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  • 1.
    Axelsson, K. F.
    et al.
    Geriatric Medicine, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden.
    Werling, M.
    Department of Gastrosurgical Research & Education, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Eliasson, B.
    Department of Molecular a nd Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, sweden.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Näslund, I.
    Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Wedel, H.
    Health Metrics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Lundh, D.
    School of Bioscience, University of Skövde, Skövde, Sweden.
    Lorentzon, M.
    Geriatric Medicine, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden.
    Fracture Risk After Gastric Bypass Surgery: A Retrospective Cohort Study2018In: Osteoporosis International, ISSN 0937-941X, E-ISSN 1433-2965, Vol. 29, no Suppl. 1, p. S491-S491Article in journal (Other academic)
    Abstract [en]

    Objectives: Gastric bypass surgery constitutes the most common and effective bariatric surgery to treat obesity. Gastric bypass leads to bone oss but fracture risk following surgery has been insufficiently studied. Our objective was to investigate if gastric bypass surgery in obese patients, with and without diabetes, was associated with fracture risk, and if the fracture risk was associated with post-surgery weight loss or insufficient calcium and vitamin D supplementation.

    Methods: Using large databases, 38 971 obese patients undergoing gastric bypass were identified, 7758 with diabetes and 31 213 without. Through multivariable 1:1 propensity score matching, well-balanced controls were identified. The risk of fracture and fall injury was investigated using Cox proportional hazards and flexible parameter models. Fracture risk according to weight loss and degree of calcium and vitamin D supplementation one year post-surgery was investigated.

    Results: 77 942 patients had a median and total follow-up time of 3.1 (IQR 1.7-4.6) and 251 310 person-years, respectively. Gastric bypass was associated with increased risk of any fracture, in patients with diabetes and without diabetes using a multivariable Cox model (HR 1.26, 95%CI 1.05-1.53 and HR 1.32, 95%CI 1.18-1.47, respectively). The risk of fall injury without fracture was also increased after gastric bypass, both in patients with (HR 1.26 95%CI 1.04-1.52) and without diabetes (HR 1.24 95%CI 1.12-1.38). Weight loss or degree of calcium and vitamin D supplementation after gastric bypass were not associated with fracture risk.

    Conclusions: Gastric bypass was associated with an increased risk of fracture and fall injury. Weight loss or calcium and vitamin D supplementation following surgery were not associated with fracture risk. These findings indicate that gastric bypass increases fracture risk, which could at least partly be due to increased susceptibility to falls.

  • 2.
    Axelsson, Kristian F.
    et al.
    Department of Orthopaedic Surgery, Skaraborg Hospital, Skövde, Sweden; Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.
    Werling, Malin
    Department of Gastrosurgical Research & Education, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Eliasson, Björn
    Department of Molecular and Clinical Medicine, the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Näslund, Ingmar
    Department of Surgery. Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Wedel, Hans
    Health Metrics, Sahlgrenska Academin, University of Gothenburg, Gothenburg, Sweden.
    Lundh, Dan
    School of Bioscience, University of Skövde, Skövde, Sweden.
    Lorentzon, Mattias
    Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden; Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden.
    Fracture Risk After Gastric Bypass Surgery: A Retrospective Cohort Study2018In: Journal of Bone and Mineral Research, ISSN 0884-0431, E-ISSN 1523-4681, Vol. 33, no 12, p. 2122-2131Article in journal (Refereed)
    Abstract [en]

    Gastric bypass surgery constitutes the most common and effective bariatric surgery to treat obesity. Gastric bypass leads to bone loss, but fracture risk following surgery has been insufficiently studied. Furthermore, the association between gastric bypass and fracture risk has not been studied in patients with diabetes, which is a risk factor for fracture and affected by surgery. In this retrospective cohort study using Swedish national databases, 38,971 obese patients undergoing gastric bypass were identified, 7758 with diabetes and 31,213 without. An equal amount of well-balanced controls were identified through multivariable 1:1 propensity score matching. The risk of fracture and fall injury was investigated using Cox proportional hazards and flexible parameter models. Fracture risk according to weight loss and degree of calcium and vitamin D supplementation 1-year postsurgery was investigated. During a median follow-up time of 3.1 (interquartile range [IQR], 1.7 to 4.6) years, gastric bypass was associated with increased risk of any fracture, in patients with and without diabetes using a multivariable Cox model (hazard ratio [HR] 1.26; 95% CI, 1.05 to 1.53; and HR 1.32; 95% CI, 1.18 to 1.47; respectively). Using flexible parameter models, the fracture risk appeared to increase with time. The risk of fall injury without fracture was also increased after gastric bypass. Larger weight loss or poor calcium and vitamin D supplementation after surgery were not associated with increased fracture risk. In conclusion, gastric bypass surgery is associated with an increased fracture risk, which appears to be increasing with time and not associated with degree of weight loss or calcium and vitamin D supplementation following surgery. An increased risk of fall injury was seen after surgery, which could contribute to the increased fracture risk.

  • 3.
    Axer, Stephan
    et al.
    Örebro University, School of Medical Sciences.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Näslund, Ingmar
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Weight loss and alterations in co-morbidities after revisional gastric bypass: A case-matched study from the Scandinavian Obesity Surgery Registry2017In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 13, no 5, p. 796-800Article in journal (Refereed)
    Abstract [en]

    Background: In Sweden, Roux-en-Y gastric bypass is the most common procedure when revising a previous bariatric procedure. This study is an analysis of all revisional gastric bypass operations (rGBP) compared with a matched group of primary gastric bypass (pGBP) operated between 2007 and 2012.

    Objective: The aim was to determine whether improvement of obesity-related co-morbidity and changes in weight after revisional gastric bypass surgery were comparable with those seen after primary surgery.

    Setting: 44 hospitals in Sweden

    Methods: Retrospective data were retrieved from the Scandinavian Obesity Surgery Registry. The study group (rGBP) comprised 1224 patients, and the control group (pGBP) comprised 3612 patients matched for age and gender.

    Results: The indication for revision was weight failure in 512 patients (42%), a late complication of the initial procedure in 330 patients (27%), and a combination of weight failure and complication in 303 patients (25%). A total of 66% of patients in the rGBP group and 67% in the pGBP group completed the 2-year follow-up in the Scandinavian Obesity Surgery Registry.

    The rGBP-group had significantly less excess BMI loss (%EBMIL, 59.4 +/- 147.0 versus 79.5 +/- 24.7, P < .001) and a lower dyslipidemia remission rate (42.9% versus 62.0%, P = .005) at the time of the 2-year follow-up. Remission rates of sleep apnea, hypertension, type 2 diabetes, and depression were similar. The effects on obesity-related co-morbidity were not related to the indication for revisional surgery or the initial bariatric procedure.

    Conclusion: Even if weight results might be inferior compared with primary bypass procedures, the improvement of co-morbidity is similar. (C) 2017 American Society for Metabolic and Bariatric Surgery. All right reserved

  • 4.
    Gerber, Peter
    et al.
    Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Ersta Hospital, Stockholm, Sweden.
    Anderin, Claes
    Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Ersta Hospital, Stockholm, Sweden.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Näslund, Ingmar
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Thorell, Anders
    Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Ersta Hospital, Stockholm, Sweden.
    Impact of age on risk of complications after gastric bypass: A cohort study from the Scandinavian Obesity Surgery Registry (SOReg)2018In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 14, no 4, p. 437-442Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: An increasing number of older patients undergo bariatric surgery.

    OBJECTIVE: To define the risk for complications and mortality in relation to age after gastric bypass.

    SETTING: A national registry-based study.

    METHODS: Patients (n = 47,660) undergoing gastric bypass between May 2007 and October 2016 and registered in the Scandinavian Obesity Register were included. Risk between age groups was compared by multivariate analysis.

    RESULTS: The 30-day follow-up rate was 98.1%. In the entire cohort of patients, any complication within 30 days was demonstrated in 8.4%. For patients aged 50 to 54, 55 to 59, and ≥60 years, this risk was significantly increased to 9.8%, 10.0%, and 10.2%, respectively. Rates of specific surgical complications, such as anastomotic leak, bleeding, and deep infections/abscesses were all significantly increased by 14% to 41% in patients aged 50 to 54 years, with a small additional, albeit not significant, increase in risk in patients of older age. The risk of medical complications (thromboembolic events, cardiovascular, and pulmonary complications) was significantly increased in patients aged ≥60 years. Mortality was .03% in all patients without differences between groups.

    CONCLUSIONS: In this large data set, rates of complications and mortality after 30 days were low. For many complications, an increased risk was encountered in patients aged ≥50 years. However, rates of complications and mortality were still acceptably low in these age groups. Taking the expected benefits in terms of weight loss and improvements of co-morbidities into consideration, our findings suggest that patients of older age should be considered for surgery after thorough individual risk assessment rather than denied bariatric surgery based solely on a predefined chronologic age limit.

  • 5.
    Raoof, Mustafa
    et al.
    Lindesberg Hospital, Örebro, Sweden.
    Näslund, Ingmar
    Lindesberg Hospital, Örebro, Sweden.
    Rask, Eva
    Lindesberg Hospital, Örebro, Sweden.
    Szabo, Eva
    Lindesberg Hospital, Örebro, Sweden.
    Effect of Gastric Bypass on Bone Mineral Density, Parathyroid Hormone and Vitamin D: 5 Years Follow-up2016In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 26, no 5, p. 1141-1145Article in journal (Refereed)
    Abstract [en]

    Background: The aim of the present study was to see if there are longitudinal changes in bone mineral density (BMD), vitamin D or parathyroid hormone (PTH) in females 5 years after Laparoscopic Roux-en-Y Gastric Bypass (LRYGB).

    Methods: Thirty-two women with mean age 41.6 ± 9.3 years and mean body mass index (BMI) 44.5 ± 4.6 kg/m(2) were included. Preoperatively, 2 and 5 years postoperatively, BMD, weight, height, S-calcium, S-albumin, S-creatinine, S-25(OH)-vitamin D and fP-PTH were measured.

    Results: The mean decrease in BMI between baseline and 5 years after surgery was 29.4 %. BMD of the spine and femur measured as z- and t-scores, showed a linear, statistically significant declining trend over the years. The fall in BMD of the spine and femoral neck between baseline and 5 years after surgery was 19 and 25 %, respectively. The mean fP-PTH showed a significant increase over the study period (20.2 μg/L increase, 95 % CI:-31.99 to -8.41). S-calcium, both free and corrected for albumin, showed a decrease between baseline and 5 years after surgery. Eight patients developed osteopenia and one osteoporosis after a 5-year follow-up.

    Conclusion: LRYGB is an efficient method for sustained long-term body weight loss. There is, however, a concomitant decrease in BMD and S-calcium, and an increase in fP-PTH.

  • 6.
    Sellberg, Fanny
    et al.
    Department of Public Health Sciences, Social Medicin, Karolinska Institutet, Stockholm, Sweden.
    Possmark, Sofie
    Department of Public Health Sciences, Social Medicin, Karolinska Institutet, Stockholm, Sweden.
    Ghaderi, Ata
    Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Näslund, Erik
    Division of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
    Willmer, Mikaela
    Department of Health and Caring Sciences, University of Gävle, Gävle, Sweden.
    Tynelius, Per
    Department of Public Health Sciences, Social Medicin, Karolinska Institutet, Stockholm, Sweden; Centre for Epidemiology and Community Medicine, Stockholm County Council, Stockholm, Sweden.
    Thorell, Anders
    Department of Clinical Science, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Ersta Hospital, Stockholm, Sweden.
    Sundbom, Magnus
    Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
    Uddén, Joanna
    Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Endocrine and Obesity, Capio St Görans Hospital, Stockholm, Sweden.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Berglind, Daniel
    Department of Public Health Sciences, Social Medicin, Karolinska Institutet, Stockholm, Sweden.
    A dissonance-based intervention for women post roux-en-Y gastric bypass surgery aiming at improving quality of life and physical activity 24 months after surgery: study protocol for a randomized controlled trial2018In: BMC Surgery, ISSN 1471-2482, E-ISSN 1471-2482, Vol. 18, article id 25Article in journal (Refereed)
    Abstract [en]

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

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

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

  • 7.
    Stenberg, Erik
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital. Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Näslund, Erik
    Division of Surgery, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
    Näslund, Ingmar
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ottosson, Johan
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Risk Prediction Model for Severe Postoperative Complication in Bariatric Surgery2018In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 28, no 7, p. 1869-1875Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Factors associated with risk for adverse outcome are important considerations in the preoperative assessment of patients for bariatric surgery. As yet, prediction models based on preoperative risk factors have not been able to predict adverse outcome sufficiently.

    OBJECTIVE: This study aimed to identify preoperative risk factors and to construct a risk prediction model based on these.

    METHODS: Patients who underwent a bariatric surgical procedure in Sweden between 2010 and 2014 were identified from the Scandinavian Obesity Surgery Registry (SOReg). Associations between preoperative potential risk factors and severe postoperative complications were analysed using a logistic regression model. A multivariate model for risk prediction was created and validated in the SOReg for patients who underwent bariatric surgery in Sweden, 2015.

    RESULTS: Revision surgery (standardized OR 1.19, 95% confidence interval (CI) 1.14-0.24, p < 0.001), age (standardized OR 1.10, 95%CI 1.03-1.17, p = 0.007), low body mass index (standardized OR 0.89, 95%CI 0.82-0.98, p = 0.012), operation year (standardized OR 0.91, 95%CI 0.85-0.97, p = 0.003), waist circumference (standardized OR 1.09, 95%CI 1.00-1.19, p = 0.059), and dyspepsia/GERD (standardized OR 1.08, 95%CI 1.02-1.15, p = 0.007) were all associated with risk for severe postoperative complication and were included in the risk prediction model. Despite high specificity, the sensitivity of the model was low.

    CONCLUSION: Revision surgery, high age, low BMI, large waist circumference, and dyspepsia/GERD were associated with an increased risk for severe postoperative complication. The prediction model based on these factors, however, had a sensitivity that was too low to predict risk in the individual patient case.

  • 8.
    Stenberg, Erik
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Näslund, Ingmar
    Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro , Sweden.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Ottosson, Johan
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Impact of mesenteric defect closure technique on complications after gastric bypass2018In: Langenbeck's archives of surgery (Print), ISSN 1435-2443, E-ISSN 1435-2451, Vol. 403, no 4, p. 481-486Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Closure of mesenteric defects during laparoscopic gastric bypass surgery markedly reduces the risk for small bowel obstruction due to internal hernia. However, this procedure is associated with an increased risk for early small bowel obstruction and pulmonary complication. The purpose of the present study was to evaluate whether the learning curve and subsequent adaptions made to the technique have had an effect on the risk for complications.

    METHODS: The results of patients operated with a primary laparoscopic gastric bypass procedure, including closure of the mesenteric defects with sutures, during a period soon after introduction (January 1, 2010-December 31, 2011) were compared to those of patients operated recently (January 1, 2014-June 30, 2017). Data were retrieved from the Scandinavian Obesity Surgery Registry (SOReg). The main outcome was reoperation for small bowel obstruction within 30 days after surgery.

    RESULTS: A total of 5444 patients were included in the first group (period 1), and 1908 in the second group (period 2). Thirty-day follow-up rates were 97.1 and 97.5% respectively. The risk for early (within 30 days) small bowel obstruction was lower in period 2 than in period 1 (13/1860, 0.7% vs. 67/5285, 1.3%, OR 0.55 (0.30-0.99), p = 0.045). The risk for pulmonary complication was also reduced (5/1860, 0.3%, vs. 41/5285, 0.8%, OR 0.34 (0.14-0.87), p = 0.019).

    CONCLUSION: Closure of mesenteric defects during laparoscopic gastric bypass surgery can be performed safely and should be viewed as a routine part of that operation.

  • 9.
    Stenberg, Erik
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Ottosson, Johan
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Näslund, Ingmar
    Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Comparing Techniques for Mesenteric Defects Closure in Laparoscopic Gastric Bypass Surgery: a Register-Based Cohort Study2019In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 29, no 4, p. 1229-1235Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Routine closure of mesenteric defects is generally considered standard part of laparoscopic gastric bypass surgery today. Controversy still exists regarding the optimal method for mesenteric defects closure. The objective was to compare different methods for mesenteric defects handling in laparoscopic gastric bypass surgery.

    METHODS: Primary laparoscopic gastric bypass procedures from 2010 until 2015 reported to the Scandinavian Obesity Surgery Registry (SOReg), where the mesenteric defects closure method was identifiable, were included. Main outcome measures were serious postoperative complication within 30 days after surgery, and reoperation for small bowel obstruction within 5 years after surgery. Quality-of-life before and after surgery, duration of surgery, and risk factors for complication were also analyzed. Information on operation for small bowel obstruction was based on data from the SOReg, the Swedish National Patient Register and reviews of hospital charts.

    RESULTS: In all, 34,707 patients were included. Serious postoperative complication occurred in 174 (2.9%) patients with sutures, in 592 (3.1%, adjusted p = 0.079) with clips, and 278 (3.1%; adjusted p = 0.658) in the non-closure group. Reoperation for small bowel obstruction within 5 years after surgery was lower with sutures (cumulative incidence 6.9%) and clips (cumulative incidence 7.3%; adjusted HR 1.16, 95% CI 1.02-1.32, p = 0.026), compared to non-closure (cumulative incidence 11.2%; adjusted HR 1.63, 95% CI 1.44-1.84, p < 0.0001).

    CONCLUSION: Closure of the mesenteric defects using either non-absorbable metal clips or non-absorbable running sutures is a safe and effective measure to reduce the risk for small bowel obstruction after laparoscopic gastric bypass surgery. Sutures appear slightly more effective and should remain gold standard for mesenteric defects closure.

  • 10.
    Stenberg, Erik
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Persson, Carina
    Department of Community Medicine and Public Health, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; Department for Sustainable Development, Region Örebro County, Örebro, Sweden.
    Näslund, Erik
    Division of Surgery, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
    Ottosson, Johan
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Sundbom, Magnus
    Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Näslund, Ingmar
    Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    The impact of socioeconomic factors on the early postoperative complication rate after laparoscopic gastric bypass surgery: A register-based cohort study2019In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 15, no 4, p. 575-581Article in journal (Refereed)
    Abstract [en]

    Background: Socioeconomic factors may influence the outcome of certain surgical procedures, but it is not known whether such factors influence the risk for postoperative complication after bariatric surgery.

    Objectives: Determining whether different socioeconomic factors influence the risk for postoperative complication after laparoscopic gastric bypass surgery.

    Setting: Nationwide in Sweden.

    Methods: Retrospective register-based cohort study that includes all primary laparoscopic gastric bypass procedures in Sweden between 2010 and 2016, using data from the Scandinavian Obesity Surgery Registry, Statistics Sweden, and the Swedish Population Register. Main outcome measures were occurrence and severity of early postoperative complications.

    Results: Included in this study were 41,537 patients with 30-day follow-up percentage of 96.7%. Study groups with increased risk for postoperative complication (age, sex, body mass index, and co-morbidity adjusted odds ratio with 95% confidence intervals) were as follows: being divorced, a widow, or a widower (1.14 [1.03-1.23]); receiving disability pension (1.37 [1.23-1.53]) or social assistance (1.22 [1.07-1.401); and being first- (1.22 [1.04-1.44]) or second-generation (1.20 [1.09-1.32]) immigrant. In contrast, being single (.90 [.83.991), having higher disposable income (50th-80th percentile:.84 [.76.93]; >80th percentile:.84 [72.98]), and living in a medium (.90 [.83.98]) or small (.84 [.76.92]) town were associated with lower risk. Increased risk for severe postoperative complication was seen for divorced, widowm, or widower (1.30 [1.12-1.521) and those receiving disability pension (1.37 [1.16-1.611) or social assistance (1.32 [1.08-1.62]), while higher disposable income (50th-80th percentile:.79 [.68.92]; >80th percentile .57 [.46.72]) was associated with lower risk.

    Conclusion: Socioeconomic factors influence the risk for early postoperative complication after laparoscopic gastric bypass surgery. The impact is not enough to exclude patients from surgery, but they must be taken into account in preoperative risk assessment.

  • 11.
    Stenberg, Erik
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Näslund, Ingmar
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ottosson, Johan
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Bleeding during laparoscopic gastric bypass surgery as a risk factor for less favorable outcome: A cohort study from the Scandinavian Obesity Surgery Registry2017In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 13, no 10, p. 1735-1740Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Intraoperative adverse events are known to be associated with postoperative complications; however, little is known about whether or not blood loss during laparoscopic gastric bypass surgery affects the outcome.

    OBJECTIVE: To see if intraoperative bleeding was associated with a less favorable outcome, and to identify patient-specific risk factors for intraoperative bleeding.

    SETTING: Nationwide, Sweden.

    METHODS: Patients who underwent laparoscopic gastric bypass surgery between January 8, 2007, and September 15, 2015, were included in the study. The volume of intraoperative blood loss was compared with data from follow-up at day 30 and 1 and 2 years after surgery. Patient-specific factors were analyzed as potential risk factors for intraoperative bleeding.

    RESULTS: The study included 43,157 patients. Intraoperative bleeding was associated with an increased risk for postoperative complication (100-499 mL, odds ratio [OR] 2.97, 95% confidence interval [95%CI] 2.53-3.50;>500 mL OR 3.34, 95%CI 2.05-5.44), lower weight loss (<100 mL, 82.4±24.19% excess body mass index-loss [%EBMIL]; 100-499 mL, 76.9±24.24 %EBMIL, P<.0001;>500 mL 76.9±23.89 %EBMIL, P = .063) and lower reported quality-of-life 2 years after surgery (<100 mL, Obesity-related Problem scale (OP) 21.1±24.46; 100-499 mL, OP 25.0±26.62, P = .008;>500 mL, OP 25.2±24.46, P = .272). Diabetes (OR 1.30, 95%CI 1.08-1.58), age (OR 1.02, 95%CI 1.02-1.03), and body mass index (OR 1.03, 95%CI 1.02-1.05) were patient-specific risk factors for intraoperative bleeding≥100 mL, whereas intentional preoperative weight loss was associated with a lower risk (OR .50, 95%CI .43-.57).

    CONCLUSION: Intraoperative bleeding was associated with less favorable outcome after laparoscopic gastric bypass surgery. Age, body mass index, and diabetes were risk factors for intraoperative bleeding, while preoperative weight reduction seems to be protective.

  • 12.
    Stenberg, Erik
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ottosson, Johan
    Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Thorell, Anders
    Department of Surgery, Ersta Hospital, Stockholm, Sweden; Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
    Näslund, Ingmar
    Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Health-Related Quality-of-Life after Laparoscopic Gastric Bypass Surgery with or Without Closure of the Mesenteric Defects: a Post-hoc Analysis of Data from a Randomized Clinical Trial2018In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 28, no 1, p. 31-36Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Mesenteric defect closure in laparoscopic gastric bypass surgery has been reported to reduce the risk for small bowel obstruction. Little is known, however, about the effect of mesenteric defect closure on patient-reported outcome. The aim of the present study was to see if mesenteric defect closure affects health-related quality-of-life (HRQoL) after laparoscopic gastric bypass.

    METHODS: Patients operated at 12 centers for bariatric surgery participated in this randomized two-arm parallel study. During the operation, patients were randomized to closure of the mesenteric defects or non-closure. This study was a post-hoc analysis comparing HRQoL of the two groups before surgery, at 1 and 2 years after the operation. HRQoL was estimated using the short form 36 (SF-36-RAND) and the obesity problems (OP) scale.

    RESULTS: Between May 1, 2010, and November 14, 2011, 2507 patients were included in the study and randomly assigned to mesenteric defect closure (n = 1259) or non-closure (n = 1248). In total, 1619 patients (64.6%) reported on their HRQoL at the 2-year follow-up. Mesenteric defect closure was associated with slightly higher rating of social functioning (87 ± 22.1 vs. 85 ± 24.2, p = 0.047) and role emotional (85 ± 31.5 vs. 82 ± 35.0, p = 0.027). No difference was seen on the OP scale (open defects 22 ± 24.8 vs. closed defects 20 ± 23.8, p = 0.125).

    CONCLUSION: When comparing mesenteric defect closure with non-closure, there is no clinically relevant difference in HRQoL after laparoscopic gastric bypass surgery.

  • 13.
    Stenberg, Erik
    et al.
    Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Szabo, Eva
    Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Ågren, Göran
    Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Ottosson, Johan
    Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Marsk, Richard
    Division of Surgery, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
    Lönroth, Hans
    Institute of Surgery, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Boman, Lars
    Department of Surgery, Lycksele Hospital, Lycksele, Sweden.
    Magnuson, Anders
    Thorell, Anders
    Division of Surgery, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Ersta Hospital, Stockholm, Sweden.
    Näslund, Ingmar
    Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Closure of mesenteric defects in laparoscopic gastric bypass: a multicentre, randomised, parallel, open-label trial2016In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 387, no 10026, p. 1397-1404Article in journal (Refereed)
    Abstract [en]

    Background: Small bowel obstruction due to internal hernia is a common and potentially serious complication after laparoscopic gastric bypass surgery. Whether closure of surgically created mesenteric defects might reduce the incidence is unknown, so we did a large randomised trial to investigate.

    Method: This study was a multicentre, randomised trial with a two-arm, parallel design done at 12 centres for bariatric surgery in Sweden. Patients planned for laparoscopic gastric bypass surgery at any of the participating centres were off ered inclusion. During the operation, a concealed envelope was opened and the patient was randomly assigned to either closure of mesenteric defects beneath the jejunojejunostomy and at Petersen's space or non-closure. After surgery, assignment was open label. The main outcomes were reoperation for small bowel obstruction and severe postoperative complications. Outcome data and safety were analysed in the intention-to-treat population. This trial is registered with ClinicalTrials. gov, number NCT01137201.

    Findings: Between May 1, 2010, and Nov 14, 2011, 2507 patients were recruited to the study and randomly assigned to closure of the mesenteric defects (n= 1259) or non-closure (n= 1248). 2503 (99.8%) patients had follow-up for severe postoperative complications at day 30 and 2482 (99.0%) patients had follow-up for reoperation due to small bowel obstruction at 25 months. At 3 years after surgery, the cumulative incidence of reoperation because of small bowel obstruction was signifi cantly reduced in the closure group (cumulative probability 0.055 for closure vs 0.102 for non-closure, hazard ratio 0.56, 95% CI 0.41-0.76, p= 0.0002). Closure of mesenteric defects increased the risk for severe postoperative complications (54 [4.3%] for closure vs 35 [2.8%] for non-closure, odds ratio 1.55, 95% CI 1.01-2.39, p= 0.044), mainly because of kinking of the jejunojejunostomy.

    Interpretation: The results of our study support the routine closure of the mesenteric defects in laparoscopic gastric bypass surgery. However, closure of the mesenteric defects might be associated with increased risk of early small bowel obstruction caused by kinking of the jejunojejunostomy.

  • 14.
    Szabo, Eva
    Uppsala universitet, Institutionen för kirurgiska vetenskaper, Uppsala, Sweden.
    Molecular and clinical genetic studies of a novel variant of familial hypercalcemia2002Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Familial primary hyperparathyroidism (HPT) is a rare disorder that is treated surgically and mostly occurs in association with tumor-susceptibility syndromes, like multiple endocrine neoplasia and the hyperparathyroidism-jaw tumor syndrome. Familial hypercalciuric hypercalcemia (FHH) is another cause of hereditary hypercalcemia that generally is considered to require no treatment and is genetically and pathophysiologically distinct from HPT. Inactivating mutations in the calcium receptor gene cause FHH, whereas the down-regulated expression of the CaR in HPT never has been coupled to CaR gene mutations.

    Family screening revealed a hitherto unknown familial condition with characteristics of both FHH and HPT. The hypercalcemia was mapped to a point mutation in the intracellular domain of the CaR gene that was coupled to relative calcium resistance of the PTH release by transient expression in HEK 294 cells. Unusually radical excision of parathyroid glands was required to normalise the hypercalcemia. The mildly enlarged parathyroid glands displayed hyperplasia with nodular components. Frequent allelic loss on especially 12q was found and contrasts to findings in HPT. Allelic loss was also seen in loci typical for primary HPT like 1p, 6q and 15q, but not 11q13. Quantitative mRNA analysis showed that the glands had mild increase in a proliferation index (PCNA/GAPDH mRNA ratio) and mild reduction in genes important to parathyroid cell function, like CaR, PTH, VDR and LRP2.

    A previously unrecognized variant of hypercalcemia is explored that could be one explanation for persistent hypercalcemia after apparently typical routine operations for HPT. It also raises the issue of possibilities to treat FHH with parathyroidectomy provided it is radical enough.

  • 15.
    Wallén, Stefan
    et al.
    Örebro University, School of Medical Sciences. Pharmacology and Therapeutic Department, Region Örebro County, University Hospital of Örebro, Läkemedelscentrum, Universitetssjukhuset, Örebro, Sweden.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Palmetun-Ekbäck, Maria
    Pharmacology and Therapeutic Department, Region Örebro County, University Hospital of Örebro, Läkemedelscentrum, Universitetssjukhuset, Örebro, Sweden; Department of Dermatology, University Hospital of Örebro, Örebro, Sweden.
    Näslund, Ingmar
    Department of Surgery, University Hospital of Örebro, Örebro, Sweden.
    Use of Opioid Analgesics Before and After Gastric Bypass Surgery in Sweden: a Population-Based Study2018In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 28, no 11, p. 3518-3523Article in journal (Refereed)
    Abstract [en]

    Background: Little is known regarding the use of opioid analgesics among patients who have undergone bariatric surgery. The Roux-en-Y gastric bypass (RYGB) procedure has been shown to significantly increase the rate of absorption of and exposure to morphine, raising concerns regarding the potentially increased risk of side-effects and the development of substance-use disorder.

    Objectives: The aim of this study was to describe the pattern of opioid use over time following RYGB and to see if the pattern differs between patients with a high opioid consumption (HOC) prior to surgery and those with a low consumption (LOC).

    Setting: University Hospital of Örebro, Sweden.

    Methods: The study was a descriptive retrospective population-based cohort study where two registers with complete coverage were cross-matched.

    Results: The study population comprised 35,612 persons (1628 HOC, and 33,984 LOC). After surgery, the number of HOC patients increased to 2218. Mean daily opioid consumption in the total population and the LOC group increased after surgery (p <.0005). In the HOC group, there was no difference between mean daily consumption before and after surgery.

    Conclusion: In this nationwide study, we have showed that there is an increase in consumption of opioid analgesics after gastric bypass surgery in Sweden. The increase in the number of individuals with high opioid consumption in the total population was mainly due to an increase in the group of patients with a low consumption prior to surgery.

  • 16.
    Wanjura, Viktor
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Sandblom, Gabriel
    Department of Surgical Gastroenterology, Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden; Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.
    Österberg, Johanna
    Department of Surgery, Mora Hospital, Mora, Sweden.
    Enochsson, Lars
    Department of Surgical and Perioperative Sciences, Division of Surgery, Sunderby Hospital, Umeå University, Umeå, Sweden.
    Ottosson, Johan
    Department of Surgery, Örebro University Hospital, Lindesberg, Sweden.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Cholecystectomy after gastric bypass-incidence and complications2017In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 13, no 6, p. 979-987Article in journal (Refereed)
    Abstract [en]

    Background: Although cholecystectomy incidence is known to be high after Roux-en-Y gastric bypass (RYGB) surgery, the actual increase in incidence is not known. Furthermore, the outcome of cholecystectomy after RYGB is not known.

    Objectives: To estimate cholecystectomy incidence before and after RYGB and to compare the outcome of post-RYGB cholecystectomy with the cholecystectomy outcome in the background population.

    Setting: Nationwide Swedish multiregister study.

    Methods: The Swedish Register for Cholecystectomy and Endoscopic Retrograde Cholangiopancreatography (n = 79,386) and the Scandinavian Obesity Surgery Registry (n = 36,098) were cross-matched for the years 2007 through 2013 and compared with the National Patient Register.

    Results: The standardized incidence ratio for cholecystectomy before RYGB was 3.42 (2.75-4.26, P < .001); the ratio peaked at 11.4 (10.2-12.6, P < .001) 6-12 months after RYGB, which was 3.54 times the baseline level (2.78-4.49, P < .001). After 36 months, the incidence ratio had returned to baseline. The post-RYGB group demonstrated an increased risk of 30-day postoperative complications after cholecystectomy (odds ratio 2.13, 1.78-2.56; P < .001), including reoperation (odds ratio 3.84, 2.76-5.36; P < .001), compared with the background population. The post-RYGB group also demonstrated a higher risk of conversion, acute cholecystectomy, and complicated gallstone disease and a slightly prolonged operative time, adjusted for age, sex, American Society of Anesthesiologists class, and previous open RYGB.

    Conclusion: Compared with the background population, the incidence of cholecystectomy was substantially elevated already before RYGB and increased further 6-36 months after RYGB. Previous RYGB doubled the risk of postoperative complications after cholecystectomy and almost quadrupled the risk of reoperation, even when intraoperative cholangiography was normal. (C) 2017 American Society for Metabolic and Bariatric Surgery.

  • 17.
    Wanjura, Viktor
    et al.
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Österberg, Johanna
    Department of Surgery, Mora Hospital, Mora, Sweden.
    Ottosson, Johan
    Department of Surgery, Örebro University Hospital, Lindesberg, Sweden.
    Enochsson, Lars B.
    Department of Surgical and Perioperative Sciences, Division of Surgery, Sunderby Hospital, Umeå University, Umeå, Sweden.
    Sandblom, Gabriel
    Department of Surgical Gastroenterology, Division of Surgery, CLINTEC, Karolinska Institute, Sweden; Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.
    Morbidity of cholecystectomy and gastric bypass in a national database2018In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 105, no 1, p. 121-127Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: There is a strong association between obesity and gallstones. However, there is no clear evidence regarding the optimal order of Roux-en-Y gastric bypass (RYGB) and cholecystectomy when both procedures are clinically indicated.

    METHODS: Based on cross-matched data from the Swedish Register for Cholecystectomy and Endoscopic Retrograde Cholangiopancreatography (GallRiks; 79 386 patients) and the Scandinavian Obesity Surgery Registry (SOReg; 36 098 patients) from 2007 to 2013, complication rates, reoperation rates and operation times related to the timing of RYGB and cholecystectomy were explored.

    RESULTS: There was a higher aggregate complication risk when cholecystectomy was performed after RYGB rather than before (odds ratio (OR) 1·35, 95 per cent c.i. 1·09 to 1·68; P = 0·006). A complication after the first procedure independently increased the complication risk of the following procedure (OR 2·02, 1·44 to 2·85; P < 0·001). Furthermore, there was an increased complication risk when cholecystectomy was performed at the same time as RYGB (OR 1·72, 1·14 to 2·60; P = 0·010). Simultaneous cholecystectomy added 61·7 (95 per cent c.i. 56·1 to 67·4) min (P < 0·001) to the duration of surgery.

    CONCLUSION: Cholecystectomy should be performed before, not during or after, RYGB.

  • 18.
    Wanjura, Viktor
    et al.
    Örebro University, School of Medical Sciences.
    Szabo, Eva
    Örebro University, School of Medical Sciences.
    Österberg, Johanna
    Department of Surgery, Mora Hospital, Mora, Sweden.
    Ottosson, Johan
    Department of Surgery, Örebro University Hospital, Lindesberg, Sweden.
    Enochsson, Lars
    Department of Surgical and Perioperative Sciences, Division of Surgery, Sunderby Hospital, Umeå University, Umeå, Sweden.
    Sandblom, Gabriel
    Department of Surgical Gastroenterology, Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden; Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.
    Morbidity of cholecystectomy and gastric bypass in a national databaseManuscript (preprint) (Other academic)
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