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III. ХИРУРГИЯ
QUALITY OF LIFE ASSESSNENT IN PATIENTS AFTER FUNDOCORPOROGASROPLICATION BASED ON BAROS SCORING SYSTEM
UDC 616.4- 089.168: 616. 33
O.B. Ospanov, A.M. Orekeshova
"Astana Medical University", Department of Endosurgery.
ABOUT THE AUTHORS
O.B. Ospanov - PhD, Professor, Head of the Department Endosurgery, A.M. Orekeshova - PhD Student
Abstract
Morbid obesity together with obesity-related diseases has a negative impact on the quality of life. The aim of this study is to assess the quality of life in patients after combined treatment of GERD and obesity.
Methods: The study included 56 patients with GERD and associated with it 1st and 2nd degree obesity. All patients underwent surgical treatment in 2013-2014. 56 patients who had great curvature gastric plication combined with Nissen fundoplication. Quality of life along the following 12 month period was assessed by the means of Moorehead-Ardelt Quality of Life Questionnaire II (MA QoLQ II) included Bariatric Analysis and Reporting Outcome System (BAROS).
Results: All surgeries were performed laparoscopically. Average age 46,32±5,1,. BMI was 36.63kg/m2 (range 30.8-39.8, SD±2.41).
In the first group, excellent BAROS results were achieved in 10% of patients, very good in 14.2%, good in 46.8%, fair - in 20% and failure was reported in 9% of patients in 12 months after surgery.
The most significant improvement in the course of associated conditions were observed in the symptoms of gas-troesophageal reflux disease - 91.6%. Significant improvements were also noted in the incidence of hypertension, back pain and knee pain, Type II diabetes, and depression.
Conclusion: The study showed that the combination operation provides acceptable % EWL and good global BAROS outcomes.
Keywords
Gastroesophageal reflux disease; obesity; Nissen fundoplication; plication of greater gastric curvature, BAROS
Фундокорпорогастропликациядан кешн BAROS жуйес бойынша наукастардьщ eMip суру сапасына бага беру
О.Б. Оспанов, A.M. Орекешова
«Астана Медицина Университет!», Эндохирургия кафедрасы, Астана
Ацдатпа
дзектШп. Бариатриялык хирургияньщ непзп максаты тек кана артык салмактан жэне косалкы аурудан арылу faHa емес, сонымен катар ом'р суру сапасын жаксарту болып табылады.
Осы жумыстын непзп мaксaты-жaсaлfaн лапароскопиялык фундокорпорогастропликациядан (Nissen фундоплика-циясына асказаннын улкен и!р1м1н1ц пликациясын уйлест!ре жасау (LFN+LGP)) сон, наукастардын ом'р суру сапа-сын BAROS критерийлер!мен бafaлaу.
Эд/стер/: Зерттеуге 2013 мен 2014 жыл аралытнда гастроэзофагеалды ауруымен жэне леспе сем!зд!кт!н I-II дэрежес!не байланысты ота жaсaлfaн 56 наукас енг!з!лд!. Наукастардын вм!р суру сапасын оперaцияfa дейн жэне 1жылдан сон BAROS жуйесне енпзшген Moorehead-Ardelt II (M-A QoLQ II) сауалнамасымен жург1зшд1. Нэтижес/: 49 (86%) наукаска сауалнама журпзлд!. 87.5% эйел адамдар. Наукастардын орташа жасы 46,32 жыл (диапазон, 24тен 71 ге дей!н). Зерттеуге дейн дене салмашнын орташа индексi (ДСИ) 36.63кг/м2 (диапазон 30.839.8, SD±2.41). Эркайсында орта есеппен 1.8 косалкы ауруы бар (диапазон от 1 до 4 SD±0,92). 12 айдан сон, наукастардын орташа салмаш 85,35±8,35 кг (диапазон 66-112) жэне ДСИ 30.9±1,53 (п=49)кг/м2 (диапазон, 28,0 - 33,6). Орташа EWL 45,26% (диапазон, 37,5 - 66,7, SD±5,77). Сонымен 12 айдан сон BAROS жуйес бойынша бafaлaу келесдей болды: кереметнэтиже 10% наукаста, ете жаксы нэтиже 14.2% наукаста, жаксы нэтиже 46.8%, кaнafaттaнaрлык20% наукаста, нашар нэтиже 9% наукаста.
Цорытынды: BAROS сауалнамасы бойынша бafaлaу, фундокорпорогастропликация эдiсi тек кана артык салмакты арылтып, гастроэзофагеалды рефлюксты ауруды шеш'т кана коймай, сонымен катар наукастардын вм 'р суру сапасын арттыратындытн аныктап отыр.
АВТОРЛАР ТУРАЛЫ
Оспанов Орал Базарбаевич -м.€.д., профессор, KP курметп онертапкышы, Астана медицина университетiнiн эндохирургия кафедрасынын менгерушю. Оркешова Акжутс -Медалан кызы - 3 жыл докторанты, Астана медицина университет
Туйш сездер
гастроэзофагеалды реф-люкс ауруы, семлздк, Nissen фундопликациясы, аск,азан улкен шр1мшщ пликациясы, BAROS
Оценка качества жизни у пациентов после фундокорпорогастропликации по системе BAROS
ОБ АВТОРАХ
Оспанов Орал Базарбаевич -д.м.н., профессор, Заслуженный изобретатель РК, заведующий кафедры Эндохирургия Медицинского университета Астана
Орекешова Акжунус Медаловна -PhD докторант 3 года, Медицинский Университет Астана
Ключевые слова
ГЭРБ, ожирение, фун-допликация по Ниссен, пликация большой кривизны желудка, BAROS
О.Б. Оспанов, A.M. Орекешова
«Медицинский университет Астана», кафедра Эндохирургия, Астана
Аннотация
Актуальность. Целью бариатрической хирургии является не только адекватное снижение массы тела и ликвидация сопутствующих заболеваний, которые связаны с ожирением, а более масштабная цель - улучшение качества жизни больных.
Целью данного исследования было оценить качество жизни после проведенной лапароскопической фундокорпорогастропликации (пликация большой кривизны желудка сочетанная с фундопликацией по Floppy -Nissen (LFN+LGP)) в соответствии с критериями BAROS.
Материалы и методы. В исследование включено 56 пациентов, перенесших LFN+LGP с марта 2013 по сентябрь 2014г по поводу гастроэзофагеальной рефлюксной болезни и ожирения I-II степени. Только у 49 пациентов определяли качество жизни до и через год после операции (7 пациентов выбыли по разным причинам). Все пациенты самостоятельно отвечали на вопросы по опроснику Moorehead-Ardelt II (M-A QoLQ II) включенный в BAROS.
Результаты. Проведено 49 анкетировании из 56 пациентов (86%). 87.5% участников были женщинами. Средний возраст был 46,32 лет (диапазон, 24 до 71). Перед операцией пациенты имели средний вес 100.0 кг (диапазон 77- 134, SD±10.58) и индекс массы тела (ИМТ) 36.63кг/м2 (диапазон 30.8-39.8, SD±2.41). Они имели в среднем 1.8 сопутствующих заболеваний (диапазон от 1 до 4 SD±0,92). После 12 месяцев, пациенты достигли среднего веса 85,35±8,35 кг (диапазон 66 до 112) и ИМТ 30.9± 1,53 (п=49)кг/м2 (диапазон, 28,0 до 33,6), соответственно. Средняя EWL для группы был 45,26% (диапазон, 37,5до 66,7, SD±5,77).
Увеличение веса среди пациентов не наблюдалось, % EWL 0-24.9% наблюдалось у 7 пациентов (14.6%), % EWL 25-49,9% у 25 (50,3%) пациентов, % EWL 50-74,9% у 12(25.4%) пациентов и у 5 (9.7%) пациентов достигнут % EWL более чем 75%. Ухудшений сопутствующих заболеваний не наблюдалось. Динамика сопутствующих заболеваний распределилась следующим образом: 17 (34.6%) пациентов сообщили об отсутствии изменений в их сопутствующих заболеваниях, 20 (40.9%) пациентов отметили, что их сопутствующие заболевания улучшились, 10 (20.5%) сообщили, что 1 сопутствующее заболевание решилось и другие улучшились, и 2 пациента (4%) сообщили, что все основные сопутствующие заболевания решились и другие незначительно улучшились. По результатам подсчета баллов по качеству жизни определяет следующее, что до операции было «удовлетворительно», то после операции оценивается как «хорошо».
Таким образом, отличный результат BAROS была достигнута у 10% пациентов, очень хорошие у 14.2%, хороший у 46.8%, удовлетворительный результат у 20% и плохой у 9% больных через 12 месяцев после операции. Заключение. Оценка качества жизни у пациентов после фундокорпорогастропликации по опроснику Moorehead-Ardelt II (M-A QoLQ II), показало что данная операция не только снижает вес и решает симптомы гастроэзофагельной рефлюксной болезни, но и улучшается качество жизни после него.
Obesity is one of the major causes of morbidity and mortality, which is associated with an increased incidence of cardiovascular disease, osteoarthritis, diabetes, cancer, and gastroesophageal reflux disease (GERD).
Body mass index (BMI) is a strong predictor of the overall mortality, with a progressively increasing in mortality in cases where BMI is higher than the optimal value of 22.5-25 kg/m2, mainly due to metabolic and cardiovascular diseases [1].
Research evidence supports an association between the increasing prevalence of obesity and gastroesophageal reflux disease (GERD), which currently affects 8% to 26% of population in the western world [2,3,4]. In addition, a significant increase in the incidence of serious consequences associated with GERD, including Barrett's esophagus and adenocarcinoma of the distal esophagus, has been noted [5,6,7].
Furthermore, the incidence of GERD is significantly higher in overweight and obese patients compared to the patients with normal BMI [8,9].
Based on a massive body of evidence, bariat-ric surgery is the only effective tool for long-term weight loss. This weight loss is also associated with fixing issues of comorbid conditions associated with obesity, which increases the risk of mortality caused by obesity [10,11,12].
The most accurate evaluation of success or failure of bariatric surgery should include weight loss, improvement of comorbidities associated with pathological obesity and improvement of quality of life. Bariatric analysis of the outcomes (Bariatric Analysis and Reporting Outcome System) meets the requirements stated above and criteria proposed by the National Institutes of Health (NIH). Moreover, it provides a standard for comparing the results of different bariatric
ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА № 1-2016
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surgeries by applying a simple, objective, and unbiased method.
The aim of this study was to evaluate the quality of life after laparoscopic fundocorporogastroplica-tion (plication of greater curvature of the stomach with Floppy - Nissen fundoplication (LFN + LGP)) in accordance with the BAROS criteria.
Methods
A prospective study of 56 patients who underwent laparoscopic fundocorporogastroplication (LFN + LGP) between March 2013 and September 2014 due to gastroesophageal reflux disease and obesity of first and second degrees. Quality of life of the patients was assessed before and after the surgery. The results were evaluated 1 year after the
surgery. All patients independently completed the Moorehead-Ardelt II questionnaire (M-A QoLQ II) included in BAROS. BAROS evaluates the percentage of excess weight loss (% Excess weight loss (% EWL)), improvement and/or cure of the associated conditions and six aspects of quality of life (self-esteem, physical activity, social activity, sexual activity, work conditions and eating behavior), complications and recurrent operations.
The nature of the investigation was voluntary. Measurement of weight (Fazzini electronic scales) and identification of the percentage of excess weight loss (% EWL) was performed by members of our team.
Questionnaire templates are presented below (Pictures 1,2,3). All the responds were compiled
Picture 1. Quality of life questionnaire by Moore-head -Ardelt II.
Picture 2.
Questionnaire for analysis of comorbidities.
Name:
What is vour Current weight?
Do you currently have your bend in place? VesJ No J
Please answer the following questions regarding the presence of each disease before and after your operation.
Before surgery? After surgery?
High Blood Pressure YesJ Nu _l Worse J Same J Better J Resolved J
Heart Disease Yes J No J Worse J Same J Better J Resolved J
High Cholesterol YesJ No J Worse J Same J Better J Resolved J
Diabetes YesJ No J Worse J Same J Better J Resoled J
Sleep apnea YesJ No J Worse J Same J Better J Resolved J
Arthritis YesJ No J Worse J Same J Better J Resolved J
Heartburn YesJ No J Worse J Same J Better J Resolved J
Urinary Incontinence YesJ No J Worse J Same J Better .J Resolved J
Venous Leg Ukers YesJ No J Worse J Same J Better _i Resolved J
Table 1.
Quality of life in patients before and after surgery.
into tables in databases, and BAROS scores were assigned to each patient according to the standards established by Oria H.E. and Moorehead M.K.
Results
49 responses from 56 surveyed patients were collected (86 % response rate). 7 patients were not able to complete the survey for various reasons. 87.5% of participants were women. The average age was 46.32 years (ranging from 24 to 71). Before the operation, patients had a mean weight and body mass index of 100.0 kg (ranging from 77 to 134, SD±10.58) and 36.63kg/m2 (range 30.8-39.8, SD±2.41), respectively. They had an average of 1.8 comorbidities (ranging from 1 to 4±SD 0.92). After a 12 - month period, patients achieved an average weight of 85.35±8.35 kg (ranging from 66 to
112), and the average BMI of 30.9±1.53 (n = 49) kg/m2 (ranging from 28.0 to 33.6). Average EWL for the group was 45.26% (ranging from 37.5 to 66.7, SD±5.77).
Weight gain was not observed among the patients, % EWL 0-24.9% was observed in 7 patients (14.6%), % EWL 25-49.9% in 25 (50.3%) pa-tients,% EWL 50-74.9% in 12 (25.4%) patients, and 5 (9.7%) patients achieved %EWL more than 75%. Severity of the comorbidities did not increase. Dynamics of comorbidities was distributed as follows: 17 (34.6%) patients reported no change in their comorbidities, 20 (40.9%) patients reported that their comorbidities improved, 10 (20.5%) reported that 1 associated disease was resolved and other improved, and 2 patients (4%) reported that all of the
Quality of life indicator Preoperative Postoperative p-value
Self-esteem 0.1±0.13 (range,-0.1 to -0,3) 0.2±0.08 (range, 0.1 to 0.3) p>0.05
Physical activity - 0.1±0.14(range, -0,3 to 0,1) 0.2±0.04 (range, 0.1 to 0.3) p<0.05
Social activity 0.0±0.15(range, -0,3 to 0,2) 0.3±0.12 (range, 0.2 to 0.3) p<0.05
Work conditions 0.0±0.1(range, -0.1 to 0.1) 0.2±0.12 (range, 0.1 to 0.4) p<0.05
Sexual activity 0.1±0.13(range, -0.3 to 0.1) 0.2±0.09 (range, 0.1 to 0.3) p<0.05
Eating behavior 0.1±0.14(range, -0.3 to 0.1) 0.3±0.04 (range, 0.3 to 04) p<0.05
Total: 0.19±0.03 1.44±0.06 p<0.05
Picture 3.
BAROS with Moorehead-Ardelt II Quality of life questionnaire scoring key
major comorbidities are resolved and others slightly improved.
The results of scoring of the quality of life determine that parameters that were rated as "satisfactory", after the surgery were rated as "good" (Table 1).
Ultimately, 12 months after surgery, an excellent result according to BAROS scoring system was achieved in 10%, very good in 14.2%, good in 46.8%, satisfactory results in 20% and poor in 9% of patients.
Discussion
To evaluate the quality of life of patients, some authors use standard tools, such as SF-36 scale[13], Sickness Impact Profile 68 (SIP 68) [14], the Quality of Well-Being Scale [15]; however, they have certain disadvantages and do not take into account the specificity of obese patients.
Implementation of the BAROS evaluation system after bariatric surgery provides an opportunity
to assess the response to bariatric intervention more explicitly, considering not only the % EWL, but also changes in comorbidities and quality of life. The questionnaire can be completed in 1 minute without anyone's assistance.
BAROS scores that were used in this study, can be suitable for other fields, as mini gastric bypass and biliary pancreatic bypass. Favretti [16] in his extensive study of 170 patients, who were observed for over 18 months reported the following data: poor result was present in more than 10%, satisfactory - in 42%, good (equal to our good and very good band) in 44%, and excellent - in 4% of the patients. Promising results were obtained by Hell. In his study of 30 patients, only 3% received poor results, whereas 23% got excellent scores [17]. Reports from other researchers, such as Vic-torzon, Wolf, and Martikainen demonstrate absence of patients with excellent scores and predominance
of patients with poor results, ranging from 12% to 50% of the patients [18,19,20].
BAROS has several drawbacks including the fact that intraoperative or postoperative mortality rate due to weight loss (severe malabsorption, or liver failure) is not taken into account. Since such patients who underwent surgery with a high rate of mortality (eg, biliary pancreatic bypass), who are also associated with the highest initial weight loss in the point system, gain a good score, although in fact it is not good. BAROS system is well suited for Roux-en-Y gastric bypass (RYGB) patients. In reality, excellent results after RYBG were observed in 63% of the patients in Hell study, and poor results were shown for 0%. Nguyen [21] 6 months after surgery, reported excellent scores in 25% and very good scores in 47% of the patients who underwent laparoscopic RYGB . Marinari [22] in his 15-year long observation showed very good BAROS results in 39.5% and good scores in 23.2% patients. Given the impact of weight loss on the BAROS counting system and the absence of any measure of mortality, it is necessary to be cautious in performing comparisons among completely different bariatric surgeries [23,24].
In addition to that BAROS does not include one more important factor, which is the period of observation. Like the quality of life of a cancer patient is affected by the duration of observation after the
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