Three-Year Metabolic and Hormonal Outcomes Following Bariatric Surgery in Iraqi Patients: A Prospective Cohort Analysis Stratified by NAFLD Grade and Metabolic Syndrome

Abstract

Background: Obesity-related metabolic disorders have become alarming in Iraq, but there is limited information on the long-term surgical outcomes in this population. Bariatric surgery especially Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) is the most long-lasting therapeutic choice in the treatment of morbid obesity and metabolic sequalae's. Purpose: To compare and contrast 3-year clinical and hormonal outcomes in RYGB and SG in Iraqi patients with a special focus on the predictive value of serial metabolic biomarkers and the moderating impact of baseline non-alcoholic fatty liver disease (NAFLD) severity and metabolic syndrome (MetS) status. Methods: A two-hospital tertiary referral prospective cohort study was carried out in Wasit, Iraq, where 240 patients (RYGB: n=120; SG: n=120) were recruited between January 2020 and December 2023. The main outcomes were percent excess weight loss (percent EWL), remission of type 2 diabetes mellitus (HbA1c <6.5% with no medication) and improvement of NAFLD (cap score reduction of at least 30% with FibroScan). At baseline, 12 months and 36 months, serial measurements of leptin, adiponectin, total ghrelin, active GLP-1, HOMA-IR, and QUICKI were measured. Results: At 36 months, RYGB produced significantly greater %EWL (77.1% ± 12.8 vs. 68.3% ± 14.5; p=0.004), T2DM remission (81.2% vs. 67.5%; p=0.025), and NAFLD improvement (85.0% vs. 71.7%; p=0.015) compared with SG. RYGB also yielded more pronounced hormonal remodeling, including greater adiponectin elevation (+5.5 vs. +3.4 µg/mL; p=0.003), leptin reduction (-34.5 vs. -27.6 ng/mL; p=0.005), and active GLP-1 augmentation (+17.8 vs. +9.1 pmol/L; p<0.001). An adiponectin/HOMA-IR greater than 0.75 composite index was predictive of T2DM remission following RYGB with 90% accuracy (AUC=0.86). There were no significant differences in major complication rates in between groups (8.3 vs. 5.8; p=0.45). Conclusion: RYGB has better metabolic and hormonal effects compared to SG in three years of follow-up of patients in Iraq. The adiponectin/ HOMA-IR composite index is a pragmatic, resource-efficient preoperative method to surgery triage and prognosis.