Bariatric Surgery : Outcomes after Gastric Bypass and Duodenal Switch

Obesity is associated with increased morbidity and mortality. A BMI >40 kg/m2 shortens life expectancy by about 10 years. The obesity related comorbidities diabetes, hypertension, dyslipidemia and sleep apnea contributes to the increased risk of cardiovascular events. There is also an increased risk of some forms of cancer (e.g. colon, breast, and prostate cancer) as well as mental illness (depression and low self-esteem). Bariatric surgery is indicated for those with a BMI >35 kg/m2. Unfortunately, there are an increasing number of patients seeking bariatric surgery who are super obese (BMI >50 kg/m2), a condition more difficult to treat because of insufficient weight loss with standard operations, like the Roux-en-Y Gastric Bypass (RYGB). Therefore some surgeons advocate the Duodenal Switch (DS) in super obese patients, because DS results in greater and more sustained weight loss. However, DS is a technically more challenging operation and is associated with an increased risk of malnutrition and surgical complications. There are also concerns about an excessive loss of fat-free mass during weight loss after RYGB and especially after DS. This thesis focuses on weight-loss, effect on comorbidities, quality of life and complications after DS and RYGB, respectively, with comparisons between the two procedures in patients with super obesity.  DS resulted in a superior weight loss compared to RYGB (paper I, II and III) and body composition after weight loss did not differ compared with non-operated controls with the same BMI after surgery, for neither DS nor RYGB (paper I). Both DS and RYGB resulted in an improved metabolic control (paper II and III), but the effect on diabetes and hypertension was greater and maintained in the long-term after DS (paper III). Both DS and RYGB resulted in an improved physical quality of life, with greater improvements after DS (paper III). However, complications and long-term adverse effects were more common after DS (paper II and IV). In conclusion, the superior weight loss and greater improvements in several obesity-related comorbidities after DS must be weighed against the increased risk of complications and long-term adverse effects compared to RYGB.

Bariatric Surgery : Outcomes after Gastric Bypass and Duodenal Switch

Obesity is associated with increased morbidity and mortality. A BMI >40 kg/m2 shortens life expectancy by about 10 years. The obesity related comorbidities diabetes, hypertension, dyslipidemia and sleep apnea contributes to the increased risk of cardiovascular events. There is also an increased risk of some forms of cancer (e.g. colon, breast, and prostate cancer) as well as mental illness (depression and low self-esteem). Bariatric surgery is indicated for those with a BMI >35 kg/m2. Unfortunately, there are an increasing number of patients seeking bariatric surgery who are super obese (BMI >50 kg/m2), a condition more difficult to treat because of insufficient weight loss with standard operations, like the Roux-en-Y Gastric Bypass (RYGB). Therefore some surgeons advocate the Duodenal Switch (DS) in super obese patients, because DS results in greater and more sustained weight loss. However, DS is a technically more challenging operation and is associated with an increased risk of malnutrition and surgical complications. There are also concerns about an excessive loss of fat-free mass during weight loss after RYGB and especially after DS. This thesis focuses on weight-loss, effect on comorbidities, quality of life and complications after DS and RYGB, respectively, with comparisons between the two procedures in patients with super obesity.  DS resulted in a superior weight loss compared to RYGB (paper I, II and III) and body composition after weight loss did not differ compared with non-operated controls with the same BMI after surgery, for neither DS nor RYGB (paper I). Both DS and RYGB resulted in an improved metabolic control (paper II and III), but the effect on diabetes and hypertension was greater and maintained in the long-term after DS (paper III). Both DS and RYGB resulted in an improved physical quality of life, with greater improvements after DS (paper III). However, complications and long-term adverse effects were more common after DS (paper II and IV). In conclusion, the superior weight loss and greater improvements in several obesity-related comorbidities after DS must be weighed against the increased risk of complications and long-term adverse effects compared to RYGB.

Preoperative chronic opioid use and its impact on early complications in bariatric surgery : a Swedish nationwide cohort study of 56,183 patients

Background: The association between severe obesity and chronic pain makes opioid use common among bariatric patients. Preoperative opioid use has been identified as a risk factor in other surgical procedures. Objectives: To examine the impact of preoperative opioid use on complications after primary bariatric surgery. Setting: Sweden. Methods: All primary laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) patients from 2007-2017 were identified in the Scandinavian Obesity Surgery Register. Prescriptions for opioids within 90 days prior to surgery were retrieved from the Swedish Prescribed Drug Register and converted into oral morphine equivalents (OMEs). Patients with >= 2 prescription of opioids within 90 days prior to surgery were defined as chronic opioid users. Generalized linear regression was used to adjust for age, sex, body mass index, procedure type, year of operation, and co-morbidities. Results: Of the 56,183 patients who had undergone primary LRYGB (n = 49,615) or LSG (n = 6568), 17.5% (n = 9825) had at least 1 prescription of opioids prior to surgery, of which 4.3% (n = 2390) were defined as chronic opioid users. Chronic opioid use was associated with a higher risk of severe complications (Clavien Dindo grade >= 3b; odds ratio [OR], 1.67; 95% confidence interval [CI], 1.37-2.04), increased lengths of stay (relative risk, 1.11; 95% CI, 1.08-1.14), and higher rates of readmission (OR, 1.70; 95% CI, 1.49-1.94) and reoperation (OR, 1.87; 95% CI, 1.53-2.27; all P values < .001). Furthermore, higher OME exposure was associated with stepwise higher risks. Conclusion: Preoperative opioid use was an independent risk factor for severe complications, as well as prolonged lengths of stay, readmission, and reoperation after primary bariatric surgery

Nonsteroid anti-inflammatory drugs and the risk of peptic ulcers after gastric bypass and sleeve gastrectomy

Background: Pharmacologic pain treatment is common among bariatric patients. Nonsteroid antiinflammatory drugs (NSAID) are not recommended after Roux-en-Y gastric bypass (RYGB) because of the increased risk of marginal ulceration, but the connection with NSAID is not unambiguous. Objectives: Examine the association between NSAID exposure and peptic ulcers after primary laparoscopic RYGB and sleeve gastrectomy (SG) respectively. Setting: University Hospital, Sweden. Methods: Cross-matched data from 3 national registers were used in this retrospective, populationbased cohort study of all primary laparoscopic RYGB and SG in Sweden within the period from 2010-2015. NSAID exposure was analyzed with individual data of dispensed daily defined doses (DDD) of NSAID after surgery. Multivariate logistic regression estimated the association between NSAID exposure and peptic ulcers, expressed as odds ratios with 95% confidence intervals adjusted for confounding. Results: Of the 41,380 patients (37,913 RYGB, 3467 SG), 1.8% were diagnosed with peptic ulcers after surgery (RYGB 1.9%, SG.2%). In total, 60% of the patients had been prescribed NSAID during a follow-up period of 4.1 (1.0-7.0) years in median. The adjusted risk odds ratios for NSAID exposure were 1.10 (.88-1.38), 1.43 (1.16-1.76), and 1.52 (1.25-1.84) for >0-30 DDD, >30-100 DDD, and.100 DDD, respectively. In subanalysis, the association was similar for RYGB alone, whereas no association was found for SG. Conclusion: The results of the present study support the notion that continuous NSAID use of >= 30 days is a significant risk factor for the development of peptic ulcers after RYGB, whereas temporary use (<30 days) is not. No association between NSAID exposure and the development of peptic ulcers after SG was identified

No Weekday Effect in Bariatric Surgery-a Retrospective Cohort Study

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

Long-term Follow-up 15 Years After Duodenal Switch or Gastric Bypass for Super Obesity : a Randomized Controlled Trial

Background In super obesity, Roux-en-Y gastric bypass (RYGB) may be insufficient why some surgeons advocate biliopancreatic diversion with duodenal switch (BPD/DS), a more malabsorptive procedure. There is a paucity of evidence regarding results beyond 10 years, especially after BPD/DS. The aim of this randomized controlled trial was to compare the long-term outcome of BPD/DS, and RYGB in patients with super obesity, i.e., body mass index (BMI) > 50 kg/m2. Methods This is a 13- to 17-year follow-up study of a single-center, single-blinded randomized trial in which 47 patients (BMI > 48 and eligible for bariatric surgery) were randomized 1:1 to BPD/DS and RYGB (25 men, 24 BPD/DS, 39.1 ± 9.9 years, BMI 54.5 ± 6.1 kg/m2). The primary outcome was weight loss. The study was financed by Swedish governmental funding of clinical research (ALF). Trial registration number: ISRCTN10940791. Results Thirty-four (18 BPD/DS) of the living 42 patients (81.0%) participated. BPD/DS resulted in higher BMI loss (20.4 ± 7.9 vs. 12.4 ± 8.6, p = .008) and higher percent of total body weight loss (37.5% ± 12.2 vs. 22.8% ± 14.8, p = .004). BPD/DS was associated with lower fasting glucose, glycated hemoglobin (HbA1c), and low-density lipoprotein (LDL) as well as lower hemoglobin. Adverse events were more common after BPD/DS (2.7 vs. 0.9 per patient, p = .004). The global assessment tool BAROS (Bariatric Analysis and Reporting Outcome System) demonstrated superior scores for BPD/DS (p = .047). Conclusion When compared to RYGB, BPD/DS results in superior weight loss and metabolic control as well as superior BAROS score, however, at the cost of more adverse events