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Nilsen, I., Sundbom, M., Abrahamsson, N. & Hänni, A. (2019). Comparison of Meal Pattern and Postprandial Glucose Response in Duodenal Switch and Gastric Bypass Patients. Obesity Surgery, 29(7), 2210-2216
Open this publication in new window or tab >>Comparison of Meal Pattern and Postprandial Glucose Response in Duodenal Switch and Gastric Bypass Patients
2019 (English)In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 29, no 7, p. 2210-2216Article in journal (Refereed) Published
Abstract [en]

Background: Bariatric surgery improves glucose homeostasis; however, side effects such as hypoglycemia can occur. We investigated the effects of meals on interstitial glucose (IG) response in biliopancreatic diversion with duodenal switch (BPD-DS) and Roux-en-Y gastric bypass (RYGBP)-operated patients at least 1 year after surgery.

Methods: Thirty patients treated with BPD-DS or RYGBP were recruited at the outpatient Obesity Unit, Uppsala University Hospital. IG was measured by continuous glucose monitoring (CGM) for 3 consecutive days, and postprandial IG levels from 5 to 120 min were analyzed for 2 of these days. All intake of food and beverages was simultaneously registered in a food diary, which was processed using The Meal Pattern Questionnaire.

Results: Postprandial IG levels were significantly lower in BPD-DS (n = 14) compared to RYGBP (n = 15)-treated patients, with mean concentrations of 5.0 (+/- 1.0) and 6.3 (+/- 1.8) mmol/L respectively (p < 0.001). The mean postprandial IG increment was lower in BPD-DS than in RYGBP patients, 0.2 (+/- 0.6) vs. 0.4 (+/- 1.4) mmol/L (p < 0.001). Furthermore, the postprandial IG variability was less pronounced in BPD-DS than in RYGBP patients. The mean number of daily meals did not differ between the two groups, 7.8 (+/- 2.6) in BPD-DS and 7.2 (+/- 1.7) in the RYGBP (p = 0.56).

Conclusion: BPD-DS patients demonstrated lower postprandial IG concentrations, with smaller postprandial IG increments and less pronounced postprandial IG variability compared to RYGBP patients. The two groups had similar meal pattern and the postprandial IG responses is probably associated with differences in postoperative physiology.

Place, publisher, year, edition, pages
SPRINGER, 2019
Keywords
Continuous glucose monitoring, Roux-en-Y gastric bypass, Biliopancreatic diversion with duodenal switch, Glycemic variability, Meals, Postprandial period
National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-387721 (URN)10.1007/s11695-019-03826-3 (DOI)000469767700026 ()30919168 (PubMedID)
Available from: 2019-06-26 Created: 2019-06-26 Last updated: 2019-06-26Bibliographically approved
Katsogiannos, P., Kamble, P. G., Boersma, G. J., Karlsson, F. A., Lundkvist, P., Sundbom, M., . . . Eriksson, J. (2019). Early Changes in Adipose Tissue Morphology, Gene Expression, and Metabolism After RYGB in Patients With Obesity and T2D. Journal of Clinical Endocrinology and Metabolism, 104(7), 2601-2613
Open this publication in new window or tab >>Early Changes in Adipose Tissue Morphology, Gene Expression, and Metabolism After RYGB in Patients With Obesity and T2D
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2019 (English)In: Journal of Clinical Endocrinology and Metabolism, ISSN 0021-972X, E-ISSN 1945-7197, Vol. 104, no 7, p. 2601-2613Article in journal (Refereed) Published
Abstract [en]

Context: Roux-en-Y gastric bypass (RYGB) surgery effectively prevents or treats type 2 diabetes (T2D). Adipose tissue (AT) mechanisms may be of importance.

Objective: To assess the relationship between early changes in whole-body and AT metabolism in surgically treated patients with T2D.

Design and Setting: A randomized single-center study.

Patients: Nineteen patients with T2D with body mass index 30 to 45 kg/m(2).

Interventions: Thirteen patients were assessed at baseline and 4 and 24 weeks after RYGB (preceded by a 4-week low-calorie diet) and compared with 6 control patients continuing standard medical treatment: oral glucose tolerance test, subcutaneous AT biopsies for gene expression, adipocyte size, glucose uptake, lipolysis, and insulin action.

Results: At 4 and 24 weeks post-RYGB, all patients but one had stopped diabetes medication. Fasting glucose, HbA(1c), and insulin levels decreased and the Matsuda index increased compared with baseline (P < 0.01 for all), indicating improved whole-body insulin sensitivity. Mean adipocyte size significantly reduced, more at 4 than at 24 weeks; at 4 weeks, glucose uptake per adipocyte was lowered, and isoproterenol-stimulated lipolysis tended to increase, whereas the fold insulin effects on glucose uptake and lipolysis were unchanged. Expression of genes involved in fatty acid oxidation, CPT1b and adiponectin, was increased at 4 weeks, whereas leptin and E2F1 (involved in cell proliferation) were reduced (P < 0.05 for all).

Conclusion: Glycemic control and in vivo insulin sensitivity improved 4 weeks after RYGB, but adipocyte insulin sensitivity did not change despite a marked reduction in adipocyte size. Thus, mechanisms for a rapid improvement of T2D after RYGB may occur mainly in other tissues than adipose.

National Category
Endocrinology and Diabetes
Identifiers
urn:nbn:se:uu:diva-390982 (URN)10.1210/jc.2018-02165 (DOI)000474806300015 ()30689903 (PubMedID)
Funder
EXODIAB - Excellence of Diabetes Research in Sweden
Available from: 2019-08-19 Created: 2019-08-19 Last updated: 2019-08-19Bibliographically approved
Almby, K. E., Abrahamsson, N., Lundqvist, M. H., Hammar, U., Thombare, K., Panagiotou, A., . . . Eriksson, J. (2019). Effects of GLP-1 on counter-regulatory responses during hypoglycemia after GBP surgery. European Journal of Endocrinology, 181(2), 161-171
Open this publication in new window or tab >>Effects of GLP-1 on counter-regulatory responses during hypoglycemia after GBP surgery
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2019 (English)In: European Journal of Endocrinology, ISSN 0804-4643, E-ISSN 1479-683X, Vol. 181, no 2, p. 161-171Article in journal (Refereed) Published
Abstract [en]

Objectives: The aim of the study was to explore the role of GLP-1 receptor activation on the counter-regulation and symptoms of hypoglycemia in subjects who have undergone gastric bypass surgery (GBP).

Design: Experimental hyperinsulinemic-hypoglycemic clamp study.

Methods: Twelve post-GBP subjects participated in a randomized cross-over study with two hyperinsulinemic, hypoglycemic clamps (glucose nadir 2.7 mmol/L) performed on separate days with concomitant infusions of the GLP-1 analog exenatide or with saline, respectively. Continuous measurements of metabolites and counter-regulatory hormones as well as assessments of heart rate variability and symptoms of hypoglycemia were performed throughout the clamps.

Results: No effect of GLP-1 receptor activation on counter-regulatory hormones (glucagon, catecholamines, cortisol, GH) or glucose infusion rate was seen, but we found indications of a downregulation of the sympathetic relative to the parasympathetic nerve activity, as reflected in heart rate variability. No significant differences in symptom of hypoglycemia were observed.

Conclusions/interpretation: Short-term exposure to a GLP-1 receptor agonist does not seem to impact the counter-regulatory hormonal and metabolic responses in post-GBP subjects during hypoglycemic conditions, suggesting that the improvement in symptomatic hypoglycemia post-GBP seen following treatment with GLP-1 receptor agonists may be mediated by mechanism not directly involved in counter-regulation.

Place, publisher, year, edition, pages
BIOSCIENTIFICA LTD, 2019
National Category
Endocrinology and Diabetes
Identifiers
urn:nbn:se:uu:diva-390513 (URN)10.1530/EJE-19-0171 (DOI)000472835100013 ()31176298 (PubMedID)
Funder
Swedish Diabetes AssociationErnfors FoundationEXODIAB - Excellence of Diabetes Research in Sweden
Available from: 2019-08-12 Created: 2019-08-12 Last updated: 2019-08-12Bibliographically approved
Pouwels, S., Topal, B., Knook, M. T., Celik, A., Sundbom, M., Ribeiro, R., . . . Ugale, S. (2019). Interaction of obesity and atrial fibrillation: an overview of pathophysiology and clinical management. Expert Review of Cardiovascular Therapy, 17(3), 209-223
Open this publication in new window or tab >>Interaction of obesity and atrial fibrillation: an overview of pathophysiology and clinical management
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2019 (English)In: Expert Review of Cardiovascular Therapy, ISSN 1477-9072, E-ISSN 1744-8344, Vol. 17, no 3, p. 209-223Article, review/survey (Refereed) Published
Abstract [en]

Introduction: Obesity, defined as a Body Mass Index (BMI) of ≥30 kg/m2, is the most common chronic metabolic disease worldwide and its prevalence has been strongly increasing. Obesity is associated with various diseases such as cardiovascular disease, type 2 diabetes, and hypertension. Regarding heart rhythm disorders, obesity is associated with an increase in atrial fibrillation (AF), the most common arrhythmia in clinical practice. AF is associated with increased cardiovascular morbidity and mortality. Obesity, a novel risk factor, is responsible for a 50%-increased incidence of AF.

Areas covered: We will briefly discuss the obesity paradox and its mechanisms regarding cardiac and hemodynamic function changes. In the first main part of this review, we will be discussing risk assessment studies, pathophysiology, genetic predisposition, epicardial adipose tissue, and ventricular adaptation in relation to obesity and development of AF. In the second part, we will discuss treatment strategies like conservative management and the effect of bariatric and metabolic surgery.

Expert opinion: Cardiac arrhythmias, in particular, AF, in patients with obesity comprise complex pathophysiological mechanisms that remain poorly understood. In recent literature, there has been increased interest in the role of epicardial adipose tissue and structural remodeling in obese hearts.

Keywords
Obesity, atrial fibrillation, bariatric surgery, metabolic surgery, heart rhythm disorders
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-380673 (URN)10.1080/14779072.2019.1581064 (DOI)000460928600006 ()30757925 (PubMedID)
Available from: 2019-04-01 Created: 2019-04-01 Last updated: 2019-04-01Bibliographically approved
Moren, Å., Sundbom, M., Ottosson, J. & Granstam, E. (2019). Response: Debate continues. Gastric bypass surgery does not increase the risk for sight-threatening diabetic retinopathy [Letter to the editor]. Acta Ophthalmologica, 97(5), E807-E808
Open this publication in new window or tab >>Response: Debate continues. Gastric bypass surgery does not increase the risk for sight-threatening diabetic retinopathy
2019 (English)In: Acta Ophthalmologica, ISSN 1755-375X, E-ISSN 1755-3768, Vol. 97, no 5, p. E807-E808Article in journal, Letter (Other academic) Published
Place, publisher, year, edition, pages
John Wiley & Sons, 2019
National Category
Ophthalmology
Identifiers
urn:nbn:se:uu:diva-390414 (URN)10.1111/aos.14022 (DOI)000474806400034 ()30632673 (PubMedID)
Available from: 2019-08-12 Created: 2019-08-12 Last updated: 2019-08-12Bibliographically approved
Stenberg, E., Persson, C., Näslund, E., Ottosson, J., Sundbom, M., Szabo, E. & Näslund, I. (2019). The impact of socioeconomic factors on the early postoperative complication rate after laparoscopic gastric bypass surgery: A register-based cohort study. Surgery for Obesity and Related Diseases, 15(4), 575-581
Open this publication in new window or tab >>The impact of socioeconomic factors on the early postoperative complication rate after laparoscopic gastric bypass surgery: A register-based cohort study
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2019 (English)In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 15, no 4, p. 575-581Article in journal (Refereed) Published
Abstract [en]

Background: Socioeconomic factors may influence the outcome of certain surgical procedures, but it is not known whether such factors influence the risk for postoperative complication after bariatric surgery. Objectives: Determining whether different socioeconomic factors influence the risk for postoperative complication after laparoscopic gastric bypass surgery. Setting: Nationwide in Sweden. Methods: Retrospective register-based cohort study that includes all primary laparoscopic gastric bypass procedures in Sweden between 2010 and 2016, using data from the Scandinavian Obesity Surgery Registry, Statistics Sweden, and the Swedish Population Register. Main outcome measures were occurrence and severity of early postoperative complications. Results: Included in this study were 41,537 patients with 30-day follow-up percentage of 96.7%. Study groups with increased risk for postoperative complication (age, sex, body mass index, and co-morbidity adjusted odds ratio with 95% confidence intervals) were as follows: being divorced, a widow, or a widower (1.14 [1.03-1.23]); receiving disability pension (1.37 [1.23-1.53]) or social assistance (1.22 [1.07-1.401); and being first- (1.22 [1.04-1.44]) or second-generation (1.20 [1.09-1.32]) immigrant. In contrast, being single (.90 [.83.991), having higher disposable income (50th-80th percentile:.84 [.76.93]; >80th percentile:.84 [72.98]), and living in a medium (.90 [.83.98]) or small (.84 [.76.92]) town were associated with lower risk. Increased risk for severe postoperative complication was seen for divorced, widowm, or widower (1.30 [1.12-1.521) and those receiving disability pension (1.37 [1.16-1.611) or social assistance (1.32 [1.08-1.62]), while higher disposable income (50th-80th percentile:.79 [.68.92]; >80th percentile .57 [.46.72]) was associated with lower risk. Conclusion: Socioeconomic factors influence the risk for early postoperative complication after laparoscopic gastric bypass surgery. The impact is not enough to exclude patients from surgery, but they must be taken into account in preoperative risk assessment.

Place, publisher, year, edition, pages
ELSEVIER SCIENCE INC, 2019
Keywords
Laparoscopy, Gastric bypass, Postoperative complication, Risk factor, Socioeconomic
National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-389982 (URN)10.1016/j.soard.2019.01.025 (DOI)000471741000006 ()30826242 (PubMedID)
Funder
Novo NordiskStockholm County Council
Available from: 2019-08-02 Created: 2019-08-02 Last updated: 2019-08-02Bibliographically approved
Sellberg, F., Possmark, S., Ghaderi, A., Näslund, E., Willmer, M., Tynelius, P., . . . Berglind, D. (2018). A dissonance-based intervention for women post roux-en-Y gastric bypass surgery aiming at improving quality of life and physical activity 24 months after surgery: study protocol for a randomized controlled trial. BMC Surgery, 18(25)
Open this publication in new window or tab >>A dissonance-based intervention for women post roux-en-Y gastric bypass surgery aiming at improving quality of life and physical activity 24 months after surgery: study protocol for a randomized controlled trial
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2018 (English)In: BMC Surgery, ISSN 1471-2482, E-ISSN 1471-2482, Vol. 18, no 25Article in journal (Refereed) Published
Abstract [en]

Background: Roux-en-Y gastric bypass (RYGB) surgery is the most common bariatric procedure in Sweden and results in substantial weight loss. Approximately one year post-surgery weight regain for these patient are common, followed by a decrease in health related quality of life (HRQoL) and physical activity (PA). Our aim is to investigate the effects of a dissonance-based intervention on HRQoL, PA and other health-related behaviors in female RYGB patients 24 months after surgery. We are not aware of any previous RCT that has investigated the effects of a similar intervention targeting health behaviors after RYGB.

Methods: The ongoing RCT, the “WELL-GBP”-trial (wellbeing after gastric bypass), is a dissonance-based intervention for female RYGB patients conducted at five hospitals in Sweden. The participants are randomized to either control group receiving usual follow-up care, or to receive an intervention consisting of four group sessions three months post-surgery during which a modified version of the Stice dissonance-based intervention model is used. The sessions are held at the hospitals, and topics discussed are PA, eating behavior, social and intimate relationships. All participants are asked to complete questionnaires measuring HRQoL and other health-related behaviors and wear an accelerometer for seven days before surgery and at six months, one year and two years after surgery. The intention to treat and per protocol analysis will focus on differences between the intervention and control group from pre-surgery assessments to follow-up assessments at 24 months after RYGB. Patients’ baseline characteristics are presented in this protocol paper.

Discussion: A total of 259 RYGB female patients has been enrolled in the “WELL-GBP”-trial, of which 156 women have been randomized to receive the intervention and 103 women to control group. The trial is conducted within a Swedish health care setting where female RYGB patients from diverse geographical areas are represented. Our results may, therefore, be representative for female RYGB patients in the country as a whole. If the intervention is effective, implementation within the Swedish health care system is possible within the near future.

Trial registration: The trial was registered on February 23th 2015 with registration number ISRCTN16417174.

Keywords
Bariatric surgery, Roux-en-Y gastric bypass, Dissonance-based, Intervention, RCT, Quality of life, Physical activity
National Category
Surgery Gastroenterology and Hepatology
Identifiers
urn:nbn:se:uu:diva-356494 (URN)10.1186/s12893-018-0358-7 (DOI)000431879900001 ()29743040 (PubMedID)
Funder
Swedish Research Council
Available from: 2018-07-30 Created: 2018-07-30 Last updated: 2018-07-30Bibliographically approved
Elias, K., Bekhali, Z., Hedberg, J., Graf, W. & Sundbom, M. (2018). Changes in bowel habits and patient-scored symptoms after Roux-en-Y gastric bypass and biliopancreatic diversion with duodenal switch. Surgery for Obesity and Related Diseases, 14(2), 144-149
Open this publication in new window or tab >>Changes in bowel habits and patient-scored symptoms after Roux-en-Y gastric bypass and biliopancreatic diversion with duodenal switch
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2018 (English)In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 14, no 2, p. 144-149Article in journal (Refereed) Published
Abstract [en]

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.

Keywords
Bowel habits, Duodenal switch, Fecal incontinence, Gastric bypass, Obesity
National Category
Gastroenterology and Hepatology Surgery
Identifiers
urn:nbn:se:uu:diva-333263 (URN)10.1016/j.soard.2017.09.529 (DOI)000427662500005 ()29108895 (PubMedID)
Available from: 2017-11-09 Created: 2017-11-09 Last updated: 2019-01-25Bibliographically approved
Hultin, H., Stevens, K. & Sundbom, M. (2018). Cholecalciferol Injections Are Effective in Hypovitaminosis D After Duodenal Switch: a Randomized Controlled Study. Obesity Surgery, 28(10), 3007-3011
Open this publication in new window or tab >>Cholecalciferol Injections Are Effective in Hypovitaminosis D After Duodenal Switch: a Randomized Controlled Study
2018 (English)In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 28, no 10, p. 3007-3011Article in journal (Refereed) Published
Abstract [en]

Background: By treating obesity, one of the major epidemics of this past century, through bariatric surgery, we may cause complications due to malnourishment in a growing population. At present, vitamin D deficiency is of interest, especially in patients with inferior absorption of fat-soluble nutrients after biliopancreatic diversion with duodenal switch (BPD/DS).

Methods: Twenty BPD/DS patients, approximately 4 years postoperatively, were randomized to either intramuscular supplementation of vitamin D with a single dose of 600,000 IU cholecalciferol, or a control group. Patients were instructed to limit their supplementation to 1400 IU of vitamin D and to avoid the influence of UV-B radiation; the study was conducted when sunlight is limited (December to May).

Results: Despite oral supplementation, a pronounced deficiency in vitamin D was seen (injection 19.3; control 23.2 nmol/l) in both groups. The cholecalciferol injection resulted in elevated 25[OH]D levels at 1 month (65.4 nmol/l), which was maintained at 6 months (67.4 nmol/l). This resulted in normalization of intact parathyroid hormone (PTH) levels. No changes in vitamin D or PTH occurred in the control group.

Conclusions: In BPD/DS patients, having hypovitaminosis D despite full oral supplementation, a single injection of 600,000 IU of cholecalciferol was effective in elevating vitamin D levels and normalizing levels of intact PTH. The treatment is simple and highly effective and thus recommended, especially in cases of reduced UV-B radiation.

Keywords
Hypovitaminosis D, Cholecalciferol, Biliopancreatic diversion, Duodenal switch
National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-366951 (URN)10.1007/s11695-018-3307-8 (DOI)000444768500004 ()29869004 (PubMedID)
Available from: 2018-11-28 Created: 2018-11-28 Last updated: 2018-11-28Bibliographically approved
Morén, Å., Sundbom, M., Ottosson, J. & Granstam, E. (2018). Gastric bypass surgery does not increase the risk for sight-threatening diabetic retinopathy. Acta Ophthalmologica, 96(3), 279-282
Open this publication in new window or tab >>Gastric bypass surgery does not increase the risk for sight-threatening diabetic retinopathy
2018 (English)In: Acta Ophthalmologica, ISSN 1755-375X, E-ISSN 1755-3768, Vol. 96, no 3, p. 279-282Article in journal (Refereed) Published
Abstract [en]

PURPOSE: To study the occurrence and level of diabetic retinopathy (DRP) before and after planned bariatric surgery and to investigate potential risk factors for deterioration of DRP.

METHODS: The Scandinavian Obesity Surgery Registry (SOReg) was used to identify diabetic patients who underwent gastric bypass (GBP) surgery at three centres in Sweden during 2008-2010. Information regarding DRP screening was obtained from ophthalmological patient charts. Patients who had DRP screening before and after GBP surgery were included in the study.

RESULTS: The survey included 117 patients. Mean age was 50 (SD 10) years, body mass index (BMI) 43 (SD 8) kg/m(2) and HbA1c 64 (SD 18) mmol/mol before surgery. One year post-GBP, BMI was reduced to 31 (SD 6) kg/m(2) . HbA1c was 43 (SD 10) mmol/mol, and in 66% (77/117) treatment for diabetes had been discontinued. Occurrence of DRP before GBP was as follows: no DRP 62%, mild 26%, moderate 10%, severe 0% and proliferative DRP 2%. No significant changes in occurrence of DRP after surgery were observed. Twelve patients (16%) developed mild DRP. In seven patients with pre-existing DRP, deterioration was observed and two of these patients required treatment for sight-threatening DRP. No association between preoperative BMI, HbA1c or reduction in HbA1c and worsening of DRP was found.

CONCLUSION: In a majority of patients, no deterioration of DRP following GBP was observed. Screening for DRP before planned surgery is recommended for all diabetic patients about to undergo bariatric surgery to identify any pre-existing DRP.

Keywords
bariatric surgery, diabetes mellitus, diabetic retinopathy, gastric bypass, registry study
National Category
Ophthalmology
Identifiers
urn:nbn:se:uu:diva-333266 (URN)10.1111/aos.13555 (DOI)000430912700035 ()28857463 (PubMedID)
Available from: 2017-11-09 Created: 2017-11-09 Last updated: 2018-07-31Bibliographically approved
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0002-6243-2859

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