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Background: Bariatric surgery is increasingly performed in women of reproductive age. As bariatric surgery will result in postoperative rapid catabolic weight loss which potentially leads to fetal malnutrition and directly related impaired intra-uterine growth, it is advised to postpone pregnancy for at least 12-18 months after surgery., Objectives: To investigate the consequences of preconception gastric bypass surgery (pGB) on fetal growth parameters and maternal pregnancy outcome., Setting: Maasstad Hospital, The Netherlands, general hospital and Erasmus Medical Center, The Netherlands, university hospital., Methods: We included 97 pGB pregnancies (Maasstad hospital) and 440 non-bariatric pregnancies (Rotterdam Periconception cohort, Erasmus Medical Center). Longitudinal second and third trimester fetal growth parameters (head circumference, biparietal diameter, femur length, abdominal circumference, estimated fetal weight) were analyzed using linear mixed models, adjusting for covariates and possible confounders. Fetal growth and birthweight in pGB pregnancies were compared to non-bariatric pregnancies and Dutch reference curves. Maternal pregnancy outcome in the pGB group was compared to non-bariatric pregnancies., Results: All fetal growth parameters of pGB pregnancies were significantly decreased at 20 weeks' gestation (P < .001) and throughout the remaining part of pregnancy (P < .05) compared with non-bariatric pregnancies (crude and adjusted models). In our cohort, gestational weight gain was not significantly associated with birthweight corrected for gestational age. Birthweight was significantly lower in pGB pregnancies (estimate -241 grams [95% CI, -342.7 to -140.0]) with a 2-fold increased risk of small-for-gestational-age (SGA) (adjusted odds ratio 2.053 [95% CI, 1.058 to 3.872]). Compared to the non-bariatric pregnancies, we found no significant differences in maternal pregnancy outcome., Conclusions: PGB is associated with overall reduced fetal growth trajectories and a 2-fold increased risk of SGA, without significant adverse consequences for maternal pregnancy outcome. We recommend close monitoring of fetal growth after pGB., (Copyright © 2024 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Protein malnutrition after bariatric surgery is a severe complication and leads to significant morbidity. Previous studies have shown that protein intake and physical activity are the most important factors in the preservation of fat-free mass during weight loss. Low protein intake is very common in patients undergoing bariatric surgery despite dietary counseling. Protein powder supplements might help patients to achieve the protein intake recommendations after bariatric surgery and could therefore contribute to preserve fat-free mass. This double-blind randomized placebo-controlled intervention study aims to assess the effect of a daily consumed clear protein powder shake during the first 6 months after bariatric surgery on fat-free mass loss in the first 12 months after laparoscopic Roux-en-Y gastric bypass (LRYGB)., Methods and Analysis: Inclusion will take place at the outpatient clinic of the bariatric expertise center for obesity of the Maasstad Hospital. Patients will be randomly assigned to either the intervention or control group before surgery. The intervention group will receive a clear protein powder shake of 200 ml containing 20 g of whey protein dissolved in water which should be taken daily during the first 6 months after LRYGB on top of their normal postoperative diet. The control group will receive an isocaloric, clear, placebo shake containing maltodextrine. Postoperative rehabilitation and physiotherapeutical guidance will be standardized and similar in both groups. Also, both groups will receive the same dietary advice from specialized dieticians. The main study parameter is the percentage of fat-free mass loss 6 months after surgery, assessed by multi-frequency bioelectrical impedance analysis (MF-BIA)., Ethics and Dissemination: The protocol, version 2 (February 20, 2022) has been approved by the Medical Research Ethics Committees United (MEC-U) (NL 80414.100.22). The results of this study will be submitted to peer-reviewed journals., Trial Registration: ClinicalTrials.gov NCT05570474. Registered on October 5, 2022., (© 2023. The Author(s).)

Background: Obesity is becoming more prevalent in the end-stage renal disease population. Bariatric surgery (BS) is increasingly considered as an approach to become eligible for kidney transplant (KT) or reduce obesity-related morbidities., Objectives: To assess the short- and long-term outcomes of patients who underwent both BS and KT and to determine the optimal timing of BS., Methods: Patients who underwent both KT and BS between January 2000 and December 2020 were included and stratified according to the sequence of the 2 operations. The primary outcomes were patient and graft survival. The secondary outcomes were postoperative complications and efficacy of weight loss., Results: Twenty-two patients were included in the KT first group and 34 in the BS first group. Death-uncensored graft survival in the KT first group was significantly higher than in the BS first group (90.9% versus 71.4%, P = .009), without significant difference in patient survival and death-censored graft survival (100% versus 90.5%, P = .082; 90.9% versus 81.0%, P = .058). There was no significant difference in 1-year total weight loss (1-yr TWL: median [interquartile range {IQR}], 36.0 [28.0-42.0] kg versus 29.6 [21.5-40.6] kg, P = .424), 1-year percentage of excess weight loss (1-yr %EWL: median [IQR], 74.9 [54.1-99.0] versus 57.9 [47.5-79.4], P = .155), and the incidence of postoperative complications (36.4% versus 50.0%, P = .316) between the KT first and BS first groups., Conclusion: Both pre- and posttransplant BS are effective and safe. Different conditions of each transplant candidate should be considered in detail to determine the optimal timing of BS., (Copyright © 2023 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Metabolic syndrome is a modern world's major health hazard related to comorbidities like type 2 diabetes and cardiovascular disease. Bariatric surgery is well known to lower this health risk in patients with obesity. There is a need for an objective measure to assess the intended reduction in health hazard and indirectly the eligibility for bariatric surgery. The Metabolic Health Index (MHI) quantitatively summarizes the cumulative impact of the metabolic syndrome on health status on a scale from 1 to 6. This study describes the use of the MHI as a supportive tool in the decision for and outcome assessment of bariatric surgery., Methods: The general usability of the MHI was tested by extending its application to patient data of five other bariatric centers in the Netherlands. Retrospective laboratory and national bariatric quality registry data of 11,501 patients were collected., Results: The quantification of (improvement in) metabolic health burden as measured by the MHI was independent of the dataset that was used to derive the MHI model. Patients with MHI > 2.8 prior to surgery improved significantly more in MHI 12 mo after surgery compared to patients with MHI ≤ 2.8 (1.1 compared to 0.4 MHI points, respectively; P < 0.001)., Conclusions: The MHI is robust between centers and is suitable for general use in clinical decision-making. As changes in MHI over time reflect metabolic health alterations, it is suitable as an outcome measure of surgery. An MHI cut-off value of 2.8 helps to predict the likelihood of significant improvement after surgery, independent of body mass index and known metabolic comorbidities., (Copyright © 2022. Published by Elsevier Inc.)

Purpose: Subclinical cardiac dysfunction is common in patients with obesity. Bariatric surgery is associated with normalization of subclinical cardiac function in 50% of the patients with obesity. The aim of this study was to identify predictors for a lack of improvement of subclinical cardiac dysfunction 1-year post-bariatric surgery., Methods: Patients who were referred for bariatric surgery were enrolled in a longitudinal study. Inclusion criteria were age 35-65 years and BMI ≥ 35 kg/m 2 . Patients with a suspicion of or known cardiovascular disease were excluded. Conventional and advanced echocardiography, Holter monitoring, and blood tests were performed pre- and 1-year post-bariatric surgery. Subclinical cardiac dysfunction was defined as either a reduced left ventricular ejection fraction, decreased global longitudinal strain (GLS), diastolic dysfunction, arrhythmia, or an increased BNP or hs Troponin I., Results: A total of 99 patients were included of whom 59 patients had cardiac dysfunction at baseline. Seventy-two patients completed the 1-year follow-up after bariatric surgery. There was a significant reduction in weight and cardiovascular risk factors. Parameters of cardiac function, such as GLS, improved. However, in 20 patients cardiac dysfunction persisted. Multivariate analysis identified a decreased heart rate variability (which is a measure of autonomic function), and a decreased vitamin D pre-surgery as predictors for subclinical cardiac dysfunction after bariatric surgery., Conclusion: Although there was an overall improvement of cardiac function 1-year post-bariatric surgery, autonomic dysfunction and a decreased vitamin D pre-bariatric surgery were predictors for a lack of improvement of subclinical cardiac dysfunction., (© 2022. The Author(s).)

Morbid obesity is associated with a chronic state of low-grade inflammation, which may lead to accelerated differentiation of T and B cells. These differentiated immune cells are strongly cytotoxic and have an increased pro-inflammatory cytokine producing capacity. Furthermore, the anti-inflammatory function of the T and B cells decreases. The aim of this study was to evaluate the effect of morbid obesity on the subset profile and cytokine producing capacity of T and B cells. Subsequently, we assessed whether bariatric surgery affected the subset profile and cytokine producing capacity of these cells. We determined the proportion of T and B cell subsets and their cytokine producing capacity in peripheral blood collected from 23 morbidly obese patients before and three months after bariatric surgery using flow-cytometry. We compared this with the results of 25 lean controls. Both CD4+ and CD8+ T cells showed a more differentiated subset profile in morbidly obese patients as compared to lean controls, which was not recovered three months after bariatric surgery. The B cell composition of morbidly obese patients after bariatric surgery adjusted towards the profile of lean controls. However, the IL-2 and IFN-γ producing capacity of CD8+ T cells and the IL-2, IFN-γ, TNF-α and IL-10 producing capacity of B cells was not restored three months after bariatric surgery. In conclusion, the data suggest that the immune system has the capacity to recover from the detrimental effects of morbid obesity within three months after bariatric surgery in terms of cell composition; however, this was not seen in terms of cytokine producing capacity. The full restoration of the immune system after bariatric surgery may thus take longer., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Wijngaarden, Taselaar, Nuijten, Harst, Klaassen, Kuijper, Jongbloed, Ambagtsheer, Klepper, IJzermans, de Bruin and Litjens.)

Background: Insufficient weight loss or weight regain has many causes including a large gastric pouch. A large gastric pouch may be due to the surgical technique or can be patient related (dilation). Resizing the gastric pouch may lead to additional weight loss. Currently, there is no gold standard for the revisional surgical technique. Therefore this study was performed to determine which surgical technique for revisional bariatric surgery (BS) has superior outcomes in terms of weight loss: sleeve resection of the gastrojejunostomy and gastric pouch (SGP), or resection of the gastrojejunostomy with resizing of the pouch and creation of a new anastomosis (RGJ)., Methods: All patients who underwent revisional BS for insufficient weight loss or weight regain as a result of an enlarged pouch after LRYGB from April 2014 to June 2018 in our hospitals were included in this observational cohort study. Outcomes were measured in percentage total weight loss (%TWL)., Results: A total of 37 patients who underwent SGP and 21 patients who underwent RGJ as revisional BS were included in this study. The median body mass index before revisional BS was 37.6 kg/m 2 versus 35.7 kg/m 2 (SGP vs RGJ, respectively, P = 0.115). There was no significant difference in %TWL between the two cohorts 1 and 2 years after revisional BS, respectively; SGP 14.5% vs RGJ 11.0%, P = 0.885 and SGP 12.3% vs RGJ 10.8%, P = 0.604. Comparing %TWL based on weight at LRYGB, there was also no significant difference two years after revisional BS (SGP 22.0% vs RGJ 22.2%, P = 0.885). The average use of surgical disposables for the SGP technique were lower compared to the RGJ technique., Conclusions: Resizing a large pouch leads to additional weight loss. Both techniques have comparable outcomes in terms of weight loss. However, based on average surgical costs, the SGP technique may be preferable., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: The worldwide obesity epidemic has resulted in a rise of bariatric surgery in women of reproductive age, which can lead to 'iatrogenic undernutrition'. Long-lasting undernutrition can affect maternal health, pregnancy outcomes and offspring. We hypothesise that embryonic and placental growth are impaired in pregnancies after bariatric surgery due to the changed nutritional and microbiome dynamics. Therefore, our aim is to conduct the Bariatrics and EmbrYONic Development (BEYOND) study to investigate parameters of maternal nutritional and health status after bariatric surgery, both periconceptionally and during pregnancy, particularly concentrating on embryonic and fetal growth trajectories as well as placental development., Methods and Analysis: We designed a single-centre prospective, observational cohort, which investigates the iatrogenic nutritional and health status of women after bariatric surgery, periconceptionally and during pregnancy. The BEYOND study is embedded in the Rotterdam Periconceptional Cohort, a tertiary hospital-based birth cohort study. Eligible participants are women planning pregnancy or <12+0 weeks pregnant, ≥18 and ≤45 years of age, who have undergone bariatric surgery (cases) or without prior bariatric surgery (controls) and their male partners. Medical charts will be reviewed and questionnaires regarding general health, lifestyle and food intake will be collected. Moreover, we will perform serial three-dimensional ultrasounds to assess embryonic growth and placental development and two-dimensional ultrasounds for fetal growth assessment. The microbiome, including the virome, and blood samples will be sampled during the preconception period and in each trimester. Multivariable linear mixed model analyses will be used to assess the associations between bariatric surgery and pregnancy outcomes., Ethics and Dissemination: This proposal was approved by the Medical Ethics Committee from the Erasmus MC, Rotterdam, The Netherlands. Study results will be submitted for publication in high-impact journals, presented at scientific conferences, implemented into guidelines and communicated through the Erasmus MC and collaborating partners., Trial Registration Number: NL8217 (www.trialregister.nl)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Morbid obesity is characterized by chronic, low-grade inflammation, which is associated with 'inflamm-aging'. The presence of metabolic syndrome (MetS) might accelerate this phenomenon of metaflammation. In this study, we assessed the effects of morbid obesity and MetS on the composition of a broad spectrum of immune cells present within the circulation. A total of 117 morbidly obese patients (MOP) without MetS (MetS-), 127 MOP with MetS (MetS+) and 55 lean controls (LC) were included in this study. Absolute numbers of T cell, B cell, NK cell and monocyte subsets were assessed within peripheral blood using flow cytometry. Both absolute cell numbers and proportion of cells were evaluated correcting for covariates age, body mass index and cytomegalovirus serostatus. Although the absolute number of circulating CD4+ T cells was increased in the MetS+ group, the CD4+ T cell composition was not influenced by MetS. The CD8+ T cell and B cell compartment contained more differentiated cells in the MOP, but was not affected by MetS. Even though the absolute numbers of NK cells and monocytes were increased in the MOP as compared to LC, there was no difference in proportions of NK and monocyte subsets between the three study groups. In conclusion, although absolute numbers of CD4+ and CD8+ T cells, B cells, NK cells and monocytes are increased in MOP, obesity-induced effects of the composition of the immune system are confined to a more differentiated phenotype of CD8+ T cells and B cells. These results were not affected by MetS., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Wijngaarden, van der Harst, Klaassen, Dunkelgrun, Kuijper, Klepper, Ambagtsheer, IJzermans, de Bruin and Litjens.)

Patients with class II and III obesity and end-stage renal disease are often ineligible for kidney transplantation (KTx) due to increased postoperative complications and technically challenging surgery. Bariatric surgery (BS) can be an effective solution for KTx candidates who are considered inoperable. The aim of this study is to evaluate outcomes of KTx after BS and to compare the outcomes to obese recipients (BMI ≥ 35 kg/m 2 ) without BS. This retrospective, single-center study included patients who received KTx after BS between January 1994 and December 2018. The primary outcome was postoperative complications. The secondary outcomes were graft and patient survival. In total, 156 patients were included, of whom 23 underwent BS prior to KTx. There were no significant differences in postoperative complications. After a median follow-up of 5.1 years, death-censored graft survival, uncensored graft survival, and patient survival were similar to controls (log rank test p = .845, .659, and .704, respectively). Dialysis pre-transplantation (Hazard Ratio (HR) 2.55; 95%CI 1.03-6.34, p = .043) and diabetes (HR 2.41; 95%CI 1.11-5.22, p = .027) were independent risk factors for all-cause mortality. A kidney from a deceased donor was an independent risk factor for death-censored graft loss (HR 1.98; 95%CI 1.04-3.79, p = .038). Patients who received a KTx after BS have similar outcomes as obese transplant recipients., (© 2021 The Authors. Clinical Transplantation published by John Wiley & Sons Ltd.)

Background: Although early results of bariatric surgery are beneficial for most patients, some patients regain weight later. Cognitive behavioral therapy (CBT) has been suggested as a way to improve patients' psychological health and maintaining weight loss in the longer term. The added value of preoperative CBT to bariatric surgery was examined. Pre- and posttreatment and 1-year follow-up data are presented., Methods: In a multi-center randomized controlled trial, CBT was compared to a treatment-as-usual (TAU) control group. Measurements were conducted pre- and posttreatment/pre-surgery (T0 and T1) and at 1-year post-surgery (T2). Patients in the intervention group received 10 individual, weekly sessions of preoperative CBT focused on modifying thoughts and behaviors regarding eating behavior, physical exercise, and postoperative life style. Outcome measures included weight change, eating behavior, eating disorders, depression, quality of life, and overall psychological health., Results: Though no significant differences between conditions were found per time point, in the CBT, condition scores on external eating, emotional eating, depressive symptoms, and psychological distress decreased significantly more over time between pre- (T0) and posttreatment (T1) pre-surgery compared to TAU. No significant time x condition differences were found at 1-year post-surgery (T2)., Conclusions: Compared to TAU, preoperative CBT showed beneficial effects on eating behavior and psychological symptoms only from pretreatment to posttreatment/pre-surgery, but not from pre-surgery to 1-year post-surgery. Preoperative CBT does not seem to contribute to better long-term outcomes post-surgery. Recent studies suggest that the optimal time to initiate psychological treatment may be early in the postoperative period, before significant weight regain has occurred., Trial Registration: https://www.trialregister.nl Identifier: Trial NL3960.

Aims: Obesity doubles the lifetime risk of developing heart failure. Current knowledge on the role of obesity in causing cardiac dysfunction is insufficient for optimal risk stratification. The aim of this study was first to estimate the prevalence of subclinical cardiac dysfunction in obesity patients and second to investigate the underlying pathophysiology., Methods and Results: The CARDIOBESE study is a cross-sectional multicentre study of 100 obesity patients [body mass index (BMI) ≥ 35 kg/m 2 ] without known cardiovascular disease and 50 age-matched and gender-matched non-obese controls (BMI ≤ 30 kg/m 2 ). Echocardiography was performed, blood samples were collected, and a Holter monitor was affixed. Fifty-nine obesity patients [48 (42-50) years, 70% female] showed subclinical cardiac dysfunction: 57 patients had decreased global longitudinal strain (GLS), and two patients with normal GLS had either diastolic dysfunction or increased brain natriuretic peptide (BNP). Only one non-obese control had diastolic dysfunction, and none had another sign of cardiac dysfunction. Multivariable logistic analysis identified male gender and standard deviation of all NN intervals (SDNN) index, which is a measure of autonomic dysfunction, as independent significant risk factors for subclinical cardiac dysfunction in obesity patients., Conclusions: There was a high prevalence (61%) of subclinical cardiac dysfunction in obesity patients without known cardiovascular disease, which appeared to be best identified by GLS. Subclinical cardiac dysfunction in obesity was linked to autonomic dysfunction and male gender, and not to the presence of traditional cardiac risk factors, increased C-reactive protein, increased BNP, increased high-sensitivity troponin I, or increased left ventricular mass., (© 2020 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of the European Society of Cardiology.)

Purpose: Metabolic syndrome in patients with morbid obesity causes a higher cardiovascular morbidity, eventually leading to left ventricular hypertrophy and decreased left ventricular ejection fraction (LVEF). Roux-en-Y gastric bypass (RYGB) is considered the gold standard modality for treatment of morbid obesity and might even lead to improved cardiac function. Our objective is to investigate whether cardiac function in patients with morbid obesity improves after RYGB., Materials and Methods: In this single center pilot study, 15 patients with an uneventful cardiac history who underwent RYGB were included from May 2015 to March 2016. Cardiac function was measured by cardiac magnetic resonance imaging (CMRI), performed preoperatively and 3, 6, and 12 months postoperative. LVEF and myocardial mass and cardiac output were measured., Results: A total of 13 patients without decreased LVEF preoperative completed follow-up (mean age 37, 48.0 ± 8.8). There was a significant decrease of cardiac output 12 months postoperative (8.3 ± 1.8 preoperative vs. 6.8 ± 1.8 after 12 months, P = 0.001). Average myocardial mass declined by 15.2% (P < 0.001). After correction for body surface area (BSA), this appeared to be non-significant (P = 0.36). There was a significant improvement of LVEF/BSA at 6 and 12 months postoperative (26.2 ± 4.1 preoperative vs. 28.4 ± 3.4 and 29.2 ± 3.6 respectively, both P = 0.002). Additionally, there was a significant improvement of stroke volume/BSA 12 months after surgery (45.8 ± 8.0 vs. 51.9 ± 10.7, P = 0.033)., Conclusion: RYGB in patients with morbid obesity with uneventful history of cardiac disease leads to improvement of cardiac function.

Background: Obesity adversely affects health and is associated with subclinical systemic inflammation and features of accelerated aging, including the T-cell immune system. The presence of metabolic syndrome (MetS) may accelerate, while bariatric surgery might reverse these phenomena. To examine the effects of MetS and bariatric surgery on T-cell aging, we measured relative telomere length (RTL) and T-cell differentiation status in obese patients before and after bariatric surgery., Methods: WHO II/III classified obese patients scheduled for bariatric surgery were included: 41 without MetS and 67 with MetS. RTL and T-cell differentiation status were measured in circulating CD4 + and CD8 + T cells via flow cytometry. T-cell characteristics were compared between patients with and without MetS prior to and at 3, 6, and 12 months after surgery considering effects of age, cytomegalovirus-serostatus, and weight loss., Results: Thymic output, represented by numbers of CD31-expressing naive T cells, showed an age-related decline in patients with MetS. MetS significantly enhanced CD8 + T-cell differentiation. Patients with MetS had significant lower CD4 + RTL than patients without MetS. Within the first 6 months after bariatric surgery, RTL increased in CD4 + T cells after which it decreased at month 12. A decline in both thymic output and more differentiated T cells was seen following bariatric surgery, more pronounced in the MetS group and showing an association with percentage of body weight loss., Conclusions: In obese patients, MetS results in attrition of RTL and accelerated T-cell differentiation. Bariatric surgery temporarily reverses these effects. These data suggest that MetS is a risk factor for accelerated aging of T cells and that MetS should be a more prominent factor in the decision making for eligibility for bariatric surgery.

Introduction: In view of the increasing occurrence of both obesity and heart failure, a growing overlap of these two clinical entities in the near future is expected. Significant advances in our understanding of the pathophysiological consequences of obesity for the cardiovascular system have been made over the past two decades. However, to optimise management and treatment of obesity patients, further research is required to improve early identification of cardiac dysfunction in obesity and to gain insight in the underlying pathophysiology. The CARdiac Dysfunction In OBesity - Early Signs Evaluation (CARDIOBESE) study has been designed to address these issues., Methods and Analysis: CARDIOBESE is a cross-sectional multicentre study of 100 obesity patients scheduled for bariatric surgery (body mass index (BMI) ≥35 kg/m 2 ) without known cardiovascular disease, and 50 age-matched and gender-matched non-obese controls (BMI <30 kg/m 2 ). Echocardiography, blood and urine biomarkers and Holter monitoring will be used to identify parameters that are able to show cardiac dysfunction at a very early stage in obesity patients ( primary objective ). Furthermore, a prospective follow-up study of obesity patients before and 1 year after bariatric surgery will be done to gain insight in the pathophysiology of obesity causing cardiac dysfunction ( secondary objective )., Ethics and Dissemination: The study was approved by the Medical Ethics Committee Toetsingscommissie Wetenschappelijk Onderzoek Rotterdam e.o. (TWOR). Inclusion of patients and controls is almost complete. Analyses of the investigations are currently being performed, and dissemination through peer-reviewed publications and conference presentations is expected from the first quarter of 2019. By identifying early markers of cardiac dysfunction in obesity, and by understanding the underlying pathophysiology of the abnormalities of these markers, the CARDIOBESE study may provide guidance for risk stratification, monitoring and treatment strategies for obesity patients., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Tranexamic acid reduces blood loss associated with various surgical procedures. Postoperative bleeding caused by dissection or bleeding of the enteric staple lines is a well-known complication following bariatric surgery. Reoperation in order to restore hemostasis is frequently necessary (up to 2.5% in literature). The effect of conservative therapy using tranexamic acid for postoperative hemorrhage after bariatric surgery is still very much a novel technique. The aim is to present our results (reoperation rate and thrombo-embolic complication rate) of tranexamic acid therapy for postoperative bleeding after bariatric surgery in comparison to those in existing literature., Methods: We retrospectively reviewed 1388 patients who underwent bariatric surgery (laparoscopic gastric bypass or laparoscopic gastric sleeve). Use of tranexamic acid, reoperation rate, transfusion rate and rate of thrombo-embolic complications were reviewed., Results: Forty-five of 1388 (3.2%) total patients experienced significant hemorrhage after bariatric surgery. Tranexamic acid was administered in 44 of these patients. A failure of the treatment with tranexamic acid was observed in four patients. The incidence of reoperation was 0.4% for the entire population. No thrombo-embolic complications were registered for patients receiving tranexamic acid., Conclusion: These findings suggest that the administration of tranexamic acid appears to be safe in reducing the reoperation rate for bleeding after bariatric surgery., Competing Interests: Collection of data was performed with the approval of the Institutional Review Board: “Toetsingscommissie Onderzoek Rotterdam, (TWOR)”.Not applicableThe authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background: Internal herniation (IH) is one of the most common long-term complications after laparoscopic Roux-en-Y gastric bypass (LRYGB). Diagnosis of IH may be difficult, and not all patients with suspected IH will have full relief of symptoms after closure of both mesenteric defects., Objectives: To investigate possible predictive factors for relief of symptoms in patients with suspected IH., Methods: All patients that underwent reoperation for (suspected) IH after LRYGB from June 2009 to December 2016 were retrospectively evaluated in this multicentre cohort study. Logistic regression analysis was used to identify predictive factors for pain relief after closure of the mesenteric defects., Results: A total of 193 patients underwent laparoscopy for (suspected) IH during the study period. The median interval between LRYGB and reoperation was 18.3 ± 19.0 months. In 40.2% of cases, IH was identified on computed tomography (CT), and IH was objectified during surgery in 61.1%. Postoperative symptom relief was observed in 146 patients (77.2%). For patients in which IH was present during surgery, 82.8% had relief of pain postoperatively, as compared to 68.5% for those procedures in which no IH was found. The only significant predictor for postoperative pain relief was a swirl sign on CT (OR 4.24, 95%CI 1.63-11.05)., Conclusions: Pain relief after closure of the mesenteric defects for IH remains unpredictable. A positive CT for IH was a predictive factor for symptom relief after reoperation for (suspected) IH after LRYGB. However, many patients benefit from closure of the mesenteric defects, irrespective of perioperative presence of IH.

Frederik H. W. Jonker and Vera A. A. van Houten contributed equally to this work.

Background: Carotid intima-media thickness (CIMT) is increasingly used as a prognostic indicator for early atherosclerosis and the development of cardiovascular disease. The objective of this study is to assess the exact effects of bariatric surgery on CIMT reduction in different age groups., Methods: CIMT was measured just proximal to the bifurcation of the carotid artery in 166 patients with mean body mass index of 43.4 kg/m 2 before and at 6 and 12 months after bariatric surgery. Preoperative CIMT and Framingham Risk Score (FRS) were compared to measurements at 6 and 12 months, postoperatively. Impact of age on CIMT change and cardiovascular risk reduction was analyzed., Results: Median follow-up was 12 months; 12% were lost to follow-up. Mean CIMT values at 12 months after bariatric surgery were significantly lower compared to baseline (0.619 vs. 0.587 mm, p = 0.005 in women and 0.675 vs. 0.622 mm, p = 0.037 in men, respectively), and these effects were statistically significant in all age groups. The mean reduction of CIMT for patients < 50 years at 12 months was 0.043 mm (- 7.0%), while CIMT was reduced with 0.013 mm for patients ≥ 50 years (- 1.9%, p = 0.022). At 12 months after bariatric surgery, FRS had decreased with 52% in patients < 50 years as compared with 35% in patients ≥ 50 years (p = 0.025)., Conclusions: Bariatric surgery resulted in a significant CIMT decrease in patients with morbid obesity in all evaluated age categories. These beneficial effects of bariatric surgery were more pronounced in younger patients, while cardiovascular risk reduction by bariatric surgery appeared inferior in patients of 50 years and older.

The aim of the study was to systematically review the patient reported and functional outcomes of treatment for extra-articular proximal or middle phalangeal fractures of the hand in order to determine the best treatment options. The review methodology was registered with PROSPERO. A systematic literature search was conducted in electronic bibliographic databases. Two independent reviewers performed screening and data extraction. The evaluation of quality of the included studies was performed using the Structured Effectiveness Quality Evaluation scale. The initial search yielded 2354 studies. The full text manuscripts of 79 studies were evaluated of which 16 studies met the inclusion criteria. In total, 513 extra-articular proximal and middle phalangeal fractures of the hand were included of which 118 (23%) were treated non-operatively, 188 (37%) were treated by closed reduction internal fixation (CRIF) and 207 (40%) by open reduction internal fixation. It can be recommended that closed displaced extra-articular phalangeal fractures can be treated non-operatively, even fractures with an oblique or complex pattern, provided that closed reduction is possible and maintained. Conservative treatment is preferably performed with a cast/brace allowing free mobilization of the wrist. No definite conclusion could be drawn upon whether closed reduction with extra-articular K-wire pinning or transarticular pinning is superior; however, it might be suggested that extra-articular K-wire pinning is favoured. When open reduction is necessary for oblique or spiral extra-articular fractures, lag screw fixation is preferable to plate and screw fixation. But, similar recovery and functional results are achieved with transversally inserted K-wires compared to lag screw fixation., Type of Study/level of Evidence: therapeutic III.

Background: Failed laparoscopic adjustable gastric banding (LAGB) can be converted to laparoscopic Roux-and-Y gastric bypass (LRYGB), which is currently the gold standard for bariatric surgery. Revisional LRYGB (rLRYGB) is associated with inferior results compared with primary LRYGB (pLRYGB), but the exact influence of the initial response to LAGB is unclear., Objectives: To compare follow-up outcomes after pLRYGB with rLRYGB in nonresponders of LAGB and rLRYGB in responders of LAGB., Setting: General-community teaching hospital, Rotterdam, the Netherlands., Methods: All patients who underwent pLRYGB and rLRYGB after LAGB were reviewed in an observational study. Postoperative outcomes, excess weight loss, total weight loss, and success and failure rate were compared in patients after pLRYGB and rLRYGB (both responders and nonresponders of LAGB) at 12, 24, and 36 months., Results: A total of 1285 primary patients, 96 nonresponders, and 120 responders were included. The median follow-up was 33.9±18.0 months. After 36 months, the mean percentage excess weight loss was significantly lower in the nonresponding group compared with the responding and primary groups (48.1% versus 58.2% versus 72.8%, P<.001); the total weight loss showed the same trend. The success rate was 38.2% versus 61.0% versus 81.6% respectively, P<.001. The failure rate was significantly higher after rLRYGB compared with pLRYGB (10.9% nonresponders, 8.5% responders, and 2.5% primary, P = .001)., Conclusion: Nonresponders of LAGB show inferior weight loss results after rLRYGB compared with responders of LAGB and pLRYGB at all moments of follow-up., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Surgery-induced oxidative stress increases the risk of perioperative complications and delay in postoperative recovery. In mice, short-term preoperative dietary and protein restriction protect against oxidative stress. We investigated the feasibility of a calorie- and protein-restricted diet in two patient populations., Methods: In this pilot study, 30 live kidney donors and 38 morbidly obese patients awaiting surgery were randomized into three groups: a restricted diet group, who received a synthetic liquid diet with 30% fewer calories and 80% less protein for five consecutive days; a group who received a synthetic diet containing the daily energy requirements (DER); and a control group. Feasibility was assessed using self-reported discomfort, body weight changes, and metabolic parameters in blood samples., Results: Twenty patients (71%) complied with the restricted and 13 (65%) with the DER-diet. In total, 68% of the patients reported minor discomfort that resolved after normal eating resumed. The mean weight loss on the restricted diet was significantly greater (2.4 kg) than in the control group (0 kg, p = 0.002), but not in the DER-diet (1.5 kg). The restricted diet significantly reduced levels of serum urea and plasma prealbumin (PAB) and retinol binding protein (RBP)., Conclusions: A short-term preoperative calorie- and protein-restricted diet is feasible in kidney donors and morbidly obese patients. Compliance is high and can be objectively measured via changes in urea, PAB, and RBP levels. These results demonstrate that this diet can be used to study the effects of dietary restriction on surgery-induced oxidative stress in a clinical setting.

Several studies conducted in the USA have demonstrated that the effectiveness of bariatric surgery differs between patients from African and European origin. However, little is known on differences in outcomes after bariatric surgery between individuals from other ethnic backgrounds. In this retrospective study, we found that, in terms of weight loss, gastric bypass surgery is less effective in African, South Asian, Turkish and Moroccan patients than in their ethnic Dutch counterparts. Our results underscore that ethnic differences in the effectiveness of bariatric surgery are not limited to those between patients of African and European origin, but extend to other minority groups as well. Therefore, it is important that prospective studies both determine ethnic differences in weight loss-related improvement of co-morbidities and elucidate the exact reasons for these ethnic disparities.

Background: Laparoscopic adjustable gastric banding is a popular and effective restrictive bariatric procedure. However, with longer follow-up, it has become clear that a considerable number of patients require revisional surgery, of which Roux-en-Y gastric bypass (RYGB) is the most commonly performed procedure. Studies that compared the outcomes of primary RYGB and revisional RYGB have not been conclusive. Our objective was to determine whether significant differences exist in the 1-year outcomes between primary RYGB (prim-RYGB) and revisional RYGB after laparoscopic adjustable gastric banding (rev-RYGB) at a major training hospital in The Netherlands., Methods: All prim-RYGB and rev-RYGB procedures performed from 2007 to 2009 were analyzed. Data were collected regarding weight loss, hospitalization, operative time, postoperative complications, and co-morbidities., Results: A total of 292 RYGB procedures were performed: 66 rev-RYGB and 226 prim-RYGB procedures. The operative time was significantly shorter in the prim-RYGB group (136.6±37.5 versus 167.5±40.6 min; P<.0001). No significant differences were found in hospitalization time (4.4±1.7 versus 4.9±2.4 d; P= .063) or complication rate (14.7% versus 15.2%; P=.962). No deaths occurred in either group. The number of patients with resolved diabetes and hypertension did not differ between the 2 groups (50.1% versus 23.1%; P=.116; and 40.7% versus 25.0%; P=.384, respectively). Weight loss was significantly greater in the prim-RYGB group in terms of excess weight loss (71.6%±20.8% versus 48.4%±26.8%; P<.0001), body mass index reduction (13.0±3.8 versus 10.2±5.6 kg/m(2); P<.0001), absolute weight loss (37.4±11.5 versus 29.3±17.2 kg; P=.001), and percentage of weight loss (29.7%±8% versus 21.7%±11.5%; P<.0001)., Conclusion: rev-RYGB is a safe procedure with outcomes similar to those of prim-RYGB in terms of complication rate, hospitalization time, and effect on co-morbidity. Weight loss, however, was significantly less after rev-RYGB than after prim-RYGB., (Copyright © 2013 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: As a result of increasing numbers of patients with morbid obesity there is a worldwide demand for bariatric surgeons. The Roux-en-Y gastric bypass, nowadays performed mostly laparoscopically (LRYGB), has been proven to be a highly effective surgical treatment for morbid obesity. This procedure is technically demanding and requires a long learning curve. Little is known about implementing these demanding techniques in the training of the surgical resident. The aim of this study was to evaluate the safety and feasibility of the introduction of LRYGB into the training of surgical residents., Methods: All patients who underwent LRYGB between March 2006 and July 2010 were retrospectively analyzed. The procedure was performed by a surgical resident under strict supervision of a bariatric surgeon (group I) or by a bariatric surgeon (group II). The primary end point was the occurrence of complications. Secondary end points included operative time, days of hospitalization, rate of readmission, and reappearance in the emergency department (ED) within 30 days., Results: A total of 409 patients were found eligible for inclusion in the study: 83 patients in group I and 326 in group II. There was a significant difference in operating time (129 min in group I vs. 116 min in group II; p < 0.001) and days of hospitalization. Postoperative complication rate, reappearance in the ED, and rate of readmission did not differ between the two groups., Conclusions: Our data suggest that under stringent supervision and with sufficient laparoscopic practice, implementation of LRYGB as part of surgical training is safe and results in only a slightly longer operating time. Complication rates, days of hospitalization, and the rates of readmission and reappearance in the ED within 30 days were similar between the both groups. These results should be interpreted by remembering that all procedures in group I were performed in a training environment so occasional intervention by a bariatric surgeon, when necessary, was inevitable.

Purpose: After preoperative (radio)chemotherapy, histologic determinants for prognostication have changed. It is unclear which variables, including assessment of tumor regression, are the best indicators for local recurrence and survival., Experimental Design: A series of 201 patients with locally advanced rectal cancer (cT3/T4, M0) presenting with an involved or at least threatened circumferential margin (CRM) on preoperative imaging (<2 mm) were evaluated using standard histopathologic variables and four different histologic regression systems. All patients received neoadjuvant radiochemotherapy or radiotherapy. The prognostic value of all factors was tested with univariate survival analysis of time to local recurrence and overall survival., Results: Local recurrence occurred in only 8% of the patients with a free CRM compared with 43% in case of CRM involvement (P < 0.0001). None of the four regression systems were associated with prognosis, not even when corrected for CRM status. However, we did observe a higher degree of tumor regression after radiochemotherapy compared with radiotherapy (P < 0.001). Absence of tumor regression was associated with increasing invasion depth and a positive CRM (P = 0.02 and 0.03, respectively)., Conclusions: Assessment of CRM involvement is the most important pathologic variable after radiochemotherapy. Although tumor regression increases the chance on a free CRM, in cases with positive resection margins prognosis is poor irrespective of the degree of therapy-induced regression.

Historically, locally advanced rectal cancer is known for its dismal prognosis. The treatment of locally advanced rectal cancer is subject to continuous change due to development of new and better diagnostic tools, radiotherapeutic techniques, chemotherapeutic agents and understanding of the subject. It is clear, that a multimodality approach is the only way to achieve satisfactory local recurrence and survival rates in this type of cancer. However, which multimodality strategy is to be used still remains a point of controversy. This review summarises recent developments in imaging, (neo-) adjuvant therapy and surgical techniques in the treatment of primary locally advanced rectal cancer.