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Background: Mechanical problems at the level of the jejunojejunostomy (JJ) have been identified as a cause of small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass (RYGB). Objectives: The objective of the study was to investigate associations between specific surgical techniques used to construct the JJ and the subsequent risk of SBO. Setting: Nationwide Registry, Sweden. Methods: The risk of SBO after primary RYGB surgery during 2012-2019 was assessed using data from the Scandinavian Obesity Surgery Registry and the Swedish National Patient Register. The impact of unidirectional or bidirectional stapling and length of the mesenteric division (0, 1-4, or >= 5 cm) at the JJ was analyzed with adjustments for known covariates. Results: We analyzed outcomes from 23,448 patients (mean follow-up = 4.3 +/- 2.2 yr). In multivar-iate analysis, bidirectional stapling of the JJ was associated with a reduced 30-day risk of SBO (hazard ratio [HR] = .52, 95% confidence interval [CI] = .29-.95, P < .05), whereas limited mesenteric division (1-4 cm) increased the risk of SBO (HR = 1.66, 95% CI = 1.14-2.42, P < .01). The long-term incidence of SBO was increased by bidirectional stapling but unaffected by mesenteric division. However, mesenteric division decreased the long-term risk of SBO in patients with a bidirectionally stapled JJ (1-4 cm, HR = .59, 95% CI = .38-.90, P < .05; >= 5 cm, HR = .30, 95% CI = .14-.65, P < .005). Conclusions: The surgical technique for construction of the JJ may affect the incidence of SBO after RYGB surgery. (C) 2022 American Society for Bariatric Surgery. Published by Elsevier Inc.

Purpose Radiotherapy-induced trismus is present in up to 40% of patients treated radiotherapeutically for head and neck cancer (HNC) and impacts health-related quality of life (HRQL) negatively. This prospective study aimed to investigate the development of trismus and its influence on HRQL and trismus-related symptoms in HNC patients for up to 5 years post-radiotherapy completion as no such follow-up studies exist. Methods Patients (n = 211) were followed prospectively from pre-radiotherapy to 12 and 60 months post-radiotherapy. At each follow-up, maximum interincisal opening (MIO) was measured, and patients filled in the European Organization for Treatment of Cancer Quality-of-Life Questionnaire Core-30 (EORTC QLQ-C30), Head and Neck-35 (EORTC QLQ-HN35), and Gothenburg Trismus Questionnaire (GTQ). Trismus was defined as an MIO ≤ 35 mm. Results At 1 year post-radiotherapy, a total of 27% met the trismus criterion, and at 5 years post-radiotherapy, the corresponding figure was 28%. Patients in the trismus group scored significantly worse compared to the patients without trismus on 8/15 domains at 1 year post-radiotherapy on EORTC QLQ-C30, further worsening in 11/15 domains at 5 years post-radiotherapy. Similar results were found for EORTC QLQ-HN35. Patients with trismus reported more trismus-related symptoms according to the GTQ at both timepoints compared to those without trismus. Conclusion This study highlights that HNC patients suffering from radiotherapy-induced trismus report poorer HRQL and more trismus-specific symptoms compared to patients without trismus. These differences persist and increase up to at least 5 years following treatment completion. Hence, our results highlight that radiotherapy-induced trismus affects long-term HRQL, jaw symptoms, and pain, further stressing the need for early and structured intervention.

AIM: The aim of the study was to explore the work conditions that influence the opportunities for professional development of specialist nurses in surgical care. DESIGN: A qualitative descriptive design was used. METHODS: With a purposeful sampling procedure, 14 specialist nurses in surgical care were included. Four focus-group interviews were conducted during November to December 2021 and deductively analysed using the Job Demand-Resource theory as a guiding framework. Reporting adheres to COREQ guidelines. FINDINGS: Work conditions that were identified as job demands and that inhibited nurses' opportunities for professional development were mainly found at an organizational and leadership level. Primarily, those conditions included role ambiguity and time constraints caused by uncompensated nursing shortages that restricted the nurses from exercising their role. Such conditions could also discourage other nurses from further education. Job demands were seen as largely compensated for by work conditions identified as job resources and located mainly at an individual level, for example finding the work interesting and multifaceted. Most prominent was the participants' inner motivation to work with surgical patients and to continue to develop themselves and other nurses professionally. CONCLUSIONS: A prerequisite for professional development is that the specialist role is clearly defined in collaboration with representatives from the nursing profession and universities. Hence, hospital organizations need to reflect on how to utilize the competence. Also, it is important that nurse leaders promote the specialist nurses' motivation by supporting them in the exercise of their role. IMPACT: Findings from this study revealed work conditions that need to be acknowledged during hospital organizations' endeavours to maintain and enhance nursing competence. PATIENT OR PUBLIC CONTRIBUTION: Patient or public contribution was not applicable since the study focused on specialist nurses' working conditions. Funding: Swedish Society of Nursing

Background Laparoscopic Roux-en-Y gastric bypass (RYGB) has for long been the gold standard technique in bariatric surgery, especially in the Scandinavian countries. In a tertiary hospital setting, we observed an increasing number of patients with postprandial abdominal pain and nausea, often associated with complex hypoglycemia. Objectives The present study aimed to characterize the clinical patterns, patient characteristics, and clinical outcomes after surgical revision of dysfunctional RYGB at Sahlgrenska University Hospital in Gothenburg, Sweden. Methods This cohort study included patients with RYGB who underwent revision of the jejunojejunostomy (JJ) after 2013. Information was obtained by reviewing medical records and performing complementary interviews. Results Laparoscopic revisional surgery was performed in 115 cases with either adhesiolysis or total revision of the JJ (mean age 41 years, range 19–67 years; 90% women). The median time to assessment after the last revision was 33 months (range 12–75 months). Forty-four (38%) patients reported that they were symptom-free long-term after the intervention, and 32 (28%) patients experienced an improvement in the symptoms that were the indication for revision. However, 31 (27%) patients reported no long-term improvement, and half of them (n = 16) subsequently had a reversal of the anatomy. Eight (7%) patients were lost to follow-up. Conclusions Dysfunction of the JJ appears to be a relatively common cause of postprandial pain and nausea after ante-colic/ante-gastric RYGB. Most patients with symptoms of dysfunction experienced partial or total relief following revisional surgery, but a substantial minority had persistent problems, with one in five eventually undergoing reversal of the anatomy. Graphical Abstract

Trismus is a complication post-radiotherapy for head and neck cancer (HNC), which causes pain, eating limitations and reduced quality-of-life. However, little is known about the condition long-term or how trismus fluctuates within an irradiated population.To prospectively map trismus prevalence in irradiated HNC patients up to 5-years following treatment completion including describing intra-group fluctuation of maximum interincisal opening (MIO).211 patients receiving curatively intended radiotherapy for HNC were included in this prospective study. Patients were followed pre-radiotherapy (baseline), 3-, 6-, 12-, 24-, 36- and 60-months post-radiotherapy completion using MIO.Mean MIO at baseline, 12-months and 5-years following radiotherapy were 51.5 mm, 41.7 mm and 41.3 mm respectively. A total of 28% (Trismus is a prevalent long-term complication of HNC and its treatment, which does not appear to heal spontaneously. The majority of fluctuations in MIO occur during the first 12 months post-radiotherapy completion.

Having a culture of safety is crucial when providing high-quality health care, yet preventable adverse events are common in the Swedish healthcare system, especially in the field of surgical care. Research shows that patient participation can improve patient safety. This study aimed to explore patients' experience of the safety leaflet, "Your safety in hospital," including participation in care and feelings of safe care.This study uses a descriptive qualitative study design.Twenty patients from surgical wards received patient safety leaflets and participated in semi-structured interviews during their hospital stay. Data were analysed using qualitative content analysis.Three categories emerged from the analysis: Positive and negative experiences of provided information, Experiences of participation in own care, and Feelings of being safe arising from a perception of good quality care. Most participants were satisfied with their participation in their care and felt safe during their hospital stay. Oral information about the safety leaflet from healthcare personnel was lacking.

Background The development of obesity is most likely due to a combination of biological and environmental factors some of which might still be unidentified. We used a machine learning technique to examine the relative importance of more than 100 clinical variables as predictors for BMI. Methods BASUN is a prospective non-randomized cohort study of 971 individuals that received medical or surgical treatment (treatment choice was based on patient’s preferences and clinical criteria, not randomization) for obesity in the Västra Götaland county in Sweden between 2015 and 2017 with planned follow-up for 10 years. This study includes demographic data, BMI, blood tests, and questionnaires before obesity treatment that cover three main areas: gastrointestinal symptoms and eating habits, physical activity and quality of life, and psychological health. We used random forest, with conditional variable importance, to study the relative importance of roughly 100 predictors of BMI, covering 15 domains. We quantified the predictive value of each individual predictor, as well as each domain. Results The participants received medical (n = 382) or surgical treatment for obesity (Roux-en-Y gastric bypass, n = 388; sleeve gastrectomy, n = 201). There were minor differences between these groups before treatment with regard to anthropometrics, laboratory measures and results from questionnaires. The 10 individual variables with the strongest predictive value, in order of decreasing strength, were country of birth, marital status, sex, calcium levels, age, levels of TSH and HbA1c, AUDIT score, BE tendencies according to QEWPR, and TG levels. The strongest domains predicting BMI were: Socioeconomic status, Demographics, Biomarkers (notably TSH), Lifestyle/habits, Biomarkers for cardiovascular disease and diabetes, and Potential anxiety and depression. Conclusions Lifestyle, habits, age, sex and socioeconomic status are some of the strongest predictors for BMI levels. Potential anxiety and / or depression and other characteristics captured using questionnaires have strong predictive value. These results confirm previously suggested associations and advocate prospective studies to examine the value of better characterization of patients eligible for obesity treatment, and consequently to evaluate the treatment effects in groups of patients. Trial registration March 03, 2015; NCT03152617.

Granular study of metabolic responses to alterations in the ratio of dietary macro-nutrients can enhance our understanding of how dietary modifications influence patients with impaired glycemic control. In order to study the effect of diets enriched in fat or carbohydrates, fifteen healthy, normal-weight volunteers received, in a cross-over design, and in a randomized unblinded order, two weeks of an iso-caloric high-fat diet (HFD: 60E% from fat) and a high-carbohydrate diet (HCD: 60E% from carbohydrates). A mixed meal test (MMT) was performed at the end of each dietary period to examine glucose clearance kinetics and insulin and incretin hormone levels, as well as plasma metabolomic profiles. The MMT induced almost identical glycemia and insulinemia following the HFD or HCD. GLP-1 levels were higher after the HFD vs. HCD, whereas GIP did not differ. The HFD, compared to the HCD, increased the levels of several metabolomic markers of risk for the development of insulin resistance, e.g., branched-chain amino acid (valine and leucine), creatine and α-hydroxybutyric acid levels. In normal-weight, healthy volunteers, two weeks of the HFD vs. HCD showed similar profiles of meal-induced glycemia and insulinemia. Despite this, the HFD showed a metabolomic pattern implying a risk for a metabolic shift towards impaired insulin sensitivity in the long run.

The aim of the present study was to describe the experiences of young adults living with cleft lip and palate (CLP) and to explore potential gender differences. A descriptive qualitative study was designed involving semi-structured interviews. The interviews were analyzed using qualitative content analysis, as described by Graneheim and Lundman. A total of 9 women and 8 men, aged 22 to 26 years with UCLP. The main theme identified was: the duality of living with a cleft—being normal yet different, and 2 subcategories: “My cleft and me” and “My cleft and the World.” The participants described themselves as normal yet different, both in relation to themselves and in relation to others. They also stated that gender norms regarding appearance affected their lives and how they saw the cleft. This study adds to the growing body of qualitative research on CLP. It highlights the dualistic experiences of feeling normal and different at the same time. The interviews indicated that this dualism was based on context and gender, showing the psychological complexity of an individual. The clinical implications of this study emphasizes the need of a person-centered care approach in the cleft care setting where the clinicians are aware of the potential dualistic experience that also may differ over time that individuals with cleft can experience. This can also help clinicians better understand and help patients reduce distress and strengthen positive coping mechanisms.

Background: Bariatric surgery is a standard treatment for severe obesity, but little is known about patients perceptions about the long-term impact of such surgery. Objective: The aim of this study was to explore patients experiences of living with a bariatric procedure for more than a decade. Setting: University hospital. Methods: At the 10-year follow-up after undergoing Roux-en-Y gastric bypass (RYGB) or bilio-pancreatic diversion with duodenal switch (BPD/DS), 18 consecutive patients from a previous randomized controlled trial were assessed with a semi-structured interview. Data were analyzed using thematic analysis. Results: When asked to reflect broadly on their experiences of living with bariatric surgery for over a decade, the participants rarely mentioned procedure-specific issues and complications. Instead, their accounts revealed 2 broad themes: sustained effects after surgery, incorporating subthemes of better health, brighter futures, and better eating and weight regulation, and continuing struggles, including difficulties with physical activity, finding support, helping their children with overweight, and self-criticism. Many positive changes were sustained, but continuing personal struggles were similar to those presurgery. Conclusions: Participants expressed overall satisfaction with their bariatric surgery and related outcomes. Most participants acknowledged a continued effect on their appetite, which could be important information for patients who worry about a diminished effect after the first year postsurgery. Participants were prone to self-blame when things did not turn out the way they wanted. Therefore, healthcare providers must build a trustful relationship with their patients, so they will not hesitate to return when they face problems such as weight gain. (C) 2021 American Society for Bariatric Surgery. Published by Elsevier Inc. Funding Agencies|Local Research and Development Board for Gothenburg and Sodra Bohuslan [VGFOUGSB-765351]

Aim To assess the prevalence of neurodevelopmental problems in adolescents with severe obesity and their associations with binge eating and depression. Methods Data were collected at inclusion in a randomised study of bariatric surgery in 48 adolescents (73% girls; mean age 15.7 +/- 1.0 years; mean body mass index 42.6 +/- 5.2 kg/m(2)). Parents completed questionnaires assessing their adolescents symptoms of attention-deficit/hyperactivity disorder and autism spectrum disorder and reported earlier diagnoses. Patients answered self-report questionnaires on binge eating and depressive symptoms. Results The parents of 26/48 adolescents (54%) reported scores above cut-off for symptoms of the targeted disorders in their adolescents, but only 15% reported a diagnosis, 32% of adolescents reported binge eating, and 20% reported symptoms of clinical depression. No significant associations were found between neurodevelopmental problems and binge eating or depressive symptoms. Only a third of the adolescents reported no problems in either area. Conclusion Two thirds of adolescents seeking surgical weight loss presented with substantial mental health problems (reported by themselves or their parents). This illustrates the importance of a multi-professional approach and the need to screen for and treat mental health disorders in adolescents with obesity. Funding Agencies|VINNOVAVinnova; Stiftelsen Carlanderska Sjukhuset [ALFGBG-719711]; Tore Nilssons Foundation; SUS Foundations and Donations; Capio Research Foundation; Mary von Sydows Foundation

Injuries were the most common cause of hospitalization in Sweden in 2017. There is a lack of knowledge about trauma recovery and its relation to health-related quality of life (HRQoL) after hospitalization due to minor trauma. This study aimed to prospectively evaluate recovery and HRQoL at discharge from hospital and 3 and 6 months after the trauma.This is a secondary analysis of data from a prospective follow-up study. Fifty-seven patients who sustained physical trauma were included. Recovery was measured with postoperative recovery profile and HRQoL 3 and 6 months after discharge. The association between the outcomes was analyzed, as well as the impact of gender, age, Injury Severity Score (ISS), and trauma mechanism using nonparametric statistics.There was a significant improvement in recovery and HRQoL between discharge and 3 months after the trauma (p.001) as well as between 3 and 6 months after the trauma (p.001) except for EQ-5D VAS scale (p = .222). However, only 14 (25%) patients viewed themselves as fully recovered 6 months after the incident. Correlation between recovery and HRQoL increased after discharge and was at its strongest 6 months after the trauma (rs.071).Trauma mechanism has an impact on recovery but not gender, age, or ISS score. Most patients did not consider themselves fully recovered even at 6 months postinjury, indicating that they require additional support to manage their recovery.

ObjectivesTo compare long-term effects and complications of medical treatment (MT) of obesity including very low energy diet with bariatric surgery.Design and settingThis prospective study conducted in a clinical setting recruited individuals with body mass index (BMI) ≥35 kg/m2referred for obesity treatment. Demographic and anthropometric data, laboratory samples, and questionnaire replies were collected at baseline and 2 years.Participants and interventions971 individuals were recruited 2015–2017. 382 received MT, 388 Roux-en-Y gastric bypass (RYGB) and 201 sleeve gastrectomy (SG).Main outcome measuresPrimary outcomes included changes in anthropometric measures, metabolic variables and safety. These were analysed using a linear regression model. A logistic regression model was used to analyse composite variables for treatment success (secondary outcomes). A random forest (RF) model was used to examine the importance of 15 clinical domains as predictors for successful treatment.ResultsTwo-year data were available for 667 individuals (68.7%). Regarding primary outcomes, the decrease in excess BMI was 27.5%, 82.5% and 70.3% and proportion achieving a weight of >10% was 45.3%, 99.6% and 95.6% for MT, RYGB and SG, respectively (pConclusionsIn clinical practice, bariatric surgery by RYGB or SG is most effective, but meaningful weight loss is achievable by MT with strict caloric restriction and stepwise introduction of a normal diet. All treatments showed positive effects on well-being, cardiovascular risk factors, and levels of vitamins and minerals at 2-year follow-up and groups were similar regarding safety measures.Trial registration numberNCT03152617.

Injuries due to trauma are the leading cause of death in Sweden among people younger than 45 years, and more than 120,000 patients were admitted to hospitals in 2014 as a result of trauma. Patients suffering from less serious physical trauma are often discharged directly from the trauma unit, commonly without any follow-up plans. There is a lack of knowledge about how these patients experience their recovery process.Eight women and 6 men were interviewed 3 months after being directly discharged from a trauma unit. Data were analyzed using the constructive grounded theory approach.The main finding was the core category of social support, the key to recovery. Patients' roads to recapturing their health and to recovery had several barriers, which can be clustered together to either physical or psychological symptoms that enhanced their feelings of ill health and delayed their recovery. Participants described different strategies that they used to deal with these barriers. Most important was the support of others, that is, family, social life, work, and health care (primary health care).The participants in this study described managing the recovery process by themselves as troublesome. This is partly because they do not view themselves as healthy, as the health care providers do, and many are in need of further health care after discharge. Health care providers should give better information on the expected process of recovery and the importance of social support, as it might enable patients to better overcome physical and psychological barriers in their recovery.

Background Undergoing surgery always involves various risks of complications, often depending on the type of surgery. Because of complications, a second surgical intervention, a reoperation, must occasionally be done, which in turn often causes an extended hospital stay, a longer recovery phase, greater suffering for the patient, and higher health care costs. Even though complications after general surgery are relatively common, little is known regarding patient experience of a reoperation. Knowledge of this could impact on care models in the future. The aim of this study was to describe patients' experience of acute, unplanned reoperation during a planned hospital stay. Materials and methods A purposive sampling strategy was used, and 16 patients were included, all who had undergone acute unplanned reoperation during a planned hospital stay. Semi-structured interviews were used to collect data, and a content analysis with an inductive approach was used for data analysis. Results The analysis resulted in two main themes: (1) health professionals' importance, having its foundation in categories trust and information, and (2) reaction, based on the categories anxiety and sadness. Conclusions Unplanned reoperation caused psychological, social, and existential reactions. Health care professionals were perceived as important because good communication, accurate information, their presence, and creating feelings of confident and safe care were meaningful factors for the patients as they managed the situation.

The incidence of registered admissions in inpatient care with a diagnosis of acute pancreatitis was 58 per 100,000 capita in Sweden during the year 2013. Although acute pancreatitis is a well-explored area, there is a demand for research from the patients' perceptions. The aim of this study was to describe patients' perceptions of recovering from acute pancreatitis. Data collection for this phenomenographical study included 16 individual semistructured interviews. Analysis was done according to the 7 steps suggested by . Recovery after acute pancreatitis was perceived within 5 categories; a time of physical suffering, an emotional journey, challenges to the usual life and its good qualities, barriers and need for social support, and healthcare as an important factor. Physical and emotional symptoms influence recovery after acute pancreatitis by challenging the good things and things that are taken for granted in everyday life. Promoting factors toward good recovery was a proper support from the social network as well as healthcare providers.

Purpose In recent years, the incidence of malignant melanoma has rapidly increased worldwide. Among patients with recurrences, approximately 5% develop in-transit metastases, which can potentially be treated with isolated limb perfusion (ILP). However, little is known about patient experiences with this treatment. A more thorough understanding might guide future research and clinical care. In this study, we aimed to describe patients’ experiences of ILP treatment. Methods This study included eight patients who participated in a semi-structed interviewed, conducted at one occasion between 3 and 11 months after their ILP treatment. The mean interview duration was 26 min. Data were analyzed using qualitative inductive content analysis according to the methods of Elo-Kyngas and Graneheim and Lundman. Results Our analysis yielded three categories, each built on two subcategories: positive experiences after ILP treatment emerged from the sub-categories reduced tumor burden and living a less restricted life; negative experiences after ILP was built on the subcategories fear of relapse and complications and side effects; and experiences of healthcare was founded on the subcategories need for correct information and being viewed as sicker then experienced. Conclusion Participants showed greater focus on the healthy parts of their lives, even when negative symptoms occurred after ILP treatment. They also described how healthcare workers focused on their illness. Based on these findings, we suggest the following means of providing good nursing care to ILP patients: give correct information, strive to reduce patients’ negative symptoms, support their daily living needs, and provide emotional support to reduce fear of recurrence.

Early dumping syndrome after gastric bypass surgery due to rapid delivery of hyperosmolar nutrients into the bowel causing intense symptoms is often described as a complication. Twelve patients, mean age 47 years, were interviewed approximately 9 years post-operation. The interviews were audiotaped and transcribed verbatim, followed by an inductive content analysis to reveal patients' experience of the dumping syndrome. The core category 'Dumping syndrome is a positive consequence of Roux-en-Y gastric bypass surgery and a tool to control food intake' was identified based on the following four sub-categories: (i) 'The multidimensional emergence and effects of dumping syndrome', (ii) 'Dumping syndrome as something positive although unpleasant', (iii) 'Developing coping mechanisms and ingenious strategies' and (iv) 'My own fault if I expose myself to dumping syndrome'. From the patients' perspective, dumping syndrome gives control over food intake; although the symptoms were unpleasant, patients considered dumping syndrome as a positive protection against over-consumption. Hence, healthcare professionals should not present dumping syndrome as a complication but rather as an aid to control eating behaviour and excessive food intake.

Violence in health care is increasing globally and Sweden is no exception. Still, this topic is sparsely studied in the Swedish trauma care setting. This focus group study examined nurses' experience of violence and threats, and their consequences. The content analysis revealed two main categories, threatening situations and consequences, which led to a change in priorities in nursing care in order to avoid a potential violent situation. Furthermore, negative stress among the staff and greater vigilance and unwillingness to be near the patient resulted in altered communication and, in the end, a decreased quality of nursing care.

Background Previous non-randomized studies show similar outcomes in adolescents and adults after bariatric surgery. We describe the study protocol, recruitment, and selected baseline data of patients in a randomized multi-center study, the Adolescent Morbid Obesity Surgery 2 (AMOS2). Methods Three clinics in Sweden collaborated in designing the study and recruitment of patients from August 1, 2014 to June 30, 2017. Patients were selected among adolescents 13–16 years of age attending third-level obesity care for at least one year. Patients were randomized 1:1 to bariatric surgery (predominantly Roux-en-Y gastric bypass) or intensive non-surgical treatment starting with an eight-week low-calorie-diet. Results Fifty adolescents (37 girls) were randomized, 25 (19 girls) to bariatric surgery. Mean age was 15.7 years (range 13.3–16.9), weight 122.6 kg (range 95–183.3), Body Mass Index (BMI) 42.6 kg/m2 (range 35.7–54.9) and BMI-SDS 3.45 (range 2.9–4.1). One patient had type 2 diabetes mellitus, and 12/45 (27%) had elevated liver enzymes. There were no significant differences between the groups. For the 39 eligible patients who were offered but declined inclusion, BMI was not different from included patients. However, patients who declined were younger, 15.2 years (p = 0.021). A sex difference was also noted with more of eligible girls, 37/53 (69.8%), than boys, 13/36 (36.1%), wanting to participate in the study (p = 0.002). Conclusions This clinical trial, randomizing adolescents with severe obesity to bariatric surgery or intensive non-surgical treatment, aims at informing about whether it is beneficial to undergo bariatric surgery in early adolescence. It will also enlighten the outcome of comprehensive non-surgical treatment. The study was registered at www.clinicalTrials.gov number NCT02378259., Highlights • Bariatric surgery is already a treatment option for adolescents with severe obesity in many countries. • We recruited 50 patients 13-16 years of age to a randomized controlled trial. • We aimed at investigating the optimal time point for bariatric surgery. • Adolescents and their families seemed to make well considered decisions to participate in the study.

Background This study assessed eating disorder pathology in persons with obesity before and after Roux-en-Y gastric by- pass (RYGB) and biliopancreatic diversion with duodenal switch (DS), in a 5-year follow-up study. Methods Sixty participants with BMI 50 – 60 kg/m 2 were ran- domly assigned to RYGB ( n =31) or DS ( n =29). The partic- ipants completed the Eating Disorder Examination- Questionnaire (EDE-Q) before and 6 months, 1 year, 2 years, and 5 years after surgery. Results Before surgery, the prevalence of objective bulimic episodes was 29 % in the RYGB group and 32 % in the DS group. The prevalence improved during the first 12 months after surgery in both groups. After 5 years, the prevalence of objective bulimic episodes was 22 % in the RYGB group and 7 % in the DS group. The difference between groups through- out follow-up was non-significant (logistic regression model). A linear mixed model showed that global EDE-Q score was not a significant predictor for weight loss after surgery, but participants reporting objective bulimic episodes before sur- gery had significantly lower BMI than those with no episodes after 2 years ( p =0.042) and 5 years ( p =0.013). Global EDE-Q score was significantly lower in the DS group after 5 years ( p =0.009) (linear mixed model). Conclusions Objective bulimic episodes but not global EDE- Q score before surgery predicted greater weight loss after RYGB and DS. The DS group had a significantly lower global EDE-Q score than the RYGB group 5 years after surgery.

Physiological and psychosocial factors might contribute to differences in weight loss, eating behaviour and health-related quality of life (HRQoL) after bariatric surgery. The aim of this study was to investigate how perceived control over eating changes after bariatric surgery and whether it affects outcome in super-obese patients.In a retrospective analysis of a prospective study (n = 60), 49 patients were divided into two groups based on eating control 2 years after surgery, as assessed by the Three-Factor Eating Questionnaire-R21 (TFEQ-R21): 29 with good eating control (GC) and 20 patients with poor eating control (group PC). Eating behaviour and generic and condition-specific HRQoL was assessed by questionnaires.There were significant differences in all TFEQ-R21 domains 2 years after surgery in favour of group GC; uncontrolled eating p 0.001, emotional eating p 0.001 and for cognitive restraint p = 0.04. The improvement in HRQoL 2 years after surgery was significantly less in group PC compared to group GC in 7 of 8 SF-36 domains (p 0.05). Mean (SD) percentage of excess body mass index lost was similar between groups, 71.2 (17.8) in group GC versus 65.4 (17.4) in group PC 2 years after surgery (p = 0.27). However, group GC had a significant weight loss between first and second year after surgery (p 0.001) compared to group PC (p = 0.15).In super-obese patients, perceived poor control over eating 2 years after bariatric surgery was associated with lower HRQoL and more emotional and cognitive restraint eating, than good control overeating.

Background Bile acids have been proposed as key mediators of the metabolic effects after bariatric surgery. Currently no reports on bile acid profiles after duodenal switch exist, and long-term data after gastric bypass are lacking. Objective To investigate bile acid profiles up to 5 years after Roux-en-Y gastric bypass and biliopancreatic diversion with duodenal switch and to explore the relationship among bile acids and weight loss, lipid profile, and glucose metabolism. Settings Two Scandinavian University Hospitals. Methods We present data from a randomized clinical trial of 60 patients with body mass index 50–60 kg/m 2 operated with gastric bypass or duodenal switch. Repeated measurements of total and individual bile acids from fasting serum during 5 years after surgery were performed. Results Mean concentrations of total bile acids increased from 2.3 µmol/L (95% confidence interval [CI], –.1 to 4.7) at baseline to 5.9 µmol/L (3.5–8.3) 5 years after gastric bypass and from 1.0 µmol/L (95% CI, –1.4 to 3.5) to 9.5 µmol/L (95% CI, 7.1–11.9) after duodenal switch; mean between-group difference was –4.8 µmol/L (95% CI, –9.3 to –.3), P = .036. Mean concentrations of primary bile acids increased more after duodenal switch, whereas secondary bile acids increased proportionally across the groups. Higher levels of total bile acids at 5 years were associated with lower body mass index, greater weight loss, and lower total cholesterol. Conclusions Total bile acid concentrations increased substantially over 5 years after both gastric bypass and duodenal switch, with greater increases in total and primary bile acids after duodenal switch. (Surg Obes Relat Dis 2017;0:000-000.) © 2017 American Society for Metabolic and Bariatric Surgery. All rights reserved.

Duodenal switch provides greater weight loss than gastric bypass in severely obese patients; however, comparative data on the changes in gastrointestinal symptoms, bowel function, eating behavior, dietary intake, and psychosocial functioning are limited.The setting for the present study was 2 university hospitals in Norway and Sweden. Participants with a body mass index of 50-60 kg/m(2) were randomly assigned to gastric bypass (n = 31) or duodenal switch (n = 29) and followed up for 2 years. Of the 60 patients, 97% completed the study. Their mean weight decreased by 31.2% after gastric bypass and 44.8% after duodenal switch. At inclusion and 1 and 2 years of follow-up, the participants completed the Gastrointestinal Symptom Rating Scale, a bowel function questionnaire, the Three-Factor Eating Questionnaire-R21, a 4-day food record, and the Obesity-related Problems scale.Compared with the gastric bypass group, the duodenal switch group reported more symptoms of diarrhea (P = .0002), a greater mean number of daytime defecations (P = .007), and more anal leakage of stool (50% versus 18% of participants, respectively; P = .015) after 2 years. The scores for uncontrolled and emotional eating were significantly and similarly reduced after both operations. The mean total caloric intake and intake of fat and carbohydrates were significantly reduced in both groups. Protein intake was significantly reduced only after gastric bypass (P = .008, between-group comparison). Psychosocial function was significantly improved after both operations (P = .23, between the 2 groups).Gastrointestinal side effects and anal leakage of stool were more pronounced after duodenal switch than after gastric bypass. Both procedures led to reduced uncontrolled and emotional eating, reduced caloric intake, and improved psychosocial functioning.

Background: The understanding of the association between the objective conditions of health and the subjective perceptions of morbidly obese patients appears to be poor. The use of objective indicators alone produces results totally unrelated to the feelings and experiences of the bariatric patients studied. No study has approached the bariatric patient from both an inside and a preoperative perspective. Purpose: The aim of this study was to investigate the meaning of awaiting bariatric surgery due to morbid obesity. Method: Twenty-three patients admitted to a Swedish University Hospital for bariatric surgery were included. Data were collected by interviews and the analysis was performed using the phenomenological hermeneutics method developed by Lindseth and Norberg. Main Findings: Two structural thematic analyses revealed six main themes: experiencing food as a complex element in life, feeling hopeless regarding weight loss, living in fear of future sickness and death, living a restricted life, being ignored by health care professionals and hoping for control and opportunities. The informants experienced addiction to food and dependence on others for managing their daily life, which constituted an infringement of their freedom. Loss of control meant giving in to the desire for food, but also being subjected to stigmatizing remarks from persons in their environment or uncaring approaches from health care professionals. Conclusion: Being scheduled for bariatric surgery meant developing an awareness of how completely dependent they were on surgery for their survival and prospective health. The scheduled bariatric surgery constituted tangible confirmation that weight loss and restored health were possible.

There is no consensus as to which bariatric procedure is preferred to reduce weight and improve health in patients with a body mass index higher than 50.To compare 5-year outcomes after Roux-en-Y gastric bypass (gastric bypass) and biliopancreatic diversion with duodenal switch (duodenal switch).Randomized clinical open-label trial at Oslo University Hospital, Oslo, Norway, and Sahlgrenska University Hospital, Gothenburg, Sweden. Participants were recruited between March 17, 2006, and August 20, 2007, and included 60 patients aged 20 to 50 years with a body mass index of 50 to 60. The current study provides the 5-year follow-up analyses by intent to treat, excluding one participant accepted for inclusion who declined being operated on prior to knowing to what group he was randomized.Laparoscopic gastric bypass and laparoscopic duodenal switch.Body mass index and secondary outcomes including anthropometric measures, cardiometabolic risk factors, pulmonary function, vitamin status, gastrointestinal symptoms, health-related quality of life, and adverse events.Sixty patients were randomly assigned and operated on with gastric bypass (n = 31) and duodenal switch (n = 29). Fifty-five patients (92%) completed the study. Five years after surgery, the mean reductions in body mass index were 13.6 (95% CI, 11.0-16.1) and 22.1 (95% CI, 19.5-24.7) after gastric bypass and duodenal switch, respectively. The mean between-group difference was 8.5 (95% CI, 4.9-12.2; P .001). Remission rates of type 2 diabetes mellitus and metabolic syndrome and changes in blood pressure and lung function were similar between groups. Reductions in total cholesterol, low-density lipoprotein cholesterol, triglycerides, and fasting glucose were significantly greater after duodenal switch compared with gastric bypass. Serum concentrations of vitamin A and 25-hydroxyvitamin D were significantly reduced after duodenal switch compared with gastric bypass. Duodenal switch was associated with more gastrointestinal adverse effects. Health-related quality of life was similar between groups. Patients with duodenal switch underwent more surgical procedures related to the initial procedure (13 [44.8%] vs 3 [9.7%] patients; P = .002) and had significantly more hospital admissions compared with patients with gastric bypass.In patients with a body mass index of 50 to 60, duodenal switch resulted in greater weight loss and greater improvements in low-density lipoprotein cholesterol, triglyceride, and glucose levels 5 years after surgery compared with gastric bypass while improvements in health-related quality of life were similar. However, duodenal switch was associated with more surgical, nutritional, and gastrointestinal adverse effects.clinicaltrials.gov Identifier: NCT00327912.

BACKGROUND Gastric bypass and duodenal switch are currently performed bariatric surgical procedures. Uncontrolled studies suggest that duodenal switch induces greater weight loss than gastric bypass. OBJECTIVE To determine whether duodenal switch leads to greater weight loss and more favorable improvements in cardiovascular risk factors and quality of life than gastric bypass. DESIGN Randomized, parallel-group trial. (ClinicalTrials.gov registration number: NCT00327912) SETTING 2 academic medical centers (1 in Norway and 1 in Sweden). PATIENTS 60 participants with a body mass index (BMI) between 50 and 60 kg/m(2). INTERVENTION Gastric bypass (n = 31) or duodenal switch (n = 29). MEASUREMENTS The primary outcome was the change in BMI after 2 years. Secondary outcomes included anthropometric measures; concentrations of blood lipids, glucose, insulin, C-reactive protein, and vitamins; and health-related quality of life and adverse events. RESULTS Fifty-eight of 60 participants (97%) completed the study. The mean reductions in BMI were 17.3 kg/m(2) (95% CI, 15.7 to 19.0 kg/m(2)) after gastric bypass and 24.8 kg/m(2) (CI, 23.0 to 26.5 kg/m(2)) after duodenal switch (mean between-group difference, 7.44 kg/m(2) [CI, 5.24 to 9.64 kg/m(2)]; P < 0.001). Total cholesterol concentration decreased by 0.24 mmol/L (CI, -0.03 to 0.50 mmol/L) (9.27 mg/dL [CI, -1.16 to 19.3 mg/dL]) after gastric bypass and 1.07 mmol/L (CI, 0.79 to 1.35 mmol/L) (41.3 mg/dL [CI, 30.5 to 52.1 mg/dL]) after duodenal switch (mean between-group difference, 0.83 mmol/L [CI, 0.48 to 1.18 mmol/L]; 32.0 mg/dL [CI, 18.5 to 45.6 mg/dL]; P ≤ 0.001). Reductions in low-density lipoprotein cholesterol concentration, anthropometric measures, fat mass, and fat-free mass were also greater after duodenal switch (P ≤ 0.010 for each between-group comparison). Both groups had reductions in blood pressure and mean concentrations of glucose, insulin, and C-reactive protein, with no between-group differences. The duodenal switch group, but not the gastric bypass group, had reductions in concentrations of vitamin A and 25-hydroxyvitamin D. Most Short Form-36 Health Survey dimensional scores improved in both groups, with greater improvement in 1 of 8 domains (bodily pain) after gastric bypass. From surgery until 2 years, 10 participants (32%) had adverse events after gastric bypass and 18 (62%) after duodenal switch (P = 0.021). Adverse events related to malnutrition occurred only after duodenal switch. LIMITATION Clinical experience was greater with gastric bypass than with duodenal switch at the study centers. CONCLUSION Duodenal switch surgery was associated with greater weight loss, greater reductions of total and low-density lipoprotein cholesterol concentrations, and more adverse events. Improvements in other cardiovascular risk factors and quality of life were similar after both procedures. PRIMARY FUNDING SOURCE South-Eastern Norway Regional Health Authority.

Background Laparoscopic Roux-en- gastric bypass (LRYGB) and laparoscopic biliopancreatic diversion with duodenal switch (LDS) are surgical options for superobesity. A randomized trial was conducted to evaluate perioperative (30-day) safety and 1-year results. Methods Sixty patients with a body mass index (BMI) of 50–60 kg/m2 were randomized to LRYGB or LDS. BMI, percentage of excess BMI lost, complications and readmissions were compared between groups. Results Patient characteristics were similar in the two groups. Mean operating time was 91 min for LRYGB and 206 min for LDS (P < 0·001). One LDS was converted to open surgery. Early complications occurred in four patients undergoing LRYGB and seven having LDS (P = 0·327), with no deaths. Median stay was 2 days after LRYGB and 4 days after LDS (P < 0·001). Four and nine patients respectively had late complications (P = 0·121). Mean BMI at 1 year decreased from 54·8 to 38·5 kg/m2 after LRYGB and from 55·2 to 32·5 kg/m2 after LDS; percentage of excess BMI lost was greater after LDS (74·8 versus 54·4 per cent; P < 0·001). Conclusion LRYGB and LDS can be performed with comparable perioperative safety in superobese patients. LDS provides greater weight loss in the first year. Registration number: NCT00327912 (http://www.clinicaltrials.gov).

Background: Bariatric surgery is widely performed to induce weight loss. Objective: The objective was to examine changes in vitamin status after 2 bariatric surgical techniques. Design: A randomized controlled trial was conducted in 2 Scandinavian hospitals. The subjects were 60 superobese patients [body mass index (BMI; in kg/m 2 ): 50–60]. The surgical interventions were either laparoscopic Roux-en-Y gastric bypass or laparoscopic biliopancreatic diversion with duodenal switch. All patients received multivitamins, iron, calcium, and vitamin D supplements. Gastric bypass patients also received a vitamin B-12 substitute. The patients were examined before surgery and 6 wk, 6 mo, and 1 y after surgery. Results: Of 60 surgically treated patients, 59 completed the followup. After surgery, duodenal switch patients had lower mean vitamin A and 25-hydroxyvitamin D concentrations and a steeper decline in thiamine concentrations than did the gastric bypass patients. Other vitamins (riboflavin, vitamin B-6, vitamin C, and vitamin E adjusted for serum lipids) did not change differently in the surgical groups, and concentrations were either stable or increased. Furthermore, duodenal switch patients had lower hemoglobin and total cholesterol concentrations and a lower BMI (mean reduction: 41% compared with 30%) than did gastric bypass patients 1 y after surgery. Additional dietary supplement use was more frequent among duodenal switch patients (55%) than among gastric bypass patients (26%). Conclusions: Compared with gastric bypass, duodenal switch may be associated with a greater risk of vitamin A and D deficiencies in the first year after surgery and of thiamine deficiency in the initial months after surgery. Patients who undergo these 2 surgical interventions may require different monitoring and supplementation regimens in the first year after surgery. This trial was registered at clinicaltrials.gov as NCT00327912. Am J Clin Nutr 2009;90: 15–22.