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Chronic abdominal pain and quality of life after Roux-en-Y gastric bypass and sleeve gastrectomy – a cross-cohort analysis of two prospective longitudinal observational studies
Correspondence: Monica Chahal-Kummen, M.D., Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, P.O. Box 4950 Nydalen, Oslo 0424, Norway.
Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
Department of Endocrinology, Morbid Obesity and Preventive Medicine and Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
Chronic abdominal pain (CAP) increased after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG).
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Gastrointestinal symptom profile varied after RYGB and SG.
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Quality of life scores changes differently after RYGB and SG.
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Gastrointestinal symptoms and quality of life was lower in patients with chronic abdominal pain after both procedures.
Abstract
Background
Chronic abdominal pain (CAP) after bariatric surgery is not extensively explored and may impact the postoperative outcomes.
Objective
To compare the prevalence of patient-reported chronic abdominal pain (CAP) after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). Secondarily, we compared other abdominal and psychological symptoms and quality of life (QoL). Preoperative predictors of postoperative CAP were also explored.
Setting
Tertiary referral centers for bariatric surgery in Norway.
Methods
Analyses of 2 separate prospective longitudinal cohort studies evaluating CAP, abdominal and psychological symptoms and QoL before and 2 years after RYGB and SG.
Results
Follow-ups were attended by 416 patients (85.8%), 300/416 (72.1%) were females and 209/416 (50.2%) were RYGB procedures. At follow-up, the mean age was 44.9 (10.0) years, BMI 29.5 (5.4) kg/m2, and total weight loss 31.6 (10.3) %. The prevalence of CAP was 28/236 (11.9%) before and 60/209 (28.7%) after RYGB (P < .001) and 32/223 (14.3%) before and 50/186 (26.9%) after SG (P < .001). Gastrointestinal symptom rating scale scores showed greater deterioration of diarrhea and indigestion after RYGB and reflux after SG. The improvement in depression symptoms was greater after SG, as well as several QoL scores improved more after SG. Patients with CAP after RYGB experienced deterioration in several QoL scores, while these scores improved in patients with CAP after SG. Preoperative hypertension, bothersome reflux symptoms, and CAP predicted postoperative CAP.
Conclusions
The prevalence of CAP increased comparably after RYGB and SG, with worsening of gastroesophageal reflux after SG and greater deterioration of diarrhea and indigestion after RYGB. In patients with CAP at follow-up, several QoL scores improved more after SG than RYGB.
Many studies have reported beneficial outcomes after bariatric surgery, with significant weight loss and improvement in metabolic measures. Adverse outcomes have been well explored and documented [
Quality of life parameters, weight change and improvement of co-morbidities after laparoscopic Roux Y gastric bypass and laparoscopic gastric sleeve resection--comparative study.
Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y gastric bypass on weight loss at 5 years among patients with morbid obesity: the SLEEVEPASS randomized clinical trial.
Effect of laparoscopic sleeve gastrectomy vs Roux-en-Y gastric bypass on weight loss and quality of life at 7 years in patients with morbid obesity: the SLEEVEPASS randomized clinical trial.
]. Few studies have evaluated such symptoms longitudinally, and there is limited knowledge regarding the comparative analyses of outcomes after RYGB and sleeve gastrectomy (SG) in this context [
We have previously explored the prevalence of chronic abdominal pain (CAP) and other patient-reported outcome measures after RYGB and SG in separate studies. A significant increase in such symptoms appears to be associated with reduced quality of life (QoL) scores [
]. In the present study we explored this further by comparing RYGB and SG in terms of abdominal pain, symptoms, and QoL. To our knowledge, no previous longitudinal study has focused primarily on comparative analyses of CAP between RYGB and SG. One study, however, compared CAP cross-sectionally 2–4 years after RYGB and SG indicating higher abdominal pain scores after RYGB [
Self-reported gastrointestinal symptoms two to four years after bariatric surgery. A cross-sectional study comparing Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy.
]. The findings of our study may enlighten aspects of RYGB and SG in the setting of CAP relevant for preoperative and postoperative patient counseling and for holistic assessments of outcomes.
Methods
Study design, setting, and participants
Two separate and prospective longitudinal cohort studies were planned and conducted consecutively. Patients scheduled for RYGB and SG were invited to participate from February 2014 to June 2015 and from November 2015 to May 2017, respectively [
]. All RYGB patients were recruited at Oslo University Hospital, while SG patients were recruited at Oslo University Hospital and Voss Hospital. Patient handling and routines were at large similar during the study period. Both hospitals are tertiary referral institutions for bariatric surgery, operating on 200–300 patients annually. Follow-up consultations after RYGB were performed from April 2016 to June 2017 and after SG from November 2017 to August 2020.
The participants responded to a set of questionnaires, followed by consultations with a physician at baseline, and at follow-up. The inability to understand spoken language and previous and redo bariatric procedures were the exclusion criteria. Written consent for study participation was provided by all participants. The study was approved by the Regional Committee for Medical and Health Research Ethics and registered at ClinicalTrials.gov (identifier NCT03456024 and NCT03455998). The STROBE reporting guidelines were followed.
Outcomes and variables
The primary outcome was the prevalence of patient-reported CAP 2 years after RYGB and SG. CAP was defined as sustained or recurrent abdominal pain lasting ≥3 months [
]. Secondary outcomes included prevalence of other abdominal and psychological symptoms, level of QoL, as well as potential preoperative predictors of postoperative CAP. Surgical complications within 30 days were defined as early and subsequent adverse events as late and were reported as serious if categorized as Clavien Dindo grade IIIb or more [
]. Briefly, RYGB was performed with a gastric pouch of approximately 25 ml, antecolic alimentary (or Roux) limb of 150 cm, and biliopancreatic limb of 50 cm. Mesenteric defects were closed routinely. SG was performed along a 30–32 Fr tube. At Oslo University Hospital, the staple line was inverted from the top to the angulus of the stomach using resorbable sutures and started approximately 4 cm proximal to the pylorus. At Voss Hospital, stapling started approximately 2–3 cm from the pylorus, no reinforcement was used but gastropexy was performed in most patients [
]. Patients were discharged 1–2 days after surgery, with multivitamins, iron, vitamin D, calcium, and vitamin B12. Ursodeoxycholic acid (Ursofalk) was prescribed for 6 months at Oslo University Hospital. Routine follow-ups were scheduled at 6–8 weeks after surgery, 6 months and 1, 2 and 5 years after surgery.
Questionnaires
The first nonvalidated questionnaire was used to evaluate the CAP. The inlet question was “Are you experiencing long-term or recurrent abdominal pain lasting for more than 3 months?” If answering “yes”- the participant was instructed to respond to the rest of the items. Pain severity was graded on a Numerical Rating Scale (NRS) from 0 to 10 (0 = no pain, 10 = worst imaginable pain), with the following cut-off values; mild (0–5), moderate (6–7), and severe (8–10). Interference with sleep, daily activities, and work was graded on the same NRS (0 = not affected, 10 = completely affected), with the same cut-off values [
Cut-off points for mild, moderate, and severe pain on the numeric rating scale for pain in patients with chronic musculoskeletal pain: variability and influence of sex and catastrophizing.
The Gastrointestinal Symptom Rating Scale (GSRS) questionnaire with 1 week recall was used to evaluate abdominal symptoms. We used both mean and cut-off scores (scores ≥3 defining bothersome symptoms). The Hospital Anxiety and Depression Scale (HADS) questionnaire was used to evaluate psychological symptoms using mean scores and cut-off scores of ≥8 as symptoms of depression and anxiety. QoL was assessed using the Short-Form 36 version 2 (SF-36v2). All these questionnaires are previously validated [
Reliability and validity of the gastrointestinal symptom rating scale (GSRS) and quality of life in reflux and dyspepsia (QOLRAD) questionnaire in dyspepsia: a six-country study.
]. Apart from SF-36v2, higher scores meant worse symptoms.
Questionnaire scores were given as mean scores and delta scores. Delta scores were defined by postoperative scores minus preoperative scores. Negative values indicated decreased scores at follow-up and meant improvement for GSRS and HADS and deterioration for SF-36v2. Positive values indicated increased scores at follow-up and meant deterioration for GSRS and HADS and improvement for SF-36v2.
Statistical analyses
Student’s t test, Wilcoxon signed rank-test, or Wilcoxon rank-sum test/Mann Whitney U-test were used to compare continuous variables and McNemar's test or Chi-Square or χ2 test were used for categorical variables. Continuous variables are presented as means (standard deviations, SD) and categorical variables as numbers (percentage, %). The effect sizes of the changes in scores between 2 means were estimated with Cohen’s d (continuous variables). Suggested cut-off values for Cohen’s d, used cautiously were small .2, medium .5, and large .8 [
CAP at 2 years was the dependent variable in the logistic regression model. The independent variables were entered simultaneously and chosen if they were significant in the univariate analyses and included based on their clinical relevance. The model was limited to the type of surgical procedure and 12 preoperative variables (sex, age, BMI, occupational status, diabetes type 2, hypertension, musculoskeletal pain, previous abdominal surgery, gastroesophageal reflux (from GSRS, scores ≥3), symptoms of anxiety and depression (HADS score ≥8), and preoperative CAP). Statistical analyses were performed using the IBM SPSS Statistics version 28 (IBM Corp.). Patients with missing data were excluded from the analyses.
Results
Of the 532 patients eligible for inclusion, 236 patients scheduled for RYGB and 249 for SG were enrolled in the study, giving a baseline population of 485 patients (91.1%). Of these, 416 patients (85.8%) attended 2-year follow-up (Supplementary Fig. 1). Table 1 shows baseline and follow-up characteristics.
Table 1Patient characteristics before and 2 years after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG)
Serious postoperative complications up to 2 years were reported in 17/209 (8.1%) patients who underwent RYGB and in 8/207 (3.9%) patients who underwent SG (P = .079, Table 2).
Table 2Serious surgical complications (Clavien Dindo ≥3b) after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG)
In patients receiving RYGB, CAP was present in 28/236 (11.9%) patients at baseline and in 60/209 (28.7%) patients at follow-up (P < .001). The corresponding figures for SG were 32/223 (14.3%) and 50/186 (26.9%), respectively (P < .001).
CAP at follow-up was of new onset in 76.7% of patients after both RYGB and SG. Endoscopic evaluations were performed in 8/60 (13.3%) patients with CAP after RYGB. In patients with CAP after SG at Oslo University Hospital, 12/21 (57.1%) received endoscopic evaluations (data missing for study center II). Among patients with CAP at follow-up, 9/60 (15.0%) patients with RYGB and 1/50 (2.0%) with SG had surgical interventions for postoperative complications (P = .021). A total of 15/57 (26.3%) patients after RYGB and 13/49 (26.5%) patients after SG (P = .225), reported using analgesics for CAP at the time of answering the questionnaire. Opioid analgesics were used by 5/57 (8.8%) patients after RYGB and by 1/49 (2.0%) patients after SG (P = .137). More than 50% of patients reported experiencing CAP more often than once a week after both procedures. There were no differences in the reported severity of CAP (NRS score) between RYGB and SG (P = .097), with the majority reporting it as mild (approximately 50%). The most frequent location of pain was right upper quadrant after RYGB and left upper quadrant after SG. Sleep was mildly affected by CAP in more than 60% of the patients and comparably in both groups (P = .608), while work and daily activities were more severely affected after RYGB (Fig. 1).
Fig. 1Characteristics of patient-reported abdominal pain 2 years after RYGB, n = 60, and SG, n = 50. (A) and (B) Frequency and duration of CAP at 2-year follow-up. (C) Multiple response item. (D) In patients with RYGB, mild, moderate, and severe pain was seen in 32/60 (53.3%), 15/60 (25.0%), and 13/60 (21.7%), respectively. Corresponding figures in patients with SG were 25/49 (51.0%), 14/49 (28.6%), and 10/49 (20.4%), respectively. The difference between RYGB and SG was insignificant (P = .907, Mann-Whitney test). (E) In patients with RYGB, mild, moderate, and severe interference with sleep was seen in 40/60 (66.7%), 5/60 (8.3%), and 15/60 (25.0%), respectively. Corresponding figures in patients with SG were 36/48 (75.0%), 3/48 (6.3%), and 9/48 (18.8%), respectively. The difference between RYGB and SG was insignificant (P = .608, Mann-Whitney test). (F) After RYGB, mild, moderate, and severe interference with work and daily activities were seen in 34/58 (58.6%), 5/48 (8.6%), and 19/48 (32.8%) of the patients, respectively. The corresponding figures after SG were seen in 33/48 (68.8%), 9/48 (18.8%), and 6/48 (12.5%) of the patients, respectively. The difference between RYGB and SG was significant (P = .031, Mann-Whitney test). RYGB = Roux-en-Y gastric bypass; SG = sleeve gastrectomy.
At follow-up for the entire cohort, the mean GSRS reflux syndrome and constipation syndrome scores were significantly higher in patients with SG (with high effect sizes [ES] for reflux scores), while the indigestion syndrome scores were higher in patients with RYGB. Significant differences in the delta scores between RYGB and SG were seen for reflux, diarrhea, and indigestion syndromes (Table 3). Mean scores before RYGB and SG are given in Supplementary Table 1. The prevalence of all bothersome symptoms (cut-off scores ≥3) except reflux symptoms increased after RYGB, while the prevalence of bothersome abdominal pain, reflux, and constipation symptoms increased after SG (Supplementary Table 3A).
Table 3Questionnaire scores 2 years after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG)
Delta scores: Postoperative scores minus preoperative scores. Negative values indicate decreased scores at follow-up, and positive values indicate increased scores at follow-up (See Supplementary Material for preoperative scores).
§ Delta scores: Postoperative scores minus preoperative scores. Negative values indicate decreased scores at follow-up, and positive values indicate increased scores at follow-up (See Supplementary Material for preoperative scores).
In patients with CAP at follow-up, significantly higher GSRS reflux syndrome scores were observed after SG than after RYGB, with large ES. Significant differences in delta scores between RYGB and SG were seen for reflux and indigestion syndromes (Table 4). For mean and delta scores in patients without CAP after surgery see Supplementary Table 2. Bothersome indigestion symptoms increased in patients with CAP after RYGB and bothersome reflux symptoms increased in patients with CAP after SG (Supplementary Table 3D).
Table 4Questionnaire scores for patients with chronic abdominal pain (CAP), 2 years after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG)
Delta scores: Postoperative scores minus preoperative scores in patients with CAP at follow-up. Negative values indicate decreased scores at follow-up, and positive values indicate increased scores at follow-up.
§ Delta scores: Postoperative scores minus preoperative scores in patients with CAP at follow-up. Negative values indicate decreased scores at follow-up, and positive values indicate increased scores at follow-up.
At follow-up, no differences in mean HADS anxiety and depression symptom scores were observed (Table 3). Significant difference in delta scores between RYGB and SG was seen for depression symptoms. In patients with CAP at follow-up, no difference in mean and delta HADS anxiety and depression symptom scores was observed between RYGB and SG (Table 4). Symptoms of depression (cut-off scores ≥ 8) decreased significantly after SG, and no difference in anxiety and depression symptoms were seen between RYGB and SG in patients with CAP at follow-up (Supplementary Table 3, A and D).
Quality of life scores
At baseline, most SF-36v2 scores were higher in patients opting for RYGB than in those opting for SG (Fig. 2A and Supplementary Table 1), while at follow-up there were no significant differences in the mean scores between the 2 groups (Fig. 2B and Table 3). Delta scores showed significantly greater improvement in 4 out of 8 domains after SG (Fig. 2C and Table 3).
Fig. 2Quality of life scores from SF-36v2 questionnaire at baseline and 2 years after RYGB and SG. (A) SF-36v2 scores at baseline in patients opting for RYGB and SG. At baseline, significant higher mean QoL scores were found in patients opting for RYGB for all SF36v2 domains except for Physical functioning and Role physical. (B) SF-36v2 scores 2 years after RYGB and SG. At follow-up, no significant differences were seen between RYGB and SG. (C) Delta SF-36v2 scores at 2-year follow-up after RYGB and SG. Delta SF36v2 scores were significantly different between RYGB and SG for Bodily pain, Vitality, Social functioning, and Mental health. (D) Delta SF-36v2 scores in patients with CAP 2 years after RYGB and SG. In patients with CAP at follow-up, delta SF36v2 scores were significantly different between RYGB and SG for Physical functioning, Bodily pain, Social functioning, and Role emotional. (E) Delta SF-36v2 scores in patients without CAP 2 years after RYGB and SG. In patients without CAP at follow-up, delta SF36v2 scores were significantly different between RYGB and SG for Bodily pain and Mental health. RYGB = Roux-en-Y gastric bypass; SG = sleeve gastrectomy; SF-36v2 = Short-Form 36 version 2; CAP = chronic abdominal pain.
In patients with CAP at follow-up, significantly higher mean scores were seen for physical functioning after SG, with small ES (Table 4). Delta scores for physical functioning improved after both RYGB and SG, the improvement being greater after SG. Delta scores for bodily pain, social functioning, and role emotional improved in patients with CAP after SG while deteriorated in patients with CAP after RYGB (Table 4 and Fig. 2D). Delta SF-36v2 scores in patients without CAP after RYGB and SG are given in Fig. 2E.
Predictors of CAP
Multiple analyses revealed preoperative hypertension, CAP, and GSRS bothersome reflux symptoms (scores ≥3) as likely predictors associated with postoperative CAP, with odds ratios (95% CI) 2.80 (1.42–5.54), 5.14 (1.92–13.75), and 9.70 (2.60–36.18), respectively (Table 5).
Table 5Analyses of preoperative predictors and the risk of chronic abdominal pain (CAP) 2 years after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG)
As continuous variable in univariate and multivariate analyses. In univariate analyses given as mean with standard deviations. Remaining variables in univariate analyses given as number of patients with percentage.
As continuous variable in univariate and multivariate analyses. In univariate analyses given as mean with standard deviations. Remaining variables in univariate analyses given as number of patients with percentage.
RYGB = Roux-en-Y gastric bypass; CI = Confidence Interval; BMI = Body mass index; CAP = Chronic abdominal pain; GSRS = Gastrointestinal Symptom Rating Scale; HADS = Hospital Anxiety Depression Scale.
Patients with missing data were excluded from the analyses.
Bold = Significant association between the preoperative variable and postoperative chronic abdomina pain (CAP).
∗ As continuous variable in univariate and multivariate analyses. In univariate analyses given as mean with standard deviations. Remaining variables in univariate analyses given as number of patients with percentage.
We found a significant increase in the prevalence of patient-reported CAP after RYGB and SG. The changes in GSRS and HADS scores from baseline to follow-up were significantly different between RYGB and SG for reflux, diarrhea, indigestion syndrome scores, and for depression scores. Among patients with CAP at follow-up, delta scores differed significantly between RYGB and SG for reflux and indigestion syndrome scores. For several QoL delta scores, significant differences were observed between RYGB and SG, for the entire cohort as well as patients with CAP at follow-up.
The more than 2-fold increase in the prevalence of CAP from baseline to follow-up was our main finding. Currently, more studies are focusing on abdominal pain after bariatric surgery indicating increased attention to such symptoms as a clinically relevant outcome [
Self-reported gastrointestinal symptoms two to four years after bariatric surgery. A cross-sectional study comparing Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy.
]. These studies are encouraged as patients with CAP may not necessarily report their symptoms unless they are specifically confronted. Increased focus during follow-up could potentially improve patient outcomes and satisfaction. In the present study, more than half of the patients reported pain once or more a week, but the majority used no pain medication. Patients with CAP after RYGB seemed to be more affected by abdominal pain in daily life and work (Fig. 1F). A previous study found that although a substantial subset of patients reported abdominal pain and fatigue, they also reported improved well-being, thus illustrating the complex interaction between symptoms before and after surgery [
] found in a longitudinal study that GSRS scores increased from before to 2-year after RYGB. Another study found significantly increased GSRS reflux scores after SG and higher abdominal pain scores after RYGB, although this was restricted to postoperative evaluations only [
Self-reported gastrointestinal symptoms two to four years after bariatric surgery. A cross-sectional study comparing Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy.
]. We observed higher mean GSRS reflux and constipation scores after SG and higher mean indigestion scores after RYGB. Delta reflux scores were significantly different between RYGB and SG, both in the entire population, as well as in patients with CAP at follow-up. Our findings indicate that reflux symptoms may be a greater challenge after SG and could contribute to the different characteristics and perception of CAP. The difference in delta scores for diarrhea and indigestion syndromes between RYGB and SG indicate that these symptoms may increase more after RYGB than SG. These findings correlate with previous reports [
Prevalence and impact of acid-related symptoms and diarrhea in patients undergoing Roux-en-Y gastric bypass, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch.
]. In patients with CAP at follow-up, significant delta scores showed that reflux symptoms increased more after SG and indigestion symptoms increased more after RYGB. These associations should be evaluated cautiously as our data are observational and the population is not matched. Patients with abdominal symptoms after SG may respond well to antireflux medications after endoscopic diagnostics, whereas CAP after RYGB may often necessitate diagnostic imaging such as CT scans, ultrasound, and diagnostic laparoscopy [
]. Indigestion symptoms may be related to CAP after RYGB, although causality cannot be manifested in present study.
The CAP was located more frequently in the right upper quadrant after RYGB and in the left upper quadrant after SG. The risk of gallstone formation after RYGB is well known and a frequent cause of abdominal symptoms [
]. Undiagnosed gallstone disease may be related to CAP after RYGB. After SG, there is an increased risk of gastroesophageal reflux symptoms and this may explain the frequent location of pain in the left upper quadrant [
]. Details regarding surgical interventions during follow-up after RYGB and SG are presented in the 2 previous paper describing outcome after RYGB and SG [
We found greater reduction in depression scores after SG. Improved mental health early after surgery during continuous weight loss and improved QoL may be related to lower scores [
]. In patients with CAP at follow-up, no differences were seen in the delta anxiety and depression scores between RYGB and SG. Long-term evaluations of psychological symptoms are needed, as improvements in mental health after bariatric surgery may not be sustained in longer terms. Common symptoms after bariatric surgery, such as dumping and CAP, are associated with depression [
]. These findings need to be evaluated in future studies to explore the relationship between CAP and psychological symptoms. Focus on abdominal symptoms could be relevant in the follow-up of mental health after surgery.
Several studies have compared QoL scores after RYGB and SG and have found comparable improvements [
Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y gastric bypass on weight loss at 5 years among patients with morbid obesity: the SLEEVEPASS randomized clinical trial.
Effect of laparoscopic sleeve gastrectomy vs Roux-en-Y gastric bypass on weight loss and quality of life at 7 years in patients with morbid obesity: the SLEEVEPASS randomized clinical trial.
]. However, in our study, significant differences in several delta scores between RYGB and SG were observed, with greater increase after SG, also among patients with CAP after SG. The greater improvement in several QoL after SG, should be considered carefully as delta score associations between RYGB and SG are observational. Furthermore, the QoL scores differed preoperatively with lower QoL scores in patients with SG. Since the ES’s were small, the clinical relevance of the differences preoperatively is uncertain. Patients opting for RYGB had a higher disease burden, and those opting for SG had higher psychological burden. An interesting note to be tested in future controlled studies.
Attempting to find likely preoperative risk factors of postoperative CAP, we performed multiple logistic regression analyses. As baseline characteristics showed significant differences in age, obesity-related diseases, and previous intra-abdominal surgery between the RYGB and SG groups, these variables were included in the regression analyses (Table 1). The HADS anxiety and depression cut-off scores were included in the model as they may be more clinically relevant than the mean scores. Smoking increases the risk of complications and symptoms after surgery [
]. However, this variable was not included in the model as data were missing among several patients and smoking may be underreported, particularly preoperatively. Preoperative hypertension, reflux symptoms, and CAP were significant predictors of postoperative CAP. Hypertension as risk for postoperative CAP remains challenging to explain and demands further investigation. Contrary to previous reports, young age before surgery did not predict CAP in multivariate analyses, neither did unemployment [
The strengths of this observational study include the relatively large cohort, the low attrition rates, and physical attendance. The extensive use of validated questionnaires and the possibility to compare several symptoms often involved in the complex setting of chronic pain allowed for the evaluations of symptoms from several perspectives. Misclassification bias were reduced by inquiring many of the same symptoms from several perspectives. Responses to the inlet question inquiring about CAP in the last 3 months may introduce recall biases. However, the findings were supported by the 1-week recall GSRS questionnaire for gastrointestinal symptoms. Data on preoperative opioid use at one of the study centers were missing for SG, limiting evaluations of longitudinal use of opioids. The selection of patients for SG may have differed between the 2 study centers. Patients operated at Voss University Hospital were not prescribed Ursodeoxycholic acid. Due to the observational design of the study, we could observe the effect of the exposure (bariatric surgery) on the outcome (CAP). However, the nonrandomized nonmatched approach was a limitation for the comparative analyses. Efforts were made to present the data as descriptive as possible. Multiple regression analysis was used to adjust for confounding but confounding still may influence the associations evaluated otherwise. However, insight to potential associations and trends may have been identified for future studies. We performed multiple tests and sub analyses, what may increase the risk of statistical type I error. Randomized controlled studies are encouraged to assist in further elaboration on our findings.
Conclusion
In our study a significant increase in patient reported CAP was observed after RYGB and SG. The gastrointestinal symptoms profiles differed, with larger changes in reflux syndrome scores after SG and in diarrhea and indigestion syndrome scores after RYGB. These findings were also reflected in patients with CAP after surgery regarding reflux and indigestion syndrome scores. Depression symptoms improved more after SG, but no differences were seen in psychological symptom scores between RYGB and SG in patients with CAP after surgery. Several QoL scores changed differently at 2-year follow-up and in favor of SG, both in the populations at large and in subgroup analyses of patients with CAP.
Acknowledgments
Special thanks to statistician Ole Klungsøyr, Ph.D., for his expertise and assistance.
Disclosures
The authors have no commercial associations that might be a conflict of interest in relation to this article.
Quality of life parameters, weight change and improvement of co-morbidities after laparoscopic Roux Y gastric bypass and laparoscopic gastric sleeve resection--comparative study.
Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y gastric bypass on weight loss at 5 years among patients with morbid obesity: the SLEEVEPASS randomized clinical trial.
Effect of laparoscopic sleeve gastrectomy vs Roux-en-Y gastric bypass on weight loss and quality of life at 7 years in patients with morbid obesity: the SLEEVEPASS randomized clinical trial.
Self-reported gastrointestinal symptoms two to four years after bariatric surgery. A cross-sectional study comparing Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy.
Cut-off points for mild, moderate, and severe pain on the numeric rating scale for pain in patients with chronic musculoskeletal pain: variability and influence of sex and catastrophizing.
Reliability and validity of the gastrointestinal symptom rating scale (GSRS) and quality of life in reflux and dyspepsia (QOLRAD) questionnaire in dyspepsia: a six-country study.
Prevalence and impact of acid-related symptoms and diarrhea in patients undergoing Roux-en-Y gastric bypass, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch.
A constant in the history of metabolic and bariatric surgery (MBS) has been the shift in use of various procedures throughout the decades. Differences in their outcomes have become evident through studies which compared them and ultimately guided their utilization [1]. Now among the safest commonly performed operations, MBS procedures offer an excellent risk-to-benefit ratio for peri-operative (30-day) morbidity and mortality [2]. An interest is now also developing to study the prevalence of long-term effects and how they differ among the modern-day operations.
I would like to congratulate the authors on their article “Chronic Abdominal Pain and Quality of Life After Roux-en-Y Gastric Bypass and Sleeve Gastrectomy – a Cross-Cohort Analysis of Two Prospective Longitudinal Observational Studies” [1]. In this study from Norway, the authors compared the occurrence of chronic abdominal pain (CAP) in patients that underwent laparoscopic Roux-en-Y gastric bypass (RYGB) to patients who underwent sleeve gastrectomy (SG). There were 2 different institutions involved in the study.
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