Long-Term Effects of Laparoscopic Sleeve Gastrectomy and Roux-en-Y Gastric Bypass on Body Composition and Bone Mass Density

Short-term effects of Roux-en-Y gastric bypass or gastric sleeve on bone mineral density and calciotropic hormones: a systematic review and meta-analysis

Roux-en-Y gastric bypass (RYGB) and gastric sleeve (GS) have been associated with significant reductions in bone mineral density (BMD) and fluctuations in serum levels of calciotropic hormones. These changes pose a risk to bone health. The study assessed the short-term (12 and 24 months) effects of RYGB and GS on BMD and calciotropic hormones. PubMed, Embase, and Cochrane Library databases were searched. Analyses considered follow-up (12 and 24 months) with BMD as main outcome at three sites (femoral neck, total hip, and lumbar spine) and one for each calciotropic hormone (25 OH vitamin D and parathyroid hormone [PTH]). Estimated effect sizes were calculated as standardized mean differences (SMD), confidence interval of 95%, and P value. Nine studies totaling 473 participants (RYGB = 261 and GS = 212) were included. RYGB resulted in lower BMD than GS at 12 months for femoral neck (SMD = -0.485, 95% CI [-0.768, -0.202], P = .001), lumbar spine (SMD = -0.471, 95% CI [-0.851, -0.092], P = .015), and total hip (SMD = -0.616, 95% CI [-0.972, -0.259], P = .001), and at 24 months for total hip (SMD = -0.572, 95% CI [-0.907, -0.238], P = .001). At 24 months, 25 OH vitamin D was lower in RYGB than GS (SMD = -0.958 [-1.670, -0.245], P = .008) and PTH levels were higher in RYGB than in GS (SMD = 0.968 [0.132, 1.804, P = .023]). RYGB demonstrated significant reduction in regional BMD. It also induces lower serum 25 OH vitamin D and higher PTH levels than GS. The results support the need for preventive bone health measures in the short-term postoperative period, especially in the case of RYGB.

Long-term prevalence of vitamin deficiencies after bariatric surgery: a meta-analysis

BACKGROUND

Bariatric surgery can lead to short-mid-term vitamin deficiencies, but the long-term vitamin deficiencies is unclear. This study aimed to conduct a meta-analysis regarding the long-term prevalence (≥ 5 years) of vitamin deficiencies after bariatric surgery.

METHODS

We searched the EMBASE, PubMed, and CENTRAL databases for clinical studies until June 2023. Meta-analysis, sensitivity, subgroup, and meta-regression analyses were performed.

RESULTS

This meta-analysis included 54 articles with follow-up duration ranging from 5 to 17 years. The most prevalent vitamin deficiencies after surgery were vitamin D (35.8%), followed by vitamin E (16.5%), vitamin A (13.4%), vitamin K (9.6%), and vitamin B12 (8.5%). Subgroup analyses showed that the prevalence of vitamin A and folate deficiencies increased with the follow-up time. Roux-en-Y gastric bypass had a higher rate of vitamin B12 deficiency than sleeve gastrectomy and biliopancreatic diversion with duodenal switch (BPD-DS). Studies conducted in Europe had higher vitamin A deficiency (25.8%) than in America (0.8%); Asian studies had more vitamin B12 but less vitamin D deficiency than European and American studies. Meta-regression analysis displayed that publication year, study design, preoperative age, BMI, and quality assessment score were not associated with vitamin A, B12, D, and folate deficiencies rate.

CONCLUSION

A high prevalence of vitamin deficiencies was found after bariatric surgery in the long-term follow-up, especially vitamin D, E, A, K, and B12. The variation in study regions, surgical procedures, and follow-up time are associated with different postoperative vitamin deficiencies; it is necessary to develop more targeted vitamin supplement programs.

Risk of fractures following bariatric surgery with Roux-en-Y gastric bypass or sleeve gastrectomy: a Danish population-based cohort study

OBJECTIVE

We examined the association between Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) and fracture risk, including major osteoporotic fractures (MOF), and the use of anti-osteoporosis medication (AOM). While RYGB is associated with impaired bone health and increased fracture risk, it remains uncertain whether SG has a similar impact and whether this risk is primarily due to MOF or any fracture.

DESIGN

We conducted a nationwide cohort study covering patients treated with RYGB (n = 16 121, 10.2-year follow-up) or SG (n = 1509, 3.7-year follow-up), from 2006 to 2018, comparing them with an age- and sex-matched cohort (n = 407 580).

METHODS

We computed incidence rates and adjusted hazard ratios (HRs) with 95% CIs, using Cox regression for any fracture, MOF, and use of AOM with adjustment for comorbidities.

RESULTS

Compared with the general population cohort, RYGB was associated with an increased risk of any fracture (HR 1.56 [95% CI, 1.48-1.64]) and MOF (HR 1.49 [1.35-1.64]). Sleeve gastrectomy was associated with an increased risk of any fracture (HR 1.38 [1.13-1.68]), while the HR of MOF was 1.43 (0.97-2.12). The use of AOM was low but similar in all cohorts (approximately 1%).

CONCLUSIONS

Bariatric surgery increased the risk of any fracture and MOF to similar extend. Risks were similar for RYGB and SG. However, SG had a shorter follow-up than RYGB, and the cohort size was rather small. More research is needed for long-term SG fracture risk assessment. The use of AOM was low in all cohorts.

Effect of laparoscopic sleeve gastrectomy versus laparoscopic Roux-en-Y gastric bypass on body composition

BACKGROUND

There is limited data with respect to body composition changes for laparoscopic sleeve gastrectomy (SG) and laparoscopic Roux-en-Y gastric bypass (RYGB). The objective of this study was to analyse changes in body composition between these two procedures during the first year after bariatric surgery.

METHODS

A prospective study was performed in patients undergoing bariatric surgery at two tertiary hospitals between 2017 and 2023. Body composition was assessed with dual-energy x-ray absorptiometry immediately before surgery, and at 1-, 6-, 12-, 18- and 24-months post-operatively, with a subgroup analysis performed for patients who undertook a scan at 18- and 24-months. Total weight loss (TWL), body mass index (BMI), fat mass (FM), lean body mass (LBM) and bone mineral content (BMC) parameters were compared between SG and RYGB.

RESULTS

Forty-five patients were included in this series (SG n = 30, RYGB n = 15). There was a significant reduction in mean %TWL of 26.94 ± 8.86% and mean BMI of 11.12 ± 3.70 kg/m2 over 12-months. LBM accounted for 17.8% of TWL over 12-months, SG and RYGB did not differ in terms of loss of FM or LBM. For both procedures, the loss of LBM appeared to plateau at 6-months post-operatively. The only statistically significant finding between the two procedures was that RYGB resulted in an additional 0.06 kg loss compared with SG.

CONCLUSION

SG and RYGB have been shown to have comparable weight loss and body composition changes in the short-to-medium term following surgery. LBM reduction was most significant in the early post-operative period across the entire cohort.

Vitamin and Mineral Deficiency 12 Years After Roux-en-Y Gastric Bypass a Cross-Sectional Multicenter Study

PURPOSE

Micronutrient deficiencies are common after Roux-en-Y gastric bypass (RYGB). This study explores whether vitamin and mineral deficiency was associated with adherence to recommended supplementation 12 years after RYGB.

MATERIALS AND METHODS

The cross-sectional Bariatric Surgery Observation Study (BAROBS) was conducted in 2018-2020 at three hospitals in Central Norway. We report data on 490 patients' self-reported adherence to recommended supplements and vitamin and mineral levels in the blood. The patients, who had RYGB between 2003 and 2009, were recommended an over-the-counter multivitamin-mineral supplement, calcium/vitamin D (1000 mg/20 µg) and vitamin B12 injections (reimbursed), since bariatric supplements were not available then.

RESULTS

Mean (SD) age was 40.1 ± 9 years at RYGB, and time to follow-up 11.7 ± 1.6 years. Of 490 patients, 393 (80%) were women. Among 361 (74%) patients' adherent to multivitamin-mineral supplements; folate, vitamin B2, and vitamin B6 deficiency were present in 39 (11%), 103 (29%), and 63 (17%) patients, respectively. The same deficiencies occurred in 44 (34%), 67 (52%), and 67 (52%) patients' non-adherent to recommendations. Although 466 (95%) patients reported adherence to vitamin B12 supplements, sub-optimal levels were found in 73 (16%) patients. Though 336 (69%) patients adhered to calcium/vitamin D supplements (1000 mg/20 µg), sub-optimal vitamin D levels (< 75 nmol/l) were found in 174/336 (52%) adherent patients and 120/154 (78%) non-adherent patients.

CONCLUSION

Twelve years after RYGB, adherence to supplements, though in sub-optimal doses of new recommendations, decreases the probability of vitamin and mineral deficiency, especially for thiamine, vitamin B2, vitamin B6, folate, vitamin B12, and vitamin D, but does not eliminate it.

Changes in Lean Tissue Mass, Fat Mass, Biological Parameters and Resting Energy Expenditure over 24 Months Following Sleeve Gastrectomy

Sleeve gastrectomy (SG) induces weight loss but its effects on body composition (BC) are less well known. The aims of this longitudinal study were to analyse the BC changes from the acute phase up to weight stabilization following SG. Variations in the biological parameters related to glucose, lipids, inflammation, and resting energy expenditure (REE) were concomitantly analysed. Fat mass (FM), lean tissue mass (LTM), and visceral adipose tissue (VAT) were determined by dual-energy X-ray absorptiometry in 83 obese patients (75.9% women) before SG and 1, 12 and 24 months later. After 1 month, LTM and FM losses were comparable, whereas at 12 months the loss of FM exceeded that of LTM. Over this period, VAT also decreased significantly, biological parameters became normalized, and REE was reduced. For most of the BC, biological and metabolic parameters, no substantial variation was demonstrated beyond 12 months. In summary, SG induced a modification in BC changes during the first 12 months following SG. Although the significant LTM loss was not associated with an increase in sarcopenia prevalence, the preservation of LTM might have limited the reduction in REE, which is a longer-term weight-regain criterion.

Marked weight loss on liraglutide 3.0 mg: Real-life experience of a Swiss cohort with obesity

OBJECTIVE

This study investigated the effectiveness of liraglutide 3.0 mg daily in combination with a standardized multidisciplinary intervention on body weight and body composition changes in a real-life setting.

METHODS

A prospective, observational cohort study design was used. Adult patients with BMI > 35 kg/m² , or BMI > 28 kg/m² with greater than or equal to one metabolic comorbidity, were included (n = 54, 65% women). Liraglutide treatment was covered by Swiss health insurance. Clinical and biological data were collected at baseline, 4 months, and 10 months. Body composition was assessed by dual-energy x-ray absorptiometry at baseline and 10 months.

RESULTS

At 10 months, mean (SD) percentage weight loss (WL%) was -12.4% (5.5%) or -14.1 (6.6) kg. WL% was ≥5% in 87% of patients at 4 months and in 96% at 10 months. WL% was higher in women (-9.5% [3.1%] vs. men -7.2% [2.5%], p = 0.02) at 4 months and persisted at 10 months (-13.7% [5.2%] vs. -9.6% [5.1%], p = 0.006). WL% was associated with baseline percentage fat mass but not with age or BMI. Body composition showed a decrease in fat mass, visceral adipose tissue, and absolute lean mass.

CONCLUSIONS

In a real-world setting, liraglutide 3.0 mg led to beneficial changes in WL and body composition, with a greater impact in women.

Risedronate use may blunt appendicular lean mass loss secondary to sleeve gastrectomy: Results from a pilot randomized controlled trial

Background

Despite robust weight loss and cardiometabolic benefit, lean mass loss following sleeve gastrectomy (SG) confers health risk. Bisphosphonates are a potential therapeutic agent for lean mass maintenance. Thus, our objective was to explore the effect of six months of risedronate (vs placebo) on change in dual energy x-ray absorptiometry (DXA) and computed tomography (CT) derived lean mass metrics in the year following SG.

Methods

24 SG patients were randomized to six months of 150 mg oral risedronate or placebo capsules (NCT03411902). Body composition was assessed at baseline and six months with optional 12-month follow-up using whole-body DXA and CT at the lumbar spine and mid-thigh. Group treatment effects and 95% CIs were generated from a mixed model using contrast statements at six and 12 months, adjusted for baseline values.

Results

Of 24 participants enrolled [55.7±6.7 years (mean±SD), 79% Caucasian, 83% women, body mass index (BMI) 44.7±6.3kg/m2], 21 returned for six-month testing, and 14 returned for 12-month testing. Six-month weight loss was -16.3 kg (-20.0, -12.5) and -20.9 kg (-23.7, -18.1) in the risedronate and placebo groups, respectively (p=.057). Primary analysis at six-months revealed a non-significant sparing of appendicular lean mass in the risedronate group compared to placebo [-1.2 kg (-2.3, -0.1) vs -2.1 kg (-3.0, -1.2)]; p=.20. By 12-months, the risedronate group displayed no change in appendicular lean mass from baseline [-0.5 kg (-1.5, 0.6)]; however, the placebo group experienced significantly augmented loss [-2.9 kg (-3.6, -2.1)].

Conclusion

Pilot data indicate risedronate treatment may mitigate appendicular lean mass loss following SG. Further study is warranted.

Body composition changes at 12 months following different surgical weight loss interventions in adults with obesity: A systematic review and meta-analysis of randomized control trials

To determine relative lean mass and fat mass changes in adults with obesity following surgical weight loss interventions, a systematic review and meta-analysis was conducted. The Cochrane Central Register of Controlled Trials, PubMed, Web of Science, EMBASE, and Scopus were screened for eligible studies. Inclusion criteria included randomized controlled trials (RCTs) performed in populations with obesity (body mass index ≥30 kg/m² ) aged over 18 years, who underwent any type of bariatric surgery and reported body composition measures via dual-energy X-ray absorptiometry or bio-electrical impedance analysis. Authors conducted full text screening and determined that there were six RCTs eligible for inclusion, with data extracted at 12 months post-surgery. Meta-analysis revealed that, relative to gastric banding, Roux-en-Y gastric bypass (RYGB) led to greater total body mass loss (mean difference [MD]: -9.33 kg [95% CI: -12.10, -6.56]) and greater fat mass loss (MD: -8.86 kg [95% CI: -11.80, -5.93], but similar lean mass loss (MD: -0.55 kg [95% CI: -3.82, 2.71]. RYGB also led to similar changes in total body mass, fat mass, and lean mass compared with sleeve gastrectomy. RYGB results in greater 12-month weight and fat loss, but similar changes in lean mass, compared with gastric banding. Further RCTs comparing body composition changes following different bariatric surgery procedures are required.

Prevalence of low skeletal muscle mass following bariatric surgery

BACKGROUND AND AIMS

Evidence on the occurrence of low skeletal muscle mass (low-SMM) following bariatric surgery (BS) as well as on the impact of low-SMM antedating BS on post-surgical body composition (BC) are scant. In this context, we aimed to prospectively evaluate the prevalence of low-SMM prior to and up to 5 years after BS, and to evaluate pre-surgical low-SMM as an independent risk factor for the presence of low-SMM after BS.

METHODS

Retrospective analysis of prospectively collected database. BC was assessed by bioelectrical impedance analysis (BIA). A BIA-based formula was used to calculate skeletal muscle mass (SMM). Class I and class II low-SMM were defined respectively as a SMM index (SMMI = SMM/height²) value between -1 and -2, or > -2 standard deviations from the gender-specific regression line of the BMI versus the SMMI relationship in our reference group.

RESULTS

A total 952 subjects were included, with BC being available for 877 (92%) subjects at 12 months and for 576 subjects (60%) at 60 months after BS. Prior to surgery, and at 12-, or at 60-months after surgery, class I and class II low-SMM was ascertained respectively in 15.6% and 4.6%, 5.3% and 1.4%, and 16.6% and 6.3% of the study participants. Logistic regression analysis showed that the occurrence of low-SMM at 12- and 60-months follow-up, was independently predicted not only by age at the time of surgery [respectively, HR: 1.052 (95% CI 1.020-1.084), p = 0.001; and 1.042 (95% CI 1.019-1.066); p < 0.001] but also by the presence of low-SMM prior to surgery [respectively, HR: 10.717 (95% CI 5.771-19.904), p < 0.001; and 5.718 (95% CI 3.572-9.153); p < 0.001].

CONCLUSIONS

Our data suggest that a low-SMM phenotype occurs not only in obesity surgery candidates but also after BS, and that low-SMM prior to surgery is an important risk factor for low-SMM throughout post-surgical follow-up.

Long-term body composition improvement in post-menopausal women following bariatric surgery: a cross-sectional and case-control study

OBJECTIVE

Bariatric surgery (BS) induces loss of body fat mass (FM) with an inexorable loss of lean mass (LM). Menopause leads to deleterious changes in body composition (BC) related to estrogen deficiency including LM loss and increase in total and visceral adipose tissue (VAT). This study aims to describe the long-term weight evolution of post-menopausal women after Roux-en-Y gastric bypass (RYGB) and to compare the BC between BS patients vs post-menopausal non-operated women.

DESIGN

Cross-sectional study of 60 post-menopausal women who underwent RYGB ≥2 years prior to the study with nested case-control design.

METHODS

Post-menopausal BS women were matched for age and BMI with controls. Both groups underwent DXA scan, lipids and glucose metabolism markers assessment.

RESULTS

Median follow-up was 7.5 (2-18) years. Percentage of total weight loss (TWL%) was 28.5 ± 10%. After RYGB, LM percentage of body weight (LM%) was positively associated with TWL% and negatively associated with nadir weight. Forty-one post-BS women were age- and BMI-matched with controls. Post-BS patients showed higher LM% (57.7% (±8%) vs 52.5% (±5%), P = 0.001), reduced FM% (39.4% (±8.4%) vs 45.9% (±5.4%), P < 0.01) and lower VAT (750.6 g (±496) vs 1295.3 g (±688), P < 0.01) with no difference in absolute LM compared to controls. While post-BS women showed a better lipid profile compared to controls, no difference was found in glucose markers.

CONCLUSIONS

Post-menopausal women after RYGB have a lower FM and VAT, preserved LM and a better lipid profile compared to controls. Weight loss after RYGB seems to have a persistent positive impact on metabolic health.

Bone Mineral Density Trends During the First Year After Laparoscopic Sleeve Gastrectomy-a Cohort Study on 241 Patients

Purpose

Laparoscopic sleeve gastrectomy (LSG) is an effective weight loss procedure, but detrimental effects on bone health have been described. We aimed to assess the dynamics of regional and total bone mineral density (BMD) in a cohort of patients undergoing LSG and to capture gender differences in terms of evolution.

Materials and Methods

We conducted a retrospective study on 241 patients who underwent LSG to determine the regional and total BMD changes at 6 and 12 months after the intervention.

Results

One hundred ten males and 140 females (97 pre-, 43 postmenopausal) were included. Mean baseline body mass index (BMI) was 44.16 ± 6.11 kg/m² in males and 41.60 ± 5.54 kg/m² in females, reaching 28.62 ± 4.26 kg/m² and 27.39 ± 4.2 kg/m², respectively, at 12 months. BMD showed a continuous decline, with significant loss from 6 months postoperatively. There was a positive correlation between BMD and BMI decline at 12 months (r = 0.134, p < 0.05). Total BMD loss at 12 months was significantly greater in males than premenopausal females, independent of BMI variation and age. During the first 6 months, men lost significantly more bone mass than premenopausal and postmenopausal women (BMD variation was 2.62%, 0.27%, 1.58%, respectively). The second period (6–12 months) was similar in all three groups, revealing a further steady (~ 1.4%) BMD decline.

Conclusions

Our results are consistent with previous findings that LSG negatively impacts BMD, stressing the importance of bone health-oriented measures in postoperative care. Moreover, the impact that seems more significant in males warrants future exploration, as it might change clinical practice.

Graphical abstract