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Background: After Roux-en-Y gastric bypass (RYGB), 15% to 35% of patients fail to lose sufficient weight. Distalization of the limbs of the RYGB (D-RYGB) with shortening of the common channel (CC), has been used to induce additional weight loss. However, this may increase the risk of malnutrition., Objective: The aim of this study was to assess postoperative outcomes after D-RYGB with an alimentary limb of 250 to 300 cm and CC of 100 cm., Setting: General hospital, specialized in bariatric surgery., Methods: We retrospectively studied all patients who underwent revision of RYGB to D-RYGB between January 2014 and April 2018. Data were collected from medical records, including weight loss, nutritional deficiencies, and co-morbidities. Questionnaires on defecation pattern, quality of life, and patient satisfaction were obtained., Results: Forty-seven patients were included. Total weight loss (%TWL) increased significantly from 12% to 30% after D-RYGB. In 62% of patients %TWL >25% was achieved. Patients with %TWL <25% after primary RYGB, lost significantly more weight than initially reached after RYGB. Diabetes and hypertension remission occurred in 67% and 50%, respectively. Five patients (11%) needed subsequent lengthening of the CC to 250 cm due to protein malnutrition or debilitating defecation patterns. Nutritional deficiencies were present in 89% of patients after D-RYGB despite the prescription of specialized multivitamins., Conclusion: Conversion of the primary RYGB to D-RYGB improves weight loss and co-morbidities in patients with insufficient weight loss after primary RYGB. After D-RYGB, nutritional complications and diarrhea are a risk. Based on this study, a modified D-RYGB with a longer CC of >200 cm will be considered., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: After laparoscopic Roux-en-Y gastric bypass (RYGB), approximately 10-35% of patients with morbid obesity regain weight after an initial good result or fail to achieve a sufficient amount of weight loss. Patients in which conservative measures are not successful may potentially benefit from revisional surgery., Objective: To evaluate the effect of a non-adjustable ring placed around the gastric pouch in patients with insufficient weight loss or weight regain after RYGB., Setting: Four specialized bariatric hospitals in The Netherlands, Germany, and Switzerland., Methods: From 2011 to 2017, 79 patients underwent revisional surgery using a non-adjustable silicone ring because of insufficient results after RYGB. Data on weight loss and complications up to 2 years after revisional surgery was collected and analyzed retrospectively., Results: A follow-up percentage of 86% after 1 year and 61% after 2 years was achieved. In 75% of patients, further weight regain was prevented. Percentage total body weight loss improved by 7 to 26% 1 year after revisional surgery and remained stable during 2 years of follow-up. The additional weight loss effect of placing a non-adjustable ring was more pronounced in patients with an initial good result after primary RYGB. Eighteen (23%) rings were removed, most often due to dysphagia., Conclusion: Especially for patients who experience weight regain after initial good weight loss, placing a non-adjustable silicone ring around the gastric pouch results in modest improvements in weight loss. To prevent the risk of ring removal due to dysphagia, surgeons should take notice not to place the ring too tight around the gastric pouch during revisional surgery.

Background: Mutations in the leptin-melanocortin pathway genes are known to cause monogenic obesity. The prevalence of these gene mutations and their effect on weight loss response after bariatric surgery are still largely unknown., Objective: To determine the prevalence of genetic obesity in a large bariatric cohort and evaluate their response to bariatric surgery., Methods: Mutation analysis of 52 obesity-associated genes. Patient inclusion criteria were a BMI > 50 kg/m 2 , an indication for revisional surgery or an early onset of obesity (< 10 years of age)., Results: A total of 1014 patients were included, of whom 30 (3%) were diagnosed with genetic obesity, caused by pathogenic heterozygous mutations in either MC4R, POMC, PCSK1, SIM1, or PTEN. The percentage total body weight loss (%TBWL) after Roux-en-Y gastric bypass (RYGB) surgery was not significantly different for patients with a mutation in MC4R, POMC, and PCSK1 compared with patients lacking a molecular diagnosis. Of the confirmed genetic obesity cases, only patients with MC4R mutations receiving a sleeve gastrectomy (SG) showed significantly lower %TBWL compared with patients lacking a molecular diagnosis, during 2 years of follow-up., Conclusions: In this cohort of morbid obese bariatric patients, an estimated prevalence of monogenic obesity of 3% is reported. Among these patients, the clinical effects of heterozygous mutations in POMC and PCSK1 do not interfere with the effectiveness of most commonly performed bariatric procedures within the first 2 years of follow-up. Patients with MC4R mutations achieved superior weight loss after primary RYGB compared with SG.

Background: Although the Roux-en-Y gastric bypass (RYGB) is considered a standard procedure, many variations exist in the basic design. In order to achieve more pronounced and sustainable results after RYGB, factors such as diameter of the gastroenterostomy, limb length, and pouch size are gripping points for improvement of design. Extending the pouch could improve results by altering food passage through the pouch., Objective: The aim of this randomized controlled trial was to evaluate the effect of an extended pouch RYGB (EP-GB) and standard pouch RYGB (S-GB)., Methods: In total, 132 patients were randomized in two groups: 68 patients received an EP-GB (pouch length 10 cm) and 64 a S-GB (pouch length 5 cm). Subsequently, weight loss, remission of comorbidities, nutritional status, complications, quality of life, and GERD-symptoms were assessed during a follow-up of 3 years., Results: During the first 2 years of follow-up, no significant differences in terms of weight loss were observed. In the third year of follow-up, the S-GB group regained 3 kg, while in the EP-GB group no weight regain was observed. The mean TBWL after 36 months in the EP-GB group was 31% versus 27% in the S-GB group (p = 0.023). Additionally, besides a better remission rate of hypertension in the EP-GB group, no differences in complications, quality of life, and GERD-symptoms were found., Conclusion: Creation of an extended gastric pouch is a safe and effective modification in RYGB design. An EP-GB improves mid-term weight loss, potentially driven by a lower occurrence of weight regain.

Introduction: One of the current criteria for bariatric surgery is to be of an age between 18 and 65 years. In all the available literature, there is a lack of studies focusing on the results of bariatric surgery in younger patient. This could be of great interest because the weight loss response can be altered by differences in metabolism or compliance rate. In recent years, a high amount of patients between 18 and 25 years of age have undergone bariatric surgery in our center, and it is our aim to evaluate the weight loss results in this youngest patient group., Methods: All preoperative and perioperative data from patients aged 18-25 and 35-55 years (control group) were collected retrospectively. Bariatric procedures took place between 2011 and 2014. Follow-up data were gathered prospectively by collecting (laboratory) measurements and questionnaires., Results: In total, 103 young adults (mean age 22.5) were matched to 103 adult control patients (mean age 42.6) on BMI and date of surgery. Of the young adults' group, 75 patients underwent a Roux-en-Y gastric bypass (RYGB) compared with 80 patients in the control group. Three years after RYGB, mean %total body weight loss (%TBWL) was 34 (± 9) and 30.3 (± 9) (p = 0.03), respectively., Conclusion: Bariatric surgery is effective in young adults, and results after RYGB are even better compared with age groups in which bariatric surgery is most often performed. The high remission rate of comorbidities shows the importance of effective treatment options at a young age and preventing damaging effects in the long term.

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.)

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: Morbidly obese patients are at increased risk to develop venous thromboembolism (VTE), especially after bariatric surgery. Adequate postoperative thrombosis prophylaxis is of utmost importance. It is assumed that morbidly obese patients need higher doses of low molecular weight heparin (LMWH) compared to normal-weight patients; however, current guidelines based on relative efficacy in obese populations are lacking., Objectives: First, we will evaluate the relationship between body weight descriptors and anti-Xa activity prospectively. Second, we will determine the dose-linearity of LMWH in morbidly obese patients., Setting: This study was performed in a general hospital specialized in bariatric surgery., Methods: Patients were scheduled for a Roux-en-Y gastric bypass with a total bodyweight (TBW) of ≥ 140 kg. Patients (n = 50, 64% female) received a daily postoperative dose of 5700 IU of nadroparin for 4 weeks. Anti-Xa activity was determined 4 h after the last nadroparin administration. To determine the dose linearity, anti-Xa was determined following a preoperative dose of 2850 IU nadroparin in another 50 patients (52%)., Results: TBW of the complete group was 148.5 ± 12.6 kg. Mean anti-Xa activity following 5700 IU nadroparin was 0.19 ± 0.07 IU/mL. Of all patients, 32% had anti-Xa levels below the prophylactic range. Anti-Xa activity inversely correlated with TBW (correlation coefficient - 0.410) and lean body weight (LBW; correlation coefficient - 0.447); 67% of patients with a LBW ≥ 80 kg had insufficient anti-Xa activity concentrations. No VTE events occurred., Conclusions: In morbidly obese patients, a postoperative dose of 5700 IU of nadroparin resulted in subprophylactic exposure in a significant proportion of patients. Especially in patients with LBW ≥ 80 kg, a higher dose may potentially be required to reach adequate prophylactic anti-Xa levels.

Background: The endoscopic ally implanted DJBL is a 60-cm impermeable fluoropolymer device, which prevents food from making contact with the proximal intestine. It was designed to induce weight loss and treat type 2 diabetes mellitus (T2DM)., Objectives: To evaluate the feasibility, safety, and effectiveness of duodenal-jejunal bypass liner (DJBL) reimplantation., Setting: Prospective, observational study was conducted at the department of surgery and gastroenterology of the Rijnstate hospital, Arnhem, the Netherlands, between 2009 and 2011., Methods: Five obese patients with T2DM with body mass index (BMI) = Mass (kg) / height (m(2)), ranging from 30-35 kg/m(2) who completed the follow-up after their first implant and underwent removal of the DJBL after 6 months, were selected for reimplantation after an additional 18 months of follow-up. Weight loss, BMI, and HbA1 c were analyzed before and twelve months after reimplantation., Results: In all 5 patients, the DJBL was implanted and explanted without any complications. Also the reimplantation and reexplantation occurred without any complications. Median weight decreased significantly from 105 kg to 95 kg, and BMI decreased from 33 to 29. The glycated hemoglobin (HbA1 c) level decreased from 8.4% to 7.3% by the first implantation but it wasn't significant., Conclusions: Reimplantation of DJBL is feasible, deemed safe, and showed additional weight loss., (Copyright © 2015 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Severely obese patients have an increased risk for developing metabolic complications such as type 2 diabetes mellitus (T2DM), dyslipidaemia (DL) and hypertension (HT). The aim of the present study is to research the effect of a primary laparoscopic Roux-en-Y gastric bypass (LRYGB) on T2DM, HT and DL in the long-term., Methods: Fifty-two out of 89 (58 %) adult severely obese patients with T2DM who had received a LRYGB between January 2000 and December 2008 were evaluated. Primary outcome of evaluation was remission of T2DM according to the definition of 2009 consensus statement. Complete remission was defined as achievement fasting plasma glucose (FPG) of <5.6 mmol/l (<100.8 mg/dL) and HbA1c <42 mmol/mol (<6.0 %)) without glucose-lowering medication for at least 1 year. Partial remission was defined as a FPG of 5.6-6.9 mmol/l (100.8-124.2 mg/dL) and HbA1c 42-48 mmol/mol (6.0-6.5 %), without glucose-lowering medication for at least 1 year. Remission of T2DM was considered if the patient met the criteria for complete or partial remission. Secondary outcomes were remission of HT, DL and changes in medication use., Results: Patients had a mean age of 47.5 ± 9.6 years, body mass index of 46.6 ± 6.4 kg/m(2) and a mean duration of T2DM of 6.1 ± 5.4 years at the time of surgery. The mean post-operative follow-up period was 6.9 ± 2.3 years. At the end of the follow-up, mean weight loss was 60 ± 24 % excess weight loss (EWL) and 26 ± 10 % total body weight loss (TBWL). Mean HbA1c level had significantly decreased from 64.8 ± 19.7 mmol/mol to 46.4 ± 12.9 mmol/l (p < 0.0001). Overall medication use was reduced from 85 % to 37 % of the patients (p < 0.0001), while the number of insulin users was reduced from 40 % to 6 % (p < 0.0001). Nineteen percent of the patients had a relapse of T2DM during follow-up. Pre-operative HbA1ac level (odds ratio 0.911, p = 0.020) and duration of T2DM (odds ratio 0.637, p = 0.010) were independent risk factors for failed remission of T2DM. The number of patients with HT was significantly reduced from 73 % to 54 % (p = 0.042), and number of patients with DL was non-significantly decreased from 71 % to 54 % (p = 0.068)., Conclusions: The laparoscopic RYGB operation results in a sustained EWL of 60 % (26 % TBWL) with 52 % long-term remission of T2DM. However, 19 % of the patients had a relapse of their T2DM. Furthermore, HT and DL improved markedly.

Background: The most performed restrictive bariatric procedure is the laparoscopic adjustable gastric band (LAGB). With many patients still receiving a LAGB in Europe and the United States, inevitably, the number of complications also increases. For many complications revisional bariatric surgery is necessary. In this study, the outcomes of one-stage LAGB conversion to a Roux-en-Y gastric bypass (RYGB) at our institution are presented. The objective of this study was to investigate the safety and efficiency of RYGB performed as a one-stage procedure after failed LAGB., Methods: Patients were retrospectively selected using a prospectively collected database. The gastric band had to be in situ for at least 1 year and minimum postoperative follow-up was 12 months. The revisional RYGB had to be performed as a 1-step procedure., Results: A total of 195 patients were included while 3 were lost to follow up. Overall, 178 (91%) procedures were performed without perioperative complications, and only 8 (4%) patients required reoperation within 30 days. The mean follow-up was 40 months (±24) after RYGB. Mean excess weight loss (EWL) increased from 25% (±26/-50- 120%) to 60% (±21.2/0- 130), 65% (±23.5/0- 131), 63% (±24.2/2- 132), 60% (±24.1/0- 111) and 53% (±28.7/-39- 109) in the first 5 postoperative years., Conclusion: Converting a gastric band to a RYGB in a one-stage procedure is safe and feasible, with acceptable complication rates when performed in a specialized institution. The RYGB conversion results in a good EWL of 65% after 2 years. However, proper patient selection is of the utmost importance., (Copyright © 2014 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Obesity-related hypogonadotrophic hypogonadism (OrHH) occurs in over 40% of morbidly obese men. Obesity-related hypogonadotrophic hypogonadism may reduce the beneficial effects of bariatric surgery., Objective: To assess the impact of OrHH on the outcome of bariatric surgery in men., Patients and Methods: Observational study with measurement of serum gonadal hormones, and assessment of body composition, glucose, lipid and bone metabolism during the first year after bariatric surgery in 13 men with OrHH (free testosterone (free T) <225 pmol/l) and 11 age-matched eugonadal morbidly obese men (free T > 225 pmol/l)., Results: Serum free T was inversely related to body weight (R = -0·65, P < 0·0001) and rose gradually after bariatric surgery, in eugonadal as well as in OrHH men, by 30 pmol/l for every 10 kg loss of weight. In three patients, serum free T remained within the hypogonadal range despite substantial weight loss. Gonadal hormone status prior to surgery did not affect the 1-year outcome of surgery., Conclusion: Obesity-related hypogonadotrophic hypogonadism is a reversible condition in the majority of obese men. It does not reduce the efficacy of bariatric surgery. Preoperative weight-adjusted normal values are recommended to avoid an incorrect diagnosis of hypogonadism in obese men., (© 2013 John Wiley & Sons Ltd.)

Background: For over a decade, the laparoscopic adjustable gastric band (LAGB) was 1 of the most performed bariatric procedures in Europe. This study is a retrospective analysis with prospectively collected data of the experience in 1 specialized Dutch center with the adjustable gastric band over 14 years., Methods: Between 1995 and 2003, 201 patients underwent an LAGB for morbid obesity in our hospital. Data on preoperative clinical characteristic, postoperative outcome and weight loss patterns, and co-morbidities for up to 18 years are presented and evaluated using the Bariatric Analysis and Reporting Outcome System (BAROS)., Results: Average follow-up was 13.6 (± 2.0) years (163 mo) and 99% of patients with complete follow-up. Two thirds of patients reached an excess weight loss (EWL)>50% at some point after LAGB placement. However, due to insufficient weight loss or complications in 53% of patients, the LAGB had to be removed or converted to a Roux-en-Y gastric bypass. Additionally, half of the remaining patients had disappointing results according to the BAROS score. In total, less than one quarter (22%) of patients had a functioning band with a good result after the follow-up period. Although initially the number of patients experiencing co-morbidities was reduced, most of them returned and a large number of patients developed new co-morbidities. Complications, other than weight regain, were numerous as 47% of patients experienced at least 1. In total, 204 reoperations were performed in 137 (68%) patients. Furthermore, patients who were lost to follow-up did almost twice as bad in terms of EWL compared to patients who had regular follow-up., Conclusion: Morbid obesity is a chronic disease that can be resolved with bariatric surgery. One of the treatment options is the LAGB, which in the short term shows good results in terms of EWL and co-morbidity reduction. In the long term, however, EWL and co-morbidity reduction are disappointing, and the LAGB does not seem to live up to expectations. Besides the decrease in EWL over time, the number of reoperations required is alarming. In total, less than a quarter of patients still had a functioning band after a mean 14 years of follow-up., (Copyright © 2014 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: To evaluate whether preoperative measurement of fasting plasma C-peptide levels is useful to predict diabetes outcome after Roux-en-Y gastric bypass (RYGB) surgery., Materials and Methods: Diabetes outcome after RYGB was evaluated in 126 obese patients: 41 non-diabetic controls (NDC), 29 with impaired glucose tolerance (IGT) and 56 had type 2 diabetes mellitus (T2DM). Body weight, fasting plasma glucose, fasting C-peptide levels, and HbA1c were measured at baseline and 3.6 ± 0.16 years after GBS. Complete resolution of diabetes was defined as: fasting glucose <7.0 mmol/l, HbA1c <6.5 %, achieved without anti-diabetic medication., Results: Patients with complete resolution of diabetes had a more recent diagnosis of T2DM, lower preoperative HbA1c levels and lower daily doses of metformin and insulin use. These parameters were related to postoperative HbA1c levels but they failed to mark the specific patients who had not reached complete resolution of T2DM. Fasting preoperative C-peptide levels had better predictive power: 90 % of T2DM patients with preoperative fasting C-peptide levels >1.0 nmol/l achieved a postoperative HbA1c <6.5 %, and 74 % achieved complete resolution of their diabetes. In contrast, none of the T2DM patients with a preoperative fasting C-peptide <1.0 nmol/l attained these goals., Conclusions: A preoperative fasting plasma C-peptide level <1.0 nmol/l in severely obese T2DM patients indicates partial β-cell failure, and is associated with a markedly reduced chance of complete resolution of T2DM after RYGB. We therefore advocate measuring C-peptide levels in all diabetic patients up for bariatric surgery to improve the prediction of outcome.

The global obesity epidemic is also affecting the Netherlands, paralleled by a proportional increase in the number of morbidly obese persons. Bariatric surgery has been included as a treatment for morbid obesity in the Dutch Guideline for Obesity (2008). Nonetheless, bariatric surgery is applied in only a limited number of morbidly obese subjects in the Netherlands. Based on the most recent literature and Dutch statistics, this review provides a summary of current knowledge on the impact of obesity on health and health care and highlights the effective role of bariatric surgery in reducing this threat to public health.

Background: The most common bariatric surgical operation in Europe, laparoscopic adjustable gastric banding (LAGB), is reported to have a high incidence of long-term complications. Also, insufficient weight loss is reported. We investigated whether revision to Roux-en-Y gastric bypass (RYGBP) is a safe and effective therapy for failed LAGB and for further weight loss., Methods: From Jan 1999 to May 2004, 613 patients underwent LAGB. Of these, 47 underwent later revisional Roux-en-Y gastric bypass (RYGBP). Using a prospectively collected database, we analyzed these revisions. All procedures were done by two surgeons with extensive experience in bariatric surgery., Results: All patients were treated with laparoscopic (n=26) or open (n=21) RYGBP after failed LAGB. Total follow-up after LAGB was 5.5+/-2.0 years. For the RYGBP, mean operating time was 161+/-53 minutes, estimated blood loss was 219+/-329 ml, and hospital stay was 6.7+/-4.5 days. There has been no mortality. Early complications occurred in 17%. There was only one late complication (2%)--a ventral hernia. The mean BMI prior to any form of bariatric surgery was 49.2+/-9.3 kg/m2, and decreased to 45.8+/-8.9 kg/m2 after LAGB and was again reduced to 37.7+/-8.7 kg/m2 after RYGBP within our follow-up period., Conclusion: Conversion of LAGB to RYGBP is effective to treat complications of LAGB and to further reduce the weight to healthier levels in morbidly obese patients.