Mohammad Kermansaravi1, Islam Omar2, Kamal Mahawar3, Shahab Shahabi4, Ahmad Bashir5, Ashraf Haddad5, Alaa Abbass6, Syed Imran Abbas7, Mujjahid Abbas8, Tarek Abouzeid6, Faki Akin9, Ebrahim Aghajani10, Ali Aminian11, Mohanad AlAnsari12, Syed Tanseer Asghar13, Ahmet Ziya Balta14, Waleed Bukhari15, Mohamad Hayssam Elfawal16, Waleed Gado17, Khaled Gawdat6, Tikfu Gee18, Bijan Ghavami19, Ramen Goel20, Mohammed AlHadad21, Bader AlHadhrami22, Mohammad AlHaifi23, Ali AlHamdani24, Ibrahim Hassan25, Selim Jalil Illan26, Atif Inam27, Aiman Ismaeil28, Yasser Kayyal29, Khaleel Mohammad30, Amir Ulhagh Khan31, Mousa Khoursheed32, Haris Khwaja33, K S Kular34, Laurent Abram Layani35, Tarek Mahdy36, Mumtaz Maher37, Ebrahim Mansoor38, Salman Mirza31, Muhammad S Niam39, Taryel Omarov40, Abdolreza Pazouki1, Aayed R Alqahtani41, Mohamed Qassem6, Masoud Rezvani42, Karim Sabry6, Safauldeen Salim43, Asim Shabbir44, Mehdi Skalli45, Osama Taha46, Mohammad Talebpour47, Halit Eren Taskin48, Mustafa Taskin48, Tahir Yunus49, Amir Hossein Davarpanah Jazi4, Radwan Kassir50, Abdelrahman Nimeri51. 1. Department of Surgery, Minimally Invasive Surgery Research Center, Division of Minimally Invasive and Bariatric Surgery, Rasool-E Akram Hospital, Iran University of Medical Sciences, Tehran, Iran. 2. Wirral University Teaching Hospital, NHS Foundation Trust, Birkenhead, Wirral, UK. 3. Bariatric Unit, South Tyneside and Sunderland NHS Trust, Sunderland, SR4 7TP, UK. 4. Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran. 5. Minimally Invasive and Bariatric Surgery, Gastrointestinal Bariatric and Metabolic Center (GBMC)-Jordan Hospital, Queen Noor Street, Amman, 11152, Jordan. 6. Bariatric Surgery Unit, Faculty of Medicine, Ain Shams University, Cairo, 11591, Egypt. 7. Iranian Hospital, Alwasl Road, Dubai, UAE. 8. University Hospitals Cleveland Medical Center, Cleveland, OH, USA. 9. Bariatric and Metabolic Surgery, Istanbul, Turkey. 10. Department of Surgery, Aleris Hospital, Fredrik Stangs gate 11-13, 0264, Oslo, Norway. 11. Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, USA. 12. Robotic Surgery Academy, International Modern Hospital, Baghdad, Iraq. 13. Capital Hospital, CDA, Islamabad, Pakistan. 14. Faculty of Health Sciences, Istanbul Rumeli University, Istanbul, Turkey. 15. International Medical Center, Jeddah, Saudi Arabia. 16. Makassed General Hospital, Beirut, Lebanon. 17. Endocrine and Bariatric Surgery Unit, Mansoura University, Mansoura, Egypt. 18. Department of Medical Science, School of Healthcare and Medical Sciences, Sunway UniversityJalan UniversitySelangor Darul Ehsan, 47500, Bandar SunwayPetaling Jaya, Malaysia. 19. , Vinet Lausanne, Switzerland. 20. Wockhardt Hospitals, Mumbai, India. 21. Healthpoint Hospital, Mubadala Health Care, Abu Dhabi, UAE. 22. Royal Hospital, Muscat, Oman. 23. Alhaifi Private Clinic, Kuwait, Kuwait. 24. Wellington Hospital, Wellington, UK. 25. Sidra Hospital, Kuwait, Kuwait. 26. International Center of Excellence in Bariatric and Metabolic Surgery, Hospital BC, Tijuana, Mexico. 27. In Charge Metabolic, Thoracic and General Surgery Unit III, Department of General Surgery, Pakistan Institute of Medical Sciences, Islamabad, Pakistan. 28. Faculty of Medicine, Aswan University, Aswan, Egypt. 29. Cork University Hospital, Cork, Ireland. 30. Ministry of Health, Kuwait, Kuwait. 31. Walsall Healthcare NHS Trust, Walsall, UK. 32. Health Sciences Center, Department of Surgery, Kuwait, Kuwait. 33. Chelsea and Westminster Hospital, London, UK. 34. Founding President MGB-OAGB Club, Kular Research Institute, Bija, India. 35. HOD Surgical Bariatric Department, Dubai, UAE. 36. Sharjah University Hospital, Mansoura Faculty of Medicine, Sharjah, UAE. 37. South City Hospital, Karachi, Pakistan. 38. Private Practice, Durban, South Africa. 39. Faculty of Medicine, Brawijaya University, Dr Saiful Anwar General Hospital, Malang, Indonesia. 40. First Surgical Disease Department, Azerbaijan Medical University, Baku, Azerbaijan. 41. New You Medical Center, King Saud University, Obesity Chair, Riyadh, Saudi Arabia. 42. Inova Fair Oaks Hospital, COE Bariatric Center, 14904 Jefferson Davis Hwy, Suite 205, Woodbridge, VA, 22191, USA. 43. Alsadir Teaching Hospital, Najaf, Iraq. 44. Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Surgery, University Surgical Cluster, National University Health System, Singapore, Singapore. 45. CHU de Montpellier, Montpellier, France. 46. Bariatric Unit, Plastic and Obesity Surgery Department, Assiut University Hospital, Assiut, Egypt. 47. Department of General Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran. 48. Cerrahpasa Medical Faculty, Department of Surgery, Istanbul University Cerrahpasa, Istanbul, Turkey. 49. Evercare Hospital, Lahore, Pakistan. 50. Department of Digestive Surgery, CHU Félix Guyon, Saint Denis, La Réunion, France. 51. Chief, Bariatric and Metabolic Surgery Carolinas Medical Center, Ballantyne and Gastonia Director, Atrium Health University of North Carolina-Charlotte Campus Director, Bariatric Fellowship Program Carolinas Medical Center-Mercy, Atrium Health Weight Management Charlotte, ConcordCharlotte, NC, USA. Abdelrahman.Nimeri@atriumhealth.org.
Abstract
BACKGROUND: Fasting during Ramadan is one of the five pillars of the Muslim faith. Despite the positive effects of fasting on health, there are no guidelines or clear recommendations regarding fasting after metabolic/bariatric surgery (MBS). The current study reports the result of a modified Delphi consensus among expert metabolic/bariatric surgeons with experience in managing patients who fast after MBS. METHODS: A committee of 61 well-known metabolic and bariatric surgeons from 24 countries was created to participate in the Delphi consensus. The committee voted on 45 statements regarding recommendations and controversies around fasting after MBS. An agreement/disagreement ≥ of 70.0% was regarded as consensus. RESULTS: The experts reached a consensus on 40 out of 45 statements after two rounds of voting. One hundred percent of the experts believed that fasting needs special nutritional support in patients who underwent MBS. The decision regarding fasting must be coordinated among the surgeon, the nutritionist and the patient. At any time after MBS, 96.7% advised stopping fasting in the presence of persistent symptoms of intolerance. Seventy percent of the experts recommended delaying fasting after MBS for 6 to 12 months after combined and malabsorptive procedures according to the patient's situation and surgeon's experience, and 90.1% felt that proton pump inhibitors should be continued in patients who start fasting less than 6 months after MBS. There was consensus that fasting may help in weight loss, improvement/remission of non-alcoholic fatty liver disease, dyslipidemia, hypertension and type 2 diabetes mellitus among 88.5%, 90.2%, 88.5%, 85.2% and 85.2% of experts, respectively. CONCLUSION: Experts voted and reached a consensus on 40 statements covering various aspects of fasting after MBS.
BACKGROUND: Fasting during Ramadan is one of the five pillars of the Muslim faith. Despite the positive effects of fasting on health, there are no guidelines or clear recommendations regarding fasting after metabolic/bariatric surgery (MBS). The current study reports the result of a modified Delphi consensus among expert metabolic/bariatric surgeons with experience in managing patients who fast after MBS. METHODS: A committee of 61 well-known metabolic and bariatric surgeons from 24 countries was created to participate in the Delphi consensus. The committee voted on 45 statements regarding recommendations and controversies around fasting after MBS. An agreement/disagreement ≥ of 70.0% was regarded as consensus. RESULTS: The experts reached a consensus on 40 out of 45 statements after two rounds of voting. One hundred percent of the experts believed that fasting needs special nutritional support in patients who underwent MBS. The decision regarding fasting must be coordinated among the surgeon, the nutritionist and the patient. At any time after MBS, 96.7% advised stopping fasting in the presence of persistent symptoms of intolerance. Seventy percent of the experts recommended delaying fasting after MBS for 6 to 12 months after combined and malabsorptive procedures according to the patient's situation and surgeon's experience, and 90.1% felt that proton pump inhibitors should be continued in patients who start fasting less than 6 months after MBS. There was consensus that fasting may help in weight loss, improvement/remission of non-alcoholic fatty liver disease, dyslipidemia, hypertension and type 2 diabetes mellitus among 88.5%, 90.2%, 88.5%, 85.2% and 85.2% of experts, respectively. CONCLUSION: Experts voted and reached a consensus on 40 statements covering various aspects of fasting after MBS.