Location via proxy:   [ UP ]  
[Report a bug]   [Manage cookies]                
SlideShare a Scribd company logo

SCOPE School Dublin - Torsten Olbers

•Download as PPT, PDF•
•
_
_IASO_

This document provides information about bariatric/metabolic surgery and what patients should know. It discusses why weight loss is important for improving health and quality of life. The goals of surgery are lower body weight, improved quality of life, reduced morbidity, and cost effectiveness. Different types of operations are described, including gastric band, gastric bypass, and sleeve gastrectomy. Expected weight loss is 25-30% of excess weight long term. Surgery resolves many obesity-related health conditions and complications are rare. Close follow up is required after surgery. Surgery is now being considered as a treatment for type 2 diabetes and other metabolic conditions even in patients with mild obesity.

1 of 46
Bariatric/ metabolic surgery-Bariatric/ metabolic surgery- What should patients know?What should patients know? Torsten Olbers MD, PhDTorsten Olbers MD, PhD
Why lose weight?Why lose weight? Improve health-Improve health- live healthier and longerlive healthier and longer Quality of lifeQuality of life-- ability to live a normal lifeability to live a normal life
What do we want to achieve? Lower body weightLower body weight Not per seNot per se Improved QoLImproved QoL YesYes Reduced morbidityReduced morbidity Yes!Yes! Cost effective treatmentCost effective treatment Yes!Yes! Prevent premature deathPrevent premature death YES!YES!
Not medicineNot medicine OROR surgery,surgery, ratherrather medicinemedicine ANDAND surgerysurgery
An important question..An important question.. Do we suggest surgery,Do we suggest surgery, or is it the patient driving..?or is it the patient driving..?
Who can be a surgical candidate?Who can be a surgical candidate?  BMI >35 kg/m² (BMI >30)BMI >35 kg/m² (BMI >30)  > 18 y> 18 y  Previous failure on conventional attemptsPrevious failure on conventional attempts  No unstable psychiatric diseaseNo unstable psychiatric disease  No current addiction (alcohol, pills, drugsNo current addiction (alcohol, pills, drugs))
Type of operationsType of operations  Gastric bandGastric band  Gastric BypassGastric Bypass  Sleeve gastrectomySleeve gastrectomy
Laparoscopic gastric bypass Olbers, Lönroth et al, Obesity Surgery 2003
SCOPE School Dublin - Torsten Olbers
How does it work?How does it work?  Less hungerLess hunger  Faster fullnessFaster fullness  Changes in food preferenceChanges in food preference  Altering energy expenditureAltering energy expenditure Altering in signals regulating food intake and energy expenditure
Gastric bypass vs. SleeveGastric bypass vs. Sleeve Gastric bypassGastric bypass  ””Gold standardGold standard””  Since 70iesSince 70ies  Long term results- 20yLong term results- 20y  AllAll ””spare partsspare parts”” left in situleft in situ  Cures reflux diseaseCures reflux disease  Some more need forSome more need for supplementssupplements SleeveSleeve  Newcomer (5-10 y)Newcomer (5-10 y)  No involvement of small bowelNo involvement of small bowel  AsAs ””majormajor”” surgerysurgery  ””Spare partsSpare parts”” resectedresected  Reflux, vomitingReflux, vomiting
What to expect in weight loss?What to expect in weight loss? Short term 33%, long term 25-30% weight lossShort term 33%, long term 25-30% weight loss Loss of half to all of overweight over one yearLoss of half to all of overweight over one year >90% have a good long term effect>90% have a good long term effect
Sjöström et al NEJM -07 SOS- Swedish Obese Subjects study
Sleep apnaeSleep apnae AsthmaAsthma NASH, NAFLDNASH, NAFLD Cardio-vascularCardio-vascular Type 2 diabetes Hyperlipidemia Hypertension InfertilityInfertility PCOSPCOS Osthoarthritis,Osthoarthritis, pain, mobilitypain, mobility GallstoneGallstone CancerCancer What about health? StrokeStroke Psoriasis, RAPsoriasis, RA
Could you never eatCould you never eat ””normallynormally”” again?again?  Can be tough in the beginning (weeks-months)Can be tough in the beginning (weeks-months)  Changes in sensations around foodChanges in sensations around food  Not always liking same type of foodsNot always liking same type of foods  You should be able to eat everything–You should be able to eat everything– in smaller amountsin smaller amounts
Diet before and after surgeryDiet before and after surgery  Low calorie diet some weeks before surgeryLow calorie diet some weeks before surgery  Gradually increase in texture over first monthGradually increase in texture over first month
Portion sizePortion size  Varies!Varies!  After some months- small normal portionAfter some months- small normal portion
Eating after gastric bypassEating after gastric bypass  Chew properlyChew properly  Regular mealsRegular meals  Keep the pace slowKeep the pace slow  Planning!Planning!  DonDon’’t drink when eatingt drink when eating  Eat on a small plateEat on a small plate
It is not normal with vomiting orIt is not normal with vomiting or abdominal pain after gastric bypass!abdominal pain after gastric bypass! If early:If early: suspect complicationsuspect complication If late:If late: suspect internal herniationsuspect internal herniation
SupplementationSupplementation •• Less food intake initiallyLess food intake initially •• Impaired uptakeImpaired uptake  Vitamin BVitamin B1212  Calcium + Vitamin DCalcium + Vitamin D  Multi vitamin- andMulti vitamin- and mineral tabletmineral tablet  Iron to fertile womenIron to fertile women
Healthy choices!Healthy choices!  VariationVariation  Prioritize proteinPrioritize protein  A lot of fruit and vegetablesA lot of fruit and vegetables  Full corn breadFull corn bread  Fast food less appealingFast food less appealing
DumpingDumping  Food enters directly to the intestineFood enters directly to the intestine  Not harmful, just very unpleasant!Not harmful, just very unpleasant!  Tiredness/weakness, nausea, palpitation,Tiredness/weakness, nausea, palpitation, cold sweatingcold sweating  Disappears within 15-30 minDisappears within 15-30 min – Sweet and fat foodsSweet and fat foods – Too large amountToo large amount – Too fastToo fast
Normal courseNormal course  Early mobilisationEarly mobilisation  Start drinking- often and littleStart drinking- often and little  First 24 h can be toughFirst 24 h can be tough  1-2 days in hospital1-2 days in hospital  3 weeks sick leave3 weeks sick leave  Physical activity allowed, almost no restrictionPhysical activity allowed, almost no restriction
What can go wrong?What can go wrong? • Complication 1/20Complication 1/20 1-2/100 serious (possibly reoperation)1-2/100 serious (possibly reoperation)  HaemorrhageHaemorrhage  LeakageLeakage  Pulmonary embolismPulmonary embolism • Complications usually early after surgeryComplications usually early after surgery • What is the risk of dying? 0,5/ 1000What is the risk of dying? 0,5/ 1000
Late complaintsLate complaints  Feeling cold and tiredFeeling cold and tired  Modest hair loss after some 3-6 monthsModest hair loss after some 3-6 months  Risk for vitamin/mineral deficienciesRisk for vitamin/mineral deficiencies  Excessive skinExcessive skin  ””HypoglycaemiaHypoglycaemia””  AlcoholAlcohol  Abdominal painAbdominal pain
SCOPE School Dublin - Torsten Olbers
Treatment of reactive hypoglycaemiaTreatment of reactive hypoglycaemia Patti ME. Diabetologia 2005; 48: 2236-2240 Goldfine AB. J Clin Endocrinol Metab 2007; 92: 4678-4685 Kellogg TA. Surg Obes Relat Dis 2008; 4: 492-499 Tack J. Nat Rev Gastroenterol Hepatol. 2009;6: 583-90
Bariatric/ metabolic surgeryBariatric/ metabolic surgery  Do the patient need help with signals?Do the patient need help with signals?  Reasonable expectationsReasonable expectations  Be aware about risk of complicationsBe aware about risk of complications  Weight loss does not resolve all problems..Weight loss does not resolve all problems..
Follow upFollow up  2 months2 months  6 months6 months  12 months12 months  24 months24 months Thereafter yearly assessments and bloodsThereafter yearly assessments and bloods Availability for extra visits!Availability for extra visits!
Metabolic surgery-Metabolic surgery- a novel indication?..a novel indication?..
Bariatric surgery reduces CV eventsBariatric surgery reduces CV events Sjöström et al JAMA 2012
...but only fasting insulin predict benefit (not BMI)...but only fasting insulin predict benefit (not BMI)
Bariatric surgery reverses endBariatric surgery reverses end organ damageorgan damage Mingrone et al Diabetes Care 2011Mingrone et al Diabetes Care 2011
SCOPE School Dublin - Torsten Olbers
Effects of Gastric Bypass Surgery in Patients With Type 2 Diabetes and Only Mild Obesity Ricardo V. Cohen, M.D., Jose C. Pinheiro, M.D., Carlos A. Schiavon, M.D., João E. Salles, M.D., Bernardo L. Wajchenberg, M.D., David E. Cummings, M.D. Diabetes Care Volume 35: 1420-1428 July, 2012
SCOPE School Dublin - Torsten Olbers
Roux-en-Y Gastric Bypass vs Intensive Medical ManagementRoux-en-Y Gastric Bypass vs Intensive Medical Management for the Control of Type 2 Diabetes, Hypertension, andfor the Control of Type 2 Diabetes, Hypertension, and Hyperlipidemia: The Diabetes Surgery Study RandomizedHyperlipidemia: The Diabetes Surgery Study Randomized Clinical TrialClinical Trial Ikramuddin et al, JAMA 2013Ikramuddin et al, JAMA 2013
EOSSEOSS
The IDF Position Statement onThe IDF Position Statement on Bariatric Surgery in obese type 2Bariatric Surgery in obese type 2 diabetes 2011diabetes 2011 Bariatric Surgical and Procedural Interventions in theBariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 DiabetesTreatment of Obese Patients with Type 2 Diabetes
Management Algorithm for MetabolicManagement Algorithm for Metabolic Control in Type 2 DiabetesControl in Type 2 Diabetes Basal Premixed Basal Bolus insulin Sulphonylurea Acarbose DPP-4 inhibitor/ GLP-1 analogues Glitazone Insulin Lifestyle Modification •diet modification •weight control •physical activity Metformin Bariatric Surgery BMI > 30 eligible & BMI > 35 prioritized *If HbA1c >7.5% despite optimized conventional therapy, especially if weight is increasing, or if other weight responsive comorbidities are not reaching target on conventional therapy. Bariatric Surgery BMI > 35 eligible BMI > 40 prioritised Bariatric Surgical and Procedural Interventions in theBariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 DiabetesTreatment of Obese Patients with Type 2 Diabetes
Metabolic surgeryMetabolic surgery - Reconstructions of the GI tract can resolve:Reconstructions of the GI tract can resolve: - Type 2 diabetes mellitusType 2 diabetes mellitus - Sleep apnoeaSleep apnoea - HyperlipidemiaHyperlipidemia - HypertensionHypertension - NASH/NAFLDNASH/NAFLD - Renal impairmentRenal impairment - AsthmaAsthma - PsoriasisPsoriasis - EtcEtc Which patients benefit most?Which patients benefit most?
ConclusionConclusion  Currently strongest evidence for benefits inCurrently strongest evidence for benefits in patients having a BMI>35patients having a BMI>35  No problem justifying surgery for metabolicallyNo problem justifying surgery for metabolically impaired patients having a BMI<35impaired patients having a BMI<35  Need of hard endpoint studies: RCTs for T2D-Need of hard endpoint studies: RCTs for T2D- best medical vs. best medical+ surgerybest medical vs. best medical+ surgery  Surgery should be regarded as add on therapySurgery should be regarded as add on therapy
Future • Metabolic surgery • Diabetic surgery • Tailored surgery/medication- phenotypes • Studies of the mechanism of action
An important question..An important question.. Do we suggest surgery, or doDo we suggest surgery, or do patients need to claim right topatients need to claim right to treatment?....treatment?....
AcknowledgementsAcknowledgements  UCD- DublinUCD- Dublin – Carel le RouxCarel le Roux  Imperial College LondonImperial College London – Alex MirasAlex Miras – Dimitris PournarasDimitris Pournaras – Sam SchoultzSam Schoultz  Sahlgrenska AcademySahlgrenska Academy – Hans LönrothHans Lönroth – Lars SjöströmLars Sjöström – Lars FändriksLars Fändriks – Marlin WerlingMarlin Werling – Anna LaureniusAnna Laurenius  University Hospital OsloUniversity Hospital Oslo – Torgeir SövikTorgeir Sövik – Eerlend AasheimEerlend Aasheim – Tom MalaTom Mala  University of ZurichUniversity of Zurich – Thomas LutzThomas Lutz – Marco BueterMarco Bueter
””Metabolic surgery”Metabolic surgery” Duodeno-jejunal bypass Ileal transposition Endoluminal sleeve

More Related Content

SCOPE School Dublin - Torsten Olbers

  • 1. Bariatric/ metabolic surgery-Bariatric/ metabolic surgery- What should patients know?What should patients know? Torsten Olbers MD, PhDTorsten Olbers MD, PhD
  • 2. Why lose weight?Why lose weight? Improve health-Improve health- live healthier and longerlive healthier and longer Quality of lifeQuality of life-- ability to live a normal lifeability to live a normal life
  • 3. What do we want to achieve? Lower body weightLower body weight Not per seNot per se Improved QoLImproved QoL YesYes Reduced morbidityReduced morbidity Yes!Yes! Cost effective treatmentCost effective treatment Yes!Yes! Prevent premature deathPrevent premature death YES!YES!
  • 4. Not medicineNot medicine OROR surgery,surgery, ratherrather medicinemedicine ANDAND surgerysurgery
  • 5. An important question..An important question.. Do we suggest surgery,Do we suggest surgery, or is it the patient driving..?or is it the patient driving..?
  • 6. Who can be a surgical candidate?Who can be a surgical candidate?  BMI >35 kg/m² (BMI >30)BMI >35 kg/m² (BMI >30)  > 18 y> 18 y  Previous failure on conventional attemptsPrevious failure on conventional attempts  No unstable psychiatric diseaseNo unstable psychiatric disease  No current addiction (alcohol, pills, drugsNo current addiction (alcohol, pills, drugs))
  • 7. Type of operationsType of operations  Gastric bandGastric band  Gastric BypassGastric Bypass  Sleeve gastrectomySleeve gastrectomy
  • 8. Laparoscopic gastric bypass Olbers, Lönroth et al, Obesity Surgery 2003
  • 10. How does it work?How does it work?  Less hungerLess hunger  Faster fullnessFaster fullness  Changes in food preferenceChanges in food preference  Altering energy expenditureAltering energy expenditure Altering in signals regulating food intake and energy expenditure
  • 11. Gastric bypass vs. SleeveGastric bypass vs. Sleeve Gastric bypassGastric bypass  ””Gold standardGold standard””  Since 70iesSince 70ies  Long term results- 20yLong term results- 20y  AllAll ””spare partsspare parts”” left in situleft in situ  Cures reflux diseaseCures reflux disease  Some more need forSome more need for supplementssupplements SleeveSleeve  Newcomer (5-10 y)Newcomer (5-10 y)  No involvement of small bowelNo involvement of small bowel  AsAs ””majormajor”” surgerysurgery  ””Spare partsSpare parts”” resectedresected  Reflux, vomitingReflux, vomiting
  • 12. What to expect in weight loss?What to expect in weight loss? Short term 33%, long term 25-30% weight lossShort term 33%, long term 25-30% weight loss Loss of half to all of overweight over one yearLoss of half to all of overweight over one year >90% have a good long term effect>90% have a good long term effect
  • 13. Sjöström et al NEJM -07 SOS- Swedish Obese Subjects study
  • 14. Sleep apnaeSleep apnae AsthmaAsthma NASH, NAFLDNASH, NAFLD Cardio-vascularCardio-vascular Type 2 diabetes Hyperlipidemia Hypertension InfertilityInfertility PCOSPCOS Osthoarthritis,Osthoarthritis, pain, mobilitypain, mobility GallstoneGallstone CancerCancer What about health? StrokeStroke Psoriasis, RAPsoriasis, RA
  • 15. Could you never eatCould you never eat ””normallynormally”” again?again?  Can be tough in the beginning (weeks-months)Can be tough in the beginning (weeks-months)  Changes in sensations around foodChanges in sensations around food  Not always liking same type of foodsNot always liking same type of foods  You should be able to eat everything–You should be able to eat everything– in smaller amountsin smaller amounts
  • 16. Diet before and after surgeryDiet before and after surgery  Low calorie diet some weeks before surgeryLow calorie diet some weeks before surgery  Gradually increase in texture over first monthGradually increase in texture over first month
  • 17. Portion sizePortion size  Varies!Varies!  After some months- small normal portionAfter some months- small normal portion
  • 18. Eating after gastric bypassEating after gastric bypass  Chew properlyChew properly  Regular mealsRegular meals  Keep the pace slowKeep the pace slow  Planning!Planning!  DonDon’’t drink when eatingt drink when eating  Eat on a small plateEat on a small plate
  • 19. It is not normal with vomiting orIt is not normal with vomiting or abdominal pain after gastric bypass!abdominal pain after gastric bypass! If early:If early: suspect complicationsuspect complication If late:If late: suspect internal herniationsuspect internal herniation
  • 20. SupplementationSupplementation •• Less food intake initiallyLess food intake initially •• Impaired uptakeImpaired uptake  Vitamin BVitamin B1212  Calcium + Vitamin DCalcium + Vitamin D  Multi vitamin- andMulti vitamin- and mineral tabletmineral tablet  Iron to fertile womenIron to fertile women
  • 21. Healthy choices!Healthy choices!  VariationVariation  Prioritize proteinPrioritize protein  A lot of fruit and vegetablesA lot of fruit and vegetables  Full corn breadFull corn bread  Fast food less appealingFast food less appealing
  • 22. DumpingDumping  Food enters directly to the intestineFood enters directly to the intestine  Not harmful, just very unpleasant!Not harmful, just very unpleasant!  Tiredness/weakness, nausea, palpitation,Tiredness/weakness, nausea, palpitation, cold sweatingcold sweating  Disappears within 15-30 minDisappears within 15-30 min – Sweet and fat foodsSweet and fat foods – Too large amountToo large amount – Too fastToo fast
  • 23. Normal courseNormal course  Early mobilisationEarly mobilisation  Start drinking- often and littleStart drinking- often and little  First 24 h can be toughFirst 24 h can be tough  1-2 days in hospital1-2 days in hospital  3 weeks sick leave3 weeks sick leave  Physical activity allowed, almost no restrictionPhysical activity allowed, almost no restriction
  • 24. What can go wrong?What can go wrong? • Complication 1/20Complication 1/20 1-2/100 serious (possibly reoperation)1-2/100 serious (possibly reoperation)  HaemorrhageHaemorrhage  LeakageLeakage  Pulmonary embolismPulmonary embolism • Complications usually early after surgeryComplications usually early after surgery • What is the risk of dying? 0,5/ 1000What is the risk of dying? 0,5/ 1000
  • 25. Late complaintsLate complaints  Feeling cold and tiredFeeling cold and tired  Modest hair loss after some 3-6 monthsModest hair loss after some 3-6 months  Risk for vitamin/mineral deficienciesRisk for vitamin/mineral deficiencies  Excessive skinExcessive skin  ””HypoglycaemiaHypoglycaemia””  AlcoholAlcohol  Abdominal painAbdominal pain
  • 27. Treatment of reactive hypoglycaemiaTreatment of reactive hypoglycaemia Patti ME. Diabetologia 2005; 48: 2236-2240 Goldfine AB. J Clin Endocrinol Metab 2007; 92: 4678-4685 Kellogg TA. Surg Obes Relat Dis 2008; 4: 492-499 Tack J. Nat Rev Gastroenterol Hepatol. 2009;6: 583-90
  • 28. Bariatric/ metabolic surgeryBariatric/ metabolic surgery  Do the patient need help with signals?Do the patient need help with signals?  Reasonable expectationsReasonable expectations  Be aware about risk of complicationsBe aware about risk of complications  Weight loss does not resolve all problems..Weight loss does not resolve all problems..
  • 29. Follow upFollow up  2 months2 months  6 months6 months  12 months12 months  24 months24 months Thereafter yearly assessments and bloodsThereafter yearly assessments and bloods Availability for extra visits!Availability for extra visits!
  • 30. Metabolic surgery-Metabolic surgery- a novel indication?..a novel indication?..
  • 31. Bariatric surgery reduces CV eventsBariatric surgery reduces CV events Sjöström et al JAMA 2012
  • 32. ...but only fasting insulin predict benefit (not BMI)...but only fasting insulin predict benefit (not BMI)
  • 33. Bariatric surgery reverses endBariatric surgery reverses end organ damageorgan damage Mingrone et al Diabetes Care 2011Mingrone et al Diabetes Care 2011
  • 35. Effects of Gastric Bypass Surgery in Patients With Type 2 Diabetes and Only Mild Obesity Ricardo V. Cohen, M.D., Jose C. Pinheiro, M.D., Carlos A. Schiavon, M.D., João E. Salles, M.D., Bernardo L. Wajchenberg, M.D., David E. Cummings, M.D. Diabetes Care Volume 35: 1420-1428 July, 2012
  • 37. Roux-en-Y Gastric Bypass vs Intensive Medical ManagementRoux-en-Y Gastric Bypass vs Intensive Medical Management for the Control of Type 2 Diabetes, Hypertension, andfor the Control of Type 2 Diabetes, Hypertension, and Hyperlipidemia: The Diabetes Surgery Study RandomizedHyperlipidemia: The Diabetes Surgery Study Randomized Clinical TrialClinical Trial Ikramuddin et al, JAMA 2013Ikramuddin et al, JAMA 2013
  • 39. The IDF Position Statement onThe IDF Position Statement on Bariatric Surgery in obese type 2Bariatric Surgery in obese type 2 diabetes 2011diabetes 2011 Bariatric Surgical and Procedural Interventions in theBariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 DiabetesTreatment of Obese Patients with Type 2 Diabetes
  • 40. Management Algorithm for MetabolicManagement Algorithm for Metabolic Control in Type 2 DiabetesControl in Type 2 Diabetes Basal Premixed Basal Bolus insulin Sulphonylurea Acarbose DPP-4 inhibitor/ GLP-1 analogues Glitazone Insulin Lifestyle Modification •diet modification •weight control •physical activity Metformin Bariatric Surgery BMI > 30 eligible & BMI > 35 prioritized *If HbA1c >7.5% despite optimized conventional therapy, especially if weight is increasing, or if other weight responsive comorbidities are not reaching target on conventional therapy. Bariatric Surgery BMI > 35 eligible BMI > 40 prioritised Bariatric Surgical and Procedural Interventions in theBariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 DiabetesTreatment of Obese Patients with Type 2 Diabetes
  • 41. Metabolic surgeryMetabolic surgery - Reconstructions of the GI tract can resolve:Reconstructions of the GI tract can resolve: - Type 2 diabetes mellitusType 2 diabetes mellitus - Sleep apnoeaSleep apnoea - HyperlipidemiaHyperlipidemia - HypertensionHypertension - NASH/NAFLDNASH/NAFLD - Renal impairmentRenal impairment - AsthmaAsthma - PsoriasisPsoriasis - EtcEtc Which patients benefit most?Which patients benefit most?
  • 42. ConclusionConclusion  Currently strongest evidence for benefits inCurrently strongest evidence for benefits in patients having a BMI>35patients having a BMI>35  No problem justifying surgery for metabolicallyNo problem justifying surgery for metabolically impaired patients having a BMI<35impaired patients having a BMI<35  Need of hard endpoint studies: RCTs for T2D-Need of hard endpoint studies: RCTs for T2D- best medical vs. best medical+ surgerybest medical vs. best medical+ surgery  Surgery should be regarded as add on therapySurgery should be regarded as add on therapy
  • 43. Future • Metabolic surgery • Diabetic surgery • Tailored surgery/medication- phenotypes • Studies of the mechanism of action
  • 44. An important question..An important question.. Do we suggest surgery, or doDo we suggest surgery, or do patients need to claim right topatients need to claim right to treatment?....treatment?....
  • 45. AcknowledgementsAcknowledgements  UCD- DublinUCD- Dublin – Carel le RouxCarel le Roux  Imperial College LondonImperial College London – Alex MirasAlex Miras – Dimitris PournarasDimitris Pournaras – Sam SchoultzSam Schoultz  Sahlgrenska AcademySahlgrenska Academy – Hans LönrothHans Lönroth – Lars SjöströmLars Sjöström – Lars FändriksLars Fändriks – Marlin WerlingMarlin Werling – Anna LaureniusAnna Laurenius  University Hospital OsloUniversity Hospital Oslo – Torgeir SövikTorgeir Sövik – Eerlend AasheimEerlend Aasheim – Tom MalaTom Mala  University of ZurichUniversity of Zurich – Thomas LutzThomas Lutz – Marco BueterMarco Bueter