Quality of Life 10 Years After Bariatric Surgery

The obesity epidemic remains a major health concern, which results in a constantly growing number of patients being treated with bariatric procedures [1, 2]. The effectiveness of bariatric surgery in the treatment of morbid obesity has been established, and for an increasing number of patients, many years have passed since the time of their initial surgery [3, 4]. Re-evaluating the most commonly performed bariatric procedures (laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB)) from a long-term perspective is essential to provide a new insight into their effectiveness [5].

The majority of published studies that present mostly long-term outcomes after bariatric surgery focus only on weight loss and remission of type 2 diabetes mellitus or other obesity-related comorbidities [6‐8]. However, a major objective of surgical treatment of obesity, apart from decreasing mortality and morbidity, is to achieve long-lasting improvement in the quality of life (QoL) [8]. QoL has been recognized as an important marker of health for the general population and those with chronic or life-threatening conditions [9]. Patients seek surgical care most often because of impaired QoL, and improvement in QoL is how they usually assess the effectiveness of the treatment [10].

Previous studies have confirmed improvement in QoL in short term after bariatric surgery, but studies rarely include very long-term observations or compare outcomes of LSG and LRYGB [11‐15]. Assessing QoL at a more distant time point could help to confirm the durability of the bariatric and metabolic effects after LSG and LRYGB and may reveal potential advantages or disadvantages of these procedures. This study aimed to analyze the effect of bariatric surgery on long-term QoL based on the type of surgery.

Our study focused on long-term outcomes, including weight loss and improvement of QoL, of the two most commonly performed bariatric procedures [2, 20]. QoL was assessed with the SF-36 and MA-QoLQII questionnaires, which are very often incorporated into studies evaluating QoL outcomes after bariatric surgery [21, 22]. This study aimed to verify the long-term effectiveness of bariatric and metabolic surgery in terms of improving the QoL among patients suffering from morbid obesity.

Although the bariatric surgery contribution to the improvement of QoL in the short-term is currently well established, there is still a need for evaluating very long-term outcomes (10 years or more) [21]. There are few studies presenting very long-term outcomes of LSG, and even fewer studies comparing LSG with LRYGB. In our opinion, when qualifying patients for bariatric treatment, surgeons often focus on short-term effects, whereas long-term improvement of the QoL is the most important outcome for the majority of patients. There is a correlation between weight loss or improvement in obesity-related comorbidities and the increase in health-related QoL. A recent review by Kolotkin and Andersen suggests a further need to conduct longer-term studies to evaluate the durability of the short-term outcomes [22]. Additionally, a review by Colquitt et al. suggests that the majority of published evidence presenting beneficial QoL outcomes after bariatric surgery is currently of very low quality [23].

At present, there are multiple published articles comparing weight loss outcomes after LSG and LRYGB, including randomized controlled trials [24]. Peterli et al. and Salminian et al. reported comparable beneficial results in terms of weight loss 5 years after LSG and LRYGB [25, 26]. At the 1-year follow-up, our results demonstrate superior weight loss after LRYGB, which is consistent with previously published data [27].

Literature on very long-term weight loss after bariatric surgery is limited, especially with data concerning LSG. The majority of articles present outcomes of bariatric operations 5 years or more after surgery focusing only on a single procedure [28‐30]. According to Kowalewski et al. and Mandeville et al., patients after LSG, in a very long observation (6 to 10 years), achieved a %EWL of 51–60% [28, 31]. In our study, patients achieved a comparable mean %EWL of 45.4% in the very long-term follow-up. Although this outcome is relatively low, there are studies reporting similar results. For instance, Sadot and Spivak reported a %EWL of 53% 20 years after LRYGB [32]. It is important to remember that the patients in our group did not undergo any additional bariatric revisional procedures. In the case of LRYGB, other authors reported %EWL between 58.5 and 78% at 10-year follow-up and %TWL between 26 and 28% [29, 30, 33, 34]. Mantziari et al. reported no significant difference in weight loss between patients < 40 years old, 40–55 years old, and > 50 years old (32.2%, 32.9%, and 32.3% of TWL, respectively) at a 10-year follow-up [35]. Our results seem to be consistent with the abovementioned research, with a mean %EWL of 62.2% and a mean %TWL of 36.5% at a 10-year follow-up examination. There are few studies comparing weight loss outcomes of LSG and LRYGB after more than 5 years. In our study group, patients after LRYGB sustained superior weight loss over a very long-term period compared with patients in the LSG group, which also seems to be consistent with the existing data [36].

Our results present a large improvement of QoL 1 year after bariatric surgery in physical as well as in mental aspects, which seem to be consistent with previously published research. Studies by Amichaud et al. and Charalampakis et al., which presented short-term QoL outcomes of bariatric surgery, reported satisfactory results with significant improvement of QoL after LSG [37, 38]. Poelemeijer et al. reported significant improvement in the majority of QoL domains compared with reference values 1 year after bariatric surgery. Improvement was comparable between LSG and LRYGB, except for physical functioning and general health perception for which RYGB was more beneficial [39]. In the short-term follow-up (1–2 years), authors report comparable outcomes with significant improvement of QoL after both LSG and LRYGB [40, 41]. A study by Takemoto et al. reported significant improvement in both mental and physical aspects of QoL 1 year after bariatric procedures, which remained stable during the following 5 years [42]. Our results did not show a significant difference in QoL improvement between groups undergoing LSG an LRYGB 1 year after surgery.

It was established using observational studies that bariatric procedures after a very long-term may be associated with various problems, including recurrence of morbid obesity or new ailments resulting from complications of the operations. LSG has increased in popularity more recently, and there are very few reports of LSG outcomes with a follow-up of 10 years or longer; available long-term studies investigating QoL focus mostly on LRYGB. Findings included in a meta-analysis by Driscoll et al. present a substantial and significant improvement up to 25 years after the initial bariatric operation [43]. There is scarcely any research on the influence of LSG on QoL 10 years or more after the operation. According to Csendes et al., patients who underwent LSG can develop hiatal hernia, erosive esophagitis, and GERD after a long term (10.5 years), which can potentially influence their QoL [44]. LRYGB, however, has been a popular operation for a long time, and multiple articles present very long-term (10 years or more) outcomes after this procedure. Raoof et al. presented a favorable impact of LRYGB on QoL at a long-term follow-up (7–17 years) in comparison with controls [13]. According to a study by Mantziari et al., the 10-year mean Moorehead–Ardeldt scores were not significantly different between age groups: 1.67 for patients < 40 years old, 1.66 for a group between 40 and 55 years old, and 1.64 for patients > 55 years old [35]. The reported outcomes of LRYGB are mostly favorable, although it seems that this operation is also associated with several long-term complications, for instance, internal or incisional hernia, gallstones, or nutritional deficiencies [45]. Developing such complications would significantly influence QoL; however, this subject requires further investigation. In our study, QoL remained significantly improved at a long-term follow-up; however, there was a slight decrease in QoL between the first and second post-surgery follow-up examinations. Moreover, our data demonstrate that improvement of QoL in patients after LSG may be more sustainable in the long term compared with patients who undergo LRYGB. Unfortunately, in our study group, there was a higher number of patients who were lost to follow-up in LRYGB group compared with the LSG group, which may have affected the statistical significance of the results observed in the LRYGB patients. However, the results of a regression analysis did not reveal potential intergroup differences influencing changes in the QoL.

Surgical treatment of obesity is a physical intervention, and it affects physical QoL to the greatest extent. Patients may require additional psychological care after surgery to regain their mental QoL [21]. Improvement of QoL can have a beneficial impact on multiple aspects of life, including occupational outcomes such as employment or reduction of annual sick days; therefore, improvement of QoL should be regarded as a major goal of bariatric surgery [46]. Knowledge of potential long-term outcomes (including QoL improvement) after each operation should be considered during qualification for bariatric surgery.

Further research investigating the long-term influence of bariatric surgery on QoL should be conducted on a larger study group. It would also be desirable to include analysis of obesity-related comorbidities as factors contributing to QoL.

Our study has several limitations. Unfortunately, the small sample size and the loss of some patients to follow-up (27.7%) are potentially introducing bias and influencing the validity of the results. Although, there was no significant difference in the patients’ baseline characteristics, it may be the result of the small study group. It is also important to note that there were more patients who were lost to follow-up in the LRYGB group than in the LSG group, which may have affected the statistical significance of the results in the LRYGB patients. Therefore, the results of the LSG and LRYGB comparison should be interpreted with caution. In our study group, patients were lost to follow-up due to distant relocation or changing contact data (phone number and address), which prevented us from arranging 10-year follow-up visits. However, considering the very long-time follow-up regimen included in our study design, the loss to follow-up rate was relatively minor. In similar studies, conducted for a long period of time, the follow-up rate is between 26 and 87% [47, 48].

Unfortunately, there were no additional re-evaluations of QoL between years 1 and 10, because our research was not initially planned for such a long period. The QoL may be additionally influenced by aging, which potentially lowers the score 10 years after the surgery.

There was no possibility to include data on improvement or remission of obesity-related comorbidities after bariatric treatment. These data would provide a more comprehensive insight into the long-term outcomes of the evaluated procedures. However, follow-up examinations were conducted exclusively by surgical staff in our center, and assessment of the severity level of each comorbidity would result in deficient data.

LSG led to significant, durable weight loss and a substantial improvement of QoL in a 10-year follow-up.