SF-BARI Score for assessment of long-term results in patients with BMI ≥ 50 Kg/m2 submitted to Roux-en-Y Gastric Bypass or Sleeve Gastrectomy

doi:10.21203/rs.3.rs-5026667/v1

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SF-BARI Score for assessment of long-term results in patients with BMI ≥ 50 Kg/m2 submitted to Roux-en-Y Gastric Bypass or Sleeve Gastrectomy

https://doi.org/10.21203/rs.3.rs-5026667/v1

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Introduction: To improve treatment of patients with BMI ≥ 50 Kg/m², it is necessary to standardize reports and to assess long-term outcomes. The SF-BARI score was developed to provide a comprehensive evaluation of MBS outcomes. This article explores the long-term results of RYGB and SG in patients with BMI ≥ 50 Kg/m²using the SF-BARI Score, and assesses variables that may influence this score.

Methods: Retrospective cohort study of patients with BMI ≥ 50kg/m² submitted to Roux-en-Y Gastric Bypass (RYGB) or Sleeve Gastrectomy (SG) between January 2010 and September 2021, with more than 5 years of follow-up. Several data were collected, and the SF-BARI score was calculated and analyzed. Statistical analysis was performed to identify variables that influenced the score.

Results: We identified 89 patients with long-term follow-up (mean 96.6 months, SD 18.9) after RYGB or SG. The mean SF-BARI score was 94.2 (SD 29.5) with most patients’ outcomes categorized as Good. Seventy-six (85.4%) patients had %TWL ≥ 20, but only 34.8% patients had a final BMI < 35 kg/m². Statistical analysis revealed that younger patients have higher SF-BARI score related to comorbidities improvement.

Conclusion: Our findings suggest that both RYGB and SG lead to satisfactory long-term outcomes for treatment of patients with BMI above 50 kg/m², according to the SF-BARI Score. However only one third achieved a BMI below 35 kg/m². Younger patients seem to achieve better results, particularly comorbidity improvements. SF-BARI score is a comprehensive and intuitive web-based tool that may contribute for the standardization of reporting outcomes after MBS.

SF-BARI Score is a standardized, comprehensive and intuitive tool to assess MBS outcomes

RYGB and SG result in satisfactory long-term outcomes in patients with BMI ≥ 50 Kg/m²

Only a third of these patients achieved a BMI < 35 Kg/m² at long term after MBS

Younger patients seem to benefit most from MBS, particularly in comorbidities improvement

Severe obesity is on the rise globally, exerting a profound impact on various diseases, quality of life, and health-related costs [1, 2]. Among patients with obesity, those with a BMI ≥ 50kg/m² present unique challenges related to increased complications. Nonetheless, this subset of patients may benefit the most from effective treatments.

Metabolic and Bariatric Surgery (MBS) remains the most successful long-term treatment for obesity and its metabolic complications. In patients with BMI ≥ 50kg/m², MBS is considered a crucial treatment that may achieve reasonable outcomes, but many challenges arise when considering surgery for this high-risk group of patients [3]. In a large cohort study [4] that included 173.110 patients with BMI ≥ 50 kg/m² submitted to Roux-en-Y Gastric Bypass (RYGB) or Sleeve Gastrectomy (SG), it was concluded that BMI ≥ 50 kg/m² remains an independent risk factor for serious complications and the greatest independent risk factor for 30-day postoperative mortality.

Furthermore, these patients tend to demonstrate less favorable long-term outcomes following MBS compared to their less severely obese counterparts. Patients with BMI ≥ 50 kg/m² face distinct challenges in achieving and maintaining weight loss, which can lead to complications, reduced quality of life, and significant healthcare burden. Objectives after MBS for these subgroup of complex patients must be tailored, with management of patients’ expectations.

There is a scarcity of published long-term outcomes for MBS in patients with BMI ≥ 50 kg/m², as highlighted by recent systematic reviews and meta-analysis [5, 6]. Moreover, few studies extend beyond 5 years of follow-up. Standardizing outcome reporting after MBS is crucial to ensure consistency in this field [7]. Historically, outcomes following MBS have been primarily evaluated on weight loss [8–10]. However, more recently, improvements in associated comorbidities, quality of life, and the impact of potential complications, have been increasingly recognized as critical markers in evaluating MBS outcomes. Therefore, developing a comprehensive score that integrates all these key dimensions in a standardized and user-friendly manner is of paramount importance. The Swiss-Finnish Bariatric metabolic outcome score (SF-BARI Score) is a free, web-based tool, that incorporates many of these essential considerations.

Our study aims to explore the long-term results of RYGB and SG in patients with BMI ≥ 50kg/m², using the SF-BARI Score. As a secondary objective, we assessed the variables that may influence long-term outcomes after MBS in patients with BMI ≥ 50kg/m².

Study Population

We performed a retrospective cohort study of all adult patients (18 to 65 years) submitted to MBS between January 2010 and September 2021 in a single high-volume center. We selected patients with BMI ≥ 50kg/m², submitted to RYGB or SG, with follow-up ≥ 5 years after MBS. Patients submitted to RYGB or SG after adjustable gastric band were excluded. Patients submitted to secondary revisional surgeries after initial RYGB or SG were included only if last follow-up ≥ 5 years was available after last surgery.

Pre-operative protocol

All patients were submitted to a rigorous preoperative protocol, including extensive blood and urine analysis, upper endoscopy, abdominal sonography and barium swallow abdominal radiographies, and offered a multidisciplinary approach including pre and post-operative consultations with a bariatric surgeon, endocrinologist, psychiatrist and a dietitian. Most patients were also evaluated pre-operatively by Anesthesiology, Pneumology and Cardiology, to further stratify risk and/or optimize co-morbidities.

Surgical treatment

Surgical techniques were standardized and performed by a team of five surgeons. In RYGB, we used a small gastric pouch of approximately 4x8cm, the gastro-jejunostomy was calibrated with a 36Fr bougie, and performed side-to-side using a linear stapler. The limbs lengths were 100cm for the biliopancreatic limb and 120cm for the alimentary/roux limb. In SG, we preserved 6cm of antrum and used a 48Fr bougie for calibration. Between 2009 and 2016, all patients with predictable high risk for surgery (ex: central obesity, chronic respiratory disease) had Intra-Gastric Balloon (IGB) for 6 months before proceeding to surgery.

Follow-up

As per the selection criteria, all patients had a minimum follow-up period of at least five years after last MBS. The follow-up included annual consultations with a surgeon, endocrinologist, dietitian, and/or psychologist.. Per protocol, all patients submitted to MBS in our institution are advised to take high dose multivitamin supplementation Additionally, annual blood and urine analysis were performed.

Clinical Data Evaluated

Several variables were examined including demographic characteristics, preoperative BMI, use of IGB before surgery, surgical procedure performed, postoperative surgical complications assessed using the Comprehensive Complication Index, weight loss outcomes (percentage total weight loss %TWL, percentage excess weight loss %EWL, final BMI), and major co-morbidities before and after surgery. The need for revisional surgery was also evaluated.

The SF-BARI Score [11] was employed: SF-BARI Score Calculator 1.0 available at https://sites.utu.fi/sfbariscore/calculator. This score encompasses %TW), improvement of co-morbidities (diabetes, dislipidemia, hypertension and sleep apnea) and the Comprehensive Complication Index. The SF-BARI Score generates a continuous variable ranging from − 100 to + 200 that can be grouped into five distinct categories: suboptimal, fair, good, very good and excellent. Assessment of quality of life was not performed in this study.

Statistical Analysis

The data were analysed using IBM SPSS Statistics 29.0^® (SPSS Inc., Chicago, Ill., USA). Statistical significance (p-value) was assumed for 5%. In descriptive statistics, central values were described as mean or median to variables with normal or non-normal distribution, respectively. The preferred dispersion measures were standard deviation (SD) for mean, and interquartile range (IQR) for median. Variables were assessed for normality using both visual (histogram and Q-Q Plot) and Shapiro-Wilk test.

Assessment of variables influencing SF-BARI Score was performed. Standard parametric tests (T-Student) were used for comparison of variables with normal distributions (after Levene test for variance). Relations between continuous variable were studied using Spearman correlation test.

Between January 2010 and September 2021, MBS was performed in 4014 cases, including 172 duplicates – revisional procedures from the same institution, in a total of 3842 different patients. RYGB was performed in 2529 cases (63,0%). Mean BMI was 43,3 kg/m² (SD 5,8) and 469 (11,7%) patients had a BMI ≥ 50 kg/m². Long-term (> 5 years) follow-up was available for 19,0% of patients with BMI ≥ 50 kg/m².

Applying the selection criteria described, we had a total of 89 patients with BMI ≥ 50 kg/m², submitted to RYGB or SG, with last available follow-up > 5 years since last procedure. Most patients were female (80.9%), the median initial BMI was 53.0 kg/m² (IQR 4.3) and the surgery most performed was RYGB (66.3%). Demographic and peri-operative data are presented in Table 1.

Table 1

– Demographics and Peri-Operative Data (n = 89)
Age (years)	mean (SD)	44,0	(11,7)
Female Gender	n (%)	72	(80,9)
Initial BMI (kg/m²)	median (IQR)	53,0	(4,3)
Preoperative BMI (kg/m²)	median (IQR)	52,4	(4,0)
IGB before surgery	n (%)	19	(21,3)
Diabetes	n (%)	37	(41,6)
Dyslipidemia	n (%)	28	(31,5)
Hypertension	n (%)	57	(64,0)
Surgery performed	n (%)	RYGB = 59 SG = 30	(66,3) (33,7)
SD: standard deviation; IQR: interquartile range (Q3-Q1); IGB: intragastric balloon; RYGB: Roux-en-Y Gastric Bypass; SG: Sleeve Gastrectomy

In this series, 19 (21,3%) patients had intra-gastric balloon previously to surgery that result in a median %TWL of 8,3% (minimum 6,9%; maximum 32,4%; IQR = 12.3). There were 3 patients that required a secondary surgery for insufficient weight loss. Those 3 patients were initially submitted to Sleeve Gastrectomy and 22, 25 and 38 months later were converted to RYGB. Note that many other patients with initial BMI ≥ 50kg/m² were submitted to secondary procedures, but not included in this series because they didn´t met the selection criteria of last available follow up above 5 years since last surgery. All surgeries were performed by laparoscopic approach, without any conversion to laparotomy.

Several outcomes are presented in Table 2, including SF-BARI Score and its components: complications, weight loss and co-morbidities outcomes.

Table 2

– Outcomes at last available follow-up (n = 89)
Follow up (months)	Mean (SD)	96,6	(18,9)
SF-BARI Score	Mean (SD)	94,2	(29,5)
SF-BARI Score – Categories
Suboptimal (< 35)	n (%)	2	(2,2)
Fair (35 to < 70)	n (%)	15	(16,9)
Good (70 to < 110)	n (%)	44	(49,4)
Very good (110 to < 135)	n (%)	23	(25,8)
Excellent (≥ 135)	n (%)	5	(5,6)
Complications
Major surgical complications	n (%)	1	(1,1)
CCI	Mean (min-max)	0	(0–20,9)
Mortality	n (%)	0	0
Weight loss
% TWL	Median (IQR)	31,8	(13,3)
Patients with %TWL > 20	n (%)	76	(85,4)
% EWL	Median (IQR)	60,5	(23,3)
Patients with %EWL > 50	n (%)	64	(71,9)
Weight Lost (kg)	Mean (SD)	44,2	(16,2)
Final BMI (kg/m²)	Mean (SD)	37,4	(5,3)
Patients with final BMI < 30 kg/m²	n (%)	3	(3,4)
Patients with final BMI < 35 kg/m²	n (%)	31	(34,8)
Patients with final BMI < 40 kg/m²	n (%)	64	(71,9)
Co-morbidities at last follow-up
Diabetes (DM)	n (%)	16	(18)
Dyslipidemia (DLP)	n (%)	25	(28,1)
Hypertension (HT)	n (%)	37	(41,6)
Obstructive sleep apnea (OSA)	n (%)	4	(4,5)
Co-morbidities improvement*	Mean (SD)	37,9	(16,3)
SD: standard deviation; IQR: interquartile range (Q1-Q3); CCI: Comprehensive Complication Index

* Co-morbidities improvement was defined as a part of SF-Bari Score: for diabetes, dyslipidemia and hypertension, no disease/medication at baseline or at follow up receives + 10points. Worsened or “de novo” (medication increase/started) -10 points. Medication unchanged (if disease at baseline) 0 points. Improved receives + 10points, and remission + 20 points. For obstructive sleep apnea, no CPAP receives 10 points, and CPAP 0 points. As a result, co-morbidities improvement can vary between − 30points to + 70 points.

The mean follow-up was 96.6 months (SD 18.9).

The SF-BARI Score had a mean value of 94.2 (SD 29.5). SF-BARI score was categorized in groups: 2.2% of patients had suboptimal scores (< 35), 16.9% had fair scores (35 to < 70), 49.4% had good scores (70 to < 110), 25.8% had very good scores (110 to < 135), and 5.6% had excellent scores (≥ 135).

Regarding complications, the median Comprehensive Comorbidity Index was 0, ranging from 0 to 20.9. There were no mortalities reported and we only had 1 major surgical complication during this long period of follow-up: one case of marginal ulcer after RYGB that resulted in upper gastrointestinal bleeding. The patient was readmitted to hospital several months after surgery. Endoscopic treatment was necessary to control the bleeding. Conservative treatment of the ulcer was posteriorly used, and the patient did not require any other treatments.

Nutritional complications were not considered in this study.

In terms of weight loss at last follow-up available, the median %TWL was 31.8 (IQR 13.3). A significant majority of patients (85.4%) achieved a %TWL greater than 20. At the final follow-up, the mean BMIwas 37.4 kg/m² (SD 5.3) and 34.8% of patients had a final BMI below 35 kg/m².

When examining co-morbidities at the last follow-up, 18% of patients had diabetes, 28.1% had dyslipidemia, 41.6% had hypertension, and 4.5% had obstructive sleep apnea. The mean improvement in co-morbidities was substantial, with a mean score of 37.9.

The type of surgery (RYGB vs. SG) did not significantly impact the SF-BARI Score or its components. The distribution of patients regarding SF-BARI Score (category/score) according to the type of surgery performed and the initial BMI are represented in Graphic 1 and Fig. 1, respectively.

Graphic 1 - Categories of SF-BARI Score according to surgery performed, at last follow-up.

Statistical analysis regarding relations between SF-Bari Score and type of surgery, gender, age, initial BMI and diabetes are presented in Table 3.

Table 3

SF-BARI Score, %TWL and improvement in comorbidities according to type of surgery, gender, BMI, diabetes and age.
	SF-BARI Score Mean (SD)	p value	%TWL Mean (SD)		Co-morbidities improv. Mean (SD)	p value
Type of surgery
RYGB (n = 59)	96,5 (29,1)	p = 0,30	31,0 (9,2)	p = 0,24	39,3 (17,3)	p = 0,86
SG (n = 30)	89,7 (30,3)	p = 0,30	30,5 (10,6)	p = 0,24	35,0 (14,1)	p = 0,86
Gender
Female (n = 72)	96,0 (28,8)	p = 0,28	31,0 (9,8)	p = 0,62	39,0 (15,5)	p = 0,24
Male (n = 17)	86,6 (32,2)	p = 0,28	29,8 (9,1)	p = 0,62	32,9 (19,3)	p = 0,24
BMI
BMI > 60 (n = 6)	103,6 (34,2)	p = 0,42	37,2 (5,8)	p = 0,09	35,0 (10,5)	p = 0,66
BMI 50–60 (n = 83)	93,5 (29,3)	p = 0,42	30,3 (9,7)	p = 0,09	38,1 (16,7)	p = 0,66
Diabetes
Diabetic (n = 37)	90,0 (37,1)	p = 0,30	35,9 (20,6)	p = 0,39	28,6 (11,9)	p = 0.10
Non-diabetic (n = 52)	97,2 (22,7)	p = 0,30	39,2 (12,5)	p = 0,39	32,3 (7,4)	p = 0.10
Age
<40years (n = 32)	101,7 (22,9)	p = 0,07	32,1 (9,9)	p = 0,32	43,1 (6,9)	p = 0,005
≥ 40years (n = 57)	90,0 (32,1)	p = 0,07	30,0 (9,5)	p = 0,32	34,9 (19,2)	p = 0,005
%TWL – percentage of total weight lost; RYGB – Roux-en-Y Gastric Bypass; SG – Sleeve Gastrectomy; SD – Standard Deviation; BMI – Body Mass Index;

We observed that younger age was statistically associated to higher scores in co-morbidities improvement. To assess the strength of this association, we used the Spearman correlation coefficient to determine the rank correlation between the continuous variables (initial BMI and age) and SF-BARI Score, %TWL and co-morbidities improvement - Table 4. The analysis revealed that younger patients tend to have higher SF-BARI Score and comorbidities improvement, although with a weak correlation (𝜌=-0.23 and 𝜌=-0.33, respectively).

The other variables studied did not seem to statistically influence SF-BARI Score.

Table 4

Spearman correlation test between initial BMI, age and the outcomes.
	SF-BARI Score		%TWL		Co-morbidities improvement
	SCC (𝜌)	p value	SCC (𝜌)	p value	SCC (𝜌)	p value
BMI	-	p = 0,072	-	p = 0,135	-	p = 0,413
Age	-0,23	p = 0,028	-	p = 0,242	-0,33	p = 0,001
SCC – Spearman Correlation Coefficient; %TWL – percentage of total weight lost; BMI – Body Mass Index;

We report long term results (mean follow-up higher than 8 years) of 89 patients with initial BMI ≥ 50kg/m² submitted to RYGB or SG. All patients had at least 5 years follow-up after surgery.

The outcomes were reported using a comprehensive and standardized score. The Swiss-Finnish Bariatric metabolic outcome score (SF-BARI Score) [11] was developed by an international team led by two renowned and experienced bariatric surgeons, from the merged data from two large randomized clinical trial [12, 13]. The SF-BARI Score considers different outcomes after surgery: weight loss, co-morbidities improvement, complications and, optionally, quality of life. The easy-to-use scoring system, based on a simple website without any patient identification, provides a continuous and categorical variable that sums all the relevant information regarding outcomes after MBS. We consider it an excellent tool to standardize reports of treatment outcomes and very useful to compare results within and between different centers around the world.

In our study, at last follow-up available, 81% of patients achieved good, very good or excellent results according to SF-BARI Score. These findings reflect that 85% patients had %TWL > 20, and 72% patients had %EWL > 50, which are commonly referred as markers of adequate weight loss after MBS. As expected, we also observed a high rate of co-morbidities improvement and a low complication rate.

Although most patients achieved a “good” or better category according to the SF-BARI Score in the long term, fewer than 35% attained a BMI < 35 kg/m², and less than 3.5% were classified as non-obese (BMI < 30 kg/m²). A BMI above 50 kg/m² has been associated to reduced weight loss outcomes after MBS [14, 15], demanding adjustments in the criteria for satisfactory weight loss in this population. Consistent with other authors [10], a BMI < 40 kg/m² may be considered a satisfactory weight loss outcome at long-term follow-up. In our series, 72% of patients achieved a final BMI below 40 kg/m², aligning more closely with the outcomes obtained by the SF-BARI Score.

As previously discussed, the comprehensive evaluation of MBS outcomes must incorporate various factors beyond weight loss alone. Nevertheless, these findings also highlight the need for more effective strategies to achieve better weight loss results. This may involve considering more “aggressive” surgical options or two-step approaches, combining pharmacotherapy or endoscopic therapy with subsequent MBS. Some studies suggest that surgeries such as One-Anastomosis Gastric Bypass (OAGB) [16], Single Anastomosis Duodenal-Ileostomy with Sleeve (SADI-S) [17], or biliopancreatic diversion with duodenal switch (BPD-DS) [18] may be more effective for patients with BMI ≥ 50kg/m², although probably with higher long term nutritional complications. There is a paucity of data on long-term outcomes of these procedures in patients with BMI ≥ 50 kg/m².

Patients should be thoroughly informed about the potential challenges in achieving an optimal weight even after undergoing MBS. It is also important to emphasize that this limitation may restrict access to body contouring surgeries, as most plastic surgeons set a BMI threshold of 28–30 kg/m² for such procedures due to the increased risk of wound healing complications [19]. Comprehensive counselling, careful management of expectations, and clear communication regarding objectives, risks and benefits of MBS are essential for all patients, particularly those with a BMI ≥ 50 kg/m².

Recent systematic review and meta-analysis [5, 6] comparing long term outcomes of RYGB and SG in patients with BMI ≥ 50kg/m², suggested that RYGB leads to improved outcomes at 12 months, but no difference was found at 24 or at 36 months. There are conflicting published data regarding which surgery may be the best for patients with BMI ≥ 50kg/m². In our study, the type of surgery (RYGB or SG) did not significantly impact the SF-BARI Score or its components. Nonetheless, we observed that RYGB consistently demonstrated higher mean weight loss, greater resolution of comorbidities, higher percentage of patients achieving a final BMI < 35 kg/m² and higher mean SF-BARI Score. These differences, however, did not achieve statistical significance, which may be explained by the small population sample. As for surgical complications, some studies report that RYGB is related to a higher rates of reoperation and readmission at 30 and 90 days [20], but this data was inconsistent with our findings and other studies [21, 22]. It seems that both surgeries have a high safety profile even in patients with BMI ≥ 70kg/m² when performed by experienced teams [23].

We examined the statistical association of SF-BARI Score with variables such as age, gender, diabetes and initial BMI. Significant associations were found only with age. When categorizing age into younger (18–39 years) and older (40–65 years) groups, significant differences were identified in the SF-BARI Score in the long term after bariatric surgery, particularly regarding the improvement in comorbidity scores. The analysis of continuous variables confirmed these findings, but the correlation strength was low. It must be noted that the higher scores observed in the young population were mostly explained by the improvement of comorbidities rather than %TWL or surgical complications. Some studies suggests that older age may be considered an additional risk factor for post-operative complications [24], particularly in this group of patients with BMI ≥ 50kg/m² who typically present with more severe associated diseases, reduced functional reserve and an overall higher risk of anesthetic complications.

Despite its utility, the SF-BARI Score presents some limitations that may affect its interpretation and clinical application. A primary limitation is the potential overlap of different outcomes. For example, a patient who experiences complication such as Petersen's hernia, which is promptly resolved via laparoscopic surgery with minimal long-term impact on quality of life, may nonetheless exhibit a significant change in score. Additionally, the SF-BARI score does not account for nutritional complications, which are not uncommon following MBS and can profoundly influence a patient’s health [25]. Another limitation is the omission of the patient’s goal of obesity improvement, with far-reaching implications such as the pivotal role of MBS as a bridge to other surgeries (eg. orthopedic or transplantation). The absence of this consideration prevents the score from fully capturing the patient's progress toward a critical outcome. Furthermore, the SF-BARI score is restricted to evaluating a specific set of comorbidities — diabetes, dyslipidemia, hypertension, and obstructive sleep apnea – thereby excluding other significant associated diseases that may play a vital role in determining the overall success of surgery and the patient's long-term health. We recognize that SF-BARI Score aimed to provide a simple and intuitive tool that could not encompass the many complexities of MBS outcomes.

We must acknowledge some limitations in our study. We had a small number of patients, especially those with a BMI greater than 60 kg/m² (only 6 patients, 6.7%). These patients with very high BMI are often lost to follow-up, which could be attributed to various factors such as unsatisfactory outcomes leading to loss of motivation, greater psychosocial sequelae [26] or mobility difficulties. Thus, the selection criteria requiring available follow-up data above five years likely selected the most motivated patients who continued in follow-up, and probably those with more satisfactory results. Another potential source of bias is that we did not analyse the use of non-surgical treatments that patients might have undergone during the follow-up period. There is also some admitted heterogeneity in our population, as some patients underwent intragastric balloon placement before surgery. We did not integrate the quality of life in the score, so no conclusions could be made about this very relevant topic.

Most patients with a BMI above 50 kg/m² who underwent RYGB or SG achieved “good” or better outcomes at long-term follow-up, as assessed by the SF-BARI Score. These results suggest that both surgical options provide satisfactory long-term outcomes in terms of weight loss, improvement of comorbidities, and safety. However, only one-third of patients achieved BMI < 35 kg/m² at long term follow up, underscoring the eventual need for more aggressive strategies. Additionally, younger patients appear to attain higher SF-BARI scores, particularly with respect to improvements in comorbidities.

SF-BARI score is a comprehensive and intuitive web-based tool that may contribute for the standardization of reporting outcomes after MBS.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Ethics Approval:

This study was approved by the Health Ethics Committee of our hospital (deliberation no. 416/2023).

Informed consent:

Informed consent does not apply.

Conflict of Interest:

All authors declare no competing interests.

Data Availability

All the data supporting the findings of this study are available from the authors upon reasonable request.

Author Contribution

A.C.P., J.P.A.T. and S.R. contributed to the acquisition, analysis, and interpretation of the patient data and in writing the manuscript. H.S.S., F.R., J.P. and E.L.C. drafted the work and substantively revised it. All authors read and approved the final manuscript.

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Graphic 1 is available in the Supplementary Files section.

No competing interests reported.

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Graphic 1 - Categories of SF-BARI Score according to surgery performed, at last follow-up.

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Reviewers agreed at journal
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Reviewers agreed at journal
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SF-BARI Score for assessment of long-term results in patients with BMI ≥ 50 Kg/m2 submitted to Roux-en-Y Gastric Bypass or Sleeve Gastrectomy

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Abstract

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Introduction

Materials and Methods

Study Population

Pre-operative protocol

Surgical treatment

Follow-up

Clinical Data Evaluated

Statistical Analysis

Results

Discussion

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Supplementary Files

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Version 1