Abstract
Purpose
Metabolic bariatric surgery (MBS) is an effective treatment for obesity and obesity-related diseases, but long-term data on its outcomes remain limited, particularly in Poland. These data are crucial for understanding the durability of weight loss, trends in weight regain, and comorbidity remission, as well as for refining surgical techniques and improving long-term care. This study aims to evaluate the 10-year outcomes of MBS in Poland, focusing on weight loss and remission of obesity-related diseases in patients who completed follow-up.
Materials and methods
This multicenter retrospective study, named BARI-10-POL, analyzed 485 patients (mean age: 41.0 years, 71.5% female, median BMI: 43.4 kg/m²) who underwent laparoscopic MBS between 2008 and 2014 across five bariatric centers. Data collected included demographics, type of surgery, weight loss (%TWL, %EWL), and remission of type 2 diabetes (T2D) and hypertension (HT).
Results
The follow-up rate was 28.5% (485/1703). Among the procedures, 317 (65.4%) were sleeve gastrectomies (SG). The median %EWL and %TWL were 59.2% and 22.8%, respectively. Revisional procedures were required in 23.9% of patients, most commonly after SG (24.3%) and adjustable gastric banding (100%). The remission rates for T2D and HT were 70.8% and 56.7%, respectively. One anastomosis gastric bypass (OAGB) demonstrated superior median %EWL (80.1%) compared to SG (55.0%, p < 0.001) and Roux-en-Y gastric bypass (RYGB) (51.4%, p < 0.001).
Conclusions
Conducting long-term follow-up after bariatric surgery is challenging. MBS leads to significant long-term outcomes in both weight loss and remission of obesity-related diseases.
Keywords: Bariatric surgery, 10-years follow-up, Long-term follow-up, Weight loss
Introduction
Obesity is a complex and multifactorial disease that significantly impacts global public health, contributing to increased morbidity, mortality, and healthcare costs. Metabolic bariatric surgery (MBS) is widely recognized as the most effective intervention for achieving substantial and sustained weight loss in individuals with severe obesity, alongside improving obesity-related diseases such as type 2 diabetes (T2D), hypertension (HT), or obstructive sleep apnea (OSA). However, despite the initial success of bariatric procedures, questions remain about the durability of these benefits over extended periods and the challenges of long-term patient follow-up [1–3].
The 10-year follow-up after MBS provides a unique opportunity to evaluate the enduring effects of these procedures on weight loss, metabolic health, quality of life, and the development of potential complications. Long-term data are critical for understanding the sustainability of surgical benefits, identifying trends in weight regain, and assessing the long-term resolution or remission of obesity-related diseases. Such insights are essential for refining surgical techniques, improving patient selection criteria, and developing evidence-based guidelines for postoperative care and monitoring [4, 5].
However, maintaining high follow-up rates over a decade is challenging. Studies consistently report attrition in patient follow-up, often resulting in incomplete datasets and potential biases in long-term outcome reporting. Follow-up rates vary significantly across studies, ranging from as low as 30% to approximately 70%, depending on the population, healthcare system, and study design. These variations underscore the importance of discussing the proportion of patients retained in follow-up when interpreting long-term outcomes [6]. To achieve a higher follow-up rate among patients, the American Society for Metabolic and Bariatric Surgery (ASMBS) recommends attempting to contact patients at least twice within the designated timeframes before removing them from follow-up [7]. The follow-up process itself can be managed by a dedicated team using modern tools such as web-based applications [7–8]. Unfortunately, in Poland, most centers have so far relied on surgeons themselves to conduct follow-up, which becomes problematic in high-volume centers.
AIMS
In this study, we present a comprehensive analysis of the 10-year outcomes of patients who underwent MBS, focusing on those who remained in follow-up. We report on weight loss outcomes, improvement in obesity related-diseases and the incidence of complications.
Materials and methods
It is a multicenter, retrospective analysis of a collected database of patients undergoing laparoscopic MBS in Poland from 2008 to 2014. Inclusion criteria for this study were meeting the eligibility criteria for MBS and there should be at least 10 year-follow-up data. Patients who were not eligible for bariatric surgery or laparoscopic surgery due to their overall health condition, with missing or inconsistent data were excluded from the study. The data were collected from 5 centers. The Metabolic and Bariatric Surgery Chapter took patronage of the study. The study group named Bariatric Ten Years Outcomes in Poland (BARI-10-POL) was created.
Data was collected during in-person visits 10 years after surgery or through online consultations conducted by the operating surgeons depending on the capabilities of each center. The database contained demographic characteristics of patients (sex, age, maximal weight, weight before the surgery, body mass index) and information on obesity-related diseases: T2D, HT, OSA, gastroesophageal reflux disease (GERD). It also included information on the surgery (type of surgery, duration of surgery, length of hospital stay, all 30-day complications and long-term complications that required surgical treatment), and outcomes of bariatric treatment (current weight and BMI, obesity-related diseases remission). The outcomes of MBS were described according to the standardized outcomes reporting [9]. Remission of T2D is normal measures of glucose metabolism (HbA1c < 6.4%, fasting blood glucose (FBG) < 125 mg/dL) in the absence of antidiabetic medications. Remission of HT is being normotensive (blood pressure (BP) < 140/90) off antihypertensive medication. Weight loss was described as percentage of excess weight loss (%EWL) and percentage of total weight loss (%TWL). All results correspond to the follow-up time.
Surgical techniques and perioperative care
Four types of bariatric procedures were performed laparoscopically: sleeve gastrectomy (SG), Roux-en-Y Gastric Bypass (RYGB), one anastomosis gastric bypass (OAGB) and adjustable gastric banding (AGB). The surgical techniques were performed in accordance with the guidelines [10]. SG was performed using bougie size of 36 F, starting 4–6 cm from the pylorus. For RYGB, the biliopancreatic limb length was approximately 100 cm and Roux-en-Y limb length was approximately 150 cm. In OAGB, the length of the biliopancreatic limb was approximately 200 cm from the ligament of Treitz. Pre-, peri- and post-operative protocols were standardized at each participating centers.
Statistical analysis
A descriptive statistical analysis was conducted. All data were analyzed using Statistica software 13.PL (StatSoft Inc.). Patients who did not complete the follow-up were excluded from the analysis. The normal distribution was checked using the Shapiro-Wilk test. Due to the lack of a normal distribution, continuous values were presented as medians with interquartile ranges. U Mann–Whitney test was used for continuous variables due to the non-normal distribution of the data. A linear regression model was constructed with the %TWL as the dependent variable, including all covariates with p-value ≤ 0.001 in the univariate analysis. P-values ≤ 0.05 were considered statistically significant.
Ethical considerations
The data were anonymized. The study was conducted in accordance with the ethical standards.
of the 1964 Declaration of Helsinki and its subsequent amendments. The study was approved by the Bioethics Committee of The Bioethics Committee of the University of Warmia and Mazury in Olsztyn (10/2024).
Results
Total population included 1703 patients. Due to missing data and loss to follow-up, a total of 485 patients were included in the study. The follow-up rate is 28.5%, Fig. 1.
Fig. 1.
Flow chart of the study
Patient characteristics and indications
The group consisted of 485 patients (347 women, 71.5%). The median age was 41.0 years. The median BMI before surgery was 43.4 kg/m2. A total of 134 (27.6%) patients suffered from T2D, 244 (50.3%) from HT, 60 (12.4%) GERD and 32 (6.6%) OSA. The median follow-up was 11.8 years, Table 1.
Table 1.
Characteristics of patients. (IQR interquartile range, BMI body mass index, T2D type 2 diabetes, HT hypertension, OSA obstructive sleep apnea, SG sleeve gastrectomy, RYGB Roux-en-Y gastric bypass, OAGB one anastomosis gastric bypass, AGB adjusted gastric band)
| Variable | Value (IQR) |
|---|---|
| Age | 41.0 (34.0–51.0) |
| Sex [female/male] | 347/138 |
| Preoperative BMI [kg/m2] | 43.4 (39.4–47.9) |
| Follow up [years] | 11.8 (10.6–12.6) |
| T2D | 134 (27.6%) |
| HT | 244 (50.3%) |
| GERD | 60 (12.4%) |
| OSA | 32 (6.6%) |
| Primary procedure | |
| SG | 317 (65.4%) |
| RYGB | 69 (14.2%) |
| OAGB | 65 (13.4%) |
| AGB | 34 (7.0%) |
| Revisional procedure | 117 (24.1%) |
Type of surgeries
There were 317 (65.4%) SG, 69 (14.2%) RYGB, 65 (13.4%) OAGB and 34 (7.0%) AGB, Table 2. The median operative time was 75 min for SG, 120 min for RYGB, 75 min for OAGB, and 52.5 min for AGB.
Table 2.
Outcomes of patients undergoing single procedures. (IQR interquartile range, BMI body mass index, %TWL percentage of total weight loss, %EWL percentage of excess weight loss, T2D type 2 diabetes, HT hypertension, OSA obstructive sleep apnea)
| Variable, median (IQR) | Value (IQR) |
|---|---|
| Age | 42.5 (35.0–53.0) |
| Sex [female/male] | 253/115 |
| Preoperative BMI [kg/m2] | 42.7 (38.8–46.5) |
| Follow up [years] | 10.9 (10.5–11.7) |
| Lowest BMI [kg/m2] | 28.7 (25.4–32.4) |
| Time to lowest BMI [years] | 2.0 (1.0–3.0) |
| Actual BMI [kg/m2] | 32.3 (27.9–37.4) |
| %TWL | 22.8 (11.8–32.5) |
| %EWL | 59.0 (29.3–81.1) |
| T2D remission, n/total (%) | 80/113 (70.8) |
| HT remission, n/total (%) | 110/194 (56.7) |
| OSA remission, n/total (%) | 19/26 (73.1) |
Revisional procedures
117 (24.1%) patients underwent revisional surgeries. 7 (6.0%) because of GERD, 96 (82.1%) because of weight regain, 13 (11.1%) because of both reasons and 1 (0.9%) because of anastomosis ulceration. All of performed AGB were revised. The most revisions were performed after SG and there were OAGB.
Outcomes after single procedures
The median %EWL after surgeries was 59.2%, the median %TWL was 22.8%, Table 2. After surgeries, 80 patients (70.8%) achieved remission of T2D and, 110 patients (56.7%) achieved remission of HT and 19 (73.1%) patients achieved remission of OSA, Table 2.
Patients who underwent SG were younger than those who underwent RYGB and OAGB (p = 0.003, p < 001, respectively), Table 3. Patients who underwent RYGB had more often HT than those who underwent SG and OAGB (p < 0.001, 0 < 0.001, respectively). The highest preoperative BMI was observed in patients who underwent RYGB, while the lowest was in those who underwent SG. The outcomes differed between the procedures. There was a statistically significant difference between SG and OAGB in %EWL and %TWL (p < 0.001, p = 0.003, respectively), and between RYGB and OAGB in %EWL (p < 0.001).
Table 3.
Characteristics and outcomes after different procedures. (IQR interquartile range, BMI body mass index, %TWL percentage of total weight loss, %EWL percentage of excess weight loss, T2D type 2 diabetes, HT hypertension, SG sleeve gastrectomy, RYGB Roux-en-Y gastric bypass, OAGB one anastomosis gastric bypass)
| SG n = 240 |
RYGB n = 65 | OAGB n = 63 |
p-value | |||
|---|---|---|---|---|---|---|
| RYGB vs. OAGB | SG vs. OAGB | SG vs. RYGB | ||||
| Age, median (IQR) |
40.0 (33.5–50.0) |
45.0 (39.0–55.0) |
48.0 (40.0–59.0) |
0.161 | < 0.001 | 0.003 |
| Sex, female/male | 172/68 | 43/22 | 25/38 | 0.493 | 0.082 | 0.387 |
| T2D, n (%) | 65 (27.1) | 21 (32.3) | 27 (42.9) | 0.218 | 0.015 | 0.406 |
| HT, n (%) | 113 (47.1) | 51 (78.5) | 30 (47.6) | < 0.001 | 0.940 | < 0.001 |
| preoperative BMI, median (IQR) |
30.7 (39.4–46.6) |
45.8 (40.8–51.4) |
39.6 (35.7–42.0) |
< 0.001 | < 0.001 | 0.003 |
| %EWL, median (IQR) |
55.0 (26.0-76.6) |
51.4 (17.3–73.1) |
80.1 (54.6–97.4) |
< 0.001 | < 0.001 | 0.497 |
| %TWL, median (IQR) |
21.6 (10.3–31.6) |
22.8 (7.5–32.8) |
27.6 (19.3–36.1) |
0.084 | 0.003 | 0.744 |
The multivariable regression analysis showed that preoperative BMI was a significant predictor of %TWL (B = 0.927, p < 0.001), Table 4. Patients who underwent OAGB had greater %TWL compared to those who underwent RYGB (B=-5.371, p = 0.002) and SG (B=-2.680, p = 0.039).
Table 4.
Linear regression model with the %TWL (percentage of total weight loss) as dependent variable. (B least squares estimates, t value of the statistic test used, BMI body mass index, T2D type 2 diabetes, HT hypertension, SG sleeve gastrectomy, RYGB Roux-en-Y gastric bypass, OAGB one anastomosis gastric bypass)
| B | Standard error | t | p-value | Confidence interval | |
|---|---|---|---|---|---|
| Sex, male | 0.842 | 0.998 | 0.843 | 0.400 | -1.1–2.8 |
| Age | -0.082 | 0.084 | -0.977 | 0.329 | -0.3–0.1 |
| Preoperative BMI | 0.927 | 0.154 | 6.027 | < 0.001 | 0.6–1.2 |
| SG vs. OAGB | -2.680 | 1.297 | -2.067 | 0.040 | -5.2 - -0.1 |
| RYGB vs. OAGB | -5.371 | 1.735 | -3.096 | 0.002 | -8.8 - -2.0 |
| T2D | -1.946 | 1.117 | -1.743 | 0.082 | -4.1–0.3 |
| HT | 0.924 | 1.027 | 0.900 | 0.369 | -1.1–2.9 |
| OSA | -0.146 | 1.77 | -0.082 | 0.932 | -3.6–3.3 |
Complications and length of stay
There were 29 (6.0%) complications in the whole analyzed group. There were 16 (3.3%) 30-day Clavien Dindo III complications: 6 (1.2%) intraperitoneal bleedings, 6 (1.2%) leak and 4 (0.8%) intraoperatively iatrogenic injuries of intestine, which had been treated during the primary procedure. There were 3 (0.6%) band slippages, 7 (1.4%) rhabdomyolysis and 2 (0.4%) gastroparesis. There was no postoperative death. The median length of hospital stay was 4.0 days.
Discussion
Our study is a retrospective, multicenter analysis examining a 10-year follow-up of patients undergoing MBS in Poland. To the best of our knowledge, it is the largest study with such a long follow-up period describing this population. At that time, only a few centers in Poland were performing bariatric procedures. Most of the surgeries conducted were SG (65.4%), which aligns with contemporary research trends [11, 12].
The follow-up rate in our study was 28.5%, which is a very low percentage that introduces potential bias into the results of the analysis. This demonstrates that conducting long-term observations is very challenging. As studies show, over time, fewer patients attend postoperative visits despite reminders [8]. Nowadays online applications dedicated to bariatric patients or even telephone follow-up could help improve the follow-up rate.
Out of the 485 patients analyzed in our study, 368 (75.9%) did not require or did not opt for revisional procedures. One-fourth of the patients after SG (24.3%) and all patients after AGB (100%) required revisional surgery. Koh et al. reported SG to be one of the most common procedures requiring revisional surgery (27.1%) [13]. Recently, we have observed a decline in the use of AGB, which is undoubtedly influenced by the high rate of revisional surgeries following this procedure [14, 15].
Among patients who underwent SG without revisional surgery, the median %EWL and %TWL at 10 years of follow-up were 55.0% and 21.6%, respectively. Similar findings have been reported by other authors. In the Sleevepass study, %EWL after SG were 43.5%, while Muselli et al. demonstrated a %EWL of 50.1% and %TWL of 22.2% over a 10-year follow-up period [16, 17]. Our results after RYGB are less promising compared to those described in the literature. Salminen et al. reported a %EWL of 50.7%, while Verras et al. observed as much as %EWL of 76.8% and %TWL of 37.6% [16, 18]. While SG is a relatively standardized procedure, the execution of RYGB can vary significantly between centers. Factors such as the length of the alimentary and biliopancreatic limbs or size of a gastric pouch may influence outcomes [19, 20].
In our study, OAGB demonstrated statistically significant better outcomes compared to other procedures, with a %EWL of 80.1% and %TWL of 27.6%. While the literature lacks a consensus on the superiority of OAGB over other bariatric surgeries in terms of weight loss, the observed results are nonetheless satisfactory [21, 22]. Carandina et al. reported a %EWL of 64.1% and %TWL of 33.4% at 10 years after OAGB, while Makkapati et al. observed a %EWL of 68.9% [23, 24]. Despite the superior weight loss outcomes of OAGB compared to SG and RYGB, considering the low follow-up rate, we should be cautious in drawing conclusions that it is the best procedure. Each of the surgeries analyzed in our study achieved good results. Specific complications may arise after each procedure, such as GERD after SG or marginal ulceration after bypasses [25]. Therefore, when choosing the surgical method, we suggest tailoring it to the patient and their needs.
In our analyzed group, patients achieved 70.8% remission rate for T2D and 56.7% for HT. Salminen et al. reported a 26% remission rate of T2D and 33% after SG and RYGB, respectively, and 8% and 24% remission of HT for the same procedures [16]. Meanwhile, Makkapati et al. observed an 80% remission rate of T2D and 71% for HT following OAGB [24]. In our analysis, we presented an overall remission rate for obesity-related diseases, as a detailed breakdown exceeded the scope of this study. However, nearly 42.5% of patients with T2D underwent OAGB and RYGB. Furthermore, it is well known that remission of comorbidities largely depends on the duration of the disease prior to surgery [26–28]. The mean age in our study was 42.5 years, which also contributes to better postoperative outcomes in terms of remission of comorbidities.
The most severe complications in our analysis were bleeding and leaks (1.2% each), which is consistent with global trends [29, 30]. Additionally, 1.4% of cases of rhabdomyolysis were reported; however, following the implementation of protocols such as ERAS, this percentage is likely to decrease in the coming years [31, 32].
The study has several limitations. The retrospective design of the study may introduce potential biases, especially in data collection and reporting. Another bias is introduced by the low follow-up rate achieved. Patients who completed the follow-up are typically more disciplined and, as a result, tend to achieve better outcomes. Patients who did not reach the predefined goals are less likely to attend follow-up visits. This could lead to reporting better postoperative outcomes, including the remission of obesity-related diseases, than would be observed if the results of the entire group were included. Additionally, while the study included five centers and surgical practices or patient management protocols may vary. However, the study included bariatric centers that perform the highest number of surgeries annually in Poland.
Ten years ago, MBS was still developing in Poland, so 485 patients from five centers can be considered a satisfactory result. Moreover, the analyzed outcomes do not include current patient data, such as HbA1c levels or blood pressure measurements. The analysis is based solely on data reported by co-authors. Furthermore, we do not have data on individual years or trends, as the analysis focuses only on the final outcomes after a minimum of 10 years. Analyzing them would certainly be valuable, and future research should focus on this aspect. We also do not have data regarding the nutritional status of the patients, the quality of life assessment and data on patients lost to follow-up. Future studies should also include an assessment of nutritional aspects and quality of life, as these, alongside weight loss and obesity-related diseases, contribute to surgical success. Nevertheless, we believe that this study provides valuable data on MBS in long-term follow-up, and its results can certainly be clinically applied.
Conclusions
Conducting long-term follow-up after surgeries is challenging. Our follow-up rate is 28.5%. Due to the low follow-up rate, the results of this study should be interpreted with caution. They apply only to patients for whom follow-up data were obtained, which may limit their generalizability to the broader bariatric population. Nevertheless, MBS leads to significant long-term outcomes, with a median %EWL of 59.2% and %TWL of 22.8% in 10 years follow-up. 23.9% patients underwent revisional surgeries. The remission rates for comorbidities after single bariatric procedures were 70.8% for T2D and 56.7% for HT.
Author contributions
Study conception and design– Natalia Dowgiałło-Gornowicz, Paweł Jaworski, Piotr MajorAcquisition of data– Natalia Dowgiałło-Gornowicz, Paweł Jaworski, Michał Orłowski, Paula Franczak, Monika Proczko-Stepaniak, Anna Kloczkowska, Izabela Karpińska, Paweł Lech, Piotr MajorAnalysis and interpretation of data– Natalia Dowgiałło-Gornowicz, Paweł JaworskiDrafting of manuscript - Natalia Dowgiałło-Gornowicz, Michał Orłowski, Paula Franczak, Monika Proczko-Stepaniak, Anna KloczkowskaCritical revision of manuscript– Piotr Major.
Funding
No funding was received for this study.
Data availability
Data is available upon request from the corresponding author.
Declarations
Ethics approval and consent to participate
The study was conducted according to the guidelines of the Declaration of Helsinki.
Competing interests
The authors declare no competing interests.
Informed consent
Informed consent was obtained from the participant included in the study.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data is available upon request from the corresponding author.