To Örebro University

Global obesity rates have risen dramatically, now exceeding deaths from starvation. Metabolic and bariatric surgery (MBS), initially for severe obesity (BMI ≥35 kg/m2), is performed globally over 500 000 times annually, offering significant metabolic benefits beyond weight loss. However, varying eligibility criteria globally impact patient care and healthcare resources. Updated in 2022, ASMBS and IFSO guidelines aim to standardise MBS indications, reflecting current understanding and emphasising comprehensive preoperative assessments. Yet, clinical variability persists, necessitating consensus-based recommendations. This modified Delphi study engaged 45 global experts to establish consensus on perioperative management in MBS. Experts selected from bariatric societies possessed expertise in MBS and participated in a two-round Delphi protocol. Consensus was achieved on 90 of 169 statements (53.3%), encompassing multidisciplinary team composition, patient selection criteria, preoperative testing, and referral pathways. The agreement highlighted the critical role of comprehensive preoperative assessments and the integration of healthcare professionals in MBS. These findings offer essential insights to standardise perioperative practices and advocate for evidence-based guidelines in MBS globally. The study underscores the need for unified protocols to optimise outcomes and guide future research in MBS.

After bariatric surgery, adherence to lifestyle recommendations is crucial. Health literacy and self-efficacy may impact recovery after surgery. In this multicentre study performed in three hospitals in Sweden, we evaluated any relation between preoperative health literacy and general self-efficacy on the one side and weight loss, health-related quality of life, length of stay, and complications up to 2 years after bariatric surgery on the other. Of 686 included patients, 56% (n = 382) had limited functional health literacy, 42% (n = 278) had limited communicative and critical health literacy, and 40% (n = 266) reported low general self-efficacy. Preoperative functional, communicative and critical health literacy, and general self-efficacy were not associated with the degree of weight loss at 1 or 2 years after surgery. However, limited health literacy and low general self-efficacy scores were associated with both reduced quality of life and obesity-related problems postoperatively. Further, a higher proportion of those with inadequate health literacy had a prolonged length of stay. Although patients with limited health literacy and self-efficacy may experience similar maximum weight loss after bariatric surgery as other patients, they still might have reduced health-related quality of life in terms of obesity-related problems. Increased awareness of this association as well as patient-centered support before and after bariatric surgery may be of benefit.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has gained increasing popularity worldwide, yet concerns persist regarding the development of gastroesophageal reflux disease (GERD) postoperatively.

OBJECTIVES: This study aimed to evaluate the influence of technical aspects of LSG, specifically bougie size and distance from the pylorus to resection line edge, on the risk of developing symptomatic GERD within 2years following surgery.

SETTING: Data from the Scandinavian Obesity Surgery Registry (SOReg) and the National Prescribed Drug Register were utilized for this analysis.

METHODS: A retrospective observational study was conducted encompassing all LSG patients in Sweden between 2012 and 2020 who did not receive preoperative proton pump inhibitor (PPI) prescriptions. Patients were categorized based on bougie size and pyloric distance. Regular PPI use, defined as a dispensed prescription of more than 300 tablets per year, was employed as a proxy measure of symptomatic GERD and was compared between the groups.

RESULTS: The study included 7,435 patients with complete data on dispensed PPI prescription both preoperatively and throughout the 2-year follow-up period. Information on bougie size and pyloric distance was available for 97.4% and 84.9%, respectively. Narrower bougie size and greater pyloric distance were associated with increased risk of regular PPI use postsurgery. Advanced age and female sex were independent risk factors for post-LSG regular PPI use, while initial body mass index (BMI), total weight loss (%TWL), and comorbidities showed no significant associations.

CONCLUSIONS: Using a narrow bougie and initiating resection at a greater distance from the pylorus were associated with higher risk of symptomatic de novo GERD following LSG.

INTRODUCTION: Obesity may increase complexity of surgical procedures and increase the risk of perioperative complications. Weight reduction by the use of low energy diet (LED, ≤1200 kcal/day) or very low energy diet (VLED, ≤800 kcal/day) can reduce postoperative complications after bariatric surgery, but for most other types of surgery the evidence for its use remains uncertain. The aim of this systematic review was therefore to evaluate the scientific evidence in general for this routine.

METHODS: The Medline, Embase, Web of Science and Cochrane databases were searched up until November 20, 2024 using the Cochrane risk of bias assessment tool for observational studies and the NIH quality assessment of controlled intervention studies for randomized trials. Operation time, surgeon's perceived difficulty, intraoperative complications, postoperative complications and relevant efficacy measures for specific procedures were considered as endpoints. A random-effects model was used to pool effect sizes for the main analyses.

RESULTS: A total of 7053 studies were identified. After screening by title and abstract, followed by full text, 18 studies (9 RCTs and 9 observational studies) remained for the analyses including 854 patients who received the intervention and 979 controls. Preoperative LED/VLED resulted in an overall shorter operation time (standard mean difference 0.36, 95 % CI 0.14-0.59, p = 0.002), and reduced risk of postoperative complications after bariatric surgery, cholecystectomy, colorectal surgery and hernia repair (pooled RR 0.63, 95%CI 0.51-0.79, p < 0.001). Heterogeneity between studies was high for operation time but very low for complications. No difference was seen for intraoperative complications, while the data did not allow further analyses on perceived difficulty of surgery or efficacy outcomes.

CONCLUSION: The results support the use of LED/VLED for short-term preoperative weight reduction in patients with obesity planned for bariatric surgery and for those undergoing cholecystectomy, colorectal surgery and hernia repair. Further studies including a comparable control group are needed to evaluate its routine use for other surgical procedures.

REGISTRATION: The protocol of this study was preregistered at the International Prospective Register of Systematic Reviews, PROSPERO.

Artificial intelligence (AI) is transforming the landscape of medicine, including surgical science and practice. The evolution of AI from rule-based systems to advanced machine learning and deep learning algorithms has opened new avenues for its application in metabolic and bariatric surgery (MBS). AI has the potential to enhance various aspects of MBS, including education and training, decision-making, procedure planning, cost and time efficiency, optimization of surgical techniques, outcome and complication prediction, patient education, and access to care. However, concerns persist regarding the reliability of AI-generated decisions and associated ethical considerations. This study aims to establish a consensus on the role of AI in MBS using a modified Delphi method. A panel of 68 leading metabolic and bariatric surgeons from 35 countries participated in this consensus-building process, providing expert insights into the integration of AI in MBS. Of the 28 statements evaluated, a consensus of at least 70% was achieved for all, with 25 statements reaching consensus in the first round and the remaining three in the second round. Experts agreed that AI has the potential to enhance the evaluation of surgical skills in MBS by providing objective, detailed assessments, enabling personalized feedback, and accelerating the learning curve. Most experts also recognized AI's role in identifying qualified candidates for MBS referrals, helping patient and procedure selection, and addressing specific clinical questions. However, concerns were raised about the potential overreliance on AI-generated recommendations. The consensus emphasized the need for ethical guidelines governing AI use and the inclusion of AI's role in decision-making within the patient consent process. Furthermore, the results suggest that AI education should become an essential component of future surgical training. Advancements in AI-driven robotics and AI-integrated genomic applications were also identified as promising developments that could significantly shape the future of MBS.

BACKGROUND: Randomized, controlled trials (RCTs) comparing the effectiveness of metabolic bariatric surgery (MBS) in addition to one or more treatment interventions for obesity (i.e., lifestyle structured interventions-LSI, medical therapy-MT, obesity management medication-OMM or endobariatric procedures-EP) are lacking. This study aims to assess the effectiveness of multiple simultaneous (before or immediately after MBS) interventions for treating obesity.

METHODS: We performed a meta-analysis including all RCTs enrolling patients undergoing different MBS procedures add-on to other anti-obesity strategies (LSI, MT, OMM or ES) versus MBS alone, with a duration of at least 6 months. The primary outcome was BMI at the end-point; secondary end-points included percentage total and excess weight loss (%TWL%, and EBWL%), total weight loss (TWL), fasting plasma glucose (FPG), HbA1c, surgical and non-surgical severe adverse events (SAE), mortality, remission of type 2 diabetes, hypertension, dyslipidemia and health-related quality of life (HR-QoL).

RESULTS: A total of 25 RCTs were retrieved. The addition of either OMM (i.e., liraglutide) or EP (i.e., intragastric balloon-IB, endosleeve-ES) to MBS was associated with a significantly lower BMI at the end-point (p = 0.040). The addition of liraglutide only to MBS was associated with a greater %EWL%, but not %TWL and TBWL (p = 0.008). Three trials evaluated end-point HbA1c, showing a significant reduction in favour of liraglutide as an add-on therapy to MBS (p = 0.007). There was no mortality.

CONCLUSIONS: MBS combined with non-surgical approaches appears more effective than MBS alone in reducing BMI. Further RCTs on combined therapies to MBS for severe obesity are needed to enhance the tailoring of treatment for severe obesity.

Dumping and post-bariatric hypoglycaemia (PBH) are side effects that occur after bariatric surgery. The aim of this study was to estimate the prevalence of dumping and PBH symptoms before Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) at 6 months, 1 year, 2 years and 5 years after surgery in a Swedish population. A cross-sectional single-centre study was performed at Lindesberg Hospital, Region Örebro County, Sweden, between 2020 and 2023. The Swedish version of the Dumping Severity Scale (DSS-Swe) questionnaire, which includes eight items regarding dumping symptoms and six items regarding hypoglycaemia symptoms, was used. A total of 742 DSS-Swe questionnaires were included. The average age at surgery was 42.0 years (standard deviation [SD] = 11.9), and the average body mass index was 41.8 kg/m2 (SD = 5.9). The surgical methods consisted of RYGB (66.3%) and SG (33.7%). The proportion of RYGB patients with highly suspected dumping increased from 4.9% before surgery to 26.3% (adjusted odds ratio [OR] = 7.35, 95% confidence interval [CI] = 3.08-17.52) at the 5-year follow-up. PBH symptoms increased from 1.4% before surgery to 19.3% at the 5-year follow-up (adjusted OR = 17.88, 95% CI = 4.07-78.54). For SG patients, no significant increase in dumping or PBH symptoms was observed. In patients with persistent type 2 diabetes (T2D), there were no cases of highly suspected hypoglycaemia following RYGB or SG. Symptoms of dumping and PBH were common after RYGB, while no clear increase was observed after SG. Persistent T2D seems to be a protective factor against PBH symptoms.

IMPORTANCE: Laparoscopic sleeve gastrectomy (SG) and laparoscopic Roux-en-Y gastric bypass (RYGB) are widely used bariatric procedures for which comparative efficacy and safety remain unclear.

OBJECTIVE: To compare perioperative outcomes in SG and RYGB.

DESIGN, SETTING, AND PARTICIPANTS: In this registry-based, multicenter randomized clinical trial (Bypass Equipoise Sleeve Trial), baseline and perioperative data for patients undergoing bariatric surgery from October 6, 2015, to March 31, 2022, were analyzed. Patients were from university, regional, county, and private hospitals in Sweden (n = 20) and Norway (n = 3). Adults (aged ≥18 years) eligible for bariatric surgery with body mass indexes (BMIs; calculated as weight in kilograms divided by height in meters squared) of 35 to 50 were studied.

INTERVENTIONS: Laparoscopic SG or RYGB.

MAIN OUTCOMES AND MEASURES: Perioperative complications were analyzed as all adverse events and serious adverse events (Clavien-Dindo grade >IIIb). Ninety-day mortality was also assessed.

RESULTS: A total of 1735 of 14 182 eligible patients (12%; 1282 [73.9%] female; mean (SD) age, 42.9 [11.1] years; mean [SD] BMI, 40.8 [3.7]) were included in the study. Patients were randomized and underwent SG (n = 878) or RYGB (n = 857). The mean (SD) operating time was shorter in those undergoing SG vs RYGB (47 [18] vs 68 [25] minutes; P < .001). The median (IQR) postoperative hospital stay was 1 (1-1) day in both groups. The 30-day readmission rate was 3.1% after SG and 4.0% after RYGB (P = .33). There was no 90-day mortality. The 30-day incidence of any adverse event was 40 (4.6%) and 54 (6.3%) in the SG and RYGB groups, respectively (odds ratio, 0.71; 95% CI, 0.47-1.08; P = .11). Corresponding figures for serious adverse events were 15 (1.7%) for the SG group and 23 (2.7%) for the RYGB group (odds ratio, 0.63; 95% CI, 0.33-1.22; P = .19).

CONCLUSIONS AND RELEVANCE: This randomized clinical trial of 1735 patients undergoing primary bariatric surgery found that both SG and RYGB were performed with a low perioperative risk without clinically significant differences between groups.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02767505.

Metabolic and bariatric surgery (MBS) is widely considered the most effective option for treating obesity, a chronic, relapsing, and progressive disease. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued new guidelines on the indications for MBS, which have superseded the previous 1991 National Institutes of Health guidelines. The aim of this study is to establish the first set of consensus guidelines for selecting procedures in Class I and II obesity, using an Expert Modified Delphi Method. In this study, 78 experienced bariatric surgeons from 32 countries participated in a two-round Modified Delphi consensus voting process. The threshold for consensus was set at an agreement or disagreement of ≥ 70.0% among the experts. The experts reached a consensus on 54 statements. The committee of experts reached a consensus that MBS is a cost-effective treatment option for Class II obesity and for patients with Class I obesity who have not achieved significant weight loss through non-surgical methods. MBS was also considered suitable for patients with Type 2 diabetes mellitus (T2DM) and a body mass index (BMI) of 30 kg/m2 or higher. The committee identified intra-gastric balloon (IGB) as a treatment option for patients with class I obesity and endoscopic sleeve gastroplasty (ESG) as an option for patients with class I and II obesity, as well as for patients with T2DM and a BMI of ≥ 30 kg/m2. Sleeve gastrectomy (1) and Roux-en-Y gastric bypass (RYGB) were also recognized as viable treatment options for these patient groups. The committee also agreed that one anastomosis gastric bypass (OAGB) is a suitable option for patients with Class II obesity and T2DM, regardless of the presence or severity of obesity-related medical problems. The recommendations for selecting procedures in Class I and II obesity, developed through an Expert Modified Delphi Consensus, suggest that the use of standard primary bariatric endoscopic (IGB, ESG) and surgical procedures (SG, RYGB, OAGB) are acceptable in these patient groups, as consensus was reached regarding these procedures. However, randomized controlled trials are still needed in Class I and II Obesity to identify the best treatment approach for these patients in the future.

Background: The prevalence of obesity is already a worldwide health concern. The development of straightforward guidelines regarding the whole available armamentarium (i.e., medical, endoscopic, and surgical interventions in conjunction with a guidance program) is paramount to offering the best multimodal approach to patients with obesity.

Methods: The International Federation for Surgery of Obesity and Metabolic Disorders-European Chapter (IFSO-EC) identified a panel of experts to develop the present guidelines. The panel formulated a series of clinical questions (based on the patient, intervention, comparison, and outcome conceptual framework), which have been voted on and approved. A GRADE methodology will be applied to assess the quality of evidence and formulate recommendations employed to minimize selection and information biases. This approach aims to enhance the reliability and validity of recommendations, promoting greater adherence to the best available evidence.

Results: These guidelines are intended for adult patients with a body mass index (BMI) ≥ 30 kg/m2 who are candidates for metabolic bariatric surgery (MBS). The expert panel responsible for developing these guidelines comprised 25 panelists (92% were bariatric surgeons) and 3 evidence reviewers, with an average age of 50.1 ± 10.2 years. The panel focused on 3 key questions regarding the combined use of structured lifestyle interventions, approved obesity management medications, and endoscopic weight loss procedures with MBS.

Conclusions: The complexity of obesity as a chronic disease requires a comprehensive knowledge of all the available and feasible therapeutic options. The IFSO-EC society felt the urgent need to develop methodologically valid guidelines to give a full picture and awareness of the possible surgical and non-surgical therapeutic strategies employed with a multimodal approach.