Publications by authors named "Edo O Aarts"

49 Publications

First Inventory of Access and Quality of Metabolic Surgery Across Europe.

Obes Surg 2021 Dec 10;31(12):5196-5206. Epub 2021 Sep 10.

Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania.

Introduction: Europe consists of 51 independent countries. Variation in healthcare regulations results in differing challenges faced by patients and professionals. This study aimed to gain more insight into the accessibility, patient pathway and quality indicators of metabolic and body contouring surgery.

Methods And Materials: Expert representatives in the metabolic field from all 51 countries were sent an electronic self-administered online questionnaire on their data and experiences from the previous year exploring accessibility to and quality indicators for metabolic surgery and plastic surgery after weight loss.

Results: Forty-five responses were collected. Sixty-eight percent of countries had eligibility criteria for metabolic surgery; 59% adhered to the guidelines. Forty-six percent had reimbursement criteria for metabolic surgery. Forty-one percent had eligibility criteria for plastic surgery and 31% reimbursement criteria. Average tariffs for a metabolic procedure varied € 800 to 16,000. MDTs were mandated in 78%, with team members varying significantly. Referral practices differed. In 45%, metabolic surgery is performed by pure metabolic surgeons, whilst re-operations were performed by a metabolic surgeon in 28%. A metabolic training programme was available in 23%. Access to metabolic surgery was rated poor to very poor in 33%. Thirty-five percent had a bariatric registry. Procedure numbers and numbers of hospitals performing metabolic surgery varied significantly. Twenty-four percent of countries required a minimum procedure number for metabolic centres, which varied from 25 to 200 procedures.

Conclusion: There are myriad differences between European countries in terms of accessibility to and quality indicators of metabolic surgery. Lack of funding, education and structure fuels this disparity. Criteria should be standardised across Europe with clear guidelines.
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http://dx.doi.org/10.1007/s11695-021-05633-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8595173PMC
December 2021

Single Anastomosis Duodenoileal Bypass or Roux-en-Y Gastric Bypass After Failed Sleeve Gastrectomy: Medium-Term Outcomes.

Obes Surg 2021 11 16;31(11):4708-4716. Epub 2021 Aug 16.

WeightWorks Clinics, Amersfoort, The Netherlands.

Background: Although the sleeve gastrectomy (SG) has good short-term results, it comes with a significant number of patients requiring revisional surgery because of insufficient weight loss or functional complications.

Objective: To investigate the effectiveness of the single anastomosis duodenoileal bypass (SADI-S) versus the Roux-en-Y gastric bypass (RYGB) on health outcomes in (morbidly) obese patients who had previously undergone SG, with up to 5 years of follow-up.

Methods: Data from patients who underwent revisional SADI-S or RYGB after SG were retrospectively compared on indication of surgery, weight loss, quality of life, micronutrient deficiencies, and complications.

Results: From 2007 to 2017, 141 patients received revisional laparoscopic surgery after SG in three specialized Dutch bariatric hospitals (SADI-S n=63, RYGB n=78). Percentage total weight loss following revisional surgery at 1, 2, 3, 4, and 5 years was 22%, 24%, 22%, 18%, and 15% for SADI-S and 10%, 9%, 7%, 8%, and 2% for RYGB (P<.05 for 1-4 years). Patients who underwent RYGB surgery for functional complications experienced no persistent symptoms of GERD or dysphagia in 88% of cases. No statistical difference was found in longitudinal analysis of change in quality of life scores or cross-sectional analysis of complication rates and micronutrient deficiencies.

Conclusion: Conversion of SG to SADI-S leads to significantly more total weight loss compared to RYGB surgery with no difference in quality of life scores, complication rates, or micronutrient deficiencies. When GERD in sleeve patients has to be resolved, RYGB provides adequate outcomes.
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http://dx.doi.org/10.1007/s11695-021-05609-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8490218PMC
November 2021

Correction to: Preventing Peterson's space hernia using a BIO synthetic mesh.

BMC Surg 2021 Jun 28;21(1):301. Epub 2021 Jun 28.

WeightWorks Clinics, Surgical Weight Loss Clinic, Amersfoort, The Netherlands.

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http://dx.doi.org/10.1186/s12893-021-01295-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8240257PMC
June 2021

Preventing Peterson's space hernia using a BIO synthetic mesh.

BMC Surg 2021 May 4;21(1):236. Epub 2021 May 4.

WeightWorks Clinics, Surgical weight Loss Clinic, Amersfoort, The Netherlands.

Background: Internal hernias occur after Roux-en-Y gastric bypass surgery (RYGB) when small bowel herniates into the intermesenteric spaces that have been created. The closure technique used is related to the internal hernia risks outcomes. Using a non-resorbable double layered suture, this risk can be significantly reduced from 8.9 to 2.5% in the first three postoperative years. By closing over a BIO mesh, the risk might be reduced even more.

Setting: Two large private hospitals specialized in bariatric surgery.

Methods: All patients receiving a RYGB for (morbid) obesity between 2014 and 2018 were included in this retrospective study. In all patients, the entero-enterostomy (EE) was closed using a double layered non-absorbable suture. In 2014, Peterson's space was closed exclusively using glue, the years hereafter in a similar fashion as the EE, combined with a piece of glued BIO Mesh.

Results: The glued RYGB patients showed 25% of patients with an internal hernia (14%) or open Peterson's space compared to 0.5% of patients (p < 0.001) who had a combined sutured and BIO Mesh Closure of their Peterson's space defect. Although this was an ideal technique for Peterson's space, it led to 1% of entero-enterostomy kinking due to the firm adhesion formation.

Conclusion: Gluing the intermesenteric spaces is not beneficial but placing a BIO Mesh in Peterson's space is a promising new technique to induce local adhesions. It is above all safe, effective and led to an almost complete reduction of Peterson's internal herniations. In the future, a randomized controlled trial comparing this technique to a double layered, non-absorbable suture should give more insights into which is the optimal closure technique.
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http://dx.doi.org/10.1186/s12893-021-01197-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8097920PMC
May 2021

Optimizing Multivitamin Supplementation for Sleeve Gastrectomy Patients.

Obes Surg 2021 06 23;31(6):2520-2528. Epub 2021 Feb 23.

Department of Bariatric Surgery, Vitalys, part of Rijnstate Hospital, PO box 9555, 6800, Arnhem, The Netherlands.

Purpose: Micronutrient deficiencies are frequently reported after sleeve gastrectomy (SG), and therefore lifelong daily multivitamin supplementation is highly recommended. Based on literature and the results of a previous randomized controlled trial, a specialized multivitamin supplement for SG patients was further optimized (WLS Optimum 2.0, FitForMe). The present study reports on its short-term effectiveness.

Materials And Methods: An open-label study was performed in which 76 patients were included to receive WLS Optimum 2.0 for 12 months (Opt 2.0 group). This group was compared with a group of 75 patients that had received WLS Optimum 1.0 for 12 months during a previous study (Opt 1.0 group).

Results: Intention-to-treat analysis (Opt 1.0, n = 69; Opt 2.0, n = 75) showed higher serum levels of vitamin B12, vitamin B6, and zinc, and a lower prevalence of deficiencies for vitamin B12 and phosphate in the Opt 2.0 group. MCV and serum folic acid levels were higher in the Opt 1.0 group. Over the 12-month study period, mean increase in serum levels of phosphate, vitamin B6, and zinc was higher in the Opt 2.0 group, and MCV and serum vitamin D levels increased more in the Opt 1.0 group.

Conclusion: The present study showed that the use of a specialized multivitamin supplement for SG patients is effective at preventing deficiencies for most vitamins and minerals, specifically in compliant patients. However, a strict follow-up regime remains necessary to monitor nutritional status and to improve patient compliance.
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http://dx.doi.org/10.1007/s11695-021-05282-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8113195PMC
June 2021

Three-year follow-up of bone status in male patients after bariatric surgery-a prospective single-center cohort study.

Surg Obes Relat Dis 2021 Apr 27;17(4):771-779. Epub 2020 Nov 27.

WeighWorks Clinics, Obesity Treatment, Oosterbeek, Netherlands; Obesity Treatment, Allurion Clinic, Hilversum, Netherlands.

Background: In women, bariatric surgery (BS) leads to a decline in bone mineral density (BMD) and may ultimately lead to premature osteoporosis. The impact in men is largely unknown.

Objective: To assess the effect of BS on bone metabolism in males.

Setting: Single-center prospective cohort study.

Methods: Twenty-four male BS candidates were prospectively enrolled. Anthropometric characteristics, serum gonadal hormones, markers of bone metabolism, and BMD were measured at baseline, 6-, 12- and 36-months postoperatively.

Results: Roux-en-Y gastric bypass (RYGB) and adjustable gastric banding (AGB) were performed in 15 and 9 patients, respectively. Nineteen patients completed the 3-year follow-up. At 3 years, BMD of the right and left femur had decreased by 9.1 ± 7.2% and 9.4 ± 5.8% for RYGB and by 6.7 ± 3.9% and 4.5 ± 2.8% for AGB. Radius BMD had decreased by 14.0 ± 5.6% for RYGB and 5.9 ± 4.1% for AGB, i.e., significantly stronger for RYGB (P = .006). Serum parathyroid hormone increased in both groups and 13 of 19 patients developed Vitamin D deficiency. A significant increase of the bone resorption marker was seen only during the first year despite continuation of bone loss. Four patients developed de novo osteopenia or osteoporosis. No fractures were observed.

Conclusion: There are strong indications that male bone metabolism response after BS differs from female metabolism. The most affected site is the radius. In males, the cause of this BMD loss seems multifactorial, including mechanical unloading, hyperparathyroidism, and hypogonadism. However, clinical relevance remains unknown and therefore studies with longer-term follow-up are necessary.
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http://dx.doi.org/10.1016/j.soard.2020.11.019DOI Listing
April 2021

A Matter of Timing-Pregnancy After Bariatric Surgery.

Obes Surg 2021 May 11;31(5):2072-2079. Epub 2021 Jan 11.

Department of Bariatric Surgery, Vitalys, part of Rijnstate hospital, Postal number 1191, PO box 9555, 6800TA, Arnhem, The Netherlands.

Purpose: Current guidelines recommend to avoid pregnancy for 12-24 months after bariatric surgery because of active weight loss and an increased risk of nutritional deficiencies. However, high-quality evidence is lacking, and only a few studies included data on gestational weight gain. We therefore evaluated pregnancy and neonatal outcomes by both surgery-to-conception interval and gestational weight gain.

Materials And Methods: A multicenter retrospective analysis of 196 singleton pregnancies following Roux-en-Y gastric bypass, sleeve gastrectomy, and one anastomosis gastric bypass was conducted. Pregnancies were divided into the early group (≤ 12 months), the middle group (12-24 months), and the late group (> 24 months) according to the surgery-to-conception interval. Gestational weight gain was classified as inadequate, adequate, or excessive according to the National Academy of Medicine recommendations.

Results: Pregnancy in the early group (23.5%) was associated with lower gestational age at delivery (267.1 ± 19.9 days vs 272.7 ± 9.2 and 273.1 ± 13.5 days, P = 0.029), lower gestational weight gain (- 0.9 ± 11.0 kg vs + 10.2 ± 5.6 and + 10.0 ± 6.4 kg, P < 0.001), and lower neonatal birth weight (2979 ± 470 g vs 3161 ± 481 and 3211 ± 465 g, P = 0.008) than pregnancy in the middle and late group. Inadequate gestational weight gain (40.6%) was associated with lower gestational age at delivery (266.5 ± 20.2 days vs 273.8 ± 8.4 days, P = 0.002) and lower neonatal birth weight (3061 ± 511 g vs 3217 ± 479 g, P = 0.053) compared to adequate weight gain. Preterm births were also more frequently observed in this group (15.9% vs 6.0%, P = 0.037).

Conclusion: Our findings support the recommendation to avoid pregnancy for 12 months after bariatric surgery. Specific attention is needed on achieving adequate gestational weight gain.
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http://dx.doi.org/10.1007/s11695-020-05219-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8041698PMC
May 2021

From the Knife to the Endoscope-a History of Bariatric Surgery.

Curr Obes Rep 2020 Sep;9(3):348-363

Bariatric Unit, Department of General Surgery, Sunderland Royal Hospital, Sunderland, UK.

Purpose Of Review: This review was conducted to gain insight into the history, present and future of bariatric and/or metabolic surgery and endoscopic treatments of obesity. The challenges that have been overcome, the challenges we still face and our recommendations for the future are discussed.

Recent Findings: Over the last few decades, a number of treatment strategies have emerged for the treatment of obesity. Both endoscopic and surgical options are available and they lead to significant weight loss and comorbidity reduction. However, to remain a credible treatment alternative to the obesity pandemic, we need to perform these procedures in much larger numbers than we currently do. Even though significant gains have been made in reducing the morbidity and mortality of surgical interventions, there is further room for improvement, especially when it comes to long-term issues. Due to its impact on almost every single organ system in the human body, bariatric surgery has attracted the attention of academics from a variety of medical disciplines. This has led to a rapidly enlarging body of high-quality scientific literature, supporting its wider use and cost-effectiveness.

Conclusion: Despite the advances made in bariatric surgery, the criteria determining suitability of patients for bariatric surgery in most parts of the world are still based on a consensus agreed upon in the USA in 1991. There is a need to formulate some new consensus and guidelines that would allow for a significant expansion of the pool of patients that can be offered these procedures.
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http://dx.doi.org/10.1007/s13679-020-00382-1DOI Listing
September 2020

A randomized controlled trial comparing oral and intravenous iron supplementation after Roux-en-Y gastric bypass surgery.

Clin Nutr 2020 12 21;39(12):3779-3785. Epub 2020 Apr 21.

Department of Surgery, Rijnstate, Arnhem, the Netherlands.

Background: Iron deficiency (ID) is one of the most common postoperative deficiencies that may develop after Roux-en-Y gastric bypass (RYGB). The optimal mode of treatment is uncertain.

Aim: To compare the efficacy of oral ferrous fumarate (FF), oral ferrous gluconate (FG), and a single intravenous infusion of ferric carboxymaltose (FCM) in women with ID after RYGB.

Methods: Multicenter randomized controlled trial including 120 women with a serum ferritin <20 μg/l during follow-up after RYGB. They were randomized into three groups: 41 patients were treated with FF 200 mg three times a day (total daily dose: 195 mg elemental iron), 39 received FG 695 mg twice a day (total daily dose: 160 mg elemental iron) for three months, and 39 patients were treated with a single intravenous dose of FCM (1000 mg elemental iron). Serum ferritin levels were measured at six weeks, and three, six and twelve months after the start of supplementation.

Results: At three months, persistence of ID was observed in 29.4% and 42.4% of the patients treated with FF and FG, respectively, but in none of those treated with FCM (p < 0.001). Over the next nine months, recurrence of ID was observed in 56.5% of patients treated with FF, in 52.9% treated with FG, and in 27.8% of those treated with FCM. Adverse effects were most common during oral treatment.

Conclusion: In women developing ID after RYGB, a single dose of intravenous FCM is more effective and better tolerated than the standard treatment with either FF or FG.

Clinical Trial Registry Number And Website: The study was registered at clinicaltrials.gov under number NCT02271997.
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http://dx.doi.org/10.1016/j.clnu.2020.04.010DOI Listing
December 2020

Correction to: Do Specialized Bariatric Multivitamins Lower Deficiencies After Sleeve Gastrectomy?

Obes Surg 2020 Feb;30(2):439

Praeclarum BV, Oosterbeek, The Netherlands.

The second sentence of the Conclusion section should read as follows.
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http://dx.doi.org/10.1007/s11695-019-04322-4DOI Listing
February 2020

Obesity affects brain structure and function- rescue by bariatric surgery?

Neurosci Biobehav Rev 2020 01 30;108:646-657. Epub 2019 Nov 30.

Donders Institute for Brain, Cognition and Behaviour, Department of Anatomy, Radboud University Medical Center, Nijmegen, the Netherlands. Electronic address:

Obesity has a major impact on metabolic health thereby negatively affecting brain function and structure, however mechanisms involved are not entirely understood. The increasing prevalence of obesity is accompanied by a growing number of bariatric surgeries (BS). Weight loss after BS appears to improve cognitive function in patients. Therefore, unraveling mechanisms how BS influences brain function may be helpful to develop novel treatments or treatments in combination with BS preventing/inhibiting neurodegenerative disorders like Alzheimer's disease. This review shows the relation between obesity and impaired circulation to and in the brain, brain atrophy, and decreased cognitive functioning. Weight loss seems to recover some of these brain abnormalities as greater white matter and gray matter integrity, functional brain changes and increased cognitive functioning is seen after BS. This relation of body weight and the brain is partly mediated by changes in adipokines, gut hormones and gut microbiota. However, the exact underlying mechanisms remain unknown and further research should be performed.
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http://dx.doi.org/10.1016/j.neubiorev.2019.11.025DOI Listing
January 2020

The True Story on Deficiencies After Sleeve Gastrectomy: Results of a Double-Blind RCT.

Obes Surg 2020 04;30(4):1280-1290

Department of Surgery, Vitalys Clinic and Rijnstate Hospital, Wagnerlaan 55, Arnhem, 6800 TA, The Netherlands.

Background: Since a few years, the laparoscopic sleeve gastrectomy (SG) has become the most performed bariatric operation worldwide. However, as with all bariatric procedures, SG also leads to vitamin and mineral deficiencies post-operatively and standard multivitamin supplements are probably not sufficient.

Objective: The present study evaluates the effectiveness of a specialized multivitamin supplement for SG patients (WLS Optimum 1.0, FitForMe, Rotterdam, the Netherlands), compared to a standard multivitamin supplement (sMVS).

Design: A double-blind randomized controlled trial was performed. For 12 months, patients in the intervention group received WLS Optimum, containing elevated doses of multiple vitamins and minerals. Patients in the control group were provided with sMVS, containing 100% of the recommended dietary allowance.

Results: In total, 139 patients were available for analysis (WLS Optimum, n = 69; sMVS, n = 70). Intention-to-treat analyses revealed more folic acid deficiencies and higher serum vitamin B1 levels in the WLS Optimum group. Per protocol analyses showed that in patients using WLS Optimum, serum folic acid and vitamin B1 levels were higher, serum PTH levels were lower, and only one patient (2.6%) was anemic compared to 11 patients (17.5%) using a sMVS (p < 0.05 for all). No differences were found in prevalence of deficiencies for iron, vitamin B12, vitamin D, and other vitamins and minerals.

Conclusions: This optimized multivitamin supplement only affected serum levels of folic acid, PTH and vitamin B1, and anemia rates compared to a sMVS. There is a clear need to further optimize multivitamin supplementation for SG patients. Besides, non-compliance with multivitamin supplements remains an important issue that should be dealt with.

Clinical Trial Registry: The study protocol was registered at the clinical trials registry of the National Institutes of Health (ClinicalTrials.gov; identifier NCT01609387).
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http://dx.doi.org/10.1007/s11695-019-04252-1DOI Listing
April 2020

Safety of Continuous Postoperative Pulse Oximetry Monitoring Without Obstructive Sleep Apnea Screening in > 5000 Patients Undergoing Bariatric Surgery.

Obes Surg 2020 03;30(3):1079-1085

Department of Bariatric Surgery, Rijnstate Hospital, Postal number 1190, 6800 TA, Arnhem, The Netherlands.

Introduction: Obstructive sleep apnea (OSA) is common but often undiagnosed in obese patients undergoing bariatric surgery, and is associated with increased risk of cardiopulmonary complications. The aim of this study is to evaluate the safety of continuous postoperative pulse oximetry (CPOX) without preoperative OSA screening in bariatric patients.

Methods: Retrospective, single-center cohort study of all consecutive patients who underwent bariatric surgery between 2011 and 2017. All patients were postoperatively monitored with CPOX and received oxygen supplementation. Patients with no history of OSA (the "CPOX" only group) were compared with patients with adequately treated OSA as a reference group. The primary outcome was the incidence of cardiopulmonary complications within 30 days after surgery. Secondary outcomes included overall 30-day complications, mortality, intensive care unit (ICU) admissions, readmissions, and length of stay.

Results: In total, 5682 patients were included, 89.6% (n = 5089) had no history of OSA, 10.4% (n = 593) had adequately treated OSA. Cardiopulmonary complications occurred in the CPOX group and OSA group in 0.6% (n = 31) and 0.8% (n = 5), respectively (p = 0.171). No mortality occurred due to cardiopulmonary complications. In both groups, one patient required ICU admission for respiratory failure (p = 0.198). Non-cardiopulmonary complications occurred in 6.4% in the CPOX group and 7.8% in the OSA group (p = 0.792). Mortality, ICU admissions, readmissions, and length of stay were not significantly different between groups.

Conclusions: These data suggest that CPOX monitoring without preoperative OSA screening is a safe and effective strategy in perioperative care of bariatric patients. Future studies are needed to assess whether this strategy is also cost-effective.
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http://dx.doi.org/10.1007/s11695-019-04297-2DOI Listing
March 2020

Do Specialized Bariatric Multivitamins Lower Deficiencies After Sleeve Gastrectomy?

Obes Surg 2020 02;30(2):427-438

Praeclarum BV, Oosterbeek, The Netherlands.

Background: Vitamin and mineral deficiencies are common after a sleeve gastrectomy (SG). The aim of this study is to examine the effectiveness of a specialized bariatric multivitamin (WLS Optimum) for SG patients on deficiencies compared with a regular multivitamin (MVS) for up to 5 years.

Methods: Data of all patients who underwent a SG procedure in the Catharina Hospital Eindhoven (CZE) between July 2011 and July 2016 were collected and retrospectively analyzed. All patients who completed a preoperative blood test and at least one blood withdrawal during the first operative year were included in this study.

Results: This study included 970 patients; 291 patients in the WLS-user group and 679 patients in the non-WLS-user group. In favor of the user group, significantly less de novo deficiencies were found of vitamin B (2 years) and vitamin B (two and three), folic acid (1 and 2 years), and vitamin B (at 1 year). Binomial logistic regression showed a significant influence of multivitamin supplementation mainly on ferritin; vitamins B, B, B, and D; and folic acid, (all p < 0.05). The total number of de novo deficiencies was significantly reduced during the whole study for all WLS Optimum users.

Conclusions: Vitamin deficiencies are common, and postoperative nutritional management after SG is underestimated. The use of a specialized multivitamin supplement resulted in higher mean serum concentrations and less deficiencies of vitamin B, folic acid, and vitamin B. This study shows that SG patients benefit from the specialized multivitamin supplements, but adjustments are required for iron and vitamin B content.
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http://dx.doi.org/10.1007/s11695-019-04191-xDOI Listing
February 2020

A novel abdominal wall entry suction device to increase Veress needle safety: A prospective cohort pilot study.

Ann Med Surg (Lond) 2019 Nov 7;47:70-74. Epub 2019 Oct 7.

Department of Surgery, Rijnstate Hospital, Arnhem, the Netherlands.

Background: In laparoscopic surgery, the Veress needle technique is most often used to initiate a pneumoperitoneum. Although low, entry-related injuries of the intestines and major vascular structures occur in 0.04-0.1% of cases. Up to 50% of these injuries remain undiagnosed at the time of surgery, resulting in mortality rates between 2.5 and 30%. In an effort to minimize such injuries we objectively assessed a novel abdominal wall entry suction device (AWESD) that was hypothesized to lift the abdominal wall and create an additional post-peritoneum safe margin for safer Veress needle introduction.

Materials And Methods: A prospective pilot study was conducted in which CT-scans with and without AWESD application (centered above the umbilicus) were assessed to determine its effect on the distance from the linea alba to the intestines, vena cava and abdominal aorta. Paired measurements were subjected to the Wilcoxon signed rank test.

Results: Twelve participants were included. The AWESD significantly increased the median distance towards the intestines in the axial and sagittal plane ( = 0.01 and  = 0.006) from 0.93 (Inter Quartile Range (IQR): 0.33-1.51) and 0.85 (IQR: 0.32-1.47) to 1.35 (IQR: 0.39-2.27) and 1.25 (IQR: 0.42-2.10) centimeters, respectively. Similarly, for the median axial distances towards the vena cava and abdominal aorta (both  = 0.002) that were increased from 10.00 (IQR: 7.18-11.12) and 9.33 (IQR: 6.55-10.28) to 13.23 (IQR: 11.76-14.31) and 12.49 (IQR: 10.98-13.32) centimeters, respectively.

Conclusion: The AWESD significantly increased the distances between the peritoneum and main intra-abdominal structures. However, conclusions on subsequent increased safety cannot be drawn as high-volume studies are required to determine its clinical relevance.
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http://dx.doi.org/10.1016/j.amsu.2019.10.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6804323PMC
November 2019

The Relationship Between Energy Intake and Weight Loss in Bariatric Patients.

Obes Surg 2019 12;29(12):3874-3881

Department of Surgery, Rijnstate Hospital & Vitalys Clinics, Postal number 1190, 6800 TA, Arnhem, The Netherlands.

Introduction: There is a huge variation in weight loss outcomes between bariatric patients, possibly due to differences in caloric intake and changes in the amount physical activity. However, the association between the change in energy intake and weight loss has not yet been the subject of an extensive investigation.

Objective: To explore the relationship between total energy intake and % total body weight loss (%TBWL) over a period of 4 years post-surgery.

Methods: Of the 466 patients who were asked to participate, a total 135 patients were included in this study. They all underwent bariatric surgery, 54 with primary Roux-en-Y Gastric Bypass, 43 redo Roux-en-Y gastric bypass after laparoscopic gastric banding and 38 laparoscopic sleeve gastrectomy. Pre- and post-operative dietary intake and physical activity were collected for both a weekday and a weekend day. The main analysis was performed using multiple regression analyses and was adjusted for age at surgery, BMI at baseline, obstructive sleep apnoea syndrome, type of eating behaviour, change in physical activity and protein intake (g/kg body weight).

Results: %TBWL over time, post-operative energy intake and change in physical activity did not differ between the different procedure groups (p = 0.312, p = 0.988 and p = 0.050, respectively). Change in energy intake did differ between different procedure groups (p = 0.031) and linear regression showed that this was related to total body weight loss for the fully adjusted model (β = - 0.004, p = 0.014).

Conclusion: This study showed a higher decrease in energy intake to be related with a higher %TBWL.
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http://dx.doi.org/10.1007/s11695-019-04072-3DOI Listing
December 2019

Correction to: Adequate Multivitamin Supplementation after Roux-En-Y Gastric Bypass Results in a Decrease of National Health Care Costs: a Cost-Effectiveness Analysis.

Obes Surg 2019 Jun;29(6):2007

Department of Surgery, Rijnstate Hospital, Postal Number 1190, 6800 TA, Arnhem, The Netherlands.

In the original article, there are some incorrect data in the "Results" section of the Abstract.
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http://dx.doi.org/10.1007/s11695-019-03820-9DOI Listing
June 2019

Study rationale and protocol of the BARICO study: a longitudinal, prospective, observational study to evaluate the effects of weight loss on brain function and structure after bariatric surgery.

BMJ Open 2019 01 9;9(1):e025464. Epub 2019 Jan 9.

Department of Anatomy, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands.

Introduction: Weight loss after bariatric surgery (BS) is often associated with improved cognition and structural brain recovery. However, improved cognition after BS is not always exhibited by patients, in fact, in some cases there is even a decline in cognition. Long-term consequences of BS weight loss, in terms of obesity and related diseases, can be hard to determine due to studies having short follow-up periods and small sample sizes.The aim of the BARICO study (riatric surgery ijnstate and Radboudumc neuromaging and ognition in besity) is to determine the long-term effect of weight loss after BS on brain function and structure, using sensitive neuropsychological tests and (functional) MRI ((f)MRI). Secondary study endpoints are associated with changes in metabolic and inflammation status of adipose tissue, liver and gut, in relation to brain structure and function. Also, the possible correlation between weight loss, gut microbiota composition change and neuropsychological outcomes will be investigated.

Methods And Analysis: Data from 150 Dutch BS patients (ages between 35 and 55, men and women) will be collected at various time points between 2 months before and up to 10 years after surgery. Neuropsychological tests, questionnaires, blood, faeces and tissue samples will be collected before, during and after surgery to measure changes in cognition, microbiota, metabolic activity and inflammation over time. A subgroup of 75 participants will undergo (f)MRI in relation to executive functioning (determined by the Stroop task), grey and white matter volumes and cerebral blood flow. Regression analyses will be used to explore associations between weight loss and outcome measures.

Ethics And Dissemination: This study has been approved by the medical review ethics committee CMO Region Arnhem and Nijmegen (NL63493.091.17). Research findings will be published in peer-reviewed journals and at conferences.

Trial Registration Number: NTR7288.
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http://dx.doi.org/10.1136/bmjopen-2018-025464DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6340014PMC
January 2019

Adequate Multivitamin Supplementation after Roux-En-Y Gastric Bypass Results in a Decrease of National Health Care Costs: a Cost-Effectiveness Analysis.

Obes Surg 2019 05;29(5):1638-1643

Department of Surgery, Rijnstate Hospital, Postal number 1190, 6800 TA, Arnhem, The Netherlands.

Introduction: Patients with morbid obesity undergoing metabolic surgery are prone to develop vitamin and mineral deficiencies, which may worsen in time. In order to prevent these deficiencies after metabolic surgery, all patients are advised to take daily multivitamin supplementation. The aim of the study was to assess the cost-effectiveness of specially developed multivitamins (WLS Forte®) for metabolic surgery and over-the-counter (standard) multivitamin supplementation (sMVS).

Methods: This cost-effectiveness analysis was preformed alongside an RCT for the Netherlands. Between June 2011 and March 2012, a total of 148 patients were randomized to one tablet daily of either WLS Forte® or sMVS. The patients were followed for 12 months. Data on costs within the health sector and outside the health sector were collected. The primary outcome is financial and logistic advantages, in terms of less patient visits to the outpatient department and the relevant costs to the employer due to absenteeism.

Results: In total, 10 (14%) patients in the WLS Forte® group versus 23 (30%) patients in the sMVS group developed a deficiency. The costs for the WLS forte® supplement were €38 versus €23 for sMVS. Additional return visits and associated costs for medical staff were the largest costs, up to 43% in the sMVS group. Total costs for supplementation with sMVS were €243 versus €134 for WLS Forte®.

Conclusion: Preventing deficiencies with WLS Forte® seem initially more expensive than sMVS. However, treatment with WLS Forte® resulted in less vitamin and mineral deficiencies, which eventually resulted in less overall costs.
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http://dx.doi.org/10.1007/s11695-019-03750-6DOI Listing
May 2019

Failed Sleeve Gastrectomy: Single Anastomosis Duodenoileal Bypass or Roux-en-Y Gastric Bypass? A Multicenter Cohort Study.

Obes Surg 2018 12;28(12):3834-3842

Department of Surgery, Rijnstate Hospital/Vitalys Clinics, Arnhem, Netherlands.

Background: Sleeve gastrectomy (SG) has become the most performed bariatric procedure to induce weight loss worldwide. Unfortunately, a significant portion of patients show insufficient weight loss or weight regain after a few years.

Objective: To investigate the effectiveness of the single anastomosis duodenoileal (SADI) bypass versus the Roux-en-Y gastric bypass (RYGB) on health outcomes in morbid obese patients who had undergone SG previously, with up to 2 years of follow-up.

Methods: From 2007 to 2017, 140 patients received revisional laparoscopic surgery after SG in four specialized Dutch bariatric hospitals. Data was analyzed retrospectively and included comparisons for indication of surgery, vitamin/mineral deficiencies, and complications; divided into short-, medium-term. To compare weight loss, linear regression and linear mixed models were used.

Results: Conversion of a SG to SADI was performed in 66 patients and to RYGB in 74 patients. For patients in which additional weight loss was the main indication for surgery, SADI achieved 8.7%, 12.4%, and 19.4% more total body weight loss at 6, 12, and 24 months compared to RYGB (all p < .001). When a RYGB was indicated in case of gastroesophageal reflux or dysphagia, it greatly reduced complaints almost directly after surgery. Furthermore, a similar amount of complications and nutritional deficiencies was observed for both groups. There was no intra- or post-operative mortality.

Conclusion: Conversion into a SADI resulted in significantly more weight loss while complications rates and nutritional deficiencies were similar and may therefore be considered the recommended operation for patients in which only additional weight loss is required.
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http://dx.doi.org/10.1007/s11695-018-3429-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6223754PMC
December 2018

Altered neural responsivity to food cues in relation to food preferences, but not appetite-related hormone concentrations after RYGB-surgery.

Behav Brain Res 2018 11 21;353:194-202. Epub 2018 Jul 21.

Division of Human Nutrition and Health, Wageningen University, Wageningen, The Netherlands. Electronic address:

Background: After Roux-en-Y gastric bypass (RYGB) surgery, patients report a shift in food preferences away from high-energy foods.

Objective: We aimed to elucidate the potential mechanisms underlying this shift in food preferences by assessing changes in neural responses to food pictures and odors before and after RYGB. Additionally, we investigated whether altered neural responsivity was associated with changes in plasma endocannabinoid and ghrelin concentrations.

Design: 19 RYGB patients (4 men; age 41 ± 10 years; BMI 41 ± 1 kg/m before; BMI 36 ± 1 kg/m after) participated in this study. Before and two months after RYGB surgery, they rated their food preferences using the Macronutrient and Taste Preference Ranking Task and BOLD fMRI responses towards pictures and odors of high-, and low-energy foods and non-food items were measured. Blood samples were taken to determine plasma endocannabinoid and ghrelin concentrations pre- and post-surgery.

Results: Patients demonstrated a shift in food preferences away from high-fat/sweet and towards low-energy/savory food products, which correlated with decreased superior parietal lobule responsivity to high-energy food odor and a reduced difference in precuneus responsivity to high-energy versus low-energy food pictures. In the anteroventral prefrontal cortex (superior frontal gyrus) the difference in deactivation towards high-energy versus non-food odors reduced. The precuneus was less deactivated in response to all cues. Plasma concentrations of anandamide were higher after surgery, while plasma concentrations of other endocannabinoids and ghrelin did not change. Alterations in appetite-related hormone concentrations did not correlate with changes in neural responsivity.

Conclusions: RYGB leads to changed responsivity of the frontoparietal control network that orchestrates top-down control to high-energy food compared to low-energy food and non-food cues, rather than in reward related brain regions, in a satiated state. Together with correlations with the shift in food preference from high- to low-energy foods this indicates a possible role in new food preference formation.
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http://dx.doi.org/10.1016/j.bbr.2018.07.016DOI Listing
November 2018

Efficacy of oral compared with intramuscular vitamin B-12 supplementation after Roux-en-Y gastric bypass: a randomized controlled trial.

Am J Clin Nutr 2018 07;108(1):6-12

Department of Surgery, Rijnstate Hospital, Arnhem, Netherlands.

Background: After Roux-en-Y gastric bypass (RYGB), patients often develop a vitamin B-12 deficiency.

Objective: Our objective was to investigate whether oral supplementation increases and normalizes low vitamin B-12 concentrations (vitamin B-12 > 200 pmol/L) in RYGB patients as compared to intramuscular injections.

Design: A randomized controlled trial in RYGB patients with subnormal serum B-12 concentrations was performed. One group (IM B-12) received bimonthly intramuscular hydroxocobalamin injections (2000 µg as loading dose and 1000 µg at follow-up) for 6 mo. The second group (oral B-12) received daily doses of oral methylcobalamin (1000 µg). Serum vitamin B-12 was determined at baseline (T0) and at 2 (T1), 4 (T2), and 6 mo (T3) after start of treatment. Concentrations of the secondary markers methylmalonic acid (MMA) and homocysteine (Hcy) were measured at T0 and T3.

Results: Fifty patients were included and randomized, 27 in IM B-12 and 23 in oral B-12. The median vitamin B-12 concentration at T0 was 175 pmol/L (range: 114-196 pmol/L) for IM B-12 and 167 pmol/L (range: 129-199 pmol/L) for oral B-12. Vitamin B-12 normalized in all individuals, and there was no significant difference in vitamin B-12 between the two groups. MMA and Hcy concentrations decreased significantly after 6 mo within each group (P < 0.001 and P < 0.001 for MMA and P = 0.03 and P = 0.045 for Hcy, respectively). There was no significant difference between the groups at 6 mo for both MMA and Hcy (P = 0.53 and P = 0.79).

Conclusion: The efficacy of oral vitamin B-12 supplementation was similar to that of hydroxocobalamin injections in the present study. Oral supplementation can be used as an alternative to hydroxocobalamin injections to treat RYGB patients with low values of serum vitamin B-12. This trial was registered at clinicaltrials.gov as NCT02270749.
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http://dx.doi.org/10.1093/ajcn/nqy072DOI Listing
July 2018

Preperitoneal Bupivacaine Infiltration Reduces Postoperative Opioid Consumption, Acute Pain, and Chronic Postsurgical Pain After Bariatric Surgery: a Randomized Controlled Trial.

Obes Surg 2018 10;28(10):3102-3110

Department of Anesthesiology, Rijnstate Hospital, Postbus 9555, 6800 TA, Arnhem, The Netherlands.

Introduction: A multimodal pain treatment including local anesthetics is advised for perioperative analgesia in bariatric surgery. Due to obesity, bariatric surgery patients are at risk of respiratory complications. Opioid consumption is an important risk factor for hypoventilation. Furthermore, acute postoperative pain is an important risk factor for chronic postsurgical pain. In this study, we aimed to evaluate whether preperitoneal anesthesia with bupivacaine would reduce pain and opioid consumption after bariatric surgery.

Methods: One hundred adults undergoing laparoscopic bariatric surgery were randomized to receive either preperitoneal bupivacaine 0.5% or normal saline before incision. Postoperative opioid consumption, postoperative pain, and postoperative recovery parameters were assessed for the first 24 h after surgery. One year after surgery, chronic postsurgical pain and influence of pain on daily living were evaluated.

Results: Postoperative opioid consumption during the first hour after surgery was 2.8 ± 3.0 mg in the bupivacaine group, whereas in the control group, it was 4.4 ± 3.4 mg (p = 0.01). Pain scores were significantly reduced in this first hour at rest and at 6 h during mobilization on the ward. One year after surgery, the incidence of chronic postsurgical pain was 13% in the bupivacaine group versus 40% in the placebo group.

Conclusion: This study shows that preperitoneal local anesthesia with bupivacaine results in a reduction in opioid consumption and postoperative pain and seems to lower the incidence rate of chronic postsurgical pain after laparoscopic bariatric surgery.
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http://dx.doi.org/10.1007/s11695-018-3341-6DOI Listing
October 2018

Do specialized bariatric multivitamins lower deficiencies after RYGB?

Surg Obes Relat Dis 2018 07 3;14(7):1005-1012. Epub 2018 Apr 3.

Department of Surgery, Rijnstate Hospital, Arnhem, the Netherlands.

Background: One of the side effects of bariatric surgery is the risk of vitamin and mineral deficiencies. Vitamin B12, vitamin D, folate, and iron deficiencies are especially common among Roux-en-Y gastric bypass patients.

Objective: To examine the effectiveness of a specialized multivitamin supplement for Roux-en-Y gastric bypass patients on deficiencies the first 3 years postoperatively, retrospectively in a large, prospectively collected cohort.

Setting: Large specialized bariatric hospital.

Results: One thousand one hundred sixty patients were included, 883 users and 258 who were nonusers of the specialized multivitamin. Patient characteristics and total weight were comparable. Higher serum concentrations of ferritin (124.7 ± 96.2 µg/L versus 106.0 ± 83.0 µg/L, P = .016), vitamin B12 (347.3 ± 145.1 pmol/L versus 276.8 ± 131.4 pmol/L, P<.001), folic acid (34.9 ± 9.6 nmol/L versus 25.4 ± 10.7 nmol/L, P<.001), and vitamin D (98.4 ± 28.7 nmol/L versus 90.0 ± 34.5 nmol/L, P = .002) were observed in users compared with nonusers after 1 year. Less new deficiencies were found for ferritin (1% versus 4%, P = .029), vitamin B12 (9% versus 23%, P<.001), and vitamin D (0% versus 4%, P<.001) in users compared with nonusers. Two and 3 years after the surgery these findings remained almost identical.

Conclusions: The use of specialized multivitamin supplements resulted in less deficiencies of vitamin B12, vitamin D, folic acid, and ferritin. The study showed that Roux-en-Y gastric bypass patients benefited from the specialized multivitamin supplements and it should be advised to this patient group.
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http://dx.doi.org/10.1016/j.soard.2018.03.029DOI Listing
July 2018

Regulation of angiopoietin-like 4 and lipoprotein lipase in human adipose tissue.

J Clin Lipidol 2018 May - Jun;12(3):773-783. Epub 2018 Feb 17.

Nutrition, Metabolism and Genomics group, Division of Human Nutrition and Health, Wageningen University, Wageningen, The Netherlands. Electronic address:

Background: Elevated plasma triglycerides are increasingly viewed as a causal risk factor for coronary artery disease. One protein that raises plasma triglyceride levels and that has emerged as a modulator of coronary artery disease risk is angiopoietin-like 4 (ANGPTL4). ANGPTL4 raises plasma triglyceride levels by inhibiting lipoprotein lipase (LPL), the enzyme that catalyzes the hydrolysis of circulating triglycerides on the capillary endothelium.

Objective: The objective of the present study was to assess the association between ANGPTL4 and LPL in human adipose tissue, and to examine the influence of nutritional status on ANGPTL4 expression.

Methods: We determined ANGPTL4 and LPL mRNA and protein levels in different adipose tissue depots in a large number of severely obese patients who underwent bariatric surgery. Furthermore, in 72 abdominally obese subjects, we measured ANGPTL4 and LPL mRNA levels in subcutaneous adipose tissue in the fasted and postprandial state.

Results: ANGPTL4 mRNA levels were highest in subcutaneous adipose tissue, whereas LPL mRNA levels were highest in mesenteric adipose tissue. ANGPTL4 and LPL mRNA levels were strongly positively correlated in the omental and subcutaneous adipose tissue depots. In contrast, ANGPTL4 and LPL protein levels were negatively correlated in subcutaneous adipose tissue, suggesting a suppressive effect of ANGPTL4 on LPL protein abundance in subcutaneous adipose tissue. ANGPTL4 mRNA levels were 38% higher in the fasted compared to the postprandial state.

Conclusion: Our data provide valuable insights into the relationship between ANGPTL4 and LPL in human adipose tissue, as well as the physiological function and regulation of ANGPTL4 in humans.
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http://dx.doi.org/10.1016/j.jacl.2018.02.006DOI Listing
September 2019

Diagnosing Internal Herniation After Roux-en-Y Gastric Bypass Surgery: Literature Overview, Cadaver Study and the Added Value of 3D CT Angiography.

Obes Surg 2018 07;28(7):1822-1830

Department of Bariatric Surgery, Rijnstate Hospital and Vitalys Clinic, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands.

Purpose: The purposes of the study are to outline the complexity of diagnosing internal herniation after Roux-en-Y gastric bypass (RYGB) surgery and to investigate the added value of computed tomography angiography (CTA) for diagnosing internal herniation.

Materials And Methods: A cadaver study was performed to investigate the manifestations of internal hernias and mesenteric vascularization. Furthermore, a prospective, ethics approved study with retrospective interpretation was conducted. Ten patients, clinically suspected for internal herniation, were prospectively included. After informed consent was obtained, these subjects underwent abdominal CT examination, including additional arterial phase CTA. All subjects underwent diagnostic laparoscopy for suspected internal herniation. The CTA was used to create a 3D reconstruction of the mesenteric arteries and surgical staples (3D CTA). The 3D CTA was interpreted, taking into account the presence and type of internal hernia that was found upon laparoscopy.

Results: Cadaveric analysis demonstrated the complexity of internal herniation. It also confirmed the expected changes in vascular structure and surgical staple arrangement in the presence of internal herniation. 3D CTA studies of the subjects with active internal hernias demonstrated remarkable differences when compared to control 3D CTA studies. The blood supply of herniated intestinal limbs in particular showed abnormal trajectories. Additionally, enteroenterostomy staple lines had migrated or altered orientation.

Conclusion: 3D CTA is a promising technique for diagnosing active internal hernias. Our findings suggest that for diagnosing internal hernias, focus should probably shift from routine abdominal CT examination towards the 3D assessment of the mesenteric vasculature and surgical staples.
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http://dx.doi.org/10.1007/s11695-018-3121-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6107799PMC
July 2018

Changes in Iron Absorption After Roux-en-Y Gastric Bypass.

Obes Surg 2018 06;28(6):1738-1744

Department of Internal Medicine, Rijnstate Hospital, Arnhem, The Netherlands.

Introduction: Iron deficiency is one of the most common deficiencies that may occur after Roux-en-Y gastric bypass (RYGB). Little is known about the optimal treatment of post-RYGB iron deficiency.

Aim: The aim of this study is to evaluate the changes in iron absorption characteristics after RYGB for two oral iron formulations, one presented in tablet form and one as in the form of a solution.

Method: Iron absorption in 24 obese women was studied before and 1 month after RYGB. Twelve patients were tested with a single dose of 600 mg ferrous fumarate in tablet form (195 mg of elementary iron, group 1), and 12 patients received a single dose of 1390 mg ferrous gluconate as a solution (160 mg of elementary iron, group 2). Serum iron levels were measured before (T) and every hour after ingestion of the supplement (T-T).

Results: Before surgery, iron absorption was similar for the two supplements (P = 0.71). However, RYGB was associated with a decrease in fumarate iron absorption (P < 0.001) but did not affect gluconate iron absorption (P = 0.13). Postoperative absorption of fumarate iron was significantly lower than gluconate iron at T1 (P < 0.05), but the overall difference over 9 h did not reach statistical significance (P = 0.53).

Conclusion: RYGB adversely affects the absorption of ferrous fumarate tablets but not that of solubilized ferrous gluconate. A solubilized supplement is therefore preferred as the supplement of first choice after RYGB.
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http://dx.doi.org/10.1007/s11695-017-3088-5DOI Listing
June 2018

Inflammatory Bowel Disease Is Not a Contraindication for Bariatric Surgery.

Obes Surg 2018 06;28(6):1681-1687

Rijnstate Hospital, Arnhem, 6815 AD, Gelderland, Netherlands.

Background: Inflammatory bowel diseases (IBD) are listed as a contraindication for bariatric surgery in various guidelines due to a theoretical higher complication risk. Therefore, little is known about safety and efficacy of bariatric surgery in IBD patients.

Aim: We assessed the safety and efficacy of bariatric surgery and postoperative quality of life (QoL) in IBD patients.

Setting: The study was conducted in a large peripheral hospital in the Netherlands.

Methods: All IBD patients who underwent bariatric surgery in our facility were included. Complications, mortality, reoperations, and micronutrient deficiencies were analyzed. Weight loss was assessed 6, 12, and 24 months after surgery. Postoperative QoL was assessed using a disease-specific Inflammatory Bowel Disease Questionnaire (IBDQ).

Results: Forty-five patients were included in this study, all diagnosed with IBD (16 ulcerative colitis (UC) and 29 Crohn's disease (CD)) prior to bariatric surgery. Bariatric procedures included Roux-en-Y gastric bypass, sleeve gastrectomy, gastric banding, and revisional surgery. There was no mortality in the entire follow-up period and there were no major perioperative complications. Two major complications in two CD patients occurred during follow-up, gastro-enterostomy bleeding and pyelonephritis with secondary pancreatitis. Mean percentage (± SD) of overall excess weight loss (%EWL) and total body weight loss (%TBWL), 12 months after surgery, were 62.9 ± 27.1 and 26.2 ± 10.6%, respectively. Twenty-four months postoperatively, mean overall %EWL and %TBWL were similar for both UC and CD patients and were 62.9 ± 31.0 and 26.6 ± 12.2, respectively. Mean Bariatric Analysis and Reporting Outcome System (BAROS) score was 3.34 ± 2.42. Median total IBDQ score was 170.8 (min. 77; max. 218). Both scores did not differ significantly between UC and CD patients.

Conclusion: As bariatric procedures appear safe and effective in this CU and CD population, one could question why bariatric surgery is contraindicated in the patients. Nevertheless, close lifelong monitoring to assure safety and a favorable outcome remains essential.
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http://dx.doi.org/10.1007/s11695-017-3076-9DOI Listing
June 2018

Risk of Metformin-Associated Lactic Acidosis (MALA) in Patients After Gastric Bypass Surgery.

Obes Surg 2018 04;28(4):1080-1085

Departments of Internal Medicine, Rijnstate Hospital, Arnhem, The Netherlands.

Background: Pharmacokinetic data suggest that the risk of metformin-associated lactic acidosis (MALA) may be increased after Roux-en-Y gastric bypass (RYGB) surgery. The aim of this study was to examine the impact of metformin on plasma lactate levels before and after RYGB surgery.

Methods: Retrospective study of plasma lactate levels before and 3 months after RYGB surgery in patients with type 2 diabetes mellitus (T2DM) not using metformin (MET-0, N = 58), on a stable dose (MET-S, N = 138), or on a decreasing dose (MET-D, N = 85) of metformin.

Results: Preoperatively, lactate levels were similar in patients on metformin (1.8 ± 0.05 mmol/L) and those not on metformin (1.7 ± 0.08 mmol/L), P = 0.21. Three months postoperatively, lactate levels had decreased in all groups (P < 0.001) to 1.3 ± 0.07 (SE), 1.4 ± 0.05, and 1.2 ± 0.05 mmol/l in MET-0, MET-S, and MET-D, respectively. Lactate levels differed between the groups (P = 0.03), with the lowest level in MET-D. The number of patients with hyperlactatemia (lactate > 2 mmol/l) decreased from 31 to 14%, from 22 to 8.6%, and from 26 to 4.7% in MET-S, MET-0, and MET-D, respectively.

Conclusion: Mild hyperlactatemia (lactate > 2 mmol/l) is common in morbidly obese patients with T2DM. It is probably related to increase lactate production by adipocytes. Lactate levels decreased after RYGB-induced weight loss, irrespective of the use of metformin. We therefore conclude that there is no need for routinely lowering of the metformin dose after uncomplicated RYGB surgery, as long as normal renal function is preserved.
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http://dx.doi.org/10.1007/s11695-017-2974-1DOI Listing
April 2018

Gastric pouch emptying of solid food in patients with successful and unsuccessful weight loss after Roux-en-Y gastric bypass surgery.

Surg Obes Relat Dis 2017 Nov 12;13(11):1840-1846. Epub 2017 Aug 12.

Vitalys Clinic, Velp, the Netherlands; Department of Surgery, Rijnstate Hospital, Arnhem, the Netherlands.

Background: After Roux-en-Y gastric bypass (RYGB), approximately 10% of patients have insufficient weight loss (excess body mass index loss<50%). Gastric pouch emptying may have a role in weight loss.

Objectives: To compare pouch emptying of patients with poor weight loss and patients with successful weight loss after RYGB.

Setting: A research-intensive nonacademic hospital and center of expertise in bariatric surgery in the Netherlands METHODS: Female patients were included from among patients with the least (poor weight loss group [P-WL]) and the most weight loss (successful weight loss group [S-WL]) in our center 2 years after RYGB. Pouch emptying scintigraphy was performed after ingestion of a radiolabeled solid meal. Emptying curves, intestinal content (IC) at meal completion and after 15, 30, 45, and 60 minutes, half emptying time, and maximal pouch emptying rate were compared.

Results: Five individuals were included in P-WL and 5 in S-WL, on average 2.5 ± .3 years after RYGB. Total weight loss was 18 ± 4.1% in P-WL and 44 ± 5.7% in S-WL (P<.001). In P-WL, a fast initial pouch emptying and exponential emptying curve was observed, compared with a slower initial emptying and more linear curve in S-WL. Faster emptying in P-WL was also shown by a larger IC (42 ± 18% versus 4.0 ± 3.3%,), IC (76 ± 15% versus 35 ± 22%), and IC (85 ± 12% versus 54 ± 25%), and a greater maximal pouch emptying rate (17 ± 4.7 versus 5.6 ± 3.4%/min) compared with S-WL (P<.05). A linear correlation was found between total weight loss and maximal pouch emptying rate (Pearson R = .82, P = .004).

Conclusions: Pouch emptying for solid food was faster in patients with the least weight loss compared with patients with the most weight loss after RYGB. If pouch emptying is an important mechanism in weight loss, altering the pouch outlet may improve poor weight loss management.
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http://dx.doi.org/10.1016/j.soard.2017.07.031DOI Listing
November 2017
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