To Örebro University

BACKGROUND: Bariatric surgery is currently one of the most performed elective laparoscopic procedures. Continuous refinement elevates standards.

OBJECTIVES: This retrospective cohort study aimed to determine aspirational benchmarks for laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) in an unselected cohort, developing adjusted reference values for groups at risk of severe complications.

SETTING: Nationwide registry study including every bariatric facility in Sweden.

METHODS: Using data from the Scandinavian Obesity Surgery Registry encompassing Swedish primary LRYGB and LSG procedures from 2012 to 2021, the Achievable Benchmark of Care methodology was employed to establish reference values for quality-related surgical outcomes, notably severe complications. The data included perioperative and postoperative data up to 30 days after surgery. Logistic regression identified risk factors for severe complications (Clavien-Dindo > II). Adjusted benchmarks were developed for relevant subgroups using the Achievable Benchmark of Care methodology.

RESULTS: The study included 36,846 LRYGB and 15,246 LSG patients. Severe postoperative complications occurred in 3.6% (interquartile range: 2.5%-5.1%) of LRYGB cases, with a benchmark of 1.5%. Risk factors included prior deep vein thrombosis and ongoing antidepressant use. In the LSG group, 1.9% (interquartile range: .5%-3.7%) experienced severe complications, compared to a benchmark of .4%. Risk factors encompassed age, body mass index, smoking, dyspepsia, and diabetes. Only diabetes in the LSG group increased the benchmark to 1.2% for severe complications.

CONCLUSIONS: These benchmarks, developed from validated national registry data, are more demanding than previous global benchmarks. They prompt reflection on surgical quality and will hopefully inspire further quality improvement initiatives across bariatric surgery providers.

BACKGROUND: Bariatric surgery increases the risk of anemia, but long-term data from large cohorts are sparse, and it is unclear if certain groups are at a higher risk. OBJECTIVES: Define factors associated with anemia at 5 years of follow-up after bariatric surgery. SETTING: Data from a national quality register.

METHODS: This cross-sectional study uses Scandinavian Obesity Surgery Registry data on primary Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) procedures in Sweden from 2007 to 2020. Hemoglobin and ferritin were analyzed preoperatively and up to 10 years postoperatively. Factors associated with anemia were evaluated using hemoglobin and ferritin samples 5 years postsurgery.

RESULTS: The study included 73,612 patients (RYGB: 80.7%, SG: 19.3%). Hemoglobin and/or ferritin data were available for 18,993 patients 5 years postsurgery, of whom 3508 patients (18.5%) had anemia and 691 patients (27.0%) subnormal ferritin levels. Anemia and subnormal ferritin were more prevalent after RYGB than SG (19.6% versus 11.3%, adjusted odds ratio [aOR] = .58 and 24.1% versus 15.6%, aOR = .43). Females had a higher prevalence of anemia than males (20.6% versus 11.1%, aOR = .50). Young age was associated with a higher risk of anemia (31.0%), as was large postoperative weight loss (highest quartile 25.2%). Results regarding iron supplementation were not conclusive.

CONCLUSIONS: The prevalence of anemia, likely secondary to iron deficiency, increases up to 10 years post bariatric surgery. Female sex, young age at surgery, large weight loss, and undergoing RYGB were associated with an increased risk of anemia, indicating a need for targeted strategies for vitamin and mineral supplementation in these groups.

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.

BACKGROUND: Core outcome sets are an established method for standardising the collection, measurement and reporting of treatment outcomes in effectiveness trials. Using Delphi survey methodology, core sets are developed by prioritising and re-prioritising data items facilitated by provision of feedback of other stakeholders' responses. It is unknown how best to provide feedback to ensure that it influences the re-prioritisation of items effectively. This study examined whether informing participants of the top-rated items from the previous survey round may influence the re-prioritisation of data items in a subsequent survey round during the development of core data sets.

METHODS: This study was nested in the development of a registry core data set. In round two of the Delphi survey, participants were randomised to receive 'standard' or 'enhanced' instructions. 'Enhanced' instructions included summarised data of the top five data items scored by participants in the previous survey round) in addition to standard feedback (the median round 1 score per item). Items scored 7-9 by ≥70% of participants in round 2 were considered 'prioritised'. Concordant/discordant items were determined and extent of agreement between groups calculated (kappa statistics).

RESULTS: Both groups prioritised a larger number of items in round 2 than in round 1 and there was little difference in the percentage of respondents prioritising the 'Top 5' items in round 2 (mean change in prioritisation of Top 5 items for all four core sets combined - 2.3% increase in standard group and 3.2% increase in enhanced group). Overall agreement in data items prioritised by both groups improved in round 2 (discordant items - 11% in round 1 and 4% in round 2).

CONCLUSION: Providing participants with additional feedback during the process of item prioritisation did not promote prioritisation of items during development of a core set. In the development of health core sets, where often many items are prioritised, further work to determine how to clearly and optimally communicatee feedback in a manner that promotes consensus effectively is required. Specifically, qualitative work with relevant stakeholders, exploring and clarifying the concepts of prioritisation and consensus, is warranted.

PURPOSE: Breast augmentation after massive weight loss (MWL) is surgically challenging owing to altered anatomy and tissue quality. Previous case series suggest higher revision rates, but controlled, population-based evidence is lacking. We aimed to evaluate long-term outcomes, including reoperation frequency and indications, after primary augmentation in MWL patients compared with matched controls.

METHODS: We performed a nationwide, population-based case-control study using prospectively collected registry data (SOReg and BRIMP). The cohort comprised 817 MWL patients undergoing 1634 primary augmentations and 3512 matched controls with 7023 procedures (2004-2022). Follow-up averaged 5.4 (SD 2.9) and 5.6 (SD 2.8) years, respectively. Revision procedures, indications for re-operations, and intraoperative findings were analyzed. Statistical comparisons employed the Mann-Whitney U and Fisher's exact tests with Bonferroni-Holm correction.

RESULTS: Reoperation was more frequent in MWL patients (9.4% vs. 7.1%, p<0.001), with shorter time to first revision (1.5 (SD 1.8) vs. 2.3 (SD 2.4) years, p<0.001). Implant malposition (20% vs. 11%, p=0.004), rotation (9.5% vs. 3.1%, p=0.002), and seroma (6.9% vs. 1.7%, p=0.002) were more common in MWL revisions. Indications were similar, most often patient-driven changes.

CONCLUSION: Breast augmentation after MWL carries a higher and earlier risk of reoperation compared with the controls, though absolute complication rates remain low. These findings provide population-based evidence to guide patient counseling and surgical planning in this complex group.

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.

PURPOSE: Massive weight loss after bariatric surgery is often associated with alterations in breast morphology, including ptosis, excess skin, poor tissue elasticity, and altered nipple position, which frequently motivate requests for breast surgery. However, data on implant-based augmentation after massive weight loss are sparse and often limited to small series. This study aimed to compare surgical techniques and implant selection in post-bariatric patients versus non-bariatric women undergoing primary augmentation.

METHODS: We conducted a national, population-based case-control study within the Breast Reconstruction After Bariatric Surgery protocol (NCT07059104). Patients occurring in both the Scandinavian Obesity Surgery Registry and the Swedish Breast Implant Registry were identified. A non-bariatric control group having breast augmentation was created.

RESULTS: A total of 817 post-bariatric patients (1634 breasts) and 3512 controls (7023 breasts) were analysed. Surgery occurred a median of 3.4 years after bariatric surgery. Post-bariatric patients reported greater dissatisfaction with breast volume. They more often received larger implants, round shapes, and micro- or macro-textured or polyurethane surfaces. Dual-plane or submuscular placement was predominant in both groups, whereas subfascial and subglandular placements were less common in post-bariatric patients. Augmentation mastopexy was more frequent, while the use of mesh/ADM and lipofilling remained rare. Postoperative antibiotics were prescribed more often to post-bariatric patients.

CONCLUSION: Breast augmentation after massive weight loss differs from standard practice, with larger and more textured implants and a higher frequency of mastopexies, highlighting surgical adaptation to complex anatomy.

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.

The lack of standardization in patient-reported outcome measures (PROMs) has made measurement and comparison of quality of life (QoL) outcomes in research focused on obesity treatment challenging. This study reports on the results of the second and third global multidisciplinary Standardizing Quality of life measures in Obesity Treatment (S.Q.O.T.) consensus meetings, where a core set of PROMs to measure nine previously selected patient-reported outcomes (PROs) in obesity treatment research was established. The S.Q.O.T. II online and S.Q.O.T. III face-to-face hybrid consensus meetings were held in October 2021 and May 2022. The meetings were led by an independent moderator specializing in PRO measurement. Nominal group techniques, Delphi exercises, and anonymous voting were used to select the most suitable PROMs by consensus. The meetings were attended by 28 and 27 participants, respectively, including a geographically diverse selection of people living with obesity (PLWO) and experts from various disciplines. Out of 24 PROs and 16 PROMs identified in the first S.Q.O.T. consensus meeting, the following nine PROs and three PROMs were selected via consensus: BODY-Q (physical function, physical symptoms, psychological function, social function, eating behavior, and body image), IWQOL-Lite (self-esteem), and QOLOS (excess skin). No PROM was selected to measure stigma as existing PROMs deemed to be inadequate. A core set of PROMs to measure QoL in research focused on obesity treatment has been selected incorporating patients' and experts' opinions. This core set should serve as a minimum to use in obesity research studies and can be combined with clinical parameters.

BACKGROUND: More than 10% of the global population has a BMI above 35. Bariatric surgery is an efficient way to treat this condition. Unfortunately, there is a risk of nutritional deficiencies. The number of studies after a longer time span is scarce. The aim of this study was to determine the occurrence of anaemia five and ten years after bariatric surgery and how it was related to substitution therapy.

PATIENTS AND METHODS: Registry data from individuals having primary bariatric surgery in the Scandinavian Obesity Surgery Registry (SOReg) from 2007 to 2022 and with a follow-up at five or ten years was retrieved. Demographic data including weight, as well as method of surgery, Hb levels, supplementation, PPI use and stomal ulcerations were recorded.

RESULTS: In total, 39,992 individuals (mean age 41 years, range 18-74, 77% women) could be included. The majority, 78%, had undergone laparoscopic Roux-en-Y gastric bypass. After five years, 2838/13,944 women (20.3%) and 456/4049 men (11.2%) had anaemia. After ten years, 644/3400 women (18.9%) and 178/947 men (18.8%) had anaemia. The use of oral iron increased from 40 to 45%, and the need for parenteral iron intake increased from 5 to 11%.

CONCLUSIONS: Anaemia is a significant but manageable condition five and ten years after bariatric surgery. Despite the prescription of oral iron supplements to 45% ten years after surgery, the Hb levels could still not be fully restored. Consequently, the importance of follow-up visits and continuous supplementation is emphasised.