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- Löfling Skogar, Martin, 1983-
(author)
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Bariatric Surgery : Outcomes after Gastric Bypass and Duodenal Switch
- 2019
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Doctoral thesis (other academic/artistic)abstract
- 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.
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| 2. |
- Löfling Skogar, Martin, 1983-, et al.
(author)
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Complications, Adverse Events and Healthcare Consumption the First Ten Years after Duodenal Switch and Gastric Bypass in a Matched National Cohort
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Other publication (other academic/artistic)abstract
- Background:Roux-en-Y Gastric Bypass (RYGB), risk unsatisfactory weight loss in super obese patients. Duodenal switch (DS) is more effective, however, considered to have an increased complication rate. Objectives:To compare early complications, healthcare consumption, long-term adverse events and mortality up until 10 years after primary DS and RYGB, respectively. Setting:Nationwide study in Sweden Methods:In this nationwide population-based cohort study, propensity-score matching (1DS:4RYGB) was used. Five national registers were cross-matched; the Scandinavian Obesity Surgery Register (perioperative data), the Prescribed Drug Register (comorbidities, i.e. medication for the specific conditions), Statistics Sweden (socioeconomic data), the National Patient Register (subsequent healthcare) and the Death Register (mortality). Results:The study population consisted of 333 DS and 1332 RYGB, operated 2007-2017 (BMI of 55 kg/m2, 38.5 years and 60.7% females). Early complications (≤30 days) were more common after DS (15.3% vs. 8.1%, p<0.01). Hospital admissions and in-hospital days over the 10-year period were similar (1.3 vs. 1.1 admission, p=0.30 and 6.6 vs. 7.2 in-hospital days, p=0.81), while DS had more visits to specialized outpatient clinics (7.1 vs. 4.2, p<0.01). DS were associated with an increased risk of protein-malnutrition/malabsorption (OR 11.7 [3.1-43.5]) and having an additional abdominal operation (any type) (OR 1.9 [1.4-2.6]). Overall mortality did not differ between groups. Conclusion:DS was associated with more early complications and an increased risk for protein-malnutrition/malabsorption and more additional abdominal surgeries, however, the overall mortality and long-term requirement of in-hospital care were similar to RYGB.
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| 3. |
- Löfling Skogar, Martin, 1983-, et al.
(author)
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Weight loss, Effect on Comorbidities and Quality of Life in the Long Term after Duodenal Switch and Gastric Bypass : A population-based cohort study
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Other publication (other academic/artistic)abstract
- Objective:To compare long-term weight-loss, effect on comorbidities and quality of life after duodenal switch (DS) and gastric bypass (RYGB) in super obese patients. 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. Methods:Population-based cohort-study of primary DS and RYGB (BMI≥48 kg/m2), in Sweden 2007-2017, with cross-matching of four national registers. Baseline characteristics were used for propensity score matching (1DS:4RYGB). Weight loss and quality of life were analyzed up until 5 years after surgery. Medication for obesity-related conditions (diabetes, hypertension, dyslipidemia, depression, pain) and gastrointestinal symptoms were analyzed up until 10 years. Results:The study population consisted of 333 DS and 1332 RYGB, with 60.7% females, 38.5 years old and BMI 55.0 kg/m2at baseline. DS resulted in a lower BMI at 5 years compared to RYGB, 32.2±5.5 and 37.8±7.3, respectively, (p<0.01). 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 anti-depressants and a maintained a high use of opioids. Reflux and diarrhea were more common after DS. Improvement in physical quality of life was seen for both groups, with superior improvement after DS. Mental quality of life remained unchanged at 5 years. Conclusion:This study indicates that super obese patients have a more favorable outcome after DS compared to RYGB, regarding weight loss, effect on diabetes and hypertension, and physical quality of life.
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| 4. |
- Möller, Filip, et al.
(author)
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Long-term Follow-up 15 Years After Duodenal Switch or Gastric Bypass for Super Obesity : a Randomized Controlled Trial
- 2023
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In: Obesity Surgery. - : Springer. - 0960-8923 .- 1708-0428. ; 33:10, s. 2981-2990
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Journal article (peer-reviewed)abstract
- BackgroundIn 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.MethodsThis 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.ResultsThirty-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).ConclusionWhen 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.
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| 5. |
- Skogar, Martin, 1983-, et al.
(author)
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Early complications, long-term adverse events, and quality of life after duodenal switch and gastric bypass in a matched national cohort
- 2020
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In: Surgery for Obesity and Related Diseases. - : ELSEVIER SCIENCE INC. - 1550-7289 .- 1878-7533. ; 16:5, s. 614-619
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Journal article (peer-reviewed)abstract
- 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/m(2), 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.
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| 6. |
- Skogar, Martin, 1983-, et al.
(author)
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No Weekday Effect in Bariatric Surgery-a Retrospective Cohort Study
- 2022
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In: Obesity Surgery. - : Springer-Verlag New York. - 0960-8923 .- 1708-0428. ; 32:6, s. 1990-1995
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Journal article (peer-reviewed)abstract
- 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.
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| 7. |
- Skogar, Martin, 1983-, et al.
(author)
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Nonsteroid anti-inflammatory drugs and the risk of peptic ulcers after gastric bypass and sleeve gastrectomy
- 2022
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In: Surgery for Obesity and Related Diseases. - : Elsevier. - 1550-7289 .- 1878-7533. ; 18:7, s. 888-893
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Journal article (peer-reviewed)abstract
- 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.
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| 8. |
- Skogar, Martin, 1983-, et al.
(author)
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Preoperative chronic opioid use and its impact on early complications in bariatric surgery : a Swedish nationwide cohort study of 56,183 patients
- 2021
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In: Surgery for Obesity and Related Diseases. - : Elsevier. - 1550-7289 .- 1878-7533. ; 17:7, s. 1256-1262
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Journal article (peer-reviewed)abstract
- 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.
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| 9. |
- Skogar, Martin, 1983-, et al.
(author)
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Time trends and outcomes of gastrostomy placement in a Swedish national cohort over two decades
- 2024
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In: World Journal of Gastroenterology. - : Baishideng Publishing Group Inc.. - 1007-9327 .- 2219-2840. ; 30:10
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Journal article (peer-reviewed)abstract
- 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.
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| 10. |
- Skogar, Martin, 1983-, et al.
(author)
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Weight loss and effect on co-morbidities in the long-term after duodenal switch and gastric bypass : a population-based cohort study
- 2020
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In: Surgery for Obesity and Related Diseases. - : ELSEVIER SCIENCE INC. - 1550-7289 .- 1878-7533. ; 16:1, s. 17-23
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Journal article (peer-reviewed)abstract
- Background: Unsatisfactory weight loss is common after bariatric surgery in patients with super obesity (body mass index [BMI] >= 50 kg/m(2)). 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/m(2)) 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/m(2) 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.
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