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  • 1.
    Al-Tai, Saif
    et al.
    Örebro University, School of Medical Sciences.
    Axer, Stephan
    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.
    Stenberg, Erik
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    THE IMPACT OF THE BOUGIE SIZE AND THE EXTENT OF ANTRAL RESECTION ON WEIGHT-LOSS AND POSTOPERATIVE COMPLICATIONS FOLLOWING SLEEVE GASTRECTOMY: RESULTS FROM THE SCANDINAVIAN OBESITY SURGERY REGISTRY2023In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 33, no Suppl. 2, p. 332-332, article id O-316Article in journal (Other academic)
    Abstract [en]

    Background: Laparoscopic sleeve gastrectomy (LSG) as a primary bariatric procedure has gained increasing popularity world-wide. However, controversies still exist regarding several operative aspects, such as the optimal diameter of thesleeve and the optimal distance from the pylorus to the edge of the resection line, and whether these aspects haveeffects on weight-loss results and the risk to develop postoperative complications.

    Objective: The aim of this study was to compare weight-loss results and the incidence of postoperative complications betweensleeve with different diameters measured in bougie size and with different distances from the pylorus to the edge ofthe resection line measured in centimeter.

    Setting: Nationwide registry-based study.

    Method: This study is an analysis of sleeve gastrectomy performed in Sweden between 2012 and 2019. Data were collectedfrom Scandinavian Obesity Surgery Registry (SOReg). Patients with bougie size 30-32 and 35-36 and patients withdistance from pylorus 1-4 cm, 5 cm, 6-8 cm were identified and compared regarding weight-loss results and the riskto develop postoperative complications.

    Results: 9,360 patients were included. Follow-up rate was 96% at day 30, 78.8% at one year and 50% at two years. Bothbougie size 30-32 compared to 35-36 and distance from the pylorus 1-4 cm compared to 5 cm were associated withsignificant higher weight-loss at one and two years. No difference in the risk for early or late complications was seenbetween bougie size groups 30-32 and 35-36. Resection starting 1-4 cm from the pylorus compared to 5 cm was as-sociated with higher risk for overall early postoperative complications (OR 1.46 (1.17-1.82, P=.001)), but there wasno significant difference in the risk to develop late complication at 1 and 2 years. No difference in the leak rate andin the risk to develop stricture was seen between different Bougie sizes, nor distances from the Pylorus.

    Conclusion: Using a smaller Bougie size and starting the resection closer to the pylorus was associated with better maximumweight-loss. Closer resection to the Pylorus, but not Bougie size was associated with increased risk for early postop-erative complications after sleeve gastrectomy.

  • 2.
    Al-Tai, Saif
    et al.
    Örebro University, School of Medical Sciences. Department of Surgery, Torsby Hospital, Torsby, Sweden.
    Axer, Stephan
    Department of Surgery, Torsby Hospital, Torsby, Sweden; 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.
    Stenberg, Erik
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    The impact of the bougie size and the extent of antral resection on weight-loss and postoperative complications following sleeve gastrectomy: results from the Scandinavian Obesity Surgery Registry2024In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 20, no 2, p. 139-145Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The optimal sleeve diameter and distance from the pylorus to the edge of the resection line in laparoscopic sleeve gastrectomy (LSG) remain controversial.

    OBJECTIVES: To evaluate the influence of bougie size and antral resection distance from the pylorus on postoperative complications and weight-loss results in LSG.

    SETTING: Nationwide registry-based study.

    METHODS: This study included all LSGs performed in Sweden between 2012 and 2019. Data were obtained from the Scandinavian Obesity Surgery Registry. Reference bougie size of 35-36 Fr and an antral resection distance of 5 cm from the pylorus were compared to narrower bougie size (30-32 Fr), shorter distances (1-4 cm), and extended distances (6-8 cm) from the pylorus in assessing postoperative complications and weight loss as the outcomes of LSG. RESULTS: The study included 9,360 patients with postoperative follow-up rates of 96%, 79%, and 50% at 30 days, 1 year, and 2 years, respectively. Narrow bougie and short antral resection distance from the pylorus were significantly associated with increased postoperative weight loss. Bougie size was not associated with increased early or late complications. However, short antral resection distance was associated with high risk of overall early complications [odds ratio: 1.46 (1.17-1.82, P = .001)], although no impact on late complications at 1 and 2 years was observed.

    CONCLUSIONS: Using a narrow bougie and initiating resection closer to the pylorus were associated with greater maximum weight loss. Although a closer resection to the pylorus was associated with an increased risk of early postoperative complications, no association was observed with the use of narrow bougie for LSG.

  • 3.
    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.

  • 4.
    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.

  • 5.
    Axer, S.
    et al.
    Department of Surgery, Torsby Hospital, Torsby, Sweden.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Näslund, I.
    Örebro University, Department of Surgery, Faculty of Health and Medicine, Örebro University, Örebro, Sweden.
    NON-RESPONSE AFTER GASTRIC BYPASS AND SLEEVE GASTRECTOMY - THE THEORETICAL NEED FOR REVISIONAL BARIATRIC SURGERY RESULTS FROM THE SCANDINAVIAN OBESITY SURGERY REGISTRY: Revisional surgery2022In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 32, no Suppl. 2, p. 381-381Article in journal (Other academic)
    Abstract [en]

    Background: Revisional surgery is a second-line treatment option after sleeve gastrectomy (SG) and gastric bypass (GBP) in patients with primary or secondary non-response. This study is an analysis of the theoretical need for revisional surgery when applying four indication benchmarks.

    Objective: The aim was to analyze the risk for primary and secondary non-response after SG and GBP.

    Setting: 44 hospitals in Sweden.

    Methods: Based on data from the Scandinavian Obesity Surgery Registry, SG and GBP were compared regarding four endpoints: 1. Excess Weight Loss (%EWL) < 50%; 2. weight regain of more than 10 kg after nadir; 3. fulfillment of IFSO-guidelines; or 4. ADA-criteria for bariatric surgery two years after primary surgery.

    Results: 60 426 individuals were included in the study (SG: n=7856 and GBP: n=52 570). Compared to patients in the GBP-group, more SG patients failed to achieved a %EWL > 50% (23.0% versus 8.5%, p < .001), regained more than 10 kg after nadir (4.3% versus 2.5%, p < .001), more often fulfilled the IFSO-criteria (8.0% vs. 4.5%, p < .001) or the ADA criteria (3.3% vs. 1.8%, p < 001) for bariatric/metabolic surgery at the 2-year follow-up.

    Conclusions: SG is associated with a higher risk for primary and secondary non-response compared to gastric bypass. To offer revisional bariatric surgery to all non-responders exceeds the bounds of feasibility and operability. Hence, individual prioritization and intensified evaluation of alternative second-line treatments is necessary.

  • 6.
    Axer, Stephan
    et al.
    Örebro University, School of Medical Sciences. Department of Surgery, Torsby Hospital.
    Lederhuber, Hans Christian
    Stiede, Franziska
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Näslund, Ingmar
    Department of Surgery, Faculty of Health and Medicine, Örebro University.
    Weight-related outcomes after revisional bariatric surgery in patients with primary or secondary non-response after sleeve gastrectomy: a systematic reviewManuscript (preprint) (Other academic)
  • 7.
    Axer, Stephan
    et al.
    Faculty of Health and Medicine, Örebro University, Campus USÖ, 701 82, Örebro, Sweden. Stephan.axer@gmail.com; Department of General Surgery, Torsby Hospital, Box 502, 685 29, Torsby, Sweden. Stephan.axer@gmail.com.
    Lederhuber, Hans
    Royal Devon University Healthcare NHS Foundation Trust, Church Lane, Exeter, EX2 5DW, UK.
    Stiede, Franziska
    GP Practice Dr. Fritz Weidinger & Dr. Katharina Klein, Hauptstraße 93, 82327, Tutzing, Germany.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Näslund, Ingmar
    Department of Surgery, Faculty of Health and Medicine, Örebro University, Campus USÖ, 701 82, Örebro, Sweden.
    Weight-Related Outcomes After Revisional Bariatric Surgery in Patients with Non-response After Sleeve Gastrectomy: a Systematic Review2023In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 33, no 7, p. 2210-2218Article, review/survey (Refereed)
    Abstract [en]

    Weight non-response after sleeve gastrectomy is an emerging issue. This systematic review compared revisional procedures for weight-related outcomes. We searched several databases for relevant articles and included adult patients with revisional bariatric procedures after primary sleeve gastrectomy. Twelve trials with 1046 patients were included, covering five revisional procedures. There were no randomised controlled trials, and 10 studies had a critical risk of bias. Significant variations in inclusion criteria, therapy benchmarks, follow-up schemes, and outcome measurements were observed, preventing meaningful comparison of results. Evidence-based treatment strategies for weight non-response after sleeve gastrectomy cannot be deduced from the current literature. Prospective studies with well-defined indications, standardised techniques, and strict adherence to outcome measurements are needed.

  • 8.
    Axer, Stephan
    et al.
    Örebro University, School of Medical Sciences.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Agerskov, Simon
    Department of Surgery, Torsby Hospital, Torsby, Sweden.
    Näslund, Ingmar
    Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Predictive factors of complications in revisional gastric bypass surgery: results from the Scandinavian Obesity Surgery Registry2019In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 15, no 12, p. 2094-2100Article in journal (Refereed)
    Abstract [en]

    Background: Roux-en-Y gastric bypass is the most common procedure for revisional bariatric surgery. This study is an analysis of revisional gastric bypass operations (rGBP) compared with primary gastric bypass (pGBP) performed in Sweden between 2007 and 2016.

    Objective: The aim was to compare the incidence of adverse events in primary and revisional gastric bypass surgery and to identify predictive factors of intraoperative, early, and late complications in revisional gastric bypass surgery.

    Setting: Forty-four hospitals.

    Methods: Registered study from the Scandinavian Obesity Surgery Registry. The study group (rGBP) comprised 1795 patients, and the control group (pGBP) comprised 46,055 patients.

    Results: Median follow-up time was 28 months. The rate of open procedures was significantly higher in the rGBP group (39.1% versus 2.4%; P < .001) decreasing from 70.8% in 2007 to 8.5% in 2016. Intraoperative complications (15.5% versus 3.0%, P < .001), early complications (24.6% versus 8.7%; P < .001), and late complications (17.7% versus 8.7%; P < .001) occurred more often in the rGBP group. Open access in revisional surgery was an independent risk factor for intraoperative complications (odds ratio 3.87; 95% confidence interval: 2.69-5.57, P < .001), early complications (odds ratio 2.08; 95% confidence interval: 1.53-2.83, P < .001), and late complications (odds ratio 1.91; 95% confidence interval: 1.31-2.78, P = .001). Indication for revision or type of index operation were not associated with complications.

    Conclusion: RGBP was associated with a higher incidence of intraoperative, early, and late complications compared with pGBP. Open access in revisional surgery was predictive of complications regardless of the index operation or indication for revision.

  • 9.
    Axer, Stephan
    et al.
    Örebro University, School of Medical Sciences. Department of Surgery, Torsby Hospital.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Näslund, Ingmar
    Department of Surgery, Faculty of Health and Medicine, Örebro University.
    Non-response after gastric bypass and sleeve gastrectomy: The theoretical need for revisional bariatric surgery Results from the Scandinavian Obesity Surgery RegistryManuscript (preprint) (Other academic)
  • 10.
    Axer, Stephan
    et al.
    Faculty of Health and Medicine, Örebro University, Campus USÖ, Örebro, Sweden; Department of Surgery, Torsby Hospital, Box 502, 685 29, Torsby, Sweden.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Näslund, Ingmar
    Department of Surgery, Faculty of Health and Medicine, Örebro University, Campus USÖ, Örebro, Sweden.
    Non-response After Gastric Bypass and Sleeve Gastrectomy-the Theoretical Need for Revisional Bariatric Surgery: Results from the Scandinavian Obesity Surgery Registry2023In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 33, no 10, p. 2973-2980Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Revisional surgery is a second-line treatment option after sleeve gastrectomy (SG) and gastric bypass (GBP) in patients with primary or secondary non-response. The aim was to analyze the theoretical need for revisional surgery after SG and GBP when applying four indication benchmarks. METHOD: Based on data from the Scandinavian Obesity Surgery Registry, SG and GBP were compared regarding four endpoints: 1. excess weight loss (%EWL) < 50%, 2. weight regain of more than 10 kg after nadir, 3. fulfillment of previous IFSO-guidelines, or 4. ADA criteria for bariatric metabolic surgery 2 years after primary surgery.

    RESULTS: A total of 60,426 individuals were included in the study (SG: n = 7856 and GBP: n = 52,570). Compared to patients in the GBP group, more SG patients failed to achieve a %EWL > 50% (23.0% versus 8.5%, p < .001), regained more than 10 kg after nadir (4.3% versus 2.5%, p < .001), and more often fulfilled the IFSO criteria (8.0% versus 4.5%, p < .001) or the ADA criteria (3.3% versus 1.8%, p < 001) at the 2-year follow-up.

    CONCLUSION: SG is associated with a higher risk for weight non-response compared to GBP. To offer revisional bariatric surgery to all non-responders exceeds the bounds of feasibility and operability. Hence, individual prioritization and intensified evaluation of alternative second-line treatments are necessary.

  • 11.
    Axer, Stephan
    et al.
    Örebro University, School of Medical Sciences.
    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.
    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

  • 12.
    Cao, Yang
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Raoof, Mustafa
    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.
    Näslund, Ingmar
    Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Using Bayesian Networks to Predict Long-Term Health-Related Quality of Life and Comorbidity after Bariatric Surgery: A Study Based on the Scandinavian Obesity Surgery Registry2020In: Journal of Clinical Medicine, E-ISSN 2077-0383, Vol. 9, no 6, article id E1895Article in journal (Refereed)
    Abstract [en]

    Previously published literature has identified a few predictors of health-related quality of life (HRQoL) after bariatric surgery. However, performance of the predictive models was not evaluated rigorously using real world data. To find better methods for predicting prognosis in patients after bariatric surgery, we examined performance of the Bayesian networks (BN) method in predicting long-term postoperative HRQoL and compared it with the convolution neural network (CNN) and multivariable logistic regression (MLR). The patients registered in the Scandinavian Obesity Surgery Registry (SOReg) were used for the current study. In total, 6542 patients registered in the SOReg between 2008 and 2012 with complete demographic and preoperative comorbidity information, and preoperative and postoperative 5-year HROoL scores and comorbidities were included in the study. HRQoL was measured using the RAND-SF-36 and the obesity-related problems scale. Thirty-five variables were used for analyses, including 19 predictors and 16 outcome variables. The Gaussian BN (GBN), CNN, and a traditional linear regression model were used for predicting 5-year HRQoL scores, and multinomial discrete BN (DBN) and MLR were used for 5-year comorbidities. Eighty percent of the patients were randomly selected as a training dataset and 20% as a validation dataset. The GBN presented a better performance than the CNN and the linear regression model; it had smaller mean squared errors (MSEs) than those from the CNN and the linear regression model. The MSE of the summary physical scale was only 0.0196 for GBN compared to the 0.0333 seen in the CNN. The DBN showed excellent predictive ability for 5-year type 2 diabetes and dyslipidemia (area under curve (AUC) = 0.942 and 0.917, respectively), good ability for 5-year hypertension and sleep apnea syndrome (AUC = 0.891 and 0.834, respectively), and fair ability for 5-year depression (AUC = 0.750). Bayesian networks provide useful tools for predicting long-term HRQoL and comorbidities in patients after bariatric surgery. The hybrid network that may involve variables from different probability distribution families deserves investigation in the future.

  • 13.
    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.

  • 14.
    Hedberg, Jakob
    et al.
    Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
    Sundbom, Magnus
    Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
    Edholm, David
    Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
    Aahlin, Eirik Kjus
    Department of GI and HPB Surgery, Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway; Department of GI and HPB Surgery, University Hospital of Northern Norway, Tromsø, Norway.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Lindberg, Fredrik
    Department of Surgical and Perioperative Sciences Surgery, Umeå University, Umeå, Sweden.
    Johnsen, Gjermund
    Department of Gastrointestinal Surgery, Norwegian University of Science and Technology, Trondheim, Norway.
    Førland, Dag Tidemann
    Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Oslo, Norway.
    Johansson, Jan
    Department of Surgery, Skane University Hospital, Lund, Sweden.
    Kauppila, Joonas H
    Department of Surgery, University of Oulu and Oulu University Hospital, Oulu, Finland.
    Svendsen, Lars Bo
    Department of Surgery and Transplantation, Copenhagen University Hospital, Copenhagen, Denmark.
    Nilsson, Magnus
    Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institutet, Stockholm, Sweden; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.
    Lindblad, Mats
    Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institutet, Stockholm, Sweden.
    Lagergren, Pernilla
    Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholn, Sweden; Department of Surgery and Cancer, Imperial College London, London, UK.
    Larsen, Michael Hareskov
    Department of Surgery, Odense University Hospital, Odense, Denmark.
    Åkesson, Oscar
    Department of Surgery, Skane University Hospital, Lund, Sweden.
    Löfdahl, Per
    Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Mala, Tom
    Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Oslo, Norway.
    Achiam, Michael Patrick
    Department of Surgery and Transplantation, Copenhagen University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
    Randomized controlled trial of nasogastric tube use after esophagectomy: study protocol for the kinetic trial2024In: Diseases of the esophagus, ISSN 1120-8694, E-ISSN 1442-2050, article id doae010Article in journal (Refereed)
    Abstract [en]

    Esophagectomy is a complex and complication laden procedure. Despite centralization, variations in perioparative strategies reflect a paucity of evidence regarding optimal routines. The use of nasogastric (NG) tubes post esophagectomy is typically associated with significant discomfort for the patients. We hypothesize that immediate postoperative removal of the NG tube is non-inferior to current routines. All Nordic Upper Gastrointestinal Cancer centers were invited to participate in this open-label pragmatic randomized controlled trial (RCT). Inclusion criteria include resection for locally advanced esophageal cancer with gastric tube reconstruction. A pretrial survey was undertaken and was the foundation for a consensus process resulting in the Kinetic trial, an RCT allocating patients to either no use of a NG tube (intervention) or 5 days of postoperative NG tube use (control) with anastomotic leakage as primary endpoint. Secondary endpoints include pulmonary complications, overall complications, length of stay, health related quality of life. A sample size of 450 patients is planned (Kinetic trial: https://www.isrctn.com/ISRCTN39935085). Thirteen Nordic centers with a combined catchment area of 17 million inhabitants have entered the trial and ethical approval was granted in Sweden, Norway, Finland, and Denmark. All centers routinely use NG tube and all but one center use total or hybrid minimally invasive-surgical approach. Inclusion began in January 2022 and the first annual safety board assessment has deemed the trial safe and recommended continuation. We have launched the first adequately powered multi-center pragmatic controlled randomized clinical trial regarding NG tube use after esophagectomy with gastric conduit reconstruction.

  • 15.
    Holmén, Anders
    et al.
    Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Södersjukhuset, Stockholm, Sweden.
    Hayami, Masaru
    Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden: Department of Upper Abdominal Cancer, Karolinska University Hospital, Stockholm, Sweden.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden; Scandinavian Obesity Surgery Registry, Örebro, Sweden.
    Rouvelas, Ioannis
    Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden: Department of Upper Abdominal Cancer, Karolinska University Hospital, Stockholm, Sweden.
    Agustsson, Thorhallur
    Department of Surgery, Södersjukhuset, Stockholm, Sweden; Department of Clinical Science and Education, Karolinska Institutet | Södersjukhuset, Stockholm, Sweden.
    Klevebro, Fredrik
    Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden: Department of Upper Abdominal Cancer, Karolinska University Hospital, Stockholm, Sweden.
    Nutritional jejunostomy in esophagectomy for cancer, a national register-based cohort study of associations with postoperative outcomes and survival2021In: Langenbeck's archives of surgery (Print), ISSN 1435-2443, E-ISSN 1435-2451, Vol. 406, no 5, p. 1415-1423Article in journal (Refereed)
    Abstract [en]

    PURPOSE: Insertion of a nutritional jejunostomy in conjunction with esophagectomy is performed with the intention to decrease the risk for postoperative malnutrition and improve recovery without adding significant catheter-related complications. However, previous research has shown no clear benefit and there is currently no consensus of practice.

    METHODS: All patients treated with esophagectomy due to cancer during the period 2006-2017 reported in the Swedish National Register for Esophageal and Gastric Cancer were included in this register-based cohort study from a national database. Patients were stratified into two groups: esophagectomy alone and esophagectomy with jejunostomy.

    RESULTS: A total of 847 patients (45.27%) had no jejunostomy inserted while 1024 patients (54.73%) were treated with jejunostomy. The groups were comparable, but some differences were seen in histological tumor type and tumor stage between the groups. No significant differences in length of hospital stay, postoperative surgical complications, Clavien-Dindo score, or 90-day mortality rate were seen. There was no evidence of increased risk for significant jejunostomy-related complications. Patients in the jejunostomy group with anastomotic leaks had a statistically significant lower risk for severe morbidity defined as Clavien-Dindo score ≥ IIIb (adjusted odds ratio 0.19, 95% CI: 0.04-0.94, P = 0.041) compared to patients with anastomotic leaks and no jejunostomy.

    CONCLUSION: A nutritional jejunostomy is a safe method for early postoperative enteral nutrition which might decrease the risk for severe outcomes in patients with anastomotic leaks. Nutritional jejunostomy should be considered for patients undergoing curative intended surgery for esophageal and gastro-esophageal junction cancer.

  • 16.
    Jans, Anders
    et al.
    Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Näslund, Ingmar
    Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    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, Erik
    Division of Surgery, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
    Stenberg, Erik
    Örebro University, School of Medical Sciences. Department of Surgery.
    Duration of type 2 diabetes and remission rates after bariatric surgery in Sweden 2007-2015: A registry-based cohort study2019In: PLoS Medicine, ISSN 1549-1277, E-ISSN 1549-1676, Vol. 16, no 11, article id e1002985Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Although bariatric surgery is an effective treatment for type 2 diabetes (T2D) in patients with morbid obesity, further studies are needed to evaluate factors influencing the chance of achieving diabetes remission. The objective of the present study was to investigate the association between T2D duration and the chance of achieving remission of T2D after bariatric surgery.

    METHODS AND FINDINGS: We conducted a nationwide register-based cohort study including all adult patients with T2D and BMI ≥ 35 kg/m2 who received primary bariatric surgery in Sweden between 2007 and 2015 identified through the Scandinavian Obesity Surgery Registry. The main outcome was remission of T2D, defined as being free from diabetes medication or as complete remission (HbA1c < 42 mmol/mol without medication). In all, 8,546 patients with T2D were included. Mean age was 47.8 ± 10.1 years, mean BMI was 42.2 ± 5.8 kg/m2, 5,277 (61.7%) were women, and mean HbA1c was 58.9 ± 17.4 mmol/mol. The proportion of patients free from diabetes medication 2 years after surgery was 76.6% (n = 6,499), and 69.9% at 5 years (n = 3,765). The chance of being free from T2D medication was less in patients with longer preoperative duration of diabetes both at 2 years (odds ratio [OR] 0.80/year, 95% CI 0.79-0.81, p < 0.001) and 5 years after surgery (OR 0.76/year, 95% CI 0.75-0.78, p < 0.001). Complete remission of T2D was achieved in 58.2% (n = 2,090) at 2 years, and 46.6% at 5 years (n = 681). The chance of achieving complete remission correlated negatively with the duration of diabetes (adjusted OR 0.87/year, 95% CI 0.85-0.89, p < 0.001), insulin treatment (adjusted OR 0.25, 95% CI 0.20-0.31, p < 0.001), age (adjusted OR 0.94/year, 95% CI 0.93-0.95, p < 0.001), and HbA1c at baseline (adjusted OR 0.98/mmol/mol, 95% CI 0.97-0.98, p < 0.001), but was greater among males (adjusted OR 1.57, 95% CI 1.29-1.90, p < 0.001) and patients with higher BMI at baseline (adjusted OR 1.07/kg/m2, 95% CI 1.05-1.09, p < 0.001). The main limitations of the study lie in its retrospective nature and the low availability of HbA1c values at long-term follow-up.

    CONCLUSIONS: In this study, we found that remission of T2D after bariatric surgery was inversely associated with duration of diabetes and was highest among patients with recent onset and those without insulin treatment.

  • 17.
    Jans, Anders
    et al.
    Örebro University, School of Medical Sciences. Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Rask, Eva
    Örebro University, School of Medical Sciences. University Health Care Research Centre.
    Ottosson, Johan
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Magnuson, Anders
    Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Stenberg, Erik
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Reliability of the DSS-Swe Questionnaire2023In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 33, no 11, p. 3487-3493Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Symptomatic postbariatric hypoglycemia (PBH) is a known complication that can occur a few years after Roux-en-Y gastric bypass (RYGB). There is currently no established rating scale for PBH-associated symptoms developed for use in Swedish populations. The aim of the study was to translate an already existing questionnaire into Swedish and to test its reliability.

    METHODS: The study included forward and backward translations of the original Dumping Severity Scale (DSS) questionnaire with 8 items regarding symptoms of early dumping and 6 items regarding hypoglycemia, with each item graded on a 4-point Likert scale. The reliability of the Swedish translated questionnaire (DSS-Swe) was estimated using internal consistency and test-retest methods.

    RESULTS: A total of 200 patients were included in the study. Good internal consistency was demonstrated regarding the items related to early dumping symptoms, with a Cronbach's alpha coefficient of 0.82, and very good agreement in terms of test-retest reliability, with an overall intraclass correlation coefficient (ICC) of 0.91 (95% CI 0.88-0.93). The items related to hypoglycemia yielded a good Cronbach's alpha coefficient of 0.76 and an ICC of 0.89 (95% CI 0.85-0.91).

    CONCLUSION: The DSS-Swe questionnaire shows good reliability regarding both internal consistency and test-retest performance for use in Swedish populations.

  • 18.
    Jans, Anders
    et al.
    Örebro University, School of Medical Sciences. 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.
    Ottosson, Johan
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Näslund, Erik
    Division of Surgery, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
    Stenberg, Erik
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Factors affecting relapse of type 2 diabetes after bariatric surgery in Sweden 2007-2015: a registry-based cohort study2022In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 18, no 3, p. 305-312Article, review/survey (Refereed)
    Abstract [en]

    BACKGROUND: Although a large proportion of patients with type 2 diabetes (T2DM) who have undergone metabolic surgery experience initial remission some patients later suffer from relapse. While several factors associated with T2D remission are known, less is known about factors that may influence relapse.

    OBJECTIVES: To identify possible risk factors for T2D relapse in patients who initially experienced remission.

    SETTING: Nationwide, registry-based study.

    METHODS: We conducted a nationwide registry-based retrospective cohort study including all adult patients with T2D and body mass index ≥35 kg/m2 who received primary metabolic surgery with Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) in Sweden between 2007 and 2015. Patients who achieved complete diabetes remission 2 years after surgery was identified and analyzed. Main outcome measure was postoperative relapse of T2D, defined as reintroduction of diabetes medication.

    RESULTS: In total, 2090 patients in complete remission at 2 years after surgery were followed for a median of 5.9 years (interquartile range [IQR] 4.3-7.2 years) after surgery. The cumulative T2D relapse rate was 20.1%. Duration of diabetes (hazard ratio [HR], 1.09; 95% confidence interval [CI], 1.05-1.14; P < .001), preoperative glycosylated hemoglobin A1C (HbA1C) level (HR, 1.01; 95% CI, 1.00-1.02; P = .013), and preoperative insulin treatment (HR, 2.67; 95% CI, 1.84-3.90; P < .001) were associated with higher rates for relapse, while postoperative weight loss (HR, .93; 95% CI, .91-.96; P < .001), and male sex (HR, .65; 95% CI, .46-.91; P = .012) were associated with lower rates.

    CONCLUSION: Longer duration of T2D, higher preoperative HbA1C level, less postoperative weight loss, female sex, and insulin treatment prior to surgery are risk factors for T2D relapse after initial remission.

  • 19.
    Kanold, Philip
    et al.
    Department of Internal Medicine, Division of Gastroenterology, Örebro University Hospital, Örebro, Sweden.
    Nyhlin, Nils
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Gastroenterology.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    van Nieuwenhoven, Michiel A.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Gastroenterology.
    The Swedish Standardized Course of Care-Diagnostic Efficacy in Esophageal and Gastric Cancer2023In: Diagnostics, ISSN 2075-4418, Vol. 13, no 23, article id 3577Article in journal (Refereed)
    Abstract [en]

    Fast-track pathways for diagnosing esophageal or gastric cancer (EGC) have been implemented in several European countries. In Sweden, symptoms such as dysphagia, early satiety, and other alarm symptoms call for a referral for gastroscopy, according to the Swedish Standardized Course of Care (SCC). The aim of this study was to evaluate the diagnostic yield of the SCC criteria for EGC, to review all known EGC cases in Region Örebro County between March 2017 and February 2021, and to compare referral indication(s), waiting times, and tumor stage. In our material, EGC was found in 6.2% of the SCC referrals. Esophageal dysphagia had a positive predictive value (PPV) of 5.6%. The criterion with the highest PPV for EGC was suspicious radiological findings, with a PPV of 24.5%. A total of 139 EGCs were diagnosed, 99 (71%) through other pathways than via the SCC. Waiting times were approximately 14 days longer for patients evaluated via non-SCC pathways. There was no statistically significant association between referral pathway and primary tumor characteristics. The results show that a majority of the current SCC criteria are poor predictors of EGC, and some alarm symptoms lack a sufficiently specific definition, e.g., dysphagia. Referral through this fast track does not seem to have a positive impact on disease outcomes.

  • 20.
    Nilsson, Klara
    et al.
    Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institute, Stockholm, Sweden.
    Klevebro, Fredrik
    Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institute, Stockholm, Sweden.
    Rouvelas, Ioannis
    Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institute, Stockholm, Sweden.
    Lindblad, Mats
    Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institute, Stockholm, Sweden.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Halldestam, Ingvar
    Department of Surgery, University Hospital of Linköping, Linköping, Sweden.
    Smedh, Ulrika
    Department of Surgery, Sahlgrenska University Hospital, Gothenburg Sweden.
    Wallner, Bengt
    Department of Surgical and Perioperative Sciences, Umeå University Hospital, Umeå, Sweden.
    Johansson, Jan
    Department of Surgery, Skåne University Hospital, Lund, Sweden.
    Johnsen, Gjermund
    Department of Gastrointestinal Surgery, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway.
    Aahlin, Eirik Kjus
    Department of GI and HPB Surgery, University Hospital of Northern Norway, Tromsø, Norway.
    Johannessen, Hans-Olaf
    Department of Gastrointestinal Surgery, Oslo University Hospital, Oslo, Norway.
    Hjortland, Geir Olav
    Department of Oncology, Oslo University Hospital, Oslo, Norway.
    Bartella, Isabel
    Department of General, Visceral, Cancer and Transplantation Surgery, University of Cologne, Cologne, Germany.
    Schröder, Wolfgang
    Department of General, Visceral, Cancer and Transplantation Surgery, University of Cologne, Cologne, Germany.
    Bruns, Christiane
    Department of General, Visceral, Cancer and Transplantation Surgery, University of Cologne, Cologne, Germany.
    Nilsson, Magnus
    Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institute, Stockholm, Sweden.
    Surgical Morbidity and Mortality From the Multicenter Randomized Controlled NeoRes II Trial: Standard Versus Prolonged Time to Surgery After Neoadjuvant Chemoradiotherapy for Esophageal Cancer.2020In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 272, no 5, p. 684-689Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To investigate if prolonged TTS after completed nCRT improves postoperative outcomes for esophageal and esophagogastric junction cancer.

    SUMMARY OF BACKGROUND DATA: TTS has traditionally been 4-6 weeks after completed nCRT. However, the optimal timing is not known.

    METHODS: A multicenter clinical trial was performed with randomized allocation of TTS of 4-6 or 10-12 weeks. The primary endpoint of this sub-study was overall postoperative complications defined as Clavien-Dindo grade II-V. Secondary endpoints included complication severity according to Clavien-Dindo grade IIIb-V, postoperative 90-day mortality, and length of hospital stay. The study was registered in Clinicaltrials.gov (NCT02415101).

    RESULTS: In total 249 patients were randomized. There were no significant differences between standard TTS and prolonged TTS with regard to overall incidence of complications Clavien-Dindo grade II-V (63.2% vs 72.6%, P = 0.134) or regarding Clavien-Dindo grade IIIb-V complications (31.6% vs 34.9%, P = 0.603). There were no statistically significant differences between standard and prolonged TTS regarding anastomotic leak (P = 0.596), conduit necrosis (P = 0.524), chyle leak (P = 0.427), pneumonia (P = 0.548), and respiratory failure (P = 0.723). In the standard TTS arm 5 patients (4.3%) died within 90 days of surgery, compared to 4 patients (3.8%) in the prolonged TTS arm (P = 1.0). Median length of hospital stay was 15 days in the standard TTS arm and 17 days in the prolonged TTS arm (P = 0.234).

    CONCLUSION: The timing of surgery after completed nCRT for carcinoma of the esophagus or esophagogastric junction, is not of major importance with regard to short-term postoperative outcomes.

  • 21.
    Raoof, Mustafa
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Näslund, Ingmar
    Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Rask, Eva
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Karlsson, Jan
    Centre for Health Care Sciences, Örebro University Hospital, Örebro, Sweden; Department of Medicine, School of Health and Medical Sciences, Örebro University, Örebro, Sweden .
    Sundbom, Magnus
    Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
    Edholm, David
    Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
    Karlsson, F. Anders
    Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
    Svensson, Felicity
    Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
    Szabo, Eva
    Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden .
    Health-Related Quality-of-Life (HRQoL) on an Average of 12 Years After Gastric Bypass Surgery2015In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 25, no 7, p. 1119-1127Article in journal (Refereed)
    Abstract [en]

    It is evident that morbidly obese patients have a low health-related quality-of-life (HRQoL), and this low HRQoL has become a common reason for them to seek bariatric surgery. Several HRQoL studies demonstrate a dramatic postoperative improvement, but most of these have had a short follow-up period.

    An observational, cross-sectional study for HRQoL was conducted to study 486 patients (average age of 50.7 +/- 10.0 years, with 84 % of them being female) operated with gastric bypass (GBP) in the period 1993 to 2003 at the University Hospitals of A-rebro and Uppsala. Mean follow-up after gastric bypass was 11.5 +/- 2.7 years (range 7-17). Two HRQoL instruments were used, SF-36 and the Obesity-related Problems scale (OP). The study group was compared with two control groups, both matched for age and gender, one from the general population and one containing morbidly obese patients evaluated and awaiting bariatric surgery.

    The study group scored better in the SF-36 domains (all four physical domains and the vitality subscore) and OP scale compared to obese controls, but their HRQoL scores were lower than those of the general population. HRQoL was better among younger patients and in the following subgroups: men, patients with satisfactory weight loss, satisfied with the procedure, free from co-morbidities and gastrointestinal symptoms, employment, good oral status and those not hospitalised or regularly followed up for non-bariatric reasons.

    Long-term follow-up after GBP for morbid obesity showed better scores in most aspects of HRQoL compared to obese controls but did not achieve the levels of the general population. Patients with better medical outcome after gastric bypass operation had better HRQoL.

  • 22.
    Raoof, Mustafa
    et al.
    Örebro University, School of Medical Sciences. Department of Surgery.
    Näslund, Ingmar
    Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Rask, Eva
    Örebro University, School of Medical Sciences.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Bone mineral density, parathyroid hormone and vitamin D after gastric bypass surgery: a 10-year longitudinal follow-upManuscript (preprint) (Other academic)
  • 23.
    Raoof, Mustafa
    et al.
    Örebro University, School of Medical Sciences. Department of Surgery.
    Näslund, Ingmar
    Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Rask, Eva
    Örebro University, School of Medical Sciences. Department of Medicine.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Bone Mineral Density, Parathyroid Hormone, and Vitamin D After Gastric Bypass Surgery: a 10-Year Longitudinal Follow-Up2020In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 30, no 12, p. 4995-5000Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The aim of the present study was to study longitudinal changes in bone mineral density (BMD), vitamin D, and parathyroid hormone (PTH) levels in females over a 10-year period after laparoscopic Roux-en-Y gastric bypass (LRYGB).

    METHODS: at baseline, were included. BMD, BMI, S-calcium, S-25(OH)-vitamin D, and fP-PTH were measured preoperatively and 2, 5, and 10 years postoperatively.

    RESULTS: Ten years after surgery, BMD of the spine and femoral neck decreased by 20% and 25%, respectively. Changes in serum levels of vitamin D, PTH, and calcium over the same period were small.

    CONCLUSION: After LRYGB with subsequent massive weight loss, a large decrease in BMD of the spine and femoral neck was seen over a 10-year postoperative period. The fall in BMD largely occurred over the first 5 years after surgery.

  • 24.
    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.

  • 25.
    Raoof, Mustafa
    et al.
    Örebro University, School of Medical Sciences. Department of Surgery.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Karlsson, Jan
    Örebro University, School of Medical Sciences. Örebro University Hospital. University Health Care Research Centre.
    Näslund, Erik
    Department of Clinical Sciences, Danderyd Hospital Karolinska Institutet, Stockholm, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Näslund, Ingmar
    Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Improvements of health-related quality of life 5 years after gastric bypass. What is important besides weight loss? A study from Scandinavian Obesity Surgery Register2020In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 16, no 9, p. 1249-1257Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Obesity continues to increase in the world. It is strongly associated with morbidity, mortality, and decrease of health-related quality of life (HRQoL). Surgery is the most effective treatment for obesity, resulting in sustained weight loss and improvements of HRQoL. The aim of this study was to examine whether other factors, apart from weight loss, are associated with improvement in HRQoL scores between the preoperative visit and the 5-year follow-up.

    OBJECTIVES: To examine whether there are factors besides weight loss that affect the improvement of HRQoL from before to 5 years after gastric bypass surgery.

    SETTING: Large, nationwide, observational study with national quality and research registry.

    METHODS: Patients operated with a primary gastric bypass in Sweden between January 2008 and December 2012 were identified in the Scandinavian Obesity Surgery Register. Patients with HRQoL data available at both baseline and 5 years after surgery were included. Two HRQoL instruments, the RAND Short form-36 and the obesity-related problems scale, were used in the study.

    RESULTS: The study sample comprised 6998 patients (21% men). Differences in HRQoL change according to sex were minor. Younger patients showed greater improvements in physical health scales. In general linear regression model analyses, age and weight loss correlated significantly with improvement in HRQoL after 5 years. Patients treated medically for depression preoperatively (13%) experienced less improvement in HRQoL than patients without such treatment. Patients with postoperative complications (26%) had significantly less improvements in all aspects of HRQoL compared with those without any form of postoperative complication.

    CONCLUSION: The study confirmed the importance of weight loss for improvement in HRQoL after bariatric surgery. Preoperative medication for depression and suffering a complication during the 5-year follow-up period were associated with less improvement in HRQoL.

  • 26.
    Raoof, Mustafa
    et al.
    Örebro University, School of Medical Sciences. Department of Surgery.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Karlsson, Jan
    Örebro University, School of Medical Sciences. Örebro University Hospital. University Health Care Research Centre.
    Näslund, Erik
    Department of Clinical Sciences, Danderyd Hospital Karolinska Institutet, Stockholm, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Näslund, Ingmar
    Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Improvements of health-related quality of life five years after gastric bypass. What is important besides weight loss? A study from Scandinavian Obesity Surgery RegisterManuscript (preprint) (Other academic)
  • 27.
    Reda, Souheil
    et al.
    Örebro University, School of Medical Sciences. Division of Upper Gastrointestinal Surgery, Department of Surgery, Örebro University Hospital, Örebro, Swede.
    Ahl, Rebecka
    Örebro University, School of Medical Sciences. Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Upper Gastrointestinal Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Stenberg, Erik
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Upper Gastrointestinal Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Forssten, Maximilian Peter
    Örebro University, School of Medical Sciences. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Sjölin, Gabriel
    Örebro University, School of Medical Sciences. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Pre-operative beta-blocker therapy does not affect short-term mortality after esophageal resection for cancer2020In: BMC Surgery, ISSN 1471-2482, E-ISSN 1471-2482, Vol. 20, no 1, article id 333Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: It has been postulated that the hyperadrenergic state caused by surgical trauma is associated with worse outcomes and that β-blockade may improve overall outcome by downregulation of adrenergic activity. Esophageal resection is a surgical procedure with substantial risk for postoperative mortality. There is insufficient data to extrapolate the existing association between preoperative β-blockade and postoperative mortality to esophageal cancer surgery. This study assessed whether preoperative β-blocker therapy affects short-term postoperative mortality for patients undergoing esophageal cancer surgery.

    METHODS: All patients with an esophageal cancer diagnosis that underwent surgical resection with curative intent from 2007 to 2017 were retrospectively identified from the Swedish National Register for Esophagus and Gastric Cancers (NREV). Patients were subdivided into β-blocker exposed and unexposed groups. Propensity score matching was carried out in a 1:1 ratio. The outcome of interest was 90-day postoperative mortality.

    RESULTS: A total of 1466 patients met inclusion criteria, of whom 35% (n = 513) were on regular preoperative β-blocker therapy. Patients on β-blockers were significantly older, more comorbid and less fit for surgery based on their ASA score. After propensity score matching, 513 matched pairs were available for analysis. No difference in 90-day mortality was detected between β-blocker exposed and unexposed patients (6.0% vs. 6.6%, p = 0.798).

    CONCLUSION: Preoperative β-blocker therapy is not associated with better short-term survival in patients subjected to curative esophageal tumor resection.

  • 28.
    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.

  • 29.
    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.

  • 30.
    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.
    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.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Sundbom, Magnus
    Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
    Ottosson, Johan
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Näslund, Erik
    Division of Surgery, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
    The association between socioeconomic factors and weight loss 5 years after gastric bypass surgery2020In: International Journal of Obesity, ISSN 0307-0565, E-ISSN 1476-5497, Vol. 44, no 11, p. 2279-2290Article in journal (Refereed)
    Abstract [en]

    Introduction: Patients with low socioeconomic status have been reported to have poorer outcome than those with a high socioeconomic status after several types of surgery. The influence of socioeconomic factors on weight loss after bariatric surgery remains unclear. The aim of the present study was to evaluate the association between socioeconomic factors and postoperative weight loss.

    Materials and methods: This was a retrospective, nationwide cohort study with 5-year follow-up data for 13,275 patients operated with primary gastric bypass in Sweden between January 2007 and December 2012 (n = 13,275), linking data from the Scandinavian Obesity Surgery Registry, Statistics Sweden, the Swedish National Patient Register, and the Swedish Prescribed Drugs Register. The assessed socioeconomic variables were education, profession, disposable income, place of residence, marital status, financial aid and heritage. The main outcome was weight loss 5 years after surgery, measured as total weight loss (TWL). Linear regression models, adjusted for age, preoperative body mass index (BMI), sex and comorbid diseases were constructed.

    Results: The mean TWL 5 years after surgery was 28.3 +/- 9.86%. In the adjusted model, first-generation immigrants (%TWL, B -2.4 [95% CI -2.9 to -1.9],p < 0.0001) lost significantly less weight than the mean, while residents in medium-sized (B 0.8 [95% CI 0.4-1.2],p = 0.0001) or small towns (B 0.8 [95% CI 0.4-1.2],p < 0.0001) lost significantly more weight.

    Conclusions: All socioeconomic groups experienced improvements in weight after bariatric surgery. However, as first-generation immigrants and patients residing in larger towns (>200,000 inhabitants) tend to have inferior weight loss compared to other groups, increased support in the pre- and postoperative setting for these two groups could be of value. The remaining socioeconomic factors appear to have a weaker association with postoperative weight loss.

  • 31.
    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.

  • 32.
    Stenberg, Erik
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Hand and Orthopedic Surgery.
    Ottosson, Johan
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Magnuson, Anders
    Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Wallén, Stefan
    Örebro University, School of Medical Sciences. Pharmacology and Therapeutic Department, School of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Näslund, Erik
    Division of Surgery, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
    Thorell, Anders
    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.
    Long-term Safety and Efficacy of Closure of Mesenteric Defects in Laparoscopic Gastric Bypass Surgery: A Randomized Clinical Trial2023In: JAMA Surgery, ISSN 2168-6254, E-ISSN 2168-6262, Vol. 158, no 7, p. 709-717Article in journal (Refereed)
    Abstract [en]

    IMPORTANCE: Short-term and midterm data suggest that mesenteric defects closure during laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery reduces the risk of internal herniation with small bowel obstruction (SBO) but may increase risk of kinking of the jejunojejunostomy in the early postoperative period. However, to our knowledge, there are no clinical trials reporting long-term results from this intervention in terms of risk for SBO or opioid use.

    OBJECTIVE: To evaluate long-term safety and efficacy outcomes of closure of mesenteric defects during LRYGB.

    DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial with a 2-arm, parallel, open-label design included patients with severe obesity scheduled for LRYGB bariatric surgery at 12 centers in Sweden from May 1, 2010, through November 14, 2011, with 10 years of follow-up after the intervention. INTERVENTIONS: During the operation, patients were randomly assigned 1:1 to closure of mesenteric defects beneath the jejunojejunostomy and at the Petersen space using nonabsorbable running sutures during LRYGB or to nonclosure.

    MAIN OUTCOME AND MEASURES: The primary outcome was reoperation for SBO. New incident, chronic opioid use was a secondary end point as a measure of harm.

    RESULTS: A total of 2507 patients (mean [SD] age, 41.7 [10.7] years; 1863 female [74.3%]) were randomly assigned to closure of mesenteric defects (n = 1259) or nonclosure (n = 1248). After censoring for death and emigration, 1193 patients in the closure group (94.8%) and 1198 in the nonclosure group (96.0%) were followed up until the study closed. Over a median follow-up of 10 years (IQR, 10.0-10.0 years), a reoperation for SBO from day 31 to 10 years after surgery was performed in 185 patients with nonclosure (10-year cumulative incidence, 14.9%; 95% CI, 13.0%-16.9%) and in 98 patients with closure (10-year cumulative incidence, 7.8%; 95% CI, 6.4%-9.4%) (subhazard ratio [SHR], 0.42; 95% CI, 0.32-0.55). New incident chronic opioid use was seen among 175 of 863 opioid-naive patients with nonclosure (10-year cumulative incidence, 20.4%; 95% CI, 17.7%-23.0%) and 166 of 895 opioid-naive patients with closure (10-year cumulative incidence, 18.7%; 95% CI, 16.2%-21.3%) (SHR, 0.90; 95% CI, 0.73-1.11).

    CONCLUSIONS AND RELEVANCE: This randomized clinical trial found long-term reduced risk of SBO after mesenteric defects closure in LRYGB. The findings suggest that routine use of this procedure during LRYGB should be considered.

    TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01137201.

  • 33.
    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.

  • 34.
    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.

  • 35.
    Stenberg, Erik
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Rask, Eva
    Örebro University, School of Medical Sciences. Department of Endocrinology.
    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.
    Ottosson, Johan
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    The Effect of Laparoscopic Gastric Bypass Surgery on Insulin Resistance and Glycosylated Hemoglobin A1c: a 2-Year Follow-up Study2020In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 30, no 9, p. 3489-3495Article in journal (Refereed)
    Abstract [en]

    Background: Bariatric surgery improves insulin sensitivity and secretion in patients with type 2 diabetes, but the effect on patients with prediabetes or even normal glucose tolerance deserves further consideration.

    Methods: Cohort study including patients operated with laparoscopic Roux-en-Y gastric bypass surgery (LRYGB) between November 2012 and June 2017 at the orebro University Hospital (n = 813) with follow-up of 742 patients 2 years after surgery. Fasting insulin, glucose, glycosylated hemoglobin (HbA1c), and homeostatic model assessment of insulin resistance (HOMA-IR) were analyzed at baseline and 2 years after surgery for patients with overt type 2 diabetes, prediabetes, or non-diabetes.

    Results: Fasting insulin levels improved for all groups (diabetics baseline 25.5 mIU/L, IQR 17.5-38.0, 2 years 7.6 mIU/L, IQR 5.4-11.1, p < 0.001; prediabetics baseline 25.0 mIU/L, IQR 17.5-35.0, 2 years 6.7mIU/L, IQR 5.3-8.8, p < 0.001; non-diabetics baseline 20.0 mIU/L, IQR 14.0-30.0, 2 years 6.4 mIU/L, IQR 5.0-8.5, p < 0.001). HbA1c improved in all groups (diabetics baseline 56 mmol/mol, IQR 49-74 [7.3%, IQP 6.6-8.9], 2 years 38 mmol/mol, IQR 36-47 [5.6%, IQR 5.4-6.4], p < 0.001; prediabetics baseline 40 mmol/mol, IQR 39-42 [5.8%, IQR5.7-6.0], 2 years 36 mmol/mol, IQR 34-38 [5.5%, IQR 5.3-5.6], p < 0.001; non-diabetics baseline 35 mmol/mol, IQR 33-37 [5.4%, IQR 5.2-5.5]; 2 years 34 mmol/mol, IQR 31-36 [5.3%, IQR 5.0-5.4], p < 0.001). HOMA-IR improved in all groups (diabetics baseline 9.3 mmol/mol, IQR 5.4-12.9, 2 years 1.9 mmol/mol, IQR 1.4-2.7, p < 0.001; prediabetics baseline 7.0 mmol/mol, IQR 4.3-9.9, 2 years 1.6 mmol/mol, IQR 1.2-2.1, p < 0.001; non-diabetics 4.9 mmol/mol, IQR 3.4-7.3, 2 years 1.4 mmol/mol, IQR 1.1-1.9, p < 0.001).

    Conclusion: Insulin homeostasis and glucometabolic control improve in all patients after LRYGB, not only in diabetics but also in prediabetics and non-diabetic obese patients, and this improvement is sustained 2 years after surgery.

  • 36.
    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.

  • 37.
    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.

  • 38.
    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.

  • 39.
    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.

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  • 40.
    Wallhuss, Andreas
    et al.
    Department of Surgery, Faculty of Medicine and Health, Örebro University, Sweden.
    Ottosson, Johan
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital. Clinical Epidemiology and Biostatistics.
    Andersson, Ellen
    Department of Biomedical and Clinical Sciences, Linköping University and Department of Surgery, Vrinnevi, Norrköping, Sweden.
    Bergemalm, Daniel
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Gastroenterology.
    Eriksson, Carl
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Gastroenterology, Faculty of Medicine and Health, Örebro University, Sweden; Clinical Epidemiology Department, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.
    Olén, Ola
    Clinical Epidemiology Department, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Sachs' Children and Youth Hospital, Stockholm South General Hospital, Sweden.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Stenberg, Erik
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Outcomes of bariatric surgery for patients with prevalent inflammatory bowel disease: A nationwide registry-based cohort study2023In: Surgery, ISSN 0039-6060, E-ISSN 1532-7361, Vol. 174, no 2, p. 144-151Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Obesity is becoming more prevalent in patients with inflammatory bowel disease. Although bariatric surgery is an effective treatment for obesity, questions remain regarding its safety and effectiveness for patients with inflammatory bowel disease. The aim of this study was to evaluate the safety and effectiveness of bariatric surgery in patients with inflammatory bowel disease.

    METHOD: This registry-based, propensity-matched cohort study included all patients who had primary Roux-en-Y gastric bypass or sleeve gastrectomy in Sweden from January 2007 to June 2020 who had an inflammatory bowel disease diagnosis and matched control patients without an inflammatory bowel disease diagnosis. The study included data from the Scandinavian Obesity Surgery Registry, the National Patient Register, the Swedish Prescribed Drugs Register, the Total Population Register, and the Education Register from Statistics Sweden.

    RESULTS: In total, 71,093 patients who underwent bariatric surgery, including 194 with Crohn's disease and 306 with ulcerative colitis, were 1:5 matched to non-inflammatory bowel disease control patients. The patients with Crohn's disease had a higher readmission rate within 30 days (10.7% vs 6.1%, odds ratio = 1.84, 95% confidence interval 1.02-3.31) than the control patients, with no significant difference between the surgical methods. The patients with ulcerative colitis had a higher risk for serious postoperative complications after Roux-en-Y gastric bypass (8.0% vs 3.7%, odds ratio = 2.64, 95% confidence interval 1.15-6.05) but not after sleeve gastrectomy compared to control patients (0.8% vs 2.3%). No difference was observed in postoperative weight loss or postoperative health-related quality of life.

    CONCLUSION: Sleeve gastrectomy appears to be a safe and effective treatment for obesity in patients with inflammatory bowel disease, whereas Roux-en-Y gastric bypass was associated with a higher risk for postoperative complications in patients with ulcerative colitis.

  • 41.
    Wallén, Stefan
    et al.
    Örebro University, School of Medical Sciences. Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; Pharmacology and Therapeutic Department, Region Örebro County, University Hospital of Örebro, Sweden.
    Bruze, Gustaf
    Department of Medicine, Solna, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden.
    Ottosson, Johan
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Marcus, Claude
    Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.
    Sundström, Johan
    Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Olbers, Torsten
    Institute of Clinical and Experimental Medicine and Wallenberg Centre for Molecular Medicine, University of Linköping and Department of Surgery, Vrinnevi, Norrköping, Sweden.
    Ekbäck, Maria Palmetun
    Pharmacology and Therapeutic Department, Region Örebro County, University Hospital of Örebro, Sweden.
    Näslund, Ingmar
    Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Neovius, Martin
    Department of Medicine, Solna, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden.
    Opioid Use After Gastric Bypass, Sleeve Gastrectomy or Intensive Lifestyle Intervention2023In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 277, no 3, p. e552-e560Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To compare opioid use in patients with obesity treated with bariatric surgery versus adults with obesity who underwent intensive lifestyle modification. SUMMARY OF

    BACKGROUND DATA: Previous studies of opioid use after bariatric surgery have been limited by small sample sizes, short follow-up, and lack of control groups.

    METHODS: Nationwide matched cohort study including individuals from the Scandinavian Obesity Surgery Registry and the Itrim health database with individuals undergoing structured intensive lifestyle modification, between August 1, 2007 and September 30, 2015. Participants were matched on Body Mass Index, age, sex, education, previous opioid use, diabetes, cardiovascular disease, and psychiatric status (n = 30,359:21,356). Dispensed opioids were retrieved from the Swedish Prescribed Drug Register from 2 years before to up to 8 years after intervention.

    RESULTS: During the 2-year period before treatment, prevalence of individuals receiving ≥1 opioid prescription was identical in the surgery and lifestyle group. At 3 years, the prevalence of opioid prescriptions was 14.7% versus 8.9% in the surgery and lifestyle groups (mean difference 5.9%, 95% confidence interval 5.3-6.4) and at 8 years 16.9% versus 9.0% (7.9%, 6.8-9.0). The difference in mean daily dose also increased over time and was 3.55 mg in the surgery group versus 1.17 mg in the lifestyle group at 8 years (mean difference [adjusted for baseline dose] 2.30 mg, 95% confidence interval 1.61-2.98).

    CONCLUSIONS: Bariatric surgery was associated with a higher proportion of opioid users and larger total opioid dose, compared to actively treated obese individuals. These trends were especially evident in patients who received additional surgery during follow-up.

  • 42.
    Wallén, Stefan
    et al.
    Örebro University, School of Medical Sciences. Pharmacology and Therapeutic Department, School of Medical Sciences, Örebro University, Örebro, Sweden.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Ekbäck, Maria Palmetun
    Örebro University Hospital. Örebro University, School of Medical Sciences. Pharmacology and Therapeutic Department.
    Näslund, Ingmar
    Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Ottosson, Johan
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Näslund, Erik
    Division of Surgery, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
    Stenberg, Erik
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Impact of socioeconomic status on new chronic opioid use after gastric bypass surgery2023In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 19, no 12, p. 1375-1381Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Socioeconomic status may influence weight loss, postoperative complications, and health-related quality of life after bariatric surgery. Chronic use of opioid analgesics is a known risk after bariatric surgery, but whether socioeconomic factors are associated with new chronic use of opioid analgesics has not been investigated in depth.

    OBJECTIVES: The aim of this study was to identify socioeconomic factors associated with the development of new chronic use of opioid analgesics after gastric bypass surgery.

    SETTING: All hospitals performing bariatric surgery in Sweden.

    METHODS: This was a retrospective cohort study with prospectively collected data including all primary gastric bypass procedures in Sweden between 2007 and 2015. Data were collected from the Scandinavian Obesity Surgery Registry, the Swedish Prescribed Drug Register, and Statistics Sweden. The primary outcome was new chronic opioid use.

    RESULTS: Of the 44,671 participants, 1438 patients became new chronic opioid users. Longer education (secondary education; odds ratio [OR] = .71; 95% CI, .62-.81) or higher education (OR = .45; 95% CI, .38-.53), higher disposable income (20th-50th percentile: OR = .75; 95% CI, .66-.85; 50th-80th percentile: OR = .50; 95% CI, .43-.58; and the highest 80th percentile: OR = .40; 95% CI, .32-.51) were significantly associated with lower risk for new chronic opioid use. Being a second-generation immigrant (OR = 1.54; 95% CI, 1.24-1.90), being on a disability pension or early retirement (OR = 3.04; 95% CI, 2.67-3.45), receiving social benefits (OR = 1.88; 95% CI, 1.59-2.22), being unemployed for <100 days (OR = 1.25; 95% CI, 1.08-1.45), being unemployed for >100 days (OR = 1.41; 95% CI, 1.16-1.71), and being divorced or a widow or widower (OR = 1.35; 95% CI, 1.17-1.55) were significantly associated with a higher risk for chronic opioid use.

    CONCLUSION: Given that long-term opioid use has detrimental effects after bariatric surgery, it is important that information and follow-up are optimized for patients with shorter education, lower income, and disability pension or early retirement because they are at an increased risk of new chronic opioid analgesics use.

  • 43.
    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.

  • 44.
    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.

  • 45.
    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.

  • 46.
    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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