Impact of a severe complication two years after laparoscopic Roux-en-Y gastric bypass: a cohort study from the Scandinavian Obesity Surgery Registry.

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.

Incidence and treatment of small bowel leak after Roux-en-Y gastric bypass: a cohort study from the Scandinavian Obesity Surgery Registry.

BACKGROUND: Anastomotic leak at the gastrojejunostomy in Roux-en-Y gastric bypass is a rare, but serious, complication. Little has been published on leaks at other sites. OBJECTIVES: To assess incidence, risk factors, treatment, and outcome of small bowel leaks at the enteroenteral anastomosis (EA) and undiagnosed iatrogenic small bowel perforations in primary Roux-en-Y gastric bypass. SETTING: Nationwide cohort, Sweden. METHODS: All leaks within 30 days in 41,342 patients (age 40.8 [standard deviation 11.1] yr, females 68%, and body mass index 42.4 [standard deviation 5.4] kg/m2) between 2007 and 2014 in the Scandinavian Obesity Surgery Registry were assessed. Register data and outcomes were verified by reviewing patient charts. Logistic regression estimated odds ratios (OR) and 95% confidence intervals for significant risk factors. RESULTS: The incidence of small bowel leaks was .3%. Iatrogenic perforations were diagnosed earlier than EA leaks, 3.6 versus 6.5 days after surgery (P = .02). EA leaks were seen in 75 patients (.2%), with surgery at a low-volume center (<125 cases/yr, OR 2.1 [1.0-4.1]) and prolonged operative time (≥90 min, OR 3.5 [1.1-11.0]) as risk factors. The risk of iatrogenic small bowel perforations, .1%, was tripled by prolonged operative time (OR 3.4 [1.2-9.4]). Surgical reintervention was required in 97% of leaks, repairing the defect and draining the abdominal cavity in most cases. A third of the patients required intensive care, of which 5% developed multiorgan failure and 1% died. CONCLUSION: Small bowel leaks, seen in .3%, were associated to prolonged operative time, and surgery at a low-volume center for EA leaks. Surgical reintervention was common, while mortality was low.

Low overall mortality during 10 years of bariatric surgery: nationwide study on 63,469 procedures from the Scandinavian Obesity Registry.

BACKGROUND: Bariatric surgery results in an improvement in quality of life, co-morbid diseases, and an increased life expectancy. However, to obtain these benefits perioperative mortality rates need to be low. OBJECTIVES: Evaluate 90-day and 1-year mortality after bariatric surgery in Sweden from 2008 to 2017. SETTING: National quality register. METHODS: Data on applicable patients from the Scandinavian Obesity Surgery Registry, including 63,469 patients (85.1% gastric bypass, 12.5% sleeve gastrectomy, .8% duodenal switch, .5% minor revisions, and 1.1% other procedures), were retrieved and matched to the Cause of Death registry. RESULTS: During the 10-year period, 36 patients died within 90 days, resulting in a .06% overall mortality. The 1-year mortality rate was .19% (n = 111). Both mortality rates decreased over the study period. In a multivariate analysis, depression (odds ratio [OR] 2.38, [95% confidence interval 1.48-3.84]), leakage (OR 9.32 [4.85-17.94]), and thromboembolic events (OR 7.60 [1.63-35.37]) increased mortality risks at both 90 days and 1 year, whereas age (OR 1.03 [1.01-1.06] per increased year of age) and abdominal circumference (OR 1.03 [1.01-1.05] per cm) were also associated with increased mortality at 1 year. The predictive value of the Obesity Surgery Mortality Risk Score was confirmed. CONCLUSIONS: The low 90-day and 1-year mortality, .06% and .19%, respectively, demonstrates that bariatric surgery in Sweden is safe. The use of antidepressants and 2 serious postoperative complications were the most significant risk factors for early deaths, while increased age and preoperative abdominal circumference also contributed at 1 year.

Incidence and treatment of leak at the gastrojejunostomy in Roux-en-Y gastric bypass: a cohort study of 40,844 patients.

BACKGROUND: Leak at the gastrojejunostomy (GJ) after Roux-en-Y gastric bypass is a rare but life-threatening complication. OBJECTIVES: To assess incidence, risk factors, treatment, and outcome of leaks at the GJ after Roux-en-Y gastric bypass in a nationwide cohort. SETTING: Sweden. METHODS: Leaks at GJ within 30 days postoperatively in 40,844 patients (age 41 yr, females 76%, and body mass index of 42.4 kg/m2) between 2007 and 2014 in the Scandinavian Obesity Surgery Registry were assessed. Register data and outcomes were verified by reviewing patient charts. Logistic regression was done to estimate odds ratios (ORs) for significant risk factors. RESULTS: Leak at the GJ was registered in 262 (.6%) patients, with 44% diagnosed within the first 3 postoperative days. Risk factors were male sex (OR 1.5 [1.1-1.9]), age ≥49 years (OR 1.9 [1.3-2.7]), diabetes (OR 1.4 [1.1-1.9]), conversion to open surgery (OR 3.9 [2.2-6.9]), and operative time ≥90 minutes (OR 2.6 [1.8-3.8]). In most patients, the leak resulted in a severe complication. Reoperative surgery was done in 85%, with the placement of a feeding gastrostomy in 24%. Stents were used at some time point in 31% of leaks. Of all patients with leaks, 25% required intensive care, 4% developed multiorgan failure, and 1% died. Median duration of stay for patients with leaks was 22 days, versus 2 days for others (P < .001). CONCLUSION: GJ leaks occurred in .6% of patients. Risk factors were male sex, age ≥49 years, diabetes, operative time ≥90 minutes, and conversion to open surgery. Surgical reintervention was common. Mortality was 1%.

Shorter overall operative time when barbed suture is used in primary laparoscopic gastric bypass: A cohort study of 25,006 cases.

BACKGROUND: Closing the remaining opening in a linear stapled anastomosis, for example in laparoscopic Roux-en-Y gastric bypass (LRYGB), can be challenging. OBJECTIVES: To evaluate if the novel unidirectional barbed suture (BS) is of value in LRYGB compared with polyfilament (PS) suture. We have compared operative time, early complications, and length of stay, as well as anastomotic strictures and small bowel obstruction during the first year. SETTING: Retrospective study from the Scandinavian Obesity Surgery Registry (SOReg). METHODS: A nationwide cohort of 25,006 primary LRYGB (2211 BS and 22,795 PS) from SOReg were studied. No preoperative differences in age or gender were noted; however, BS patients had lower Body Mass Index (BMI) (41.3 versus 42.3 kg/m2, P<.001) and less diabetes (13.7% versus 15.4%, P = .03). RESULTS: Total operative time was 11 minutes (16%) shorter using BS compared with PS (58 versus 69 minutes, P<.001), although the mesenteric openings were more frequently closed among BS patients (94% versus 71%, P<.001). No differences were seen in early complications; anastomotic leaks or intra-abdominal abscesses were noted in 1.8% and 1.4%, respectively, P = .17. The incidence of anastomotic strictures was similar (.13% versus .17%, P = .73) as was the incidence of surgery for small bowel obstruction (1.8% versus 1.6%, P = .69). CONCLUSIONS: The use of barbed suture for closing the remaining opening in the gastrojejunostomy shortened the operative time without increasing the risk of complications. BS is still uncommon in LRYGB, but its implementation could have significant impact on operative time.

Arteriovenous fistula in an autotransplanted kidney segment: successful angiographic management.

Autotransplantation is a management option in complex renal or ureteral diseases. This report describes a case of bilateral renal cell carcinoma treated with partial nephrectomy using bench surgery followed by a contralateral total nephrectomy. This procedure was complicated by an arteriovenous fistula in the transplanted segment that was successively embolized angiographically.