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Background: Roux-en-Y gastric bypass (RYGB) is associated with an increased risk of kidney stone formation. This is not observed after sleeve gastrectomy (SG)., Objectives: Aim of this study was to assess whether preoperative metabolic profiling is helpful in selecting the most optimal bariatric procedure for patients with a kidney stone history., Setting: General hospital, the Netherlands., Methods: Patients with a kidney stone history and in the run up to bariatric surgery were screened with non-contrast abdominal computed tomography (CT), serum profiling, and 24-hour urine analysis. Those with stones on radiologic imaging and/or high preoperative urinary oxalate were advised to undergo SG instead of RYGB. Pre- and postoperative urine and serum profile differences between both groups were evaluated retrospectively., Results: Postoperatively, RYGB (N = 28, M:F = 8:20) was associated with a 23.5% reduction in urinary volume, a 85% increase in urinary oxalate excretion with a 230% increase in calcium oxalate (CaOx) supersaturation and a 62% decrease in urinary citrate. Although SG (N = 30, M:F = 12:18) was also associated with a reduction in urinary volume, it had no adverse effects on urinary oxalate and citrate excretion, nor on calcium oxalate supersaturation (CaOx-SS). Both RYGB and SG showed favorable effects on postoperative sodium, calcium, uric acid, and phosphate excretion., Conclusions: This study indicates that preoperative metabolic profiling is important to select the optimal bariatric procedure in patients with an a priori increased risk of kidney stone development. These patients should be strongly encouraged to undergo SG instead of RYGB to prevent progressive or recurrent kidney stone disease., (Copyright © 2023 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Despite limited evidence about the efficacy and safety of anticoagulation in patients post bariatric surgery, both vitamin K antagonists (VKA) and direct-acting oral anticoagulants (DOACs) are commonly prescribed., Aim: To evaluate plasma anti-Xa levels of DOACs in morbidly obese (MO) patients before and after a Roux-en-Y gastric bypass (RYGB) procedure., Patients and Methods: Retrospective, cross-sectional, and longitudinal study of anti-Xa activity of apixaban or rivaroxaban in MO patients (N = 41)., Results: Preoperative analysis of plasma anti-Xa levels were within the normal range in patients using apixaban (n = 29; body mass index [BMI] 44.5 ± 5.1 kg/m 2 ) as well as those using rivaroxaban (n = 12; BMI 42.6 ± 5.9 kg/m 2 ). Postoperative anti-Xa levels of apixaban were all within the therapeutic range, whereas anti-Xa levels of rivaroxaban were subtherapeutic in nine out of 14 (64%) patients. Perioperative longitudinal follow-up in patients using apixaban (n = 18) showed no significant change in anti-Xa levels after RYGB., Conclusion: Plasma anti-Xa levels of apixaban in MO patients remained within the therapeutic range up to a body weight of 144 kg. In patients using rivaroxaban, no statistically significant relation between anti-Xa levels and bodyweight was found. After RYGB, plasma anti-Xa levels of apixaban were unaffected, whereas plasma anti-Xa levels of rivaroxaban tended to become subtherapeutic., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: In women, bariatric surgery (BS) leads to a decline in bone mineral density (BMD) and may ultimately lead to premature osteoporosis. The impact in men is largely unknown., Objective: To assess the effect of BS on bone metabolism in males., Setting: Single-center prospective cohort study., Methods: Twenty-four male BS candidates were prospectively enrolled. Anthropometric characteristics, serum gonadal hormones, markers of bone metabolism, and BMD were measured at baseline, 6-, 12- and 36-months postoperatively., Results: Roux-en-Y gastric bypass (RYGB) and adjustable gastric banding (AGB) were performed in 15 and 9 patients, respectively. Nineteen patients completed the 3-year follow-up. At 3 years, BMD of the right and left femur had decreased by 9.1 ± 7.2% and 9.4 ± 5.8% for RYGB and by 6.7 ± 3.9% and 4.5 ± 2.8% for AGB. Radius BMD had decreased by 14.0 ± 5.6% for RYGB and 5.9 ± 4.1% for AGB, i.e., significantly stronger for RYGB (P = .006). Serum parathyroid hormone increased in both groups and 13 of 19 patients developed Vitamin D deficiency. A significant increase of the bone resorption marker was seen only during the first year despite continuation of bone loss. Four patients developed de novo osteopenia or osteoporosis. No fractures were observed., Conclusion: There are strong indications that male bone metabolism response after BS differs from female metabolism. The most affected site is the radius. In males, the cause of this BMD loss seems multifactorial, including mechanical unloading, hyperparathyroidism, and hypogonadism. However, clinical relevance remains unknown and therefore studies with longer-term follow-up are necessary., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Iron deficiency (ID) is one of the most common postoperative deficiencies that may develop after Roux-en-Y gastric bypass (RYGB). The optimal mode of treatment is uncertain., Aim: To compare the efficacy of oral ferrous fumarate (FF), oral ferrous gluconate (FG), and a single intravenous infusion of ferric carboxymaltose (FCM) in women with ID after RYGB., Methods: Multicenter randomized controlled trial including 120 women with a serum ferritin <20 μg/l during follow-up after RYGB. They were randomized into three groups: 41 patients were treated with FF 200 mg three times a day (total daily dose: 195 mg elemental iron), 39 received FG 695 mg twice a day (total daily dose: 160 mg elemental iron) for three months, and 39 patients were treated with a single intravenous dose of FCM (1000 mg elemental iron). Serum ferritin levels were measured at six weeks, and three, six and twelve months after the start of supplementation., Results: At three months, persistence of ID was observed in 29.4% and 42.4% of the patients treated with FF and FG, respectively, but in none of those treated with FCM (p < 0.001). Over the next nine months, recurrence of ID was observed in 56.5% of patients treated with FF, in 52.9% treated with FG, and in 27.8% of those treated with FCM. Adverse effects were most common during oral treatment., Conclusion: In women developing ID after RYGB, a single dose of intravenous FCM is more effective and better tolerated than the standard treatment with either FF or FG., Clinical Trial Registry Number and Website: The study was registered at clinicaltrials.gov under number NCT02271997., Competing Interests: Conflicts of interest Patients who participated in the study received multivitamins of FitForMe (FitForMe WLS Forte®, Rotterdam, The Netherlands) for free during the study. FB, IJ and EA are consultants for FitForMe, which did not influence the content of the manuscript. FitForMe and the farmaceutical companies producing the oral and intravenous iron supplements were not involved in the design or analysis of the study, nor in the writing of the paper. All the other authors have no potential conflicts of interests. We did not receive payment from a third party for this study. There were no relevant financial activities outside the submitted work. There were no patents relevant to the work., (Copyright © 2020 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Background: After Roux-en-Y gastric bypass (RYGB), 15% to 35% of patients fail to lose sufficient weight. Distalization of the limbs of the RYGB (D-RYGB) with shortening of the common channel (CC), has been used to induce additional weight loss. However, this may increase the risk of malnutrition., Objective: The aim of this study was to assess postoperative outcomes after D-RYGB with an alimentary limb of 250 to 300 cm and CC of 100 cm., Setting: General hospital, specialized in bariatric surgery., Methods: We retrospectively studied all patients who underwent revision of RYGB to D-RYGB between January 2014 and April 2018. Data were collected from medical records, including weight loss, nutritional deficiencies, and co-morbidities. Questionnaires on defecation pattern, quality of life, and patient satisfaction were obtained., Results: Forty-seven patients were included. Total weight loss (%TWL) increased significantly from 12% to 30% after D-RYGB. In 62% of patients %TWL >25% was achieved. Patients with %TWL <25% after primary RYGB, lost significantly more weight than initially reached after RYGB. Diabetes and hypertension remission occurred in 67% and 50%, respectively. Five patients (11%) needed subsequent lengthening of the CC to 250 cm due to protein malnutrition or debilitating defecation patterns. Nutritional deficiencies were present in 89% of patients after D-RYGB despite the prescription of specialized multivitamins., Conclusion: Conversion of the primary RYGB to D-RYGB improves weight loss and co-morbidities in patients with insufficient weight loss after primary RYGB. After D-RYGB, nutritional complications and diarrhea are a risk. Based on this study, a modified D-RYGB with a longer CC of >200 cm will be considered., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

A 28-year-old female was admitted 2 years after gastric bypass limb distalization because of severe weight loss, fatigue, chronic diarrhea, massive edema, and a serum albumin of 10 g/L without proteinuria. A diagnosis of severe energy and protein malnutrition was made, and enteral tube feeding was started in combination with pancreatic enzyme supplementation every 3 h. Within 24 h after the start of tube feeding, she developed severe hyperammonemia. Tube feeding was stopped immediately, and this led to a normalization of serum ammonia levels within 8 h. When tube feeding was resumed, albeit at a lower rate and with preventive measures taken, hyperammonemia occurred again. The underlying causes and treatments of hyperammonemia during tube feeding are discussed.

Introduction: Iron deficiency is one of the most common deficiencies that may occur after Roux-en-Y gastric bypass (RYGB). Little is known about the optimal treatment of post-RYGB iron deficiency., Aim: The aim of this study is to evaluate the changes in iron absorption characteristics after RYGB for two oral iron formulations, one presented in tablet form and one as in the form of a solution., Method: Iron absorption in 24 obese women was studied before and 1 month after RYGB. Twelve patients were tested with a single dose of 600 mg ferrous fumarate in tablet form (195 mg of elementary iron, group 1), and 12 patients received a single dose of 1390 mg ferrous gluconate as a solution (160 mg of elementary iron, group 2). Serum iron levels were measured before (T 0 ) and every hour after ingestion of the supplement (T 1 -T 9 )., Results: Before surgery, iron absorption was similar for the two supplements (P = 0.71). However, RYGB was associated with a decrease in fumarate iron absorption (P < 0.001) but did not affect gluconate iron absorption (P = 0.13). Postoperative absorption of fumarate iron was significantly lower than gluconate iron at T1 (P < 0.05), but the overall difference over 9 h did not reach statistical significance (P = 0.53)., Conclusion: RYGB adversely affects the absorption of ferrous fumarate tablets but not that of solubilized ferrous gluconate. A solubilized supplement is therefore preferred as the supplement of first choice after RYGB.

Background & Aims: Roux-en-Y gastric bypass (RYGB) is an effective treatment for obesity. However, it also leads to multiple nutritional deficiencies. Much is known about the short term prevalence, but hardly any long term data is available on deficiencies. The aim of this study was to assess the long term outcome of nutritional status after RYGB., Methods: We performed a retrospective analysis of prospectively collected data obtained from 51 morbidly obese patients who underwent a primary laparoscopic RYGB. Primary outcomes were iron, vitamin B12 and vitamin D deficiencies. Secondary outcomes were deficiencies of other vitamins and minerals and compliance of the patients to multivitamin use., Results: The mean follow-up was 81 ± 27 months. A total of 35%, 16% and 55% of the patients had deficiencies for iron, vitamin B12 and vitamin D respectively. Sixty-nine percent of patients used a (nonspecific) multivitamin supplement on a daily basis. Patients with multivitamin usage had a lower rate of iron deficiency (26% vs. 56%, p = 0.034), vitamin B12 (11% vs. 25%, p = 0.46) and vitamin D (46% vs. 75%, p = 0.07), compared to non-compliant patients., Conclusions: Nutritional deficiencies are common after a RYGB operation. Therefore, strict follow-up by a bariatric surgeon, endocrinologist or general practitioner is required, both short and long term., (Copyright © 2017 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Background: Subclinical hypothyroidism (SH), defined as a raised serum thyroid-stimulating hormone (TSH) with a normal free thyroxine (FT4), is occasionally observed in morbidly obese patients., Objectives: It is currently not known whether thyroid hormone treatment is indicated. The aim of the present study was to assess the changes in thyroid hormone levels in thyroxine-naïve patients with SH in response to weight loss induced by Roux-en-Y gastric bypass (RYGB)., Setting: General hospital specialized in bariatric surgery., Methods: Serum levels of TSH and FT4 were measured at baseline in 503 patients presenting for RYGB. In patients diagnosed with SH, these measurements were repeated 12 months postoperatively., Results: SH de novo was present in 71 out of 503 patients (14.1%). One-year follow-up was available in 61 out of 71 patients (86%). TSH level >10 mU/L was observed in 3 patients (.5%). RYGB induced a decrease in BMI from 47±8 kg/m(2) to 33±6 kg/m(2) at 12-month follow-up (P<.001), and this was associated with a decrease in TSH from 5.8±2.0 to 2.8±1.3 mU/L (P<.001) and a decrease in FT4 from 15.2±2.1 to 13.9±2.3 pmol/L (P<.001), respectively. SH completely resolved in 53 (87%) of the de novo cases., Conclusion: The prevalence of SH de novo is high in morbidly obese patients. After RYGB it resolves in about 90% of patients. This high degree of spontaneous recovery suggests that follow-up alone is sufficient in the majority of patients., (Copyright © 2015 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Iron, vitamin B12, and folic acid deficiencies are among the most common deficiencies occurring after laparoscopic Roux-en-Y gastric bypass (LRYGB). The present study evaluates the effectiveness of a specially designed multivitamin supplement (WLS Forte, FitForMe, Rotterdam, the Netherlands) specifically developed for LRYGB patients.A triple-blind, randomized, 12-month study was conducted comparing WLS forte with a standard multivitamin supplement (sMVS) containing approximately 100% of the recommended daily allowance (RDA) for iron, vitamin B12, and folic acid. WLS Forte contains vitamin B12 14000% RDA, iron 500% RDA, and folic acid 300% RDA.In total, 148 patients (74 in each group) underwent a LRYGB procedure. Baseline characteristics were similar for both groups. Per protocol analysis demonstrated that sMVS treatment was associated with a decline in ferritin (-24.4 ± 70.1 μg/L) and vitamin B12 (-45.9 ± 150.3 pmol/L) over 12 months, whereas in WLS Forte patients, ferritin remained stable (+3.2 ± 93.2 μg/L) and vitamin B12 increased significantly (+55.1 ± 144.2 pmol/L). The number of patients developing ferritin or vitamin B12 deficiency was significantly lower with WLS Forte compared with sMVS (P < 0.05). Iron deficiency (ID) was reduced by 88% after WLS Forte compared with sMVS. Adverse events related to supplement use did not occur.An optimized multivitamin supplement is safe and reduces the development of iron and vitamin B12 deficiencies after LRYGB.

Background: Hyperinsulinemic hypoglycemia is a rare complication of Roux-en-Y gastric bypass (RYGB) surgery. Meals with a high carbohydrate (carb) content and high glycemic index (GI) may provoke these hypoglycemic attacks. The aim of this study is to assess the effects of reducing meal carb content and GI on glycemic responses in patients with post-RYGB hypoglycemia., Methods: Fourteen patients with post-RYGB hypoglycemia underwent two meal tests: a mixed meal test (MMT) with a carb content of 30 g and a meal test with the low GI supplement, Glucerna SR 1.5® (Glucerna meal test (GMT)). Plasma glucose and serum insulin levels were measured for a period of 6 h., Results: Peak glucose levels were reached at T 30 during GMT and at T 60 during MMT, and they were 1.5 ± 0.3 mmol/L lower during GMT than during MMT (7.5 ± 0.4 vs 9.0 ± 0.4 mmol/L, P < 0.005). GMT induced the most rapid rise in plasma insulin: at T 30 plasma, insulin was 30.7 ± 8.5 mU/L higher during GMT than during MMT (P < 0.005). None of the carb-restricted meals induced post-prandial hypoglycemia., Conclusion: A 30-g carb-restricted meal may help to prevent post-prandial hypoglycemia in patients with post-RYGB hypoglycemia. The use of a liquid, low GI, supplement offers no additional advantage.

Background: Severe vitamin D deficiency is a common finding in morbid obesity, and the incidence increases markedly after RYGB. Normalization of vitamin D levels after RYGB is difficult to achieve because the degree of surgery-induced malabsorption is not known., Objective: To develop a test that quantifies the changes in intestinal cholecalciferol absorption induced by Roux-en-Y gastric bypass (RYGB) surgery., Methods: Absorption characteristics of cholecalciferol were studied in 14 morbidly obese, premenopausal women before and 4 weeks after laparoscopic RYGB. Serum cholecalciferol levels were measured at baseline and 1, 2, 3, and 14 days after a single oral dose of 50 000 IU solubilized cholecalciferol., Results: Peak serum cholecalciferol levels were observed on day 1 in all patients. They were 26.6±3.7% lower after RYGB (P=0.02). Inter-individual variability was high., Conclusion: Peak cholecalciferol levels are reduced by about 25% after RYGB. Further analysis suggested that the timing of sampling in the current study was not optimal. This might have caused an underestimation of the true decrease in cholecalciferol absorption induced by RYGB.