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  • 1.
    Bekhali, Zakaria
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery. Gävle City Hospital, Sweden..
    Hedberg, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Hedenström, Hans
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Clinical Physiology.
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Large Buffering Effect of the Duodenal Bulb in Duodenal Switch: a Wireless pH-Metric Study2017In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 27, no 7, p. 1867-1871Article in journal (Refereed)
    Abstract [en]

    Bariatric procedures result in massive weight loss, however, not without side effects. Gastric acid is known to cause marginal ulcers, situated in the small bowel just distal to the upper anastomosis. We have used the wireless BRAVO (TM) system to study the buffering effect of the duodenal bulb in duodenal switch (DS), a procedure in which the gastric sleeve produces a substantial amount of acid. We placed a pre- and a postpyloric pH capsule in 15 DS-patients (seven men, 44 years, BMI 33) under endoscopic guidance and verified the correct location by fluoroscopy. Patients were asked to eat and drink at their leisure, and to register their meals for the next 24 h. All capsules but one could be successfully placed, without complications. Total registration time was 17.2 (1.3-24) hours prepyloric and 23.1 (1.2-24) hours postpyloric, with a corresponding pH of 2.66 (1.74-5.81) and 5.79 (4.75-7.58), p < 0.01. The difference in pH between the two locations was reduced from 3.55 before meals to 1.82 during meals, p < 0.01. Percentage of time with pH < 4 was 70.0 (19.9-92.0) and 13.0 (0.0-34.6) pre and postpylorically, demonstrating a large buffering effect. By this wireless pH-metric technique, we could demonstrate that the duodenal bulb had a large buffering effect, thus counteracting the large amount of gastric acid passing into the small bowel after duodenal switch. This physiologic effect could explain the low incidence of stomal ulcers.

  • 2. Berglind, Daniel
    et al.
    Willmer, Mikaela
    Eriksson, Ulf
    Thorell, Anders
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Uddén, Joanna
    Raoof, Mustafa
    Hedberg, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Tynelius, Per
    Näslund, Erik
    Rasmussen, Finn
    Longitudinal Assessment of Physical Activity in Women Undergoing Roux-en-Y Gastric Bypass2015In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 25, no 1, p. 119-125Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    Patients undergoing bariatric surgery do not seem to increase objectively measured physical activity (PA) after surgery, despite substantial weight loss. The aims of the present study were (i) to objectively characterize 3 months pre-surgery to 9 months postsurgery PA and sedentary behavior changes in women undergoing Roux-en-Y gastric bypass (RYGB) using tri-axial accelerometers and (ii) to examine associations between pre-surgery versus postsurgery PA and sedentary behavior with anthropometric measures taken in home environment.

    METHODS:

    Fifty-six women, with an average pre-surgery body mass index (BMI) of 37.6 (SD 2.6) and of age 39.5 years (SD 5.7), were recruited at five Swedish hospitals. PA was measured for 1 week by the Actigraph GT3X+ accelerometer, and anthropometric measures were taken at home visits 3 months pre-surgery and 9 months postsurgery, thus limiting seasonal effects.

    RESULTS:

    Average BMI loss, 9 months postsurgery, was 11.7 (SD 2.7) BMI units. There were no significant pre- to postsurgery differences in PA or sedentary behavior. However, pre-surgery PA showed negative association with PA change and positive association with postsurgery PA. Adjustments for pre-surgery BMI had no impact on these associations.

    CONCLUSIONS:

    No significant differences were observed in objectively measured changes in PA or time spent sedentary from 3 months pre-surgery to 9 months postsurgery among women undergoing RYGB. However, women with higher pre-surgery PA decreased their PA postsurgery while women with lower pre-surgery PA increased their PA.

  • 3.
    Claassen, Y. H. M.
    et al.
    Leiden Univ, Med Ctr, Dept Surg, K6-R,POB 9600, NL-2300 RC Leiden, Netherlands.
    Bastiaannet, E.
    Leiden Univ, Med Ctr, Dept Surg, K6-R,POB 9600, NL-2300 RC Leiden, Netherlands;Leiden Univ, Med Ctr, Dept Med Oncol, Leiden, Netherlands.
    Hartgrink, H. H.
    Leiden Univ, Med Ctr, Dept Surg, K6-R,POB 9600, NL-2300 RC Leiden, Netherlands.
    Dikken, J. L.
    Leiden Univ, Med Ctr, Dept Surg, K6-R,POB 9600, NL-2300 RC Leiden, Netherlands.
    de Steur, W. O.
    Leiden Univ, Med Ctr, Dept Surg, K6-R,POB 9600, NL-2300 RC Leiden, Netherlands.
    Slingerland, M.
    Leiden Univ, Med Ctr, Dept Med Oncol, Leiden, Netherlands.
    Verhoeven, R. H. A.
    Netherlands Comprehens Canc Org IKNL, Dept Res, Utrecht, Netherlands.
    van Eycken, E.
    Belgian Canc Registry, Brussels, Belgium.
    de Schutter, H.
    Belgian Canc Registry, Brussels, Belgium.
    Lindblad, M.
    Karolinska Univ Hosp, Dept Surg Gastroenterol, Stockholm, Sweden.
    Hedberg, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Johnson, E.
    Oslo Univ Hosp, Dept Gastroenterol, Oslo, Norway;Oslo Univ Hosp, Dept Paediat Surg, Oslo, Norway;Oslo Univ Hosp, Dept Oncol, Oslo, Norway.
    Hjortland, G. O.
    Univ Oslo, Inst Clin Med, Oslo, Norway.
    Jensen, L. S.
    Aarhus Univ Hosp, Dept Surg, Aarhus, Denmark.
    Larsson, H. J.
    Natl Qual Improvement Programme RKKP, Danish Natl Registries, Aarhus, Denmark.
    Koessler, T.
    Geneva Univ Hosp, Dept Med Oncol, Geneva, Switzerland.
    Chevallay, M.
    Geneva Univ Hosp, Dept Surg, Geneva, Switzerland.
    Allum, W. H.
    Royal Marsden NHS Fdn Trust, Dept Surg, London, England.
    van de Velde, C. J. H.
    Leiden Univ, Med Ctr, Dept Surg, K6-R,POB 9600, NL-2300 RC Leiden, Netherlands.
    International comparison of treatment strategy and survival in metastatic gastric cancer2019In: BJS OPEN, ISSN 2474-9842, Vol. 3, no 1, p. 56-61Article in journal (Refereed)
    Abstract [en]

    BackgroundIn the randomized Asian REGATTA trial, no survival benefit was shown for additional gastrectomy over chemotherapy alone in patients with advanced gastric cancer with a single incurable factor, thereby discouraging surgery for these patients. The purpose of this study was to evaluate treatment strategies for patients with metastatic gastric cancer in daily practice in five European countries, along with relative survival in each country. MethodsNationwide population-based data from Belgium, Denmark, the Netherlands, Norway and Sweden were combined. Patients with primary metastatic gastric cancer diagnosed between 2006 and 2014 were included. The proportion of gastric resections performed and the administration of chemotherapy (irrespective of surgery) within each country were determined. Relative survival according to country was calculated. ResultsOverall, 15 057 patients with gastric cancer were included. The proportion of gastric resections varied from 81 per cent in the Netherlands and Denmark to 183 per cent in Belgium. Administration of chemotherapy was 392 per cent in the Netherlands, compared with 632 per cent in Belgium. The 6-month relative survival rate was between 390 (95 per cent c.i. 378 to 402) per cent in the Netherlands and 541 (521 to 569) per cent in Belgium. ConclusionThere is variation in the use of gastrectomy and chemotherapy in patients with metastatic gastric cancer, and subsequent differences in survival.

  • 4.
    Edholm, David
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Axer, S
    Department of Surgery, Torsby Hospital, Torsby, Sweden.
    Hedberg, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Laparoscopy in Duodenal Switch: Safe and Halves Length of Stay in a Nationwide Cohort from the Scandinavian Obesity Registry2017In: Scandinavian Journal of Surgery, ISSN 1457-4969, E-ISSN 1799-7267, Vol. 106, no 3, p. 230-234Article in journal (Refereed)
    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.

  • 5.
    Edholm, David
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Kullberg, Joel
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Radiology, Oncology and Radiation Science, Radiology.
    Hänni, Arvo
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Geriatrics.
    Karlsson, Anders F.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences.
    Ahlström, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Hedberg, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Ahlström, Håkan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Radiology, Oncology and Radiation Science, Radiology.
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Preoperative 4-week low-calorie diet reduces liver volume and intrahepatic fat, and facilitates laparoscopic gastric bypass in morbidly obese2011In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 21, no 3, p. 345-350Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The aim of this study was to explore changes in liver volume and intrahepatic fat in morbidly obese patients during 4 weeks of low-calorie diet (LCD) before surgery and to investigate if these changes would facilitate the following laparoscopic gastric bypass.

    METHODS: Fifteen female patients (121.3 kg, BMI 42.9) were treated preoperatively in an open study with LCD (800-1,100 kcal/day) during 4 weeks. Liver volume and fat content were assessed by magnetic resonance imaging and spectroscopy before and after the LCD treatment.

    RESULTS: Liver appearance and the complexity of the surgery were scored at the operation. Eighteen control patients (114.4 kg, BMI 40.8), without LCD were scored similarly. Average weight loss in the LCD group was 7.5 kg, giving a mean weight of 113.9 kg at surgery. Liver volume decreased by 12% (p < 0.001) and intrahepatic fat by 40% (p < 0.001). According to the preoperative scoring, the size of the left liver lobe, sharpness of the liver edge, and exposure of the hiatal region were improved in the LCD group compared to the controls (all p < 0.05).

    CONCLUSIONS: The overall complexity of the surgery was perceived lower in the LCD group (p < 0.05), due to improved exposure and reduced psychological stress (both p < 0.05). Four weeks of preoperative LCD resulted in a significant decrease in liver volume and intrahepatic fat content, and facilitated the subsequent laparoscopic gastric bypass as scored by the surgeon

  • 6.
    Elias, Khalid
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Bekhali, Zakaria
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Hedberg, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Graf, Wilhelm
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Changes in bowel habits and patient-scored symptoms after Roux-en-Y gastric bypass and biliopancreatic diversion with duodenal switch2018In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 14, no 2, p. 144-149Article in journal (Refereed)
    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.

  • 7.
    Hansen, Tomas
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Radiology.
    Nilsson, M.
    Karolinska Inst, CLINTEC, Div Surg, Stockholm, Sweden;Karolinska Univ Hosp, Dept Upper Abdominal Surg, Div Canc, Stockholm, Sweden.
    Lindholm, Daniel P
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology.
    Sundström, Johan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Clinical Epidemiology.
    Hedberg, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Normal radiological lymph node appearance in the thorax2019In: Diseases of the esophagus, ISSN 1120-8694, E-ISSN 1442-2050, Vol. 32, no 10, p. 1-6Article in journal (Refereed)
    Abstract [en]

    Modern treatment of esophageal cancer is multimodal and highly dependent on a detailed diagnostic assessment of clinical stage, which includes nodal stage. Clinical appraisal of nodal stage is highly dependent on knowledge of normal radiological appearance, information of which is scarce. We aimed to describe lymph node appearance on computed tomography (CT) investigations in a randomly selected cohort of healthy subjects. In a sample of the Swedish Cardiopulmonary bioimage study, which investigates a sample of the Swedish population aged 50-64 years, the CT scans of 426 subjects were studied in detail concerning intrathoracic node stations relevant in clinical staging of esophageal cancer. With stratification for sex, the short axis of visible lymph nodes was measured and the distribution of lymph node sizes was calculated as well as proportion of patients with visible nodes above 5 and 10 millimeters for each station. Probability of having any lymph node station above 5 and 10 millimeters was calculated with a logistic regression model adjusted for age and sex. In the 214 men (aged: 57.3 +/- 4.1 years) and 212 women (aged: 57.8 +/- 4.4 years) included in this study, a total of 309 (72.5%) had a lymph node with a short axis of 5 mm or above was seen in at least one of the node stations investigated. When using 10 mm as a cutoff, nodes were visible in 29 (6.81%) of the subjects. Men had higher odds of having any lymph node with short axis 5 mm or above (OR 3.03 95% CI 1.89-4.85, P < 0.001) as well as 10 mm or above (OR 2.31 95% CI 1.02-5.23, P = 0.044) compared to women. Higher age was not associated with propensity for lymph nodes above 5 or 10 millimeters in this sample. We conclude that, in a randomly selected cohort of patients between 50 and 64 years, almost 10% of the men and 4% of the women had lymph nodes above 10 millimeters, most frequently in the subcarinal station (station 107). More than half of the patients had nodes above 5 millimeters on CT and men were much more prone to have this finding. The probability of finding lymph nodes in specific stations relevant of esophageal cancer is now described.

  • 8.
    Hedberg, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Gastrointestinal Physiology and Results following Bariatric Surgery2010Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The number of operations for morbid obesity is rising fast. We have examined aspects of postoperative physiology and results after bariatric surgery.

    The pH in the proximal pouch after Roux-en-Y gastric bypass (RYGBP) was investigated with catheter-based and wire-less technique. Gastric emptying, PYY-levels in the fasting state and after a standardized meal was evaluated after biliopancreatic diversion with duodenal switch (DS). A clinical trial was undertaken, comparing DS to RYGBP in patients with BMI>48. Main outcome variables were safety and long-term weight results as well as abdominal symptoms and laboratory results.

    Patients with stomal ulcer had significantly lower pH in their proximal gastric pouch as compared to asymptomatic control subjects. Long-time pH measurements with the wire-less BRAVO-system were feasible and demonstrated pH<4 in median 10.5% of the time in asymptomatic post-RYGBP patients. After DS, the T50 of gastric emptying was 28±16 minutes. PYY-levels were higher after DS than in age-matched control subjects. BMI-reduction was greater after DS (24 BMI-units) than after RYGBP (17 BMI-units) in median 3.5 (2.0-5.3) years after surgery (p<0.001). Fasting glucose and HbA1c levels were lower one and three years after DS as compared to RYGBP. On the other hand, DS-patients reported having more diarrhea and malodorous flatus.

    This thesis has resulted in deepened knowledge. Acid produced in the proximal pouch is an important pathogenetic factor in the development of stomal ulcer after RYGBP. However, symptom-free patients have an acidic environment in the proximal Roux-limb as well. After DS, gastric emptying is fast, but not instantaneous, and PYY-levels are high. DS results in superior weight reduction and better glucose control as compared to RYGBP in patients with BMI>48. We believe that DS has a place in surgical treatment of the super-obese, even though symptoms of diarrhea and malodorous flatus are more common after DS.

     

    List of papers
    1. Role of gastric acid in stomal ulcer after gastric bypass.
    Open this publication in new window or tab >>Role of gastric acid in stomal ulcer after gastric bypass.
    Show others...
    2005 (English)In: Obes Surg, ISSN 0960-8923, Vol. 15, no 10, p. 1375-8Article in journal (Refereed) Published
    Keywords
    Adult, Aged, Angiography/*methods, Artifacts, Balloon Dilatation, Contrast Media/administration & dosage, Female, Humans, Imaging; Three-Dimensional, Kidney Transplantation/radiography, Male, Middle Aged, Renal Artery/*radiography/*transplantation, Renal Artery Obstruction/*radiography, Reproducibility of Results, Research Support; Non-U.S. Gov't, Rotation
    Identifiers
    urn:nbn:se:uu:diva-75443 (URN)16354514 (PubMedID)
    Available from: 2006-06-29 Created: 2006-06-29 Last updated: 2011-01-11
    2. Wire-less pH-metry at the gastrojejunostomy after Roux-en-Y Gastric Bypass: a novel use of the BRAVO™-system
    Open this publication in new window or tab >>Wire-less pH-metry at the gastrojejunostomy after Roux-en-Y Gastric Bypass: a novel use of the BRAVO™-system
    2011 (English)In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 25, no 7, p. 2302-2307Article in journal (Refereed) Published
    Abstract [en]

    Background

    The number of gastric bypass operations being preformed is increasing rapidly due to good weight loss and alleviation of co-morbidities in combination with low mortality and morbidity. Stomal ulcers are, however, a clinical problem after gastric bypass, giving patients discomfort, risk of bleeding or even perforation. To measure the acidity in the proximal jejunum, we adopted the wire-less pH-metry (BRAVO-system) developed for evaluating reflux esophagitis.

    Methods

    25 patients (4 men, median age 44 years, BMI 29.3) who had undergone RYGBP 4 years earlier were recruited. Twenty-one asymptomatic, non-PPI users and in addition, four symtomatic patients (ongoing or stopped PPI-treatment) were studied. The wire-less BRAVO-capsule was positioned at the level of the gastrojejunal anastomosis under visual control with the endoscope. pH was registered for up to 48 hours. Time with pH<4 was calculated. Two patients were studied with two capsules.

    Results

    Of the 25 recruited patients capsule placement was successful in all but 2 patients, and in 3 patients a constant neutral environment was seen before a premature loss of signal, indicating early loss of position, thus 20 successful measurements were made. The mean time of registration was 25.7 hours (6.1-47.4, n=20). In the 16 asymtomatic patients, median percentage of time with pH<4 at the gastrojejunostomy was 10.6% (range 0.4 -37.7%). When dividing the registration time in day (08.00-22.00) and night (22.00-06.00), the median percentage of time with pH<4 was 8.4 and 6.3, respectively, (p=0.08). The two double measurements gave similar results indicating consistency. No complications occurred.

    Conclusion

    Wire-less pH-measurements in the proximal jejunum after gastric bypass are feasible and safe. The acidity was significant (10.5% of the registration time) even in asymptomatic patients with small gastric pouches. The described method could be useful in evaluation of epigastralgia after gastric bypass and in appraisal of PPI treatment of stomal ulcer.

     

    Keywords
    Gastric bypass, Stomal ulcer, Ulcer, pH-metry, Acid
    National Category
    Medical and Health Sciences
    Research subject
    Surgery
    Identifiers
    urn:nbn:se:uu:diva-131886 (URN)10.1007/s00464-010-1553-5 (DOI)000291690100034 ()21298531 (PubMedID)
    Available from: 2010-10-09 Created: 2010-10-09 Last updated: 2017-12-12Bibliographically approved
    3. Gastric Emptying and Postprandial PYY Response After Biliopancreatic Diversion with Duodenal Switch
    Open this publication in new window or tab >>Gastric Emptying and Postprandial PYY Response After Biliopancreatic Diversion with Duodenal Switch
    Show others...
    2011 (English)In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 21, no 5, p. 609-615Article in journal (Refereed) Published
    Abstract [en]

    BACKGROUND: Super-obesity (BMI > 50) is increasing rapidly. We use the biliopancreatic diversion with duodenal switch (BPD-DS) as one option in this patient category. The aim of the present study was to investigate the emptying of the gastric tube, PYY levels and dumping symptoms after BPD-DS.

    METHODS: Emptying of the gastric tube was investigated with scintigraphy after an overnight fast. Twenty patients (median age 43 years, BMI 31.1 kg/m(2)) having undergone BPD-DS in median 3.5 years previously were included in the scintigraphic study. A technetium-labelled omelette was ingested and scintigraphic evaluation of gastric emptying was undertaken. Ten of the patients also underwent PYY measurements after a standardised meal and were compared to nine non-operated age-matched normal weight controls, both in the fasting state and after the test meal. Frequency of dumping symptoms was evaluated in all patients.

    RESULTS: The half-emptying time was 28 ± 16 min. Lag phase was present in 30% of the patients. PYY levels were significantly higher in BPD-DS patients as compared to controls both in the fasting state (p < 0.001) and after the test meal (p < 0.001). Dumping symptoms were scarce and occurred in 17 of the 20 patients only few times yearly or less.

    CONCLUSIONS: Although the pylorus is preserved in BPD-DS, the stomach emptying is faster than in non-operated subjects. PYY levels are elevated in the fasting state after BPD-DS and a marked response to a test meal is seen, likely due to the rapid stimulation of intraluminal nutrients in the distal ileum. In spite of this, dumping symptoms are uncommon.

    Keywords
    Duodenal switch, Gastric emptying, PYY, Scintigraphy, Morbid obesity, Dumping
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:uu:diva-131876 (URN)10.1007/s11695-010-0288-7 (DOI)000289114300011 ()20862615 (PubMedID)
    Available from: 2010-10-08 Created: 2010-10-08 Last updated: 2017-12-12Bibliographically approved
    4. Superior weight loss and lower HbA1c 3 years after duodenal switch compared with Roux-en-Y gastric bypass: a randomized controlled trial
    Open this publication in new window or tab >>Superior weight loss and lower HbA1c 3 years after duodenal switch compared with Roux-en-Y gastric bypass: a randomized controlled trial
    2012 (English)In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 8, no 3, p. 338-343Article in journal (Refereed) Published
    Abstract [en]

    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 1SRCTN10940791), 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.

    Keywords
    Duodenal switch, Roux-en-Y gastric bypass, Weight loss, Abdominal symptoms, Glucose control
    National Category
    Surgery
    Research subject
    Surgery
    Identifiers
    urn:nbn:se:uu:diva-131888 (URN)10.1016/j.soard.2012.01.014 (DOI)000304520900015 ()
    Note
    Manuscript title: Superior weight loss and glucose control three years after duodenal switch compared to Roux-en-Y gastric bypassAvailable from: 2010-10-09 Created: 2010-10-09 Last updated: 2017-12-12Bibliographically approved
  • 9.
    Hedberg, Jakob
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Gustavsson, Sven
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Long-term follow-up in patients undergoing open gastric bypass as a revisional operation for previous failed restrictive procedures2012In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 8, no 6, p. 696-701Article in journal (Refereed)
    Abstract [en]

    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/m2, 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/m2. 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.

  • 10.
    Hedberg, Jakob
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Hedenström, Hans
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Clinical Physiology.
    Karlsson, F. Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences.
    Edén-Engström, Britt
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences.
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Gastric Emptying and Postprandial PYY Response After Biliopancreatic Diversion with Duodenal Switch2011In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 21, no 5, p. 609-615Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Super-obesity (BMI > 50) is increasing rapidly. We use the biliopancreatic diversion with duodenal switch (BPD-DS) as one option in this patient category. The aim of the present study was to investigate the emptying of the gastric tube, PYY levels and dumping symptoms after BPD-DS.

    METHODS: Emptying of the gastric tube was investigated with scintigraphy after an overnight fast. Twenty patients (median age 43 years, BMI 31.1 kg/m(2)) having undergone BPD-DS in median 3.5 years previously were included in the scintigraphic study. A technetium-labelled omelette was ingested and scintigraphic evaluation of gastric emptying was undertaken. Ten of the patients also underwent PYY measurements after a standardised meal and were compared to nine non-operated age-matched normal weight controls, both in the fasting state and after the test meal. Frequency of dumping symptoms was evaluated in all patients.

    RESULTS: The half-emptying time was 28 ± 16 min. Lag phase was present in 30% of the patients. PYY levels were significantly higher in BPD-DS patients as compared to controls both in the fasting state (p < 0.001) and after the test meal (p < 0.001). Dumping symptoms were scarce and occurred in 17 of the 20 patients only few times yearly or less.

    CONCLUSIONS: Although the pylorus is preserved in BPD-DS, the stomach emptying is faster than in non-operated subjects. PYY levels are elevated in the fasting state after BPD-DS and a marked response to a test meal is seen, likely due to the rapid stimulation of intraluminal nutrients in the distal ileum. In spite of this, dumping symptoms are uncommon.

  • 11.
    Hedberg, Jakob
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Hedenström, Hans
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences.
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Wire-less pH-metry at the gastrojejunostomy after Roux-en-Y Gastric Bypass: a novel use of the BRAVO™-system2011In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 25, no 7, p. 2302-2307Article in journal (Refereed)
    Abstract [en]

    Background

    The number of gastric bypass operations being preformed is increasing rapidly due to good weight loss and alleviation of co-morbidities in combination with low mortality and morbidity. Stomal ulcers are, however, a clinical problem after gastric bypass, giving patients discomfort, risk of bleeding or even perforation. To measure the acidity in the proximal jejunum, we adopted the wire-less pH-metry (BRAVO-system) developed for evaluating reflux esophagitis.

    Methods

    25 patients (4 men, median age 44 years, BMI 29.3) who had undergone RYGBP 4 years earlier were recruited. Twenty-one asymptomatic, non-PPI users and in addition, four symtomatic patients (ongoing or stopped PPI-treatment) were studied. The wire-less BRAVO-capsule was positioned at the level of the gastrojejunal anastomosis under visual control with the endoscope. pH was registered for up to 48 hours. Time with pH<4 was calculated. Two patients were studied with two capsules.

    Results

    Of the 25 recruited patients capsule placement was successful in all but 2 patients, and in 3 patients a constant neutral environment was seen before a premature loss of signal, indicating early loss of position, thus 20 successful measurements were made. The mean time of registration was 25.7 hours (6.1-47.4, n=20). In the 16 asymtomatic patients, median percentage of time with pH<4 at the gastrojejunostomy was 10.6% (range 0.4 -37.7%). When dividing the registration time in day (08.00-22.00) and night (22.00-06.00), the median percentage of time with pH<4 was 8.4 and 6.3, respectively, (p=0.08). The two double measurements gave similar results indicating consistency. No complications occurred.

    Conclusion

    Wire-less pH-measurements in the proximal jejunum after gastric bypass are feasible and safe. The acidity was significant (10.5% of the registration time) even in asymptomatic patients with small gastric pouches. The described method could be useful in evaluation of epigastralgia after gastric bypass and in appraisal of PPI treatment of stomal ulcer.

     

  • 12.
    Hedberg, Jakob
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Hänni, Arvo
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Geriatrics.
    Increased plasma magnesium concentrations 3 years after biliopancreatic diversion with duodenal switch2012In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 22, no 11, p. 1708-1713Article in journal (Refereed)
    Abstract [en]

    Background Biliopancreatic diversion with duodenal switch, BPD-DS, is a surgical procedure for treatment of super obese patients. It renders very good weight results and it strongly reduces the incidence of type 2 diabetes. One important mechanism of weight reduction after BPD-DS is malabsorption. Hypomagnesemia is an established cardiovascular risk factor. While it is wellknown that magnesium levels decline after jejuno-ileal bypass and increase after gastric bypass surgery, information on how magnesium status is affected by BPDDS is scant. The aim of the present study was to evaluate plasma magnesium concentrations (P-Mg) after BPD-DS. Methods Thirty-one patients, all Caucasians (9 diabetics, 12 men, age 38±8 years, weight 159±22 kg, body mass index (BMI) 53.9±5.2 kg/m 2) underwent BPD-DS. We evaluated weight, glycated hemoglobin levels (HbA1c) and P-Mg preoperatively as well as at 1 and 3 years after surgery. All subjects were treated with vitamin and mineral substitution after surgery, including 100 mg of magnesium salt. P-Mg was analyzed with respect to changes over time, correlation to BMI and HbA1c levels before and 3 years after surgery. Results The plasma magnesium concentrations increased by 15 % from 0.77±0.07 to 0.88±0.09 mmol/l over 3 years (p &lt;0.001). The weight loss was 71±25 kg. No patient had diabetes at follow-up. No correlations between P-Mg and BMI or HbA1c were seen. Conclusions Although exerting much of its weightreducing effect by a malabsorptive mechanism, BPD-DS yields a rise in P-Mg 3 years postoperatively, possibly contributing to the improved metabolic state after this operation.

  • 13.
    Hedberg, Jakob
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Reply to Gastric Emptying After Sleeve Gastrectomy (OBSU-D-11-00201)2011In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 21, no 11, p. 1812-1813Article in journal (Refereed)
  • 14.
    Hedberg, Jakob
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Superior weight loss and lower HbA1c 3 years after duodenal switch compared with Roux-en-Y gastric bypass: a randomized controlled trial2012In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 8, no 3, p. 338-343Article in journal (Refereed)
    Abstract [en]

    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 1SRCTN10940791), 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.

  • 15.
    Hedberg, Jakob
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Sundström, Johan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology.
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    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 comparisons2014In: Obesity Reviews, ISSN 1467-7881, E-ISSN 1467-789X, Vol. 15, no 7, p. 555-563Article in journal (Refereed)
    Abstract [en]

    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.

  • 16.
    Hedberg, Jakob
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Sundström, Johan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiovascular epidemiology. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, UCR-Uppsala Clinical Research Center.
    Thuresson, M.
    Aarskog, P.
    Oldgren, Jonas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, UCR-Uppsala Clinical Research Center. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology.
    Bodegard, J.
    Low-dose acetylsalicylic acid and gastrointestinal ulcers or bleeding - a cohort study of the effects of proton pump inhibitor use patterns2013In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 274, no 4, p. 371-380Article in journal (Refereed)
    Abstract [en]

    Objective 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). Design and setting A nationwide cohort study in Sweden. Patients All Swedish residents 40years of age, without cancer and receiving LDA treatment (80% adherence for 365days between 2005 and 2009) were identified in the Swedish Prescription Register. Continuous PPI use was defined as >60 of 90days covered by daily PPI doses and further divided into high (80%) or moderate (<80) adherence. All other PPI use was defined as intermittent use. Main outcome measures The risk of a combined end-point of gastrointestinal ulcer or bleeding was analysed using Cox proportional hazard models. We also investigated risk of >45days of LDA treatment interruption. Results During a median follow-up of 2.5years, 7880 of 648807 (1.2%) LDA-treated patients experienced gastrointestinal events. In multivariable-adjusted models, both intermittent-PPI and no-PPI use were associated with increased risk of gastrointestinal ulcers or bleeding compared with continuous PPI use with a high level of adherence [hazard ratio (HR) 1.83 (95% CI 1.66-2.02) and 1.14 (95% CI 1.05-1.23), respectively]. Amongst continuous PPI users, moderate adherence also increased the risk of gastrointestinal ulcers or bleeding [HR 1.22 (95% CI 1.07-1.40)]. The risk of LDA treatment interruption was higher with intermittent PPI use [HR 1.16 (95% CI 1.14-1.19)] than continuous PPI use with high adherence. Conclusions In this large cohort of LDA users, intermittent PPI use was associated with higher risk of gastrointestinal ulcers or bleeding and interrupted LDA treatment, compared with continuous PPI use.

  • 17.
    Hedberg, Jakob
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Zacharias, Hanna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Janson, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Preoperative Slow-Release Morphine Reduces Need of Postoperative Analgesics and Shortens Hospital Stay in Laparoscopic Gastric Bypass2016In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 26, no 4, p. 757-761Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: As most bariatric procedures are performed by laparoscopy, hospital stay is exceptionally short, despite the habitus of patients and the rather extensive intra-abdominal surgery. To facilitate postoperative mobilization, most patients are given repeated single doses of morphine, a drug with several side effects. We aimed to evaluate the effect of preoperative treatment with a tablet of slow-release morphine (SRM) on postoperative analgesic consumption and length of stay (LOS) in laparoscopic gastric bypass (LGBP).

    METHODS: The SRM group (244 patients) was retrospectively compared to a control group (197 patients) concerning postoperative pain management and hospital stay by studying medical charts and data from Scandinavian Obesity Surgery Registry (SOReg).

    RESULTS: Patients in the SRM group needed significantly less analgesics during days 0, 1, and 2 postoperatively, morphine 10.7 vs. 13.6 mg, 10.2 vs. 13.9 mg, and 1.1 vs. 3.6 mg, respectively, p < 0.05, as well as acetaminophen, p < 0.05. According to a subgroup analysis, 20 mg of SRM was needed to obtain these effects. In addition, SRM patients had shorter hospital stay (2.3 vs. 3.5 days, p < 0.05) than the control group. No negative side effects were seen.

    CONCLUSIONS: Preoperatively administered slow-release morphine significantly reduced the need for postoperative analgesics and shortened hospital stay, without side effects or other complications. At our department, the studied regime is now routinely used in all bariatric surgery and we have started to use the concept in other groups of surgical patients.

  • 18.
    Lagerros, Ylva Trolle
    et al.
    Karolinska Inst, Dept Med, Clin Epidemiol Unit, Stockholm, Sweden; Karolinska Univ Hosp Huddinge, Dept Endocrinol Metab & Diabet, Stockholm, Sweden.
    Brandt, Lena
    Karolinska Inst, Dept Med, Clin Epidemiol Unit, Stockholm, Sweden.
    Hedberg, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Bodén, Robert
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Psychiatry, University Hospital. Karolinska Inst, Dept Med, Clin Epidemiol Unit, Stockholm, Sweden.
    Suicide, Self-harm, and Depression After Gastric Bypass Surgery: A Nationwide Cohort Study2017In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 265, no 2, p. 235-243Article in journal (Refereed)
    Abstract [en]

    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.

  • 19. Lagerros, Ylva Trolle
    et al.
    Brandt, Lena
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Hedberg, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Boden, Robert
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Psychiatry, University Hospital.
    Risk of Suicide, Self-Harm and Depression after Gastric Bypass2015In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 25, p. S127-S127Article in journal (Other academic)
  • 20.
    Linder, Gustav
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Hedberg, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Perfusion of the gastric conduit during esophagectomy2017In: Diseases of the esophagus, ISSN 1120-8694, E-ISSN 1442-2050, Vol. 30, no 1, p. 143-149Article in journal (Refereed)
    Abstract [en]

    In esophageal cancer surgery, perfusion of the gastric conduit is a critical issue. Measurement of gastric intramucosal pH (pHi ) is a method to identify anaerobic metabolism as a sign of impaired perfusion. In this study we aimed to monitor changes in the perfusion of the gastric conduit at key steps during and after esophagectomy. pHi was measured per- and postoperatively using intermittent gastric tonometry in 32 patients undergoing open, 65%, or video-assisted thoracoscopic esophagectomy for esophageal cancer. Measurements focused on the surgical steps when the vascular supply to the gastric conduit was altered. A tonometry catheter was successfully placed in all patients and a decrease in pHi (mean ± SD) was observed from baseline to after the division of the short gastric vessels (7.33 ± 0.07 to 7.29 ±  0.07, P  = 0.005). A further reduction after the ligation of the left gastric artery (7.26 ± 0.08, P  < 0.001) and after final linear stapling the gastric conduit (7.15 ± 0.13, P  < 0.001) was observed. Two hours after surgery, pHi increased (7.24 ± 0.09, P  = 0.002). In contrast to open surgery, a trend towards less reduction in pHi was seen in thoracoscopic surgery. Patients with anastomotic leaks had lower pHi on the first postoperative day (7.12 ± 0.05 vs. 7.27 ± 0.08, P  = 0.040). It can be concluded that each surgical step altering the vascular supply to the gastric conduit resulted in detectable changes, however transient, in pHi . Patients with low pHi on the first postoperative day were more prone to have clinically relevant anastomotic leaks.

  • 21.
    Linder, Gustav
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Jestin, Christine
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Hedberg, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Increased lymph node yield with minimally invasive compared to open esophagectomyManuscript (preprint) (Other academic)
  • 22.
    Linder, Gustav
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Korsavidou Hult, Nafsika
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Radiology.
    Bjerner, Tomas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Radiology.
    Ahlström, Håkan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Radiology. Antaros Med AB, Molndal, Sweden.
    Hedberg, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    F-18-FDG-PET/MRI in preoperative staging of oesophageal and gastroesophageal junctional cancer2019In: Clinical Radiology, ISSN 0009-9260, E-ISSN 1365-229X, Vol. 74, no 9, p. 718-725Article in journal (Refereed)
    Abstract [en]

    AIM: To evaluate integrated 2-[F-18]-fluoro-2-deoxy-D-glucose (F-18-FDG) positron-emission tomography (PET)/magnetic resonance imaging (MRI), in comparison with the standard technique, integrated F-18-FDG-PET/computed tomography (CT), in preoperative staging of oesophageal or gastroesophageal junctional cancer.

    MATERIALS AND METHODS: In the preoperative staging of 16 patients with oesophageal or gastroesophageal junctional cancer, F-18-FDG-PET/MRI was performed immediately following the clinically indicated F-18-FDG-PET/CT. MRI-sequences included T1-weighted fat-water separation (Dixon's technique), T2-weighted, diffusion-weighted imaging (DWI), and gadolinium contrast-enhanced T1-weighted three-dimensional (3D) imaging. PET was performed with F-18-FDG. Two separate teams of radiologists conducted structured blinded readings of F-18-FDG-PET/MRI or F-18-FDG-PET/CT, which were then compared regarding tumour measurements and characteristics as well as assessment of inter-rater agreement (Cohen's kappa) for the clinical tumour, nodal and metastatic (TNM) stage.

    RESULTS: There were no medical complications. Comparison of tumour measurements revealed high correlations without significant differences between modalities. The maximum standardised uptake value (SUVmax) values of the primary tumour with F-18-FDG-PET/MRI had excellent correlation to those of F-18-FDG-PET/CT (0.912, Spearman's rho). Inter-rater agreement between the techniques regarding T-stage was only fair (Cohen's kappa, 0.333), arguably owing to relative over-classification of the T-stage using F-18-FDG-PET/CT. Agreements in the assessment of N- and M-stage were substantial (Cohen's kappa, 0.849 and 0.871 respectively).

    CONCLUSION: Preoperative staging with F-18-FDG-PET/MRI is safe and promising with the potential to enhance tissue resolution in the area of interest. F-18-FDG-PET/MRI and F-18-FDG-PET/CT correlated well for most of the measured values and discrepancies were seen mainly in the assessment of the T-stage. These results facilitate further studies investigating the role of F-18-FDG-PET/MRI in, e.g., predicting or determining the response to neoadjuvant therapy. 

  • 23.
    Linder, Gustav
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Korsavidou-Hult, Nafsika
    Bjerner, Tomas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Radiology.
    Ahlström, Håkan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Radiology.
    Hedberg, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    18F-FDG-PET/MRI in preoperative staging of esophageal- and gastroesophageal junctional cancerManuscript (preprint) (Other academic)
  • 24.
    Linder, Gustav
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Sandin, Fredrik
    Regional Cancer Center Sweden, Uppsala, Sweden.
    Johansson, Jan
    Department of Surgery, Skåne University Hospital, Lund, Sweden.
    Lindblad, Mats
    University Hospital and Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.
    Lundell, Lars
    University Hospital and Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.
    Hedberg, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Patient education-level affects treatment allocation and prognosis in esophageal- and gastroesophageal junctional cancer in Sweden.2018In: Cancer Epidemiology, ISSN 1877-7821, E-ISSN 1877-783X, Vol. 52, p. 91-98Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Low socioeconomic status and poor education elevate the risk of developing esophageal- and junctional cancer. High education level also increases survival after curative surgery. The present study aimed to investigate associations, if any, between patient education-level and treatment allocation after diagnosis of esophageal- and junctional cancer and its subsequent impact on survival.

    METHODS: A nation-wide cohort study was undertaken. Data from a Swedish national quality register for esophageal cancer (NREV) was linked to the National Cancer Register, National Patient Register, Prescribed Drug Register, Cause of Death Register and educational data from Statistics Sweden. The effect of education level (low; ≤9 years, intermediate; 10-12 years and high >12 years) on the probability of allocation to curative treatment was analyzed with logistic regression. The Kaplan-Meier-method and Cox proportional hazard models were used to assess the effect of education on survival.

    RESULTS: A total of 4112 patients were included. In a multivariate logistic regression model, high education level was associated with greater probability of allocation to curative treatment (adjusted OR: 1.48, 95% CI: 1.08-2.03, p = 0,014) as was adherence to a multidisciplinary treatment-conference (adjusted OR: 3.13, 95% CI: 2.40-4.08, p < 0,001). High education level was associated with improved survival in the patients allocated to curative treatment (HR: 0.82, 95% CI: 0.69-0.99, p = 0,036).

    DISCUSSION: In this nation-wide cohort of esophageal- and junctional cancer patients, including data regarding many confounders, high education level was associated with greater probability of being offered curative treatment and improved survival.

  • 25.
    Norlén, Olov
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Endocrine Surgery.
    Stålberg, Peter
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Endocrine Surgery.
    Öberg, Kjell
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences.
    Eriksson, John
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Endocrine Surgery.
    Hedberg, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Hessman, Ola
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Endocrine Surgery.
    Tiensuu Janson, Eva
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences.
    Hellman, Per
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Endocrine Surgery.
    Åkerström, Göran
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Endocrine Surgery.
    Long-Term Results of Surgery for Small Intestinal Neuroendocrine Tumors at a Tertiary Referral Center2012In: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 36, no 6, p. 1419-1431Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    Small intestinal neuroendocrine tumors (SI-NETs) are uncommon, with an annual incidence of about 1 per 100,000 individuals. The primary tumor (PT) is generally small, but nevertheless the majority of patients have mesenteric lymph node metastases and liver metastases at diagnosis. Our aim was to identify prognostic factors for survival and to evaluate outcome after surgery in SI-NET patients.

    MATERIAL AND METHODS:

    We included 603 consecutive patients (325 men; age at diagnosis 63 ± 11 years [mean ± SD]) with histopathologically verified SI-NET, who were diagnosed between 1985 and 2010. Hospital charts were reviewed and were scrutinized for carcinoid heart disease (CHD), flush and/or diarrhea, proliferation by Ki-67 index, mesenteric lymph node metastases (m.lgllm), distant abdominal lymph node metastases (da.lgllm), liver tumor load (LTL), extra-abdominal metastases (EAM), locoregional resective surgery, as well as debulking of LTL, and adverse events after surgery.

    RESULTS:

    Median overall survival (OS) was 8.4 years; 5-year OS was 67%, and 5-year relative survival was 74%. Independent prognostic factors by univariate and multivariate analysis were age at diagnosis, CHD, m.lgllm, da.lgllm, LTL, EAM, peritoneal carcinomatosis (PC), and proliferation. Locoregional resective surgery was associated with increased survival on crude and multivariate analysis. The 30-day mortality in our institution after initial locoregional resective surgery was 0.5% (1/205).

    CONCLUSIONS:

    For the first time, m.lgllm and da.lgllm, LTL, PC, and EAM are demonstrated to be independent prognostic factors by multivariate analysis. Locoregional removal of the PT/m.lgllm. was a positive prognostic factor by crude and adjusted analysis and may influence survival.

  • 26.
    Sima, Eduardo
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Hedberg, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Ehrenborg, A
    University Hospital, 75185, Uppsala, Sweden.
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Differences in Early Complications between Circular and Linear Stapled Gastrojejunostomy in Laparoscopic Gastric Bypass2014In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, no 4, p. 599-603Article in journal (Refereed)
    Abstract [en]

    BACKGROUND

    Laparoscopic gastric bypass (LGBP) is the most common bariatric procedure worldwide. The gastrojejunostomy can be stapled with a circular or linear stapler, each with their own specific advantages. We have evaluated differences in postoperative complications between the two techniques.

    METHODS

    We studied operative data and postoperative complications in 560 patients (79.8 % females, median age 42, BMI 42.5) operated with LGBP between 2008 and 2012 at our center. The gastrojejunostomy was initially performed using a circular stapler (CS) in 288 patients and later by linear stapler (LS) in 272. Complications, operative time, and length of stay were retrieved from our database. The risk of developing a port site infection was evaluated with multivariate logistic regression.

    RESULTS

    Port site infections were more common with CS than LS, 5.2 and 0.4 %, respectively (p < 0.01). Multivariate analysis demonstrated CS to be an independent risk factor for port site infections (OR 16.3 (2.09-126), p < 0.01), as well as for stomal ulcers (OR 10.1, 1.15-89, p = 0.04). Major postoperative complications remained unchanged (anastomotic leak 1.0 vs. 1.1 %, abscess 0.7 vs. 0.4 %), while operative time and length of stay were found to be shorter using the LS (122 vs. 83 min, p < 0.001 and 4 vs. 3 days, p < 0.001).

    CONCLUSIONS

    The linear stapled technique yielded lower incidence of port site infections, probably by avoiding the passage of a contaminated circular stapler through the abdominal wall. No difference in major complications was seen, but operative time was shorter using a linear stapler instead of a circular stapler.

  • 27.
    Sima, Eduardo
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Hedberg, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Gastrointestinal symptoms, weight loss and patient satisfaction 5 years after gastric bypass: a study of three techniques for the gastrojejunal anastomosis.2016In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 30, no 4, p. 1553-1558Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The optimal operative technique in gastric bypass (RYGB) is still under debate. We have studied patient-reported gastrointestinal symptoms and weight loss 5 years after RYGB performed with three different stapling techniques for the gastrojejunal anastomosis (GJ).

    METHODS: Out of 593 patients operated with RYGB, 489 patients [80.2 % women, body mass index (BMI) 44.9 (33-68) kg/m(2)] answered our 5-year follow-up questionnaire concerning gastrointestinal symptoms (vomiting, reflux, dumping, abdominal pain or diarrhea), weight loss, need for postoperative endoscopic interventions and overall satisfaction with the procedure. We compared the results for three different GJ techniques: linear stapler (LS, n = 103), 21-mm circular stapler (C21, n = 88) and 25-mm circular stapler (C25, n = 298).

    RESULTS: Dumping was the most commonly reported symptom (14.1 % of all patients on a weekly to daily basis), however, less frequently reported in the C25 group (p < 0.05). Vomiting, prevalent in 2.9 % of all patients, was more frequently reported in the C21 group (p < 0.01). No group consistently showed greater weight loss compared to the other two groups. A higher incidence of endoscopic dilatations due to strictures was reported in the C21 group (12.5 % compared to 4.5 % of all patients, p < 0.05). Overall patient satisfaction was high (88 %).

    CONCLUSION: Our data suggest that the technique for the construction of the GJ in RYGB affects gastrointestinal symptoms 5 years postoperatively. The difference is moderate but indicates that a narrow GJ results in increased frequency of vomiting and need for endoscopic interventions without improving the weight result.

  • 28.
    Skogar, Martin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Holmbäck, Ulf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism.
    Hedberg, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Risérus, Ulf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism.
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Preserved Fat-Free Mass after Gastric Bypass and Duodenal Switch2017In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 27, no 7, p. 1735-1740Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Concerns for the possibility of an excessive loss of fat-free mass (FFM) and resting metabolic rate (RMR) after bariatric surgery, such as Roux-en-Y gastric bypass (RYGB) and duodenal switch (BPD/DS), have been raised.

    OBJECTIVES: This study aims to examine body composition and RMR in patients after RYGB and BPD/DS and in non-operated controls.

    METHODS: Body composition and RMR were studied with Bod Pod and indirect calorimetry in weight-stable RYGB (n = 15) and BPD/DS patients (n = 12) and compared with non-operated controls (n = 17). All patients were 30-55 years old and weight stable with BMI 28-35 kg/m(2).

    RESULTS: FFM% was 58% (RYGB), 61% (BPD/DS), and 58% (controls). Body composition did not differ after RYGB and BPD/DS compared to controls, despite 27 and 40% total body weight loss, respectively. No difference in RMR or RMR/FFM was observed (1539, 1617, and 1490 kcal/24 h; and 28.9, 28.4, and 28.8 kcal/24 h/kg).

    CONCLUSION: Weight-stable patients with BMI 28-35 kg/m(2) after RYGB and BPD/DS have a body composition and RMR similar to that of non-operated individuals within the same BMI interval.

  • 29.
    Sundbom, Magnus
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Edholm, David
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Sima, Eduardo
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Hedberg, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Superior Weight Loss and Improvement in Comorbidities After Duodenal Switch Compared to Gastric Bypass in Patients with BMI > 482013In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 23, no 8, p. 1155-1155Article in journal (Other academic)
  • 30.
    Sundbom, Magnus
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Hedberg, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Geographical differences in upper abdominal resectional surgery and high-volume procedures in Sweden during 2009-20112014In: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 49, no 2, p. 246-252Article in journal (Refereed)
    Abstract [en]

    Background

    Upper abdominal surgery comprises many different procedures, from major resectional surgery on the esophagus, stomach, liver, and pancreas, to high-volume operations such as cholecystectomy and bariatric surgery. The aim of the present study was to evaluate geographical differences, if any, in number of procedures performed per capita among the 6 healthcare regions and the 21 Swedish counties, responsible for the health care of its inhabitants.

    Methods

    Data on resectional surgery and high-volume procedures were collected for the study period (2009-2011) from the Swedish National Patient Register. Annual number of procedures and procedures performed per 100,000 inhabitants was registered based on the place of residence of patients.

    Results

    In the six healthcare regions, the number of resections per 100,000 inhabitants on the esophagus varied from 1.8 to 3.9, stomach 5.3-6.7, liver 6.7-13.2, and pancreas 4.9-8.3. Corresponding figures for cholecystectomies were 146.7-191.3 and for bariatric surgery 33.1-97.4. The southeast region had the highest incidence of major resectional surgery, except for gastric resections. A high number of cholecystectomies were performed in all regions. Bariatric surgery was most common in the Stockholm region. At county level, the variations were larger, particularly for liver surgery and high-volume procedures.

    Conclusion

    Significant geographical differences were observed between the six healthcare regions and at county level, when studying the number of procedures performed per 100,000 inhabitants. We believe that this reflects local traditions in selection of patients for resectional surgery and differences in capacity for meeting the high demand for bariatric surgery.

  • 31.
    Sundbom, Magnus
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Hedberg, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Successful stenting of four spontaneous oesophageal perforations in a single patient during a 3-year period2016In: Journal of Surgical Case Reports, ISSN 2042-8812, E-ISSN 2042-8812, no 5, article id rjw046Article in journal (Refereed)
    Abstract [en]

    Spontaneous oesophageal perforation, a rare condition associated with high mortality due to mediastinitis and multi-organ failure, can be treated surgically or with endoscopic stents. We present a case of four right-sided oesophageal perforations during a 3-year period in a single patient, all successfully stented. The 51-year-old Caucasian male had his first oesophageal perforation in 2012, which was successfully treated with a fully covered endoscopic stent. No residual pathology was seen at stent removal. Two years later, the patient was successfully treated with stents twice for recurrent perforations. The fourth spontaneous perforation at the same site occurred this fall, and again endoscopic treatment was successful. The patient does not report any squeals. In spite of the successful outcome, we would like to emphasize the need for close surveillance and readiness for definitive surgical treatment.

  • 32.
    Sundbom, Magnus
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Hedberg, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Trends in use of upper abdominal procedures in sweden 1998-2011: a population-based study2014In: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 38, no 1, p. 33-39Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    Surgical care is constantly developing as demographic shifts occur and indications change when new techniques are introduced. The purpose of this study was to describe trends of in-hospital upper abdominal procedures in Sweden during 1998-2011.

    METHODS:

    Data were collected from the National Patient Register containing annual number of procedures and procedures per 100,000 inhabitants. Comparisons were made between the first 3 years (1998-2000) and last 3 years (2009-2011). High-volume procedures and resectional surgery were studied in particular.

    RESULTS:

    During the study period, a total of 435,394 upper abdominal procedures were performed in 318,991 individuals. The number of procedures increased 44.9 % between the early and late period. Bariatric surgery increased almost sixfold, with a substantial increase in laparoscopic gastric bypass to 58.2/100,000/year. The most common operation was cholecystectomy, 144.9/100,000/year. Liver resections tripled and, in total, major resectional surgery, performed on the esophagus, stomach, liver, and pancreas, increased by 36.3 %. Per 100,000 adult inhabitants and year, resections of the esophagus was performed in 2.3 patients, stomach in 5.9, liver in 9.0, and pancreas in 5.7, in late time period. An increase in all types of endoscopic work was observed.

    CONCLUSIONS:

    In total, the number of upper abdominal procedures performed per inhabitant increased. Laparoscopic gastric bypass increased substantially and became the second most common procedure after laparoscopic cholecystectomy. An increase in resectional surgery was observed.

  • 33.
    Sundbom, Magnus
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Hedberg, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Use of Laparoscopy in Gastrointestinal Surgery in Sweden 1998-2014: A Nationwide Study2017In: Scandinavian Journal of Surgery, ISSN 1457-4969, E-ISSN 1799-7267, Vol. 106, no 1, p. 34-39Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND AIMS: One by one, minimally invasive alternatives to established gastrointestinal procedures have become clinical routine. We have studied the use of laparoscopy in four common procedures-cholecystectomy, appendectomy, reflux surgery, and bariatric surgery-as well as in major resectional gastrointestinal surgery in Sweden.

    MATERIALS AND METHODS: The National Patient Registry was used to identify all in-hospital procedures performed in patients above the age of 15 during 1998-2014, meeting our inclusion criteria. For each group, the annual number of procedures and proportion of laparoscopic surgery were studied, as well as applicable subgroups. Differences in age, gender, as well as geographical differences were evaluated in the most recent 3-year period (2012-2014).

    RESULTS: In total, 537,817 procedures were studied, 43% by laparoscopic approach. In 2012-2014, the proportion of laparoscopic surgery ranged from high rates in the four common procedures (cholecystectomy 81%, appendectomy 47%, reflux surgery 72%, and bariatric surgery 97%) to rather low numbers in resectional surgery (4%-10%), however, increasing in the last years. In appendectomy and cholecystectomy, men were less likely to have laparoscopic surgery (42% versus 51% and 74% versus 85%, respectively, p < 0.001). Substantial geographical differences in the use of laparoscopy were also noted, for example, the proportion of laparoscopic appendectomy varied from 11% to 76% among the 21 different Swedish counties.

    CONCLUSION: The proportion of laparoscopy was high in the four common procedures and low, but rising, in major resectional surgery. A large variation in the proportion of laparoscopic surgery by age, gender, and place of residence was noted.

  • 34.
    Sundbom, Magnus
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Hedberg, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Ottosson, Johan
    Aortic injuries during laparoscopic gastric bypass for morbid obesity in Sweden 2009-2010: a nationwide survey2014In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 10, no 2, p. 203-207Article in journal (Refereed)
    Abstract [en]

    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.

  • 35.
    Sundbom, Magnus
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Hedberg, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Ljungman, Christer
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Haglund, Ulf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Aortaskada - ovanlig men svårt komplikation vid gastrisk bypass: överviktsoperation kan ge livshotande blödning, visar tre fallbeskrivningar2011In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 108, no 4, p. 146-9Article in journal (Refereed)
  • 36.
    Sundström, Johan
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, UCR-Uppsala Clinical Research Center.
    Hedberg, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Thuresson, Marcus
    Statisticon AB, Uppsala, Sweden..
    Aarskog, Pernilla
    AstraZeneca Nord Balt, Sodertalje, Sweden..
    Johannesen, Kasper Munk
    Linkoping Univ, Linkoping, Sweden..
    Oldgren, Jonas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, UCR-Uppsala Clinical Research Center.
    Low-Dose Aspirin Discontinuation and Risk of Cardiovascular Events: A Swedish Nationwide, Population-Based Cohort Study2017In: Circulation, ISSN 0009-7322, E-ISSN 1524-4539, Vol. 136, no 13, p. 1183-1192Article in journal (Refereed)
    Abstract [en]

    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.

  • 37. Willmer, Mikaela
    et al.
    Berglind, Daniel
    Thorell, Anders
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Uddén, Joanna
    Raoof, Mustafa
    Hedberg, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Tynelius, Per
    Ghaderi, Ata
    Näslund, Erik
    Rasmussen, Finn
    Changes in BMI and Psychosocial Functioning in Partners of Women Who Undergo Gastric Bypass Surgery for Obesity2015In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 25, no 2, p. 319-324Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    There is very little research exploring the effects of Roux-en-Y gastric bypass surgery (RYGB) on the patient's partner. The aim of the present study was to investigate longitudinally whether male partners of female RYGB patients were affected in terms of BMI, sleep quality, body dissatisfaction, depression, and anxiety.

    METHODS:

    Thirty-seven women, with partners who were willing to participate, were recruited from RYGB waiting lists at five Swedish hospitals. Data collection took place during two home visits, 3 months before and 9 months after RYGB surgery. Anthropometrical data were documented, and both women and men completed the Hospital Anxiety and Depression Scale (HADS) and the Karolinska Sleep Questionnaire (KSQ). The men also completed the Male Body Dissatisfaction Scale (MBDS).

    RESULTS:

    The men's BMI changes between the two time points that were analysed using general estimating equation (GEE) regression. Their BMI decreased significantly (β = -0.9, p = 0.004). The change was more pronounced in the 26 men who had a baseline BMI of ≥25 (β = -1.4, p < 0.001). Fixed-effects regression showed a statistically significant association between the men's weight loss and that of the women (β = 0.3, p = 0.004). There were no significant changes in the men's HADS, KSQ, or MBDS scores.

    CONCLUSIONS:

    Overweight/obese male partners of RYGB patients also lose weight during the first 9 months post-operatively. However, symptoms of body dissatisfaction, anxiety, and depression remain unchanged, as does self-reported sleep quality.

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