Ten-Year Outcomes Following Roux-en-Y Gastric Bypass vs Duodenal Switch for High Body Mass Index: A Randomized Clinical Trial.

Importance: Results from long-term follow-up after biliopancreatic diversion with duodenal switch (DS) are scarce. Objective: To compare weight loss, health outcomes, and quality of life 10 years or more after Roux-en-Y-gastric bypass (RYGB) and DS surgery in patients with severe obesity-that is, a body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 50 to 60. Design, Setting, and Participants: This open-label randomized clinical trial was conducted at 2 academic bariatric centers in Sweden and Norway. Sixty patients with a BMI of 50 to 60 were included from March 1, 2006, to August 31, 2007. Data were analyzed from August 12, 2022, to January 25, 2023. Interventions: Laparoscopic RYGB or laparoscopic DS. Main Outcomes and Measures: The main outcome was change in BMI after 10 or more years. Secondary outcomes included anthropometric measures, lipid and glycemic profiles, bone mass density, adverse events, gastrointestinal tract symptoms, and health-related quality of life. Results: Forty-eight of the original 60 patients (80%) were assessed after a median of 12 (range, 9-13) years (mean [SD] age, 48.0 [6.0] years; 35 women [73%]). At follow-up, the mean BMI reductions were 11.0 (95% CI, 8.3-13.7) for RYGB and 20.3 (95% CI, 17.6-23.0) for DS, with a mean between-group difference of 9.3 (95% CI, 5.4-13.1; P < .001). Total weight loss was 20.0% (95% CI, 15.3%-24.7%) for RYGB and 33.9% (95% CI, 27.8%-40.0%) for DS (P = .001). Mean serum lipid levels, except high-density lipoprotein cholesterol and hemoglobin A1c, improved more in the DS group during follow-up. Bone mass was reduced for both groups from 5 to 10 years, with lower bone mass after DS at 10 years. Quality-of-life scores (Obesity-Related Problem Scale and the 36-Item Short Form Health Survey) were comparable across groups at 10 years. The total number of adverse events was higher after DS (135 vs 97 for RYGB; P = .02). More patients in the DS group developed vitamin deficiencies (21 vs 11 for RYGB; P = .008) including 25-hydroxyvitamin D deficiency (19 for DS vs 9 for RYGB; P = .005). Four of 29 patients in the DS group (14%) developed severe protein-caloric malnutrition, of whom 3 (10%) underwent revisional surgery. Conclusions and Relevance: In this randomized clinical trial, BMI reduction was greater after DS, but RYGB had a better risk profile over 10 years. Biliopancreatic diversion with DS may not be a better surgical strategy than RYGB for patients with a BMI of 50 to 60. Trial Registration: ClinicalTrials.gov Identifier: NCT00327912.

Postradiation trismus in head and neck cancer survivors: a qualitative study of effects on life, rehabilitation, used coping strategies and support from the healthcare system.

PURPOSE: This study aimed to explore the experiences of head and neck cancer (HNC) survivors with postradiation trismus, specifically how oncological treatment affected their lives, rehabilitation, use of coping strategies, and healthcare experiences. METHODS: A qualitative descriptive approach was used and semi-structured interviews of 10 HNC survivors with postradiation trismus were conducted 6-30 months after completing oncological treatment. The interviews were transcribed verbatim and analyzed by qualitative content analysis. RESULTS: The analysis of interviews yielded four main categories: Bodily symptoms, Effects on life, Support from the healthcare system, and Strategies to handle life and symptoms. Participants reported ongoing problems with xerostomia, dysgeusia, eating, and limited physical fitness. Pain related to trismus was not a major issue in this cohort. Participants expressed limitations in their social lives due to their eating difficulties, yet a sense of thankfulness for life and overall satisfaction with the healthcare they received. Psychological and practical coping strategies developed by the participants were also revealed. CONCLUSION: The results highlight areas of unmet need among HNC survivors that healthcare providers can target by establishing multi-professional teams dedicated to individualizing post-cancer rehabilitation care.

'My goal was to become normal'-A qualitative investigation of coping with stigma, body image and self-esteem long-term after bariatric surgery.

Improved self-esteem and body image, as well as reduced experiences of weight stigma are important patient-reported obesity treatment outcomes. However, more knowledge is needed about how individuals who have undergone metabolic and bariatric surgery (MBS) perceive themselves and their bodies and use different coping strategies in relation to body image and self-esteem long-term after MBS. In this qualitative study body image, self-esteem, weight stigma and coping strategies were explored among 18 individuals who underwent MBS more than 10 years ago when interviewed. Using reflexive thematic analysis, two primary themes were identified: 'Experiences of living with a stigmatised body' and 'Coping with weight stigma, body image and self-esteem', and eight sub-themes. Findings capture frequent experiences of weight stigma before bariatric surgery, the need for coping with stigma and body dissatisfaction before and after MBS, and how different coping strategies are related to participants' perceptions of their bodies and self-concepts. More adaptive coping strategies, such as confrontation and cognitive restructuring may facilitate more positive body image outcomes, than more ruminative and avoidant strategies. Understanding adaptive coping strategies can be useful to develop interventions to reduce negative consequences of weight stigma on body image and self-esteem.

Facial pain, health-related quality of life and trismus-related symptoms up to 5 years post-radiotherapy for head and neck cancer.

PURPOSE: Pain is a frequent symptom of head and neck cancer (HNC) but longitudinal studies investigating facial pain are scarce. We aimed to investigate prevalence of facial pain, its effect on health-related quality of life (HRQL) and trismus-related symptoms in a HNC cohort. METHODS: Patients (n = 194) were prospectively followed post completion of radiotherapy (RT). Outcome measures included facial pain, HRQL, trismus-specific symptoms, and maximal interincisal opening (MIO). RESULTS: Facial pain was reported by 50% at baseline. Corresponding figures for 3-, 12-, and 60 months post-RT were 70%, 54% and 41%. Moderate to severe pain was reported in 29-44% of patients reporting pain during the study period. Patients reporting pain scored significantly worse on more HRQL variables and trismus symptoms, as well as had significantly smaller MIO at all follow-up time points. CONCLUSIONS: Facial pain was common in HNC patients pre- and post-RT and remained prevalent up to 5 years after completion of RT. Reductions in MIO were associated with more facial pain. Pain was also associated with worse HRQL.

Non-alcohol substance use disorder after bariatric surgery in the prospective, controlled Swedish Obese Subjects study.

OBJECTIVE: The goal of this study was to investigate whether bariatric surgery is associated with substance use disorder (SUD) with substances other than alcohol. METHODS: The prospective, controlled Swedish Obese Subjects study enrolled 2010 patients with obesity who underwent bariatric surgery (gastric bypass n = 265; vertical banded gastroplasty n = 1369; gastric banding n = 376) and 2037 matched control individuals receiving usual obesity care. Participants with SUD other than alcohol use disorder were identified using International Statistical Classification of Diseases (ICD) codes from the Swedish National Patient Register (covering treatment in hospital but not primary care). Those with a history of non-alcohol SUD were excluded. Median follow-up was 23.8 years. RESULTS: During follow-up, non-alcohol SUD incidence rates per 1000 person-years with 95% CI were 1.6 (0.8-3.1), 0.8 (0.5-1.2), 1.1 (0.5-2.2), and 0.6 (0.4-0.8) for gastric bypass, vertical banded gastroplasty, gastric banding, and control individuals, respectively. Only gastric bypass was associated with increased incidence of non-alcohol SUD (adjusted hazard ratio 2.54 [95% CI: 1.14-5.65], p = 0.022) compared with control participants. CONCLUSIONS: Gastric bypass surgery was associated with increased risk of non-alcohol SUD, and this should be considered in long-term postoperative care.

Anaemia in patients with self-reported use of iron supplements in the BAriatric surgery SUbstitution and nutrition study: A prospective cohort study.

BACKGROUND AND AIMS: After bariatric surgery, micronutrient deficiencies may lead to anaemia. To prevent post-operative deficiencies, patients are recommended lifelong micronutrient supplementation. Studies investigating the effectiveness of supplementation to prevent anaemia after bariatric surgery are scarce. This study aimed to investigate the relationship between nutritional deficiencies and anaemia in patients who report use of supplementation two years after bariatric surgery versus patients who do not. METHODS AND RESULTS: Obese (BMI≥35 kg/m2) individuals (n = 971) were recruited at Sahlgrenska University Hospital in Gothenburg, Sweden between 2015 and 2017. The interventions were Roux-en-Y gastric bypass (RYGB), n = 382, sleeve gastrectomy (SG), n = 201, or medical treatment (MT), n = 388. Blood samples and self-reported data on supplements were collected at baseline and two years post treatment. Anaemia was defined as haemoglobin <120 g/L for females and <130 g/L for males. Standard statistical methods, including a logistic regression model and a machine learning algorithm, were used to analyse data. The frequency of anaemia increased from baseline in patients treated with RYGB (3·0% vs 10·5%; p < 0·05). Neither iron-dependent biochemistry nor frequency of anaemia differed between participants who reported use of iron supplements and those who did not at the two-year follow-up. Low preoperative level of haemoglobin and high postoperative percent excessive BMI loss increased the predicted probability of anaemia two years after surgery. CONCLUSION: The results from this study indicate that iron deficiency or anaemia may not be prevented by substitutional treatment per current guidelines after bariatric surgery and highlights there is reason to ensure adequate preoperative micronutrient levels. TRIAL REGISTRATION: March 03, 2015; NCT03152617.

Metabolic and bariatric surgery versus intensive non-surgical treatment for adolescents with severe obesity (AMOS2): a multicentre, randomised, controlled trial in Sweden.

BACKGROUND: Severe obesity in adolescents has a profound impact on current and future health. Metabolic and bariatric surgery (MBS) is increasingly used in adolescents internationally. However, to our knowledge, there are no randomised trials examining the currently most used surgical techniques. Our aim was to evaluate changes in BMI and secondary health and safety outcomes after MBS. METHODS: The Adolescent Morbid Obesity Surgery 2 (AMOS2) study is a randomised, open-label, multicentre trial done at three university hospitals in Sweden (located in Stockholm, Gothenburg, and Malmö). Adolescents aged 13-16 years with a BMI of at least 35 kg/m2, who had attended treatment for obesity for at least 1 year, passed assessments from a paediatric psychologist and a paediatrician, and had a Tanner pubertal stage of at least 3, were randomly assigned (1:1) to MBS or intensive non-surgical treatment. Exclusion criteria included monogenic or syndromic obesity, major psychiatric illness, and regular self-induced vomiting. Computerised randomisation was stratified for sex and recruitment site. Allocation was concealed for both staff and participants until the end of the inclusion day, and then all participants were unmasked to treatment intervention. One group underwent MBS (primarily gastric bypass), while the other group received intensive non-surgical treatment starting with 8 weeks of low-calorie diet. The primary outcome was 2-year change in BMI, analysed as intention-to-treat. The trial is registered at ClinicalTrials.gov, NCT02378259. FINDINGS: 500 people were assessed for eligibility between Aug 27, 2014, and June 7, 2017. 450 participants were excluded (397 did not meet inclusion criteria, 39 declined to participate, and 14 were excluded for various other reasons). Of the 50 remaining participants, 25 (19 females and six males) were randomly assigned to receive MBS and 25 (18 females and seven males) were assigned to intensive non-surgical treatment. Three participants (6%; one in the MBS group and two in the intensive non-surgical treatment group) did not participate in the 2-year follow-up, and in total 47 (94%) participants were assessed for the primary endpoint. Mean age of participants was 15·8 years (SD 0·9) and mean BMI at baseline was 42·6 kg/m2 (SD 5·2). After 2 years, BMI change was -12·6 kg/m2 (-35·9 kg; n=24) among adolescents undergoing MBS (Roux-en-Y gastric bypass [n=23], sleeve gastrectomy [n=2]) and -0·2 kg/m2 (0·4 kg; [n=23]) among participants in the intensive non-surgical treatment group (mean difference -12·4 kg/m2 [95% CI -15·5 to -9·3]; p<0·0001). Five (20%) patients in the intensive non-surgical group crossed over to MBS during the second year. Adverse events (n=4) after MBS were mild but included one cholecystectomy. Regarding safety outcomes, surgical patients had a reduction in bone mineral density, while controls were unchanged after 2 years (z-score change mean difference -0·9 [95% CI -1·2 to -0·6]). There were no significant differences between the groups in vitamin and mineral levels, gastrointestinal symptoms (except less reflux in the surgical group), or in mental health at the 2-year follow-up. INTERPRETATION: MBS is an effective and well tolerated treatment for adolescents with severe obesity resulting in substantial weight loss and improvements in several aspects of metabolic health and physical quality of life over 2 years, and should be considered in adolescents with severe obesity. FUNDING: Sweden's Innovation Agency, Swedish Research Council Health.

Trismus, health-related quality of life, and trismus-related symptoms up to 5 years post-radiotherapy for head and neck cancer treated between 2007 and 2012.

PURPOSE: Radiotherapy-induced trismus is present in up to 40% of patients treated radiotherapeutically for head and neck cancer (HNC) and impacts health-related quality of life (HRQL) negatively. This prospective study aimed to investigate the development of trismus and its influence on HRQL and trismus-related symptoms in HNC patients for up to 5 years post-radiotherapy completion as no such follow-up studies exist. METHODS: Patients (n = 211) were followed prospectively from pre-radiotherapy to 12 and 60 months post-radiotherapy. At each follow-up, maximum interincisal opening (MIO) was measured, and patients filled in the European Organization for Treatment of Cancer Quality-of-Life Questionnaire Core-30 (EORTC QLQ-C30), Head and Neck-35 (EORTC QLQ-HN35), and Gothenburg Trismus Questionnaire (GTQ). Trismus was defined as an MIO ≤ 35 mm. RESULTS: At 1 year post-radiotherapy, a total of 27% met the trismus criterion, and at 5 years post-radiotherapy, the corresponding figure was 28%. Patients in the trismus group scored significantly worse compared to the patients without trismus on 8/15 domains at 1 year post-radiotherapy on EORTC QLQ-C30, further worsening in 11/15 domains at 5 years post-radiotherapy. Similar results were found for EORTC QLQ-HN35. Patients with trismus reported more trismus-related symptoms according to the GTQ at both timepoints compared to those without trismus. CONCLUSION: This study highlights that HNC patients suffering from radiotherapy-induced trismus report poorer HRQL and more trismus-specific symptoms compared to patients without trismus. These differences persist and increase up to at least 5 years following treatment completion. Hence, our results highlight that radiotherapy-induced trismus affects long-term HRQL, jaw symptoms, and pain, further stressing the need for early and structured intervention.

A prospective 5-year study of trismus prevalence and fluctuation in irradiated head and neck cancer patients.

BACKGROUND: Trismus is a complication post-radiotherapy for head and neck cancer (HNC), which causes pain, eating limitations and reduced quality-of-life. However, little is known about the condition long-term or how trismus fluctuates within an irradiated population. AIM/OBJECTIVE: To prospectively map trismus prevalence in irradiated HNC patients up to 5-years following treatment completion including describing intra-group fluctuation of maximum interincisal opening (MIO). MATERIALS AND METHODS: 211 patients receiving curatively intended radiotherapy for HNC were included in this prospective study. Patients were followed pre-radiotherapy (baseline), 3-, 6-, 12-, 24-, 36- and 60-months post-radiotherapy completion using MIO. RESULTS: Mean MIO at baseline, 12-months and 5-years following radiotherapy were 51.5 mm, 41.7 mm and 41.3 mm respectively. A total of 28% (n = 36) fulfilled the trismus criterion at 5-years post-radiotherapy. Eighty percent of patients (n = 24) with trismus at 5 years post-radiotherapy also suffered from trismus at 12 months post-radiotherapy, whilst 88-92% of all patients reported reduced MIO at any given timepoint compared to baseline. 15% of patients never exceeded an MIO of >35 mm at any time-point. CONCLUSION: Trismus is a prevalent long-term complication of HNC and its treatment, which does not appear to heal spontaneously. The majority of fluctuations in MIO occur during the first 12 months post-radiotherapy completion.

Surgical technique in constructing the jejunojejunostomy and the risk of small bowel obstruction after Roux-en-Y gastric bypass.

BACKGROUND: Mechanical problems at the level of the jejunojejunostomy (JJ) have been identified as a cause of small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass (RYGB). OBJECTIVES: The objective of the study was to investigate associations between specific surgical techniques used to construct the JJ and the subsequent risk of SBO. SETTING: Nationwide Registry, Sweden. METHODS: The risk of SBO after primary RYGB surgery during 2012-2019 was assessed using data from the Scandinavian Obesity Surgery Registry and the Swedish National Patient Register. The impact of unidirectional or bidirectional stapling and length of the mesenteric division (0, 1-4, or ≥5 cm) at the JJ was analyzed with adjustments for known covariates. RESULTS: We analyzed outcomes from 23,448 patients (mean follow-up = 4.3 ± 2.2 yr). In multivariate analysis, bidirectional stapling of the JJ was associated with a reduced 30-day risk of SBO (hazard ratio [HR] = .52, 95% confidence interval [CI] = .29-.95, P < .05), whereas limited mesenteric division (1-4 cm) increased the risk of SBO (HR = 1.66, 95% CI = 1.14-2.42, P < .01). The long-term incidence of SBO was increased by bidirectional stapling but unaffected by mesenteric division. However, mesenteric division decreased the long-term risk of SBO in patients with a bidirectionally stapled JJ (1-4 cm, HR = .59, 95% CI = .38-.90, P < .05; ≥5 cm, HR = .30, 95% CI = .14-.65, P < .005). CONCLUSIONS: The surgical technique for construction of the JJ may affect the incidence of SBO after RYGB surgery.

Comparing effects of obesity treatment with very low energy diet and bariatric surgery after 2 years: a prospective cohort study.

OBJECTIVES: To compare long-term effects and complications of medical treatment (MT) of obesity including very low energy diet with bariatric surgery. DESIGN AND SETTING: This prospective study conducted in a clinical setting recruited individuals with body mass index (BMI) ≥35 kg/m2 referred for obesity treatment. Demographic and anthropometric data, laboratory samples, and questionnaire replies were collected at baseline and 2 years. PARTICIPANTS AND INTERVENTIONS: 971 individuals were recruited 2015-2017. 382 received MT, 388 Roux-en-Y gastric bypass (RYGB) and 201 sleeve gastrectomy (SG). MAIN OUTCOME MEASURES: Primary outcomes included changes in anthropometric measures, metabolic variables and safety. These were analysed using a linear regression model. A logistic regression model was used to analyse composite variables for treatment success (secondary outcomes). A random forest (RF) model was used to examine the importance of 15 clinical domains as predictors for successful treatment. RESULTS: Two-year data were available for 667 individuals (68.7%). Regarding primary outcomes, the decrease in excess BMI was 27.5%, 82.5% and 70.3% and proportion achieving a weight of >10% was 45.3%, 99.6% and 95.6% for MT, RYGB and SG, respectively (p<0.001). The groups were comparable regarding levels of vitamins, minerals and haemoglobin or safety measures. Likelihood for success (secondary outcome) was higher in the surgical groups (RYGB: OR 5.3 (95% CI 3.9 to 7.2) vs SG: OR 4.3 ((95% CI 3.0 to 6.2)) in reference to MT. Baseline anthropometry had the strongest predictive value for treatment success, according to the RF model. CONCLUSIONS: In clinical practice, bariatric surgery by RYGB or SG is most effective, but meaningful weight loss is achievable by MT with strict caloric restriction and stepwise introduction of a normal diet. All treatments showed positive effects on well-being, cardiovascular risk factors, and levels of vitamins and minerals at 2-year follow-up and groups were similar regarding safety measures. TRIAL REGISTRATION NUMBER: NCT03152617.

Perceptions of Experiences of Recovery After Pancreaticoduodenectomy-A Phenomenographic Interview Study.

BACKGROUND: Pancreatic surgery in the context of enhanced recovery has mainly been evaluated using clinical variables. However, there is limited knowledge about patients' perceptions of recovery in this context. Hence, the aim of this study was to explore patients' perceptions of recovery after pancreatic surgery within an enhanced recovery program. OBJECTIVE: To explore the variations in patients' perceptions, a qualitatively designed study was undertaken. METHODS: Data in this phenomenographic study consisted of interviews with 19 patients at 4 to 6 weeks after surgery. RESULTS: Recovery after pancreatic surgery was classified into 5 categories, based on patients' perceptions: to be as before, affected by symptoms, physical activity, understanding the process, and facilitated by other people. CONCLUSION: The study focused on various areas of recovery, which took place between the in-hospital and after-discharge phases. Physical experiences were found to disturb recovery, in contrast to social and emotional experiences, which facilitated recovery. Variations in perceptions of recovery suggest that care may need to be more individualized, both in the preoperative and the postoperative phase. Working with realistic expectations and early patient education might better prepare patients to continue working on their own recovery after discharge from the hospital. IMPLICATIONS FOR PRACTICE: Major cancer surgery needs to be perceived as a personal journey for the patient, even in enhanced recovery program care. Preoperative education is good, but adding continuous and individually adopted education during recovery is better. Knowledge about both hindering and facilitating factors for recovery is important for the healthcare personal.

Glycemic Control and Metabolic Adaptation in Response to High-Fat versus High-Carbohydrate Diets-Data from a Randomized Cross-Over Study in Healthy Subjects.

Granular study of metabolic responses to alterations in the ratio of dietary macro-nutrients can enhance our understanding of how dietary modifications influence patients with impaired glycemic control. In order to study the effect of diets enriched in fat or carbohydrates, fifteen healthy, normal-weight volunteers received, in a cross-over design, and in a randomized unblinded order, two weeks of an iso-caloric high-fat diet (HFD: 60E% from fat) and a high-carbohydrate diet (HCD: 60E% from carbohydrates). A mixed meal test (MMT) was performed at the end of each dietary period to examine glucose clearance kinetics and insulin and incretin hormone levels, as well as plasma metabolomic profiles. The MMT induced almost identical glycemia and insulinemia following the HFD or HCD. GLP-1 levels were higher after the HFD vs. HCD, whereas GIP did not differ. The HFD, compared to the HCD, increased the levels of several metabolomic markers of risk for the development of insulin resistance, e.g., branched-chain amino acid (valine and leucine), creatine and α-hydroxybutyric acid levels. In normal-weight, healthy volunteers, two weeks of the HFD vs. HCD showed similar profiles of meal-induced glycemia and insulinemia. Despite this, the HFD showed a metabolomic pattern implying a risk for a metabolic shift towards impaired insulin sensitivity in the long run.

The BAriatic surgery SUbstitution and nutrition (BASUN) population: a data-driven exploration of predictors for obesity.

BACKGROUND: The development of obesity is most likely due to a combination of biological and environmental factors some of which might still be unidentified. We used a machine learning technique to examine the relative importance of more than 100 clinical variables as predictors for BMI. METHODS: BASUN is a prospective non-randomized cohort study of 971 individuals that received medical or surgical treatment (treatment choice was based on patient's preferences and clinical criteria, not randomization) for obesity in the Västra Götaland county in Sweden between 2015 and 2017 with planned follow-up for 10 years. This study includes demographic data, BMI, blood tests, and questionnaires before obesity treatment that cover three main areas: gastrointestinal symptoms and eating habits, physical activity and quality of life, and psychological health. We used random forest, with conditional variable importance, to study the relative importance of roughly 100 predictors of BMI, covering 15 domains. We quantified the predictive value of each individual predictor, as well as each domain. RESULTS: The participants received medical (n = 382) or surgical treatment for obesity (Roux-en-Y gastric bypass, n = 388; sleeve gastrectomy, n = 201). There were minor differences between these groups before treatment with regard to anthropometrics, laboratory measures and results from questionnaires. The 10 individual variables with the strongest predictive value, in order of decreasing strength, were country of birth, marital status, sex, calcium levels, age, levels of TSH and HbA1c, AUDIT score, BE tendencies according to QEWPR, and TG levels. The strongest domains predicting BMI were: Socioeconomic status, Demographics, Biomarkers (notably TSH), Lifestyle/habits, Biomarkers for cardiovascular disease and diabetes, and Potential anxiety and depression. CONCLUSIONS: Lifestyle, habits, age, sex and socioeconomic status are some of the strongest predictors for BMI levels. Potential anxiety and / or depression and other characteristics captured using questionnaires have strong predictive value. These results confirm previously suggested associations and advocate prospective studies to examine the value of better characterization of patients eligible for obesity treatment, and consequently to evaluate the treatment effects in groups of patients. TRIAL REGISTRATION: March 03, 2015; NCT03152617 .

The Jejunojejunostomy: an Achilles Heel of the Roux-en-Y Gastric Bypass Construction.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (RYGB) has for long been the gold standard technique in bariatric surgery, especially in the Scandinavian countries. In a tertiary hospital setting, we observed an increasing number of patients with postprandial abdominal pain and nausea, often associated with complex hypoglycemia. OBJECTIVES: The present study aimed to characterize the clinical patterns, patient characteristics, and clinical outcomes after surgical revision of dysfunctional RYGB at Sahlgrenska University Hospital in Gothenburg, Sweden. METHODS: This cohort study included patients with RYGB who underwent revision of the jejunojejunostomy (JJ) after 2013. Information was obtained by reviewing medical records and performing complementary interviews. RESULTS: Laparoscopic revisional surgery was performed in 115 cases with either adhesiolysis or total revision of the JJ (mean age 41 years, range 19-67 years; 90% women). The median time to assessment after the last revision was 33 months (range 12-75 months). Forty-four (38%) patients reported that they were symptom-free long-term after the intervention, and 32 (28%) patients experienced an improvement in the symptoms that were the indication for revision. However, 31 (27%) patients reported no long-term improvement, and half of them (n = 16) subsequently had a reversal of the anatomy. Eight (7%) patients were lost to follow-up. CONCLUSIONS: Dysfunction of the JJ appears to be a relatively common cause of postprandial pain and nausea after ante-colic/ante-gastric RYGB. Most patients with symptoms of dysfunction experienced partial or total relief following revisional surgery, but a substantial minority had persistent problems, with one in five eventually undergoing reversal of the anatomy.

Patients' views of long-term results of bariatric surgery for super-obesity: sustained effects, but continuing struggles.

BACKGROUND: Bariatric surgery is a standard treatment for severe obesity, but little is known about patients' perceptions about the long-term impact of such surgery. OBJECTIVE: The aim of this study was to explore patients' experiences of living with a bariatric procedure for more than a decade. SETTING: University hospital. METHODS: At the 10-year follow-up after undergoing Roux-en-Y gastric bypass (RYGB) or biliopancreatic diversion with duodenal switch (BPD/DS), 18 consecutive patients from a previous randomized controlled trial were assessed with a semi-structured interview. Data were analyzed using thematic analysis. RESULTS: When asked to reflect broadly on their experiences of living with bariatric surgery for over a decade, the participants rarely mentioned procedure-specific issues and complications. Instead, their accounts revealed 2 broad themes: sustained effects after surgery, incorporating subthemes of better health, brighter futures, and better eating and weight regulation, and continuing struggles, including difficulties with physical activity, finding support, helping their children with overweight, and self-criticism. Many positive changes were sustained, but continuing personal struggles were similar to those presurgery. CONCLUSIONS: Participants expressed overall satisfaction with their bariatric surgery and related outcomes. Most participants acknowledged a continued effect on their appetite, which could be important information for patients who worry about a diminished effect after the first year postsurgery. Participants were prone to self-blame when things did not turn out the way they wanted. Therefore, healthcare providers must build a trustful relationship with their patients, so they will not hesitate to return when they face problems such as weight gain.

High prevalence of neurodevelopmental problems in adolescents eligible for bariatric surgery for severe obesity.

AIM: To assess the prevalence of neurodevelopmental problems in adolescents with severe obesity and their associations with binge eating and depression. METHODS: Data were collected at inclusion in a randomised study of bariatric surgery in 48 adolescents (73% girls; mean age 15.7 ± 1.0 years; mean body mass index 42.6 ± 5.2 kg/m2 ). Parents completed questionnaires assessing their adolescents' symptoms of attention-deficit/hyperactivity disorder and autism spectrum disorder and reported earlier diagnoses. Patients answered self-report questionnaires on binge eating and depressive symptoms. RESULTS: The parents of 26/48 adolescents (54%) reported scores above cut-off for symptoms of the targeted disorders in their adolescents, but only 15% reported a diagnosis, 32% of adolescents reported binge eating, and 20% reported symptoms of clinical depression. No significant associations were found between neurodevelopmental problems and binge eating or depressive symptoms. Only a third of the adolescents reported no problems in either area. CONCLUSION: Two thirds of adolescents seeking surgical weight loss presented with substantial mental health problems (reported by themselves or their parents). This illustrates the importance of a multi-professional approach and the need to screen for and treat mental health disorders in adolescents with obesity.

A randomized controlled trial comparing intensive non-surgical treatment with bariatric surgery in adolescents aged 13-16 years (AMOS2): Rationale, study design, and patient recruitment.

BACKGROUND: Previous non-randomized studies show similar outcomes in adolescents and adults after bariatric surgery. We describe the study protocol, recruitment, and selected baseline data of patients in a randomized multi-center study, the Adolescent Morbid Obesity Surgery 2 (AMOS2). METHODS: Three clinics in Sweden collaborated in designing the study and recruitment of patients from August 1, 2014 to June 30, 2017. Patients were selected among adolescents 13-16 years of age attending third-level obesity care for at least one year. Patients were randomized 1:1 to bariatric surgery (predominantly Roux-en-Y gastric bypass) or intensive non-surgical treatment starting with an eight-week low-calorie-diet. RESULTS: Fifty adolescents (37 girls) were randomized, 25 (19 girls) to bariatric surgery. Mean age was 15.7 years (range 13.3-16.9), weight 122.6 kg (range 95-183.3), Body Mass Index (BMI) 42.6 kg/m2 (range 35.7-54.9) and BMI-SDS 3.45 (range 2.9-4.1). One patient had type 2 diabetes mellitus, and 12/45 (27%) had elevated liver enzymes. There were no significant differences between the groups. For the 39 eligible patients who were offered but declined inclusion, BMI was not different from included patients. However, patients who declined were younger, 15.2 years (p = 0.021). A sex difference was also noted with more of eligible girls, 37/53 (69.8%), than boys, 13/36 (36.1%), wanting to participate in the study (p = 0.002). CONCLUSIONS: This clinical trial, randomizing adolescents with severe obesity to bariatric surgery or intensive non-surgical treatment, aims at informing about whether it is beneficial to undergo bariatric surgery in early adolescence. It will also enlighten the outcome of comprehensive non-surgical treatment. The study was registered at www.clinicalTrials.gov number NCT02378259.

Patient experiences with isolated limb perfusion for malignant melanoma - A qualitative study.

PURPOSE: In recent years, the incidence of malignant melanoma has rapidly increased worldwide. Among patients with recurrences, approximately 5% develop in-transit metastases, which can potentially be treated with isolated limb perfusion (ILP). However, little is known about patient experiences with this treatment. A more thorough understanding might guide future research and clinical care. In this study, we aimed to describe patients' experiences of ILP treatment. METHODS: This study included eight patients who participated in a semi-structed interviewed, conducted at one occasion between 3 and 11 months after their ILP treatment. The mean interview duration was 26 min. Data were analyzed using qualitative inductive content analysis according to the methods of Elo-Kyngäs and Graneheim and Lundman. RESULTS: Our analysis yielded three categories, each built on two subcategories: positive experiences after ILP treatment emerged from the sub-categories reduced tumor burden and living a less restricted life; negative experiences after ILP was built on the subcategories fear of relapse and complications and side effects; and experiences of healthcare was founded on the subcategories need for correct information and being viewed as sicker then experienced. CONCLUSION: Participants showed greater focus on the healthy parts of their lives, even when negative symptoms occurred after ILP treatment. They also described how healthcare workers focused on their illness. Based on these findings, we suggest the following means of providing good nursing care to ILP patients: give correct information, strive to reduce patients' negative symptoms, support their daily living needs, and provide emotional support to reduce fear of recurrence.