Bariatric Surgery Outcomes in People with Severe Obesity (BMI ≥ 50 kg/m2)

Bariatric Surgery Outcomes in People with Severe Obesity (BMI ≥ 50 kg/m2) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Bariatric Surgery Outcomes in People with Severe Obesity (BMI ≥ 50 kg/m2) Sarah Ying Tse Tan, Trilene Ruiting Liang, Jasmine Kai Ling Chua, and 11 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4528310/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 Introduction The benefits of metabolic bariatric surgery (MBS) in people with body mass index (BMI) ≥50kg/m 2 are not well-established, with concerns of increased risk and poorer weight loss. Optimal surgical type (gastric bypass [GB] versus sleeve gastrectomy [SG]) is unclear, with studies comparing complication rates, weight loss, and glycemic outcomes reporting mixed results. Methods Participants with BMI≥50kg/m 2 undergoing MBS (SG or GB) from 2008-2022 were recruited. Demographics, anthropometrics, biochemistry and diabetes status were analysed at baseline, 12-months, and 24-months post-operatively. Surgical outcomes and complications were analysed. Results The study included n=184 with BMI≥50kg/m 2 (57.6% female, age 38.6±10.5years, BMI 55.3±6.0kg/m 2 ). Pre-operatively, 21.1% had pre-diabetes and 33.2% had diabetes (mean HbA1c 8.0±1.7%). Most subjects (89.1%) underwent SG. The overall 30-day adverse event rate was 4.9%, higher in GB group (GB=15%, SG=3.7%, p=0.061). The GB group had longer length of stay (GB =4.5±0.6days, SG=3.1±0.2, p=0.023). The 30-day readmission rate was 2.2%, and rate of revisional surgery was 2.7%, with no significant difference between groups. The follow-up rate was 67.9% at 12-months, 51.1% at 24-months. Average %total weight loss at 12-months (27.4±9.0%, SG=27.6±9.0%, GB=26.0±9.4%, p=0.481) and 24-months (27.1±10.9%, SG=27.4±11.1%, GB=24.9±8.9%, p=0.495) were similar between groups. The GB group had a larger HbA1c reduction (3.2±1.1%) than SG (1.9 ±1.3%, p=0.030), but no difference in diabetes remission rates (69.2% at 12-months, 76.7% at 24-months). Conclusion MBS is safe and effective for individuals with BMI≥50kg/m 2 , with good weight loss and glycemic outcomes with both SG and GB. Complication rates were low, although higher in the GB group. Figures Figure 1 Key Points In individuals with BMI ≥50kg/m 2 undergoing MBS, %TWL at 12 and 24 months was similar between SG and GB groups. Diabetes remission rate was high at 12-months (69.2%) and at 24-months (76.7%), with no difference between SG and GB groups. The GB group had a greater HbA1c reduction at 24 months than the SG group. Overall 30-day adverse event rate was low at 4.9%, but higher in the GB group than SG group. Introduction Metabolic bariatric surgery (MBS) is an effective treatment option for people with clinically severe obesity, and has been shown to produce significant and durable long-term weight loss, improvement and resolution of obesity-related complications, and reduction in mortality.(1–3) The two most commonly performed procedures, the sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), are generally safe, with perioperative mortality rates ranging from 0.03% - 0.2%, and 30-day risks of serious adverse events of <6%.(4) However, the benefits and risks of MBS in people with very high body mass index (BMI) ≥ 50 kg/m 2 are not as well-established.(5) There is a higher burden of obesity-related complications such as diabetes, hypertension, and obstructive sleep apnoea,(6) potentially increasing the operative and anaesthetic risks in this population. Surgical anatomy may also be more challenging due to the higher amount of visceral adiposity, which could result in longer operating times and rate of surgical complications. Existing data on surgical complications post-MBS in people with BMI ≥ 50 – 60 kg/m 2 is mixed, with some studies reporting an increase in post-operative complications, 30-day adverse events, and mortality(6–9), and others reporting no difference in adverse outcomes.(10–12) Weight loss outcomes post-MBS in this population are also a concern, as a high pre-operative BMI is traditionally associated with less post-operative weight loss.(13) Lastly, there is no consensus on the recommended type of surgery in this population, with some studies advocating for RYGB due to potentially greater long-term weight loss(7,14), while others opt for SG, citing a lower rate of surgical complications.(9) Studies from Asia on MBS for people with very high BMI (≥ 50 kg/m 2 ) are scarce. At a given BMI, Asians have higher visceral adiposity than Whites (15), potentially increasing the technical difficulty of MBS in this population. Asians are also described to have inferior weight loss outcomes post-MBS compared to Whites.(16) Thus, the risks and benefits of MBS amongst Asian people with very high BMI (≥ 50 kg/m 2 ) require further assessment. This study aimed to evaluate the outcomes of MBS in people with very high BMI (≥ 50 kg/m 2 ), including post-operative complications, mortality, weight loss outcomes, and diabetes remission. Outcomes were also compared between people who underwent SG versus gastric bypass (GB). Methods Participants This study was conducted at a tertiary centre. Participants' information was collected prospectively from 2008 to 2022. Patients with BMI ≥ 50 kg/m 2 who underwent MBS were included in the study. The patients were managed by a multidisciplinary team: suitability for bariatric surgery was assessed according to the local recommended clinical guidelines and offered to eligible patients.(17) All bariatric procedures were performed by our team of experienced bariatric surgeons, using techniques that we have reported previously for SG, RYGB, and one-anastomosis gastric bypass (OAGB).(18,19) Written informed consent was obtained from all individual participants, and the study was approved by the hospital’s Centralized Institutional Review Board. Baseline demographic and anthropometric data were collected. Post-operative outcomes including operative time, length of stay, rate of 30-day adverse events (including surgical complications, readmissions, and re-operations), rate of revisional surgery, and mortality were recorded. Weight and glycemic outcomes (including diabetes remission, HbA1c, and diabetes medications) were measured pre-operatively, 12 months post-operatively, and 24 months post-operatively. Post-operative weight loss was measured by percentage of total weight loss (%TWL). Diabetes remission was defined as HbA1c <6.5% without the use of diabetes medications for 3 months.(20) Statistical Analysis Statistical analysis was performed using IBM SPSS Statistics 26.0 (Armonk, NY: IBM Corp). Descriptive statistics were computed and expressed as mean ± standard deviation (continuous variables), and frequency (categorical variables). Post-operative outcomes amongst the SG group and RYGB group were compared using Student’s t-tests and Pearson’s χ2 tests for continuous and categorical variables respectively. P < 0.05 were regarded to indicate nominal statistical significance. Results Baseline Data A total of 184 participants were included in this study, of whom 164 (89.1%) underwent SG and 20 (10.9%) underwent gastric bypass (GB). At baseline, the mean age was 38.6 ± 10.5 years old and 57.6% were female. Ethnic distribution included 17.9% Chinese, 50.5% Malay, 23.4% Indian, and 8.2% others (including Whites and Eurasians). Mean pre-operative weight was 148.23 ± 22.0kg and mean pre-operative BMI was 55.3 ± 6.0 kg/m 2 . The prevalence of obesity-related complications was high : 39 (21.2%) had pre-diabetes, 61 (33.2%) had diabetes, 86 (46.7%) had pre-hypertension or hypertension, and 109 (59.2%) had obstructive sleep apnoea. Of those with diabetes, mean pre-operative HbA1c was 8.0 ± 1.7%. There was no significant difference in pre-operative weight or BMI amongst participants who underwent SG and GB. However, significantly more participants who underwent GB had obesity-related complications compared to those who underwent SG, including diabetes or pre-diabetes, hypertension and hyperlipidaemia. Baseline characteristics are described in Table 1. Post-operative Outcomes The GB group had a significantly longer mean operating time (GB = 249.4 ± 76.3 minutes, SG=112.4 ± 43.4 minutes, p<0.0001) and length of stay (GB = 4.5 ± 0.6 days, SG = 3.1 ± 0.2, p=0.023) compared to the SG group. The overall rate of 30-day adverse events was 4.9%. However, this was higher in the GB group (15%) compared to the SG group (3.7%), with a trend towards significance (p=0.061). The 30-day readmission rate was 2.2%, and rate of revisional surgery was 2.7%, with no significant difference between SG and GB groups. Median time from primary procedure to revisional surgery was 79.8 months (32 to 128 months). There were no 30-day mortalities in this cohort. Post-operative outcomes are summarized in Table 2. Weight Outcomes Overall, participants had a %TWL of 27.4 ± 9.0% at 12 months and 27.1 ± 10.9% at 24 months. There was no significant difference in %TWL between the SG and GB groups at 12 months (SG = 27.6 ± 9.0%, GB = 26.0 ± 9.4%, p=0.481) and 24 months (SG = 27.4 ± 11.1%, GB = 24.9 ± 8.9%, p=0.495) post-operatively. Weight outcomes are summarized in Table 3 and represented in Figure 1. Follow-up rate was 67.9% at 12 months and 51.1% at 24 months, with no difference in follow-up rates between SG and GB groups at 24 months (SG=51.2%, GB=50%, p=0.553). Glycaemic Outcomes Amongst participants with pre-existing DM (n=61), mean HbA1c was significantly lower post-operatively at 12 months (5.5 ± 0.5%) and 24 months (5.7 ± 0.8%) compared to baseline (8.0 ± 1.7%). The rate of remission of diabetes was 69.2% at 12 months and 76.7% at 24 months, with no statistically significant difference between SG and GB groups. There was no statistically significant difference in the mean HbA1c in SG and GB groups at 12 months (SG = 5.6 ± 0.5%, GB = 5.3 ± 0.3%, p=0.186) and 24 months (SG = 5.7 ± 0.7%, GB = 5.7 ± 0.9%, p=0.934) post-operatively. However, the GB group had a larger HbA1c reduction at 24 months (3.2 ± 1.1%) compared to the SG group (1.9 ± 1.3%, p=0.030). Glycaemic outcomes are summarized in Table 4 and 5. Discussion This study showed that MBS in people with BMI ≥ 50 kg/m 2 produces good weight loss and glycemic outcomes at 12 and 24 months post-operatively, and is generally safe with a low rate of complications. There was no difference in weight outcomes at 12 and 24 months between the groups that underwent SG and GB. Overall diabetes remission rate was good (76.7%) at 24 months post-operatively, with no significant difference between SG and GB groups. However, participants with diabetes who underwent GB had a significantly greater HbA1c reduction at 24 months compared to those who underwent SG. Those who underwent GB had a higher rate of 30-day adverse events compared to the SG group. The treatment of people with severe obesity, traditionally defined as BMI ≥ 50–60 kg/m 2 , is challenging. The burden of obesity-related complications increases as BMI increases(6) with higher rates of multiple complex comorbidities. In this study, more than half the cohort had diabetes or pre-diabetes (54.4%). Amongst those with diabetes, control was poor, with a mean HbA1c of 8.0 ± 1.7%. Obstructive sleep apnoea was also present in the majority (59.2%). In view of the high BMI and multiple obesity-related complications, lifestyle therapy and pharmacotherapy may not be adequate to produce clinically significant weight loss in this population. MBS would be the treatment of choice, as it is able to produce greater and more durable weight loss as well as improvement in obesity-related complications compared to pharmacological options.(1) However, the high BMI, larger amounts of visceral adiposity, and greater number of medical comorbidities lead to increased surgical and anaesthetic difficulties.(21) In this study, the rate of post-operative 30-day adverse events was reassuringly low at 4.9%, in keeping with rates reported in general cohorts undergoing MBS.(4,22) A study by Howell looking at 208 people with BMI ≥60kg/m 2 undergoing RYGB or SG also reported a similar complication rate of 5.3%.(23) Several other studies comparing the rate of early complications and mortality post-MBS showed no difference between people with BMI < 60kg/m 2 and those with BMI ≥ 60kg/m 2 .(10,11,24) However, most experts advocate that MBS on patients with BMI over 50kg/m 2 should be performed by experienced bariatric surgeons, with the support of bariatric anesthesiologists.(25) Participants who underwent GB had a higher rate of 30-day adverse events (15%) compared to those who underwent SG (3.7%). Similar findings were reported in a study by Wilkinson et al, a database study that analysed the outcomes of 24,940 people with BMI 50 – 60 kg/m 2 and 5723 people with BMI >60kg/m 2 who underwent RYGB and SG.(9) People with BMI >60kg/m 2 who underwent RYGB had a higher rate of post-operative complications (including unplanned intubations, intensive care unit admissions, blood transfusions, readmissions, and re-operations) compared to those who underwent SG.(9) The trend towards a higher rate of post-operative complications in patients undergoing RYGB must be weighed against long-term weight and metabolic outcomes, which have traditionally been described to be superior compared to SG.(26) Weight loss and metabolic outcomes post-MBS are not as clear in people with BMI ≥ 50kg/m 2 , especially since a high pre-operative BMI is associated with lower post-operative weight loss. In this study, good weight loss outcomes of 27 – 28% TWL on average were achieved at 12 and 24 months, with no significant difference between the SG and GB groups. Results are similar to %TWL achieved by our general population undergoing MBS (previously reported).(13) However, longer-term studies may be needed to compare the durability of weight loss between GB and SG. There are several studies looking at mid to long-term weight loss outcomes post-MBS in patients with BMI above 50 – 60kg/m 2 , but results are mixed. Studies by Singla et al and Gonzalez-Heredia et al described greater weight loss in GB groups compared to SG groups at 12–24 months post-operatively.(14,27) On the other hand, Arapis et al and Hong et al assessed longer-term weight loss at 36–72 months post-MBS, and described that weight loss outcomes were similar between GB and SG groups.(7,28) Results on metabolic outcomes between SG and GB groups are also mixed. On the whole, this study showed that MBS in patients with BMI ≥ 50kg/m 2 yielded good rates of diabetes remission of 69.7% at 12 months and 76.7% at 24 months. Diabetes remission rates were higher than those previously reported in our general MBS cohort (55.9% at 12 months)(2). Higher baseline BMI has been described to be a predictive factor for post-operative diabetes remission.(29) In this study, there was no difference in remission rates between the GB and SG groups. However, participants with diabetes who underwent GB did have significantly greater HbA1c reduction (3.2 ± 1.1%) at 24 months compared to the SG group (1.9 ± 1.3%). This difference was not appreciated at 12 months post-operatively, suggesting that the metabolic benefits of GB over SG may be more apparent and durable in the long run. Most other studies described comparable diabetes remission rates between SG and GB, with duration of follow up ranging from 12 to 41 months post-MBS.(27,28,30)However, two studies showed superior diabetes remission rates with GB compared to SG, with one study by Thereaux et al describing a diabetes remission rate of 70.7% amongst GB patients compared to 47.5% amongst SG patients at 1 year post-MBS.(7,31) Notably, none of these studies reported the change in HbA1c level post-operatively. This is one of the few studies to assess the MBS outcomes in people with very high BMI in an Asian population. Compared to Whites, Asians have a higher amount of visceral adiposity and higher risk of developing diabetes at a given BMI.(32) This potentially poses increased surgical and anaesthetic risks especially amongst Asians with BMI ≥ 50kg/m 2 . These risks must be weighed against the benefits of MBS. However, weight loss outcomes are also a concern in Asians with BMI ≥ 50kg/m 2 , as high pre-operative BMI and Asian ethnicity have both been described to be associated with poorer weight loss post-MBS. Two small studies in Asia (India and Singapore) described overall safety of MBS in patients with BMI >47.5 – 50 kg/m 2 , with low rates of short-term complications.(27,33) Only short-term weight loss outcomes were reported (6 months and 1-year post-MBS respectively). Post-operative weight loss at 6 months was not inferior compared to patients with BMI < 47.5kg/m 2 in one study.(33) The other study compared SG and one anastomosis GB (OAGB) outcomes in patients with BMI ≥ 50kg/m 2 , and described superior TWL in the OAGB group at 1 year post-operatively (%TWL 39.9% versus 30%, p<0.0001), but similar rates of diabetes and hypertension remission. Our study adds to the body of evidence to demonstrate the safety and effectiveness of MBS in Asians with BMI ≥ 50kg/m 2 . This study also provides longer term weight and glycemic outcome data, and illustrated no difference in weight and diabetes remission between SG and GB at 24 months post-MBS. However, the GB cohort did have greater HbA1c reduction compared to the SG cohort at 24 months. This study has a few limitations. Firstly, the choice of bariatric procedure was not randomised, and considerably fewer patients underwent GB compared to SG. This could indicate intrinsic bias from the bariatric team and/or patients to opt for SG in this more complex group, and is reflective of real-world practice. Secondly, the role of pre-operative weight loss via very low caloric diet or pharmacotherapy, which has been proposed by some experts(25,34), was not evaluated, and would be a useful area of research in future studies. Lastly, follow-up rates were suboptimal (67.9% at 12 months, 51.1% at 24 months). However, this high rate of patient attrition post-MBS has been well described. Two studies reporting mid to long-term bariatric outcomes in patients with high BMI illustrated a dramatic decline in follow-up data after 12 months.(7,28) Importantly, there was no difference in follow-up rates between the SG and GB groups in this study. The rate of follow up in this cohort was also higher than that of our general bariatric cohort (40.3% at 18 months).(13) In conclusion, MBS is an effective and safe treatment option for severe obesity in Asians with BMI ≥ 50kg/m 2 , with successful weight loss outcomes and comorbidity resolution at 24 months post-operatively. In terms of choice of bariatric procedure, available studies including this one do not demonstrate a clear benefit of GB over SG in terms of weight loss and diabetes remission in patients with very high BMI. This study showed an increased risk in 30-day adverse events amongst patients who underwent GB, although other studies show mixed results. The optimal bariatric procedure in this population remains an ongoing debate(35), although there is emerging expert opinion advocating for SG to be selected as a primary procedure, reserving RYGB as a revision procedure if weight loss is suboptimal.(7,25) Management should be individualised, and further studies are required to compare the risks and long-term outcomes between SG and GB in patients with very high BMI. Declarations Funding Statement No funding was received for this study. Ethical Statements All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study. References Sjöström L. 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Tables Table 1: Baseline Characteristics Characteristics Total (n=184) SG (n=164) GB (n=20) p -value Age (years) 38.6 ± 10.5 38.7 ± 10.5 37.9 ± 10.2 0.731 Gender Male 78 (42.4%) 71 (43.3%) 7 (35%) 0.323 Female 106 (57.6%) 93 (56.7%) 13 (65%) Race Chinese 33 (17.9%) 29 (17.7%) 4 (20%) 0.896 Malay 93 (50.5%) 81 (49.4%) 12 (60%) Indian 43 (23.4%) 40 (24.4%) 3 (15%) Others 14 (8.2%) 14 (8.5%) 1 (5%) Pre-operative weight (kg) 149.1 ± 21.5 149.7 ±21.8 144.5 ± 18.7 0.105 Pre-operative BMI (kg/m 2 ) 55.1 ± 7.3 56.2 ± 5.5 56.1 ± 6.6 0.104 Glycemic Status No diabetes 84 (45.7%) 79 (48.2%) 5 (25%) 0.040 Pre-diabetes 39 (21.2%) 35 (21.3%) 4 (20%) Diabetes 61 (33.2%) 50 (30.5%) 11 (55%) Mean HbA1c of those with diabetes (%) 8.0 ± 1.7 7.9 ± 1.8 8.2 ± 1.2 0.576 Pre-hypertension or hypertension 86 (46.7%) 72 (43.9%) 14 (70%) 0.024 Hyperlipidaemia 44 (23.9%) 34 (20.7%) 10 (50%) 0.007 Obstructive sleep apnoea 109 (59.2%) 95 (70.9%) 14 (70%) 0.215 Table 2: Post-operative Outcomes Outcomes Total (n=184) SG (n=164) GB (n=20) p -value Operating time (minutes)* 125.6 ± 62.3 112.4 ± 43.4 249.4 ± 76.3 <0.0001 Length of stay (days) 3.3 ± 2.5 3.1 ± 0.2 4.5 ± 0.6 0.023 30-day adverse events (%) 9 (4.9%) 6 (3.7%) 3 (15%) 0.061 Types of adverse events Haemorrhage 3 3 0 - Infection 3 1 2 Leak 1 0 1 Venous thrombosis 1 0 1 Ureteric stone 1 0 1 Readmission rate (%) 4 (2.2%) 3 (1.8%) 1 (5%) 0.371 Revisional surgery (%) 5 (2.7%) 4 (2.4%) 1 (5%) 0.441 30-day Mortality (%) 0 0 0 - *Excluding those who underwent concurrent operations (n=18) Table 3: Post-operative Weight Loss Outcomes Total SG GB p -value % TWL at 12 months (n=125) 27.4 ± 9.0 27.6 ± 9.0 26.0 ± 9.4 0.481 % TWL at 24 months (n=94) 27.1 ± 10.9 27.4 ± 11.1 24.9 ± 8.9 0.495 Table 4: HbA1c at 12 and 24 Months for patients with diabetes Outcomes Total SG GB p -value HbA1c at 12 months (%) 5.5 ± 0.5 5.6 ± 0.5 5.3 ± 0.3 0.186 HbA1c reduction at 12 months (%) 2.4 ± 1.7 2.1 ± 1.8 3.3 ± 1.9 0.017 HbA1c at 24 months (%) 5.7 ± 0.8 5.7 ± 0.7 5.7 ± 0.9 0.934 HbA1c reduction at 24 months (%) 2.2 ± 1.4 1.9 ± 1.3 3.2 ± 1.1 0.030 Table 5: Post-operative Diabetes Remission Rates Outcomes Total SG GB p -value Diabetes remission rate at 12 months (n=39) 27 (69.2%) 21 (67.7%) 6 (75%) 0.527 Diabetes remission rate at 24 months (n=30) 23 (76.7%) 18 (78.3%) 5 (71.4%) 0.532 Additional Declarations No competing interests reported. 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Hospital","correspondingAuthor":false,"prefix":"","firstName":"Angelina","middleName":"Xiangying","lastName":"Foo","suffix":""},{"id":315173705,"identity":"24c4a978-d2f8-4df6-9489-cb0bc293f684","order_by":12,"name":"Orlanda Qi Mei Goh","email":"","orcid":"","institution":"Singapore General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Orlanda","middleName":"Qi Mei","lastName":"Goh","suffix":""},{"id":315173706,"identity":"09a8aa48-87f9-4bbf-97bc-767c971fd611","order_by":13,"name":"Phong Ching Lee","email":"","orcid":"","institution":"Singapore General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Phong","middleName":"Ching","lastName":"Lee","suffix":""}],"badges":[],"createdAt":"2024-06-04 13:15:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4528310/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4528310/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60338759,"identity":"1ad40b40-51c1-42c4-83f9-98b56027fe88","added_by":"auto","created_at":"2024-07-15 17:48:50","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":47525,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4528310/v1/22a3916ccc1f238bacdc6d7c.png"},{"id":60339590,"identity":"91bd56d4-523d-45fc-99d5-de789773a009","added_by":"auto","created_at":"2024-07-15 18:04:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":568359,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4528310/v1/cfd035a5-b1ac-4ee1-b864-dae895b1de1c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Bariatric Surgery Outcomes in People with Severe Obesity (BMI ≥ 50 kg/m2)","fulltext":[{"header":"Key Points","content":"\u003cul class=\"decimal_type\"\u003e\n \u003cli\u003eIn individuals with BMI \u0026ge;50kg/m\u003csup\u003e2\u003c/sup\u003e undergoing MBS, %TWL at 12 and 24 months was similar between SG and GB groups.\u003c/li\u003e\n \u003cli\u003eDiabetes remission rate was high at 12-months (69.2%) and at 24-months (76.7%), with no difference between SG and GB groups.\u003c/li\u003e\n \u003cli\u003eThe GB group had a greater HbA1c reduction at 24 months than the SG group.\u003c/li\u003e\n \u003cli\u003eOverall 30-day adverse event rate was low at 4.9%, but higher in the GB group than SG group.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eMetabolic bariatric surgery (MBS) is an effective treatment option for people with clinically severe obesity, and has been shown to produce significant and durable long-term weight loss, improvement and resolution of obesity-related complications, and reduction in mortality.(1–3)\u0026nbsp;The two most commonly performed procedures, the sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), are generally safe, with perioperative mortality rates ranging from 0.03% - 0.2%, and 30-day risks of serious adverse events of \u0026lt;6%.(4)\u003c/p\u003e\n\u003cp\u003eHowever, the benefits and risks of MBS in people with very high body mass index (BMI) ≥ 50 kg/m\u003csup\u003e2\u003c/sup\u003e are not as well-established.(5)\u0026nbsp;There is a higher burden of obesity-related complications such as diabetes, hypertension, and obstructive sleep apnoea,(6)\u0026nbsp;potentially increasing the operative and anaesthetic risks in this population. \u0026nbsp;Surgical anatomy may also be more challenging due to the higher amount of visceral adiposity, which could result in longer operating times and rate of surgical complications. Existing data on surgical complications post-MBS in people with BMI ≥ 50 – 60 kg/m\u003csup\u003e2\u003c/sup\u003e is mixed, with some studies reporting an increase in post-operative complications, 30-day adverse events, and mortality(6–9), and others reporting no difference in adverse outcomes.(10–12)\u0026nbsp;Weight loss outcomes post-MBS in this population are also a concern, as a high pre-operative BMI is traditionally associated with less post-operative weight loss.(13)\u0026nbsp;Lastly, there is no consensus on the recommended type of surgery in this population, with some studies advocating for RYGB due to potentially greater long-term weight loss(7,14), while others opt for SG, citing a lower rate of surgical complications.(9)\u003c/p\u003e\n\u003cp\u003eStudies from Asia on MBS for people with very high BMI (≥ 50 kg/m\u003csup\u003e2\u003c/sup\u003e) are scarce. At a given BMI, Asians have higher visceral adiposity than Whites\u0026nbsp;(15), potentially increasing the technical difficulty of MBS in this population. Asians are also described to have inferior weight loss outcomes post-MBS compared to Whites.(16)\u0026nbsp;Thus, the risks and benefits of MBS amongst Asian people with very high BMI (≥ 50 kg/m\u003csup\u003e2\u003c/sup\u003e) require further assessment.\u003c/p\u003e\n\u003cp\u003eThis study aimed to evaluate the outcomes of MBS in people with very high BMI (≥ 50 kg/m\u003csup\u003e2\u003c/sup\u003e), including post-operative complications, mortality, weight loss outcomes, and diabetes remission. Outcomes were also compared between people who underwent SG versus gastric bypass (GB).\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cu\u003eParticipants\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted at a tertiary centre. Participants' information was collected prospectively from 2008 to 2022. Patients with BMI ≥ 50 kg/m\u003csup\u003e2\u003c/sup\u003e who underwent MBS were included in the study. The patients were managed by a multidisciplinary team: suitability for bariatric surgery was assessed according to the local recommended clinical guidelines and offered to eligible patients.(17)\u0026nbsp;All bariatric procedures were performed by our team of experienced bariatric surgeons, using techniques that we have reported previously for SG, RYGB, and one-anastomosis gastric bypass (OAGB).(18,19)\u0026nbsp;Written informed consent was obtained from all individual participants, and the study was approved by the hospital’s Centralized Institutional Review Board.\u003c/p\u003e\n\u003cp\u003eBaseline demographic and anthropometric data were collected. Post-operative outcomes including operative time, length of stay, rate of 30-day adverse events (including surgical complications, readmissions, and re-operations), rate of revisional surgery, and mortality were recorded. Weight and glycemic outcomes (including diabetes remission, HbA1c, and diabetes medications) were measured pre-operatively, 12 months post-operatively, and 24 months post-operatively. Post-operative weight loss was measured by percentage of total weight loss (%TWL). Diabetes remission was defined as HbA1c \u0026lt;6.5% without the use of diabetes medications for 3 months.(20)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eStatistical Analysis\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analysis was performed using IBM SPSS Statistics 26.0 (Armonk, NY: IBM Corp). Descriptive statistics were computed and expressed as mean\u0026nbsp;±\u0026nbsp;standard deviation (continuous variables), and frequency (categorical variables). Post-operative outcomes amongst the SG group and RYGB group were compared using Student’s t-tests and Pearson’s χ2 tests for continuous and categorical variables respectively.\u003cem\u003e\u0026nbsp;P\u003c/em\u003e \u0026lt; 0.05 were regarded to indicate nominal statistical significance.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cu\u003eBaseline Data\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eA total of 184 participants were included in this study, of whom 164 (89.1%) underwent SG and 20 (10.9%) underwent gastric bypass (GB). At baseline, the mean age was 38.6\u0026nbsp;±\u0026nbsp;10.5 years old and 57.6% were female. Ethnic distribution included 17.9% Chinese, 50.5% Malay, 23.4% Indian, and 8.2% others (including Whites and Eurasians). Mean pre-operative weight was 148.23\u0026nbsp;±\u0026nbsp;22.0kg and mean pre-operative BMI was 55.3\u0026nbsp;±\u0026nbsp;6.0 kg/m\u003csup\u003e2\u003c/sup\u003e. The prevalence of obesity-related complications was \u003cs\u003ehigh\u003c/s\u003e: 39 (21.2%) had pre-diabetes, 61 (33.2%) had diabetes, 86 (46.7%) had pre-hypertension or hypertension, and 109 (59.2%) had obstructive sleep apnoea. Of those with diabetes, mean pre-operative HbA1c was 8.0\u0026nbsp;±\u0026nbsp;1.7%. There was no significant difference in pre-operative weight or BMI amongst participants who underwent SG and GB. However, significantly more participants who underwent GB had obesity-related complications compared to those who underwent SG, including diabetes or pre-diabetes, hypertension and hyperlipidaemia. Baseline characteristics are described in Table 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003ePost-operative Outcomes\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe GB group had a significantly longer mean operating time (GB = 249.4\u0026nbsp;±\u0026nbsp;76.3 minutes, SG=112.4\u0026nbsp;±\u0026nbsp;43.4 minutes, p\u0026lt;0.0001) and length of stay (GB = 4.5\u0026nbsp;±\u0026nbsp;0.6 days, SG = 3.1\u0026nbsp;±\u0026nbsp;0.2, p=0.023) compared to the SG group. The overall rate of 30-day adverse events was 4.9%. However, this was higher in the GB group (15%) compared to the SG group (3.7%), with a trend towards significance (p=0.061). The 30-day readmission rate was 2.2%, and rate of revisional surgery was 2.7%, with no significant difference between SG and GB groups. Median time from primary procedure to revisional surgery was 79.8 months (32 to 128 months). There were no 30-day mortalities in this cohort. Post-operative outcomes are summarized in Table 2.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eWeight Outcomes\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eOverall, participants had a %TWL of 27.4\u0026nbsp;±\u0026nbsp;9.0% at 12 months and 27.1\u0026nbsp;±\u0026nbsp;10.9% at 24 months. There was no significant difference in %TWL between the SG and GB groups at 12 months (SG = 27.6\u0026nbsp;±\u0026nbsp;9.0%, GB = 26.0\u0026nbsp;±\u0026nbsp;9.4%, p=0.481) and 24 months (SG = 27.4\u0026nbsp;±\u0026nbsp;11.1%, GB = 24.9\u0026nbsp;±\u0026nbsp;8.9%, p=0.495) post-operatively. Weight outcomes are summarized in Table 3 and represented in Figure 1. Follow-up rate was 67.9% at 12 months and 51.1% at 24 months, with no difference in follow-up rates between SG and GB groups at 24 months (SG=51.2%, GB=50%, p=0.553).\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eGlycaemic Outcomes\u0026nbsp;\u003c/u\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmongst participants with pre-existing DM (n=61), mean HbA1c was significantly lower post-operatively at 12 months (5.5 ± 0.5%) and 24 months (5.7 ± 0.8%) compared to baseline (8.0 ± 1.7%). The rate of remission of diabetes was 69.2% at 12 months and 76.7% at 24 months, with no statistically significant difference between SG and GB groups. There was no statistically significant difference in the mean HbA1c in SG and GB groups at 12 months (SG = 5.6 ± 0.5%, GB = 5.3 ± 0.3%, p=0.186) and 24 months (SG = 5.7 ± 0.7%, GB = 5.7 ± 0.9%, p=0.934) post-operatively. However, the GB group had a larger HbA1c reduction at 24 months (3.2 ± 1.1%) compared to the SG group (1.9 ± 1.3%, p=0.030). Glycaemic outcomes are summarized in Table 4 and 5.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study showed that MBS in people with BMI ≥ 50 kg/m\u003csup\u003e2\u003c/sup\u003e produces good weight loss and glycemic outcomes at 12 and 24 months post-operatively, and is generally safe with a low rate of complications. There was no difference in weight outcomes at 12 and 24 months between the groups that underwent SG and GB. Overall diabetes remission rate was good (76.7%) at 24 months post-operatively, with no significant difference between SG and GB groups. However, participants with diabetes who underwent GB had a significantly greater HbA1c reduction at 24 months compared to those who underwent SG. Those who underwent GB had a higher rate of 30-day adverse events compared to the SG group.\u003c/p\u003e\n\u003cp\u003eThe treatment of people with severe obesity, traditionally defined as BMI ≥ 50–60 kg/m\u003csup\u003e2\u003c/sup\u003e, is challenging. The burden of obesity-related complications increases as BMI increases(6)\u0026nbsp;with higher rates of multiple complex comorbidities. In this study, more than half the cohort had diabetes or pre-diabetes (54.4%). Amongst those with diabetes, control was poor, with a mean HbA1c of 8.0\u0026nbsp;±\u0026nbsp;1.7%. Obstructive sleep apnoea was also present in the majority (59.2%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn view of the high BMI and multiple obesity-related complications, lifestyle therapy and pharmacotherapy may not be adequate to produce clinically significant weight loss in this population. MBS would be the treatment of choice, as it is able to produce greater and more durable weight loss as well as improvement in obesity-related complications compared to pharmacological options.(1)\u0026nbsp;However, the high BMI, larger amounts of visceral adiposity, and greater number of medical comorbidities lead to increased surgical and anaesthetic difficulties.(21)\u0026nbsp;In this study, the rate of post-operative 30-day adverse events was reassuringly low at 4.9%, in keeping with rates reported in general cohorts undergoing MBS.(4,22)\u0026nbsp;A study by Howell looking at 208 people with BMI ≥60kg/m\u003csup\u003e2\u003c/sup\u003e undergoing RYGB or SG also reported a similar complication rate of 5.3%.(23)\u0026nbsp;Several other studies comparing the rate of early complications and mortality post-MBS showed no difference between people with BMI \u0026lt; 60kg/m\u003csup\u003e2\u003c/sup\u003e and those with BMI ≥ 60kg/m\u003csup\u003e2\u003c/sup\u003e.(10,11,24)\u0026nbsp;However, most experts advocate that MBS on patients with BMI over 50kg/m\u003csup\u003e2\u003c/sup\u003e should be performed by experienced bariatric surgeons, with the support of bariatric anesthesiologists.(25)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants who underwent GB had a higher rate of 30-day adverse events (15%) compared to those who underwent SG (3.7%). Similar findings were reported in a study by Wilkinson et al, a database study that analysed the outcomes of 24,940 people with BMI 50 – 60 kg/m\u003csup\u003e2\u003c/sup\u003e and 5723 people with BMI \u0026gt;60kg/m\u003csup\u003e2\u003c/sup\u003e who underwent RYGB and SG.(9)\u0026nbsp;People with BMI \u0026gt;60kg/m\u003csup\u003e2\u003c/sup\u003e who underwent RYGB had a higher rate of post-operative complications (including unplanned intubations, intensive care unit admissions, blood transfusions, readmissions, and re-operations) compared to those who underwent SG.(9)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe trend towards a higher rate of post-operative complications in patients undergoing RYGB must be weighed against long-term weight and metabolic outcomes, which have traditionally been described to be superior compared to SG.(26)\u0026nbsp;Weight loss and metabolic outcomes post-MBS are not as clear in people with BMI ≥ 50kg/m\u003csup\u003e2\u003c/sup\u003e, especially since a high pre-operative BMI is associated with lower post-operative weight loss. In this study, good weight loss outcomes of 27 – 28% TWL on average were achieved at 12 and 24 months, with no significant difference between the SG and GB groups. Results are similar to %TWL achieved by our general population undergoing MBS (previously reported).(13)\u0026nbsp;However, longer-term studies may be needed to compare the durability of weight loss between GB and SG. There are several studies looking at mid to long-term weight loss outcomes post-MBS in patients with BMI above 50 – 60kg/m\u003csup\u003e2\u003c/sup\u003e, but results are mixed. Studies by Singla et al and \u0026nbsp;Gonzalez-Heredia et al described greater weight loss in GB groups compared to SG groups at 12–24 \u0026nbsp;months post-operatively.(14,27)\u0026nbsp;On the other hand, Arapis et al and Hong et al assessed longer-term weight loss at 36–72 months post-MBS, and described that weight loss outcomes were similar between GB and SG groups.(7,28)\u003c/p\u003e\n\u003cp\u003eResults on metabolic outcomes between SG and GB groups are also mixed. On the whole, this study showed that MBS in patients with BMI ≥ 50kg/m\u003csup\u003e2\u003c/sup\u003e yielded good rates of diabetes remission of 69.7% at 12 months and 76.7% at 24 months. Diabetes remission rates were higher than those previously reported in our general MBS cohort (55.9% at 12 months)(2). Higher baseline BMI has been described to be a predictive factor for post-operative diabetes remission.(29)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn this study, there was no difference in remission rates between the GB and SG groups. However, participants with diabetes who underwent GB did have significantly greater HbA1c reduction (3.2\u0026nbsp;±\u0026nbsp;1.1%) at 24 months compared to the SG group (1.9\u0026nbsp;±\u0026nbsp;1.3%). This difference was not appreciated at 12 months post-operatively, suggesting that the metabolic benefits of GB over SG may be more apparent and durable in the long run. Most other studies described comparable diabetes remission rates between SG and GB, with duration of follow up ranging from 12 to 41 months post-MBS.(27,28,30)However, two studies showed superior diabetes remission rates with GB compared to SG, with one study by Thereaux et al describing a diabetes remission rate of 70.7% amongst GB patients compared to 47.5% amongst SG patients at 1 year post-MBS.(7,31)\u0026nbsp;Notably, none of these studies reported the change in HbA1c level post-operatively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis is one of the few studies to assess the MBS outcomes in people with very high BMI in an Asian population. Compared to Whites, Asians have a higher amount of visceral adiposity and higher risk of developing diabetes at a given BMI.(32)\u0026nbsp;This potentially poses increased surgical and anaesthetic risks especially amongst Asians with BMI ≥ 50kg/m\u003csup\u003e2\u003c/sup\u003e. These risks must be weighed against the benefits of MBS. However, weight loss outcomes are also a concern in Asians with BMI ≥ 50kg/m\u003csup\u003e2\u003c/sup\u003e, as high pre-operative BMI and Asian ethnicity have both been described to be associated with poorer weight loss post-MBS. Two small studies in Asia (India and Singapore) described overall safety of MBS in patients with BMI \u0026gt;47.5 – 50 kg/m\u003csup\u003e2\u003c/sup\u003e, with low rates of short-term complications.(27,33)\u0026nbsp;Only short-term weight loss outcomes were reported (6 months and 1-year post-MBS respectively). Post-operative weight loss at 6 months was not inferior compared to patients with BMI \u0026lt; 47.5kg/m\u003csup\u003e2\u003c/sup\u003e in one study.(33)\u0026nbsp;The other study compared SG and one anastomosis GB (OAGB) outcomes in patients with BMI ≥ 50kg/m\u003csup\u003e2\u003c/sup\u003e, and described superior TWL in the OAGB group at 1 year post-operatively (%TWL 39.9% versus 30%, p\u0026lt;0.0001), but similar rates of diabetes and hypertension remission. Our study adds to the body of evidence to demonstrate the safety and effectiveness of MBS in Asians with BMI ≥ 50kg/m\u003csup\u003e2\u003c/sup\u003e. This study also provides longer term weight and glycemic outcome data, and illustrated no difference in weight and diabetes remission between SG and GB at 24 months post-MBS. However, the GB cohort did have greater HbA1c reduction compared to the SG cohort at 24 months.\u003c/p\u003e\n\u003cp\u003eThis study has a few limitations. Firstly, the choice of bariatric procedure was not randomised, and considerably fewer patients underwent GB compared to SG. This could indicate intrinsic bias from the bariatric team and/or patients to opt for SG in this more complex group, and is reflective of real-world practice. Secondly, the role of pre-operative weight loss via very low caloric diet or pharmacotherapy, which has been proposed by some experts(25,34), was not evaluated, and would be a useful area of research in future studies. Lastly, follow-up rates were suboptimal (67.9% at 12 months, 51.1% at 24 months). However, this high rate of patient attrition post-MBS has been well described. Two studies reporting mid to long-term bariatric outcomes in patients with high BMI illustrated a dramatic decline in follow-up data after 12 months.(7,28)\u0026nbsp;Importantly, there was no difference in follow-up rates between the SG and GB groups in this study. The rate of follow up in this cohort was also higher than that of our general bariatric cohort (40.3% at 18 months).(13)\u003c/p\u003e\n\u003cp\u003eIn conclusion, MBS is an effective and safe treatment option for severe obesity in Asians with BMI ≥ 50kg/m\u003csup\u003e2\u003c/sup\u003e, with successful weight loss outcomes and comorbidity resolution at 24 months post-operatively. In terms of choice of bariatric procedure, available studies including this one do not demonstrate a clear benefit of GB over SG in terms of weight loss and diabetes remission in patients with very high BMI. This study showed an increased risk in 30-day adverse events amongst patients who underwent GB, although other studies show mixed results. The optimal bariatric procedure in this population remains an ongoing debate(35), although there is emerging expert opinion advocating for SG to be selected as a primary procedure, reserving RYGB as a revision procedure if weight loss is suboptimal.(7,25) Management should be individualised, and further studies are required to compare the risks and long-term outcomes between SG and GB in patients with very high BMI. \u0026nbsp;\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this study.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthical Statements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSj\u0026ouml;str\u0026ouml;m L. Review of the key results from the Swedish Obese Subjects (SOS) trial - a prospective controlled intervention study of bariatric surgery. J Intern Med. 2013 Mar;273(3):219\u0026ndash;34. \u003c/li\u003e\n\u003cli\u003eLee PC, Tham KW, Ganguly S, Tan HC, Eng AKH, Dixon JB. Ethnicity Does Not Influence Glycemic Outcomes or Diabetes Remission After Sleeve Gastrectomy or Gastric Bypass in a Multiethnic Asian Cohort. Obes Surg. 2018 Jun;28(6):1511\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eSyn NL, Cummings DE, Wang LZ, Lin DJ, Zhao JJ, Loh M, et al. Association of metabolic\u0026ndash;bariatric surgery with long-term survival in adults with and without diabetes: a one-stage meta-analysis of matched cohort and prospective controlled studies with 174 772 participants. The Lancet. 2021 May;397(10287):1830\u0026ndash;41. \u003c/li\u003e\n\u003cli\u003eArterburn DE, Telem DA, Kushner RF, Courcoulas AP. Benefits and Risks of Bariatric Surgery in Adults: A Review. JAMA. 2020 Sep 1;324(9):879. \u003c/li\u003e\n\u003cli\u003eEisenberg D, Shikora SA, Aarts E, Aminian A, Angrisani L, Cohen RV, 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. 2022 Dec;18(12):1345\u0026ndash;56. \u003c/li\u003e\n\u003cli\u003eSinghal R, Omar I, Madhok B, Ludwig C, Tahrani AA, Mahawar K, et al. Effect of BMI on safety of bariatric surgery during the COVID-19 pandemic, procedure choice, and safety protocols \u0026ndash; An analysis from the GENEVA Study. Obes Res Clin Pract. 2022 May;16(3):249\u0026ndash;53. \u003c/li\u003e\n\u003cli\u003eArapis K, Macrina N, Kadouch D, Ribeiro Parenti L, Marmuse JP, Hansel B. Outcomes of Roux-en-Y gastric bypass versus sleeve gastrectomy in super-super-obese patients (BMI \u0026ge;60 kg/m2): 6-year follow-up at a single university. Surg Obes Relat Dis. 2019 Jan;15(1):23\u0026ndash;33. \u003c/li\u003e\n\u003cli\u003eSun Y, Liu B, Smith JK, Correia MLG, Jones DL, Zhu Z, et al. Association of Preoperative Body Weight and Weight Loss With Risk of Death After Bariatric Surgery. JAMA Netw Open. 2020 May 14;3(5):e204803. \u003c/li\u003e\n\u003cli\u003eWilkinson KH, Helm M, Lak K, Higgins RM, Gould JC, Kindel TL. The Risk of Post-operative Complications in Super-Super Obesity Compared to Super Obesity in Accredited Bariatric Surgery Centers. Obes Surg. 2019 Sep;29(9):2964\u0026ndash;71. \u003c/li\u003e\n\u003cli\u003eDupr\u0026eacute;e A, El Gammal AT, Wolter S, Urbanek S, Sauer N, Mann O, et al. Perioperative Short-Term Outcome in Super-Super-Obese Patients Undergoing Bariatric Surgery. Obes Surg. 2018 Jul;28(7):1895\u0026ndash;901. \u003c/li\u003e\n\u003cli\u003eHon P, Taylor J, Leitman I, Horowitz M, Panagopoulos G. Outcome and Complications of Gastric Bypass in Super-Super Obesity versus Morbid Obesity. Obes Surg. 2006 Jan 1;16(1):16\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eKushnir L, Dunnican WJ, Benedetto B, Wang W, Dolce C, Lopez S, et al. Is BMI greater than 60 kg/m2 a predictor of higher morbidity after laparoscopic Roux-en-Y gastric bypass? Surg Endosc. 2010 Jan;24(1):94\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eTan SYT, Syn NL, Lin DJ, Lim CH, Ganguly S, Ong HS, et al. Centile Charts for Monitoring of Weight Loss Trajectories After Bariatric Surgery in Asian Patients. Obes Surg. 2021 Nov;31(11):4781\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eGonzalez-Heredia R, Sanchez-Johnsen L, Valbuena VSM, Masrur M, Murphey M, Elli E. Surgical management of super\u0026ndash;super obese patients: Roux-en-Y gastric bypass versus sleeve gastrectomy. Surg Endosc. 2016 May;30(5):2097\u0026ndash;102. \u003c/li\u003e\n\u003cli\u003eTham KW, Abdul Ghani R, Cua SC, Deerochanawong C, Fojas M, Hocking S, et al. Obesity in South and Southeast Asia\u0026mdash;A new consensus on care and management. Obes Rev. 2023 Feb;24(2):e13520. \u003c/li\u003e\n\u003cli\u003eKoh ZJ, Tai BC, Kow L, Toouli J, Lakdawala M, Delko T, et al. Influence of Asian Ethnicities on Short- and Mid-term Outcomes Following Laparoscopic Sleeve Gastrectomy. Obes Surg. 2019 Jun;29(6):1781\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eMinistry of Health Clinical Practice Guidelines, Singapore. 2016; \u003c/li\u003e\n\u003cli\u003eLim CH, Lee PC, Lim E, Tan J, Chan WH, Tan HC, et al. Correlation Between Symptomatic Gastro-Esophageal Reflux Disease (GERD) and Erosive Esophagitis (EE) Post-vertical Sleeve Gastrectomy (VSG). Obes Surg. 2019 Jan;29(1):207\u0026ndash;14. \u003c/li\u003e\n\u003cli\u003eLim CH, Jahansouz C, Abraham AA, Leslie DB, Ikramuddin S. The future of the Roux-en-Y gastric bypass. Expert Rev Gastroenterol Hepatol. 2016 Jul 2;10(7):777\u0026ndash;84. \u003c/li\u003e\n\u003cli\u003eRiddle MC, Cefalu WT, Evans PH, Gerstein HC, Nauck MA, Oh WK, et al. Consensus Report: Definition and Interpretation of Remission in Type 2 Diabetes. Diabetes Care. 2021 Oct 1;44(10):2438\u0026ndash;44. \u003c/li\u003e\n\u003cli\u003eKaye A, Lingle B, Brothers J, Rodriguez J, Morris A, Greeson E, et al. The patient with obesity and super-super obesity: Perioperative anesthetic considerations. Saudi J Anaesth. 2022;16(3):332. \u003c/li\u003e\n\u003cli\u003eToh BC, Chan WH, Eng AKH, Lim EKW, Lim CH, Tham KW, et al. Five‐year long‐term clinical outcome after bariatric metabolic surgery: A multi‐ethnic Asian population in Singapore. Diabetes Obes Metab. 2018 Jul;20(7):1762\u0026ndash;5. \u003c/li\u003e\n\u003cli\u003eHowell RS, Liu HH, Boinpally H, Akerman M, Carruthers E, Brathwaite BM, et al. Outcomes of Bariatric Surgery: Patients with Body Mass Index 60 or Greater. JSLS J Soc Laparosc Robot Surg. 2021;25(2):e2020.00089. \u003c/li\u003e\n\u003cli\u003eAbeles D, Kim JJ, Tarnoff ME, Shah S, Shikora SA. Primary Laparoscopic Gastric Bypass Can Be Performed Safely in Patients with BMI \u0026ge; 60. J Am Coll Surg. 2009 Feb;208(2):236\u0026ndash;40. \u003c/li\u003e\n\u003cli\u003eKermansaravi M, Lainas P, Shahmiri SS, Yang W, Jazi AD, Vilallonga R, et al. The first survey addressing patients with BMI over 50: a survey of 789 bariatric surgeons. Surg Endosc. 2022 Aug;36(8):6170\u0026ndash;80. \u003c/li\u003e\n\u003cli\u003eSchauer PR, Bhatt DL, Kirwan JP, Wolski K, Aminian A, Brethauer SA, et al. Bariatric Surgery versus Intensive Medical Therapy for Diabetes \u0026mdash; 5-Year Outcomes. N Engl J Med. 2017 Feb 16;376(7):641\u0026ndash;51. \u003c/li\u003e\n\u003cli\u003eSingla V, Aggarwal S, Singh B, Tharun G, Katiyar V, Bhambri A. Outcomes in Super Obese Patients Undergoing One Anastomosis Gastric Bypass or Laparoscopic Sleeve Gastrectomy. Obes Surg. 2019 Apr;29(4):1242\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eHong J, Park S, Menzo EL, Rosenthal R. Midterm outcomes of laparoscopic sleeve gastrectomy as a stand-alone procedure in super-obese patients. Surg Obes Relat Dis. 2018 Mar;14(3):297\u0026ndash;303. \u003c/li\u003e\n\u003cli\u003eLee WJ, Hur KY, Lakadawala M, Kasama K, Wong SKH, Chen SC, et al. Predicting success of metabolic surgery: age, body mass index, C-peptide, and duration score. Surg Obes Relat Dis. 2013 May;9(3):379\u0026ndash;84. \u003c/li\u003e\n\u003cli\u003eEce I, Yilmaz H, Alptekin H, Yormaz S, Colak B, Yilmaz F, et al. Comparative Effectiveness of Laparoscopic Sleeve Gastrectomy on Morbidly Obese, Super-Obese, and Super-Super Obese Patients for the Treatment of Morbid Obesity. Obes Surg. 2018 Jun;28(6):1484\u0026ndash;91. \u003c/li\u003e\n\u003cli\u003eThereaux J, Corigliano N, Poitou C, Oppert JM, Czernichow S, Bouillot JL. Comparison of results after one year between sleeve gastrectomy and gastric bypass in patients with BMI\u0026ge;50 kg/m\u003csup\u003e2\u003c/sup\u003e. Surg Obes Relat Dis. 2015 Jul;11(4):785\u0026ndash;90. \u003c/li\u003e\n\u003cli\u003eOh TJ, Lee H, Cho YM. East Asian perspectives in metabolic and bariatric surgery. J Diabetes Investig. 2022 May;13(5):756\u0026ndash;61. \u003c/li\u003e\n\u003cli\u003eNg HJ, Kim G, Chew CAZ, San MT, So JB, Shabbir A. Is Laparoscopic Sleeve Gastrectomy for Asian Super Obese a Safe and Effective Procedure? Ann Acad Med Singapore. 2018 May;47(5):177\u0026ndash;84. \u003c/li\u003e\n\u003cli\u003eLee Y, Dang JT, Switzer N, Malhan R, Birch DW, Karmali S. Bridging interventions before bariatric surgery in patients with BMI \u0026ge; 50 kg/m2: a systematic review and meta-analysis. Surg Endosc. 2019 Nov;33(11):3578\u0026ndash;88. \u003c/li\u003e\n\u003cli\u003eDeMaria EJ, Schauer P, Patterson E, Nguyen NT, Jacob BP, Inabnet WB, et al. The Optimal Surgical Management of the Super Obese Patient: The Debate. Surg Innov. 2005 Jun;12(2):107\u0026ndash;8.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1: Baseline Characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.5%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=184)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSG\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=164)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGB\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=20)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.5%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.5%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e38.6\u0026nbsp;\u0026plusmn;\u0026nbsp;10.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e38.7\u0026nbsp;\u0026plusmn;\u0026nbsp;10.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e37.9\u0026nbsp;\u0026plusmn;\u0026nbsp;10.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.5%\" valign=\"top\"\u003e\n \u003cp\u003e0.731\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.166666666666666%\" colspan=\"2\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e78 (42.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e71 (43.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e7 (35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.5%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.323\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.379146919431278%\" valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.96208530805687%\" valign=\"top\"\u003e\n \u003cp\u003e106 (57.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.540284360189574%\" valign=\"top\"\u003e\n \u003cp\u003e93 (56.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.118483412322274%\" valign=\"top\"\u003e\n \u003cp\u003e13 (65%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.166666666666666%\" colspan=\"2\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eRace\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eChinese\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e33 (17.9%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e29 (17.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e4 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.5%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e0.896\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.379146919431278%\" valign=\"top\"\u003e\n \u003cp\u003eMalay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.96208530805687%\" valign=\"top\"\u003e\n \u003cp\u003e93 (50.5%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.540284360189574%\" valign=\"top\"\u003e\n \u003cp\u003e81 (49.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.118483412322274%\" valign=\"top\"\u003e\n \u003cp\u003e12 (60%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.379146919431278%\" valign=\"top\"\u003e\n \u003cp\u003eIndian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.96208530805687%\" valign=\"top\"\u003e\n \u003cp\u003e43 (23.4%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.540284360189574%\" valign=\"top\"\u003e\n \u003cp\u003e40 (24.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.118483412322274%\" valign=\"top\"\u003e\n \u003cp\u003e3 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.379146919431278%\" valign=\"top\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.96208530805687%\" valign=\"top\"\u003e\n \u003cp\u003e14 (8.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.540284360189574%\" valign=\"top\"\u003e\n \u003cp\u003e14 (8.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.118483412322274%\" valign=\"top\"\u003e\n \u003cp\u003e1 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.5%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003ePre-operative weight (kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e149.1\u0026nbsp;\u0026plusmn;\u0026nbsp;21.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e149.7\u0026nbsp;\u0026plusmn;21.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e144.5\u0026nbsp;\u0026plusmn;\u0026nbsp;18.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.5%\" valign=\"top\"\u003e\n \u003cp\u003e0.105\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.5%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003ePre-operative BMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e55.1\u0026nbsp;\u0026plusmn;\u0026nbsp;7.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e56.2\u0026nbsp;\u0026plusmn;\u0026nbsp;5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e56.1\u0026nbsp;\u0026plusmn;\u0026nbsp;6.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.5%\" valign=\"top\"\u003e\n \u003cp\u003e0.104\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.479201331114808%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eGlycemic Status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.139767054908486%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eNo diabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.633943427620633%\" valign=\"top\"\u003e\n \u003cp\u003e84 (45.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.63560732113145%\" valign=\"top\"\u003e\n \u003cp\u003e79 (48.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.63727121464226%\" valign=\"top\"\u003e\n \u003cp\u003e5 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.474209650582363%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e0.040\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.401847575057737%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003ePre-diabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.25173210161663%\" valign=\"top\"\u003e\n \u003cp\u003e39 (21.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.86605080831409%\" valign=\"top\"\u003e\n \u003cp\u003e35 (21.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.480369515011546%\" valign=\"top\"\u003e\n \u003cp\u003e4 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.401847575057737%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.25173210161663%\" valign=\"top\"\u003e\n \u003cp\u003e61 (33.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.86605080831409%\" valign=\"top\"\u003e\n \u003cp\u003e50 (30.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.480369515011546%\" valign=\"top\"\u003e\n \u003cp\u003e11 (55%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.5%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eMean HbA1c of those with diabetes (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e8.0\u0026nbsp;\u0026plusmn;\u0026nbsp;1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e7.9\u0026nbsp;\u0026plusmn;\u0026nbsp;1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e8.2\u0026nbsp;\u0026plusmn;\u0026nbsp;1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.5%\" valign=\"top\"\u003e\n \u003cp\u003e0.576\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.5%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003ePre-hypertension or hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e86 (46.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e72 (43.9%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e14 (70%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.5%\" valign=\"top\"\u003e\n \u003cp\u003e0.024\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.5%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eHyperlipidaemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e44 (23.9%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e34 (20.7%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e10 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.5%\" valign=\"top\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.5%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eObstructive sleep apnoea\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e109 (59.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e95 (70.9%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e14 (70%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.5%\" valign=\"top\"\u003e\n \u003cp\u003e0.215\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2: Post-operative Outcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.3953488372093%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.435215946843854%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=184)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.774086378737543%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSG\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=164)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.272425249169434%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGB\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=20)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.122923588039868%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.3953488372093%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eOperating time (minutes)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.435215946843854%\" valign=\"top\"\u003e\n \u003cp\u003e125.6\u0026nbsp;\u0026plusmn;\u0026nbsp;62.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.774086378737543%\" valign=\"top\"\u003e\n \u003cp\u003e112.4\u0026nbsp;\u0026plusmn;\u0026nbsp;43.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.272425249169434%\" valign=\"top\"\u003e\n \u003cp\u003e249.4\u0026nbsp;\u0026plusmn;\u0026nbsp;76.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.122923588039868%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.3953488372093%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eLength of stay (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.435215946843854%\" valign=\"top\"\u003e\n \u003cp\u003e3.3\u0026nbsp;\u0026plusmn;\u0026nbsp;2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.774086378737543%\" valign=\"top\"\u003e\n \u003cp\u003e3.1\u0026nbsp;\u0026plusmn;\u0026nbsp;0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.272425249169434%\" valign=\"top\"\u003e\n \u003cp\u003e4.5\u0026nbsp;\u0026plusmn;\u0026nbsp;0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.122923588039868%\" valign=\"top\"\u003e\n \u003cp\u003e0.023\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.3953488372093%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e30-day adverse events (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.435215946843854%\" valign=\"top\"\u003e\n \u003cp\u003e9 (4.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.774086378737543%\" valign=\"top\"\u003e\n \u003cp\u003e6 (3.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.272425249169434%\" valign=\"top\"\u003e\n \u003cp\u003e3 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.122923588039868%\" valign=\"top\"\u003e\n \u003cp\u003e0.061\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.479201331114808%\" rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eTypes of adverse events\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.80199667221298%\" valign=\"top\"\u003e\n \u003cp\u003eHaemorrhage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.467554076539102%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.803660565723792%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.302828618968388%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.144758735440933%\" rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.27964205816555%\" valign=\"top\"\u003e\n \u003cp\u003eInfection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.174496644295303%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.937360178970916%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.60850111856823%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.27964205816555%\" valign=\"top\"\u003e\n \u003cp\u003eLeak\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.174496644295303%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.937360178970916%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.60850111856823%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.27964205816555%\" valign=\"top\"\u003e\n \u003cp\u003eVenous thrombosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.174496644295303%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.937360178970916%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.60850111856823%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.27964205816555%\" valign=\"top\"\u003e\n \u003cp\u003eUreteric stone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.174496644295303%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.937360178970916%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.60850111856823%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.3953488372093%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eReadmission rate (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.435215946843854%\" valign=\"top\"\u003e\n \u003cp\u003e4 (2.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.774086378737543%\" valign=\"top\"\u003e\n \u003cp\u003e3 (1.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.272425249169434%\" valign=\"top\"\u003e\n \u003cp\u003e1 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.122923588039868%\" valign=\"top\"\u003e\n \u003cp\u003e0.371\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.3953488372093%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eRevisional surgery (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.435215946843854%\" valign=\"top\"\u003e\n \u003cp\u003e5 (2.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.774086378737543%\" valign=\"top\"\u003e\n \u003cp\u003e4 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.272425249169434%\" valign=\"top\"\u003e\n \u003cp\u003e1 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.122923588039868%\" valign=\"top\"\u003e\n \u003cp\u003e0.441\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.3953488372093%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e30-day Mortality (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.435215946843854%\" valign=\"top\"\u003e\n \u003cp\u003e0\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.774086378737543%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.272425249169434%\" valign=\"top\"\u003e\n \u003cp\u003e0\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.122923588039868%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003e*Excluding those who underwent concurrent operations (n=18)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3: Post-operative Weight Loss\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.282861896838604%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.966722129783694%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.302828618968388%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSG\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.302828618968388%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.144758735440933%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.282861896838604%\" valign=\"top\"\u003e\n \u003cp\u003e% TWL at 12 months\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e(n=125)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.966722129783694%\" valign=\"top\"\u003e\n \u003cp\u003e27.4\u0026nbsp;\u0026plusmn;\u0026nbsp;9.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.302828618968388%\" valign=\"top\"\u003e\n \u003cp\u003e27.6\u0026nbsp;\u0026plusmn;\u0026nbsp;9.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.302828618968388%\" valign=\"top\"\u003e\n \u003cp\u003e26.0\u0026nbsp;\u0026plusmn;\u0026nbsp;9.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.144758735440933%\" valign=\"top\"\u003e\n \u003cp\u003e0.481\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.282861896838604%\" valign=\"top\"\u003e\n \u003cp\u003e% TWL at 24 months\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e(n=94)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.966722129783694%\" valign=\"top\"\u003e\n \u003cp\u003e27.1\u0026nbsp;\u0026plusmn;\u0026nbsp;10.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.302828618968388%\" valign=\"top\"\u003e\n \u003cp\u003e27.4\u0026nbsp;\u0026plusmn;\u0026nbsp;11.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.302828618968388%\" valign=\"top\"\u003e\n \u003cp\u003e24.9\u0026nbsp;\u0026plusmn;\u0026nbsp;8.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.144758735440933%\" valign=\"top\"\u003e\n \u003cp\u003e0.495\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 4: HbA1c at 12 and 24 Months for patients with diabetes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSG\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003eHbA1c at 12 months (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e5.5\u0026nbsp;\u0026plusmn;\u0026nbsp;0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e5.6\u0026nbsp;\u0026plusmn;\u0026nbsp;0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e5.3\u0026nbsp;\u0026plusmn;\u0026nbsp;0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e0.186\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003eHbA1c reduction at 12 months (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e2.4\u0026nbsp;\u0026plusmn;\u0026nbsp;1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e2.1\u0026nbsp;\u0026plusmn;\u0026nbsp;1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e3.3\u0026nbsp;\u0026plusmn;\u0026nbsp;1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e0.017\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003eHbA1c at 24 months (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e5.7\u0026nbsp;\u0026plusmn;\u0026nbsp;0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e5.7 \u0026nbsp;\u0026plusmn;\u0026nbsp;0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e5.7\u0026nbsp;\u0026plusmn;\u0026nbsp;0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e0.934\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003eHbA1c reduction at 24 months (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e2.2\u0026nbsp;\u0026plusmn;\u0026nbsp;1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e1.9\u0026nbsp;\u0026plusmn;\u0026nbsp;1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e3.2\u0026nbsp;\u0026plusmn;\u0026nbsp;1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e0.030\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 5: Post-operative Diabetes Remission Rates\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.116472545757073%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.966722129783694%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.469217970049918%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSG\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.469217970049918%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.9783693843594%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.116472545757073%\" valign=\"top\"\u003e\n \u003cp\u003eDiabetes remission rate at 12 months\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e(n=39)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.966722129783694%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;27 (69.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.469217970049918%\" valign=\"top\"\u003e\n \u003cp\u003e21 (67.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.469217970049918%\" valign=\"top\"\u003e\n \u003cp\u003e6 (75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.9783693843594%\" valign=\"top\"\u003e\n \u003cp\u003e0.527\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.116472545757073%\" valign=\"top\"\u003e\n \u003cp\u003eDiabetes remission rate at 24 months\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e(n=30)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.966722129783694%\" valign=\"top\"\u003e\n \u003cp\u003e23 (76.7%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.469217970049918%\" valign=\"top\"\u003e\n \u003cp\u003e18 (78.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.469217970049918%\" valign=\"top\"\u003e\n \u003cp\u003e5 (71.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.9783693843594%\" valign=\"top\"\u003e\n \u003cp\u003e0.532\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\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":"","lastPublishedDoi":"10.21203/rs.3.rs-4528310/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4528310/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cu\u003eIntroduction\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe benefits of metabolic bariatric surgery (MBS) in people with body mass index (BMI) ≥50kg/m\u003csup\u003e2\u003c/sup\u003e are not well-established, with concerns of increased risk and poorer weight loss. Optimal surgical type (gastric bypass [GB] versus sleeve gastrectomy [SG]) is unclear, with studies comparing complication rates, weight loss, and glycemic outcomes reporting mixed results.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eMethods\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eParticipants with BMI≥50kg/m\u003csup\u003e2\u003c/sup\u003e undergoing MBS (SG or GB) from 2008-2022 were recruited. Demographics, anthropometrics, biochemistry and diabetes status were analysed at baseline, 12-months, and 24-months post-operatively. Surgical outcomes and complications were analysed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eResults\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe study included n=184 with BMI≥50kg/m\u003csup\u003e2\u003c/sup\u003e (57.6% female, age 38.6±10.5years, BMI 55.3±6.0kg/m\u003csup\u003e2\u003c/sup\u003e). Pre-operatively, 21.1% had pre-diabetes and 33.2% had diabetes (mean HbA1c 8.0±1.7%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMost subjects (89.1%) underwent SG. The overall 30-day adverse event rate was 4.9%, higher in GB group (GB=15%, SG=3.7%, p=0.061). The GB group had longer length of stay (GB =4.5±0.6days, SG=3.1±0.2, p=0.023). The 30-day readmission rate was 2.2%, and rate of revisional surgery was 2.7%, with no significant difference between groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe follow-up rate was 67.9% at 12-months, 51.1% at 24-months. Average %total weight loss at 12-months (27.4±9.0%, SG=27.6±9.0%, GB=26.0±9.4%, p=0.481) and 24-months (27.1±10.9%, SG=27.4±11.1%, GB=24.9±8.9%, p=0.495) were similar between groups. The GB group had a larger HbA1c reduction (3.2±1.1%) than SG (1.9 ±1.3%, p=0.030), but no difference in diabetes remission rates (69.2% at 12-months, 76.7% at 24-months).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eConclusion\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eMBS is safe and effective for individuals with BMI≥50kg/m\u003csup\u003e2\u003c/sup\u003e, with good weight loss and glycemic outcomes with both SG and GB. Complication rates were low, although higher in the GB group.\u003c/p\u003e","manuscriptTitle":"Bariatric Surgery Outcomes in People with Severe Obesity (BMI ≥ 50 kg/m2)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-15 17:48:45","doi":"10.21203/rs.3.rs-4528310/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":"f02c9aae-9418-4cee-aca3-4043f1993d10","owner":[],"postedDate":"July 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-15T17:56:47+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-15 17:48:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4528310","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4528310","identity":"rs-4528310","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}