Obesity has become a rapidly growing global health concern, particularly in developed countries, where its prevalence has significantly increased among adults and children over the past three decades. This condition is associated with a heightened risk of chronic illnesses, including coronary artery disease, diabetes mellitus, hypertension, and hypercholesterolemia, contributing to considerable morbidity and mortality [1] . When conservative measures such as diet and exercise fail to achieve adequate weight loss, bariatric surgery emerges as the most effective and sustainable treatment option for morbid obesity. Procedures like sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) facilitate weight reduction through complex mechanisms, including alterations in gastrointestinal anatomy and motility, changes in gut hormone levels, and behavioral modifications. Despite the well-documented benefits of bariatric surgery in reducing weight and resolving comorbidities, it is not without complications [2] . Among these are anorectal disorders, such as hemorrhoids and anal fissures, which may significantly impact patients’ quality of life. However, the relationship between bariatric surgery and the development of anorectal complications remains underexplored, particularly in Arab countries. While general complications associated with bariatric surgery have been documented [3] [4] , specific studies focusing on anal complications post-surgery are scarce, and no such studies have been conducted in Saudi Arabia. This study aims to address this gap by analyzing the prevalence of anal diseases in patients who underwent sleeve gastrectomy at Almoosa Specialist Hospital, a tertiary-level private hospital in Alhassa, Saudi Arabia. Additionally, it seeks to identify associated risk factors, evaluate the impact of these complications on patients’ quality of life, and propose preventive strategies.

The data were entered into Microsoft excel and data was analyzed by using the statistical package of social science (IBM. SPSS) version 26.0 Categorical variables (sex, age groups, surgery outcomes, lifestyle and dietary habits,) were expressed as frequencies with percentages. The Chi-square test was used to check the association between the variables. The statistical significance will be set at p < 0.05.

Bariatric surgery is considered as one of the possible treatment strategies for reducing body weight, especially with the failure of other treatment strategies [5] . Some epidemiological investigations demonstrated that weight reduction through bariatric surgeries could reduce the incidence of comorbidities [6] . Anal Complications are long-term complications of bariatric surgery. Despite routine treatment by bariatric and colorectal surgeons in daily practice, little has been published on management. Only few articles have been published on the incidence of anal complications after BS [7] [8] .

The analysis of data collected from participants who underwent bariatric surgery at our center offers valuable insights into their demographics, surgical outcomes, and lifestyle changes following the procedure. The gender distribution in our study revealed a higher percentage of females (59.5%) compared to males (40.5%), aligning with trends commonly observed in bariatric surgery demographics. This finding is consistent with research by Young et al., which reported that approximately 80% of bariatric surgery patients are women [9] . This trend may suggest that women are more likely to pursue surgical interventions for weight loss or are more frequently represented in clinical studies.

The age distribution of our participants highlights a diverse group, with the largest cohort aged 35 - 45 years (28.4%) and a significant proportion over 45 years (31.8%). This suggests that bariatric surgery is often sought by middle-aged individuals, likely due to the increasing health risks associated with obesity in this age group, as well as the desire to improve overall quality of life and reduce obesity-related comorbidities.

In terms of surgical outcomes, the majority of participants (81.1%) reported a weight reduction of less than 50%. These findings are consistent with the study conducted by Alhuzaim WM et al. [10] , as well as with results from Sjöström et al. [11] , which indicated that approximately 60% of patients achieved significant weight loss post-surgery, though outcomes varied depending on adherence to post-operative guidelines.

Regarding bowel habits post-surgery, most participants reported no change, while a notable minority experienced constipation (24.3%) or diarrhea (9.5%). These results align with findings by Afshar et al. [12] , who observed similar post-operative bowel changes in their cohort study and highlighted the importance of dietary modifications to manage these symptoms. Similar trends were also noted by Alhuzaim WM et al. [10] , who reported constipation in 22.2% and diarrhea in 14.5% of patients post-surgery. These findings underscore the need for ongoing monitoring and support to address gastrointestinal issues that may arise after bariatric surgery.

In this study, anal problems were relatively infrequent, affecting 8.8% of participants, with anal fissures (53.8%), hemorrhoids (38.5%), and abscesses (7.7%) being the most commonly reported complications. Comparatively, a study from Spain reported a significantly higher prevalence of anal complications after bariatric surgery at 37.2%, with hemorrhoids accounting for 43.1% and fissures-in-ano for 27.5% of cases [13] .

In a separate study published in 2008 on patients who underwent Modified Biliopancreatic Diversion (MBPD), the incidence of anal complications was 18%, with fissures-in-ano being the most common disorder, occurring in 8% of patients [14] . Similarly, Parés et al. [15] . noted that while gastrointestinal complications are commonly documented after bariatric surgery, specific anal problems, such as fissures and hemorrhoids, are often underreported. Their study emphasized the need for greater focus on these issues in post-operative care.

Potoczna et al. [16] reported comparable findings, with a 10% incidence of anal complications following bariatric procedures, highlighting the prevalence of hemorrhoids and anal fissures. Globally, these conditions are among the most commonly reported anorectal disorders [3] [17] [18] .

Our findings suggest that normal bowel habits are crucial in preventing and managing anal complications following bariatric procedures. This emphasizes the importance of patient education, dietary adjustments, and adequate hydration to minimize the risk and impact of these conditions.

The lifestyle and dietary habits of participants in this study indicate a positive trend toward physical activity, with 64.9% engaging in some form of exercise. However, a considerable portion (35.1%) of participants did not engage in physical activity, highlighting a potential area for improvement in post-surgical care plans. These findings align with the research of Bastos et al. [19] , who demonstrated that increased physical activity is associated with better weight maintenance after bariatric surgery. Their study emphasized the importance of incorporating structured exercise programs into post-operative care to enhance long-term outcomes.

Additionally, while many participants reported dietary changes, particularly an increase in protein intake, a significant proportion (60.1%) did not modify their eating habits. This suggests that despite the known benefits of dietary adjustments post-surgery, there is room for improvement in dietary counseling and patient adherence to recommended nutritional guidelines. Providing comprehensive nutritional education and support may help address this gap and further optimize surgical outcomes.

The significant percentage (69.2%) of participants indicating that anal problems affected their lifestyle aligns with findings from Cano‐Valderrama et al. [20] , who observed that such complications can lead to substantial reductions in quality of life. This highlights the necessity for comprehensive post-operative care to mitigate these impacts.

The analysis of the association between anal problems and lifestyle factors post-bariatric surgery provides important insights into patient experiences and the role of lifestyle choices in health outcomes. Physical activity emerged as a significant protective factor, with participants engaging in physical activity reporting significantly fewer anal problems (23.1%), as evidenced by a p-value of 0.001. This finding is consistent with research by Adil et al. [21] , who demonstrated that regular physical activity post-bariatric surgery improves gastrointestinal function and reduces complications, including anal issues. Their study also emphasized that patients who maintain an active lifestyle experience fewer bowel-related problems, underlining the importance of encouraging exercise as part of post-operative care to enhance health outcomes.

Conversely, the study found no significant association between dietary changes and the occurrence of anal problems. Among participants with anal issues, 23.1% reported dietary changes compared to 41.5% of those without problems, with a p-value of 0.196. This is consistent with findings from Lupoli et al. [22] , who suggested that while dietary modifications are common after surgery, they do not consistently correlate with gastrointestinal complications. Their research highlighted the variability in individual responses to dietary changes, indicating that dietary adjustments alone may not suffice to prevent anal complications.

Similarly, the use of dietary supplements showed no significant relationship with the occurrence of anal problems. In this study, 53.8% of participants with anal problems reported using supplements compared to 54.8% of those without, with a p-value of 0.175. This finding aligns with Gasmi et al. [23] , who reported that although supplement use is widespread post-surgery and essential for nutrient absorption, it does not directly influence the development of anal complications.

Adequate fluid intake, however, emerged as a significant factor, with participants who consumed sufficient fluids reporting significantly fewer anal problems (46.2%), supported by a p-value of 0.006. This corroborates findings by Dagan et al. [24] , who emphasized the role of hydration in preventing constipation and other gastrointestinal issues post-surgery. Their study concluded that higher fluid intake improves bowel regularity and reduces complications, reinforcing the need to prioritize hydration in post-operative care.

The data also revealed gender-based differences in the impact of anal problems on lifestyle. A higher percentage of males reported lifestyle disruptions due to anal issues compared to females, though this was not statistically significant (p-value = 0.19). Similarly, age did not show a strong association with the lifestyle impact of anal problems, as indicated by non-significant p-values across age groups.

The association between satisfaction and demographics observed in this study aligns with research by Hult et al. [25] , who noted that younger patients and women often report differing levels of satisfaction based on surgical outcomes. These findings emphasize the importance of personalized care to address the unique needs and expectations of various demographic groups.

In summary, this study underscores the critical role of physical activity and fluid intake in reducing the risk of anal complications post-bariatric surgery. While dietary changes and supplement use did not show significant associations, these findings highlight the need for targeted post-operative strategies to optimize patient outcomes and quality of life.

While this study provides valuable insights into anal complications following sleeve gastrectomy, several limitations must be acknowledged. The relatively small sample size (n = 148) may limit the generalizability of the findings, as a larger, more diverse sample could yield more robust and widely applicable results. Additionally, the reliance on self-reported data introduces the potential for recall bias or inaccuracies, particularly regarding sensitive issues like anal health, as patients might underreport or misinterpret symptoms. Incorporating clinical assessments or validated tools in future studies could address this limitation. As the study was conducted at a single institution, the findings may not reflect the experiences of patients from other regions or healthcare settings, highlighting the need for multi-center studies to account for variations in surgical techniques, post-operative care, and patient demographics.

Moreover, the retrospective design constrained the ability to observe long-term outcomes, underscoring the value of prospective longitudinal studies to better understand the progression and sustained impact of anal complications.

In addition, while this study relied on patient-reported symptoms, incorporating standardized objective measures, such as physical examinations or anoscopy, could strengthen the validity of findings. These measures would enable accurate grading of complication severity and provide a more comprehensive understanding of their clinical impact.

Finally, our study provides a valuable understanding of anal complications post-sleeve gastrectomy. However, it is important to acknowledge that confounding variables, such as pre-existing conditions and variations in surgical technique, could influence the outcomes. While we documented these factors during data collection, statistical adjustments were not performed due to the study’s retrospective design. This limitation highlights an area for improvement in future research, where the use of multivariable analysis could help isolate the effects of primary risk factors and strengthen the causal inferences drawn. Incorporating objective clinical assessments alongside robust statistical models would provide a more comprehensive understanding of the determinants of anal complications post SG surgery.

This study highlights a low incidence of anal problems following bariatric surgery, with specific conditions such as anal fissures and hemorrhoids requiring attention in post-operative care plans. The findings underscore the need for enhanced patient support, particularly in addressing weight loss challenges and post-surgical gastrointestinal issues. The higher prevalence of female and middle-aged participants suggests a demand for targeted educational programs and support tailored to these demographics. The data also emphasizes the positive impact of physical activity and adequate hydration on recovery and quality of life, underscoring their importance in post-operative counseling.

Comprehensive pre-and post-operative guidance is crucial to improving surgical outcomes and patient satisfaction.

Future research should prioritize long-term follow-up to better understand the progression of complications and the effectiveness of interventions aimed at improving lifestyle habits among bariatric surgery patients. By addressing the complexities of weight management and post-operative care, ongoing research can contribute to enhancing the overall health outcomes and quality of life for this population.

All participants were fully informed about the study’s purpose, objectives, and procedures before data collection began. Participants were assured that their responses would remain confidential and that their personal information would be securely stored and used solely for research purposes. Additionally, participants were made aware of their right to withdraw from the study at any time without providing a reason and without any consequences to their medical care. The study received ethical approval from the Institutional Review Board (IRB) of Almoosa Specialist Hospital, under reference number IRB ARC-24.1.02.