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Quality of Life and Bariatric Surgery
correlation with results of SF but less correlation with BAROS, EWL, and other
questionnaires [26]. The verified version of BQL was also validated by a study on
466 patients [27].
405
4 The Food Tolerance Score (FT Q)/Quality
of Alimentation Questionnaire
This questionnaire of 27 points was developed to assess food tolerance after bariatric surgery through assessing 4 components including: tolerance of different
food types, timing and content of meals, frequency of vomiting/regurgitation, and
patient satisfaction with alimentation. It is easy to use and useful when comparing
food tolerance before and after surgery and between different procedures [18].
Quality of Life After Sleeve Gastrectomy
Several studies of different follow-up intervals have assessed the effect of sleeve
gastrectomy on QOL and compared it to other procedures.
1. Short-Term Effect (1–3 years)
Kirkir et al. conducted a study on 562 patients undergoing SG with a mean follow up time of 7 months and showed the mean scores for QOL to be significantly
increased after SG (p < 0.05 to < 0.001), with 19.6% of the study sample to be classified as excellent, 25.6% as very good, 34.9% as good, 15.3% as fair, and 4.6%
as failure results on the updated BAROS scoring system. They concluded that SG
is a very effective bariatric intervention for weight control and improvement in
comorbidities and QOL in short- and mid-term [28]. Peterli et al. also conducted
a prospective study to measure QOL of patients undergoing SG and RYGB using
the BQL and other scores and showed QOL to improve significantly when comparing pre- and post-operative results at 1 and 2 years but results were poorer at
3 years. They reported a tendency of SG patients’ QOL to improve shortly after
the surgery but continue to deteriorate overtime; however, they concluded that
both surgery types are equally effective in terms of weight loss, quality of life, and
complication rate [29]. In addition, Fezzi et al. used the SF36 questionnaire for 78
consecutive patients undergoing SG. The patients completed the questionnaire preoperatively and one year post-operatively. All areas of the questionnaire regarding
patients’ QOL showed significant improvement, and they concluded that SG is an
effective procedure with measurable improvement in HRQOL as well as weight
reduction [30]. Even more, Nadalini et al. [20] examined 110 patients using the
SF36 questionnaire to assess the effects of 3 different surgeries; GB, RYGB, and
SG. Patients completed the questionnaire pre-operatively and at mean of 3 years’
post-operatively. All categories of the questionnaire showed significant improvement, except general and mental health, and satisfaction was greater in patients
with higher EWL and in those who underwent RYGB or SG as compared to GB,
with a significant relation to weight loss after each surgery. The authors also examined the possibility of different domains of the questionnaire being able to predict
406
R. El-Abd and S. Al-Sabah
weight loss and found physical functioning domain to be a significant predictor of the weight lost after surgery independent of age, sex and type of surgery
(p = 0.01).
2. Medium-Term Effect (4–5 years)
AlKhalifa et al. compared SG to GB in 48 patients and showed the former surgery
to result in better food tolerance (P < 0.001) and better eating behaviors (P = 0.001)
when compared with gastric banding after 1–4 years of follow-up. They also
reported that SG patients showed significant improvement in all parameters of
HRQOL except for mental health status [21]. Also, Flølo et al. [31] studied the
effect of SG using SF36 on 168 patients and reported their outcomes at 5 years
post-operatively, which showed patients to score better on mental and physical
components of the questionnaire than the non-surgical cohort but not the general
population. Strain et al., in addition, conducted a study on 77 patients undergoing
SG by using the SF36 at 1, 3, and 5 years post-operatively and found QOL to initially improve but then deteriorate in most domains overtime which was associated
with weight regain [32].
3. Long-Term Effect (6–10 years)
D’Hondt et al. [33] used the BAROS and SF36 questionnaires to investigate the
effect of SG on quality of life of 83 patients up to 6 years post-operatively. They
concluded that SG results in good to excellent improvement in HRQOL. The
authors divided patients into 2 groups according to %EWL (<50 or >50) and found
QOL to improve dramatically with significant differences in 2 domains: physical
functioning and general health. According to the BAROS score, authors reported
that 75 (90.4%) of their study participants scored a ‘‘good’’ to ‘‘excellent’’
score. They also reported that different groups of patients may experience different changes in their QOL depending on factors like the development of reflux
or weight regain. They concluded that SG procedure results in good to excellent
improvement in HRQL. Furthermore, Felsenrich et. al conducted a study to assess
QOL of patients 10 years after SG through BQL and SF 36 questionnaires and
found that symptomatic reflux, but not %EWL, impairs patients’ long-term QOL
after SG. BQL showed significant differences between patients with and without
any symptoms of reflux but failed to detect a statistically significant difference
between those with >50% or <50% %EWL. The results with SF36 also showed
reflux to be a determinant of lower QOL but this score also found %EWL >50 to
correlate with better QOL scores in 3 categories; these were less body pain (p =
0.02), better emotional role (p = 0.04), and better mental health (p = 0.04) [34].
Conclusion
In conclusion, sleeve gastrectomy as a bariatric surgery is associated with significant improvement in HRQL that is most prominent in the first months after surgery and can be maintained in the long term and up to 10 years, which is largely
dependent on maintained weight loss and absence of gastroesophageal reflux
disease.
Quality of Life and Bariatric Surgery
407
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R. El-Abd and S. Al-Sabah
LSG: Risks and Considerations
Risks Associated with Sleeve Gastrectomy
Aparna Govil Bhasker and Kamal Mahawar
Approximately 46% of all bariatric operations performed worldwide consist of
Sleeve Gastrectomy (SG). Thus, making it the most commonly performed bariatric
operation worldwide [1]. Technical ease, simplicity, no alteration of gastrointestinal continuity, and relative safety are some of the reasons behind its immense
popularity. SG also has a lower learning curve as compared to gastric bypass
procedures which are technically more challenging. In a review, the outcomes of
sleeve gastrectomy were compared with other bariatric operations and the complication rate in the SG group was much lower than the gastric bypass group [2].
However, though less frequent, the complications after SG, especially leaks, can
be devastating and very difficult to treat. It is, therefore, important that surgeons
undergo appropriate training and mentoring before they start performing this procedure. Careful attention to a number of preoperative, intra-operative, and postoperative considerations is the only way to deliver safety. Newer surgeons should
recognise that bariatric surgery poses a number of unique challenges that go
beyond the general, technical expertise of the surgeon. Even surgeons well versed
with other complex gastrointestinal procedures need to be involved with at least
50–100 bariatric procedures before independent practice. Best outcomes are delivered by surgeons who are appropriately trained and mentored and have a reasonable volume that allow for the maintenance of skills. Surgeons should consider
teaming up with other surgeons if the volumes are low in their practice.
A. G. Bhasker (*)
Bariatric and Laparoscopic Surgeon, Gleneagles Global Hospital, Parel, Mumbai, India
e-mail: draparnagovil@gmail.com
K. Mahawar
Consultant General & Bariatric Surgeon, Sunderland Royal Hospital, Sunderland, UK
e-mail: kmahawar@gmail.com
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer
Nature Switzerland AG 2021
S. Al-Sabah et al. (eds.), Laparoscopic Sleeve Gastrectomy,
https://doi.org/10.1007/978-3-030-57373-7_40
411
A. G. Bhasker and K. Mahawar412
The early complication rate after sleeve gastrectomy varies from 5.4 to 7.3%.
The overall rate of severe complications after sleeve gastrectomy is approximately 1.2 to 2.2% and the 30 days readmission rate is reported as 2.8% [3–6].
Complications after sleeve gastrectomy can be classified as:
• Intra-operative complications—Anaesthesia related complications, Injury to
internal organs, Haemorrhage
• Early complications (≤30 day)—Haemorrhage, Staple line leaks, Deep Vein
Thrombosis and Pulmonary Embolism, Porto-mesenteric venous thrombosis,
Trocar site herniation
• Late complications (>30 day)—Abscesses, Late leaks, Strictures, Twists and
kinks, Gastro-esophageal reflux disease, Cholelithiasis, Iron and vitamin B 12
deficiency, Secondary hyperparathyroidism, Neuropathy.
Like any other surgery, complications after sleeve gastrectomy may be graded
as per the Clavien Dindo classification and surgeons are encouraged to use them
whilst reporting (Table 1).
It is crucial to not only pay attention to technical details but also diagnose and
manage complications promptly to further improve the safety of this procedure.
Currently, there is enormous variation amongst bariatric surgeons concerning various aspects of this procedure [8]. Future studies and consensus building exercises
Table 1 Clavien Dindo classification of surgical complications [7]
Grade
Grade I Any deviation from the normal postoperative course without the need for pharma-
Grade II Requiring pharmacological treatment with drugs other than such allowed for
Grade III
Grade IIIa
Grade IIIb
Grade IV
Grade IVa
Graade IVb
Grade V Death of a patient
Suffix “d” If the patient suffers from a complication at the time of discharge, the suffix “d”
*
Brain hemorrhage, ischemic stroke, subarrachnoidal bleeding, but excluding transient ischemic
attacks. CNS, central nervous system; IC, intermediate care; ICU, intensive care unit
Definition
cological treatment or surgical, endoscopic, and radiological interventions
Allowed therapeutic regimens are: drugs as antiemetics, antipyretics, analgetics,
diureties, electrolytes, and physiotherapy. This grade also includes wound infections opened at the bedside
grade I complications Blood transfusions and total parenteral nutrition are also
included
Requiring surgical, endoscopy or radiological intervention
Intervention not under general anesthesia
Intervention under general anesthesia
Life-threatening complication (including CNS complications)* requiring IC/ICU
management
Single organ dysfunction (including dialysis)
Multiorgan dysfunction
(for “disability”) is added to the respective grade of complication. This label
indicates the need for a follow up to fully evaluate the complication
Risks Associated with Sleeve Gastrectomy
413
will need to identify the best options from amongst a range of practices being used
worldwide.
Patients suffering from obesity pose a greater challenge when it comes to diagnosing severe early surgical complications. They may not present in the manner
other general surgery patients do. Hence the onus is on the bariatric professionals
to be extra-vigilant and pick up the subtle signs that may be the only indication of
an impending catastrophe.
In general, unexplained tachycardia, tachypnoea, fever, pain, nausea, vomiting
and not feeling well should prompt further evaluation. In particular, a heart rate of
over 100 should alert the surgeon and a heart rate of > 120 should prompt further
investigation or even a diagnostic laparoscopy as appropriate. A full blood count,
CRP, urine routine, pro-calcitonin, X-ray studies of chest and abdomen, CT scan and
other tests as appropriate may be performed as indicated clinically. In general, bariatric surgeons advise early laparoscopy in cases of persistent doubt and uncertainty.
Best outcomes are achieved when the complications are detected and treated
early. Early action also helps to reduce the morbidity and mortality. Ensuing chapters in this section discuss the management of some of the commonest and most
dreaded complications of this procedure in detail.
References
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graphic description and One-Year Outcomes from the Fourth IFSO global registry report
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Surg. 2020 Feb; 30(2):483–92.
Outcomes and Complications After Sleeve Gastrectomy
Shujhat Khan and Hutan Ashrafian
1 Introduction
The SG does not involve intestinal bypass and is simply a restrictive procedure.
The evolution from an open duodenal switch procedure to the laparoscopic sleeve
gastrectomy that is now routinely performed was initially reserved for high risk,
super-morbidly obese patients as a staged procedure. It was then subsequently
adapted as a single-staged operation in those with a lower BMI. However, the beneficial effects of SG go beyond that of simply reducing obesity, and has positive
effects on diabetes, dyslipidaemia, and hypertension.
2 Impact on Obesity
Studies have shown that SG can produce outcomes that are equivalent to or better than Roux-en-Y gastric bypass in alleviating obesity-related comorbidities [2].
Patients report an improvement in hypertension, type 2 diabetes, increased HDL
levels, and reduction in uraemia levels, that were present even after 10 years [3].
Whilst these changes vary amongst the population, it appears that it typically
occurs within 17 months [4–6]. However, after approximately 2–3 years, patients
start to regain weight following the bariatric operation, although the amount
of overall mass that patients lose varies within the literature, with some studies
S. Khan
Milton Keynes University Hospital, London, UK
e-mail: shujhat.khan15@imperial.ac.uk
H. Ashrafian (*)
Institute of Global Health Innovation at Imperial College London, London, UK
e-mail: h.ashrafian@imperial.ac.uk
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer
Nature Switzerland AG 2021
S. Al-Sabah et al. (eds.), Laparoscopic Sleeve Gastrectomy,
https://doi.org/10.1007/978-3-030-57373-7_41
415
S. Khan and H. Ashrafian416
Table 1 Meta-analysis demonstrating changes in weight (pooled mean (95% confidence
interval)).
Time after surgery Change in BMI
6 months −11.49 (−8.81 to −14.18) −50.40 (−26.29 to −74.50)
12 months −13.05 (−9.68 to −16.42) −61.12 (−20.26 to −101.98)
24 months – −71.00 (−57.00 to −85.00)
36 months −13.00 (−11.00 to −15.00) −75.90 (−67.62 to −84.18)
Adapted from Pedroso et al. [1]. BMI = body mass index; EWL = excess weight loss
Change in EWL
Fig. 1 Meta-analysis results assessing weight loss following bariatric operations. (GB = gas-
tric bypass; AGB = adjustable gastric banding; SG = laparoscopic sleeve gastrectomy). Adapted
from Chang et al. [16]
suggesting there is an estimated weight loss of 46% whilst others suggest estimated weight loss as high as 86% (Table 1, Fig. 1) [7–16].
3 Impact on Diabetes
Bariatric surgery is highly effective at improving outcomes in diabetic patients
and has demonstrated superior results to medication alone [17]. Additionally, surgery can significantly improve microvascular and macrovascular effects which
are often responsible for the complications of diabetes [18–20]. Approximately
56–59% of patients experience type 2 diabetes mellitus remission after a year
following a SG operation, and the beneficial effects of the operation on diabetes continue long after a year, with 84–86% of patients noting remission after a
5-year period. However, it does appear that many patients will also relapse. The
HBA1c level reduces significantly in the several months following a SG but starts
to steadily increase again (Fig. 2) [21]. There is however conflicting evidence