Magnus Sundbom

Transcatheter Arterial Embolization versus Surgery in the Treatment of Upper Gastrointestinal Bleeding after Therapeutic Endoscopy Failure

PURPOSE To retrospectively compare the outcome of transcatheter arterial embolization (TAE) and surgery as salvage therapy of upper gastrointestinal bleeding after failed endoscopic treatment. MATERIALS AND METHODS From January 1998 to December 2005, 658 patients were referred to diagnostic/therapeutic emergency endoscopy and diagnosed with upper gastrointestinal bleeding. Ninety-one of these 658 patients (14%) had repeat bleeding or continued to bleed. Forty of those 91 patients were treated with TAE and 51 were treated with surgery. From the medical records, the following variables were recorded: demographic data, endoscopic diagnoses, comorbidities, lowest hemoglobin levels, total transfusion requirements, lengths of hospitalization stays, postprocedure complications, and mortality rates. The relative survival rate was calculated, and survival probability was calculated with the Kaplan-Meier technique. RESULTS Patients treated with TAE were older (mean age, 76 years; age range, 40-94 years) and had slightly more comorbidities compared to patients who underwent surgery (mean age, 71 years; age range, 45-89 years). The 30-day mortality rate in patients treated with TAE was one of 40 (3%) compared to seven of 51 (14%) in patients treated with surgery (P < .07). Most repeat bleeding could be effectively treated with TAE, both in the surgical and TAE groups. CONCLUSIONS The results of this study suggest that, after failure of therapeutic endoscopy for upper gastrointestinal bleeding, TAE should be the treatment of choice before surgery and that TAE can also be used to effectively control bleeding after failed surgery or TAE. There was a clear trend to lower 30-day mortality with use of TAE instead of surgery.

Investigation of the Excluded Stomach after Roux-en-Y Gastric Bypass

Background: One problem with Roux-en-Y gastric bypass (RYGBP) is that it leaves the bypassed segment not readily available for endoscopic or radiographic examinations. Materials and Methods:Three males, 50, 54 and 64 years old, suffered from repeated, gastrointestinal bleeding of unknown origin requiring transfusion 1/2, 1 and 7 years after RYGBP. Access to the stomach was obtained by an ultrasound-guided percutaneous gastrostomy. Results: We could perform endoscopy, barium studies and gastric acid output measurements through the gastrostomy. Histological gastritis, low acid output and absence of H. pylori infection were found. Conclusion: We were able to exclude severe gastric disease in our patients.

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.

Early Complications After Laparoscopic Gastric Bypass Surgery : Results From the Scandinavian Obesity Surgery Registry

Objective:To identify risk factors for serious and specific early complications of laparoscopic gastric bypass surgery using a large national cohort of patients. Background:Bariatric procedures are among the most common surgical procedures today. There is, however, still a need to identify preoperative and intraoperative risk factors for serious complications. Methods:From the Scandinavian Obesity Surgery Registry database, we identified 26,173 patients undergoing primary laparoscopic gastric bypass operation for morbid obesity between May 1, 2007, and September 30, 2012. Follow-up on day 30 was 95.7%. Preoperative data and data from the operation were analyzed against serious postoperative complications and specific complications. Results:The overall risk of serious postoperative complications was 3.4%. Age (adjusted P = 0.028), other additional operation [odds ratio (OR) = 1.50; confidence interval (CI): 1.04–2.18], intraoperative adverse event (OR = 2.63; 1.89–3.66), and conversion to open surgery (OR = 4.12; CI: 2.47–6.89) were all risk factors for serious postoperative complications. Annual hospital volume affected the rate of serious postoperative complications. If the hospital was in a learning curve at the time of the operation, the risk for serious postoperative complications was higher (OR = 1.45; CI: 1.22–1.71). The 90-day mortality rate was 0.04%. Conclusions:Intraoperative adverse events and conversion to open surgery are the strongest risk factors for serious complications after laparoscopic gastric bypass surgery. Annual operative volume and total institutional experience are important for the outcome. Patient related factors, in particular age, also increased the risk but to a lesser extent.

Complication rate lower after percutaneous endoscopic gastrostomy than after surgical gastrostomy: a prospective, randomized trial

BackgroundPercutaneous endoscopic gastrostomy (PEG) has increasingly replaced surgical gastrostomy (SG) as the primary procedure for the long-term nutrition of patients with swallowing disorders. This prospective randomized study compares PEG with SG in terms of effectiveness and safety.MethodsThis study enrolled 70 patients with swallowing disorders, mainly attributable to neurologic impairment. All the patients, eligible for both techniques, were randomized to PEG (pull method) or SG. The groups were comparable in terms of age, body mass index, and underlying diseases. Complications were reported 7 and 30 days after the operative procedure.ResultsThe procedures were successfully completed for all the patients. The median operative time was 15 min for PEG and 35 min for SG (p < 0.001). The rate of complications was lower for PEG (42.9%) than for SG (74.3%; p < 0.01). The 30-day mortality rates were 5.7% for PEG and 14.3% for SG (nonsignificant difference).ConclusionThe findings show PEG to be an efficient method for gastrostomy tube placement with a lower complication rate than SG. In addition, PEG is faster to perform and requires fewer medical resources. The authors consider PEG to be the primary procedure for gastrostomy tube placement.

Postprandial changes in gut regulatory peptides in gastric bypass patients

Objective:The marked weight loss induced by Roux-en-Y gastric bypass (RYGBP) for morbid obesity is still incompletely understood. It has been suggested that, besides the restriction imposed by the surgical procedure, alterations in gut regulatory peptides signaling the brain might contribute. The aim of this study was to measure the putative satiety peptides peptide YY (PYY), glucagon-like peptide-1 (GLP-1), pancreatic polypeptide (PP) and pro-neurotensin (pro-NT) in response to fasting and feeding.Design:The study is a cross-sectional study. After a prolonged overnight 14 h fast, a standardized mixed meal (574 kcal) was provided. Blood samples for peptide measurements were obtained before and after the meal.Subjects:Forty subjects (20 males and females) were included; 10 morbidly obese; (mean age 41±7 years; mean BMI 44±3 kg/m2), 10 operated with RYGBP (age 45±5 years; BMI 35±6 kg/m2), 10 aged-matched lean (age 44±5 years; BMI 24±3 kg/m2) and 10 young lean subjects (age 26±2 years; BMI 23±2 kg/m2).Measurements:Plasma concentrations of PYY, GLP-1, PP and pro-NT were obtained.Results:PYY levels increased more in the RYGBP group than in the other groups after the test meal. GLP-1 levels rose in the RYGBP patients, with a small increase seen in the age-matched lean group. PP concentrations increased similarly in all groups postprandially. Pro-NT levels were highest in surgical patients, with no meal effect.Conclusion:RYGBP subjects displayed exaggerated PYY and GLP-1 responses to a standardized meal and demonstrated higher pro-NT levels both pre- and postprandially. The findings indicate that possibly the alterations in gut peptide secretion may promote weight loss after gastric bypass surgery.

Long-term results 11 years after primary gastric bypass in 384 patients

BACKGROUND Roux-en-Y gastric bypass surgery (RYGB) as treatment of morbid obesity results in substantial weight loss. Most published long-term studies have included few patients at the last follow-up point. The aim of the present study was to explore long-term results in a large cohort of patients 7-17 years after gastric bypass. METHODS All 539 patients who had undergone primary RYGB from 1993 to 2003 at Uppsala and Örebro University Hospitals received a questionnaire regarding their postoperative status. Blood samples were obtained and the medical charts studied. RESULTS Of the 539 patients, 384 responded (71.2% response rate, mean age 37.9 yr, body mass index 44.5 kg/m(2) at surgery, 317 women, and 67 men). At a mean follow-up of 11.4 years (range 7-17), the body mass index had decreased to 32.5 kg/m(2), corresponding to an excess body mass index loss of 63.3%. Similar weight loss was observed, regardless of the length of follow-up. Orally treated diabetes resolved in 72% and sleep apnea and hyperlipidemia were improved. Revisional bariatric surgery had been performed in 2.1% and abdominoplasty in 40.2%. The gastrointestinal symptoms were considered tolerable. The overall result was satisfactory for 79% of the patients and 92% would recommend Roux-en-Y gastric bypass to a friend. Attendance to the annual checkups was 37%. Vitamin B12 supplements were taken by 72% and multivitamins by 24%. CONCLUSION At 11 years, substantial weight loss was maintained and revisional surgery was rare. Surprisingly few patients were compliant with the recommendation of lifelong supplements and yearly evaluations; however, patient satisfaction was high.

The proximal gastric pouch invariably contains acid-producing parietal cells in Roux-en-Y gastric bypass

Background: Roux-en-Y gastric bypass (RYGBP) is well tolerated and effective in ameliorating diseases common to morbidly obese patients. A potential drawback, however, is the risk for stomal ulcers, probably due to acid and peptic digestion of the mucosa in the proximal Roux limb. Methods: In 23 RYGBP patients (mean BMI 45 kg/m2, age 39 years), the gastro-jejunostomy was performed by circular stapler and the gastric suture ring retrieved for histological examination. 13 consecutive patients received our standard totally transected 4 × 3 cm proximal gastric pouch. The anvil was passed transgastricly and reference biopsies were taken from the gastrotomy in the corpus of the stomach. In the last 10 patients, the pouch size was reduced to 2 × 3 cm by a modified surgical technique. Results: All suture rings from the standard pouches consisted of corpus-fundus mucosa with a large amount of parietal cells, histologically identical to the reference biopsies from the gastrotomy. Also, the 10 suture rings from the modified small pouches contained corpus-fundus mucosa. In 5 of these samples, cardiac mucosa was found, but only in a small segment (6 mm). In addition, 3 patients had esophageal epithelium in the suture ring. Conclusion: The proximal pouch invariably contains acid-producing parietal cells. In order to reduce acid production and, hence, the risk of stomal ulcers, the pouch has to be made as small as possible.

Endoscopic Marking with a Metallic Clip Facilitates Transcatheter Arterial Embolization in Upper Peptic Ulcer Bleeding

PURPOSE To enable accurate transcatheter arterial embolization (TAE) of the target vessel, a new technique to localize the exact position of a bleeding ulcer was tested that involves endoscopic marking of the ulcer with a metallic clip. MATERIALS AND METHODS In 13 patients (mean age, 75 years) with acute bleeding ulcers (11 duodenal ulcers, two malignant ulcers), a metallic clip was placed at gastroscopy followed or preceded by routine endoscopic treatment. The metallic clip was placed in the fibrous edge of the ulcer adjacent to the bleeding point. In 10 patients, TAE was indicated as a result of continued or recurrent bleeding. The artery was embolized with microcoils as close as possible to the clip. In three patients, there was no indication for TAE, so plain abdominal radiography was performed to determine whether the marking clip was still in place. RESULTS In 11 patients, the clip was still in place on radiography; in two, it had disappeared. Hemostasis was achieved in eight of 10 patients after TAE. In six patients, the clip was essential to identify the bleeding vessel. CONCLUSION Marking of the bleeding ulcer with a clip before TAE enhances the possibility that the correct vessel is embolized. This will most likely minimize the risk of recurrent bleeding after embolization, especially in patients who do not show contrast medium extravasation.

CRP reduction following gastric bypass surgery is most pronounced in insulin-sensitive subjects

OBJECTIVE:Obesity is frequently associated with insulin resistance, dyslipidemia, hypertension and an increased risk of cardiovascular disease, reflected in elevated markers of inflammation, in particular C-reactive protein (CRP). To what extent the insulin resistance or the obesity per se contributes to increased CRP levels is unclear. In morbidly obese patients, gastric bypass surgery causes marked changes in body weight and improves metabolism, thereby providing informative material for studies on the regulation of inflammatory markers.DESIGN:Prospective, surgical intervention study of inflammatory markers in morbidly obese subjects.SUBJECTS:In total, 66 obese subjects with mean age 39 y and mean body mass index (BMI) 45 kg/m2 were studied prior to and 6 and 12 months following Roux-en-Y gastric bypass (RYGBP) surgery.MEASUREMENTS:Serum concentrations of high sensitivity CRP, serum amyloid A (SAA) and interleukin-6 (IL-6), as well as markers of glucose and lipid metabolism.RESULTS:Prior to surgery, CRP levels were elevated compared to the reference range of healthy, normal-weight subjects. CRP correlated with insulin sensitivity, as reflected by the homeostatic model assessment (HOMA) index, but not BMI, when corrected for age and gender. Surgery reduced BMI from 45 to 31 kg/m2 and lowered CRP, SAA and IL-6 levels by 82, 57 and 50%, respectively, at 12 months. The reduction in CRP was inversely related to HOMA at baseline independently of the change in body weight (r=−0.36, P=0.005). At 12 months, 140 and 40% reductions in CRP were seen in subjects with HOMA < 4 (insulin sensitive) and HOMA>9 (insulin resistant) despite similar reductions in BMI. Reductions in SAA and IL-6 tended to parallel the changes in CRP, but were less informative.CONCLUSION:In morbidly obese subjects, gastric bypass surgery lowers energy intake, reduces inflammatory markers and improves insulin sensitivity. Despite a marked reduction in body weight, only a small effect on CRP levels was seen in insulin-resistant patients, indicating that flexibility of circulating CRP levels is primarily dependent upon insulin sensitivity rather than energy supply.