Quality of Life After Bariatric Surgery—a Systematic Review with Bayesian Network Meta-analysis

Depression, anxiety, and low self-esteem can be significant psychological consequences of obesity [1]. Both physical and psychological consequences can be debilitating and decrease overall Health-Related Quality of Life (HRQoL). Bariatric surgery causes significant changes in patients’ life, including HRQoL. There is a growing body of literature demonstrating an improvement of both the physical and psychological status of the patients following bariatric procedures [2].

Objective assessment of QoL can be made using validated and standardized tools. A variety of those tools have gained popularity among researchers, but HRQoL assessment tools most commonly used in surgical literature are Short Form-36 (SF-36) [3], Moorehead-Ardelt Quality of Life [4], Gastrointestinal Quality of Life (GIQLI) [5], and Impact of Weight on Quality of Life (IWQOL) [6]. Although there are numerous studies on HRQoL after different bariatric procedures, the heterogeneity of different tools used and types of bariatric procedures make the interpretation of these data complex. Considering the paucity of literature on this topic, we aim to conduct a systematic review and a network meta-analysis to produce a comprehensive comparison of HRQoL after different bariatric procedures.

The initial reference search yielded 8892 records. After removing duplicates, 6346 titles and abstracts were reviewed and 484 papers were selected for full-text screening. Finally, 47 studies (17 RCTs and 30 non-RCTs) conducted in 17 countries were included in the network meta-analysis (Fig. 1). The studies included a total of 26,629 patients. A total of 11 surgical procedures were evaluated in the primary studies, which included laparoscopic sleeve gastrectomy (LSG, 25 studies), laparoscopic Roux-en-Y gastric bypass (LRYGB, 37 studies), laparoscopic biliopancreatic diversion with duodenal switch (BPD-DS, 6 studies), laparoscopic vertical banded gastroplasty (VBG, 1 study), laparoscopic adjustable gastric banding (LAGB, 8 studies), laparoscopic banded Roux-en-Y gastric bypass (banded-GB, 2 studies), laparoscopic greater curvature plication (LGCP, 1 study), laparoscopic distal Roux-en-Y gastric bypass (distal-GB, 2 studies), laparoscopic one anastomosis gastric bypass (OAGB, 5 studies), prolonged biliopancreatic limb gastric bypass (LB-GB, 1 study), and distal one anastomosis gastric bypass (distal-OAGB, 1 study). General characteristics of included studies are presented in Table 1 with NOS quality score or Cochrane risk of bias assessments. The analyses are presented separately for each of the pre-specified periods of follow-up: 1, 2, 3, and 5 years. The number of studies included in the analysis was decreasing with the length of follow-up, as was the number of procedures studied. Results for secondary outcomes are available in supplement files. The networks of studies for each follow-up period are presented in Fig. 2.

To our knowledge, this network meta-analysis is the first to attempt to summarize and compare HRQoL after different bariatric procedures in patients with severe obesity. In total, we included 47 studies with 26,629 patients and 11 different surgical techniques covering the follow-up period from 1 to 5 years. Our analysis included both RCTs and observational studies to assess a wide number of different interventions as possible. Short-term results (1 year) showed that only LSG, LRYGB, and OAGB offer better QoL in comparison to non-surgical interventions, with LRYGB showing better results than LSG. Pairwise comparisons showed that LAGB and VBG result in worse HRQoL in comparison to LSG or LRYGB. Medium-term results (2- years) showed that patients who received banded-GB reported better HRQoL improvement than non-surgical patients, while LAGB resulted in worse results than other techniques, excluding OAGB and distal-GB. Long-term results (3 and 5 years) showed that LRYGB and LSG maintain HRQoL after surgery. BPD-DS at 5 years showed significant improvement to control, which is in contrast to previous years.

Previous network meta-analysis by Park et al. compared weight loss and remission of comorbidities following various bariatric procedures; however, this study did not explore the effects of those interventions on HRQoL [65]. The only meta-analysis which focused on HRQoL after bariatric surgery contained only pairwise comparisons and compared bariatric with non-bariatric patients showing an improvement in the HRQoL, mainly in the domain of physical functioning and activity [66]. Previous pairwise comparison by Hu et al. showed no statistically significant differences in HRQoL between LSG and LRYGB [67]. In general, LSG and LRYGB are the most commonly performed types of surgery worldwide, which is also represented in the number of studies in our review comparing these two techniques. Even though both techniques are well established and have been performed for several years, the debate on which method is better is ongoing, with both pros and cons for each one. In recent years, this resulted in conducting several RCTs, including the SLEEVEPASS (5-year results) and SM-BOSS (5-year results) showing no differences in HRQoL between those two procedures [54, 56, 68]. Our analysis found that both LSG and LRYGB in the long term (3–5 years) are associated with better HRQoL than no surgical intervention. Pairwise comparisons show that LAGB and VBG will likely result in worse HRQoL than other techniques, which is consistent with previous literature [69]. The present study suggests that LAGB may worsen HRQoL in comparison to LSG, LRYGB, or BPD-DS. Finally, with the current evidence, it is unclear whether BPD-DS in short term either improves or worsens HRQoL after the surgery. This may be associated with malnutrition and a more demanding diet than other techniques [70]. Results from a 5-year follow-up demonstrate that surgical interventions such as LSG, LRYGB, BPD-DS, and OAGB provide better HRQoL as compared to non-surgical methods.

One of the advantages of this network meta-analysis is the comparison of different variations of gastric bypass. In general, the most commonly performed bypass is LRYGB and OAGB. In our review, we compared other less common versions such as banded gastric bypass (elastic band placed on the pouch), distal gastric bypass (long alimentary limb), long biliopancreatic limb gastric bypass, and distal-OAGB (long biliopancreatic limb). Our results show that banded-GB and LB-GB sometimes are associated with better HRQoL than standard LRYGB, whereas distal-GB did not improve HRQoL. A systematic review by Shoar et al. showed that although banded-GB is associated with higher weight loss, it came with the expense of a higher incidence of food intolerance and postoperative vomiting, which can impact HRQoL [71]. The weight loss outcomes are similar for LRYGB and LB-GB. However, at 2 years, LB-GB was associated with better HRQoL than LRYGB [55, 72‐74]. OAGB is still a controversial method with limited literature on long-term effectiveness [75‐78]. The main modifications of this technique include a different length of the biliopancreatic limb [60]. The analysis of pooled data in the review showed that variation with the longer biliopancreatic limb in OAGB is associated with worse HRQoL in comparison to standard OAGB.

BPD-DS as a technique that alters the gastrointestinal tract in the greatest fashion requires more time for patients to adjust to new dietary patterns or the need for proper vitamin supplementation. Strain’s et al. study demonstrated that patients’ HRQoL improves after BPD-DS in the long run (9-year follow-up) [79]. BPD-DS in our analysis showed better HRQoL improvement than LSG.

This systematic review is the first comprehensive analysis of the impact of different bariatric procedures on HRQoL. Although a multi-arm RCT would be a preferable choice to establish which method is better, the task at hand would be very difficult to perform as most bariatric surgeons do not perform limited types of bariatric procedures in their elective practice. This network meta-analysis demonstrates that the most commonly performed surgeries, such as LSG and LRYGB, are associated with better HRQoL. It also demonstrates that some novel techniques, such as LB-GB, are worth investigating to a greater extent, whereas others (distal-OAGB) are less promising from an HRQoL standpoint. Finally, this meta-analysis showed that LAGB is associated with worse QoL, which cements LAGB as the least favorable bariatric procedure in all aspects.

This is the first network meta-analysis comparing HRQoL after different bariatric procedures. It demonstrates LSG and LRYGB may lead to better HRQoL across most follow-up time points. Long-term analysis shows that bariatric intervention results in better HRQoL than non-surgical interventions. Our analysis indicates that some procedures such as VBG or LAGB may lead to worse HRQoL. Future studies comparing different types of bariatric procedures should include HRQoL-related measures to their list of outcomes besides weight loss, comorbidities, and complications to provide a holistic perspective of each procedure.