RESUMEN
BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) and laparoscopically inserted gastrostomy have become the gold standard for adult patients and children, respectively, requiring long-term enteral nutrition support. Procedure-related mortality is a rare event, often reported to be zero in smaller studies. National data on 30-d mortality and long-term survival rates after gastrostomy placement are scarce in the literature. AIM: To study the use of gastrostomies in Sweden from 1998-2019 and to analyze procedure-related mortality and short-term (< 30 d) and long-term survival. METHODS: In this retrospective, population-based cohort study, individuals that had received a gastrostomy between 1998-2019 in Sweden were included. Individuals were identified in the Swedish National Patient Register, and survival analysis was possible by cross-referencing the Swedish Death Register. The cohort was divided into three age groups: Children (0-18 years); adults (19-64 years); and elderly (≥ 65 years). Kaplan-Meier with log-rank test and Cox regression were used for survival analysis. RESULTS: In total 48682 individuals (52% males, average age 60.9 ± 25.3 years) were identified. The cohort consisted of 12.0% children, 29.5% adults, and 58.5% elderly. An increased use of gastrostomies was observed during the study period, from 13.7/100000 to 22.3/100000 individuals (P < 0.001). The use of PEG more than doubled (about 800 to 1800/year), with a corresponding decrease in open gastrostomy (about 700 to 340/year). Laparoscopic gastrostomy increased more than ten-fold (about 20 to 240/year). Overall, PEG, open gastrostomy, and laparoscopic gastrostomy constituted 70.0% (n = 34060), 23.3% (n = 11336), and 4.9% (n = 2404), respectively. Procedure-related mortality was 0.1% (n = 44) overall (PEG: 0.05%, open: 0.24%, laparoscopic: 0.04%). The overall 30-d mortality rate was 10.0% (PEG: 9.8%, open: 12.4%, laparoscopic: 1.7%) and decreased from 11.6% in 1998-2009 vs 8.5% in 2010-2019 (P < 0.001). One-year and ten-year survival rates for children, adults, and elderly were 93.7%, 67.5%, and 42.1% and 79.9%, 39.2%, and 6.8%, respectively. The most common causes of death were malignancies and cardiovascular and respiratory diseases. CONCLUSION: The annual use of gastrostomies in Sweden increased during the study period, with a shift towards more minimally invasive procedures. Although procedure-related death was rare, the overall 30-d mortality rate was high (10%). To overcome this, we believe that patient selection should be improved.
Asunto(s)
Nutrición Enteral , Gastrostomía , Masculino , Adulto , Niño , Humanos , Anciano , Persona de Mediana Edad , Anciano de 80 o más Años , Recién Nacido , Lactante , Preescolar , Adolescente , Femenino , Gastrostomía/efectos adversos , Gastrostomía/métodos , Suecia/epidemiología , Estudios Retrospectivos , Estudios de Cohortes , Nutrición Enteral/efectos adversos , Nutrición Enteral/métodosRESUMEN
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.
Asunto(s)
Desviación Biliopancreática , Derivación Gástrica , Obesidad Mórbida , Masculino , Humanos , Derivación Gástrica/métodos , Obesidad Mórbida/cirugía , Estudios de Seguimiento , Obesidad/cirugía , Desviación Biliopancreática/métodos , Pérdida de Peso , Estudios RetrospectivosRESUMEN
BACKGROUND: Pharmacologic pain treatment is common among bariatric patients. Nonsteroid anti-inflammatory 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, population-based 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.
Asunto(s)
Derivación Gástrica , Obesidad Mórbida , Úlcera Péptica , Antiinflamatorios , Antiinflamatorios no Esteroideos/efectos adversos , Estudios de Cohortes , Gastrectomía/efectos adversos , Gastrectomía/métodos , Derivación Gástrica/efectos adversos , Derivación Gástrica/métodos , Humanos , Obesidad Mórbida/etiología , Obesidad Mórbida/cirugía , Úlcera Péptica/epidemiología , Úlcera Péptica/etiología , Úlcera Péptica/cirugía , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
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.
Asunto(s)
Cirugía Bariátrica , Derivación Gástrica , Obesidad Mórbida , Cirugía Bariátrica/efectos adversos , Gastrectomía/efectos adversos , Derivación Gástrica/efectos adversos , Humanos , Obesidad Mórbida/cirugía , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Although severe complications (SCs) after laparoscopic Roux-en-Y gastric bypass (LRYGB) are rare, they can be devastating for the affected patient. OBJECTIVE: To access the impact of SCs (Clavien-Dindo ≥3b) 2 years after LRYGB by using a nationwide Swedish cohort of 48,201 primary cases between 2007 and June 2016. SETTING: University hospital, Sweden. METHODS: Patients with SC were matched 1:1 on age, sex, diabetic status, body mass index (BMI), and year of operation to patients without an SC. Weight loss, patient-scored quality of life (QoL), antidepressant use, proton pump inhibitors (PPI) and opioids, and in-hospital care were gathered from 3 national registers. RESULTS: A total of 1411 (2.9%) patients suffered an SC and 16 (.03%) died. In total, 1403 patients with SC (mean age, 42 yr; female, 75%; with diabetes, 15.7%; mean BMI, 41.9 kg/m2) could be matched. Both groups had a total body weight loss of 32% at 2 years. A lower physical QoL was observed in SCs throughout the study period. Antidepressant, PPI and opioid use was higher among patients with SC, even 2 years after surgery. At this time point, a doubling of oral morphine equivalents (7.3 to 17.0 mg/d) was found in patients with SC compared with prior to surgery. The SC group required more in-hospital care after the initial 30 days (3.8 versus .9 d in the remaining part of the first year). CONCLUSION: An SC resulted in higher antidepressant, PPI and opioid use as well as higher need for in-hospital care during the first 2 postoperative years. Affected patients should therefore receive special attention during follow up.
Asunto(s)
Derivación Gástrica , Laparoscopía , Obesidad Mórbida , Adulto , Índice de Masa Corporal , Estudios de Cohortes , Femenino , Derivación Gástrica/efectos adversos , Humanos , Obesidad Mórbida/cirugía , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Calidad de Vida , Sistema de Registros , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
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.
Asunto(s)
Cirugía Bariátrica , Derivación Gástrica , Laparoscopía , Obesidad Mórbida , Analgésicos Opioides/uso terapéutico , Cirugía Bariátrica/efectos adversos , Estudios de Cohortes , Gastrectomía , Humanos , Obesidad Mórbida/cirugía , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Estudios Retrospectivos , Suecia/epidemiologíaRESUMEN
BACKGROUND: Insufficient weight loss is common in super-obese patients (body mass index >50) after Roux-en-Y gastric bypass (RYGB). Duodenal switch (DS) is more effective; however, it is considered to have an increased complication rate. OBJECTIVES: To compare early complications (≤30 d), long-term adverse events, and quality of life (QoL) between primary DS and RYGB. SETTING: Sweden. METHODS: National cohort-study of super-obese patients after primary DS or RYGB in Sweden 2007 to 2017. Propensity-score matching was used to reduce confounders. Five national registers were cross-matched. RESULTS: The study population consisted of 333 DS and 1332 RYGB (body mass index 55 ± 5 kg/m2, 38.5 ± 11 yr, and 60.7% females). Laparoscopic approach was used in 25% of DS and 91% of RYGB. Early complications were more common after DS (15.3% versus 8.1%, P < .01), mainly because of more open surgery and related surgical site infections. During 4.6 ± 2.3 years mean follow-up, hospital admission rate was 1.4 ± 2.3 versus 1.1 ± 3.3 (P = .18), with 6.7 ± 18.3 versus 7.0 ± 43.0 in-hospital days, for DS and RYGB, respectively. An increased risk of malnutrition/malabsorption requiring inpatient care (2.8% versus .2%, odds ratio 12.3 [3.3-45.7]) and greater need for additional abdominal surgery (25.8% versus 15.3%, odds ratio 2.0 [1.5-2.7]) was observed for DS. However, QoL was more improved after DS. CONCLUSION: DS was associated with more early complications because of more open surgery, but long-term requirement of inpatient care was similar to RYGB. The increased risk of malnutrition/malabsorption and need for additional abdominal surgeries was contrasted with a greater improvement in QoL for DS.
Asunto(s)
Desviación Biliopancreática , Derivación Gástrica , Obesidad Mórbida , Índice de Masa Corporal , Femenino , Derivación Gástrica/efectos adversos , Humanos , Masculino , Obesidad Mórbida/cirugía , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Calidad de Vida , Estudios Retrospectivos , Suecia/epidemiología , Resultado del TratamientoRESUMEN
BACKGROUND: Unsatisfactory weight loss is common after bariatric surgery in patients with super obesity (body mass index [BMI] ≥50 kg/m2). Unfortunately, this group of patients is increasing worldwide. OBJECTIVE: The aim of this study was to compare long-term weight loss and effect on co-morbidities after duodenal switch (DS) and gastric bypass (RYGB) in super-obese patients. SETTING: University hospital, Sweden, national cohort. METHODS: This observational population-based cohort-study of primary DS and RYGB (BMI ≥48 kg/m2) in Sweden from 2007 to 2017 used data from 4 national registers. Baseline characteristics were used for propensity score matching (1 DS:4 RYGB). Weight loss was analyzed up until 5 years after surgery. Medication for diabetes, hypertension, dyslipidemia, depression, and pain were analyzed up until 10 years after surgery. RESULTS: The study population consisted of 333 DS and 1332 RYGB, with 60.7% females averaging 38.5 years old and BMI 55.0 kg/m2 at baseline. DS resulted in a lower BMI at 5 years compared with RYGB, 32.2 ± 5.5 and 37.8 ± 7.3, respectively, (P < .01). DS reduced prevalence of diabetes and hypertension more than RYGB, while reduction in dyslipidemia was similar for both groups, during the 10-year follow-up. Both groups increased their use of antidepressants and a maintained a high use of opioids. CONCLUSION: This study indicates that super-obese patients have more favorable outcomes regarding weight loss and effect on diabetes and hypertension, after DS compared with RYGB.
Asunto(s)
Derivación Gástrica , Obesidad Mórbida , Pérdida de Peso/fisiología , Adulto , Estudios de Cohortes , Comorbilidad , Depresión , Diabetes Mellitus Tipo 2 , Dislipidemias , Femenino , Humanos , Hipertensión , Masculino , Persona de Mediana Edad , Obesidad Mórbida/epidemiología , Obesidad Mórbida/cirugía , Suecia , Resultado del TratamientoRESUMEN
BACKGROUND: It is not clear which bariatric procedure that gives the best outcome for patients with super obesity (body mass index [BMI] > 50 kg/m2). This study aims to compare outcomes in patients with super obesity after Roux-en-Y gastric bypass (RYGB) and duodenal switch (BPD/DS) using the Bariatric Analysis and Reporting Outcome System (BAROS) and a local questionnaire for gastrointestinal symptoms. METHODS: A retrospective mail survey including 211 patients, 98 RYGB and 113 BPD/DS, with a mean follow-up time of 4 years for both groups. Gender distribution, age, and comorbidities were similar. Weight loss, changes in comorbidities, quality of life (QoL), and adverse events were registered, as well as gastrointestinal symptoms. RESULTS: Preoperative BMI was higher in the BPD/DS group (56 ± 6.7 vs. 52 ± 4.0 kg/m2, p < 0.01); despite this, the postoperative BMI was lower (31 ± 5.5 vs. 36 ± 7.1 kg/m2, p < 0.01). The effect on diabetes was superior after BPD/DS; otherwise, both groups had a similar reduction in comorbidities. There was no difference in QoL. Adverse events were less common after RYGB (14 vs. 27%). Overall, the BPD/DS group had a superior BAROS score (4.7 ± 2.0 vs. 4.0 ± 2.1, p < 0.05). Dumping was more common after RYGB (p < 0.01), while reflux, diarrhea, fecal incontinence, and problems with malodorous flatus were more common after BPD/DS (all p < 0.05). Frequency of nausea/vomiting and abdominal pain were similar. CONCLUSION: Patients with super obesity have a better weight reduction and metabolic control with BPD/DS, at the cost of higher incidence of adverse events, compared to patients operated with RYGB.
Asunto(s)
Desviación Biliopancreática/métodos , Índice de Masa Corporal , Derivación Gástrica/métodos , Obesidad Mórbida/cirugía , Adulto , Comorbilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Obesidad Mórbida/epidemiología , Calidad de Vida , Estudios Retrospectivos , Pérdida de PesoRESUMEN
BACKGROUND: Concerns for the possibility of an excessive loss of fat-free mass (FFM) and resting metabolic rate (RMR) after bariatric surgery, such as Roux-en-Y gastric bypass (RYGB) and duodenal switch (BPD/DS), have been raised. OBJECTIVES: This study aims to examine body composition and RMR in patients after RYGB and BPD/DS and in non-operated controls. METHODS: Body composition and RMR were studied with Bod Pod and indirect calorimetry in weight-stable RYGB (n = 15) and BPD/DS patients (n = 12) and compared with non-operated controls (n = 17). All patients were 30-55 years old and weight stable with BMI 28-35 kg/m2. RESULTS: FFM% was 58% (RYGB), 61% (BPD/DS), and 58% (controls). Body composition did not differ after RYGB and BPD/DS compared to controls, despite 27 and 40% total body weight loss, respectively. No difference in RMR or RMR/FFM was observed (1539, 1617, and 1490 kcal/24 h; and 28.9, 28.4, and 28.8 kcal/24 h/kg). CONCLUSION: Weight-stable patients with BMI 28-35 kg/m2 after RYGB and BPD/DS have a body composition and RMR similar to that of non-operated individuals within the same BMI interval.
Asunto(s)
Metabolismo Basal/fisiología , Composición Corporal/fisiología , Derivación Gástrica/estadística & datos numéricos , Obesidad Mórbida , Adulto , Estudios de Casos y Controles , Humanos , Persona de Mediana Edad , Obesidad Mórbida/epidemiología , Obesidad Mórbida/cirugíaRESUMEN
BACKGROUND: Since 2000, the annual number of bariatric procedures has increased more than 10-fold in Sweden, and in 2012, 94% of these procedures were primary laparoscopic gastric bypass. METHODS: We studied claims from the national Patient Insurance (Landstingens Ömsesidiga Försäkringsbolag, LÖF) to evaluate if the number of adverse events (AEs) from a patient perspective had increased unproportionally. All claims related to bariatric surgery from January 2000 to March 2012 were identified by ICD-10 codes and divided into 3 main groups: (1) procedure-related AEs (occurring within 30 days), (2) late AEs, and (3) nonsurgical AEs. Logistic regression was used to study the change in claim rate over time. The setting was a university hospital in Sweden. RESULTS: In total, 359 claims were included, corresponding to 14 claims per 1,000 bariatric procedures (laparoscopic 59%, open 24%, revision 17%). Numbers correlated with the expansion of bariatric surgery and type of procedure routinely performed. Of the procedure-related claims (74% of all claims), postoperative leaks or bleedings were most common. In this group, patients frequently needed additional surgery (69%) and intensive care (42%). Half of the late AEs (69 in total) were related to abdominal pain or malnutrition, including 5 cases of Wernicke's encephalopathy. In total 2% died. Of 344 settled claims, economical compensation was given to 29%. CONCLUSION: In this cohort of patients with insurance claims after bariatric surgery (1.4% of all procedures), procedure-related AEs were severe, with a large amount of patients requiring reoperation and intensive care. No change in claim rate was seen, in spite of the 10-fold increase of bariatric surgery.