Bariatric and metabolic surgical care in daily practice

The aim of this dissertation is to optimize the pre-, peri- and postoperative bariatric and metabolic surgical care. A general introduction and outline of the thesis is provided in chapter 1. In the first part of this thesis the definition of success after weight-loss surgery is evaluated. Chapter 2 shows the results of a systematic review of weight loss after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) with use of percentage total weight loss (%TWL). Results indicate a more favorable short-term weight loss after RYGB than after SG. Long-term data is insufficient. In chapter 3 the sensitivity and specificity of thirteen commonly used bariatric weight loss criteria for successful weight loss is assessed. Most criteria were able to recognize successful weight loss, but left poor response unnoticed. In chapter 4 the results of a standardized survey on patient’s weight loss expectations and acceptance of morbidity and mortality risks after RYGB are reported. Weight loss was overestimated by three quarters of participants and almost 40% was disappointed with the predicted weight loss. Median (IQR) accepted risks on short-term complications and mortality were (35.8 (21.0-58.0%) and 4.5 (1.0-10.0)% respectively. The remission of type 2 diabetes mellitus (T2DM) after bariatric and metabolic surgery is the subject of the second part of this thesis. In chapter 5 glycemic control was compared 12 months after laparoscopic one-anastomosis gastric bypass (OAGB) and RYGB in a retrospective cohort study. The results indicate that OAGB has potential metabolic benefits over RYGB with lower glycated hemoglobin in short-term follow-up. In chapter 6 the design and study protocol of the DIABAR-trial is presented. The DIABAR-trial is an open, two-armed, multi-center, randomized controlled clinical trial with 10 years follow-up in 220 patients with obesity, diagnosed with T2DM and treated with glucose-lowering agents. Primary objective is to compare glycemic control 12 months after RYGB and OAGB. Secondary aims are various and include remission of T2DM (10 years follow-up), weight-loss, surgical complications, psychologic status, quality of life, dietary behavior, gastrointestinal symptoms, and to phenotype patients and to identify driving mechanisms in the interplay between obesity and metabolic disease. The third part of this thesis reports on the learning curve (LC) of surgical residents in RYGB. In chapter 7 the LC of surgical residents in RYGB is compared to the LC of their proctors in a large bariatric center-of-excellence. The study shows that residents benefit from the experience of their proctors and fit faultlessly in the LC of the surgical team, as set out by their proctors . In the last part of this thesis abdominal complaints after RYGB are evaluated. Chapter 8 shows the results of a systematic review on emergency department (ED) visits and readmission after laparoscopic RYGB. Abdominal pain was the most common reason for ED visits and readmission. The results show that nearly one in three patients visits the ED longer than 30 days after RYGB. The main findings of the studies in this thesis are discussed in chapter 9 and perspectives for future research are given.