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Complications in Bariatric Surgery with Focus on Gastric Bypass

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Complications in Bariatric Surgery with Focus on Gastric Bypass Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine 1676 Complications in bariatric surgery with focus on gastric bypass BJARNI VIDARSSON ACTA UNIVERSITATIS UPSALIENSIS ISSN 1651-6206 ISBN 978-91-513-0991-0 UPPSALA urn:nbn:se:uu:diva-417549 2020 Dissertation presented at Uppsala University to be publicly examined in H:son Holmdahlsalen, Entrance 100/101, Akademiska Sjukhuset, Uppsala, Friday, 9 October 2020 at 09:00 for the degree of Doctor of Philosophy (Faculty of Medicine). The examination will be conducted in Swedish. Faculty examiner: Associate Professor Jacob Freedman ( Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm). Abstract Vidarsson, B. 2020. Complications in bariatric surgery with focus on gastric bypass. Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine 1676. 56 pp. Uppsala: Acta Universitatis Upsaliensis. ISBN 978-91-513-0991-0. Obesity is rising in pandemic proportions. At present, one third of the world’s population has become overweight or obese, and estimates predict 60% in 2030. Thus, the problem is gigantic. Obesity is associated with numerous diseases such as diabetes, high blood pressure, sleep apnea and cancer. Untreated obesity decreases life expectancy by about 10 years. Gastric bypass has been one of the cornerstones of surgical treatment. Since 1994 this is done by laparoscopic technique (LRYGB) In this thesis, we have primarily used data from our national quality register, the Scandinavian Obesity Surgical Registry (SOReg), on patients that have been operated with LRYGB. In the first paper, we evaluated the use of a novel suture for closing the gastrojejunostomy (upper anastomosis). Paper II and III focused on incidence, risk factors, treatment and outcome of anastomotic leaks. Paper IV compares the weight results, quality of life, use of medications and healthcare consumption in patients suffering from a serious complication within 30 days after LRYGB. In Paper I, the use of the barbed suture resulted in shorter operative time compared to a standard polyfilament, without increased risk for complications. Paper II showed that the incidence of anastomotic leaks at the gastrojejunostomy was 0.6%. Risk factors were male sex, higher age (≥49 years), diabetes, conversion to open surgery and prolonged operative time (≥ 90 minutes). Almost all patients were reoperated and 1% died. Paper III showed that the incidence of small bowel leaks was 0.3% and these leaks were associated with prolonged operative time, and surgery at a low-volume centre for leaks at the enteroaenteral anastomosis. Surgical re-intervention was common. Paper IV showed that severe complications within 30 days postoperatively after LRYGB occurred in 2.9% of cases. Two years later, the patients still reported inferior quality of life and had a higher use of antidepressants, proton pump inhibitors and opioids compared to uncomplicated cases. The need for additional in-hospital care was higher, even after the first 30 days. In conclusion, the novel barbed suture reduced operative time without increasing risks. Anastomotic leaks are rare, but serious complications in LRYGB do affect the patient in numerous ways and increase healthcare costs. Keywords: Barbed suture; Operative time; Complications; LRYGB; Gastric bypass; RYGB; Leaks; Reoperation; Enteroenteral anastomosis; Small bowel; Reintervention; Healthcare consumption; Roux-en-Y gastric bypass; RAND-36; Quality of life Bjarni Vidarsson, Department of Surgical Sciences, Upper Abdominal Surgery, Akademiska sjukhuset ing 70 1 tr, Uppsala University, SE-751 85 Uppsala, Sweden. © Bjarni Vidarsson 2020 ISSN 1651-6206 ISBN 978-91-513-0991-0 urn:nbn:se:uu:diva-417549 (http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-417549) To my beloved family Harpa, Viðar Elí, Daníel and Óskar List of Papers This thesis is based on the following papers, which are referred to in the text by their Roman numerals. I Bjarni Vidarsson, Magnus Sundbom and David Edholm. (2017) Shorter overall operative time when barbed suture is used in primary laparoscopic gastric bypass: A cohort study of 25,006 cases. Surgery for Obesity and Related Diseases. 13(9):1484- 1488. II Bjarni Vidarsson, Magnus Sundbom and David Edholm. (2019) Incidence and treatment of leak at the gastrojejunostomy in Roux-en-Y gastric bypass: A cohort study of 40,844 patients. Surgery for Obesity and Related Diseases. 15(7):1075-1079. III Bjarni Vidarsson, Magnus Sundbom and David Edholm. (2020) Incidence and treatment of small bowel leak after Roux-en-Y gastric bypass: A cohort study from the Scandinavian Obesity Surgery registry. Surgery for Obesity and Related Diseases.16 (8):1005-1010. IV Bjarni Vidarsson, Martin Löfling Skogar and Magnus Sund- bom. Impact of a severe complication two years after laparo- scopic Roux-en-Y gastric bypass: A cohort study from the Scandinavian Obesity Surgery registry. Manuscript Reprints were made with permission from the respective publishers. Contents Introduction ................................................................................................... 11 Background ................................................................................................... 14 Definitions of overweight and obesity ..................................................... 14 Risk factors of obesity .............................................................................. 14 Gastric bypass .......................................................................................... 14 Early complications in Roux-en-Y Gastric Bypass (RYGB) ................... 15 Anastomotic leak ...................................................................................... 16 Suture types .............................................................................................. 17 Other complications in RYGB ................................................................. 17 Grading complications by the Clavien Dindo system .............................. 18 Operative time .......................................................................................... 19 In-hospital stay ......................................................................................... 19 Weight loss after RYGB .......................................................................... 19 Effect on quality of life ............................................................................ 19 Quality of life after RYGB ....................................................................... 20 Aims .............................................................................................................. 21 Material and methods .................................................................................... 22 Paper I ...................................................................................................... 22 Statistics ............................................................................................... 22 Paper II ..................................................................................................... 22 Statistics ............................................................................................... 23 Paper III .................................................................................................... 23 Statistics ............................................................................................... 23 Paper IV ................................................................................................... 24 Statistics ............................................................................................... 24 Ethics ........................................................................................................ 24 Results ........................................................................................................... 25 Paper I ...................................................................................................... 25 Paper II ..................................................................................................... 26 Paper III .................................................................................................... 30 Paper IV ................................................................................................... 31 Discussion ..................................................................................................... 36 Paper I ...................................................................................................... 36 Paper II ..................................................................................................... 37 Paper III .................................................................................................... 38 Paper IV ................................................................................................... 39 Strength and limitations ........................................................................... 41 Conclusions ................................................................................................... 42 Paper I ...................................................................................................... 42 Paper II ..................................................................................................... 42 Paper III .................................................................................................... 42 Paper IV ..................................................................................................
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