Current recommendations for procedure selection in class I and II obesity developed by an expert modified Delphi consensus.

Metabolic and bariatric surgery (MBS) is widely considered the most effective option for treating obesity, a chronic, relapsing, and progressive disease. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued new guidelines on the indications for MBS, which have superseded the previous 1991 National Institutes of Health guidelines. The aim of this study is to establish the first set of consensus guidelines for selecting procedures in Class I and II obesity, using an Expert Modified Delphi Method. In this study, 78 experienced bariatric surgeons from 32 countries participated in a two-round Modified Delphi consensus voting process. The threshold for consensus was set at an agreement or disagreement of ≥ 70.0% among the experts. The experts reached a consensus on 54 statements. The committee of experts reached a consensus that MBS is a cost-effective treatment option for Class II obesity and for patients with Class I obesity who have not achieved significant weight loss through non-surgical methods. MBS was also considered suitable for patients with Type 2 diabetes mellitus (T2DM) and a body mass index (BMI) of 30 kg/m2 or higher. The committee identified intra-gastric balloon (IGB) as a treatment option for patients with class I obesity and endoscopic sleeve gastroplasty (ESG) as an option for patients with class I and II obesity, as well as for patients with T2DM and a BMI of ≥ 30 kg/m2. Sleeve gastrectomy (1) and Roux-en-Y gastric bypass (RYGB) were also recognized as viable treatment options for these patient groups. The committee also agreed that one anastomosis gastric bypass (OAGB) is a suitable option for patients with Class II obesity and T2DM, regardless of the presence or severity of obesity-related medical problems. The recommendations for selecting procedures in Class I and II obesity, developed through an Expert Modified Delphi Consensus, suggest that the use of standard primary bariatric endoscopic (IGB, ESG) and surgical procedures (SG, RYGB, OAGB) are acceptable in these patient groups, as consensus was reached regarding these procedures. However, randomized controlled trials are still needed in Class I and II Obesity to identify the best treatment approach for these patients in the future.

A Matched Comparative Analysis of Type-2 Diabetes Mellitus Remission Between Roux-en-Y Gastric Bypass and Sleeve Gastrectomy.

OBJECTIVE: Multiple scores validate long-term type-2 diabetes mellitus (T2DM) remission after metabolic and bariatric surgery (MBS). However, studies comparing Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) have not adequately controlled for certain parameters, which may influence procedure selection. METHODS: We conducted a multicenter retrospective review of patients with T2DM who underwent RYGB or SG between 2008 and 2017. Data on demographics, clinical, laboratory, and metabolic values were collected annually for up to 14 years. Each eligible RYGB patient was individually matched to an eligible SG patient based on diabetes severity, weight loss, and follow-up duration. RESULTS: Among 1149 T2DM patients, 467 were eligible for matching. We found 97 matched pairs who underwent RYGB or SG. RYGB showed significantly higher T2DM remission rates (46.4%) compared to SG (33.0%) after matching. SG patients had higher insulin usage (35.1%) than RYGB patients (20.6%). RYGB patients also experienced greater decreases in HbA1c levels and diabetes medication usage than SG patients. CONCLUSIONS: RYGB demonstrates higher efficacy for T2DM remission compared to SG, regardless of baseline characteristics, T2DM severity, weight loss, and follow-up duration. Further studies are needed to understand the long-term metabolic effects of MBS and the underlying pathophysiology of T2DM remission after MBS.

Type 2 diabetes remission after Roux-en-Y gastric bypass: a multicentered experience with long-term follow-up.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) is associated with short- and mid-term type 2 diabetes (T2D) remission. Long-term outcomes and predictive parameters associated with remission following RYGB have not been well elucidated. OBJECTIVE: Determining the overall long-term T2D remission rates following RYGB and identifying predictive variables associated with remission. SETTING: Multicentered study including patients who underwent RYGB at 3 tertiary referral centers for bariatric surgery. METHODS: We performed a retrospective cohort study between 2008-2017 to allow a minimum of 5 years of follow-up. We evaluated long-term T2D remission rates and annual T2D clinical and metabolic parameters up to 14 years after surgery. Predictors of remission were assessed using multivariate logistic regression. Patients were divided into 4 groups based on quartiles of total body weight loss percentage (%TBWL) to compare remission rates between groups. RESULTS: A total of 815 patients were included (68.9% female, age 52.1 ± 11.5 yr; body mass index 45.1 ± 7.7 kg/m2) with a follow-up of 7.3 ± 3.8 years. Remission was demonstrated in 51% of patients. Predictors of remission included pre-operative duration of diabetes, baseline HbA1C, insulin use prior to surgery, number of antidiabetic medications and %TBWL (all P < .01). Remission rates were proportionally associated with %TBWL quartile (Q1, 40.9%; Q2, 52.7%; Q3, 53.1%; Q4, 56.1%) (P = .02). CONCLUSIONS: Longer duration and higher severity of T2D were negatively associated with remission while higher %TBWL had a positive association. A significant proportion of patients in all quartiles experienced long-term remission after RYGB with a greater likelihood of remission correlated with greater weight loss.

FIB-4 Reliability in Patients With Severe Obesity: Lower Cutoffs Needed?

BACKGROUND: Liver biopsy is the gold standard to evaluate hepatic fibrosis; however, it has many drawbacks, especially in patients with severe obesity. Noninvasive testing such as the FIB-4 score is increasingly being used as the initial screening tool to identify patients at risk for advanced fibrosis. The broader applicability of FIB-4 and the precision of its cutoff values remain uncertain in metabolic dysfunction-associated steatotic liver disease and patients with severe obesity. Our study explored the correlation between FIB-4 scores and intraoperative liver biopsy in patients with severe obesity undergoing bariatric surgery. METHODS: A total of 632 patients with severe obesity underwent preoperative vibration-controlled transient elastography and intraoperative liver biopsy during bariatric surgery from January 2020 to August 2021. Variables collected included patient demographics, laboratory values, abdominal ultrasound, vibration-controlled transient elastography, and liver biopsy results. ANOVA 1-way test, χ2 tests, and Fisher exact tests were used for quantitative and qualitative variables, respectively. The 95% CIs for the mean FIB-4 scores were used to generate surrogate cutoff values. The proposed FIB-4 cutoffs for F0-1, F2, F3, and F4 were 0.62 (CI: 0.59, 0.64), 0.88 (0.74, 1.01), 1.24 (0.94, 1.54), and 1.53 (0.82, 2.24), respectively. Area under the curve (AUC) methods were used to compare traditional to proposed cutoff values. RESULTS: Applying the traditional FIB-4 cutoffs to approximate advanced fibrosis yielded an AUC of 0.5748. Use of the proposed FIB-4 cutoffs increased the AUC to 0.6899. The proposed FIB-4 cutoffs correctly identified 40 patients with biopsy-proven advanced fibrosis (F3-F4), all of which would have been missed using traditional cutoffs. CONCLUSION: Our study revealed that the use of the currently accepted FIB-4 cutoffs as the screening modality for identifying patients with advanced fibrosis due to metabolic dysfunction-associated steatotic liver disease is insufficient and will result in missing patients with histologically confirmed advanced fibrosis. Use of the revised FIB-4 scores should be considered to diagnose patients with severe obesity at high risk of liver disease progression.

Surgical Management of Bariatric Complications and Weight Regain.

The history and evolution of bariatric/metabolic surgical procedures allows for only a brief introduction to complications and surgical approaches for improved weight loss. Our specialty lacks standardization of our operations such as gastric pouch size, intestinal bypass lengths, and consensus on which procedure is best for each individual patient. Anatomic construct as well as adherence to lifestyle modifications can affect short- and long-term outcomes.

The role of diabetes severity scores in predicting disease remission in patients with BMI > 50 kg/m2 undergoing Roux-En-Y gastric bypass and sleeve gastrectomy: a multi-centered study.

BACKGROUND: Roux-En-Y gastric bypass (RYGB) and Sleeve Gastrectomy (SG) have shown to be two of the most effective interventions to enhance weight loss and associated type-2 diabetes mellitus (T2DM) remission. However, a significant number of patients, particularly with BMI ≥ 50 kg/m2, do not achieve T2DM remission after bariatric surgeries. The individualized metabolic surgery (IMS) and Robert et al. scores are two scores that characterize T2DM severity and predict disease remission after bariatric surgeries. We aim to assess the validity of these scores in predicting T2DM remission in our cohort of patients with BMI ≥ 50 kg/m2 with long-term follow-up. METHODS: This is a retrospective cohort study of all patients with T2DM, have a BMI ≥ 50 kg/m2, and underwent RYGB or SG in two different US bariatric surgery centers of excellence. The study endpoints included validating the IMS and Robert et al. scores in our cohort and evaluating the presence of any significant differences between RYGB and SG in terms of T2DM remission predicted by each of these scores. Data are presented as mean (standard deviation). RESULTS: A total of 160 patients (66.3% females, mean age 51.0 [11.8] years) had IMS score and 238 patients (66.4% females, age 50.8 [11.4] years) had Robert et al. score data. Both scores predicted T2DM remission in our patients with BMI ≥ 50 kg/m2 with ROC AUC 0.79 for the IMS score and 0.83 for Robert et al. score. Patients with lower IMS scores and higher Robert et al. scores had higher T2DM remission rates. RYGB and SG had similar T2DM remission rates over the long-term follow-up. CONCLUSION: We demonstrate the ability of the IMS and Robert et al. scores to predict T2DM remission in patients with BMI ≥ 50 kg/m2. T2DM remission was shown to decrease with more severe IMS scores and lower Robert et al. scores.

Diabetes Mellitus Remission in Patients with BMI > 50 kg/m2 after Bariatric Surgeries: A Real-World Multi-Centered Study.

INTRODUCTION: Type 2 diabetes mellitus (T2DM) is a common comorbidity associated with obesity, particularly in patients with body mass index (BMI) ≥ 50 kg/m2. We aim to study real-world T2DM long-term remission in patients with BMI ≥ 50 kg/m2 following Roux-En-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). METHODS: This was a retrospective study of the electronic medical records of all patients with BMI ≥ 50 kg/m2, T2DM, and have undergone RYGB or SG at three tertiary referral centers in the United States. We assessed the change in T2DM outcomes after bariatric surgery using a matched paired t-test for continuous variables and Bowker and Pearson test for categorical variables. We performed a multivariate logistic regression to determine predictors of remission. RESULTS: A total of 279 patients with T2DM (65% females, mean age 51.0 ± 11.7 years, 89% white, BMI 56.6 ± 5.9 kg/m2) were analyzed. Long-term T2DM remission (≥ 5 years) was demonstrated in 47% of patients. The duration of T2DM (p < 0.0001), number of T2DM medications (p = 0.003) and weight loss (p = 0.048) were the only independent factors for long-term T2DM remission. CONCLUSIONS: In this cohort of patients with BMI ≥ 50 kg/m2, RYGB and SG demonstrated significant and similar long-term T2DM remission rates and weight loss outcomes.

Effect of metabolic surgery on immunosuppressive medication use in patients with rheumatic diseases.

BACKGROUND: Obesity is an inflammatory condition associated with higher rheumatic disease (RD) incidence, increased disease activity, and functional impairment. OBJECTIVE: We aimed to assess whether metabolic and bariatric surgery (MBS) decreases immunosuppressant use in patients with RD. SETTING: Bariatric surgery academic centers of excellence. METHODS: We conducted a retrospective review of MBS procedures in patients using immunosuppressants for RD between 2008 and 2020 at 2 academic institutions. Patient data were analyzed at 3-, 6-, 12-, and 24-month follow-up intervals. We examined paired differences in the number of preoperative medications relative to different postoperative follow-up periods using McNemar tests for the prednisone-only comparisons and paired t tests for all other comparisons. RESULTS: We identified 53 patients with RD who underwent MBS (mean age = 53 years; mean follow-up = 19 months). Of these patients, 64% had Roux-en-Y gastric bypass, 30% sleeve gastrectomy, and 6% duodenal switch. Rheumatoid arthritis was the most common RD (42%), followed by psoriasis (19%) and lupus (11%). Mean percent total weight loss and change in body mass index were 31.3% and 15.9 kg/m2, respectively, at 24-month follow-up. At 24 months, 10 patients (30%) stopped prednisone (P = .007), and 13 patients (33%) showed a reduction in immunosuppressant use (disease-modifying antirheumatic drugs or glucocorticoids) (P = .01). One patient started glucocorticoids postoperatively, and 2 patients had an increase in immunosuppressant use. At the last encounter, 5 patients were off immunosuppressants, and all medication classes, except biological disease-modifying antirheumatic drugs, showed significant reductions. CONCLUSION: There is significant decrease in the use of immunosuppressant agents after MBS in patients with RD. Further studies are needed to confirm the correlation.

Defining Global Benchmarks in Elective Secondary Bariatric Surgery Comprising Conversional, Revisional, and Reversal Procedures.

OBJECTIVE: To define "best possible" outcomes for secondary bariatric surgery (BS). BACKGROUND: Management of poor response and of long-term complications after BS is complex and under-investigated. Indications and types of reoperations vary widely and postoperative complication rates are higher compared to primary BS. METHODS: Out of 44,884 BS performed in 18 high-volume centers from 4 continents between 06/2013-05/2019, 5,349 (12%) secondary BS cases were identified. Twenty-one outcome benchmarks were established in low-risk patients, defined as the 75th percentile of the median outcome values of centers. Benchmark cases had no previous laparotomy, diabetes, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, thromboembolic events, BMI> 50 kg/m2 or age> 65 years. RESULTS: The benchmark cohort included 3143 cases, mainly females (85%), aged 43.8 ±â€Š10 years, 8.4 ±â€Š5.3 years after primary BS, with a BMI 35.2 ±â€Š7 kg/m2. Main indications were insufficient weight loss (43%) and gastro-esophageal reflux disease/dysphagia (25%). 90-days postoperatively, 14.6% of benchmark patients presented ≥1 complication, mortality was 0.06% (n = 2). Significantly higher morbidity was observed in non-benchmark cases (OR 1.37) and after conversional/reversal or revisional procedures with gastrointestinal suture/stapling (OR 1.84). Benchmark cutoffs for conversional BS were ≤4.5% re-intervention, ≤8.3% re-operation 90-days postoperatively. At 2-years (IQR 1-3) 15.6% of benchmark patients required a reoperation. CONCLUSION: Secondary BS is safe, although postoperative morbidity exceeds the established benchmarks for primary BS. The excess morbidity is due to an increased risk of gastrointestinal leakage and higher need for intensive care. The considerable rate of tertiary BS warrants expertise and future research to optimize the management of non-success after BS.

Development of an International Standardized Curriculum for Laparoscopic Sleeve Gastrectomy Teaching Utilizing Modified Delphi Methodology.

BACKGROUND: The performance of laparoscopic sleeve gastrectomy has increased markedly to become the single-most performed bariatric surgical procedure globally. To date, a means of standardized trainee teaching has not been developed. The aim of this study was to design a laparoscopic curriculum for trainees of bariatric surgery utilizing modified Delphi consensus methodology. METHODS: A panel of surgeons was assembled to devise an academic framework of technical, non-technical and cognitive skills utilized in the performance of laparoscopic sleeve gastrectomy. The panel invited 18 bariatric surgeons experienced in laparoscopic gastrectomy from 11 countries to rate the items for inclusion in the curriculum to a predefined level of agreement. RESULTS: A consensus of experts was achieved for 24 of the 30 proposed elements for inclusion within the first round of the curriculum Delphi panel. All components pertaining to anatomical knowledge, peri-operative considerations and non-technical items were accepted. A second round further examined six statements, of which three were accepted. Agreement of the panel was reached for 27 of the cognitive, technical and non-technical components after two rounds. Three statements found no consensus. CONCLUSIONS: Utilizing modified Delphi methodology, a curriculum outlining the most important components of teaching the procedure of laparoscopic sleeve gastrectomy, has been determined by a consensus of international experts in bariatric surgery. The curriculum is suggested as a standard in proficiency-based training of this procedure. It forms a generic template which facilitates individual jurisdictions to perform content validation, adapting the curriculum to local requirements in teaching the next generation of bariatric surgeons.

IFSO Update Position Statement on One Anastomosis Gastric Bypass (OAGB).

The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued a position statement on the role of one anastomosis gastric bypass (OAGB) in the field of bariatric/metabolic surgery in 2018 De Luca et al. (Obes Surg. 28(5):1188-206, 2018). This position statement was issued by the IFSO OAGB task force and approved by the IFSO Scientific Committee and IFSO Executive Board. In 2018, the OAGB task force recognized the necessity to update the position statement in the following 2 years since additional high-quality data could emerge. The updated IFSO position statement on OAGB was issued also in response to inquiries to the IFSO by society members, universities, hospitals, physicians, insurances, patients, policy makers, and media. The IFSO position statement on OAGB has been reviewed within 2 years according to the availability of additional scientific evidence. The recommendation of the statement is derived from peer-reviewed scientific literature and available knowledge. The IFSO update position statement on OAGB will again be reviewed in 2 years provided additional high-quality studies emerge.

Bariatric-Metabolic Surgery Utilisation in Patients With and Without Diabetes: Data from the IFSO Global Registry 2015-2018.

BACKGROUND: Comparative international practice of patients undergoing bariatric-metabolic surgery for type 2 diabetes mellitus (T2DM) is unknown. We aimed to ascertain baseline age, sex, body mass index (BMI) and types of operations performed for patients with T2DM submitted to the IFSO Global Registry. MATERIALS AND METHODS: Cross-sectional analysis of patients having primary surgery in 2015-2018 for countries with ≥90% T2DM data completion and ≥ 1000 submitted records. RESULTS: Fifteen countries including 11 national registries met the inclusion criteria. The rate of T2DM was 24.2% (99,537 of 411,581 patients, country range 12.0-55.1%) and 77.1% of all patients were women. In every country, patients with T2DM were older than those without T2DM (overall mean age 49.2 [SD 11.4] years vs 41.8 [11.9] years, all p < 0.001). Men were more likely to have T2DM than women, odds ratio (OR) 1.68 (95% CI 1.65-1.71), p < 0.001. Men showed higher rates of T2DM for BMI <35 kg/m2 compared to BMI ≥35.0 kg/m2, OR 2.76 (2.52-3.03), p < 0.001. This was not seen in women, OR 0.78 (0.73-0.83), p < 0.001. Sleeve gastrectomy was the commonest operation overall, but less frequent for patients with T2DM, patients with T2DM 54.9% vs without T2DM 65.8%, OR 0.63 (0.63-0.64), p < 0.001. Twelve out of 15 countries had higher proportions of gastric bypass compared to non-bypass operations for T2DM, OR 1.70 (1.67-1.72), p < 0.001. CONCLUSION: Patients with T2DM had different characteristics to those without T2DM. Older men were more likely to have T2DM, with higher rates of BMI <35 kg/m2 and increased likelihood of food rerouting operations.

The IFSO Worldwide One Anastomosis Gastric Bypass Survey: Techniques and Outcomes?

INTRODUCTION: One anastomosis gastric bypass (OAGB) has become one of the most commonly performed gastric bypass procedures in some countries. OBJECTIVES: To assess how surgeons viewed the OAGB, perceptions, indications, techniques, and outcomes, as well as the incidence of short- and long-term complications and how they were managed worldwide. METHODS: A questionnaire was sent to all IFSO members in all 5 chapters to study the pattern of practice and outcomes of OAGB. RESULTS: Seven hundred and forty-two surgeons responded. The most commonly performed procedures were sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and OAGB. Preoperatively, 70% of the surgeons performed endoscopy routinely. In regards to weight loss, 83% (570 surgeons) responded that OAGB produces better weight loss than SG, and 49% (342 surgeons) responded that OAGB produces better weight loss than RYGB. The most common length of the biliopancreatic limb (BPL) utilized was 200 cm. Sixty-seven percent of surgeons did not measure the total length of the small bowel. In patients with reflux disease and history of smoking, 53% and 22% of surgeons respectively still offered OAGB as a treatment option. Postoperatively, leak was documented in 963 patients, and it was the leading cause for mortality. Leak management was conservative in 35%. Conversion to RYGB was performed in 31%. In 16% the anastomosis was reinforced, 6% of the patients were reversed, and other procedures were performed in 12%. Revision of OAGB for malnutrition/steatorrhea or severe bile reflux was reported at least once by 37% and 45% of surgeons, respectively (200 cm was the most commonly encountered biliopancreatic limb BPL in those revised for malnutrition). Most common strategy for revision was conversion to RYGB (43%), reversal to normal anatomy (32%), shortening of the BPL (20%), and conversion to SG (5%). Nevertheless, 5 out of 98 mortalities (5%) were due to liver failure/malnutrition. CONCLUSION: There are infrequent but potentially severe specific complications including malnutrition, liver failure, and bile reflux that may require surgical correction after OAGB.

Barrett's Oesophagus and Bariatric/Metabolic Surgery-IFSO 2020 Position Statement.

The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) has been playing an integral role in educating both the metabolic surgical and the medical community at large about the importance of surgical and/or endoscopic interventions in treating adiposity-based chronic diseases. The occurrence of chronic conditions following bariatric/metabolic surgery (BMS), such as gastro-oesophageal reflux disease (GERD) and columnar (intestinal) epithelial metaplasia of the distal oesophagus (also known as Barrett's oesophagus (BE)), has long been discussed in the metabolic surgical and medical community. Equally, the risk of neoplastic progression of Barrett's oesophagus to oesophageal adenocarcinoma (EAC) and the resulting requirement for surgery are the source of some concern for many involved in the care of these patients, as the surgical alteration of the gastrointestinal tract may lead to impaired reconstructive options. As such, there is a requirement for guidance of the community.The IFSO commissioned a task force to elucidate three aspects of the presenting problem: First, to determine what the estimated incidence of Barrett's oesophagus is in patients presenting for BMS; second, to determine the frequency at which Barrett's oesophagus may develop following BMS (with a particular focus on the laparoscopic sleeve gastrectomy (LSG)); and third, to determine if regression of Barrett's oesophagus may occur following BMS given the close relationship of obesity and the development of BE/EAC. Based on these findings, a position statement regarding the management of this pathology in the context of BMS was developed. The following position statement is issued by the IFSO Barrett's Oesophagus task force andapproved by the IFSO Scientific Committee and Executive Board. This statement is based on current clinical knowledge, expert opinion and published peer-reviewed scientific evidence. It will be reviewed regularly.

Single Anastomosis Duodenal-Ileal Bypass with Sleeve Gastrectomy/One Anastomosis Duodenal Switch (SADI-S/OADS) IFSO Position Statement-Update 2020.

PreambleThe International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) has played an integral role in educating both the metabolic surgical and the medical communities at large about the role of innovative and new surgical and or endoscopic interventions in treating adiposity-based chronic diseases. The single anastomosis duodenal-ileal bypass with sleeve gastrectomy/one anastomosis duodenal switch (SADI-S/OADS) is a relatively new procedure that has been proposed as an alternative to the conventional duodenal switch (DS) procedure. The IFSO published a position paper on SADI-S/OADS in 2018 with which concluded that this procedure was likely to be a safe and efficacious treatment for adiposity and its related diseases. However, it noted that there was insufficient long-term data and minimal high-level evidence available. The position statement called for patients to be enrolled in long-term multidisciplinary care encouraged the registration of patients in national registries, and called for more randomized controlled trials (RCT) (Obes Surg 28:1207-16, 2018) involving the procedure. The following position statement is an update of the previous position statement. It is issued by the IFSO SADI-S/OADS task force and has been reviewed and approved by both the IFSO Scientific Committee and Executive Board. This statement is based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence. It will be reviewed again in 2 years.

IFSO Position Statement on the Role of Esophago-Gastro-Duodenal Endoscopy Prior to and after Bariatric and Metabolic Surgery Procedures.

One of the roles of the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) is to provide guidance on the management of patients seeking surgery for adiposity-based chronic diseases. The role of endoscopy around the time of endoscopy is an area of clinical controversy. In 2018, IFSO commissioned a task force to determine the role of endoscopy before and after surgery for the management of adiposity and adiposity-based chronic diseases. The following position statement is issued by the IFSO Endoscopy in Bariatric/Metabolic Surgery Taskforce. It has been approved by the IFSO Scientific Committee and Executive Board. This statement is based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence. It will be reviewed regularly.