First Experience in Quality of Life Analysis After Bariatric Surgery

Transcription

1 DOI: /v ACTA CHIRURGICA LATVIENSIS 2009 (9 ) ORIGINAL ARTICLE First Experience in Qulity of Life Anlysis After Britric Surgery Arturs Ozolins*,**, Mris Pvrs*, Jnis Grdovskis*,** *Deprtment of Generl Surgery, Puls Strdins University Hospitl, Rig, Ltvi **Rig Strdins University, Ltvi Summry Introduction. The prevlence of obesity hs incresed mrkedly in the pst 20 yers therefore, britric surgery plys n importnt role in obesity tretment. Aim of the study. The im of this study ws to evlute the efficcy of Lproscopic djustble gstric bnding (LAGB) nd it influence on ptients qulity of life (QOL) in the mngement of morbid obesity. Mterils nd methods. 18 ptients with morbid obesity underwent LAGB procedure t the Pul Strdins Clinicl University Hospitl, Rig, Ltvi. Dt collected were: ge, sex, weight, height nd opertion time, body mss index (BMI), excessive body weight (EBW) nd comorbidities. Ptients fulfilled generl Short Form Helth Survey with 36 questions before opertion (), 6 month (b) nd 12 month (c) fter opertion. License ws cquired for SF-36v2 use in the study. Results. The men ± SD ge of ptients ws 42.5 ± 11.8 yers (25-63) with 83.3% of them femle. The men ± SD weight ws ± 20.3 kg ( ), men ± SD height ± 9.4 cm ( ) nd men BMI 46.2 ± 6.6 kg/m2 ( ). The men ± SD weight t 6 month follow up ws ± 17.8 kg (p=0.001). The postopertive men BMI t 6 month follow up ws ± 6.1 kg/m2 (p=0.001). The men percentge of excessive body weight (EBW) loss t 6 months ws 30.4%. QOL life ws higher fter opertion (b, c) compring to preopertive dt (), but there were no sttisticlly significnt difference in ny of the scles Conclusions. The efficcy of LAGB surgery in long-term is still uncertin, but our erly results re comprble to other series. To determine the true efficcy of LAGB in weight control nd impct on QOL, longer follow-up period is necessry, more cses to nlyze nd dt from control group of generl popultion. Our findings suggest tht life qulity questionnire SF-36v2 is good tool to mesure ptient s qulity of life before nd fter opertion, to discuss effectiveness of opertions techniques nd to observe qulity of life dynmics. Key words: lproscopic djustble gstric bnding, LAGB, QOL, SF-36, obesity. INTRODUCTION The prevlence of obesity hs incresed mrkedly in the pst 20 yers, becoming mjor public helth issue (18, 19, 26). According to the World Helth Orgniztion, overweight is defined s body mss index (BMI), ie weight (kg)/[height (m)] 2, of greter thn 25 kg/m 2, wheres obese is defined s BMI of greter thn 30 kg/m 2 (29). Obesity surgery is currently one of the most frequently performed surgicl procedures in the USA nd Europe with stedily incresing numbers (15). It is well-known tht the higher one s BMI vlue, the higher his or her mortlity wherewith mny obesityrelted comorbidities hve been documented (2, 8). The helth risks of obesity include coronry rtery disese, hypertension, dibetes, gllstones, cncer, orthopedic problems, sleep pnoe nd generl debility (4). Morbid obesity, defined s BMI of greter thn 35 kg/ m 2, occurs in 2% to 5% of the popultion of Europe, Austrli, nd the USA, nd it is becoming incresingly common (1, 24). Despite nonsurgicl tretment of obesity such s behviorl nd phrmcologic methods hve been proved to hve n effect on short-term weight loss of pproximtely 5 to 10% of body weight (7), these methods re not very effective on long-term resolution of excesive body weight nd its relted comorbidities. Therefore, britric surgery plys n importnt role in obesity tretment (6, 12). Nowdys mny surgeons hve lerned to perform this type of surgery lproscopiclly rther thn using n open pproch (22). Currently LAGB nd the lproscopic Roux-en-Y gstric bypss re the most widely used methods for obesity tretment (16). LAGB which ws introduced in erly 1990s offers the dvntges of minimlly invsive surgery, djustbility, nd reversibility. This purely gstric restrictive procedure involves the use of n djustble silicone bnd plced round the gstric crdi, which cretes smll gstric pouch (15 ml) with nrrow outlet. We used Ethicon Endo-Surgery LGB12 Adjustble Gstric Bnd nd Gstric Clibrtion Tube GCT-360. To dte, comprtive studies re minly looking t clinicl dt of weight loss, chnge of comorbidities nd morbidity (27), but only few comprtive studies on helth-relted qulity of life exist (10, 28). QOL is relevnt prmeter in evlution of surgicl tretment becuse it perfectly shows physicl s well s mentl helth of the ptient nd it is one of the most importnt criteri to judge bout ptient s well being fter opertion. 16

2 ACTA CHIRURGICA LATVIENSIS 2009 (9) AIM OF THE STUDY The im of this study ws to evlute the efficcy of lproscopic djustble gstric bnding nd it influence on ptients QOL in the mngement of morbid obesity. MATERIALS AND METHODS Between 1 Jnury 2008 nd 1 My 2009, totl of 18 ptients with morbid obesity underwent LAGB procedure t the Pul Strdins Clinicl University Hospitl, Rig, Ltvi. Ptients were considered s cndidtes for opertion if the following conditions were met: ged between 18 nd 65 yers, BMI of greter thn 40 kg/m 2 or greter thn 35 kg/m 2 with serious comorbidities, no excessive intke of sweets or lcohol. All ptients hd history of obesity for more thn 5 yers nd hd filed conservtive mngement such s diet, behviorl therpy, nd phrmcotherpy in the pst. Obesity-relted comorbidities ws present in 55.5% of ptients, which included 3 ptients with dibetes mellitus (DM), 6 ptients with hypertension, 6 ptients with joint nd spine pin, nd 1 ptient with dyspnoe. Exclusion criteri included previous gstric surgery, lrge hitl herni, nd history of lcohol ddiction nd poorly controlled non-obesity-relted medicl diseses. This study ws pproved by the Ethics Committee of Pul Strdins Clinicl University Hospitl. Written consent ws given by ll ptients. Opertive procedure. A high-dose low-moleculr-weight heprin ws given in the morning of opertion, nd n ntibiotic prophylxis ws given during induction. The opertion ws performed under generl nesthesi. The ptient ws in the reverse Trendelenburg position with the legs extended in stirrup, nd the operting surgeon ws stnding between the ptient s legs. A five-trocr technique ws used with 15-mm port to llow insertion of the gstric bnd into the peritonel cvity. After the liver ws retrcted with lproscopic retrctor, the prs flccid technique ws performed (30). The dissection begn t the bse of the left crus well bove the first short gstric rtery to free the ngle of the His of the stomch. Following the opening of the left phrenoesophgel ligment, the gstro-heptic ligment (prs flccid) ws divided, nd blunt dissection ws performed to crete pssge between the diphrgmtic pillrs nd the posterior spect of the gstro-oesophgel junction. The empty bnd ws then inserted through the 15-mm trocr nd pulled through the retrogstric tunnel with the help of the Goldfinger dissector. Once the bnd ws locked in plce, the device ws nchored nteriorly by three gstrogstric stitches with non-bsorbble sutures. The fundus of the stomch below the bnd ws stitched to the gstroesophgel junction completely covering the nterior spect of the bnd to prevent hernition of the fundus. After the bnd ws secured, seprte incision ws mde just bove the xiphoid, nd the port ws connected nd sutured subcutneously to the presternl fsci (29). In the postopertive course, ll the ptients received contrst study of the esophgus nd stomch 1 dy fter procedure. The ptients were dischrged s soon s sufficient orl fluid nd soft food intke ws possible. For ll ptients, the dt collected were ge, sex, weight, height nd opertion time, BMI, excessive body weight (EBW) nd comorbidities. At two points in time, ptients were weighed, nd BMI ws clculted. The first mesurement ws tken before surgery nd the second 6 month fter opertion. Ptients fulfilled generl SF-36v2 Short Form Helth Survey with 36 questions before opertion (), 6 month (b) nd 12 month (c) fter opertion. License ws cquired for SF-36v2 helth survey questionnire use in the study. Questionnire consists of interntionlly ccepted SF-36v2 helth reserch protocol which set so tht minimum psychometricl stndrd prmeters which re not specific neither to ge nor illness or tretment method where included (9). Acquired dt entered into the dt bse nd sttisticl processing ws mde. After dt processing eight helth concepts is possible to mesure: physicl functioning PF, role physicl - RP, bodily pin - BP, generl helth GH, vitlity VT, socil functioning SF, role emotionl RE, mentl helth MH. For scles the highest possible score of 100 is chieved when no limittions or disbilities re observed. Missing vlues in the SF-36v2 were replced by men individul scores, s recommended in the mnul. 3 helth scles (PF, RP, nd BP) with sttisticl significnce mesure physicl helth but ech of them describes different spects: physicl functioning (PF) mesure limittion in physicl ctivities; role physicl (RP) - inbility to do everydy ctivities due to physicl problems; bodily pin (BP) focuses on physicl pin. Mentl component consist of MH, RE nd SF prmeters: socil functioning (SF) nd role emotionl (RE) shows limittions due to personl or emotionl problems; mentl helth (MH) indictes psychologicl stress symptoms. Generl helth (GH) nd vitlity (VT) scles re sensitive on physicl nd mentl helth. Vitlity (VT) chrcterises tiredness or joy of living. Twelve month fter opertion ptients nswered lso to specific questions relted to opertion result. For cquiring dt nd further processing ABBYY FormReder 6.5, QulityMetric Helth Outcomes Scoring Softwre 2.0, SPSS 16.0 nd Microsoft Excel progrms were used. For nlysis, the presence of the questionnires t the three points in time ws required. For nlysis, the nonprmetric Friedmn K-relted smples test ws used, s vribles were not normlly distributed. Sttisticl significnce ws defined s p<0.05. To nlyze QOL between 2 surveys we used Wilcoxon Signed Rnks test. RESULTS Eighteen ptients were enrolled in the study. The men ± SD ge of ptient ws 42.5 ± 11.8 yers (25-63) with 83.3% of them femle. The men ± SD weight ws ± 20.3 kg ( ), men ± SD height ± 9.4 cm ( ) nd men BMI 46.2 ± 6.6 kg/m 2 (

3 ACTA CHIRURGICA LATVIENSIS 2009 (9 ) 58.8). The demogrphic nd clinicl chrcteristics of 18 ptients with morbid obesity re summrized in Tble 1. Medin operting time ws 100 minutes ( minutes) nd ll cses were successfully performed without open conversion. The medin hospitl stys 3 dys (2 4 dys). The men ± SD weight t 6 month follow up ws ± 17.8 kg (p=0.001). The postopertive men BMI t 6 month follow up ws ± 6.1 kg/m 2 (p=0.001). The men percentge of excessive body weight (EBW) loss [% EBW loss=weight loss/(initil body weight idel body weight t BMI 25) x 100%] t 6 months ws 30.4%. The results re summrized in Tble 2. There were no intropertive complictions nd no blood trnsfusion ws needed. We nlyzed qulity of life using SF-36v2 Short Form Helth Survey before opertion (), 6 weeks (b) nd 6 month fter opertion (c). To nlyze QOL dynmics we used Friedmn test nd evidently QOL life ws higher fter opertion (b, c) compring to preopertive dt (), but there were no sttisticlly significnt difference in ny of the scles (Figure 1). Using Wilcoxon Signed Rnks test we nlyzed QOL between 2 surveys: c-, c-b, b-, nd there were no sttisticlly significnt improvement in ny of the scles. With the center-specific questionnire 12 month fter opertion, the ptients were sked how stisfied they were with results of the opertion. Of the ptients, 100% stted to be stisfied with the opertion. However two from five ptients wish to hve greter weight reduction. All ptients reported to hve increse in their QOL nd could recommend this type of opertion to others. DISCUSSION Obesity is becoming worldwide phenomenon. Since the first jejuno-ilel bypss performed by Kremer nd Linner in 1960s, vrious pproches nd procedures hve been developed to del with obesity. Surgicl tretment hs hd n estblished role in the mngement of morbid obesity. The criteri for selecting ptients for britric procedures re bsed minly on the BMI definition of obesity s recommended by the World Helth Orgniztion. Numerous comprtive studies for the tretment of morbid obesity hve been done, but the britric procedure of choice is still under debte. Mlbsorptive procedures, such s jejuno-ilel, biliopncretic, or gstric bypss llow the ptient to lose weight while eting (20). The Roux-en-Y gstric bypss hs recently been dpted for use with lproscopy, chieving n cceptbly low rte of complictions (3.3% mjor nd 27% minor) nd n excellent weight loss of t lest 60% EBW (21). However, this procedure is both difficult nd lengthy (2 to 3 times longer thn our procedure), nd complictions, such s nstomotic filure nd intestinl obstruction, re potentilly lethl. Restrictive procedures like LAGB induce slow gstric emptying vi smll pouch nd crete erly stition llowing 40% to 50% reduction in the excess weight in 1 to 2 yers (17). An djustble gstric bnding (AGB) device which ws introduced by Kuzmk (11) hs been dopted nd nowdys is widely used in Europe, Austrli, nd the US. Min dvntges of AGB include its simplicity, reversibility, the djustbility of the bnd s stom size. In the medicl literture, the SF-36 questionnire is widely used nd well vlidted in ll types of studies s well s in the obesity literture (3). Severl studies suggest tht qulity of life is improved by britric procedures in generl nd tht bypss ffects the clinicl spects of weight loss nd comorbidities more positively thn the bnding procedure (13, 25, nd 27). In comprtive study of lproscopic bnding vs Rouxen-Y gstric bypss Muller et l. ssessed the QOL using SF-36 nd Moorehed-Ardelt II (MA II) questionnire nd found tht ptients fter lproscopic gstric bypss nd lproscopic gstric bnding hve good qulity of life, s mesured by the MA II. This finding ws reinforced by the SF 36 tht lso demonstrted postopertive qulity of life scoring similr to norml vlues. Qulity of life indexes were not different between the two opertion procedures, s long s the bnding procedure ws successful without conversion to nother procedure in the long term (15). Sers et l. in his study hs shown tht significnt weight loss is chieved fter gstric bypss surgery nd tht there is significnt improvement in both qulity of life scores nd obesity-relted conditions (23). Mui et l. in prospective study evluted the outcome of intrgstric blloon (IGB) on weight loss nd the impct of it on obesityrelted illnesses nd qulity of life. He ws ble to show tht IGB improves seven out of eight domins nd both physicl nd mentl component of qulity of life of SF- 36. It is very vlid option for those who do not opt for or not suitble for britric surgery (14). Chng et l. in his study included helthy control subjects nd found tht QOL for ptients with morbid obesity in Tiwn is worse thn for those of generl popultion nd if BMI level is bove 32 then lower re the domin scores (4). In the pst decde, the LAGB technique hs improved with n estimted ptients hving hd this procedure (5). The LAGB procedure coupled with the incresed experience of the surgeon seems to minimize the chnces of compliction. In our study of the LAGB for the tretment of morbid obesity we nlyzed QOL outcomes s well s weight reduction. In our series, we chieved men excessive weight loss of 30.4% in the 6 month period which is comprble to results published in literture. 6 month nd 12 month fter opertion compred to preopertive dt, QOL improved in ll the scles of SF-36v2 but it ws not sttisticlly significnt due to smll number of cses. To determine the true efficcy of LAGB in weight control nd impct on QOL, longer follow-up period is necessry, more cses to nlyze nd dt from control group of generl popultion. 18

4 ACTA CHIRURGICA LATVIENSIS 2009 (9) CONCLUSIONS For morbidly obese ptients weight reduction surgery is the only proven method for long-term weight control. The efficcy of LAGB surgery in long-term is still uncertin, but our erly results re comprble to other series. The lproscopic pproch llows erly mobilistion, short hospitl sty, erly return to work, nd fewer wound complictions. This reversible nd dptble procedure promises to be good lterntive to other britric surgeries, provided tht the morbidity rte remins low. Multidisciplinry tem consisting of physicin, nutritionist, surgeon, together with the psychologist is essentil in tretment of obese ptients. Our findings suggest tht life qulity questionnire SF-36v2 is good tool to mesure ptient s qulity of life before nd fter opertion, to discuss effectiveness of opertions techniques nd to observe qulity of life dynmics. Conflict of interest: None REFERENCES 1. Abrhm S, Johnson CL. Prevlence of severe obesity in dults in the United Sttes // Am J Clin Nutr, 1980; 33(2 Suppl): Adms KF, et l. Overweight, obesity, nd mortlity in lrge prospective cohort of persons 50 to 71 yers old // N Engl J Med, 2006; 355(8): Bllntyne GH. Mesuring outcomes following britric surgery: weight loss prmeters, improvement in co-morbid conditions, chnge in qulity of life nd ptient stisfction // Obes Surg, 2003; 13(6): Chng CY, et l. Helth-relted Qulity of Life in Adult Ptients with Morbid Obesity Coming for Britric Surgery // Obes Surg, 2008; [Epub hed of print] 5. Cottm DR, Mttr SG, Schuer PR. Lproscopic er of opertions for morbid obesity // Arch Surg, 2003; 138(4): Dvis MM, et l. Ntionl trends in britric surgery // Arch Surg, 2006; 141(1):71-4; discussion Delinsky SS, Ltner JD, Wilson GT. Binge eting nd weight loss in self-help behvior modifiction progrm // Obesity (Silver Spring), 2006; 14(7): Flegl KM, et l. Excess deths ssocited with underweight, overweight, nd obesity // JAMA, 2005; 293(15): Guytt GH, Feeny DH, Ptrick DL. Mesuring helth-relted qulity of life // Ann Intern Med, 1993; 118(8): Hell E, et l. Evlution of helth sttus nd qulity of life fter britric surgery: comprison of stndrd Roux-en-Y gstric bypss, verticl bnded gstroplsty nd lproscopic djustble silicone gstric bnding // Obes Surg, 2000; 10(3): Kuzmk LI. A Review of Seven Yers Experience with Silicone Gstric Bnding // Obes Surg, 1991; 1(4): Mggrd MA, et l. Met-nlysis: surgicl tretment of obesity // Ann Intern Med, 2005; 142(7): Mognol P, Chosidow D, Mrmuse JP. Lproscopic gstric bypss versus lproscopic djustble gstric bnding in the super-obese: comprtive study of 290 ptients // Obes Surg, 2005; 15(1): Mui WL, et l. Impct on Obesity-Relted Illnesses nd Qulity of Life Following Intrgstric Blloon // Obes Surg, 2008; [Epub hed of print] 15. Muller MK, et l. Qulity of life fter britric surgery- comprtive study of lproscopic bnding vs. bypss // Obes Surg, 2008; 18(12): Nguyen NT, et l. Result of ntionl udit of britric surgery performed t cdemic centers: 2004 University HelthSystem Consortium Benchmrking Project // Arch Surg, 2006; 141(5):445 9; discussion Nightengle ML, et l. Prospective evlution of verticl bnded gstroplsty s the primry opertion for morbid obesity // Myo Clin Proc, 1991; 66(8): Ogden CL, et l. Prevlence of overweight nd obesity in the United Sttes, // Jm, 2006; 295(13): Prentice AM. The emerging epidemic of obesity in developing countries // Int J Epidemiol, 2006; 35(1): Requrth JA, et l. Long-term morbidity following jejunoilel bypss. The continuing potentil need for surgicl reversl // Arch Surg, 1995; 130(3): Schuer PR, et l. Outcomes fter lproscopic Roux-en-Y gstric bypss for morbid obesity // Ann Surg, 2000; 232(4): Schirmer B. Lproscopic britric surgery // Surg Endosc, 2006; 20 Suppl 2: Sers D, et l. Evlution of gstric bypss ptients 1 yer fter surgery: chnges in qulity of life nd obesity-relted conditions // Obes Surg, 2008; 18(12): Seidell JC. Obesity in Europe: scling n epidemic // Int J Obes Relt Metb Disord, 1995; 19 Suppl 3: S Sjostrom L, et l. Lifestyle, dibetes, nd crdiovsculr risk fctors 10 yers fter britric surgery // N Engl J Med, 2004; 351(26): Sturm R. Increses in cliniclly severe obesity in the United Sttes, // Arch Intern Med, 2003; 163(18): Weber M, et l. Lproscopic gstric bypss is superior to lproscopic gstric bnding for tretment of morbid obesity // Ann Surg, 2004; 240(6):975 82; discussion Wolf AM, et l. BAROS: n effective system to evlute the results of ptients fter britric 19

5 ACTA CHIRURGICA LATVIENSIS 2009 (9 ) surgery // Obes Surg, 2000; 10(5): Wong SK, et l. Lproscopic djustble gstric bnding for the tretment of morbidly obese ptients: erly outcome in Chinese cohort // Hong Kong Med J, 2005; 11(1): Zinzindohoue F, et l. Lproscopic gstric bnding: minimlly invsive surgicl tretment for morbid obesity: prospective study of 500 consecutive ptients // Ann Surg, 2003; 237(1):1 9 Address: Arturs Ozolins, Puls Strdins Clinicl University Hospitl Deprtment of Surgery Pilsonu street 13, Rig, LV-1002 E-mil: rch_oz@inbox.lv Tble 1. Demogrphic nd clinicl chrcteristics of ptients Totl no. of ptients 18 Age (yer) 42.5 ± 11.8 Gender (F:M) 15/3 Weight (kg) ± 20.3 Height (cm) ± 9.4 BMI (kg/m 2 ) 46.2 ± 6.6 % with comorbidities 55.5 Men ± SD Tble 2. Weight reduction results Before LAGB n=18 After LAGB (6 month), n=18 p vlue Weight (kg) ± ± b BMI (kg/m 2 ) 46.2 ± ± b EBW loss (%) 30.4 Men ± SD b Sttisticlly significnt PF 100 MH p=0,327 p=0,092 RP 50 p=0,115 RE p=0,331 0 p=0,291 BP b c p=0,801 p=0,549 SF p=0,444 GH VT PF RP BP GH VT SF RE MH b c p Friedmn test Fig 1. Preopertive, 6 month nd 12 month postopertive SF-36v2 QOL dynmics 20