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A Cohort Study on the Outcomes of Laparoscopic Roux-en-Y Gastric Bypass and Laparoscopic Sleeve Gastrectomy Regarding the Change in Body Mass Index, Remission of Comorbidities and Quality of Life After 12-Month Follow-up

  • Daniela M. SuethEmail author
  • Augusto C. A. Tinoco
  • Wendel M. Pompilho
  • Jaylla F. F. O. Raeli
  • Gersana T. R. Zambrotti
  • Carlos M. Antunes
Surgery
  • 174 Downloads
Part of the following topical collections:
  1. Topical Collection on Surgery

Abstract

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is recognized as the gold-standard procedure in bariatric surgery, although laparoscopic sleeve gastrectomy (LSG) is becoming accepted as an appropriate technique in its own right. The purpose of our study was to compare the effectiveness of these two techniques with respect to weight reduction, remission of obesity-associated comorbidities and enhancement of quality of life after 12-month follow-up in a Brazilian setting. Our prospective observational cohort study involved 110 patients undergoing LRYGB and LSG at a hospital in south-east Brazil during the period August 2016–March 2017. Patients were assessed prior to and 12 months after intervention with respect to body mass index (BMI), the presence of comorbidities, and quality of life as determined by Short Form 36 Health Survey and World Health Organization Quality of Life questionnaires. No significant differences were detected between LRYGB and LSG regarding reduction in BMI. Both procedures engendered positive impacts on the quality of life that were essentially similar, although the level of improvement was not necessarily associated with the degree of weight loss. Patients who had undergone LRGYB experienced a higher resolution of comorbidities, especially type 2 diabetes, than those who had received LSG. LSG is effective in achieving weight loss, resolving comorbidities and improving the quality of life, reinforcing the current tendency for its use as a stand-alone procedure in the surgical treatment of obesity.

Keywords

LRYGB LSG Quality of life Obesity-associated comorbidities 

Introduction

The significant increase in prevalence of obesity that has been documented over the last decades is not restricted to developed countries but is a phenomenon that affects developing countries as well. According to the Brazilian Ministry of Health [1], the prevalence of obesity in Brazil has increased from 11.8% in 2006 to 18.9% in 2016. The mounting incidence of the disease is a matter of considerable concern because it engenders increases in morbidity and mortality among the economically active segment of the population [2, 3].

Obesity can lead to type 2 diabetes (DM2), obstructive sleep apnea syndrome (OSAS), systemic arterial hypertension (SAH), dyslipidemia (DLP), early arthritis, menstrual irregularities, infertility, and other severe comorbidities [4]. In addition, obese individuals are at increased risk of psychological and eating disorders, the effects of which are more pronounced in those who do not follow some treatment. All of these problems affect the quality of life both physically and psychologically [5].

Bariatric surgery is the only effective method for the reduction and long-term maintenance of body mass index (BMI) along with remission of comorbidities and improvement in quality of life. The success and effectiveness of bariatric surgery are defined by the attainment of a BMI < 35 kg/m2 or a 50% total weight loss (%TWL) after surgery, and this implies a significant reduction in comorbidities and a better quality of life [6, 7]. Various techniques may be employed in bariatric surgery including restrictive, disabsorptive, and mixed approaches, each of which offers advantages and disadvantages [8]. Currently, laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are the most common interventions. The LRYGM procedure is recognized as the gold-standard method while LSG was, until recently, employed as a bridge for other surgeries in super-obese patients. However, LSG is now accepted as an appropriate technique in its own right by virtue of the satisfactory outcomes achieved in respect of %TWL and resolution of comorbidities [9, 10].

In view of the above, we aimed to evaluate the effects of LRYGB and LSG on change in BMI, remission of obesity-associated comorbidities and enhancement of quality of life after 12-month follow-up in a Brazilian setting.

Methods

The prospective observational cohort study involved 110 patients undergoing LRYGB and LSG at the Center for Surgical Treatment of Obesity and Diabetes of the Hospital São José do Avaí (Itaperuna, RJ, Brazil) during the period August 2016–March 2017. However, 15 of the selected patients were subsequently excluded owing to the impossibility of follow-up, hence the study cohort included 95 patients, 48 of whom had been submitted to LRYGB and 47 to LSG. Values of BMI were determined and the presence of comorbidities and the level of quality of life assessed for each patient prior to surgery and 12 months after the procedure. Patients were classified according to their preoperative BMI value into ≤ 40.0, 40.1–45.0, ≥ 45.1 kg/m2 groups. Indication of the surgical procedure to be used in each case did not take into account preoperative BMI or the severity of the condition of the patient, except that individuals with gastroesophageal reflux disease (GERD) were always allocated to the LRYGB group since it is known that LSG worsens GERD.

Quality of life was assessed using internationally validated instruments, namely the Medical Outcomes Study Questionnaire Short Form 36 Health Survey (SF-36) and World Health Organization Quality of Life (WHOQOL-BREF) questionnaires. In the SF-36 questionnaire, the indicators of quality of life relating to satisfaction with own health and health change perception were scored from 1 (best) to 5 (worse), while physical functioning, physical role functioning, bodily pain, general health perceptions, vitality, social role functioning, emotional role functioning and mental health were rated from 0 (worst) to 100 (best). In the WOQUOL-BREF questionnaire, the perception of quality of life and satisfaction with own health were graded from 1 (very poor) to 5 (very good), while physical and psychological domains, social relations, and environment were classified 1–2.9 (require improvement), 3.0–3.9 (regular), 4–4.9 (good), and 5 (very good).

Comparisons between variables were performed as follows: sex and comorbidities (Fisher exact test), and age and scores from questionnaires (Mann-Whitney test). Spearman’s correlation coefficients (rs) were calculated to determine the association between numerical variables. Analyses were performed using SPSS 20.0, Sigma Plot, Bioestat or Prisma software with statistical significance set to 5%.

Results

The mean age of the cohort was 37.53 (range 18–68) years while the mean BMI was 42.49 (range 35–55.6) kg/m2. Predominant among the study population were white individuals (85%) and females (63%), while 54% of participants were married at the time of surgery. The distribution of obesity-associated comorbidities among the study population separated according to the type of surgical intervention (LRYGB or LSG) shows that SAH, DLP, and arthralgia were the most frequent conditions (Table 1). The comorbidities were resolved satisfactorily and there were no significant differences (p < 0.05) between the two groups regarding the frequency of remission (Table 1).
Table 1

Distribution of patients according to existing comorbidities prior to surgery and resolved comorbidities after intervention

Comorbidity

LRYGB group (N = 48)

n (%)

LSG group (N = 47)

n (%)

p value between groups*

Existing illnesses before surgery

 SAH

22 (45.8)

15 (31.9)

0.2081

 DM2

13 (27.1)

3 (6.4)

0.0119

 DLP

18 (37.5)

9 (19.1)

0.0683

 Arthralgia

18 (37.5)

6 (12.8)

0.0087

 OSAS

6 (12.5)

5 (10.6)

0.5151

Resolved illnesses after surgery

 SAH

18 (81.8)

12 (80.0)

0.9994

 DM2

11 (84.6)

2 (66.7)

0.4878

 DLP

16 (88.9)

7 (77.8)

0.5815

 Arthralgia

15 (83.3)

3 (50.0)

0.2770

 OSAS

5 (83.3)

3 (60.0)

0.5455

Abbreviations: LRYGB laparoscopic Roux-en-Y gastric bypass, LSG laparoscopic sleeve gastrectomy, SAH systemic arterial hypertension, DM2 type 2 diabetes mellitus, DLP dyslipidemia, OSAS obstructive sleep apnea syndrome

*According to Fisher’s exact test (significance set at p < 0.05)

Post-operative BMI values were significantly lower (p = 0.0001) than the preoperative values in patients that had been submitted to LRYGB or LSG procedures. Thus, the mean BMI value of the LRYGB group was reduced from 43.0 (± 5.5) to 26.7 (± 3.4) kg/m2, while that of the LSG group was reduced from 41.9 (± 4.2) to 26.0 (± 2.8) kg/m2.

The WOQUOL-BREF questionnaire revealed that quality of life improved after surgery, irrespective of the type of procedure, as shown by the increased mean scores of the indicators in the post-operative period (Table 2). Similar increases in post-operative quality of life indicators were observed when patients were classified according to severity of obesity, implying that LRYGB and LSG procedures improved the quality of life of patients regardless of their original BMI (Table 3).
Table 2

Scores of quality of life obtained by application of the WOQUOL-BREF questionnaire to patients in the preoperative period and at 12 month follow-up

WOQUOL-BREF indicator

LRYGB group (n = 48)

LSG group (n = 47)

Preoperative

Follow-up

Preoperative

Follow-up

Perception of quality of life

3.3 ± 0.9

4.8 ± 0.4A

3.3 ± 0.9

4.7 ± 0.5A

Satisfaction with own health

2.5 ± 0.9

4.8 ± 0.4A

2.6 ± 1.2

4.7 ± 0.5A

Physical domain

3.1 ± 0.8

4.5 ± 0.4A

3.1 ± 0.7

4.5 ± 0.5A

Psychological domain

3.3 ± 0.7

4.4 ± 0.4

3.3 ± 0.6

4.5 ± 0.5

Social relations

3.8 ± 0.6

4.6 ± 0.5A

4.0 ± 0.7B

4.7 ± 0.4A

Environment

3.6 ± 0.6

4.2 ± 0.4A

3.6 ± 0.6

4.2 ± 0.4A

Abbreviations: LRYGB laparoscopic Roux-en-Y gastric bypass, LSG laparoscopic sleeve gastrectomy

Means (± standard deviations) followed by “A” indicate significant differences between the preoperative period and follow-up values, whereas those followed by “B” indicate significant differences between group values in the preoperative period according to Mann-Whitney test (significance set at p < 0.05)

Table 3

Scores of quality of life obtained at 12 month follow-up by application of the WOQUOL-BREF questionnaire to patients classified according to the severity of obesity in the preoperative period

WOQUOL-BREF indicator

LRYGB group/BMI subgroups

(n = 48)

LSG group/BMI subgroups

(n = 47)

≤ 40.0 kg/m2

40.1–45.0 kg/m2

≥ 45.1 kg/m2

≤ 40.0 kg/m2

40.1–45.0 kg/m2

≥ 45.1 kg/m2

Perception of quality of life

4.9 ± 0.3

4.8 ± 0.4

4.6 ± 0.9

4.8 ± 0.4

4.7 ± 0.7

4,6 ± 1.0

Satisfaction with own health

4.9 ± 0.3

4.9 ± 0.4

4.6 ± 1.0

4.8 ± 0.4

4.6 ± 0.4

4.6 ± 1.0

Physical domain

4.5 ± 0.4

4.6 ± 0.4

4.3 ± 0.9

4.6 ± 0.4

4.4 ± 0.5

4.4 ± 0.9

Psychological domain

4.4 ± 0.4

4.5 ± 0.2

4.2 ± 0.9

4.6 ± 0.4

4.4 ± 0.7

4.3 ± 0.9

Social relations

4.5 ± 0.6

4.8 ± 0.4

4.4 ± 0.9

4.8 ± 0.3

4.7 ± 0.4

4.6 ± 0.9

Environment

4.2 ± 0.4

4.1 ± 0.3

4.0 ± 0.8

4.3 ± 0.4

4.1 ± 0.4

4.1 ± 0.8

Abbreviations: LRYGB laparoscopic Roux-en-Y gastric bypass, LSG laparoscopic sleeve gastrectomy, BMI body mass index

Data expressed as mean values ± standard deviations

The results obtained using the SF-36 questionnaire confirmed that both types of bariatric surgery afforded positive benefits on the quality of life. However, perceptions of satisfaction with own health were significantly more palpable within the LRYGB group, while perceptions of vitality were significantly more evident within the LSG group (Table 4). Improvements in quality of life regardless of their original BMI were also observed when patients were classified according to severity of obesity (Table 5).
Table 4

Differences between preoperative and 12 month follow-up scores relating to quality of life obtained by application of the SF-36 questionnaire to patients

SF-36 indicator

LRYGB group (n = 48)

LSG group (n = 47)

Preoperative

Follow-up

Preoperative

Follow-up

Physical functioning

58.9 ± 24.0

95.8 ± 11.8

51.9 ± 22.6

94.7 ± 11.7

Physical role functioning

44.1 ± 38.6

97.9 ± 11.3

47.6 ± 39.2

94.7 ± 18.0

Bodily pain

54.8 ± 18.3

91.9 ± 15.6

59.0 ± 22.4

88.7 ± 18.8

General health perceptions

56.6 ± 18.3

93.3 ± 11.0

61.6 ± 22.2

96.5 ± 7.8

Vitality

50.8 ± 24.4

78.6 ± 15.5

46.5 ± 21.6

87.7 ± 10.9A

Social role functioning

64.0 ± 26.0

94.2 ± 10.0

65.5 ± 25.8

91.4 ± 13.9

Emotional role functioning

56.2 ± 42.5

98.6 ± 9.6

52.4 ± 43.8

95.1 ± 15.4

Mental health

49.3 ± 23.0

81.2 ± 12.0

50.0 ± 23.6

86.1 ± 11.4A

Abbreviations: LRYGB laparoscopic Roux-en-Y gastric bypass, LSG laparoscopic sleeve gastrectomy

Means (± standard deviations) followed by “A” indicate significant differences between the preoperative period and follow-up values according to Mann-Whitney test (significance set at p < 0.05)

Table 5

Scores of quality of life obtained at 12 month follow-up by application of the SF-36 questionnaire to patients classified according to the severity of obesity in the preoperative period

SF-36 indicator

LRYGB group/BMI subgroups

(n = 48)

LSG group/BMI subgroups

(n = 47)

≤ 40.0 kg/m2

40.1–45.0 kg/m2

≥ 45.1 kg/m2

≤ 40.0 kg/m2

40.1–45.0 kg/m2

≥ 45.1 kg/m2

Physical functioning

99.4 ± 1.6

97.5 ± 3.8

90.3 ± 19.3

97.9 ± 3.0

93.9 ± 12.0

91.3 ± 20.5

Physical role functioning

95.8 ± 17.7

100.0 ± 0.0

98.4 ± 6.3

100.0 ± 0.0

94.4 ± 16.2

91.4 ± 24.3

Bodily pain

90.9 ± 19.5

94.9 ± 10.3

90.6 ± 14.9

90.5 ± 16.4

92.7 ± 11.2

85.9 ± 23.3

General health perceptions

93.8 ± 10.5

94.9 ± 12.8

91.2 ± 10.2

98.9 ± 1.6

93.7 ± 11.9

93.0 ± 19.2

Vitality

82.8 ± 13.4

79.6 ± 6.9

73.1 ± 21.4

89.7 ± 7.9

86.4 ± 14.7

84.7 ± 18.3

Social role functioning

95.8 ± 9.6

94.6 ± 9.5

92.2 ± 11.1

96.2 ± 7.1

85.7 ± 18.7

88.3 ± 20.4

Emotional role functioning

96.3 ± 15.7

100.0 ± 0.0

100.0 ± 0.0

98.4 ± 6.9

96.3 ± 10.8

91.8 ± 22.5

Mental health

82.8 ± 11.1

85.1 ± 8.9

75.9 ± 14.1

90.5 ± 6.2

81.2 ± 15.8

83.1 ± 18.4

Abbreviations: LRYGB laparoscopic Roux-en-Y gastric bypass, LSG laparoscopic sleeve gastrectomy

Data expressed as mean values ± standard deviations

Correlations between quality of life scores and change in BMI after surgery were considered weak, as shown by the rs values, with just a few indicators showing significant correlations with reduction in BMI (Table 6).
Table 6

Associations between change in BMI and improvement in quality of life at 12 month follow-up as determined by the WOQUOL-BREF and SF-36 indicators

Improvement in quality of life

Change in BMI

LRYGB group (n = 48)

LSG group (n = 47)

Spearman rs

P value

Spearman rs

p value

WOQUOL-BREF indicator

 Perception of quality of life

0.341

0.018*

0.101

0.498

 Satisfaction with own health

0.416

0.003*

0.256

0.082

 Physical domain

0.244

0.095

− 0.089

0.553

 Psychological domain

0.327

0.023*

0.053

0.724

 Social relations

0.144

0.328

0.094

0.528

 Environment

− 0.056

0.708

− 0.128

0.392

SF-36 indicator

 Physical functioning

0.010

0.949

0.051

0.732

 Physical role functioning

0.014

0.926

0.114

0.447

 Bodily pain

0.142

0.335

− 0.105

0.484

 General health perceptions

− 0.062

0.674

0.336

0.021*

 Vitality

0.386

0.007*

0.094

0.530

 Social role functioning

0.295

0.042*

0.096

0.522

 Emotional role functioning

0.276

0.058

0.263

0.075

 Mental health

0.177

0.228

0.167

0.261

Abbreviations: LRYGB laparoscopic Roux-en-Y gastric bypass, LSG laparoscopic sleeve gastrectomy

*Statistically significant (p < 0.05)

Discussion

While LRYGB is a well-established procedure for the treatment of morbidly and super-obese patients, the use of LSG as a primary bariatric intervention is still controversial although it has gained acceptance among surgeons in recent years. Thus, Fischer et al. [11] carried out a systematic review of 123 papers describing 12,129 patients who had been submitted to LSG and concluded that the technique is effective and results in lasting benefits with regard to excess weight loss (EWL). According to these authors, mean EWL values attained by LSG were 56.1, 64.3, and 66.0%, respectively, at 12, 24, and 36 month follow-ups, although the 12 month EWL was significantly lower (P < 0.01) than the mean value of 68.3% recorded for patients treated by LRYGB. However, following a study of 490 patients submitted to LSG, Bellanger et al. [12] reported somewhat higher mean EWL values of 65.92, 66.11, and 64.42%, respectively, at 12, 24, and 36 month follow-ups. Furthermore, a prospective study by Leyba et al. [13] involving 117 obese patients revealed that the LRYGB approach resulted in a mean EWL of 86% at the 12 month follow-up while the analogous value for the LSG technique was 78.8% with no significant difference between the procedures. These authors concluded that both procedures were equivalent in terms of safety and effectiveness. Our results support these findings by demonstrating that both LRYGB and LSG patients presented reductions of 38% in BMI at 12 month follow-up. On the other hand, Mohos et al. [14] reported that patients submitted to LRYGB showed a 39% reduction in BMI (88% EWL) at 15.7 months while those treated by LSG presented a 33.4% reduction in BMI (70% EWL) after 38.3 months, from which it was concluded that LRYGM was the superior choice.

Regarding obesity-associated comorbidities, our 12 month follow-up results showed that LRYGB and LSG were equally successful in resolving comorbidities. These findings are in general agreement with the conclusions of a meta-analysis of 32 studies involving 6526 patients conducted by Li et al. [15], except that these authors describe a better resolution of SAH by LRYGB. In contrast, a study involving an Asian population [16] indicated that both interventions showed comparable efficiency in resolving DM2, DLP, arthralgia, OSAS and SAH, although LRYGB resulted in a more rapid resolution of DM2, a finding that has been supported by evidence presented in other studies [17, 18].

Alongside the changes in BMI and the resolution of obesity-associated comorbidities, it is necessary to assess the efficacy of bariatric surgery in terms of other outcomes, particularly quality of life. In this context, the weight-specific WOQUOL-BREF and the generic SF-36 questionnaires [19, 20, 21] have been valuable in evaluating the positive changes in quality of life after LRYBG and LSG [22, 23]. For example, Fezzi et al. [21] demonstrated that LSG resulted in 57.18% EWL and used both WOQUOL-BREF and SF-36 measures to show that quality of life scores improved significantly after surgery, although such changes were not always associated with the amount of weight lost. Mohos et al. [14] employed the SF-36 tool to evaluate changes in quality of life after submission to LRYBG and LSG and found that patients expressed high levels of satisfaction with both procedures, although those that had been treated by LRYBG perceived a better, but not statistically significant, quality of life compared with those submitted to LSG.

According to results obtained in the present study using the WOQUOL-BREF tool, the quality of life of LRYBG and LSG patients improved equally regardless of preoperative BMI values. However, according to the SF-36 questionnaire, the perception of own health was significantly more positive in LRYBG patients compared with their LSG counterparts, although the opposite situation was observed with respect to vitality. Interestingly, the positive enhancements in quality of life achieved by the two procedures were, at best, only weakly associated with change in BMI, implying that patients who lost most weight did not necessarily attain a better quality of life. The negligible or absence of correlation between improved quality of life and weight loss after bariatric surgery has been reported previously [24, 25, 26] and explained by the divergence among patients in attributes such as age, gender, marital status, presence of comorbidities, and physical activities.

The strength of the study is that the prospective nature of the investigation was not biased by knowledge of outcomes, while the main limitation is the short-term follow-up (12 months).

Conclusions

Considering the clinical outcomes reported herein, which are supported by earlier evidence, it may be concluded that the benefits of LRYGB and LSG are comparable in terms of change in BMI, resolution of comorbidities and improvement in quality of life. In this respect, our study reinforces the prevailing idea that LSG is a valuable bariatric procedure in its own right for the treatment of obese individuals. This report is important because the outcomes of LRYGB and LSG procedures were compared taking into account patients that had been previously classified according to preoperative BMI values, thus providing an insight into the effects of the surgical procedures on individuals with dissimilar degrees of obesity. Moreover, it is important to recognize that the personal circumstances and requirements of individual patients will be different, and that the success of a procedure does not depend exclusively on the skill of the surgeon or on the criteria considered during decision making. Bariatric surgery is an important undertaking and patients need to understand that they must follow a planned diet and exercise regime in perpetuity and monitor their progress on a regular basis. In this sense, seeking the help of nutritionists and health therapists is of utmost importance. In order to achieve a better understanding of the effects of LRYGB and LSG on the remission of obesity-associated diseases, it would be important to investigate the metabolic adaptations imposed by these procedures mainly relating to insulin resistance.

Notes

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval Statement

All procedures performed in the study were in accordance with the ethical standards of the Comissão Nacional de Ética em Pesquisa (CONEP)/Comitê de Ética em Pesquisa da Santa Casa de Belo Horizonte (protocol number CAAE 65939417.0.0000.5138) and with the 1964 Helsinki declaration and its later amendments.

Informed Consent Statement

Informed consent was obtained from all individual participants included in the study.

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Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  • Daniela M. Sueth
    • 1
    Email author return OK on get
  • Augusto C. A. Tinoco
    • 1
  • Wendel M. Pompilho
    • 2
    • 3
  • Jaylla F. F. O. Raeli
    • 3
  • Gersana T. R. Zambrotti
    • 3
  • Carlos M. Antunes
    • 4
  1. 1.Serviço de Cirurgia BariátricaHospital São José do AvaíItaperunaBrazil
  2. 2.Departamento de BiologiaUniversidade Federal FluminenseNiteróiBrazil
  3. 3.Faculdade de MedicinaUniversidade Iguaçu, Campus VItaperunaBrazil
  4. 4.Instituto de Ensino e Pesquisa da Santa Casa Misericordia de Belo HorizonteBelo HorizonteBrazil

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