Efficacy of Bariatric Surgery in Improving the Anthropomertics and Metabolic Outcomes: A Retrospective Study from A Single Private Center in Dubai, UAE in the Retrospective Study

Background: Prevalence of obesity is increasing worldwide, and the Middle East is not an exception to this rise. Bariatric surgery is an effective treatment for obesity in terms of weight loss and remission of metabolic syndrome and has become more popular in recent years. Methods: This is a retrospective cohort study of 69 patients who underwent bariatric surgery at Mediclinic to 1.02 ± 0.26 and 3.50 ± 0.93 to 3.4 ± 0.98 respectively. (P<0.08) AST and ALT improved from 27.85 ± 18.39 to 15.24 ± 4.07 and 40.58 ± 35.49 to 17.84 ± 7.37 respectively at 12 months postoperatively. Only one patient developed postoperative peritonitis causing sepsis. Conclusions: The results show that bariatric surgery was effective in achieving weight loss as well as improvement in lipid and liver profile over a follow up period of one year. Further studies are needed to see whether favorable outcomes of bariatric surgery can be sustained over long term in this mixed population.


Introduction
The prevalence of obesity is increasing worldwide and according to World Health Organisation (WHO) 650 million people were reported as obese in 2016 and the number has tripled since 1975 [1]. According to World Obesity Federation, prevalence of obesity in United Arab Emirates (UAE) is reported as 27.8% between age of 18-69 years in 2017-2018 [2]. There are many treatment options available for management of obesity, including physical activity, dietary intervention, behavior therapy, pharmacological treatment and bariatric surgery. Bariatric surgery however, is an effective treatment of severe obesity and as a result the number of bariatric surgeries that are being performed has increased in recent years. According to 4 th International Federation for the surgery of obesity and metabolic disorders (IFSO) Global registry report 634,897 bariatric surgeries were performed worldwide in 2016 [3]. Bariatric surgery has shown improved longterm metabolic outcomes in patients with obesity [4,5]. The aim of our study was to look at anthropometric measurements and metabolic outcomes of our cohort at 12 months postoperatively.

Methods
This is a retrospective cohort study of sixty-nine patients who underwent bariatric surgery at Mediclinic Parkview Hospital in Dubai, UAE between January 2019-September 2021 as part of a multi-disciplinary weight management program. Patients were screened for inclusion/exclusion criteria according to the American Society for Metabolic and Bariatric Surgery (ASMBS) guidelines [6]. The ASMBS inclusion criteria for bariatric surgery candidates are: 1-Patients with BMI ≥ 40 kg/m 2 .
3-Patients with BMI 30-34.9 kg/m 2 with recent onset type 2 diabetes or metabolic syndrome may be offered bariatric procedure.
Patients were excluded from the bariatric surgery based on exclusion criteria, which are as follows: current drug or alcohol abuse; any underlying reversible endocrine disorder causing obesity; severe psychiatric illness; and lack of comprehension of the risks/benefits/expected outcomes/lifestyle changes associated with bariatric surgery.

Data Collection
Data was collected from electronic medical records Bayanaty ® (InterSystems IRIS, US) and the body composition analyzer (Seca ® , Germany). Data collection was done as follows: Demographic data included age, gender and nationality. Anthropometric measures included height, weight, BMI, fat mass, body fat percentage, visceral fat mass, WC, HC and WHR at baseline, 3,6 and 12 months post-operatively. Laboratory measurements included glycated haemoglobin (HbA1c), renal function such as Estimated Glomerular Filtration Rate (eGFR), liver function tests including AST and ALT, lipid profile including cholesterol, triglyceride, LDL, and HDL at baseline, 3, 6 and 12 months post-operatively.

Data Analysis
Data were analyzed using IBM-SPSS for Windows version 28.0 (SPSS Inc., Chicago, IL). Categorical variables are described by using proportions. Continuous variables are described by a measure of tendency and a measure of dispersion. Continuous data was tested for normality by using the Shapiro-Wilk test. Friedman's one-way ANOVA was used to compare between related data in more than two groups. A P-value of less than 0.05 was considered significant for all analyses.

Ethical Statement
Ethical approvals were taken from local Mediclinic Institutional Research Board; and Dubai Scientific Research Ethics Committee, Dubai Health Authority, Dubai, UAE.  Following surgical procedures were done. Laparoscopic sleeve gastrectomy 51 (73.9%), Minigastric bypass 7 (10%), Roux en Y gastric bypass (RYGB) 3 (4.3%), endoscopic sleeve gastrectomy 3 (4.3%), revision of minigastric bypass 2 (2.9%) and revision of sleeve gastrectomy 3 (4.3%). Table 2       29 patients didn't come for follow up after 1 year, n=20/69 (42%). Out of these, 2 patients were followed up in Abu Dhabi.7 patients were from medical tourism, n=7/69 (10%), 3 patients went back to United Kingdom, 2 to Canada, 1 to United States and 1 to Nigeria. Detailed medical reports were given to patients for follow up in their respective countries. N=9/13 (69.2%) patients prediabetes was resolved, 7 patients didn't have follow up at one year as they were from medical tourism. N= 5/7 (71.4%) patients type 2 diabetes was resolved with normal HbA1c. 4 patients were on oral hypoglycaemic medications which were stopped and one patient discontinued insulin post operatively at one 1 year follow up. One patient had sepsis secondary to post-operative peritonitis which required antibiotics and conservative management.

Discussion
This was a retrospective study which showed statistically significant reduction in BMI, fat mass, visceral fat and waist circumference from baseline to 12 months post-operatively. Fat mass reduced from 59.28±22.72 to 34.77±17.22, Visceral fat reduced from 5.76±3.70 to 2.70±1.82 at 12 months and WC reduced from 118.82±17.03 to 100.59±.11.36 at 12 months (p values <0.001). Our study has shown 24.5 kg (41.3%)reduction in fat mass and 3 kg (52%) reduction in visceral fat at 12 months. Abusanana et al demonstrated 46% reduction in fat mass and Ciangura et al showed 45.2% decrease in fat mass but in Roux en Y gastric bypass procedure whereas in our study laproscopic sleeve gastrectomy was the main procedure [7,8]. Eduardo et al in 2021 has shown a decrease in visceral fat at 6 months after surgery in both men and women (Baseline 7.5 ± 3L, 6 months 2.5 ± 2 L (p = 0.001). An average decrease in visceral adipose tissue of 70 ± 22% in women and 60 ± 21% in men (p = 0.53) 6 months after surgery. The highest percentage of visceral fat at 6 months was seen with Laparoscopic One-Anastomosis Gastric Bypass (OAGB), however, this was not statistically significant when compared with Y-Roux Gastric bypass (YRGB) [9]. Bhatti et al has already shown that there is strong correlation between visceral fat, waist circumference and risk of metabolic disease [10].
Lipid profile improved at 12 months postoperatively with total cholesterol, triglycerides and Low Density Lipoproteins (LDL) dropping from 9.26 ± 30.6 to 4.98 ± 0.92 (P<0.08), 1.71 ± 1.08 to 1.02 ± 0.26 (P<0.09) and 3.50 ± 0.93 to 3.4 ± 0.98 respectively. (P<0.2), however it was not statistically significant. Similar results were shown by meta-analysis published by Heffron et al. In post sleeve gastrectomy subjects, there was non-significant reduction in mean TC at one year compared with baseline (P=0.11), reduction in LDL (P=0.13) [10]. AST  42% of patients were lost to follow up, out of which 7/29 (24.1%) were from medical tourism and 2 were followed up in another emirate. This reflects the fact that Dubai is a very multinational society with more than 200 nationalities. Limitations of our study include the small sample size and retrospective nature of analysis. Therefore, more studies with large sample size would help in this guidance. Another limitation of our study is there are more patients with laproscopic sleeve gastrectomy compared to other procedures so we cannot look at outcomes based on type of procedure performed.

Conclusions
The results show that bariatric surgery was effective in achieving weight loss in terms of reduction in BMI, fat mass, visceral fat, waist circumference as well as improvement in lipid and liver profile over a follow up period of one year. Further studies are needed to see whether favorable outcomes of bariatric surgery can be sustained over long term in this mixed population.