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DOI 10.1007/s11695-015-1746-z

ORIGINAL CONTRIBUTIONS

Gender Influence on Long-Term Weight Loss and Comorbidities

After Laparoscopic Sleeve Gastrectomy and Roux-en-Y Gastric
Bypass: a Prospective Study With a 5-Year Follow-up

Federico Perrone 1 & Emanuela Bianciardi 3 &

Domenico Benavoli 1 & Valeria Tognoni 1 & Cinzia Niolu 3 &
Alberto Siracusano 3 & Achille L. Gaspari 1 &
Paolo Gentileschi 1,2

# Springer Science+Business Media New York 2015

Abstract 90 % of patients showed improvements in comorbidities in the

Background Gender might be important in predicting out-
comes after bariatric surgery. The aim of the study was to
investigate the influence of gender on long-term weight loss
and comorbidity improvement after laparoscopic sleeve gas-
trectomy (LSG) and laparoscopic Roux-en-Y gastric bypass
(LRYGB).
Methods A cohort of 304 consecutive patients underwent sur-
gery in 2006–2009: 162 (98 women, 64 men) underwent LSG
and 142 (112 women, 30 men) underwent LRYGB. The mean
follow-up time was 75.8±8.4 months (range, 60–96 months).
Results Overall mean (95 % CI) reduction in BMI was 23.5
(24.3–22.7) kg/m2 after 5 years, with no statistical difference
between LSG and LRYGB groups (P=0.94). The overall
means±standard deviations of %EBMIL after 5 years were
78.8±23.5 and 81.6±21.4 in the LSG and LRYGB groups,
respectively. Only for LSG group %EBMIL after 24–36 and
60 months differed significantly between male and female
patients (P=0.003 versus P=0.06 in LRYGB), and 89 versus
LSG and LRYGB groups, respectively. Only two patients
(women) were lost to follow-up: 1/162 (0.6 %) for LSG at
the 4th year and 1/142 (0.7 %) for LRYGB to the 5th year.
Conclusions LSG was more effective in obese male than in
female patients in terms of %EBMIL, with no difference in
comorbidities. LRYGB elicited similar results in both genders
in terms of %EBMIL and comorbidities.
Keywords Obesity . Predictors . Gender . Weight loss .
Bariatric surgery . Sleeve gastrectomy . Gastric Bypass
Introduction/Purpose
Although bariatric surgery is the most effective treatment for
morbid obesity, long-term weight loss is influenced by many
factors, most of which are still unknown. Successful weight

* Federico Perrone Achille L. Gaspari

fed.perrone@gmail.com gaspari@med.uniroma2.it
Emanuela Bianciardi
emanuelabianciardi@libero.it Paolo Gentileschi
gentilp@yahoo.com
Domenico Benavoli
dobenavoli@yahoo.com 1
General Surgery Unit, Department of Experimental Medicine and
Valeria Tognoni Surgery, University of Rome, Tor Vergata, Italy
vtognoni@gmail.com
2
Bariatric Surgery Unit, Department of Experimental Medicine and
Cinzia Niolu Surgery, University of Rome, Tor Vergata, Italy
niolu@med.uniroma2.it
3
Alberto Siracusano Psychiatric Unit, Department of System Medicine, University of
siracusano@med.uniroma2.it Rome, Tor Vergata, Italy
 OBES SURG

loss after bariatric surgery is often defined as >50 % excess
weight loss. However, >30 % of patients are reported to fail to
achieve this goal in the long-term [1, 2]. We believe that iden-
tifying preoperative predictors of weight loss after bariatric
surgery is important in improving patient selection and, there-
fore, long-term results. Studies evaluating potential predictors
of weight loss after bariatric surgery are inconclusive. Based
on our experience, we hypothesized that predictors of weight
loss after bariatric surgery differ according to gender. Fat stor-
age and metabolism differ greatly between men and women
[3], but little is known about the influence of these findings on
the outcome of obesity surgery. Therefore, this study aimed to
explore the influence of gender on long-term weight loss and
comorbidities after laparoscopic sleeve gastrectomy (LSG)
and Roux-en-Y gastric bypass (LRYGB).
Material and Methods
A cohort of 304 consecutive patients underwent surgery be-
tween January 2006 and December 2009. All patients were
invited to participate in this prospective cohort study.
Informed consent was obtained from all individual partici-
pants included in the study. All procedures performed in stud-
ies involving human participants were in accordance with the
ethical standards of the institutional and/or national research
committee and with the 1964 Helsinki declaration and its later
amendments or comparable ethical standards. The study was
approved by the Ethics Committee.
Data were analyzed in 2014, resulting in a minimum
follow-up of 5 years.
One-hundred-sixty-two patients (98 women, 64 men)
underwent LSG, and 142 (112 women, 30 men) underwent
LRYGB.
An interdisciplinary team evaluated candidates based on a
medical, nutritional, endocrinological, and psychiatric work-up.
Standard preoperative assessments included barium x-ray of the
upper gastrointestinal tract or esophagogastroduodenoscopy,
blood examinations, cardiologic evaluation, and chest radiogra-
phy. Psychiatric counseling was conducted to evaluate mental
health contraindications to surgery and obstacles to postoperative
success in order to identify patients unsuitable for surgery.
Psychiatric contraindications to bariatric surgery were
mental retardation with an IQ below 50, current illicit drug
and alcohol abuse, and severe active, uncontrolled psychiatric
symptomatology [4].
Further examinations were performed on the basis of individ-
ual clinical history. Inclusion criteria were failure to lose weight
via other methods, BMI>40.0 kg/m2 or ≥35.0 kg/m2 with
obesity-related comorbidities, no previous bariatric surgery, no
alcohol or drug issues, and no active psychosis. Surgical proce-
dures (LSG and LRYGB) were selected based on the preoperative
work-up. All procedures were performed laparoscopically, using
four or five ports, by the same surgeon. At our institution, LSG is
performed with a 36-F bougie and gastric resection is carried out
with a reinforced linear stapler. LRYGB is performed using a 75-
cm biliopancreatic limb and a 150-cm alimentary limb.
Postoperative advice included a diet consisting of clear
liquids and puréed foods for 15 days after surgery and a
semisolid-consistency diet for the next 15 days. After the first
30 days, patients gradually began a low-fat, low-carbohydrate,
high-protein solid diet based on the advice of a dietitian. One

Table 1 Patient
characteristics Patient characteristics (n°304) LSG LRYGB P value

Number of patients (2001–2009) 162 142

(98 F, 64 M) (112 F, 30 M)
Mean age (±SD years) 41.8±4.6 43.8±4.6 NS
Previous bariatric surgery (%) 0% 0%
Previous abdominal surgery n/N:
Cesarean section 12/162 13/142
Abdominoplasty 2/162 1/142
Appendectomy 14/162 11/142
LPS cholecystectomy 5/162 8/142
LPS ovarian cyst removal 3/162 1/142
Mean BMI at surgery (±SD) 47.4±4.2 46.8±3.6 NS
(44.8±3.8 F, 48.7±4.2 M) (44.2±3.7 F, 48.1±4.1 M)
Comorbidities (T2DM, hypertension, 24.3 % (15/162) 36.9 %(26/142) NS
dyslipidemia, obstruction sleep
apnea syndrome)
Mean follow-up 75.8±8.4 months (range 60–96)
Lost to follow-up 1/162 (F, 4th year) 1/142 (F, 5th year)

LSG laparoscopic sleeve gastrectomy, LRYGB laparoscopic Roux-en-Y gastric Bypass, M male, F female, NS not
statistically significant, SD standard deviation, T2DM type 2 diabetes mellitus
OBES SURG
Table 2 Overall outcome
Overall outcome LSG LRYGB P value
Comorbidity improvement 89 % 90 % NS
(reduction or discontinuation
of therapy after 5 years) (%)
%EBMIL after 5 years, 78.8±23.5 81.6±21.4 NS
mean±standard deviation (kg/m2)
multivitamin tablet, daily intake, was recommended for three
months after surgery, as well as high-frequency water intake
and physical activity.
Weight loss was defined as overall mean (95 % CI) reduction
in BMI and as percent excess body mass index loss (%EBMIL),
with excess BMI>25 kg/m2, calculated as follows: 100–(follow-
up BMI–25/beginning BMI–25)×100 [5]. Comorbidity improve-
ment was defined as a reduction or discontinuation of therapy.
The mean follow-up was 75.8±8.4 months (range, 60–
96 months). Data were collected at the outpatient clinic 1 week
after surgery and then 1, 3, 6, and 12 months postoperatively
for the 1st year, twice in the 2nd to 5th years, and annually
thereafter. In 2014, all patients were visited at the outpatient
clinic or were telephoned if not available to visit the clinic.
Statistical analyses were performed using IBM SPSS ver-
sion 20 for Windows. Categorical variables were analyzed
using the chi-squared test, Fisher’s exact test, or the Student’s
t test for quantitative and qualitative variables, as appropriate.
Data are expressed as median and range, unless specified oth-
erwise. P values are two-sided, and values <0.05 were consid-
ered statistically significant. Continuous variables are described
as mean and standard deviation (SD), whereas categorical var-
iables were described as number and percentage.
Results
For the LSG patients, the mean age was 41.8±4.6 years, the
mean preoperative BMI was 47.4 ± 4.2 kg/m 2 , and the
Fig. 1 LSG was more effective in obese male than in obese female
patients in terms of %EBMIL after 24–36 months and 60 months
(P=0.003). For LRYGB, the difference between male and female patients
percentage of patients with comorbidities was 24.8 %. These
values were 43.8±4.6 years, 46.8±3.6 kg/m2, and 36.6 % for
the LRYGB patients. The two groups had similar mean ages,
mean BMI at surgery, and obesity-related comorbidities (type
2 diabetes mellitus (T2DM), hypertension, dyslipidemia, and
obstruction sleep apnea syndrome). Some patients had previ-
ous abdominal surgery. There were no postoperative or long-
term mortality. The mean follow-up was 75.8±8.4 months
(range, 60–96 months) (Table 1). Only two patients
(women) were lost to follow-up: 1/162 (0.6 %) for LSG at
the 4th year and 1/142 (0.7 %) for LRYGB to the 5th year.
Overall mean (95 % CI) reduction in BMI was 23.5 (24.3–
22.7) kg/m2 after 5 years, with no statistical difference be-
tween LSG and LRYGB groups (P = 0.94). The overall
means±standard deviations of %EBMIL after 5 years were
78.8±23.5 and 81.6±21.4 in the LSG and LRYGB groups,
respectively; this was not significantly different. Comorbidity
improvement (reduction or discontinuation of therapy after
5 years) was also similar in the two groups (89 % in the
LSG group, 90 % in the LRYGB group) (Table 2).
LSG was more effective in obese male than in obese female
patients in terms of %EBMIL, although long-term comorbid-
ity outcomes did not differ according to gender. LRYGB pa-
tients showed similar results in terms of both %EBMIL and
comorbidity outcomes in both genders. In the LSG group,
%EBMIL after 24–36 months and 60 months was significant-
ly different between male and female patients (P=0.003);
89 % of patients showed comorbidity improvement. For
LRYGB, %EBMIL after 24–36 months and 60 months did
not differ significantly between male and female patients (P=
0.06); 90 % of patients showed comorbidity improvement
(Figs. 1 and 2, Table 3).
Discussion
Many individual biological, medical, psychosocial, and envi-
ronmental factors influence weight loss success. Many
was not statistically significant (P=0.06). LSG laparoscopic sleeve
gastrectomy, LRYGB laparoscopic Roux-en-Y gastric Bypass, %EBMIL
percent excess body mass index loss, yr years, Pre-op preoperative
 OBES SURG

Fig. 2 Gender-specific results for

comorbidity improvement LSG

OSAS
(reduction or discontinuation of
therapy) after 5 years of follow- LRYGB

up. LSG laparoscopic sleeve

Dyslipidemia
LSG
gastrectomy, LRYGB
laparoscopic Roux-en-Y gastric
LRYGB
Bypass, M male, F female, T2DM
type 2 diabetes mellitus, OSAS F
LSG

T2DM
obstruction sleep apnea syndrome M

LRYGB

hypertension
LSG

Arterial
LRYGB

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

attempts have been made to clarify the relationship between
these predictors and bariatric surgery outcomes. Some authors
have tried to create an algorithm for weight loss after gastric
bypass surgery, considering body mass index, gender, and age
[6].
Several studies have analyzed predictors of bariatric sur-
gery outcome, although the results are inconsistent. For exam-
ple, while some authors report a positive relationship between
T2DM and EBMIL% after bariatric surgery, others report a
negative relationship [1, 7]. Furthermore, other studies have
reported a positive association between preoperative weight
loss and EBMIL% after bariatric surgery [1, 7, 8].
Fat storage and metabolism differ greatly between men and
women. The difference in response to treatment other than
surgery between males and females is well acknowledged
[9], although the reason for this is not well understood [10].
Reports on the difference in weight loss between male and
female patients after bariatric surgery are scarce. Tiwari et al.
[11] reported that male gender was associated with more com-
plications after RYGB. Likewise, Sucandy and Antanavicius
[12] reported male gender as a predictor of adverse outcomes
after duodenal switch. According to Stroh et al. [13], male
gender was associated with more preoperative comorbidities
and, subsequently, a lower rate of amelioration.
In our study, LSG was more effective in obese male than in
obese female patients in terms of %EBMIL, although long-
term comorbidity outcomes did not differ. LRYGB patients
showed similar outcomes for both %EBMIL and comorbidity
improvement in both genders.
In previous studies, age was found to be a significant pre-
dictor of outcome after RYGB, as reported by Scozzari et al.
[14] Contreras et al. [15] observed similar findings at a cutoff
point of 45 years. In our study as well, a negative association
was noted between age and %EBMIL in men from both
groups, with borderline statistical significance. This may sug-
gest a role for gender in the negative association between age
and weight loss [6, 7]. Declining physical activity and ongo-
ing physiological reduction in lean body mass in old age may
have a particularly important negative metabolic effect on
weight loss in men, who constitutionally have greater lean
mass than women [16]. These physiological differences be-
tween men and women could partially explain different

Table 3 %EBMIL
outcome Male Female Pvalue
%EBMIL mean±standard %EBMIL mean±standard
deviation (kg/m2) deviation (kg/m2)

LSG
12 months 75.1±18.9 74.9±19.2 0.0528
24 months 76.7±20.4 74.8±21.7 0.0038
36 months 78.7±24.3 75.5±23.6 0.0033
60 months 79.1±24.1 76.2±22.5 0.0036
LRYGB
12 months 76.9±24.3 76.8±23.6 0.0587
24 months 78.9±25.6 78.8±26.0 0.0621
36 months 80.1±22.3 80.6±22.8 0.0692
60 months 82.6±23.4 82.1±22.8 0.0654

%EBMIL percent excess body mass index loss

OBES SURG
gender-based outcomes in terms of %EBMIL after bariatric
surgery. Why this happens only in restrictive bariatric surgery
procedures is still to be investigated in studies that target the
differences in bariatric surgery response, such as different
physiologic and metabolic pathways [17], different eating be-
haviors [18] due to several surgeries, and physiologic mecha-
nisms of action associated with LSG other than pure restric-
tion [19].
To our knowledge, this is the first prospective study to
investigate gender as a predictor of weight loss and co-
morbidity outcome after bariatric surgery with a minimum
follow-up of 5 years, performed in a single center by a
single surgeon, using two well-known bariatric proce-
dures, LSG and LRYGB. The strength of the study is in
the prospective design, long follow-up, and low chance of
surgical biases.
Identifying factors that influence weight loss after bariatric
surgery is one way to predict a successful surgical outcome. In
a recent retrospective study, Bekheit et al. [20] found that
gastric banding is less effective in males and suggested that
gastric banding should not be offered as a first-choice treat-
ment for obese male patients. Taken together with these find-
ings, our results suggest that obese male patients could be
treated by a more invasive and effective procedure, such as
sleeve gastrectomy. Thus, knowledge of preoperative predic-
tors of successful weight loss after bariatric surgery could
improve patient and procedure selection. For this reason, we
consider our study of great importance, although further in-
vestigations are needed.
Our study has limitations. Long-term data on diet or
physical activity after surgery were not available, and
the male sample size was smaller than the female sample
size (mostly in the LRYGB group), reflecting that fewer
men than women choose bariatric surgery [1, 7]. In this
regard, Kennedy-Dalby et al. [21] observed that the global
frequency of bariatric surgery is significantly lower in
men than in women, despite the high prevalence of mor-
bid obesity. It is unclear whether this is due to the percep-
tion of poorer outcomes in men. The authors compared
gastric bypass and sleeve gastrectomy, concluding that
weight loss and metabolic outcomes are similar in men
and women, and therefore, bariatric surgery in eligible
men should be encouraged. Male gender has traditionally
been cited as a significant independent risk factor for the
development of cardiovascular disease. Therefore, men
might potentially benefit even more from bariatric surgery
than women.
In a further study, we will analyze other important predic-
tors, such as psychological factors (anxiety, depression, eating
disorders, and personality traits), unemployment and shift-
work patterns, and educational and marital status, which seem
to have great importance in determining weight loss and clin-
ical success [16, 22–29].
Conclusion
Our findings suggest that LSG is more effective in obese male
than in obese female patients in terms of %EBMIL, although
long-term comorbidity outcomes were not different.
Identifying preoperative predictive factors might be useful in
developing strategies to improve bariatric surgery outcomes
and patient selection. To date, results from studies evaluating
potential predictors of weight loss after bariatric surgery have
been relatively inconclusive, and further studies with new ap-
proaches are needed. Such gender differences could explain
some of the inconsistent results in previous studies. Further
studies, including an analysis of gender-specific predictors,
should be conducted.
Conflict of Interest The authors declare that they have no competing
interests.
Ethical Approval All procedures performed in studies involving hu-
man participants were in accordance with the ethical standards of the
institutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable ethical
standards.
Informed Consent informed consent was obtained from all individual
participants included in the study.
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