Incarcerated paraesophageal hernia complicated by pancreatic damage and unusual comorbidity: Two retrospective case series

•

We present two cases of paraesophageal hernia that both needed total gastrectomy due to gangrene.

•

Both patients had clinical relevant comorbidities, respectively trisomy 21 and hereditary spastic paresis.

•

Due to compression from the dilated stomach one of the patients developed ischemia of the pancreas with leakage of peptidases which in turn caused anastomotic dehisence and intraabdominal abscess.

•

The pancreatic damage and anastomotic leakage was treated conservatively with repeated stenting and percutaeous drainage.

•

Immediate diagnosis and treatment for incarcerated paraesophageal hernias are vital to reduce morbidity and mortality.

Introduction: About 1% of paraesophageal hernias (PEH) require emergency surgery due to obstruction or gangrene. We present two complicated cases of incarcerated PEH.

Presentation of cases: A patient aged 18 with trisomy 21 was admitted after four days of vomiting and epigastric pain. CT scan revealed a large PEH. The stomach was massively dilated with compression of adjacent viscera and the celiac trunk. The stomach was repositioned laparoscopically and deflated by endoscopy in an attempt to avoid resection. During second look laparoscopy a gastrectomy was necessary. The patient was reoperated for intestinal obstruction, and treated for dehiscence of the esophagojejunostomy and a pancreatic fistula. A patient aged 65 with hereditary spastic paresis had two days history of emesis and epigastric pain. Upon arrival he was hemodynamically unstable and a CT scan revealed perforation of the herniated stomach. A subtotal gastrectomy without reconstruction was performed with vacuum closure of the abdomen. Later a gastrectomy was completed with a Roux-en-Y reconstruction. Except from reoperation for wound dehiscence after 14 days, the recovery was uneventful.

Discussion: Trisomy 21 and hereditary spastic paresis may increase the risk of developing PEH. Challenges in regard to symptom evaluation may delay diagnosis. The pressure of the dilated stomach can give rise to ischemic and mechanical damage from compression of major blood vessels and organs. Urgent diagnosis and gastric deflation is required.

Conclusions: In patients with known PEH or with comorbidity that may increase the risk of PEH, this diagnosis should be considered early on.

Patient-Reported Outcome Measures 2 Years After Standard and Distal Gastric Bypass-a Double-Blind Randomized Controlled Trial

BACKGROUND

The preferred surgical procedure for treating morbid obesity is debated. Patient-reported outcome measures (PROMs) are relevant for evaluation of the optimal bariatric procedure.

METHODS

A total of 113 patients with BMI from 50 to 60 were randomly assigned to standard (n = 57) or distal (n = 56) Roux-en-Y gastric bypass (RYGB). Validated PROMS questionnaires were completed at baseline and 2 years after surgery. Data were analyzed using mixed models for repeated measures and the results are expressed as estimated means and mean changes.

RESULTS

Obesity-related quality of life improved significantly after both procedures, without significant between-group differences (- 0.4 (95% CI = - 8.4, 7.2) points, p = 0.88, ES = 0.06). Both groups had significant reductions in the number of weight-related symptoms and symptom distress score, with a mean group difference (95% CI) of 1.4 (- 0.3, 3.3) symptoms and 5.0 (2.9. 12.8) symptom distress score points. There were no between-group differences for uncontrolled eating (22.0 (17.2-26.7) vs. 28.9 (23.3-34.5) points), cognitive restraint (57.4 (52.0-62.7) vs. 62.1 (57.9-66.2) points), and emotional eating (26.8 (20.5-33.1) vs. 32.6 (25.5-39.7) points). The prevalence of anxiety was 33% after standard and 25% after distal RYGB (p = 0.53), and for depression 12 and 9%, respectively (p = 0.76).

CONCLUSIONS

There were no statistically significant differences between standard and distal RYGB 2 years post surgery regarding weight loss, obesity-related quality of life, weight-related symptoms, anxiety, depression, or eating behavior.

TRIAL REGISTRATION

Clinical Trials.gov number NCT00821197.

Standard vs Distal Roux-en-Y Gastric Bypass in Patients With Body Mass Index 50 to 60: A Double-blind, Randomized Clinical Trial

Importance

Up to one-third of patients undergoing bariatric surgery have a body mass index (BMI) of more than 50. Following standard gastric bypass, many of these patients still have a BMI greater than 40 after peak weight loss.

Objective

To assess the efficacy and safety of standard gastric bypass vs distal gastric bypass in patients with a BMI of 50 to 60.

Design, Setting, and Participants

Double-blind, randomized clinical parallel-group trial at 2 tertiary care centers in Norway (Oslo University Hospital and Vestfold Hospital Trust) between May 2011 and April 2013. The study included 113 patients with a BMI of 50 to 60 aged 20 to 60 years. The 2-year follow-up was completed in May 2015.

Interventions

Standard gastric bypass (alimentary limb, 150 cm) and distal gastric bypass (common channel, 150 cm), both with a biliopancreatic limb of 50 cm and a gastric pouch of about 25 mL.

Main Outcomes and Measures

Primary outcome was the change in BMI from baseline until 2 years after surgery. Secondary outcomes were cardiometabolic risk factors, nutritional outcomes, adverse events, gastrointestinal symptoms, and health-related quality of life.

Results

At baseline, the mean age of the patients was 40 years (95% CI, 38-41 years), 65% were women, mean BMI was 53.5 (95% CI, 52.9-54.0), and mean weight was 158.8 kg (95% CI, 155.3-162.3 kg). The mean reduction in BMI was 17.8 (95% CI, 16.9-18.6) after standard gastric bypass and 17.2 (95% CI, 16.3-18.0) after distal gastric bypass, and the mean between-group difference was 0.6 (95% CI, -0.6 to 1.8; P = .32). Reductions in mean levels of total and low-density lipoprotein cholesterol were greater after distal gastric bypass than standard gastric bypass, and between-group differences were 19 mg/dL (95% CI, 11-27 mg/dL ) and 28 mg/dL (95% CI, 21 to 34 mg/dL), respectively (P < .001 for both). Reductions in fasting glucose levels and hemoglobin A1c were greater after distal gastric bypass. Secondary hyperparathyroidism and loose stools were more frequent after distal gastric bypass. The number of adverse events and changes in health-related quality of life did not differ between the groups. Importantly, 1 patient developed liver failure and 2 patients developed protein-caloric malnutrition treated by elongation of the common channel following distal gastric bypass.

Conclusions and Relevance

Distal gastric bypass was not associated with a greater BMI reduction than standard gastric bypass 2 years after surgery. However, we observed different changes in cardiometabolic risk factors and nutritional markers between the groups.

Trial Registration

Clinicaltrials.gov Identifier: NCT00821197.

Five-year outcomes after laparoscopic gastric bypass and laparoscopic duodenal switch in patients with body mass index of 50 to 60: a randomized clinical trial

IMPORTANCE

There is no consensus as to which bariatric procedure is preferred to reduce weight and improve health in patients with a body mass index higher than 50.

OBJECTIVE

To compare 5-year outcomes after Roux-en-Y gastric bypass (gastric bypass) and biliopancreatic diversion with duodenal switch (duodenal switch).

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical open-label trial at Oslo University Hospital, Oslo, Norway, and Sahlgrenska University Hospital, Gothenburg, Sweden. Participants were recruited between March 17, 2006, and August 20, 2007, and included 60 patients aged 20 to 50 years with a body mass index of 50 to 60. The current study provides the 5-year follow-up analyses by intent to treat, excluding one participant accepted for inclusion who declined being operated on prior to knowing to what group he was randomized.

INTERVENTIONS

Laparoscopic gastric bypass and laparoscopic duodenal switch.

MAIN OUTCOMES AND MEASURES

Body mass index and secondary outcomes including anthropometric measures, cardiometabolic risk factors, pulmonary function, vitamin status, gastrointestinal symptoms, health-related quality of life, and adverse events.

RESULTS

Sixty patients were randomly assigned and operated on with gastric bypass (n = 31) and duodenal switch (n = 29). Fifty-five patients (92%) completed the study. Five years after surgery, the mean reductions in body mass index were 13.6 (95% CI, 11.0-16.1) and 22.1 (95% CI, 19.5-24.7) after gastric bypass and duodenal switch, respectively. The mean between-group difference was 8.5 (95% CI, 4.9-12.2; P < .001). Remission rates of type 2 diabetes mellitus and metabolic syndrome and changes in blood pressure and lung function were similar between groups. Reductions in total cholesterol, low-density lipoprotein cholesterol, triglycerides, and fasting glucose were significantly greater after duodenal switch compared with gastric bypass. Serum concentrations of vitamin A and 25-hydroxyvitamin D were significantly reduced after duodenal switch compared with gastric bypass. Duodenal switch was associated with more gastrointestinal adverse effects. Health-related quality of life was similar between groups. Patients with duodenal switch underwent more surgical procedures related to the initial procedure (13 [44.8%] vs 3 [9.7%] patients; P = .002) and had significantly more hospital admissions compared with patients with gastric bypass.

CONCLUSIONS AND RELEVANCE

In patients with a body mass index of 50 to 60, duodenal switch resulted in greater weight loss and greater improvements in low-density lipoprotein cholesterol, triglyceride, and glucose levels 5 years after surgery compared with gastric bypass while improvements in health-related quality of life were similar. However, duodenal switch was associated with more surgical, nutritional, and gastrointestinal adverse effects.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00327912.

Application of the International Diabetes Federation and American Diabetes Association criteria in the assessment of metabolic control after bariatric surgery

The International Diabetes Federation (IDF) and the American Diabetes Association (ADA) have introduced specific criteria to define the 'optimization' of the metabolic state and glycaemic 'remission' of type 2 diabetes mellitus (T2DM) after bariatric surgery, respectively. Our objective was to assess the percentage of patients achieving these criteria. Data were collected for body mass index, glycaemic markers, lipids, blood pressure, hypoglycaemia and medication usage from 396 morbidly obese T2DM patients who underwent bariatric surgery in two centres and followed up for 2 years. At year 1, 14% of patients achieved the IDF criteria and 38% the ADA criteria, whereas at 2 years 8 and 9% satisfied these criteria, respectively. A relatively low proportion of patients achieved optimization of the metabolic state and T2DM remission. These patients may potentially benefit from the combination of bariatric surgery and adjuvant medical therapy to achieve optimal metabolic outcomes.

[Follow-up after bariatric surgery]

BACKGROUND

The number of bariatric surgical procedures in Norway is increasing. Patients who undergo bariatric surgery may experience surgical, medical and nutritional complications. Follow-up of these patients is therefore important.

METHODS

The article is based on non-systematic literature searches in PubMed and on the clinical experience of the authors.

RESULTS

Bariatric surgery induces significant and sustained weight loss and improves obesity-related disorders. Gastric bypass is the most commonly performed bariatric procedure in Norway. This procedure is associated with a 30-day mortality of below 0.5 %, while severe complications occur in approximately 5 % of patients. Late complications include internal herniation, intestinal ulcers and gallbladder disease. After surgery all patients are given iron, vitamin D/calcium and vitamin B12 supplements to prevent vitamin and mineral deficiencies. Gastrointestinal symptoms and postprandial hypoglycaemia after surgery can be improved by dietary modifications, and the need for anti-diabetic and blood pressure lowering medications is reduced. Dose adjustment of other medications may also be necessary. Pregnancy is not recommended during the first year after bariatric surgery. Many patients need plastic surgery after the operation.

INTERPRETATION

Complications after bariatric surgery may manifest in the long term. Regular follow-up is required. General practitioners should be responsible for follow-up in the long term, and should be familiar with common and serious complications as well as normal symptomatology after bariatric surgery.

Effect of the definition of type II diabetes remission in the evaluation of bariatric surgery for metabolic disorders

BACKGROUND

The American Diabetes Association recently defined remission of type II diabetes as a return to normal measures of glucose metabolism (haemoglobin (Hb) A1c below 6 per cent, fasting glucose less than 5·6 mmol/l) at least 1 year after bariatric surgery without hypoglycaemic medication. A previously used common definition was: being off diabetes medication with normal fasting blood glucose level or HbA1c below 6 per cent. This study evaluated the proportion of patients achieving complete remission of type II diabetes following bariatric surgery according to these definitions.

METHODS

This was a retrospective review of data collected prospectively in three bariatric centres on patients undergoing gastric bypass, sleeve gastrectomy and gastric banding.

RESULTS

Some 1006 patients underwent surgery, of whom 209 had type II diabetes. Median follow-up was 23 (range 12-75) months. HbA1c was reduced after operation in all three surgical groups (P < 0·001). A total of 72 (34·4 per cent) of 209 patients had complete remission of diabetes, according to the new definition; the remission rates were 40·6 per cent (65 of 160) after gastric bypass, 26 per cent (5 of 19) after sleeve gastrectomy and 7 per cent (2 of 30) after gastric banding (P < 0·001 between groups). The remission rate for gastric bypass was significantly lower with the new definition than with the previously used definition (40·6 versus 57·5 per cent; P = 0·003).

CONCLUSION

Expectations of patients and clinicians may have to be adjusted as regards remission of type II diabetes after bariatric surgery. Focusing on improved glycaemic control rather than remission may better reflect the benefit of this type of surgery and facilitate improved glycaemic control after surgery.

[Treating morbid obesity with laparoscopic biliopancreatic diversion with duodenal switch]

BACKGROUND

Biliopancreatic diversion with duodenal switch is used in the treatment of morbid obesity. Few centres perform the procedure laparoscopically. We aimed to evaluate the perioperative outcomes and weight loss after laparoscopic duodenal switch.

MATERIAL AND METHODS

All patients operated with biliopancreatic diversion with duodenal switch at the Centre for Morbid Obesity at Oslo University Hospital (2004-2009) were included. The perioperative period was defined as within 30 days of surgery.

RESULTS

A total of 48 patients were operated, all laparoscopically. Median preoperative BMI was 54 kg/m2 (range 41-88), and 33 patients (69 %) were women. Ten patients (21 %) were operated in two steps: first gastric sleeve and later duodenal switch. Median operation time was 200 minutes (100-658). Twelve patients (25 %) had complications, four (8 %) were reoperated, and one died. Median postoperative hospital stay was three (1-56) days. After two years, median BMI was 32 kg/m2 (24-45), median weight loss 39 % (22-60) and median excess BMI (> 25 kg/m2) loss 73 % (43-106).

INTERPRETATION

Duodenal switch was applied in a minority of patients operated for morbid obesity. The procedure can be performed laparoscopically with a short hospital stay and leads to a substantial weight loss. Perioperative morbidity was high and was comparable to the results from other series.

Weight loss, cardiovascular risk factors, and quality of life after gastric bypass and duodenal switch: a randomized trial

BACKGROUND

Gastric bypass and duodenal switch are currently performed bariatric surgical procedures. Uncontrolled studies suggest that duodenal switch induces greater weight loss than gastric bypass.

OBJECTIVE

To determine whether duodenal switch leads to greater weight loss and more favorable improvements in cardiovascular risk factors and quality of life than gastric bypass.

DESIGN

Randomized, parallel-group trial. (ClinicalTrials.gov registration number: NCT00327912)

SETTING

2 academic medical centers (1 in Norway and 1 in Sweden).

PATIENTS

60 participants with a body mass index (BMI) between 50 and 60 kg/m(2).

INTERVENTION

Gastric bypass (n = 31) or duodenal switch (n = 29).

MEASUREMENTS

The primary outcome was the change in BMI after 2 years. Secondary outcomes included anthropometric measures; concentrations of blood lipids, glucose, insulin, C-reactive protein, and vitamins; and health-related quality of life and adverse events.

RESULTS

Fifty-eight of 60 participants (97%) completed the study. The mean reductions in BMI were 17.3 kg/m(2) (95% CI, 15.7 to 19.0 kg/m(2)) after gastric bypass and 24.8 kg/m(2) (CI, 23.0 to 26.5 kg/m(2)) after duodenal switch (mean between-group difference, 7.44 kg/m(2) [CI, 5.24 to 9.64 kg/m(2)]; P < 0.001). Total cholesterol concentration decreased by 0.24 mmol/L (CI, -0.03 to 0.50 mmol/L) (9.27 mg/dL [CI, -1.16 to 19.3 mg/dL]) after gastric bypass and 1.07 mmol/L (CI, 0.79 to 1.35 mmol/L) (41.3 mg/dL [CI, 30.5 to 52.1 mg/dL]) after duodenal switch (mean between-group difference, 0.83 mmol/L [CI, 0.48 to 1.18 mmol/L]; 32.0 mg/dL [CI, 18.5 to 45.6 mg/dL]; P ≤ 0.001). Reductions in low-density lipoprotein cholesterol concentration, anthropometric measures, fat mass, and fat-free mass were also greater after duodenal switch (P ≤ 0.010 for each between-group comparison). Both groups had reductions in blood pressure and mean concentrations of glucose, insulin, and C-reactive protein, with no between-group differences. The duodenal switch group, but not the gastric bypass group, had reductions in concentrations of vitamin A and 25-hydroxyvitamin D. Most Short Form-36 Health Survey dimensional scores improved in both groups, with greater improvement in 1 of 8 domains (bodily pain) after gastric bypass. From surgery until 2 years, 10 participants (32%) had adverse events after gastric bypass and 18 (62%) after duodenal switch (P = 0.021). Adverse events related to malnutrition occurred only after duodenal switch.

LIMITATION

Clinical experience was greater with gastric bypass than with duodenal switch at the study centers.

CONCLUSION

Duodenal switch surgery was associated with greater weight loss, greater reductions of total and low-density lipoprotein cholesterol concentrations, and more adverse events. Improvements in other cardiovascular risk factors and quality of life were similar after both procedures.

PRIMARY FUNDING SOURCE

South-Eastern Norway Regional Health Authority.

Randomized clinical trial of laparoscopic gastric bypass versus laparoscopic duodenal switch for superobesity

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic biliopancreatic diversion with duodenal switch (LDS) are surgical options for superobesity. A randomized trial was conducted to evaluate perioperative (30-day) safety and 1-year results.

METHODS

Sixty patients with a body mass index (BMI) of 50-60 kg/m(2) were randomized to LRYGB or LDS. BMI, percentage of excess BMI lost, complications and readmissions were compared between groups.

RESULTS

Patient characteristics were similar in the two groups. Mean operating time was 91 min for LRYGB and 206 min for LDS (P < 0.001). One LDS was converted to open surgery. Early complications occurred in four patients undergoing LRYGB and seven having LDS (P = 0.327), with no deaths. Median stay was 2 days after LRYGB and 4 days after LDS (P < 0.001). Four and nine patients respectively had late complications (P = 0.121). Mean BMI at 1 year decreased from 54.8 to 38.5 kg/m(2) after LRYGB and from 55.2 to 32.5 kg/m(2) after LDS; percentage of excess BMI lost was greater after LDS (74.8 versus 54.4 per cent; P < 0.001).

CONCLUSION

LRYGB and LDS can be performed with comparable perioperative safety in superobese patients. LDS provides greater weight loss in the first year.

Vitamin status after bariatric surgery: a randomized study of gastric bypass and duodenal switch

BACKGROUND

Bariatric surgery is widely performed to induce weight loss.

OBJECTIVE

The objective was to examine changes in vitamin status after 2 bariatric surgical techniques.

DESIGN

A randomized controlled trial was conducted in 2 Scandinavian hospitals. The subjects were 60 superobese patients [body mass index (BMI; in kg/m(2)): 50-60]. The surgical interventions were either laparoscopic Roux-en-Y gastric bypass or laparoscopic biliopancreatic diversion with duodenal switch. All patients received multivitamins, iron, calcium, and vitamin D supplements. Gastric bypass patients also received a vitamin B-12 substitute. The patients were examined before surgery and 6 wk, 6 mo, and 1 y after surgery.

RESULTS

Of 60 surgically treated patients, 59 completed the follow-up. After surgery, duodenal switch patients had lower mean vitamin A and 25-hydroxyvitamin D concentrations and a steeper decline in thiamine concentrations than did the gastric bypass patients. Other vitamins (riboflavin, vitamin B-6, vitamin C, and vitamin E adjusted for serum lipids) did not change differently in the surgical groups, and concentrations were either stable or increased. Furthermore, duodenal switch patients had lower hemoglobin and total cholesterol concentrations and a lower BMI (mean reduction: 41% compared with 30%) than did gastric bypass patients 1 y after surgery. Additional dietary supplement use was more frequent among duodenal switch patients (55%) than among gastric bypass patients (26%).

CONCLUSIONS

Compared with gastric bypass, duodenal switch may be associated with a greater risk of vitamin A and D deficiencies in the first year after surgery and of thiamine deficiency in the initial months after surgery. Patients who undergo these 2 surgical interventions may require different monitoring and supplementation regimens in the first year after surgery. This trial was registered at ClinicalTrials.gov as NCT00327912.

Establishing laparoscopic Roux-en-Y gastric bypass: perioperative outcome and characteristics of the learning curve

BACKGROUND

Bariatric surgery was established at several Norwegian hospitals in 2004. This study evaluates the perioperative outcome and the learning curves for two surgeons while introducing laparoscopic Roux-en-Y gastric bypass (LRYGB).

METHODS

Morbidly obese patients undergoing primary LRYGB were included. Lengths of surgery and postoperative hospital stay, and 30-day rates of morbidity, reoperations, and readmissions were set as indicators of the learning curve. Learning effects were evaluated by graphical analyses and comparing the first and last 40 procedures for both surgeons.

RESULTS

The 292 included patients had a mean age of 40.0 +/- 9.5 years and a mean body mass index (BMI) of 46.7 +/- 5.3 kg/m(2). The mean length of surgery was 101 +/- 55 min. Complications occurred in 43 patients (14.7%), with no conversions to open surgery in the primary procedure and no mortality. Reoperations were performed in 14 patients (4.8%), of which five patients required open surgery. The median length of stay was 3 days (range 1-77), and 19 patients (6.5%) were readmitted. High patient age, but not high BMI, was associated with an increased risk of complication. For both surgeons, lengths of surgery and hospital stay were significantly reduced (p < 0.001), leveling out after 100 procedures. Reductions in the rates of morbidity, reoperations and readmissions were not found.

CONCLUSION

LRYGB was introduced with an acceptable morbidity rate and no mortality. Only the length of surgery and postoperative hospital stay were suitable indicators of a learning curve, which comprised about 100 cases.

[Surgical treatment of morbid obesity at a regional center]

BACKGROUND

Aker University Hospital has since 2004 offered laparoscopic surgery for morbid obesity. This study describes the characteristics of the patients undergoing surgery, the preoperative evaluation and the perioperative outcome after the first 139 laparoscopic procedures for morbid obesity.

MATERIAL AND METHODS

All patients operated between June 2004 and March 2006 are included in the study. The registration of data was first retrospective, and from 2006 prospective using specially designated registration forms.

RESULTS

Surgery was performed on 105 women (76%) and 33 men. The median age was 39 years (range 22-60), and the median preoperative body mass index was 47 kg/m2 (37-71). Frequent comorbidities included joint pain (44%), hypertension (31%), asthma (30%) and diabetes mellitus (27%). The patients underwent gastric bypass (86%), duodenal switch (10%) or gastric sleeve (4%). Two procedures (1%) were converted to open surgery. Perioperative morbidity (within 30 days) was 19%. The most frequent major complications were leakage from the stomach or bowel in seven patients (5%), intra-abdominal bleeding in four patients (3%) and deep infection (3%). Reoperation was performed on 13 patients (9%). One patient died following surgery (1%).

INTERPRETATION

. Laparoscopic bariatric surgery has now been established at Aker University Hospital. The complication rates seem acceptable, considering the patients'comorbid conditions and the introduction of advanced laparoscopic procedures.

[Surgical treatment of morbid obesity]

BACKGROUND

Patients with morbid obesity are prone to weight-related disease, reduced quality of life and shortened life expectancy. Long-term weight loss is unsatisfactory with conservative treatment and weight-reducing surgery is increasingly performed in all Norwegian health regions.

METHODS

This review is based on electronic database searches. We describe the two procedures most commonly performed in Norway, i.e. gastric bypass and biliopancreatic diversion with duodenal switch, including preoperative workup and expected results after surgery. The domestic use of different surgical techniques is also outlined.

RESULTS

In Norway, around 750 bariatric procedures were planned in 2006. Gastric bypass yields a weight reduction of 30% two years after the operative. Resolution of type 2-diabetes, hypertension, hyperlipidemia, and obstructive sleep apnea has been demonstrated in most patients. A majority of patients report improved quality of life. Procedure-related mortality is less than 1% and surgical complications occur in approximately 20%. Nutritional deficiencies are frequent. Weight loss is somewhat greater after biliopancreatic diversion with duodenal switch, but the procedure is more complex. Life-long follow-up is recommended after bariatric surgery.

INTERPRETATION

In selected patients with morbid obesity, bariatric surgery is a viable treatment. However, prospective long- term studies are needed.

[Use of influenza vaccine in Norway]

Following the 1993/94 influenza season a questionnaire study was carried out to evaluate the use of influenza vaccine among at-risk groups. 275,000 doses of influenza vaccine were provided free of charge by the National Institute of Public Health to about 500 municipal health care units. 104 of 150 randomly selected units responded to our questionnaire. A majority correctly estimated the vaccine efficacy to be 70-80%, and 90% of the persons who were vaccinated belonged to the defined target groups. Two of three respondents were in favour of the government's support. Influenza among the target groups was mainly regarded as an individual problem, but considered to be a community issue for the general public. The strain on public health budgets for treatment of the old and infirm during influenza epidemics is obviously not fully appreciated.