Laparoscopic sleeve gastrectomy (LSG) patients experienced an increase in clinically relevant -reported chronic abdominal pain two years after the procedure, according to researchers from Norway. The authors, who published their findings in the paper, ‘A prospective longitudinal study of chronic abdominal pain and symptoms after sleeve gastrectomy’, in SOARD, said that further evaluations of these findings were required.
Although LSG has been associated with gastroesophageal reflux disease, the authors noted, there is a scarcity of papers on the prevalence of abdominal symptoms and pain. Highlighting patient-reported chronic abdominal pain after LSG is necessary for preoperative and postoperative consultations and guidance, they stated. Therefore, in this study they examined the prevalence of patient-reported chronic abdominal pain before and two years after LSG (primary outcome), as well as abdominal symptoms, psychological aspects and quality of life (secondary outcomes). Chronic abdominal pain was defined as sustained or recurrent abdominal pain lasting for more than three months.
The researchers performed a prospective, longitudinal cohort study at two institutions in Norway. At one of the study institutions, sleeve gastrectomy (SG) was the dominant procedure and used in most patients, although not in those with severe gastroesophageal reflux disease. At the other institution SG was used only for patients with no reflux symptoms or verified gastroesophageal reflux disease, with Roux-en-Y gastric bypass offered to those with reflux disease.
Patient-reported outcomes were collated via a primary questionnaire was used to evaluate chronic abdominal pain and included a pain severity grading (0 to 10, 0=no pain, 10=worst imaginable pain). Interference with sleep, daily activities and work were graded (0=not affected, 10=completely affected).
Abdominal symptoms were evaluated with the Gastrointestinal Symptom Rating Scale (GSRS, 1 week recall), which gives a total score and five syndrome scores (abdominal pain-, gastroesophageal reflux-, diarrhoea-, indigestion- and constipation syndrome).
Outcomes
The baseline population included 249 patients and follow-up data was available for 207/249 (83.1%) patients. At two-year follow-up, mean change in BMI was 14.1 (6.3) kg/m2, mean percentage TWL was 31.9 (10.4)% and mean percentage EWL 77.1 (25.6)%.
Serious perioperative complications were reported in one patient with stricture at the gastroesophageal junction handled by endoscopy. Late abdominal surgeries were reported in three patients: one with dysphagia and hiatal hernia treated with diaphragm crural repair and gastropexy, one with cholecystectomy and one with diagnostic laparoscopy for abdominal pain. No patients with CAP at follow-up reported complications related to LSG.
A total 14.3% (32/223) patients reported CAP at baseline, compared to 50/186 (26.9%) at follow-up (p=0.002). Chronic abdominal pain was a new onset at follow-up in 33/43 (76.7%) patients. At the first institution, 8/80 (10.0%) reported CAP at baseline and 21/64 (32.8%) at follow-up (p=0.017). The corresponding figures at the second institution were 24/143 (16.8%) and 29/122 (23.8%), respectively (p=0.093). Use of analgesics for CAP was reported by 8/23 (34.8%) patients at baseline and 13/50 (26.0%) at follow-up (p=0.221). No patients used opioids for CAP at baseline and one patient used opioids at follow-up for CAP.
The GSRS scores increased significantly from baseline to follow-up for abdominal pain-, gastroesophageal reflux- and constipation syndrome and for total scores, with small to medium effect size. The number of patients with bothersome symptoms (scores ≥ 3) increased for abdominal pain from 35/237 (14.8%) at baseline to 44/186 (23.7%) at follow-up (p=0.012); for gastroesophageal reflux from 31/237 (17.0%) to 58/187 (31.0%) (p<0.001); and for constipation from 32/234 (13.7%) to 47/185 (25.4%) (p<0.001), respectively.
At follow-up, patients with CAP had higher scores for all GSRS syndromes compared to patients without CAP and with medium to large effect size. Bothersome symptoms were more common in patients with CAP at follow-up; for abdominal pain symptoms (24/49 (49.0%) vs. 20/134 (14.9%), p<0.001), diarrhoea symptoms (20/49 (41.7%) vs. 16/134 (11.9%), p<0.001), indigestion symptoms (23/47 (48.9%) vs. 27/131 (20.6%), p=0.001) and constipation symptoms (20/48 (41.7%) vs. 27/134 (20.1%), p=0.006).
At baseline and follow-up, 20/204 (9.8%) and 27/171 (15.8%) had a high likelihood of GERD (GERDq score ≥ 9) (p=0.099), respectively. At follow-up, the rate of likelihood of GERD did not differ statistically in patients with and without CAP.
According to the BPI questionnaire, the abdominal area was marked as the location of pain (p=0.017) in 10/142 (7.0%) of the patients at baseline and 31/108 (28.7%) of the patients at follow-up.
“The importance of patient-reported CAP in the context of RYGB has previously been described, and surprisingly such emphasis may also be relevant for patients opting for SG,” the author’s caution. “Severity, characteristics and impact of symptoms may vary between RYGB and LSG, as may also the pathophysiology of symptoms. Comparative analyses elaborating on this may contribute to a more individualised approach to bariatric surgery.”
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