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (9.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (6.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (7.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.7 (c)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEF\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64.98 +/- 5.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.2 +/- 6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65.1 +/- 5.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.8 (t)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRVSP\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36.8 +/- 9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.2 +/- 8.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39.1 +/- 8.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.11 (t)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClo test\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (45.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (42.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47 (43.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.8 (c)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEGD\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eAbnormal\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eNormal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (66.6%)\u003c/p\u003e \u003cp\u003e11 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (50.7%)\u003c/p\u003e \u003cp\u003e37 (49.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59 (54. 6%)\u003c/p\u003e \u003cp\u003e49 (45.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.4 (c)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTypes of Surgery.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of Surgery\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRobotic gastric sleeve resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e91/ 108 (84.26%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRobotic Roux en Y gastric bypass\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8/ 108 (7.41%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaparoscopic sleeve gastrectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6/ 108 (5.56%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRevision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2/108 (1.85%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaparoscopic Roux en Y gastric bypass\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1/108 (0.93%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn eligible patients, bariatric surgery results in substantial weight loss. In a study on individuals between age 20 and 64 in NHANES comparing individuals who had bariatric surgery with those who were eligible for it, but did not get surgery, it was found that post- bariatric surgery, there is five times more likelihood of achieving at least 20% weight loss. Participants who had surgery had a reduction of 15.5 BMI units and a 31% weight loss compared to 4.4 BMI units and 9.9% weight loss in the eligible but not operated group. 86.2% of the operated patients achieved 20% weight loss compared to 15.3% of the non- operated group [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Most patients in our study (84.26%) underwent robotic gastric sleeve resection.\u003c/p\u003e \u003cp\u003eFactors that have been implicated as being impactful in post-operative weight loss include age, race, socioeconomic status, gender, marital status, behavioral disorders, pre-operative weight status, comorbidities such as diabetes mellitus, psychiatric illness, and sexual abuse, and institutional differences etc. Only a few are consistently supported in literature [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our review, we found a few studies that looked at OSA as a predictor of post-bariatric surgery weight loss. In the larger of the studies by de Raaff et al, 816 patients were analyzed retrospectively. Out of these, 522 (64%) had OSA and 294 (36%) did not have OSA. The study was aimed at evaluating the impact of OSA on % EWL at 12 months and BMI changes at 12 months after bariatric surgery. No information about ethnicity was available in the article. After adjustment for waist circumference, BMI, and age, no effect of OSA was seen on either the %EWL or BMI change at the end of 12 months [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In another study on a similar topic, Guggino et al analyzed 371 patients included in a prospective cohort, the Severe Obesity Outcome Network cohort. 210 out of these had moderate \u0026ndash; severe OSA, and 161 had no OSA. Multivariable analysis of the data showed that age, initial BMI, and surgery type were associated with differences in % EWL. OSA independently, was not shows to be associated with % EWL [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In a similar study by Mihalache et al. The authors analyzed a bariatric population that underwent laparoscopic sleeve gastrectomy. The primary outcome was % body fat change at 6 months and 12 months. The study revealed that patients with OSA had lesser loss of body fat as compared to patients without OSA. The weight loss experienced by both group of patients was the same. All participants in this study were Caucasian [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In our study, we noted a similar lack of difference in the weight loss attained between patients with and without OSA at the end of 6 and 12 months.\u003c/p\u003e \u003cp\u003ePrevalence of DM ranges from 6.6% in patients without OSA to 28.9% in patients with severe OSA, thus showing an increase with severity [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. OSA results in sleep fragmentation and intermittent hypoxemia, which in turn lead to increased sympathetic neural activity, oxidative stress, systemic inflammation, activation of hypothalamic pituitary axis and alternation of circulating adipokines. These result in insulin resistance and beta cell dysfunction culminating to diabetes. Even in patients without T2DM, severity of OSA has been shown to be independently associated with insulin resistance. In reverse, the neuropathy that DM induces, can affect the central control of respiration and upper airway neural reflexes. This can lead to emergence of sleep apnea. Hence, the relationship between OSA and DM has been cited as being bi-directional [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Bariatric surgery results in improvement in obesity and drop in AHI. This is thought to be beneficial in the control of DM [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The American Society of Metabolic and Bariatric Surgery (ASMBS) now recommends bariatric surgery for individuals with BMI of 30-34.9 with metabolic disease including hyperglycemia that does not respond to non-surgical options [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In our study, no significant difference was noted in the A1C levels or the prevalence of diabetes mellitus in the two groups.\u003c/p\u003e \u003cp\u003eHypothyroidism is associated with OSA. Deposition of muco-proteins in the upper airway resulting in upper airway obstruction, neuropathy induced disruption of the regulatory control of pharyngeal dilator muscles and respiratory center depression have been cited as possible causes of OSA in hypothyroidism. Prevalence of hypothyroidism in OSA is low (0.4%), but subclinical hypothyroidism seems to be more common in OSA (11.1%) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. TSH levels are positively correlated with BMI [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In our study we noted that the mean TSH level in the OSA group was higher than the non-OSA group, although the difference did not reach statistical significance (2.3 +/- 2.3 vs 1.85 +/- 1)\u003c/p\u003e \u003cp\u003eA meta-analysis from 2023 including 5592 individuals from 18 observational studies found a lower levels of Vitamin D in patients with OSA compared to those without (18.2 +/- 5.6 ng/ml vs. 23.2 +/- 4.3 ng/ml). The effect was significant only in people with moderate to severe OSA, and not in mild OSA [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].Similarly, another meta-analysis, reveals a 35% higher prevalence of vitamin D deficiency in obese subjects [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Perception of low social acceptance leading to decreased outdoor activities and increased use of clothes to cover more body is one theory cited to explain vitamin D deficiency in the obese. Sequestration of cholecalciferol by excess fat, and greater local use of 25 (OH)D are other theories in obese individuals [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Hypoxia induced in OSA is related to vitamin D deficiency via HIF 1 alpha (Hypoxia inducible factor 1 alpha) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. There was no significant difference in the vitamin D levels between the 2 groups in our study. One of the possibilities for this, could be the smaller number of severe OSA patients in our study.\u003c/p\u003e \u003cp\u003eIn many centers esophagogastroduodenoscopy is routinely performed before bariatric surgery, the rationale behind this being that the bariatric procedure might alter the foregut anatomy. Gomez et al analyzed 232 patients cleared to undergo bariatric surgery, and noted abnormal findings in 61.6% patients, with 15.1% requiring medical management alterations and 1.7% requiring alterations in surgical management. The commonest finding on EGD was a small hiatal hernia (23.7%) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In our study, the commonest EGD finding was erythematous mucosa.\u003c/p\u003e \u003cp\u003eA few studies have demonstrated association between OSA and H pylori, whereas others have not [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].In our study the prevalence of H pylori infection was found to be 43% in the total cohort, with no statistically significant difference between the two groups. However, this is higher than the average H pylori prevalence of 36% in the country [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOSA is linked with pulmonary hypertension [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The mean Pulmonary Artery Pressure increases during OSA. The OSA patient performs a series of inspiratory efforts against a completely obstructed upper airway. These can last from 10 seconds to 2 minutes with negative pleural pressures that can go up to -60 mmH2O before resumption of ventilation. Such sleep related events result in hypoxemia, hypercapnia, variations in intrathoracic pressure and arousals associated with sympathetic upswings. The consequent changes in vascular tone and cardiac output modify the pulmonary artery pressure. Pulmonary Hypertension (PH) due to lung diseases is classified as group 3 PH [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Independent of OSA, obesity has been linked with pulmonary hypertension as well [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Two parameters were recorded on echocardiography in our bariatric population- Ejection Fraction (EF) and PASP (Pulmonary Artery Systolic Pressure), both showing no significant difference.\u003c/p\u003e \u003cp\u003eOSA is a known risk factor for HTN [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], T2DM [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], CAD [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], CVA [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], Atrial fibrillation [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] and MDD [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Difference was not noted in any of these diseases.\u003c/p\u003e \u003cp\u003eThe study has certain limitations. The behavioral changes such as increased sedentary lifestyle and reduced physical exertion as a result of the coronavirus pandemic, might have affected the findings in the study. This was a single center study. Post-operative data was available only for weight and BMI, and not for other metabolic parameters such as A1C, TSH, cortisol, Vitamin D etc.\u003c/p\u003e \u003cp\u003eWe noted the following major strengths of this study. Majority of the patients in this study were Hispanic. The population was predominantly from the inner-city area. This population is underserved and has traditionally not been well studied.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eNo significant differences exist between patients with or without OSA, who qualify for bariatric surgery, either in pre-operative anthropometric or lab characteristics. Post-operatively, there exists no difference in the amount of weight loss achieved between patients with or without OSA.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAfib- Atrial Fibrillation \u003c/p\u003e\n\u003cp\u003eBMI- Body Mass Index\u003c/p\u003e\n\u003cp\u003eCAD- Coronary Artery Disease \u003c/p\u003e\n\u003cp\u003eCampylobacter Like Organism test - CLO test \u003c/p\u003e\n\u003cp\u003eCVA- Cerebrovascular accident\u003c/p\u003e\n\u003cp\u003eEF- Ejection Fraction\u003c/p\u003e\n\u003cp\u003eEGD- Esophagogastroduodenoscopy\u003c/p\u003e\n\u003cp\u003eEWL 6 %- Excess Weight Loss % at 6 months \u003c/p\u003e\n\u003cp\u003eEWL 12 %- Excess Weight Loss % at 12 months\u003c/p\u003e\n\u003cp\u003eHTN- Hypertension \u003c/p\u003e\n\u003cp\u003eKg - kilograms \u003c/p\u003e\n\u003cp\u003eMDD- Major Depressive Disorder\u003c/p\u003e\n\u003cp\u003eOSA- Obstructive Sleep Apnea\u003c/p\u003e\n\u003cp\u003ePASP- Pulmonary Artery Systolic Pressure \u003c/p\u003e\n\u003cp\u003eT2DM -Type 2 Diabetes Mellitus\u003c/p\u003e\n\u003cp\u003eTSH- Thyroid Stimulating Hormone\u003c/p\u003e\n\u003cp\u003eTWL 6 % - Total Weight Loss % at 6 months\u003c/p\u003e\n\u003cp\u003eTWL 12 %- Total Weight Loss % at 12 months\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCompeting interests:\u003c/h2\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003ePreparation of manuscript was done by A.J. Figures and tables were prepared by A.J. Data collection and tabulation was done by A.J, J.M, L.R.P. All authors were involved in the review of manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eDr Gilda Diaz-Fuentes for valuable inputs. Pravash Budhathoki and Siddarth Hanumanthu for tabulation and statistical analysis.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eOgden, CL. et al. Trends in obesity prevalence by race and hispanic origin\u0026mdash;1999\u0026ndash;2000 to 2017\u0026ndash;2018. JAMA.;324(12):1208. Sep 22 2020\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGami, AS. Caples, SM. Somers, VK. Obesity and obstructive sleep apnea. Endocrinol Metab Clin North Am;32(4):869\u0026ndash;94. Dec 2003\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl Oweidat, K. Toubasi, AA. Tawileh, RBA. Tawileh, HBA. Hasuneh, MM. Bariatric surgery and obstructive sleep apnea: a systematic review and meta-analysis. \u003cem\u003eSleep Breath\u003c/em\u003e. 1;27(6):2283\u0026ndash;94. Dec 2023\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhao, J. Samaan, JS. Abboud, Y. Samakar, K. Racial disparities in bariatric surgery postoperative weight loss and co-morbidity resolution: a systematic review. Surg Obes Relat Dis;17(10):1799\u0026ndash;823. Oct 2021\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrevalence of obesity among New York State adults by county. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.health.ny.gov/statistics/prevention/injury_prevention/information_for_action/docs/2021-02_ifa_report.pdf\u003c/span\u003e\u003cspan address=\"https://www.health.ny.gov/statistics/prevention/injury_prevention/information_for_action/docs/2021-02_ifa_report.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e 2021\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXie, W. Johnston, SS. Waggoner, JR. Doshi, ID. Stokes, AC. Bariatric surgery and weight loss in the short- and long‐term: Evidence from NHANES 2015\u0026ndash;2018. Clin Obes.;13(1):e12563. Feb 2023\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdams, ST. Salhab, M. Hussain, ZI. Miller, GV. Leveson, SH. Roux-en-Y gastric bypass for morbid obesity: what are the preoperative predictors of weight loss? \u003cem\u003ePostgrad Med J.\u003c/em\u003e 1;89(1053):411\u0026ndash;6. Jul 2013\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Raaff, CAL. et al. Predictive factors for insufficient weight loss after bariatric surgery: does obstructive sleep apnea influence weight loss? Obes Surg;26(5):1048\u0026ndash;56. May 2016\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuggino, J. et al. Bariatric surgery short-term outcomes in patients with obstructive sleep apnoea: the severe obesity outcome network prospective cohort. Int J Obes;45(11):2388\u0026ndash;95. Nov 2021\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMihalache L, et al. The influence of obstructive sleep apnea syndrome on anthropometric parameters at 12 months after laparoscopic sleeve gastrectomy. \u003cem\u003eSci Rep\u003c/em\u003e. 11;11(1):5781. Mar 2021\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKent. BD, et al. Diabetes mellitus prevalence and control in sleep-disordered breathing. \u003cem\u003eCHEST\u003c/em\u003e;146(4):982\u0026ndash;90. Oct 2014\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReutrakul. S, Mokhlesi, B. Obstructive sleep apnea and diabetes. Chest;152(5):1070\u0026ndash;86. Nov 2017\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEisenberg. D, et al. 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): Indications for metabolic and bariatric surgery. Surg Obes Relat Dis;18(12):1345\u0026ndash;56. Dec 2022\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBahammam, SA. Sharif, MM. Jammah, AA. BaHammam, AS. Prevalence of thyroid disease in patients with obstructive sleep apnea. Respir Med.;105(11):1755\u0026ndash;60. Nov 2011\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSanyal, D. Raychaudhuri, M. Hypothyroidism and obesity: an intriguing link. Indian J Endocrinol Metab.;20(4):554. 2016\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLoh, HH. et al. Obstructive sleep apnea and vitamin D: an updated systematic review and meta-analysis. Hormones. 22(4):563\u0026ndash;80. Dec 2023\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePereira-Santos, M. Costa, PRF. Assis, AMO. Santos, CAST. Santos, DB. Obesity and vitamin D deficiency a systematic review and meta-analysis. Obesity Reviews, 16 (4), 2015.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eG\u0026oacute;mez, V. et al. Routine screening endoscopy before bariatric surgery: is it necessary? Bariatr Surg Pract Patient Care.;9(4):143\u0026ndash;9. Dec 2014\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhazaie, H. Sharafkhaneh, A. Maroufi, A. Khazaie, S. Ghadami, MR. Obstructive sleep apnea and helicobacter pylori infection: is there a link? Scandinavian Journal of Sleep Medicine. 1(1): 21\u0026ndash;26. 2021\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGultepe, B., G\u0026uuml;nbatar, H., \u0026amp; D\u0026uuml;lger, A. C. Helicobacter pylori seroprevalance in patients with obstructive sleep apnea syndrome. Eastern Journal of Medicine, 19(1), 13\u0026ndash;15. 2014\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUnal, M. Ozturk, L. Ozturk, C. Kabal, A. The seroprevalence of helicobacter pylori infection in patients with obstructive sleep apnoea: a preliminary study. Clin Otolaryngol Allied Sci;28(2):100\u0026ndash;2. Apr 2003\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShah, S. et al. Diagnosis and treatment patterns among patients with newly diagnosed helicobacter pylori infection in the United States 2016\u0026ndash;2019. Sci Rep;13(1):1375. Jan 25 2023\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdir, Y. Humbert, M. Chaouat, A. Sleep-related breathing disorders and pulmonary hypertension. Eur Respir J ;57(1):2002258. Jan 2021\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHumbert, M. et al. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J;43(38):3618\u0026ndash;731. Oct 11, 2022\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFrank, RC. et al. Obesity is associated with pulmonary hypertension and modifies outcomes. J Am Heart Assoc;9(5):e014195. Mar 3, 2020\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarlson, JT. Hedner, JA. Ejnell, H. Peterson, LE. High prevalence of hypertension in sleep apnea patients independent of obesity. Am J Respir Crit Care Med;150(1):72\u0026ndash;7. Jul 1994\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeker, Y. Carlson, J. Hedner, J. Increased incidence of coronary artery disease in sleep apnoea: a long-term follow-up. Eur Respir J;28(3):596\u0026ndash;602. Sep 1, 2006\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWu, Z. Chen, F. Yu, F. Wang, Y. Guo, Z. A meta-analysis of obstructive sleep apnea in patients with cerebrovascular disease. Sleep Breath. 22(3):729\u0026ndash;742. Sep 2018\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGami, AS. et al. Association of atrial fibrillation and obstructive sleep apnea. Circulation;110(4):364\u0026ndash;7. Jul 27, 2004\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStubbs, B. et al. The prevalence and predictors of obstructive sleep apnea in major depressive disorder, bipolar disorder and schizophrenia: A systematic review and meta-analysis. J Affect Disord;197:259\u0026ndash;67. Jun 2016\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Sleep apnea, Obstructive, Bariatric Surgery, Health Disparity Population, Weight Loss","lastPublishedDoi":"10.21203/rs.3.rs-4414267/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4414267/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eObese patients are at increased risk of Obstructive Sleep Apnea (OSA). Bariatric surgery is an important therapeutic measure in obese patients for management of weight and management of comorbidities. There is a scarcity of data on OSA, in inner city Hispanic and Black patients who undergo bariatric surgery. Differences between patients with and without OSA have not been assessed in this population. The study aims to answer these questions.\u003c/p\u003e","manuscriptTitle":"Characteristics of patients undergoing bariatric surgery in an underserved minority population - Does OSA affect postoperative weight loss?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-04 19:01:59","doi":"10.21203/rs.3.rs-4414267/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8c88c0c9-f38e-46e0-8f2e-932338accc5a","owner":[],"postedDate":"June 4th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":32578682,"name":"Health sciences/Diseases/Endocrine system and metabolic diseases/Obesity"},{"id":32578683,"name":"Health sciences/Medical research/Outcomes research"}],"tags":[],"updatedAt":"2024-06-05T07:11:51+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-04 19:01:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4414267","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4414267","identity":"rs-4414267","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}