Characteristics and outcomes in patients with a prior myocardial infarction treated with extended dual antiplatelet therapy with ticagrelor 60 mg: findings from ALETHEIA, a multi-country observational study.

BACKGROUND: Guidelines recommend extended dual antiplatelet therapy, including ticagrelor 60 mg twice daily, in high-risk post-myocardial infarction (MI) patients who have tolerated 12 months and are not at high bleeding risk. The real-world utilization and bleeding and ischaemic outcomes associated with long-term ticagrelor 60 mg in routine clinical practice have not been well described. METHODS: Register and claims data from the USA (Optum Clinformatics, IBM MarketScan, and Medicare) and Europe (Sweden, Italy, UK, and Germany) were extracted. Patients initiating ticagrelor 60 mg ≥12 months after MI, meeting eligibility criteria for the PEGASUS-TIMI (Prevention of Cardiovascular Events in Patients with Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin - Thrombolysis in Myocardial Infarction 45) 54 trial, were included. The cumulative incidence of the composite of MI, stroke, or all-cause mortality and that of bleeding requiring hospitalization were calculated. Meta-analyses were performed to combine estimates from each source. RESULTS: A total of 7035 patients treated with ticagrelor 60 mg met eligibility criteria. Median age was 67 years and 29% were females; 12% had a history of multiple MIs. The majority (95%) had been treated with ticagrelor 90 mg prior to initiating ticagrelor 60 mg. At 12 months from initiation of ticagrelor 60 mg, the cumulative incidence [95% confidence interval (CI)] of MI, stroke, or mortality was 3.33% (2.73-4.04) and was approximately three-fold the risk of bleeding (0.96%; 0.69-1.33). CONCLUSIONS: This study provides insights into the use of ticagrelor 60 mg in patients with prior MI in clinical practice. Observed event rates for ischaemic events and bleeding generally align with those in the pivotal trials, support the established safety profile of ticagrelor, and highlight the significant residual ischaemic risk in this population.Clinical Trials.gov Registration NCT04568083.

Burden of in-hospital care in oesophageal cancer: national population-based study.

BACKGROUND: Oesophageal cancer management requires extensive in-hospital care. This cohort study aimed to quantify in-hospital care for patients with oesophageal cancer in relation to intended treatment, and to analyse factors associated with risk of spending a large proportion of survival time in hospital. METHODS: All patients with oesophageal cancer in three nationwide registers over a 10-year period were included. In-hospital care during the first year after diagnosis was evaluated, and the proportion of survival time spent in hospital, stratified by intended treatment (curative, palliative or best supportive care), was calculated. Associations between relevant factors and a greater proportion of survival time in hospital were analysed by multivariable logistic regression. RESULTS: In-hospital care was provided for a median of 39, 26, and 15 days in the first year after diagnosis of oesophageal cancer in curative, palliative, and best supportive care groups respectively. Patients receiving curatively intended treatment spent a median of 12 per cent of their survival time in hospital during the first year after diagnosis, whereas those receiving palliative or best supportive care spent 19 and 23 per cent respectively. Factors associated with more in-hospital care included older age, female sex, being unmarried, and chronic obstructive pulmonary disease. CONCLUSION: The burden of in-hospital care during the first year after diagnosis of oesophageal cancer was substantial. Important clinical and socioeconomic factors were identified that predisposed to a greater proportion of survival time spent in hospital.

Impact of surgical resection rate on survival in gastric cancer: nationwide study.

BACKGROUND: There are marked geographical variations in the proportion of patients undergoing resection for gastric cancer. This study investigated the impact of resection rate on survival. METHODS: All patients with potentially curable gastric cancer between 2006 and 2017 were identified from the Swedish National Register of Oesophageal and Gastric Cancer. The annual resection rate was calculated for each county per year. Resection rates in all counties for all years were grouped into tertiles and classified as low, intermediate or high. Survival was analysed using the Cox proportional hazards model. RESULTS: A total of 3465 patients were diagnosed with potentially curable gastric cancer, and 1934 (55.8 per cent) were resected. Resection rates in the low (1261 patients), intermediate (1141) and high (1063) tertiles were 0-50.0, 50.1-62.5 and 62.6-100 per cent respectively. The multivariable Cox analysis revealed better survival for patients diagnosed in counties during years with an intermediate versus low resection rate (hazard ratio (HR) 0.81, 95 per cent c.i. 0.74 to 0.90; P < 0.001) and high versus low resection rate (HR 0.80, 0.73 to 0.88; P < 0.001). CONCLUSION: This national register study showed large regional variation in resection rates for gastric cancer. A higher resection rate appeared to be beneficial with regard to overall survival for the entire population.

Geographical differences in cancer treatment and survival for patients with oesophageal and gastro-oesophageal junctional cancers.

BACKGROUND: Only around one-quarter of patients with cancer of the oesophagus and the gastro-oesophageal junction (GOJ) undergo surgical resection. This population-based study investigated the rates of treatment with curative intent and resection, and their association with survival. METHODS: Patients diagnosed with oesophageal and GOJ cancer between 2006 and 2015 in Sweden were identified from the National Register for Oesophageal and Gastric Cancer (NREV). The NREV was cross-linked with several national registries to obtain information on additional exposures. The annual proportion of patients undergoing treatment with curative intent and surgical resection in each county was calculated, and the counties divided into groups with low, intermediate and high rates. Treatment with curative intent was defined as definitive chemoradiation therapy or surgery, with or without neoadjuvant oncological treatment. Overall survival was analysed using a multilevel model based on county of residence at the time of diagnosis. RESULTS: Some 5959 patients were included, of whom 1503 (25·2 per cent) underwent surgery. Median overall survival after diagnosis was 7·7, 8·8 and 11·1 months respectively in counties with low, intermediate and high rates of treatment with curative intent. Corresponding survival times for the surgical resection groups were 7·4, 9·3 and 11·0 months. In the multivariable analysis, a higher rate of treatment with curative intent (time ratio 1·17, 95 per cent c.i. 1·05 to 1·30; P < 0·001) and a higher resection rate (time ratio 1·24, 1·12 to 1·37; P < 0·001) were associated with improved survival after adjustment for relevant confounders. CONCLUSION: Patients diagnosed in counties with higher rates of treatment with curative intent and higher rates of surgery had better survival.

ANTECEDENTES: En los pacientes con cáncer en el esófago y de la unión gastroesofágica (gastroesophageal junction, GOJ), solamente en una cuarta parte se practica una resección quirúrgica. Este estudio de base poblacional analizó las tasas de tratamiento con intención curativa y de resección y su asociación con la supervivencia. MÉTODOS: A partir del Registro Nacional Sueco de Cáncer de Esófago y Estómago (National Register for Oesophageal and Gastric Cancer, NREV), se identificaron los pacientes diagnosticados de cáncer de esófago y de la GOJ entre 2006-2015. El NREV se cruzó con otros registros nacionales para obtener información adicional. Se calculó la proporción anual de pacientes tratados con intención curativa o mediante resección quirúrgica en cada una de las áreas territoriales de los condados y se categorizaron en baja, intermedia y alta. El tratamiento con intención curativa se definió como la quimiorradioterapia definitiva (definitive chemoradiation therapy, dCRT) o la cirugía, con o sin tratamiento oncológico neoadyuvante. Se analizó la supervivencia global con un modelo multinivel basado en el condado de residencia en el momento del diagnóstico. RESULTADOS: Se incluyeron 5.959 pacientes, de los que 1.503 (25,2%) fueron tratados quirúrgicamente. La mediana de supervivencia global después del tratamiento con intención curativa fue de 7,7, 8,8 y 11,1 meses para los condados de volumen bajo, intermedio y alto. Para el grupo de cirugía fue de 7,4, 9,3 y 11,0 meses, respectivamente. En el análisis multivariable, una mayor tasa de tratamiento con intención curativa y una mayor tasa de resección se asociaron con una mejor supervivencia (tiempo ganado 1,17; i.c. del 95% 1,05-1,30, P < 0,001 y tiempo ganado 1,24; i.c. del 95% 1,12-1,37, P < 0,001) después del ajuste para los factores principales de confusión. CONCLUSIÓN: Los pacientes diagnosticados en condados con tasas altas de tratamiento con intención curativa y de cirugía tuvieron una mejor supervivencia.

Safe Introduction of Minimally Invasive Esophagectomy at a Medium Volume Center.

BACKGROUND AND AIMS: Minimally invasive esophagectomy is a favored alternative in high-volume centers. We evaluated the introduction of, and transition to, minimally invasive esophagectomy at a medium volume tertiary referral center (10-20 esophagectomies annually) with focus on surgical results. MATERIAL AND METHODS: Patients who underwent minimally invasive esophagectomy or open transthoracic surgery for carcinoma of the esophagus or gastroesophageal junction (Siewert I and II) during 2007-2016 were retrospectively studied. Sorted on surgical approach, perioperative data, surgical outcomes, and postoperative complications were analyzed and multivariate regression models were used to adjust for possible confounders. RESULTS: One hundred and sixteen patients were included, 51 minimally invasive esophagectomy (21 hybrid and 30 totally minimally invasive) and 65 open resections. The groups were well matched. However, higher body mass index, neoadjuvant chemoradiotherapy, and cervical anastomosis were more frequent in the minimally invasive esophagectomy group. Minimally invasive esophagectomy was associated with less peroperative bleeding (384 vs 607 mL, p = 0.036) and reduced length of stay (14 vs 15 days, p = 0.042). Duration of surgery, radical resection rate, and postoperative complications did not differ between groups. Lymph node yield was higher in the minimally invasive esophagectomy group, 18 (13-23) vs 12 (8-16), p < 0.001, confirmed in a multivariate regression model (adjusted odds ratio 3.15, 95% class interval 1.11-8.98, p = 0.032). CONCLUSION: The introduction of minimally invasive esophagectomy at a medium volume tertiary referral center resulted in superior lymph node yield, less peroperative blood loss and shorter length of stay, without compromising the rate of radical resection, or increasing the complication rate.

Improvements in esophageal and gastric cancer care in Sweden-population-based results 2007-2016 from a national quality register.

The Swedish National Register for Esophageal and Gastric cancer was launched in 2006 and contains data with adequate national coverage and of high internal validity on patients diagnosed with these tumors. The aim of this study was to describe the evolution of esophageal and gastric cancer care as reflected in a population-based clinical registry. The study population was 12,242 patients (6,926 with esophageal and gastroesophageal junction (GEJ) cancers and 5,316 with gastric cancers) diagnosed between 2007 and 2016. Treatment strategies, short- and long-term mortality, gender aspects, and centralization were investigated. Neoadjuvant oncological treatment became increasingly prevalent during the study period. Resection rates for both esophageal/GEJ and gastric cancers decreased from 29.4% to 26.0% (P = 0.022) and from 38.8% to 33.3% (P = 0.002), respectively. A marked reduction in the number of hospitals performing esophageal and gastric cancer surgery was noted. In gastric cancer patients, an improvement in 30-day mortality from 4.2% to 1.6% (P = 0.005) was evident. Overall 5-year survival after esophageal resection was 38.9%, being higher among women compared to men (47.5 vs. 36.6%; P < 0.001), whereas no gender difference was seen in gastric cancer. During the recent decade, the analyses based on the Swedish National Register for Esophageal and Gastric cancer database demonstrated significant improvements in several important quality indicators of care for patients with esophagogastric cancers. The Swedish National Register for Esophageal and Gastric cancer offers an instrument not only for the control and endorsement of quality of care but also a unique tool for population-based clinical research.

Association between time interval from neoadjuvant chemoradiotherapy to surgery and complete histological tumor response in esophageal and gastroesophageal junction cancer: a national cohort study.

The optimal time interval from neoadjuvant therapy to surgery in the treatment of esophageal cancer is not known. The aim of this study was to investigate if a prolonged interval between completed neoadjuvant chemoradiotherapy and surgery was associated with improved histological response rates and survival in a population-based national register cohort. The population-based cohort study included patients treated with neoadjuvant chemoradiotherapy and esophagectomy due to cancer in the esophagus or gastroesophageal junction. Patients were divided into two groups based on the median time from completed neoadjuvant treatment to surgery. The primary outcome was complete histological response. Secondary outcomes were lymph node tumor response, postoperative complications, R0 resection rate, 90-day mortality, and overall survival. In total, 643 patients were included, 344 (54%) patients underwent surgery within 49 days, and 299 (47%) after 50 days or longer. The groups were similar concerning baseline characteristics except for a higher clinical tumor stage (P = 0.009) in the prolonged time to surgery group. There were no significant differences in complete histological response, R0 resection rate, postoperative complications, 90-day mortality, or overall survival. Adjusted odds ratio for ypT0 in the prolonged time to surgery group was 0.99 (95% confidence interval: 0.64-1.53). Complete histological response in the primary tumor (ypT0) was associated with significantly higher overall survival: adjusted hazard ratio: 0.55 (95% CI 0.41-0.76). If lymph node metastases were present in these patients, the survival was, however, significantly lower: adjusted hazard ratio for ypT0N1: 2.30 (95% CI 1.21-4.35). In this prospectively collected, nationwide cohort study of esophageal and junctional type 1 and 2 cancer patients, there were no associations between time to surgery and histological complete response, postoperative outcomes, or overall survival. The results suggest that it is safe for patients to postpone surgery at least 7 to 10 weeks after completed chemoradiotherapy, but no evidence was seen in favor of recommending a prolonged time to surgery after neoadjuvant chemoradiotherapy for esophageal cancer. A definitive answer to this question requires a randomized controlled trial of standard vs. prolonged time to surgery.

18F-FDG-PET/MRI in preoperative staging of oesophageal and gastroesophageal junctional cancer.

AIM: To evaluate integrated 2-[18F]-fluoro-2-deoxy-d-glucose (18F-FDG) positron-emission tomography (PET)/magnetic resonance imaging (MRI), in comparison with the standard technique, integrated 18F-FDG-PET/computed tomography (CT), in preoperative staging of oesophageal or gastroesophageal junctional cancer. MATERIALS AND METHODS: In the preoperative staging of 16 patients with oesophageal or gastroesophageal junctional cancer, 18F-FDG-PET/MRI was performed immediately following the clinically indicated 18F-FDG-PET/CT. MRI-sequences included T1-weighted fat-water separation (Dixon's technique), T2-weighted, diffusion-weighted imaging (DWI), and gadolinium contrast-enhanced T1-weighted three-dimensional (3D) imaging. PET was performed with 18F-FDG. Two separate teams of radiologists conducted structured blinded readings of 18F-FDG-PET/MRI or 18F-FDG-PET/CT, which were then compared regarding tumour measurements and characteristics as well as assessment of inter-rater agreement (Cohen's kappa) for the clinical tumour, nodal and metastatic (TNM) stage. RESULTS: There were no medical complications. Comparison of tumour measurements revealed high correlations without significant differences between modalities. The maximum standardised uptake value (SUVmax) values of the primary tumour with 18F-FDG-PET/MRI had excellent correlation to those of 18F-FDG-PET/CT (0.912, Spearman's rho). Inter-rater agreement between the techniques regarding T-stage was only fair (Cohen's kappa, 0.333), arguably owing to relative over-classification of the T-stage using 18F-FDG-PET/CT. Agreements in the assessment of N- and M-stage were substantial (Cohen's kappa, 0.849 and 0.871 respectively). CONCLUSION: Preoperative staging with 18F-FDG-PET/MRI is safe and promising with the potential to enhance tissue resolution in the area of interest. 18F-FDG-PET/MRI and 18F-FDG-PET/CT correlated well for most of the measured values and discrepancies were seen mainly in the assessment of the T-stage. These results facilitate further studies investigating the role of 18F-FDG-PET/MRI in, e.g., predicting or determining the response to neoadjuvant therapy.

International comparison of treatment strategy and survival in metastatic gastric cancer.

Background: In the randomized Asian REGATTA trial, no survival benefit was shown for additional gastrectomy over chemotherapy alone in patients with advanced gastric cancer with a single incurable factor, thereby discouraging surgery for these patients. The purpose of this study was to evaluate treatment strategies for patients with metastatic gastric cancer in daily practice in five European countries, along with relative survival in each country. Methods: Nationwide population-based data from Belgium, Denmark, the Netherlands, Norway and Sweden were combined. Patients with primary metastatic gastric cancer diagnosed between 2006 and 2014 were included. The proportion of gastric resections performed and the administration of chemotherapy (irrespective of surgery) within each country were determined. Relative survival according to country was calculated. Results: Overall, 15 057 patients with gastric cancer were included. The proportion of gastric resections varied from 8·1 per cent in the Netherlands and Denmark to 18·3 per cent in Belgium. Administration of chemotherapy was 39·2 per cent in the Netherlands, compared with 63·2 per cent in Belgium. The 6-month relative survival rate was between 39·0 (95 per cent c.i. 37·8 to 40·2) per cent in the Netherlands and 54·1 (52·1 to 56·9) per cent in Belgium. Conclusion: There is variation in the use of gastrectomy and chemotherapy in patients with metastatic gastric cancer, and subsequent differences in survival.

Normal radiological lymph node appearance in the thorax.

Modern treatment of esophageal cancer is multimodal and highly dependent on a detailed diagnostic assessment of clinical stage, which includes nodal stage. Clinical appraisal of nodal stage is highly dependent on knowledge of normal radiological appearance, information of which is scarce. We aimed to describe lymph node appearance on computed tomography (CT) investigations in a randomly selected cohort of healthy subjects. In a sample of the Swedish Cardiopulmonary bioimage study, which investigates a sample of the Swedish population aged 50-64 years, the CT scans of 426 subjects were studied in detail concerning intrathoracic node stations relevant in clinical staging of esophageal cancer. With stratification for sex, the short axis of visible lymph nodes was measured and the distribution of lymph node sizes was calculated as well as proportion of patients with visible nodes above 5 and 10 millimeters for each station. Probability of having any lymph node station above 5 and 10 millimeters was calculated with a logistic regression model adjusted for age and sex. In the 214 men (aged: 57.3 ± 4.1 years) and 212 women (aged: 57.8 ± 4.4 years) included in this study, a total of 309 (72.5%) had a lymph node with a short axis of 5 mm or above was seen in at least one of the node stations investigated. When using 10 mm as a cutoff, nodes were visible in 29 (6.81%) of the subjects. Men had higher odds of having any lymph node with short axis 5 mm or above (OR 3.03 95% CI 1.89-4.85, P < 0.001) as well as 10 mm or above (OR 2.31 95% CI 1.02-5.23, P = 0.044) compared to women. Higher age was not associated with propensity for lymph nodes above 5 or 10 millimeters in this sample. We conclude that, in a randomly selected cohort of patients between 50 and 64 years, almost 10% of the men and 4% of the women had lymph nodes above 10 millimeters, most frequently in the subcarinal station (station 107). More than half of the patients had nodes above 5 millimeters on CT and men were much more prone to have this finding. The probability of finding lymph nodes in specific stations relevant of esophageal cancer is now described.

Large Buffering Effect of the Duodenal Bulb in Duodenal Switch: a Wireless pH-Metric Study.

INTRODUCTION: Bariatric procedures result in massive weight loss, however, not without side effects. Gastric acid is known to cause marginal ulcers, situated in the small bowel just distal to the upper anastomosis. We have used the wireless BRAVO™ system to study the buffering effect of the duodenal bulb in duodenal switch (DS), a procedure in which the gastric sleeve produces a substantial amount of acid. METHODS: We placed a pre- and a postpyloric pH capsule in 15 DS-patients (seven men, 44 years, BMI 33) under endoscopic guidance and verified the correct location by fluoroscopy. Patients were asked to eat and drink at their leisure, and to register their meals for the next 24 h. RESULTS: All capsules but one could be successfully placed, without complications. Total registration time was 17.2 (1.3-24) hours prepyloric and 23.1 (1.2-24) hours postpyloric, with a corresponding pH of 2.66 (1.74-5.81) and 5.79 (4.75-7.58), p < 0.01. The difference in pH between the two locations was reduced from 3.55 before meals to 1.82 during meals, p < 0.01. Percentage of time with pH < 4 was 70.0 (19.9-92.0) and 13.0 (0.0-34.6) pre and postpylorically, demonstrating a large buffering effect. CONCLUSION: By this wireless pH-metric technique, we could demonstrate that the duodenal bulb had a large buffering effect, thus counteracting the large amount of gastric acid passing into the small bowel after duodenal switch. This physiologic effect could explain the low incidence of stomal ulcers.

Use of Laparoscopy in Gastrointestinal Surgery in Sweden 1998-2014: A Nationwide Study.

BACKGROUND AND AIMS: One by one, minimally invasive alternatives to established gastrointestinal procedures have become clinical routine. We have studied the use of laparoscopy in four common procedures-cholecystectomy, appendectomy, reflux surgery, and bariatric surgery-as well as in major resectional gastrointestinal surgery in Sweden. MATERIALS AND METHODS: The National Patient Registry was used to identify all in-hospital procedures performed in patients above the age of 15 during 1998-2014, meeting our inclusion criteria. For each group, the annual number of procedures and proportion of laparoscopic surgery were studied, as well as applicable subgroups. Differences in age, gender, as well as geographical differences were evaluated in the most recent 3-year period (2012-2014). RESULTS: In total, 537,817 procedures were studied, 43% by laparoscopic approach. In 2012-2014, the proportion of laparoscopic surgery ranged from high rates in the four common procedures (cholecystectomy 81%, appendectomy 47%, reflux surgery 72%, and bariatric surgery 97%) to rather low numbers in resectional surgery (4%-10%), however, increasing in the last years. In appendectomy and cholecystectomy, men were less likely to have laparoscopic surgery (42% versus 51% and 74% versus 85%, respectively, p < 0.001). Substantial geographical differences in the use of laparoscopy were also noted, for example, the proportion of laparoscopic appendectomy varied from 11% to 76% among the 21 different Swedish counties. CONCLUSION: The proportion of laparoscopy was high in the four common procedures and low, but rising, in major resectional surgery. A large variation in the proportion of laparoscopic surgery by age, gender, and place of residence was noted.

Laparoscopy in Duodenal Switch: Safe and Halves Length of Stay in a Nationwide Cohort from the Scandinavian Obesity Registry.

BACKGROUND AND AIMS: Unsatisfactory weight loss after gastric bypass or sleeve gastrectomy in super-obese patients (body mass index > 50) is a growing concern. Biliopancreatic diversion with duodenal switch results in greater weight loss, but is technically challenging to perform, especially as a laparoscopic procedure (Lap-DS). The aim of this study was to compare perioperative outcomes of Lap-DS and the corresponding open procedure (O-DS) in Sweden. MATERIAL AND METHODS: The data source was a nationwide cohort from the Scandinavian Obesity Surgery Registry and 317 biliopancreatic diversion with duodenal switch patients (mean body mass index = 56.7 ± 6.6 kg/m2, 38.4 ± 10.2 years, and 57% females) were analyzed. Follow-up at 30 days was complete in 98% of patients. RESULTS: The 53 Lap-DS patients were younger than the 264 patients undergoing O-DS (35.0 vs 39.1 years, p = 0.01). Operative time was 163 ± 38 min for lap-DS and 150 ± 31 min for O-DS, p = 0.01, with less bleeding in Lap-DS (94 vs 216 mL, p < 0.001). There was one conversion to open surgery. Patients undergoing Lap-DS had a shorter length of stay than O-DS, 3.3 versus 6.6 days, p = 0.02. No significant differences in overall complications within 30 days were seen (12% and 17%, respectively). Interestingly, the two leaks in Lap-DS were located at the entero-enteric anastomosis, while three out of four leaks in O-DS occurred at the top of the gastric tube. CONCLUSION: Lap-DS can be performed by dedicated bariatric surgeons as a single-stage procedure. The use of laparoscopic approach halved the length of stay, without increasing the risk for complications significantly. Any difference in long-term weight result is pending.

Validation of data quality in the Swedish National Register for Oesophageal and Gastric Cancer.

BACKGROUND: The Swedish National Register for Oesophageal and Gastric Cancer (NREV) was launched in 2006. Data are reported at diagnosis (diagnostic survey), at the time of surgery (surgical survey) and at first outpatient follow-up (follow-up survey). The aim of this study was to evaluate data originating from NREV in terms of comparability, completeness, accuracy and timeliness. METHODS: Coding routines were compared with international standards and completeness was evaluated by means of a 5-year (2009-2013) comparison with mandatory national registers. Validity was tested by comparison with reabstracted data from source medical records in 400 patients chosen randomly with stratification for hospital size and catchment area population. Timeliness of registration was described. RESULTS: Coding routines followed national and international guidelines. Compared with the Swedish Cancer Registry from 2009 to 2013, 6069 (95·5 per cent) of 6354 patients were registered in NREV at the time of data extraction. Of 60 variables investigated, 10 966 of 12 035 original entries were correct in the reabstraction, resulting in an exact agreement of 91·1 per cent in the register. There were 782 (6·5 per cent) incorrect and 287 (2·4 per cent) missing entries. Median time to registration was 3·9, 3·4 and 4·1 months for diagnostic, surgical and follow-up surveys respectively. CONCLUSION: NREV has reached a position with good coverage of those with the relevant diagnoses, and contains comparable and valid data. Quality data on each variable are available. Timeliness is an area with potential for improvement.

Gastrointestinal symptoms, weight loss and patient satisfaction 5 years after gastric bypass: a study of three techniques for the gastrojejunal anastomosis.

BACKGROUND: The optimal operative technique in gastric bypass (RYGB) is still under debate. We have studied patient-reported gastrointestinal symptoms and weight loss 5 years after RYGB performed with three different stapling techniques for the gastrojejunal anastomosis (GJ). METHODS: Out of 593 patients operated with RYGB, 489 patients [80.2% women, body mass index (BMI) 44.9 (33-68) kg/m(2)] answered our 5-year follow-up questionnaire concerning gastrointestinal symptoms (vomiting, reflux, dumping, abdominal pain or diarrhea), weight loss, need for postoperative endoscopic interventions and overall satisfaction with the procedure. We compared the results for three different GJ techniques: linear stapler (LS, n = 103), 21-mm circular stapler (C21, n = 88) and 25-mm circular stapler (C25, n = 298). RESULTS: Dumping was the most commonly reported symptom (14.1% of all patients on a weekly to daily basis), however, less frequently reported in the C25 group (p < 0.05). Vomiting, prevalent in 2.9% of all patients, was more frequently reported in the C21 group (p < 0.01). No group consistently showed greater weight loss compared to the other two groups. A higher incidence of endoscopic dilatations due to strictures was reported in the C21 group (12.5% compared to 4.5% of all patients, p < 0.05). Overall patient satisfaction was high (88%). CONCLUSION: Our data suggest that the technique for the construction of the GJ in RYGB affects gastrointestinal symptoms 5 years postoperatively. The difference is moderate but indicates that a narrow GJ results in increased frequency of vomiting and need for endoscopic interventions without improving the weight result.

Duodenal switch versus Roux-en-Y gastric bypass for morbid obesity: systematic review and meta-analysis of weight results, diabetes resolution and early complications in single-centre comparisons.

Long-term weight loss after Roux-en-Y gastric bypass (RYGB) in super-obese patients has not been ideal. Biliopancreatic diversion with duodenal switch (DS) is argued to be better; however, additional side effects are feared. The aim of the present study was to determine differences in results after DS and RYGB in publications from single-centre comparisons. A systematic review of studies containing DS and RYGB performed at the same centre was performed. Outcome data were weight results, resolution of comorbid conditions, perioperative results and complications. Main outcome was difference in weight loss after DS and RYGB. Secondary outcomes were difference in resolution of comorbidities, perioperative results and complications. The final analysis included 16 studies with in total 874 DS and 1,149 RYGB operations. When comparing weight results at the longest follow-up of each study, DS yielded 6.2 (95% confidence interval 5.0-7.5) body mass index units additional weight loss compared with RYGB, P < 0.001. Operative time and length of stay were significantly longer after DS, as well as the risk for post-operative leaks, P < 0.05. DS is more effective than RYGB as a weight-reducing procedure. However, this comes at the price of more early complications and might also yield slightly higher perioperative mortality.

Differences in early complications between circular and linear stapled gastrojejunostomy in laparoscopic gastric bypass.

BACKGROUND: Laparoscopic gastric bypass (LGBP) is the most common bariatric procedure worldwide. The gastrojejunostomy can be stapled with a circular or linear stapler, each with their own specific advantages. We have evaluated differences in postoperative complications between the two techniques. METHODS: We studied operative data and postoperative complications in 560 patients (79.8 % females, median age 42, BMI 42.5) operated with LGBP between 2008 and 2012 at our center. The gastrojejunostomy was initially performed using a circular stapler (CS) in 288 patients and later by linear stapler (LS) in 272. Complications, operative time, and length of stay were retrieved from our database. The risk of developing a port site infection was evaluated with multivariate logistic regression. RESULTS: Port site infections were more common with CS than LS, 5.2 and 0.4 %, respectively (p < 0.01). Multivariate analysis demonstrated CS to be an independent risk factor for port site infections (OR 16.3 (2.09-126), p < 0.01), as well as for stomal ulcers (OR 10.1, 1.15-89, p = 0.04). Major postoperative complications remained unchanged (anastomotic leak 1.0 vs. 1.1 %, abscess 0.7 vs. 0.4 %), while operative time and length of stay were found to be shorter using the LS (122 vs. 83 min, p < 0.001 and 4 vs. 3 days, p < 0.001). CONCLUSIONS: The linear stapled technique yielded lower incidence of port site infections, probably by avoiding the passage of a contaminated circular stapler through the abdominal wall. No difference in major complications was seen, but operative time was shorter using a linear stapler instead of a circular stapler.

Low-dose acetylsalicylic acid and gastrointestinal ulcers or bleeding--a cohort study of the effects of proton pump inhibitor use patterns.

OBJECTIVE: The aim of this study was to investigate the associations between proton pump inhibitor (PPI) usage patterns and risk of severe gastrointestinal events in patients treated with low-dose acetylsalicylic acid (LDA). DESIGN AND SETTING: A nationwide cohort study in Sweden. PATIENTS: All Swedish residents ≥ 40 years of age, without cancer and receiving LDA treatment (≥ 80% adherence for 365 days between 2005 and 2009) were identified in the Swedish Prescription Register. Continuous PPI use was defined as > 60 of 90 days covered by daily PPI doses and further divided into high (≥ 80%) or moderate (< 80) adherence. All other PPI use was defined as intermittent use. MAIN OUTCOME MEASURES: The risk of a combined end-point of gastrointestinal ulcer or bleeding was analysed using Cox proportional hazard models. We also investigated risk of > 45 days of LDA treatment interruption. RESULTS: During a median follow-up of 2.5 years, 7880 of 648,807 (1.2%) LDA-treated patients experienced gastrointestinal events. In multivariable-adjusted models, both intermittent-PPI and no-PPI use were associated with increased risk of gastrointestinal ulcers or bleeding compared with continuous PPI use with a high level of adherence [hazard ratio (HR) 1.83 (95% CI 1.66-2.02) and 1.14 (95% CI 1.05-1.23), respectively]. Amongst continuous PPI users, moderate adherence also increased the risk of gastrointestinal ulcers or bleeding [HR 1.22 (95% CI 1.07-1.40)]. The risk of LDA treatment interruption was higher with intermittent PPI use [HR 1.16 (95% CI 1.14-1.19)] than continuous PPI use with high adherence. CONCLUSIONS: In this large cohort of LDA users, intermittent PPI use was associated with higher risk of gastrointestinal ulcers or bleeding and interrupted LDA treatment, compared with continuous PPI use.

Surface-protein interactions on different stainless steel grades: effects of protein adsorption, surface changes and metal release.

Implantation using stainless steels (SS) is an example where an understanding of protein-induced metal release from SS is important when assessing potential toxicological risks. Here, the protein-induced metal release was investigated for austenitic (AISI 304, 310, and 316L), ferritic (AISI 430), and duplex (AISI 2205) grades in a phosphate buffered saline (PBS, pH 7.4) solution containing either bovine serum albumin (BSA) or lysozyme (LSZ). The results show that both BSA and LSZ induce a significant enrichment of chromium in the surface oxide of all stainless steel grades. Both proteins induced an enhanced extent of released iron, chromium, nickel and manganese, very significant in the case of BSA (up to 40-fold increase), whereas both proteins reduced the corrosion resistance of SS, with the reverse situation for iron metal (reduced corrosion rates and reduced metal release in the presence of proteins). A full monolayer coverage is necessary to induce the effects observed.

Interactions between surfactants and silver nanoparticles of varying charge.

The interaction between silver nanoparticles (Ag NPs) of different surface charge and surfactants relevant to the laundry cycle has been investigated to understand changes in speciation, both in and during transport from the washing machine. Ag NPs were synthesized to exhibit either a positive or a negative surface charge in solution conditions relevant for the laundry cycle (pH 10 and pH 7). These particles were characterized in terms of size and surface charge and compared to commercially laser ablated Ag NPs. The surfactants included anionic sodium dodecylbenzenesulfonate (LAS), cationic dodecyltrimethylammoniumchloride (DTAC) and nonionic Berol 266 (Berol). Surfactant-Ag NP interactions were studied by means of dynamic light scattering, Raman spectroscopy, zeta potential, and Quartz Crystal Microbalance. Mixed bilayers of CTAB and LAS were formed through a co-operative adsorption process on positively charged Ag NPs with pre-adsorbed CTAB, resulting in charge reversal from positive to negative zeta potentials. Adsorption of DTAC on negatively charged synthesized Ag NPs and negatively charged commercial Ag NPs resulted in bilayer formation and charge reversal. Weak interactions were observed for nonionic Berol with all Ag NPs via hydrophobic interactions, which resulted in decreased zeta potentials for Berol concentrations above its critical micelle concentration. Differences in particle size were essentially not affected by surfactant adsorption, as the surfactant layer thicknesses did not exceed more than a few nanometers. The surfactant interaction with the Ag NP surface was shown to be reversible, an observation of particular importance for hazard and environmental risk assessments.