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Poliwoda J, Neville A, Yadav K, Nemnom MJ, Walmsley CG, Stiell IG. Presentations, management and outcomes of postoperative bariatric patients seen in the emergency department. Am J Emerg Med 2024; 81:82-85. [PMID: 38677198 DOI: 10.1016/j.ajem.2024.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/17/2024] [Accepted: 04/18/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Bariatric surgery is becoming increasingly common and postoperative patients often present to the emergency department (ED) with complications. We sought to describe the presenting complaints, management, and outcomes of postoperative bariatric surgery patients seen in the ED. METHODS We conducted a health records review of 300 consecutive postoperative Roux-en-Y bypass surgery patients who presented to two tertiary care EDs of a major bariatric surgery center within one year of surgery. Cases were identified using a data analytic tool, and two evaluators abstracted clinical variables, imaging, treatments, and outcomes using the electronic health record. Attending emergency physicians verified the data and an experienced bariatric surgeon interpreted the computed tomography (CT) results and surgical procedures. RESULTS We included 300 patients with mean age 43.0 years, 89.7% female. Of these, 70.0% presented within 30 days of surgery and 41.7% were admitted to hospital. ED treatments included intravenous fluids (67.0%), antiemetics (53.3%), and analgesia (61.9%). Patients presenting within 30 days of surgery were more likely to undergo a CT (74.3% vs 63.3%; p = 0.06) and to have clinically important CT findings (31.9% vs 6.6%; p ≤0.001). More of the ≤30-day patients were admitted to hospital (46.2% vs 31.1%; p = 0.02). While a higher proportion of patients presenting after 30 days underwent a procedure, a large number of those were not directly related to bariatric surgery, such as appendectomy and cholecystectomy. Of the 34 patients undergoing a procedure, the majority presented with abdominal pain (76.5%). CONCLUSION This is the first detailed health records review of postoperative bariatric patients seen in the ED in the emergency medicine literature. Those presenting with abdominal pain were more likely to undergo CT abdomen and a surgical procedure. Similarly, those presenting within 30 days of surgery were more likely to have significant CT findings and require hospital admission. Others presenting with primarily nausea and vomiting may improve with ED symptom management and be discharged home with bariatric team follow-up.
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Affiliation(s)
| | - Amy Neville
- Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Marie-Joe Nemnom
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
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Callaway Kim K, Argetsinger S, Wharam JF, Zhang F, Arterburn DE, Fernandez A, Ross-Degnan D, Wallace J, Lewis KH. Acute Care Utilization and Costs Up to 4 Years After Index Sleeve Gastrectomy or Roux-en-Y Gastric Bypass: A National Claims-based Study. Ann Surg 2023; 277:e78-e86. [PMID: 34102668 PMCID: PMC8648857 DOI: 10.1097/sla.0000000000004972] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To compare acute care utilization and costs following sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). SUMMARY BACKGROUND DATA Comparing postbariatric emergency department (ED) and inpatient care use patterns could assist with procedure choice and provide insights about complication risk. METHODS We used a national insurance claims database to identify adults undergoing SG and RYGB between 2008 and 2016. Patients were matched on age, sex, calendar-time, diabetes, and baseline acute care use. We used adjusted Cox proportional hazards to compare acute care utilization and 2-part logistic regression models to compare annual associated costs (odds of any cost, and odds of high costs, defined as ≥80th percentile), between SG and RYGB, overall and within several clinical categories. RESULTS The matched cohort included 4263 SG and 4520 RYGB patients. Up to 4 years after surgery, SG patients had slightly lower risk of ED visits [adjusted hazard ratio (aHR): 0.90; 95% confidence interval (CI): 0.85,0.96] and inpatient stays (aHR: 0.80; 95% CI: 0.73,0.88), especially for events associated with digestive-system diagnoses (ED aHR: 0.68; 95% CI: 0.62,0.75; inpatient aHR: 0.61; 95% CI: 0.53,0.72). SG patients also had lower odds of high ED and high total acute costs (eg, year-1 acute costs adjusted odds ratio (aOR) 0.77; 95% CI: 0.66,0.90) in early follow-up. However, observed cost differences decreased by years 3 and 4 (eg, year-4 acute care costs aOR 1.10; 95% CI: 0.92,1.31). CONCLUSIONS SG may have fewer complications requiring emergency care and hospitalization, especially as related to digestive system disease. However, any acute care cost advantages of SG may wane over time.
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Affiliation(s)
- Katherine Callaway Kim
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical, School, Boston, Massachusetts
| | - Stephanie Argetsinger
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical, School, Boston, Massachusetts
| | - James Frank Wharam
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical, School, Boston, Massachusetts
| | - Fang Zhang
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical, School, Boston, Massachusetts
| | - David E Arterburn
- Kaiser Permanente Washington Health Research Institute, Seattle,Washington
| | - Adolfo Fernandez
- Department of Surgery,Wake Forest University Health Sciences,Winston-Salem, North Carolina
| | - Dennis Ross-Degnan
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical, School, Boston, Massachusetts
| | - Jamie Wallace
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical, School, Boston, Massachusetts
| | - Kristina H Lewis
- Department of Surgery,Wake Forest University Health Sciences,Winston-Salem, North Carolina
- Department of Epidemiology and Prevention, Department of Implementation Science, Division of Public Health Sciences, Wake Forest University Health Sciences, Winston-Salem, North Carolina
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Elnahas AI, Reid JN, Lam M, Doumouras AG, Anvari M, Schlachta CM, Alkhamesi NA, Hawel JD, Urbach DR. Bariatric Center Designation and Outcomes Following Repeat Abdominal Surgery in Bariatric Patients. J Surg Res 2022; 280:421-428. [PMID: 36041342 DOI: 10.1016/j.jss.2022.07.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 06/13/2022] [Accepted: 07/05/2022] [Indexed: 10/15/2022]
Abstract
INTRODUCTION Repeat abdominal surgery in the bariatric surgery patient population may be challenging for non-bariatric-accredited institutions. The impact of regionalized bariatric care on clinical outcomes for bariatric surgery patients requiring repeat abdominal surgery is currently unknown. This study aims to investigate the association between bariatric center designation and clinical outcomes following hepatobiliary, hernia, and upper and lower gastrointestinal operations among patients with prior bariatric surgery. METHODS This is a cohort study of a large sample of Ontario residents who underwent primary bariatric surgery between 2010 and 2017. A comprehensive list of eligible abdominal operations was captured using administrative data. The primary outcome was 30-d complications. Secondary outcomes included 30-d mortality, readmission, and length of stay. RESULTS Among the 3301 study patients, 1305 (40%) received their first abdominal reoperation following bariatric surgery at a designated bariatric center. Nonbariatric center designation was not associated with significantly higher rates of 30-d complications (5.73% versus 5.72%), mortality (0.80% versus 0.77%), readmissions (1.11% versus 1.85%), or median postoperative length of stay (4 versus 4 d). After grouping the category of reoperations, upper gastrointestinal (odds ratio [OR] 0.66, confidence interval [CI] 0.39-1.11) and abdominal wall hernia surgery (OR 0.52, CI 0.27-0.99) showed a lower adjusted OR for complications among bariatric centers. CONCLUSIONS Our study demonstrates that after adjustment for case-mix and patient characteristics, bariatric surgery patients undergoing repeat abdominal surgery at nonbariatric centers is not associated with higher proportion of complications or mortality. Complex hernia surgery may be considered the most appropriate for referral.
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Affiliation(s)
- Ahmad I Elnahas
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; ICES, London, Ontario, Canada.
| | | | | | - Aristithes G Doumouras
- ICES, London, Ontario, Canada; Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Mehran Anvari
- ICES, London, Ontario, Canada; Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Christopher M Schlachta
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Nawar A Alkhamesi
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Jeffrey D Hawel
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - David R Urbach
- ICES, London, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Elnahas AI, Reid JN, Lam M, Doumouras AG, Anvari M, Schlachta CM, Alkhamesi NA, Hawel J, Urbach DR. Risk factors for abdominal reoperations in bariatric patients. Surg Obes Relat Dis 2021; 18:233-240. [PMID: 34789420 DOI: 10.1016/j.soard.2021.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 09/13/2021] [Accepted: 10/21/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND With a growing bariatric population, a better understanding of the patient and health provider-related factors associated with later reoperations could help providers enhance follow-up and develop reliable benchmarking targets. OBJECTIVES To investigate the patient and provider-related risk factors associated with abdominal reoperations in bariatric patients. SETTING This is a cohort study using data from a large clinical registry of Ontario bariatric patients between 2010 and 2016. METHODS A multilevel mixed effect logistic regression model using hospital and surgeon identifiers as random effects was performed to adjust for clustering of patients. The primary outcome was any abdominal operation performed within 2 years of primary bariatric surgery. RESULTS Among a cohort of 10,946 bariatric patients (86.6% receiving gastric bypass surgery), 15.8% underwent an abdominal operation within 2 years and about a third of these were urgent. The multilevel analysis demonstrated that 98% of patient variation among reoperations was a result of patient characteristics rather than disparities between surgeons or center experience. Type of procedure was not a significant factor after adjustment for surgeon and hospital level experience (OR [odds ratio] .85, 95% CI [confidence interval] .70-1.03). Concurrent abdominal wall (OR 2.40, 95% CI 1.26-4.59), hiatal hernia repairs (OR 1.29, 95% CI 1.02-1.62), and previously higher health care users (OR 1.30, 95% CI 1.15-1.46) were most significantly associated with reoperations. CONCLUSION Reoperations are significantly more common among certain bariatric patients, especially those undergoing concurrent hernia procedures. Reoperations were not associated with provider-related factors and may not be a suitable target for health provider benchmarking.
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Affiliation(s)
- Ahmad I Elnahas
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; ICES, London, Ontario, Canada.
| | | | | | - Aristithes G Doumouras
- ICES, London, Ontario, Canada; Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Mehran Anvari
- ICES, London, Ontario, Canada; Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Christopher M Schlachta
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Nawar A Alkhamesi
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Jeff Hawel
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - David R Urbach
- ICES, London, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Tarride JE, Doumouras AG, Hong D, Paterson JM, Tibebu S, Perez R, Ma J, Taylor VH, Xie F, Boudreau V, Pullenayegum E, Urbach DR, Anvari M. Association of Roux-en-Y Gastric Bypass With Postoperative Health Care Use and Expenditures in Canada. JAMA Surg 2020; 155:e201985. [PMID: 32697298 DOI: 10.1001/jamasurg.2020.1985] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Importance Results of previous studies are mixed regarding the economic implications of a Roux-en-Y gastric bypass (RYGB). Objective To assess the 5-year incremental health care use and expenditures after RYGB. Design, Setting, and Participants This population-based cohort study conducted in Ontario, Canada, used a difference-in-differences approach to compare health care use and expenditures between patients who underwent a publicly funded RYGB from March 1, 2010, to March 31, 2013, and propensity score-matched control individuals who did not undergo a surgical bariatric procedure. The study period allowed for a minimum 60 months of follow-up because, at that time, the most recent date for which administrative data on health care and expenditures were available was March 31, 2018. Data sources included the Ontario Bariatric Registry linked to several Ontario health administrative databases and the Electronic Medical Record Administrative Data Linked Database. Health care use and expenditures data for 5 years before and 5 years after the index date (procedure date for RYGB group; random date for controls) were analyzed. Data analyses were performed March 12, 2019, to March 10, 2020. Intervention RYGB procedure. Main Outcomes and Measures The primary outcome was total health care expenditures. Results The final propensity score-matched cohorts comprised 1587 individuals in the RYGB group (mean [SD] age, 47 [10.2] years) and 1587 controls (mean [SD] age, 47 [12.2] years); each group had 1228 women (77.4%) and a mean body mass index (calculated as weight in kilograms divided by height in meters squared) of 46. Mean total health care expenditures (2017 Canadian dollars) per patient in the RYGB group increased from CAD $15 594 (95% CI, CAD $14 743 to CAD $16 614) (US $12 008 [95% CI, US $11 353 to US $12 794]) in the 5 years before the procedure to CAD $30 389 (95% CI, CAD $28 789 to CAD $32 232) (US $23 401 [95% CI, US $22 169 to US $24 821]) over the 5 years after the procedure, a difference of CAD $14 795 (95% CI, CAD $13 172 to CAD $16 480) (US $11 393 [95% CI, US $10 143 to US $12 691]). For the control group, mean total health care expenditures per individual increased from CAD $16 109 (95% CI, CAD $14 727 to CAD $17 591) (US $12 405 [95% CI, US $11 341 to US $13 546]) 5 years before the index date to CAD $20 073 (95% CI, CAD $18 147 to CAD $22 169) (US $15 457 [95% CI, US $13 974 to US $17 071]) 5 years after the date, a difference of CAD $3964 (95% CI, CAD $2250 to CAD $5875) (US $3053 [95% CI, US $1733 to US $4524]). Overall, the difference-in-differences estimate of the net cost of RYGB was CAD $10 831 (95% CI, CAD $8252 to CAD $13 283) (US $8341 [95% CI, $6355 to $10 229]) over the 5-year period. This amount excluded the mean (SD) cost associated with the index date: CAD $6501 (CAD $1087) (US $5006 [US $837]) for the RYGB cohort and CAD $9 (CAD $72) (US $7 [US $55]) for the controls. The cost differential was primarily associated with increased hospitalizations in the first months immediately after RYGB. Expenditures leveled off in year 3 after the index date; differences in total expenditures between the RYGB and control cohorts were not statistically significantly different in years 4 and 5. Conclusions and Relevance Health care expenditures in the 3 years after publicly funded RYGB were higher in patients who underwent the procedure than in control individuals, but the costs were similar thereafter. This finding suggests the need to decrease hospital and emergency department readmissions after surgical bariatric procedures because such use is associated with increased spending.
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Affiliation(s)
- Jean-Eric Tarride
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.,Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada.,Programs for Assessment of Technology in Health (PATH), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Aristithes G Doumouras
- Division of General Surgery, McMaster University, Hamilton, Ontario, Canada.,Centre for Minimal Access Surgery, St Joseph's Healthcare, McMaster University, Hamilton, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | - Dennis Hong
- Division of General Surgery, McMaster University, Hamilton, Ontario, Canada.,Centre for Minimal Access Surgery, St Joseph's Healthcare, McMaster University, Hamilton, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | - J Michael Paterson
- ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | | | | | - Valerie H Taylor
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
| | - Feng Xie
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.,Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada
| | - Vanessa Boudreau
- Division of General Surgery, McMaster University, Hamilton, Ontario, Canada.,Centre for Minimal Access Surgery, St Joseph's Healthcare, McMaster University, Hamilton, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | - Eleanor Pullenayegum
- Dalla Lana School of Public Health, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Hospital for Sick Children, Toronto, Ontario, Canada
| | - David R Urbach
- Women's College Hospital Research Institute, Departments of Surgery and Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Mehran Anvari
- Division of General Surgery, McMaster University, Hamilton, Ontario, Canada.,Centre for Minimal Access Surgery, St Joseph's Healthcare, McMaster University, Hamilton, Ontario, Canada.,ICES, Toronto, Ontario, Canada
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Exploring pre-surgery and post-surgery substance use disorder and alcohol use disorder in bariatric surgery: a qualitative scoping review. Int J Obes (Lond) 2019; 43:1659-1674. [PMID: 31213657 DOI: 10.1038/s41366-019-0397-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 04/15/2019] [Accepted: 05/12/2019] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Bariatric surgery (BS) produces superior weight loss compared to non-surgical interventions. However, studies suggest bariatric patients who have undergone gastric-bypass surgery have an increased risk of developing new onset substance use disorder (SUD) or suffer negative outcomes after surgery. As such, many bariatric programs consider alcohol/ illicit drug misuse a contraindication to BS. The purpose of this systematic review was to investigate weight loss outcomes, post-surgery substance use patterns and other morbidity/mortality in BS patients with a history of substance use/SUD. METHODS Studies were identified by searching Ovid Medline(R), Embase, and PsychInfo. We included all study types investigating humans of any age/sex who had undergone any BS procedure with data regarding substance use before and/or after surgery. Outcome measures included metabolic outcomes and psychiatric outcomes after bariatric surgery in patients reporting substance use prior to bariatric surgery and substance use patterns after bariatric surgery. RESULTS Fifty-eight studies were included in the review. Studies reporting weight loss after BS did not demonstrate an association between substance use and negative weight loss outcomes. Several studies reported a significant portion of participants having new onset or increased substance use after BS. Factors associated with new onset or increased substance use/SUD after BS included the type of surgery, a history of SUD, a family history of SUD, coping skills/life stressors, age, male sex and alcohol sensitization after surgery. CONCLUSION Substance use history does not appear to influence weight loss after BS, however it may contribute to increased substance use after BS. Clinicians should ensure valid screening tools when assessing BS candidates for substance use history and ensure long term follow-up care post-operatively.
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Kakoulidis TP, Arvidsson D, Graf W, Sundbom M. Reduced Need for In-hospital Care After Sleeve Gastrectomy: a Single Center Observational Study. Obes Surg 2019; 29:3228-3231. [PMID: 31161563 DOI: 10.1007/s11695-019-03968-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
SETTING Private clinic, Stockholm, and nation-wide in-hospital care, Sweden. OBJECTIVES The use of sleeve gastrectomy (SG) for treatment of morbid obesity has increased worldwide, but information about long-term outcome is still limited. Our objective was to evaluate the need for additional in-hospital care after SG for obesity (body mass index [BMI] > 30) in 862 patients, all operated at a single center. METHODS Two national registries, the Inpatient Registry and the Death Registry, were used to collect long-term data on in-hospital care, grouped by the International Statistical Classification of Diseases and Related Health Problems (ICD-10) and mortality, respectively. RESULTS In-hospital care for SG-operated females was decreased for four groups of obesity-related ICD-10 diagnoses: endocrine and metabolic diseases and circulatory, digestive, and genitourinary diseases, as well as injuries and poisoning (p < 0.001 for all). However, female SG patients still required in-hospital care above the national level for women of corresponding ages. CONCLUSIONS Although a significant reduction in in-hospital care was observed, SG patients did not reach national levels.
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Affiliation(s)
- Thanos P Kakoulidis
- Department of Surgical Sciences, Uppsala University, Entrance 70, SE-751 85, Uppsala, Sweden. .,Center for Minimally Invasive Surgery, Stockholm, Sweden.
| | - Dag Arvidsson
- Center for Minimally Invasive Surgery, Stockholm, Sweden
| | - Wilhelm Graf
- Department of Surgical Sciences, Uppsala University, Entrance 70, SE-751 85, Uppsala, Sweden
| | - Magnus Sundbom
- Department of Surgical Sciences, Uppsala University, Entrance 70, SE-751 85, Uppsala, Sweden
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