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Johansson, H.-E., Edholm, D., Kullberg, J., Rosqvist, F., Rudling, M., Straniero, S., . . . Risérus, U. (2019). Energy restriction in obese women suggest linear reduction of hepatic fat content and time-dependent metabolic improvements. Nutrition & Diabetes, 9(1), Article ID 34.
Open this publication in new window or tab >>Energy restriction in obese women suggest linear reduction of hepatic fat content and time-dependent metabolic improvements
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2019 (English)In: Nutrition & Diabetes, ISSN 2044-4052, E-ISSN 2044-4052, Vol. 9, no 1, article id 34Article in journal (Refereed) Published
Abstract [en]

Energy restriction reduces liver fat, improves hepatic insulin resistance and lipid metabolism. However, temporal data in which these metabolic improvements occur and their interplay is incomplete. By performing repeated MRI scans and blood analysis at day 0, 3, 7, 14 and 28 the temporal changes in liver fat and related metabolic factors were assessed at five times during a low-calorie diet (LCD, 800-1100 kcal/day) in ten obese non-diabetic women (BMI 41.7 ± 2.6 kg/m2) whereof 6 had NAFLD. Mean weight loss was 7.4 ± 1.2 kg (0.7 kg/day) and liver fat decreased by 51 ± 16%, resulting in only three subjects having NAFLD at day 28. Marked alteration of insulin, NEFA, ALT and 3-hydroxybuturate was evident 3 days after commencing LCD, whereas liver fat showed a moderate but a linear reduction across the 28 days. Other circulating-liver fat markers (e.g. triglycerides, adiponectin, stearoyl-CoA desaturase-1 index, fibroblast growth factor 21) demonstrated modest and variable changes. Marked elevations of NEFA, 3-hydroxybuturate and ALT concentrations occurred until day 14, likely reflecting increased tissue lipolysis, fat oxidation and upregulated hepatic fatty acid oxidation. In summary, these results suggest linear reduction in liver fat, time-specific changes in metabolic markers and insulin resistance in response to energy restriction.

National Category
Endocrinology and Diabetes Nutrition and Dietetics
Identifiers
urn:nbn:se:uu:diva-397554 (URN)10.1038/s41387-019-0100-2 (DOI)000497994200004 ()31685793 (PubMedID)
Available from: 2019-11-21 Created: 2019-11-21 Last updated: 2019-12-18Bibliographically approved
Vidarsson, B., Sundbom, M. & Edholm, D. (2019). Incidence and treatment of leak at the gastrojejunostomy in Roux-en-Y gastric bypass: a cohort study of 40,844 patients. Surgery for Obesity and Related Diseases, 15(7), 1075-1079
Open this publication in new window or tab >>Incidence and treatment of leak at the gastrojejunostomy in Roux-en-Y gastric bypass: a cohort study of 40,844 patients
2019 (English)In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 15, no 7, p. 1075-1079Article in journal (Refereed) Published
Abstract [en]

Background: Leak at the gastrojejunostomy (GJ) after Roux-en-Y gastric bypass is a rare but life-threatening complication. Objectives: To assess incidence, risk factors, treatment, and outcome of leaks at the GJ after Roux-en-Y gastric bypass in a nationwide cohort. Setting: Sweden. Methods: Leaks at GJ within 30 days postoperatively in 40,844 patients (age 41 yr, females 76%, and body mass index of 42.4 kg/m(2)) between 2007 and 2014 in the Scandinavian Obesity Surgery Registry were assessed. Register data and outcomes were verified by reviewing patient charts. Logistic regression was done to estimate odds ratios (ORs) for significant risk factors. Results: Leak at the GJ was registered in 262 (.6%) patients, with 44% diagnosed within the first 3 postoperative days. Risk factors were male sex (OR 1.5 [1.1-1.9]), age >= 49 years (OR 1.9 [1.3-2.7]), diabetes (OR 1.4 [1.1-1.9]), conversion to open surgery (OR 3.9 [2.2-6.9]), and operative time >= 90 minutes (OR 2.6 [1.8-3.8]). In most patients, the leak resulted in a severe complication. Reoperative surgery was done in 85%, with the placement of a feeding gastrostomy in 24%. Stents were used at some time point in 31% of leaks. Of all patients with leaks, 25% required intensive care, 4% developed multiorgan failure, and 1% died. Median duration of stay for patients with leaks was 22 days, versus 2 days for others (P < .001). Conclusion: GJ leaks occurred in .6% of patients. Risk factors were male sex, age >= 49 years, diabetes, operative time >= 90 minutes, and conversion to open surgery. Surgical reintervention was common. Mortality was 1%. (C) 2019 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.

Place, publisher, year, edition, pages
ELSEVIER SCIENCE INC, 2019
Keywords
Complications, RYGB, Gastric bypass, Leaks, Reoperation
National Category
Gastroenterology and Hepatology Surgery
Identifiers
urn:nbn:se:uu:diva-394171 (URN)10.1016/j.soard.2019.04.033 (DOI)000483453000006 ()31201112 (PubMedID)
Available from: 2019-10-08 Created: 2019-10-08 Last updated: 2019-10-08Bibliographically approved
Edholm, D. (2018). Early intake of solid food after Roux-en-Y gastric bypass and complications. A cohort study from the Scandinavian Obesity Surgery Registry. Surgery for Obesity and Related Diseases, 14(9), 1256-1260
Open this publication in new window or tab >>Early intake of solid food after Roux-en-Y gastric bypass and complications. A cohort study from the Scandinavian Obesity Surgery Registry
2018 (English)In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 14, no 9, p. 1256-1260Article in journal (Refereed) Published
Abstract [en]

Background: Roux-en-Y gastric bypass (RYGB) is the most common bariatric procedure worldwide. There are few studies investigating how early return to solid food affects complications.

Objective: The aim of this study was to explore how oral intake was resumed in RYGB patients and how the postoperative food regimen affects outcomes, such as complications and length of stay. Setting: Retrospective nationwide registry study.

Methods: The Scandinavian Obesity Surgery Registry included prospective data from RYGB patients operated in 2009 to 2014. A questionnaire assessed the postoperative reintroduction of solid food applied at each bariatric center. The postoperative regimen was established in 23,589 patients. Outcomes were recorded at 30-day follow-up according to the standard Scandinavian Obesity Surgery Registry routine.

Results: Nine percent of patients (n = 2074) returned to solid food within the first week after surgery. Most commonly solid food was resumed in week 4 (37%, n=8659). Median length of stay was 2 days for all. Of all, 2.8% suffered from a severe complication (>Clavien-Dindo 3a). After adjusting for the annual volume of procedures at hospitals, there was no correlation that the timing of solid food affected complication rates. The odds ratio for a severe complication was significantly lower for intermediate- (odds ratio .64 95% confidence interval .48.85) or high (odds ratio .52 95% confidence interval .42.66) volume centers. The rate of leaks and small bowel obstructions were evenly distributed between the different postoperative food regimens.

Conclusion: Early return to solid food after RYGB did not affect the risk of severe complications. Patients operated at centers with an annual volume of > 100 procedures have a lower risk of severe complications. (C) 2018 American Society for Bariatric Surgery. 

Place, publisher, year, edition, pages
ELSEVIER SCIENCE INC, 2018
Keywords
Gastric bypass, Enhanced recovery, Fast track, Bariatric surgery
National Category
Gastroenterology and Hepatology Surgery
Identifiers
urn:nbn:se:uu:diva-369522 (URN)10.1016/j.soard.2018.05.023 (DOI)000448491100006 ()30001890 (PubMedID)
Available from: 2018-12-19 Created: 2018-12-19 Last updated: 2018-12-19Bibliographically approved
Vidarsson, B., Sundbom, M. & Edholm, D. (2018). LEAK AT GASTROJEJUNOSTOMY AFTER ROUX-EN-Y GASTRIC BYPASS-40,844 PATIENTS FROM THE SCANDINAVIAN OBESITY SURGERY REGISTRY (SOREG). Paper presented at 23rd World Congress of the International-Federation-for-the-Surgery-of-Obesity-and-Metabolic-Disord ers (IFSO), SEP 26-29, 2018, Dubai, U ARAB EMIRATES.. Obesity Surgery, 28(Issue 2 Supplement), 215-215
Open this publication in new window or tab >>LEAK AT GASTROJEJUNOSTOMY AFTER ROUX-EN-Y GASTRIC BYPASS-40,844 PATIENTS FROM THE SCANDINAVIAN OBESITY SURGERY REGISTRY (SOREG)
2018 (English)In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 28, no Issue 2 Supplement, p. 215-215Article in journal, Meeting abstract (Other academic) Published
National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-369224 (URN)10.1007/s11695-018-3411-9 (DOI)000445203700214 ()
Conference
23rd World Congress of the International-Federation-for-the-Surgery-of-Obesity-and-Metabolic-Disord ers (IFSO), SEP 26-29, 2018, Dubai, U ARAB EMIRATES.
Note

Meeting Abstract: O (215)

Available from: 2018-12-11 Created: 2018-12-11 Last updated: 2018-12-11Bibliographically approved
Visser, E., Edholm, D., Smithers, B. M., Thomson, I. G., Burmeister, B. H., Walpole, E. T., . . . Barbour, A. P. (2018). Neoadjuvant chemotherapy or chemoradiotherapy for adenocarcinoma of the esophagus. Journal of Surgical Oncology, 117(8), 1687-1696
Open this publication in new window or tab >>Neoadjuvant chemotherapy or chemoradiotherapy for adenocarcinoma of the esophagus
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2018 (English)In: Journal of Surgical Oncology, ISSN 0022-4790, E-ISSN 1096-9098, Vol. 117, no 8, p. 1687-1696Article in journal (Refereed) Published
Abstract [en]

BackgroundThe optimal treatment strategy for patients with esophageal adenocarcinoma (EAC) remains undetermined. This study compared outcomes in patients undergoing neoadjuvant chemotherapy (nCT) and neoadjuvant chemoradiotherapy (nCRT) for EAC. MethodsPatients who underwent nCT or nCRT followed by surgery for EAC were identified from a prospective database (2000-2017) and included. After propensity score matching, the impact of the treatments on postoperative complications, in-hospital mortality, pathological outcomes, and survival rates were compared. ResultsOf the 396 eligible patients, 262 patients were analysed following matching with 131 patients in both groups. There were no significant differences between the nCT and nCRT groups for overall complications (59% vs 57%, P=0.802) or in-hospital mortality (2% vs 0%, P=0.156). Patients who had nCRT had more R0 resections (93% vs 83%, P=0.013), and higher pathological complete response rates (15% vs 5%, P<0.001). No differences in 5-year overall survival rates (nCT vs nCRT; 44% vs 33%, P=0.645) were found. ConclusionIn this study no differences between nCT and nCRT were seen in postoperative complications and in-hospital mortality in patients treated for EAC. Inspite of improved complete resection and pathological response there was no difference in the overall survival between the treatment modalities.

Place, publisher, year, edition, pages
WILEY, 2018
Keywords
adenocarcinoma, esophageal carcinoma, neoadjuvant therapy, outcome, survival
National Category
Surgery Cancer and Oncology
Identifiers
urn:nbn:se:uu:diva-365990 (URN)10.1002/jso.25089 (DOI)000444419500009 ()29806960 (PubMedID)
Funder
The Swedish Medical Association
Available from: 2018-11-22 Created: 2018-11-22 Last updated: 2018-11-22Bibliographically approved
Straniero, S., Rosqvist, F., Edholm, D., Ahlström, H., Kullberg, J., Sundbom, M., . . . Rudling, M. (2017). Acute caloric restriction counteracts hepatic bile acid and cholesterol deficiency in morbid obesity. Journal of Internal Medicine, 281(5), 507-517
Open this publication in new window or tab >>Acute caloric restriction counteracts hepatic bile acid and cholesterol deficiency in morbid obesity
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2017 (English)In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 281, no 5, p. 507-517Article in journal (Refereed) Published
Abstract [en]

Background

Bile acid (BA) synthesis is regulated by BA signalling in the liver and by fibroblast growth factor 19 (FGF19), synthesized and released from the intestine. In morbid obesity, faecal excretion and hepatic synthesis of BAs and cholesterol are strongly induced and caloric restriction reduces their faecal excretion considerably. We hypothesized that the high intestinal food mass in morbidly obese subjects promotes faecal excretion of BAs and cholesterol, thereby creating a shortage of both BAs and cholesterol in the liver.

Methods

Ten morbidly obese women (BMI 42 ± 2.6 kg m−2) were monitored on days 0, 3, 7, 14 and 28 after beginning a low‐calorie diet (800–1100 kcal day−1). Serum was collected and liver size and fat content determined. Synthesis of BAs and cholesterol was evaluated from serum markers, and the serum levels of lipoproteins, BAs, proprotein convertase subtilisin/kexin type 9 (PCSK9), insulin, glucose and FGF19 were monitored. Fifty‐four nonobese women (BMI <25 kg m−2) served as controls.

Results

At baseline, synthesis of both BAs and cholesterol and serum levels of BAs and PCSK9 were elevated in the obese group compared to controls. Already after 3 days on a low‐calorie diet, BA and cholesterol synthesis and serum BA and PCSK9 levels normalized, whereas LDL cholesterol increased. FGF19 and triglyceride levels were unchanged, and liver volume was reduced by 10%.

Conclusions

The results suggest that hepatic BAs and cholesterol are deficient in morbid obesity. Caloric restriction rapidly counteracts these deficiencies, normalizing BA and cholesterol synthesis and circulating PCSK9 levels, indicating that overproduction of cholesterol in enlarged peripheral tissues cannot explain this phenotype. We propose that excessive food intake promotes faecal loss of BAs and cholesterol contributing to their hepatic deficiencies.

Keywords
bile acid synthesis, cholesterol synthesis, proprotein convertase subtilisin/kexin type 9
National Category
Nutrition and Dietetics Gastroenterology and Hepatology
Identifiers
urn:nbn:se:uu:diva-316832 (URN)10.1111/joim.12599 (DOI)000458735700009 ()28261926 (PubMedID)
Funder
Swedish Research Council, 2015-02781Swedish Heart Lung Foundation, 20160491Stockholm County Council, ALF 20150447Swedish Diabetes Association
Available from: 2017-03-07 Created: 2017-03-07 Last updated: 2019-12-16Bibliographically approved
Petrus, P., Edholm, D., Rosqvist, F., Dahlman, I., Sundbom, M., Arner, P., . . . Risérus, U. (2017). Depot-specific differences in fatty acid composition and distinct associations with lipogenic gene expression in abdominal adipose tissue of obese women. International Journal of Obesity, 41(8), 1295-1298
Open this publication in new window or tab >>Depot-specific differences in fatty acid composition and distinct associations with lipogenic gene expression in abdominal adipose tissue of obese women
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2017 (English)In: International Journal of Obesity, ISSN 0307-0565, E-ISSN 1476-5497, Vol. 41, no 8, p. 1295-1298Article in journal (Refereed) Published
Abstract [en]

Cardiometabolic diseases are primarily linked to enlarged visceral adipose tissue (VAT). However, some data suggest heterogeneity within the subcutaneous adipose tissue (SAT) depot with potential metabolic differences between the superficial SAT (sSAT) and deep SAT (dSAT) compartments. We aimed to investigate the heterogeneity of these three depots with regard to fatty acid (FA) composition and gene expression. Adipose tissue biopsies were collected from 75 obese women undergoing laparoscopic gastric bypass surgery. FA composition and gene expression were determined with gas chromatography and quantitative real-time-PCR, respectively. Stearoyl CoA desaturase-1 (SCD-1) activity was estimated by product-to-precursor FA ratios. All polyunsaturated FAs (PUFA) with 20 carbons were consistently lower in VAT than either SAT depots, whereas essential PUFA (linoleic acid, 18:2n-6 and α-linolenic acid, 18:3n-3) were similar between all three depots. Lauric and palmitic acid were higher and lower in VAT, respectively. The SCD-1 product palmitoleic acid as well as estimated SCD-1 activity was higher in VAT than SAT. Overall, there was a distinct association pattern between lipid metabolizing genes and individual FAs in VAT. In conclusion, SAT and VAT are two distinct depots with regard to FA composition and expression of key lipogenic genes. However, the small differences between sSAT and dSAT suggest that FA metabolism of SAT is rather homogenous.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-333246 (URN)10.1038/ijo.2017.106 (DOI)000407050500023 ()28465608 (PubMedID)
Funder
Swedish Research Council
Available from: 2017-11-09 Created: 2017-11-09 Last updated: 2017-11-21Bibliographically approved
Edholm, D., Axer, S., Hedberg, J. & Sundbom, M. (2017). Laparoscopy in Duodenal Switch: Safe and Halves Length of Stay in a Nationwide Cohort from the Scandinavian Obesity Registry. Scandinavian Journal of Surgery, 106(3), 230-234
Open this publication in new window or tab >>Laparoscopy in Duodenal Switch: Safe and Halves Length of Stay in a Nationwide Cohort from the Scandinavian Obesity Registry
2017 (English)In: Scandinavian Journal of Surgery, ISSN 1457-4969, E-ISSN 1799-7267, Vol. 106, no 3, p. 230-234Article in journal (Refereed) Published
Abstract [en]

BACKGROUND AND AIMS:

Unsatisfactory weight loss after gastric bypass or sleeve gastrectomy in super-obese patients (body mass index > 50) is a growing concern. Biliopancreatic diversion with duodenal switch results in greater weight loss, but is technically challenging to perform, especially as a laparoscopic procedure (Lap-DS). The aim of this study was to compare perioperative outcomes of Lap-DS and the corresponding open procedure (O-DS) in Sweden.

MATERIAL AND METHODS:

The data source was a nationwide cohort from the Scandinavian Obesity Surgery Registry and 317 biliopancreatic diversion with duodenal switch patients (mean body mass index = 56.7 ± 6.6 kg/m2, 38.4 ± 10.2 years, and 57% females) were analyzed. Follow-up at 30 days was complete in 98% of patients.

RESULTS:

The 53 Lap-DS patients were younger than the 264 patients undergoing O-DS (35.0 vs 39.1 years, p = 0.01). Operative time was 163 ± 38 min for lap-DS and 150 ± 31 min for O-DS, p = 0.01, with less bleeding in Lap-DS (94 vs 216 mL, p < 0.001). There was one conversion to open surgery. Patients undergoing Lap-DS had a shorter length of stay than O-DS, 3.3 versus 6.6 days, p = 0.02. No significant differences in overall complications within 30 days were seen (12% and 17%, respectively). Interestingly, the two leaks in Lap-DS were located at the entero-enteric anastomosis, while three out of four leaks in O-DS occurred at the top of the gastric tube.

CONCLUSION:

Lap-DS can be performed by dedicated bariatric surgeons as a single-stage procedure. The use of laparoscopic approach halved the length of stay, without increasing the risk for complications significantly. Any difference in long-term weight result is pending.

National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-310879 (URN)10.1177/1457496916673586 (DOI)000408224300007 ()27765899 (PubMedID)
Available from: 2016-12-20 Created: 2016-12-20 Last updated: 2017-12-13Bibliographically approved
Vidarsson, B., Sundbom, M. & Edholm, D. (2017). Shorter overall operative time when barbed suture is used in primary laparoscopic gastric bypass: A cohort study of 25,006 cases. Surgery for Obesity and Related Diseases, 13(9), 1484-1488, Article ID S1550-7289(17)30204-6.
Open this publication in new window or tab >>Shorter overall operative time when barbed suture is used in primary laparoscopic gastric bypass: A cohort study of 25,006 cases
2017 (English)In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 13, no 9, p. 1484-1488, article id S1550-7289(17)30204-6Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Closing the remaining opening in a linear stapled anastomosis, for example in laparoscopic Roux-en-Y gastric bypass (LRYGB), can be challenging.

OBJECTIVES: To evaluate if the novel unidirectional barbed suture (BS) is of value in LRYGB compared with polyfilament (PS) suture. We have compared operative time, early complications, and length of stay, as well as anastomotic strictures and small bowel obstruction during the first year.

SETTING: Retrospective study from the Scandinavian Obesity Surgery Registry (SOReg).

METHODS: A nationwide cohort of 25,006 primary LRYGB (2211 BS and 22,795 PS) from SOReg were studied. No preoperative differences in age or gender were noted; however, BS patients had lower Body Mass Index (BMI) (41.3 versus 42.3 kg/m(2), P<.001) and less diabetes (13.7% versus 15.4%, P = .03).

RESULTS: Total operative time was 11 minutes (16%) shorter using BS compared with PS (58 versus 69 minutes, P<.001), although the mesenteric openings were more frequently closed among BS patients (94% versus 71%, P<.001). No differences were seen in early complications; anastomotic leaks or intra-abdominal abscesses were noted in 1.8% and 1.4%, respectively, P = .17. The incidence of anastomotic strictures was similar (.13% versus .17%, P = .73) as was the incidence of surgery for small bowel obstruction (1.8% versus 1.6%, P = .69).

CONCLUSIONS: The use of barbed suture for closing the remaining opening in the gastrojejunostomy shortened the operative time without increasing the risk of complications. BS is still uncommon in LRYGB, but its implementation could have significant impact on operative time.

Keywords
Barbed suture, Complications, Gastric bypass, LRYGB, Operative time
National Category
Gastroenterology and Hepatology Surgery
Identifiers
urn:nbn:se:uu:diva-333250 (URN)10.1016/j.soard.2017.04.017 (DOI)000413392900003 ()28732747 (PubMedID)
Available from: 2017-11-09 Created: 2017-11-09 Last updated: 2018-02-01Bibliographically approved
Edholm, D. & Näslund, I. (2016). Anastomotic techniques in open Roux-en-Y gastric bypass: primary open surgery and converted procedures. Surgery for Obesity and Related Diseases, 12(4), 784-788
Open this publication in new window or tab >>Anastomotic techniques in open Roux-en-Y gastric bypass: primary open surgery and converted procedures
2016 (English)In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 12, no 4, p. 784-788Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Open Roux-en-Y gastric bypass (RYGB) may be chosen because of known widespread adhesions or as a result of conversion during laparoscopic surgery. Although conversions are rare, they occur even in experienced hands. The gastrojejunostomy may be performed with a circular stapler (CS) or a linear stapler (LS) or may be entirely hand sewn (HS). Our aim was to study differences in outcomes regarding the anastomotic techniques utilized in open surgery.

SETTING: Nationwide cohort.

METHODS: Data on open surgery, both primary open and converted procedures from Scandinavian Obesity Surgery Registry were analyzed for the years 2007-2013. Outcomes were assessed through multivariate analysis, adjusting for gender, age, preoperative body mass index, diabetes, conversion, and technique used for the gastrojejunostomy.

RESULTS: CS was the most common method used for primary open RYGB (58%), whereas LS was the most common for converted RYGB (63%). HS was uncommon in both groups. Operative time was shorter for LS than for CS in the primary open RYGB (110±40 min versus 132±46 min; P<.001). Anastomotic leakage rates were similar in primary open RYGB (1.0%-2.4%), but leakage rates for LS in converted procedures was 10.1%, thus higher compared with 2.1% in converted CS patients (P = .02). Odds ratio for leakage was 2.87 (95% confidence interval 1.18-6.97) for LS using CS as a reference when adjusting for variables above.

CONCLUSION: LS was associated to increased risk of leakage in patients with conversion from laparoscopic RYGB to open RYGB. Conversion to open surgery was associated to increased risk of leakage. Technique used for the gastrojejunostomy did not affect weight loss.

Keywords
Morbid obesity; Gastric bypass; Gastrojejunostomy; Complications; Anastomosis; Stapling technique
National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-285843 (URN)10.1016/j.soard.2015.11.026 (DOI)000378365000009 ()26833186 (PubMedID)
Available from: 2016-04-19 Created: 2016-04-19 Last updated: 2017-11-30Bibliographically approved
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0003-2172-5310

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