Symptoms, Hospitalization Common Following Gastric Bypass

Miriam E Tucker

January 11, 2016

Most patients who undergo gastric-bypass surgery report improved postsurgical well-being, despite a high prevalence of symptoms and subsequent hospitalizations, a new study finds.

Results of the analysis of 1429 patients who underwent Roux-en-Y gastric-bypass procedures in Denmark from 2006 to 2011 were published online January 6 in JAMA Surgery by Sigrid Bjerge Gribsholt, MD, of Aarhus University Hospital, Denmark, and colleagues.

While 87% of the patients reported greater well-being after the procedure, 89% reported one or more symptoms in a median of 4.7 years of follow-up, most commonly abdominal pain, dumping syndrome, fatigue, and anemia. Approximately two-thirds had contact with a healthcare professional due to their symptoms, and 29% were hospitalized postsurgically.

The same symptoms were reported by 79% of a comparison group of 89 overweight individuals who did not have surgery, but just under 7% were hospitalized.

Previous studies typically have only examined certain specific complications such as those related to the procedure itself, whereas this study attempted to capture all postbypass complications including medical and nutritional problems, Dr Gribsholt told Medscape Medical News.

"We attempted to investigate more or less all complications that may occur after gastric bypass. Thus, our investigation is more comprehensive than most other studies in this area. We think this reflects worldwide experiences, since we found the prevalence of complications comparable to other studies of these complications individually examined."

Some of the nutritional complications such as anemia, dumping, and hypoglycemia may present with rather unspecific symptoms and may easily be overlooked by primary-care clinicians as complications after gastric bypass, she said, noting, "More education of the GPs may help to diagnose these complications at an earlier stage, which will help the patients, since these complications are generally treatable."

Not Clear if Symptoms Related to Surgery, Weight Loss, or Illness

Asked to comment, Philip Schauer, MD, director of the Cleveland Clinic Bariatric and Metabolic Institute, Ohio, agrees with the finding of improved well-being but disputes the adverse-event results, calling the study methodology into question.

In particular, Dr Schauer faults the use of a small comparison group that was matched to the surgical patients for their postsurgical, rather than presurgical, body mass index (BMI): the baseline median BMI of the surgery patients was 46.4 kg/m2, defined as morbidly obese, whereas after the bypass it was 29.7 kg/m2, placing them in the overweight category.

The comparison group, intentionally matched to the bypass group for BMI and sex, were comparably overweight but not obese, with a median BMI of 29.4 kg/m 2.

Dr Schauer said that the study may have overestimated the symptom rates, since many of them are common before surgery for patients who are morbidly obese and less so in overweight patients. And morbidly obese people are also hospitalized more often.

"Some patients will develop symptoms that may be undesirable and may be caused by the surgical procedure. However, this study doesn't show what symptoms are caused by surgery, what symptoms are caused by underlying chronic illnesses and/or due to morbid obesity, [and] what symptoms are caused by significant weight loss. All of these elements can cause the symptoms highlighted in the study, such as anemia and fatigue," he commented.

In response, Dr Gribsholt said, "Our aim was to examine the differences in symptoms possibly caused by the surgery and not the difference in weight. We….agree that it would have been interesting to have included an obese group compared with the preoperative BMI levels as well, but you then compare two groups with different BMIs. Thus, all designs have limitations."

But Dr Schauer did praise the study's findings regarding improved well-being.

"The first part of their conclusion is good.…I think this study says these people have a chronic disease, lose about 100 pounds, and their quality of life is better than before. Some will have residual symptoms of chronic obesity or may develop new symptoms that may be attributable to surgery. However, despite those symptoms, an overwhelming percentage is better off than before. That's pretty remarkable."

Happy Despite Complications

In March 2014, the investigators mailed study questionnaires to 2238 eligible patients who underwent Roux-en-Y gastric-bypass procedures from 2006 to 2011, identified through the Central Denmark Region's Civil Registration System. Nearly all were performed laparoscopically.

The questionnaire elicited demographic and clinical information, including the Edinburgh Hypoglycemia Scoring System and the Dumping Symptom Rating Scale. Quality of life was assessed via the Mental Composite score and the Physical Composite score of the 12-Item Short-Form Health Survey, which has been validated in the general Danish population.

Of the 1429 patients who responded, 20.0% were male. Median time since bypass surgery was 4.7 years. The current median BMI of 29.7 kg/m2 represented a total weight loss of 35.7%. While matched for BMI and gender, the comparison group was slightly younger (38 vs 47 years).

The most common symptoms reported following bypass among the 1266 who reported symptoms were fatigue in 54%, dumping in 52%, and abdominal pain in 54%. About two-thirds reporting one of those symptoms also reported a second one.

Symptoms leading to any healthcare contact were reported by about two-thirds of those who had bypass surgery, vs one-third of the comparison group. Fatigue, abdominal pain, and anemia were the most frequent postsurgical symptoms that led to any healthcare contact, while dumping and hypoglycemia were less common causes.

Inpatient hospitalizations owing to any symptom after surgery were reported by 29% of those who underwent bypass surgery, vs 7% of the comparison group.

Of the hospitalizations in the bypass group, 79% were attributed to surgical symptoms and 21% to medical and nutritional symptoms.

Symptoms led to healthcare contacts significantly more often in women (prevalence ratio, 1.23), patients with surgical symptoms before bypass surgery (1.34),  unemployed patients (1.15), smokers (1.11), and patients younger than 35 years (1.24). Adjustment for demographic, clinical, socioeconomic, and lifestyle factors did not change the findings significantly.

Overall, 87% of the patients reported feeling better or much better after surgery, while just 8% reported reduced well-being. Those who felt worse had a substantially higher prevalence of symptoms after surgery (P < .001), and quality of life was inversely associated with the number of symptoms (P < .001).

Is Sleeve Gastrectomy Better?

Dr Gribsholt told Medscape Medical News that alternative newer procedures such as the sleeve gastrectomy might offer a lower complication rate, although long-term follow-up data for that procedure are lacking.

Dr Schauer, who has been performing sleeve gastrectomies since 2010, said that the procedure does appear to have a lower complication rate than bypass, but that head-to-head studies find that weight loss and diabetes-remission rates are better with gastric bypass.

"You have to balance higher symptoms with better weight loss," he said, adding, "These operations may not restore the body to completely normal health, but [patients are] better off than they were before."

Dr Gribsholt and colleagues have no relevant financial relationships. Dr Schauer receives research funding from the National Institutes of Health, Ethicon, and Medtronic and consults for Ethicon.

JAMA Surg. Published online January 6, 2016. Abstract

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