To Örebro University

BACKGROUND: Metabolic and bariatric surgery (MBS) can be challenging in patients with a very high body mass index (BMI). OBJECTIVES: The objective of the study is to evaluate the outcomes of different weight categories in a publicly funded healthcare system with high adherence to current guidelines for perioperative optimization.

SETTING: Nationwide, registry-based. METHODS: Based on nationwide data from the Scandinavian Obesity Surgery Registry, patients operated on with Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and biliopancreatic diversion with duodenal switch (BPD/DS) from 2007 until 2024 were included. Patients were stratified according to preoperative BMIs of 35-49 kg/m2, 50-59 kg/m2, 60-69 kg/m2, and ≥70 kg/m2.

RESULTS: The study included data for 83,057 patients. A postoperative complication occurred for 5855 (7.2%) with no difference between BMI groups. Operation time was longer for higher BMI groups for all procedures. At 2 years, patients lost the highest percentage of their total weight (%TWL) in all BMI categories after BPD/DS (37.9% ± 10.1% to 45.4% ± 15.3%), followed by RYGB (32.4% ± 8.6% to 36.8% ± 10.9%) and SG (26.6% ± 9.5% to 31.3% ± 8.9%). Mortality rates over a median of 9.8 years remained higher in the higher BMI groups (BMI: 50-59, odds ratio [OR] = 1.29 [1.15-1.46]; BMI: 60-69, OR = 1.66 [1.18-2.33]; BMI ≥70, OR = 2.33 [.96-5.68]).

CONCLUSION: MBS can be performed safely in patients with obesity class 4 or higher. Higher BMI was associated with longer operating times and superior weight loss, especially after BPD/DS. Despite greater weight loss and similar remission of metabolic co-morbid diseases, patients with higher preoperative BMI still have an increased long-term risk of all-cause mortality.

Social anxiety disorder is common among patients considered for metabolic and bariatric surgery (MBS). The combination of social anxiety with obesity may, however, be associated with a higher risk for adverse outcomes after surgery. In this nationwide, registry-based, matched cohort study, all patients who underwent primary MBS in Sweden from 2007 until 2019 and who had a diagnosis of moderate to severe social anxiety disorder (n = 586) were matched using a Propensity score to controls who underwent the same treatment but who did not have social anxiety disorder (n = 5791) with a mean follow-up time of 6.9 years. Patients with social anxiety disorder experienced an increased risk for non-serious postoperative complications (OR 1.59; 95%CI 1.21-2.09), self-harm (HR 2.44 CI 95% 1.84-3.25 p < 0.001) and alcohol or substance abuse (HR 2.41, 95%CI 1.96-2.96, p < 0.001), and reported lower psychosocial health-related quality of life before and after surgery. However, patients with social anxiety disorder significantly improved in health-related quality of life compared to baseline, and experienced similar effects on weight reduction at 2 years after surgery (total weight loss: 32.8 ± 10.3% compared to 32.6 ± 9.7%) and risks for cardiovascular events compared to the matched control group. MBS appears to be a safe and effective treatment for severe obesity in patients with social anxiety disorder, but an individualized and increased peri- and postoperative support should be considered for patients with moderate to severe social anxiety disorder and severe obesity.

OBJECTIVE: To assess incidence, indications, symptom relief, complications, and weight outcomes following Roux-en-Y gastric bypass (RYGB) reversal. BACKGROUND: RYGB is an effective treatment for obesity but may in rare cases be associated with severe long-term complications requiring RYGB reversal. Evidence on incidence and outcomes is limited.

METHODS: This nationwide, multi-center, retrospective cohort study included all patients undergoing RYGB reversal in Sweden between 2007 and 2023. Data were obtained from the Scandinavian Obesity Surgery Registry (SOReg) and medical records.

RESULTS: During the study period, 199 patients (84% female, mean age 42.5 y) underwent RYGB reversal at 13 centers, corresponding to an incidence of 0.3% of 63,797 RYGB-procedures performed. Patients usually had multiple indications, most often abdominal pain (70%), malnutrition (45%), gastrointestinal symptoms (34%), and postbariatric hypoglycemia (29%). Most procedures (84%) were performed laparoscopically, with a median hospital stay of 4 days. Mean body weight increased from 77 kg at reversal to 89 kg at one year. Overall, 86% of patients reported partial or complete symptom relief, highest rates among those with postbariatric hypoglycemia (94.6%). Early severe complications (Clavien-Dindo grade ≥IIIb) occurred in 24.6% and late severe complications in 21.6%, with seven not surgery-related deaths (3.5%) during follow-up.

CONCLUSIONS: Reversal of RYGB is rare but can be considered in patients with a substantial burden of complications. Although postoperative morbidity was common, most patients achieved symptom relief. Careful patient selection, perioperative optimization, and realistic expectations are essential. Further studies are needed to determine optimal surgical techniques and long-term outcomes.

Background: Patients with initial body mass index > 50 kg/m(2) are vastly under-represented in randomized clinical trials demonstrating similar weight loss and diabetes remission rates after sleeve gastrectomy and Roux-en-Y gastric bypass.

Methods: Propensity score matching 1 : 1 was used to compare outcomes regarding weight loss and diabetes control after sleeve gastrectomy and Roux-en-Y gastric bypass in patients with body mass index > 50 kg/m(2) between 2012 and 2022 in a cohort from 13 centres in six European countries. The primary endpoint was percentage total bodyweight loss; secondary endpoints were diabetes remission rate and rate of persistent body mass index > 40 kg/m(2).

Results: In total, 3976 of 8160 patients were matched and included in the analysis (1988 in each group). Median age at baseline was 40.0 (range 16-76) years in the sleeve gastrectomy group and 39.5 (15-71) years in the Roux-en-Y gastric bypass group. Median body mass index at baseline was 56.2 (range 50.0-100.0) and 54.3 (50.0-83.9) kg/m(2), respectively (P < 0.001). The follow-up rate was 70.5% at 1 year and 24.4% at 5 years. Percentage total bodyweight loss at 1 and 5 years after sleeve gastrectomy was 30.2 (2.2-63.7) and 25.4 (-4.8 to 56.0)%, respectively, versus 31.2 (7.4-54.5) and 28.2 (-6.6 to 62.9)% in the Roux-en-Y gastric bypass group (P < 0.001 between groups in both time points). The prevalence of persistent body mass index > 40 kg/m(2) after 1 and 5 years was 42.7 and 57.6%, respectively, after sleeve gastrectomy versus 24.5 and 39.2% after Roux-en-Y gastric bypass (P < 0.001 between groups in both time points). A 5-year follow-up, the prevalence of a pathological haemoglobin A1c level (> 6.5%) was 12.9% after sleeve gastrectomy and 11.6% after Roux-en-Y gastric bypass (P = 0.323).

Conclusion: This study suggests that Roux-en-Y gastric bypass results in greater weight loss than sleeve gastrectomy in patients with body mass index > 50 kg/m(2), whereas improvements in diabetes appear comparable between procedures.

BACKGROUND/OBJECTIVES: Studies show equal or better resolution of type 2 diabetes mellitus (T2D) and other metabolic outcomes after Roux-en-Y gastric bypass (RYGB) compared to sleeve gastrectomy (SG), but it is unclear whether this is related only to the higher weight loss after RYGB, or if there are weight-loss-independent factors. The objective of this study was to examine weight-loss-independent differences in metabolic outcomes between RYGB and SG.

METHODS: This study utilized the Scandinavian Obesity Surgery Registry and the Swedish National Diabetes Register. All included patients had presurgical T2D and matching was between RYGB or SG using a 1:1 propensity score, matching with a generalized linear model including age, sex, BMI at baseline, comorbidities (cardiovascular, dyslipidemia, sleep apnea, and hypertension), T2D parameters at baseline (HbA1c, number of T2D medications, insulin use, duration of T2D), year of surgery and percentage Total Weight Loss (%TWL) at nadir. The ensuing cohort was compared regarding remission and improvements in T2D, and other cardiometabolic outcomes, including major adverse cardiovascular events (MACE).

RESULTS: 1440 individuals (720 RYGB; 720 SG) were matched 1:1 using Propensity score. There were 494 (68.6%) patients in complete T2D remission at 2 years after RYGB, and 438 (60.8%) after SG, (OR: 0.75, 95% CI 0.60 - 0.93, p = 0.010) despite similar TWL (Standardized mean difference 0.12). SG also had a lower rate of pharmacological remission for T2D (OR 0.71, 95% CI 0.56-0.88, p = 0.002), and hypertension remission (OR 0.70, 95% CI 0.52-0.94, p = 0.019), but there was no significant difference in pharmacological remission regarding dyslipidemia (OR 0.83, 95%CI 0.66-01.04, p = 0.11). No difference was seen in the risk for MACE (SG vs. RYGB HR:1.45, 95%CI 0.89-2.38, p = 0.136).

CONCLUSIONS: RYGB is associated with a greater rate of T2D remission compared to SG. This study suggests that these improved outcomes are independent of the degree of weight loss.

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.

INTRODUCTION: Emergency department visits are common following bariatric surgery and may be partially preventable. Health literacy and general self-efficacy are factors that may influence health-seeking behaviors in these patients. This study aimed to assess whether health literacy and general self-efficacy are associated with an increased frequency of emergency department visits after bariatric surgery.

METHODS: Patients who underwent bariatric surgery at a single hospital from 2018 to 2020 were evaluated for their health literacy and general self-efficacy levels before surgery. Data on emergency department visits within the patient's residential region were evaluated over a three-year period, with repeated emergency department visits for abdominal pain as the primary outcome.

RESULTS: During the follow-up period, 69 of 231 patients (29.9%) had at least one emergency department visit for abdominal pain, and 20 patients (8.7%) had three or more visits. Inadequate functional health literacy (OR 5.56, 95% CI 1.80-17.19, p = 0.003) and inadequate communicative and critical health literacy (OR 10.48, 95% CI 3.13-35.08, p < 0.001) were both significantly associated with an increased risk of repeated emergency department visits over the three-year period. No significant association was found between low general self-efficacy and the frequency of emergency department visits.

CONCLUSIONS: Inadequate health literacy is associated with an increased risk of repeated emergency department visits for abdominal pain following bariatric surgery.

BACKGROUND: Opioid-free anaesthesia (OFA) may enhance postoperative recovery after bariatric surgery, but its combined effect with opioid-free interventions has not been studied.

OBJECTIVES: To compare postoperative pain and recovery after laparoscopic bariatric surgery with a total opioid-free care pathway and conventional opioid-based treatment. DESIGN: A multicentre nonblinded controlled trial. SETTING: Two university hospitals in Sweden.

PATIENTS: Adult patients scheduled for laparoscopic bariatric surgery were enrolled between May 2019 and November 2023. Of 837 patients screened, 112 were randomised, and 110 were included in the analysis: 55 in the intervention and 55 in the control group.

INTERVENTIONS: Patients were randomised to an opioid-based standard care (control group) or to an opioid-free care pathway (intervention group), including intraoperative OFA and postoperative first-line transcutaneous electrical nerve stimulation (TENS) treatment.

MAIN OUTCOME MEASURES: The primary outcome was the change in patient-reported postoperative pain intensity on a numerical rating scale (NRS) from arrival in the postanaesthesia care unit (PACU) until discharge to the surgical ward. Key secondary outcomes were postoperative pain intensity, in-hospital opioid consumption, and postoperative quality of recovery scale (PQRS) scores.

RESULTS: There was no difference between the groups regarding the changes in pain intensity from arrival in PACU until discharge to the ward, with mean ± SD changes in NRS of 3.20 ± 3.01 (intervention) vs. 3.15 ± 2.25 (control); mean difference (MD) 0.04 [(95% confidence interval (CI), -1.00 to 1.08); P = 0.97], and pain intensity at 24 h (P = 0.078), 72 h (P = 0.060), and 3 months (P = 0.30) postoperatively. The intervention group had a significantly lower opioid consumption in the PACU; mean morphine equivalents 6.08 ± 12.31 vs. 51.1 ± 14.9 mg; MD -45.0 (95% CI, -50.1 to -39.8) mg; P < 0.0001; and during the hospital stay MD -40.3 (95% CI, -54.4 to -25.9) mg; P < 0.0001. Total PQRS scores did not differ significantly over the 3-month follow-up.

CONCLUSION: The opioid-free care pathway offers patients pain relief and recovery outcomes comparable to conventional opioid-based care and reduces opioid use after laparoscopic bariatric surgery.

TRIAL REGISTRATION: ClinicalTrials.gov NCT03756961.

BACKGROUND: With over 1 billion individuals affected globally, obesity and obesity related diseases is now a leading cause of death. Metabolic and bariatric surgery (MBS) has emerged as a cornerstone intervention for severe obesity and its associated comorbidities. Despite its efficacy, postoperative care and follow-up after MBS remains highly variable worldwide.

OBJECTIVE: The PARTNER study aimed to evaluate global clinical practices in the postoperative management following MBS by surveying multidisciplinary healthcare professionals.

METHODS: This study was an international online survey conducted between October 2024 and January 2025. A multidisciplinary team developed the questionnaire based on existing literature and international guidelines. The survey assessed five domains: follow-up care, postoperative treatment, dietary management, patient support, and measurement of surgical outcomes. Responses were analysed descriptively.

RESULTS: A total of 262 responses were received from 62 countries. Most respondents were bariatric surgeons (72.1%) working in public healthcare systems (73.3%). While 78.7% reported conducting three-month postoperative reviews, only 23.7% offered indefinite follow-up. Hybrid models of care (virtual and in-person) were common (56.9%). VTE prophylaxis and postoperative PPI use were recommended by 64.1% and 84.3% respectively. Nearly all respondents (98.1%) provided dietary advice, with protein and micronutrient supplementation widely endorsed. Only 56.1% routinely referred patients for psychological follow-up. Definitions of surgical success and failure varied widely, with inconsistent objective outcome measures.

CONCLUSION: The PARTNER study reveals significant international variation in postoperative management practices following MBS. These findings underscore the need for more standardized, evidence-based guidelines to improve long-term outcomes and equity of care worldwide.

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.