Patient-Reported Outcome Measures 2 Years After Standard and Distal Gastric Bypass-a Double-Blind Randomized Controlled Trial.

BACKGROUND: The preferred surgical procedure for treating morbid obesity is debated. Patient-reported outcome measures (PROMs) are relevant for evaluation of the optimal bariatric procedure. METHODS: A total of 113 patients with BMI from 50 to 60 were randomly assigned to standard (n = 57) or distal (n = 56) Roux-en-Y gastric bypass (RYGB). Validated PROMS questionnaires were completed at baseline and 2 years after surgery. Data were analyzed using mixed models for repeated measures and the results are expressed as estimated means and mean changes. RESULTS: Obesity-related quality of life improved significantly after both procedures, without significant between-group differences (- 0.4 (95% CI = - 8.4, 7.2) points, p = 0.88, ES = 0.06). Both groups had significant reductions in the number of weight-related symptoms and symptom distress score, with a mean group difference (95% CI) of 1.4 (- 0.3, 3.3) symptoms and 5.0 (2.9. 12.8) symptom distress score points. There were no between-group differences for uncontrolled eating (22.0 (17.2-26.7) vs. 28.9 (23.3-34.5) points), cognitive restraint (57.4 (52.0-62.7) vs. 62.1 (57.9-66.2) points), and emotional eating (26.8 (20.5-33.1) vs. 32.6 (25.5-39.7) points). The prevalence of anxiety was 33% after standard and 25% after distal RYGB (p = 0.53), and for depression 12 and 9%, respectively (p = 0.76). CONCLUSIONS: There were no statistically significant differences between standard and distal RYGB 2 years post surgery regarding weight loss, obesity-related quality of life, weight-related symptoms, anxiety, depression, or eating behavior. TRIAL REGISTRATION: Clinical Trials.gov number NCT00821197.

Standard vs Distal Roux-en-Y Gastric Bypass in Patients With Body Mass Index 50 to 60: A Double-blind, Randomized Clinical Trial.

Importance: Up to one-third of patients undergoing bariatric surgery have a body mass index (BMI) of more than 50. Following standard gastric bypass, many of these patients still have a BMI greater than 40 after peak weight loss. Objective: To assess the efficacy and safety of standard gastric bypass vs distal gastric bypass in patients with a BMI of 50 to 60. Design, Setting, and Participants: Double-blind, randomized clinical parallel-group trial at 2 tertiary care centers in Norway (Oslo University Hospital and Vestfold Hospital Trust) between May 2011 and April 2013. The study included 113 patients with a BMI of 50 to 60 aged 20 to 60 years. The 2-year follow-up was completed in May 2015. Interventions: Standard gastric bypass (alimentary limb, 150 cm) and distal gastric bypass (common channel, 150 cm), both with a biliopancreatic limb of 50 cm and a gastric pouch of about 25 mL. Main Outcomes and Measures: Primary outcome was the change in BMI from baseline until 2 years after surgery. Secondary outcomes were cardiometabolic risk factors, nutritional outcomes, adverse events, gastrointestinal symptoms, and health-related quality of life. Results: At baseline, the mean age of the patients was 40 years (95% CI, 38-41 years), 65% were women, mean BMI was 53.5 (95% CI, 52.9-54.0), and mean weight was 158.8 kg (95% CI, 155.3-162.3 kg). The mean reduction in BMI was 17.8 (95% CI, 16.9-18.6) after standard gastric bypass and 17.2 (95% CI, 16.3-18.0) after distal gastric bypass, and the mean between-group difference was 0.6 (95% CI, -0.6 to 1.8; P = .32). Reductions in mean levels of total and low-density lipoprotein cholesterol were greater after distal gastric bypass than standard gastric bypass, and between-group differences were 19 mg/dL (95% CI, 11-27 mg/dL ) and 28 mg/dL (95% CI, 21 to 34 mg/dL), respectively (P < .001 for both). Reductions in fasting glucose levels and hemoglobin A1c were greater after distal gastric bypass. Secondary hyperparathyroidism and loose stools were more frequent after distal gastric bypass. The number of adverse events and changes in health-related quality of life did not differ between the groups. Importantly, 1 patient developed liver failure and 2 patients developed protein-caloric malnutrition treated by elongation of the common channel following distal gastric bypass. Conclusions and Relevance: Distal gastric bypass was not associated with a greater BMI reduction than standard gastric bypass 2 years after surgery. However, we observed different changes in cardiometabolic risk factors and nutritional markers between the groups. Trial Registration: Clinicaltrials.gov Identifier: NCT00821197.

Changes in Health-Related Quality of Life After Gastric Bypass in Patients With and Without Obesity-Related Disease.

BACKGROUND: A substantial proportion of severely obese patients undergoing bariatric surgery have not developed disease as a consequence of obesity. Little is known about the effects of bariatric surgery on health-related quality of life (HRQL) in this patient group. In a prospective study at a public hospital, we compared HRQL in gastric bypass patients with and without obesity-related disease before and 2 years after surgery. METHODS: HRQL was assessed in 232 severely obese patients before, 1 year, and 2 years after Roux-en-Y gastric bypass. We used a general HRQL questionnaire, the Short Form 36, and an obesity-specific questionnaire, the Obesity-related Problems scale. The patients were divided into two groups based on the presence of obesity-related disease (n = 146) or not (n = 86) before surgery. We defined obesity-related disease as having at least one of the following conditions: type 2 diabetes mellitus, hypertension, dyslipidemia, coronary heart disease, obstructive sleep apnea, gastroesophageal reflux disease, or osteoarthritis. Linear mixed models were used to analyze the HRQL outcomes. RESULTS: Before surgery, patients with no obesity-related disease reported equal HRQL compared with patients with obesity-related disease. Two years after gastric bypass, substantial improvements in all subscales of Short Form 36 and in Obesity-related Problems scale were observed in both groups, and the improvements were similar in 7 out of 8 subscales of Short Form 36 as well as for the Obesity-related Problems scale. CONCLUSIONS: Baseline HRQL was similar in patients with and without obesity-related disease prior to gastric bypass. After surgery, patients with no comorbidity had similar positive changes in HRQL as patients with one or several comorbidities. These findings indicate that other factors than obesity-related disease are at least as important for severely obese patients' impaired HRQL.

Perception of control over eating after bariatric surgery for super-obesity--a 2-year follow-up study.

BACKGROUND: Physiological and psychosocial factors might contribute to differences in weight loss, eating behaviour and health-related quality of life (HRQoL) after bariatric surgery. The aim of this study was to investigate how perceived control over eating changes after bariatric surgery and whether it affects outcome in super-obese patients. METHODS: In a retrospective analysis of a prospective study (n = 60), 49 patients were divided into two groups based on eating control 2 years after surgery, as assessed by the Three-Factor Eating Questionnaire-R21 (TFEQ-R21): 29 with good eating control (GC) and 20 patients with poor eating control (group PC). Eating behaviour and generic and condition-specific HRQoL was assessed by questionnaires. RESULTS: There were significant differences in all TFEQ-R21 domains 2 years after surgery in favour of group GC; uncontrolled eating p < 0.001, emotional eating p < 0.001 and for cognitive restraint p = 0.04. The improvement in HRQoL 2 years after surgery was significantly less in group PC compared to group GC in 7 of 8 SF-36 domains (p < 0.05). Mean (SD) percentage of excess body mass index lost was similar between groups, 71.2 (17.8) in group GC versus 65.4 (17.4) in group PC 2 years after surgery (p = 0.27). However, group GC had a significant weight loss between first and second year after surgery (p < 0.001) compared to group PC (p = 0.15). CONCLUSIONS: In super-obese patients, perceived poor control over eating 2 years after bariatric surgery was associated with lower HRQoL and more emotional and cognitive restraint eating, than good control overeating.

Perioperative Outcomes of Proximal and Distal Gastric Bypass in Patients with BMI Ranged 50-60 kg/m(2)--A Double-Blind, Randomized Controlled Trial.

BACKGROUND: Proximal Roux-en-Y gastric bypass may not ensure adequate weight loss in superobese patients. Bypassing a longer segment of the small bowel may increase weight loss. The objective of the study was to compare the perioperative outcomes of laparoscopic proximal and distal gastric bypass in a double-blind randomized controlled trial of superobese patients. The study was conducted at two public tertiary care obesity centers in Norway. METHODS: Patients with body mass index (BMI) 50-60 kg/m(2) were randomly assigned to a proximal (150 cm alimentary limb) or a distal (150 cm common channel) gastric bypass. The biliopancreatic limb was 50 cm in both operations. Patients and follow-up personnel were blinded to the type of procedure. Thirty-day outcomes including complications are reported. RESULTS: We operated on 115 patients, of whom two were excluded at surgery, leaving 56 and 57 patients in the proximal group and distal group, respectively. The median (range) operating time was 72 (36-151) and 101 (59-227) min, respectively (p < 0.001). Two distal procedures were converted to laparotomy during the primary procedure. Median length of hospital stay was 2 (1-4) days in the proximal group and 2 (1-24) days in the distal group. The number of patients with complications and complications categorized according to the Contracted Accordion classification did not differ significantly. However, all six reoperations were performed in the distal group, of which three were completed by laparoscopy (p = 0.01 between groups). There were no deaths. CONCLUSIONS: In superobese patients with BMI between 50 and 60 kg/m(2), distal gastric bypass was associated with longer operating time and more severe complications resulting in reoperation than proximal gastric bypass.

Five-year outcomes after laparoscopic gastric bypass and laparoscopic duodenal switch in patients with body mass index of 50 to 60: a randomized clinical trial.

IMPORTANCE: There is no consensus as to which bariatric procedure is preferred to reduce weight and improve health in patients with a body mass index higher than 50. OBJECTIVE: To compare 5-year outcomes after Roux-en-Y gastric bypass (gastric bypass) and biliopancreatic diversion with duodenal switch (duodenal switch). DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical open-label trial at Oslo University Hospital, Oslo, Norway, and Sahlgrenska University Hospital, Gothenburg, Sweden. Participants were recruited between March 17, 2006, and August 20, 2007, and included 60 patients aged 20 to 50 years with a body mass index of 50 to 60. The current study provides the 5-year follow-up analyses by intent to treat, excluding one participant accepted for inclusion who declined being operated on prior to knowing to what group he was randomized. INTERVENTIONS: Laparoscopic gastric bypass and laparoscopic duodenal switch. MAIN OUTCOMES AND MEASURES: Body mass index and secondary outcomes including anthropometric measures, cardiometabolic risk factors, pulmonary function, vitamin status, gastrointestinal symptoms, health-related quality of life, and adverse events. RESULTS: Sixty patients were randomly assigned and operated on with gastric bypass (n = 31) and duodenal switch (n = 29). Fifty-five patients (92%) completed the study. Five years after surgery, the mean reductions in body mass index were 13.6 (95% CI, 11.0-16.1) and 22.1 (95% CI, 19.5-24.7) after gastric bypass and duodenal switch, respectively. The mean between-group difference was 8.5 (95% CI, 4.9-12.2; P < .001). Remission rates of type 2 diabetes mellitus and metabolic syndrome and changes in blood pressure and lung function were similar between groups. Reductions in total cholesterol, low-density lipoprotein cholesterol, triglycerides, and fasting glucose were significantly greater after duodenal switch compared with gastric bypass. Serum concentrations of vitamin A and 25-hydroxyvitamin D were significantly reduced after duodenal switch compared with gastric bypass. Duodenal switch was associated with more gastrointestinal adverse effects. Health-related quality of life was similar between groups. Patients with duodenal switch underwent more surgical procedures related to the initial procedure (13 [44.8%] vs 3 [9.7%] patients; P = .002) and had significantly more hospital admissions compared with patients with gastric bypass. CONCLUSIONS AND RELEVANCE: In patients with a body mass index of 50 to 60, duodenal switch resulted in greater weight loss and greater improvements in low-density lipoprotein cholesterol, triglyceride, and glucose levels 5 years after surgery compared with gastric bypass while improvements in health-related quality of life were similar. However, duodenal switch was associated with more surgical, nutritional, and gastrointestinal adverse effects. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00327912.

Experience of excess skin after gastric bypass or duodenal switch in patients with super obesity.

BACKGROUND: There is a lack of knowledge about the patient's experience of excess skin after bariatric surgery in patients with body mass index, (BMI)>50 kg/m(2). The objective of this study was to evaluate experience of excess skin after laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) or laparoscopic Roux-en-Y gastric bypass (LRYGB) and explore possible gender differences. Another aim was to analyze possible correlation between the reported experiences of excess skin with changes in weight, BMI, and hip and waist circumference after surgery. METHODS: One and/or 2 years after gastric bypass or duodenal switch surgery 57 patients responded to a specific questionnaire. The questionnaire included questions about the amount of excess skin and how much discomfort it caused. Furthermore, the patients were measured concerning weight and waist and hip circumference. RESULTS: One year after surgery, a majority of the patients experienced excess skin scored as>2 ("a lot of" or "very much"). The patients in the BPD/DS group experienced significantly more excess skin compared to patients in the LRYGB group. Women experienced more excess skin and discomfort on several body parts than men. The correlations between changes in BMI and the reported experience and discomfort of excess skin were low. There was a low to moderate correlation between changes in waist and hip circumference measures and the experience of excess skin on stomach and buttocks. CONCLUSION: Weight loss after LRYGB and BPD/DS in super-obese patients is associated with substantial discomfort from excess skin. Women reported more discomfort and experienced more excess skin than men. There was a low correlation between experience of excess skin and changes in weight, BMI, and circumference measures.

Long-term improvements in pulmonary function 5 years after bariatric surgery.

BACKGROUND: Obesity is associated with reduced pulmonary function. We evaluated pulmonary function and status of asthma and obstructive sleep apnoea syndrome (OSAS) before and 5 years after bariatric surgery. METHODS: Spirometry was performed at baseline and 5 years postoperatively. Information of asthma and OSAS were recorded. Of 113 patients included, 101 had undergone gastric bypass, 10 duodenal switch and 2 sleeve gastrectomy. RESULTS: Eighty (71%) patients were women, mean preoperative age was 40 years and preoperative weight was 133 kg in women and 158 kg in men. Five years postoperatively, weight reduction was 31% (42 kg; p < 0.001) in women and 24% (38 kg; p < 0.001) in men. Forced expiratory volume in 1 s (FEV1) increased 4.1% (116 ml; p < 0.001) in women and 6.7% (238 ml; p = 0.003) in men. Forced vital capacity (FVC) increased 5.8% (209 ml; p < 0.001) in women and 7.6% (349 ml; p < 0.001) in men. Gender and weight loss were independently associated with the improvements in FEV1 and FVC. At follow-up, FEV1 had increased 36% of the difference towards the estimated normal FEV1, and there was a corresponding 70% recovery of FVC. These improvements occurred despite an expected decline in pulmonary function by age during the study period. Of the asthmatics and OSAS patients, 48 and 80%, respectively, were without symptoms 5 years postoperatively. CONCLUSIONS: Pulmonary function measured with spirometry was significantly improved 5 years after bariatric surgery, despite an expected age-related decline during this period. Symptoms of asthma and OSAS also improved.

Five-year outcome after gastric bypass for morbid obesity in a Norwegian cohort.

BACKGROUND: Few long-term reports with high rates of follow-up are available after gastric bypass. We report changes in weight, co-morbidity, cardiovascular risk, and health-related quality of life (HRQoL) 5 years after gastric bypass. METHODS: Patients who had gastric bypass (2004-2006) were included. Prospective data were reviewed. Long-term complications, cardiovascular risk factors, and HRQoL were evaluated, and the 10-year risk for coronary heart disease was estimated (Framingham risk score). Outcomes were compared in patients with body mass index (BMI)<50 and ≥50 kg/m(2). RESULTS: A total of 184 of 203 patients (91%) met to follow-up. The mean ± SD preoperative BMI was 46 ± 5 kg/m(2), and the mean ± SD age was 38 ± 9 years; 75% were women. Thirty-two percent of the patients had a BMI ≥50 kg/m(2), and 30% had type 2 diabetes. Follow-up was 63 ± 5 months. After 5 years, total weight loss was 27% ± 11%. Remission of type 2 diabetes had occurred in 67%. The prevalence of hypertension, dyslipidemia, sleep apnea, and metabolic syndrome had decreased. HRQoL was improved. The Framingham risk score was reduced (5.6% versus 4.6%; P = .021). Sixty-one patients (33%) had long-term complications, most commonly chronic abdominal pain (10%). BMI was 33 ± 5 and 37 ± 7 kg/m(2) in patients with preoperative BMI<50 and ≥50 kg/m(2), but changes in metabolic, cardiovascular risk profile and HRQoL were broadly similar. CONCLUSIONS: Beneficial effects on weight loss, cardiovascular risk, and HRQoL were documented 5 years after gastric bypass in morbidly and super-obese patients.

Gastrointestinal function and eating behavior after gastric bypass and duodenal switch.

BACKGROUND: Duodenal switch provides greater weight loss than gastric bypass in severely obese patients; however, comparative data on the changes in gastrointestinal symptoms, bowel function, eating behavior, dietary intake, and psychosocial functioning are limited. METHODS: The setting for the present study was 2 university hospitals in Norway and Sweden. Participants with a body mass index of 50-60 kg/m(2) were randomly assigned to gastric bypass (n = 31) or duodenal switch (n = 29) and followed up for 2 years. Of the 60 patients, 97% completed the study. Their mean weight decreased by 31.2% after gastric bypass and 44.8% after duodenal switch. At inclusion and 1 and 2 years of follow-up, the participants completed the Gastrointestinal Symptom Rating Scale, a bowel function questionnaire, the Three-Factor Eating Questionnaire-R21, a 4-day food record, and the Obesity-related Problems scale. RESULTS: Compared with the gastric bypass group, the duodenal switch group reported more symptoms of diarrhea (P = .0002), a greater mean number of daytime defecations (P = .007), and more anal leakage of stool (50% versus 18% of participants, respectively; P = .015) after 2 years. The scores for uncontrolled and emotional eating were significantly and similarly reduced after both operations. The mean total caloric intake and intake of fat and carbohydrates were significantly reduced in both groups. Protein intake was significantly reduced only after gastric bypass (P = .008, between-group comparison). Psychosocial function was significantly improved after both operations (P = .23, between the 2 groups). CONCLUSION: Gastrointestinal side effects and anal leakage of stool were more pronounced after duodenal switch than after gastric bypass. Both procedures led to reduced uncontrolled and emotional eating, reduced caloric intake, and improved psychosocial functioning.

Blood clot obstruction of the jejunojejunostomy after laparoscopic gastric bypass.

BACKGROUND: Acute jejunojejunostomy (JJ) obstruction after laparoscopic gastric bypass secondary to the formation of an intraluminal blood clot is a rare event. We analyzed our experience with such complications from a large consecutive patient series at a university hospital that is a referral center for bariatric surgery. METHODS: A retrospective review of patient data in a register of all patients who had undergone gastric bypass from June 2004 to March 2011 was performed. Reoperations were analyzed for the cause and findings. The patients received routine postoperative administration of low-molecular-weight heparin. RESULTS: Of 1066 patients, 5 (.5%; 4 women and 1 man), who had undergone laparoscopic gastric bypass, with a median body mass index of 42 kg/m(2) (range 40-46), underwent reoperation for obstruction of the JJ secondary to a blood clot. The indications for reoperation were signs of bleeding, nausea, or findings on abdominal computed tomography. The time of reoperation was 1, 1, 2, 3, and 11 days after the primary procedure. All patients underwent reoperation by laparoscopy, with evacuation of the blood clot through an opening of the suture or staple lines without additional revision of the JJ. The gastric remnant was decompressed using a percutaneously placed gastrostomy tube. One patient had gastric leakage from the staple lines (blowout) that necessitated several later revisions for subcutaneous abscesses. Another patient developed acute pancreatitis. CONCLUSION: Blood clots can cause early obstruction of the JJ after gastric bypass. Awareness of this potentially rapidly progressive and life-threatening complication will allow immediate intervention and reduce the risk of serious sequelae.

Secondary hyperparathyroidism, vitamin D sufficiency, and serum calcium 5 years after gastric bypass and duodenal switch.

BACKGROUND: The prevalence of secondary hyperparathyroidism (SHPT) is high after bariatric surgery. Vitamin D is supplied to counteract SHPT and bone disease, and we studied vitamin D associations with SHPT. METHODS: We measured serum levels of 25-OH vitamin D and parathyroid hormone (PTH) 5 years after gastric bypass and duodenal switch. One hundred twenty-five patients were included, of whom 114 (91 %) had undergone gastric bypass and 11 (9 %) had undergone duodenal switch. SHPT was defined as PTH > 7.0 pmol/l in the absence of hypercalcemia. 25-OH vitamin D levels were divided into three categories: <50, 50-74, and ≥75 nmol/l. Serum ionized calcium, magnesium, phosphate, and creatinine were divided into tertiles. RESULTS: Mean age ± SD was 44 ± 9 years at 5 years follow-up. Ninety out of 125 (72 %) patients were women. SHPT was present in 45 out of 114 (40 %) gastric bypass patients and in 11 out of 11 (100 %) duodenal switch patients. The prevalence was high in all vitamin D categories studied. An inverse association between ionized calcium and PTH was found. For the gastric bypass patients, the odds ratio for SHPT in the upper two tertiles of ionized calcium was 0.35; 95 % CI, 0.15-0.79; p = 0.011, compared with the lowest tertile. Supplements of vitamin D and calcium were not associated with a lower prevalence of SHPT at 5 years follow-up. CONCLUSIONS: The prevalence of SHPT was high 5 years after gastric bypass and duodenal switch. SHPT was inversely associated with serum ionized calcium, but not with vitamin D. The supplementation used was insufficient to compensate for the impaired calcium absorption after surgery.

[Treating morbid obesity with laparoscopic biliopancreatic diversion with duodenal switch]. / Laparoskopisk biliopankreatisk avledning med duodenal omkobling ved sykelig fedme.

BACKGROUND: Biliopancreatic diversion with duodenal switch is used in the treatment of morbid obesity. Few centres perform the procedure laparoscopically. We aimed to evaluate the perioperative outcomes and weight loss after laparoscopic duodenal switch. MATERIAL AND METHODS: All patients operated with biliopancreatic diversion with duodenal switch at the Centre for Morbid Obesity at Oslo University Hospital (2004-2009) were included. The perioperative period was defined as within 30 days of surgery. RESULTS: A total of 48 patients were operated, all laparoscopically. Median preoperative BMI was 54 kg/m2 (range 41-88), and 33 patients (69 %) were women. Ten patients (21 %) were operated in two steps: first gastric sleeve and later duodenal switch. Median operation time was 200 minutes (100-658). Twelve patients (25 %) had complications, four (8 %) were reoperated, and one died. Median postoperative hospital stay was three (1-56) days. After two years, median BMI was 32 kg/m2 (24-45), median weight loss 39 % (22-60) and median excess BMI (> 25 kg/m2) loss 73 % (43-106). INTERPRETATION: Duodenal switch was applied in a minority of patients operated for morbid obesity. The procedure can be performed laparoscopically with a short hospital stay and leads to a substantial weight loss. Perioperative morbidity was high and was comparable to the results from other series.

[Follow-up after bariatric surgery]. / Oppfølging etter fedmekirurgi.

BACKGROUND: The number of bariatric surgical procedures in Norway is increasing. Patients who undergo bariatric surgery may experience surgical, medical and nutritional complications. Follow-up of these patients is therefore important. METHODS: The article is based on non-systematic literature searches in PubMed and on the clinical experience of the authors. RESULTS: Bariatric surgery induces significant and sustained weight loss and improves obesity-related disorders. Gastric bypass is the most commonly performed bariatric procedure in Norway. This procedure is associated with a 30-day mortality of below 0.5 %, while severe complications occur in approximately 5 % of patients. Late complications include internal herniation, intestinal ulcers and gallbladder disease. After surgery all patients are given iron, vitamin D/calcium and vitamin B12 supplements to prevent vitamin and mineral deficiencies. Gastrointestinal symptoms and postprandial hypoglycaemia after surgery can be improved by dietary modifications, and the need for anti-diabetic and blood pressure lowering medications is reduced. Dose adjustment of other medications may also be necessary. Pregnancy is not recommended during the first year after bariatric surgery. Many patients need plastic surgery after the operation. INTERPRETATION: Complications after bariatric surgery may manifest in the long term. Regular follow-up is required. General practitioners should be responsible for follow-up in the long term, and should be familiar with common and serious complications as well as normal symptomatology after bariatric surgery.

Weight loss, cardiovascular risk factors, and quality of life after gastric bypass and duodenal switch: a randomized trial.

BACKGROUND: Gastric bypass and duodenal switch are currently performed bariatric surgical procedures. Uncontrolled studies suggest that duodenal switch induces greater weight loss than gastric bypass. OBJECTIVE: To determine whether duodenal switch leads to greater weight loss and more favorable improvements in cardiovascular risk factors and quality of life than gastric bypass. DESIGN: Randomized, parallel-group trial. (ClinicalTrials.gov registration number: NCT00327912) SETTING: 2 academic medical centers (1 in Norway and 1 in Sweden). PATIENTS: 60 participants with a body mass index (BMI) between 50 and 60 kg/m(2). INTERVENTION: Gastric bypass (n = 31) or duodenal switch (n = 29). MEASUREMENTS: The primary outcome was the change in BMI after 2 years. Secondary outcomes included anthropometric measures; concentrations of blood lipids, glucose, insulin, C-reactive protein, and vitamins; and health-related quality of life and adverse events. RESULTS: Fifty-eight of 60 participants (97%) completed the study. The mean reductions in BMI were 17.3 kg/m(2) (95% CI, 15.7 to 19.0 kg/m(2)) after gastric bypass and 24.8 kg/m(2) (CI, 23.0 to 26.5 kg/m(2)) after duodenal switch (mean between-group difference, 7.44 kg/m(2) [CI, 5.24 to 9.64 kg/m(2)]; P < 0.001). Total cholesterol concentration decreased by 0.24 mmol/L (CI, -0.03 to 0.50 mmol/L) (9.27 mg/dL [CI, -1.16 to 19.3 mg/dL]) after gastric bypass and 1.07 mmol/L (CI, 0.79 to 1.35 mmol/L) (41.3 mg/dL [CI, 30.5 to 52.1 mg/dL]) after duodenal switch (mean between-group difference, 0.83 mmol/L [CI, 0.48 to 1.18 mmol/L]; 32.0 mg/dL [CI, 18.5 to 45.6 mg/dL]; P ≤ 0.001). Reductions in low-density lipoprotein cholesterol concentration, anthropometric measures, fat mass, and fat-free mass were also greater after duodenal switch (P ≤ 0.010 for each between-group comparison). Both groups had reductions in blood pressure and mean concentrations of glucose, insulin, and C-reactive protein, with no between-group differences. The duodenal switch group, but not the gastric bypass group, had reductions in concentrations of vitamin A and 25-hydroxyvitamin D. Most Short Form-36 Health Survey dimensional scores improved in both groups, with greater improvement in 1 of 8 domains (bodily pain) after gastric bypass. From surgery until 2 years, 10 participants (32%) had adverse events after gastric bypass and 18 (62%) after duodenal switch (P = 0.021). Adverse events related to malnutrition occurred only after duodenal switch. LIMITATION: Clinical experience was greater with gastric bypass than with duodenal switch at the study centers. CONCLUSION: Duodenal switch surgery was associated with greater weight loss, greater reductions of total and low-density lipoprotein cholesterol concentrations, and more adverse events. Improvements in other cardiovascular risk factors and quality of life were similar after both procedures. PRIMARY FUNDING SOURCE: South-Eastern Norway Regional Health Authority.

Effect of bariatric surgery on sulphur amino acids and glutamate.

Plasma total cysteine (tCys) concentrations are associated with BMI. To study the relationship between tCys and BMI, we monitored the changes in serum concentrations of tCys and metabolically related compounds in sixty obese patients (BMI 50-60 kg/m(2)) from before to 1 year after either gastric bypass surgery (mean 30 % weight loss) or duodenal switch surgery (mean 41 % weight loss). A total of fifty-eight healthy persons (BMI 17-31 kg/m(2)) served as controls. Before surgery, obese patients had modestly (approximately 17 %) higher mean serum tCys, and markedly (>2-fold) higher glutamate concentrations, than controls (P ≤ 0·001 for both). Serial examinations after surgery revealed that gastric bypass patients had no change in tCys concentrations (P = 0·22), while duodenal switch patients showed a modest (approximately 12 %) but significant decrease in tCys (P < 0·001). Total homocysteine concentrations increased in duodenal switch patients but not in gastric bypass patients. Independent of surgery type, serum concentrations of methionine and cystathionine decreased (P < 0·05 for both), while serum glutathione and taurine remained stable. Glutamate concentrations declined, as did γ-glutamyltransferase activity (P < 0·001 for both). These results show that despite 30 % weight loss, and decreases in methionine, cystathionine and glutamate, there was no significant change in serum tCys in patients after gastric bypass surgery. The decrease in tCys in patients undergoing duodenal switch could be related to malabsorption. The present findings do not suggest that BMI is a causal determinant of plasma tCys.

[Type 2 diabetes and metabolic syndrome before and after gastric bypass]. / Type 2-diabetes og metabolsk syndrom før og etter gastrisk bypass.

BACKGROUND: Overweight and obesity are associated with an increased risk of acquiring type 2 diabetes and metabolic syndrome. We have assessed the prevalence of these conditions before and after gastric bypass surgery for morbid obesity. MATERIAL AND METHODS: The patients included had undergone laparoscopic gastric bypass at Oslo University Hospital Aker in the period 01.01.2007 - 31.12.2007 and had follow-up data for more than six months. Type 2 diabetes was defined as one or more of the following: an established diagnosis of diabetes before surgery, fasting plasma glucose >or= 7.0 mmol/l or HbA1c >or= 6.5 %. The metabolic syndrome was defined according to criteria laid out by the National Cholesterol Education Program. RESULTS: 136 patients (79 % women) with a mean (+/- SD) age of 43 +/- 9 years were included. Mean follow-up time was 17 months (range 8 - 26). The patients' body mass index (kg/m2) was reduced from 47 +/- 6 before to 32 +/- 6 after surgery (p<0.001). 34 % of patients had type 2 diabetes before and 10 % after surgery (p < 0.001). 80 % of patients had metabolic syndrome before and 24 % after surgery (p < 0.001). Fasting plasma glucose, HbA1c, and all variables included in the definition of metabolic syndrome were statistically significantly improved after surgery. INTERPRETATION: Gastric bypass has favourable effects on type 2 diabetes. Blood glucose normalised in most patients after the operation. The prevalence of metabolic syndrome was significantly lower after surgery.