Factors Associated with Persistent Obstructive Sleep Apnea After Bariatric Surgery: A Narrative Review

Abstract

The prevalence of obstructive sleep apnea (OSA) among the bariatric surgery population is estimated to be 45–70%. However, weight loss obtained by bariatric surgery is not always associated with full remission of OSA, suggesting that other confounding factors are present. This article aims to review the current literature, focusing on factors that could predict the persistence of OSA after bariatric surgery. For this purpose, relevant studies of more than 50 patients that assessed pre- and post-operative presence and severity of OSA detected by poly(somno)graphy (PG/PSG) in bariatric populations were collected. Six retrospective and prospective studies were evaluated that included 1302 OSA patients, with a BMI range of 42.6 to 56 kg/m², age range of 44.8 to 50.7 years, and percentage of women ranging from 45% to 91%. The studies were very heterogeneous regarding type of bariatric surgery, diagnostic criteria for OSA and OSA remission, and delay of OSA reassessment. OSA remission was observed in 26% to 76% of patients at 11–12 months post-surgery. Loss to follow-up was high in all studies, leading to a potential underestimation of OSA remission. Based on this limited sample of bariatric patients, age, pre-operative OSA severity, proportion of weight loss, and type 2 diabetes (T2D) were identified as factors associated with OSA persistence but the results were inconsistent between studies regarding the impact of age and the magnitude of weight loss. Several other factors may potentially lead to OSA persistence in the bariatric surgery population, such as fat distribution, ethnicity, anatomical predisposition, pathophysiological traits, supine position, and REM-predominant hypopnea and apnea. Further well-conducted multicentric prospective studies are needed to document the importance of these factors to achieve a better understanding of OSA persistence after bariatric surgery in obese patients.

Keywords:

• bariatric surgery
• gastric sleeve
• gastric bypass
• obstructive sleep apnea
• polygraphy
• polysomnography

Abbreviations

AASM, American Academy of Sleep Medicine; AHI, apnea-hypopnea index; AT, arousal threshold; BiPAP, bilevel positive airway pressure; BMI, body mass index; CPAP, continuous positive airway pressure; DL, dyslipidemia; EDS, excessive daytime sleepiness; EWL, ; HbA1c, glycated hemoglobin; HT, hypertension; LAGB, laparoscopic gastric banding; LG, loop gain; OA, oral appliance; OAGB, one anastomosis gastric bypass; OSA, obstructive sleep apnea; OSAS, OSA-associated with symptoms and/or comorbidities; PG, polygraphy; PSG, polysomnography; RDI, respiratory disturbance index; REM, rapid eye movement; RYGB, Roux-en-Y gastric bypass; SG, sleeve gastrectomy; T2D, type 2 diabetes; TER, threshold of effective recruitment; UA, upper airway; UAG, muscular upper airway gain; VE, ventilation.

Ethics Approval and Informed Consent

This review did not require any ethics and informed consent.

Consent for Publication

Authors give consent for the publication of the present material.

Acknowledgments

The authors acknowledge the contribution of a medical writer, Sandy Field, PhD, for English language editing and formatting of the manuscript.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors have no competing interests to declare for this work.

Additional information

Funding

There is no funding to report.