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Preventing complications in bariatric surgery
Örebro University, School of Medical Sciences. Örebro University Hospital.ORCID iD: 0000-0003-4958-1611
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Obesity is a major public health problem. Bariatric surgery is currently the only available treatment that offers sufficient weight-loss and metabolic benefits over time. Although bariatric surgery is considered safe now, serious complications still occur. The aim of this thesis was to identify factors associated with an increased risk for postoperative complication after laparoscopic gastric bypass surgery.

Study I included patients operated with laparoscopic gastric bypass surgery in Sweden from May 2007 until September 2012. The risk for serious complication was low (3.4%). Suffering an intraoperative adverse event or conversion of the operation to open surgery were the strongest risk factors for postoperative complication. The annual operative volume and experience of the procedure at the institution were also important risk factors. Patient-specific risk factors appeared to be less important although age was associated with an increased risk. In Study II, a raised glycated haemoglobin A1c (HbA1c) was evaluated as a risk factor for serious postoperative complications in non-diabetics. A higher incidence of serious postoperative complications was seen with elevated HbA1c values, even at levels classified as ‘‘pre-diabetic’’.

Study III was a multicentre, randomised clinical trial (RCT). 2507 patients planned for laparoscopic gastric bypass surgery were randomised to either mesenteric defects closure or non-closure. Closure of the mesenteric defects reduced the rate of reoperation for small bowel obstruction from 10.2% to 5.5% at 3 years after surgery. A small increase in the rate of serious postoperative complication within the first 30 days was seen with mesenteric defects closure. This relatively small increase in risk was however outweighed by the marked reduction of later reoperations for small bowel obstruction.

Study IV was a comparison between study III and an observational study on the same population under the same period of time. Although the observational study reached the same conlusion as the RCT, the efficacy of mesenteric defects closure was less pronounced. Observational studies may thus be an alternative to RCTs under situations when RCTs are not feasible. The efficacy may however be underestimated.

Place, publisher, year, edition, pages
Örebro: Örebro university , 2016. , 103 p.
Series
Örebro Studies in Medicine, ISSN 1652-4063 ; 147
Keyword [en]
postoperative complications, bariatric surgery, morbid obesity, risk factor, randomised clinical trial, haemoglobin A1c, prevention
National Category
Surgery
Research subject
Surgery
Identifiers
URN: urn:nbn:se:oru:diva-50649ISBN: 978-91-7529-149-9 (print)OAI: oai:DiVA.org:oru-50649DiVA: diva2:934794
Public defence
2016-10-07, Campus USÖ, hörsal C1, Södra Grev Rosengatan 32, Örebro, 09:00 (English)
Opponent
Supervisors
Available from: 2016-06-09 Created: 2016-06-09 Last updated: 2017-10-18Bibliographically approved
List of papers
1. Early complications after laparoscopic gastric bypass surgery: results from the Scandinavian Obesity Surgery Registry
Open this publication in new window or tab >>Early complications after laparoscopic gastric bypass surgery: results from the Scandinavian Obesity Surgery Registry
Show others...
2014 (English)In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 260, no 6, 1040-1047 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: To identify risk factors for serious and specific early complications of laparoscopic gastric bypass surgery using a large national cohort of patients.

BACKGROUND: Bariatric procedures are among the most common surgical procedures today. There is, however, still a need to identify preoperative and intraoperative risk factors for serious complications.

METHODS: From the Scandinavian Obesity Surgery Registry database, we identified 26,173 patients undergoing primary laparoscopic gastric bypass operation for morbid obesity between May 1, 2007, and September 30, 2012. Follow-up on day 30 was 95.7%. Preoperative data and data from the operation were analyzed against serious postoperative complications and specific complications.

RESULTS: The overall risk of serious postoperative complications was 3.4%. Age (adjusted P = 0.028), other additional operation [odds ratio (OR) = 1.50; confidence interval (CI): 1.04-2.18], intraoperative adverse event (OR = 2.63; 1.89-3.66), and conversion to open surgery (OR = 4.12; CI: 2.47-6.89) were all risk factors for serious postoperative complications. Annual hospital volume affected the rate of serious postoperative complications. If the hospital was in a learning curve at the time of the operation, the risk for serious postoperative complications was higher (OR = 1.45; CI: 1.22-1.71). The 90-day mortality rate was 0.04%.

CONCLUSIONS: Intraoperative adverse events and conversion to open surgery are the strongest risk factors for serious complications after laparoscopic gastric bypass surgery. Annual operative volume and total institutional experience are important for the outcome. Patient related factors, in particular age, also increased the risk but to a lesser extent.

Place, publisher, year, edition, pages
Lippincott Williams & Wilkins, 2014
Keyword
bariatric surgery; laparoscopic gastric bypass; postoperative complications; risk factors
National Category
Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:oru:diva-40584 (URN)10.1097/SLA.0000000000000431 (DOI)000345217200018 ()24374541 (PubMedID)2-s2.0-84922330659 (Scopus ID)
Conference
6th Congress of the International Federation for the Surgery of Obesity and Metabolic Disorders, European Chapter, Brussels, Belgium, April 30 - May 3, 2014
Projects
Preventing complications in bariatric surgery
Available from: 2015-01-15 Created: 2015-01-08 Last updated: 2017-12-05Bibliographically approved
2. Is glycosylated hemoglobin A1c associated with increased risk for severe early postoperative complications in nondiabetics after laparoscopic gastric bypass?
Open this publication in new window or tab >>Is glycosylated hemoglobin A1c associated with increased risk for severe early postoperative complications in nondiabetics after laparoscopic gastric bypass?
2014 (English)In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 10, no 5, 801-805 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Glycosylated hemoglobin A1 c (HbA1 c) has been described as a risk factor for adverse outcome after cardiovascular and colorectal surgery, but not for obese patients undergoing bariatric surgery. The objective of this study was to see if there is an association between HbA1 c and adverse outcome in laparoscopic gastric bypass surgery.

METHODS: From the Scandinavian Obesity Surgery Registry we identified 12,850 patients, without treatment for diabetes and operated with laparoscopic gastric bypass between January 1, 2010 and September 30, 2012, and where a baseline HbA1 c value was registered. Preoperative data were compared with data from a 30-day follow-up. Severe complications were defined according to the Clavien-Dindo-Scale as Grade 3 b or higher.

RESULTS: HbA1 c levels below 5.7 % were associated with a lower incidence of severe complications (2.7 %) than higher levels (HbA1 c 5.7-6.49% incidence 3.5%, P = .015; HbA1 c>6.5%, incidence 4.5%, P = .012). After multivariate analysis with patient-specific confounders the difference remained significant (HbA1 c 5.7-6.49% adjusted P = .046; HbA1 c>6.5% adjusted P = .023) CONCLUSION: Elevated HbA1 c levels in patients without pharmacologic treatment for diabetes undergoing laparoscopic gastric bypass surgery is associated with an increased risk for severe complications during the first 30 postoperative days. This is the case, even at levels not regarded as diagnostic for diabetes.

Place, publisher, year, edition, pages
Elsevier, 2014
Keyword
hemoglobin A1c, Nondiabetic, Postoperative complications, laparoscopic gastric bypass, risk factor
National Category
Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:oru:diva-40585 (URN)10.1016/j.soard.2014.05.005 (DOI)000344719200009 ()25304835 (PubMedID)2-s2.0-84928828943 (Scopus ID)
Conference
Obesity week, Atlanta, Georgia, USA, November 11-16, 2013
Projects
Preventing complications in bariatric surgery
Note

Sponsor:

Orebro County Council

Available from: 2015-01-15 Created: 2015-01-08 Last updated: 2017-12-05Bibliographically approved
3. Closure of mesenteric defects in laparoscopic gastric bypass: a multicentre, randomised, parallel, open-label trial
Open this publication in new window or tab >>Closure of mesenteric defects in laparoscopic gastric bypass: a multicentre, randomised, parallel, open-label trial
Show others...
2016 (English)In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 387, no 10026, 1397-1404 p.Article in journal (Refereed) Published
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.

Place, publisher, year, edition, pages
Elsevier, 2016
National Category
Family Medicine
Research subject
Family Medicine
Identifiers
urn:nbn:se:oru:diva-50057 (URN)10.1016/S0140-6736(15)01126-5 (DOI)000373217500032 ()26895675 (PubMedID)2-s2.0-84958064283 (Scopus ID)
Note

Funding Agencies:

Örebro County Council

Stockholm City Council

Erling-Persson Family Foundation

Available from: 2016-05-02 Created: 2016-05-02 Last updated: 2017-11-30Bibliographically approved
4. Laparoscopic gastric bypass: comparison of outcomes from a randomised controlled trial and a concurrent observational study
Open this publication in new window or tab >>Laparoscopic gastric bypass: comparison of outcomes from a randomised controlled trial and a concurrent observational study
(English)Manuscript (preprint) (Other academic)
National Category
Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:oru:diva-52069 (URN)
Available from: 2016-09-09 Created: 2016-09-08 Last updated: 2017-10-17Bibliographically approved

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