Quality of life, dumping symptoms, and weight bias internalization after endoscopic bariatric revisional therapies

Abstract

BACKGROUND

Endoscopic bariatric therapies (EBT) have been developed as an adjunctive therapy to treat persistent obesity and recurrent weight gain and dumping symptoms after metabolic and bariatric surgery (MBS). While the efficacy of revisional EBTs has been documented, no studies to date have examined how these procedures impact quality of life (QOL) and internalized weight bias (IWB).

AIM

To understand how endoscopic revisional therapies impact QOL, IWB, and dumping syndrome.

METHODS

Analysis included 19 participants treated for post-MBS recurrent weight gain and/or dumping syndrome. The short-form 36 survey, weight bias internalization scale, and the Sigstad scoring system were used to measure QOL, IWB, and dumping syndrome pre- and ≥ 4 weeks post-EBT.

RESULTS

At 6-months, total body weight loss was 8.6% ± 7.15% (n = 16), at 12-months was 13.4% ± 7.46% (n = 16). Short-form 36 scores for all 8 scales significantly increased from pre- to post-procedure with the greatest improvement in the scales related to emotional (mean improvement = 59.6, P < 0.05) and physical health (mean improvement = 31.1, P < 0.05). Both total Sigstad score (mean difference = 4.947, P < 0.05) and total weight bias internalization score (mean difference = 0.761, P < 0.05) significantly decreased from pre- to post-procedure.

CONCLUSION

Findings suggest that revisional EBT may improve post-MBS QOL across a broad spectrum of outcomes beyond optimizing body weight. As early EBT results indicate positive mental and physical health outcomes, further research is needed to evaluate the relationship between these improvements, body weight and interdisciplinary post-MBS care.

Key Words: Endobariatrics; Dumping syndrome; Bariatric surgery; Weight bias; Quality of life; Transoral outlet reduction; Sleeve gastrectomy

Core Tip: Endoscopic bariatric therapies are an important adjunctive therapy for weight recurrence and dumping symptoms after metabolic and bariatric surgery. Our study aimed to understand how endoscopic bariatric therapies impact quality of life, weight bias internalization scores, and dumping symptoms as measured by the Sigstad scale. We found that quality of life improved across all scales that were measured, with the greatest improvement in emotional and physical healthy. There was also improvement in weight bias internalization scores and dumping symptoms. Patients also experience sustained weight-loss over the study period.

INTRODUCTION

Obesity is an ever-expanding epidemic in the United States. Since 2017, the Centers for Disease Control and Prevention and National Institutes of Health have estimated that 40% of United States adults are obese, defined as body mass index of 30 kg/m² or above[1-4]. Obesity, which disproportionately affects African Americans and Hispanics compared to non-Hispanic whites, increases the risk of mortality due to increased risks of cardiovascular disease, type 2 diabetes, kidney and liver disease, 13 types of cancer, and mental health challenges.

Treatment options for obesity include lifestyle modifications, anti-obesity medications (AOMs), and metabolic and bariatric surgery (MBS), which includes Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG)[5]. SG is the most commonly performed surgery in the United States followed by RYGB and studies have consistently shown that they are effective modalities for weight loss, comorbidity resolution, and decreased mortality[6,7]. However, recurrent weight gain is common with both RYGB and SG. While there is not one standard definition of weight regain (WR), commonly used measures include a gain of 10 kg or more after reaching nadir weight, an increase in body mass index of 5 kg/m² or more from the nadir, and a regain exceeding 25% of excess weight lost from the post-procedure nadir. Based on these criteria, one study reported that 37% of RYGB patients experienced WR at 7 years post-surgery[8]. Furthermore, a systematic review found that up to 75% of SG patients experienced WR 6 years post-surgery[9]. While there are multiple approaches to WR after RYGB and SG, endoscopic bariatric therapies (EBTs) are emerging options to treat persistent obesity and WR after MBS.

EBTs, such as transoral outlet reduction (TORe) and revisional endoscopic sleeve gastroplasty (r-ESG) are minimally invasive endoscopic procedures that can be used in RYGB and SG, respectively. The TORe procedure decreases the size of the gastrojejunal anastomosis, or outlet, as studies have shown that increased gastrojejunal diameter is positively associated with recurrent weight gain[10]. R-ESG aims to decrease the size of the distended SG by placing sutures within the sleeve to decrease the length and volume of the sleeve[11]. Studies have found that TORe and r-ESG can result in 15% total body weight loss and may help with symptoms of dumping syndrome[11-19].

While several studies have documented the clinical efficacy of EBTs, no studies have examined how these procedures impact quality of life (QOL). Obesity is associated with poor overall QOL, with particular impairments in physical function and psychosocial well-being[20,21]. Overweight and obese individuals have been found to have higher levels of weight bias internalization (WBI), which has been linked to poorer mental and physical health outcomes[22,23]. Studies have shown that QOL improves among those who have completed MBS[24,25]. The aims of our study are: (1) To characterize QOL before and after EBT; (2) To describe WBI before and after EBT; and (3) To describe weight loss outcomes 6-months post-EBTs. We hypothesize that people who undergo EBTs will experience an increase in QOL score and decreases in WBI that correlates to weight loss seen after EBT.

MATERIALS AND METHODS

Participants

Patients were recruited from the University of Texas Southwestern Medical Center Endobariatric Clinic and Weight Wellness Program. All patients who underwent an endoscopic revision for WR and/or dumping symptoms after RYGB or SG were eligible. Data from 19 patients were used in this analysis. Participants were asked to complete three surveys both before and after the procedure. Pre-procedure surveys were distributed electronically via REDCap, a HIPPA-protected database, at the time of their endobariatric clinic visit. Post-procedure surveys were distributed four weeks after the procedure via REDCap. Patients were sent three reminder emails to complete both their pre- and post-procedure surveys. Only patients who completed the pre-procedure surveys received post-procedure surveys. Weight was measured before the endobariatric procedure and at 6-month follow-up appointments.

Scales and variables of interest

Gender, race, ethnicity, age at the time of the procedure, and weight at the initial and 6-month visits were collected for all patients. We calculated percent weight loss for each patient. The short-form 36 (SF-36), WBI scale (WBIS), and Sigstad surveys were used to measure QOL, intrinsic weight bias, and dumping symptoms, respectively. All three surveys have been validated in prior publications[26-28].

SF-36

To assess change in QOL, SF-36 scores pre- and post- procedure were scored using the RAND 36-Item Health Survey (version 1.0) scoring rules. Responses to each item were assigned a numerical value between 0-100, with higher values indicating higher QOL. Each item was assigned to one of eight scales: Physical functioning, role limitation due to physical functioning, role limitation due to emotional problems, energy/fatigue, emotional well-being, social functioning, pain, and general health. Numerical scores for items within a given scale were averaged to calculate a numerical scale score.

WBIS

The WBIS questionnaire uses a 7-point Likert scale. Responses to each item were assigned a score from 1-7, with higher scores indicating greater internalization of weight bias. Scores from all 11 items were averaged to calculate total WBIS score.

Sigstad questionnaire

Responses to each item on the Sigstad questionnaire were assigned points according to Sigstad’s diagnostic index. Positive points were awarded if a patient endorsed having a symptom suggestive of dumping syndrome, whereas negative points were awarded if a symptom suggestive of a different pathology was endorsed (i.e. belching and vomiting). Points for each item were summed to calculate the total Sigstad score, with higher scores indicating increased dumping symptoms.

Procedure

Following the completion of informed consent, r-ESGs and TORe procedures were performed under general anesthesia by a single endoscopist at an academic medical center. Following a diagnostic upper endoscopy, the Overstich endoscopic suturing system was attached to a 2T therapeutic scope (Olympus, Center Valley, PA, United States). 2-0 non-absorbable polypropylene suture was placed in an “I” pattern from the greater to lesser curve of the stomach for r-ESGs or in a purse-string pattern around the gastrojejunal anastomosis for TORe procedures. Patients were discharged the same day on a liquid diet with instructions to advance their diet in a structured manner.

Statistical analysis

All data was analyzed in R Version 4.4.0. Six-month weight loss was calculated by subtracting weight at 6-month follow up appointment from initial weight prior to the procedure. Mean, SD, confidence intervales, mean difference, and effect sizes were calculated for each SF-36 scale and for WBIS and Sigstad scores. Paired t-tests were done to compare patients’ SF-36 scale, WBIS, and Sigstad scores before the procedure to those after the procedure.

RESULTS

Baseline demographics, total body weight loss post revision, and AOM use

A total of 19 patients were included in our study. The majority were female (95%), White (53%), non-Hispanic (89%), and within the ages of 43-51 (47%). The majority of patients had a RYGB (79%) (Table 1). No adverse events were recorded for our patient cohort. Weight was measured at 6-, 12-, and 18-months post endoscopic revision. At 6-months, the total body weight loss was 8.6% ± 7.15% (n = 16), at 12-months was 13.4% ± 7.46% (n = 16), and at 18-months was 13.6% ± 8.52% (n = 15) (Figure 1). There were three patients who were not included in the 6-month and 12-month follow-up. One patient passed from an event unrelated to their procedure and two patients were lost-to-follow-up. At 18-months, there was an additional patient who did not yet reach the time-frame for follow-up. 57.9% of our patient cohort (11/19) were on an AOM prior to the procedure and the most common medication was semaglutide (n = 9). Out of the 11 patients who were on an AOM prior to the procedure, the majority (n = 10) remained on an AOM after their procedure. 42.1% (n = 8) were not on an AOM prior to their procedure and 50% of these patients (n = 4) started an AOM after their procedure at a mean of 4.75 months after their procedure.

Figure 1 Percent weight loss. A: 6 months post-endobariatric revision; B: 12 months post-endobariatric revision; C: 18 months post-endobariatric revision.

Table 1 Study sample descriptive characteristics.

	Number of participants, n (%)
Number of participants	19 (100)
Gender
Male	1 (5)
Female	18 (95)
Race
Black or African American	8 (42)
White	10 (53)
Black or African American/White	1 (5)
Ethnicity
Hispanic/Latino	2 (11)
Non-Hispanic/Latino	17 (89)
Age, years
34-42	4 (21)
43-51	9 (47)
52-60	2 (11)
61-69	4 (21)
Prior bariatric surgery
RYGB	15 (79)
SG	4 (21)

RYGB: Roux-en-Y gastric bypass; SG: Sleeve gastrectomy.

QOL, dumping symptoms, and WBI measurements pre- and post-revision

All 19 patients included completed the pre-and post-surveys that were electronically sent out. All eight scales of the SF-36 QOL survey showed significant improvement when comparing responses from pre-revision to post- endoscopic revision (Table 2). The greatest improvement was seen in the scales “role limitations due to emotional problems” (mean improvement 59.6, P < 0.05) and “role limitations due to physical functioning” (mean improvement 31.1, P < 0.05; Table 2). The total Sigstad score and the WBIS score were also found to have a statistically significant decrease pre- and post-endoscopic revision (Sigstad score mean difference = 4.95, P < 0.05, WBIS score mean difference = 0.761, P ≤ 0.05; Table 3).

Table 2 Changes in short-form 36 score from pre- to post-procedure by survey scale.

Scale	Mean (pre)	Mean (post)	Mean improvement	P value	Confidence interval	Effect size
Physical functioning	48.4	61.6	13.2	< 0.05	4.6-21.8	0.74
Role limitations due to physical functioning	40.8	71.9	31.1	< 0.05	11.7-50.5	0.77
Role limitations due to emotional problems	24.6	84.2	59.6	< 0.05	39.9-79.4	1.46
Energy/fatigue	31.1	51.1	20.0	< 0.05	9.5-30.5	0.91
Emotional well-being	59.6	71.2	11.6	< 0.05	5.1-18.1	0.86
Social functioning	57.2	73.0	15.8	< 0.05	7.3-24.3	0.90
Pain	54.2	65.0	10.8	< 0.05	3.0-18.5	0.67
General health	46.6	57.1	10.5	< 0.05	3.5-17.6	0.72

Table 3 Changes in Sigstad and weight bias internalization scale scores from pre- to post-procedure.

	Mean (pre)	Mean (post)	Mean difference	P value	Confidence interval	Effect size
Total Sigstad score	9.95	5.00	-4.95	< 0.05	-7.45 to -2.44	-0.95
Total WBIS score	4.32	3.56	-0.76	< 0.05	-1.20 to -0.32	-0.84

WBIS: Weight bias internalization scale.

DISCUSSION

As MBS continues to be used as an obesity treatment option, is important to understand how these procedures affect both weight and QOL in patients. Results from our study suggest that endobariatric procedures are effective in both weight reduction, improving QOL, dumping symptoms, and intrinsic weight bias. Similar to previous studies[11,13-15,17,19,29], our results show that endobariatric revision procedures led to weight loss over a 12-month period. At 6-months post-procedure, nearly all participants with available data experienced weight loss. Sustained weight loss was also seen among available participants at 12 months post-endoscopic revision. Further, the majority of our patients were on an AOM prior to their procedure, making it less likely that their weight loss was due to AOMs. Among patients who started an AOM after their procedure (n = 4), the mean time to starting these medications was at about 4.75 months. Although our sample size is small, the decrease in total body weight shows the efficacy of both TORe and r-ESG.

To our knowledge, there have been no published studies to date showing a significant change in QOL post-endoscopic revision. In one study, Fiorillo et al[29] evaluated QOL after an endoscopic sleeve gastroplasty (ESG) using the Gastrointestinal QOL Index questionnaire but did not find significant differences between pre- and 6 months post-ESG QOL[29]. In contrast, our study was able to find significant improvements in all 8 survey scales of the SF-36 QOL by at least 4 weeks post-procedure. This finding is similar to published literature on QOL after bariatric surgery, which most papers have found a positive correlation between RYGB or laparoscopic sleeve gastrectomy (LSG) and improved QOL[30]. Future studies should focus on whether the degree of weight loss at 6- and 12-month post-endoscopic revision is predictive of greater improvements in QOL scores.

Similarly, dumping symptoms and WBIS scores dropped significantly from pre- to post-procedure, suggesting decreased dumping symptoms and WBI as a result of endobariatric revision. The improvement in dumping symptoms post-endoscopic revision has been shown in prior studies; however, these studies have focused on TORe procedures and have not also included patients who have undergone r-ESGs[12]. LSGs are generally believed to have a lower prevalence of dumping symptoms because of the preservation of the pylorus. However, recent studies suggest that dumping symptoms are more prevalent in LSG than once reported[31]. To our knowledge, this is one of the first studies showing that endoscopic revision after LSG can also be useful for dumping symptoms. Future studies should focus on r-ESG in a larger cohort of patients with dumping symptoms post-LSG.

The “internalization of negative weight stereotypes and subsequent self-disparagement” is known as WBI. Studies have estimated that 40% of United States adults who are overweight or obese have internalized weight bias and this internalized stigma has been shown to have negative mental and physical health outcomes[32,33]. Our study found statistically significant improvements in the WBIS after either r-ESG or TORe procedure. Although the mean difference was less than 1 point on the scale, a future study aimed at understanding the impact of endoscopic bariatric procedures on WBIS would be needed to understand how revisional procedures changes WBI. This would be especially important to help push for wider insurance coverage of endoscopic bariatric procedures given the evolving insurance coverage at this time.

There are some important limitations to our study. First, our study had a small sample size, which limited our ability to evaluate covariates that may predict QOL changes after EBT and may decrease generalizability. Second, our study did not have 6-, 12-, or 18-month weight loss on all patients. This was due to: (1) Loss-to-follow-up from the healthcare system (n = 2); (2) One patient who passed away from unrelated causes prior to the 6-month time frame; and (3) One patient who did not yet reach 18-months post-procedure. Third, patients received only one survey after their procedure. Future studies will aim to increase our sample size and increase the time-points that patients receive a survey to understand whether revisional endobariatric procedures have long-term effects on patients QOL, weight bias, and dumping symptoms. However, despite limitations, our study is the first to examine QOL and WBI after revisional endobariatric procedure. Our results indicate that these procedures have the potential to offer several benefits to our patients and for that reason warrant further investigation.

CONCLUSION

In conclusion, EBTs have been shown to be an effective tool to combat weight recurrence after bariatric surgery with little research into their impact on QOL. Our results indicate that EBT lead to significant improvements in QOL, body image, and dumping symptoms within one-month post-procedure. Further research is required to investigate the long-term impact of endobariatric procedures as they become more frequently utilized.