Search

The lack of standardization in patient-reported outcome measures (PROMs) has made measurement and comparison of quality of life (QoL) outcomes in research focused on obesity treatment challenging. This study reports on the results of the second and third global multidisciplinary Standardizing Quality of life measures in Obesity Treatment (S.Q.O.T.) consensus meetings, where a core set of PROMs to measure nine previously selected patient-reported outcomes (PROs) in obesity treatment research was established. The S.Q.O.T. II online and S.Q.O.T. III face-to-face hybrid consensus meetings were held in October 2021 and May 2022. The meetings were led by an independent moderator specializing in PRO measurement. Nominal group techniques, Delphi exercises, and anonymous voting were used to select the most suitable PROMs by consensus. The meetings were attended by 28 and 27 participants, respectively, including a geographically diverse selection of people living with obesity (PLWO) and experts from various disciplines. Out of 24 PROs and 16 PROMs identified in the first S.Q.O.T. consensus meeting, the following nine PROs and three PROMs were selected via consensus: BODY-Q (physical function, physical symptoms, psychological function, social function, eating behavior, and body image), IWQOL-Lite (self-esteem), and QOLOS (excess skin). No PROM was selected to measure stigma as existing PROMs deemed to be inadequate. A core set of PROMs to measure QoL in research focused on obesity treatment has been selected incorporating patients' and experts' opinions. This core set should serve as a minimum to use in obesity research studies and can be combined with clinical parameters., (© 2024 World Obesity Federation.)

Introduction: Interdisciplinary guidelines recommend preoperative psychological evaluation before metabolic and bariatric surgery (MBS). The Cleveland Clinic Behavioral Rating System (CCBRS) has been developed to evaluate the psychological state of individuals undergoing MBS. However, its predictive value concerning long-term weight loss and follow-up attendance has not been extensively studied. This study aims to assess the predictive value of the CCBRS regarding weight loss and follow-up attendance up to 5 years after MBS., Methods: In this cohort study (n = 1236), psychologists administered the CCBRS to each patient prior to MBS in addition to the standard psychosocial-behavioral screening. The CCBRS consists of nine psychological domains and is scored on a five-point Likert scale, from "poor" to "excellent." Linear mixed models and ordinal regression analysis were used to analyze the percentage total weight loss over time and follow-up attendance up to 5 years after surgery., Results: A total of 1086 patients underwent subsequent MBS. Significant differences in weight loss and follow-up attendance were observed between some CCBRS groups compared to the reference group "excellent." However, these differences were not consistent across all groups within any given domain., Conclusion: In this cohort, the predictive value of the CCBRS for weight loss and follow-up attendance up to 5 years after MBS was limited. It is important to consider certain limitations, such as considerable loss to follow-up. Nevertheless, the CCBRS remains valuable for structured psychological assessments by helping to identify patients' strengths and areas needing improvement., (© 2024. The Author(s).)

Purpose: The focus of measuring success in obesity treatment is shifting from weight loss to patients' health and quality of life. The objective of this study was to select a core set of patient-reported outcomes and patient-reported outcome measures to be used in clinical obesity care., Materials and Methods: The Standardizing Quality of Life in Obesity Treatment III, face-to-face hybrid consensus meeting, including people living with obesity as well as healthcare providers, was held in Maastricht, the Netherlands, in 2022. It was preceded by two prior multinational consensus meetings and a systematic review., Results: The meeting was attended by 27 participants, representing twelve countries from five continents. The participants included healthcare providers, such as surgeons, endocrinologists, dietitians, psychologists, researchers, and people living with obesity, most of whom were involved in patient representative networks. Three patient-reported outcome measures (patient-reported outcomes) were selected: the Impact of Weight on Quality of Life-Lite (self-esteem) measure, the BODY-Q (physical function, physical symptoms, psychological function, social function, eating behavior, and body image), and the Quality of Life for Obesity Surgery questionnaire (excess skin). No patient-reported outcome measure was selected for stigma., Conclusion: A core set of patient-reported outcomes and patient-reported outcome measures for measuring quality of life in clinical obesity care is established incorporating patients' and experts' opinions. This set should be used as a minimum for measuring quality of life in routine clinical practice. It is essential that individual patient-reported outcome measure scores are shared with people living with obesity in order to enhance patient engagement and shared decision-making., (© 2024. The Author(s).)

Introduction: Multiple factors are related to lower weight loss after bariatric surgery. This review and meta-analysis evaluates the influence of several mental and behavioral factors on weight loss., Method: Six electronic databases were searched. Percentage excess weight loss (%EWL) was calculated for all moderator and non-moderator groups of the variables: symptoms of depression, anxiety and binge eating, compliance, physical activity, quality of life, and body image. All moderators, surgery types, and follow-up moments were analyzed separately., Results: In total, 75 articles were included in the review; 12 meta-analyses were conducted. Higher postoperative compliance to follow-up was associated with 6.86%-13.68% higher EWL. Preoperative binge eating was related to more weight loss at 24- and 36-month follow-up (7.97% and 11.79%EWL, respectively). Patients with postoperative binge eating symptoms had an 11.92% lower EWL. Patients with preoperative depressive symptoms lost equal weight compared to patients without symptoms., Conclusion: Despite the high heterogeneity between studies, a trend emerges suggesting that the presence of postoperative binge eating symptoms and lower postoperative compliance may be associated with less weight loss after bariatric-metabolic surgery. Additionally, preoperative depressive symptoms and binge eating do not seem to significantly impact weight loss., (© 2024 The Authors. Obesity Reviews published by John Wiley & Sons Ltd on behalf of World Obesity Federation.)

Purpose: Changes in healthcare utilisation and expenditures after bariatric-metabolic surgery (BMS) for people with type 2 diabetes mellitus (T2DM) are unclear. We used the Dutch national all-payer claims database (APCD) to evaluate utilisation and expenditures in people with T2DM who underwent BMS., Methods: In this cohort study, patients with T2DM who had BMS in 2016 were identified in the APCD. This group was matched 1:2 to a control group with T2DM who did not undergo BMS based on age, gender and healthcare expenditures. Data on healthcare expenditures and utilisation were collected for 2013-2019., Results: In total, 1751 patients were included in the surgery group and 3502 in the control group. After BMS, total median expenditures in the surgery group stabilised (€ 3156 to € 3120) and increased in the control group (€ 3174 to € 3434). Total pharmaceutical expenditures decreased 28% in the surgery group (€957 to €494) and increased 55% in the control group (€605 to €936). In the surgery group, 67.1% did not use medication for T2DM in 2019 compared to 13.3% in the control group. Healthcare use for microvascular complications increased in the control group, but not in the surgery group., Conclusion: BMS in people with T2DM stabilises healthcare expenditures and decreases medication use and care use for microvascular complications. In contrast, healthcare use and expenditures in T2DM patients who do not undergo surgery gradually increase over time. Due to the progressive nature of T2DM, it is expected that these differences will become larger in the long-term., (© 2024. The Author(s).)

The extent to which genetic variations contribute to interindividual differences in weight loss and metabolic outcomes after bariatric surgery is unknown. Identifying genetic variants that impact surgery outcomes may contribute to clinical decision making. This review evaluates current evidence addressing the association of genetic variants with weight loss and changes in metabolic parameters after bariatric surgery. A search was conducted using Medline, Embase, Scopus, Web of Science, and Cochrane Library. Fifty-two eligible studies were identified. Single nucleotide polymorphisms (SNPs) at ADIPOQ (rs226729, rs1501299, rs3774261, and rs17300539) showed a positive association with postoperative change in measures of glucose homeostasis and lipid profiles (n = 4), but not with weight loss after surgery (n = 6). SNPs at FTO (rs11075986, rs16952482, rs8050136, rs9939609, rs9930506, and rs16945088) (n = 10) and MC4R (rs11152213, rs476828, rs2229616, rs9947255, rs17773430, rs5282087, and rs17782313) (n = 9) were inconsistently associated with weight loss and metabolic improvement. Four studies examining the UCP2 SNP rs660339 reported associations with postsurgical weight loss. In summary, there is limited evidence supporting a role for specific genetic variants in surgical outcomes after bariatric surgery. Most studies have adopted a candidate gene approach, limiting the scope for discovery, suggesting that the absence of compelling evidence is not evidence of absence., (© 2023 The Authors. Obesity Reviews published by John Wiley & Sons Ltd on behalf of World Obesity Federation.)

Purpose: Large inter-individual variations in post-bariatric fat-free mass loss (FFML) are observed, which might relate to differences in protein intake and physical activity across patients. We performed repetitive assessments of protein intake and physical activity before and after banded Roux-en-Y gastric bypass surgery, and examined its relations to FFML during 6 months of follow-up., Materials and Methods: FFML (bio-impedance analyses), protein intake (24-h dietary recalls) and moderate-to-vigorous physical activity (MVPA; activPAL) were assessed in 28 patients (4 males, age 42 ± 12 years) before surgery and at 1-, 3- and 6-months post-surgery. Changes in protein intake and MVPA were evaluated with mixed model analysis, whereas associations with FFML were assessed by univariate regression analysis., Results: Six-month FFML was -7.3 ± 3.6 kg. Protein intake decreased from 80 ± 29 g/day (pre-surgery) to 45 ± 26 g/day (1 month post-surgery (P < 0.001)) and did not improve thereafter (51 ± 21 g/day; P > 0.05). Seven participants (25%) consumed ≥ 60 g protein/day at 6 months post-surgery. Participants performed 7394 ± 2420 steps/day in 54 ± 20 min/day of MVPA, which did not change from pre- to post-surgery (P > 0.05). A higher step count (B = -0.002; 95%CI = [-0.004 - 0.000]; P = 0.048) and higher level of MVPA (B = -0.29; 95%CI = [-0.54 - -0.03]; P = 0.018) were related to a lower FFML., Conclusion: A lower post-surgery FFML was attributable to higher MVPA levels but not protein intake. This may be due to the low total protein intake and the observation that only a minority of patients achieved a protein intake ≥ 60 g/day. Future studies should focus on interventions to increase post-bariatric protein intake and MVPA levels., (© 2023. The Author(s).)

Background: Multidisciplinary lifestyle interventions are recommended as a first step in treating weight recurrence after bariatric-metabolic surgery (BMS). However, little is known about the experience of patients and healthcare professionals (HCP) with these interventions and how they should be tailored to the patients' needs. The aim of this study was to gain more insight into the experiences and needs of patients and HCP regarding weight recurrence after BMS and an intervention to get Back on Track. In addition, attitudes towards integrating e-Health into the care program were explored., Methods: A qualitative process evaluation of an intervention for weight recurrence, the Back on Track (BoT), was conducted by means of in-depth interviews and focus groups with 19 stakeholders, including patients and HCP involved in BoT. Interviews were transcribed verbatim. Data were analyzed through thematic analysis., Results: Patients and HCP reported a wide array of causes of weight recurrence. Patients found it difficult to decide when weight recurrence is problematic and when they should ask for help. Patients reported feeling like the exception and ashamed, therefore experiencing a high threshold to seek help. E-Health was seen as a promising way to improve tailoring, screening, autonomy for the patient, and accessible contact., Conclusion: Patients should be adequately counselled on weight recurrence after BMS and the importance of intervening early. It is important to lower the threshold for seeking help. For example by offering more long-term standard care or by adding e-Health to the intervention., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: V. Voorwinde reports financial support was provided by De Nederlandse Obesitas Kliniek BV. V.M. Monpellier reports financial support was provided by De Nederlandse Obesitas Kliniek BV. I.M.C. Janssen reports financial support was provided by De Nederlandse Obesitas Kliniek BV. V. Voorwinde reports a relationship with De Nederlandse Obesitas Kliniek BV that includes: employment. V.M. Monpellier reports a relationship with De Nederlandse Obesitas Kliniek BV that includes: employment. I.M.C. Janssen reports a relationship with De Nederlandse Obesitas Kliniek BV that includes: board membership and consulting or advisory., (© 2023 The Authors.)

Purpose: Previous studies showed that patients with lower weight loss after bariatric surgery could be identified based on early postoperative weight loss. However, these studies had only 12-36-month follow-up. This study aimed to explore whether patients in the lowest weight loss quartile at 3 months had lower weight loss trajectories up to 5 years after Roux-en-Y gastric bypass (RYGB), banded Roux-en-Y gastric bypass (BRYGB), and sleeve gastrectomy (SG) surgery., Methods: Weight was assessed preoperatively, and 3, 6, 9, 12, 24, 36, 48, and 60 months postoperatively. Patients were grouped into four categories based on quartiles of percentage total weight loss (%TWL) at 3-month follow-up. Results were compared between the lowest %TWL quartile group and other quartile groups., Results: Patients underwent either RYGB (n=13,106; 72%), SG (n=3585; 20%), or BRYGB (n=1391, 8%) surgery. Weight loss trajectories of patients in the lowest %TWL quartile group remained lower than that of other quartile groups throughout a 5-year follow-up, for all three types of surgery. Patients in the lowest %TWL quartile group had higher age at surgery, higher baseline BMI, and were more likely to be male (in the SG group), and to suffer from diabetes, hypertension, dyslipidemia, and osteoarthritis., Conclusion: This study showed a positive association between weight loss at 3 and 12 to 60 months after bariatric surgery. Weight loss at 3 months after surgery could be used to identify patients whose anticipated weight loss trajectories are below average, to potentially improve their outcomes through early behavioral or medical interventions., (© 2022. The Author(s).)

Quality of life is a key outcome that is not rigorously measured in obesity treatment research due to the lack of standardization of patient-reported outcomes (PROs) and PRO measures (PROMs). The S.Q.O.T. initiative was founded to Standardize Quality of life measurement in Obesity Treatment. A first face-to-face, international, multidisciplinary consensus meeting was conducted to identify the key PROs and preferred PROMs for obesity treatment research. It comprised of 35 people living with obesity (PLWO) and healthcare providers (HCPs). Formal presentations, nominal group techniques, and modified Delphi exercises were used to develop consensus-based recommendations. The following eight PROs were considered important: self-esteem, physical health/functioning, mental/psychological health, social health, eating, stigma, body image, and excess skin. Self-esteem was considered the most important PRO, particularly for PLWO, while physical health was perceived to be the most important among HCPs. For each PRO, one or more PROMs were selected, except for stigma. This consensus meeting was a first step toward standardizing PROs (what to measure) and PROMs (how to measure) in obesity treatment research. It provides an overview of the key PROs and a first selection of the PROMs that can be used to evaluate these PROs., (© 2022 The Authors. Obesity Reviews published by John Wiley & Sons Ltd on behalf of World Obesity Federation.)

Background: Little research has taken individual variability in weight loss into account. Furthermore, physical activity (PA) and eating style (ES) have been linked only sporadically to weight loss longitudinally., Objectives: Identify and describe latent classes of weight loss, change of PA, and change of ES up to 5 years after surgery and investigate whether these trajectories are interrelated., Setting: Multicenter outpatient clinic., Methods: This is a retrospective study of data collected during standard treatment before and up to 5 years after surgery. Latent class growth analysis was used to identify trajectories of weight loss (percent total weight loss), PA (Baecke questionnaire), and ES (Dutch Eating Behavior Questionnaire)., Results: A total of 2785 patients were included. Follow-up rate was 84% at 1 year and 34% at 5 years. Analyses revealed 5 weight loss trajectories. Most patients followed an average, fairly stable weight loss trajectory (48%) or an above-average partial-regain trajectory (36%). Other patients followed a low-responder trajectory (9%), a rapid weight loss and weight regain trajectory (6%), or a continued weight loss trajectory (2%). Patients in the most favorable weight loss trajectory were more likely to also follow the most favorable ES trajectories. Patients following the most unfavorable weight loss trajectory were never also in the PA trajectory with an initial great increase in PA., Conclusion: This study distinguishes demographic and behavioral factors that may influence long-term weight loss trajectories after bariatric surgery. Trajectories varied mainly in magnitude and less in the pattern of weight loss over time, suggesting that very deviant patterns are rare., (Copyright © 2022 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Not all patients with suboptimal weight loss after bariatric surgery are willing to participate in postoperative behavioral intervention to improve their weight loss. The objective of this study was to explore barriers to and facilitators of participation in postoperative behavioral intervention., Methods: Thirty semi-structured interviews were conducted with patients (18), physicians (6), and therapists (6) (i.e., psychologists, dieticians, or physiotherapists). A thematic analysis approach was used., Results: Emotional responses caused by confrontation with suboptimal weight loss hampered patients' deliberation about participation; insufficient exploration of their need for help limited patients' ability to make informed decisions; patients were receptive to their physician's advice when their physician respected their autonomy; using visual weight loss graphs helped to explain suboptimal weight loss to patients; and financial costs and time constraints obstructed participation., Conclusions: To improve adequate intervention participation, healthcare providers should focus on emotion regulation, support patients in exploring their own need for help, and respect patients' autonomy., (© 2022 The Author(s). Published by S. Karger AG, Basel.)

Purpose: The RAND-36 is the most frequently used patient-reported outcome measure (PROM) to evaluate health-related quality of life (HRQoL) in bariatric surgery. However, the RAND-36 has never been adequately validated in bariatric surgery. The purpose of this study was to validate the RAND-36 in Dutch patients undergoing bariatric surgery., Material and Methods: To validate the RAND-36, the following measurement properties were assessed in bariatric surgery patients: validity (the degree to which the RAND-36 measures what it purports to measure (HRQoL)), reliability (the extent to which the scores of the RAND-36 are the same for repeated measurement for patients who have not changed in HRQoL), responsiveness (the ability of the RAND-36 to detect changes in HRQoL over time)., Results: Two thousand one hundred thirty-seven patients were included. Validity was not adequate due to the irrelevance of some items and response options, the lack of items relevant to patients undergoing bariatric surgery, and the RAND-36 did not actually measure what it was intended to measure in this study (HRQoL in bariatric surgery patients). Reliability was insufficient for the majority of the scales (the scores of patients who had not changed in HRQoL were different when the RAND was completed a second time (intraclass correlation coefficient (ICC) values 0.10-0.69)). Responsiveness was insufficient., Conclusion: The RAND-36 was not supported by sufficient validation evidence in patients undergoing bariatric surgery, which means that the RAND-36 does not adequately measure HRQoL in this patient population. Future research studies should use PROMs that are specifically designed for assessing HRQoL in patients undergoing bariatric surgery., (© 2021. The Author(s).)

Postbariatric loss of muscle tissue could negatively affect long-term health due to its role in various bodily processes, such as metabolism and functional capacity. This meta-analysis aimed to unravel time-dependent changes in the magnitude and progress of lean body mass (LBM), fat-free mass (FFM), and skeletal muscle mass (SMM) loss following bariatric surgery. A systematic literature search was conducted in Pubmed, Embase, and Web of Science. Fifty-nine studies assessed LBM (n = 37), FFM (n = 20), or SMM (n = 3) preoperatively and ≥1 time points postsurgery. Random-effects meta-analyses were performed to determine pooled loss per outcome parameter and follow-up time point. At 12-month postsurgery, pooled LBM loss was -8.13 kg [95%CI -9.01; -7.26]. FFM loss and SMM loss were -8.23 kg [95%CI -10.74; -5.73] and -3.18 kg [95%CI -5.64; -0.71], respectively. About 55% of 12-month LBM loss occurred within 3-month postsurgery, followed by a more gradual decrease up to 12 months. Similar patterns were seen for FFM and SMM. In conclusion, >8 kg of LBM and FFM loss was observed within 1-year postsurgery. LBM, FFM, and SMM were predominantly lost within 3-month postsurgery, highlighting that interventions to mitigate such losses should be implemented perioperatively., (© 2021 The Authors. Obesity Reviews published by John Wiley & Sons Ltd on behalf of World Obesity Federation.)

Background: In the Netherlands, patients only qualify for bariatric surgery when they have followed a 6-month mandatory weight loss program (MWP), also called the "last resort" criterion. One of the rationales for this is that MWPs result in greater weight loss., Objectives: To determine weight loss during MWPs and the effect of delayed versus immediate qualification on weight loss 3 years after bariatric surgery., Setting: Outpatient clinic., Methods: This is a nationwide, retrospective study with prospectively collected data. All patients who underwent a primary bariatric procedure in 2016 were included. We compared weight loss between patients who did not qualify according to the last resort criterion at screening (delayed group) with patients that qualified (immediate group)., Results: In total 2628 patients were included. Mean age was 44.4 years, 81.3% were female, and baseline BMI was 42.3 kg/m 2 . Roux-en-Y gastric bypass (RYGB) was the most frequently performed surgery (77.0%), followed by sleeve gastrectomy (15.8%) and banded RYGB (7.3%). The delayed group (n = 831; 32%) compared with immediate group (n = 1797; 68%), showed less percentage of total weight loss (%TWL) during the MWP (1.7% versus 3.9%, P < .001) and time between screening and surgery was longer (42.3 versus 17.5 wk, P < .001). Linear mixed model analysis showed no significant difference in %TWL at 18- (P = .291, n = 2077), 24- (P = .580, n = 1993) and 36-month (P = .325, n = 1743) follow-up., Conclusion: This study shows that delayed qualification for bariatric surgery compared with immediate qualification does not have a clinically relevant impact on postoperative weight loss 3 years after bariatric surgery., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: The success of bariatric surgery varies largely, which may relate to variance in adopting a physically active lifestyle. This study aimed to determine whether two-year changes in physical activity (PA) were associated with weight loss, fat-free mass, cardiorespiratory fitness and quality of life up to two years after bariatric surgery., Materials and Methods: In this retrospective study, 3879 post-bariatric patients were divided into three groups: 1) decreased PA (n = 388), 2) maintained PA (n = 2002) or 3) increased PA (n = 1498). Measurements regarding PA (Baecke questionnaire), body composition (bioelectrical impedance analysis), estimated cardiorespiratory fitness (Åstrand test) and health-related quality of life (RAND-36) were performed preoperatively and two years post-surgery., Results: Bariatric patients with increased PA had greater excess weight loss (76.3% vs. 73.2% vs. 72.9%, P < 0.001), greater increases in %fat-free mass (Δ14.0% vs. 13.0% vs. 12.8%; P < 0.001), larger improvements in VO 2 max (Δ11.8 vs. 10.2 vs. 8.0 ml/kg/min, P < 0.001), and larger increases in health related quality of life subscale scores (P < 0.05) compared to patients with maintained- and decreased PA., Conclusions: Bariatric patients who managed to induce improvements in habitual physical activity had better body composition, fitness and quality of life at 2 years post-surgery, compared to patients who maintained or even reduced their PA levels. These findings underscore the importance of perioperative-bariatric care programs to change lifestyle and achieve sustainable improvements in PA levels.

Background: Iron deficiency (ID) is one of the most common postoperative deficiencies that may develop after Roux-en-Y gastric bypass (RYGB). The optimal mode of treatment is uncertain., Aim: To compare the efficacy of oral ferrous fumarate (FF), oral ferrous gluconate (FG), and a single intravenous infusion of ferric carboxymaltose (FCM) in women with ID after RYGB., Methods: Multicenter randomized controlled trial including 120 women with a serum ferritin <20 μg/l during follow-up after RYGB. They were randomized into three groups: 41 patients were treated with FF 200 mg three times a day (total daily dose: 195 mg elemental iron), 39 received FG 695 mg twice a day (total daily dose: 160 mg elemental iron) for three months, and 39 patients were treated with a single intravenous dose of FCM (1000 mg elemental iron). Serum ferritin levels were measured at six weeks, and three, six and twelve months after the start of supplementation., Results: At three months, persistence of ID was observed in 29.4% and 42.4% of the patients treated with FF and FG, respectively, but in none of those treated with FCM (p < 0.001). Over the next nine months, recurrence of ID was observed in 56.5% of patients treated with FF, in 52.9% treated with FG, and in 27.8% of those treated with FCM. Adverse effects were most common during oral treatment., Conclusion: In women developing ID after RYGB, a single dose of intravenous FCM is more effective and better tolerated than the standard treatment with either FF or FG., Clinical Trial Registry Number and Website: The study was registered at clinicaltrials.gov under number NCT02271997., Competing Interests: Conflicts of interest Patients who participated in the study received multivitamins of FitForMe (FitForMe WLS Forte®, Rotterdam, The Netherlands) for free during the study. FB, IJ and EA are consultants for FitForMe, which did not influence the content of the manuscript. FitForMe and the farmaceutical companies producing the oral and intravenous iron supplements were not involved in the design or analysis of the study, nor in the writing of the paper. All the other authors have no potential conflicts of interests. We did not receive payment from a third party for this study. There were no relevant financial activities outside the submitted work. There were no patents relevant to the work., (Copyright © 2020 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Background: Despite the publication of the American Society for Metabolic and Bariatric Surgery (ASMBS) Outcome Reporting Standards in 2015, there is still a great variety in definitions used for reporting remission of co-morbidities after bariatric surgery. This hampers meaningful comparison of results., Objective: To assess compliance with the ASMBS standards in current literature, and to evaluate use of the standards by applying them in a report on the outcomes of 5 co-morbidities after bariatric surgery., Setting: Two clinics of the Dutch Obesity Clinic, location Den Haag and Velp, and three affiliated hospitals: Haaglanden Medical Center in Den Haag, Groene Hart Hospital in Gouda, and Vitalys Clinic in Velp., Methods: A systematic search in PubMed was conducted to identify studies using the ASMBS standards. Besides, the standards were applied to a cohort of patients who underwent a primary bariatric procedure between November 2016 and June 2017. Outcomes of co-morbidities were determined at 6 and 12 months after surgery., Results: Ten previous studies applying ASMBS definitions were identified by the search, including 6 studies using portions of the definitions, and 4 using complete definitions for 3 co-morbidities or in a small population. In this study, the standards were applied to 1064 patients, of whom 796 patients (75%) underwent Roux-en-Y gastric bypass and 268 patients (25%) underwent sleeve gastrectomy. At 12 months, complete remission of diabetes (glycosylated hemoglobin <6%, off medication) was reached in 63%, partial remission (glycosylated hemoglobin 6%-6.4%, off medication) in 7%, and improvement in 28% of patients (n = 232/248, 94%). Complete remission of hypertension (normotensive, off medication) was noted in 8%, partial remission (prehypertensive, off medication) in 23% and improvement in 63% (n = 397/412, 96%). Remission rate for dyslipidemia (normal nonhigh-density lipoprotein, off medication) was 57% and improvement rate was 19% (n = 129/133, 97%). Resolution of gastroesophageal reflux disease (no symptoms, off medication) was observed in 54% (n = 265/265). Obstructive sleep apnea syndrome improved in 90% (n = 157/169, 93%)., Conclusions: Compliance with the ASMBS standards is low, despite ease of use. Standardized definitions provided by the ASMBS guideline could be used in future research to enable comparison of outcomes of different studies and surgical procedures., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: Fat-free mass (FFM) loss is a concerning aspect of bariatric surgery, but little is known about its time-course and factors related with excessive FFM loss. This study examined (i) the progress of FFM loss up to 3 years post-bariatric surgery and (ii) the prevalence and determinants of excessive FFM loss., Materials and Methods: A total of 3596 patients (20% males, 43.5 ± 11.1 years old, BMI = 44.2 ± 5.5 kg/m 2 ) underwent sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) surgery. Bioelectrical impedance analysis was performed preoperatively and 3, 6, 9, 12, 18, 24 and 36 months post-surgery. Changes in body composition were assessed by mixed model analysis. Prevalence of excessive FFM loss (based on three different cutoff values: ≥ 25%, ≥ 30% and ≥ 35% FFM loss/weight loss (= %FFML/WL)) was estimated and its determinants were assessed by linear regression analysis., Results: Highest rates of FFM loss were found at 3 and 6 months post-surgery, reflecting 57% and 73% of peak FFM loss, respectively. Prevalence of excessive FFM loss ranged from 14 to 46% at 36 months post-surgery, with an older age (β = 0.14, 95%CI = 0.10-0.18, P < .001), being male (β = 3.99, 95%CI = 2.86-5.12, P < .001), higher BMI (β = 0.13, 95%CI = 0.05-0.20, P = .002) and SG (β = 2.56, 95%CI = 1.36-3.76, P < .001) as determinants for a greater %FFML/WL., Conclusion: Patients lost most FFM within 3 to 6 months post-surgery. Prevalence of excessive FFM loss was high, emphasizing the need for more vigorous approaches to counteract FFM loss. Furthermore, future studies should assess habitual physical activity and dietary intake shortly after surgery in relation to FFM loss.

Background: Patients that have psychiatric comorbidity are thought to lose less weight than the general bariatric population and are therefore sometimes denied surgery. However, there is no scientific evidence for this assumption. The aim of this study is to evaluate the weight loss and health-related quality of life (HRQoL) in patients with psychiatric disorders who undergo bariatric surgery and compare these patients with a general bariatric population., Method: Patients who underwent bariatric surgery in 2015 were included. Patients who received individual counselling and had a current DSM IV axis 1 or 2 diagnosis were included in the psychiatric group (n = 163), all other patients in the generic group (n = 2362).Weight and HRQoL were assessed before and 12-, 24-, 36- and 48-months after surgery. Data was analysed using regression analyses., Results: The maximum total weight loss (TWL) was 27.4% in the psychiatric group vs 31.0% in the generic group. Difference in %TWL between the psychiatric and generic group was significant from baseline to all follow-up moments (P < .001). Improvement of PHS was significantly higher in the generic group from baseline to 12-month (P = .002), 24-month (P = .0018), 36-month (P = .025) and 48-monthfollow-up (P = .003). Change in mental HRQoL was only different comparing baseline to 48-monthfollow-up (P = .014)., Conclusion: Although weight loss and change in physical HRQoL was lower in patients with pre-operative psychiatric disorders, results of this group were still excellent. Thus, patients with psychiatric diagnoses benefit greatly from bariatric surgery and these patients should not be denied weight loss surgery., (© 2020 The Authors. Clinical Obesity published by John Wiley & Sons Ltd on behalf of World Obesity Federation.)

Purpose: Sleeve gastrectomy (SG) is the most popular type of bariatric surgery. It has often been compared to Roux-en-Y gastric bypass (RYGB) in terms of clinical outcomes. However, health-related quality of life (HRQoL) has been sparsely studied after SG. The goal was to study HRQoL after SG using a generic (RAND-36) and an obesity-specific (impact of weight on quality of life-lite, IWQOL-lite) questionnaire and to compare the results with RYGB., Methods: HRQoL and weight were measured before and 9, 15, and 24 months after surgery. RAND-36 physical health summary (PHS) and mental health summary (MHS), and IWQOL-lite total score were calculated. A mixed model analysis was conducted to study the change in HRQoL and compare SG with RYGB., Results: A total of 219 patients (8.7%) underwent a SG and 2309 patients (91.3%) a RYGB. PHS, MHS, and IWQOL-lite significantly improved after SG when comparing baseline to all follow-up moments (p < 0.001 in all). There were no significant differences when comparing SG with RYGB: change in PHS (β - 0.10, 95% CI - 1.24 to 1.04, p = 0.861), MHS (β - 0.51, 95% CI - 1.56 to 0.52, p = 0.330), and IWQOL-lite (β 0.310, 95% CI - 0.85 to 1.47, p = 0.601)., Conclusion: HRQoL significantly improved after SG. In the included populations, weight loss was comparable and the extent to which HRQoL improved did not differ between SG and RYGB, when measured with the RAND-36 or IWQOL-lite. This might be partly caused by the fact that these questionnaires do not assess specific bariatric HRQoL and/or complaints.

Retinol-binding protein-4 (RBP4) is elevated in serum and adipose tissue (AT) in obesity-induced insulin resistance and correlates inversely with insulin-stimulated glucose disposal. But its role in insulin-mediated suppression of lipolysis, free fatty acids (FFA), and endogenous glucose production (EGP) in humans is unknown. RBP4 mRNA or protein levels were higher in liver, subcutaneous adipose tissue (SAT), and visceral adipose tissue (VAT) in morbidly obese subjects undergoing Roux-en-Y gastric bypass surgery compared to lean controls undergoing elective laparoscopic cholecystectomy. RBP4 mRNA expression in SAT correlated with the expression of several macrophage and other inflammation markers. Serum RBP4 levels correlated inversely with glucose disposal and insulin-mediated suppression of lipolysis, FFA, and EGP. Mechanistically, RBP4 treatment of human adipocytes in vitro directly stimulated basal lipolysis. Treatment of adipocytes with conditioned media from RBP4-activated macrophages markedly increased basal lipolysis and impaired insulin-mediated lipolysis suppression. RBP4 treatment of macrophages increased TNFα production. These data suggest that elevated serum or adipose tissue RBP4 levels in morbidly obese subjects may cause hepatic and systemic insulin resistance by stimulating basal lipolysis and by activating macrophages in adipose tissue, resulting in release of pro-inflammatory cytokines that impair lipolysis suppression. While we have demonstrated this mechanism in human adipocytes in vitro, and correlations from our flux studies in humans strongly support this, further studies are needed to determine whether this mechanism explains RBP4-induced insulin resistance in humans., (© 2020 The Authors. The FASEB Journal published by Wiley Periodicals, Inc. on behalf of Federation of American Societies for Experimental Biology.)

Introduction: The prevalence and clinical significance of weight regain after bariatric surgery remains largely unclear due to the lack of a standardized definition of significant weight regain. The development of a clinically relevant definition of weight regain requires a better understanding of its clinical significance., Objectives: To assess rates of weight regain 5 years after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG), applying six definitions and investigating their association with clinical outcomes., Methods: Patients were followed up until 5 years after surgery and weight regain was calculated. Regression techniques were used to assess the association of weight regain with health-related quality of life (HRQoL) and the presence of comorbidities., Results: A total of 868 patients participated in the study, with a mean age of 46.6 (± 10.4) years, of which 79% were female. The average preoperative BMI was 44.8 (± 5.9) kg/m 2 and the total maximum weight loss was 32% (± 8%). Eighty-seven percent experienced any regain. Significant weight regain rates ranged from 16 to 37% depending on the definition. Three weight regain definitions were associated with deterioration in physical HRQoL (p < 0.05), while associations between definitions of weight regain and the presence of comorbidities 5 years after surgery were not significant., Conclusion: These results indicate that identifying one single categorical definition of clinically significant weight regain is difficult. Additional research into the clinical significance of weight regain is needed to inform the development of a standardized definition that includes all dimensions of surgery success: weight, HRQoL, and comorbidity remission.

Background: Pathogenic PTEN gene mutations are known to cause PTEN tumor hamartoma syndrome. Recent studies also suggest a role for PTEN mutations in the pathogenesis of obesity. No PTEN mutations have been reported among bariatric surgery patients and obesity treatment results are unknown. Since preventive screening for associated tumors is offered to patients with molecular proven PTEN hamartoma tumor syndrome, recognition of this condition in the bariatric surgery clinic is important., Method: We present a patient with morbid obesity who carries a known pathogenic PTEN mutation, identified at the bariatric surgery clinic using an obesity gene panel consisting of 52 obesity-associated genes. We analyzed the weight loss response during the first 3 years after Sleeve Gastrectomy., Results: At 1, 2 and 3 years after surgery, the patient achieved a Total Body Weight Loss of 39.4%, 48.8% and 44.9%, respectively. This corresponds to the results of a control group of 18 female patients with normal genetic test results., Conclusion: Our patient illustrates the importance of recognizing this serious genetic condition for which preventive cancer screening options are available. The positive weight loss results after Sleeve Gastrectomy suggest that this could be a successful treatment option for obesity patients with PTEN mutations., (© 2019 The Authors. Molecular Genetics & Genomic Medicine published by Wiley Periodicals, Inc.)

Background: Body contouring surgery improves quality of life, weight loss, and body image after bariatric surgery. It is unclear why only a minority of the post-bariatric surgery population undergoes body contouring surgery. This study assesses overhanging skin, body satisfaction, and qualification for reimbursement of body contouring surgery in a Dutch post-bariatric surgery population., Methods: Post-bariatric patients were selected from a prospective database. Electronic questionnaires evaluated demographics, desire for body contouring surgery, excess skin, and satisfaction with their body., Results: A total of 590 patients were included: 368 patients (62.4 percent) desired body contouring surgery, 157 (26.6 percent) did not and 65 (11.0 percent) had undergone body contouring surgery. There were no significant differences between the groups regarding the percentage of patients who met the qualifications for reimbursement. Patients who desired body contouring surgery had more body parts affected by overhanging skin and more often rated the overhanging skin with a Pittsburgh Rating Scale grade 3 compared with patients without a desire to undergo body contouring surgery. The plastic surgeon was never consulted by 39.1 percent of the "desire" population; 44.1 percent of these patients met the weight criteria., Conclusions: Post-bariatric patients who desired body contouring surgery had more excess skin than patients without a desire and were less satisfied with their body. Almost half of these patients never consulted a plastic surgeon, partly because of incorrect assumptions regarding reimbursement. Plastic surgeons (together with bariatric teams) should better inform these patients about body contouring surgery possibilities.

Introduction: Patients with morbid obesity undergoing metabolic surgery are prone to develop vitamin and mineral deficiencies, which may worsen in time. In order to prevent these deficiencies after metabolic surgery, all patients are advised to take daily multivitamin supplementation. The aim of the study was to assess the cost-effectiveness of specially developed multivitamins (WLS Forte®) for metabolic surgery and over-the-counter (standard) multivitamin supplementation (sMVS)., Methods: This cost-effectiveness analysis was preformed alongside an RCT for the Netherlands. Between June 2011 and March 2012, a total of 148 patients were randomized to one tablet daily of either WLS Forte® or sMVS. The patients were followed for 12 months. Data on costs within the health sector and outside the health sector were collected. The primary outcome is financial and logistic advantages, in terms of less patient visits to the outpatient department and the relevant costs to the employer due to absenteeism., Results: In total, 10 (14%) patients in the WLS Forte® group versus 23 (30%) patients in the sMVS group developed a deficiency. The costs for the WLS forte® supplement were €38 versus €23 for sMVS. Additional return visits and associated costs for medical staff were the largest costs, up to 43% in the sMVS group. Total costs for supplementation with sMVS were €243 versus €134 for WLS Forte®., Conclusion: Preventing deficiencies with WLS Forte® seem initially more expensive than sMVS. However, treatment with WLS Forte® resulted in less vitamin and mineral deficiencies, which eventually resulted in less overall costs.

Background: Insufficient weight loss and weight regain is seen in 20-30% of the post-bariatric population. More knowledge about the effect of physical activity and eating style on weight change after Roux-en-Y gastric bypass is essential since behaviour can be modified and thereby results improved. The goal of this study is to determine the relationship between weight change, self-reported physical activity and eating style., Methods: Weight, physical activity (PA) and eating style (ES) were assessed before surgery and 15, 24, 36 and 48 months after surgery. A linear mixed model was performed to assess the association between the change in PA and ES and percentage total weight loss (% TWL)., Results: There were 4569 patients included. Preoperative PA and ES were not related to weight change. Change in PA was positively associated with % TWL at 15, 36 and 48 months follow-up. Change in emotional eating was negatively related to % TWL at all follow-up moments. Change in external eating was only negatively related to weight loss at 24 months follow-up. Change in restrained eating was negatively associated with weight loss up to 36 months follow-up. More restrained eating at 36 months follow-up was related to higher weight regain, and more emotional eating at 48 months to 48-month weight regain., Conclusion: Preoperative self-reported PA and ES did not predict weight change after RYGB. Being are more physically active and showing less emotional and restrained eating was related to a higher weight loss. Emotional and restrained eating were related to higher weight regain.

Background: For a number of years the laparoscopic adjustable gastric band has been one of the leading bariatric procedures with good short-term outcomes. However, inadequate weight loss, weight regain, and other band-related complications in the long term led to an increase in revisional Roux-en-Y gastric bypass (RYGB) procedures. Lengthening the biliopancreatic limb, a relatively simple and safe adjustment of the standard technique, could improve the results of the revisional procedure., Objectives: The aim of this randomized controlled trial was to evaluate the effect of a long biliopancreatic limb RYGB (LBP-GB) and standard RYGB (S-GB) as revisional procedure after laparoscopic adjustable gastric band., Setting: General hospital specialized in bariatric surgery METHODS: One hundred forty-six patients were randomized in 2 groups; 73 patients underwent an S-GB (alimentary/biliopancreatic limb 150/75 cm), and 73 patients underwent LBP-GB (alimentary/biliopancreatic limb 75/150). Weight loss, remission of co-morbidities, quality of life, and complications were assessed during a period of 4 years., Results: Baseline characteristics between the groups were comparable. At 48 months the follow-up rate was 95%. Mean total weight loss after 24 months was 27% for LBP-GB versus 22% S-GB (P = .015); mean total weight loss after 48 months was 23% and 18%, respectively (P = .036). No significant differences in other parameters were found between the groups., Conclusions: A LBP-GB as revisional procedure after a failing laparoscopic adjustable gastric band improves short- and long-term total weight loss compared with an S-GB. Together with future modifications this technically simple adjustment of the RYGB could significantly improve disappointing results after revisional surgery., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Not responding to appetitive food items in the go/no-go training has been shown to reduce the evaluation of these items in normal-weight university students. In this preregistered study, we administered an identical go/no-go training in both morbidly obese individuals and normal-weight university students, to assess whether findings from laboratory studies on go/no-go training performed in university environments can be translated to clinical settings., Method: Obese individuals (N = 59, 14 males, M age = 46.10, MBMI = 44.49) and university students (N = 58, 15 males, M age = 23.21, MBMI = 22.64) were trained to consistently respond to certain food items (go) and withhold responses to other items (no-go). Evaluations of the go and no-go items, along with items not used in the training (untrained), were measured both before and after the training., Results: Before the training, evaluations of go, no-go and untrained items were matched; after the training, go items were evaluated more positively than no-go (p = .031 and p = .002 in obese and normal-weight individuals) and untrained items (p = .003 in normal-weight individuals). Only relatively hungry participants rated no-go items as less attractive than both go and untrained items (no-go devaluation effect). More important, effects of the training on food evaluation did not differ between the two participant groups., Conclusions: Obese and normal-weight individuals showed similar responsivity to the go/no-go training on food evaluation, suggesting that insights from laboratory studies may be translated to clinical settings to develop effective interventions to regulate food intake. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Background: Sleeve gastrectomy (SG) has become the most performed bariatric procedure to induce weight loss worldwide. Unfortunately, a significant portion of patients show insufficient weight loss or weight regain after a few years., Objective: To investigate the effectiveness of the single anastomosis duodenoileal (SADI) bypass versus the Roux-en-Y gastric bypass (RYGB) on health outcomes in morbid obese patients who had undergone SG previously, with up to 2 years of follow-up., Methods: From 2007 to 2017, 140 patients received revisional laparoscopic surgery after SG in four specialized Dutch bariatric hospitals. Data was analyzed retrospectively and included comparisons for indication of surgery, vitamin/mineral deficiencies, and complications; divided into short-, medium-term. To compare weight loss, linear regression and linear mixed models were used., Results: Conversion of a SG to SADI was performed in 66 patients and to RYGB in 74 patients. For patients in which additional weight loss was the main indication for surgery, SADI achieved 8.7%, 12.4%, and 19.4% more total body weight loss at 6, 12, and 24 months compared to RYGB (all p < .001). When a RYGB was indicated in case of gastroesophageal reflux or dysphagia, it greatly reduced complaints almost directly after surgery. Furthermore, a similar amount of complications and nutritional deficiencies was observed for both groups. There was no intra- or post-operative mortality., Conclusion: Conversion into a SADI resulted in significantly more weight loss while complications rates and nutritional deficiencies were similar and may therefore be considered the recommended operation for patients in which only additional weight loss is required.

Background: Despite the fact that the RYGB is performed on a broad scale worldwide as a reliable treatment for morbid obesity, there is no uniform technique for this operation. A number of studies have tried to demonstrate an additional weight loss effect by lengthening the alimentary limb, but to no avail. At this moment in time, the role of the biliopancreatic limb on weight loss is for the greater part unknown. The aim of this randomized controlled trial was to compare the effect on weight loss of a long biliopancreatic limb Roux-en-Y gastric bypass (LBP-GB) with a standard RYGB (S-GB)., Methods: A LBP-GB (BPL 150 cm, alimentary limb 75 cm) was compared with a S-GB (BPL 75 cm, alimentary limb 150 cm). One hundred forty-six patients were randomized in two groups. Weight loss, morbidity, reduction of comorbidities, nutritional status, and quality of life were measured during a period of 4 years., Results: Patient characteristics were comparable in both groups. Mean EWL in the LBP-GB group after 12, 24, 36, and 48 months was 81, 85, 78, and 72% respectively versus 71, 73, 68, and 64% in the S-GB group. The %EWL difference between groups was significant as soon as 9 months postoperatively and continued throughout the follow-up period., Conclusions: While LBP-GB achieved a significant increase in %EWL in the first years after surgery, no difference in long-term %TWL was observed after 4 years. In this study, the advantage of LBP-GB with respect to weight loss is modest, but shows promising gripping points for future improvements in RYGB design.

Background: Low cardiorespiratory fitness is strongly associated with cardiovascular diseases and mortality. Although increased physical activity can improve cardiorespiratory fitness, this relationship has not been examined in a large bariatric population undergoing perioperative care focusing on long-term lifestyle change., Objectives: To evaluate changes in physical activity, weight loss, and cardiorespiratory fitness up to 24 months after bariatric surgery, and to evaluate the relationships of change in physical activity with weight loss and change in cardiorespiratory fitness., Materials and Methods: Four thousand seven hundred eighty-five patients who underwent primary Roux-en-Y gastric bypass or sleeve gastrectomy between January 2012 and December 2014 were included. Physical activity was assessed by the Baecke questionnaire (work, leisure, and sport activity) and cardiorespiratory fitness, defined as VO 2 max relative to fat-free mass (VO 2 max/FFM), was assessed by the Åstrand test., Results: Twenty-four months postoperative, significant improvements were seen in sport and leisure activity assessments (n = 3548, P < 0.001), weight loss (n = 3695, P < 0.001), and VO 2 max/FFM (n = 1852, P < 0.001). Furthermore, regression analysis showed that change in leisure activity was positively associated with weight loss (n = 3535, ß = 1.352, P < 0.001) and change in sport activity was positively associated with change in VO 2 max/FFM (n = 1743, ß = 1.730, P < 0.001)., Conclusion: Bariatric surgery complemented by a comprehensive bariatric care program can lead to improvement in physical activity, as well as weight loss and improvement in cardiorespiratory fitness. The positive associations of change in leisure activity with weight loss and change in sport activity with cardiorespiratory fitness suggest that bariatric care programs can enhance postoperative outcomes by improving the patient's physical activity.

Background: After Roux-en-Y gastric bypass (RYGB) surgery, patients report a shift in food preferences away from high-energy foods., Objective: We aimed to elucidate the potential mechanisms underlying this shift in food preferences by assessing changes in neural responses to food pictures and odors before and after RYGB. Additionally, we investigated whether altered neural responsivity was associated with changes in plasma endocannabinoid and ghrelin concentrations., Design: 19 RYGB patients (4 men; age 41 ± 10 years; BMI 41 ± 1 kg/m 2 before; BMI 36 ± 1 kg/m 2 after) participated in this study. Before and two months after RYGB surgery, they rated their food preferences using the Macronutrient and Taste Preference Ranking Task and BOLD fMRI responses towards pictures and odors of high-, and low-energy foods and non-food items were measured. Blood samples were taken to determine plasma endocannabinoid and ghrelin concentrations pre- and post-surgery., Results: Patients demonstrated a shift in food preferences away from high-fat/sweet and towards low-energy/savory food products, which correlated with decreased superior parietal lobule responsivity to high-energy food odor and a reduced difference in precuneus responsivity to high-energy versus low-energy food pictures. In the anteroventral prefrontal cortex (superior frontal gyrus) the difference in deactivation towards high-energy versus non-food odors reduced. The precuneus was less deactivated in response to all cues. Plasma concentrations of anandamide were higher after surgery, while plasma concentrations of other endocannabinoids and ghrelin did not change. Alterations in appetite-related hormone concentrations did not correlate with changes in neural responsivity., Conclusions: RYGB leads to changed responsivity of the frontoparietal control network that orchestrates top-down control to high-energy food compared to low-energy food and non-food cues, rather than in reward related brain regions, in a satiated state. Together with correlations with the shift in food preference from high- to low-energy foods this indicates a possible role in new food preference formation., (Copyright © 2018 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Overhanging skin in postbariatric patients leads to a negative body image. In patients with obesity, negative body image is related to more depressive symptoms and a higher weight. This relationship might also be important in postbariatric patients, because improvement of body image via body contouring surgery (BCS) could lead to better weight loss results., Objectives: To evaluate the relationship between body image, depressive symptoms, and weight loss in a postbariatric population, focusing on desire for BCS., Setting: Outpatient clinic., Methods: One thousand twenty-four primary bariatric surgery patients were contacted, and 590 patients agreed to participate and filled in online questionnaires regarding body image (Body Shape Questionnaire and Multidimensional Body-Self Relations Questionnaire-Appearance Scales) and depression (Beck Depression Inventory-II). Differences between patients who had BCS, patients who desired BCS, and patients who did not desire BCS were studied. The mediating role of body image in the association between percentage total weight loss and depressive symptoms was assessed via a 2-mediator model., Results: There was a desire for BCS in 368 patients (62.4%); these patients had significantly lower scores on appearance evaluation and body image satisfaction scales and showed more depressive symptoms. Patients without a desire (n = 157, 26.6%) had lowest rates of depressive symptoms and a more positive body image. Sixty-five patients (11.0%) had undergone BCS. In the patients who desired BCS, percentage total weight loss was negatively affected by depressive symptoms via appearance evaluation and body-area satisfaction., Conclusions: There are striking differences regarding body image satisfaction and depressive symptoms when comparing postbariatric patients and without desire for BCS. Body image satisfaction is associated with less depressive symptoms in all postbariatric patients. In patients who desired BCS, body image is one of the mediators of the relationship between percentage total weight loss and depressive symptoms. Therefore, body image should be taken seriously and be part of outcome assessment in postbariatric patients., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: A multimodal pain treatment including local anesthetics is advised for perioperative analgesia in bariatric surgery. Due to obesity, bariatric surgery patients are at risk of respiratory complications. Opioid consumption is an important risk factor for hypoventilation. Furthermore, acute postoperative pain is an important risk factor for chronic postsurgical pain. In this study, we aimed to evaluate whether preperitoneal anesthesia with bupivacaine would reduce pain and opioid consumption after bariatric surgery., Methods: One hundred adults undergoing laparoscopic bariatric surgery were randomized to receive either preperitoneal bupivacaine 0.5% or normal saline before incision. Postoperative opioid consumption, postoperative pain, and postoperative recovery parameters were assessed for the first 24 h after surgery. One year after surgery, chronic postsurgical pain and influence of pain on daily living were evaluated., Results: Postoperative opioid consumption during the first hour after surgery was 2.8 ± 3.0 mg in the bupivacaine group, whereas in the control group, it was 4.4 ± 3.4 mg (p = 0.01). Pain scores were significantly reduced in this first hour at rest and at 6 h during mobilization on the ward. One year after surgery, the incidence of chronic postsurgical pain was 13% in the bupivacaine group versus 40% in the placebo group., Conclusion: This study shows that preperitoneal local anesthesia with bupivacaine results in a reduction in opioid consumption and postoperative pain and seems to lower the incidence rate of chronic postsurgical pain after laparoscopic bariatric surgery.

Background: Obesity is a global and severe health problem. Due to genetic heterogeneity, the identification of genetic defects in patients with obesity can be time consuming and costly. Therefore, we developed a custom diagnostic targeted next-generation sequencing (NGS)-based analysis to simultaneously identify mutations in 52 obesity-related genes. The aim of this study was to assess the diagnostic yield of this approach in patients with suspected genetic obesity., Methods: DNA of 1230 patients with obesity (median BMI adults 43.6 kg/m 2 ; median body mass index-SD children +3.4 SD) was analysed in the genome diagnostics section of the Department of Genetics of the UMC Utrecht (The Netherlands) by targeted analysis of 52 obesity-related genes., Results: In 48 patients pathogenic mutations confirming the clinical diagnosis were detected. The majority of these were observed in the MC4R gene (18/48). In an additional 67 patients a probable pathogenic mutation was identified, necessitating further analysis to confirm the clinical relevance., Conclusions: NGS-based gene panel analysis in patients with obesity led to a definitive diagnosis of a genetic obesity disorder in 3.9% of obese probands, and a possible diagnosis in an additional 5.4% of obese probands. The highest yield was achieved in a selected paediatric subgroup, establishing a definitive diagnosis in 12 out of 164 children with severe early onset obesity (7.3%). These findings give a realistic insight in the diagnostic yield of genetic testing for patients with obesity and could help these patients to receive (future) personalised treatment., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: The objective of this post-market study was to evaluate long-term safety and efficacy of aspiration therapy (AT) in a clinical setting in five European clinics., Materials and Methods: The AspireAssist® System (Aspire Bariatrics, Inc. King of Prussia, PA) is an endoscopic weight loss therapy utilizing a customized percutaneous endoscopic gastrostomy tube and an external device to aspirate approximately 30% of ingested calories after a meal, in conjunction with lifestyle counseling. A total of 201 participants, with body mass index (BMI) of 35.0-70.0 kg/m 2 , were enrolled in this study from June 2012 to December 2016. Mean baseline BMI was 43.6 ± 7.2 kg/m 2 ., Results: Mean percent total weight loss at 1, 2, 3, and 4 years, respectively, was 18.2% ± 9.4% (n/N = 155/173), 19.8% ± 11.3% (n/N = 82/114), 21.3% ± 9.6% (n/N = 24/43), and 19.2% ± 13.1% (n/N = 12/30), where n is the number of measured participants and N is the number of participants in the absence of withdrawals or lost to follow-up. Clinically significant reductions in glycated hemoglobin (HbA1C), triglycerides, and blood pressure were observed. For participants with diabetes, HbA1C decreased by 1% (P < 0.0001) from 7.8% at baseline to 6.8% at 1 year. The only serious complications were buried bumpers, experienced by seven participants and resolved by removal/replacement of the A-Tube, and a single case of peritonitis, resolved with a 2-day course of intravenous antibiotics., Conclusion: This study establishes that aspiration therapy is a safe, effective, and durable weight loss therapy in people with classes II and III obesity in a clinical setting., Trial Registration: ISRCTN 49958132.

Background: After Roux-en-Y gastric bypass (RYGB), patients often develop a vitamin B-12 deficiency., Objective: Our objective was to investigate whether oral supplementation increases and normalizes low vitamin B-12 concentrations (vitamin B-12 > 200 pmol/L) in RYGB patients as compared to intramuscular injections., Design: A randomized controlled trial in RYGB patients with subnormal serum B-12 concentrations was performed. One group (IM B-12) received bimonthly intramuscular hydroxocobalamin injections (2000 µg as loading dose and 1000 µg at follow-up) for 6 mo. The second group (oral B-12) received daily doses of oral methylcobalamin (1000 µg). Serum vitamin B-12 was determined at baseline (T0) and at 2 (T1), 4 (T2), and 6 mo (T3) after start of treatment. Concentrations of the secondary markers methylmalonic acid (MMA) and homocysteine (Hcy) were measured at T0 and T3., Results: Fifty patients were included and randomized, 27 in IM B-12 and 23 in oral B-12. The median vitamin B-12 concentration at T0 was 175 pmol/L (range: 114-196 pmol/L) for IM B-12 and 167 pmol/L (range: 129-199 pmol/L) for oral B-12. Vitamin B-12 normalized in all individuals, and there was no significant difference in vitamin B-12 between the two groups. MMA and Hcy concentrations decreased significantly after 6 mo within each group (P < 0.001 and P < 0.001 for MMA and P = 0.03 and P = 0.045 for Hcy, respectively). There was no significant difference between the groups at 6 mo for both MMA and Hcy (P = 0.53 and P = 0.79)., Conclusion: The efficacy of oral vitamin B-12 supplementation was similar to that of hydroxocobalamin injections in the present study. Oral supplementation can be used as an alternative to hydroxocobalamin injections to treat RYGB patients with low values of serum vitamin B-12. This trial was registered at clinicaltrials.gov as NCT02270749.

Purpose: The purposes of the study are to outline the complexity of diagnosing internal herniation after Roux-en-Y gastric bypass (RYGB) surgery and to investigate the added value of computed tomography angiography (CTA) for diagnosing internal herniation., Materials and Methods: A cadaver study was performed to investigate the manifestations of internal hernias and mesenteric vascularization. Furthermore, a prospective, ethics approved study with retrospective interpretation was conducted. Ten patients, clinically suspected for internal herniation, were prospectively included. After informed consent was obtained, these subjects underwent abdominal CT examination, including additional arterial phase CTA. All subjects underwent diagnostic laparoscopy for suspected internal herniation. The CTA was used to create a 3D reconstruction of the mesenteric arteries and surgical staples (3D CTA). The 3D CTA was interpreted, taking into account the presence and type of internal hernia that was found upon laparoscopy., Results: Cadaveric analysis demonstrated the complexity of internal herniation. It also confirmed the expected changes in vascular structure and surgical staple arrangement in the presence of internal herniation. 3D CTA studies of the subjects with active internal hernias demonstrated remarkable differences when compared to control 3D CTA studies. The blood supply of herniated intestinal limbs in particular showed abnormal trajectories. Additionally, enteroenterostomy staple lines had migrated or altered orientation., Conclusion: 3D CTA is a promising technique for diagnosing active internal hernias. Our findings suggest that for diagnosing internal hernias, focus should probably shift from routine abdominal CT examination towards the 3D assessment of the mesenteric vasculature and surgical staples.

Introduction: Iron deficiency is one of the most common deficiencies that may occur after Roux-en-Y gastric bypass (RYGB). Little is known about the optimal treatment of post-RYGB iron deficiency., Aim: The aim of this study is to evaluate the changes in iron absorption characteristics after RYGB for two oral iron formulations, one presented in tablet form and one as in the form of a solution., Method: Iron absorption in 24 obese women was studied before and 1 month after RYGB. Twelve patients were tested with a single dose of 600 mg ferrous fumarate in tablet form (195 mg of elementary iron, group 1), and 12 patients received a single dose of 1390 mg ferrous gluconate as a solution (160 mg of elementary iron, group 2). Serum iron levels were measured before (T 0 ) and every hour after ingestion of the supplement (T 1 -T 9 )., Results: Before surgery, iron absorption was similar for the two supplements (P = 0.71). However, RYGB was associated with a decrease in fumarate iron absorption (P < 0.001) but did not affect gluconate iron absorption (P = 0.13). Postoperative absorption of fumarate iron was significantly lower than gluconate iron at T1 (P < 0.05), but the overall difference over 9 h did not reach statistical significance (P = 0.53)., Conclusion: RYGB adversely affects the absorption of ferrous fumarate tablets but not that of solubilized ferrous gluconate. A solubilized supplement is therefore preferred as the supplement of first choice after RYGB.

Background: Inflammatory bowel diseases (IBD) are listed as a contraindication for bariatric surgery in various guidelines due to a theoretical higher complication risk. Therefore, little is known about safety and efficacy of bariatric surgery in IBD patients., Aim: We assessed the safety and efficacy of bariatric surgery and postoperative quality of life (QoL) in IBD patients., Setting: The study was conducted in a large peripheral hospital in the Netherlands., Methods: All IBD patients who underwent bariatric surgery in our facility were included. Complications, mortality, reoperations, and micronutrient deficiencies were analyzed. Weight loss was assessed 6, 12, and 24 months after surgery. Postoperative QoL was assessed using a disease-specific Inflammatory Bowel Disease Questionnaire (IBDQ)., Results: Forty-five patients were included in this study, all diagnosed with IBD (16 ulcerative colitis (UC) and 29 Crohn's disease (CD)) prior to bariatric surgery. Bariatric procedures included Roux-en-Y gastric bypass, sleeve gastrectomy, gastric banding, and revisional surgery. There was no mortality in the entire follow-up period and there were no major perioperative complications. Two major complications in two CD patients occurred during follow-up, gastro-enterostomy bleeding and pyelonephritis with secondary pancreatitis. Mean percentage (± SD) of overall excess weight loss (%EWL) and total body weight loss (%TBWL), 12 months after surgery, were 62.9 ± 27.1 and 26.2 ± 10.6%, respectively. Twenty-four months postoperatively, mean overall %EWL and %TBWL were similar for both UC and CD patients and were 62.9 ± 31.0 and 26.6 ± 12.2, respectively. Mean Bariatric Analysis and Reporting Outcome System (BAROS) score was 3.34 ± 2.42. Median total IBDQ score was 170.8 (min. 77; max. 218). Both scores did not differ significantly between UC and CD patients., Conclusion: As bariatric procedures appear safe and effective in this CU and CD population, one could question why bariatric surgery is contraindicated in the patients. Nevertheless, close lifelong monitoring to assure safety and a favorable outcome remains essential.

Objective: The aim of this research was to study the duodenal-jejunal bypass liner (DJBL) treatment for obesity and type 2 diabetes mellitus (T2DM) in patients after dietary treatment in a cross-over design., Background: DJBL treatment has been proven effective for treatment of obesity and T2DM. However, data on safety and efficacy of a 12-month DJBL treatment is limited., Methods: In 2014, our research group reported on a multicenter randomized clinical trial. Patients were randomized to DJBL or dietary treatment (control group). Twenty-eight patients crossed over after their dietary treatment and received up to 12 months of DJBL treatment. Patient visits were conducted at baseline, during DJBL treatment (1 week, 1-6, 9, 12 months) and 6 months after removal of the liner. Patients underwent a standard physical examination, blood sampling, assessment of adverse events, nutritional and diabetes counseling, and a standardized meal tolerance test., Results: Of the 28 patients included in this study, 24 patients completed 6 months of treatment. Eighteen patients were extended to 12 months of DJBL treatment; 13 patients completed this treatment period. After 6 months of DJBL treatment, a significant increase in excess weight loss (EWL) and decrease in weight, BMI, HbA1c, fasting glucose, cholesterol, HDL and LDL improved significantly. After 12 months of DJBL treatment, these parameters stabilized., Conclusions: The DJBL is an effective, minimally invasive treatment option. Even after successful treatment with dietary restrictions, the DJBL is still capable of significantly reducing weight and improving cardiovascular and type 2 diabetes mellitus parameters in obese patients.

Background: Elevated plasma triglycerides are increasingly viewed as a causal risk factor for coronary artery disease. One protein that raises plasma triglyceride levels and that has emerged as a modulator of coronary artery disease risk is angiopoietin-like 4 (ANGPTL4). ANGPTL4 raises plasma triglyceride levels by inhibiting lipoprotein lipase (LPL), the enzyme that catalyzes the hydrolysis of circulating triglycerides on the capillary endothelium., Objective: The objective of the present study was to assess the association between ANGPTL4 and LPL in human adipose tissue, and to examine the influence of nutritional status on ANGPTL4 expression., Methods: We determined ANGPTL4 and LPL mRNA and protein levels in different adipose tissue depots in a large number of severely obese patients who underwent bariatric surgery. Furthermore, in 72 abdominally obese subjects, we measured ANGPTL4 and LPL mRNA levels in subcutaneous adipose tissue in the fasted and postprandial state., Results: ANGPTL4 mRNA levels were highest in subcutaneous adipose tissue, whereas LPL mRNA levels were highest in mesenteric adipose tissue. ANGPTL4 and LPL mRNA levels were strongly positively correlated in the omental and subcutaneous adipose tissue depots. In contrast, ANGPTL4 and LPL protein levels were negatively correlated in subcutaneous adipose tissue, suggesting a suppressive effect of ANGPTL4 on LPL protein abundance in subcutaneous adipose tissue. ANGPTL4 mRNA levels were 38% higher in the fasted compared to the postprandial state., Conclusion: Our data provide valuable insights into the relationship between ANGPTL4 and LPL in human adipose tissue, as well as the physiological function and regulation of ANGPTL4 in humans., (Copyright © 2018 National Lipid Association. Published by Elsevier Inc. All rights reserved.)

Background: Pharmacokinetic data suggest that the risk of metformin-associated lactic acidosis (MALA) may be increased after Roux-en-Y gastric bypass (RYGB) surgery. The aim of this study was to examine the impact of metformin on plasma lactate levels before and after RYGB surgery., Methods: Retrospective study of plasma lactate levels before and 3 months after RYGB surgery in patients with type 2 diabetes mellitus (T2DM) not using metformin (MET-0, N = 58), on a stable dose (MET-S, N = 138), or on a decreasing dose (MET-D, N = 85) of metformin., Results: Preoperatively, lactate levels were similar in patients on metformin (1.8 ± 0.05 mmol/L) and those not on metformin (1.7 ± 0.08 mmol/L), P = 0.21. Three months postoperatively, lactate levels had decreased in all groups (P < 0.001) to 1.3 ± 0.07 (SE), 1.4 ± 0.05, and 1.2 ± 0.05 mmol/l in MET-0, MET-S, and MET-D, respectively. Lactate levels differed between the groups (P = 0.03), with the lowest level in MET-D. The number of patients with hyperlactatemia (lactate > 2 mmol/l) decreased from 31 to 14%, from 22 to 8.6%, and from 26 to 4.7% in MET-S, MET-0, and MET-D, respectively., Conclusion: Mild hyperlactatemia (lactate > 2 mmol/l) is common in morbidly obese patients with T2DM. It is probably related to increase lactate production by adipocytes. Lactate levels decreased after RYGB-induced weight loss, irrespective of the use of metformin. We therefore conclude that there is no need for routinely lowering of the metformin dose after uncomplicated RYGB surgery, as long as normal renal function is preserved.

Background: Vitamin and mineral deficiencies are a major concern after biliopancreatic diversion (BPD) and BPD with duodenal switch (BPD/DS). Evidence-based guidelines how to prevent or how to treat deficiencies in these patients are currently lacking. The aim of the current study is to give an overview of postsurgical deficiencies and how to prevent and treat these deficiencies., Methods: Retrospective evaluation of a 1-year structured monitoring and treatment schedule for various deficiencies in 34 patients after BPD or BPD/DS., Results: Patients were introduced into the program 12-90 months after surgery. Vitamin B 1 , B 6 , B 9 , and B 12 deficiencies could be prevented by mean daily doses of 2.75 mg, 980 μg, 600 μg, and 350 μg, respectively. However, many patients continued to develop deficiencies of vitamin A, D, iron, calcium, and zinc despite major dose adjustments. Current observations suggest that at least total daily doses of 200 mg Fe in premenopausal women and 100 mg in men, 100 mg of Zinc, 3000 mg of calcium, and weekly doses of at least 50,000 IU solubilized vitamin A and vitamin D are needed to prevent the occurrence of major deficiencies., Conclusion: Exceptionally high supplementation doses are needed to prevent and treat vitamin and mineral deficiencies in patients after BPD or BPD/DS. Further refinement and simplification of treatment schedules is needed. Focus on improvement of compliance to treatment is recommended.

Background: After Roux-en-Y gastric bypass (RYGB), approximately 10% of patients have insufficient weight loss (excess body mass index loss<50%). Gastric pouch emptying may have a role in weight loss., Objectives: To compare pouch emptying of patients with poor weight loss and patients with successful weight loss after RYGB., Setting: A research-intensive nonacademic hospital and center of expertise in bariatric surgery in the Netherlands METHODS: Female patients were included from among patients with the least (poor weight loss group [P-WL]) and the most weight loss (successful weight loss group [S-WL]) in our center 2 years after RYGB. Pouch emptying scintigraphy was performed after ingestion of a radiolabeled solid meal. Emptying curves, intestinal content (IC) at meal completion and after 15, 30, 45, and 60 minutes, half emptying time, and maximal pouch emptying rate were compared., Results: Five individuals were included in P-WL and 5 in S-WL, on average 2.5 ± .3 years after RYGB. Total weight loss was 18 ± 4.1% in P-WL and 44 ± 5.7% in S-WL (P<.001). In P-WL, a fast initial pouch emptying and exponential emptying curve was observed, compared with a slower initial emptying and more linear curve in S-WL. Faster emptying in P-WL was also shown by a larger IC meal (42 ± 18% versus 4.0 ± 3.3%,), IC 15 (76 ± 15% versus 35 ± 22%), and IC 30 (85 ± 12% versus 54 ± 25%), and a greater maximal pouch emptying rate (17 ± 4.7 versus 5.6 ± 3.4%/min) compared with S-WL (P<.05). A linear correlation was found between total weight loss and maximal pouch emptying rate (Pearson R = .82, P = .004)., Conclusions: Pouch emptying for solid food was faster in patients with the least weight loss compared with patients with the most weight loss after RYGB. If pouch emptying is an important mechanism in weight loss, altering the pouch outlet may improve poor weight loss management., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The duodenal-jejunal bypass liner (DJBL) is an endoscopic treatment for patients with type 2 diabetes mellitus (T2DM) and (morbid) obesity. The aim of the current study was to determine its efficacy and safety profile., Methods: Inclusion criteria for treatment with a DJBL were: age 18-70 years, BMI 28-45 kg/m 2 , and T2DM with a HbA1c > 48 mmol/mol. Primary outcomes were changes in HbA1c and body weight. Secondary outcomes included changes in blood pressure, lipids, and anti-diabetic medication. Predictive factors for success of treatment with the DJBL were determined., Results: Between 2011 and 2014, 185 out of 198 patients successfully underwent a DJBL implantation procedure, with an intended implantation time of 12 months. In these 185 patients, body weight decreased by 12.8 ± 8.0 kg (total body weight loss of 11.9 ± 6.9 %, p < 0.001), HbA1c decreased from 67 to 61 mmol/mol (p < 0.001) despite a reduction in anti-diabetic medication, and blood pressure and serum lipid levels all decreased. In total, 57 (31 %) DJBLs were explanted early after a median duration of 33 weeks. Adverse events occurred in 17 % of patients. C-peptide ≥1.0 nmol/L and body weight ≥107 kg at screening were independent predictive factors for success., Conclusions: Treatment with the DJBL in T2DM patients with (morbid) obesity results in improvement in glucose control, a reduction in anti-diabetic medication, and significant weight loss. The largest changes are observed within the first 3-6 months. Initial C-peptide levels and body weight may help to select patients with the greatest chance of success.

Background: Evidence about the impact of psychological factors on weight loss after bariatric surgery is scarce. This study explores whether patients' preoperative estimate of target weight influences actual weight loss for different types of bariatric procedures., Methods: Patients eligible for bariatric surgery were instructed twice on how to calculate their expected target weight. They were divided into three groups based on their percentage excess weight loss (%EWL) and percentage total body weight loss (%TBWL). Weight loss 12 and 24 months after surgery was analyzed for each group and per type of surgery., Results: Six hundred fifty-six patients participated in this study. Types of surgery performed were the Roux-en-Y gastric bypass (RYGB, 75%), sleeve gastrectomy (SG, 8.1%), REDO-RYGB (12.5%), and laparoscopic adjustable gastric banding (LAGB, 4.4%). Data of 622 and 410 patients were available for analysis at 12 and 24 months, respectively. Surprisingly, 415 patients (63.3%) overestimated their expected weight loss as opposed to our calculation, based on our own historic data. One hundred thirty-four patients (20.4%) estimated their weight loss correctly and 107 patients (16.3%) underestimated their weight loss. There was a significant higher %EWL 12 months after RYGB surgery for patients who overestimated their weight loss compared to those who estimated their weight loss correctly (p = 0.001). After 24 months and for other types of procedures, no statistically significant differences were found between the three groups., Conclusion: Despite instructions on how to calculate target weight, the majority of patients overestimated their weight loss. Actual %EWL 12 months after RYGB surgery might be influenced by setting a low target weight.

Background: Laparoscopic surgery for colon cancer is associated with improved recovery and similar cancer outcomes at 3 and 5 years in comparison with open surgery. However, long-term survival rates have rarely been reported. Here, we present survival and recurrence rates of the Dutch patients included in the COlon cancer Laparoscopic or Open Resection (COLOR) trial at 10-year follow-up., Methods: Between March 1997 and March 2003, patients with non-metastatic colon cancer were recruited by 29 hospitals in eight countries and randomised to either laparoscopic or open surgery. Main inclusion criterion for the COLOR trial was solitary adenocarcinoma of the left or right colon. The primary outcome was disease-free survival at 3 years, and secondary outcomes included overall survival and recurrence. The 10-year follow-up data of all Dutch patients were collected. Analysis was by intention-to-treat. The trial was registered at ClinicalTrials.gov (NCT00387842)., Results: In total, 1248 patients were randomised, of which 329 were Dutch. Fifty-eight Dutch patients were excluded and 15 were lost to follow-up, leaving 256 patients for 10-year analysis. Median follow-up was 112 months. Disease-free survival rates were 45.2 % in the laparoscopic group and 43.2 % in the open group (difference 2.0 %; 95 % confidence interval (CI) -10.3 to 14.3; p = 0.96). Overall survival rates were 48.4 and 46.7 %, respectively (difference 1.7 %; 95 % CI -10.6 to 14.0; p = 0.83). Stage-specific analysis revealed similar survival rates for both groups. Sixty-two patients were diagnosed with recurrent disease, accounting for 29.4 % in the laparoscopic group and 28.2 % in the open group (difference 1.2 %; 95 % CI -11.1 to 13.5; p = 0.73). Seven patients had port- or wound-site recurrences (laparoscopic n = 3 vs. open n = 4)., Conclusions: Laparoscopic surgery for non-metastatic colon cancer is associated with similar rates of disease-free survival, overall survival and recurrences as open surgery at 10-year follow-up.