Page 56 - Read Online

Page 6 of 9 Aly et al. Mini-invasive Surg 2020;4:21 I http://dx.doi.org/10.20517/2574-1225.2019.57

(16.7%). This is interesting since obesity is a major risk factor for osteoarthritis, which in turn is the most
common indication for a knee replacement. Similarly, LRYGB had a lower mortality rate than laparoscopic
cholecystectomy and appendectomy (0.3% vs. 0.7% and 0.5%, respectively). Future partnerships between
bariatric surgeons and PCPs are crucial to increase knowledge about the safety of weight loss surgery.

Although referral patterns seem to be a larger barrier for access to weight loss surgery, patient selection by
[34]
bariatric surgeons may also be implicated in the gender disparity. In a national survey study by Santry et al. ,
patterns of patient selection among 820 U.S. bariatric surgical specialists was examined using clinical patient
vignettes. In all BMI and comorbidity subgroups that met current NIH clinical guidelines for surgery, patient
gender did not influence patient selection. This insinuates that the overrepresentation of women undergoing
bariatric surgery likely occurs prior to evaluation by a bariatric surgeon and is either related to referral
patterns or patient preference. However, the study did find that gender had an impact on patient selection
only for the subset of patients who did not meet NIH BMI and comorbidity criteria. In this subset, men
had a 67% decreased odds of selection for surgery. While the majority of patients who do not meet NIH
[11]
criteria are often self-referred and appropriately excluded from surgical evaluation , the findings from
[34]
the Santry et al. study suggest that some surgeons may be influenced by social and cultural pressures on
women to achieve body image ideals. Bariatric surgery for this subset of patients, however, likely does not
completely account for the gender disparity across all bariatric surgical patients, the majority of which meet
NIH criteria.

SEX-BASED OUTCOMES AFTER BARIATRIC SURGERY
Similar to the knowledge gap about the safety of weight loss surgery, differential referral for and utilization
of bariatric surgery by men and women may also be founded in a lack of knowledge, on the part of both
providers and patients, surrounding the effectiveness of weight loss and health risk reduction with surgery.
[35]
Kennedy-Dalby et al. sought to compare sex-based outcomes in an observational cohort analysis of 79 men
matched to 79 women for age, BMI, bariatric procedure, and comorbidities including type 2 diabetes and
obstructive sleep apnea. At 24 months postoperatively, significant reductions in excess BMI loss were identified
for both women and men (72.9% and 65.8%, respectively). Both groups demonstrated significant reductions
in hypertension, glycosylated hemoglobin, and cholesterol without significant differences by gender.
Additionally, 77.5% of men and 90.0% of women with obstructive sleep apnea discontinued continuous
positive airway pressure use. These findings support bariatric surgery as an effective weight loss intervention
with significant improvement in metabolic and functional outcomes for both men and women.

Weight loss surgery has also been shown to have positive effects on sexual functioning, fertility, and
pregnancy outcomes in women. In a prospective cohort study of 106 women who underwent bariatric
[36]
surgery, Sarwer et al. reported that, within the first two postoperative years, women report significant
improvements in overall sexual functioning as well as in specific domains related to arousal, lubrication,
desire, and satisfaction. These observations correlated with significant improvements in levels of sex
hormones as well as in important shifts across quality of life measures, including improvement in depressive
symptoms, self-esteem, and overall emotional and physical functioning. Weight loss after bariatric surgery
is associated with improvement in conditions such as polycystic ovarian syndrome, anovulation, and
irregular menses, leading to improvement in fertility rates as well as reductions in pregnancy loss and
[24]
maternal pregnancy complications such as gestational diabetes and preeclampsia .
Among men pursing bariatric surgery, 36% report sexual dissatisfaction associated with erectile
[23]
dysfunction . Additionally, elevated BMI has been associated with impairments in semen characteristics
[37]
and reduced levels of reproductive hormones potentially affecting male fertility . In a study of 97 men
undergoing gastric bypass, participants reported significant improvement in sexual function based on
the Brief Male Sexual Function Inventory score before and after surgery. There was improvement in all