Search

Background: Undetected obstructive sleep apnea (OSA) is highly prevalent in patients undergoing bariatric surgery and increases perioperative risks. Screening for OSA using preoperative polygraphy (PG) with subsequent continuous positive airway pressure (CPAP) is costly and time-consuming. Postoperative continuous pulse oximetry (CPOX) is less invasive, and is hypothesized to be a safe and cost-effective alternative., Objectives: This nationwide multicenter prospective observational cohort study compared CPOX monitoring with OSA-screening using PG., Setting: High-volume bariatric centers., Methods: Patients were either postoperatively monitored using CPOX without preoperative OSA-screening, or underwent preoperative PG and CPAP treatment when OSA was diagnosed. Cohort placement was based on local hospital protocols. Cost-effectiveness was analyzed using quality adjusted life years (QALYs) and healthcare costs. Surgical outcomes were also analyzed. Propensity score matching was used in sensitivity analyses., Results: A total of 1390 patients were included. QALYs were similar between groups at baseline and 1-year postoperatively. Postoperative complications, intensive care unit (ICU)-admissions and admissions, particularly OSA-related, did not differ between groups. Mean costs per patient/year in the CPOX group was €3094 versus €3680 in the PG group; mean difference €-586 (95% CI €-933-€-242). Following propensity score matching, 1090 of 1390 included patients remained, and similar findings for cost-effectiveness, complications, and ICU admissions were observed., Conclusion: CPOX monitoring without preoperative OSA-screening was not associated with higher complication or readmission rates compared to PG. CPOX resulted in lower costs from a healthcare perspective and can therefore be considered a cost-effective alternative to routine OSA-screening in patients undergoing bariatric surgery., (Copyright © 2024 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: In the Netherlands, bariatric surgery in adolescents is currently only allowed in the context of scientific research. Besides this, there was no clinical pathway for bariatric surgery in adolescents. In this paper, the development of a comprehensive clinical pathway for bariatric surgery in adolescents with severe obesity in the Netherlands is described., Methods: The clinical pathway for bariatric surgery in adolescents consists of an eligibility assessment as well as comprehensive peri- and postoperative care. Regarding the eligibility assessment, the adolescents need to be identified by their attending pediatricians and afterwards be evaluated by specialized pediatric obesity units. If the provided treatment is considered to be insufficiently effective, the adolescent will anonymously be evaluated by a national board. This is an additional diligence procedure specifically established for bariatric surgery in adolescents. The national board consists of independent experts regarding adolescent bariatric surgery and evaluates whether the adolescents meet the criteria defined by the national professional associations. The final step is an assessment by a multidisciplinary team for adolescent bariatric surgery. The various disciplines (pediatrician, bariatric surgeon, psychologist, dietician) evaluate whether an adolescent is eligible for bariatric surgery. In this decision-making process, it is crucial to assess whether the adolescent is expected to adhere to postoperative behavioral changes and follow-up. When an adolescent is deemed eligible for bariatric surgery, he or she will receive preoperative counseling by a bariatric surgeon to decide on the type of bariatric procedure (Roux-en-Y gastric bypass or sleeve gastrectomy). Postoperative care consists of intensive guidance by the multidisciplinary team for adolescent bariatric surgery. In this guidance, several regular appointments are included and additional care will be provided based on the needs of the adolescent and his or her family. Furthermore, the multidisciplinary lifestyle intervention, in which the adolescents participated before bariatric surgery, continues in coordination with the multidisciplinary team for adolescent bariatric surgery, and this ensures long-term counseling and follow-up., Conclusion: The implementation of bariatric surgery as an integral part of a comprehensive treatment for adolescents with severe obesity requires the development of a clinical pathway with a variety of disciplines., (© 2024 The Author(s). Published by S. Karger AG, Basel.)

Purpose: Bariatric surgery is the most effective treatment for severe obesity in adults and has shown promising results in young adults. Lack of insight regarding efficacy and safety outcomes might result in delayed bariatric surgery utilization in young adults. Therefore, this study aimed to assess the efficacy and safety of bariatric surgery in young adults compared to adults., Methods: This is a nationwide population-based cohort study utilizing data from the Dutch Audit Treatment of Obesity (DATO). Young adults (aged 18-25 years) and adults (aged 35-55 years) who underwent primary Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) were included. Primary outcome was percentage total weight loss (%TWL) until five years postoperatively., Results: A total of 2,822 (10.3%) young adults and 24,497 (89.7%) adults were included. The follow-up rates of the young adults were lower up to five years postoperatively (46.2% versus 56.7% three years postoperatively; p < 0.001). Young adults who underwent RYGB showed superior %TWL compared to adults until four years postoperatively (33.0 ± 9.4 versus 31.2 ± 8.7 three years after surgery; p < 0.001). Young adults who underwent SG showed superior %TWL until five years postoperatively (29.9 ± 10.9 versus 26.2 ± 9.7 three years after surgery; p < 0.001). Postoperative complications ≤ 30 days were more prevalent among adults, 5.3% versus 3.5% (p < 0.001). No differences were found in the long term complications. Young adults revealed more improvement of hypertension (93.6% versus 78.9%), dyslipidemia (84.7% versus 69.2%) and musculoskeletal pain (84.6% versus 72.3%)., Conclusion: Bariatric surgery appears to be at least as safe and effective in young adults as in adults. Based on these findings the reluctance towards bariatric surgery in the younger age group seems unfounded., (© 2023. The Author(s).)

Purpose: Obstructive sleep apnea (OSA) is highly prevalent but mostly undiagnosed in obese patients scheduled for bariatric surgery. To prevent cardiopulmonary complications, many clinics perform preoperative OSA screening. Consequently, adequate adherence to continuous positive airway pressure (CPAP) therapy is essential but challenging. We aimed to evaluate CPAP adherence and its influence on postoperative outcomes., Methods: In a prospective multicenter cohort study, we compared different perioperative strategies for handling undiagnosed OSA in bariatric patients. In this subgroup analysis, patients newly diagnosed with OSA were compared to those with pre-existing OSA. We assessed inadequate CPAP adherence, defined as < 4 h/night, between the preoperative period and 6 months postoperative. Cardiopulmonary complications and (un)scheduled ICU admissions were also evaluated., Results: In total, 272 patients with newly diagnosed OSA (67.4%) and 132 patients with pre-existing OSA (32.6%) were included. Before surgery, 41 newly diagnosed patients used CPAP inadequately, compared to 5 patients with pre-existing OSA (15% vs. 4%, p = 0.049). Six months after surgery, inadequate CPAP use increased to 73% for newly diagnosed patients and 39% for patients with pre-existing OSA, respectively (p < 0.001). Incidences of cardiopulmonary complications, scheduled, and unscheduled ICU admissions were similar in the two study groups (p = 0.600, p = 0.972, and p = 0.980, respectively)., Conclusion: Inadequate CPAP adherence is higher in bariatric patients newly diagnosed with OSA when compared to patients with pre-existing OSA. Strategies to increase CPAP adherence may be valuable when considering routine OSA screening and CPAP therapy in patients undergoing bariatric surgery. Further studies are needed to improve current guidelines on perioperative OSA management of obese patients., Trial Registration: POPCORN study, registered at Netherlands Trial Register, https://www.trialregister.nl/trial/6805 . ID no: 6805., (© 2022. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Background: The increased human life expectancy and prevalence of obesity lead to more elderly people with obesity. As the popularity of bariatric surgery continues to grow, more elderly persons apply for bariatric surgery. However, because of the potentially higher surgical risk in elderly patients, bariatric surgery has been performed in small numbers. Moreover, the literature so far has shown controversial results., Objective: To determine the safety of bariatric surgery in elderly patients in terms of 2-year morbidity and mortality., Setting: Dutch nationwide mandatory registry for bariatric surgery., Methods: A population-based retrospective cohort study. Elderly patients (aged ≥65 years) who received primary bariatric surgery between January 2015 and January 2020 were compared with the general bariatric surgical population (aged 18-65 years)., Results: Of 49,553 patients, 838 elderly patients (1.7%) were included. An intraoperative complication was registered in 1.2% of the elderly patients and 1.1% of the nonelderly patients (P = .814). A severe short-term complication (≤30 days) was registered in 38 elderly patients (4.5%) and 1071 nonelderly patients (2.2%) (P < .001). The short-term mortality rates were .2% and .1%, respectively (P = .173). Bleeding was the most reported short-term complication. Significantly more nonelderly patients had a follow-up visit; 560 elderly patients (66.8%) versus 34,975 nonelderly patients (71.8%) (P = .002). The severe midterm complication rate (>30 days to ≤2 years) was significantly higher in nonelderly patients (3.7% versus 1.6%; P = .008)., Conclusions: Bariatric surgery in elderly patients is safe in terms of perioperative outcome, mortality, and midterm complication rate. However, elderly patients experienced twice as many severe short-term complications. Bariatric surgery in elderly patients should be recommended on a case-by-case basis., (Copyright © 2023 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Children and adolescents with overweight and obesity have an impaired health-related quality of life (HRQoL). However, it is unclear which of these children are most affected in their physical, psychological, and social functioning. Therefore, this study aimed to evaluate HRQoL in treatment-seeking children and adolescents with overweight, obesity, and severe obesity., Methods: A cross-sectional study was performed at the Centre for Overweight Adolescent and Children's Healthcare (COACH). Children and adolescents (8-17 years) with overweight, obesity, and severe obesity were included. The primary outcome was the self-reported HRQoL measured with the KIDSCREEN-27., Results: A total of 419 participants with overweight (N = 121), obesity (N = 182), and severe obesity (N = 116) were included. One-way ANOVA analysis showed that children and adolescents with severe obesity reported significantly lower physical well-being (41.25 ± 13.14) compared to those with overweight (47.91 ± 12.53; p < 0.001) and obesity (46.74 ± 11.93; p < 0.001). Furthermore, impaired psychological well-being was found in the group with severe obesity (45.14 ± 13.27) in comparison to the group with overweight (50.90 ± 9.48; p < 0.001) and obesity (49.71 ± 10.95; p = 0.002). Multivariable linear regression analysis, while correcting for age, sex, cardio metabolic health risk, and ethnicity, revealed similar results. Additionally, children and adolescents with severe obesity scored lower regarding autonomy and parent relation than those with overweight (B = 3.95; p = 0.009). In almost all groups and dimensions of the KIDSCREEN-27, caregivers scored lower compared to the children and adolescents themselves. Furthermore, a low child-caregiver agreement seemed to exist, especially in the children and adolescents with overweight., Conclusion: The HRQoL of treatment-seeking children and adolescents with overweight and obesity was most affected in children and adolescents with the most severe grade of obesity. Following these findings, lifestyle intervention programs targeting childhood obesity should be aware of this even more vulnerable group so that treatments can be tailored according to their needs., (© 2023 The Author(s). Published by S. Karger AG, Basel.)

Background: Bariatric complications may occur during pregnancy, potentially causing serious maternal and fetal problems. The aim of this study was to determine the current practice and preferences of bariatric surgeons regarding the pregnancy care of fertile women before and after bariatric surgery., Methods: A 26-question anonymous online survey was designed and sent to all bariatric surgeons of the Dutch Society of Metabolic and Bariatric Surgery., Results: At least one bariatric surgeon from each bariatric center ( n  = 18) completed the survey. In case of a future child, wish sleeve gastrectomy became more popular than Roux-en-Y gastric bypass. All surgeons provided preoperative education regarding bariatric complications during pregnancy. Nine centers without neonatal intensive care would not refer pregnant women with acute complications. Half of the centers had a standard operating procedure. Seven per 18 bariatric centers had seen at least one postbariatric pregnant patient with severe maternal morbidity. One case of perinatal mortality was reported., Conclusion: There is an inconsistent and often below guideline standard daily practice regarding pregnancy before and after bariatric surgery. There is limited experience with pregnant women with acute bariatric complications. Referral to tertiary centers is inadequate. Better information provision for both professionals and patients regarding possible complications is needed., Competing Interests: The authors declare that they have no conflict of interests., (© Daniëlle S. Bonouvrie et al. 2022; Published by Mary Ann Liebert, Inc.)

Lifestyle interventions are the common treatment for children and adolescents with severe obesity. The efficacy of these interventions across age groups remain unknown. Therefore, this study aimed to compare the effectiveness of a lifestyle intervention on health parameters between children and adolescents with severe obesity. A longitudinal design was carried out at the Centre for Overweight Adolescent and Children's Healthcare (COACH) between December 2010 and June 2020. Children (2-11 years old, n = 83) and adolescents (12-18 years old, n = 77) with severe obesity received a long-term, tailored, multidisciplinary lifestyle intervention. After 1 year, 24 children (28.9%) and 33 adolescents (42.9%) dropped out of the intervention. The primary outcome was the change in body mass index (BMI) z-score after one and two years of intervention. The decrease in BMI z-score over time was significantly higher in children compared to adolescents, the mean decrease was 0.15 (0.08-0.23) versus 0.03 (-0.05-0.11) after one year and 0.25 (0.15-0.35) versus 0.06 (-0.06-0.17) after two years of intervention; p values for the difference between children and adolescents were 0.035 and 0.012. After two years, multiple improvements in cardio metabolic health parameters were observed, especially in children. In conclusion, during our tailored lifestyle intervention, a positive and maintained effect on health parameters was observed in children with severe obesity. Compared to children, the effect on health parameters was less pronounced in adolescents.

Background: The most commonly performed bariatric procedures worldwide are Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG), yet outcomes following these procedures in young adults are limited. Therefore, the objective of this study was to compare weight loss outcomes between RYGB and SG in young adults., Methods: This is a nationwide retrospective cohort study of young adults, aged 18-25 years, who underwent RYGB or SG between 2015 and 2019, with data from the Dutch Audit Treatment of Obesity (DATO). The primary outcome was weight loss expressed as percentage total weight loss (%TWL) in a period of 3 years after surgery. Secondary outcomes were the incidence of complications (< 30 days) and progression of obesity-related comorbidities., Results: In total, 2313 patients were included, 1246 in the RYGB group and 1067 in the SG group. Percentage TWL was significantly higher in the RYGB group compared to the SG group at 1, 2, and 3 years after surgery (respectively 2.4%, 2.9%, and 3.3% higher, p < 0.001). RYGB was associated with an on-average 2.75 higher %TWL compared to SG in females (p < 0.001), although this was not seen in males (β = 0.63, p = 0.514). No differences were found in the incidence of complications, nor the progression of obesity-related comorbidities except for gastroesophageal reflux disease (GERD). There was more improvement or resolution of GERD in the RYGB group (95.2% vs. 56.3%, p < 0.001)., Conclusion: Similar numbers of RYGB and SG were performed in young adults, whereas RYGB was associated with greater weight loss in the short- and midterm, particularly in females., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Small bowel obstruction (SBO) is a late complication of Roux-en-Y gastric bypass (RYGB). In non-pregnant patients, computed tomography (CT) is the first choice of imaging. During pregnancy, magnetic resonance imaging (MRI) is preferred to limit exposure to ionizing radiation. However, literature regarding the diagnostic accuracy of MRI for SBO is scarce., Objective: To describe the diagnostic accuracy of MRI for SBO during pregnancy., Methods: Pregnant women with RYGB suspected for SBO who presented at our center between September 2015 and April 2020 and who received an MRI scan (index) and underwent surgery (reference) were included. Original reports were retrospectively evaluated. Available MRI scans were structurally reinterpreted by two experienced radiologists. Statistical analysis included sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and Cohen's kappa., Results: Twenty-seven original MRI reports were included. Twenty-four (89%) MRIs were of good quality. Sensitivity was 67% (confidence interval (CI) 0.43-0.85), specificity 67% (CI 0.13-0.98), PPV 93% (CI 0.66-0.99), and NPV 22% (CI 0.04-0.60). MRI was unable to detect SBO in 1 out of 3 patients. The presence of swirl sign, SBO sign, or clustered loop sign increases the likelihood of SBO. The interobserver agreement was overall wide, with the highest score for swirl sign (κ 0.762)., Discussion: MRI is a safe and feasible alternative for CT. The value is doubtful as diagnostic accuracy shows wide ranges with considerable variability in the interobserver agreement. We would cautiously advise to perform MRI in case of a mild clinical presentation, but in case of a severe clinic, the diagnostic laparoscopy should remain the gold standard., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: Transanal total mesorectal excision (TaTME) was developed to overcome surgical difficulties experienced in distal pelvic dissection. Concerns have been raised about potential worse postoperative functional outcomes after TaTME. Also, the oncological safety was questioned. This study aimed to describe the functional, surgical, oncological outcomes and quality of life (QoL) after TaTME., Methods: All consecutive TaTME cases for rectal cancer without disseminated disease between December 2016 and April 2019 were included. The Wexner incontinence score, low anterior resection syndrome (LARS) score, fecal incontinence-related QoL, and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-core questionnaire and 29-item module (EORTC QLQ-C30/CR29) were collected. Kaplan-Meier analysis was used to calculate local recurrence-free survival., Results: Thirty patients were eligible for analysis of which 23 received questionnaires. Response rate was 74%. After a median follow-up of respectively 20.0 and 23.0 months for functional and oncological outcomes, the median (interquartile range) of Wexner incontinence and LARS scores were 9.0 (7.0-12.0) and 33.1 (25.0-39.0). Major LARS was present in 73.3%. Fecal incontinence, general and colorectal-specific QoL subdomains that are associated with poor bowel function scored in line with previously reported data. The 2-year actuarial cumulative local recurrence rate was 3.7% (95% confidence interval, 2.4%-5.0%)., Conclusion: TaTME may lead to significant functional impairments. Patients should receive preoperative counseling on this topic and be fully aware of the potential consequences of their treatment. Oncological data were in line with other short- to moderate-term data and did not show alarming results.

Background: Recent studies have indicated that bariatric surgery is effective for the treatment of youth with severe obesity. The attitudes of pediatricians, parents, and adolescents regarding this topic remain unclear. Therefore, the aim of this study was to assess the current thoughts and beliefs of Dutch pediatricians, parents, and adolescents regarding bariatric surgery in youth., Methods: An online survey containing twenty questions on bariatric surgery in youth was distributed to pediatricians of the Dutch Society of Pediatrics. Parents and adolescents who participated in an interdisciplinary care program for overweight, obesity, and severe obesity filled out an online survey of twelve questions., Results: One hundred and twenty-one pediatricians, 49 parents, and 19 adolescents completed the surveys. Seventy-two pediatricians (59.5%) considered bariatric surgery to be an effective treatment for youth with severe obesity when conventional treatment fails, and intend to refer patients for bariatric surgery. The most frequently suggested conditions for bariatric surgery were a minimum age of 16 years (n = 59, 48.7%), a BMI threshold of 40 kg/m 2 (n = 51, 42.2%), and a minimum Tanner stage of IV (n = 59, 48.8%). Thirty parents (61.2%) and fourteen adolescents (73.7%) responded that bariatric surgery should become available for youth with severe obesity., Conclusion: Dutch pediatricians, parents, and adolescents increasingly accept bariatric surgery as a treatment modality in youth with severe obesity who do not respond successfully to lifestyle intervention. Whether pediatricians will actually refer youth for bariatric surgery remains to be seen when this treatment option will be implemented in the Netherlands., (© 2021. The Author(s).)

There has been little agreement on the predictive value of emotional eating on weight loss outcomes after bariatric surgery. The aim of this study was to examine the predictive value of preoperative emotional eating, in response to clearly labelled emotions and diffuse emotions, on excess weight loss (EWL) and total weight loss (TWL) 2 years after Roux-en-Y gastric bypass (RYGB). All participants included in this retrospective cohort study were screened for RYGB surgery by a multidisciplinary team. The level of emotional eating was derived from the Dutch Eating Behaviour Questionnaire (DEBQ); the level of psychological variables from the Symptom Checklist-90. Participants were clustered, based on their DEBQ score, in high and low emotional eaters. Multiple linear regression analyses were performed to examine the association between preoperative emotional eating and EWL, and TWL. There were no significant differences in EWL of the 172 included participants, defined as either high or low emotional eaters (EWL 82.7% ±18.2 versus 82.4% ±21.3, respectively). Based on the regression analysis, emotional eating was not significantly associated with EWL, nor with TWL. When corrected for psychological, demographic and biological variables, preoperative emotional eating in response to diffuse emotions negatively affected EWL (β = -0.16, P = 0.048), although this was not applicable for TWL. Preoperative emotional eating does not seem to influence EWL, nor TWL 2 years after RYGB. Since this study faced multiple limitations, further investigation is required regarding the predictive value of emotional eating., (© 2021 The Authors. Clinical Obesity published by John Wiley & Sons Ltd on behalf of World Obesity Federation.)

There is no consensus about the optimal management of patients undergoing bariatric surgery. This study aimed to identify current weight loss goals prior to bariatric surgery, as well as aimed to explore preoperative strategies related to diet, nutritional supplements and physical activity. An online survey was distributed among bariatric surgeons and dietitians in all 18 Dutch bariatric centers. This survey included the following four domains: weight loss, diet, nutritional supplements and physical activity. For the analyses one answer per center was used, either the most common answer or the answer given by the most expert responder. All 18 centers reported at least one response. Preoperative weight loss was requested in 28% of the centers, whereas 61% desired a stable weight or weight loss, and 11% had no requests. A preoperative diet was routinely recommended in 78% of the centers and on indication (ie, depending on baseline weight and/or comorbidity status) in 22%. The most frequently prescribed diet was a low-energy diet (800-1500 kcal/day) in 44% of the centers. Nutritional supplements were recommended in 78% of the centers. Physical activity with low intensity was recommended in 83% of the centers, while physical exercise training with mid- to high-intensity was recommended in 72%. Inconsistent responses within centers were observed in 56% of the questions. The current bariatric practice within the Netherlands shows high variability and inconsistencies in preoperative management. Consensus-building and standardization of strategies should be promoted in the future., (© 2021 The Authors. Clinical Obesity published by John Wiley & Sons Ltd on behalf of World Obesity Federation.)

Background: When performing a Roux-en-Y gastric bypass (RYGB), the gastroenterostomy can be constructed with a circular stapled or linear stapled technique. The size of the gastroenterostomy depends on the stapling method and this may affect weight loss outcomes. The aim of this study was to examine the impact of the stapling technique on weight loss outcomes after RYGB., Methods: This is a nationwide population-based cohort study of patients that received a RYGB. Data were derived from the Dutch Audit of Treatment of Obesity. Primary outcome was the impact of stapling technique on the rate of non-response defined as significant weight regain (≥20% of a patients' lost weight) 2-4 years post-surgery, after initial successful weight loss (≥20% total weight loss, TWL). Secondary outcomes were the rate of response, defined as successful weight loss (≥20% TWL) within 1.5 years post-surgery, the incidence of complications and the progression of comorbidities., Results: In a cohort of 12,468 patients, non-response was equally distributed between both groups (circular 18.0% vs. linear 17.6%). No differences in response rate (circular 97.0% vs. linear 96.5%) or %TWL were observed up to 4 years post-surgery. Patients in the circular stapled group experienced more complications, specifically major bleedings (2.4% vs. 1.2%; p=0.002) within 30 days postoperatively. No differences were found in deteriorated comorbidities, neither in de novo developed comorbidities., Conclusion: When comparing stapling technique in RYGB, weight loss outcomes did not differ during a 4-year follow-up period. The linear stapled gastroenterostomy could pose an advantage due to its lower complication rate., (© 2021. The Author(s).)

Despite the initial successful weight loss after bariatric surgery, a significant amount of patients experience weight loss failure and weight regain. Several factors are known to contribute to this, though the impact of employment status is unknown. The objective of this systematic review was to examine the impact of employment status on post-surgical weight loss outcomes. Eight studies were included with a follow-up ranging between 2 and 10 years. Employed patients seemed to present more weight loss (9.0-11.0% EWL, 1.3-1.6% BMI loss) compared to unemployed patients, but none of these numbers were statistically significant. Moreover, there were contrasting findings in terms of weight regain. This review may highlight the importance of working status after bariatric surgery and warrants further investigation on this topic., (© 2021. The Author(s).)

Background: As result of bariatric surgery, patients are susceptible to protein deficiency which can result in undesirable lean body mass (LBM) loss. Consumption of high-protein diets or supplements could counteract this, but evidence about the effect is scarce. This paper systematically reviewed the literature to determine the effect of additional protein intake (≥60 g/day) on LBM preservation in post-bariatric patients., Methods: An electronic search of PubMed, EMBASE and the Cochrane Library was conducted. Studies were included if patients received a high-protein diet or protein supplements for at least one month, and LBM was assessed. The primary outcome was difference in mean LBM loss between the experimental (protein) and control group. Secondary outcomes were differences in body fat mass, total body water, body mass index and resting metabolic rate., Results: Two of the five included studies (n = 223) showed that consumption of proteins resulted in significant LBM preservation. Only one study reported a significant difference in the reduction of body fat mass and resting metabolic rate in favour of a high-protein diet, but none of the studies showed a significant difference in total body water loss or body mass index change between the two groups., Conclusions: This paper showed inconclusive evidence for LBM preservation due to protein supplementation or a high-protein diet in post-bariatric patients. This outcome might be subjected to certain limitations, including a lack of blinding and a low compliance rate reported in the included studies. More specific and personalized recommendations regarding protein intake may need to be established by high quality research. Studies investigating the quantity (g/day) and quality (whey, casein or soy) of proteins are also needed.

An energy-restricted diet is often prescribed before bariatric surgery to reduce weight and liver volume. While very-low-calorie diets (VLCDs, 450-800 kcal per day) have shown to be effective, the effectiveness of low-calorie diets (LCDs, 800-1500 kcal per day) is less obvious. The objective of this systematic review was to elucidate the effectiveness of LCD on liver volume reduction in patients awaiting bariatric surgery. Eight studies (n = 251) were included describing nine different diets (800-1200 kcal, 2-8 weeks). An LCD was effective in liver volume reduction (12-27%) and weight loss (4-17%), particularly during the first weeks. The LCD showed an acceptable patients' compliance. Based on these findings, an LCD (800-1200 kcal), instead of a VLCD, for 2 to 4 weeks should be preferred.

A 26-year-old multigravida, 30 +3 weeks pregnant woman, was referred to our tertiary referral centre with acute abdominal pain and vomiting suspected for internal herniation. She had a history of a primary banded Roux-en-Y gastric bypass (B-RYGB). The MRI scan showed a clustered small bowel package with possible mesenteric swirl diagnosed as internal herniation. A diagnostic laparoscopy was converted to laparotomy showing an internal herniation of the alimentary limb through the silicone ring. The internal herniation was reduced by cutting the silicone ring. Postoperative recovery, remaining pregnancy and labour were uneventful. During pregnancy after B-RYGB, small bowel obstruction can in rare cases occur due to internal herniation through the silicone ring. Education regarding this complication should be provided before bariatric surgery. Treatment of women, 24 to 32 weeks pregnant, in a specialised centre for bariatric complications with a neonatal intensive care unit is advised to improve maternal and neonatal outcome., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Despite the frequent success of bariatric surgery, 20-30% of patients do not respond well. These patients may experience insufficient weight loss, defined as primary non-response, or may regain an excessive amount of weight after sufficient weight loss, defined as secondary non-response. The aetiology and subsequent treatment of these two types of non-response may differ. This is illustrated by three cases: a patient with primary non-response after gastric bypass (total weight loss 18%) treated conservatively; a patient with secondary non-response after gastric bypass (total weight loss 27%) treated conservatively and lost 7kg as a result of this therapy; a patient with secondary non-response after gastric bypass (total weight loss 27%) treated surgically though experienced malabsorptive complaints as result of distalisation. These cases can be used to demonstrate the challenges that are faced by professionals in the current treatment of post-bariatric surgery patients.

Introduction: Despite the high prevalence of obstructive sleep apnoea (OSA) in obese patients undergoing bariatric surgery, OSA is undiagnosed in the majority of patients and thus untreated. While untreated OSA is associated with an increased risk of preoperative and postoperative complications, no evidence-based guidelines on perioperative care for these patients are available. The aim of the POPCORN study ( P ost- O perative P ulse oximetry without OSA s C reening vs perioperative continuous positive airway pressure (CPAP) treatment following O SA sc R ee N ing by polygraphy (PG)) is to evaluate which perioperative strategy is the most cost-effective for obese patients undergoing bariatric surgery without a history of OSA., Methods and Analysis: In this multicentre observational cohort study, data from 1380 patients who will undergo bariatric surgery will be collected. Patients will receive either postoperative care with pulse oximetry monitoring and supplemental oxygen during the first postoperative night, or care that includes preoperative PG and CPAP treatment in case of moderate or severe OSA. Local protocols for perioperative care in each participating hospital will determine into which cohort a patient is placed. The primary outcome is cost-effectiveness, which will be calculated by comparing all healthcare costs with the quality-adjusted life-years (QALYs, calculated using EQ-5D questionnaires). Secondary outcomes are mortality, complications within 30 days after surgery, readmissions, reoperations, length of stay, weight loss, generic quality of life (QOL), OSA-specific QOL, OSA symptoms and CPAP adherence. Patients will receive questionnaires before surgery and 1, 3, 6 and 12 months after surgery to report QALYs and other patient-reported outcomes., Ethics and Dissemination: Approval from the Medical Research Ethics Committees United was granted in accordance with the Dutch law for Medical Research Involving Human Subjects Act (WMO) (reference number W17.050). Results will be submitted for publication in peer-reviewed journals and presented at (inter)national conferences., Trial Registration Number: NTR6991., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Pregnant women with a history of bariatric surgery (BS) may develop acute abdominal pain related to this surgery, especially after Roux-en-Y gastric bypass. Studies showed alarming results regarding maternal and foetal morbidity and mortality. The aim of this study was to analyse these outcomes for pregnant women and their offspring., Methods: Single-centre retrospective cohort study in a tertiary referral centre for bariatric complications during pregnancy. Pregnant women with a history of BS referred between September 2015 and November 2019 with acute abdominal pain suspected for a bariatric complication were included. Data were retrospectively collected from the patient files, and a questionnaire was sent regarding the postoperative course and childbirth., Results: Fifty women were included. At presentation, mean maternal age was 31 (± 4) years, and median gestational age was 28 +4 (25 +4 , 30 +5 ) weeks. Thirteen women were treated conservatively. Thirty-seven women underwent surgery for, among others, internal herniation (n = 26) and intussusception (n = 6). Six women required small bowel resection. Two women underwent an emergency caesarean section shortly after the surgery due to foetal distress. Eight women delivered preterm of whom five infants required respiratory support. There was one intrauterine foetal death. Surgery > 48 h after the onset of the symptoms was not associated with an increase in small bowel resections or preterm birth., Conclusion: Acute abdominal pain in pregnant women may be related to a bariatric complication. Further awareness of bariatric complications within the obstetric care and transferal to specialized care to prevent diagnostic delay may improve maternal and neonatal outcome.

Background: Weight loss failure or weight regain occurs in up to 25% of patients with a Roux-en-Y gastric bypass (RYGB). Post-operative anatomical changes, like pouch or stoma dilatation, might contribute. Aim of this study is to assess reliability and usefulness of upper gastro intestinal (UGI) contrast studies to detect pouch dilatation. Methods: Retrospective case-control study of patients with weight loss failure between 2010 and 2015 (failure group, n  = 101) and a control group ( n  = 101) with adequate weight loss. Pouch dilatation was systematically reassessed. Clinical parameters were extracted from the electronic patient records. Results: Systematic reassessment showed 23/101 (23%) pouch dilatation in the failure group, compared to 11/101 (11%) in the control group ( p  = .024). Revision surgery was performed in 43/101 patients in the failure group. After this surgery, only 8% of patients with pouch dilatation achieved adequate weight loss, whereas 39% of patients without pouch dilatation achieved adequate weight loss ( p  = .07). There was no difference in return to adequate weight loss between patients treated surgically and conservatively (30% vs 28%). Conclusion: Systematic reassessment of UGI contrast studies showed 23% pouch dilatation in patients with weight loss failure after RYGB. However, low interobserver agreement and discrepancy in success rate of revision surgery greatly questions the reliability and usefulness of this diagnostic modality.

Intussusception of the small intestine has been described in pregnant women with a history of a laparoscopic Roux-en-Y gastric bypass. This study provides a systematic review on the characteristics of intussusception in this population. MEDLINE, Embase, Cochrane Library, and our own hospital's electronics health records were searched for eligible studies/cases. Fifteen papers were eligible, containing 17 cases. Our hospital search included 6 cases. Seventeen of 23 intussusceptions were retrograde and were mostly (18/23) located at the jejunojejunostomy. Six patients were treated successfully with manual reduction only and 17 patients required surgical resection. Fifteen (65%) patients had an ischemic segment. Six (26%) patients delivered during the same hospital admission. One fetal death (1 of twins) was reported. Awareness of this rare but serious complication by obstetricians and bariatric surgeons is necessary to limit maternal and fetal complications., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: Primary nonresponse (1NR) - inability to achieve adequate weight loss after surgery - and secondary nonresponse (2NR) - excessive weight regain after initial adequate weight loss after surgery - can occur in up to 25-35% of patients after bariatric surgery. The aim of this study was to explore the variations in both definition as well as management of 1NR and 2NR amongst bariatric surgeons., Materials and Methods: An online survey was distributed to all members of the national bariatric societies in the Netherlands and Belgium regarding questions about definition, work-up and treatment of 1NR and 2NR after bariatric surgery., Results: A total of 45 responses from bariatric surgeons were obtained, representing 32 medical centers that perform bariatric procedures. When assessing 1NR, excess weight loss(EWL) was reported to be used by most respondents(30/45), total body weight loss(TBWL) by 18/45 and body mass index(BMI) by 25/45. A great variation in cut off values was observed. When assessing 2NR, percentage weight gain from the lowest (nadir) weight was preferred most by 22/45 respondents with cut off values varying from 5 to 20%. Most respondents deemed 18 months after initial surgery the most appropriate timeframe to determine 1NR or 2NR., Conclusions: The current practice regarding primary and secondary nonresponse after bariatric surgery has a wide variety in definitions, work-up and treatment options. Consensus on the definition of 1NR and 2NR is needed to optimize the treatment of bariatric patients.

Background: Weight loss outcomes after bariatric surgery are less favorable in super morbidly obese patients (BMI ≥50 kg/m 2 ). Non-response, either defined as insufficient weight loss or weight regain after initial successful weight loss, is a matter of serious concern in these patients. The primary banded Roux-en-Y gastric bypass has shown promising results regarding weight loss in the bariatric population. However, up to now, long-term comparative data about the banded and non-banded bypass in superobese patients is lacking. The aim of this study is to assess the added value of the banded Roux-en-Y gastric bypass in superobese patients on long-term weight loss outcomes., Methods: This single center study will evaluate superobese patients who receive a non-banded Roux-en-Y gastric bypass (NB-RYGB) and a banded Roux-en-Y gastric bypass (B-RYGB). Data from the NB-RYGB group will be collected in retrospect, while data from the B-RYGB group will be collected prospectively. When performing a B-RYGB, a 7.0-8.0 cm silastic ring (MiniMizer®) will be placed proximal to the gastrojejunostomy. The main outcomes of this study are weight loss and non-response during a 10 year follow-up period. Secondary outcomes are reduction of obesity related comorbidities and medication, (ring-related) morbidity and mortality, complications, re-operations, patient satisfaction and health-related quality of life. A total of 142 patients will be included in this study., Discussion: This study will help establish the clinical utility of the B-RYGB in superobese patients., Trial Register: NL8093. Registered 15 October 2019 - Retrospectively registered on the Dutch Registry of Clinical trials, www.trialregister.nl.

Background: Recent data support the use of bariatric surgery in adolescents with severe obesity following unsuccessful non-surgical treatments. Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) have demonstrated reasonably similar weight loss and reduction of obesity related comorbidities in randomized trials in adults. SG has internationally become the most commonly used procedure in adolescents, yet long-term outcome data are lacking. No randomized controlled trial comparing SG and RYGB has been performed in adolescents., Objective: Determine whether SG is non-inferior to RYGB in terms of total body weight (TBW) loss in adolescents with severe obesity., Methods: A multicenter randomized controlled non-inferiority trial. Two hundred sixty-four adolescents aged 13-17 (Tanner stage ≥IV) with severe obesity (corrected for age and sex) will be included. Adolescents agreeing to participate will be randomized to either RYGB or SG. The primary outcome is the proportion of participants achieving 20% TBW loss at 3 years postoperatively. Secondary outcomes include (i) change in body weight, body mass index (BMI) and BMI standard deviation score, (ii) incidence of adverse health events and need for additional surgical intervention, (iii) resolution of obesity-related comorbidities, (iv) prevalence of cardio metabolic risk factor measures, (v) bone health measures and incidence of bone fractures, (vi) quality of life including psychosocial health, patient satisfaction and educational attainment and (vii) body composition. Follow-up will extend into the long term., Results: Not applicable., Discussion: This study will, to our knowledge, be the first randomized controlled trial comparing SG and RYGB in adolescents with severe obesity., Trial Registration: The trial is registered at the Netherlands Trial Register on July 26th, 2018 - NTR7191 - https://www.trialregister.nl/trial/7191 (protocol version 5.0 - February 3th 2020).

Background: Excess lipid availability has been associated with the development of anabolic resistance. As such, obesity may be accompanied by impairments in muscle protein metabolism., Objective: We hypothesized that basal and postprandial muscle protein synthesis rates are lower in obese than in lean men., Methods: Twelve obese men [mean ± SEM age: 48 ± 2 y; BMI (in kg/m2): 37.0 ± 1.5; body fat: 32 ± 2%] and 12 age-matched lean controls (age: 43 ± 3 y; BMI: 23.4 ± 0.4; body fat: 21 ± 1%) received primed continuous L-[ring-2H5]-phenylalanine and L-[ring-3,5-2H2]-tyrosine infusions and ingested 25 g intrinsically L-[1-13C]-phenylalanine labeled whey protein. Repeated blood and muscle samples were obtained to assess protein digestion and amino acid absorption kinetics, and basal and postprandial myofibrillar protein synthesis rates., Results: Exogenous phenylalanine appearance rates increased after protein ingestion in both groups (P < 0.001), with a total of 53 ± 1% and 53 ± 2% of dietary protein-derived phenylalanine appearing in the circulation over the 5-h postprandial period in lean and obese men, respectively (P = 0.82). After protein ingestion, whole-body protein synthesis and oxidation rates increased to a greater extent in lean men than in the obese (P-interaction < 0.05), resulting in a higher whole-body protein net balance in the lean than in the obese (7.1 ± 0.2 and 4.6 ± 0.4 µmol phenylalanine · h-1 · kg-1, respectively; P-interaction < 0.001). Myofibrillar protein synthesis rates increased from 0.030 ± 0.002 and 0.028 ± 0.003%/h in the postabsorptive period to 0.034 ± 0.002 and 0.035 ± 0.003%.h-1 in the 5-h postprandial period (P = 0.03) in lean and obese men, respectively, with no differences between groups (P-interaction = 0.58)., Conclusions: Basal, postabsorptive myofibrillar protein synthesis rates do not differ between lean and obese middle-aged men. Postprandial protein handling, including protein digestion and amino acid absorption, and the postprandial muscle protein synthetic response after the ingestion of 25 g whey protein are not impaired in obese men. This trial was registered at www.trialregister.nl as NTR4060., (Copyright © American Society for Nutrition 2019.)

Background: Bariatric surgery is regarded as the most effective treatment of morbid obesity in adults. Referral patterns for bariatric surgery in adults differ among general practitioners (GPs), partially due to restricted knowledge of the available treatment options. Reluctance in referral might be present even stronger in the treatment of morbidly obese children., Objectives: The aim of this study was to investigate the current practice of GPs regarding treatment of paediatric morbid obesity and their attitudes towards the emergent phenomenon of paediatric weight loss surgery., Methods: All GPs enlisted in the local registries of two medical centres were invited for a 15-question anonymous online survey., Results: Among 534 invited GPs, 184 (34.5%) completed the survey. Only 102 (55.4%) reported providing or referring morbidly obese children for combined lifestyle interventions. A majority (n = 175, 95.1%) estimated that conservative treatment is effective in a maximum of 50% of children. Although 123 (66.8%) expect that bariatric surgery may be effective in therapy-resistant morbid obesity, only 76 (41.3%) would consider referral for surgery. Important reasons for reluctance were uncertainty about long-term efficacy and safety. The opinion that surgery is only treatment of symptoms and therefore not appropriate was significantly more prevalent amongst GPs who would not refer (58.3% vs. 27.6%, p < 0.001)., Conclusion: There is a potential for undertreatment of morbidly obese adolescents, due to suboptimal knowledge regarding guidelines and bariatric surgery, as well as negative attitudes towards surgery. This should be addressed by improving communication between surgeons and GPs and providing educational resources on bariatric surgery.

Lack of standard definitions of primary and secondary (non)responders after RYGB and SG makes it impossible to compare the literature. The aim was to analyze the different definitions used. MEDLINE® was searched for literature published between 01-07-2014 and 01-07-2017 concerning (1) patients who received a primary RYGB or SG and (2) the outcomes of primary and secondary (non)responders. One hundred twelve out of 650 papers were eligible. Forty out of 47 papers described a definition of weight loss success. Sixty-seven out of 112 papers mentioned weight loss failure of which 42 described a definition, in total 23 different definitions. Weight regain was mentioned in 77 papers; only 21 papers provided a definition. The recent literature regarding definitions of these outcomes is highly inconsistent. To compare the literature international consensus is required.