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Background: Approximately 25% of patients after bariatric surgery either do not lose enough weight or regain a considerable amount of weight, both are referred to as nonresponse. This study aimed to describe the added value of a multidisciplinary approach on treatment strategies in patients with nonresponse.Materials and Methods: The primary outcome of this retrospective cohort study was the initiated treatment by the multidisciplinary team (MDT). Outcomes were described separately for patients with primary (i.e., <50% excess weight loss [EWL]) and secondary nonresponse (i.e., >= 50% EWL followed by >5% regain).Results: Of the 83 included patients, 10 patients underwent revisional surgery. A total of 73 patients received a conservative treatment as they either had not been able to change their lifestyle or due to certain behavioral factors. Conservatively treated patients stabilized in weight after 2 years (-0.9 kg +/- 5.8, n = 27), while surgically treated patients did lose weight (-12.1 kg +/- 16.9, n = 7). One patient suffered from an ulcerative stenosis at the gastroenterostomy after limb length alteration.Conclusions: a conservative treatment was the most frequently advocated treatment by the MDT. A surgical treatment resulted in successful weight loss, although only a few patients were selected for this by the MDT. A multidisciplinary approach can be beneficial for the identification of lifestyle and behavioral factors.

Growing awareness of biological, genetic, environmental, and behavioural factors contributed to the recognition of obesity as a chronic disease. Nowadays, obesity and its medical/surgical treatment is widely acknowledgedin the medical curriculum. Bariatric surgery has long been shown to provide superior induction and maintenance of weight loss, together with improvement or resolution of obesity-related diseases. The role of revisional bariatric surgery for treatment of procedure-related complications is accepted. However, its role as second-line treatment of patients with primary or secondary non-response is still a matter of debate. This prompted Dr Henry Buchwald in 2015 to publish his article “Revisional Metabolic/Bariatric Surgery: A Moral Obligation”. Studies I and II in this doctoral thesis covered issues that fuel the ongoing controversy, namely effects and risks of revisional surgery. Conversion to gastric bypass is the most common revisional procedure in Sweden. In Studies I and II, we found revisional gastric bypass to give inferior weight loss with a higher risk for perioperative complications compared to primary gastric bypass. However, the beneficial effects on obesity-related disease were similar (Papers I and II). In Study III, the theoretical need for revisional bariatric surgery in patients with primary or secondary weight non-response was evaluated. When applying four different indication criteria, more than 13% of patients met the criteria for second-line treatment, with a significant higher probability after sleeve gastrectomy compared to gastric bypass (Paper III). To gain a clearer picture, a systematic review of the literature on revisional bariatric surgery after sleeve gastrectomy was inevitable. However, an evidence-based treatment strategy for patients with primary or secondary weight non-response could not be deduced from the current literature (Paper IV).

Background: Approximately 25% of patients after bariatric surgery either do not lose enough weight or regain a considerable amount of weight, both are referred to as nonresponse. This study aimed to describe the added value of a multidisciplinary approach on treatment strategies in patients with nonresponse.Materials and Methods: The primary outcome of this retrospective cohort study was the initiated treatment by the multidisciplinary team (MDT). Outcomes were described separately for patients with primary (i.e., <50% excess weight loss [EWL]) and secondary nonresponse (i.e., >= 50% EWL followed by >5% regain).Results: Of the 83 included patients, 10 patients underwent revisional surgery. A total of 73 patients received a conservative treatment as they either had not been able to change their lifestyle or due to certain behavioral factors. Conservatively treated patients stabilized in weight after 2 years (-0.9 kg +/- 5.8, n = 27), while surgically treated patients did lose weight (-12.1 kg +/- 16.9, n = 7). One patient suffered from an ulcerative stenosis at the gastroenterostomy after limb length alteration.Conclusions: a conservative treatment was the most frequently advocated treatment by the MDT. A surgical treatment resulted in successful weight loss, although only a few patients were selected for this by the MDT. A multidisciplinary approach can be beneficial for the identification of lifestyle and behavioral factors.

Growing awareness of biological, genetic, environmental, and behavioural factors contributed to the recognition of obesity as a chronic disease. Nowadays, obesity and its medical/surgical treatment is widely acknowledgedin the medical curriculum. Bariatric surgery has long been shown to provide superior induction and maintenance of weight loss, together with improvement or resolution of obesity-related diseases. The role of revisional bariatric surgery for treatment of procedure-related complications is accepted. However, its role as second-line treatment of patients with primary or secondary non-response is still a matter of debate. This prompted Dr Henry Buchwald in 2015 to publish his article “Revisional Metabolic/Bariatric Surgery: A Moral Obligation”. Studies I and II in this doctoral thesis covered issues that fuel the ongoing controversy, namely effects and risks of revisional surgery. Conversion to gastric bypass is the most common revisional procedure in Sweden. In Studies I and II, we found revisional gastric bypass to give inferior weight loss with a higher risk for perioperative complications compared to primary gastric bypass. However, the beneficial effects on obesity-related disease were similar (Papers I and II). In Study III, the theoretical need for revisional bariatric surgery in patients with primary or secondary weight non-response was evaluated. When applying four different indication criteria, more than 13% of patients met the criteria for second-line treatment, with a significant higher probability after sleeve gastrectomy compared to gastric bypass (Paper III). To gain a clearer picture, a systematic review of the literature on revisional bariatric surgery after sleeve gastrectomy was inevitable. However, an evidence-based treatment strategy for patients with primary or secondary weight non-response could not be deduced from the current literature (Paper IV).

This dissertation describes the downside of bariatric surgery (obesity surgery) in two parts. The first part describes the results after revision surgery after previous bariatric surgery in relation to long-term complications. The results are described with a few new studies after, among others, previous gastroplasty (Mason), gastric band and sleeve gastrectomy (gastric reduction), giving insight into the type of revision surgery that seems the best option, the psychological factors that influence this weight loss, and the fact that fast track is safe with this complex surgery. The second part describes the short-term complications after a gastric bypass, with predictors for complications, a (successful) technique for reducing complications and a description of a treatment method for one of the most difficult complications: anastomotic leakage.

This dissertation describes the downside of bariatric surgery (obesity surgery) in two parts. The first part describes the results after revision surgery after previous bariatric surgery in relation to long-term complications. The results are described with a few new studies after, among others, previous gastroplasty (Mason), gastric band and sleeve gastrectomy (gastric reduction), giving insight into the type of revision surgery that seems the best option, the psychological factors that influence this weight loss, and the fact that fast track is safe with this complex surgery. The second part describes the short-term complications after a gastric bypass, with predictors for complications, a (successful) technique for reducing complications and a description of a treatment method for one of the most difficult complications: anastomotic leakage.

Background: Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure, while laparoscopic adjustable gastric banding (LAGB) has been for a decade one of the most popular interventions for weight loss. After LSG and LAGB, some patients may require a second surgery due to weight regain or late complications. One anastomosis gastric bypass (OAGB) is a promising bariatric procedure, which provides effective long-term weight loss and has a favorable effect on type 2 diabetes. Objectives: To retrospectively analyze data from 10 Italian centers on conversion from LAGB and LSG to OAGB. Setting: High-volume centers for bariatric surgery. Methods: Prospectively collected data from 10 high-volume centers were retrospectively reviewed. Body mass index (BMI), percentage of excess BMI loss, reasons for redo, remission from co-morbidities (hypertension, diabetes, gastroesophageal reflux, and dyslipidemia), and major complications were recorded. Results: Three hundred patients were included in the study; 196 patients underwent conversion from LAGB to OAGB and 104 were converted from LSG. BMI was 45.1 ± 7 kg/m2 at the time of first intervention, 41.8 ± 6.3 kg/m2 at redo time, and 30.5 ± 5.5 kg/m2 at last follow-up appointment. Mean percentage of excess BMI loss was 13.2 ± 28.2 at conversion and 73.4 ± 27.5 after OAGB. Remission rates from hypertension, diabetes, gastroesophageal reflux, and dyslipidemia were 40%, 62.5%, 58.7% and 52%, respectively. Mean follow-up was 20.8 (range, 6–156) months and overall complications rate was 8.6%. Conclusion: Our data show that OAGB is a safe and effective revisional procedure after failed restrictive bariatric surgery.

OBJECTIVES: Postoperative complications after Laparoscopic sleeve gastrectomy (LSG) can dramatically compromise patient's outcome. The aim of this study is to analyze the per- and postoperative short-term outcomes after LSG and to assess predictive risk factors of complications. METHODS: The study group consisted of 790 patients (610 women and 180 men) who underwent LSG In 2014. All interventions were performed by 18 experienced surgeons members of the Club Coelio. Data about preoperative work-up, surgical techniques, 30-days postoperative morbidity and mortality were collected. Endpoints were perioperative morbidity and mortality and assessment of potential risk factors for complications. RESULTS: Mean age and body mass index were respectively 39 years and 41.5kg/m2. Ninety-one patients (11.5%) had previous bariatric surgery. Morbidity rate was 4.7% (37/790) including 16 leaks (2.0%) and 9 bleedings (1.1%) and no deaths. Risk factors for leak were: previous adjustable banding (p = .0051), with no difference between removal of the banding and LSG in 1 or 2 steps, and type of endostapler (p = .0129). CONCLUSIONS: Leakage after Sleeve was rare but still observed even in experienced hands. The leak rate is particularly high when LSG is performed after adjustable gastric banding removal.

Objectives: Postoperative complications after Laparoscopic sleeve gastrectomy (LSG) can dramatically compromise patient’s outcome. The aim of this study is to analyze the per- and postoperative short-term outcomes after LSG and to assess predictive risk factors of complications. Methods: The study group consisted of 790 patients (610 women and 180 men) who underwent LSG In 2014. All interventions were performed by 18 experienced surgeons members of the Club Coelio. Data about preoperative work-up, surgical techniques, 30-days postoperative morbidity and mortality were collected. Endpoints were perioperative morbidity and mortality and assessment of potential risk factors for complications. Results: Mean age and body mass index were respectively 39 years and 41.5kg/m2. Ninety-one patients (11.5%) had previous bariatric surgery. Morbidity rate was 4.7% (37/790) including 16 leaks (2.0%) and 9 bleedings (1.1%) and no deaths. Risk factors for leak were: previous adjustable banding (p =.0051), with no difference between removal of the banding and LSG in 1 or 2 steps, and type of endostapler (p =.0129). Conclusions: Leakage after Sleeve was rare but still observed even in experienced hands. The leak rate is particularly high when LSG is performed after adjustable gastric banding removal., SCOPUS: ar.j, info:eu-repo/semantics/published

症例, A 44-year-old man underwent revisional open sleeve gastrectomy for failed vertical-banded gastroplasty. Fourteen days postoperatively, he developed high fever and abdominal pain, and D-dimer level was elevated. Superior mesenteric venous(SMV)thrombosis was diagnosed on the basis of dynamic computed tomography(CT)imaging. Anticoagulation therapy with intravenous heparin and oral warfarin was initiated immediately. The patient's symptoms gradually improved, and his D-dimer level was within the normal range at 1 month. Six months later, he remained asymptomatic, and CT scanning confirmed partial recanalization of the SMV.44歳,男性.肥満症に対する垂直胃遮断胃形成術後のリバウンドに対する修正手術として開腹袖状胃切除術を施行した.術後14病日目に,高熱を伴う腹痛を呈し,血液検査上D-ダイマーの上昇を認めた.造影computed tomography(CT)にて上腸間膜静脈血栓症と診断され,速やかにヘパリンの持続注射とワーファリン内服による抗凝固療法が開始された.治療開始後,患者の状態は徐々に軽快し,1カ月以内にD-ダイマー値も正常化した.6カ月後に行った造影CTでは,上腸間膜状間静脈の部分的な開存を認め,以後無症状経過中である.

Background The Roux-en-Y gastric bypass (RYGB) performed laparoscopically (LRYGB) is the most frequently performed bariatric procedure in Belgium. However, late results in terms of weight loss or weight regain are inconsistent and may warrant a second procedure. This retrospective study analyzes the laparoscopic options for revisional surgery after LRYGB. Methods Between January 1, 2001 and December 31, 2009, 70 patients underwent a new laparoscopic procedure for poor weight loss or weight regain after LRYGB. The revisional procedure was performed a median of 2.6 years after the initial bypass operation. Fifty-eight patients were available for follow-up (82.9 %); 19 underwent distalization; and 39 a new restrictive procedure. Results The mean mass index (BMI) before the revisional procedure was 39.1±11.3 kg/m 2 (30.8-51.8), down from 42.7±19.7 kg/m2 (33.0-56.6) initially, which corresponded to a percentage of excess weight loss (EWL) of 12.4±9.3 % (-1.0-29.1). After the corrective procedure, with a follow-up of approximately 4 years, mean BMI was 29.6±12.4 kg/m 2 (18.0-45.5), for a significant additional percentage of EWL of 53.7±9.8 % (2.0-65.8). The overall complication rate was 20.7 %, and the reoperation rate was 7.3 %. The overall leak rate was 12.1 %. Patients suffering from leaks could consistently be treated conservatively or by stent placement. Two patients needed reconversion after distal bypass. The satisfaction index was good in just over 50 % of the patients. Conclusion Revisional laparoscopic surgery after RYGB performed for weight issues provides good additional weight loss but carries significant morbidity. Leaks can usually be handled non-surgically. Patient satisfaction is only fair. © Springer Science + Business Media, LLC 2012., SCOPUS: ar.j, info:eu-repo/semantics/published

Background The Roux-en-Y gastric bypass (RYGB) performed laparoscopically (LRYGB) is the most frequently performed bariatric procedure in Belgium. However, late results in terms of weight loss or weight regain are inconsistent and may warrant a second procedure. This retrospective study analyzes the laparoscopic options for revisional surgery after LRYGB. Methods Between January 1, 2001 and December 31, 2009, 70 patients underwent a new laparoscopic procedure for poor weight loss or weight regain after LRYGB. The revisional procedure was performed a median of 2.6 years after the initial bypass operation. Fifty-eight patients were available for follow-up (82.9 %); 19 underwent distalization; and 39 a new restrictive procedure. Results The mean mass index (BMI) before the revisional procedure was 39.1±11.3 kg/m 2 (30.8-51.8), down from 42.7±19.7 kg/m2 (33.0-56.6) initially, which corresponded to a percentage of excess weight loss (EWL) of 12.4±9.3 % (-1.0-29.1). After the corrective procedure, with a follow-up of approximately 4 years, mean BMI was 29.6±12.4 kg/m 2 (18.0-45.5), for a significant additional percentage of EWL of 53.7±9.8 % (2.0-65.8). The overall complication rate was 20.7 %, and the reoperation rate was 7.3 %. The overall leak rate was 12.1 %. Patients suffering from leaks could consistently be treated conservatively or by stent placement. Two patients needed reconversion after distal bypass. The satisfaction index was good in just over 50 % of the patients. Conclusion Revisional laparoscopic surgery after RYGB performed for weight issues provides good additional weight loss but carries significant morbidity. Leaks can usually be handled non-surgically. Patient satisfaction is only fair. © Springer Science + Business Media, LLC 2012., SCOPUS: ar.j, info:eu-repo/semantics/published

SCOPUS: ar.j, info:eu-repo/semantics/published

SCOPUS: ar.j, info:eu-repo/semantics/published