Quality of life after laparoscopic sleeve gastrectomy: Pre-operative, 1-year and 5-year results

Abstract

Introduction:

The negative impact of obesity on the quality of life (QoL) and its association with multiple comorbidities is unquestionable. The primary objective of this study was to compare the QoL of patients before, 1 year and 5 years after laparoscopic sleeve gastrectomy (LSG). Secondary objectives were to evaluate the resolution of obesity-related comorbidities and weight loss success.

Materials and Methods:

We included patients who underwent LSG for body mass index (BMI) ≥30 kg/m² between August 2016 and April 2017 and completed the Moorehead-Ardelt QoL Questionnaire II (MA II). Statistical analysis was conducted using SPSS IBM Statistics for Windows version 21.

Results:

In total, 64 patients participated with a female majority (73.44%) and a mean age of 36.09 with an average BMI at 40.47. Percentage of excess BMI loss and excess weight loss (% EWL) at one and 5 years after surgery went from 90.18% to 85.05% and 72.17% to 67.09%, respectively. The total MA II score before LSG was − 0.39 ± 0.94. Postoperatively, it increased to 1.73 ± 0.60 at 1 year and 1.95 ± 0.67 at 5 years. The positive impact of LSG on QoL was more significant in patients presenting ≥30% of weight loss and in females. At 5 years, a significant improvement in many comorbidities was noted except for arterial hypertension, coxalgia, gastro-oesophageal reflux disease and lower extremities’ varices.

Conclusion:

LSG maintains a long-term QoL improvement, a significant EWL and a resolution of the most common obesity-associated comorbidities such as diabetes, dyslipidaemia and symptoms related to sleep apnoea.

INTRODUCTION

Sleeve gastrectomy has surged in the last decade and became the most commonly performed bariatric intervention in the world.[1] It was first described in 1991 as a component of bilio-pancreatic diversion,[2] and was performed as a component of bilio-pancreatic diversion with duodenal switch in 2000.[3] Many advantages contributed in the flourishment of this bariatric intervention since it can be generally completed laparoscopically, even in the case of extreme obesity. It does not involve any digestive anastomosis, which implies a shorter duration of the surgery, and it does not create any mesenteric defect which eliminates any risk of internal hernia.[4] There’s no bypass or discontinuity of the digestive tract which allows it to remain accessible to endoscopic procedures. Dumping syndrome is a rare phenomenon in sleeve gastrectomy,[5] the risk of peptic ulcer is low and there’s a lesser risk of nutritional deficiencies.[6] The efficacy of sleeve gastrectomy is mainly due to its restrictive effect by reducing the gastric volume, but also by decreased ghrelin secretion, the orexigenic hormone mainly synthesised in the fundus.[7] The Moorehead-Ardelt quality of life (QoL) Questionnaire II (MA II) or the 36-Item Short Form Survey, validated in 2003, is an instrument to assess self-perceived QoL pre- and post-intervention in the obese population.[8] Many studies concluded an improvement in the QoL after bariatric surgery,[9-11] while others declared an absence of improvement or a decline.[12] A study conducted in Lebanon in 2016 showed that the prevalence of overweight in the population is 53.5%, and the prevalence of obesity is 18.16%.[13] With the rise of bariatric procedures performed in Lebanon, this prospective study’s primary objective was to compare the QoL of patients before, 1 year and 5 years after laparoscopic sleeve gastrectomy (LSG), using the MA II as an instrument of measurement of the QoL. The secondary objectives were to assess the resolution of comorbidities associated with obesity and analyse weight loss success 1 year and 5 years after LSG.

MATERIALS AND METHODS

Study design

This is a prospective study in obese subjects with a body mass index (BMI) superior or equal to 30 kg/m², who underwent LSG between August 2016 and April 2017 at our institution. Included subjects either had a BMI superior or equal to 35 kg/m² or a BMI superior or equal to 30 kg/m² with presence of comorbidities.[14,15] Aged between 18 and 65 years, with no history of previous bariatric or gastric surgery.

In total, 106 patients completed the initial pre-operative questionnaire. At the 1 year post-sleeve gastrectomy evaluation, 31 patients were lost to follow-up and a total of 75 patients were included in a published study by our department evaluating the QoL after 1 year.[16] After 5 years, 11 patients were lost to follow-up, and a total of 64 patients were included in this study.

The study was approved by the Ethics Committee of our institution. An informed consent was signed by all participants after explaining the goal and procedure of the study.

Data collection

The study was divided into three stages: perioperative, 1 year and 5 years postoperatively. Before surgery, personal data was collected such as age, occupation, social status, associated comorbidities, medical and surgical history. Moreover, complete clinical examination, a weight and height evaluation, BMI calculation and a pre-operative QoL questionnaire were performed. The next stage occurred after a LSG was performed at 1 year and 5 years after the surgery date. Participants were contacted by telephone or by E-mail, and the same data collected before the surgery was gathered at 1 year and 5 years after LSG, including the QoL questionnaire, the lowest weight reached since surgery and the current weight at the time of the follow-up.

Quality of life questionnaire

QoL was evaluated using the MA II.[8] This validated questionnaire measures the QoL in obese patients by tackling 6 main aspects of the QoL: self-esteem, physical activity, social life, work performance, pleasure during sexual activity and the food approach. Each component is scored from ‘−0.5’ to ‘+0.5’. For any ‘non-applicable’ answer, a score of ‘0’ was attributed. The calculated final score varies between ‘−3’ and ‘+3’. The final analysis is divided into intervals: the QoL is very poor when the final score is between ‘−3’ and ‘−2.1,’ poor when it is between ‘−2’ and ‘−1.1,’ fair when it is between ‘−1’ and ‘+1,’ good when it is between ‘+1.1’ and ‘+2,’ and very good when it is between ‘2.1’ and ‘+3’. The questionnaire was given to all participants and it was explained orally for patients presenting a difficulty comprehending it. The patients wrote their own answers. The 1 year and 5 years post-operative follow-up phases were conducted by telephone or E-mail. For subjects contacted by E-mail, a copy of the questionnaire was sent alongside the detailed instructions.

Statistical analysis

The data collected were analysed. To test if there was a significant difference between BMI, percentage of BMI loss, percentage of excess BMI loss (EBMIL) and percentage of excess weight loss (EWL) at 1-year follow-up and 5-year follow-up, paired sample t-test were carried out. Independent t-test were performed in order to examine if the quality-of-life questionnaire items and score differed significantly between age groups and gender at 1-year follow-up and 5-year follow-up. Pearson correlation was used to examine correlations between the percentage of BMI loss, percentage of EBMIL and percentage of EWL and the score of QoL at 1-year follow-up and 5-year follow-up. Statistical significance was determined using a two-sided alpha set at 0.05. Analyses were performed using IBM^® SPSS^® software SPSS Inc., IBM (International Business Machines Corporation), Chicago, Illinois, United States Statistics for Windows version 21.

%EWL (Percent of Excess Weight Loss) = ([pre-operative weight–current weight]/[pre-operative weight–ideal weight]) × 100

Lorentz formula[17] for ideal weight:

For men: w = (height [cm] − 100) − ([height − 150]/4)

For women: w = (height [cm] − 100) − ([height − 150]/2)

%EBMIL (Percent of Excess BMI Loss) = [(pre-operative BMI–current BMI)/(pre-operative BMI − 25)] × 100

Weight Regain: Patient can be classified into having ‘Weight Regain’ if increase in weight of >25% EWL from nadir (lowest weight since surgery).

Weight loss success catalogued using Reinhold’s criteria (modified by. Christou and Biron): An excellent result was considered %EBMIL >65%; good if 50%–65%; and failure (insufficient weight loss) if %EBMIL <50%.

RESULTS

The majority of the 64 participants (47) were females (73.44%). The mean age was 36.09 at the time of surgery with an average BMI at 40.47. The presence of a comorbidity was determined by the intake of regular medication.

Of the participants, 17 (26.56%) subjects presented arterial hypertension, 11 (17.19%) presented diabetes, and 18 (28.13%) presented dyslipidaemia. Symptoms related to sleep apnea (Apnée de sommeil) were present in 22 (34.38%) patients, defined by a symptomatology reported by the patient or by family members, such as snoring, daytime sleepiness, morning headache and the observation of AS by surrounding individuals. Polysomnography was not performed. 23 (35.94%) had clinical gastro-oesophageal reflux disease (GERD), and 10 (15.763%) had varicose veins in the lower extremities. 23 women (35.94%) in the study had an irregular menstrual cycle. 33 (51.56%) patients had chronic low back pain, 25 (39.06%) had chronic knee pain and 9 (14.06%) had chronic hip pain.

After 1 year, we had a significant improvement of all comorbidities (P < 0.05) except for smoking and lower extremities’ varices while the resolution of GERD was barely significant. After 5 years, we noted a significant improvement in many comorbidities compared to the pre-operative status such as diabetes, dyslipidaemia, symptoms related to sleep apnoea, irregularities in the menstrual cycle, chronic low back pain, chronic knee pain. A non-significant improvement was noted for arterial hypertension and coxalgia compared to the pre-operative data. However, after 5 years, we found a rise in the number of smokers, a rise in patients with GERD and a rise in patients presenting lower extremities’ varices compared to the pre-operative data [Table 1].

Table 1.

Comparison of the score of the various Moorehead-Ardelt Quality of Life Questionnaire II parameters 1 year and 5 years after surgery

	Score			Year 1 versus year 5 P
	Before surgery	After 1 year	After 5 years
Self esteem	−0.18±0.26	0.38±0.13	0.40±0.14	0.208
Physical activity	−0.28±0.23	0.30±0.20	0.29±0.20	0.408
Social	0.09±0.30	0.39±0.12	0.42±0.11	0.008
Work	0.12±0.28	0.33±0.14	0.36±0.15	0.046
Sexual pleasure	−0.01±0.22	0.23±0.19	0.28±0.20	0.001
Food approach	−0.13±0.29	0.10±0.23	0.20±0.24	0.001
Total score	−0.39±0.94	1.73±0.60	1.95±0.67	0.001

Significant differences in results between 1 and 5 years after surgery are marked in bold

According to the responses of patients to the MA II questionnaire, the total pre-operative QoL score was − 0.39 ± 0.94. Only one patient had a very poor QoL, 17 patients had a poor QoL, 43 had a fair QoL, 3 had a good QoL and no participant had a very good QoL [Figure 1].

Figure 1.

Analysis of changes in the quality of life before and after surgery according to MA II

Following the surgery, the percentage of BMI loss (% BMI) went from an average of 33.11% at 1 year to 31.23% at 5 years (P = 0.028). The excess BMI loss percentage (%EBMIL) went from an average of 90.18% at 1 year to 85.05% at 5 years (P = 0.028). The EWL went from an average of 72.17% at 1 year to 67.09% at 5 years (P = 0.012) [Table 2].

Table 2.

Comparison of body mass index, % body mass index, % excess body mass index loss, % excess weight loss at 1 and 5 years after laparoscopic sleeve gastrectomy

	Average at 1 year	Average at 5 years
BMI	27.05	27.8
BMI (%)	33.11	31.23
EBMIL (%)	90.18	85.05
EWL (%)	72.17	67.09

BMI: Body mass index, EBMIL: Excess BMI loss, EWL: Excess weight loss

As for the quality-of-life assessment, an improvement in all 6 parameters listed in the Moorehead-Ardelt Questionnaire II (MA II) was noticed 1 year after LSG compared to the pre-surgery evaluation. Five years after surgery, a significant improvement was seen in social life (P = 0.0082), work performance (P = 0.047), pleasure obtained during the sexual relation (P = 0.0017) and the food approach (P = 0.0008) compared to the results at 1 year post-surgery. No significant change was noticed on the self-esteem and physical activity level between 1 year and 5 years post-sleeve gastrectomy (P > 0.05) [Table 3]. A significant amelioration in the total MA II score was present between 1 year and 5 years after surgery [Figure 1 and Table 3].

Table 3.

Comparison of comorbidities among patients before and after sleeve gastrectomy

	Before surgery, n (%)	After 1 year		After 5 years
		n (%)	P	n (%)	P
Hypertension	17 (26.56)	7 (10.94)	0.024	11 (17.19)	0.200
Diabetes	11 (17.19)	2 (3.13)	0.008	1 (1.56)	0.002
Dyslipidaemia	18 (28.13)	6 (9.38)	0.007	4 (6.25)	0.001
Smoking	9 (14.06)	9 (14.06)	1.000	36 (56.25)	0.000
Sleep apnoea	22 (34.38)	1 (1.56)	0.000	8 (12.50)	0.003
GERD	23 (35.94)	13 (20.31)	0.049	27 (42.19)	0.469
Varices	10 (15.63)	6 (9.38)	0.285	18 (28.13)	0.087
Menstrual irregularities	23 (35.94)	8 (12.50)	0.002	7 (10.94)	0.001
Lumbago	33 (51.56)	11 (17.19)	0.000	16 (25.00)	0.002
Gonalgia	25 (39.06)	6 (9.38)	0.000	7 (10.94)	0.000
Coxalgia	9 (14.06)	2 (3.13)	0.027	5 (7.81)	0.257

GERD: Gastro-oesophageal reflux disease

We also evaluated the difference in improvement of each MA II parameter before and after LSG according to age groups (<30 vs. ≥30 years), gender (men vs. women) and percentage of weight loss (<30% vs. ≥30%) at 1 year and 5 years after LSG.

At 1 year, the amelioration in MA II parameters was independent of age, gender and percentage of weight loss, with no statistical difference observed for each of the six parameters (P > 0.05). However, the total MA II QoL score at 1 year showed significant improvement for patients ≥30 Years compared to those <30 years (P < 0.001), females compared to males (P = 0.005) and a ≥ 30% of weight loss compared to <30% weight loss (P < 0.001).

At 5 years, a significant amelioration in self-esteem was noticed for patients with ≥30% of weight loss compared to those with <30% weight loss (P = 0.045). No other statistical difference was observed for the 6 parameters depending on age, gender or percentage of weight loss. The total MA II QoL score at 5 years showed significant improvement for females compared to males (P = 0.013) and patients with ≥30% of weight loss compared to <30% weight loss (P < 0.001).

Patients were classified into having ‘Weight Regain’ if there was an increase in weight of >25% EWL from nadir.[18-20] After 1 year, 22 (34.38%) patients had significant weight regain, which dropped to 16 (25%) patients 5 years after surgery.

Weight loss success was evaluated according to Reinhold’s modified criteria. An excellent result was considered %EBMIL >65%; good if 50%–65%; and failure (insufficient weight loss) if %EBMIL <50%.

Results are shown in Figure 2.

Figure 2.

Analysis of weight loss success one and 5 years after surgery

We found a significant correlation between %EBMIL and the MA II QoL score at 1 year (P = 0.033, Spearman’s correlation coefficient = 0.267) and at 5 years (P < 0.001, Spearman’s correlation coefficient = 0.445) after LSG. We also found a significant correlation between %EWL and the MA II QoL score at 1 year (P = 0.01, Spearman’s correlation coefficient = 0.319) and at 5 years (P = 0.001, Spearman’s correlation coefficient = 0.397) after LSG. No significant correlation was found between the BMI number and the MA II QoL score at 1 year (P = 0.052), but a significant correlation was present at 5 years after LSG (P < 0.001, Spearman’s correlation coefficient = −0.451). As for the percentage of BMI lost, there’s a significant correlation with the MA II QoL score at 1 year (P = 0.001, Spearman’s correlation coefficient = 0.391) and at 5 years (P = 0.006, Spearman’s correlation coefficient = 0.338) after sleeve gastrectomy.

DISCUSSION

This study presents the 1-year and 5-year follow-up of our LSG cohort, applying the translated and validated MA II questionnaire. Previous studies[21-25] used the MA II questionnaire to assess the QOL in patients who underwent bariatric interventions. Some studies compared the long-term QoL amelioration between LSG and Roux-en-Y gastric bypass (RYGB). Fiorani et al.[26] found a better QoL improvement by the RYGB at 8 years after surgery, while et al.[25] found no significant QoL amelioration while comparing between LSG and RYGB at 7 years after surgery. A systematic review and meta-analysis by Wu et al.[27] found no significant difference in the QoL improvement while comparing LSG and RYGB. After assessing the MA II QoL mean score after LSG at 1-year and 5-year after surgery, Ignat et al.[23] (55 patients) found a mean of 1.7 and 1.2 at 1 and 5 years respectively; Charalampakis et al.[24] (95 patients) found a mean of 2.08 and 1.67 respectively; Grönroos et al.[25] (98 patients) found a mean of 1.2 and 0.85, respectively. These studies[23-25] showed a decrease of the QoL score between 1 and 5 years, while our study showed an amelioration from a mean total score of 1.73 at 1 year to a mean of 1.95 at 5 years after LSG, using the MA II questionnaire. At 5 years after LSG, we found a statistically significant increase in the overall QoL score and four out of the six assessed values except for self-esteem and physical activity, compared to the 1-year juncture, noting that the work productivity improvement was barely significant (P = 0.047). This shows a durable amelioration following LSG, knowing that 25% of our study population presented weight regain at 5 years. The physical activity status and the barely significant work productivity amelioration may be attributed to the sedentary lifestyle which was noted by many patients due the last 1 year and a half of COVID19 pandemic. The short-and long-term positive impact of LSG on QoL is statistically significant, principally in those having ≥30% of weight loss and in females which was similar to the study conducted by Charalampakis et al.[24]

Evidence about the long-term results of LSG in the management of morbid obesity is still limited. A review by Diamantis et al.[28] of a 5 years follow-up after LSG found a mean EWL of 62.3% which was almost uniform with the 5 years EWL% of 62.9% by Seyit and Alis[29] Weiner et al.[30] showed a relatively low EWL of 40% at 5 years post-surgery, without using a bougie, which may create a proportionally larger sleeve. Himpens et al.[31] had an EWL of 46.3% at 5 years. Bohdjalian et al.[32] found an EWL% of 60.8% 5 years post-LSG after reviewing 21 patients. Bakr et al.[33] had a 5 year EWL% of 63.2%. Rawlins et al.[34] reached an EWL% of 89% after 5 years while using a 26.4 Fr caliber bougie and starting the gastric section at 3 cm from the pylorus. In our centre, we used 36Fr and 40Fr bougies while beginning the section at 5 cm from the pylorus. We had an average %EWL of 67.09% at 5 years, which is slightly higher than the review data collected by Alexandrou et al.[35] regarding the long-term effect of LSG in the management of morbid obesity which implies that most of the early 60% to 65% EWL% will be tenable 5 years after surgery, and we proved that the enhancement in QoL was correlated with %EWL and %EBMIL. Some weight regains occurred, with 34.38% at 1 year and 25% at 5 years in our study but this does not refute the general quite rational success rate of the intervention with 81.25% weight loss success at 5 years after LSG.

While weight loss can be considered unsatisfactory by some patients, many of them did benefit in terms of comorbidities’ remission as seen in Table 1. However, we found no improvement for GERD in our study, as reported by Boyle et al.,[36] Chiu et al.[37] and El Moussaoui et al.[38] and most studies evaluating GERD after LSG,[39] except for very few studies who mentioned its improvement 5 years after LSG.[40,41] We also noted no improvement for varicose veins of the lower extremities which is compatible with the previous study done by our department[16] at 1 year. Also, no significant amelioration was seen for arterial hypertension contrastingly with El Moussaoui et al.[38] knowing that a systematic review done by Juodeikis and Brimas[39] showed that the mean amelioration or resolution of arterial hypertension after 5 years was 68%, and another systematic review by Graham et al.[42] showed a resolution in 62.17% of patients at 5.35 years of follow-up. In our study, we had a resolution in 35.2% of patients with arterial hypertension (6 out of 17 patients), which was statistically non-significant at 5 years after LSG.

We reported long term results according to a prospective method using the latest version of a validated obesity-specific questionnaire. The pre-operative evaluation and standardised follow-up were thoroughly carried on the same patients 1 year and 5 years after LSG at a single centre, by the same surgical team, which minimises any bias effect that could be caused by different operative technique or centre variance. However, this study has some limitations. Polysomnography was not available at the time of the study. Therefore, we based our evaluation on the symptoms related to sleep apnoea without being able to establish a full diagnosis. The sample size (64) is relatively small at 5 years postoperatively, after losing contact with 42 patients who either changed their contact number or changed addresses or simply would not answer. This number might be insufficient for a good discernment, although there are many published articles in literature implying that the number of included patients might be statistically adequate to deduce interpretations.[11,22,26,43]

CONCLUSION

This study shows the LSG as an effective primary intervention in the treatment of obesity as it was shown in the long-term QoL improvement according to the MA II questionnaire, especially in the female population. Significant EWL and BMI reduction were sustained 1 year and 5 years postoperatively and correlated with the MA II QoL score amelioration. Improvement of the most common comorbidities such as diabetes, dyslipidaemia and sleep apnoea were significant, but the impact of LSG on GERD, arterial hypertension and varicose veins of the lower extremities was limited 5 years postoperatively.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.