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Roux-en-Y gastric bypass (RYGB) is associated with an increased risk of kidney stone formation. This is not observed after sleeve gastrectomy (SG).Aim of this study was to assess whether preoperative metabolic profiling is helpful in selecting the most optimal bariatric procedure for patients with a kidney stone history.General hospital, the Netherlands.Patients with a kidney stone history and in the run up to bariatric surgery were screened with non-contrast abdominal computed tomography (CT), serum profiling, and 24-hour urine analysis. Those with stones on radiologic imaging and/or high preoperative urinary oxalate were advised to undergo SG instead of RYGB. Pre- and postoperative urine and serum profile differences between both groups were evaluated retrospectively.Postoperatively, RYGB (N = 28, M:F = 8:20) was associated with a 23.5% reduction in urinary volume, a 85% increase in urinary oxalate excretion with a 230% increase in calcium oxalate (CaOx) supersaturation and a 62% decrease in urinary citrate. Although SG (N = 30, M:F = 12:18) was also associated with a reduction in urinary volume, it had no adverse effects on urinary oxalate and citrate excretion, nor on calcium oxalate supersaturation (CaOx-SS). Both RYGB and SG showed favorable effects on postoperative sodium, calcium, uric acid, and phosphate excretion.This study indicates that preoperative metabolic profiling is important to select the optimal bariatric procedure in patients with an a priori increased risk of kidney stone development. These patients should be strongly encouraged to undergo SG instead of RYGB to prevent progressive or recurrent kidney stone disease.

To enable maximal and sustainable weight loss after bariatric surgery, bariatric lifestyle programs through multidisciplinary support are advised.To assess the association between patient attendance to a perioperative group-based bariatric lifestyle program (GBLP) and weight loss up to 48 months postoperatively.A multicenter retrospective cohort study in the Netherlands.Patients who underwent primary laparoscopic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) attended a GBLP in 2016 consisting of 18 sessions. A linear mixed model was used to assess the association between the patient attendance rate to the GBLP and total weight loss (%TWL). Independent predictors for the patient attendance rate and adequate %TWL were analyzed.A total of 3015 patients were included. Percentage of patients lost to follow-up was 5% at 1 year, 25% at 2 years, 34% at 3 years, and 42% at 4 years follow-up. Average TWL was 33% at 12 months after surgery, 33% at 24 months, 31% at 36 months, and 31% at 48 months. A small but significant adjusted positive association between the attendance rate and %TWL at 3 months until 36 months postoperatively was found (Beta between .03-.07), which disappeared at 48 months after surgery. Independent factors associated with a low attendance rate were younger age, male sex, and SG. Independent factors negatively associated with %TWL were male sex, SG, and diabetes.A higher patient attendance to GBLP sessions is associated with a small but significant increase in postoperative weight loss up to 3, but not 4 years after surgery.

Introduction: Pathogenic heterozygous MC4R variants are associated with hyperphagia and variable degrees of obesity. Several research groups have reported short-term weight loss outcomes after bariatric surgery in a few patients with MC4R variants, but lack of longer-term data prevents evidence-based clinical decision-making. Materials and Methods: Bariatric surgery patients with heterozygous (likely) pathogenic MC4R variants, from three collaborating centers in the Netherlands, France, and the UK, were compared to matched controls (matched 2:1 for age, sex, preoperative BMI, surgical procedure, and diabetes mellitus, but without MC4R mutations). Weight loss and regain outcomes up to 6 years of follow-up were compared. Results: At 60 months of follow-up after RYGB, cases with MC4R variants showed weight regain with a mean of 12.8% (± 10.4 SD) total weight loss (TWL) from nadir, compared to 7.9% (± 10.5 SD) in the controls (p = 0.062). Among patients receiving SG, the cases with MC4R variants experienced inferior weight loss (22.6% TWL) during the first year of follow-up compared to the controls (29.9% TWL) (p = 0.010). Conclusions: This multicenter study reveals inferior mid-term weight outcomes of cases with MC4R variants after SG, compared to RYGB. Since adequate weight loss outcomes were observed after RYGB, this procedure would appear to be an appropriate surgical approach for this group. However, the pattern of weight regain seen in cases with MC4R variants after both RYGB and SG highlights the need for pro-active lifelong management to prevent relapse, as well as careful expectation management. Graphical abstract: [Figure not available: see fulltext.].

Background Spinal epidural lipomatosis (SEL) is characterized by symptomatic neurogenic compression from adipose tissue in the spinal canal. The question arises whether patients with morbid obesity have higher volumes of epidural adipose tissue (EAT) in their lumbar spinal canal compared to patients with a normal weight and to which extent this decreases after bariatric surgery. Methods In this explorative study the lumbar EAT volume was assessed in 25 patients with morbid obesity (Body Mass Index (BMI)>40) using available lumbar magnetic resonance imaging (MRI) prior to their bariatric surgery. An age and gender matched control group (n=25) of patients with a normal weight (BMI 20-25) was used for comparison. Participants from the obesity group underwent a post-operative control MRI. Results The mean volume of EAT per MRI-slice of the group of patients with obesity was significantly higher than for the group of patients with normal weight (mean 83.3 mm3 ± 30.7 versus mean 56.5 mm3 ± 25; p Conclusions Patients with obesity have significantly larger volumes of EAT in comparison to patients with normal weight. After bariatric surgery, a significant weight loss coincided with a significant volumetric reduction of this adipose tissue in the spinal canal. Future prospective studies in patients with symptomatic SEL may elucidate whether decreases in EAT volume influence concurrent neurogenic claudication symptoms.

Background and ObjectiveWhile underlying pathophysiology linking obesity to brain health is not completely understood, white adipose tissue (WAT) is considered a key player. In obesity, WAT becomes dysregulated, showing hyperplasia, hypertrophy, and eventually inflammation. This disbalance leads to dysregulated secretion of adipokines influencing both (cardio)vascular and brain health. Within this study, we investigated the association between omental WAT (oWAT) and subcutaneous WAT (scWAT) with brain structure and perfusion and cognition in adults with severe obesity.MethodsWithin the cross-sectional BARICO study, brain structure and perfusion and cognitive function were measured before bariatric surgery (BS) using MRI and cognitive assessments. During BS, oWAT and scWAT depots were collected and analyzed by histopathology. The number and diameter of adipocytes were quantified together with the amount of crown-like structures (CLS) as an indication of inflammation. Blood samples were collected to analyze adipokines and inflammatory markers. Neuroimaging outcomes included brain volumes, cortical thickness, white matter (WM) integrity, WM hyperintensities, cerebral blood flow using arterial spin labeling (ASL), and the ASL spatial coefficient of variation (sCoV), reflecting cerebrovascular health.ResultsSeventy-one patients were included (mean age 45.1 ± 5.8 years; 83.1% women; mean body mass index 40.8 ± 3.8 kg/m2). scWAT showed more CLS (z= −2.72,p< 0.01,r= −0.24) and hypertrophy compared with oWAT (F(1,64) = 3.99,p< 0.05, η2= 0.06). Adiponectin levels were inversely associated with the average diameter of scWAT (β = −0.31, 95% CI −0.54 to −0.08) and oWAT (β = −0.33, 95% CI −0.55 to −0.09). Furthermore, the adipocyte diameter in oWAT was positively associated with the sCoV in the parietal cortex (β = 0.33, 95% CI 0.10–0.60), and the number of adipocytes (per mm2) was positively associated with sCoV in the nucleus accumbens (NAcc) (β = 0.34, 95% CI 0.09–0.61). Cognitive function did not correlate with any WAT parameter or plasma marker. These associations were highly influenced by age and sex. sCoV in the NAcc was positively associated with fasting plasma glucose (β = 0.35, 95% CI 0.10–0.56).DiscussionscWAT and oWAT are different in morphology and in their relationship with plasma markers and cerebrovascular health. Although scWAT showed more CLS and hypertrophy, scWAT was not associated with brain readouts. This study showed, however, important relationships between oWAT morphology and cerebrovascular health in obesity.Trial Registration InformationTrial Registration Number NTR7288 (trialregister.nl/trial/7090).

Objective:To determine the relative validity and reproducibility of the Eetscore FFQ, a short screener for assessing diet quality, in patients with (severe) obesity before and after bariatric surgery (BS).Design:The Eetscore FFQ was evaluated against 3-d food records (3d-FR) before (T0) and 6 months after BS (T6) by comparing index scores of the Dutch Healthy Diet index 2015 (DHD2015-index). Relative validity was assessed using paired t tests, Kendall’s tau-b correlation coefficients (τb), cross-classification by tertiles, weighted kappa values (kw) and Bland–Altman plots. Reproducibility of the Eetscore FFQ was assessed using intraclass correlation coefficients (ICC).Setting:Regional hospital, the Netherlands.Participants:Hundred and forty participants with obesity who were scheduled for BS.Results:At T0, mean total DHD2015-index score derived from the Eetscore FFQ was 10·2 points higher than the food record-derived score (P < 0·001) and showed an acceptable correlation (τb = 0·42, 95 % CI: 0·27, 0·55). There was a fair agreement with a correct classification of 50 % (kw = 0·37, 95 % CI: 0·25, 0·49). Correlation coefficients of the individual DHD components varied from 0·01–0·54. Similar results were observed at T6 (τb = 0·31, 95 % CI: 0·12, 0·48, correct classification of 43·7 %; kw = 0·25, 95 % CI: 0·11, 0·40). Reproducibility of the Eetscore FFQ was good (ICC = 0·78, 95 % CI: 0·69, 0·84).Conclusion:The Eetscore FFQ showed to be acceptably correlated with the DHD2015-index derived from 3d-FR, but absolute agreement was poor. Considering the need for dietary assessment methods that reduce the burden for patients, practitioners and researchers, the Eetscore FFQ can be used for ranking according to diet quality and for monitoring changes over time.

ObjectiveThere is no evidence-based treatment for persistent dysphagia after laparoscopic fundoplication. The aim of this study was to evaluate the effect of pneumatic dilation on persistent dysphagia after laparoscopic fundoplication.DesignWe performed a multicentre, single-blind, randomised sham-controlled trial of patients with persistent dysphagia (>3 months) after laparoscopic fundoplication. Patients with an Eckardt symptom score ≥4 were randomly assigned to pneumatic dilation (PD) using a 35 mm balloon or sham dilation. Primary outcome was treatment success, defined as an Eckardt score ResultsForty-two patients were randomised. In the intention-to-treat analysis, the success rates of PD (7/21 patients (33%)) and sham dilation (8/21 patients (38%)) were similar after 30 days (risk difference −4.7% (95% CI (−33.7% to 24.2%) p=0.747). There was no significant difference in change of stasis on the timed barium oesophagogram after 2 min (PD vs sham: median 0.0 cm, p25–p75 range 0.0–4.3 cm vs median 0.0 cm, p25–p75 range 0.0–0.0; p=0.122) or change in lower oesophageal sphincter relaxation pressure (PD vs sham: 10.54±6.25 vs 14.60±6.17 mm Hg; p=0.052). Quality of life, reflux and dysphagia symptoms were not significantly different between the two groups.ConclusionPneumatic dilation with a 35 mm balloon is not superior to sham dilation for the treatment of persistent dysphagia after fundoplication.

BACKGROUND Worldwide, the prevalence of obesity in women of reproductive age is increasing. Bariatric surgery is currently viewed as the most effective, long-term solution for this problem. Preconception bariatric surgery can reduce the prevalence of obesity-related subfertility and adverse maternal, pregnancy and birth outcomes. Maternal health during the periconception period is crucial for optimal gametogenesis and for embryonic and fetal development which also affects health in the later lives of both mother and offspring. Although preconception bariatric surgery improves several pregnancy outcomes, it can also increase the prevalence of pregnancy complications due to excessive and rapid weight loss. This can lead to iatrogenic malnutrition with vitamin deficiencies and derangements in metabolic and endocrine homeostasis. Thus, bariatric surgery can greatly influence periconception maternal health with consequences for reproduction, pregnancy and health in later life. However, its influence on periconception maternal health itself has never been reviewed systematically. OBJECTIVE AND RATIONALE The aim of this review was to investigate associations between bariatric surgery and determinants of periconception maternal health such as endocrine changes, fertility, vitamin status, irregular menstrual cycles, miscarriages and congenital malformations. SEARCH METHODS Medline, Embase, PubMed, Web of Science, Google Scholar and the Cochrane databases were used for the literature search until 1 November 2020. The search strategy terms included, among others, bariatric surgery, hormones, fertility, malformations, miscarriages and vitamin status. We searched for human studies that were written in English. Abstracts, reviews, meta-analyses and conference papers were excluded. The ErasmusAGE score was used to assess the quality of the included studies. OUTCOMES A total of 51 articles were analysed. The mean quality score was 5 (range 2–8). After bariatric surgery, hormonal axes normalized and menstrual cycle regularity was restored, resulting in increased fertility. Overall, there were no short-term risks for reproductive outcomes such as the increased risk of miscarriages or congenital malformations. However, the risk of vitamin deficiencies was generally increased after bariatric surgery. A meta-analysis of 20 studies showed a significant decrease in infertility (risk difference (RD) −0.24, 95% confidence interval (CI) −0.42, −0.05) and menstrual cycle irregularities (RD −0.24, 95% CI −0.34, −0.15) with no difference in rates of miscarriage (RD 0.00, 95% CI −0.09, 0.10) and congenital malformations (RD 0.01, 95% CI −0.02, 0.03). WIDER IMPLICATIONS The current systematic review and meta-analysis show associations between bariatric surgery and periconception maternal health and underlines the need for providing and personalizing preconception care for women after bariatric surgery. We recommend preconception care including the recommendation of postponing pregnancy until weight loss has stabilized, irrespective of the surgery-to-pregnancy interval, and until vitamin status is normalized. Therefore, regular monitoring of vitamin status and vitamin supplementation to restore deficiencies is recommended. Furthermore, this systematic review emphasizes the need for a long-term follow-up research of these women from the periconception period onwards as well as their pregnancies and offspring, to further improve care and outcomes of these mothers and children.

Objective To define "best possible" outcomes for secondary bariatric surgery (BS). Background Management of poor response and of long-term complications after BS is complex and under-investigated. Indications and types of reoperations vary widely and postoperative complication rates are higher compared to primary BS. Methods Out of 44,884 BS performed in 18 high-volume centers from 4 continents between 06/2013-05/2019, 5,349 (12%) secondary BS cases were identified. Twenty-one outcome benchmarks were established in low-risk patients, defined as the 75th percentile of the median outcome values of centers. Benchmark cases had no previous laparotomy, diabetes, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, thromboembolic events, BMI> 50 kg/m2 or age> 65 years. Results The benchmark cohort included 3143 cases, mainly females (85%), aged 43.8 ± 10 years, 8.4 ± 5.3 years after primary BS, with a BMI 35.2 ± 7 kg/m2. Main indications were insufficient weight loss (43%) and gastro-esophageal reflux disease/dysphagia (25%). 90-days postoperatively, 14.6% of benchmark patients presented ≥1 complication, mortality was 0.06% (n = 2). Significantly higher morbidity was observed in non-benchmark cases (OR 1.37) and after conversional/reversal or revisional procedures with gastrointestinal suture/stapling (OR 1.84). Benchmark cutoffs for conversional BS were ≤4.5% re-intervention, ≤8.3% re-operation 90-days postoperatively. At 2-years (IQR 1-3) 15.6% of benchmark patients required a reoperation. Conclusion Secondary BS is safe, although postoperative morbidity exceeds the established benchmarks for primary BS. The excess morbidity is due to an increased risk of gastrointestinal leakage and higher need for intensive care. The considerable rate of tertiary BS warrants expertise and future research to optimize the management of non-success after BS.

Background This study investigated whether a supervised exercise programme improves quality of life (QoL), fatigue and cardiorespiratory fitness in patients in the first year after oesophagectomy. Methods The multicentre PERFECT trial randomly assigned patients to an exercise intervention (EX) or usual care (UC) group. EX patients participated in a 12-week moderate- to high-intensity aerobic and resistance exercise programme supervised by a physiotherapist. Primary (global QoL, QoL summary score) and secondary (QoL subscales, fatigue and cardiorespiratory fitness) outcomes were assessed at baseline, 12 and 24 weeks and analysed as between-group differences using either linear mixed effects models or ANCOVA. Results A total of 120 patients (mean(s.d.) age 64(8) years) were included and randomized to EX (61 patients) or UC (59 patients). Patients in the EX group participated in 96 per cent (i.q.r. 92–100 per cent) of the exercise sessions and the relative exercise dose intensity was high (92 per cent). At 12 weeks, beneficial EX effects were found for QoL summary score (3.5, 95 per cent c.i. 0.2 to 6.8) and QoL role functioning (9.4, 95 per cent c.i. 1.3 to 17.5). Global QoL was not statistically significant different between groups (3.0, 95 per cent c.i. –2.2 to 8.2). Physical fatigue was lower in the EX group (–1.2, 95 per cent c.i. –2.6 to 0.1), albeit not significantly. There was statistically significant improvement in cardiorespiratory fitness following EX compared with UC (peak oxygen uptake (1.8 ml/min/kg, 95 per cent c.i. 0.6 to 3.0)). After 24 weeks, all EX effects were attenuated. Conclusions A supervised exercise programme improved cardiorespiratory fitness and aspects of QoL. Trial registration Dutch Trial Register NTR 5045 (www.trialregister.nl/trial/4942).

Background Epicardial adipose tissue (EAT) has been implicated in the pathophysiology of heart failure (HF) with left ventricular ejection fraction (LVEF) >40%, but whether this is due to a regional or global effect of EAT remains unclear.Hypothesis Regional EAT is associated with alterations in local cardiac structure and function.Methods Patients with HF and LVEF >40% were studied. Cardiac Magnetic Resonance imaging was used to localize EAT surrounding the right ventricle (RV) and LV separately, using anterior- and posterior interventricular grooves as boundaries. Atrial- and ventricular EAT were differentiated using the mitral-valve position. All EAT depots were related to the adjacent myocardial structure.Results 102 consecutive HF patients were enrolled. The majority of EAT was present around the RV (42% of total EAT, p < .001). RV-EAT showed a strong association with increased RV mass (beta = 0.60, p < .001) and remained associated with RV mass after adjusting for total EAT, sex, N-terminal prohormone of brain natriuretic peptide (NT-proBNP), renal function and blood glucose. LV-EAT showed a similar association with LV mass in univariable analysis, albeit less pronounced (beta = 0.24, p = .02). Atrial EAT was increased in patients with atrial fibrillation compared to those without atrial fibrillation (30 vs. 26 ml/m(2), p = .04), whereas ventricular EAT was similar (74 vs. 75 ml/m(2), p = .9).Conclusions Regional EAT is strongly associated with local cardiac structure and function in HF patients with LVEF >40%. These data support the hypothesis that regional EAT is involved in the pathophysiology of HF with LVEF >40%.

Purpose Micronutrient deficiencies are frequently reported after sleeve gastrectomy (SG), and therefore lifelong daily multivitamin supplementation is highly recommended. Based on literature and the results of a previous randomized controlled trial, a specialized multivitamin supplement for SG patients was further optimized (WLS Optimum 2.0, FitForMe). The present study reports on its short-term effectiveness. Materials and Methods An open-label study was performed in which 76 patients were included to receive WLS Optimum 2.0 for 12 months (Opt 2.0 group). This group was compared with a group of 75 patients that had received WLS Optimum 1.0 for 12 months during a previous study (Opt 1.0 group). Results Intention-to-treat analysis (Opt 1.0, n = 69; Opt 2.0, n = 75) showed higher serum levels of vitamin B12, vitamin B6, and zinc, and a lower prevalence of deficiencies for vitamin B12 and phosphate in the Opt 2.0 group. MCV and serum folic acid levels were higher in the Opt 1.0 group. Over the 12-month study period, mean increase in serum levels of phosphate, vitamin B6, and zinc was higher in the Opt 2.0 group, and MCV and serum vitamin D levels increased more in the Opt 1.0 group. Conclusion The present study showed that the use of a specialized multivitamin supplement for SG patients is effective at preventing deficiencies for most vitamins and minerals, specifically in compliant patients. However, a strict follow-up regime remains necessary to monitor nutritional status and to improve patient compliance.

Aims Obesity is a global health problem, associated with significant morbidity and mortality, often due to cardiovascular (CV) diseases. While bariatric surgery is increasingly performed in patients with obesity and reduces CV risk factors, its effect on CV disease is not established. We conducted a systematic review and meta-analysis to evaluate the effect of bariatric surgery on CV outcomes, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Methods and results PubMed and Embase were searched for literature until August 2021 which compared bariatric surgery patients to non-surgical controls. Outcomes of interest were all-cause and CV mortality, atrial fibrillation (AF), heart failure (HF), myocardial infarction, and stroke. We included 39 studies, all prospective or retrospective cohort studies, but randomized outcome trials were not available. Bariatric surgery was associated with a beneficial effect on all-cause mortality [pooled hazard ratio (HR) of 0.55; 95% confidence interval (CI) 0.49–0.62, P < 0.001 vs. controls], and CV mortality (HR 0.59, 95% CI 0.47–0.73, P < 0.001). In addition, bariatric surgery was also associated with a reduced incidence of HF (HR 0.50, 95% CI 0.38–0.66, P < 0.001), myocardial infarction (HR 0.58, 95% CI 0.43–0.76, P < 0.001), and stroke (HR 0.64, 95% CI 0.53–0.77, P < 0.001), while its association with AF was not statistically significant (HR 0.82, 95% CI 0.64–1.06, P = 0.12). Conclusion The present systematic review and meta-analysis suggests that bariatric surgery is associated with reduced all-cause and CV mortality, and lowered incidence of several CV diseases in patients with obesity. Bariatric surgery should therefore be considered in these patients.

Background Obesity is associated with cardiovascular (CV) risk factors and diseases. Because bariatric surgery is increasingly performed in relatively elderly patients, a risk for pre- and postoperative CV complications exists. Objectives We aimed to assess the value of plasma N-terminal-probrain natriuretic peptide (NT-proBNP) as a CV screening tool. Setting High-volume bariatric center. Methods Between June 2019 and January 2020, all consecutive bariatric patients 50 years and older underwent preoperative NT-proBNP assessment in this cohort study to screen for CV disease. Patients with elevated NT-proBNP (≥125 pg/mL) were referred for further cardiac evaluation, including electrocardiography and echocardiography. Results We included 310 consecutive patients (median age, 56 years; 79% female; body mass index = 43±6.5 kg/m2). A history of CV disease was present in 21% of patients, mainly atrial fibrillation (7%) and coronary artery disease (10%). A total of 72 patients (23%) had elevated NT-proBNP levels, and 67 of them underwent further cardiac workup. Of these 67 patients, electrocardiography (ECG) showed atrial fibrillation in 7 patients (10%). On echocardiography, 3 patients had left ventricular ejection fraction (LVEF), Highlights • This study assessed NT-proBNP as a cardiac screening tool in bariatric patients. • Elevated NT-proBNP levels were present in 23% of patients ≥50 years. • In 37% of them (n=25), echocardiography showed LV dysfunction or heart failure. • NT-proBNP is a non-invasive tool that can detect new CV diseases in bariatric patients

Despite the publication of the American Society for Metabolic and Bariatric Surgery (ASMBS) Outcome Reporting Standards in 2015, there is still a great variety in definitions used for reporting remission of co-morbidities after bariatric surgery. This hampers meaningful comparison of results.To assess compliance with the ASMBS standards in current literature, and to evaluate use of the standards by applying them in a report on the outcomes of 5 co-morbidities after bariatric surgery.Two clinics of the Dutch Obesity Clinic, location Den Haag and Velp, and three affiliated hospitals: Haaglanden Medical Center in Den Haag, Groene Hart Hospital in Gouda, and Vitalys Clinic in Velp.A systematic search in PubMed was conducted to identify studies using the ASMBS standards. Besides, the standards were applied to a cohort of patients who underwent a primary bariatric procedure between November 2016 and June 2017. Outcomes of co-morbidities were determined at 6 and 12 months after surgery.Ten previous studies applying ASMBS definitions were identified by the search, including 6 studies using portions of the definitions, and 4 using complete definitions for 3 co-morbidities or in a small population. In this study, the standards were applied to 1064 patients, of whom 796 patients (75%) underwent Roux-en-Y gastric bypass and 268 patients (25%) underwent sleeve gastrectomy. At 12 months, complete remission of diabetes (glycosylated hemoglobin6%, off medication) was reached in 63%, partial remission (glycosylated hemoglobin 6%-6.4%, off medication) in 7%, and improvement in 28% of patients (n = 232/248, 94%). Complete remission of hypertension (normotensive, off medication) was noted in 8%, partial remission (prehypertensive, off medication) in 23% and improvement in 63% (n = 397/412, 96%). Remission rate for dyslipidemia (normal nonhigh-density lipoprotein, off medication) was 57% and improvement rate was 19% (n = 129/133, 97%). Resolution of gastroesophageal reflux disease (no symptoms, off medication) was observed in 54% (n = 265/265). Obstructive sleep apnea syndrome improved in 90% (n = 157/169, 93%).Compliance with the ASMBS standards is low, despite ease of use. Standardized definitions provided by the ASMBS guideline could be used in future research to enable comparison of outcomes of different studies and surgical procedures.

BACKGROUND: The LIR!C trial showed that laparoscopic ileocaecal resection is a cost-effective treatment that has similar quality-of-life outcomes to treatment with infliximab, an anti-tumour necrosis factor (TNF) drug. We aimed to compare long-term outcomes of both interventions and identify baseline factors associated with the duration of treatment effect in each group.METHODS: In this retrospective follow-up study, we collected data from patients who participated in the LIR!C trial, a multicentre randomised controlled trial that compared quality of life after surgical resection versus infliximab in adult patients with non-stricturing and immunomodulator-refractory ileocaecal Crohn's disease. From Jan 1 to May 1, 2018, we collected follow-up data from the time from enrolment in the LIR!C trial until the last visit at either the gastrointestinal surgeon or gastroenterologist. In this study, outcomes of interest were need for surgery or repeat surgery or anti-TNF therapy, duration of treatment effect, and identification of factors associated with the duration of treatment effect. Duration of treatment effect was defined as the time without need for additional Crohn's disease-related treatment (corticosteroids, immunomodulators, biologics, or surgery).FINDINGS: We collected long-term follow-up data for 134 (94%) of 143 patients included in the LIR!C trial, of whom 69 were in the resection group and 65 were in the infliximab group. Median follow-up was 63·5 months (IQR 39·0-94·5). In the resection group, 18 (26%) of 69 patients started anti-TNF therapy and none required a second resection. 29 (42%) patients in the resection group did not require additional Crohn's disease-related medication, although 14 (48%) of these patients were given prophylactic immunomodulator therapy. In the infliximab group, 31 (48%) of 65 patients had a Crohn's disease-related resection, and the remaining 34 patients maintained, switched, or escalated their anti-TNF therapy. Duration of treatment effect was similar in both groups, with a median time without additional Crohn's disease-related treatment of 33·0 months (95% CI 15·1-50·9) in the resection group and 34·0 months (0·0-69·3) in the infliximab group (log-rank p=0·52). In both groups, therapy with an immunomodulator, in addition to the allocated treatment, was associated with duration of treatment effect (hazard ratio for resection group 0·34 [95% CI 0·16-0·69] and for infliximab group 0·49 [0·26-0·93]).INTERPRETATION: These findings further support laparoscopic ileocaecal resection as a treatment option in patients with Crohn's disease with limited (affected segment ≤40 cm) and predominantly inflammatory terminal ileitis for whom conventional treatment is not successful.FUNDING: None.

Sakran, Nasser/0000-0002-6658-8981; Kurian, Marina/0000-0003-1480-626X The purpose of this study was to achieve consensus amongst a global panel of expert bariatric surgeons on various aspects of resuming Bariatric and Metabolic Surgery (BMS) during the Coronavirus Disease-2019 (COVID-19) pandemic. A modified Delphi consensus-building protocol was used to build consensus amongst 44 globally recognised bariatric surgeons. The experts were asked to either agree or disagree with 111 statements they collectively proposed over two separate rounds. An agreement amongst >= 70.0% of experts was construed as consensus as per the predetermined methodology. We present here 38 of our key recommendations. This first global consensus statement on the resumption of BMS can provide a framework for multidisciplinary BMS teams planning to resume local services as well as guide future research in this area. WOS:000554457600001 32740826 Q1

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/m2) 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 β = 3.99, 95%CI = 2.86–5.12, P β = 0.13, 95%CI = 0.05–0.20, P = .002) and SG (β = 2.56, 95%CI = 1.36–3.76, P 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.

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.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.General hospital, specialized in bariatric surgery.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.Forty-seven patients were included. Total weight loss (%TWL) increased significantly from 12% to 30% after D-RYGB. In 62% of patients %TWL25% was achieved. Patients with %TWL25% 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.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 of200 cm will be considered.

BACKGROUND Bariatric surgery is an effective procedure for the treatment of obesity. Despite this, only 0.1% to 2% of eligible individuals undergo surgery worldwide. The stigma surrounding surgery might be a reason for this. Thus far, no research has systematically studied the nature and implications of bariatric surgery stigma. The limited studies on bariatric surgery stigma are often conducted from the perspective of the public or health care professions and either use small and nonrepresentative samples or fail to capture the full essence and implications of the stigma altogether, including attitudes toward patients and perpetrators of the stigma. In addition, studies from patients’ perspectives are limited and tend to address bariatric surgery stigma superficially or implicitly. Finally, the extent to which cultural factors shape and facilitate this stigma and the experiences of patients have not yet been researched. OBJECTIVE This study aimed to explore the perceptions, experiences, and consequences of bariatric surgery stigma from the perspective of the public, health care professionals, and patients before and after bariatric surgery. Furthermore, although the concept of stigma is universal, every society has specific cultural norms and values that define acceptable attributes and behaviors for its members. Therefore, this study also aimed to explore the extent to which cultural factors influence bariatric surgery stigma by comparing the Netherlands, France, and the United Kingdom. METHODS This paper describes the protocol for a multiphase mixed methods research design. In the first part, we will conduct a scoping review to determine the current knowledge on bariatric surgery stigma and identify knowledge gaps. In the second part, semistructured interviews among patients before and after bariatric surgery will be conducted to explore their experiences and consequences of bariatric surgery stigma. In the third part, surveys will be conducted among both the public and health care professionals to determine the prevalence, nature, and impact of bariatric surgery stigma. Surveys and interviews will be conducted in the Netherlands, France, and the United Kingdom. Finally, data integration will be conducted at the interpretation and reporting levels. RESULTS The study began in September 2020 and will continue through September 2025. With the results of the review, we will create an overview of the current knowledge regarding bariatric surgery stigma from patients’ perspectives. Qualitative data will provide insights into patients’ experiences with bariatric surgery stigma. Quantitative data will provide information related to the prevalence and nature of bariatric surgery stigma from the perspective of the public and health care professionals. Both qualitative and quantitative data will be compared for each country. CONCLUSIONS The findings from this study will lead to new insights that can be used to develop strategies to reduce bariatric surgery stigma and improve access, use, and outcomes of bariatric surgery. INTERNATIONAL REGISTERED REPORT PRR1-10.2196/36753

Purpose Lifelong daily multivitamin supplementation is highly recommended after sleeve gastrectomy (SG). Based on previous research, a specialized multivitamin supplement (MVS) for SG patients was developed and optimized (WLS Optimum 1.0 and 2.0). This study presents its mid-term effectives and compares micronutrient status of SG patients using this specialized MVS to users of standard MVS (sMVS) and non-users of multivitamin supplementation during the first three years post-surgery. Materials and Methods Of the 226 participants that were included at baseline, yearly follow-up blood tests were completed by 193 participants (85%) at 12 months, 176 participants (78%) at 24 months, and 140 participants (62%) at 36 months of follow-up. At each time point, participants were divided into four groups: (1) Optimum 1.0, (2) Optimum 2.0, (3) sMVS, and (4) non-users. Serum concentrations (linear mixed-effects models) and the prevalence of micronutrient deficiencies (chi-square tests) during follow-up were compared between the groups. Results Users of specialized MVS (Optimum 1.0 and 2.0) had higher serum concentrations of hemoglobin, folic acid, and vitamin D compared to sMVS users and non-users during follow-up. Serum concentrations of vitamin B12 and (corrected) calcium were also higher in specialized MVS users than in non-users. Overall, fewer deficiencies for folic acid and vitamin D were observed in the Optimum groups. Conclusion Although the perfect multivitamin supplement for all SG patients does not exist, WLS Optimum was more effective in sustaining normal serum concentrations than standard, over-the-counter supplementation. Non-users of MVS presented with most micronutrient deficiencies and will evidently develop poor nutritional status on the longer term. Graphical abstract

Contains fulltext : 249155.pdf (Publisher’s version ) (Open Access) Postbariatric loss of muscle tissue could negatively affect long-term health due to its role in various bodily processes, such as metabolism and functional capacity. This meta-analysis aimed to unravel time-dependent changes in the magnitude and progress of lean body mass (LBM), fat-free mass (FFM), and skeletal muscle mass (SMM) loss following bariatric surgery. A systematic literature search was conducted in Pubmed, Embase, and Web of Science. Fifty-nine studies assessed LBM (n = 37), FFM (n = 20), or SMM (n = 3) preoperatively and ≥1 time points postsurgery. Random-effects meta-analyses were performed to determine pooled loss per outcome parameter and follow-up time point. At 12-month postsurgery, pooled LBM loss was -8.13 kg [95%CI -9.01; -7.26]. FFM loss and SMM loss were -8.23 kg [95%CI -10.74; -5.73] and -3.18 kg [95%CI -5.64; -0.71], respectively. About 55% of 12-month LBM loss occurred within 3-month postsurgery, followed by a more gradual decrease up to 12 months. Similar patterns were seen for FFM and SMM. In conclusion, >8 kg of LBM and FFM loss was observed within 1-year postsurgery. LBM, FFM, and SMM were predominantly lost within 3-month postsurgery, highlighting that interventions to mitigate such losses should be implemented perioperatively. 01 januari 2022

Preoperative assessment of obstructive sleep apnea (OSA) in patients scheduled for bariatric surgery can be performed by in-laboratory polysomnography (PSG) or by portable polygraphy (PP) at home. We aimed to evaluate the association between PSG/PP, OSA diagnosis, and implementation of continuous positive airway pressure (CPAP) therapy.All patients who underwent bariatric surgery from 2015 to 2017 were retrospectively reviewed. Patients underwent preoperative PSG or PP, based on prevailing protocols or at the physician's discretion. Logistic regression analyses were performed to determine predictors of CPAP implementation. OSA-related postoperative complications were analyzed in both groups.During the study period, 1464 patients were included. OSA was diagnosed in 79% of 271 patients undergoing PSG, compared to 64% of 1193 patients undergoing PP (p 0.001), with median apnea-hypopnea index (AHI) of 15.8 and 7.7, respectively. CPAP treatment was initiated in 52% and 27% of patients, respectively, p 0.001. Predictors (with adjusted odds ratio) in multivariate regression analysis for CPAP implementation were as follows: male gender (5.15), BMI ≥ 50 (3.85), PSG test (2.74), hypertension (2.38), and age ≥ 50 (1.87). OSA-related complications did not differ between groups (p = 0.277).Both PSG and PP are feasible options for preoperative OSA assessment in bariatric patients. When PP is performed, some underdiagnosis may occur as cases of mild OSA may be missed. However, clinically relevant OSA is detected by both diagnostic tools. No difference in OSA-related complications was found. PP is a safe, less invasive option and can be considered as a suitable measure for OSA assessment in this population.

Pathogenic heterozygous MC4R variants are associated with hyperphagia and variable degrees of obesity. Several research groups have reported short-term weight loss outcomes after bariatric surgery in a few patients with MC4R variants, but lack of longer-term data prevents evidence-based clinical decision-making.Bariatric surgery patients with heterozygous (likely) pathogenic MC4R variants, from three collaborating centers in the Netherlands, France, and the UK, were compared to matched controls (matched 2:1 for age, sex, preoperative BMI, surgical procedure, and diabetes mellitus, but without MC4R mutations). Weight loss and regain outcomes up to 6 years of follow-up were compared.At 60 months of follow-up after RYGB, cases with MC4R variants showed weight regain with a mean of 12.8% (± 10.4 SD) total weight loss (TWL) from nadir, compared to 7.9% (± 10.5 SD) in the controls (p = 0.062). Among patients receiving SG, the cases with MC4R variants experienced inferior weight loss (22.6% TWL) during the first year of follow-up compared to the controls (29.9% TWL) (p = 0.010).This multicenter study reveals inferior mid-term weight outcomes of cases with MC4R variants after SG, compared to RYGB. Since adequate weight loss outcomes were observed after RYGB, this procedure would appear to be an appropriate surgical approach for this group. However, the pattern of weight regain seen in cases with MC4R variants after both RYGB and SG highlights the need for pro-active lifelong management to prevent relapse, as well as careful expectation management.

BackgroundCurrent studies mainly focus on total weight loss and comorbidity reduction. Only a few studies compare Quality of Life (QoL) after sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). This study was conducted to examine the extent of improvement in QoL on different domains after primary bariatric surgery and compare these results to Dutch reference values.MethodsThe study included prospectively collected data from patients who underwent primary bariatric surgery in five Dutch hospitals. The RAND-36 questionnaire was used to measure the patient’s QoL; preoperatively and twelve months postoperatively. Postoperative scores were compared to Dutch reference values, standardized for age, usingt-test. A difference of more than 5% was considered a minimal important difference. A multivariate linear regression analysis was used to compare SG and RYGB on the extent of improvement, adjusted for case-mix factors.ResultsIn total, 4864 patients completed both the pre- and postoperative questionnaire. Compared with Dutch reference values, patients postoperatively reported clinically relevant betterphysical functioning(RYGB + 6.8%),physical role limitations(SG + 5.6%; RYGB + 6.2%) andhealth change(SG + 77.1%; RYGB + 80.0%), but worsegeneral health perception(SG − 22.8%; RYGB − 17.0%). Improvement in QoL was similar between SG and RYGB, except forphysical functioning(β2.758;p-value 0.008) andgeneral health perception(β2.607;p-value ConclusionsSG and RYGB patients achieved a better postoperative score inphysical functioning,physical role limitationsandhealth change comparedto Dutch reference values, and a worse score ingeneral health perception.

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. 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. Four specialized bariatric hospitals in The Netherlands, Germany, and Switzerland. 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. 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. 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.

To define "best possible" outcomes for bariatric surgery (BS)(Roux-en-Y gastric bypass [RYGB] and sleeve gastrectomy [SG]).Reference values for optimal surgical outcomes in well-defined low-risk bariatric patients have not been established so far. Consequently, outcome comparison across centers and over time is impeded by heterogeneity in case-mix.Out of 39,424 elective BS performed in 19 high-volume academic centers from 3 continents between June 2012 and May 2017, we identified 4120 RYGB and 1457 SG low-risk cases defined by absence of previous abdominal surgery, concomitant procedures, diabetes mellitus, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, anticoagulation, BMI50 kg/m and age65 years. We chose clinically relevant endpoints covering the intra- and postoperative course. Complications were graded by severity using the comprehensive complication index. Benchmark values were defined as the 75th percentile of the participating centers' median values for respective quality indicators.Patients were mainly females (78%), aged 38±11 years, with a baseline BMI 40.8 ± 5.8 kg/m. Over 90 days, 7.2% of RYGB and 6.2% of SG patients presented at least 1 complication and no patients died (mortality in nonbenchmark cases: 0.06%). The most frequent reasons for readmission after 90-days following both procedures were symptomatic cholelithiasis and abdominal pain of unknown origin. Benchmark values for both RYGB and SG at 90-days postoperatively were 5.5% Clavien-Dindo grade ≥IIIa complication rate, 5.5% readmission rate, and comprehensive complication index ≤33.73 in the subgroup of patients presenting at least 1 grade ≥II complication.Benchmark cutoffs targeting perioperative outcomes in BS offer a new tool in surgical quality-metrics and may be implemented in quality-improvement cycle.ClinicalTrials.gov Identifier NCT03440138.

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. 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). 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. 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. 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.

Background: Severe protein malnutrition, with a serum albumin < 25 g/L, is one of the complications that may develop after bariatric surgery. It is associated with increased morbidity and mortality and requires timely diagnosis and appropriate treatment to prevent rapid clinical deterioration. However, evidence-based recommendations for a specific treatment approach are currently not available. The present study describes the efficacy of a newly developed treatment regimen for post-bariatric patients presenting with severe hypoalbuminemia. Methods: A single-centre, retrospective analysis of eleven post-bariatric patients presenting with severe hypoalbuminemia, treated with continuous 24 h nasal-jejunal tube feeding of a medium chain triglyceride (MCT) formulation in combination with pancreatic enzyme supplementation every 3 h. Results: Duration of tube feeding ranged from 25 to 156 days (median 64 days) and pancreatic enzyme was supplemented for 22–195 days (median 75 days). An increase in serum albumin levels of 5 g/L and 10 g/L was achieved after a median period of 20 (range 6–26 days) and 36 days (range 21–57 days), respectively. Albumin levels were > 35 g/L after a median period of 58 days (range 44–171 days). Conclusion: In this case series, a continuous 24-h nasal-jejunal MCT tube feed combined with frequent pancreatic enzyme supplementation was effective in all patients presenting with severe post-bariatric hypoalbuminemia and was not associated with adverse effects.

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. 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. 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. 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 AND OBJECTIVES It is unclear what time interval is optimal between presentation and surgical resection of left-sided obstructive colon cancer (LSOCC). This study aims to determine whether a time interval beyond 4 weeks is associated with a better outcome. MATERIALS AND METHODS Consecutive patients who underwent surgical resection of LSOCC between January 2010 and December 2019 were collected from a prospective database. Patients were divided into three groups: (1) Emergency resection (ER group), (2) surgery in less than 4 weeks (early group), and (3) surgery beyond 4 weeks (late group). RESULTS The ER group consisted of 74 (44.0%), the early group of 38 (22.6%), and the late group of 56 (33.3%) patients. Ninety-day mortality was lower in the Late group than in the ER group and the early group (1.8% vs. 12.2%, p = 0.029 vs. 15.3%, p = 0.011). In the late group 5-year recurrence-free survival was better than in the early group (82.1% vs. 63.2%, p = 0.039) and 5-year overall survival (OS) was better than in the ER group (75% vs. 51.4%, p = 0.021). Definitive surgical resection beyond 4 weeks was an independent prognostic factor for OS (Hazard ratio: 0.402, 95% CI: 0.204-0.793, p = 0.009). CONCLUSION In this study surgical resection beyond 4 weeks after presentation seems to have a better short- and long-term outcome for LSOCC.

Prevailing recommendations on reporting weight loss after bariatric and metabolic surgery are not evidence-based. They promote the outcome metric percentage excess weight loss (%EWL), sometimes indicated as percentage excess body mass index loss (%EBMIL). Many studies proved that this popular outcome measure, in contrast to other weight loss metrics, is inaccurate and error-sensitive when comparing weight loss within and between studies. It is inappropriate for assessing poor weight loss response and weight regain as well. The percentage (total) weight loss metric is the best alternative. The Dutch Society for Metabolic and Bariatric Surgery (DSMBS) recommends to stop using the %EWL (or %EBMIL) metric as primary outcome measure in all cases and calls on the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) to propagate this evidence-based recommendation.

Objective Management of poor response and of long-term complications after bariatric surgery (BS) is complex and under-investigated. Indications and types of reoperations vary widely and postoperative complication rates are higher compared to primary BS. Benchmarking uses best performance in a given field as reference point for improvement. Our aim was to define ‘‘best possible’’ outcomes for elective secondary BS. Methods The establishment of benchmarks in secondary BS followed a standardized methodology, based on recommendations of a Delphi consensus panel of experts. This multicenter study analyzed patients undergoing elective secondary BS in 18 high-volume centers on 4 continents from 06/2013 to 05/2019. Twenty-one outcome benchmarks were established in low-risk patients, defined as the 75th percentile of the median outcome values of the centers. Benchmark cases had no: previous laparotomy, diabetes, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, history of thromboembolic events, BMI>50kg/m2 or age>65 years. Descriptive statistics, multivariate logistic regression and data visualization were performed using the R software. Results Out of 44’884 elective bariatric procedures performed in the participating centers, 5’328 secondary BS cases were identified. The benchmark cohort included 3143 cases, mainly females (85%), aged 43.8±10 years, 8.4±5.3 years after primary BS, with a body mass index 35.2±7kg/m2. Main indications were insufficient weight loss (43%) and gastro-esophageal reflux disease/dysphagia (25%). 90-days postoperatively, 14.57% of benchmark patients presented ≥1 complication, mortality was 0.06% (n = 2). Significantly higher morbidity was observed in non-benchmark cases (OR 1.36) and after conversional or revisional procedures with gastrointestinal suture/stapling (OR 1.7). Benchmark cutoffs at 90-days postoperatively were ≤5.8% re-intervention and ≤8.8% re-operation rate. At 2-years (IQR 1-3) 15.6% of benchmark patients required a reoperation. Conclusion Secondary BS is safe, although postoperative morbidity exceeds the established benchmarks for primary BS. The excess morbidity is due to an increased risk of gastrointestinal leakage and higher need for intensive care. The considerable rate of tertiary BS warrants expertise and future research to optimize the management of non-success after BS.

Background Although the sleeve gastrectomy (SG) has good short-term results, it comes with a significant number of patients requiring revisional surgery because of insufficient weight loss or functional complications. Objective To investigate the effectiveness of the single anastomosis duodenoileal bypass (SADI-S) versus the Roux-en-Y gastric bypass (RYGB) on health outcomes in (morbidly) obese patients who had previously undergone SG, with up to 5 years of follow-up. Methods Data from patients who underwent revisional SADI-S or RYGB after SG were retrospectively compared on indication of surgery, weight loss, quality of life, micronutrient deficiencies, and complications. Results From 2007 to 2017, 141 patients received revisional laparoscopic surgery after SG in three specialized Dutch bariatric hospitals (SADI-S n=63, RYGB n=78). Percentage total weight loss following revisional surgery at 1, 2, 3, 4, and 5 years was 22%, 24%, 22%, 18%, and 15% for SADI-S and 10%, 9%, 7%, 8%, and 2% for RYGB (P Conclusion Conversion of SG to SADI-S leads to significantly more total weight loss compared to RYGB surgery with no difference in quality of life scores, complication rates, or micronutrient deficiencies. When GERD in sleeve patients has to be resolved, RYGB provides adequate outcomes. Graphical abstract

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

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

Background Inguinal hernia repair, gallbladder removal, and knee- and hip replacements are the most commonly performed surgical procedures, but all are subject to practice variation and variable patient-reported outcomes. Shared decision-making (SDM) has the potential to reduce surgery rates and increase patient satisfaction. This study aims to evaluate the effectiveness of an SDM strategy with online decision aids for surgical and orthopaedic practice in terms of impact on surgery rates, patient-reported outcomes, and cost-effectiveness. Methods The E-valuAID-study is designed as a multicentre, non-randomized stepped-wedge study in patients with an inguinal hernia, gallstones, knee or hip osteoarthritis in six surgical and six orthopaedic departments. The primary outcome is the surgery rate before and after implementation of the SDM strategy. Secondary outcomes are patient-reported outcomes and cost-effectiveness. Patients in the usual care cluster prior to implementation of the SDM strategy will be treated in accordance with the best available clinical evidence, physician’s knowledge and preference and the patient’s preference. The intervention consists of the implementation of the SDM strategy and provision of disease-specific online decision aids. Decision aids will be provided to the patients before the consultation in which treatment decision is made. During this consultation, treatment preferences are discussed, and the final treatment decision is confirmed. Surgery rates will be extracted from hospital files. Secondary outcomes will be evaluated using questionnaires, at baseline, 3 and 6 months. Discussion The E-valuAID-study will examine the cost-effectiveness of an SDM strategy with online decision aids in patients with an inguinal hernia, gallstones, knee or hip osteoarthritis. This study will show whether decision aids reduce operation rates while improving patient-reported outcomes. We hypothesize that the SDM strategy will lead to lower surgery rates, better patient-reported outcomes, and be cost-effective. Trial registration: The Netherlands Trial Register, Trial NL8318, registered 22 January 2020. URL: https://www.trialregister.nl/trial/8318.

Purpose Current guidelines recommend to avoid pregnancy for 12–24 months after bariatric surgery because of active weight loss and an increased risk of nutritional deficiencies. However, high-quality evidence is lacking, and only a few studies included data on gestational weight gain. We therefore evaluated pregnancy and neonatal outcomes by both surgery-to-conception interval and gestational weight gain. Materials and Methods A multicenter retrospective analysis of 196 singleton pregnancies following Roux-en-Y gastric bypass, sleeve gastrectomy, and one anastomosis gastric bypass was conducted. Pregnancies were divided into the early group (≤ 12 months), the middle group (12–24 months), and the late group (> 24 months) according to the surgery-to-conception interval. Gestational weight gain was classified as inadequate, adequate, or excessive according to the National Academy of Medicine recommendations. Results Pregnancy in the early group (23.5%) was associated with lower gestational age at delivery (267.1 ± 19.9 days vs 272.7 ± 9.2 and 273.1 ± 13.5 days, P = 0.029), lower gestational weight gain (− 0.9 ± 11.0 kg vs + 10.2 ± 5.6 and + 10.0 ± 6.4 kg, P P = 0.008) than pregnancy in the middle and late group. Inadequate gestational weight gain (40.6%) was associated with lower gestational age at delivery (266.5 ± 20.2 days vs 273.8 ± 8.4 days, P = 0.002) and lower neonatal birth weight (3061 ± 511 g vs 3217 ± 479 g, P = 0.053) compared to adequate weight gain. Preterm births were also more frequently observed in this group (15.9% vs 6.0%, P = 0.037). Conclusion Our findings support the recommendation to avoid pregnancy for 12 months after bariatric surgery. Specific attention is needed on achieving adequate gestational weight gain.