GI Complaints Common 2 Years After Gastric Bypass

Miriam E Tucker

December 22, 2016

Patients who undergo laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity often experience gastrointestinal complaints as long as 2 years after the surgery, a new study suggests.

Findings from a cross-sectional comparison of 249 patients who underwent the surgery and morbidly obese controls were published online December 19 in the British Journal of Surgery by Dr Thomas CC Boerlage, of the Academic Medical Center, Amsterdam, and colleagues.

Few studies have followed patients for more than a year post–bypass surgery, even though it's likely that symptoms beyond the first year may change after weight and diet stabilize. Indeed, the current study revealed some unexpectedly common complaints at 2 years, including indigestion, flatulence, and intolerances to certain foods.

"We knew from our clinical experience that many patients experience these complaints after surgery — that is what first brought us the idea for this study. However, we had no clear idea about the exact prevalence and which symptoms would be most prominent. To give one example, we were a little surprised that flatulence is such a big problem," Dr Boerlage told Medscape Medical News.

Nonetheless, he advised, "Clinicians should definitely continue referring eligible patients for gastric bypass. In most cases the health benefits outweigh the side effects by far. However, it helps them to better inform their patients about what to expect after surgery."

But in a commentary, journal editor Kjetil Søreide, MD, PhD, from the department of surgery, Stavanger University Hospital, Norway, had a different take on the findings. "This study reports an alarming number of gastrointestinal complaints after laparoscopic gastric bypass surgery," he says, also pointing out that the study didn't look at the sequelae of the reported problems, such as sick days and drug prescriptions.

"While obesity remains a major health challenge in many countries, this study highlights the factors that need to be considered when consenting patients for treatment and when evaluating the consequences of bariatric surgery," Dr Søreide writes.

At 2 Years: Abdominal Pain, Nausea, Dysphagia, and Flatulence

The 249 subjects had all undergone primary LRYGB from May to October 2013 at a high-volume bariatric center. They were asked 2 years later to complete a validated general health questionnaire, the Gastrointestinal Symptom Rating Scale (GSRS), which was modified to include dysphagia, a common immediate symptom post-LRYGB. The GSRS consists of 16 gastrointestinal symptoms, each scored on a 7-point scale.

Subjects also filled out a food-intolerance questionnaire designed especially for the study, with "food intolerance" defined as any adverse event — such as nausea, dumping syndrome, or abdominal pain — that causes the patient to stop eating the food.

Results were compared with those of 295 morbidly obese people who had not had previous bariatric surgery.

The total mean overall GSRS score was significantly higher in the postoperative group, 2.19 vs 1.76 (P < .001). Individual symptoms scoring significantly higher for the postoperative group compared with controls included abdominal pain, nausea/vomiting, borborygmus, dysphagia, flatulence, and constipation (all P < .001).

On the other hand, both acid regurgitation and hunger pangs were significantly more common among the controls (P = .001 and P < .001, respectively).

Scores on the GSRS did not correlate with either percent total weight lost or current body mass index among the postoperative patients (P = .413 and .081, respectively). Weight loss did correlate with abdominal pain specifically (P = .014), but not with nausea/vomiting (P = .88) or dysphagia (P = .385).

Food Intolerance Common

Food intolerances were reported by 70.7% of the postoperative patients, vs just 16.9% of the controls (P < .001), and median number of food intolerances were four vs two, respectively. For 92% of the postoperative patients, the food intolerance developed after the surgery.

But of the total 176 postsurgical patients reporting food intolerance, only 13.6% reported that the intolerance bothered them much or very much, "so most patients don't seem to suffer very much from the complaints," Dr Boerlage noted.

The most commonly reported nontolerated foods among the postoperative patients were fried products, carbonated drinks, and cakes/pies/pastries, in 30%, 28%, and 23%, respectively. Whipped cream, chocolate, and red meat intolerance were each reported by about one in five subjects. Of particular concern, according to Dr Søreide, were the 8% who reported intolerance to water.

Among the controls, the most commonly reported intolerances were to milk and fried foods (4.4% for both).

There were no relationships between percent total body weight lost or current body mass index (BMI) and the presence of food intolerance or number of food intolerances, but the total mean GSRS score did correlate with the presence of food intolerance and with the number of food intolerances (P = .006 and P < .001, respectively).

In addition, patients with intolerance to red meat scored higher for dysphagia (P = .001).

Do the Benefit Outweigh the Risks?

Dr Boerlage told Medscape Medical News, "For the clinician, this study provides a framework regarding which complaints can be considered 'normal' and 'abnormal' after surgery. This helps in clinical decision making, for example when a patient has certain complaints and the clinician has to decide whether or not to order further examinations."

He added, "Not all symptoms can be prevented, but in general it is advisable for patients to stick tightly to the dietary guidelines that are given after surgery."

But Dr Søreide pointed out, "Not reported here were the number of added hospital admissions, outpatient visits, and further endoscopic and imaging investigations caused by symptoms after the surgery. Also, days of sick leave, number requiring disability pension, as well as prescriptions of drugs, including painkillers, need to be investigated to gather a full picture of the health effects of bariatric surgery."

Dr Boerlage responded, "I think the editor's comment is a good summary of the content and implications of our study, and I agree that further research into the healthcare consumption due to obesity and bariatric surgery is essential. In fact, we will soon start a large clinical trial in which a cost/benefit analysis of several aspects of bariatric surgery is also made."

His group is also currently working on a longitudinal study to confirm these GI symptom findings, as well as several studies examining potential mechanisms, including possible roles for lactose intolerance or intestinal bacteria.

Also needed, Dr Boerlage said, are studies looking at long-term symptoms following other bariatric-surgery procedures, including the newer sleeve gastrectomy and the mini (or "omega-loop") gastric bypass. "Studies into the long-term side effects of these procedures are essential.…Although different symptoms might be more prominent with these procedures, I am fairly certain that these give gastrointestinal complaints as well."

The study authors and Dr Søreide have no relevant financial relationships.

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Br J Surg. Published online December 19, 2016. Abstract

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