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DOI 10.1007/s11695-015-1746-z

ORIGINAL CONTRIBUTIONS

Gender Influence on Long-Term Weight Loss and Comorbidities

After Laparoscopic Sleeve Gastrectomy and Roux-en-Y Gastric
Bypass: a Prospective Study With a 5-Year Follow-up

Federico Perrone 1 & Emanuela Bianciardi 3 &

Domenico Benavoli 1 & Valeria Tognoni 1 & Cinzia Niolu 3 &
Alberto Siracusano 3 & Achille L. Gaspari 1 &
Paolo Gentileschi 1,2

# Springer Science+Business Media New York 2015

Abstract 90 % of patients showed improvements in comorbidities in the

Background Gender might be important in predicting out- LSG and LRYGB groups, respectively. Only two patients
comes after bariatric surgery. The aim of the study was to (women) were lost to follow-up: 1/162 (0.6 %) for LSG at
investigate the influence of gender on long-term weight loss the 4th year and 1/142 (0.7 %) for LRYGB to the 5th year.
and comorbidity improvement after laparoscopic sleeve gas- Conclusions LSG was more effective in obese male than in
trectomy (LSG) and laparoscopic Roux-en-Y gastric bypass female patients in terms of %EBMIL, with no difference in
(LRYGB). comorbidities. LRYGB elicited similar results in both genders
Methods A cohort of 304 consecutive patients underwent sur- in terms of %EBMIL and comorbidities.
gery in 2006–2009: 162 (98 women, 64 men) underwent LSG
and 142 (112 women, 30 men) underwent LRYGB. The mean
Keywords Obesity . Predictors . Gender . Weight loss .
follow-up time was 75.8±8.4 months (range, 60–96 months).
Bariatric surgery . Sleeve gastrectomy . Gastric Bypass
Results Overall mean (95 % CI) reduction in BMI was 23.5
(24.3–22.7) kg/m2 after 5 years, with no statistical difference
between LSG and LRYGB groups (P=0.94). The overall
means±standard deviations of %EBMIL after 5 years were Introduction/Purpose
78.8±23.5 and 81.6±21.4 in the LSG and LRYGB groups,
respectively. Only for LSG group %EBMIL after 24–36 and Although bariatric surgery is the most effective treatment for
60 months differed significantly between male and female morbid obesity, long-term weight loss is influenced by many
patients (P=0.003 versus P=0.06 in LRYGB), and 89 versus factors, most of which are still unknown. Successful weight

* Federico Perrone Achille L. Gaspari

fed.perrone@gmail.com gaspari@med.uniroma2.it
Emanuela Bianciardi
emanuelabianciardi@libero.it Paolo Gentileschi
gentilp@yahoo.com
Domenico Benavoli
dobenavoli@yahoo.com 1
General Surgery Unit, Department of Experimental Medicine and
Valeria Tognoni Surgery, University of Rome, Tor Vergata, Italy
vtognoni@gmail.com
2
Bariatric Surgery Unit, Department of Experimental Medicine and
Cinzia Niolu Surgery, University of Rome, Tor Vergata, Italy
niolu@med.uniroma2.it
3
Alberto Siracusano Psychiatric Unit, Department of System Medicine, University of
siracusano@med.uniroma2.it Rome, Tor Vergata, Italy
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loss after bariatric surgery is often defined as >50 % excess One-hundred-sixty-two patients (98 women, 64 men)
weight loss. However, >30 % of patients are reported to fail to underwent LSG, and 142 (112 women, 30 men) underwent
achieve this goal in the long-term [1, 2]. We believe that iden- LRYGB.
tifying preoperative predictors of weight loss after bariatric An interdisciplinary team evaluated candidates based on a
surgery is important in improving patient selection and, there- medical, nutritional, endocrinological, and psychiatric work-up.
fore, long-term results. Studies evaluating potential predictors Standard preoperative assessments included barium x-ray of the
of weight loss after bariatric surgery are inconclusive. Based upper gastrointestinal tract or esophagogastroduodenoscopy,
on our experience, we hypothesized that predictors of weight blood examinations, cardiologic evaluation, and chest radiogra-
loss after bariatric surgery differ according to gender. Fat stor- phy. Psychiatric counseling was conducted to evaluate mental
age and metabolism differ greatly between men and women health contraindications to surgery and obstacles to postoperative
[3], but little is known about the influence of these findings on success in order to identify patients unsuitable for surgery.
the outcome of obesity surgery. Therefore, this study aimed to Psychiatric contraindications to bariatric surgery were
explore the influence of gender on long-term weight loss and mental retardation with an IQ below 50, current illicit drug
comorbidities after laparoscopic sleeve gastrectomy (LSG) and alcohol abuse, and severe active, uncontrolled psychiatric
and Roux-en-Y gastric bypass (LRYGB). symptomatology [4].
Further examinations were performed on the basis of individ-
ual clinical history. Inclusion criteria were failure to lose weight
Material and Methods via other methods, BMI>40.0 kg/m2 or ≥35.0 kg/m2 with
obesity-related comorbidities, no previous bariatric surgery, no
A cohort of 304 consecutive patients underwent surgery be- alcohol or drug issues, and no active psychosis. Surgical proce-
tween January 2006 and December 2009. All patients were dures (LSG and LRYGB) were selected based on the preoperative
invited to participate in this prospective cohort study. work-up. All procedures were performed laparoscopically, using
Informed consent was obtained from all individual partici- four or five ports, by the same surgeon. At our institution, LSG is
pants included in the study. All procedures performed in stud- performed with a 36-F bougie and gastric resection is carried out
ies involving human participants were in accordance with the with a reinforced linear stapler. LRYGB is performed using a 75-
ethical standards of the institutional and/or national research cm biliopancreatic limb and a 150-cm alimentary limb.
committee and with the 1964 Helsinki declaration and its later Postoperative advice included a diet consisting of clear
amendments or comparable ethical standards. The study was liquids and puréed foods for 15 days after surgery and a
approved by the Ethics Committee. semisolid-consistency diet for the next 15 days. After the first
Data were analyzed in 2014, resulting in a minimum 30 days, patients gradually began a low-fat, low-carbohydrate,
follow-up of 5 years. high-protein solid diet based on the advice of a dietitian. One

Table 1 Patient
characteristics Patient characteristics (n°304) LSG LRYGB P value

Number of patients (2001–2009) 162 142

(98 F, 64 M) (112 F, 30 M)
Mean age (±SD years) 41.8±4.6 43.8±4.6 NS
Previous bariatric surgery (%) 0% 0%
Previous abdominal surgery n/N:
Cesarean section 12/162 13/142
Abdominoplasty 2/162 1/142
Appendectomy 14/162 11/142
LPS cholecystectomy 5/162 8/142
LPS ovarian cyst removal 3/162 1/142
Mean BMI at surgery (±SD) 47.4±4.2 46.8±3.6 NS
(44.8±3.8 F, 48.7±4.2 M) (44.2±3.7 F, 48.1±4.1 M)
Comorbidities (T2DM, hypertension, 24.3 % (15/162) 36.9 %(26/142) NS
dyslipidemia, obstruction sleep
apnea syndrome)
Mean follow-up 75.8±8.4 months (range 60–96)
Lost to follow-up 1/162 (F, 4th year) 1/142 (F, 5th year)

LSG laparoscopic sleeve gastrectomy, LRYGB laparoscopic Roux-en-Y gastric Bypass, M male, F female, NS not
statistically significant, SD standard deviation, T2DM type 2 diabetes mellitus
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Table 2 Overall outcome percentage of patients with comorbidities was 24.8 %. These
Overall outcome LSG LRYGB P value values were 43.8±4.6 years, 46.8±3.6 kg/m2, and 36.6 % for
the LRYGB patients. The two groups had similar mean ages,
Comorbidity improvement 89 % 90 % NS mean BMI at surgery, and obesity-related comorbidities (type
(reduction or discontinuation 2 diabetes mellitus (T2DM), hypertension, dyslipidemia, and
of therapy after 5 years) (%)
%EBMIL after 5 years, 78.8±23.5 81.6±21.4 NS
obstruction sleep apnea syndrome). Some patients had previ-
mean±standard deviation (kg/m2) ous abdominal surgery. There were no postoperative or long-
term mortality. The mean follow-up was 75.8±8.4 months
(range, 60–96 months) (Table 1). Only two patients
multivitamin tablet, daily intake, was recommended for three (women) were lost to follow-up: 1/162 (0.6 %) for LSG at
months after surgery, as well as high-frequency water intake the 4th year and 1/142 (0.7 %) for LRYGB to the 5th year.
and physical activity. Overall mean (95 % CI) reduction in BMI was 23.5 (24.3–
Weight loss was defined as overall mean (95 % CI) reduction 22.7) kg/m2 after 5 years, with no statistical difference be-
in BMI and as percent excess body mass index loss (%EBMIL), tween LSG and LRYGB groups (P = 0.94). The overall
with excess BMI>25 kg/m2, calculated as follows: 100–(follow- means±standard deviations of %EBMIL after 5 years were
up BMI–25/beginning BMI–25)×100 [5]. Comorbidity improve- 78.8±23.5 and 81.6±21.4 in the LSG and LRYGB groups,
ment was defined as a reduction or discontinuation of therapy. respectively; this was not significantly different. Comorbidity
The mean follow-up was 75.8±8.4 months (range, 60– improvement (reduction or discontinuation of therapy after
96 months). Data were collected at the outpatient clinic 1 week 5 years) was also similar in the two groups (89 % in the
after surgery and then 1, 3, 6, and 12 months postoperatively LSG group, 90 % in the LRYGB group) (Table 2).
for the 1st year, twice in the 2nd to 5th years, and annually LSG was more effective in obese male than in obese female
thereafter. In 2014, all patients were visited at the outpatient patients in terms of %EBMIL, although long-term comorbid-
clinic or were telephoned if not available to visit the clinic. ity outcomes did not differ according to gender. LRYGB pa-
Statistical analyses were performed using IBM SPSS ver- tients showed similar results in terms of both %EBMIL and
sion 20 for Windows. Categorical variables were analyzed comorbidity outcomes in both genders. In the LSG group,
using the chi-squared test, Fisher’s exact test, or the Student’s %EBMIL after 24–36 months and 60 months was significant-
t test for quantitative and qualitative variables, as appropriate. ly different between male and female patients (P=0.003);
Data are expressed as median and range, unless specified oth- 89 % of patients showed comorbidity improvement. For
erwise. P values are two-sided, and values <0.05 were consid- LRYGB, %EBMIL after 24–36 months and 60 months did
ered statistically significant. Continuous variables are described not differ significantly between male and female patients (P=
as mean and standard deviation (SD), whereas categorical var- 0.06); 90 % of patients showed comorbidity improvement
iables were described as number and percentage. (Figs. 1 and 2, Table 3).

Results Discussion

For the LSG patients, the mean age was 41.8±4.6 years, the Many individual biological, medical, psychosocial, and envi-
mean preoperative BMI was 47.4 ± 4.2 kg/m 2 , and the ronmental factors influence weight loss success. Many

Fig. 1 LSG was more effective in obese male than in obese female was not statistically significant (P=0.06). LSG laparoscopic sleeve
patients in terms of %EBMIL after 24–36 months and 60 months gastrectomy, LRYGB laparoscopic Roux-en-Y gastric Bypass, %EBMIL
(P=0.003). For LRYGB, the difference between male and female patients percent excess body mass index loss, yr years, Pre-op preoperative
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Fig. 2 Gender-specific results for

comorbidity improvement LSG

OSAS
(reduction or discontinuation of
therapy) after 5 years of follow- LRYGB

up. LSG laparoscopic sleeve

Dyslipidemia
LSG
gastrectomy, LRYGB
laparoscopic Roux-en-Y gastric
LRYGB
Bypass, M male, F female, T2DM
type 2 diabetes mellitus, OSAS F
LSG

T2DM
obstruction sleep apnea syndrome M

LRYGB

hypertension
LSG

Arterial
LRYGB

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

attempts have been made to clarify the relationship between after duodenal switch. According to Stroh et al. [13], male
these predictors and bariatric surgery outcomes. Some authors gender was associated with more preoperative comorbidities
have tried to create an algorithm for weight loss after gastric and, subsequently, a lower rate of amelioration.
bypass surgery, considering body mass index, gender, and age In our study, LSG was more effective in obese male than in
[6]. obese female patients in terms of %EBMIL, although long-
Several studies have analyzed predictors of bariatric sur- term comorbidity outcomes did not differ. LRYGB patients
gery outcome, although the results are inconsistent. For exam- showed similar outcomes for both %EBMIL and comorbidity
ple, while some authors report a positive relationship between improvement in both genders.
T2DM and EBMIL% after bariatric surgery, others report a In previous studies, age was found to be a significant pre-
negative relationship [1, 7]. Furthermore, other studies have dictor of outcome after RYGB, as reported by Scozzari et al.
reported a positive association between preoperative weight [14] Contreras et al. [15] observed similar findings at a cutoff
loss and EBMIL% after bariatric surgery [1, 7, 8]. point of 45 years. In our study as well, a negative association
Fat storage and metabolism differ greatly between men and was noted between age and %EBMIL in men from both
women. The difference in response to treatment other than groups, with borderline statistical significance. This may sug-
surgery between males and females is well acknowledged gest a role for gender in the negative association between age
[9], although the reason for this is not well understood [10]. and weight loss [6, 7]. Declining physical activity and ongo-
Reports on the difference in weight loss between male and ing physiological reduction in lean body mass in old age may
female patients after bariatric surgery are scarce. Tiwari et al. have a particularly important negative metabolic effect on
[11] reported that male gender was associated with more com- weight loss in men, who constitutionally have greater lean
plications after RYGB. Likewise, Sucandy and Antanavicius mass than women [16]. These physiological differences be-
[12] reported male gender as a predictor of adverse outcomes tween men and women could partially explain different

Table 3 %EBMIL
outcome Male Female Pvalue
%EBMIL mean±standard %EBMIL mean±standard
deviation (kg/m2) deviation (kg/m2)

LSG
12 months 75.1±18.9 74.9±19.2 0.0528
24 months 76.7±20.4 74.8±21.7 0.0038
36 months 78.7±24.3 75.5±23.6 0.0033
60 months 79.1±24.1 76.2±22.5 0.0036
LRYGB
12 months 76.9±24.3 76.8±23.6 0.0587
24 months 78.9±25.6 78.8±26.0 0.0621
36 months 80.1±22.3 80.6±22.8 0.0692
60 months 82.6±23.4 82.1±22.8 0.0654

%EBMIL percent excess body mass index loss

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gender-based outcomes in terms of %EBMIL after bariatric Conclusion

surgery. Why this happens only in restrictive bariatric surgery
procedures is still to be investigated in studies that target the Our findings suggest that LSG is more effective in obese male
differences in bariatric surgery response, such as different than in obese female patients in terms of %EBMIL, although
physiologic and metabolic pathways [17], different eating be- long-term comorbidity outcomes were not different.
haviors [18] due to several surgeries, and physiologic mecha- Identifying preoperative predictive factors might be useful in
nisms of action associated with LSG other than pure restric- developing strategies to improve bariatric surgery outcomes
tion [19]. and patient selection. To date, results from studies evaluating
To our knowledge, this is the first prospective study to potential predictors of weight loss after bariatric surgery have
investigate gender as a predictor of weight loss and co- been relatively inconclusive, and further studies with new ap-
morbidity outcome after bariatric surgery with a minimum proaches are needed. Such gender differences could explain
follow-up of 5 years, performed in a single center by a some of the inconsistent results in previous studies. Further
single surgeon, using two well-known bariatric proce- studies, including an analysis of gender-specific predictors,
dures, LSG and LRYGB. The strength of the study is in should be conducted.
the prospective design, long follow-up, and low chance of
surgical biases.
Identifying factors that influence weight loss after bariatric Conflict of Interest The authors declare that they have no competing
surgery is one way to predict a successful surgical outcome. In interests.
a recent retrospective study, Bekheit et al. [20] found that
gastric banding is less effective in males and suggested that Ethical Approval All procedures performed in studies involving hu-
man participants were in accordance with the ethical standards of the
gastric banding should not be offered as a first-choice treat- institutional and/or national research committee and with the 1964
ment for obese male patients. Taken together with these find- Helsinki declaration and its later amendments or comparable ethical
ings, our results suggest that obese male patients could be standards.
treated by a more invasive and effective procedure, such as
sleeve gastrectomy. Thus, knowledge of preoperative predic- Informed Consent informed consent was obtained from all individual
participants included in the study.
tors of successful weight loss after bariatric surgery could
improve patient and procedure selection. For this reason, we
consider our study of great importance, although further in-
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