with type 2 diabetes and a BMI > 30 kg/m2.12 These thresholds have also been advocated for in the Dutch guidelines on the surgical treatment of obesity.13 In 2022, 50.2% of the Dutch population classified as overweight and 15.1% had obesity (Table 1).6 If desired by the patient and deemed feasible by a team of licensed health care professionals, MBS can be presented as a treatment option. In the Netherlands, 10,000 - 12,000 MBS procedures are performed in 18 metabolic bariatric centres each year.10 The effects of these procedures are a combination of restricted food intake, an altered absorption of macro- and micronutrients, combined with more complex mechanisms such as the alteration in gut hormones signalling hunger and appetite, changes in gut microbiome, bile acids and brain function, including changes in reward systems.14–16 Surgical Technique Although both the RYGB and SG are used extensively, the surgical technique varies amongst countries, centres, and individual surgeons. Attempts have been made to both standardize the components of these procedures, as well as the execution.17 The use of a laparoscopic technique instead of an open approach has been considered the standard in MBS. The RYGB, as a treatment option for obesity, was introduced by Mason in 1966. It consists of a gastric pouch, which is connected to the small bowel with a Roux-en-Y reconstruction, bypassing the duodenum and first part of the jejunum.8 After technical modifications with a much smaller gastric pouch and variations in limb length, the ‘standard’ RYGB now consists of a 30 ml pouch, a 50-150 cm biliopancreatic limb (BPL) connected to this pouch, a 50-150 cm alimentary limb (AL) which in turn connects to the BPL and continue together as the common channel (CC) (Figure 2).17 Many variations exist of the anastomosis between the pouch and BPL, the gastrojejunostomy, with for instance a circular stapled, a linear stapled and a handsewn technique. In the Netherlands the use of an antegastric antecolic linear stapled gastrojejunostomy, is the most used technique.18 The SG (Figure 3) was historically used as the first step of a RYGB or biliopancreatic diversion/duodenal switch (BPD/DS) and has been in use as a stand-alone operation from the year 2000 onwards. The vertical transection of the stomach is started 2-6 cm proximal of the pylorus at the greater curvature and continued upwards to 1-2 cm lateral of the esophageal gastric junction. This leaves a 2.5-3 cm wide tube, with a volume of 75-150 ml. The lateral remainder is resected.17 10 1
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