Awareness of Bariatric Sleeve Gastrectomy Complications Among the General Population of Saudi Arabian Regions

Sleeve gastrectomy (SG) is a type of procedure called bariatric surgery that provides large weight loss and has a positive impact on diseases associated with obesity. However, it has brought several complications that have an impact on those undergoing surgery, which are classified into intraoperative and postoperative issues. The study's goal is to assess the Saudi Arabian population's awareness of SG consequences. This study assessed the general population's knowledge in Saudi Arabia in 2023 using a cross-sectional approach. The total number of participants was 1,013, the majority of whom were individuals between the ages of 18 and 25 (471, 46%), and females (692, 68%). A total of 692 (68%) participants showed awareness of BMI; in addition, 987 (97%) were aware of gastric sleeve surgery, and 538 (53%) understood its indications correctly. Regarding SG complications, approximately 821 (81%) of participants showed awareness. There were significant associations between knowledge of gastric sleeve surgery and residence in the northern region of Saudi Arabia. In conclusion, our study indicated that the general population is aware of the complications of gastric sleeve surgery, but it found a deficiency in their knowledge about BMI.


Introduction
Obesity is still a major public health issue around the world, and the number of individuals affected by it is increasing.It is characterized by a BMI of 30 kg/m 2 or more and can affect people of all ages [1].Obesity is classified into three categories: those having a BMI of 30 kg/m 2 to less than 35 kg/m 2 are classified as Class 1, those having a BMI of 35 kg/m 2 to under 40 kg/m 2 are classified as Class 2, and those having a BMI of over 40 kg/m 2 are classified as Class 3 [2].Based on the WHO report in Saudi Arabia in 2019, 38% of the total population was overweight and 20% were obese, indicating that obesity is spreading at a worrying pace [3].Obesity has been linked to various diseases, such as metabolic disorders, endocrine disorders, and joint disorders [4].It is also strongly linked to high blood pressure, heart disease, and obstructive sleep apnea [5,6].The management of obesity is a step-by-step process.Obese patients have to be counseled for lifestyle modification first, which includes diet, increased physical activity, and behavior therapies.Treatment with pharmacological agents is considered the second step [7].Pharmacological therapies for weight-loss maintenance are fairly limited.They are only approved for use in individuals with a BMI of ≥30 kg/m 2 and those with a BMI of 27 kg/m 2 .Few drugs are used for managing obesity, one of them being orlistat, which is an irreversible pancreatic lipase inhibitor and comes with gastrointestinal side effects such as oily stool, fecal urgency, fecal incontinence, and flatulence with discharge.Liraglutide is a glucagon-like peptide 1 (GLP-1) analog, which is an incretin hormone released from the intestines in response to meals.It slows down gastrointestinal transit, enhances endogenous secretion of insulin in response to meals, alters glucose homeostasis, and suppresses appetite [2].Surgical management is considered the most effective treatment for individuals with severe obesity, moderate obesity with other comorbidities, or patients who are not responsive to the first two steps [7].
The most popular bariatric surgery nowadays is sleeve gastrectomy (SG), which has been carried out all over the world.Sleeve gastrectomy alone has grown favorable among doctors as well as patients over the past 20 years because it is successful at reducing body mass and is technically less difficult than other traditional bariatric surgeries [8].However, there are unfavorable complications, including stomach fistulas, hemorrhaging, leaking, and issues during the operation [9].The early challenges are that the period following surgery is prone to a variety of issues.The most common issues patients are currently experiencing include hemorrhage, lung infections, the formation of abscesses, and infections of the wound.Furthermore, dumping usually occurs sixty minutes following meals [9,10].Gastroesophageal reflux disease (GERD) and stricture are both later complications [10].Because GERD will worsen following surgery, it is one of the relative contraindications [9,11].Also, deficiencies in nutrition, such as thiamine deficiency (Wernicke-Korsakoff syndrome), might occur.By limiting the capacity of the stomach, the potential to absorb thiamine is significantly decreased [9,12].This medical study aims to determine the level of awareness among the general population in Saudi Arabia regarding SG complications and design a cross-sectional survey to collect data related to this topic.Despite the significant benefits that SG brings to patients suffering from gastric disorders, it is essential to understand and address the potential complications associated with this surgical procedure.Public awareness plays a crucial role in early detection, timely intervention, and improved patient outcomes.Currently, there is limited information available regarding the awareness of bariatric sleeve gastrectomy complications in the general population.This research seeks to fill this gap by conducting a comprehensive cross-sectional study or survey.By assessing public knowledge, perceptions, and misconceptions regarding SG complications, we can identify areas of low awareness and develop targeted educational interventions to bridge the gaps.Ultimately, improved awareness among the general population can prevent or minimize complications, empower patients to seek appropriate medical help when needed and facilitate shared decision-making between patients and healthcare providers.

Materials And Methods
This cross-sectional survey of adult Saudi citizens residing in Saudi Arabia's five regions (Central, East, West, South, and North) was carried out between July and November 2023.Both genders, aged 18 years or older, were included.The study excluded participants who had cognitive impairments or language problems.Three hundred and eighty-five was the bare minimum sample size needed to achieve.A validated Arabic/English questionnaire was used to collect the data (Appendix A).We used online distribution methods for dispersing our questionnaires at random.Our study data were collected through a pre-designed online questionnaire from a previous study conducted in the Western region of Saudi Arabia [13].The questionnaire format is presented in Table 1.

Section number Details
The first section Participants' consent form The second section Demographic information such as gender, level of education, age, and place of residence The third section Questions on general awareness and knowledge of sleeve gastrectomy The fourth section Assessed knowledge of sleeve gastrectomy indications The fifth section Assessed knowledge of complications associated with sleeve gastrectomy (95% confidence level)

FIGURE 1: Knowledge of sleeve gastrectomy, its complications, and indications
Regarding SG complications, approximately 821 (81%) of the participants exhibited awareness.Most of the respondents were aware of hemorrhage, nutritional and mineral deficiencies, and iron deficiency as acute complications, while most of the respondents were aware of chronic complications, including anemia, iron deficiency, and nutritional and mineral deficiencies (Table 4).

TABLE 4: Association of demographic characteristics and knowledge of sleeve gastrectomy and its indication (n = 1013)
There were significant associations between knowledge of SG and residing in the Northern region of Saudi Arabia (P = 0.031).Additionally, individuals aged 18-25 years, possessing a bachelor's degree and residing in either the Northern or Southern regions of Saudi Arabia exhibited significant knowledge of SG indications (P < 0.05) (Table 5).

Discussion
The aim of the research was to evaluate public knowledge of the indications and complications of SG.People considering bariatric surgery, including SG, should be thoroughly informed of what to anticipate.The findings of this study revealed that the knowledge of the general population was adequate.Based on our accounts, 692 (68%) were sure about the indications, and 821 (81%) knew about the complications.However, their knowledge about BMI seemed to be lacking since almost half of the subjects (475,47%) were unaware of the term BMI, and only 357 (35%) were able to identify the BMI range of obese individuals, which was 30 kg/m 2 or more.Out of the 1,013 respondents in our poll, 692 (68%) were aware of BMI; however, only 357 (35%) defined obesity as 30 kg/m 2 .Consistent with Alolayan, research indicated that awareness about BMI was insufficient [7].
These results fall in line with the research conducted by Gowanlock et al. [14] that discovered a shortage of comprehension of SG.Of those surveyed, 41% and 64.8% had been aware of the indications and complications of the procedure, respectively, but the majority were unaware of the term BMI and had only insufficient awareness of the appropriate BMI for an obese person [15].Of those who are unsure about the surgical indications, 475 (47%) say they are unaware, but their group's knowledge about SG and living in the Northern region of Saudi Arabia was significantly correlated (P = 0.031).Furthermore, those with a bachelor's degree who were between the ages of 18 and 25 and who lived in Saudi Arabia's Northern or Southern regions demonstrated a noteworthy level of understanding regarding the indications for sleeve gastrectomy (P < 0.05), which contradicts the findings of Alolayan's study on gender and educational attainment [7].Moreover, 821 (81%) of the participants knew about complications, and there was a significant correlation (P < 0.05) found between the following characteristics: female gender, aged between 18 and 25, with a bachelor's degree, and aware of complications related to SG, which is consistent with the study conducted by Alamri et al. [16].Also, the interest of females in beauty and health is an indicator of their awareness of the complications of gastric sleeve surgery [16].Additionally, comparable with the study of Gowanlock et al. [14], the participants selected hemorrhage as the most common acute problem and anemia and iron deficiency as the most chronic complications.
A limitation of our study is that there is only one method for monitoring data, and it is preferable that more methods be considered in order to obtain better results.This was the case in some regions where the numbers were shrinking due to difficulty in reaching the participants, such as the Central region, where their number reached 70 (7.1%),followed by the Eastern region, where they reached 130 (13%), so the sample is not well distributed.Another limitation is a lack of diverse perspectives.Our result shows that 63% of participants have a bachelor's degree, which can impact our results by being skewed towards people with higher educational backgrounds, and this can limit the representation of individuals with lower educational levels with different awareness and knowledge levels.It is now simple to find information and answers about any procedure or problem thanks to the Internet's rapid development, widespread presence, and the involvement and help of doctors on social media.We recommend that doctors post more information on social media.

TABLE 1 : The five-part questionnaire was divided into five sections Ethical
Data were collected in a Microsoft Excel sheet (Microsoft Corp., Redmond, WA) and analyzed using RStudio (R version 4.3.0;R Foundation for Statistical Computing, Vienna, Austria).Descriptive statistics were used, with categorical data presented as numbers and percentages.Chi-square and Fisher's exact tests were used to evaluate the determinants of knowledge of SG complications and knowledge of SG indications.

TABLE 2 : Demographic characteristics of the participants (n = 1013)
Notably, 692 (68%) of the participants demonstrated awareness of BMI, with 35% identifying a BMI of 30 kg/m 2 or higher as indicative of obesity.Additionally, 987 (97%) were familiar with SG, and 538 (53%) correctly understood its indications.The majority of validated Arabic and English questionnaires were used to collect the data.The majority concurred that adults with a BMI exceeding 35 kg/m 2 and those with a BMI surpassing 40 kg/m 2 were suitable candidates for SG (Table3).

Knowledge of sleeve gastrectomy indications
Do you know the complications of sleeve gastrectomy?

TABLE 5 : Awareness of the complications of sleeve gastrectomy (n=1013)
Furthermore, a significant association was observed between being female, falling within the 18-25 age group, having a bachelor's education, and possessing knowledge about SG complications (P < 0.05) (Table6).