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MGB and one-anastomosis gastric bypass are on the rise

The MGB-OAGB 4th Annual Consensus Conference was held in Naples, Italy July 3-4, 2017 under the superb organisation of Professor Mario Musella, at a beautiful site on the Mediterranean seaside. The meeting was attended by 169 experienced surgeons from bariatric teams in 29 countries, where important studies were presented and discussed.

This article was authored by Mervyn Deitel, MD, SFASMBS, FACN, Director MGB-OAGB Club, Toronto, Canada

A French group reviewed their 2,014 MGBs; abscesses had occurred in 2.2% and were treated by endoscopic or percutaneous drainage, with no mortality. Methylene blue test has been important for operative detection of leaks. Revision for GE bile reflux or malnutrition was rarely necessary in the long-term. The operations were highly effective for excess weight loss. Studies suggested that the length of the bypassed limb may only influence weight loss in the early months after surgery. Bypasses of 150-250 cm were performed, depending on BMI and sociocultural conditions, but with the longer bypasses, total bowel length should be measured to be certain that 300 cm of common limb is left distally.

Figure 1: MGB with a long gastric pouch, starting from below the crow’s foot, and going proximally to the left of the angle of His. An anterior wide gastrojejunostomy is constructed 180-200 cm distal to Treitz’ ligament.

MGB or OAGB was performed safely as both a primary operation or a revision for failed gastric banding or sleeve gastrectomy (SG). Improvement in quality of life and co-morbidities resulted, with resolution of type 2 diabetes in >95%.

Cady of Paris, with 3,500 cases (using a 175-200 cm bypass limb), found that under-nutrition occurred in 1.5%, and if there is no quick result from replenishment, reversal is necessary to avoid death. The French group from Cornevarrieu-Toulouse reported that in their series of 2,400 patients with a 150-cm biliary limb, had 0.04% severe malnutrition (only 1 patient) requiring reversal. Weight loss after MGB-OAGB depends mainly on malabsorption. Malnutrition in patients in India (where 50% are vegetarian) is avoided by a bypass no greater than 200 cm and proper diet.

Figure 2: OAGB with long, narrow gastric pouch (15-18 cm) and an antecolic antegastric latero-lateral anastomosis between pouch and afferent enteric loop which is suspended ~8-10 cm above the anastomosis through an initial continuous suture which secures the afferent limb to the gastric pouch’s staple-line and with final fixation of the loop’s apex to the excluded stomach. Biliopancreatic limb averages 250-350 cm.

With the usual MGB gastric channel constructed 2-3 cm distal to the crow’s foot, bile GE reflux was negligible. The Kazakhstan group found that a longer gastric pouch significantly reduced postop bile reflux. Tolone’s group from Naples (S Tolone SOARD 2016), using multiple scientific studies, confirmed that GE reflux does not occur after MGB (unlike after SG which maintains the pylorus).

Carbajo of Spain and Luque-de-Leon of Mexico presented their outcomes from 2,850 OAGBs since 2002, with negligible bile reflux, marginal ulcer in <1%, and EWL and EBMIL >75%. Again, the OAGB was an excellent rescue after other failed operations. Long-term %EWL and co-morbidity resolution after OAGB were similar to the best results obtained with more aggressive and complex operations.

The importance of differentiating type 1 (auto-immune) diabetes (T1D) in the adult from type 2 diabetes was emphasised. Obesity can occur in type 1 if the patient takes excessive insulin, becomes hypoglycaemic, and then has to eat more (a vicious cycle). This can be controlled by dietary surveillance; if not, bariatric surgery for obese T1D will decrease weight, lower HbA1c, and lower insulin requirement. However, the T1D patient will always require insulin.

Unlike following other bariatric operations, carcinoma in the gastric channel or esophagus has not occurred. Some workers are performing robotic MGB, and note speed and technical ease.

A number of long-term studies comparing MGB-OAGB with SG and RYGB were presented. SG was followed by occasional serious high leaks, GE reflux, Barrett’s esophagus, and weight regain. Most MGB and OAGB surgeons had previously performed RYGB for many years. RYGB took longer to perform, was more complex, had longer learning curve, more marginal ulcers, increased internal hernias and bowel obstruction, more hypoglycemia, late weight regain and more difficulty to revise.

In comparison, MGB was relatively simple, rapid, safe, and had greater elevation of GLP-1, durable weight loss, ease of revision and reversal, and resolved GERD. With both RYGB and MGB, watch for iron deficiency anemia and hypoalbuminemia.

In many countries outside USA, MGB and OAGB have become the most common bypass operation for bariatric patients.



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Gastric band aftercare London

Dear patients, we will organize a clinic in London on Friday 28/07 between 9am and 1pm.

For appointments please book online on our website.

Have a nice summer and we 're looking forward to see you again soon.



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OAGB – the long-term outcomes from 1,200 procedures

Laparoscopic one-anastomosis gastric bypass (OAGB) is a safe and effective procedure, that reduces difficulty, operating time and early and late complications associated roux-en-Y gastric bypass, according to the authors of a study from the Centre of Excellence for the Study and Treatment of Obesity and Diabetes, Valladolid, Spain. They also note that long-term weight loss, resolution of comorbidities, and degree of satisfaction “are similar to results obtained with more aggressive and complex techniques. It is currently a robust and powerful alternative in bariatric surgery.”

The paper, ‘Laparoscopic One-Anastomosis Gastric Bypass: Technique, Results, and Long-Term Follow-Up in 1200 Patients’, published in Obesity Surgery, sought to evaluate experience and long-term follow-up (FU) in a large cohort of patients with morbid obesity who underwent laparoscopic OAGB at a single institution. The retrospective review of a prospectively maintained database included 1,200 consecutive patients from July 2002 to October 2008, and included follow up from six to 12 years.

Outcomes

There were 744 female (62 %) and 456 male (38 %) patients with a mean age of 43 years (range, 12–74). Mean pre-operative BMI46 (range, 33–86) and mean preoperative excess weight was 65kg (range, 34–220). The cohort included 697 patients (58 %) with no previous or simultaneous abdominal operations (subgroup 1). Another 273 (23 %) had had prior open abdominal operations and thus required adhesiolysis of variable complexity, and a total of 203 (17 %) had abdominal operations performed simultaneously, particularly gallbladder removal and/or hiatal or ventral hernia repairs (subgroup 2). Finally, in 27 (2 %), laparoscopic OAGB was performed as a revision of other (failed) bariatric procedures (subgroup 3) including previous laparoscopic gastric bands (n=13), as well as open vertical banded gastroplasties (n=14).

Intraoperative complications requiring conversion to an open approach occurred in four patients (0.3 %). Early major complications requiring reoperations occurred in 16 patients (1.3 %) and included intra-abdominal bleeding (9), leaks (3), and early small bowel obstruction (2). Late complications included 6 stomal stenosis (0.5 %) 6 (0.5 %) anastomotic or marginal ulcers (MU).

The 30-day readmission rate was 0.8 % (10 patients). Late readmissions were required in 13 patients (1 %) for stomal stenosis (6), GI bleeding due to MU (5), and malnourishment (2). Two patients died in this series (0.16 %); both had super-obesity, multiple comorbidities and risk factors. One suffered a pulmonary thromboembolism 3 days after BS (without warning symptoms or additional postoperative complications). The other suffered gastric wall necrosis, was re-operated on, and developed refractory nosocomial pneumonia. Both deaths occurred during the initial part of the series, and there were no other casualties in >1000 patients operated on thereafter.

Pre-operative nutritional deficits were found in some patients including iron (∼10 %), vitamin D (∼15 %), and calcium (∼4 %). After OAGB, a few patients developed excessive weight loss and/or nutrient deficits (usually within the first 2–3 postoperative years). A total of 14 patients (1.2 %) required further treatment for hypoalbuminemia; all received high-protein enteral supplements and pancreatic enzymes. Iron deficiency was rather common, especially in fertile women with copious menstrual bleeding and up to one third required oral supplements beyond the expected time for intestinal adaptation, and 15 patients (1.3 %) required parenteral iron.

Among liposoluble vitamins, vitamin D insufficiency was present in more than half of patients at three years and one third in the long term; this required continuous supplementation in ∼20 % of them. Longer supplementation was also needed for vitamins A and K in ∼3 and 0.5 %, respectively.

Patients lost a mean of ∼15–20 kg in the first month and ∼30–40 kg in the first trimester. The number and percentage of patients followed up at each time interval are included; only from 13 % (at 6 years) to 30 % (at 12 years) of the cumulative number of patients were lost for follow-up. Substantial weight loss was documented for most patients; through time, there was a slight weight increase in a few, which was not clinically relevant. Therefore, the authors stated that excess weight loss was maintained in most of these patients and according to Reinhold’s classification their results ranged from good (EWL >50 %) to excellent (EWL >75 %), and a long-term successful treatment (EWL >50 %) was achieved in almost all patients.

Severe metabolic comorbidities such as type II diabetes mellitus, insulin resistance, hypertension, and sleep apnoea either totally resolved or substantially improved, most from the first day after surgery (Table 1). Remission was also demonstrated in most patients for other metabolic conditions like hyperlipidaemia and liver steatosis when the first biochemical tests were ordered at the 3rd postoperative month. Interestingly, 53 % of patients had gastroesophageal reflux disease (GERD) of some degree before surgery, and all were relieved after the operation.

Table 1: Outcomes of one-anastomosis gastric bypass (OAGB) on comorbid conditions in 1200 morbidly obese patients

“We call again on the various bariatric teams that are performing the original MGB or our modified version, the OAGB, to aid in the dissemination and acceptance of this procedure by presenting and publishing their experiences and standardising the name (to MGB/OAGB), in order for all of us to be recognized as a whole,” the authors write. “Now that many of its controversies are being surpassed and the bariatric surgical community is accepting the procedure as a rational alternative in the bariatric repertoire, we should make all efforts in order to conciliate in regard to the name, avoid new disagreements, and work towards making MGB/OAGB mainstream in obesity and metabolic surgery.”

“Concerns regarding bile reflux and its potential consequences currently seem unsubstantiated but await studies with even longer-term outcomes,” the authors conclude. “So far, development of subsequent cancer has not been reported. Long-term substantial EWL, remission of comorbidities through its metabolic benefits, and degree of satisfaction are similar to the best results obtained with more aggressive and complex operations. OAGB is a safe and effective powerful alternative which is slowly (but surely) becoming mainstream in bariatric surgery.”

The article was edited from the original article, under the Creative Commons license.

To access this article, please click here



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