Biomedical subjects

Sven Gustavsson

Publications and source records attributed to Sven Gustavsson.

12 recordsLinked to original sources

PubMed2006

Endoscopic marking with a metallic clip facilitates transcatheter arterial embolization in upper peptic ulcer bleeding.

PURPOSE: To enable accurate transcatheter arterial embolization (TAE) of the target vessel, a new technique to localize the exact position of a bleeding ulcer was tested that involves endoscopic marking of the ulcer with a metallic clip. MATERIALS AND METHODS: In 13 patients (mean age, 75 years) with acute bleeding ulcers (11 duodenal ulcers, two malignant ulcers), a metallic clip was placed at gastroscopy followed or preceded by routine endoscopic treatment. The metallic clip was placed in the fibrous edge of the ulcer adjacent to the bleeding point. In 10 patients, TAE was indicated as a result of continued or recurrent bleeding. The artery was embolized with microcoils as close as possible to the clip. In three patients, there was no indication for TAE, so plain abdominal radiography was performed to determine whether the marking clip was still in place. RESULTS: In 11 patients, the clip was still in place on radiography; in two, it had disappeared. Hemostasis was achieved in eight of 10 patients after TAE. In six patients, the clip was essential to identify the bleeding vessel. CONCLUSION: Marking of the bleeding ulcer with a clip before TAE enhances the possibility that the correct vessel is embolized. This will most likely minimize the risk of recurrent bleeding after embolization, especially in patients who do not show contrast medium extravasation.

Adult↗

PubMed2004

[Arterial embolization can often substitute surgery in bleeding ulcer. When endoscopic hemostasis is not successful an alternative emergency treatment is needed].

Peptic ulcer disease is the most common cause of acute haemorrhage from the upper gastrointestinal tract. Despite therapeutical improvements, the mortality rate remains high. Massive bleeding may, if haemostasis is not achieved by endoscopic treatment, require surgery. Often these patients are elderly with high comorbidity and, hence, are poor surgical candidates. We have therefore used angiography and selective arterial embolisation as an alternative option in 18 patients with massive ulcer bleeding. 13 patients were treated after failed endoscopic treatment, and 5 patients were treated for recurrent bleeding after previous emergency operations for bleeding ulcers. Embolisation of the arterial branch supplying the ulcer was possible in all patients. Permanent haemostasis was achieved in all but one patient, in whom the bleeding was controlled at an emergency operation. Our opinion is that angiographic embolisation is an effective way to control massive bleeding from peptic ulcers. In this way emergency operations in poor surgical candidates can be avoided.

Aged↗

PubMed2003

Excellent weight result after Roux-en-Y gastric bypass in spite of gastro-gastric fistula.

A male patient (age 37 years, BMI 38 kg/m(2)) underwent a revisional gastric bypass after failed gastric banding. Unfortunately he developed a leak from the proximal pouch and subsequently a gastro-gastric fistula between the pouch and the main stomach. He recovered fully and could eat and drink without any restriction. Repeat examination with x-ray and endoscopy revealed that the fistula remained widely open. Remarkably, the patient lost weight to a BMI of 27 kg/m(2) (ie. lost 80% of his original excess body weight), thus challenging the widely held opinion that gastro-gastric fistulas inevitably lead to poor weight loss. In our patient the weight loss was stable for 2 years, when the fistula was closed surgically to avoid chronic proton pump inhibitor medication for stomal ulcer.

Adult↗

PubMed2002

Incidence of deep venous thrombosis in patients undergoing obesity surgery.

The aim of this study was to investigate prospectively the incidence of deep venous thrombosis (DVT) after surgery for morbid obesity. The series comprised 116 consecutive patients undergoing Roux-en-Y gastric bypass. The median age and body mass index were 35 years (range 19-59 years) and 42 kg/m2 (range 32-68 kg/m2), respectively. The patients were examined with duplex ultrasonography pre- and postoperatively. No patient had any symptoms or signs of DVT postoperatively, and ultrasonography showed no signs of thrombosis in iliac, femoral, and popliteal veins in any of the patients. Two patients (1.7%) had a thrombus in the peroneal vein of one leg. Repeated ultrasonographic investigation after 1 week showed complete resolution of both. One patient with a previously unknown activated protein C resistance had an angiographically confirmed minor pulmonary embolus. The incidence of venous thromboembolism after obesity surgery seems to be low, and obesity as a risk factor for thromboembolic disease might have been overestimated in the past.

Adult↗

PubMed2002

Duodenogastric bile reflux after gastric bypass: a cholescintigraphic study.

In this exploratory study, we examined the occurrence of duodenogastric bile reflux to the excluded stomach after Roux-en-Y gastric bypass, a standard surgical therapy for morbid obesity. We studied 22 unselected patients (median age 44, 20 females) 18 months postoperatively. BMI at surgery and cholescintigraphy was 45 and 29 kg/m2, respectively. Mebrofenin labeled with 200 MBq 99mT was injected intravenously and the fate of radioactivity followed for 90 min. Bile flow was enhanced with cholecystokinin. We found scintigraphic evidence of duodenogastric bile reflux in 36% of the patients. The tracer remained in the excluded stomach throughout the study period. In conclusion, our investigation indicates that in more than one third of the patients undergoing gastric bypass, the gastric mucosa in the excluded stomach is exposed to the potential deleterious effects of bile.

Adolescent↗

PubMed2002

Arterial embolisation in management of massive bleeding from gastric and duodenal ulcers.

OBJECTIVE: We have tried angiography and selective arterial embolisation as a complement or another option in patients with massive bleeding from peptic ulcers who were considered poor candidates for surgery. DESIGN: Prospective, descriptive study. SETTING: University hospital, Sweden. PATIENTS: Since 1998, 18 patients (11 women) with a median age of 78 years (range 53-94) had selective arterial embolisation for uncontrollable bleeding from peptic ulcers. INTERVENTION: Superselective angiographic catheterisation and embolisation of the arterial branch that was supplying the ulcer. MAIN OUTCOME MEASURES: The success rate of haemostasis and the overall outcome. RESULTS: 13 patients were treated after failed endoscopic treatment to stop bleeding or to control recurrent bleeding after initial arrest, while 5 patients were treated for recurrent bleeding after emergency operations for bleeding ulcers. Most of the ulcers were in the duodenum. The patients were haemodynamically unstable and had a median haemoglobin concentration of 72 g/L (50-98). Embolisation of the arterial branch that was supplying the ulcer was feasible in all patients. Permanent haemostasis was achieved in all but one patient, although two patients needed a second embolisation for recurrent bleeding. One patient had the bleeding controlled at an emergency operation, but eventually died of respiratory complications. There were no serious complications of embolisation. CONCLUSION: Angiographic embolisation may be an effective way to stop massive bleeding from gastroduodenal ulcers. Emergency operations in poor surgical candidates can therefore be avoided.

Aged↗

PubMed2002

Laparoscopic adjustable gastric banding: complications and side effects responsible for the poor long-term outcome.

In a remarkably short time, Laparoscopic Adjustable Gastric Banding (LAGB) has become a common operation for morbid obesity in Europe and elsewhere. More than 70,000 such procedures have been performed in recent years. We used LAGB as a routine treatment for morbid obesity in 90 patients between 1994 and 1996. We agree with other authors that LAGB is the least invasive of all gastric restrictive procedures, resulting in a low perioperative mortality and morbidity. The weight loss appears to be similar to that obtained by vertical banded gastroplasty (VBG). However, our long-term follow-up studies, including endoscopic examinations, as well as recent data in the literature also indicate a number of significant problems with LAGB. Patient discomfort occurs frequently in the postoperative course. When questioned according to a standardized protocol 2 years after surgery, every other patient in our series admitted heartburn and acid regurgitation. Regular endoscopic surveillance revealed a prevalence of erosive esophagitis of 44%. After a median follow-up of 7 years, 58% of the patients had been reoperated on, almost always with excision of the banding system and conversion to Roux-en-Y gastric bypass (RYGBP). The reasons for reoperation were esophagitis, band erosion, pouch dilatation, leakage from the balloon, and esophageal dilatation, complications that also have been described in several recent papers in the literature. Our prediction is that LAGB will not stand the test of time.

Adult↗

PubMedDate not supplied

Bariatric surgery.

At present, surgery is necessary to counter extreme obesity. The outcomes in bariatric surgery have improved steadily and today most co-morbidities in the massively overweight can be improved or even resolved by surgery. The procedures work in one of two ways; by restricting the patient's ability to eat or by interfering with the ingested nutrient absorption. The operative treatment is in no way cosmetic. Drawbacks to the surgical therapy exist; major life-long rearrangement of the gastrointestinal tract, an operative mortality (<0.5%) and morbidity (about 10%). Surgically induced weight loss is currently the most effective treatment for the severely obese patient.

Body Mass Index↗

PubMedDate not supplied

Roux-en-Y gastric bypass after previous unsuccessful gastric restrictive surgery.

In the treatment of morbid obesity, simple gastric restrictive methods such as silicone adjustable gastric banding, vertical banded gastroplasty, and nonadjustable gastric banding often fail to control weight in the long run or give rise to intolerable side effects. Here we review our results from conversion of such failures to Roux-en-Y gastric bypass. The study comprised 44 patients (median age 42 years, range 24 to 60 years) who underwent revision surgery in 1996 and 1997. Body mass index at revision was 35 kg/m(2) (range 21 to 49 kg/m(2)). Previous bariatric procedures included silicone adjustable gastric banding (n = 26), vertical banded gastroplasty (n = 13), and gastric banding (n = 5). The most common reasons for conversion after silicone adjustable gastric banding and nonadjustable gastric banding were band erosion (n = 12) and esophagitis (n = 11). Staple line disruption (n = 12) with subsequent weight loss failure was the primary cause after vertical banded gastroplasty. There were no postoperative deaths or anastomotic leaks. One patient underwent reexploration because of an infected hematoma. Reflux symptoms and vomiting resolved promptly. At global assessment 2 years later, 70% of the patients were very satisfied. Median body mass index had decreased to 28 kg/m(2) (range 18 to 42 kg/m(2)). No patient was lost to follow-up. As reported previously, failure after vertical gastric banding can be treated by conversion to Roux-en-Y gastric bypass with good results. In this study we found that failure after silicone adjustable gastric banding can be treated successfully with Roux-en-Y gastric bypass as well.

Adult↗

PubMedDate not supplied

Reduction in serum pepsinogen I after Roux-en-Y gastric bypass.

The excluded stomach after Roux-en-Y gastric bypass (RYGBP) cannot be readily examined by endoscopy for obvious anatomic reasons. Thus it is difficult to monitor possible changes in the gastric mucosa. However, the type and severity of gastritis can now be assessed by a combination of serologic tests: pepsinogen I and antibodies to Helicobacter pylori and H,K-ATPase. Morbidly obese patients were examined before and 1 to 4 years after surgery. A group of 34 patients (mean age 39 years, BMI 44 kg/m(2)) underwent RYGBP; another group of 30 patients (mean age 42 years, BMI 44 kg/m(2)) had simple gastric restriction and served as control subjects. All patients, except one in the control group, had normal titers of pepsinogen I before surgery. One year after RYGBP, pepsinogen I levels were significantly reduced, as compared to the control group (P<0.0001), and remained low throughout the study. The control group had stable pepsinogen I levels. In both groups, few patients had increased titers of H. pylori or H,K-ATPase antibodies, but these abnormalities remained unchanged. Low pepsinogen I levels, similar to those we observed in our RYGBP patients, have been linked to chronic atrophic gastritis. However, the absence of food stimulation in the excluded stomach could also be a reason for the low pepsinogen I levels.

Adult↗

PubMedDate not supplied

The proximal gastric pouch invariably contains acid-producing parietal cells in Roux-en-Y gastric bypass.

BACKGROUND: Roux-en-Y gastric bypass (RYGBP) is well tolerated and effective in ameliorating diseases common to morbidly obese patients. A potential drawback, however, is the risk for stomal ulcers, probably due to acid and peptic digestion of the mucosa in the proximal Roux limb. METHODS: In 23 RYGBP patients (mean BMI 45 kg/m(2), age 39 years), the gastro-jejunostomy was performed by circular stapler and the gastric suture ring retrieved for histological examination. 13 consecutive patients received our standard totally transected 4 x 3 cm proximal gastric pouch. The anvil was passed transgastricly and reference biopsies were taken from the gastrotomy in the corpus of the stomach. In the last 10 patients, the pouch size was reduced to 2 x 3 cm by a modified surgical technique. RESULTS: All suture rings from the standard pouches consisted of corpus-fundus mucosa with a large amount of parietal cells, histologically identical to the reference biopsies from the gastrotomy. Also, the 10 suture rings from the modified small pouches contained corpus-fundus mucosa. In 5 of these samples, cardiac mucosa was found, but only in a small segment (6 mm). In addition, 3 patients had esophageal epithelium in the suture ring. CONCLUSION: The proximal pouch invariably contains acid-producing parietal cells. In order to reduce acid production and, hence, the risk of stomal ulcers, the pouch has to be made as small as possible.

Adult↗

PubMedDate not supplied

Role of gastric acid in stomal ulcer after gastric bypass.

BACKGROUND: The pathogenetic mechanisms of stomal ulcer after Roux-en-Y gastric bypass (RYGBP) are unclear. In order to study the role of gastric acid, we measured acidity in the proximal pouch using a pH-sensitive probe. METHODS: 6 patients (5 females, mean age 45 years old at time of operation) with endoscopically confirmed stomal ulcer, were studied 2 to 6 years after RYGBP. All complained of epigastric pain that improved during proton pump inhibitor (PPI) therapy. Control subjects were 6 females (50 years old) who had had RYGBP at least 5 years earlier and denied symptoms of epigastric pain or heartburn. The pH-sensitive probe (Digitrapper-pH, Medtronic) was passed through the nose to the proximal pouch, guided by the calculated distance and pH response. The probe was left in place for 4 hours. The percentage of time with pH <4 was calculated. RESULTS: The probe could be accurately positioned in the proximal pouch both in symptomatic patients and in controls as evidenced by the acid pH reaction. The proximal pouches of patients with stomal ulcer were significantly more exposed to acid compared to controls. The median percentage of time with pH <4 was 69% and 20% in the stomal ulcer and the control group, respectively (P<0.01). Barium follow-through excluded gastro-gastric fistula in stomal ulcer patients. CONCLUSION: RYGBP patients with stomal ulcer have increased acid production in their proximal pouch in comparison with asymptomatic RYGBP patients. Gastric acid appears to have an important role in the pathogenesis of stomal ulcer.

Adult↗