Long-Term Changes to the Microbiome, Blood Lipid Profiles and IL-6 in Female and Male Swedish Patients in Response to Bariatric Roux-en-Y Gastric Bypass.

Lipid metabolism dysregulation is a critical factor contributing to obesity. To counteract obesity-associated disorders, bariatric surgery is implemented as a very effective method. However, surgery such as Roux-en-Y gastric bypass (RYGB) is irreversible, resulting in life-long changes to the digestive tract. The aim of the present study was to elucidate changes in the fecal microbiota before and after RYGB in relation to blood lipid profiles and proinflammatory IL-6. Here, we studied the long-term effects, up to six years after the RYGB procedure, on 15 patients' gut microbiomes and their post-surgery well-being, emphasizing the biological sex of the patients. The results showed improved health among the patients after surgery, which coincided with weight loss and improved lipid metabolism. Health changes were associated with decreased inflammation and significant alterations in the gut microbiome after surgery that differed between females and males. The Actinobacteriota phylum decreased in females and increased in males. Overall increases in the genera Prevotella, Paraprevotella, Gemella, Streptococcus, and Veillonella_A, and decreases in Bacteroides_H, Anaerostipes, Lachnoclostridium_B, Hydrogeniiclostridium, Lawsonibacter, Paludicola, and Rothia were observed. In conclusion, our findings indicate that there were long-term changes in the gut microbiota after RYGB, and shifts in the microbial taxa appeared to differ depending on sex, which should be investigated further in a larger cohort.

Linear and circular stapled gastrojejunal anastomoses in Roux-en-Y gastric bypass: stomal diameter at onset and at long-term follow-up.

BACKGROUND: In the laparoscopic Roux-en-Y gastric bypass procedure, the gastrojejunal stoma is constructed with either a circular (CSD) or a linear stapling device (LSD). The diameter of the stoma following stapling with the 21 mm CSD is expected to be approximately 12 mm (diameter of the anvil). Measuring the stoma diameter after linear stapling is a little more complex since the remaining opening in the linear anastomosis is closed by hand. The aim of this prospective randomized study was to follow up on changes in the diameter of gastrojejunal stomata after laparoscopic Roux-en-Y gastric bypass using either a CSD or an LSD between that at construction and at a long-term follow-up of 12-72 months later. METHODS: Twenty patients were randomly assigned to gastrojejunostomy with either a 21 mm CSD or a 45 mm LSD. Directly after completion of the surgery, the diameter of the gastrojejunal stoma was measured using a Fogarty occlusion catheter and again at follow-up 12-72 months later. RESULTS: Five patients were lost for follow-up, and 15 patients remained. The mean diameter of the CSD stomata at construction was 19.3 ± 5.3 mm (mean ± SD) and increased to 26.4 ± 6.6 mm at follow-up after a mean of 46 months (P = 0.02). The corresponding figures for the LSD stomata were 26.2 ± 4.1 mm, increasing to 32.7 ± 3.0 mm also after a mean follow-up of 46 months (P = 0.03). CONCLUSIONS: The mean diameter of the circular stapled gastrojejunostomy stomata at construction was 20 mm, that is, considerably larger than the 12 mm expected. After a mean of 5 years, the mean diameter had increased by 37%. The mean diameter of the linear stapled stomata increased by 25%.

Thoracoabdominal gastrectomy and distal 2/3 esophageal resection with wide lymph node dissection for type II and III adenocarcinoma at the gastro-esophageal junction.

BACKGROUND: For locally advanced Siewert type II and III tumors we have performed total gastrectomy including resection of the distal 2/3 of the esophagus, through separate abdominal and right chest incisions (THX-ABD). The procedure involves wide lymphadenectomy in the abdomen/chest and a Roux-en-Y jejunostomy to the level of the azygos vein or above. The aim of the study was to investigate short- and long-term results for this rarely used procedure. METHODS: Retrospective study of 83 radio-chemotherapy naïve patients with adenocarcinoma at the gastro-esophageal junction (Siewert type II n = 65 and type III n = 18) operated upon 1986-2011. RESULTS: 2/83 (2.4%) patients died in hospital. 70/83 (84%) patients had R0-resections. 82/83 (99%) patients had free longitudinal resection margins. Overall 5-year survival was 22/83 (27%). CONCLUSION: THX-ABD can be performed with high rates of R0 resections and with low in-hospital mortality. Long-term survival rate was not better compared with less extensive surgical procedures.

Laparoscopic minimally invasive total gastrectomy with linear stapled oesophagojejunostomy--experience from the first thirty procedures.

BACKGROUND: There are only few reports on total gastrectomy by a laparoscopic surgical approach. One explanation is the fear of complications due to anastomotic dehiscence in oesophagojejunal anastomosis known to carry high morbidity and mortality. The introduction of staplers have contributed to making anastomosis safer and easier to perform and has facilitated more advanced laparoscopic surgery. In open surgery, most surgeons use a circular stapler for oesophagojejunal anastomosis or a hand sutured technique. Both techniques are difficult to use in laparoscopic surgery, especially if the oesophagus is narrow. To facilitate the creation of oesophagojejunal anastomoses, we have adopted a technique with a linear stapled anastomosis. Our method is based on a stapling technique where the oesophagus is divided above the gastric cardia followed by a oesophagojejunostomy performed with Covidien's new Endo GIA-60™ Ultra Universal stapler. The residual opening is closed with a 3-0 re-absorbable suture. PATIENTS AND METHODS: From June 2009 to May 2012, 14 men and 16 women (median age=66 years, range=39-84 years) underwent laparoscopic total gastrectomy due to gastric cancer. RESULTS: One patient died during hospital stay; corresponding to a postoperative mortality of 3,3%. Leakage in the oesophagojejunal anastomosis occurred in three patients (10%). Two of the patients with leakage in the oesophagojejunal anastomosis had an additional duodenal bulb leakage, which might have caused anastomotic dehiscence. The patients had a median postoperative hospital stay of six days (range=3-156 days). Six patients had a re-operation due to complications, including one endoscopic stent application in the anastomosis. CONCLUSION: Even though a leakage rate of 10% can be considered high, this study describes a simple method for performing oesophagojejunostomy after gastrectomy by a laparoscopic approach independently of the width of the oesophagus. This study also shows that laparoscopic gastrectomy can be performed in more advanced stages of gastric cancer.

Esophageal perforation in South of Sweden: results of surgical treatment in 125 consecutive patients.

BACKGROUND: For many years there has been a debate as to which is the method of choice in treating patients with esophageal perforation. The literature consists mainly of small case series. Strategies for aiding patients struck with this disease is changing as new and less traumatic treatment options are developing. We studied a relatively large consecutive material of esophageal perforations in an effort to evaluate prognostic factors, diagnostic efforts and treatment strategy in these patients. METHODS: 125 consecutive patients treated at the University Hospital of Lund from 1970 to 2006 were studied retrospectively. Prognostic factors were evaluated using the Cox proportional hazards model. RESULTS: Pre-operative ASA score was the only factor that significantly influenced outcome. Neck incision for cervical perforation (n = 8) and treatment with a covered stent with or without open drainage for a thoracic perforation (n = 6) had the lowest mortality. Esophageal resection (n = 8) had the highest mortality. A CAT scan or an oesophageal X-ray with oral contrast were the most efficient diagnostic tools. The preferred treatment strategy changed over the course of the study period, from a more aggressive surgical approach towards using covered stents to seal the perforation. CONCLUSION: Pre-operative ASA score was the only factor that significantly influenced outcome in this study. Treatment strategies are changing as less traumatic options have become available. Sealing an esophageal perforation with a covered stent, in combination with open or closed drainage when necessary, is a promising treatment strategy.

Impact of proton pump inhibitors on benign anastomotic stricture formations after esophagectomy and gastric tube reconstruction: results from a randomized clinical trial.

OBJECTIVE: The primary aim of this study was to evaluate if the use of proton pump inhibitors (PPIs) reduced the prevalence of benign anastomotic strictures after uncomplicated esophagectomies with gastric tube reconstruction and circular stapled anastomoses. SUMMARY BACKGROUND DATA: Benign anastomotic strictures are associated with anastomotic leaks or conduit ischemia. Also patients without those complications develop benign anastomotic strictures. We hypothesize that patients without postoperative anastomotic complications may develop benign anastomotic strictures due to exposure of acid gastric tube contents to the anastomotic area, and that the formation of such strictures may be reduced by prophylactic use of PPIs. METHODS: Eighty patients without preoperative chemo- or radiotherapy, without clinical or radiological signs of anastomotic leaks were included in this clinical trial. The patients were randomized to b.i.d. PPIs or no treatment for 1 year. Benign anastomotic strictures were defined as anastomotic narrowing not allowing a standard diagnostic endoscope to pass without dilatation. The study was registered in the EudraCT database (2009-009997-28) for clinical trials. RESULTS: : Seventy-nine patients were evaluated. Benign anastomotic strictures developed in 5/39 (13%) patients in the PPI group and in 18/40 (45%) in the control group (RR 5.6, 95% CI: 2.0-15.9, P = 0.001). The use of a narrower 25 mm cartridge as compared to a wider 28 or 31 mm cartridge significantly increased stricture formations (RR 2.9, 95% CI: 1.1-7.6, P = 0.025). CONCLUSIONS: Prophylactic PPI treatment reduced the prevalence of benign anastomotic strictures following esophagectomy with gastric tube reconstruction and circular stapled anastomoses. Larger sized circular staple cartridges additionally reduced the stricture prevalence.

Total gastrectomy causes a sustained, long-term elevation of somatostatin in plasma, independent of the mode of reconstruction in pigs.

AIM: The long-term effects of gastrectomy and various reconstructions of the gastrointestinal tract on fasting plasma levels of gastrointestinal hormones known to contribute to the control of gastrointestinal motor function were evaluated in pigs. MATERIALS AND METHODS: Domestic pigs were randomly selected to sham surgery or total gastrectomy (TG) followed by reconstruction with oesophago-jejunostomy on a Roux-en-Y loop (OJRY), jejunal interposition between the oesophagus and the duodenum (OJD), or an oesophagojejunostomy with a proximal jejunal pouch reservoir (J-pouch) on a Roux-en-Y loop. Blood was collected just before surgery and ten weeks later and peptide levels were analysed by radioimmunoassay. RESULTS: Somatostatin levels were sustained at a high level after TG, regardless of the mode of reconstruction, but were significantly lower in sham-operated animals. Levels of vasoactive intestinal peptide (VIP), neurotensin and motilin were unchanged. CONCLUSION: TG by itself leads to high levels of somatostatin long term, however, somatostatin, motilin, neurotensin and VIP are unaffected by the mode of reconstruction.

Jejunal pouch reconstruction but not preservation of duodenal passage after total gastrectomy reduces plasma cholecystokinin and pancreatic polypeptide long term in pigs.

AIM: The long-term effects of reconstructions of the gastrointestinal tract after gastrectomy on plasma levels of gastrointestinal hormones that contribute to food intake controls were evaluated. MATERIALS AND METHODS: Domestic pigs were randomly assigned to sham-surgery or total gastrectomy followed by reconstruction with oesophagojejunostomy on a Roux-en-Y loop (OJRY), jejunal interposition between the oesophagus and the duodenum (OJD), or an oesophagojejunostomy with a jejunal pouch reservoir (J-pouch) on a Roux-en-Y loop. Plasma levels of peptides were analysed by radioimmunoassay (RIA). RESULTS: Ten weeks after surgery, levels of cholecystokinin (CCK) and pancreatic polypeptide (PP) were significantly lowered (79.6% and 67.0%, respectively) in animals with a J-pouch, but not in sham-operated animals or animals with OJRY or OJD, as compared to preoperative levels. The levels of neuropeptide Y (NPY) and peptide YY (PYY) remained unchanged, irrespective of the mode of reconstruction. CONCLUSION: J-pouch, but not preservation of duodenal passage after total gastrectomy, lowers levels of CCK and PP, peptides that reduce food intake.

Decreasing incidence of peptic ulcer complications after the introduction of the proton pump inhibitors, a study of the Swedish population from 1974-2002.

BACKGROUND: Despite a decreasing incidence of peptic ulcer disease, most previous studies report a stabile incidence of ulcer complications. We wanted to investigate the incidence of peptic ulcer complications in Sweden before and after the introduction of the proton pump inhibitors (PPI) in 1988 and compare these data to the sales of non-steroid anti-inflammatory drugs (NSAID) and acetylsalicylic acid (ASA). METHODS: All cases of gastric and duodenal ulcer complications diagnosed in Sweden from 1974 to 2002 were identified using the National hospital discharge register. Information on sales of ASA/NSAID was obtained from the National prescription survey. RESULTS: When comparing the time-periods before and after 1988 we found a significantly lower incidence of peptic ulcer complications during the later period for both sexes (p < 0.001). Incidence rates varied from 1.5 to 7.8/100000 inhabitants/year regarding perforated peptic ulcers and from 5.2 to 40.2 regarding peptic ulcer bleeding. The number of sold daily dosages of prescribed NSAID/ASA tripled from 1975 to 2002. The number of prescribed sales to women was higher than to males. Sales of low-dose ASA also increased. The total volume of NSAID and ASA, i.e. over the counter sale and sold on prescription, increased by 28% during the same period. CONCLUSION: When comparing the periods before and after the introduction of the proton pump inhibitors we found a significant decrease in the incidence of peptic ulcer complications in the Swedish population after 1988 when PPI were introduced on the market. The cause of this decrease is most likely multifactorial, including smoking habits, NSAID consumption, prevalence of Helicobacter pylori and the introduction of PPI. Sales of prescribed NSAID/ASA increased, especially in middle-aged and elderly women. This fact seems to have had little effect on the incidence of peptic ulcer complications.

Two different surgical approaches in the treatment of adenocarcinoma at the gastroesophageal junction.

BACKGROUND: Adenocarcinoma at the gastroesophageal junction may be regarded as of esophageal or of gastric origin, and tumor removal may follow the principles of esophagectomy or extended gastrectomy. We determined the impact of this strategy on our patients with tumors at this site. METHODS: Baseline patient and tumor characteristics were collected, and tumors were categorized according to Siewert's classification (I, II, or III) of gastroesophageal junction tumors. Totally, 133 patients were operated on between 1990 and 2001. Ninety-six patients with type I (n = 67), II (n = 26), and III (n = 3) tumors underwent esophagectomy and gastric tube reconstruction, and 37 patients with type I (n = 5), II (n = 26), and III (n = 6) tumors underwent extended gastrectomy and long Roux-en-Y reconstructions. RESULTS: After adjusting for the independently significant impact factors-tumor stage, tumor dissection (R0-R2), and length of tumor free resection margins-we did not find any specific survival benefit associated with either of the two evaluated surgical approaches for tumor resection and reconstruction. The EORTC quality of life forms revealed good results as indicated by the functional scales and the symptom scales. CONCLUSIONS: Provided that adequate tumor dissection is performed, patients with adenocarcinoma at the gastroesophageal junction can be resected and reconstructed using the principles for esophagectomy or extended gastrectomy.

Perforated peptic duodenal ulcer in a paraesophageal hernia--a case report of a rare surgical emergency.

BACKGROUND: Paraesophageal hernias are quite common and sometimes feared due to the risk of incarceration and strangulation of any herniated organ. The hereby reported combination of an incarcerated paraesophageal hernia containing a perforated peptic ulcer is extremely rare. CASE PRESENTATION: An elderly man with multiple medical conditions was admitted due to severe upper abdominal pain. The patient was found to have a paraesophageal hernia and underwent a laparotomy. In the hernia, a perforated benign peptic duodenal ulcer was found. The duodenal defect was over-sewn, the hernial defect was closed and the former hernial cavity was drained by a right-sided chest tube. The patient was discharged one month after surgery and was found to do well at follow-up one month after discharge. CONCLUSION: This is the first report of a patient surviving the extremely rare and life-threatening combination of a perforated peptic duodenal ulcer in a paraesophageal hernia.

The influence of surgical volume on hospital mortality and 5-year survival for carcinoma of the oesophagus and gastric cardia.

OBJECTIVE: To study the effects of hospital operation volume on hospital mortality and 5-year survival in patients treated with resection for carcinoma of the oesophagus and gastric cardia. INTRODUCTION: Surgery due to tumours of the oesophagus and gastric cardia is probably associated with the highest postoperative morbidity and mortality of all elective surgical procedures. Concentration to high-volume centres has been suggested to improve the outcome. MATERIALS AND METHODS: Between 1987 and 1996, all patients with squamous cell carcinoma or adenocarcinoma of the oesophagus or gastric cardia were identified from the Swedish Cancer Registry and the Swedish Hospital Discharge Registry. The study population was assessed according to patients operated at hospitals with a low (L-V), intermediate (I-V) or high operation volume (H-V), defined as <5 resections/year, 5-15 resections/year and >15 resections/year, respectively. We analyzed hospital mortality and 5-year survival. RESULTS: During the study period, 1429 patients were treated with resection for carcinoma of the oesophagus (n=665) or the gastric cardia (n = 764). A total of 74 hospitals were registered with at least one surgical resection, of which 90% performed <5 resections/year. The distribution of gender and age was comparable in the three groups. Hospital mortality was 10.4, 6.3 and 3.5% in the L-V, I-V and H-V groups, respectively. Overall 5-year survival was 17% (L-V), 19% (I-V) and 22% (H-V). Multivariate analysis showed an improved long-term survival for patients operated at H-V compared to L-V hospitals (p=0.02). CONCLUSION: This study supports an inverse relationship between hospital volume and hospital mortality after surgical tumour resection of the oesophagus or gastric cardia. Overall 5-year survival was significantly higher at high-volume hospitals compared to low-volume centres. We believe that concentrating these patients in high-volume hospitals is necessary to achieve high quality surgical treatment and to facilitate research aiming to improve prognosis.

[Strongly increasing incidence of adenocarcinoma of the esophagus and gastric cardia]. / Adenocancer i esofagus och ventrikelns kardiaregion ökar kraftigt.

The objective of this retrospective study was to see whether there was an increasing incidence of adenocarcinoma of the oesophagus and gastric cardia in the Swedish population 1970-1997. If there was, could it be explained as a period or cohort phenomenon? The data were compared with the incidence of squamous cell carcinoma and gastric adenocarcinoma with the gastric cardia excluded. Age standardised incidence for each sex was calculated using the age distribution of the world population as a reference. For the combined group of adenocarcinoma in the oesophagus and gastric cardia incidence gradually increased during the study period. The median increase between adjacent five-year intervals was 14% in men and 20% in women. Previously described risk factors are gastro-oesophageal reflux, obesity and smoking. This study suggests that the increasing incidence also can be explained as a shift in classification from squamous cell carcinoma to adenocarcinoma after 1985.

Cervical or thoracic anastomosis after esophageal resection and gastric tube reconstruction: a prospective randomized trial comparing sutured neck anastomosis with stapled intrathoracic anastomosis.

OBJECTIVE: The purpose of the study was to compare in prospective randomized fashion a manually sutured esophagogastric anastomosis in the neck and a stapled in the chest after esophageal resection and gastric tube reconstruction. SUMMARY BACKGROUND DATA: Despite the fact that all reconstructions after esophagectomy will result in a cervical or a thoracic anastomosis, controversy still exists as to the optimal site for the anastomosis. In uncontrolled studies, both neck and chest anastomoses have been advocated. The only reported randomized study is difficult to evaluate because of varying routes of the substitute and different anastomotic techniques within the groups. The reported high failure rate of stapled anastomoses in the neck and the fact that most surgeons prefer to suture cervical anastomoses made us choose this technique for anastomosis in the neck. Our routine and the preference of most surgeons to staple high thoracic anastomoses became decisive for type of thoracic anastomoses. METHODS: Between May 9, 1990 and February 5, 1996, 83 patients undergoing esophageal resection were prospectively randomized to receive an esophagogastric anastomosis in the neck (41 patients) or an esophagogastric anastomosis in the chest (42 patients). To evaluate selection bias, patients undergoing esophageal resection during the same period but not randomized (n = 29) were also followed and compared with those in the study (n = 83). Objective measurements of anastomotic level and diameter were assessed with an endoscope and balloon catheter 3, 6, and 12 months after surgery. The long-term survival rates were compared with the log-rank test. RESULTS: Two patients (1.8%) died in hospital, and the remaining 110 patients were followed until death or for a minimum of 60 months. The genuine 5-year survival rate was 29% for chest anastomoses and 30% for neck anastomoses. The overall leakage rate was 1.8% (2 cases of 112) with no relation to mortality or anastomotic method. All patients in the randomized group had tumor-free proximal and distal resection lines, but 1 patient in the nonrandomized group had tumor infiltrates in the proximal resection margin. At 3, 6, and 12 months after operation, there was no difference in anastomotic diameter between the esophagogastric anastomosis in the neck and in the thorax (P = 0.771), and both increased with time (P = 0.004, ANOVA repeated measures). Body weight development was the same in the two groups. With similar results in randomized and nonrandomized patients, study bias was eliminated. CONCLUSIONS: When performed in a standardized way, neck and chest anastomoses after esophageal resection are equally safe. The additional esophageal resection of 5 cm in the neck group did not increase tumor removal and survival; on the other hand, it did not adversely influence morbidity, anastomotic diameter, or eating as reflected by body weight development.

Human liver resection with the aid of a stapling device.

OBJECTIVE: To evaluate if linear stapling devices are useful in human liver resection. PATIENTS AND METHODS: This was an explorative study conducted on 20 patients undergoing liver resection at the teaching hospital, Lund, Sweden. Twenty-one liver resections were performed in 20 patients during the period 1990 to 1999. RESULTS: All of the resections caused minimal blood loss. Support with ultrasonic dissection (Sonocut) or Vicryl band was needed in 4 patients. CONCLUSION: The technique can be recommended for small liver resections, especially in patients subjected to contemporarily extensive (thoraco) abdominal operations.