Differences in Psychological Health and Weight Loss after Bariatric Metabolic Surgery between Patients with and without Pain Syndromes.

PURPOSE: Chronic pain and obesity often co-occur, negatively affecting one another and psychological wellbeing. Pain and psychological wellbeing improve after bariatric metabolic surgery (BMS), however, it is unknown whether psychological wellbeing improves differently after weight loss between patients with and without chronic pain. We investigated whether weight loss is associated with greater psychological wellbeing and functioning change after BMS, comparing patients with and without preoperative pain syndromes. METHODS: Depression, health-related quality of life, self-esteem, self-efficacy to exercise and controlling eating behaviours, physical activity, and food cravings were measured before and 24 months after BMS among 276 patients with obesity. The presence of preoperative chronic pain syndromes was examined as a moderator for the relationship between 24-month weight loss and changes in psychological outcomes. RESULTS: Chronic pain syndromes were present among 46% of patients. Weight loss was associated with greater improvement in health-related quality of life, self-efficacy to exercise and controlling eating behaviours, self-esteem and greater amelioration in food cravings. Pain syndromes only moderated negatively the relationship between the postoperative weight loss and change in self-efficacy to control eating behaviours (b = -0.49, CI [-0.88,-0.12]). CONCLUSION: Patients with and without chronic pain showed similar improvements in weight and psychological wellbeing and behaviours after BMS. The relationship between weight loss and the improvement of self-efficacy to control eating behaviours was weaker among patients with chronic pain syndrome. Further work, measuring pain severity over time, is needed to shed light on the mechanism underlying pain and postoperative change in psychological wellbeing and weight loss.

The burden of abdominal pain after bariatric surgery in terms of diagnostic testing: the OPERATE study.

BACKGROUND: Abdominal pain after bariatric surgery (BS) is frequently observed. Despite numerous diagnostic tests, the cause of abdominal pain is not always found. OBJECTIVES: To quantify type and number of diagnostic tests performed in patients with abdominal pain after BS and evaluate the burden and their yield in the diagnostic process. SETTING: A bariatric center in the Netherlands. METHODS: In this prospective study, we included patients who presented with abdominal pain after BS between December 1, 2020, and December 1, 2021. All diagnostic tests and reoperations performed during one episode of abdominal pain were scored using a standardized protocol. RESULTS: A total of 441 patients were included; 401 (90.9%) were female, median time after BS was 37.0 months (IQR, 11.0-66.0) and mean percentage total weight loss was 31.41 (SD, 10.53). In total, 715 diagnostic tests were performed, of which 355 were abdominal CT scans, 155 were ultrasounds, and 106 were gastroscopies. These tests yielded a possible explanation for the pain in 40.2% of CT scans, 45.3% of ultrasounds, and 34.7% of gastroscopies. The diagnoses of internal herniation, ileus, and nephrolithiasis generally required only 1 diagnostic test, whereas patients with anterior cutaneous nerve entrapment syndrome, irritable bowel syndrome, and constipation required several tests before diagnosis. Even after several negative tests, a diagnosis was still found in the subsequent test: 86.7% of patients with 5 or more tests had a definitive diagnoses. Reoperations were performed in 37.2% of patients. CONCLUSION: The diagnostic burden in patients with abdominal pain following BS is high. The most frequently performed diagnostic test is an abdominal CT scan, yielding the highest number of diagnoses in these patients.

Are male patients undergoing bariatric surgery less healthy than female patients?

BACKGROUND: Male patients are underrepresented in bariatric surgery (BS) despite a relatively equal proportion of men and women experiencing obesity. OBJECTIVES: Differences in frequency and severity of obesity-associated medical problems (OAMPs) between men and women undergoing BS or in a control group (HELIUS [HEalthy Life In an Urban Setting]) were evaluated. The hypothesis was that men undergoing BS are less healthy than women. SETTING: A cross-sectional study of 2 cohorts undergoing BS in 2013 (BS2013) and 2019 (BS2019) and a control group of patients with severe obesity from a general population (HELIUS). METHODS: Characteristics concerning weight and OAMPs, medication usage, intoxications, postoperative complications (for BS2019) were compared between men and women. Members of the HELIUS cohort were tested for eligibility for BS. RESULTS: Of 3244 patients included, the majority were female (>78.4%). Median (interquartile range) age and body mass index (kg/m2) in male versus female patients were 47.0 (41.0-53.8) versus 43.0 (36.0-51.0) years and 41.5 (38.4-45.2) versus 42.3 (40.2-45.9), respectively, in BS2013, and 52.0 (39.8-57.0) versus 45.0 (35.0-53.0) years and 40.4 (37.4-43.8) versus 41.3 (39.0-44.1) in BS2019 (P < .05). The rates of men with OAMPs were 71.4% and 82.0% compared with 50.2% and 56.9% of women in BS2013 and BS2019, respectively. Overall medication usage was higher in male patients (P = .014). In BS2019, male patients exhibited a higher median HbA1C (P < .001) and blood pressure (P = .003) and used more antihypertensives and antidiabetics (P = .004). Postoperative complications did not differ between men and women. In the control cohort, 66.5% of men and 66.6% of women were eligible for BS. CONCLUSION: Men undergoing BS more often experience OAMPs than women, and OAMPs are more advanced in men.

Identifying Gut Microbiota associated with Gastrointestinal Symptoms upon Roux-en-Y Gastric Bypass.

PURPOSE: Roux-en-Y gastric bypasses (RYGB) are frequently accompanied by long-term gastrointestinal (GI) symptoms. Direct mechanistic insight into the causation of these symptoms is lacking, but changes in the intestinal microbiome have been proposed to play a role. With this study, we aimed to investigate whether a microbial predisposition exists before RYGB which is associated with GI symptoms during follow-up and to evaluate which microbial groups are involved. MATERIALS AND METHODS: In total, 67 RYGB patients were included. Shotgun metagenomic sequencing was performed on fecal samples obtained just before and 1 year after surgery. To assess GI symptoms, patients filled out Gastrointestinal Quality of Life Index (GIQLI) questionnaires and were divided into groups based on their total GIQLI score and change in score (postsurgery versus baseline). Extremely randomized tree predictor models were used to identify the most distinctive microbial species associated with postoperative GI symptoms. RESULTS: Beta diversity differed significantly between baseline and 1-year post-surgery samples, with the post-surgery microbiome resembling a more dysbiotic profile. The most predictive species regarding total GIQLI (AUC 0.77) or delta GIQLI score (AUC 0.83) were identified. Many of these species are known butyrate producers or species known to support them and/or species with anti-inflammatory properties, including Coprococcus eutactus, Faecalibacterium prausnitzii, and Ruminococcus callidus. CONCLUSION: Beneficial commensal gut microbiota related to a high GI score were associated to adequate intestinal fermentative capacity, suggesting these species might have protective properties against postoperative GI malfunctioning.

Attachment style and post-bariatric surgery health behaviours: the mediating role of self-esteem and health self-efficacy.

BACKGROUND: Attachment avoidance and anxiety have been linked to overweight and poor health behaviours, yet the mechanisms that underpin the relationship between attachment and health behaviours are not fully understood. Self-esteem and self-efficacy have been found to differ between attachment styles, rendering these variables potential mediators of the relationship. This longitudinal study investigated the serial mediation between preoperative attachment and 2-year post-operative health behaviours through self-esteem and health self-efficacy. METHODS: Participants were 263 bariatric surgery patients (75.7% females, aged 47.7 ± 10.4 years, BMI 38.9 ± 3.6 kg/m2) assessed before the operation and again one and two years after the surgery. Patients completed the Experiences for Close Relationships Brief Scale, Rosenberg Self-esteem scale, Weight Efficacy Lifestyle Questionnaire, Bariatric Surgery Self-Management Questionnaire, Exercise Self-Efficacy Scale and the Exercise Behaviour Scale. RESULTS: Higher preoperative attachment anxiety and avoidance were associated with lower self-esteem one year after bariatric surgery and poorer health self-efficacy two years after the surgery. Self-esteem and health self-efficacy mediated the relationships between preoperative anxious and avoidant attachment and 2- year post-operative diet adherence and physical activity. CONCLUSIONS: Helping patients to feel more worthy and reinforcing their beliefs about their own competences could lead to higher engagement with healthy lifestyle and adherence to treatment protocols, ultimately helping patients to achieve their goals for bariatric surgery. CLINICAL TRIAL REGISTRATION: BARIA: Netherlands Trial Register: NL5837 (NTR5992) https://www.trialregister.nl/trial/5837 . Diabaria: ClinicalTrials.gov identifier (NCT number): NCT03330756.

A Prospective Study on the Diagnoses for Abdominal Pain After Bariatric Surgery: The OPERATE Study.

PURPOSE: Long-term follow-up after bariatric surgery (BS) reveals high numbers of patients with abdominal pain that often remains unexplained. The aim of this prospective study was to give an overview of diagnoses for abdominal pain, percentage of unexplained complaints, number and yield of follow-up visits, and time to establish a diagnosis. MATERIALS AND METHODS: Patients who visited the Spaarne Gasthuis Hospital, The Netherlands, between December 2020 and December 2021 for abdominal pain after BS, were eligible and followed throughout the entire episode of abdominal pain. Distinction was made between presumed and definitive diagnoses. RESULTS: The study comprised 441 patients with abdominal pain; 401 (90.9%) females, 380 (87.7%) had Roux-en-Y gastric bypass, mean (SD) % total weight loss was 31.4 (10.5), and median (IQR) time after BS was 37.0 (11.0-66.0) months. Most patients had 1-5 follow-up visits. Readmissions and reoperations were present in 212 (48.1%) and 164 (37.2%) patients. At the end of the episode, 88 (20.0%) patients had a presumed diagnosis, 183 (41.5%) a definitive diagnosis, and 170 (38.5%) unexplained complaints. Most common definitive diagnoses were cholelithiasis, ulcers, internal herniations, and presumed diagnoses irritable bowel syndrome (IBS), anterior cutaneous nerve entrapment syndrome, and constipation. Median (IQR) time to presumed diagnoses, definitive diagnoses, or unexplained complaints was 16.0 (3.8-44.5), 2.0 (0.0-31.5), and 13.5 (1.0-53.8) days (p < 0.001). Patients with IBS more often had unexplained complaints (OR 95%CI: 4.457 [1.455-13.654], p = 0.009). At the end, 71 patients (16.1%) still experienced abdominal pain. CONCLUSION: Over a third of abdominal complaints after BS remains unexplained. Most common diagnoses were cholelithiasis, ulcers, and internal herniations.

Pancreatic exocrine insufficiency after bariatric surgery.

BACKGROUND: Chronic abdominal complaints after bariatric surgery may be explained by pancreatic exocrine insufficiency (PEI). OBJECTIVES: We aimed to evaluate the clinical value of the Pancreatic Exocrine Insufficiency Questionnaire (PEI-Q) as a screening tool to identify patients with a high probability of having PEI. SETTING: Outpatient clinic for bariatric surgery. METHODS: Patients scheduled for a screening or follow-up appointment were asked to complete the PEI-Q and the Gastrointestinal Quality of Life Index questionnaire (GIQLI). Postoperative patients with a high PEI-Q score (0,6) were offered a fecalelastase (FE) test (abnormal if <200 µg/g). RESULTS: Between June 2020 and February 2021, a total of 1600 of 1629 PEI-Qs were completed, 1073 (67%) of which after surgery. The postoperative group consisted mostly of females (81.9%), aged 49.0 ± 10.6 years, with a total weight loss of 30.3% ± 8.8%. Among them, 63.4% had abnormal PEI-Q scores compared with 34.9% before surgery (P < .01). In contrast, the median GIQLI score increased (119 [interquartile range (IQR), 107-129.25] versus 110 [IQR, 95-121.75]) before surgery (P < .01). Additionally, 310 FE tests were performed, of which only 11.9% was suggestive of PEI. No correlation was found between the PEI-Q scores and FE levels (c-index .55). CONCLUSION: The PEI-Q in its current version is not able to distinguish complaints of PEI and bariatric surgery itself and therefore cannot be used as a screening tool for PEI. The specificity of the FE test seems to be reduced after surgery. Future research should include a more direct pancreatic function test, which may provide more insight into PEI after bariatric surgery.

What Is Weight Loss After Bariatric Surgery Expressed in Percentage Total Weight Loss (%TWL)? A Systematic Review.

Percentage total weight loss (%TWL) might be better than percentage excess weight loss to express weight loss in bariatric surgery. In this systematic review, performed according to the PRISMA statement, results of laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (LRYGB) are assessed in %TWL. A total of 13,426 studies were screened and 49 included, reporting data of 24,760 patients. The results show that, despite limiting data, LRYGB is favorable over LSG in terms of weight loss in short-term follow-up. Although recent guidelines recommend to use %TWL when reporting outcome in bariatric surgery, this study shows that there is still insufficient quality data in %TWL, especially on LSG. The use of %TWL as the primary outcome measure in bariatric surgery should be encouraged.