Good to excellent Quality of Life in patients suffering from severe obesity post bariatric surgery - A single-center retrospective study report using BAROS Questionnaire.

CONTEXT: Despite the positive outcomes reported in terms of weight loss and resolution of co-morbidities, the impact of bariatric surgery on patient-reported outcomes of quality of life (QoL) still remains scarce, particularly in the Indian population. The present study was conducted to evaluate the efficacy of laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB) procedures in patients with severe obesity over a period of 2 years in terms of weight loss, resolution of comorbidities, safety and changes in QoL using the Bariatric analysis and reporting outcome system (BAROS). SUBJECTS AND METHODS: The data of 100 patients who underwent RYGB and LSG between March 2014 and December 2017 were analyzed. The study endpoints such as QoL, major and minor complication rates, co-morbidity resolutions and the percentage of excess weight loss (%EWL) were measured using the Moorehead-Ardelt BAROS questionnaire II.
RESULTS: At a follow-up point of 2 years, patients achieved a mean %EWL of 79.2 (±28.9) % and the mean postoperative body mass index decreased to 31.7 (±6.22) kg/m2. No major complications were reported to have occurred. Excellent global BAROS outcome was obtained in 20% of patients, very good in 47%, good in 29%, fair 2% and failure in 2% patients 24 months post-surgery. The mean BAROS score was 5.8 ± 1.73, and a 'good' to 'excellent' QoL outcome was observed in 96% of patients.
CONCLUSION: RYGB and LSG are safe and effective bariatric procedures. These procedures provided substantial results in good to excellent health-related QoL, weight loss and medical conditions.

INTRODUCTION

The obesity pandemic is a public health concern worldwide. Rising obesity prevalence rates have led to a surge in the demand for bariatric surgeries (BS) since it is the only method to provide satisfactory long-term excess weight loss (EWL), compared with nonsurgical interventions alone.[1] BS procedures have proved to generate significant improvements in patients with severe and complex obesity, leading to substantial weight loss, minimising co-morbidities, post-operative complications and prolonging survival.[23] However, the association of BS on psychosocial outcomes is less clear in these patients. Thus, it is essential to evaluate the predictors of a higher quality of life (QoL) after bariatric surgery from a short- to long-term perspective as this procedure modifies many parameters than weight alone.

In addition to measuring standard clinical outcomes, the primary objective of BS procedures in the treatment of obesity is to achieve long-lasting improvement in the QoL.[4] QoL is one of the most important criteria to determine about patient's well-being after BS. It is a relevant criterion in the evaluation of surgical treatment because it shows both physical and mental health of the patient. The assessment of QoL primarily involves the patient-reported measurements, thus making it crucial, as the patient perspective could help to assess valuable information that cannot be obtained solely through the clinical outcome metrics. Till date, several methods have been introduced to evaluate the outcomes of BS with an emphasis on providing unique grading to individuals. Bariatric analysis and reporting outcome system (BAROS) is one of the most acceptable methods in evaluating bariatric QoL and to reinforce the continuity of care following bariatric surgery.[5]

Introduced by Oria and Moorehead at the 2nd congress of the International Federation for the Surgery of Obesity, BAROS offers a standard method for comparing distinct bariatric procedure outcomes using a simple, effective and objective method in an evidence-based fashion.[67] BAROS is a simple scoring system comprising of mainly three points: percentage of EWL, variations in medical conditions and evaluation of the QoL parameters such as changes in self-esteem, physical activities, social relationships, work performance and sexual activity. Several institutional-based studies reported significant outcomes by using BAROS, with a follow-up duration of 1–2 years.[89] However, in the Indian scenario, studies assessing QoL outcomes using the BAROS scores are scarce with limited literature. To the best of our knowledge, this study could bring additional value to compare BAROS scores and to establish whether individual obesity-related patient-reported outcomes of QoL are associated with suboptimal outcomes.

The purpose of this study, which is unique of its own in the Indian population, is to evaluate the impact of Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) procedures in patients suffering from severe obesity over a period of 2 years by analysing the three domains of the BAROS scoring system with the intention of assessing our patients not only from the EWL point of view but also with respect to their QoL, before and after bariatric surgery.

SUBJECTS AND METHODS

This is a single centre, retrospective and descriptive analytical study. A total of 100 patients suffering from severe obesity and who have had a bariatric surgery procedure between March 2014 and December 2017 were included in the study. All patients were followed up over a time point of 2 years. All surgical procedures were performed according to the standard techniques by a team of experienced surgeons. Informed consent form was obtained in a written format from all the participants before the study. This study was carried out according to the principles of the Helsinki declaration. Data were collected through the institutional database which includes patient demographic data, past medical history, co-morbidities, weight, body mass index (BMI), complication rates and follow-up.

A BAROS questionnaire, based on specifications proposed by Oria and Moorehead, was used to assess and evaluate the post-operative outcome measures such as loss of excess weight, improvement in medical conditions and QoL.[1011] The self-perceived QoL chart was measured based on five key areas such as self-esteem, physical activities, social life, work conditions and interest in sexual activity.

The protocol and all other applicable documents were approved by the ethical committee (Ref No./01/KD/IEC/2020).

Statistics

All the data were analysed using the IBM SPSS Statistics for Windows, Version 20.0. (Armonk, NY: IBM Corp.). Descriptive statistics of continuous variables were presented as mean ± standard deviation (SD), and categorical data were presented as median, range and frequencies. The Shapiro–Wilk test was used to test the normality of distributions. Statistical evaluations were performed using the independent sample t-test to find the differences in the outcomes according to type of surgery. P value below 0.05 was considered to indicate statistical significance.

RESULTS

One hundred respondents, comprising 36 male and 64 female were enrolled in this study. The mean age was 48.7 ± 15.58 for males and 49.6 ± 15.52 for females. The overall mean age is 49.3 ± 15.47 and the range is 17–75 years. The mean pre-operative BMI was 48.9 ± 9.41 kg/m2, and the gender and age characteristics of the study group are represented in Table 1. No previous bariatric operation was reported in none of these patients. All patients were followed up over a period of 2 years from their date of surgery for BAROS measurements.

Table 1

Baseline characteristics, pre-operative and post-operative clinical variables of the patients (n=100)

	Mean±SD/n (%)	Range
Age (years)	49.3±15.47	17-75
Gender
Male	36 (36)
Female	64 (64)
Pre-BMI (kg/m2)	48.9±9.41	308-7.5
Pre-operative
Hypertension	65 (65)
Diabetes mellitus	27 (27)
OSA#	6 (6)
Follow-up time (months)	24
Post-operative
Type of surgery-RYGB	60 (60)
Type of surgery-sleeve	40 (40)
Post-operative BMI (kg/m2)	31.7±6.22	21.95-8.64
EWL % (kg)	79.2±28.92	−17.65-192.31
Change in BMI (kg/m2)	17.2±7.47	−1.64-54.74
Change in BMI percentage	34±10.07	−5.48-70.54

RYGB: Roux-en-Y gastric bypass, SD: Standard deviation, BMI: Body mass index, OSA: Obstructive sleep apnoea, EWL: Excess weight loss

Sixty patients underwent RYGB procedure, whereas forty patients underwent LSG. Females were significantly higher among RYGB (58.3%) and LSG (72.5%) groups compared to 41.7% of males in RYGB and 27.5% in LSG. However, the difference between these two procedures was found not to be statistically significant, hence BAROS scores from the individual procedures will not impact the overall significance of BAROS score [Table 2].

Table 2

Comparison of different bariatric analysis and reporting outcome system measurements according to type of surgery

Characteristics	RYGB		Sleeve		P
	Mean±SD	95% CI	Mean±SD	95% CI
EWL % points	2.5±0.77	0.99-4.01	2.5±0.64	1.25-3.75	1
Medical condition point	1.2±1.22	−1.19-3.59	1.4±1.22	−0.99-3.79	0.463
QoL scores	2±0.82	0.39-3.61	2±1.07	−0.1-4.1	0.661
Total BAROS score	5.8±1.63	2.61-8.99	5.9±1.9	2.18-9.62	0.779
Change in BMI	17.4±7.81	2.09-32.71	16.9±7.01	3.16-30.64	0.752
Change in BMI percentage	34.4±11.13	12.59-56.21	33.5±8.29	17.25-49.75	0.639

BAROS: Bariatric analysis and reporting outcome system, EWL: Excess weight loss, BMI: Body mass index, SD: Standard deviation, CI: Confidence interval, RYGB: Roux-en-Y gastric bypass, QoL: Quality of life

At a follow-up period of 2 years, the patients achieved a mean BMI of 31.7 ± 6.22 which was statistically significant (Pair t-test for pre- and post-operative BMI, P < 0.05). The mean %EWL was measured as 79.2 ± 28.92, respectively. The average weight loss after RYGB and LSG procedures was compared using independent sample t-test before and after the surgery which revealed a substantial weight reduction in the study group [Table 1].

Regarding obesity-related co-morbidities, hypertension, diabetes mellitus and obstructive sleep apnoea (OSA) have been reported by few patients. The prevalence rate of hypertension is 65%, whereas the prevalence of diabetes mellitus is 27% and OSA is 6% in the study group, respectively. Compared with hypertensive patients, non-hypertensive patients showed better results in terms of %EWL and QoL improvements. On the other hand, medical condition points and total BAROS scores were coming out to be significant for patients with pre-operative hypertension. Medical conditions of individuals suffering from diabetes showed significant improvement after bariatric surgery, whereas irrespective of pre-operative OSA condition, the results were found to be statistically insignificant in the two groups.

With regard to QOL, patients reported feeling very positive post-surgery. Larger number of these patients reported enhancement of their self-esteem, social and family activities, physical activities, working ability and sexual interest and the mean scores for how patients feel about themselves were significantly increased after RYGB and LSG [Table 3]. Comparing all the results for BAROS outcomes, we achieved good results in 29 participants, very good in 47 and excellent results in 20. However, two have a fair result and two are classed as a failure. The mean age for very good outcome patients’ was coming out to be 48.1 years, whereas 71 years were the mean age for the patients in fair outcome. The outcome for gender was not coming out to be statistically significant (Chi-square test, P = 0.71 > 0.05).

Table 3

Comparison of bariatric analysis and reporting outcome system score according to different bariatric analysis and reporting outcome system parameters

BAROS outcome points	Mean±SD
	Failure (n=2)	Fair (n=2)	Good (n=29)	Very good (n=47)	Excellent (n=20)
Self-esteem	0±1.41	0.8±0.35	0.7±0.32	0.8±0.36	0.9±0.21
Physical activities	−0.3±0.35	0.1±0.18	0.3±0.27	0.5±0.67	0.4±0.15
Social relationships	−0.3±0.35	0±0.35	0.3±0.25	0.4±0.2	0.4±0.14
Work ability	−0.3±0.35	0.1±0.18	0.3±0.24	0.3±0.23	0.4±0.14
Interest in sex		0.1±0.2	0.2±0.24	0.2±0.19
EWL points	0.5±2.12	1.5±0.71	2.2±0.71	2.7±0.52	2.9±0.37
Medical condition points	0.5±0.71	0.4±0.63	1.2±1.06	3±0.22
QoL points	−0.8±2.47	1±0	1.7±0.84	2.2±0.78	2.3±0.57
Total BAROS score	0.3±0.35	2.5±0.71	4.3±0.59	6.1±0.6	8.1±0.6

BAROS: Bariatric analysis and reporting outcome system, EWL: Excess weight loss, SD: Standard deviation, QoL: Quality of life

DISCUSSION

RYGB and LSG are among the very well-established bariatric surgery procedures. Very few large series studies reported the outcomes of bariatric surgery, and the outcomes for LSG in particular, are difficult to compare due to the usage of multiple outcome measures and assessment instruments.[1213] The present study explored whether LSG compared with the RYGB is equally effective in, weight loss, remission of comorbidities, surge in QoL and whether the two procedures are equally safe in the long-term outcome. The outcomes following bariatric surgery in routine clinical practice were assessed using the BAROS questionnaire. BAROS offers a comprehensive assessment of the outcome than the use of %EWL on its own including QoL, resolution of co-morbidities and complications as well.[614]

Weight loss

Degree of weight loss is also correlated with the improvement in QoL, and it is known that RYGB and LSG are associated with favourable effects on weight loss.[1516] In our study, after a period of 2 years, a significant weight reduction in terms of %EWL is achieved. Patients showed mean %EWL of 79.2 (±28.92) and BMI reduction of 17.2 (±7.47). These findings are similar to a recent meta-analysis study which reported the BMI reduction of 14.5 and mean %EWL of 74.4% in randomised controlled studies of patients who received gastric bypass after a follow-up of 2-year.[1718]

Variations in medical conditions

Improvement of co-morbid conditions associated with obesity is considered as the most crucial parameter in the success of bariatric treatment. According to the BAROS system, which sum up weight loss, correction of co-morbidities and improvement of QoL, results were considered excellent by 20% of patients, very good by 47% and good by 29%. Overall, the majority of patients (96%) demonstrated results ranging from good to excellent. The mean BAROS score was 5.8 ± 1.73 at a follow-up point of 24 months. Only 4% in total were classified as failures and fair.

These results are consistent with the data of other similar studies suggesting that RYGB and LSG bariatric surgery is associated with durable weight loss, significant resolution of co-morbidities and improvement in QoL reassuring patients, surgeons and local health-care providers.[10111920] In our study, the overall mean BAROS score is reported to be 5.8 ± 1.73 SD which represents that the results are ‘very good’ in both RYGB and LSG procedures providing significant better yield in terms of weight loss and overall QoL. No major complications requiring reoperation were observed in this study.

Quality of life assessment

BAROS system is the preferred system used by surgical teams to analyse QoL variables in the follow-up of bariatric patients. Despite gender, participants in our study scored a mean of 2.0 (SD = 0.92) in the items of QoL indicating that gender had no influence on QoL outcomes [Table 4]. This results are similar to those presented in the latest literature.[19] In accordance with the BAROS scalar ranking for QoL evaluation, major number of our patients reported significant positive changes in QoL with regard to self-esteem, social involvement, physical activity, working ability and the interest in sex domains.

Table 4

Results showing total score of bariatric analysis and reporting outcome system

Gender	BAROS EWL %	BAROS QoL	BAROS medical conditions	BAROS complications	Total BAROS
Men (n=36)	2.7±0.57	2.0±1.12	1.2±1.33	0.28±0.45	5.9±1.81
Women (n=64)	2.4±0.77	2.0±0.8	1.3±1.16	0.16±0.37	5.7±1.69
Total (n=100)	2.5±0.72	2.0±0.92	1.3±1.22	0.20±0.40	5.8±1.73
Independent t-test (P)	0.019	0.91	0.68	0.15	0.55

EWL: Excess weight loss, BAROS: Bariatric analysis and reporting outcome system, QoL: Quality of life

However, it is wise to detail some of the study limitations: Retrospective nature of the study comes with inherent bias. Another limitation is the small sample size with short-term follow-up. Putative characteristics of patients which includes fat mass, psychiatric state, education levels, physical activity and ethnicity were not recorded that may impact results concerning weight loss and QoL. In addition, the male participants in the present study were significantly smaller compared to the female participants, and a follow-up of longer period would be specially emphasised to determine the firmness of the results.

CONCLUSION

We conclude that the presented series of RYGB and LSG results shows that these procedures provide an acceptable percentage with regard to weight reduction and good global BAROS outcomes. LSG and RYGB are found to be equally effective and safe bariatric procedures at a 2-year follow-up with an improved QoL in Indian patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.