Year : 2020 | Volume
: 5 | Issue : 1 | Page : 1--5
Bariatric surgeries' complications in Saudi Arabia
Sultan Ali Alwajeeh1, Rawan Saeed Alasmari2, Ibtihal Mohammed Alattas3, Razan Aiydh Abu Hassan2, Raged Ibrahim Alrawaji2,
1 Department of Health Policy, Ministry of Health, Riyadh, Saudi Arabia
2 Almareefa Medical College, Riyadh, Saudi Arabia
3 Department of Emergency Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
Dr. Sultan Ali Alwajeeh
Red Sea Research Group, Jeddah
As obesity is becoming a global epidemic, many solutions have been proposed to patients from medical to psychological to surgical. Recently, with the advances of laparoscopic surgery and the safety of the anesthesia, bariatric surgeries are expanding, particularly in the countries affected by obesity the most. Saudi Arabia is one of the highest countries with an obesity rate. This study aims to explore the complications of various bariatric surgeries (gastric banding, gastric bypass, and vertical sleeve gastrectomy) by reviewing the literature that has been published in Saudi Arabia. The findings from this study would enlighten the clinicians and patients about the prevalence of these complications in this geographical area and allow a thoughtful comparison between the complication rate among different countries and practice types.
|How to cite this article:|
Alwajeeh SA, Alasmari RS, Alattas IM, Abu Hassan RA, Alrawaji RI. Bariatric surgeries' complications in Saudi Arabia.Saudi J Laparosc 2020;5:1-5
|How to cite this URL:|
Alwajeeh SA, Alasmari RS, Alattas IM, Abu Hassan RA, Alrawaji RI. Bariatric surgeries' complications in Saudi Arabia. Saudi J Laparosc [serial online] 2020 [cited 2021 Apr 22 ];5:1-5
Available from: https://www.saudijl.org/text.asp?2020/5/1/1/296785
Obesity is becoming a global epidemic in many countries. It is the leading cause of coronary artery disease, diabetes, and many other diseases. Obesity causes more than 150 diseases, and it is an utterly preventable cause of morbidity and mortality.
Obesity affected both the developed and developing countries at a variable rate. Among the developed countries, the United States is one of the countries that is significantly affected by obesity. The gulf area, and particularly Saudi Arabia, is one of the developing countries that has been influenced tremendously by obesity.
As an effort to battle obesity, many medical and surgical treatments were introduced. In the past two decades, bariatric surgeries have become popular, especially with the advancement of the laparoscopic technique that has reduced both the postoperative period and the complication rate.
The indication for bariatric surgery is body mass index (BMI) above 40 or above 35 with significant comorbidities. However, obese people are considering undergoing gastric sleeve as the procedure price is reducing. According to Al-Arabiya website, the price for bariatric surgery in 2018 in Jeddah ranges from 30,000 to 35,000 in most clinic, while it cost 65,000 in famous clinic. The new law mandates the private health insurance to cover 20,000 SR per person for indicated procedure. Medical insurance also started covering bariatric surgeries, and the Saudi Ministry of Health is having a dedicated initiative for bariatric services. In addition, the Saudi Government dedicated 500 million Saudi riyals to treat obesity in 2018.
Based on our last PubMed search on July/2019, we have not found a research article dedicated to the general complication of bariatric surgeries. A few studies, mainly case report or series, were published about a specific topic such as neuropathy or leak, but the general complications are not studied in the Saudi population yet.
This study aims to come up with the prevalence of complications of bariatric surgeries in Saudi Arabia. This study targets intraoperative, short, and intermediate terms complications of bariatric surgeries. It includes both private and government health-care sectors to compare them and to know Saudi Arabia's complication rate compared to the standard International Benchmark.
Obesity and obesity-related chronic illnesses are one of the leading causes of deaths in Saudi Arabia. With the warm weather, lack of walkable areas in many neighborhoods, and lack of health awareness, many people are struggling to keep their weight within the normal BMI (18–24.9). In addition to that, some research report states that women, particularly in the gulf area have one of the highest rate of obesity globally. This is because of the cultural conservatism and the social norm of how women dress, behave, etc. Therefore, as the number of people who fail to lose weight by diet or physical activity, many opt to have bariatric surgeries. However, the booming of the bariatric surgeries, especially in some private hospitals comes with a price.
Higher complications of the operation and higher failure rate might deter many from doing the surgery. Up to the current date, we could not find a resource, indicating the prevalence of these complications in Saudi Arabia. This is a critical piece of information for the patients to make an educated decision and weigh the benefit against the risk of the surgery. This study would be the first to explore the general not only one illness complications of bariatric surgeries.
We did an initial search in Google.com as a background search. We used both Arabic and English languages to find out all about the topics in most of the websites (government, commercial, and educational). We then did a thorough MEDLINE search using PubMed, EBSCO, and Ovid.
PubMed search involved the following terms: “Saudi Arabia,” “Bariatric Surgery,” and “complications.” We used MeSH terms to refine the key terms for the search and to account for variability in the nomenclature.
Obesity is becoming a global epidemic in many countries. In the United States, 27% of adults are obese, and addition of 34% of adults are overweight. According to the World Health Organization, in 1995, there were more than 200 million obese adult wordwide and more than 18 million children below 5 years old are overweight (WHO, controlling). Five years later, this number jumped to 300 million and a noticeable trend of obesity started to increase more in developing countries not only restricted to developed countries. In 2016, according to the WHO, more than 1.9 billion adults (age 18 years and above) were overweight and 650 million of these were obese.
Saudi Arabia is not immune from obesity global epidemic. In 2005, according to a national community-based survey that involved more than 17,000 people found that 36.9% of the population were obese and 35.6% were overweight. Later, in 2007, a national nutritional surgery was done and found rate varies from 11.7% in Jizan to 33.9% in Hail. In the same study, females were higher in the prevalence of obesity (23.6%) than males (14.2%), while the rate of overweight among males were higher than females 30% and 28%, respectively.
Many treatment methods have been suggested to reduce weight such as diet, exercise, and medical therapy. However, bariatric surgeries have been shown to be effective way too durable and significant weight lose., Bariatric surgery was shown to completely resolve obesity-related illnesses such as obstructive sleep apnea, hyperlipidemia, type II diabetes, and hypertension., With the advances of medical technology and the improvement in laparoscopic surgeries, bariatric surgeries have become feasible for many and a valid treatment option. However, the surgeries are not free from complications, which vary from center to center, from procedure to another, and from surgeon/hospital to another.
In Saudi Arabia, with the high prevalence of obesity, many private and governmental hospitals offer bariatric surgeries as a treatment option. According to Al-Arabiya website, more than 20,000 bariatric surgeries are performed in Saudi Arabia with more than 24 surgeries in the King Khaled University Hospital every week.
McBride et al. found that the complication of gastric bypass surgery can sometimes require a large part of the bowl to be resected which might lead to short-bowel syndrome.
Gastric sleeve is a plausible cause of iron deficiency anemia (IDA) since it reduces 85% of the stomach (the fondus and most part of the stomach), which most of partial cells are located to secret both hydrochloride (HCL) and the intrinsic factor. HCL is required to convert iron ferric (Fe+3) to ferrous (Fe+2) form before it gets absorbed in the duodenum. However, Hakeam et al. could not find a relationship between gastric sleeve and IDA in a study that followed up patients for 1 year.
Zafar, in 2015, reported a case of Wernicke encephalopathy of a 40-year-old patient who presented with confusion, ataxia, and ophalmoplagia. The patient had gastric bypass surgery 3 months before his presentation. The author suggest that Wernicke's encephalopathy should be considered as a possible complication of bypass surgery and emphasize the importance of early detection and treatment to avoid permanent damage.
Algahtani et al. conducted a chart review over 5 years period at the National Guard Hospital in Jeddah and found 3% (15 cases) of bariatric patients developed neurological complications. The authors reported that the International Benchmark complication rate is between 5% and 16%. They advised a follow-up after the surgery with dietitian, surgeon, and family physicians where patients can visit them whenever they have the symptoms.
Osland et al. in a metaanalysis in 2016 found no difference between minor and major complication of gastric bypass as compared to gastric sleeve. The author suggest that surgery is quite safe as long as the surgeon is skilled, experience, and the procedure is performed in a high volume center.
Al-Sulaiman reported a case in 2016 of an 18-year-old patient who presented with severe painful lower limb weakness with sensory motor polyneuropathy postbariatric surgery. According to the author, the symptoms/signs were not correlated to the patient previous surgery (gastric sleeve) and thus were not a provisional diagnosis.
Yasawy and Hassan, in 2017, reported three cases of peripheral neuropathy resembling Guillain–Barre syndrome following gastric sleeve surgery. They recommend the panel of Vitamin test every 6 weeks, 3, 6 months, and 1 year after the surgery. They also found that the patient before the gastric sleeve surgery has the deficiency of Vitamin B1, B6, B12, and copper which can get worse after the surgery due to severe malnutrition. This percentage can reach to 5%–30% and need to be investigated before the surgery.
Hakeam and Al-Sanea review the literature in 2017 to explore the oral anti-coagulant agents such as rivaroxaban and dabigatran in patient with gastric bypass surgery who need anticoagulation. They found these anticoagulant agents are preferred to be avoided in patient with gastric bypass due to the lack of studies on the pharmacokinetics absorption of these medication.
Al-Shurafa et al. found that although the gastropulmonary complication of gastric sleeve is rare, as they surgery is becoming common and the complications are life-threatening clinicians need to consider it in postbariatric surgery patients with recurrent or chronic pulmonary infection, especially the gastric sleeve patients.
Althuwaini et al. surveyed patients who had gastric sleeve for gastroesophageal reflux disease (GERD) and compared them with previous situation before the surgery. The researchers found a significant increase in GERD score but could not find a predicting tool to know who are people at the risk of developing GERD postoperatively.
Sunbol et al. reported three cases of Guillain–Barre syndrome in 2018 who underwent gastric sleeve and had lower limb weakness. The researchers suggest a clear communication with patients who are going to have such procedure and a robust follow-up after the surgery with the surgeon, family physician, and a nutritionist.
Alghanim et al. reported a rare but life-threatening complications of gastric sleeve as a gastroplural fistula that can present with recurrent respiratory tract infection after gastric sleeve.
Zafar and Khatri reported that the most common nervous system complications postbariatric surgery include encephalopathy, behavioral and psychiatric disorder, myelopathy, and optic neuropathy.
The prevalence of obesity and overweight published by Al-Nozha et al. indicates an alarm and a surge in noncommunicable disease. Such a high prevalence would create high demand for obesity treatment. However, the type of treatment and the facility where the patient receives it matters the most. The total number of bariatric surgeries in the US for 2017 is 228,000, according to the American Society of Metabolic and Bariatric Surgery. This results in a 71 bariatric surgery per 100,000 population. In Saudi Arabia, the number is 62 bariatric surgeries per 100,000 population, according to Alarabiya report for 2018. The volume in the two countries is not surprising, especially with the epidemic of obesity. However, the quality of the procedure and the outcome are still to be explored.
The majority of the studies in the past, before 2010, were outcomes of gastric bypass, which is a type of malabsorptive procedure. McBride found that short-bowel syndrome is a possible complication of gastric bypass, and Hakeam et al. did not find a relationship between the surgery and IDA. The later finding could be due to the reservation of the fundus and body of the stomach in the bypass surgery, which secret HCL, an essential element to turn iron from ferric to the ferrous form. As in many countries, especially Saudi Arabia, the type of surgery is shifting toward the restrictive surgery (gastric sleeve). Anemia is becoming a concern as many studies showed.
Neurological and behavioral complications
The rate of the neurological complications postbariatric surgeries varies from country to country and center to center. In one bariatric center in Jeddah, Algahtani et al. found the rate as 3% while the international rate is 15%. However, 3% was done on patients mostly having gastric bypass while recently most of the patients are having gastric sleeve. Another complication is Wernicke encephalopathy, a rare Vitamin B1 deficiency, that is seen exclusively in alcoholic but now starts to happen in postgastric sleeve patients. Furthermore, sensory-motor polyneuropathy was presented in a few patients and some presented with Guillain–Barre-like syndrome. The author emphasizes how such symptoms are rarely correlated with surgery that has been done many months or year before. Zafar and Alkhathri reported behavioral, psychiatric disorders, encephalopathy, and optic neuropathy.
Later, gastrointestinal (GI) complications have been reported in other studies such as stomal anastomosis, and marginal ulcer. The early complication could be due to intraoperative injuries or later as a leak. A fistula between the stomach and the trachea and the pleural space was also reported in a few cases. In most of the previous studies, the complications were not correlated with the surgery as they happen many years later. This could be due to most of the patients presented in the emergency department, and as they have GI structure, doctors do not expect such rare complications to happen.
All of the previous complications emphasize the rule of having only accredited centers to do the surgery by well-trained surgeons who are specialized in bariatric surgery. Accredited center should play a major rule in follow-up after the surgery, emergency admission if complications happen and revisions surgery in complicated cases. Patients should have offered the surgery as a last resource after trying to lose weight through diet, exercise, etc. Furthermore, emergency physicians should be aware of the complications of bariatric surgery and the different types of surgery that might affect the patients' anatomy.
Saudi Arabia has a rapid increase in bariatric surgery as a result of the increase in obesity. However, the rate of the complications is not well understood by the research to compare it to the benchmarks, locally or internationally. More research is required to explore the complications and safety of the bariatric surgery, bariatric centers are needed to be accredited and surgeons are required to be trained/certified in doing laparoscopic bariatric surgery.
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Conflicts of interest
There are no conflicts of interest.
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