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Bariatric surgery is becoming an increasingly common procedure for the treatment of obesity. In large studies, patients who undergo procedures such as Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy typically lose approximately 60% of their body weight,¹ which is a level adequate to reverse or improve weight-related health problems, including type 2 diabetes mellitus.² Some studies have also demonstrated improved health-related quality of life (HRQOL) following bariatric procedures. Data on long-term outcomes, such as abdominal pain, remain limited, however.³

Recently, several studies evaluating long-term outcomes, including one that examined gastrointestinal (GI) symptoms 5 years after RYGB, have provided evidence that persistent GI symptoms may be more common than widely appreciated.³ These symptoms don鈥檛 necessarily negate the benefits of bariatric surgery鈥攑articularly the reduction in serious health risks that weight loss provides鈥攂ut the symptoms are sufficiently common³ that it may be appropriate for patients considering bariatric surgery to think about their impact prior to selecting this treatment.

Tracking the effects of weight-loss surgery

In a long-term follow-up of 160 of 234 adults who underwent RYGB within a 12-month period, patients were assessed an average of 64 months after their procedure. These 160 patients, all of whom underwent laparoscopic RYGB for morbid obesity, completed questionnaires regarding abdominal pain, GI symptoms, and HRQOL prior to a physician鈥檚 clinical exam. The goal of the study was to identify the prevalence, characteristics, and possible predictors of persistent GI symptoms.³

Chronic abdominal pain was reported by 33.8% of patients 5 years after RYGB, of which 70% had symptoms at least once a week. Of those reporting chronic abdominal pain, these episodes lasted from less than an hour to up to 4 hours. More than half of patients (52%) rated their pain a 7 or higher on a scale of 0 to 10, and slightly more than half who agreed to a diagnostic workup during the study had previously sought medical attention for the pain. Females were 2.64 times more likely to report chronic abdominal pain than men. HRQOL scores, assessed with the 36-item Short Form (SF-36) survey, were lower for 5 of 10 domains in those patients with chronic pain relative to those without.³

These data support the conclusion that persistent abdominal pain of sufficient severity to interfere with HRQOL is frequent after RYGB. The study鈥檚 authors didn鈥檛 evaluate the degree to which patients considered these symptoms to have adversely affected their perception of the value of bariatric surgery, but they did recommend routine evaluation of abdominal pain following RYGB.³

Similar studies reach the same conclusion

Other research has provided corroborating evidence of GI complaints after bariatric surgery. In a survey of 1429 patients who underwent RYGB, 1 or more symptoms attributed to surgery were reported by 88.6% of respondents a median of 4.7 years after the procedure, yet only 67.6% had sought contact with the healthcare system about these symptoms. The most commonly identified lingering side effect was abdominal pain, identified by 34.2% of respondents. Other common symptoms included fatigue (34.1%) and anemia (27.7%). In this study, the higher the number of symptoms, the poorer the quality of life, and vice versa (P<.001).⁴

In another study, which evaluated patient satisfaction with RYGB 10 years after the procedure, only 12% of the 115 patients who agreed to share comments provided negative responses. The majority (63%) of responses were positive, the remaining ones neutral. Of the patients who had negative comments, only 21% expressed regret at having had the procedure, but many of these complaints involved disappointment at not having reached weight loss goals.⁵

Overall, the long-term data suggest that informed consent about bariatric surgery should include information about persistent symptoms such as GI complaints, rather than a risk-to-benefit discussion largely focused on the expected weight loss or the risk of surgical complications. This is appropriate, say the authors of these studies, not only for patients to fully weigh variables likely to influence their satisfaction but to allow them to understand and respond to complications when they occur.

What the investigators say

鈥淪ome of the nutritional complications, such as anemia, dumping, and hypoglycemia, may鈥�easily be overlooked as a complication after bypass,鈥� reports Sigrid B. Gribsholt, MD, PhD, of the Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark. Principal investigator of the 1429-patient survey, Dr. Gribsholt suggests that informing patients about these risks increases the likelihood that they鈥檒l contact their primary care physician when they arise. 鈥淭hese complications are generally treatable,鈥� she adds.

Like Dr. Gribsholt, Peter T. Hallowell, MD, Director of Bariatric Surgery at the University of Virginia, Charlottesville, emphasized that while it鈥檚 essential to provide full information about positive and negative consequences of bariatric surgery to any candidate, patients鈥攁long with their primary care physicians鈥攎ay overlook late complications like GI complaints if unaware of the risk.

鈥淧atients are not typically followed by their surgeons but by their primary care physician, and the connection between GI symptoms and other complaints with the bariatric surgery may be missed, even though they can often be controlled,鈥� says Dr. Hallowell, an author of the previously mentioned 10-year follow-up study. Although he believes the biggest challenge to bariatric surgery is the large number of patients who could benefit but never receive information about this option, informed consent about all potential risks and benefits is the foundation of appropriate medical care, he says.

Published: September 05, 2017