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Objective. Determine the impact of loss of excess weight in patients undergoing bariatric surgery regarding quality of life with no comorbidities. Materials and methods: A quasi-experimental epidemiological study carried out with 42 patients who underwent bariatric surgery with Da Vinci robotic and laparoscopic technique of gastric sleeve and bypass types. In [HRAEZ - Regional Highly Specialized Hospital of Zumpango, Estado de Mexico]. Results: The patients intervened with the robotic technique 59%, the laparoscopic technique 41%, the bypass 61% and sleeve type 39%. In addition, 45% of the intervened patients had type 2 diabetes mellitus, 19% had systemic arterial hypertension, 32% had depression, 23% had gastroesophageal reflux and dyslipidemia. At the end denotes remission of complications due to obesity of the 10 patients, loss of minimum excess of weight was 40.9%, a maximum was 110%, with an average of 65.69%; this is within the quality standards of bariatric surgery. As part of the outcomes, the quality of life was very good and good. The comparative analysis, H A is accepted. Conclusion: The percentage of loss of excess weight after surgery was accurate according to the parameters established in prior specialized theoretical frameworks; bariatric surgery improved the quality of life of patients with obesity.
Keywords: Bariatric surgery; percentage of loss of excess weight; comorbidities; quality of life; Bariatricsurgery; percentageoflossofexcessweight; qualityoflife
1.Introduction According to the World Health Organization [WHO], obesity is a chronic disease, characterized by an in- creaseofbodyfat,associatedwithincreasedhealthrisk [1][3].Itisdefinedasadiseasetheresultofanimbal- ancebetweentheenergyingestedandexpended,char- acterizedbyanexcessiveincreaseofbodyfat,whose magnitudeanddistributioncompromisesthehealthof organsandsystems.Obesityhasamultifactorialorigin inwhichgeneticsusceptibility,lifestylesandenviron- mentalcharacteristicsareinvolved,withtheinfluence ofvariousunderlyingdeterminants,suchasglobaliza- tion,culture,economicstatus,education,urbanization andpoliticalandsocialenvironment[4]. TheOrganizationforEconomicCooperationandDe- velopment[OECD]placesMexicoinsecondplacefor global obesity in adults, surpassing the USA. Some studieshavementionedthattheproportionofnormal weightintheMexicanpopulationisdeclininganditis projectedthatby2050therewillbemorepeoplewith majorobesity.Ananalysisoftheepidemiologicaltran- sitioninMexicofoundthatchronicnon-communicable diseasescaused75%ofalldeathsand68%lossofpo- tentialyearsoflife[4].Thisepidemiologicalscenario allowsustomeasuretheseriousnessthatobesityrep- resentsinMexicoandjustifiesthemanagementofprof- itableandsuccessfulhealthprogramsandprojectsto helpsolvethisproblem[5][6].
InMexico,attentiontoobesityanditscomplications generatedanexpenseof42billionpesosayear,plus 25billionassociatedwithlossesduetolowproductiv- ity.Obesityisaserioushealthproblemwhosegrowth inrecentdecadeshasincreasedconsiderably.Itisre- sponsibleforseriousphysical,psychological,andso- cialproblems,affectingthequalityoflife[QoL]ofthe peoplewhosufferfromit.Bariatricsurgeryhasproven tobethebestobesitytreatment,eveninitsmostse- veredegrees.Besidesreducingexcessweight,ahigh rateofimprovementandremissionofmetabolicco- morbiditiestakeplace,whichhaveanimpactonthe qualityoflifeandimprovethelifeexpectancyofinter- venedpatients[7].
Bariatricsurgeryisasurgicalprocedureperformedon thestomachand/orintestinesthathelpstoloseweight inamorbidlyobeseperson.Itallowsacompletereso- lutionorimprovementof:diabetesmellitus,hyperlipi- demia,systemicarterialhypertensionandobstructive sleepapnea[7].Existingscientificevidence,whichen- dorsesthatcurrentlyonlysurgeryallowsaneffective and sustained treatment over time, with the conse- quentbenefitsforpatientsevenincasesofextreme obesity[8][9][10][11][12].
The Official Mexican Standard [NOM-008SSA3-2010] wasupdated,whichestablishesthehealthcriteriato regulatethetreatmentofexcessweightandobesity. Thisstandardestablishestheindicationforbariatric surgeryinadultindividualswithaBMIgreaterthanor equalto40kg/m2orgreaterthanorequalto35kg/m2 associatedwithcomorbidities,whoseorigin,inboth cases,isnotpurelyendocrineandwithahistoryofre- centcomprehensivemedicaltreatment. Inaddition totheabove,inthecaseofpeoplebetween16and18 yearsofage,surgicaltreatmentmaybeperformedex- clusivelyonthosewhohavecompletedtheirphysical, psychologicalandsexualdevelopment.Theselection ofthetypeofsurgicaltechniquemustbebasedand justifiedontheevaluationofamultidisciplinaryhealth team, made up ofat least, but not limited of: a sur- geon,ananesthesiologist,aninternist,anutritionist andaclinicalpsychologist;thisindicationmustbees- tablishedinamedicalprescription[3].
Scientificprogresshasallowed,throughnewtechnolo- giessuchastheDaVincisystem,tobeanefficientsup- portforsurgeons,obtainingbetterresults. However, therearestillsomedisadvantagesintheuseofrobot: 1]asingletradingcompany[monopolistic],2]highcost ofboththerobotanditsmaintenanceandinstruments, 3]difficultapplicationinmultiquadrantsurgeries.4] absenceoftactilefeedback,5]largesizeofthecarriage andwideradiusofrotationofthearms[13]. Bariatricsurgerytechniquesaretraditionallydivided into3types:restrictivesurgery,malabsorptivesurgery andmixedrestrictive-malabsorptivetechniques[11]. Restrictivetechniquesconsistofreducingthecapacity ofthestomach, thusrestrictingthefoodintake. On theotherside,malabsorptivetechniquesreducethe capacityofthestomachbyhalfandproduceacrossing withtheintestine.Mixedtechniquesconsistofreduc- ingthestomachto15–30milliliters,togetherwitha crossingintheintestinethatinducesacertaindegree ofmalabsorptionproteinandvitamindeficienciesare veryscarce[14][15][16][17][18][19][20]. PathologiesassociatedwithObesity Weight loss leads to an improvement in the comor- biditiesassociatedwithobesityandisdirectlyrelated to the decrease in mortality, with bariatric surgery currentlybeingthemosteffectivetreatmentformor- bid obesity [21]. Among the major comorbidities, thefollowingareidentified:type2diabetesmellitus, hypoventilation-obesitysyndrome,obstructivesleep apneasyndrome, highbloodpressure, cardiovascu- lardisease,sometypesofneoplasms[endometrium, breast, liver] and degenerative arthropathy of load- bearingjoints. Amongtheminorcomorbidities,dys- lipidemia,gastroesophagealreflux,cholelithiasis,fatty liver, infertility, polycystic ovary syndrome, urinary incontinence, nephrolithiasis, other types of cancer [esophagus,colon-rectum,prostate,gallbladder],ve- nousinsufficiency,atrialfibrillation,congestiveheart failure,certaintypesofdementiasandbenignintracra- nial hypertension [22]. Schauer [2001] identifies an averageof6.8comorbiditiesperpatient[23]. Diabetesmellitustype2 DM2is5timesmorefrequentinobesitygrade1and10 timesmorefrequentinobesitygrade2andinmorbid obesity,comparedtothenon-obesepopulation[24] [25][26][27]. TheInternationalDiabetesFederation recommendssurgicaltreatmentforpeoplewithtype 2diabetesassociatedwithobesity[BMI ≥35kg/m ] and, undersomecircumstances, forpatientswitha BMIbetween30and35kg/m ,suchasglycosylatedHb 7.5%,despitebeingtreatedwithoptimalconventional therapy,especiallyifweightisincreasingorsomeco- morbiditiescannotbecontrolledwithstandardther- apy[6].Aftera16-yearfollow-up,aDM2remissionrate of83%,animprovementinDM2complications,anda reductioninmortalitywereconfirmedcomparedwith acohortofpatientswhorefusedsurgeryandpatients withthesameepidemiologicalparametersthanthose intervened[1%vs4.5%,p<.0001][27].
Hypertension Theriskofmortalityfromcardiovasculardiseaseisin- creasedinobesity. TheAmericanHeartAssociation classifiesobesity asa majorrisk factorfor coronary heartdisease.Obesityaccountsfor78%and65%ofes- sentialhypertensioninmenandwomen,respectively. Thiscorrelationvarieswithage,sex,andraceandis strongestinsubjectsunder40yearsofage,especially inmen[28].AnincreaseinBMIof1.7kg/m inmenand 1.25inwomenoranincreaseinabdominalcircumfer- enceof4.5cminmenand2.5inwomenrepresentsa 1mmHgincreaseinsystolicbloodpressure. Obesity triggersaseriesofadaptivedisordersthatindividually andsynergisticallyproducehypertensionandother cardiovascularpathologies.Forinstance,obesitycon- troleliminates48%ofhypertensioninCaucasiansand 28%inBlacks[29].
Dyslipidemia Thealterationsinthelipidprofileobservedinpeople withvisceralobesityareduetoalterationsinthehome- ostasisofglucoseandinsulin. Themostcharacteris- ticalterationsarehypertriglyceridemia—Triglyceride levels >150GS/dl—andadecreaseinhigh-density lipoproteincholesterol[HDL-C][29].
Depression Certainpsychiatricillnessesareriskfactorsforobesity, suchasbulimiaandanxietydisorders.Inreturn,obe- sityisapredisposingfactorforpsychiatricdisorders suchasdepression. Forthisreason,morbidobesity shouldnotonlybeconsideredaphysicaldisease,but alsoamentalone,andhealthcarespecialistsshould ensure a treatment that encompasses both aspects [30].
Gastroesophagealrefluxdisease[GERD]iscloselyre- latedtoobesity;infact,upto45%ofmorbidlyobese patientssufferfromit.Inthesecases,surgeryisrecog- nizedasthemosteffectivetreatmentforsevereand refractorydisease.Currently,fundoplicationcontinues tobethegoldstandardforSevereGERD[31]. Qualityoflife Intermsofhealth,itisespeciallyimportantinpeople withadvancedage,thechronicallyill[suchasthose sufferingfrommorbidobesity],terminalanddisabled populations,medicineassociatesitwiththepsychoso- matichealthoftheorganism,functionality,symptoma- tology,ortheabsenceofdisease. TheWorldHealth Organization[WHO]hasdefinedqualityoflifeasan individual’sperceptionofone’spositioninlifewithin thecontextoftheculturalandvaluesysteminwhich onelivesandinrelationtoone’sgoals,hopes,norms andconcerns[32][33][34].
Qualityoflifeinbariatricpatients Instrumentsformeasuringqualityoflifeinbariatricpa- tients • Obesitynotonlyhasanimpactonmorbidityand mortality,butalsoonthequalityoflifeofthose whosufferfromit[22].Itisunderstoodasasub- jectiveperception,influencedbytheirhealthsta- tusandtheabilitytocarryoutactivitiesthatare importantintheirlives.[35][36].
• Thehealth-relatedqualityoflifeoftheobeseis affectedinatleastfouraspects: • Problems directly related to problems of [im- pairedphysicalperformance],mentalones[im- pairedself-esteem, depression]orsocialones [impairedrelationshipswithothers,socialinte- gration,sexualrelationships,etc].
• Complications derived from obesity, such as chronicdegenerativediseases.
• Problemsrelatedtothevitalprognosisandpos- siblediseasethattheycanendtheirlifes. • Changesinhealth-relatedqualityoflifeinlight oftheresultsofagenerallylongtreatment,with slowresultsandfrequentrelapses.
• Therefore,thequalityoflifeisnotaimedatelim- inatingthediseasebutratheratimprovingthe qualityofliferelatedtothehealthofpatients duringsurvivaltime[22][34].
TheBAROSscore[BariatricAnalysisandReportingOut- comeSystem],hasbeenvalidatedasthebestsystem forcomprehensiveandobjectiveassessmentofthe benefitsofbariatricsurgery,sincethatconsidersdif- ferentvariablessuchaslossofexcessweight,correc- tionofdiseasesassociatedwithsevereobesity,mor- bidityandmortalityoftheprocedureintheshortand longterm,andaboveall,incorporatestheevaluationof postoperativequalityoflife[37].Fromthislastinstru- mentarisestheTestMoorehead-Ardeltinstrumentthat evaluates5dimensions:self-esteem,physicalactivity, socialrelationships,workperformance,andsexuality [38],theSpanishversionofthisinstrumentaddsasixth dimensionthattakesintoaccounteatinghabits[34]. Itisworthmentioningthat,innoneofthevalidated instruments, thepastiscomparedwiththepresent, consideringonlythepresent,diagnosedwithascore; itissuggestedtoimplementstudiesandinstruments toknowwhatthequalityoflifeofthepatientswaslike andtoconsiderthepersonalopinionofthepatients.In thecaseofmorbidobesity,qualityoflifebecomeseven moreimportant,sinceitisahighlyprevalentdisease inourenvironmentandconsumesalargeamountof resourcesintheHealthCareSystem[34].Theresults shouldnotbeassessedonlyaccordingtotheinitialloss ordelayedweightgain,complicationsorsequelaeof onetechniqueoranother,orthesubsequentneedfor cosmeticsurgery,butratheraseriesoffactorsderived fromthepatienthimselfshouldbetakenintoaccount which,together,definequalityoflife[17]. However, moreimportantthanthenumberofkiloslostisthe improvementincomorbiditiesassociatedwithexcess weight[21].
Objective: Todetermineifthelossofexcessweightin patientsundergoingbariatricsurgeryisaparameterfor improvingqualityoflifeandreducingcomorbidities. Hypothesis.
• H0=Thereisnosignificantdifferencebetween thepercentageoflossofexcessweightwithim- provementinqualityoflifeandcontrolofcomor- bidities.
• HA=Thereisasignificantdifferencebetween thepercentageoflossofexcessweight,withim- provementinqualityoflifeandcontrolofcomor- bidities.
2.MaterialsandMethods 2.1Aquasi-experimentalepidemiologicalstudywas carriedoutin42patients.Anon-probabilisticsampling wasusedfortheinclusionofconsecutivecases.Infor- mation from the electronic file was collected, using the“SorianMedSuite”electronicsystemandtheappli- cationoftheMOOREHEAD-ARDELTII-Questionnaire AdaptedtoSpanish,duringfollow-upcheckupsatthe RegionalHighlySpecializedHospitalofZumpango,Es- tadodeMexico,inMexico,whosedatawasrecorded onaspreadsheetforitsanalysis.
Subsequently,thedatacollectedfromtheintervened patientswithabariatricsurgery[6monthsafterwards] wasevaluatedattheRegionalHighlySpecializedHospi- talofZumpango,EstadodeMexico,inMéxicothrough thecriteriaofinclusion,exclusionandeliminationof therepresentativesample.Thepercentageofweight lostinpatientswillbeidentifiedandanassociationwill besoughtwiththequalityoflifetheycurrentlyhave andthepresenceofcomorbidities.
2.2StudyVariables Thevariablesusedwere:age,gender,presenceofpre- surgicalcomorbiditiesassociatedwithobesity,initial anthropometric data, post-surgical anthropometric data,laboratorystudiesbeforeandaftersurgery,eval- uationofqualityoflife,andmortality.
2.3StatisticalAnalysis Statisticalanalysiswasperformedbyfrequencydistri- bution,percentages,measuresofcentraltendencyand dispersion,forquantitativevariablesandchi-square forqualitativevariables. Statisticalanalysiswascar- riedoutbymeansdifferenceforvariablesthatdenote anthropometricindicatorsandforbiochemicalindi- cators,basedonavalueofp<0.05andCIof95%,the statisticalanalysiswasperformedinSPSSversion23. 2.4EthicalAspectsofResearch TheresearchandethicalguidelinesoftheHelsinkiprin- cipleswerecompliedwithtoconductthisstudy. Ac- cordingtothestudycarriedout,whatisestablishedin theRegulationsoftheGeneralHealthLawonResearch forHealthinArticle7. Theprojectwasapprovedby theresearchcommitteeoftheRegionalHighlySpecial- izedHospitalofZumpango,EstadodeMexicoinMexico. (CI/HRAEZ/2018/12) 3.Results Informationfrom42patientswhounderwentbariatric surgeryattheHRAEZ[RegionalHighlySpecializedHos- pitalofZumpango,EstadodeMexico]wasanalyzed, fromwhichpreoperativedatawasobtainedfrom31 patientsandpostoperativedatawhere23werefemale and8weremale,aged25to71yearsandanaverage of44yearsold,themostperformedsurgicaltechnique with59%wasrobotic,inrelationtothelaparoscopic Inclusioncriteria: -Patientsundergoinglaparoscopicorrobot-assistedbariatricsurgeryproce- dures,suchasgastricsleeveandgastricbypass.-Patientsintervenedwith bariatricsurgerywithfollow-upequaltoorgreaterthan6monthswithcom- plete pre- and post-studies. -Patients aged 18 years or older undergoing bariatricsurgery.-Patientswhosigntheinformedconsent. Exclusioncriteria: -Bariatricsurgerypatientsunder18yearsofage.-Patientstreatedwithen- doscopic gastric balloon. -Patients withperioperative complicationsthat requiredsurgicalre-intervention.
Eliminationcriteria: -Femalepatientswithpregnancyduring6monthsafterthesurgicalprocedure. -Patientsinwhomitwasimpossibletocollectsufficientdata.-Patientswho refuseparticipationinthestudy.
with41%.Thetwotypesofsurgerythatwereapplied were bypass and gastric sleeve in 61% and 39%, re- spectively.Oftheintervenedpatients,45%presented adiagnosisoftype2diabetesmellitus,19%adiagno- sisofsystemicarterialhypertension,32%depression, 23%gastroesophagealrefluxdiseaseaswellasdyslipi- demia.
Accordingtopreoperativeanthropometricdata,itwas foundthattheminimumheightwas1.40m,themaxi- mum1.83m.andtheaverageof1.63mt.[SD=10.59], thepreoperativeweightrangedbetweenwere84.5kg. and188kg.,withanaverageof129.76kg.[SD=26.93]. Theminimumidealexcessofweightis48kg,themax- imum83.38kg,theaverage66.78kg.[SD=7.63].The excessofweightofpatientscomparedtotheirideal weightrangesfrom25.4kg. and108.19kg. withan averageof62.98kg.[SD=24.18].Theminimuminitial excessofweightpercentagewas43.09%,themaximum 221.69%andthemean94.91%[SD=38.73].Themini- mumpreoperativebodymassindexwas35.6kg/mt andthemaximumwas80kg/mt withameanof48.5 kg/mt [SD=9.64],whichindicatesthatthepatients hadgradeIIIobesity[Table1].
Source:SorianMedSuiteelectronicfile,2019. Inthepostoperativeresults,itwasobservedthatthe obesitycomplicationsofthe10patientswereremit- ted,ofwhich4patientshadpresentedapreoperative diagnosisoftype2diabetesmellitus,2systemicarte- rialhypertension, 1depression, 1gastroesophageal refluxdiseaseand2dyslipidemia;theinformationof theotherpatientswasnotobtainedduetolackofreg- istrationandupdatingofdatafortheircontact. Inrelationtothepostoperativeanthropometricmea- surements,ofthe10patientsitwasobtainedthatthe minimumfinalweightwas61.6kg,themaximumwas 126.3kg,obtaininganaverageof83.97kg.[SD=20.54], theminimumBMIwas24.0kg/mt ,themaximumwas 2 2 48.72kg/mt withameanof32.47kg/mt [SD=7.42]. Figure1.Selectioncriteriaforthestudy. Aminimumweightlossof26kgandamaximumof72 kgwasachieved. Withanaverageof42.21kg. [SD= 14.10],representedinaminimumlossofexcessweight percentageof40.9%,amaximumof110%andamean of65.69%,whichindicatesthatitiswithinthequality standardsofbariatricsurgery[Table2]. Source:SorianMedSuiteelectronicfile,2019. Thequalityoflifewasevaluatedbythescoreandthe resultwasverygoodin8patientsandgoodin2.There- sultsregardingthehypothesistestdifferedwithavalue oft=8.96betweenthevariableinitialweightandfinal weightandavalueofp=.000,inthesamewaytheini- tialBMIandthefinalBMIhaveavalueoft=-3.412with avalueofp=.008.Betweenthevariablepercentageof initialexcessofweightandpercentageoflossofexcess ofweighttherewasasignificantdifferencewithavalue oft=7.06andavalueofp=.000.Likewise,betweenthe initialglucosevaluesandthefinalglucose,avalueof t=4.22andavalueofp=.002wereobtained,between thevariableoftheinitialLDLlevelsandthefinalLDL levels,avalueoft=5.52andavalueofp=.000.and% excessweightloss–Qualityoflifeavalueofp=9.545 andavalueofp=0.005.(Table3).
Significancevalueofp < 0.05CI95% Basedontheresultsobtainedgiventhatthevalueofp is <0.05andCI95%,forthevariablesstudied,where theresearchhypothesisindicatesthatthereisasignifi- cantdifferencebetweenthepercentageoflossofex- cessofweight,withimprovementinqualityoflifeand controlofcomorbiditiesanditisrejectedthatthere isnosignificantdifferencebetweenthepercentageof lossofexcessweightwithimprovementinqualityof lifeandcontrolofcomorbidities.
4.Discussion Attemptshavebeenmadetoisolatecertainvariables, suchasgenderandageaspredictorsofdesertionto Variable N Minimum Maximum Half Standarddeviation[SD] Size[mt] 31 1.40 Initialweight[kg] 31 84.5 Maximumidealweight[kg] 31 48 Excessofweight[kg] 31 25.44 %initialexcessofweight 31 43.09 InitialBMI[kg/mt ] 31 35.69
Table 2. Table2. Descriptiveanalysisofpostoperativeanthropometricvariables
Variable N Minimum Maximum Half Standarddeviation[SD] Finishedweight[kg] 10 61.6 126.3 83.97 20.54 FinalBMI[kg/mt ] 10 24.0 48.72 32.47 7.42 Finallostweight[kg] 10 26.0 %lossofexcessweight 10 40.9 110.18 65.69 21.3
Table 3. Table3. ComparisonofimpactindicatorsinBariatric Surgery.
Variable tValue pValue Initialweight– Finalweight InitialBMI– FinalBMI %Initialexcessweight- %Finalexcessweight Initialglucose– Finalglucose InitialLDL–FinalLDL %excessweightloss– Qualityoflife postoperativecareprograms,findingpreliminaryre- sultsindicatingthatfemalegender,youngerage,and seriouspsychiatricdisorders[suchaspersonalitydisor- ders]areassociatedwithhigherdropoutrates[39].Re- gardingourstudy,ahigherpercentageofbariatricsurg- erieswereperformedtowomenin74%ofthecasesand 26%inmen,withagesbetween25and71yearsandan averageof44years,whichsuggeststhatthevastmajor- ityoftheintervenedpatientswerewomenandthisis associatedwithgreaterdropoutratesinpost-surgical treatment,leadingtolosingpartofoursample. Inthestudy,theroboticsurgicaltechniquewasem- ployedin59%ofthepatients,inrelationtothelaparo- scopic techniquewith41%, whichmatchestheone fromthestudybyAhlering,T.E.[2003][40].Although laparoscopyrevolutionizedthefieldofsurgery,today, roboticshasrevolutionizedthefieldofminimallyinva- sivesurgerysincemanyofthelaparoscopicprocedures arehighlytechnicallydemandingandtechnologyhas providedameansbywhichendoscopicsurgicalper- formancecouldbeimproved[41].Theuseofrobotic 1.83 1.65 .09334 188 129.76 26.93 83.38 66.78 7.63 108.19 62.98 24.18 221.69 94.91 38.73 80.10 48.53 9.64 72.0 42.21 14.10 surgeryisexpandinginthefieldofbariatric/metabolic surgery,andthefirststudiescarriedoutduringitstech- nologicaldevelopmentconfirmitssafety,achievinga 8.96 0.000* reductionincomplications,butwithalongersurgical timeandhighercosts[42].
-3.412 0.008* Thetwotypesofsurgerythatwereappliedinthisstudy 7.06 .000* were bypass and gastric sleeve in 61% and 39% re- spectively, which is related to what David Pacheco 4.22 .002* Sánchezandothers[2019]mentioninpriorstudies, 5.52 0.000* wheremostofthesurgicaltechniquesdescribedinthe pastdecadeshavebeenabandonedandcurrentlythe 9.545 .005* gastricsleeveandgastricbypassin“YdeRoux”both withlaparoscopicapproachare,inthisorder,thetwo most used techniques. Both have similar results in termsofweightlossandresolutionorimprovementof comorbiditiesandasimilarsafetyprofile[42]. According to the results obtained, the patients pre- sentedatleastonecomorbidityassociatedwithobe- sity,whichweretype2diabetesmellitus,systemicarte- rialhypertension,depression,refluxdisease,anddys- lipidemia,asdescribedbyZugastiandMoreno[2005] regardingobesity,especiallyobesitydistribution.cen- tral,representsasignificantincreaseinmorbiditydue to its association with diseases that affect most of thebody’ssystems[hypertension,dyslipidemia,type 2diabetes,coronarydisease,cerebralinfarction,bil- iarypathology,obstructivesleepapneasyndrome,os- teoarthropathy,andcertaintypesofcancer][29]. Inrelationtotheanthropometricdata,thepatientspre- sentedameanBMIof48.5kg/mt ,wheretheminimum 2 2 was 35.6 kg/mt and the maximum was 80 kg/mt , whichcomplieswiththeguidelinesestablishedbythe officialMexicanstandardNOM-008-SSA3-2010,forthe comprehensivetreatmentofexcessweightandobesity, whereitstatesthatsurgicaltreatmentwillbeindicated inadultindividualswithaBMIgreaterthanorequalto 40kg/m2orgreaterthanorequalto35kg/m2associ- atedwithcomorbidity,whoseorigininbothcasesis notpurelyendocrine[7].
Fromthepostoperativeresults,thecomorbiditiesof thepatientsthatcouldbeevaluatedwereidentified as,type2diabetesmellitus,systemicarterialhyper- tension,depression,gastroesophagealrefluxdisease, anddyslipidemia. Inrelationtotheremissionofdi- abetes,Papapietro[2012]pointsoutthatinaddition tothereductionofexcessweight,themostbeneficial effectofbariatricsurgeryhasbeentheimprovement inglycemiccontrolofpatientswithDM2,whichisob- servedearlyaftersurgery. Inaddition,itmentionsa Buchwaldmeta-analysisthatincluded136studieswith atotalof22,094patients,whereitwasshownthatDM2 remittedin76.8%ofthepatients[hypoglycemicagents werediscontinued]andimproved[thedoseofhypo- glycemicagentswasreduced]inthe86.0%ofcases. Thesamestudyshowedthatcompleteremissionof DM2occurredin48%ofpatientsafterGBP,84%after GBP,and95%afterDBP.Ingeneral,recurrenceofdi- abetes after surgery has been uncommon in follow- upstudiesupto10yearsafterGBPorDVP[2].García Caballero[2010]describesa16-yearfollow-upstudy, whereheconfirmedaDM2remissionrateof83%,an improvementinDM2complications,andareductionin mortalitycomparedtoacohortofpatientswhorefused surgeryandhadthesameepidemiologicalparameters asthoseintervenedon[1%vs4.5%, p .0001]. The resultsofbariatricsurgeryinobesepatientsshowthat theresolutionofdiabetesdoesnotdependonweight loss,sincetheresolutionofdiabetesis“almostinstan- taneous”[27].
Inthisstudy,systemicarterialhypertensionwascon- trolledinpostoperativepatients.Otherstudieshave alsoconfirmedthedecreaseinmortalityassociated with cardiovascular risk in patients with bariatric surgery. A significant reduction in the incidence of preeclampsia,hypertensivedisease,anddiabetesdur- ingpregnancyhasalsobeenobservedinwomenwith ahistoryofbariatricsurgery.
Regardingdyslipidemia,inthisstudyitwasfoundthat aftertheinterventiontherewascontrolinLDL[low- densitylipoprotein]levels,asshowninthestudythe assessmentoftheevolutionofcomorbiditiesofmor- bidobesity,whereitisspecifiedthatabnormalitiesin bloodlipidsmayalsoimproveasaresultofbariatric surgery.Moreover,dyslipidemia,generallyimproves in85%oftheintervenedpatients, andresultsinan improvementofover95%inthosewhohavebeenin- tervenedwithmalabsorptiontechniques[2].Inthisin- vestigation,itwasfoundthatgastroesophagealreflux diseasealsoremittedinoperatedpatients.Thisfinding matchesthatofthestudybySpaventaIbarola[2013], whereallpatientsshowedsignificantimprovementin GERD; however, the greatest improvement in reflux wasseeninpatientswhounderwentgastricbypass, followedbygastricbandingandfinallygastricsleeve surgery.Underthisperspective,theauthorsconclude thatallcommonbariatricproceduresimproveGERD [31].
According to the anthropometric results Méndez Martínez[2013]pointsoutthat,althoughmostpatients achievesuccessinweightlossaftersurgery[definedas lossofmorethan50%ofexcessofweight],therehave beenreportsintheliteraturethataround20%ofpa- tientsfailtoachievethisgoalayearaftersurgery[24]. Ameta-analysisofweightlossafterbariatricsurgery showedareductioninthepercentageoflossofexcess weightof61.2%[25].After5years,theaverageexcess ofweightlossis50–60%,andtheincidenceofinade- quateweightlossafterbariatricsurgeryis20–25%[26]. In1981,HalversonandKoehler[1981]werethefirstto classifytheresultsbasedonthepercentageoflossof excessweight,consideringassuccessthosecasesin whichthelosswasgreaterthan50%[43]. Twoyears later,LechnerandElliot[1983]consideredtheresult asgoodifweightlossisbetween50%and79%ofthe excessofweightandfailure,ifitisbetween25and49% [44],andMartínetal[1985]separatethesuccessesin 2groups: goodifweightlossexceeds70%ofexcess < weight,andsatisfactoryifweightlossisbetween40 and60%[45]. In1982,Reinholdintroducestheeval- uationoftheresultsbasedonthefinallossofexcess weightandtheidealweight,indicatingthatiftheex- cessofweightislessthan25%withrespecttotheideal weight,theresultisexcellent;iftheexcessofweight remainsbetween25and50%,theresultisgood;ifit isbetween50and75%,theresultisacceptable,and ifitisgreaterthan75%, itisconsideredafailure25 [46]. Followingasimilartrend,MacLeanetal[1990] consideraresultasgoodifthefinalweightexceeds theidealweightbynomorethan30%;satisfactoryif theweightlossisgreaterthan25%oftheinitialweight, andunsatisfactoryiftheweightlostislessthan25% oftheinitialweight[17][47].Therefore,anthropomet- rically, the indicators of success in bariatric surgery ofpatientsinrelationtotheliteraturearewithinac- ceptableparameters,whichdemonstratethequality oftreatment.
Inrelationtothelossofthesample,theimplementa- tionofaninstrumentmustbetakenintoaccountto haveanadequateadherencetothetreatmentforat least5yearsasmentionedbyLarand[2014]whode- scribesthatitistheminimumtimeacceptedforany assessment.Pataky,Carrard&Golay[2011],inareview ofstudies,showthatintensivefollow-upisacrucial factorinpreservingpost-surgeryweightloss,including regularvisitstoaspecialistandparticipationinlifestyle changeprograms[39][48].
Finally,inthisstudythequalityoflifeofthepatients aftersurgerywasobtainedatacertainpercentage,in which8wereverygoodqualityand2weregoodac- cordingtothescorecriteriaemployed;demonstrating thatinthetreatedpatientsthequalityofliferesulted asadequate,meaningthatnotonlythepercentageof lossofexcessweight,butalsotakeintoaccountthe qualityoflifeofpatientstookplace.Therefore,these factorswereconsideredimportantparameterinthe successofsurgery[17].
In the questionnaire to assess quality of life, it was foundthatallthepatientshadagoodrelationshipwith food,whichmaymatchwiththefamilysupportofthe patients,asmentionedinthestudyofbariatricsurgery inadults:facilitatorsandthosewhohinderweightloss fromtheperspectiveofthepatients,wheretheyvalue thatthechangeineatinghabitsoftheirclosestfamily membersandthefactthattheycouldadapttothere- strictionsthatareimposedonfoodaftersurgery,helps thepatientnottofeelaloneinthisprocessofchanging habits.Ontheotherhand,thechangeineatinghabits isrelatedtothefearofgainingweightagain,whichis anewconcern, whichreferstothemeasurementof caloriesinthefood,andthereforegreatercontrolover whatiseatenandhowitiseaten[39].
5.Conclusions • Thepatientspresentedahigherpercentageof thecomorbidityofType2DiabetesMellitusinre- lationtoHypertension,GERD,Dyslipidemiaand Depressionandoncethebariatricsurgerywas performed,thecomorbiditieswereremitted. • Moresurgeriesareperformedbymeansofthe Robot than by laparoscopy in this study, the sameoccurswithbypasssurgerieswithrespect togastricsleevesurgeries.
• The percentage of loss of excess weight after surgery was correct according to the parame- tersestablishedinthespecializedbibliography. Bariatricsurgeryimprovesthequalityoflifeof patientswithobesity.
• Theadherenceofthepatientstothemultidis- ciplinaryhealthgroupisneededtohavebetter controlforatleast5years,andthusbecertain thattheywillhaveagoodqualityoflife.Andthe implementationofaprogramthatcommitsthe patienttothisfollow-upissuggested.
• The comparative analysis by mean difference betweenanthropometricandbiochemicalindi- catorsdenotesasignificantdifferencep<0.05, whichallowsustopointoutthattheirstateof healthandqualityoflifeimproved,forwhichthe H0isaccepted.
Authors’contributions: Allauthorslistedhavemade asubstantial,directandintellectualcontributionto thework,andapproveditforpublication. The authors are deeply grate- Acknowledgments.
ful to the Hospital Regional de Alta Especialidad de Zumpango, State of Mexico, to the participating pa- tients,tothepersonnelassignedtotheareaofsurgery, aswellasaspecialmentionofthankstothecompany IntuitiveSurgical,creatoroftheDaVincisurgicalrobot fortheirparticipationinthesurgeriesofthepatients, sincewithoutalltheirsupportitwouldnothavebeen possibletocarryoutthisresearch,toCONACYT/grant holder860003tostudytheMasterofPublicHealthat UAEHandtoYeseniaElizabethRuvalcabaCobiánfor hercollaborationinthetranslationandeditionofthis article.situationthatincreasesthepossibilityoftrans- ferringscientificknowledge.
Conflictofinterests: Theauthorsdeclarenoconflict ofinterest.
ArtificialIntelligence. Theauthorsdeclarethatno artificialintelligencewasusedinanyofthesections.