Gastrointestinal symptoms and eating behavior among morbidly obese patients undergoing Roux-en-Y gastric bypass

Attitudes and Behaviors towards Food and Weight in Late Pregnancy: A Comparative Approach between Individuals with and without Previous Bariatric Surgery

The aims of this study were to compare, between pregnant individuals with and without bariatric surgery: (1) eating behaviors, (2) intuitive eating components and, (3) attitudes towards weight gain. This retrospective study included data collected in healthy pregnant individuals with and without previous bariatric surgery who were recruited at the Centre Hospitalier Universitaire (CHU) de Québec-Université Laval. Pregnant individuals who underwent bariatric surgery (biliopancreatic bypass with duodenal switch [n = 14] or sleeve gastrectomy [n = 5]) were individually matched, for age (±0.4 years) and body mass index (BMI) (±0.3 kg/m2), with pregnant individuals who have not received bariatric surgery. In the second trimester, participants completed the Three Factor Eating Questionnaire (TFEQ) and the Intuitive Eating Scale 2 (IES-2). In the third trimester, participants completed the French version of the Pregnancy Weight Gain Attitude Scale assessing attitudes towards weight gain. Pregnant individuals who have had bariatric surgery had a higher score for flexible restraint and a lower score for situational susceptibility to disinhibition compared to individuals who have not had undergone bariatric surgery (2.89 ± 1.15 vs. 1.95 ± 1.31; p = 0.04 and 1.11 ± 1.29 vs. 2.79 ± 1.44, respectively; p < 0.001). Regarding intuitive eating, pregnant individuals who experienced bariatric surgery had a higher score for reliance on internal hunger and satiety cues and a lower one for unconditional permission to eat compared with those who had not experienced bariatric surgery (3.99 ± 0.81 vs. 3.30 ± 1.03; p = 0.02 and 3.28 ± 0.54 vs. 3.61 ± 0.68, respectively; p = 0.03). No difference in attitudes towards weight gain was observed between groups. Overall, pregnant individuals who had undergone bariatric surgery had different eating behaviors and intuitive eating components compared to pregnant individuals without bariatric surgery. These results need to be confirmed in further studies with larger sample sizes.

Effects of Sleeve Gastrectomy on Pelvic Floor Disorders in Female Patients with Severe Obesity: a Prospective Study

INTRODUCTION

Obesity is associated with pelvic floor disorders (PFD). Sleeve gastrectomy (SG) is one of the most effective weight loss methods. Although SG has been found to improve urinary incontinence (UI) and overactive bladder (OAB), its impact on fecal incontinence (FI) remains controversial.

MATERIALS AND METHODS

This prospective, randomized study involved 60 female patients with severe obesity who were randomly assigned to two groups: the SG group and the diet group. The SG group underwent SG, while the diet group received a low-calorie, low-lipid diet for 6 months. The patients' condition was assessed before and after the study using three questionnaires: the International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms (ICIQ-FLUTS), the Overactive Bladder 8-Question Awareness Tool (OAB-V8), and the Wexner Score (CCIS).

RESULTS

After 6 months, the SG group had a significantly higher percentage of total weight loss (%TWL) compared to the diet group (p<0.01). Both groups showed a decrease in the ICIQ-FLUTS, OAB-V8, and CCIS scores (p<0.05). UI, OAB, and FI improved significantly in the SG group (p<0.05), but no improvement was observed in the diet group (p>0.05). The correlation between %TWL and PFD was statistically significant but weak, with the strongest correlation between %TWL and ICIQ-FLUTS score and the weakest correlation between %TWL and CCIS score (p<0.05).

CONCLUSIONS

We recommend bariatric surgery for the treatment of PFD. However, given the weak correlation between %TWL and PFD after SG, further research should explore factors other than %TWL that are effective in recovery, particularly in relation to FI.

The Impact of COVID-19 Pandemic on Weight Loss, Eating Behaviour and Quality of Life after Roux-en-Y Gastric Bypass

Background and Objectives: The global pandemic of coronavirus disease (COVID-19), declared on 11 March 2020, had an extensive impact on bariatric patients. The aim of this study was to evaluate short-term weight loss outcomes, changes in eating behaviour, and health-related quality of life (HRQoL) among patients who had Roux-en-Y gastric bypass (RYGB) before and during the COVID-19 pandemic. Materials and Methods: This cohort study included 72 patients (Group S) who underwent RYGB surgery in the Surgery Department of the Lithuanian University of Health Sciences during the COVID-19 pandemic in the years 2020-2022. Data for the control group (Group C) of 87 patients (operated on in 2010-2012) were collected from a prospective study. The data referred to the period before and a year after the RYGB. The information about patients' weight changes, hunger, satiety, fullness sensations, appetite, diet, and eating patterns was queried. Eating behaviour and HRQoL evaluation were conducted by the Three-Factor Eating Questionnaire (TFEQ-R18) and the medical outcomes study Short-Form-36 (SF-36), respectively. Results: One year after the surgery, % excess body mass index loss (%EBMIL) was 77.88 (26.33) in Group S, 76.21 (19.98) in Group C, p = 0.663. Patients in Group S tended more to choose snacks between main meals: 79.2% versus 28.7%, p < 0.0001. Cognitive restraint significantly increased in Group S from 45.93 (13.37) up to 54.48 (13.76), p = 0.001; additionally, significantly worse overall health status was found in Group S compared to Group C, 53.27 (24.61) versus 70.11 (31.63), p < 0.0001. Mental HRQoL (50.76 versus 60.52 score, p < 0.0001) and social functioning (44.79 versus 57.90, p < 0.0001) were worse in Group S. Conclusions: In this study, the COVID-19 pandemic had no impact on short-term weight loss after RYGB. However, one year after, RYGB patients tended to snack more, and mental HRQoL and social functioning were worse in the study group.

Preoperative Oesophagogastroduodenoscopy and the Effect on Bariatric Surgery: a Systematic Review and Meta-Analysis

Preoperative oesophagogastroduodenoscopy (OGD) in bariatric surgery remains a controversial topic, with a large variety in practice globally. An electronic database search of Medline, Embase and PubMed was performed in an aim to categorise the findings of preoperative endoscopies in bariatric patients. A total of 47 studies were included in this meta-analysis resulting in 23,368 patients being assessed. Of patients assessed, 40.8% were found to have no novel findings, 39.7% had novel findings which did not affect surgical planning, 19.8% had findings that affected their surgery and 0.3% were ruled to not be suitable for bariatric surgery. Preoperative OGD is altering surgical planning in one-fifth of patients; however, further comparative studies are required to determine if each patient should undergo this procedure especially if asymptomatic.

Exocrine pancreatic insufficiency after bariatric surgery: a bariatric surgery center of excellence experience

INTRODUCTION

Gastrointestinal symptoms such as diarrhea, bloating, abdominal pain, and nausea are common after bariatric surgery (BS) and can lead to significant morbidity. While many diagnoses can explain these symptoms, post-bariatric exocrine pancreatic insufficiency (EPI) is becoming increasingly recognized as contributor to gastrointestinal symptoms. The frequency and outcomes of EPI after BS are not well understood. We investigated the prevalence and outcomes of EPI over 18 years at a tertiary bariatric referral center.

METHODS

A retrospective review of patients who underwent primary or revisional BS from 2002 to 2020 was performed. Patients were included if they were suspected of having EPI or underwent fecal elastase testing (FE-1). EPI diagnosis was defined as positive FE-1 testing or improvement with empiric pancreatic enzyme replacement therapy (PERT).

RESULTS

EPI was suspected in 261 patients, and 190 were tested via FE-1 (89.5%) or empirically treated (10.5%). EPI was diagnosed in 79 (41.6%) patients and was associated with older age and lower BMI. Therapeutic PERT was given to 65 patients diagnosed with EPI, and 56 (86.2%) patients reported improved symptoms. Patients who underwent RYGB and BPD-DS were more likely to have EPI than those after SG (47.9% and 70.0% vs 17.4%, p < 0.01). EPI diagnosis was associated with a history chronic pancreatitis. While diarrhea and abdominal pain were the most common symptoms prompting FE-1 testing, no symptoms were significantly associated with EPI. EPI was also associated with abnormal fecal fat results and treatment with bile acid sequestrants, but not small intestinal bacterial overgrowth.

CONCLUSION

This study highlights that exocrine pancreatic insufficiency can account to for previously unexplained GI complaints after bariatric surgery. Therefore, bariatric surgery programs should consider this diagnosis in symptomatic patients, especially following RYGB and BPD-DS. Further work to define patient factors that should prompt evaluation, optimal treatment, and prevention is necessary.

Resolution of diabetes, gastrointestinal symptoms, and self-reported dietary intake after gastric bypass vs sleeve gastrectomy – a randomized study

BACKGROUND

There is a lack of randomized studies examining diabetes remission and dietary intake between patients undergoing Roux-en-Y gastric bypass (RYGB) versus sleeve gastrectomy (SG).

OBJECTIVE

To examine longitudinal differences in diabetes resolution, dietary intake, and gastrointestinal (GI) symptoms in patients with obesity and type 2 diabetes (T2D) randomized to either RYGB or SG and according to remission of T2D.

SETTING

Four hospitals in Sweden, 2 of which are university hospitals.

METHODS

Dietary intake and GI symptoms were calculated from questionnaires and morphometric differences between surgical methods and T2D remission were compared using the Student t test, effect size (ES) for parametric parameters, and Mann-Whitney U test for nonparametric parameters.

RESULTS

Five years after RYGB or SG there was no significant difference in the rate of remission of T2D between RYGB and SG (43% versus 20%, P = .176). RYGB (n = 19) patients had greater weight loss than SG patients (n = 14) (26.4 [9.5] versus 13.1 [9.6] kg, P < .001), despite reporting higher daily caloric intake (Δ 669 kcal, P = .059, ES .67) and food weight (Δ 1029 g/d, P = .003, ES 1.11). RYGB patients, compared with SG patients, also ate 1 more fruit per day (P = .023). Pooled data showed no differences between patients with and without T2D remission regarding weight loss, but those in remission drank more nonalcoholic drinks and milk.

CONCLUSIONS

Five years postoperatively, patients randomized to RYGB reported considerably higher food intake compared with SG despite lower body weight. The reason and importance of the higher food intake after RYGB compared with SG needs to be further studied.

Patient-reported bowel and bladder function is not adversely impacted by bariatric surgery

INTRODUCTION

This study aims to assess the effect of bariatric surgery on patient-reported outcomes of bowel and bladder function. We hypothesized that bariatric surgery does not worsen bowel and bladder function.

METHODS AND PROCEDURES

A retrospective review was conducted of a prospectively maintained surgical quality database. We included patients who underwent primary bariatric surgery at a single institution between 2012 and 2020, excluding revisional procedures. Patient-reported outcomes were assessed using Surgical Outcomes Measurement System (SOMS) bowel and bladder function questionnaires at time of pre-operative consult and routine post-operative follow-up visits through 2 years. Data were analyzed using a statistical mixed effects model.

RESULTS

573 patients (80.6% female) were identified with completed SOMS questionnaire data on bowel and bladder function. Of these, 370 (64.6%) underwent gastric bypass, 190 (33.2%) underwent sleeve gastrectomy, and 13 (2.3%) underwent either gastric banding or duodenal switch. Compared to pre-operative baseline scores, patients reported a transient worsening of bowel function at 2-weeks post-op (p = 0.009). However, by 3-months post-op, bowel function improved and was significantly better than baseline (p = 0.006); this improvement was sustained at every point through 2-year follow-up (p = 0.026). Bladder function scores improved immediately at 2-weeks post-op (p = 0.026) and showed sustained improvement through 1-year follow-up. On subgroup analysis, sleeve patients showed greater improvement in bowel function than bypass patients at 1-year (p = 0.031). Multivariable analysis showed significant improvement in bowel function associated with greater total body weight loss (TBWL) (p = 0.002).

CONCLUSIONS

Bariatric surgery does not worsen patient-reported bowel or bladder function. In fact, there is overall improvement from pre-operative scores for both bowel and bladder function by 3-months post-op which is sustained through 2-year and 1-year follow-up, respectively. Most encouragingly, a greater TBWL is significantly associated with improved bowel function after bariatric surgery.

Effect of Bariatric Surgery on Metabolic Diseases and Underlying Mechanisms

Obesity is a highly prevalent public health concern, attributed to multifactorial causes and limited in treatment options. Several comorbidities are closely associated with obesity such as the development of type 2 diabetes mellitus (T2DM), cardiovascular and cerebrovascular diseases, and nonalcoholic fatty liver disease (NAFLD). Bariatric surgery, which can be delivered in multiple forms, has been remarked as an effective treatment to decrease the prevalence of obesity and its associated comorbidities. The different types of bariatric surgery create a variety of new pathways for food to metabolize in the body and truncate the stomach's caliber. As a result, only a small quantity of food is tolerated, and the body mass index noticeably decreases. This review describes the improvements of obesity and its comorbidities following bariatric surgery and their mechanism of improvement. Additionally, endocrine function improvements after bariatric surgery, which contributes to the patients' health improvement, are described, including the role of glucagon-like peptide-1 (GLP-1), fibroblast growth factors 19 and 21 (FGF-19, FGF-21), and pancreatic peptide YY (PYY). Lastly, some of the complications of bariatric surgery, including osteoporosis, iron deficiency/anemia, and diarrhea, as well as their potential mechanisms, are described.

Reflux After Sleeve Gastrectomy: An Update

Background: Modifications of gastric anatomy, function, and of the esophagogastric junction secondary to sleeve gastrectomy (SG) can worsen the symptoms of gastroesophageal reflux disease (GERD). Its late diagnosis and poor treatment can lead to serious complications. In recent years, attempts have been made to optimize preoperative studies and improve surgical techniques to prevent this problem. The aim of this study was to update on the presence of GERD and their symptoms post-SG. Methods: A literature review of articles based on randomized clinical trials on the presence of GERD after SG was carried out, in a period of 10 years. Results: A result of 336 articles was obtained, of which 327 were discarded and 9 were included. The variables of GERD post-SG were analyzed according to their symptoms ("improved," "worsened," and "unchanged"), "remission," or appearance "de novo." Conclusion: GERD is a frequently associated pathology in obese patients. Several authors reported that symptoms worsen after SG, and has been diagnosed de novo. The application of exhaustive preoperative studies and a correct surgical technique could reduce its incidence.

Self-Reported Gastrointestinal Symptoms Two To Four Years After Bariatric Surgery. A Cross-Sectional Study Comparing Roux-en-Y Gastric Bypass and Laparoscopic Sleeve Gastrectomy

BACKGROUND

Roux-en-Y gastric bypass (RYGBP) and laparoscopic sleeve gastrectomy (LSG) are efficient methods for weight loss (WL) and WL maintenance in severe obesity. However, the knowledge of gastrointestinal (GI) symptoms after surgery is limited. This study aimed to compare the severity of GI symptoms, pain, and self-rated health 2 to 4 years after RYGBP and LSG surgery.

METHODS

In this cross-sectional study, RYGBP and LSG patients answered a questionnaire including the Gastrointestinal Symptom Rating Scale (GSRS), questions from the Brief Pain Inventory (BPI), and self-rated health (SRH).

RESULTS

A total of 172/303 (57%) responded, RYGBP (n=73) and LSG (n=99). The mean age was 45.3 (SD 11.1) years (74% females). There was no evidence of a difference in total GSRS scores between the surgical methods (p=0.638). There were higher scores of reflux symptoms in LSG vs. RYGBP (both median 1, 75-percentile 2.5 vs. 1.0, p <0.001) and higher consumption of acid-reducing medication after LSG (32% vs. 12%, p <0.001). Pain scores were low in both groups; however, average abdominal pain was higher for RYGBP, median 2 (IQR 0-4) vs. median 1 (IQR 0-3) for LSG (p = 0.025). There was no significant difference in SRH.

CONCLUSIONS

Patients undergoing RYGBP and LSG surgery reported similar total GSRS scores and low pain scores 2 to 4 years after surgery. However, reflux symptoms and use of acid-reducing medication occurred more frequently after LSG surgery, while abdominal pain was more frequent in RYGBP surgery. These findings are important for surgical decision-making and follow-up.

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.

Ecological momentary assessment of gastrointestinal symptoms and risky eating behaviors in Roux-en-Y gastric bypass and sleeve gastrectomy patients

BACKGROUND

Gastrointestinal symptoms (GIS) are common after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). However, little is known about frequencies of GIS and their co-occurrence with risky eating behaviors.

OBJECTIVES

Compare RYGB and SG on GIS and risky eating behaviors, and test associations between GIS and behaviors.

SETTING

Two university hospitals in Northeastern United States.

METHODS

RYGB (n = 18) and SG (n = 53) patients completed smartphone-based ecological momentary assessment of GIS and risky eating behaviors at 4 semi-random times daily for 10 days preoperatively and at 3, 6, and 12 months postoperatively. Study objectives were evaluated using generalized linear mixed-effects models.

RESULTS

All available data from each assessment were included in the analysis: participant attrition was 18%, 30%, and 38% at 3, 6, and 12 months. All GIS were reduced at 12 months postoperative. Bloating decreased consistently whereas cramping, dehydration, and dumping first increased at 3 to 6 months then decreased to 12 months. Diarrhea, nausea, reflux, and vomiting decreased to 12 months for RYGB, but first increased at 3 to 6 months then decreased to 12 months for SG. Consumption of carbonated and sugar-sweetened beverages, fatty meats, and sweets decreased to 6 months then rebounded at 12 months. Eating past the first sign of fullness, drinking liquids with meals, not starting meals with protein, and fried foods consumption decreased to 6 months and then rebounded for RYGB only at 12 months. Alcohol consumption did not change. Sweets consumption and eating past the first sign of fullness were most consistently associated with GIS for both RYGB and SG patients.

CONCLUSION

GIS and risky eating behaviors improved postoperatively, although patterns of change were variable and occasionally differed between RYGB and SG. Pending replication, patients may benefit from intervention to limit risky behaviors that are tailored to their surgery type.

Is Routine Preoperative Esophagogastroduodenoscopy Prior to Bariatric Surgery Mandatory? Systematic Review and Meta-analysis of 10,685 Patients

BACKGROUND

This systematic review and meta-analysis searched, retrieved and synthesized the evidence as to whether preoperative esophagogastroduodenoscopy (p-EGD) should be routine before bariatric surgery (BS).

METHODS

Databases searched for retrospective, prospective, and randomized (RCT) or quasi-RCT studies (01 January 2000-30 April 2019) of outcomes of routine p-EGD before BS. STROBE checklist assessed the quality of the studies. P-EGD findings were categorized: Group 0 (no abnormal findings); Group 1 (abnormal findings that do not necessitate changing the surgical approach or postponing surgery); Group 2 (abnormal findings that change the surgical approach or postpone surgery); and Group 3 (findings that signify absolute contraindications to surgery). We assessed data heterogeneity and publication bias. Random effect model was used.

RESULTS

Twenty-five eligible studies were included (10,685 patients). Studies were heterogeneous, and there was publication bias. Group 0 comprised 5424 patients (56%, 95% CI: 45-67%); Group 1, 2064 patients (26%, 95% CI: 23-50%); Group 2, 1351 patients (16%, 95% CI: 11-21%); and Group 3 included 31 patients (0.4%, 95% CI: 0-1%).

CONCLUSION

For 82% of patients, routine p-EGD did not change surgical plan/ postpone surgery. For 16% of patients, p-EGD findings necessitated changing the surgical approach/ postponing surgery, but the proportion of postponements due to medical treatment of H Pylori as opposed to "necessary" substantial change in surgical approach is unclear. For 0.4% patients, p-EGD findings signified absolute contraindication to surgery. These findings invite a revisit to whether p-EGD should be routine before BS, and whether it is judicious to expose many obese patients to an invasive procedure that has potential risk and insufficient evidence of effectiveness. Further justification is required.

Bariatric Surgery and Its Complications in Inflammatory Bowel Disease Patients

Recent data have suggested that bariatric procedures, especially laparoscopic sleeve gastrectomy (SG), are safe and effective weight loss measures in patients with inflammatory bowel disease (IBD). But most of the studies have looked at short-term outcomes, and there is a general lack of awareness of underlying disease processes and baseline comorbidities in IBD patients undergoing bariatric procedures. Postbariatric issues in IBD patients including diarrhea from dumping syndrome, choleretic diarrhea, a high prevalence of small intestinal bacterial overgrowth, gastroesophageal reflux disease, Barrett's esophagus, stomal ulcerations, stenosis, and renal and gallstones can complicate the natural history of IBD. This could lead to unnecessary hospitalizations, change of medical therapy, and poor surgical and quality of life outcomes. In this review, we will discuss major complications after common bariatric procedures (SG, Roux-en-Y gastric bypass, and gastric banding) and suggest possible management strategies.

Change in emotional eating after bariatric surgery: systematic review and meta-analysis

BACKGROUND

The effect of bariatric surgery on 'emotional eating' (EE) in people with obesity is unclear. This systematic review and meta-analysis aimed to examine changes in self-reported emotional eating behaviour after bariatric surgery.

METHODS

Fifteen electronic databases were searched from inception to August 2019. Included studies encompassed patients undergoing primary bariatric surgery, quantitatively assessed EE, and reported EE scores before and after surgery in the same participants. Studies were excluded if they were not in English or available in full text. The systematic review and meta-analysis were conducted according to the PRISMA guidelines. Random-effects models were used for quantitative analysis. Study quality was assessed using the National Heart, Lung, and Blood Institute quality assessment tool for before-after (pre-post) studies with no control group.

RESULTS

Some 23 studies containing 6749 participants were included in the qualitative synthesis, with follow-up of from 2 weeks to 48 months. EE scores decreased to 12 months after surgery. Results were mixed beyond 12 months. Quantitative synthesis of 17 studies (2811 participants) found that EE scores decreased by a standardized mean difference of 1·09 (95 per cent c.i. 0·76 to 1·42) 4-18 months after surgery, indicating a large effect size.

CONCLUSION

Bariatric surgery may mitigate the tendency to eat in response to emotions in the short to medium term.

Pre-operative Restraint and Post-operative Hunger, Disinhibition and Emotional Eating Predict Weight Loss at 2 Years Post-laparoscopic Adjustable Gastric Banding

INTRODUCTION

A principal mechanism of action in bariatric surgery is reduction in calorie consumption due to decreased hunger and increased satiety. Patients' ability to perceive post-operative changes to their hunger is therefore central to optimal results. This study examined factors that may impact how patients perceive post-operative hunger and how perception of hunger impacts eating and subsequent weight loss after laparoscopic adjustable gastric banding (LAGB).

METHODS

Patients undertaking LAGB (n = 147) provided pre-surgery and 2-year weight loss data and pre-surgery and 12-month psychological data (perception of hunger, disinhibition related to eating, emotional eating).

RESULTS

Path analysis demonstrated that patients with lower levels of pre-surgery cognitive restraint over eating experienced significantly greater reduction in perception of hunger at 12 months post-surgery. Perceived reduction in hunger was significantly associated with lower levels of both emotional eating and disinhibited eating. Finally, reduced emotional eating at 12 months significantly predicted 9% of the variance in percentage of total weight loss (%TWL) at 2 years after surgery.

CONCLUSION

These initial findings suggest that preparation for bariatric surgery may be enhanced by psychoeducation regarding cognitive restraint over eating and its effect on hunger perception. In addition, psychological treatment that focuses on identifying and responding to changes in hunger may contribute to improved outcomes for those who have difficulty adjusting to post-operative eating behaviours.

The effects of bariatric surgery on psychological aspects of eating behaviour and food intake in humans

Bariatric surgery has emerged as an increasingly popular weight loss intervention, with larger and more endurable weight loss compared to pharmacological and behavioural interventions. The degree of weight loss patients experience varies, between individuals, surgeries and over time. An explanation as to why differing weight loss trajectories exist post-surgery could be due to the complex interplay of individual differences in relation to eating behaviours and appetite. Thus the aim of this narrative review is to explore literature between 2008 and 2018, to assess the impact of impact of bariatric surgery on food selection and nutrient status, on eating behaviour traits and on disturbed and disordered eating behaviour, to determine their impact of weight loss success and weight loss trajectories. Immediately post-surgery, up until 1-2 years post-surgery, there is a reliance upon the surgery's alteration of the gastrointestinal tract to control food intake and subsequently lose weight. Energy intake is reduced, dietary adherence is higher, supplement intake is higher, appetite ratings are lower, there is a reduction in psychopathology, and an increase in wellbeing. After this point, patients become more susceptible to weight regain, as this is the point where passive observation of the weight reducing action of surgery, moves into more cognitive effort, on the part of the individual, to control energy intake. There are various factors which influence an individual's ability to successfully regulate their energy intake post-surgery, such as their level of Disinhibition, Restraint, Hunger, Emotional Eating, Uncontrolled Eating, psychopathology and wellbeing. The need for continued psychological and nutritional support post-surgery is necessary to reduce weight regain susceptibility.

Review of the management of diarrhea syndrome after a bariatric surgery

Obesity is a prevalent health problem in our population. Bariatric surgery is the indicated treatment for severe cases. It is very effective (together with an adequate lifestyle modification) but it is also associated with frequent adverse events. One of the most frequent and disturbing adverse event is diarrhea. Diarrhea after bariatric surgery may be secondary to multiple causes and the physiopathogenic mechanisms may depend on the type of surgery performed. The most frequent diarrhea mechanisms are dumping syndrome, vagotomy, short bowel syndrome, carbohydrate malabsorption, protein malabsorption, alterations of the microbiota, Clostridium difficile infection, bacterial overgrowth, bile salt malabsorption, pancreatic insufficiency, endocrinological disorders, addictive disorders, and other digestive disorders not necessarily related to surgery.

Obesity and Eating Disturbance: the Role of TFEQ Restraint and Disinhibition

PURPOSE OF REVIEW

Literature from the past five years exploring roles of Three-Factor Eating Questionnaire (TFEQ) Restraint and Disinhibition in relation to adult obesity and eating disturbance (ED) was reviewed.

RECENT FINDINGS

Restraint has a mixed impact on weight regulation, diet quality, and vulnerability to ED, where it is related detrimentally to weight regulation, diet, and psychopathology, yet can serve as a protective factor. The impact of Disinhibition is potently related to increased obesity, poorer diet, hedonically driven food choices, and a higher susceptibility to ED. Restraint and Disinhibition have distinct influences on obesity and ED and should be targeted differently in interventions. Further work is required to elucidate the mechanisms underlying TFEQ eating behavior traits.

Changes in gastrointestinal symptoms and food tolerance 6 months following weight loss surgery: associations with dietary changes, weight loss and the surgical procedure

Background

Gastrointestinal (GI) co-morbidity is common in obese patients, but the effect of weight loss surgery on GI symptoms is incompletely elucidated. The aims of the present study were to explore changes in GI symptoms and food tolerance following weight loss surgery and to study whether such changes were associated with dietary modifications and/or the type of surgical procedure [Roux-en-Y Gastric Bypass (RYGB) versus Vertical Sleeve Gastrectomy (VSG)].

Methods

Participants: Patients with morbid obesity scheduled for weight loss surgery.The patients filled in paper-based questionnaires addressing diet, GI symptoms (bloating, pain, satiety, constipation and diarrhea) and food tolerance/quality of alimentation (satisfaction about current food intake, tolerance to specific foods and frequency of vomiting/regurgitation/reflux) 6 months prior to and 6 months after the surgery. Patients with pre-existing major GI co-morbidity or previous major GI surgery were excluded.

Results

Fifty-four patients (RYGB/VSG: 43/11) were included. Constipation and satiety increased and food tolerance decreased significantly after the surgery (all p-values < 0.05). The increase in satiety was significantly more notable after VSG than after RYGB (p < 0.05).The increase in satiety also correlated with an overall reduction in food tolerance (rho: -0.488, p < 0.01). Divergent changes were seen in the frequency of vomiting/regurgitation/reflux, with a decline after RYGB (p = 0.01) and an increase after VSG (p = 0.06). Intakes of energy, macronutrients, fiber and fluid decreased significantly after the surgery (all p-values < 0.05), but did not correlate with the changes in constipation, satiety or food tolerance (all p-values > 0.05). Pre-operatively, total energy intake correlated with bloating and abdominal pain (rho = 0.343 and 0.310 respectively, p < 0.05 for both), but these correlations did not persist 6 months after the surgery (rho = 0.065 and 0.054 respectively, p > 0.05 for both).

Conclusion

A high caloric intake may explain some of the GI symptoms experienced by non-operated obese patients. The worsening or new-onset of symptoms post-surgery is likely due to anatomical or physiological alterations following surgery. The increase in satiety and the decrease in food tolerance are likely explained by the restrictive nature of the surgeries, as satiety increased more after VSG than after RYGB and correlated with an overall reduction in food tolerance.

Abdominal Pain After Roux-En-Y Gastric Bypass for Morbid Obesity

Background and Aims:

Roux-en-Y gastric bypass is widely used as treatment of morbid obesity. Weight loss, effects on obesity-related co-morbidities and quality of life are well documented post Roux-en-Y gastric bypass. Other outcome measures are less well studied. This review explores aspects of prevalence, diagnostic evaluations, etiology, and treatment of abdominal pain specific to Roux-en-Y gastric bypass.

Methods:

The review is based on PubMed searches and clinical experience with Roux-en-Y gastric bypass. Symptoms in the early postoperative phase (<30 days) were not included.

Results:

Based on limited evidence, up to about 30% of the patients may perceive recurrent abdominal pain post Roux-en-Y gastric bypass in the long term. A substantial subset of patients will need health-care evaluation for acute abdominal pain and hospital admission. The etiology of abdominal pain is heterogeneous and includes gallstone-related disease, intestinal obstruction, anastomotic ulcerations and strictures, intestinal dysmotility, dysfunctional eating, and food intolerance. Surgical treatment and guidance on diet and eating habits may allow symptom relief. The cause of pain remains undefined for a subset of patients. Impact of abdominal pain post Roux-en-Y gastric bypass on the perception of well-being, quality of life, and patient satisfaction with the procedure needs to be further evaluated and may be influenced by complex interactions between new symptoms post Roux-en-Y gastric bypass and relief of pre-existing symptoms.

Conclusion:

Abdominal pain should be part of follow-up consultations post Roux-en-Y gastric bypass. Future studies should focus on combined evaluations before and after surgery to enlighten potential casual relationships between abdominal pain and Roux-en-Y gastric bypass.

Suboptimal Weight Loss and Weight Regain after Gastric Bypass Surgery-Postoperative Status of Energy Intake, Eating Behavior, Physical Activity, and Psychometrics

BACKGROUND

Suboptimal weight loss (SWL) and weight regain (WR) after gastric bypass surgery (GB) remains poorly understood.

OBJECTIVES

This study aims to compare GB patients experiencing SWL or significant WR (SigWR) with successful controls, regarding postoperative food intake, eating behavior, physical activity (PA), and psychometrics.

METHODS

Forty-nine patients with >1 year post-surgery were classified as either experiencing SWL (excess body weight loss, EWL, <50%, n = 22) or SigWR (total weight regain ≥15%, n = 38), with respective control groups. Energy intake (EI) was measured with a Food Frequency Questionnaire, eating behavior using the Dutch Eating Behavior Questionnaire and the Three-Factor Eating Questionnaire, and PA using both SenseWear Armbands and the International Physical Activity Questionnaire. Eating disorders, depression, and quality of life (QoL) were measured using the Eating Disorder Examination Questionnaire, Beck Depression Inventory II, and Impact of Weight on Quality of Life, respectively.

RESULTS

EI, macronutrient distribution, and meal frequency were similar among groups. However, disinhibited eating behavior score was higher, while most subcategories from IWQOL were significantly lower in both SWL and SigWR groups compared with their respective controls. PA was significantly lower in the SWL and SigWR groups compared with the respective controls. There were no differences between groups regarding depression.

CONCLUSIONS

Lower PA levels, disordered eating behavior and lower QoL are associated with unsuccessful weigh loss outcome after GB surgery. Longitudinal studies are needed to clarify the potential causal relationship between the previously described variables and SWL/SigWR after GB.

Emotional eating behavior hinders body weight loss in women after Roux-en-Y gastric bypass surgery

OBJECTIVE

Successful weight loss and maintenance after Roux-en-Y gastric bypass (RYGB) may be related to eating behavior. The aim of this study was to assess the eating behavior domains that prevail in women during the RYGB postoperative period and their associations with surgery outcome.

METHODS

This cross-sectional study investigated eating behavior in 95 women (47.3 ± 9.8 y old)  ≥ 2 y after Roux-en-Y gastric bypass. Patients were grouped according to surgery outcome: successful group (SG; n = 67), defined as having lost ≥ 50% of the preoperative excess weight loss (EWL), and an unsuccessful group (UG; n = 28). Mean postoperative time was 59.5 ± 21.2 mo (55.7 ± 19.9 in the SG and 68.6 ± 21.9 in the UG). The short version of the Three-Factor Eating Questionnaire was used to assess cognitive restraint, emotional eating, and uncontrolled eating behaviors. Multivariate analysis was used to investigate associations between eating behavior scores and EWL.

RESULTS

The highest score in both groups was for the cognitive restraint domain, followed by emotional and uncontrolled eating. Emotional eating was negatively associated with percentage of EWL (β = -0.286; P = 0.033), regardless of age, educational attainment, and postoperative time.

CONCLUSION

The cognitive restraint domain was the main type of eating behavior observed, and patients with higher emotional eating score were at a higher risk for having insufficient weight loss after RYGB. These results indicate the relevance of monitoring emotional components during the long-term nutritional follow-up of bariatric patients to achieve better surgery outcomes.

Diarrhea after bariatric procedures: Diagnosis and therapy

Diarrhea after bariatric procedures, mainly those with malabsorptive elements including Roux-Y Gastric Bypass and Biliopancreatic Diversion, is common and an essential determinant of quality of life and micro- and macronutrient deficiencies. Bariatric surgery is the only sustainably successful method to address morbid obesity and its comorbidities, particularly gaining more and more importance in the specific treatment of diabetic patients. Approximately half a million procedures are annually performed around the world, with numbers expected to rise drastically in the near future. A multitude of factors exert their influence on bowel habits; preoperative comorbidities and procedure-related aspects are intertwined with postoperative nutritional habits. Diagnosis may be challenging owing to the characteristics of post-bariatric surgery anatomy with hindered accessibility of excluded segments of the small bowel and restriction at the gastric level. Conventional testing measures, if available, generally yield low accuracy and are usually not validated in this specific population. Limited trials of empiric treatment are a practical alternative and oftentimes an indispensable part of the diagnostic process. This review provides an overview of causes for chronic post-bariatric surgery diarrhea and details the particularities of its diagnosis and treatment in this specific patient population. Topics of current interest such as the impact of gut microbiota and the influence of bile acids on morbid obesity and especially their role in diarrhea are highlighted in order to provide a better understanding of the specific problems and chances of future treatment in post-bariatric surgery patients.

A genetic variant in proximity to the gene LYPLAL1 is associated with lower hunger feelings and increased weight loss following Roux-en-Y gastric bypass surgery

OBJECTIVE

Bariatric surgery is the most efficient treatment of severe obesity. We investigated to what extent BMI- or waist-hip ratio (WHR)-related genetic variants are associated with excess BMI loss (EBMIL) two years after Roux-en-Y gastric bypass (RYGB) surgery, and elucidated the affected biological pathways.

METHODS

Two-hundred fifty-one obese patients (age: 43 ± 10.7, preoperative BMI: 45.1 ± 6.1 kg/m(2), 186 women) underwent RYGB surgery and were followed up after two years with regard to BMI. Patients were genotyped for 32 single-nucleotide polymorphisms (SNPs) that were investigated with regard to their impact on response to RYGB and preoperatively measured Three Factor Eating Questionnaire (TFEQ) scores.

RESULTS

Homozygous T carriers of the SNP rs4846567 in proximity to the Lysophospholipase-like 1 (LYPLAL1) gene showed a 7% higher EBMIL compared to wild-type and heterozygous carriers (p = 0.031). TT-allele carriers showed furthermore lower scores for Hunger (74%, p < 0.001), lower Disinhibition (53%, p < 0.001), and higher Cognitive restraint (21%, p = 0.017) than GG/GT carriers in the TFEQ. Patients within the lowest quartile of Hunger scores had a 32% greater EBMIL compared to patients in the highest quartile (p < 0.001).

CONCLUSION

The LYPLAL1 genotype is associated with differences in eating behavior and loss of extensive body weight following RYGB surgery. Genotyping and the use of eating behavior-related questionnaires may help to estimate the RYGB-associated therapy success.

Changes in problematic and disordered eating after gastric bypass, adjustable gastric banding and vertical sleeve gastrectomy: a systematic review of pre-post studies

Despite differences in their mechanisms and outcomes, little is known about whether postsurgical changes in eating behaviours also differ by bariatric procedure. Following a systematic search, 23 studies on changes in binge eating disorder (BED) and related behaviours, bulimia nervosa and related behaviours, night eating syndrome, grazing and emotional eating after Roux-en-Y gastric bypass (RYGB), adjustable gastric banding (AGB) and vertical sleeve gastrectomy (VSG) were reviewed. Significant methodological problems and a dearth of literature regarding many behaviours and VSG were seen. Regarding BED and related behaviours, although later re-increases were noted, short to medium-term reductions after RYGB were common, and reported changes after AGB were inconsistent. Short to medium-term reductions in emotional eating, and from a few studies, short to long-term reductions in bulimic symptoms, were reported after RYGB. Reoccurrences and new occurrences of problem and disordered eating, especially BED and binge episodes, were apparent after RYGB and AGB. Further conclusions and comparisons could not be made because of limited or low-quality evidence. Long-term comparison studies of changes to problematic and disordered eating in RYGB, AGB and VSG patients are needed. It is currently unclear whether any bariatric procedure leads to long-term improvement of any problematic or disordered eating behaviours.

The role of routine preoperative upper endoscopy in bariatric surgery: a systematic review and meta-analysis

BACKGROUND

The necessity of routine preoperative esophagogastroduodenoscopy (EGD) before bariatric surgery is controversial. European guidelines recommend routine EGD while North American guidelines recommend a selective approach.

OBJECTIVE

Perform a systematic review and meta-analysis to determine the proportion and scope of clinical findings discovered at preoperative EGD.

SETTING

Academic hospital, Canada.

METHODS

A search of MEDLINE, Embase, and Cochrane databases included MeSH terms "bariatric surgery," "endoscopy," and "preoperative." Inclusion criteria were any case series, cohort study, or clinical trial describing results of preoperative EGD for any bariatric surgery. Exclusion criteria were studies with<10 patients, patients<18 years of age, or revisional operations. Changes in surgical and medical management and proportions of pathologic findings were extracted and combined in a meta-analysis using the random effects model.

RESULTS

Initial search identified 532 citations. Forty-eight were included after full text review. Included studies comprised 12,261 patients with a mean (SD) age of 40.5 (1.3) years and body mass index of 46.3 (1.5) kg/m(2). The majority of patients (77.1%) were female. The proportion of EGDs resulting in a change in surgical management was 7.8%. After removing benign findings with controversial impact on management (hiatal hernia, gastritis, peptic ulcer), this was found to be .4%. Changes in medical management were seen in 27.5%, but after eliminating Helicobacter pylori eradication, this was found to be 2.5%.

CONCLUSION

Preoperative EGD in average-risk, asymptomatic bariatric surgery patients should be considered optional, as the proportion of EGDs that resulted in important changes in management was low.