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Background: Patients undergoing metabolic bariatric surgery are at risk of both venous thromboembolism (VTE) and bleeding complications, but the optimal thromboprophylaxis strategy remains uncertain. Therefore, this retrospective cohort study evaluated perioperative outcomes depending on the perioperative thromboprophylaxis strategy

Methods: This study used data from the validated nationwide Scandinavian Obesity Surgery Registry, including all primary bariatric procedures in Sweden between 2008 and 2023. Exposures were timing of initiation (preoperative, postoperative, other) and the duration of thromboprophylaxis (< 7, 7-10, 11-14, or > 14 days). The primary outcome was VTE; secondary outcomes were intraoperative and postoperative bleeding. Outcomes were analysed using logistic regression models, adjusting for demographic, clinical, and surgical covariates.

Results: Among 83 801 patients (76.9% female, mean age 40.9 years, mean body mass index 41.8 kg/m²), the incidences of VTE, intraoperative bleeding, and postoperative bleeding were 0.1% (76 patients), 0.7% (577), and 1.6% (1373), respectively. No statistically significant associations were observed between the timing of thromboprophylaxis and VTE, or between thromboprophylaxis duration and either VTE or postoperative bleeding. Initiation of prophylaxis after surgery was associated with a lower risk of intraoperative bleeding than preoperative initiation (odds ratio 0.52; 95% confidence interval 0.37 to 0.74). Risk factors for VTE included previous VTE, intraoperative bleeding, and longer operating time, whereas risk factors for postoperative bleeding included higher age, male sex, cardiovascular co-morbidity, and antidepressant use.

Conclusion: The overall incidence of thrombotic complications after metabolic bariatric surgery was low, whereas bleeding events were more common. Compared with preoperative thromboprophylaxis initiation, postoperative initiation was associated with reduced intraoperative bleeding, whereas no increase in VTE was detected.

Background: The global prevalence of obesity is rising and has been linked to increased perioperative risks in esophageal cancer surgery, while its impact on long-term survival remains uncertain. This study aims to examine the association between body mass index (BMI, kg/m²) and perioperative complications and long-term survival.

Methods: This nationwide, population-based cohort study included all patients undergoing esophageal cancer resection in Sweden between 2006 and 2018. Data were obtained from the National Register for Esophageal and Gastric Cancer. Patients were categorized by BMI as underweight (<20), normal (20-24.9), overweight (25-30), or obese (>30). Logistic regression and Cox regression were used for adjusted analyses, reporting odds ratios (ORs) and hazard ratios (HRs) with 95% confidence intervals (CIs).

Results: A total of 1494 patients (81.6% male) were included, and out of these, there were 227 (15.2%) patients with obesity. Patients with obesity had more comorbidities, more often adenocarcinoma, and underwent surgery more frequently during the later time period of the study. Compared with patients with normal weight, obesity was not associated with increased risk of surgical complications (OR = 0.92, 95% CI: 0.62-1.39), but obesity was linked to higher risk of non-surgical complications, including pulmonary embolism (OR = 1.64, 95% CI: 1.10-2.45). Obesity was associated with reduced all-cause mortality (HR = 0.75, 95% CI: 0.57-0.98).

Conclusion: Patients with obesity undergoing esophagectomy did not have higher rates of surgical complications but faced an elevated risk of non-surgical complications. Obesity appeared linked to better long-term survival. However, residual confounding, including potential reverse causation from pre-diagnosis weight loss, cannot be excluded.

Studying the pathogenesis of human-adapted microorganisms is challenging, since small animal models often fail to recapitulate human physiology. Hence, the comprehensive genetic and regulatory circuits driving the infection process of principal human pathogens such as Shigella flexneri remain to be defined. We combined large-scale Shigella infections of enteroids and colonoids with transposon-directed insertion sequencing and Bayesian statistical modeling to address infection bottlenecks, thereby establishing the comprehensive genome-wide map of Shigella genes required to infect human intestinal epithelium. This revealed the Shigella virulence effectors essential for epithelial cell colonization across geometries and intestinal segments, identified over 100 chromosomal genes involved in the process and uncovered a post-transcriptional mechanism whereby tRNA-modification enzymes and differential codon usage exert global control of a bacterial virulence program. Our findings provide a broadly applicable framework for combining advanced organotypic tissue culture with functional genomics and computational tools to map human–microorganism interactions at scale.

Despite their relatedness, Salmonella and Shigella enteropathogens differ in infectious dose, pathogenesis, and disease kinetics. The prototype strains Salmonella enterica serovar Typhimurium (Salmonella) and Shigella flexneri (Shigella) use Type-3-secretion-systems (T3SSs) to colonize intestinal epithelial cells (IECs). However, they have evolved unique sets of T3SS effectors and accessory virulence factors. A synthesis of how these differences impact the temporal progression of infection in non-transformed human epithelia is missing. Here, we followed Salmonella and Shigella infections of human enteroids and colonoids by time-lapse imaging to pinpoint virulence factor modules that shape the divergent epithelial colonization strategies. By an apical targeting module that integrates flagella and the SPI-4-encoded adhesin system with T3SS-1, Salmonella accomplishes appreciable numbers of apical IEC invasion events. These are promptly counteracted by IEC death, thus fostering a polyclonal iterative epithelial colonization strategy. The lack of a corresponding apical targeting module in Shigella makes this pathogen reliant on external factors, for example, preexisting damage, for rare apical access to the intraepithelial environment. However, Shigella compensates for this ineptness by an intraepithelial expansion module reliant on the tight coupling of OspC3-dependent temporal delay of cell death and IcsA-mediated mobility. This module enables intraepithelial Shigella to evade the IEC death response just long enough to expand laterally, thus fostering an essentially monoclonal colonization strategy. Taken together, the study reveals how a small set of virulence factors shapes divergent epithelial colonization strategies by related enterobacteria.

Introduction

Biliopancreatic diversion with duodenal switch (BPD/DS) is a highly effective metabolic bariatric procedure. However, the decreased gastric volume and exclusion of small bowel to reduce uptake of fat-soluble nutrients can induce gastrointestinal side effects. The aim of this study was to assess gastrointestinal transit times for bile and food using a novel dual-isotope scintigraphy method and explore associations with gastrointestinal symptoms.

Methods

This is an explorative single-center clinical study in 10 patients after primary BPD/DS; 99mTc Bromo-biliaron-labeled bile acid analogue was injected intravenously, 111In-DTPA-labeled omelet was ingested orally, and scintigraphic images were taken every 10 min for 180 min. Gastrointestinal symptoms were scored using the fecal incontinence quality of life (FIQL) questionnaire, and the patients were stratified by stool frequency (≥ 3 stools/day).

Results

All scintigraphic examinations gave interpretable data. FIQL scores of 3.2–3.6 out of 5 demonstrated a clear quality of life impact. Gastric emptying half-time was 40 min. Median time to the enteroenterostomy was 70 min (IQR 55–138) for food and 105 min (IQR 38–148) for bile. In patients with ≥ 3 stools/day, food reached the enteroenterostomy faster than bile (70 vs 115 min), while the opposite was seen in the remaining patients (110 vs 75 min). However, no statistically significant associations between stool frequency and transit times were identified.

Conclusion

Dual-isotope scintigraphy enables assessment of gastric and small bowel transit after BPD/DS. Although transit times were variable, we believe that the novel imaging technique can add valuable information in patients with severe gastrointestinal symptoms.

Pathogen invasion of intestinal epithelial cells (IECs) is a key gut infection event. The dynamics of this process in intact epithelia and the factors governing IEC susceptibility remain underexplored. We present a resource for live-cell infection imaging in human enteroid-/colonoid-derived IEC layers across maturation states and in the presence or absence of soluble mucus production. Utilization of this resource shows how human IEC maturation fortifies the apical surface against invasion by Salmonella Typhimurium (S.Tm). Immature IEC layers appear permissive to S.Tm invasion, but maturation toward an enterocyte/colonocyte phenotype reduces the susceptibility by up to 10-fold. This shift couples to downregulated expression of actin regulatory proteins exploited by the pathogen, an increased dependence on the S.Tm effector SipA, and the build-up of the apical IEC glycocalyx linked to surface-attached mucins like MUC13 and nullifiable by StcE-enzyme treatment. This underscores how the maturation state of human IECs governs susceptibility to bacterial invasion.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) and laparoscopically inserted gastrostomy have become the gold standard for adult patients and children, respectively, requiring long-term enteral nutrition support. Procedure-related mortality is a rare event, often reported to be zero in smaller studies. National data on 30-d mortality and long-term survival rates after gastrostomy placement are scarce in the literature. AIM To study the use of gastrostomies in Sweden from 1998-2019 and to analyze procedure-related mortality and short-term (< 30 d) and long-term survival.

METHODS: In this retrospective, population-based cohort study, individuals that had received a gastrostomy between 1998-2019 in Sweden were included. Individuals were identified in the Swedish National Patient Register, and survival analysis was possible by cross-referencing the Swedish Death Register. The cohort was divided into three age groups: Children (0-18 years); adults (19-64 years); and elderly (>= 65 years). Kaplan-Meier with log-rank test and Cox regression were used for survival analysis.

RESULTS: In total 48682 individuals (52% males, average age 60.9 +/- 25.3 years) were identified. The cohort consisted of 12.0% children, 29.5% adults, and 58.5% elderly. An increased use of gastrostomies was observed during the study period, from 13.7/100000 to 22.3/100000 individuals (P < 0.001). The use of PEG more than doubled (about 800 to 1800/year), with a corresponding decrease in open gastrostomy (about 700 to 340/year). Laparoscopic gastrostomy increased more than ten-fold (about 20 to 240/year). Overall, PEG, open gastrostomy, and laparoscopic gastrostomy constituted 70.0% (n = 34060), 23.3% (n = 11336), and 4.9% (n = 2404), respectively. Procedure-related mortality was 0.1% (n = 44) overall (PEG: 0.05%, open: 0.24%, laparoscopic: 0.04%). The overall 30-d mortality rate was 10.0% (PEG: 9.8%, open: 12.4%, laparoscopic: 1.7%) and decreased from 11.6% in 1998-2009 vs 8.5% in 2010-2019 (P < 0.001). One-year and ten-year survival rates for children, adults, and elderly were 93.7%, 67.5%, and 42.1% and 79.9%, 39.2%, and 6.8%, respectively. The most common causes of death were malignancies and cardiovascular and respiratory diseases.

CONCLUSION: The annual use of gastrostomies in Sweden increased during the study period, with a shift towards more minimally invasive procedures. Although procedure-related death was rare, the overall 30-d mortality rate was high (10%). To overcome this, we believe that patient selection should be improved.

Background

In super obesity, Roux-en-Y gastric bypass (RYGB) may be insufficient why some surgeons advocate biliopancreatic diversion with duodenal switch (BPD/DS), a more malabsorptive procedure. There is a paucity of evidence regarding results beyond 10 years, especially after BPD/DS. The aim of this randomized controlled trial was to compare the long-term outcome of BPD/DS, and RYGB in patients with super obesity, i.e., body mass index (BMI) > 50 kg/m².

Methods

This is a 13- to 17-year follow-up study of a single-center, single-blinded randomized trial in which 47 patients (BMI > 48 and eligible for bariatric surgery) were randomized 1:1 to BPD/DS and RYGB (25 men, 24 BPD/DS, 39.1 ± 9.9 years, BMI 54.5 ± 6.1 kg/m²). The primary outcome was weight loss. The study was financed by Swedish governmental funding of clinical research (ALF). Trial registration number: ISRCTN10940791.

Results

Thirty-four (18 BPD/DS) of the living 42 patients (81.0%) participated. BPD/DS resulted in higher BMI loss (20.4 ± 7.9 vs. 12.4 ± 8.6, p = .008) and higher percent of total body weight loss (37.5% ± 12.2 vs. 22.8% ± 14.8, p = .004). BPD/DS was associated with lower fasting glucose, glycated hemoglobin (HbA1c), and low-density lipoprotein (LDL) as well as lower hemoglobin. Adverse events were more common after BPD/DS (2.7 vs. 0.9 per patient, p = .004). The global assessment tool BAROS (Bariatric Analysis and Reporting Outcome System) demonstrated superior scores for BPD/DS (p = .047).

Conclusion

When compared to RYGB, BPD/DS results in superior weight loss and metabolic control as well as superior BAROS score, however, at the cost of more adverse events.

Purpose Major abdominal surgery carried out in the later part of the week has been associated with increased complication rates. The aim of this study was to explore whether the weekday of surgery affects the 30-day complication risks after primary Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). Material and Methods Prospectively collected data, extracted from the Scandinavian Obesity Surgery Registry (SOReg), of all patients who underwent primary laparoscopic RYGB or SG between 2010 and 2017 were included in this retrospective cohort study. Multivariate logistic regression adjusted for differences in case-mix and operating center by weekday of surgery. Results In total, 49,349 patients were included in this study. The overall 30-day complication rate was 7.2% (n = 3574), whereof 2.9% (n = 1428) had a severe complication, i.e., requiring intervention in general anesthesia or more. The 30-day mortality rate and readmission rate were 0.02% (n= 12) and 7.6% (n= 3726), respectively. The highest overall complication rate was seen in patients operated on Wednesdays and Thursdays (7.7%), while severe complications were most common on Wednesdays (3.3%). However, a large variation in severe complications was seen between centers, from 0.4 to 8.0%. After adjustment for case-mix and operating center, there was no significant increased risk of overall complications, severe complications, or readmission rates by weekday of surgery, except for a lower readmission rate in patients operated on Tuesdays. Conclusion The result of the present study supports the notion that bariatric surgery can be performed safely on all weekdays.

Background: Pharmacologic pain treatment is common among bariatric patients. Nonsteroid antiinflammatory drugs (NSAID) are not recommended after Roux-en-Y gastric bypass (RYGB) because of the increased risk of marginal ulceration, but the connection with NSAID is not unambiguous.

Objectives: Examine the association between NSAID exposure and peptic ulcers after primary laparoscopic RYGB and sleeve gastrectomy (SG) respectively.

Setting: University Hospital, Sweden.

Methods: Cross-matched data from 3 national registers were used in this retrospective, populationbased cohort study of all primary laparoscopic RYGB and SG in Sweden within the period from 2010-2015. NSAID exposure was analyzed with individual data of dispensed daily defined doses (DDD) of NSAID after surgery. Multivariate logistic regression estimated the association between NSAID exposure and peptic ulcers, expressed as odds ratios with 95% confidence intervals adjusted for confounding.

Results: Of the 41,380 patients (37,913 RYGB, 3467 SG), 1.8% were diagnosed with peptic ulcers after surgery (RYGB 1.9%, SG.2%). In total, 60% of the patients had been prescribed NSAID during a follow-up period of 4.1 (1.0-7.0) years in median. The adjusted risk odds ratios for NSAID exposure were 1.10 (.88-1.38), 1.43 (1.16-1.76), and 1.52 (1.25-1.84) for >0-30 DDD, >30-100 DDD, and.100 DDD, respectively. In subanalysis, the association was similar for RYGB alone, whereas no association was found for SG.

Conclusion: The results of the present study support the notion that continuous NSAID use of >= 30 days is a significant risk factor for the development of peptic ulcers after RYGB, whereas temporary use (<30 days) is not. No association between NSAID exposure and the development of peptic ulcers after SG was identified.