Accepted Manuscript

Obstructive sleep apnea: the effect of bariatric surgery after 12 months. A prospective
multicenter trial

P. Peromaa-Haavisto, MD, PhD, H. Tuomilehto, MD, PhD, J. Kössi, MD, PhD, J.

Virtanen, MD, M. Luostarinen, MD, PhD, J. Pihlajamäki, MD, PhD, P. Käkelä, MD, M.
Victorzon, MD, PhD
PII: S1389-9457(17)30004-7
DOI: 10.1016/j.sleep.2016.12.017
Reference: SLEEP 3270

To appear in: Sleep Medicine

Received Date: 21 August 2016

Revised Date: 11 December 2016
Accepted Date: 21 December 2016

Please cite this article as: Peromaa-Haavisto P, Tuomilehto H, Kössi J, Virtanen J, Luostarinen M,
Pihlajamäki J, Käkelä P, Victorzon M, Obstructive sleep apnea: the effect of bariatric surgery after 12
months. A prospective multicenter trial, Sleep Medicine (2017), doi: 10.1016/j.sleep.2016.12.017.

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OBSTRUCTIVE SLEEP APNEA: THE EFFECT OF BARIATRIC SURGERY AFTER 12

MONTHS. A PROSPECTIVE MULTICENTER TRIAL.

Peromaa-Haavisto P, MD, PhD1, Tuomilehto H, MD, PhD2,3 , Kössi J, MD, PhD4,8 , Virtanen J,

MD5 , Luostarinen M, MD, PhD5, Pihlajamäki J, MD, PhD 3,6 , Käkelä P, MD6, Victorzon M, MD,

PhD7,8

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Hatanpää City Hospital, Department of surgery, Tampere, Finland

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Oivauni Sleep Clinic, Kuopio and Tampere, Finland. henri.tuomilehto@oivauni.fi

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Institute of Public Health and Clinical Nutrition, Department of Clinical Nutrition, University of

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Eastern Finland AN
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Kantahäme Central Hospital, Department of surgery, Hämeenlinna, Finland. jyrki.kossi@khshp.fi

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Lahti Region Central Hospital, Department of surgery,Lahti, Finland. juha.virtanen@phsotey.fi,

markku.luostarinen@phsotey.fi
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Clinical Nutrition and Obesity Center, Kuopio University Hospital, Kuopio, Finland.
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jussi.pihlajamaki@uef.fi, pirjo.kakela@kuh.fi
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Vaasa Central Hospital, Department of surgery,Vaasa, Finland. mikael.victorzon@vshp.fi

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University of Turku, Turku, Finland

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Key words; bariatric surgery, obstructive sleep apnea, effect of bariatric surgery, obesity surgery,

metabolic surgery, OSA, Apnoea-hypopnea index, AHI

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Correspondence:

Pipsa Peromaa-Haavisto, M.D, PhD.

Department of Surgery

Hatanpää City Hospital

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PL 437

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FIN-33101 Tampere

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Finland

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Email: pipsa.peromaa@kolumbus.fi
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Telephone: +358 50 3449574
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Conflict of interest: none

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ABSTRACT

Background: Obstructive sleep apnea (OSA) is a highly prevalent sleep disorder, particularly in

bariatric patients. It is known to be tightly linked with metabolic abnormalities and cardiovascular

morbidity. Obesity is the most noteworthy individual risk factor for OSA. The aim of this study was

to investigate the effect of a laparoscopic Roux–en–Y gastric bypass (LRYGB) on OSA 12 months

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after surgery.

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Methods: In this prospective multicenter study standard overnight cardiorespiratory recording was

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conducted 12 months after bariatric surgery in 132 patients who had OSA in the baseline recording

prior to the operation. The main outcome measures were changes in the prevalence of OSA and

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apnoea-hypopnea index (AHI). In addition, the changes in anthropometric and demographic
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measurements including weight, body mass index (BMI), and waist and neck circumference were

evaluated. A sleep symptom questionnaire was administered at baseline and at 12 months.

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Results: The prevalence of OSA decreased from 71% at baseline to 44% at 12 months after surgery
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(p<0.001). OSA was cured in 45% and cured or improved in 78% of the patients, but moderate or
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severe OSA still persisted in 20% of the patients after the operation. De novo OSA occurred in eight

percent of the patients, and total AHI decreased from 27.8 events/h to 9.9 events/h (p<0.001).
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Conclusions: LRYGB is effective in treating OSA. However, the findings demonstrate that a
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postoperative cardiorespiratory recording is needed in order to identify the patients with persistent
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moderate to severe OSA after the operation.

Clinical Trial Registration: ClinalTrials.gov; No.: NCT01080404; URL: www.clinicaltrials.gov

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ABBREVIATION LIST

AHI = apnea-hypopnea index

BMI = body mass index

CPAP = continuous positive airway pressure

ESS = Epworth Sleepiness Scale

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ILI = intensive lifestyle intervention

LRYGB = laparoscopic Roux-en-Y gastric bypass

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OSA = obstructive sleep apnea

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SOS = Snore Outcome Survey

VLCD = very low calorie diet

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1. INTRODUCTION

Millions of people around the world are suffering from sleep disturbances, with obstructive sleep

apnea (OSA) being one of the most common. OSA is characterized by recurrent episodes of

complete obstruction (apnea) or partial obstruction (hypopnea) of upper airways, which leads to

sleep fragmentation and intermittent hypoxia during sleep [1]. OSA is tightly linked with metabolic

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abnormalities, and particularly the more severe stages of OSA have been linked to an increased

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morbidity and mortality in cardiovascular diseases [2, 3].

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Obesity is the greatest risk factor for OSA. It is estimated that OSA affects 15–20% of the adult

population, but in the obese population (especially in bariatric surgery candidates), the prevalence is

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60–83 % [4]. Approximately 70% of diagnosed OSA patients are obese [1]. The first-line treatment
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for OSA is an effective treatment of obesity. Even a mild reduction in weight (less than five

percent) by lifestyle intervention was shown to reduce the progression of OSA, and 50% of mild
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OSA went into remission [5]. Unfortunately, successful conventional lifestyle and weight reduction
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interventions are not easy to sustain in a long-term follow-up. In contrast, the more permanent
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weight reduction achieved by bariatric surgery has favorable effects on diabetes, hyperlipidemia,

hypertension, and OSA. In recent years, many studies have demonstrated that it is not only the
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weight loss that leads to favorable changes in co-morbidities but also the endocrine changes in gut

hormone profile due to a surgical manipulation of the gastrointestinal tract. For this reason bariatric
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surgery is nowadays commonly known as metabolic surgery. Traditionally the bariatric procedures
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have been categorized according to the mechanism of weight loss; restriction of food intake (ie,

gastric banding and sleeve gastrectomy), malabsorption (ie, biliopancreatic diversions, duodenal

switch), or a combination of the two (ie, laparoscopic Roux–en–Y gastric bypass (LRYGB)) [6].

The effectiveness and safety of LRYGB has been shown in many studies; mean excess weight loss

after three to five years of follow-up was 66% in a systematic review of long-term follow-up after

bariatric surgery [7]. A meta-analysis of more than 85000 patients showed an overall mortality of
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0.28% within 30 days in all bariatric patients, and 0.16% in LRYGB patients [8]. Long-term

complication rate requiring treatment was less than three percent [7]. The impact of LRYGB on

obesity comorbidities was shown to be good in a comprehensive meta-analysis; type 2 diabetes

was improved in 84%, hyperlipidemia in 97%, hypertension in 79%, and OSA in 86% of the

patients. However, in this meta-analysis OSA was defined using the apnoea-hypopnea index in

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only four studies, and only two of those studied LRYGB patients [9].

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LRYGB still is the most common bariatric operation worldwide. The aim of this prospective

multicenter study was to investigate the remission rate of OSA 12 months after LRYGB surgery.

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2. PATIENTS AND METHODS

Out of 554 consecutive bariatric surgery candidates in three different hospitals, a total of 197

patients (36%) agreed to participate in this prospective multicenter study: 103 patients in Vaasa

Central Hospital, 48 patients in Lahti Region Central Hospital, and 46 patients in Kuopio University

Hospital. The patients were recruited between November 2010 and September 2013. Inclusion

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criteria for the study were the same as for bariatric surgery: ages 18–65 years, BMI more than 35

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with co- morbidity, or BMI more than 40. Written informed consent from the patients was required.

The exclusion criteria were alcohol or drug abuse, severe eating disorder, severe psychiatric

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disorder, or other severe disease contraindicating surgery.

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The Research Ethics Committee of the Hospital District of Northern Savo in Kuopio granted an
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ethical approval for the study, and it was further approved in the other two Central Hospital

districts.
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All the participants had failed conservative treatment for weight management before admission to a
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bariatric clinic and had undergone the hospital’s normal preoperative protocol for bariatric surgery.
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The patients followed a very low calorie diet (VLCD) for a minimum of four weeks prior to the

operation. All the patients were scheduled for a standard LRYGB with a small gastric pouch, a 150
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cm alimentary limb, and a 50–75 cm biliary limb.

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Standard overnight cardiorespiratory recording by Embletta® was conducted for all the participants
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at their homes, in accordance with accepted guidelines for diagnosing OSA, prior to the LRYGB

operation [10]. Embletta® is a level III polygraphy investigation and was chosen for practical and

financial reasons. Apnea was defined as cessation (more than 90 %) of airflow for more than 10

seconds. Hypopnea was defined as a reduction (more than 30 %) of airflow for more than 10

seconds with oxygen desaturation of at least four percent. Apnea-hypopnea index (AHI) was

defined as the number of apnea and hypopnea events per hour. AHI less than five events per hour

was considered normal,

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5–15 events/h was considered as mild, 15–30 events/h as moderate, and AHI more than 30 events/h

as severe OSA. The cardiorespiratory recording was repeated approximately 12 months after the

bariatric operation according to the study design and no reports of delays were reported.

Study nurses met the patients before the operation, measured the anthropometric data, and helped

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patients to fill out a symptom questionnaire for OSA patients. The questionnaire consisted of three

validated questionnaires: SOS (Snore Outcome Survey), BNSQ (Basic Nordic Sleep

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Questionnaire), and ESS (Epworth Sleepiness Scale). SOS score is designed to evaluate sleep-

related quality of life in patients with sleep-disordered breathing. It consists of eight items relating

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to the intensity, duration, frequency, and impact of snoring. The scale is from 0 to 100 with highest

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values indicating the least symptomatic patients [11]. ESS score evaluates the general daytime
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sleepiness by rating the probability to doze off in eight common daily life situations. The scale is

from 0 to 24 and a score of 10 or higher indicates abnormal sleepiness [12]. Also comorbidities and
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medications were self-reported in a symptom questionnaire as were smoking and drinking habits.

Later visits with the surgeon and study nurse are shown in the study flow chart (Figure 1).
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2.1. STATISTICAL ANALYSIS

IBM SPSS Statistics 22 was used to carry out statistical analyses. The comparison between different

sleep apnea groups was analyzed with independent samples t-test and Pearson’s Chi-Square test.

The paired samples t-test was used to analyze the statistical significance of changes within the

groups, except in those variables where deviation in distribution of values was detected and

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Wilcoxon test was used instead. P-value less than 0.05 was considered statistically significant.

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The change in the prevalence of OSA was analyzed from the data of all patients with a baseline

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cardiorespiratory recording (n=187), while the change in severity of OSA was analyzed from the

data of patients with OSA at the baseline recording (n=132).

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3. RESULTS

A total of 197 patients were recruited into the study, 125 (64%) women and 72 (36%) men. One

patient dropped out before the baseline cardiorespiratory recording, and the recording technically

failed for nine patients. The data of the baseline cardiorespiratory recordings were available for 187

patients, and 132 (71%) of them fulfilled the diagnostic criteria for OSA. Demographic and

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anthropometric characteristics of these 132 OSA patients at baseline and at one year after the

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operation are shown in Table 1. There was a significant difference (p<0.001) between weight, BMI,

waist and neck circumference, AHI results, heart rate, and ESS points at baseline and at one year,

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but no such difference in oxygen saturation percentage and SOS points.

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The mean initial BMI of patients with OSA was 43.9 kg/m2. The decrease in BMI after bariatric
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surgery was 10.1 kg/m2. Mean percentage of total weight loss (%TWL) was 24.6% and mean

excess BMI loss percentage (%EBMIL) was 59.6%.

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The prevalence of OSA decreased from 71% at baseline to 44% at one year after surgery (p<0.001).
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Prior to the operation, prevalence of OSA was significantly higher in male patients (90%) than in
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female patients (60%) (p<0.001). The follow-up cardiorespiratory recording was available for 164

patients: 102 women and 62 men. Of these patients, 40 women (39%) and 32 men (52%) had OSA.
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Again, the difference in prevalence between genders was significant (p<0.05). Despite a significant

weight loss, six patients were diagnosed with de novo OSA (8%) in the follow-up recording; five of
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them with mild OSA, one of them with severe OSA. One patient with mild OSA at baseline had
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moderate OSA at the one year recording. When evaluating the change in AHI and BMI in these

patients, the mean AHI had increased from three events per hour to 15 events/h (p=0.023) although

BMI had decreased from 45 kg/m2 to 32 kg/m2 (p<0.001).

Of those 132 patients, who were diagnosed with OSA at baseline, the follow-up cardiorespiratory

recordings were available for 119 (90%) patients. Sixty-five (55%) of them still had OSA, but the
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number of patients with AHI >15 had decreased from 40% at baseline to 20% at the follow-up.

Total AHI decreased from 27.8 events/h to 9.9 events/h (p<0.001). There was a similar reduction in

both apnea (9.4 to 2.3 events/h) and hypopnea (11.7 to 5.4 events/h) events. The reduction was

statistically significant in both. Of those 54 patients (45%), who had their OSA in remission after

one year, 29 (24%) had formerly a mild OSA, 18 (15%) moderate OSA, and seven (six percent

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severe OSA. The change in OSA groups of those patients with OSA at baseline is shown in Figure

2.

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There was no change in 32 patients’ AHI-groups; 20 of them being in the mild, four in the

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moderate and eight in the severe group. However, in only twelve of them (38%) AHI was

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unchanged or increased in the follow-up cardiorespiratory recording (the mean AHI increased from
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18 events/h to 19 events/h), and in the rest of these patients (62%) the mean AHI decreased from 31

events/h to 19 events/h (p=0.015). When evaluating the severe OSA group separately, the decrease
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of AHI was from 68 events/h to 43 events/h (p=0.051).

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All patients lost weight after bariatric operation, varying from 6 kg to 82 kg (mean 32 kg). In Figure
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3, the change in mean AHI is shown in relation to changes in body weight dividing patients in three

different weight categories, approximately one third of patients in each. The proportion of patients
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(expressed in percentages) with OSA (AHI>5) was also analyzed in these weight categories, and it

was equally distributed in all categories (34%/31%/35%).

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We could not find any predictors for success of the surgery. There was no statistically significant

difference between gender, high BMI (more than 40) at the baseline nor need for medication prior

to the operation and remission of sleep apnea.

In the beginning of this study, the majority (75%) of patients had two or more comorbidities and

only seven percent did not have any comorbidities. The number of patients with multiple

comorbidities decreased to 56% one year after bariatric surgery and the number of healthy subjects

increased to 14%. The change in different comorbidities is shown in Table 2. The mean number of
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medications prescribed decreased from 3.8 per patient (range 0-15) to 2.2 per patient (range 0-9)

(p<0.001).

In the beginning of this study 81% of OSA patients were non-smokers, and at one year the number

had remained unchanged. There was no change in alcohol habits; neither in the frequency of use nor

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in the amount of alcohol consumed.

In the ESS questionnaire 10 points or more indicates excessive daytime somnolence. The number of

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patients scoring at least 10 points decreased from 38 patients (32%) at baseline to nine patients

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(10%) at one year after surgery (p<0.001).

The mean SOS values changed from 63.5 to 65.2 (p=0.26). The highest mean SOS values (ie, the

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least symptomatic) were seen in the group with moderate OSA and the lowest values (ie, the most
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symptomatic) in the group with severe OSA.
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4. DISCUSSION

This study demonstrates that bariatric surgery is an effective treatment for OSA. Following surgery

the total AHI decreased from 27.8 events/h to 9.9 events/h (p<0.001), and the prevalence of OSA

from 71% to 44% (p<0.001). Of all 119 OSA patients who underwent bariatric surgery, 90% had

either the disease improved or completely resolved at one year follow-up; 54 patients had OSA in

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remission (45%), 33 patients (28%) moved into a milder OSA-group, and 20 patients (17%) had

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their total AHI improved even though the OSA group did not change. Of those patients still having

OSA, 35% had mild OSA, 13% had moderate OSA, and seven percent had severe OSA at 12

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months’ follow- up, compared to 31%, 18%, and 22% prior to the operation. It is particularly

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noteworthy that the number of patients with severe OSA was reduced from 22% at baseline to
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seven percent at 12 months (p<0.001). Men had a very high prevalence of OSA (90%) at baseline,

but the proportion decreased to 52% at 12 months after the operation.

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In our study we found less effect on AHI in supine position compared to non-supine position. It has
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been previously demonstrated that the severity of individual respiratory events decreased more in
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the non-supine position [13]. This could be due to the fact that the pharyngeal fat pad (situated

mostly laterally in pharynx) seems to play an important role in the development of OSA as shown
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in another previous study [14].

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Obesity is the most important risk factor for OSA, and most OSA patients (at least two out of three)
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are obese [15]. Weight loss has been recommended as a first choice treatment for OSA. A

randomized controlled trial studied 63 obese men with moderate to severe OSA, treated with

continuous positive airway pressure (CPAP). They were randomized to the intervention group or

the control group. The intervention group followed a very low calorie diet (VLCD) for seven

weeks. The control group adhered to their usual diet. At nine weeks the mean body weight was 20

kg lower and mean AHI 23 events/h lower in the VLCD group than in the control group. In the

VLCD group
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17% of the subjects had OSA in remission and 50% had mild OSA, whereas in the control group all

patients but one still had moderate to severe OSA [16]. In another randomized controlled trial with

long-term follow-up of 264 obese adults with OSA and T2DM, intensive lifestyle intervention (ILI)

groups’ mean weight loss was 11 kg, 7 kg, and 5 kg at one, two, and four years respectively,

compared to less than one kilogram weight loss in control group at each time. The ILI group had

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significantly lower AHIs than control group in every follow-up, and remission of OSA at four years

was five times more common in ILI group (21 %) than in control group (4%) [17].

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The efficacy of conventional therapy on OSA was presented also in a study of the impact of weight

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reduction in the prevention of progression of OSA. Patients in the ILI group had a one-year

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lifestyle intervention and they were followed up for five years. A moderate but sustained weight
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loss was shown to prevent the progression of OSA or even cure mild OSA [5]. Weight loss may not

be sufficient treatment for OSA, but according to the recent randomized studies more aggressive
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treatment of obesity in OSA patients is justified [16, 18-19]. Although the prevalence of obesity has

reached a plateau and is not increasing at the moment, it is not decreasing either [20]. Conservative
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treatment of obesity consisting of nutritional and physical activity counseling has proven to be
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ineffective in the long-term follow-up in these patients [21]. Because of the high morbidity
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associated with obesity, more effective treatment is needed. The number of bariatric operations is

constantly increasing, and in 2013 nearly 469000 bariatric operations were performed worldwide
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[22].
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In a study comparing LRYGB and ILI the bariatric operation was demonstrated to be more effective

than ILI (66% vs. 40% OSA remission). However, the study analysis suggested that weight loss

explained the beneficial effects rather than the surgical procedure. In this study, the weight loss was

eight percent in ILI group and 30% in the bariatric surgery group [23]. The remission rate in that

study compared to our study was slightly better in the surgery group (66% vs 45%) as was the weight

loss (30% vs 25%). Surgical and conventional therapies were also compared in a randomized

controlled
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trial of 60 obese patients with recently diagnosed (less than six months) OSA and AHI of 20

events/h or more. CPAP had been prescribed to all patients. Even though gastric banding operation

resulted in greater weight loss (27.8 kg vs. 5.1 kg), it did not result in a statistically greater

reduction in AHI (25.5 events/h vs. 14.0 events/h) compared to the conventional therapy group.

CPAP adherence did not differ between groups. The study confirmed that weight loss is associated

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with improvement in AHI, but suggested that much of the benefit can be achieved with only mild to

moderate weight loss [24]. In our study the reduction of AHI was 17.9 events/h 12 months after

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surgery.

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The present study is one of the largest prospective studies of the effect of LRYGB on OSA, and

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availability of a second cardiorespiratory recording in patients with OSA at baseline was as high as
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90%. In a systematic review comparing the effect of different bariatric procedures on OSA, all the

procedures resulted in an improvement in more than 75% of all patients [25]. In a meta-analysis of
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twelve studies, a significant reduction in AHI was observed, but the authors pointed out that the

mean AHI after surgical weight loss was 15.8 events/hour, which equates to moderate OSA, and
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additional treatment of OSA may still be needed after surgery. Only five of the studies concentrated
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on gastric bypass patients, three of them prospectively. The study sample sizes were generally
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modest [26]. The study of 58 moderate to severe OSA patients undergoing gastric bypass did not

report a single total resolution of OSA after bariatric surgery. However, only 11 (19%) of the
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patients had polysomnography recorded 3–21 months after bariatric surgery [27]. In another study
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of 24 patients with OSA at baseline and significant weight loss after gastric banding, only one (four

percent) patient experienced a resolution of OSA and 71% still had moderate to severe OSA one

year after the bariatric operation. The mean AHI changed from 47.9 to 24.5 events/h [28]. The

mean AHI after surgery was 9.9 events/h in our study, which is equivalent to only mild OSA.

Some limitations in the present study have to be addressed. Despite the attempts to recruit

consecutive patients, only 36% of all candidates agreed to participate. This was mainly due to

practical reasons caused by additional travelling related to overnight sleep recording and clinical
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controls. A systematic bias is always MANUSCRIPT
possible outside of a randomized trial, but the baseline

prevalence of sleep apnea in our study is consistent with the measured prevalence of obese patients in

previous large studies. Therefore we consider this a representative study population. Since the

cardiorespiratory recording was planned as ambulatory home recording, many patients found the idea

of a return trip back to hospital the next day unpleasant, and thus did not want to participate. Finland

is a fairly large country with broad hospital districts; patients undergoing bariatric surgery may live

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hundreds of kilometers from the hospital where surgery is performed. Instead of using in-laboratory

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polysomnography, portable recording devices were used in the present study. Clinical guidelines for

the use of portable monitors have been introduced, and there is now a recommendation that portable

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monitoring may be used as an alternative to polysomnography for the diagnosis and treatment

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follow-up of OSA [29]. In this study, results were based on single- night cardiorespiratory
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recordings, because repeated recordings would have been very demanding to schedule and would

have dropped the participating rate even more. However, the findings of single- night recordings
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have been found to be reliable in most patients [30]. Unfortunately, the data regarding possible

change in sleeping position (ie, supine or non-supine or quality-of-life over the follow-up) was not
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evaluated.
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The baseline anthropometric parameters (weight, height, and waist and neck circumferences) were
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measured prior to the bariatric operation when patients had already started their VLCD. It is

possible that the numbers were somewhat smaller than what they had been at the time when patients
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were referred for bariatric surgery.

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Bariatric surgery is an effective treatment for OSA, but it is impossible to predict which patients

will have persisting symptoms. Bariatric surgery should be at least kept in mind while treating

severely or morbidly obese OSA patients. As generally in obesity treatment, multidisciplinary

collaboration is needed. Also more long-term follow-up studies are needed to investigate the

recurrence rate of OSA after bariatric operations.

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5. CONCLUSIONS

LRYGB is effective in treating OSA, but postoperative cardiorespiratory recordings are needed in

order to find the approximately 20% of patients who will still have persistent moderate or severe

OSA 12 months after surgery.

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Ethical approval:

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All procedures performed in this study were in accordance with the ethical standards of the national

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research committee and with the 1964 Helsinki declaration and its later amendments or comparable

ethical standards.

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Informed consent:

Informed consent was obtained from all individual participants included in the study.
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Funding:
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This research did not receive any specific grant from funding agencies in the public, commercial, or
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not-for-profit sectors.
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ACKNOWLEDGEMENTS
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The authors cordially acknowledge Miia Artama, PhD and Jani Raitanen MSc for their critical

assistance with statistical analysis, Jaana Elberkennou MD, MA for her kind revision of the English

language, and the clinical research nurses Synnöve Liukku, Helinä Mäkipää, Taina Poutiainen,

Matti Laitinen and Marjo Soini, and research assistant Ville Ruohoranta.
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11. Gliklich RE, Wang PC. Validation of the snore outcomes survey for patients with sleep-
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loss alters severity of individual nocturnal respiratory events depending on sleeping
position. Physiol Meas. 2014; 35: 2037-52.
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14. Pahkala R, Seppa J, Ikonen A, Smirnov G, Tuomilehto H. The impact of pharyngeal fat
tissue on the pathogenesis of obstructive sleep apnea. Sleep Breath. 2014; 18: 275-82.

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Fig 1. Study flow chart

Patient referrals (n=554)

-Department of Surgery in Vaasa and Lahti
Region Central Hospitals and Kuopio
University Hospital

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Patients not willing
to participate
(n=357)

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Inclusion(n=197)

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Inclusion criteria=

bariatric surgery criteria Participant willing to

drop out
(n=1)

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Sleep recordings (n=187)
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LRYGB operation
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3 months visit to surgeon

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-Anthropometric data
-Questionnaires
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12 months
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sleep recordings (n=164) and visit

to study nurse
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-Anthropometric data

-Questionnaires
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Figure 2. Number of OSA patients in different OSA groups before and 12 months after the bariatric

operation.

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before
50

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12 months after
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10
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no OSA mild OSA moderate OSA severe OSA

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Fig 3. Changes in apnea-hypopnea-index (AHI) in relation to changes in body weight

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(n=46) (n=36) (n=46)

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Table 1 Demographic and anthropometric characteristics and sleep registration data at baseline and

one year after bariatric operation of the patients with diagnosed OSA at the baseline.

Baseline (n=132) 1 year (n=128) p-value

Age (years), mean(SD) 50.7 (8.8) 51.3 (10.7)

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Weight (kg), mean (SD) 128.0 (25.0) 96.1 (19.3) < 0.001

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BMI (kg/m2), mean (SD) 43.9 (6.4) 33.0 (5.1) <0.001

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Waist circumference (cm), median* (SD) 132.0 (14.8) 108.8 (18.8) <0.001*

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Neck circumference (cm), median* (SD) AN45.0 (6.8) 39.3 (9.2) <0.001*

Baseline (n=132) 1 year (n=119)

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Patients with AHI 5-15, n (%) 57 (30.5) 41 (34.5) 0.26

Patients with AHI 15-30, n (%) 34 (18.2) 16 (13.4) 0.012

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Patients with AHI > 30, n (%) 41 (21.9) 8 (6.7) <0.001

AHI, total, mean (SD) 27.6 (24.6) 9.9 (11.2) <0.001

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AHI, supine, mean (SD) 32.1(27.8) 15.8 (17.7) <0.001

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AHI, other than supine, mean (SD) 24.4 (27.4) 6.3 (12.0) <0.001
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SpO2 % , mean (SD) 92.0 (2.8) 93.3 (8.4) 0.11

SpO2 below 90% (min), mean (SD) 71.4 (88.2) 19.4 (37.1) <0.001

Heart rate (beats/min), 66.4 ( 9.6) 59.4 (8.1) <0.001

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mean (SD)

ESS, points, mean (SD) 7.7 (4.5)** 4.6 (3.2) <0.001

SOS, points, mean (SD) 63.5 (15.2)*** 65.2 (6.2) 0.26

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BMI= body mass index (kg/m2)

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cm= centimetres

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AHI= apnoea-hypopnea index (the number of apnoea-hypopnea events per hour)

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SpO2= arterial oxygen saturation, pulse oximetry
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SOS= Snore Outcomes Survey
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ESS= Epworth Sleepiness Scale

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because of the deviation in distribution

**In Epworth Sleepiness Scale n=119, both at baseline and at one year
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*** In Snore Outcomes Survey n=132 at baseline and n=126 at one year
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Table 2. The co-morbidities of patients at baseline and one year after bariatric operation.

At baseline, n (%) At one year, n (%)

Healthy obese subjects, 13 (7) 23 (14)

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One co-morbidity 33 (18) 50 (30)

2 - 3 co-morbidities 80 (43) 71 (42)

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More than 3 co-morbidities 59 (32) 23 (14)

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OSA 133 (71) 72 (44)

Hypertension 114 (62) 84 (50)

DMII / with insulin

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70 (38) / 21 (11) 33(20) / 8 (5)
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Asthma 42 (23) 25 (15)

Hypothyroidism 38 (21) 36 (21)

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Hyperlipidemia 35 (19) 13 (8)

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Depression 31 (17) 21 (12)

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Other 122 (66) 86 (51)

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Highlights
- Bariatric surgery is an effective treatment for obstructive sleep apnea.
- The prevalence of obstructive sleep apnea decreased from 71% to 44% 12 months after
bariatric surgery.
- Especially the number of patients with severe obstructive sleep apnea was reduced.
- Approximately 20% of patients still have persistent moderate or severe obstructive sleep
apnea 12 months after surgery.

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