Dag Stockeld

Increased Admission for Alcohol Dependence After Gastric Bypass Surgery Compared With Restrictive Bariatric Surgery

IMPORTANCE We demonstrate that patients who have undergone gastric bypass surgery (GBS) have a higher risk of inpatient care for alcohol dependence than those who have undergone restrictive surgery. This highlights a need for health care providers to be aware of this so that early detection and treatment can be put in place. OBJECTIVE To evaluate inpatient care for alcohol abuse before and after GBS compared with restrictive surgery (vertical banded gastroplasty and gastric banding). DESIGN Retrospective population-based cohort study including all patients who underwent GBS, vertical banded gastroplasty, and gastric banding in Sweden from 1980 through 2006. The relative risk of inpatient care for alcohol abuse was studied before and after surgery. SETTING All hospitals in Sweden performing bariatric surgery. PARTICIPANTS A total of 11,115 patients older than 18 years (mean [SD] age, 40.0 [10.3] years; 77% women) who underwent a primary gastric bypass procedure, vertical banded gastroplasty, and gastric banding during the study period. MAIN OUTCOME MEASURES Inpatient care for alcohol abuse, substance abuse, depression, and attempted suicide. RESULTS Mean follow-up time was 8.6 years. Before surgery, there was no difference in inpatient treatment of alcohol abuse among patients who underwent gastric bypass or a restrictive procedure (incidence rate ratio, 1.1; 95% CI, 0.8-1.4). After surgery, there was a 2-fold increased risk of inpatient care for alcohol abuse among patients who had GBS compared with those who had restrictive surgery (hazard ratio, 2.3; 95% CI, 1.7-3.2). CONCLUSIONS AND RELEVANCE Patients who had undergone GBS had more than double the risk of inpatient care for alcohol abuse postoperatively compared with patients undergoing a restrictive procedure, highlighting a need for healthcare professionals to be aware of this for early detection and treatment.

Percutaneous endoscopic gastrostomy for nutrition in patients with oesophageal cancer.

OBJECTIVE To evaluate the technical aspects and risks of using percutaneous endoscopic gastrostomy (PEG) in the treatment of patients with oesophageal cancer. DESIGN Retrospective study. SETTING Teaching hospital, Sweden. SUBJECTS 229 consecutive patients who presented with oesophageal cancer between January 1990 and the end of December 1999. INTERVENTION Insertion of a PEG after diagnosis and before treatment. MAIN OUTCOME MEASURES Morbidity and mortality. RESULTS PEGs were successfully inserted in 222/229 (97%), and the tumour required dilatation in 103 (45%). There was 1 oesophageal perforation and 1 tear of the stomach wall, both of which resulted in death (mortality 0.9%). In 1 operated patient the right gastroepiploic artery was injured by the PEG, but this did not prevent the stomach being used successfully as the oesophageal substitute. PEGs were removed because of leaks in 2 patients. There was 1 possible implantation metastasis. CONCLUSION PEG is a safe and a well tolerated way of ensuring enteral nutrition in patients with oesophageal cancer. The risk of the PEG complicating any later operation is minimal.

High revision rates after laparoscopic vertical banded gastroplasty

BACKGROUND To evaluate, in a surgical department at a university hospital in Stockholm, Sweden, the long-term results after laparoscopic vertical banded gastroplasty (VBG), with special emphasis on revisional surgery. Few studies are available with long-term results after laparoscopic VBG. Some short-term studies have shown results similar to gastric banding. METHODS All consecutive patients who underwent attempted laparoscopic VBG between 1995 and 2005 were followed up regarding weight loss and the need for revisional surgery. Follow-up was from the date of surgery to the end of the observational period (December 2006). RESULTS In 486 patients, laparoscopic VBG was attempted. Of the 486 cases, 64 were converted to open surgery. Conversions were common in the first patients, with a conversion rate of 4% during the last 100 patients. The mean body mass index at surgery was 42.4 kg/m2. The median follow-up was 3 years (range 0-11). All patients lost weight. A total of 104 patients (21%) required revisional surgery 114 times during the follow-up period, with food intolerance/vomiting and insufficient weight loss the most common reasons. Of the 104 patients, 31 underwent repeat VBG, of whom 10 needed a secondary revisional procedure, and 49 required conversion to gastric bypass, of whom none have required additional revisional surgery. CONCLUSION Laparoscopic VBG is associated with high revisional rates. In the case of failed VBG, repeat VBG seems to be a poor option and conversion to gastric bypass yields better results. We have abandoned VBG as a surgical option in the treatment of obesity.

Three-Year Results of Laparoscopic Vertical Banded Gastroplasty

Background: Despite the development of pharmacologic agents for the treatment of massive obesity, surgery remains the only treatment option that has been shown to offer long-term weight reduction. Laparoscopic surgery appears to offer rapid recovery and low postoperative morbidity. The aim of the present study was to assess the outcome of laparoscopic vertical banded gastroplasty (lap VBG) in 60 obese patients. Patients and Methods: 60 massively obese patients (50 female) with a mean ± SEM body mass index (BMI) of 44.4 ± 1.0 kg/m2 were followed up prospectively for an average of 23.0 ± 1.5 months. Lap VBG was performed using 5 trocars placed in a standard fashion for laparoscopic upper gastrointestinal surgery. A 4-row stapler was used for the vertical staple-line, and a stretched polytetrafluoroethylene (Gore-Tex) band was used to reinforce the outlet. The patients were seen postoperatively 2, 6, 12, 24, and 36 months after surgery. Results: Conversion to open surgery was performed in 15 cases. Preoperative median BMI and postoperative hospital stay were higher in the open group than in the laparoscopic group: 47.8 kg/m2 (37.7-65.7) and 5 days (3-13), and 41.9 kg/m2 (32.5-57.3) and 3 days (2-6), respectively (P < 0.01 for both). After 36 months of follow-up, the median BMI was 36.9 kg/m2 (24.6-50.7) (n = 9) in the open group and 37.0 kg/m2 (25.8-53.3) (n = 14) (NS) in the laparoscopic group. The number of conversions to open surgery and the median operating time were higher in the first 30 cases than in the last 30 cases: 11 and 137.5 min (96-225) and 4 and 115.0 min (85-190), respectively, with similar preoperative BMI: 44.1 kg/m2 (33.8-65.8) and 41.2 kg/m2 (32.4-57.8). Conclusions: Lap VBG can be performed safely and results in a shorter postoperative stay than does open surgery. Weight loss was maintained over the 3-year follow-up period. There is a learning curve, resulting in fewer conversions to open surgery and shorter operating time. Long follow-up studies are needed to ascertain that long-term weight loss equals that of open VBG.

Five-Year Results of Laparoscopic Vertical Banded Gastroplasty in the Treatment of Massive Obesity

Background: Laparoscopic surgery appears to offer rapid recovery and low postoperative morbidity.The aim of the present study was to assess the outcome of laparoscopic vertical banded gastroplasty (LVBG) in 154 obese patients with a follow-up of 12-60 months. Patients and Methods: 154 massively obese patients (132 female) with a mean ±SEM body mass index (BMI) of 43.4±0.6 kg/m2 were followed prospectively for an average of 31.7±1.4 months. LVBG was performed using 5 trocars placed in a standard fashion for laparoscopic upper gastrointestinal surgery. A 4-row stapler was used for the vertical staple-line and a stretched polytetrafluoroethylene (Gore-tex®) band was used to reinforce the outlet. After the first 67 cases, the procedure was altered so that a 5-cm length was marked on the band. Results: Conversion to open surgery was performed in 33 cases. All patients lost weight. At 60 months follow-up, the postoperative weight was similar in the open and laparoscopic group.The subjects where 5 cm length was marked on the band had a significantly better weight loss at 36 months (30.4 ±1.2). Both early (<1 month postoperative) and late (>1 month postoperative) complications were more common in the group converted to open surgery. Postoperative stay was shorter in the laparoscopic group. Conclusions: LVBG can be performed safely and results in shorter postoperative stay than openVBG. With adherence to surgical technique (5-cm band circumference), weight-loss is maintained at an adequate level. Complications after LVBG do not exceed open VBG.

Treatment of leaking gastrojejunostomy after gastric bypass surgery with special emphasis on stenting

BACKGROUND Gastric bypass is one of the most common operations for morbid obesity. One of the most feared complications is a leak, most commonly encountered in the gastrojejunal anastomosis (GJA), leading to significant morbidity and increased costs. Our objective was to evaluate the effectiveness of stenting leaks in the GJA. The setting was a university hospital in Stockholm, Sweden. METHODS We performed a retrospective analysis of all gastric bypasses from January 2001 to August 2011, with special reference to the treatment of leaks in the GJA. RESULTS A postoperative leak in the GJA occurred in 69 of 2214 patients. The risk was greater with open surgery and revisional surgery. The risk was also greater with age >50 years but not with a body mass index >50 kg/m(2). There was no mortality. In the later part of the series, stents were used, with a stent time of 2 weeks. The migration rate was 23%, and need for restenting was 20%. CONCLUSION It is safe and advantageous to use stents in the treatment of leaks at the GJA. Patients can be on oral nutrition and oral medication, reducing the need for in-hospital care.

A Swedish study of chemoradiation in squamous cell carcinoma of the esophagus

This multicenter study describes the development of a chemoradiation protocol for the treatment of non-metastatic squamous cell carcinoma of the esophagus. Eighty patients were treated with three courses of chemotherapy (cisplatinum and 5-fluorouracil) with concomitant radiotherapy (40 Gy) during the last two courses of chemotherapy. Esophagectomy was performed, when feasible. If no operation was performed, patients were planned to receive a target dose of 64 Gy. Toxicity was mainly attributable to hematological impairment and led to two adjustments of the treatment protocol (addition of filgrastim and lowering of the 5-fluorouracil dose). These changes made it possible to administer the planned treatment in a gradually higher proportion of patients (13:23 [57%] before changes of treatment compared with 30:36 [83%] after changes). Treatment-related mortality was 3.75% (3 patients, associated with leucopenic septicemia after chemotherapy). Fifty-four patients were resected. No per- or postoperative mortality was encountered. The complete response (pathological CR) rate in operated patients was 46% (27:59 patients) after chemoradiation. In the whole series the CR rate (including clinical CR for non-resected patients) was 44%. With a minimum follow-up of 37 months, the 3-year survival for the whole group was 31% compared with 57% for the CR patients. Total 5-year survival thus far (July 1999) is 26%.

Alcohol and substance abuse, depression and suicide attempts after Roux-en-Y gastric bypass surgery

Small studies suggest that subjects who have undergone bariatric surgery are at increased risk of suicide, alcohol and substance use disorders. This population‐based cohort study aimed to assess the incidence of treatment for alcohol and substance use disorders, depression and attempted suicide after primary Roux‐en‐Y gastric bypass (RYGB).

Marlex Mesh Gastric Banding: A 7-12 Year Follow-up.

This paper presents a 7-12 year (mean 9.8 years) followup of 92 extremely obese patients treated with Marlex® mesh gastric banding (GB). The follow-up rate was 92% (85 patients). Weight loss was initially good (an average reduction in BMI of 13 during the first year), but late weight gain has been a common complaint and a reason for reoperation. Other complications that necessitated reoperation were severe vomiting and esophagitis not amenable to medical treatment. Four patients have developed signs of Barretts esophagus at late follow-up. Forty-six patients (50%) were reoperated 70 times for correction of the band or conversion to vertical banded gastroplasty (VBG). The most common reoperative procedure was conversion to VBG (38 patients). Only 25 (31%) of the 80 patients with long-term follow-up have an intact band. Our results show the need of long follow-up and that this GB cannot be recommended for the treatment of morbid obesity.

Inflammatory response to subcutaneously implanted Marlex® and GORE-TEX® in massively obese patients☆

In both vertical banded gastroplasty and in gastric banding, synthetic bands are used to reinforce the outlet from the pouch to the rest of the stomach. Two materials commonly used for these bands are polypropylene (Marlex) and polytetrafluoroethylene (GORE-TEX). As a measure of their suitability, human inflammatory response to subcutaneous implants was investigated. In a randomized series of 17 superobese patients a patch of GORE-TEX was implanted subcutaneously in one groin under local anaesthesia and Marlex mesh was implanted in the other groin. After about 2 months the implants were exstirpated and investigated in a single blind procedure by an experienced pathologist. Marlex gave a significantly greater chronic inflammatory reaction and fibrosis than GORE-TEX. The foreign body giant cell reaction was, however, significantly greater with GORE-TEX. The possible implications of these results are discussed.