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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).)

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).)

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).)

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).)

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).)

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.

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.

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.

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: 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.

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.

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.

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: 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: 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.

Introduction: Effect of bariatric surgery on health-related quality of life (HRQOL) varies greatly. This might be caused by the diversity in questionnaires used to assess HRQOL and the weight loss of the studied population. This study assesses the relationship between weight loss and HRQOL in primary Roux-en-Y gastric bypass (RYGB) patients by using an obesity-specific (impact of weight on quality of life-lite, IWQOL-lite) and a generic (RAND-36) questionnaire., Methods: HRQOL and weight parameters were assessed before and 15 and 24 months after RYGB surgery. HRQOL was assessed by using IWQOL-lite (an obesity-specific questionnaire consisting of one total score and five domains) and RAND-36 (a generic questionnaire consisting of two subtotal scores, the physical health summary (PHS) and mental health summary (MHS), and nine scales)., Results: Two thousand one hundred thirty-seven patients were included. HRQOL improved significantly after RYGB. Preoperative BMI was negatively related to baseline PHS (p < 0.001) and IWQOL-lite total (p < 0.001). Percentage total weight loss (%TWL) was positively related to HRQOL score at both follow-up moments. Change in HRQOL from baseline to 24 months was related to %TWL at 24 months in both subtotals of RAND-36 and IWQOL-lite total score (p ≤ 0.001 in all)., Conclusion: HRQOL improves after RYGB. Higher %TWL is related to greater improvement in HRQOL and better HRQOL 15 and 24 months after RYGB. The variance in the effect of RYGB surgery on HRQOL can be explained by the questionnaire used and weight loss of the population.

Introduction: Malabsorptive bariatric procedures, like the biliopancreatic diversion (BPD) and BPD with duodenal switch (BPD/DS), have excellent results in terms of weight loss. However, these malabsorptive techniques are associated with severe malnutrition and vitamin deficiencies. The aim of this study was to evaluate the vitamin and mineral status after BPD and BPD/DS in the long term., Methods: All patients who underwent BPD or BPD/DS were selected and invited for an additional follow-up (FU) visit, including blood sampling for vitamin and mineral levels., Results: Forty patients completed the blood sampling with a median FU of 42 (range 12-90) months. At that time, all patients used some kind of supplementation. However, 93 % of all patients were diagnosed with a deficiency. There were no significant differences in mean serum level vitamins and minerals between BPD and BPD/DS. Forty-three per cent of the patients were anaemic, and 40 % had an iron deficiency (ID). High deficiency rates for fat-soluble vitamins were present: vitamin A in 28 %, vitamin D in 60 %, vitamin E in 10 % and vitamin K in 60 % of the patients. Hypervitaminosis was found in 43 % of the patients for vitamin B1 and in 50 % for vitamin B6., Conclusion: High numbers of vitamin and mineral deficiencies were found after BPD and BPD/DS despite vitamin supplementation. Anaemia, ID and deficiencies for fat-soluble vitamins are frequently diagnosed. Repeated monitoring is necessary to detect deficiencies at an early stage. Taking all of this into consideration, a stringent multivitamin supplementation regimen should be implemented after malabsorptive procedures.

Background: Laparoscopic adjustable gastric band (LAGB), laparoscopic sleeve gastrectomy (LSG), and laparoscopic Roux-en-Y gastric bypass (LRYGB) are the most performed procedures worldwide (92 %) nowadays. However, comparative clinical trials are scarce in literature. The objective of this study was to compare the effectiveness and safety of the three most performed bariatric procedures., Methods: A multicenter, retrospective, matched cohort study was conducted. Patients were eligible for analysis when a primary procedure was performed between 2007 and 2010 in one of the two specialized bariatric centers. Primary outcome was weight loss, expressed in the percentage excess weight loss (%EWL). Secondary outcome parameters are hospital stay, complication rate, and revisional surgery., Results: In total, 735 patients, 245 in each group, were included for analysis. The groups were comparable for age and gender after matching. Mean postoperative follow-up was 3.1 ± 1.2 years. LAGB patients showed less %EWL compared to LSG and LRYGB at all postoperative follow-up visits. LRYGB showed a %EWL of 71 ± 20 % compared to LSG (76 ± 23 %; p=0.008) after 1-year follow-up; thereafter, no significant difference was observed. After 3 years of follow-up, LAGB showed a higher complication rate compared to LSG and LRYGB (p<0.05). Revisional surgery after LAGB was needed in 21 %, while 9 % of the LSG underwent conversion to RYGB., Conclusions: LRYGB is a safe and effective treatment in morbid obese patients with good long-term outcomes. LSG seems to be an appropriate alternative as a definitive procedure, in terms of weight reduction and complication rate. LAGB is inferior to both LRYGB and LSG.

Background: Due to the increased incidence of morbid obesity, the demand for bariatric surgery is increasing. Therefore, the methods for optimising perioperative care for the improvement of surgical outcome and to increase efficacy are necessary. The aim of this prospective matched cohort study is to objectify the effect of the fast-track surgery (FTS) programme in patients undergoing primary Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) surgery compared to conventional perioperative care (CPC)., Methods: This study compared the perioperative outcome data of two groups of 75 consecutive morbid obese patients who underwent a primary LRYGB according to international guidelines in the periods January 2011-April 2011 (CPC group) and April 2012-June 2012 (FTS group). The two groups were matched for age and sex. Primary endpoints were surgery and hospitalisation time, while secondary endpoints were intraoperative medication use and complication rates., Results: Baseline patient characteristics for age, sex, weight and ASA classification were similar (p > 0.05) for CPC and FTS patients. BMI and waist circumference were significantly lower (p < 0.05) in the FTS compared to CPC. The total time from arrival at the operating room to the arrival at the recovery was reduced from 119 to 82 min (p < 0.001). Surgery time was reduced from 80 to 56 min (p < 0.001); mean hospital stay was reduced from 65 to 43 h (p < 0.001). Major complications occurred in 3 versus 4 % in the FTS and CPC, respectively., Conclusions: The introduction of a fast-track programme after primary LRYGB improves short-term recovery and may reduces direct hospital-related resources.

Background: Hyperinsulinemic hypoglycemia is a rare complication of Roux-en-Y gastric bypass (RYGB) surgery. Meals with a high carbohydrate (carb) content and high glycemic index (GI) may provoke these hypoglycemic attacks. The aim of this study is to assess the effects of reducing meal carb content and GI on glycemic responses in patients with post-RYGB hypoglycemia., Methods: Fourteen patients with post-RYGB hypoglycemia underwent two meal tests: a mixed meal test (MMT) with a carb content of 30 g and a meal test with the low GI supplement, Glucerna SR 1.5® (Glucerna meal test (GMT)). Plasma glucose and serum insulin levels were measured for a period of 6 h., Results: Peak glucose levels were reached at T 30 during GMT and at T 60 during MMT, and they were 1.5 ± 0.3 mmol/L lower during GMT than during MMT (7.5 ± 0.4 vs 9.0 ± 0.4 mmol/L, P < 0.005). GMT induced the most rapid rise in plasma insulin: at T 30 plasma, insulin was 30.7 ± 8.5 mU/L higher during GMT than during MMT (P < 0.005). None of the carb-restricted meals induced post-prandial hypoglycemia., Conclusion: A 30-g carb-restricted meal may help to prevent post-prandial hypoglycemia in patients with post-RYGB hypoglycemia. The use of a liquid, low GI, supplement offers no additional advantage.

Background: Recently, the laparoscopic sleeve gastrectomy (LSG) has become popular as a single-stage procedure for the treatment of morbid obesity and its co-morbidities. However, the incidence of micronutrient deficiencies after LSG have hardly been researched., Methods: From January 2005 to October 2008, 60 patients underwent LSG. All patients were instructed to take daily vitamin supplements. Patients were tested for micronutrient deficiencies 6 and 12 months after surgery., Results: Anemia was diagnosed in 14 (26%) patients. Iron, folic acid, and vitamin B12 deficiency was found in 23 (43%), eight (15%), and five (9%) patients, respectively. Vitamin D and albumin deficiency was diagnosed in 21 (39%) and eight (15%) patients. Hypervitaminosis A, B1, and B6 were diagnosed in 26 (48%), 17 (31%), and 13 (30%) patients, respectively., Conclusions: Due to inadequate intake and uptake of micronutrients, patients who underwent LSG are at serious risk for developing micronutrient deficiencies. Moreover, some vitamins seem to increase to chronic elevated levels with possible complications in the long-term. Multivitamins and calcium tablets should be regarded only as a minimum and supplements especially for iron, vitamin B12, vitamin D, and calcium should be added to this regimen based on regular blood testing.

Background: Leakage of a laparoscopically placed Swedish adjustable gastric band (SAGB) was observed 2 1/2 years after placement. The band was evaluated for mechanical inaccuracies by a laboratory., Methods: The ruptured SAGB was investigated microscopically and wall thicknesses were measured. An unused SAGB was tested, both empty and filled, for mechanical deformity after exposure to saline solution., Results: A permanent transformation of the silicone rubber was found, caused by bowing of the device. 2 tears were present at the end of a kink. The mean wall thickness was within acceptable limits. Exposure of the gastric band to saline solution did not cause any sign of permanent deformity of the silicone rubber., Conclusion: The rupture of the gastric band did not seem to be caused by a production error. Long-term deformity, in combination with a continuous dynamic load, may increase the risk of tearing. Long-term follow up is recommended for patients treated with this device.

Morbid obesity is associated with various disorders and may effectively be treated by restrictive surgery, such as laparoscopic adjustable gastric banding (LAGB). We observed a patient suffering from cardiac arrhythmias following LAGB. These cardiac events were likely evoked by hypokalemia due to persistent vomiting after placement of the band. We describe a case of continuing vomiting following a gastric banding procedure. Causes may include both mechanical, i.e. gastric prolapse, and psychological factors. The present case stresses the need for frequent follow-up for patients after a gastric restrictive operation.

Background: Surgery for morbid obesity has increased since the introduction of the adjustable gastric bands (AGB), which can be placed laparoscopically. There are two AGB in wide use: the Swedish Adjustable Gastric Band (SAGB, Obtech), and the Lap-Band (Inamed Health). We present the results of a comparative study between the 2 AGB., Methods: 101 patients with a minimal follow-up of 6 months were included. 49 patients received a Swedish Adjustable Gastric Band (SAGB), and the remaining 52 received the Lap-Band (LB). Postoperative weight loss and complications were compared at set intervals of 3 months in the first postoperative year, and 6 months in the years following., Results: Mean follow-up was 9.9 months for the SAGB and 7.2 months for the LB. All but 5 procedures were performed laparoscopically. Mean operating-time was 102 minutes for the SAGB and 86 minutes for the LB. No significant difference in complications was noted between the 2 AGB. 1 SAGB was repositioned and 2 were removed, compared to 2 repositions and 2 removals of the LB. We excluded 5 patients with leakage of a SAGB due to technical failure. Mean preoperative weight kg/BMI of the SAGB patients was 133/45.3; in the LB patients 138/46.4. Mean weight loss at 6 months was 28 kg with the SAGB and 30 kg with the LB, and mean weight loss at 1 year 36 kg and 38 kg respectively. After 2 years, weight loss was 46 kg and 42 kg respectively., Conclusion: There was no significant difference in postoperative weight loss and complications between the SAGB and the LB.