Skip to main content

Bariatric Surgery or Non-Surgical Weight Loss for Obstructive Sleep Apnoea? A Systematic Review and Comparison of Meta-analyses

Abstract

Background

Obstructive sleep apnoea (OSA) is a well-recognised complication of obesity. Non-surgical weight loss (medical, behavioural and lifestyle interventions) may improve OSA outcomes, although long-term weight control remains challenging. Bariatric surgery offers a successful strategy for long-term weight loss and symptom resolution.

Objectives

To comparatively appraise bariatric surgery vs. non-surgical weight loss interventions in OSA treatment utilising body mass index (BMI) and apnoea-hypopnoea index (AHI) as objective measures of weight loss and apnoea severity.

Methods

A systematic literature review revealed 19 surgical (n = 525) and 20 non-surgical (n = 825) studies reporting the primary endpoints of BMI and AHI before and after intervention. Data were meta-analysed using random effects modelling. Subgroup analysis, quality scoring and risk of bias were assessed.

Results

Surgical patients had a mean pre-intervention BMI of 51.3 and achieved a significant 14 kg/m2 weighted decrease in BMI (95%CI [11.91, 16.44]), with a 29/h weighted decrease in AHI (95%CI [22.41, 36.74]). Non-surgical patients had a mean pre-intervention BMI of 38.3 and achieved a significant weighted decrease in BMI of 3.1 kg/m2 (95%CI [2.42, 3.79]), with a weighted decrease in AHI of 11/h (95%CI [7.81, 14.98]). Heterogeneity was high across all outcomes.

Conclusions

Both bariatric surgery and non-surgical weight loss may have significant beneficial effects on OSA through BMI and AHI reduction. However, bariatric surgery may offer markedly greater improvement in BMI and AHI than non-surgical alternatives. Future studies must address the lack of randomised controlled and comparative trials in order to confirm the exact relationship between metabolic surgery and non-surgical weight loss interventions in OSA resolution.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3

References

  1. 1.

    World_Health_Organization. Obesity and overweight, WHO Fact sheet N°311 (http://www.who.int/mediacentre/factsheets/fs311/en/). 2014.

  2. 2.

    World_Health_Organization. Chronic Respiratory Diseases (http://www.who.int/gard/publications/chronic_respiratory_diseases.pdf). 2013.

  3. 3.

    Lee W, Nagubadi S, Kryger MH, Mokhlesi B. Epidemiology of obstructive sleep apnea: a population-based perspective. Expert Rev Respir Med. 2008;2(3):349–64.

    PubMed Central  PubMed  Article  Google Scholar 

  4. 4.

    Young T, Peppard PE, Gottlieb DJ. Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med. 2002;165(9):1217–39.

    PubMed  Article  Google Scholar 

  5. 5.

    Young T, Peppard PE, Taheri S. Excess weight and sleep-disordered breathing. J Appl Physiol. 2005;99(4):1592–9.

    PubMed  Article  Google Scholar 

  6. 6.

    Collop NA. Advances in treatment of obstructive sleep apnea syndrome. Curr Treat Options Neurol. 2009;11(5):340–8.

    PubMed  Article  Google Scholar 

  7. 7.

    Araghi MH, Chen YF, Jagielski A, Choudhury S, Banerjee D, Hussain S, et al. Effectiveness of lifestyle interventions on obstructive sleep apnea (OSA): systematic review and meta-analysis. Sleep. 2013;36(10):1553–62. 62A-62E.

    PubMed Central  PubMed  Google Scholar 

  8. 8.

    Anandam A, Akinnusi M, Kufel T, Porhomayon J, El-Solh AA. Effects of dietary weight loss on obstructive sleep apnea: a meta-analysis. Sleep Breath Schlaf Atmung. 2013;17(1):227–34.

    Article  Google Scholar 

  9. 9.

    Ashrafian H, Darzi A, Athanasiou T. Bariatric surgery - can we afford to do it or deny doing it? Front Gastroenterol. 2011;2(2):82–9.

    Article  Google Scholar 

  10. 10.

    Sarkhosh K, Switzer NJ, El-Hadi M, Birch DW, Shi X, Karmali S. The impact of bariatric surgery on obstructive sleep apnea: a systematic review. Obes Surg. 2013;23(3):414–23.

    PubMed  Article  Google Scholar 

  11. 11.

    Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA. 2000;283(15):2008–12.

    CAS  PubMed  Article  Google Scholar 

  12. 12.

    Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:b2535.

    PubMed Central  PubMed  Article  Google Scholar 

  13. 13.

    Busetto L, Enzi G, Inelmen EM, Costa G, Negrin V, Sergi G, et al. Obstructive sleep apnea syndrome in morbid obesity: effects of intragastric balloon. Chest. 2005;128(2):618–23.

    PubMed  Article  Google Scholar 

  14. 14.

    Dixon JB, Schachter LM, O'Brien PE. Polysomnography before and after weight loss in obese patients with severe sleep apnea. Int J Obes (Lond). 2005;29(9):1048–54.

    CAS  Article  Google Scholar 

  15. 15.

    Haines KL, Nelson LG, Gonzalez R, Torrella T, Martin T, Kandil A, et al. Objective evidence that bariatric surgery improves obesity-related obstructive sleep apnea. Surgery. 2007;141(3):354–8.

    PubMed  Article  Google Scholar 

  16. 16.

    Lettieri CJ, Eliasson AH, Greenburg DL. Persistence of obstructive sleep apnea after surgical weight loss. J Clin Sleep Med. 2008;4(4):333–8.

    PubMed Central  PubMed  Google Scholar 

  17. 17.

    Fredheim JM, Rollheim J, Sandbu R, Hofso D, Omland T, Roislien J, et al. Obstructive sleep apnea after weight loss: a clinical trial comparing gastric bypass and intensive lifestyle intervention. J Clin Sleep Med. 2013;9(5):427–32.

    PubMed Central  PubMed  Google Scholar 

  18. 18.

    Pallayova M, Steele KE, Magnuson TH, Schweitzer MA, Smith PL, Patil SP, et al. Sleep apnea determines soluble TNF-alpha receptor 2 response to massive weight loss. Obes Surg. 2011 Feb 6.

  19. 19.

    Pillar G, Peled R, Lavie P. Recurrence of sleep apnea without concomitant weight increase 7.5 years after weight reduction surgery. Chest. 1994;106(6):1702–4.

    CAS  PubMed  Article  Google Scholar 

  20. 20.

    Poitou C, Coupaye M, Laaban JP, Coussieu C, Bedel JF, Bouillot JL, et al. Serum amyloid A and obstructive sleep apnea syndrome before and after surgically-induced weight loss in morbidly obese subjects. Obes Surg. 2006;16(11):1475–81.

    PubMed  Article  Google Scholar 

  21. 21.

    Rajala R, Partinen M, Sane T, Pelkonen R, Huikuri K, Seppalainen AM. Obstructive sleep apnoea syndrome in morbidly obese patients. J Intern Med. 1991;230(2):125–9.

    CAS  PubMed  Article  Google Scholar 

  22. 22.

    Rasheid S, Banasiak M, Gallagher SF, Lipska A, Kaba S, Ventimiglia D, et al. Gastric bypass is an effective treatment for obstructive sleep apnea in patients with clinically significant obesity. Obes Surg. 2003;13(1):58–61.

    PubMed  Article  Google Scholar 

  23. 23.

    Valencia-Flores M, Orea A, Herrera M, Santiago V, Rebollar V, Castano VA, et al. Effect of bariatric surgery on obstructive sleep apnea and hypopnea syndrome, electrocardiogram, and pulmonary arterial pressure. Obes Surg. 2004;14(6):755–62.

    PubMed  Article  Google Scholar 

  24. 24.

    Sugerman HJ, Fairman RP, Sood RK, Engle K, Wolfe L, Kellum JM. Long-term effects of gastric surgery for treating respiratory insufficiency of obesity. Am J Clin Nutr. 1992;55(2 Suppl):597S–601.

    CAS  PubMed  Google Scholar 

  25. 25.

    Guardiano SA, Scott JA, Ware JC, Schechner SA. The long-term results of gastric bypass on indexes of sleep apnea. Chest. 2003;124(4):1615–9.

    PubMed  Article  Google Scholar 

  26. 26.

    Dixon JB, Schachter LM, O'Brien PE, Jones K, Grima M, Lambert G, et al. Surgical vs conventional therapy for weight loss treatment of obstructive sleep apnea: a randomized controlled trial. JAMA. 2012;308(11):1142–9.

    CAS  PubMed  Article  Google Scholar 

  27. 27.

    Tuomilehto H, Gylling H, Peltonen M, Martikainen T, Sahlman J, Kokkarinen J, et al. Sustained improvement in mild obstructive sleep apnea after a diet- and physical activity-based lifestyle intervention: postinterventional follow-up. Am J Clin Nutr. 2010;92(4):688–96.

    CAS  PubMed  Article  Google Scholar 

  28. 28.

    Barnes M, Goldsworthy UR, Cary BA, Hill CJ. A diet and exercise program to improve clinical outcomes in patients with obstructive sleep apnea–a feasibility study. J Clin Sleep Med. 2009;5(5):409–15.

    PubMed Central  PubMed  Google Scholar 

  29. 29.

    Ferland A, Poirier P, Series F. Sibutramine versus continuous positive airway pressure in obese obstructive sleep apnoea patients. Eur Respir J. 2009;34(3):694–701.

    CAS  PubMed  Article  Google Scholar 

  30. 30.

    Kansanen M, Vanninen E, Tuunainen A, Pesonen P, Tuononen V, Hartikainen J, et al. The effect of a very low-calorie diet-induced weight loss on the severity of obstructive sleep apnoea and autonomic nervous function in obese patients with obstructive sleep apnoea syndrome. Clin Physiol. 1998;18(4):377–85.

    CAS  PubMed  Article  Google Scholar 

  31. 31.

    Nerfeldt P, Nilsson BY, Mayor L, Udden J, Friberg D. A two-year weight reduction program in obese sleep apnea patients. J Clin Sleep Med. 2010;6(5):479–86.

    PubMed Central  PubMed  Google Scholar 

  32. 32.

    Pasquali R, Colella P, Cirignotta F, Mondini S, Gerardi R, Buratti P, et al. Treatment of obese patients with obstructive sleep apnea syndrome (OSAS): effect of weight loss and interference of otorhinolaryngoiatric pathology. Int J Obes. 1990;14(3):207–17.

    CAS  PubMed  Google Scholar 

  33. 33.

    Phillips CL, Yee BJ, Trenell MI, Magnussen JS, Wang D, Banerjee D, et al. Changes in regional adiposity and cardio-metabolic function following a weight loss program with sibutramine in obese men with obstructive sleep apnea. J Clin Sleep Med. 2009;5(5):416–21.

    PubMed Central  PubMed  Google Scholar 

  34. 34.

    Rubinstein I, Colapinto N, Rotstein LE, Brown IG, Hoffstein V. Improvement in upper airway function after weight loss in patients with obstructive sleep apnea. Am Rev Respir Dis. 1988;138(5):1192–5.

    CAS  PubMed  Article  Google Scholar 

  35. 35.

    Sampol G, Munoz X, Sagales MT, Marti S, Roca A, Dolors de la Calzada M, et al. Long-term efficacy of dietary weight loss in sleep apnoea/hypopnoea syndrome. Eur Respir J. 1998;12(5):1156–9.

    CAS  PubMed  Article  Google Scholar 

  36. 36.

    Suratt PM, McTier RF, Findley LJ, Pohl SL, Wilhoit SC. Changes in breathing and the pharynx after weight loss in obstructive sleep apnea. Chest. 1987;92(4):631–7.

    CAS  PubMed  Article  Google Scholar 

  37. 37.

    Suratt PM, McTier RF, Findley LJ, Pohl SL, Wilhoit SC. Effect of very-low-calorie diets with weight loss on obstructive sleep apnea. Am J Clin Nutr. 1992;56(1 Suppl):182S–4.

    CAS  PubMed  Google Scholar 

  38. 38.

    Foster GD, Borradaile KE, Sanders MH, Millman R, Zammit G, Newman AB, et al. A randomized study on the effect of weight loss on obstructive sleep apnea among obese patients with type 2 diabetes: the Sleep AHEAD study. Arch Intern Med. 2009;169(17):1619–26.

    PubMed Central  PubMed  Article  Google Scholar 

  39. 39.

    Johansson K, Neovius M, Lagerros YT, Harlid R, Rossner S, Granath F, et al. Effect of a very low energy diet on moderate and severe obstructive sleep apnoea in obese men: a randomised controlled trial. BMJ. 2009;339:b4609.

    PubMed Central  PubMed  Article  Google Scholar 

  40. 40.

    Yee BJ, Phillips CL, Banerjee D, Caterson I, Hedner JA, Grunstein RR. The effect of sibutramine-assisted weight loss in men with obstructive sleep apnoea. Int J Obes (Lond). 2007;31(1):161–8.

    CAS  Article  Google Scholar 

  41. 41.

    Schwartz AR, Gold AR, Schubert N, Stryzak A, Wise RA, Permutt S, et al. Effect of weight loss on upper airway collapsibility in obstructive sleep apnea. Am Rev Respir Dis. 1991;144(3 Pt 1):494–8.

    CAS  PubMed  Article  Google Scholar 

  42. 42.

    Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg. 2013;23(4):427–36.

    PubMed  Article  Google Scholar 

  43. 43.

    Ashrafian H, le Roux CW, Rowland SP, Ali M, Cummin AR, Darzi A, et al. Metabolic surgery and obstructive sleep apnoea: the protective effects of bariatric procedures. Thorax. 2012;67(5):442–9.

    PubMed  Article  Google Scholar 

  44. 44.

    Simpson L, Mukherjee S, Cooper MN, Ward KL, Lee JD, Fedson AC, et al. Sex differences in the association of regional fat distribution with the severity of obstructive sleep apnea. Sleep. 2010;33(4):467–74.

    PubMed Central  PubMed  Google Scholar 

  45. 45.

    Coughlin SR, Mawdsley L, Mugarza JA, Calverley PM, Wilding JP. Obstructive sleep apnoea is independently associated with an increased prevalence of metabolic syndrome. Eur Heart J. 2004;25(9):735–41.

    PubMed  Article  Google Scholar 

  46. 46.

    Meslier N, Gagnadoux F, Giraud P, Person C, Ouksel H, Urban T, et al. Impaired glucose-insulin metabolism in males with obstructive sleep apnoea syndrome. Eur Respir J. 2003;22(1):156–60.

    CAS  PubMed  Article  Google Scholar 

  47. 47.

    Punjabi NM, Sorkin JD, Katzel LI, Goldberg AP, Schwartz AR, Smith PL. Sleep-disordered breathing and insulin resistance in middle-aged and overweight men. Am J Respir Crit Care Med. 2002;165(5):677–82.

    PubMed  Article  Google Scholar 

  48. 48.

    Vgontzas AN, Papanicolaou DA, Bixler EO, Kales A, Tyson K, Chrousos GP. Elevation of plasma cytokines in disorders of excessive daytime sleepiness: role of sleep disturbance and obesity. J Clin Endocrinol Metab. 1997;82(5):1313–6.

    CAS  PubMed  Article  Google Scholar 

  49. 49.

    Punjabi NM, Beamer BA. C-reactive protein is associated with sleep disordered breathing independent of adiposity. Sleep. 2007;30(1):29–34.

    PubMed  Google Scholar 

  50. 50.

    Kopp HP, Kopp CW, Festa A, Krzyzanowska K, Kriwanek S, Minar E, et al. Impact of weight loss on inflammatory proteins and their association with the insulin resistance syndrome in morbidly obese patients. Arterioscler Thromb Vasc Biol. 2003;23(6):1042–7.

    CAS  PubMed  Article  Google Scholar 

  51. 51.

    Calvin AD, Albuquerque FN, Lopez-Jimenez F, Somers VK. Obstructive sleep apnea, inflammation, and the metabolic syndrome. Metab Syndr Relat Disord. 2009;7(4):271–8.

    PubMed Central  PubMed  Article  Google Scholar 

  52. 52.

    Ip MS, Lam KS, Ho C, Tsang KW, Lam W. Serum leptin and vascular risk factors in obstructive sleep apnea. Chest. 2000;118(3):580–6.

    CAS  PubMed  Article  Google Scholar 

  53. 53.

    Eun YG, Kim MG, Kwon KH, Shin SY, Cho JS, Kim SW. Short-term effect of multilevel surgery on adipokines and pro-inflammatory cytokines in patients with obstructive sleep apnea. Acta Otolaryngol. 2010;130(12):1394–8.

    CAS  PubMed  Article  Google Scholar 

  54. 54.

    Birkmeyer JD, Finks JF, O'Reilly A, Oerline M, Carlin AM, Nunn AR, et al. Surgical skill and complication rates after bariatric surgery. N Engl J Med. 2013;369(15):1434–42.

    CAS  PubMed  Article  Google Scholar 

  55. 55.

    Flum DR, Belle SH, King WC, Wahed AS, Berk P, et al. Longitudinal Assessment of Bariatric Surgery C. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med. 2009;361(5):445–54.

    PubMed  Article  Google Scholar 

  56. 56.

    Driver HS, Taylor SR. Exercise and sleep. Sleep Med Rev. 2000;4(4):387–402.

    PubMed  Article  Google Scholar 

  57. 57.

    Redline S, Budhiraja R, Kapur V, Marcus CL, Mateika JH, Mehra R, et al. The scoring of respiratory events in sleep: reliability and validity. J Clin Sleep Med. 2007;3(2):169–200.

    PubMed  Google Scholar 

  58. 58.

    Myers KA, Mrkobrada M, Simel DL. Does this patient have obstructive sleep apnea?: The rational clinical examination systematic review. JAMA. 2013;310(7):731–41.

    CAS  PubMed  Article  Google Scholar 

  59. 59.

    Harman EM, Wynne JW, Block AJ. The effect of weight loss on sleep-disordered breathing and oxygen desaturation in morbidly obese men. Chest. 1982;82(3):291–4.

    CAS  PubMed  Article  Google Scholar 

  60. 60.

    Peiser J, Lavie P, Ovnat A, Charuzi I. Sleep apnea syndrome in the morbidly obese as an indication for weight reduction surgery. Ann Surg. 1984;199(1):112–5.

    CAS  PubMed Central  PubMed  Article  Google Scholar 

  61. 61.

    Charuzi I, Ovnat A, Peiser J, Saltz H, Weitzman S, Lavie P. The effect of surgical weight reduction on sleep quality in obesity-related sleep apnea syndrome. Surgery. 1985;97(5):535–8.

    CAS  PubMed  Google Scholar 

  62. 62.

    Charuzi I, Fraser D, Peiser J, Ovnat A, Lavie P. Sleep apnea syndrome in the morbidly obese undergoing bariatric surgery. Gastroenterol Clin North Am. 1987;16(3):517–9.

    CAS  PubMed  Google Scholar 

  63. 63.

    Summers CL, Stradling JR, Baddeley RM. Treatment of sleep apnoea by vertical gastroplasty. Br J Surg. 1990;77(11):1271–2.

    CAS  PubMed  Article  Google Scholar 

  64. 64.

    Charuzi I, Lavie P, Peiser J, Peled R. Bariatric surgery in morbidly obese sleep-apnea patients: short- and long-term follow-up. Am J Clin Nutr. 1992;55(2 Suppl):594S–6.

    CAS  PubMed  Google Scholar 

  65. 65.

    Noseda A, Kempenaers C, Kerkhofs M, Houben JJ, Linkowski P. Sleep apnea after 1 year domiciliary nasal-continuous positive airway pressure and attempted weight reduction. Potential for weaning from continuous positive airway pressure. Chest. 1996;109(1):138–43.

    CAS  PubMed  Article  Google Scholar 

  66. 66.

    Scheuller M, Weider D. Bariatric surgery for treatment of sleep apnea syndrome in 15 morbidly obese patients: long-term results. Otolaryngol Head Neck Surg. 2001;125(4):299–302.

    CAS  PubMed  Article  Google Scholar 

  67. 67.

    Lankford DA, Proctor CD, Richard R. Continuous positive airway pressure (CPAP) changes in bariatric surgery patients undergoing rapid weight loss. Obes Surg. 2005;15(3):336–41.

    PubMed  Article  Google Scholar 

  68. 68.

    Kalra M, Inge T, Garcia V, Daniels S, Lawson L, Curti R, et al. Obstructive sleep apnea in extremely overweight adolescents undergoing bariatric surgery. Obes Res. 2005;13(7):1175–9.

    PubMed  Article  Google Scholar 

  69. 69.

    Grunstein RR, Stenlof K, Hedner JA, Peltonen M, Karason K, Sjostrom L. Two year reduction in sleep apnea symptoms and associated diabetes incidence after weight loss in severe obesity. Sleep. 2007;30(6):703–10.

    PubMed Central  PubMed  Google Scholar 

  70. 70.

    Fritscher LG, Canani S, Mottin CC, Fritscher CC, Berleze D, Chapman K, et al. Bariatric surgery in the treatment of obstructive sleep apnea in morbidly obese patients. Respiration. 2007;74(6):647–52.

    CAS  PubMed  Article  Google Scholar 

  71. 71.

    Marti-Valeri C, Sabate A, Masdevall C, Dalmau A. Improvement of associated respiratory problems in morbidly obese patients after open Roux-en-Y gastric bypass. Obes Surg. 2007;17(8):1102–10.

    CAS  PubMed  Article  Google Scholar 

  72. 72.

    Varela JE, Hinojosa MW, Nguyen NT. Resolution of obstructive sleep apnea after laparoscopic gastric bypass. Obes Surg. 2007;17(10):1279–82.

    PubMed  Article  Google Scholar 

  73. 73.

    Kuzniar TJ, Morgenthaler TI. A patient with obstructive sleep apnea undergoing bariatric surgery. J Clin Sleep Med. 2008;4(3):279–80.

    PubMed Central  PubMed  Google Scholar 

  74. 74.

    Rao A, Tey BH, Ramalingam G, Poh AG. Obstructive sleep apnoea (OSA) patterns in bariatric surgical practice and response of OSA to weight loss after laparoscopic adjustable gastric banding (LAGB). Ann Acad Med Singapore. 2009;38(7):587–7.

    CAS  PubMed  Google Scholar 

  75. 75.

    Smith PL, Gold AR, Meyers DA, Haponik EF, Bleecker ER. Weight loss in mildly to moderately obese patients with obstructive sleep apnea. Ann Intern Med. 1985;103(6 (Pt 1)):850–5.

    CAS  PubMed  Article  Google Scholar 

  76. 76.

    Kiselak J, Clark M, Pera V, Rosenberg C, Redline S. The association between hypertension and sleep apnea in obese patients. Chest. 1993;104(3):775–80.

    CAS  PubMed  Article  Google Scholar 

  77. 77.

    Nahmias J, Kirschner M, Karetzky MS. Weight loss and OSA and pulmonary function in obesity. N J Med. 1993;90(1):48–53.

    CAS  PubMed  Google Scholar 

  78. 78.

    Martinez D, Basile BR. Sibutramine does not worsen sleep apnea syndrome: a randomized double-blind placebo-controlled study. Sleep Med. 2005;6(5):467–70.

    PubMed  Article  Google Scholar 

  79. 79.

    Verhulst SL, Franckx H, Van Gaal L, De Backer W, Desager K. The effect of weight loss on sleep-disordered breathing in obese teenagers. Obesity (Silver Spring). 2009;17(6):1178–83.

    Google Scholar 

Download references

Ethical Approval

For this type of study, formal consent is not required.

Conflict of Interest

The authors declare that they have no conflict of interest.

Financial Disclosure

None

Author information

Affiliations

Authors

Corresponding author

Correspondence to Hutan Ashrafian.

Electronic supplementary material

Below is the link to the electronic supplementary material.

ESM 1

Funnel Plot assessment of publication bias: (a) BMI surgical group; (b) BMI non-surgical group; (c) AHI surgical group; (d) AHI non-surgical group. Dashed lines represent means and 95 % confidence intervals. (DOC 436 kb)

ESM 2

Criteria for quality assessment (DOC 29 kb)

ESM 3

Quality Scoring (DOC 74 kb)

ESM 4

Eggers Test for Funnel Plot Asymmetry (DOC 40 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Ashrafian, H., Toma, T., Rowland, S.P. et al. Bariatric Surgery or Non-Surgical Weight Loss for Obstructive Sleep Apnoea? A Systematic Review and Comparison of Meta-analyses. OBES SURG 25, 1239–1250 (2015). https://doi.org/10.1007/s11695-014-1533-2

Download citation

Keywords

  • Obstructive sleep apnoea
  • Body mass index
  • Intervention
  • Surgery
  • Weight loss
  • Apnoea-hypopnoea index