Richard Marsk

Nationwide cohort study of post-gastric bypass hypoglycaemia including 5,040 patients undergoing surgery for obesity in 1986–2006 in Sweden

Aims/hypothesisSymptomatic hypoglycaemia with related confusion, syncope, epilepsy or seizures is a newly recognised complication of gastric bypass surgery for obesity. The incidence of these conditions is not known. We therefore studied the incidence of post-gastric bypass hypoglycaemia and related symptoms in patients who have undergone gastric bypass and a reference cohort from the general population of Sweden.MethodsThis is a nationwide cohort study based on national registries with 5,040 persons who underwent gastric bypass, vertical banded gastroplasty or gastric banding for obesity in Sweden between 1 January 1986 and 31 December 2006 and a cohort of ten referents per patient matched for sex and age randomly sampled from the general population. The incidence rates of hospitalisation for hypoglycaemia, confusion, syncope, epilepsy or seizures before and after dates of surgery or inclusion in the reference cohort were studied.ResultsPreoperative incidences of hospitalisation for hypoglycaemia were similar in the surgical and referent cohorts. After gastric bypass surgery, the adjusted hazard ratios were significantly elevated for hypoglycaemia (2.7 [95% CI 1.2–6.3]), confusion (2.8 [1.3–6.0]), syncope (4.9 [3.4–7.0]), epilepsy (3.0 [2.1–4.3]) and seizures (7.3 [5.0–10.8]). The proportions of gastric bypass patients and reference participants affected by hypoglycaemia were very low (0.2% and 0.04%, respectively). There was no increased risk of hypoglycaemia after vertical banded gastroplasty or gastric banding compared with the referent population.Conclusions/interpretationObese persons who have undergone gastric bypass have an increased risk of hospitalisation for diagnoses associated with post-gastric bypass hypoglycaemia, although few patients are affected.

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.

Closure of mesenteric defects in laparoscopic gastric bypass: a multicentre, randomised, parallel, open-label trial

BACKGROUND Small bowel obstruction due to internal hernia is a common and potentially serious complication after laparoscopic gastric bypass surgery. Whether closure of surgically created mesenteric defects might reduce the incidence is unknown, so we did a large randomised trial to investigate. METHOD This study was a multicentre, randomised trial with a two-arm, parallel design done at 12 centres for bariatric surgery in Sweden. Patients planned for laparoscopic gastric bypass surgery at any of the participating centres were offered inclusion. During the operation, a concealed envelope was opened and the patient was randomly assigned to either closure of mesenteric defects beneath the jejunojejunostomy and at Petersens space or non-closure. After surgery, assignment was open label. The main outcomes were reoperation for small bowel obstruction and severe postoperative complications. Outcome data and safety were analysed in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NCT01137201. FINDINGS Between May 1, 2010, and Nov 14, 2011, 2507 patients were recruited to the study and randomly assigned to closure of the mesenteric defects (n=1259) or non-closure (n=1248). 2503 (99·8%) patients had follow-up for severe postoperative complications at day 30 and 2482 (99·0%) patients had follow-up for reoperation due to small bowel obstruction at 25 months. At 3 years after surgery, the cumulative incidence of reoperation because of small bowel obstruction was significantly reduced in the closure group (cumulative probability 0·055 for closure vs 0·102 for non-closure, hazard ratio 0·56, 95% CI 0·41-0·76, p=0·0002). Closure of mesenteric defects increased the risk for severe postoperative complications (54 [4·3%] for closure vs 35 [2·8%] for non-closure, odds ratio 1·55, 95% CI 1·01-2·39, p=0·044), mainly because of kinking of the jejunojejunostomy. INTERPRETATION The results of our study support the routine closure of the mesenteric defects in laparoscopic gastric bypass surgery. However, closure of the mesenteric defects might be associated with increased risk of early small bowel obstruction caused by kinking of the jejunojejunostomy. FUNDING Örebro County Council, Stockholm City Council, and the Erling-Persson Family Foundation.

Antiobesity surgery in Sweden from 1980 to 2005: a population-based study with a focus on mortality.

Background:Antiobesity surgery reduces mortality, but this reduction is dependent to a great extent on surgical perioperative mortality. Population-based perioperative mortality after antiobesity surgery is not well known. Objective:To evaluate mortality after antiobesity surgery in Sweden. Design:Retrospective cohort study. Setting:All patients who underwent antiobesity surgery in Sweden between 1980 and 2005. Main Outcome Measures:All-cause mortality after antiobesity surgery. Results:A total of 12,379 patients (9,614 women) with mean age (±SD) of 39.5 ± 10.4 years underwent 14,768 antiobesity procedures. Mean follow-up time was 10.9 ± 6.3 years. A total of 751 (6.1%) patients died during the follow-up period and the cumulative 30-day, 90-day, and 1-year mortality was 0.2, 0.3, and 0.5%, respectively. Early cumulative mortality was higher for men and patients older than 50 years of age. Long-term mortality was higher in men than in women (90 vs. 50 per 10,000 person years when excluding early deaths, mortality rate ratio 1.8 (95% CI, 1.5–2.1)). There was no difference in the rates of early mortality when primary procedures were compared with reoperations. Myocardial infarction and malignancy were the most common late causes of death after surgery. Conclusions:Antiobesity surgery can be performed safely in unselected populations of obese patients with low rates of early mortality. Men are at a higher risk of early death, which is carried through over long-term follow-up, and that is why a future specific study of the effect of antiobesity surgery on mortality in men is warranted.

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.

Morbidity and mortality before and after bariatric surgery for morbid obesity compared with the general population

Bariatric surgery reduces morbidity and mortality in obese subjects, but it is unclear how rates compare with those in the population. The aim was to assess the risk of admission to hospital for obesity‐related co‐morbidities and overall mortality after bariatric surgery in relation to the general population.

Bariatric surgery reduces mortality in Swedish men

Mortality is lower in obese patients who have undergone surgery for obesity than in those who have not. The majority of patients in these studies have been women. Perioperative mortality is known to be higher among men, and this may counterbalance the survival advantage seen after surgery. This cohort study compared mortality among operated obese patients, non‐operated obese patients and a general control cohort of men.

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.

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).

Short-term morbidity and mortality after open versus laparoscopic gastric bypass surgery. A population-based study from Sweden.

BackgroundThe number of anti-obesity procedures performed continues to increase and most are now performed laparoscopically. Few population-based studies have examined outcomes after open and laparoscopic anti-obesity surgery.MethodsAll-cause mortality and cause-specific morbidity was studied in patients who underwent laparoscopic or open gastric bypass (GBP) surgery in all public Swedish hospitals between 1997 and 2006.ResultsFour thousand seven hundred one (3,852 primary) GBP procedures were performed during the study period. Of these, 1,661 were performed laparoscopically and 3,040 by open access. There was no difference in 30-, 90-, or 365-day mortality between open and laparoscopic access. Complications were more common after conversion from previous anti-obesity surgery to GBP (OR 1.9; 95% CI 1.5–2.4; 30-day readmission). Surgical re-intervention due to anastomotic leak or deep infection was higher in laparoscopic GBP compared to open GBP (OR 2.1; 1.3–3.6). Subgroup analysis showed higher leak rates with revisional laparoscopic procedures (conversion to GBP from previous anti-obesity surgery) compared to revisional open (OR 4.1; 1.5–11.2) whereas after primary GBP no statistically significant difference was seen between laparoscopic and open approach (OR 1.7; 1.0–3.1) (p = 0.07).ConclusionLaparoscopic GBP is as safe as open surgery in terms of mortality. Care needs to be taken when converting previous anti-obesity surgery to GBP.