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Background: Roux-en-Y gastric bypass (RYGB) is one of the most common bariatric procedures. Internal herniation may lead to small bowel ischemia requiring small bowel resection, resulting in short bowel syndrome., Objective: To determine the incidence of extensive small bowel resection in patients operated with RYGB. We also aimed to look for early clinical warning signs among patients requiring extensive small bowel resection., Setting: Cohort from national quality registers., Methods: All patients having undergone RYGB between January 2007 to June 2019 were analyzed in the Scandinavian Obesity Surgery Registry (SOReg). We identified patients with small bowel obstruction (SBO) for whom small bowel resection was necessary. Additionally, we assessed clinical signs in these patients., Results: The study included 57,255 patients having undergone RYGB. Closure of the mesenteric openings was performed in 78%. Surgery for SBO was required in 3659 (6%) of patients, and small bowel resection in 188 (.3%). Extensive small bowel resection, resulting in less than 1.5 meters of remaining small bowel, was required in 7 patients (.01%). All patients with extensive small bowel resection presented with abdominal pain and had confirmed internal herniation as the cause of the small bowel resection, and 2 of 7 patients died. Closure of mesenteric defects was not associated with a reduction in overall small bowel resection rates (P = .89) CONCLUSION: Surgery for SBO after RYGB was common (6%). The risk of extensive small bowel resection leading to short bowel was low (.01%). Patients with abdominal pain after RYGB should be assessed for internal hernia, as it can be devastating., (Copyright © 2024 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Sleeve gastrectomy (SG) is the most common bariatric procedure worldwide. Obstructive symptoms, together with leaks, are among the most serious postoperative complications. This study aimed to investigate the incidence of symptomatic obstruction after SG in Sweden and to explore risk factors, treatment strategies, and outcome., Methods: A retrospective analysis of prospectively collected data from the Scandinavian Obesity Surgery Registry (SOReg) of patients undergoing SG and developed obstruction symptoms within the first postoperative year was performed. For patients who had undergone any re-intervention, such as endoscopic dilatation or remedial surgery, medical charts were reviewed., Results: From 2007 to 2018, a total of 9,726 SG were performed, and 59 (0.6%) of them developed postoperative obstruction. Intolerance of solid food was the most common symptom associated with obstruction (80%). Sixty-one percent of the patients had obstruction at the level of incisura angularis. Longer operative time, higher rate of perioperative complications, longer hospital stay, and oversewing the staple line were associated with an increased risk of obstruction. Endoscopic balloon dilatation was performed in 59% of patients (n=35) and successful in 18 patients (51%). Twenty-one patients (36%) underwent surgical conversion to Roux-en-Y gastric bypass (RYGB). After revisional surgery, 11 (52%) reported complete relief of symptoms., Conclusions: Obstruction was rare (0.6%) and most often located at the incisura angularis. Obstruction was associated with longer operative time, perioperative complications, oversewing of the staple line, and longer hospital stay. Endoscopic dilatation or surgical conversion to RYGB frequently alleviates symptoms, but despite treatment, almost 50% reported residual symptoms., (© 2021. The Author(s).)

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/m 2 ) 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., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

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/m 2 ) 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%., (Copyright © 2019 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

To compare circular stapler (CS) with linear stapler (LS) in a meta-analysis concerning operative time, anastomotic leaks, wound infections, strictures, and length of stay. Pubmed, Medline, and Scopus were searched for articles published since 2006. Four hundred and five articles were assessed, and 13 articles of which only one was a randomized controlled trial were included in all 49,331 patients from different regions of the world. The pooled analysis shows that operative time was shorter in LS than in CS (weighted mean difference 36.2 min; 95% CI 34.7-37.6.; p < 0.0001). No difference was seen concerning leaks or strictures. The relative risk (RR) of leakage after LS was 80% of the risk after CS; however, the 95% confidence interval (CI) showed overlap (0.58-1.11). The RR of anastomotic stricture after LS was 74% of the risk after CS; however, 95% CI (0.52-1.05) showed overlap. Wound infections were less common after LS than after CS; RR was 27% (95% CI 0.21-0.33). Length of stay (LOS) was 0.65 days shorter after LS than after CS (95% CI 0.51-0.78). LS compared with CS results in shorter operative time, less wound infections, and shorter length of stay, but no difference was seen concerning risks of leaks or strictures.

Background: Roux-en-Y gastric bypass (RYGB) is the most common bariatric procedure worldwide. Anastomotic stricture is a known complication of RYGB. The aim was to explore the incidence and outcomes of strictures within the Scandinavian Obesity Surgery Registry (SOReg)., Method: SOReg included prospective data from 36,362 patients undergoing bariatric surgery in the years 2007-2013. Outcomes were recorded at 30-day and at 1-year follow-up according to the standard SOReg routine. The medical charts of patients suffering from stricture after RYGB were requested and assessed., Setting: National bariatric surgery registry RESULTS: Anastomotic stricture within 1 year of surgery was confirmed in 101 patients representing an incidence of 0.3%. Risk factors for stricture were patient age above 60 years (odds ratio (OR), 6.2 95% confidence interval (CI) 2.7-14.3), circular stapled gastrojejunostomy (OR 2.7, 95% CI 1.4-5.5), postoperative anastomotic leak (OR 8.9 95%, CI 4.7-17.0), and marginal ulcer (OR 30.0, 95% CI 19.2-47.0). Seventy-five percent of the strictures were diagnosed within 70 days of surgery. Two dilatations or less was sufficient to successfully treat 50% of patients. Ten pecent of patients developed perforation during dilatation, and the risk of perforating at each dilatation was 3.8%. Perforation required surgery in six cases but there was no mortality. Strictures in SOReg may be underreported, which could explain the low incidence in the study., Conclusion: Most strictures present within 2 months and are successfully treated with two dilatations or less. Dilating a strictured gastrojejunostomy entails a risk of perforation (3.8%).

Background: Open Roux-en-Y gastric bypass (RYGB) may be chosen because of known widespread adhesions or as a result of conversion during laparoscopic surgery. Although conversions are rare, they occur even in experienced hands. The gastrojejunostomy may be performed with a circular stapler (CS) or a linear stapler (LS) or may be entirely hand sewn (HS). Our aim was to study differences in outcomes regarding the anastomotic techniques utilized in open surgery., Setting: Nationwide cohort., Methods: Data on open surgery, both primary open and converted procedures from Scandinavian Obesity Surgery Registry were analyzed for the years 2007-2013. Outcomes were assessed through multivariate analysis, adjusting for gender, age, preoperative body mass index, diabetes, conversion, and technique used for the gastrojejunostomy., Results: CS was the most common method used for primary open RYGB (58%), whereas LS was the most common for converted RYGB (63%). HS was uncommon in both groups. Operative time was shorter for LS than for CS in the primary open RYGB (110±40 min versus 132±46 min; P<.001). Anastomotic leakage rates were similar in primary open RYGB (1.0%-2.4%), but leakage rates for LS in converted procedures was 10.1%, thus higher compared with 2.1% in converted CS patients (P = .02). Odds ratio for leakage was 2.87 (95% confidence interval 1.18-6.97) for LS using CS as a reference when adjusting for variables above., Conclusion: LS was associated to increased risk of leakage in patients with conversion from laparoscopic RYGB to open RYGB. Conversion to open surgery was associated to increased risk of leakage. Technique used for the gastrojejunostomy did not affect weight loss., (Copyright © 2016 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most common bariatric procedures worldwide, but the importance of gastric pouch size is still under debate. We have studied how pouch size affects risk of marginal ulcer and excess body mass index loss (EBMIL%) at 6 weeks and 1 year postoperatively., Methods: Scandinavian Obesity Surgery Registry included 14,168 LRYGB patients with linear stapled gastrojejunostomies, having complete pre- and postoperative data concerning length of stapler needed to complete the gastric pouch, incidence of marginal ulcers and weight loss. LRYGB technique in Sweden is highly standardized, and total length of stapler was used as a proxy for pouch size., Results: Mean length of stapler used for the pouch was 145 mm. At 1 year, symptomatic marginal ulcers were noted in 0.9 % of the patients. The relative risk of marginal ulcer increased by 14 % (95 % confidence interval 9-20 %), for each centimeter of stapler used for the pouch. Body mass index (BMI) was reduced from 42.4 ± 5.1 to 36.1 kg/m(2) at 6 weeks and 28.9 kg/m(2) at 1 year. The total length of stapler predicted EBMIL% at 6 weeks but not at 1 year. Female gender, low preoperative BMI, young age and absence of diabetes predicted better EBMIL% at 1 year., Conclusion: A smaller pouch reduces the risk of marginal ulcers, but does not predict better weight loss at 1 year. Additional stapling should be avoided as each extra centimeter increases the relative risk of marginal ulcers by 14 %.

Background: Although laparoscopic Roux-en-Y gastric bypass (LRYGB) is a common bariatric procedure worldwide, no consensus on the optimal technique for the gastrojejunostomy (GJ) has been reached. Circular stapling (CS) immediately results in a GJ of standardized width, whereas linear stapling (LS) requires a technically challenging closure of the stapler defect. The aim was to study differences in outcomes between CS and LS., Setting: Nationwide Swedish cohort., Methods: The Scandinavian Obesity Registry (SOReg) included prospective data from 34,284 primary LRYGB patients operated on in 2007-2013. We studied operative time, length of hospital stay, postoperative complications, and percent excess body mass index loss (%EBMIL) after 1 year. Outcomes were assessed through multivariate analysis adjusting for gender, age, preoperative body mass index (BMI), and diabetes., Results: Preoperatively the groups were similar (40.9 yr, BMI 42.4 kg/m(2), 76% female). For CS and LS, operative time and hospital stay were 114 and 73 minutes (P<.001) and 4.6 and 2.0 days (P<.001), respectively. Using LS as a reference, adjusted odds ratio (OR) for CS patients to have anastomotic leakage was 2.8 (95% CI 1.5-5.0), postoperative hemorrhage 1.9 (95% CI 1.2-2.9), wound complication 9.7 (95% CI 6.8-13.9), and marginal ulcer 3.1 (95% CI 1.8-5.3). The %EBMIL at 1 year was 80% for both techniques and 31% of total weight was lost. Follow-up rate at 6 weeks and 1 year was 96% and 73%, respectively., Conclusion: CS was found to be associated with disadvantages regarding operative time, hospital stay, and postoperative complications compared with LS., (Copyright © 2015 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: It is evident that morbidly obese patients have a low health-related quality-of-life (HRQoL), and this low HRQoL has become a common reason for them to seek bariatric surgery. Several HRQoL studies demonstrate a dramatic postoperative improvement, but most of these have had a short follow-up period., Material and Methods: An observational, cross-sectional study for HRQoL was conducted to study 486 patients (average age of 50.7 ± 10.0 years, with 84 % of them being female) operated with gastric bypass (GBP) in the period 1993 to 2003 at the University Hospitals of Örebro and Uppsala. Mean follow-up after gastric bypass was 11.5 ± 2.7 years (range 7-17). Two HRQoL instruments were used, SF-36 and the Obesity-related Problems scale (OP). The study group was compared with two control groups, both matched for age and gender, one from the general population and one containing morbidly obese patients evaluated and awaiting bariatric surgery., Results: The study group scored better in the SF-36 domains (all four physical domains and the vitality subscore) and OP scale compared to obese controls, but their HRQoL scores were lower than those of the general population. HRQoL was better among younger patients and in the following subgroups: men, patients with satisfactory weight loss, satisfied with the procedure, free from co-morbidities and gastrointestinal symptoms, employment, good oral status and those not hospitalised or regularly followed up for non-bariatric reasons., Conclusion: Long-term follow-up after GBP for morbid obesity showed better scores in most aspects of HRQoL compared to obese controls but did not achieve the levels of the general population. Patients with better medical outcome after gastric bypass operation had better HRQoL.

Background: Bariatric surgery has gained wide acceptance as treatment for severe obesity and is associated with decreased overall mortality. The aims of this study were to evaluate the prevalence of anemia long term after Roux-en-Y gastric bypass (RYGB) and to search for factors predicting anemia., Methods: All 745 patients who underwent RYGB between 1993 and 2003 at either Örebro or Uppsala University Hospital and who were living in Sweden were invited to participate by providing a fasting blood sample and completing a questionnaire about their health status. Full blood count, serum iron, transferrin, vitamin B12, and folic acid were determined., Results: Follow-up was completed in 431 patients (58 %) with mean age 51.3 ± 10 years. Of all patients, 27 % had anemia postoperatively and related deficiencies; iron, folic acid, and vitamin B12 were seen in 20, 12, and 2 %, respectively. There was no correlation between anemia and sex, follow-up time, 25-OH vitamin D level, and preoperative or postoperative BMI. An inverse correlation was found between anemia and regular medical checkups concerning gastric bypass surgery., Conclusion: Twenty-seven percent of patients had anemia more than 10 years after RYGB. Anemia does not seem to progress with time and was less common in patients with regular medical checkups. Thus, improved long-term follow-up is needed.

Background: Weight loss before laparoscopic Roux-en-Y gastric bypass (LRYGB) is desirable, because it can reduce liver volume and thereby facilitate the procedure. The optimal duration of a low-calorie diet (LCD) has not been established. The objective of this study was to assess changes in liver volume and body composition during 4 weeks of LCD., Methods: Ten women (aged 43±8.9 years, 114±12.1 kg, and body mass index 42±2.6 kg/m(2)) were examined on days 0, 3, 7, 14, and 28 after commencing the LCD. At each evaluation, body composition was assessed through bioelectric impedance analysis, and liver volume and intrahepatic fat content were assessed by magnetic resonance imaging. Serum and urine samples were obtained. Questionnaires regarding quality of life and LCD-related symptoms were administered., Results: In total, mean weight decreased by 7.4±1.2 kg (range 5.7-9.1 kg), and 71% of the weight loss consisted of fat mass according to bioelectric impedance analysis. From day 0 to day 3, the weight loss (2.0 kg) consisted mainly of water. Liver volume decreased by 18%±6.2%, from 2.1 to 1.7 liters (P<.01), during the first 2 weeks with no further change thereafter. A continuous 51%±16% decrease was seen in intrahepatic fat content. Systolic blood pressure, insulin, and lipids improved, while liver enzymes, glucose levels, and quality of life were unaffected., Conclusion: A significant decrease in liver volume (18%) occurred during the first 2 weeks of LCD treatment, and intrahepatic fat gradually decreased throughout the study period. A preoperative 2-week LCD treatment seems sufficient in similar patients., (Copyright © 2015 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The primary aim of this study was to evaluate the prevalence of vitamin D deficiency and secondary hyperparathyroidism after Roux-en-Y gastric bypass. Secondly, we have tried to assess predictors for vitamin D deficiency., Methods: Five hundred thirty-seven patients who underwent primary Roux-en-Y gastric bypass surgery between 1993 and 2003 at the Örebro University Hospital and Uppsala University Hospital were eligible for the study. Patients were asked to provide a blood sample between November 2009 and June 2010 and to complete a questionnaire about their postoperative health status. Serum values of 25-OH vitamin D, parathyroid hormone (PTH), alkaline phosphatase (ALP) and calcium were determined., Results: Follow-up was completed in 293 patients, of which 83 % were female, with an age of 49 ± 9.9 years after a median time of 11 ± 2.8 years. Vitamin D, PTH and albumin-corrected calcium values were 42 ± 20.4 nmol/L, 89.1 ± 52.7 ng/L and 2.3 ± 0.1 mmol/L, respectively. Of all patients, 65 % were vitamin D deficient, i.e. 25-OH vitamin D <50 nmol/L, and 69 % had PTH above the upper normal reference range, i.e. >73 ng/L. Vitamin D was inversely correlated with PTH levels (p < 0.001) and positively correlated with calcium (p = 0.016). Vitamin D did not correlate with ALP. The only factor found to predict vitamin D deficiency was high preoperative body mass index (BMI) (p = 0.008), whereas gender, age, time after surgery and BMI at follow-up did not., Conclusions: Vitamin D deficiency and secondary hyperparathyroidism after Roux-en-Y gastric bypass (RYGB) were confirmed in our study because 65 % of patients had vitamin D deficiency, and 69 % had increased PTH levels more than 10 years after surgery. These data are alarming and highlight the need for improved long-term follow-up. Vitamin D deficiency does not seem to progress with time after surgery, possibly due to weight loss. Only preoperative BMI, cutoff point 43 kg/m(2), was a predictor of vitamin D deficiency at follow-up. Improved long-term follow-up of patients that undergo RYGB is needed.

Background: Gastric banding (GB) and vertical banded gastroplasty (VBG) may result in unsatisfactory weight loss or intolerable side effects. Such outcomes are potential indications for additional bariatric surgery, and Roux-en-Y gastric bypass is frequently used at such revisions (rRYGB). The present study examined long-term results of rRYGB., Methods: In total, 175 patients who had undergone rRYGB between 1993 and 2003 at 2 university hospitals received a questionnaire regarding their current status. The questionnaire was returned by 131 patients (75% follow-up rate, 66 VBG and 65 GB patients). Blood samples were obtained and medical charts studied. The reason for conversion was mainly unsatisfactory weight loss among the VBG patients and intolerable side effects among GB patients., Results: The 131 patients (112 women), mean age 41.8 years at rRYGB, were evaluated at mean 11.9 years (range 7-17) after rRYGB. Mean body mass index of those with prior unsatisfactory weight loss was reduced from 40.1 kg/m(2) (range 28.7-52.2) to 32.6 kg/m(2) (range 19.1-50.2) (P<.01). Only 2 patients (2%) underwent additional bariatric surgery after rRYGB. The overall result was satisfactory for 74% of the patients. Only 21% of the patients adhered to the recommendation of lifelong multivitamin supplements while 76% took vitamin B12. Anemia was present in 18%., Conclusions: rRYGB results in sustained weight loss and satisfied patients when VBG or GB have failed. Subsequent bariatric surgery was rare but micronutrient deficiencies were frequent., (Copyright © 2014 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Roux-en-Y gastric bypass surgery (RYGB) as treatment of morbid obesity results in substantial weight loss. Most published long-term studies have included few patients at the last follow-up point. The aim of the present study was to explore long-term results in a large cohort of patients 7-17 years after gastric bypass., Methods: All 539 patients who had undergone primary RYGB from 1993 to 2003 at Uppsala and Örebro University Hospitals received a questionnaire regarding their postoperative status. Blood samples were obtained and the medical charts studied., Results: Of the 539 patients, 384 responded (71.2% response rate, mean age 37.9 yr, body mass index 44.5 kg/m(2) at surgery, 317 women, and 67 men). At a mean follow-up of 11.4 years (range 7-17), the body mass index had decreased to 32.5 kg/m(2), corresponding to an excess body mass index loss of 63.3%. Similar weight loss was observed, regardless of the length of follow-up. Orally treated diabetes resolved in 72% and sleep apnea and hyperlipidemia were improved. Revisional bariatric surgery had been performed in 2.1% and abdominoplasty in 40.2%. The gastrointestinal symptoms were considered tolerable. The overall result was satisfactory for 79% of the patients and 92% would recommend Roux-en-Y gastric bypass to a friend. Attendance to the annual checkups was 37%. Vitamin B12 supplements were taken by 72% and multivitamins by 24%., Conclusion: At 11 years, substantial weight loss was maintained and revisional surgery was rare. Surprisingly few patients were compliant with the recommendation of lifelong supplements and yearly evaluations; however, patient satisfaction was high., (Copyright © 2013 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The aim of this study was to explore changes in liver volume and intrahepatic fat in morbidly obese patients during 4 weeks of low-calorie diet (LCD) before surgery and to investigate if these changes would facilitate the following laparoscopic gastric bypass., Methods: Fifteen female patients (121.3 kg, BMI 42.9) were treated preoperatively in an open study with LCD (800-1,100 kcal/day) during 4 weeks. Liver volume and fat content were assessed by magnetic resonance imaging and spectroscopy before and after the LCD treatment., Results: Liver appearance and the complexity of the surgery were scored at the operation. Eighteen control patients (114.4 kg, BMI 40.8), without LCD were scored similarly. Average weight loss in the LCD group was 7.5 kg, giving a mean weight of 113.9 kg at surgery. Liver volume decreased by 12% (p < 0.001) and intrahepatic fat by 40% (p < 0.001). According to the preoperative scoring, the size of the left liver lobe, sharpness of the liver edge, and exposure of the hiatal region were improved in the LCD group compared to the controls (all p < 0.05)., Conclusions: The overall complexity of the surgery was perceived lower in the LCD group (p < 0.05), due to improved exposure and reduced psychological stress (both p < 0.05). Four weeks of preoperative LCD resulted in a significant decrease in liver volume and intrahepatic fat content, and facilitated the subsequent laparoscopic gastric bypass as scored by the surgeon.