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Fracture risk following bariatric surgery: a systematic review and meta-analysis

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Abstract

Bariatric surgery may negatively impact bone health. We aimed to compare fracture risk following bariatric surgery by type (malabsorptive, restrictive), or to non-surgical weight loss, or to controls with obesity. We systematically searched four databases from inception until October 2020. We included observational and interventional studies on adults. We screened articles and abstracted data in duplicate and independently and assessed the risk of bias. We conducted random-effects model meta-analyses (Review Manager v5.3), to calculate the relative risk of any or site-specific fracture (CRD42019128536). We identified four trials of unclear-to-high risk of bias and 15 observational studies of fair-to-good quality. Data on fracture risk following bariatric surgery compared to medical weight loss is scarce and limited by the small number of participants. In observational studies, at a mean/median post-operative follow-up > 2 years, the relative risk of any fracture was 45% (p < 0.001) and 61% (p = 0.04) higher following malabsorptive procedures compared to obese controls and restrictive procedures, respectively, with moderate to high heterogeneity. Site-specific relative fracture risk (hip and wrist) was one- to two-folds higher post malabsorptive procedures compared to obese controls or restrictive procedures. The risks of any and of site-specific fracture were not increased following restrictive procedures compared to obese controls. Fracture risk seems to increase following malabsorptive bariatric surgeries, at a mean/median follow-up > 2 years. The risk is not increased with restrictive surgeries. The available evidence has several limitations. A prospective and rigorous long-term follow-up of patients following bariatric surgery is needed for a better assessment of their fracture risk with aging.

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Abbreviations

LGB:

Laparoscopic gastric banding

RYGB:

Roux-en-Y gastric bypass

BPD:

Biliopancreatic diversion without a duodenal switch

BPD-DS:

Biliopancreatic diversion with a duodenal switch

SG:

Sleeve gastrectomy

BMD:

Bone mineral density

SR/MAs:

Systematic reviews/meta-analyses

BMI:

Body mass index

ROB:

Risk of bias

NOS:

Newcastle-Ottawa Quality Assessment Scale

RR:

Risk ratio

IMT:

Intensive medical therapy

VBG:

Vertical banded gastroplasty

RCT:

Randomized controlled trials

NRCT:

Non-randomized controlled trials

DM:

Diabetes mellitus

DSS:

Diabetes Surgery Study

STAMPEDE:

Surgical Therapy And Medications Potentially Eradicate Diabetes Efficiently

SOS:

Swedish Obesity Study

aHR:

Adjusted hazard ratio

ICD:

International Classification of Disease

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Acknowledgements

The work was supported in part by the Fogarty International Center and the Office of Dietary Supplements of the National Institutes of Health (NIH), award number D43 TW009118. The content is solely the responsibility of authors and does not necessarily represent official views of the NIH. The authors thank Miss Aida Farha, Medical Information Specialist, Saab Medical Library at the American University of Beirut—Lebanon, for her assistance in designing comprehensive complex searches of the medical literature and for the provision of select articles. The authors thank Dr. Rawaa Sabbagh for her contribution in the screening process of citations and full texts. The authors also thank the corresponding authors: Dr. Kennel Kurt [68], Dr. Claudia Gagnon [48], and Dr. Peter Hallowell [43], who have replied to their queries by email.

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  1. Ghezzawi Malak and Habli Dalal contributed equally to this work.

Authors and Affiliations

  1. Calcium Metabolism and Osteoporosis Program, WHO Collaborating Center for Metabolic Bone Disorders, Division of Endocrinology and Metabolism, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon

    R. K. Saad, M. Ghezzawi & M. Chakhtoura

  2. Department of Clinical Nutrition, American University of Beirut Medical Center, Beirut, Lebanon

    D. Habli

  3. Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon

    R. S. Alami

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  1. R. K. Saad
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  2. M. Ghezzawi
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  3. D. Habli
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Correspondence to M. Chakhtoura.

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Saad, R.K., Ghezzawi, M., Habli, D. et al. Fracture risk following bariatric surgery: a systematic review and meta-analysis. Osteoporos Int 33, 511–526 (2022). https://doi.org/10.1007/s00198-021-06206-9

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