Jakob Hedberg

Role of Gastric Acid in Stomal Ulcer after Gastric Bypass

Background: The pathogenetic mechanisms of stomal ulcer after Roux-en-Y gastric bypass (RYGBP) are unclear. In order to study the role of gastric acid, we measured acidity in the proximal pouch using a pH-sensitive probe. Methods: 6 patients (5 females, mean age 45 years old at time of operation) with endoscopically confirmed stomal ulcer, were studied 2 to 6 years after RYGBP. All complained of epigastric pain that improved during proton pump inhibitor (PPI) therapy. Control subjects were 6 females (50 years old) who had had RYGBP at least 5 years earlier and denied symptoms of epigastric pain or heartburn. The pH-sensitive probe (Digitrapper-pH, Medtronic) was passed through the nose to the proximal pouch, guided by the calculated distance and pH response. The probe was left in place for 4 hours. The percentage of time with pH <4 was calculated. Results: The probe could be accurately positioned in the proximal pouch both in symptomatic patients and in controls as evidenced by the acid pH reaction. The proximal pouches of patients with stomal ulcer were significantly more exposed to acid compared to controls. The median percentage of time with pH <4 was 69% and 20% in the stomal ulcer and the control group, respectively (P<0.01). Barium follow-through excluded gastro-gastric fistula in stomal ulcer patients. Conclusion: RYGBP patients with stomal ulcer have increased acid production in their proximal pouch in comparison with asymptomatic RYGBP patients. Gastric acid appears to have an important role in the pathogenesis of stomal ulcer.

Duodenal switch versus Roux-en-Y gastric bypass for morbid obesity: systematic review and meta-analysis of weight results, diabetes resolution and early complications in single-centre comparisons

Long‐term weight loss after Roux‐en‐Y gastric bypass (RYGB) in super‐obese patients has not been ideal. Biliopancreatic diversion with duodenal switch (DS) is argued to be better; however, additional side effects are feared. The aim of the present study was to determine differences in results after DS and RYGB in publications from single‐centre comparisons. A systematic review of studies containing DS and RYGB performed at the same centre was performed. Outcome data were weight results, resolution of comorbid conditions, perioperative results and complications. Main outcome was difference in weight loss after DS and RYGB. Secondary outcomes were difference in resolution of comorbidities, perioperative results and complications. The final analysis included 16 studies with in total 874 DS and 1,149 RYGB operations. When comparing weight results at the longest follow‐up of each study, DS yielded 6.2 (95% confidence interval 5.0–7.5) body mass index units additional weight loss compared with RYGB, P < 0.001. Operative time and length of stay were significantly longer after DS, as well as the risk for post‐operative leaks, P < 0.05. DS is more effective than RYGB as a weight‐reducing procedure. However, this comes at the price of more early complications and might also yield slightly higher perioperative mortality.

Superior weight loss and lower HbA1c 3 years after duodenal switch compared with Roux-en-Y gastric bypass—a randomized controlled trial

BACKGROUND Obesity is a rising threat to public health. The relative increase in the incidence of morbid obesity is most pronounced in the most severely obese. Roux-en-Y gastric bypass (RYGB) results in inferior weight loss in this group. Therefore, we have offered biliopancreatic diversion with duodenal switch (BPD/DS) as an alternative for this patient category. Our objective was to compare BPD/DS and RYGB in the surgical treatment of morbid obesity in patients with a body mass index (BMI) >48 kg/m(2). The setting was a university hospital in Sweden. METHODS In a controlled trial (registration number ISRCTN10940791), 47 patients (25 men, BMI 54.5 ± 6.1 kg/m(2)) were randomized to RYGB (n = 23) or BPD/DS (n = 24). Biochemical data were collected preoperatively and 1 and 3 years postoperatively. A questionnaire addressing weight, general satisfaction, and gastrointestinal symptoms was distributed a median of 4 years postoperatively. RESULTS Both procedures were safe. The duration of surgery and postoperative morphine consumption were greater after BPD/DS than after RYGB (157 versus 117 min and 140 versus 93 mg, respectively). BPD/DS resulted in greater weight loss than RYGB (-23.2 ± 4.9 versus -16.2 ± 6.9 BMI units or 80% ± 15% versus 51% ± 23% excess BMI loss, P <.001). BPD/DS yielded lower glucose and glycated hemoglobin levels at 3 years. More patients listed troublesome diarrhea and malodorous flatus in the questionnaire after BPD/DS, but no significant difference was seen (P = .078 and P = .073, respectively). CONCLUSIONS BPD/DS produced superior weight results and lower glycated hemoglobin levels compared with RYGB in patients with a BMI >48 kg/m(2). Both operations yield high satisfaction rates. However, diarrhea tended to be more common after BPD/DS.

Suicide, Self-harm, and Depression After Gastric Bypass Surgery: A Nationwide Cohort Study.

Objective: The aim of this study was to examine risk of self-harm, hospitalization for depression and death by suicide after gastric bypass surgery (GBP). Summary of Background Data: Concerns regarding severe adverse psychiatric outcomes after GBP have been raised. Methods: This nationwide, longitudinal, self-matched cohort encompassed 22,539 patients who underwent GBP during 2008 to 2012. They were identified through the Swedish National Patient Register, the Prescribed Drug Register, and the Causes of Death Register. Follow-up time was up to 2 years. Main outcome measures were hazard ratios (HRs) for post-surgery self-harm or hospitalization for depression in patients with presurgery self-harm and/or depression compared to patients without this exposure; and standardized mortality ratio (SMR) for suicide post-surgery. Results: A diagnosis of self-harm in the 2 years preceding surgery was associated with an HR of 36.6 (95% confidence interval [CI] 25.5–52.4) for self-harm during the 2 years of follow up, compared to GBP patients who had no self-harm diagnosis before surgery. Patients with a diagnosis of depression preceding GBP surgery had an HR of 52.3 (95% CI 30.6–89.2) for hospitalization owing to depression after GBP, compared to GBP patients without a previous diagnosis of depression. The SMR for suicide after GBP was increased among females (n = 13), 4.50 (95% CI 2.50–7.50). The SMR among males (n = 4), was 1.71 (95% CI 0.54–4.12). Conclusions: The increased risk of post-surgery self-harm and hospitalization for depression is mainly attributable to patients who have a diagnosis of self-harm or depression before surgery. Raised awareness is needed to identify vulnerable patients with history of self-harm or depression, which may be in need of psychiatric support after GBP.

Low-Dose Aspirin Discontinuation and Risk of Cardiovascular Events : A Swedish Nationwide, Population-Based Cohort Study

Background: There are increasing concerns about risks associated with aspirin discontinuation in the absence of major surgery or bleeding. We investigated whether long-term low-dose aspirin discontinuation and treatment gaps increase the risk of cardiovascular events. Methods: We performed a cohort study of 601 527 users of low-dose aspirin for primary or secondary prevention in the Swedish prescription register between 2005 and 2009 who were >40 years of age, were free from previous cancer, and had ≥80% adherence during the first observed year of treatment. Cardiovascular events were identified with the Swedish inpatient and cause-of-death registers. The first 3 months after a major bleeding or surgical procedure were excluded from the time at risk. Results: During a median of 3.0 years of follow-up, 62 690 cardiovascular events occurred. Patients who discontinued aspirin had a higher rate of cardiovascular events than those who continued (multivariable-adjusted hazard ratio, 1.37; 95% confidence interval, 1.34–1.41), corresponding to an additional cardiovascular event observed per year in 1 of every 74 patients who discontinue aspirin. The risk increased shortly after discontinuation and did not appear to diminish over time. Conclusions: In long-term users, discontinuation of low-dose aspirin in the absence of major surgery or bleeding was associated with a >30% increased risk of cardiovascular events. Adherence to low-dose aspirin treatment in the absence of major surgery or bleeding is likely an important treatment goal.

Long-term follow-up in patients undergoing open gastric bypass as a revisional operation for previous failed restrictive procedures

BACKGROUND We have previously described our early experience with Roux-en-Y gastric bypass (RYGB) as a revisional procedure. The favorable results have stimulated us to continue using RYGB as our standard operating procedure after failed bariatric surgery. Our objective was to evaluate the perioperative risks, weight result, and abdominal symptoms 5 years after revisional RYGB surgery at a university hospital in Sweden. METHODS We studied 121 patients undergoing revisional open RYGB (age 42.0 yr, body mass index 37.7 kg/m(2), 101 women) 5 years after RYGB surgery. The patients underwent reoperation because of either intolerable side effects or inferior weight loss. The initial procedures were horizontal gastroplasty (n = 2), vertical banded gastroplasty (n = 34), gastric banding (n = 21), and silicone adjustable gastric banding (n = 64). The mean interval between the first surgery and revision was 5 years. The 5-year follow-up data were obtained annually using a questionnaire survey. RESULTS The average operating time was 162 minutes (range 75-355). In these 121 cases, 10 (8%) reoperations were performed in the first 30-day period (4 for leakage). No perioperative mortality occurred, and the 5-year follow-up rate was 91%. The mean body mass index was 30.7 kg/m(2). Seven patients (5.7%) had undergone subsequent surgery because of complications. At follow-up, 93% reported being very satisfied or satisfied with the revisional procedure. Disturbing abdominal symptoms after RYGB were rare. CONCLUSION The perioperative risks of revisional RYGB are greater than those for primary RYGB. However, because the long-term weight results and patient satisfaction are very good, we believe that the 8% reoperative rate is acceptable. We consider RYGB to be a suitable procedure for patients in whom previous bariatric procedures have failed.

Aortic injuries during laparoscopic gastric bypass for morbid obesity in Sweden 2009–2010: A nationwide survey

BACKGROUND In Sweden, bariatric surgery has increased more than tenfold in the past decade, from 700 to 8,600 procedures annually, and laparoscopic gastric bypass (LRYGB) dominates (92% of all procedures). This expansion makes safety issues crucial. The aim of this nationwide survey was to identify aortic injuries in LRYGB. METHODS All 41 centers performing LRYGB in Sweden were asked if an aortic injury had occurred during the years 2009-2010. Techniques for entering the first trocar and way of establishing pneumoperitoneum were evaluated. The total number of procedures was collected from the national quality registry, Scandinavian Obesity Surgery Registry (SOReg), and the National Patient Register. RESULTS During the study period, 11,744 LRYGBs were performed. The analysis revealed 5 aortic injuries, all occurring in patients in whom an optical trocar had been placed before establishing pneumoperitoneum. Outcomes varied from no major sequelae to bilateral lower limb amputation and death. Based on the total number of LRYGBs, the risk for an aortic injury was .043% overall and .091% when an optical trocar was used. CONCLUSION Aortic injury is a rare but serious complication in laparoscopic gastric bypass. In this survey, optical trocars constructed to reduce the risk of intraabdominal damage had been used in all 5 cases.

Low-dose acetylsalicylic acid and gastrointestinal ulcers or bleeding - a cohort study of the effects of proton pump inhibitor use patterns

The aim of this study was to investigate the associations between proton pump inhibitor (PPI) usage patterns and risk of severe gastrointestinal events in patients treated with low‐dose acetylsalicylic acid (LDA).

Validation of data quality in the Swedish National Register for Oesophageal and Gastric Cancer

The Swedish National Register for Oesophageal and Gastric Cancer (NREV) was launched in 2006. Data are reported at diagnosis (diagnostic survey), at the time of surgery (surgical survey) and at first outpatient follow‐up (follow‐up survey). The aim of this study was to evaluate data originating from NREV in terms of comparability, completeness, accuracy and timeliness.

Changes in bowel habits and patient-scored symptoms after Roux-en-Y gastric bypass and biliopancreatic diversion with duodenal switch

BACKGROUND Bariatric procedures are increasingly being used, but data on bowel habits are scarce. OBJECTIVES To assess changes in gastrointestinal function and patient-scored symptoms after Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion with duodenal switch (BPD/DS). SETTING University hospital in Sweden. METHODS We recruited 268 adult patients (mean age of 42.5 yr, body mass index 44.8, 67.9% female) listed for RYGB and BPD/DS. Patients answered validated questionnaires prospectively concerning bowel function, the Fecal Incontinence Quality of Life Scale, and the 36-Item Short Form Health Survey before and after their operation. RESULTS Postoperatively, 208 patients (78.2% of 266 eligible patients) answered the questionnaires. RYGB patients had fewer bowel motions per week (8 versus 10) and more abdominal pain postoperatively (P<.001). Postoperatively, the 35 BPD/DS patients (69% versus 23%) needed to empty their bowel twice or more than twice daily, reported more flatus and urgency, and increased need for keeping a diet (P<.001). Concerning Fecal Incontinence Quality of Life Scale, coping and behavior was slightly reduced while depression and self-perception scores were improved after RYGB. Lifestyle, coping and behavior, and embarrassment were reduced after BPD/DS (P<.05). In the 36-Item Short Form Health Survey, physical scores were markedly improved, while mental scores were largely unaffected. CONCLUSION RYGB resulted in a reduced number of bowel movements but increased problems with abdominal pain. In contrast, BPD/DS-patients reported higher frequency of bowel movements, more troubles with flatus and urgency, and increased need for keeping a diet. These symptoms affected quality of life negatively, however, general quality of life was markedly improved after both procedures. These results will be of great value for preoperative counseling.