Evaluation of Quality of Life,Clinical Parameters,and Psychological Distress after Bariatric Surgery: Comparison of the Laparoscopic Sleeve Gastrectomy and Laparoscopic Greater Curvature Plication

Abstract

Objectives:

The aim of this prospective study was to compare the effect of two surgical methods, Laparoscopic Sleeve Gastrectomy (LSG) and Laparoscopic Greater Curvature Plication (LGCP), weight loss, and clinical parameters (fat, lean body mass [LBM], glycemia) on subjective perception of quality of life (QoL) regarding health and on anxiety and depression in obese patients during 12 months after the procedure. Further aim was to ascertain which clinical parameters contribute to a positive QoL after bariatric surgery.

Methods:

The research set consisted of 68 patients undergoing bariatric treatment (LSG and LGCP). QoL data were collected by means of the WHOQOL-BREF questionnaire, and the Hospital Anxiety and Depression Scale (HADS) was used to evaluate anxiety and depression. Patients filled the questionnaire before the planned surgery and later 3, 6, and 12 months after the planned surgery.

Results:

Body mass index (BMI) and body weight decreased, all monitored clinical parameters improved, and QoL, namely physical and psychological health, improved as early as 3 months after bariatric surgery (p < 0.01). No statistically significant differences in monitored parameters were found between the surgery types. Regarding physical and psychological health, an association was determined between changes in QoL and changes in BMI and circumference of the hips.

Conclusion:

QoL improvement experienced after bariatric surgery is associated particularly with weight reduction and lower levels of anxiety and depression, but not with other clinical parameters.

Introduction

Incidence of obesity is rising significantly all over the world. It has reached epidemic proportions in the developed countries.^1,2 Over 1.6 billion adults worldwide are overweight, of which 400 million are obese. The World Health Organization predicts that 10% of the global population will be obese by 2015.^3,4 Prevalence of obesity (body mass index [BMI] >30) in Europe is 10–20% in males and 15–25% in females, and practically an entire half of the European population is overweight or obese (BMI ≥25).^5,6 According to current data from the Czech Republic,⁷ 54% of the adult Czech population has weight above the upper limit of normal, 17% suffers from obesity (BMI >30), and 1% suffers from morbid obesity (BMI ≥40). The prevalence of morbid obesity (BMI ≥40) in the United States in 2010 was 6.6%.⁸ Many obesity-related comorbidities have been described and account for considerable medical resource use worldwide.^9–12 The most frequent comorbidities are systemic arterial hypertension, type II diabetes mellitus, obstructive sleep apnea, degenerative joint disease, dyslipidemia, coronary disease, and respiratory dysfunction.^4,13 This places increasing demands on financial means used for the corresponding treatment.¹⁴ From this viewpoint, increase in obesity brings up not only health problems but also social and economic challenges. Some research proves association between increasing BMI and decreasing quality of life (QoL).^9,15–20 Sandberg et al.²¹ has demonstrated lower QoL in obese bariatric surgery candidates with food intake disorders (Binge Eating Disorder).

Bariatric surgery is presently considered the most effective method of treatment.²² Patients with BMI >40 kg/m² or with BMI from 35 to 39.9 with associated comorbidities are considered candidates for bariatric surgery. Current long-term studies show that bariatric procedure leads to a substantial reduction in weight and mortality rate, and to a decrease in the risk of developing new obesity comorbidities.^{9,15,20,23,24} Interest in long-term monitoring of not only weight reduction but also QoL evaluation in patients after bariatric treatment has increased over the past 10 years. The systematic overview of Magallares and Schomerus²⁵ reports an improvement of QoL regarding physical and psychological health in 21 studies. Karlsson et al.²⁴ proved long-term effects of bariatric surgery on QoL even after 10 years.

Over time, six main bariatric procedures have been employed: jejunoileal bypass (JIB), Roux-en-Y gastric bypass (RYGB), vertical banded gastroplasty (VBG), biliopancreatic diversion and duodenal switch (DS), adjustable gastric banding (GB), and sleeve gastrectomy (SG).²⁵ Then, there is the gastric plication or laparoscopic greater curvature plication (LGCP), which has been designed and realized in developing countries as a less expensive variant of SG, representing its potentially competitive alternative.²⁶ LGCP is a novel restrictive technique that reduces gastric volume by plication of the greater curvature. The mechanism of LGCP is notably similar to that of Laparoscopic Sleeve Gastrectomy (LSG), as both result in gastric tube formation and elimination of the greater curvature.²⁷ LGCP reduces the stomach volume by laparoscopic plication/infolding of the greater gastric curvature by placement of one or two rows of nonabsorbable sutures or staples. Thus, LGCP results in the elimination of the greater curvature and formation of a gastric tube, achieving a restrictive effect without utilizing implantable devices (e.g., a band), gastrectomy, or intestinal bypass. In addition, LGCP is potentially reversible if required.^28,29 There is a new surgical method, Therefore, its long-term efficacy is under investigation, and there are very few studies that compare it with other bariatric procedures, including LSG.

Current studies evaluating QoL and psychological distress after bariatric surgery usually evaluate QoL after a certain bariatric surgery, namely GB,^30,31 LAGB,^15,32,33 LSG,^23,30,34 gastric bypass,³⁰ DS,³⁵ and RYGB.^23,34–36 Some authors compare two or more bariatric surgery methods, for example, RYGB and DS,³⁵ RYGB, VBG, and LAGB,³⁷ GB, RYGB, DS, and LSG,³⁸ endoscopically placed gastric ballon (EPGB) and LAGB,³⁹ GB and LSG,³⁰ or even bariatric surgery and lifestyle modification.^24,36,40 There are no current studies evaluating quality of patient life after LGCP, nor studies evaluating individual clinical parameters associated with QoL.

The aim of research in this prospective study was to compare the effect of two surgical methods, LSG and LGCP, on subjective QoL perception regarding health, weight loss, and clinical parameters (fat, lean body mass [LBM], glycemia), and on anxiety and depression in obese patients 3, 6, and 12 months after the procedure. Further aim was to ascertain which clinical parameters contribute to a positive QoL after bariatric surgery.

Materials and Methods

Patients

Patients of the Gastroentero Surgery Outpatient Unit at the University Hospital of Ostrava Surgical Clinic and the Obesitology Outpatient Unit of the Gastroenterology Care Center at Vítkovice Hospital in Ostrava were included in the set. Patients enrolled in the study were selected according to preset criteria—diagnosis of morbid obesity according to the IFSO guidelines, that is, consenting individuals over 20 years of age with BMI >40 kg/m² or with BMI >35 kg/m² with associated comorbidities, with the following exclusion criteria: thyropathy, oral corticosteroid use, severe kidney function disorders, dialysis program, kidney transplantation, and gastrointestinal tract (GIT) diseases affecting intestinal resorption: gluten enteropathy, Crohn's disease, and rheumatoid arthritis. Patients were not randomly assigned to procedures (LSG, LGCP). The final selection of the type of surgery was based on a consultation with a psychologist. The patients who did not want to accept the irreversibility of the procedure performed by LSG were selected for LGCP surgery. Data were collected before the bariatric procedure (T1) and then 3 months (T2), 6 months (T3), and 12 months (T4) after the procedure. A total of 68 individuals were enrolled in the study; all of them participated in all four assessments.

To protect personal information, each study participant was assigned a numerical identifier under which he/she was registered in the database. The research was approved by the Ethics Committee at the Faculty of Medicine, University of Ostrava, and the Ethics Committee at the University Hospital Ostrava in accordance with the ethical standards of the Helsinki Declaration of 1975, as revised in 2000.

QoL and psychological distress evaluation

The World Health Organization WHOQOL-BREF QoL questionnaire was used to assess QoL. The WHOQOL-BREF⁴¹ is a generic QoL questionnaire, an abbreviated version of the WHOQOL-100 QoL assessment. It consists of 26 items rated on a five-point Likert scale and provides scores for four domains related to the QoL: physical health, psychological health, social relationships, and environment. Each domain score has the same range from 4 to 20; a higher score indicates a better QoL. It has been shown to be valid for use across different countries and different patients groups, including those with morbid obesity.^9,20 A publication by Dragomírecká and Bartoňová⁴² demonstrated good validity of the Czech version of the WHOQOL-BREF questionnaire.

Data were collected using the Hospital Anxiety and Depression Scale (HADS) self-assessment instrument for detecting states of anxiety and depression in the hospital setting.⁴³ It consists of 14 items of which 7 relate to anxiety (HADS-a) and 7 relate to depression (HADS-d). Each item has four answers and is scored from 0 to 3. Thus, the sum for each subscale ranges from 0 to 21. The original report proposed cut-off scores of 8 and 11 for possible and definite cases, respectively, for each of the two subscales.⁴⁴

Clinical evaluation

Further measurements were of height (to 1/10th of a centimeter) and weight (on a calibrated scale subject to regular checks and certifications; the measurement was performed in underwear without shoes on), BMI calculated by means of the weight/height formula, and circumference of the waist and hips (measured with a reliable tape measure).

Waist circumference was measured with the subject standing by placing a nonstretchable measuring tape in a horizontal plane around the abdomen at the level of the iliac crest. The tape should be snug, but not compressing the skin. A measurement performed at the end of normal expiration should be recorded. The same measuring tape should be employed for all subjects at the study site.

Body composition was determined by dual-energy X-ray absorptiometry (DXA; Hologic Discovery A, Waltham, MA). Serum concentrations of fasting glucose and blood lipidogram were measured. Venipuncture was performed in the morning after overnight fasting, a week before the planned procedure, and 6 and 12 months after it. Blood samples were processed for subsequent analysis within 20 min of venipuncture. The S-Monovette^® system (Sarstedt^®, Germany) was used for collection of blood samples for measurement of biochemical markers. The blood samples were immediately transported to a local laboratory. Standard biochemical parameters (glucose—reference range: 3.6–5.59 mmol/L; low-density lipoprotein (LDL) cholesterol—reference range: 1.3–3.0 mmol/L; and high-density lipoprotein (HDL) cholesterol—reference range: 1.0–2.8 mmol/L) were immediately examined (AU 5420; Beckman Coulter, Brea, CA). The blood sample was allowed to clot for 30 min and subsequently centrifuged at 2500 g for 10 min at 4°C to separate the serum. The analysis of glucose, LDL cholesterol, and HDL cholesterol showed interassay coefficients of a variation of 1.9%, 1.8%, and 2.3%, respectively.

Statistical analysis

Data were presented as a mean and standard deviation (SD) where applicable. Paired Student t-test was used for comparison of continuous variables before and after bariatric surgery. Comparisons between groups were performed using Student t-test. All tests have been two tailed, and p-values of <0.05 were assumed to represent statistical significance. A parametric test was used because of normal distribution of data (the Kolmogorov-Smirnov test). Because the parameters were characterized by a normal distribution and a positive test for equality of SD, the two-sample t-test was used to evaluate differences between groups (LSG × LGCP).

A Pearson correlation coefficient was further used to evaluate the association between a positive change in the QoL and the monitored factors. Multiple linear regression was used to determine the relative independent contribution of independent variables to dependent variables. A positive change in the QoL (domains' physical and psychological health) was assumed to contribute to a positive change in the monitored factors.

Results

Patient's characteristics

Of the total number of 68 respondents, 23 (33.8%) were males and 45 (66.2%) were females. Mean age of the total set was 44.2 years (SD = 9.6), variation interval was 27–68 years. Mean age of obesity onset of the total set was 28.7 years (SD = 44.4), variation interval was 1–50 years. Table 1 lists the sociodemographic statistics of the patients.

Table 1.

Sociodemographic Characteristics of Patients

	Total (n = 68), N (%)	LSG (n = 43), N (%)	LGCP (n = 25), N (%)	LSG versus LGCP, p
Age	44.2 (9.6)	44.5 (10.5)	43.5 (8.1)	0.659
Sex
Male	23 (33.8)	13 (30.2)	10 (40.0)	0.412
Female	45 (66.2)	30 (69.8)	15 (60.0)
Education
Elementary	2 (2.9)	1 (2.3)	1 (4.0)	0.589
Vocational	32 (47.1)	21 (48.8)	11 (44.0)
High school	27 (39.7)	17 (39.5)	10 (40.0)
College	7 (10.3)	4 (9.4)	3 (12.0)

LGCP, Laparoscopic Greater Curvature Plication; LSG, Laparoscopic Sleeve Gastrectomy.

Clinical parameters evaluation

Mean weight of the full set before surgery was 125.8 kg (SD = 22.1), variation interval 93.1–200.7 kg. Table 2 lists clinical characteristics of the set before surgery and 12 months after surgery. There was no statistically significant difference between the measured parameters in patients undergoing LSG surgery and those undergoing the LGCP. Statistically significant difference in all monitored clinical parameters was demonstrated for surgery of either type, 12 months after surgery.

Table 2.

Clinical Parameters of the Set Before Surgery (T1) and Consequently 12 Months (T4) After Bariatric Surgery Sorted by Bariatric Surgery Type

	Total (n = 68), Mean (SD)	LSG (n = 43), Mean (SD)	LGCP (n = 25), Mean (SD)	LSG versus LGCP, p^a
BMI (T1)	42.6 (5.4)	42.8 (5.4)	42.2 (5.6)	0.665
BMI (T4)	32.5 (5.5)	32.0 (5.1)	33.3 (6.2)	0.362
p^b (T1 versus T4)	<0.001	<0.001	<0.001
Weight (T1)	125.8 (22.1)	125.6 (23.1)	126.1 (20.7)	0.936
Weight (T4)	96.0 (20.7)	94.1 (20.4)	99.4 (22.1)	0.311
p^b (T1 versus T4)	<0.001	<0.001	<0.001
Waist (T1)	118.6 (14.0)	118.2 (15.3)	119.2 (11.8)	0.787
Waist (T4)	100.6 (14.9)	99.5 (15.4)	102.4 (14.2)	0.438
p^b (T1 versus T4)	<0.001	<0.001	<0.001
Hips (T1)	134.9 (13.0)	136.0 (14.6)	132.8 (9.4)	0.337
Hips (T4)	114.5 (12.8)	113.7 (11.9)	116.0 (14.5)	0.478
p^b (T1 versus T4)	<0.001	<0.001	0.036
Fat (T1)	56855 (11717)	57239 (11821)	56208 (11753)	0.731
Fat (T4)	36823 (11655)	36621 (11210)	37170 (12613)	0.853
p^b (T1 versus T4)	<0.001	<0.001	<0.001
LBM (T1)	67877 (13325)	66656 (12826)	69927 (14152)	0.335
LBM (T4)	59259 (12556)	57507 (12222)	62272 (12795)	0.132
p^b (T1 versus T4)	<0.001	<0.001	<0.001
Glycemia (T1)	6.0 (1.3)	5.9 (1.3)	6.0 (1.4)	0.929
Glycemia (T4)	5.1 (0.8)	5.1 (0.9)	5.1 (0.7)	0.824
p^b (T1 versus T4)	0.007	<0.001	0.008

Two-tailed t-test; ^bpaired t-test (comparison of the 1st and 4th assessment).

BMI, body mass index; LBM, lean body mass; SD, standard deviation.

Bold type denotes a statistically significant p-value.

Evaluation of anxiety, depression, and QoL in association with bariatric surgery

During evaluation, a higher level of anxiety and depression was determined in patients selected for the LSG surgery. Only anxiety evaluation yielded a statistically significant difference (p = 0.008). LSG surgery yielded a significant decrease in anxiety and depression as early as 3 months after surgery (Table 2).

Evaluation of QoL has shown a significant improvement in the evaluation of physical and psychological health as early as 3 months after either type of surgery, and consequently 6 and 12 months after surgery. The social relationships and environment domain yielded statistically significant difference only for LSG surgery (Table 3). QoL values regarding physical and psychological health were lower in the obese patients before operation in comparison with the population norm. The values equalized 3 months after surgery. Obese patients valued the environment domain higher than the population norm.

Table 3.

Difference in Quality of Life, Anxiety, and Depression Evaluation Sorted by Surgery Type and Measurement

			After surgery			Comparison of difference by measurement
Surgery type	Population norm N = 308 Mean (SD)	Before surgery (T1) Mean (SD)	3 Months (T2), Mean (SD)	6 Months (T3), Mean (SD)	12 Months (T4), Mean (SD)	T1 versus T2, p ^a	T1 versus T3, p ^a	T1 versus T4, p ^a
HADS-d
LSG		5.7 (3.8)	2.3 (2.6)	2.4 (2.4)	3.7 (3.4)	<0.001	<0.001	0.004
LGCP		3.3 (3.1)	2.9 (2.7)	3.4 (3.2)	2.9 (3.9)	0.231	0.899	0.329
HADS-a
LSG		9.2 (3.7)	5.8 (3.6)	6.4 (3.7)	5.8 (3.8)	<0.001	<0.001	0.024
LGCP		4.8 (3.9)	4.6 (3.3)	3.9 (4.2)	3.8 (3.3)	0.645	0.124	0.099
WHOQOL-BREF
Physical health	15.6 (2.6)
LSG		13.4 (2.4)	15.4 (2.4)	15.6 (2.7)	15.3 (2.8)	<0.001	<0.001	<0.001
LGCP		13.4 (2.6)	14.6 (3.3)	15.5 (2.9)	15.5 (2.5)	0.033	<0.001	<0.001
Psychological health	14.8 (2.4)
LSG		13.2 (2.1)	15.2 (2.4)	15.4 (2.5)	15.2 (2.8)	<0.001	<0.001	<0.001
LGCP		13.9 (2.8)	15.2 (2.1)	15.6 (2.3)	15.3 (2.1)	0.009	0.001	0.033
Social relationships	15.0 (2.9)
LSG		14.6 (3.1)	15.5 (2.8)	15.8 (2.9)	15.2 (3.2)	0.044	0.012	0.041
LGCP		14.4 (3.5)	14.5 (3.4)	15.3 (2.9)	15.2 (2.7)	0.903	0.099	0.179
Environment	13.3 (2.1)
LSG		14.0 (1.8)	14.5 (1.7)	14.4 (1.9)	14.4 (2.1)	0.041	0.194	0.225
LGCP		14.9 (1.8)	14.7 (2.2)	14.8 (1.8)	14.7 (2.0)	0.460	0.619	0.531

Paired t-test (comparison of the first examination with the others).

HADS, Hospital and Anxiety Scale.

Bold type denotes a statistically significant p-value.

Evaluation of QoL changes in the physical and psychological health domain

Overall, 46 (67.7%) patients experienced improvement in QoL in the physical health domain, and 38 (55.9%) patients experienced improvement in QoL in the psychological health domain 12 months after surgery. Thirty-two (47.1%) patients reported improvement in both parameters. A correlation of 0.66 was determined between positive changes in the physical and psychological domains. The change in social relationships and environment domain was found to be insignificant; therefore, further analysis was limited to the physical and psychological health domains.

The responder set was divided into two groups. The first group consisted of patients who did not experience any QoL change (physical health domain n = 22, psychological health domain n = 30) after 12 months (T4) in comparison with the values before surgery (T1). The second group consisted of patients who experienced QoL change (physical health domain n = 46, psychological health domain n = 38). Before operation, the only significant difference between the monitored groups was in experiencing anxiety (p = 0.042). We have found that the patient group that did not experience a QoL change after 12 months had experienced higher levels of anxiety before surgery. No statistically significant difference between the monitored groups was found 3 months after surgery. The group with improved QoL demonstrated lower levels of anxiety and depression 6 and 12 months after surgery. Patients with improved QoL in the psychological domain demonstrated higher levels of anxiety and depression, lower weight and waist circumference, and higher LDL values before surgery. Three months after surgery, this group was again found to have higher levels of anxiety and depression, lower weight, and lower glycemia and LBM values. This group demonstrated differences in six monitored parameters 6 and 12 months after surgery (Table 4).

Table 4.

Difference in Evaluation of Individual Parameters Between Patient Groups With and Without Improved Quality of Life in the Physical and Psychological Domains After 12 Months

	Physical health		Psychological health		Physical health		Psychological health
WHOQOL-BREF	No change/improvement	P	No change/improvement	p	No change/improvement	p	No change/improvement	p
T1 (before surgery)					T3 (6 months after surgery)
HADS-d	4.5/4.5	0.988	2.8/5.9	0.035	4.0/2.3	0.028	2.4/3.2	0.467
HADS-a	8.2/6.7	0.042	4.8/8.8	0.019	5.9/4.9	0.049	3.9/6.4	0.042
Weight	124.2/126.6	0.684	129.8/122.7	0.048	101.3/100.5	0.885	106.8/95.9	0.021
BMI	41.8/43.0	0.418	43.0/42.3	0.564	34.1/34.2	0.962	35.5/33.1	0.050
Waist	117.9/118.9	0.811	122.4/115.5	0.046	104.2/103.2	0.810	108.2/99.8	0.017
Hips	134.1/135.3	0.726	136.4/133.6	0.394	117.8/117.8	0.988	120.2/115.9	0.178
Fat	56548.4/57004.4	0.882	56957.2/56776.5	0.951	40759.3/40304.2	0.874	42390.1/38920.9	0.199
LBM	67709.9/67958.5	0.943	70380.6/65966.1	0.181	60554.1/60259.9	0.928	64497.4/57084.9	0.014
Glycemia	6.1/5.9	0.463	6.2/5.7	0.162	5.1/5.1	0.822	5.3/4.9	0.049
HDL	1.0/1.2	0.091	1.1/1.1	0.905	1.2/1.3	0.261	1.3/1.3	0.979
LDL	2.9/3.0	0.612	2.8/3.2	0.049	3.2/3.0	0.588	2.9/3.2	0.128
T2 (3 months after surgery)					T4 (12 months after surgery)
HADS-d	3.0/2.4	0.523	1.6/3.4	0.048	6.1/2.0	0.002	3.6/3.1	0.667
HADS-a	5.5/5.1	0.745	3.6/6.6	0.018	6.3/4.9	0.036	5.2/5.5	0.843
Weight	106.8/107.4	0.910	111.7/103.7	0.042	97.5/95.3	0.685	103.4/90.2	0.008
BMI	36.0/36.5	0.680	37.1/35.7	0.051	32.8/32.3	0.741	34.3/31.1	0.017
Waist	106.2/107.7	0.668	110.2/104.9	0.098	101.1/100.4	0.863	105.9/96.4	0.008
Hips	121.4/123.2	0.612	124.1/121.4	0.414	114.9/114.3	0.873	118.3/111.5	0.028
Fat	45120.5/46186.6	0.724	46730.2/45140.2	0.575	37925.4/36296.0	0.594	40120.1/34220.3	0.037
LBM	61789.5/61288.2	0.879	65058.8/58601.6	0.035	59634.0/59080.1	0.866	63344.5/53034.1	0.016
Glycemia	5.3/5.3	0.885	5.5/5.2	0.046	5.1/5.1	0.913	5.4/4.8	0.013
HDL	1.2/1.2	0.292	1.2/1.2	0.917	1.4/1.5	0.206	1.4/1.5	0.397
LDL	2.8/3.1	0.126	2.8/3.2	0.062	3.3/3.1	0.361	3.0/3.3	0.101

HDL, high-density lipoprotein; LDL, low-density lipoprotein.

Bold type denotes a statistically significant p-value.

Regarding physical health, an association was found between the improvement of QoL and reduction of BMI and circumference of the hips. Furthermore, an association was found between QoL improvement in the psychological health domain and weight reduction and improvement of BMI values and waist circumference (Table 5). Regression analysis did not reveal statistically significant associations between the QoL (physical and psychological health) and monitored factors. There was a statistically significant association only between the positive change of physical and psychological health and the positive change of anxiety (Table 5).

Table 5.

Correlation Between the Magnitude of Quality of Life Change and Individual Factors and Results of Regression Analysis

		Physical health		Psychological health
	Difference T4 versus T1, Mean (SD)	r	β	R	β
HADS-a	−3.5 (2.1)	−0.658^a	−0.987^a	−0.645^a	−0.876^a
HADS-d	−1.8 (1.2)	−0.321^b	−0.087	−0.299^b	−0.544
Weight	−29.8 (10.5)	−0.234	8.473	−0.301^b	9.283
BMI	−10.1 (3.4)	−0.343^b	−0.911	−0.381^b	−0.634
Waist	−18.6 (8.3)	−0.222	−0.018	−0.221	0.027
Hips	−21.2 (8.6)	−0.282^b	−0.002	−0.398^b	−0.077
Fat	−20612.8 (7848.3)	−0.233	−0.008	−0.308	−0.009
LBM	−8972.7 (4352.6)	−0.0136	−0.008	−0.206	−0.009
Glycemia	−0.9 (1.1)	−0.048	0.236	−0.013	−0.087
HDL	0.4 (0.3)	−0.052	−0.357	−0.004	0.287
LDL	0.2 (0.9)	−0.121	0.523	−0.144	−0.543

p < 0.01; ^bp < 0.05.

Discussion

In this study, we focused on the evaluation of QoL and psychological distress in patients undergoing bariatric treatment. The evaluation of health-related QoL in morbidly obese patients supplements objective indicators of health by describing the impact of the disease and treatment on the patient's everyday life, mediates his/her subjective viewpoint, and evaluates treatment efficacy or its effect.⁴² Generic questionnaire WHOQOL-BREF was used to evaluate QoL, just like in study.^9,20,45 The WHOQOL-BREF evaluates QoL regarding health; it widens the existing concept of QoL by approaching it principally as a subjective evaluation of health and everyday activities. It focuses on four principal domains, that is, physical state and functions, psychological functions, social relationships, and environment.

The research compared two bariatric surgery types—LSG and LGCP. An evaluation of the effect of LGCP on the patients' QoL and their psychological state has not been published to date. Both methods resulted in a better subjective evaluation of QoL as early as 3 months after surgery and continued to 6 and 12 months after surgery. A number of studies documented a significant effect of bariatric surgery on QoL 1 year after surgery, in general without differentiating surgery type,^30,45,46 and in particular for RYGB,^{20,23,34–36} LAGB,^15,32,33,39 EPGB,³⁹ LSG,^23,30,34,47 DS,³⁵ and GB.^30–32 The effect of LGCP on weight reduction and QoL improvement is comparable to other bariatric procedures.

Some studies further document frequent incidence of anxiety and depression associated with bariatric treatment in obese patients.^38,48,49 Patients admitted for treatment with LSG procedure in this research reported higher levels of anxiety and depression, which decreased 3 months after surgery and remained so in the following periods. LSG represents an irreversible resection of 80% of the stomach, which the patients may view very negatively and with fear. They have less information about LGCP, because it is a new method of treatment. Regarding fear, the fact that LGCP is relatively reversible gives the method an undisputable advantage, yet its efficacy appears comparable with LSG. Considering strategy for the selection of suitable procedure, LGCP could be the better choice for patients with much fear and anxiety.

To the best of our knowledge, this is the first article that describes an association between the changes of QoL after bariatric surgery, clinical parameters, and psychological state. Patients who experienced QoL improvement in the physical health domain varied only in their evaluation of anxiety and depression. They were found to have lower levels of anxiety before surgery, and later lower levels of anxiety and depression 6 and 12 months after surgery. Brunault et al.³⁰ and Andersen et al.⁴⁸ found depression to be a predictor of QoL change after bariatric surgery. More differences in clinical parameters were found during evaluation of QoL changes in the psychological health domain. In addition to the evaluated anxiety and depression, differences were determined in weight, waist circumference, BMI, Fat 1, and LBM values. Brunault et al.³⁰ also found weight reduction to be a predictor of change in QoL. Nadalini et al.²³ evaluated predictors of weight reduction after bariatric surgery. Evaluation of physical health was determined to be such a predictor. Our research also revealed an association between weight and BMI reduction and the difference in QoL evaluation—not only in the physical health domain but also in the psychological health domain.

Limitations of This Study

The selection of patients is a limitation of this study. Patients were not randomly assigned to procedures (LSG, LGCP). The reason is the respect for ethical principles and patient involvement in decisions when choosing the type of surgery, especially taking into account the irreversibility of a procedure using an LSG method. The final selection of a method of surgery was based on a consultation with a surgeon, psychologist, and patient himself/herself.

Conclusion

Both LSG and LGCP lead to BMI and weight reduction and also to QoL improvement as early as 3 months after surgery, and later 6 and 12 months after surgery. Patients demonstrated higher levels of anxiety before LGS surgery. Care for the patient's psychological state, particularly anxiety reduction before performing an irreversible bariatric surgery and later after the surgery, may improve the efficacy of bariatric surgery.

QoL improvement experienced after bariatric surgery is associated particularly with weight reduction and lower levels of anxiety and depression, but not with other clinical parameters. Only in the psychological health domain, the group of patients who experienced QoL improvement 1 year after surgery demonstrated differences in some of the clinical parameters.

Footnotes

Acknowledgments

Research was supported by grant of University of Ostrava (SGS06/LF/2014-2015).

Author Disclosure Statement

No competing financial interests exist.

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