Currently, bariatric surgery is the most effective long-term treatment of obesity. Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) are the primary types of bariatric surgery performed worldwide. To minimize the risks of surgical complications and optimize cost-effectiveness, it is essential to develop fast-track protocols and patient logistics. At Aleris Hospitals in Denmark, a fast-track methodology in bariatric surgery has been implemented and continuously optimized over the last 15 years. The main objective was to demonstrate timelines recorded during one consecutive year in a fast-track, high-volume bariatric surgery setting after logistic optimization. This study included 949 consecutive patients who had undergone primary bariatric surgery in 2021. The primary outcomes were length of hospital stay and perioperative timeline recordings that were prospectively collected. The secondary outcomes were mortality, complication rates, and weight loss data. The vast majority of our patients (99.1

Complication rates after fast-track optimization in bariatric surgery are varying. The aim of this study was to identify short-term complications in patients undergoing laparoscopic sleeve gastrectomy (SG) in an ERABS (enhanced recovery after bariatric surgery) optimized setup. This study is an observational analysis of a consecutive cohort of 1600 patients undergoing SG at an ERABS-optimized, private hospital during 2020 and 2021. Primary outcomes were length of stay, mortality, readmissions, reoperations, and complications according to the Clavien-Dindo classification (CDC) within postoperative day (POD) 30 and 90. Secondary outcomes were weight loss and quality of life (QoL) according to Moorehead-Ardelt questionnaires during the first postoperative year. Primary outcomes: 99.1

Summary Prothrombotic and metabolic variables are decreased after obesity surgery, and fibrin clot lysis is increased. It is unknown how fibrinolytic variables are affected, and whether fibrinolytic and metabolic changes predict the enhanced clot lysis. Study aims were to determine fibrinolytic biomarkers before and 6 months after Roux‐en‐Y gastric bypass (RYGB) and to identify predictors of the RYGB‐induced increase in clot lysis. Women (n = 42) and men (n = 18) with obesity underwent RYGB, and factor XIII (FXIII), thrombin activatable fibrinolysis inhibitor (TAFI), plasminogen and plasmin inhibitor (PI) were measured before and 6 months after surgery. Regression analyses identified determinants of the RYGB‐induced increase in clot lysis among changes in fibrinogen and in fibrinolytic and metabolic variables. Results showed that after RYGB, FXIII, TAFI, plasminogen and PI were reduced ( P < .0005). Reductions in PI (β = −0.59) and fibrinogen (β = −0.35), together with age (β = −0.22) and male sex (β = 0.22), predicted the enhanced clot lysis with the model explaining 56% ( P < .0005). Predictors of the reduction in PI were reductions in cholesterol (β = 0.37) and glucose (β = 0.29), together with male sex (β = −0.28), whereas reductions in fibrinogen were predicted by lowering of interleukin‐6 (IL‐6) (β = 0.32). In conclusion, fibrinolytic variables were reduced 6 months after RYGB. Targeting PI and fibrinogen, by reducing metabolic variables such as glucose, cholesterol and IL‐6, has a profibrinolytic effect in obesity.

BackgroundObesity is associated with physical inactivity and impaired health-related quality of life (HRQoL). We aim to test the hypothesis that Roux-en-Y gastric bypass (RYGB) followed by supervised physical training improves physical activity (PA) levels and HRQoL.MethodsSixty patients, qualified for RYGB, were at 6months post-surgery randomized to 26weeks of a supervised physical training intervention (INT) or to a control (CON) group. PA was assessed by accelerometry and using the questionnaire RPAQ. HRQoL was measured by the SF-36 questionnaire. All assessments were performed pre-surgery and 6, 12, and 24months post-surgery.ResultsRYGB did not improve objectively or self-reported PA, but improved all domains of SF-36 (all p<0.01). Objectively measured light PA, moderate to vigorous PA, and step counts tended to increase in INT compared to CON 12months after RYGB (0.05<p<0.09), but the effects failed to persist. The SF-36 domain general health increased in INT compared to CON 24months after RYGB (p=0.041).ConclusionRYGB improves HRQoL, but does not increase PA. Supervised physical training intervention improves general health 24months after RYGB and tends to improve certain domains of PA right after the intervention period, but fails to increase the patients' overall PA level over time. Clinical Trial Registration Registered at ClinicalTrials.govno. NCT01690728.

Summary Obesity and physical inactivity are major health problems. Roux‐en‐Y gastric bypass (RYGB) surgery results in significant weight loss and reduces obesity‐related morbidity and mortality. Physical activity lowers the risk of cardiovascular disease and premature death. The aims of this study were to elucidate the effects of RYGB followed by 6 months of supervised physical training on physical capacity. In a randomized controlled trial, 60 participants eligible for RYGB were randomized 6 months post‐surgery to either two weekly physical training sessions for 26 weeks (INT) or a control group (CON). Aerobic capacity (VO 2 max), muscle strength (MS) of the shoulder and hip and physical function were measured pre‐surgery and 6, 12 and 24 months post‐surgery. RYGB per se decreased MS in all tested muscle groups, had no effects on VO 2 max but improved physical function. After the intervention, INT had a significant 0.33 L min −1 increase in VO 2 max compared to CON (95% CI: 0.07–0.57, P = 0.013). Furthermore, MS in the hip adductor increased significantly with 13 N (95% CI: 3.6–22.4, P = 0.007) and a between‐group difference was found in the Stair Climb Test (0.46 repetitions [95% CI: 0.02–0.91, P = 0.042]). The effects were not maintained at follow‐up. Supervised physical training following RYGB improved VO 2 max, hip MS and physical function, but the positive effects were not maintained at follow‐up. While activities of daily life may become easier as a result of RYGB, the observed extensive post‐operative loss of MS requires more attention to increase the patient's physical capacity prospectively.

BACKGROUND AND AIMS:Obesity and physical inactivity are both associated with low-grade inflammation and endothelial dysfunction. Bariatric surgery improves markers of inflammation and endothelial function, but it is unknown if physical training after bariatric surgery can improve these markers even further. Therefore, we aimed to investigate the effects of Roux-en-Y gastric bypass (RYGB) followed by physical training on markers of low-grade inflammation and endothelial function. METHODS:Sixty patients approved for RYGB underwent examinations pre-surgery, 6, 12, and 24 months post-surgery. Six months post-surgery, they were randomized 1:1 to an intervention group or a control group. The interventions consisted of two weekly sessions of supervised moderate intensity physical training for a period of 26 weeks. Fasting blood samples were analyzed for concentrations of interleukin 6 (IL-6), C-reactive protein (CRP), intercellular adhesion molecule 1 (ICAM-1), tissue-type plasminogen activator antigen (t-PA:Ag) and von Willebrand factor (vWF). RESULTS:RYGB markedly improved markers of inflammation (IL-6, CRP) (p < 0.001) and endothelial function (ICAM-1, t-PA:Ag, vWF) (p < 0.05), and the improvements were sustained 24 months post-surgery (p < 0.01), except for the effects on vWF. We found no correlations between the changes in weight or BMI and the changes in markers of inflammation and endothelial function, except that the change in vWF was found to be inversely correlated with the changes in weight and BMI. We observed no effects of supervised physical training on markers on inflammation or endothelial function (p>0.1 for all). CONCLUSIONS:RYGB causes substantial and sustained favorable effects on markers of inflammation and endothelial function. Supervised physical training after RYGB did not cause additional improvements.

ObjectiveBariatric surgery results in significant weight loss and reduces cardiovascular morbidity. However, a large variation in postsurgery weight loss is seen. Physical activity promotes weight loss in nonsurgically treated subjects with obesity. The aim of this study was to investigate the effects of 6 months of supervised physical training following Roux-en-Y gastric bypass surgery (RYGB) on body weight and cardiovascular risk markers. MethodsSixty participants eligible for RYGB were included. Six months post surgery, the participants were randomly assigned to either twice-weekly supervised physical training sessions in a fitness center (INT) or a control group (CON) for 26 weeks. Before surgery and 6, 12, and 24 months after surgery, the participants underwent an examination program that included anthropometric measurements, blood pressure, heart rate, blood samples, and an abdominal computed tomography scan. ResultsRYGB significantly reduced body weight and improved cardiovascular risk markers (all P<0.01). The supervised physical training intervention resulted in a 4.2-kg (CI: -0.2 to -8.3 kg) lower body weight in INT compared with CON at the study end (P=0.042). The high-density lipoprotein concentration was significantly higher in INT than in CON at the termination of the intervention, but this was not maintained at the 24-months examination. ConclusionsPhysical training following RYGB improves weight loss and cardiovascular health.

We highly appreciate the comments of Soriano-Maldonado et al. [ [3] Soriano-Maldonado A. Ferrer-Márquez1 M. Villa-González E. Artero A. Replicability of exercise programs following bariatric surgery. Atherosclerosis. 2018 Aug 26; (In press, pii: S0021-9150(18)31331-5. [Epub ahead of print])https://doi.org/10.1016/j.atherosclerosis.2018.08.026 Abstract Full Text Full Text PDF Scopus (4) Google Scholar ] on our article "Effects of gastric bypass surgery followed by supervised physical training on inflammation and endothelial function: A randomized controlled trial" recently published in Atherosclerosis [ [1] Stolberg C.R. Mundbjerg L.H. Funch-Jensen P. Gram B. Bladbjerg E.M. Juhl C.B. Effects of gastric bypass surgery followed by supervised physical training on inflammation and endothelial function: a randomized controlled trial. Atherosclerosis. 2018; 273: 37-44 Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar ]. The paper is one of, so far, five articles related to the study. The primary variable of the study was predefined as the effect of supervised physical training on weight loss following Roux-en-Y gastric bypass (RYGB). We found that the intervention group had a higher weight loss compared to the control group, as calculated by intention to treat statistics [ [2] Mundbjerg L.H. Stolberg C.R. Cecere S. et al. Supervised physical training improves weight loss after Roux-en-Y gastric bypass surgery: a randomized controlled trial. Obesity. 2018; 26: 828-837 Crossref PubMed Scopus (38) Google Scholar ]. The present article describes secondary variables related to inflammation and endothelial function. We observed significant and sustained favorable changes after RYGB, while we found no additional effects of the supervised physical training [ [1] Stolberg C.R. Mundbjerg L.H. Funch-Jensen P. Gram B. Bladbjerg E.M. Juhl C.B. Effects of gastric bypass surgery followed by supervised physical training on inflammation and endothelial function: a randomized controlled trial. Atherosclerosis. 2018; 273: 37-44 Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar ].

INTRODUCTIONBariatric surgery offers effective obesity treatment. The aim of this study was to evaluate the cost-effectiveness of bariatric surgery in Denmark from a third-party payer perspective in the mid- (ten years) and long-term (lifetime).METHODSA state-transition Markov model was developed in which patients may experience surgery, post-surgery complications, diabetes mellitus type 2, cardiovascular diseases or die. Transition probabilities, costs and utilities were informed by the literature. Three types of surgery were included: gastric bypass, sleeve gastrectomy and adjustable gastric banding. The impact of different surgical methods on BMI level was informed by the Danish Obesity Surgery Registry (Dansk Fedmekirurgiregister).RESULTSIn the ten-year base-case analysis, bariatric surgery led to a cost increment of 19,332 DKK and generated an additional 1.1 quality-adjusted life years (QALYs). In the course of a lifetime, surgery leads to savings of 36,403 DKK, an additional 0.7 life years and 2.9 QALYs. Bariatric surgery was cost-effective at ten years with an incremental cost-effectiveness ratio of 17,818 DKK per QALY and was dominant over conservative management in the course of a lifetime. Up to three years of delay in the provision of surgery resulted in a reduction of life years, a lower QALY gain and a minor decrease in healthcare costs.CONCLUSIONSIn Denmark, bariatric surgery is cost-effective at ten years and may produce a significant reduction in healthcare costs over the course of a lifetime in persons with severe obesity.FUNDINGSynergus AB received support for economic model development from Covidien AG (now part of Medtronic).TRIAL REGISTRATIONnot relevant.

Background Diabetes remission is an important outcome after bariatric surgery. The purpose of this study was to identify risk prediction models of diabetes remission after bariatric surgery. Methods A systematic literature review was performed in MEDLINE, MEDLINE-In-Process, Embase and the Cochrane Central Register of Controlled Trials databases in April 2015. All English-language full-text published derivation and validation studies for risk prediction models on diabetic outcomes after bariatric surgery were included. Data extraction included population, outcomes, variables, intervention, model discrimination and calibration. Results Of 2330 studies retrieved, eight met the inclusion criteria. Of these, six presented development of risk prediction models and two reported validation of existing models. All included models were developed to predict diabetes remission. Internal validation using tenfold validation was reported for one model. Two models (ABCD score and DiaRem score) had external validation using independent patient cohorts with diabetes remission assessed at 12 and 14 months respectively. Of the 11 cohorts included in the eight studies, calibration was not reported in any cohort, and discrimination was reported in two. Conclusion A variety of models are available for predicting risk of diabetes following bariatric surgery, but only two have undergone external validation.

Hiatus hernia is known to be an important risk factor for developing gastroesophageal reflux disease. We aimed to use the endoscopic functional lumen imaging probe (EndoFLIP) to evaluate the functional properties of the esophagogastric junction. EndoFLIP assessments were made in 30 patients with hiatus hernia and Barrett's esophagus, and in 14 healthy controls. The EndoFLIP was placed straddling the esophagogastric junction and the bag distended stepwise to 50 mL. Cross-sectional areas of the bag and intra-bag pressures were recorded continuously. Measurements were made in the separate sphincter components and hiatus hernia cavity. EndoFLIP measured functional aspects such as sphincter distensibility and pressure of all esophagogastric junction components and visualized all hiatus hernia present at endoscopy. The lower esophageal sphincter in hiatus hernia patients had a lower pressure (e.g. 47.7 ± 13.0 vs. 61.4 ± 19.2 mm Hg at 50-mL distension volume) and was more distensible (all P < 0.001) than the common esophagogastric junction in controls. In hiatus hernia patients, the crural diaphragm had a lower pressure (e.g. 29.6 ± 10.1 vs. 47.7 ± 13.0 mm Hg at 50-mL distension volume) and was more distensible (all P < 0.001) than the lower esophageal sphincter. There was a significant association between symptom scores in patients and EndoFLIP assessment. Conclusively, EndoFLIP was a useful tool. To evaluate the presence of a hiatus hernia and to measure the functional properties of the esophagogastric junction. Furthermore, EndoFLIP distinguished the separate esophagogastric junction components in hiatus hernia patients, and may help us understand the biomechanics of the esophagogastric junction and the mechanisms behind hiatal herniation.

BACKGROUND:The approach to repair of paraesophageal hernias (PEHs) is controversial. Recent data suggest that mesh repair leads to recurrence rates similar to non-mesh approaches, while subjecting patients to mesh-associated complications. Routine fundoplication during PEH repair has been favored despite significant dysphagia rates. We present our multicenter prospective data on laparoscopic PEH repairs using a modified Boerema anterior gastropexy without fundoplication.METHODS:We prospectively followed patients after modified Boerema PEH repair at three institutions. Patient demographics, perioperative data, and postoperative outcomes were evaluated. Subjective and objective outcomes were assessed via clinical assessment, follow-up questioning, endoscopy, and radiographic swallow studies.RESULTS:A total of 101 patients were followed a mean of 10.8 (median, 12) months. We encountered 9 (8.9%) intraoperative complications and 13 (12.9%) postoperative complications. There was no mortality. Reflux symptoms were absent in 71 patients (70.3%) postoperatively. Of the remaining subjects, 8 (7.9%) had mild intermittent reflux without the need for proton pump inhibitors (PPI), 12 (11.9%) had moderate reflux necessitating PPI as needed, and 10 (9.9%) had reflux requiring daily PPI. Our recurrence rate, assessed at postoperative endoscopy/barium swallow, was 16.8%. Of these, 10 (9.9%) were small segmental recurrences and 7 (6.9%) were large recurrences.CONCLUSION:Herein, we demonstrate a favorable recurrence rate while avoiding the potential major complications associated with mesh hiatoplasty. Our data tend to support a tailored approach to incorporation of fundoplication during PEH repair. Postoperative acid reflux was absent in most of our patients, and pharmacotherapy alone was sufficient for those experiencing reflux symptoms.

The objective of the study was to provide a comprehensive overview of existing risk prediction models of mortality, complications, and remission of diabetes after bariatric surgery. A systematic literature review was performed in Medline, Medline-In-Process, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) databases in April 2015. All English language full-text published derivation and validation studies for risk prediction models focusing on safety and diabetes outcomes of bariatric surgery were included. Two reviewers independently performed screening of the studies. Data extraction included population, outcomes, variables, intervention, model discrimination, and calibration. Of the 2331 studies retrieved from the search, only 25 studies met the inclusion criteria. Of these, 20 presented development of risk prediction models/scores, and five reported validation of existing models. Six models were each developed to predict mortality (in-hospital, at 30 days, 90 days, and ten years), complications (during perioperative, at 30 days, and 90 days), and remission of type 2 diabetes (post-operative, and at one year); and two models developed to predict both mortality and complications (at 30 days). Internal validation using bootstrap resampling or tenfold validation was reported for six models, while five models had external validation using independent patient cohorts: ABCD score (remission of type 2 diabetes at one year), DiaRem Score (remission of type 2 diabetes at one year), Gupta’s model (remission of type 2 diabetes at one year), Maciejewski’s model (complication at 90 days), and OS-MRS (mortality at 90 days). Models included on average 6.9±3.5 variables (range 2-13). Calibration and discrimination statistics were not reported for all models. There are a variety of risk prediction models for safety and diabetes outcomes of bariatric surgery available. However, only few models have undergone external validation. Further research about the value and accuracy of existing instruments in clinical practice is required.

To evaluate the cost-utility of bariatric surgery in Belgium, Denmark, and Italy from a third-party payer perspective over a 10-year and a lifetime horizon. A state-transition Markov model was developed, in which patients may experience surgery, post-surgery complications, diabetes mellitus type 2, cardiovascular diseases or die. Transition probabilities, surgery effectiveness and safety, costs, and utilities were informed by the literature, patient registries and administrative databases. Three types of surgeries were considered: gastric bypass, sleeve gastrectomy, and adjustable gastric banding. A base-case analysis was performed for the population of real surgical candidates in all countries. Cost data are presented in 2012 euros for Belgium, Italy and Denmark. In Belgium, in the base-case analysis over 10 years bariatric surgery led to incremental cost of €3,261 and generated additional 1.4 quality-adjusted life years (QALYs) with incremental cost-effectiveness ratio of €2,407/QALY. Over lifetime, surgery led to savings of €10,036, and generated additional 1.1 years of life, and 5.0 QALYs. In Denmark, in the base-case analysis over 10 years bariatric surgery led to incremental cost of €2,044 and generated additional 1.5 QALYs with incremental cost-effectiveness ratio of €1,405 per QALY. Over lifetime surgery lead to savings of €5,032, additional 0.8 life years, and 4.1 QALYs. In Italy, in the base-case analysis over 10 years bariatric surgery led to incremental cost of €2,552 and generated additional 1.1 QALYs with incremental cost-effectiveness ratio of €2,314/QALY. Over lifetime, surgery led to savings of €8,874, and generated additional 0.5 years of life, and 3.2 QALYs. In a comprehensive decision analytic model, a current mix of surgical methods for bariatric surgery was cost-effective at 10 years and cost saving over the lifetime time horizon in three European countries.

The objective of this study was to evaluate the current utilization, the level of endorsement by professional societies, and health technology assessment bodies, as well as the reimbursement levels for bariatric surgery in European countries.