Torgeir T. Søvik

Vitamin status after bariatric surgery: a randomized study of gastric bypass and duodenal switch

BACKGROUND Bariatric surgery is widely performed to induce weight loss. OBJECTIVE The objective was to examine changes in vitamin status after 2 bariatric surgical techniques. DESIGN A randomized controlled trial was conducted in 2 Scandinavian hospitals. The subjects were 60 superobese patients [body mass index (BMI; in kg/m(2)): 50-60]. The surgical interventions were either laparoscopic Roux-en-Y gastric bypass or laparoscopic biliopancreatic diversion with duodenal switch. All patients received multivitamins, iron, calcium, and vitamin D supplements. Gastric bypass patients also received a vitamin B-12 substitute. The patients were examined before surgery and 6 wk, 6 mo, and 1 y after surgery. RESULTS Of 60 surgically treated patients, 59 completed the follow-up. After surgery, duodenal switch patients had lower mean vitamin A and 25-hydroxyvitamin D concentrations and a steeper decline in thiamine concentrations than did the gastric bypass patients. Other vitamins (riboflavin, vitamin B-6, vitamin C, and vitamin E adjusted for serum lipids) did not change differently in the surgical groups, and concentrations were either stable or increased. Furthermore, duodenal switch patients had lower hemoglobin and total cholesterol concentrations and a lower BMI (mean reduction: 41% compared with 30%) than did gastric bypass patients 1 y after surgery. Additional dietary supplement use was more frequent among duodenal switch patients (55%) than among gastric bypass patients (26%). CONCLUSIONS Compared with gastric bypass, duodenal switch may be associated with a greater risk of vitamin A and D deficiencies in the first year after surgery and of thiamine deficiency in the initial months after surgery. Patients who undergo these 2 surgical interventions may require different monitoring and supplementation regimens in the first year after surgery. This trial was registered at ClinicalTrials.gov as NCT00327912.

Effect of the definition of type II diabetes remission in the evaluation of bariatric surgery for metabolic disorders.

The American Diabetes Association recently defined remission of type II diabetes as a return to normal measures of glucose metabolism (haemoglobin (Hb) A1c below 6 per cent, fasting glucose less than 5·6 mmol/l) at least 1 year after bariatric surgery without hypoglycaemic medication. A previously used common definition was: being off diabetes medication with normal fasting blood glucose level or HbA1c below 6 per cent. This study evaluated the proportion of patients achieving complete remission of type II diabetes following bariatric surgery according to these definitions.

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.

Randomized clinical trial of laparoscopic gastric bypass versus laparoscopic duodenal switch for superobesity

Laparoscopic Roux‐en‐

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

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

gastric bypass (LRYGB) and laparoscopic biliopancreatic diversion with duodenal switch (LDS) are surgical options for superobesity. A randomized trial was conducted to evaluate perioperative (30‐day) safety and 1‐year results.

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

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.

Application of the International Diabetes Federation and American Diabetes Association criteria in the assessment of metabolic control after bariatric surgery

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.

Effect of bariatric surgery on sulphur amino acids and glutamate

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.

Night blindness after duodenal switch

The International Diabetes Federation (IDF) and the American Diabetes Association (ADA) have introduced specific criteria to define the ‘optimization’ of the metabolic state and glycaemic ‘remission’ of type 2 diabetes mellitus (T2DM) after bariatric surgery, respectively. Our objective was to assess the percentage of patients achieving these criteria. Data were collected for body mass index, glycaemic markers, lipids, blood pressure, hypoglycaemia and medication usage from 396 morbidly obese T2DM patients who underwent bariatric surgery in two centres and followed up for 2 years. At year 1, 14% of patients achieved the IDF criteria and 38% the ADA criteria, whereas at 2 years 8 and 9% satisfied these criteria, respectively. A relatively low proportion of patients achieved optimization of the metabolic state and T2DM remission. These patients may potentially benefit from the combination of bariatric surgery and adjuvant medical therapy to achieve optimal metabolic outcomes.