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UK report: Early results show safety and efficacy of MGB

They reported mean weight loss of 45.6kg (range 16.1–112.7), percentage body weight loss of 33.2% (range 11.4–55.4), and percentage excess body weight loss of 71.8% (range 23.2–138.3)

The outcomes showed that there were no deaths, although there were two (3.2%) 30 day and five (4.0%) late (>30 day) complications.

The procedure was also seen as a success by patients who, when asked, 96% of patients said that they would elect to have the operation again, with 82.4% of patients reporting a vast improvement in their quality of life

Wednesday, March 16, 2016 - 12:07

Owen Haskins - Editor in chief, Bariatric News

The first early outcomes from UK from centre in the UK on mini gastric bypass (MGB), ‘Mini Gastric Bypass: first report of 125 consecutive cases from United Kingdom’, published in the journal Clinical Obesity, has reported that the results are ‘encouraging’ with acceptable weight loss, comorbidity resolution rates and complication profile. Although the study authors, from Sunderland Royal Hospital, Sunderland, UK, acknowledge that longer term follow-up data with greater patient numbers are required to confirm these outcomes, the study nevertheless “demonstrates early safety and efficacy of MGB in a carefully selected British obese population in a high-volume centre.”

The study authors note that there are several apparent advantages of the MGB compared with the RYGB, including the single anastomosis, shorter learning curve, fewer internal defects for herniation and ease of revision or reversal. However, due to concerns the procedure can cause symptomatic biliary reflux and the risk of gastric/oesophageal cancer has so far limited general acceptance of the procedure.

They subsequently designed a retrospective cohort study to report their experience with an initial cohort of 125 consecutive MGB patients starting in October 2012 (ended November 2014), with the first three procedures were performed with the help of an experienced MGB surgeon from abroad. As the majority of the patients at the study centre currently undergo a gastric bypass (either RYGB or MGB), all patients were considered to be included in the study, although the presence of Gastro-Oesophageal Reflux Disease (GORD) and/or hiatus hernia was a contraindication to MGB. However, patients with perceived technical difficulty for RYGB (super-obese, male, apple shaped body habitus), were offered MGB.

The procedure

The authors developed the following standardied technique for performing MGB: Closed pneumoperitoneum was established using optical insertion of 12mm port. This port was then used for camera insertion. Two further 12mm and one 5mm ports were used as working ports. A subxiphoid tract was created using 5mm port for insertion of Nathanson liver retractor. A long gastric pouch was created using Covidien TriStapler 45mm and 60mm Purple and Tan cartridges. Dissection was started at incisura and the first firing was carried out with stapler pointing towards the left iliac fossa.

A 36 French oro-gastric tube was used for pouch calibration in most cases (KM does not use it anymore). Omentum was not routinely divided. A loop of small bowel 200 cm from DJ flexure was then brought up to the gastric pouch in an ante colic, ante gastric fashion and anastomosed to it using Covidien Tristapler 45 mm Tan/Purple cartridge. Stapler entry site was then closed using 2/0 Vicryl in two layers. No attempt was made to close Petersen's defect and a leak test was performed using a dilute methylene blue solution. No drains were used.

From October 2012 to November 2014, 125 patients underwent MGB procedure a majority (68.8%) of these patients were female. The mean age of patients in this series was 45 (range 20–70) years, mean weight and BMI was 135.8 (range 85–244) kilograms and 48.1 (range 34.5–73.8), respectively. The mean operative time was 92.4 (range 45–150) minutes and the mean post-operative hospital stay was 2.2 (range 2–17) days (median 2.0 days). Fourteen patients had had previous bariatric intervention (13 balloon insertions, one sleeve gastrectomy).

Outcomes

The outcomes showed that there were no deaths, although there were two (3.2%) 30 day and five (4.0%) late (>30 day) complications.

The study authors noted 100% follow-up and the mean follow-up was 11.4 months. They reported mean weight loss of 45.6kg (range 16.1–112.7), percentage body weight loss of 33.2% (range 11.4–55.4), and percentage excess body weight loss of 71.8% (range 23.2–138.3). Figure 1 shows mean weight loss for the whole cohort at six, 12, 18 and 24 months with respective numbers available for follow-up at each time.

Figure 1: Weight loss after Mini Gastric Bypass. EWL, excess weight loss; TWL, total weight loss (Source: Clinical Obesity, John Wiley & Sons)

Comorbidities

At the start of the study, 33 (26.4%) patients has T2DM and all noticed improvement/resolution of their diabetes; 16 of the 33 (48.4%) patients were on Insulin preoperatively; 13 of them were able to stop their Insulin and the remaining three have seen reduction in their insulin doses. Eight patients have gone into remission. In addition, from 45 hypertensive patients, 13 (29%) have stopped anti-hypertensive medications and 22 (49%) have reduced their medications.

The procedure was also seen as a success by patients who, when asked, 96% of patients said that they would elect to have the operation again, with 82.4% of patients reporting a vast improvement in their quality of life.

“It is worth noting that RYGB still accounts for approximately 75% of the surgical procedures performed within our unit and MGB accounts for an approximate 15%,” they write. “Over the years, we also seem to be recommending MGB for the patients, who in the past were offered sleeve gastrectomy for perceived technical difficulty.”

They also comment on the link between MGB and the risk of gastric and/or oesophageal cancer, and state that they cannot find any evidence that the MGB procedure puts patients at a higher risk of cancers in the long term. Despite the lack of data, they do acknowledge that MGB will continue to be ignored by some critics who claim a lack of long term, in spite of a similar lack of long term data for gastric banding and sleeve gastrectomy.

“Other surgeons are well advised to make themselves aware of all the technical and controversial aspects of this procedure before embarking on it,” they write. “As we have seen it in our practice, even in the hands of experienced bariatric surgeons, this operation has a definite learning curve. The authors believe time is now ripe for a well-designed, multicentre, adequately powered randomised controlled trial comparing MGB with RYGB and sleeve gastrectomy.”



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Omega-loop GB or MGB beats RYGB for weight loss

Omega-loop gastric bypass (OLGB) or Mini gastric bypass results in better weight loss (WL) compared to Roux-en-Y gastric bypass (RYGB), according to a retrospective study by researchers from the Medical University of Vienna, the Karl Landsteiner Institute for Obesity and Metabolic Diseases, Vienna and the Special Institute for Preventive Cardiology And Nutrition (SIPCAN), Salzburg, Austria. The study, ‘The Effect of Roux-en-Y vs. Omega-Loop Gastric Bypass on Liver, Metabolic Parameters, and Weight Loss’, published in Obesity Surgery, also reported that OLGB resulted in an increase of liver parameters in the first year after surgery, whist deteriorating after RYGB.

“The impact of these results on hepatic outcomes such as non-alcoholic steatohepatitis and fibrosis progression requires further studies. In both groups, improved insulin resistance and sensitivity were correlated with higher WL and lower liver fat percentage, respectively,” the authors write. “It remains unclear what induces the bimodal alteration in liver transaminases and cholestatic parameters during the early postoperative phase and also after 12 months.”

Due to the lack of data, the aim of the study was to compare the development of hepatic and metabolic markers as well as WL between the two surgical procedures during the first postoperative year.  It is known that bariatric surgery can adversely affect the liver with several case reports of patients with early hepatic failure after surgery.

Therefore, the aim of this evaluation was to provide data on the development of hepatic and metabolic markers as well as on WL in morbidly obese patients undergoing either Roux-en-Y gastric bypass or omega-loop gastric bypass during the first 12 postoperative months to facilitate the design of studies in larger populations.

The authors stated that all procedures were performed by the same surgical team using a laparoscopic approach. RYGB consists of a longitudinal 30ml gastric pouch which is anastomosed end-to-side with the jejunal limb and a latero-lateral jejuno-jejunal anastomosis resulting in a biliopancreatic limb of approximately 80cm and an alimentary limb of approximately 150cm . Omega-loop gastric bypass is a simplified procedure that consists of a unique gastrojejunal anastomosis between a 30–40ml sleeve gastric pouch and a jejunal omega loop of 200cm.

The researchers retrospectively evaluated the respective parameters in non-diabetic morbidly obese patients who underwent either RYGB (n=25) or OLGB (n=25). The baseline charactistics were as follows: RYGB (n=25, female=92 %, 44.6 ± 10.3a, 125 ± 18 kg, BMI 45.6 ± 4.1) and OLGB (n=25, male=88 %, 43.8 ± 13.1a, 128 ± 24 kg, BMI 45.3 ± 5.3).

Outcomes

The results revealed that WL (mean ± SD) was 30 ± 9 vs. 38 ± 7 % (%BMI loss), which equals a percentage excess WL (%EWL) of 94 ± 36 vs. 127 ± 31 % or percentage excess BMI loss (%EBMIL) of 67 ± 22 vs. 88 ± 16 % in RYGB vs. OLGB after 12 months (OR = 1.19; 95 % CI = 1.11–1.27; p<0.001).

With regards to liver function, aspartate transaminase (AST), a significant group and time difference could be found, whereas alanine transaminase (ALT) dropped in Roux-en-Y gastric bypass, while rising in omega-loop gastric bypass with a significant group and time difference. Moreover, a positive correlation could be found between ALT, surgical method (r = 0.406, p = 0.006) and De Ritis ratio >1 (r = 0.451, p = 0.002) at 12 months. There was no correlation observed between WL, ALT, and AST was observed.

Initially, Omega-loop gastric bypass group showed a significant higher count in platelets, this difference disappeared at three months. Nevertheless, a difference between the groups, as well as a negative correlation with WL (r = −0.346, p=0.002) was found.

A significant group and time interaction also could be found for prothrombin time, as well as a significant increasing proportion of low prothrombin time in omega-loop gastric bypass at three months (RYGB vs. OLGB; operative date: 8 vs. 0 %, n.s.; three months: 5 vs. 8 %, p<0.05). A negative correlation between prothrombin time and WL was found in omega-loop gastric bypass (r = −0.543, p<0.001).

No differences appeared in the course of albumin, while protein diminished significantly over time and group. A negative correlation between protein and WL in both groups (r = −0.428, p<0.001), as well as for albumin and hsCRP (r = −0.611, p<0.01) in omega-loop gastric bypass was found at six months.

The authors also report that in the RYGB group, gamma-glutamyltransferase (GGT) significantly decreased by nearly half of the initial value, while it remained stable in OLGB and a significant group and time difference was found. Younger patients (<50 years) had a greater chance of lower GGT quartiles over time (p<0.001; adjusted for initial BMI). A negative correlation between GGT and WL could be seen in Roux-en-Y gastric bypass (p<0.001).

“The superiority of omega-loop gastric bypass over Roux-en-Y gastric bypass in terms of WL was demonstrated in previous studies, as well as in our study. We did not observe any influence of gender, age, or preoperative BMI on WL regardless of the procedure…Importantly, we could not detect a correlation between liver transaminases and WL,” they write.

NAFLD liver fat score showed a significant higher proportion of NAFLD in RYGB until six months (13 vs. 5 %, n.s). Liver fat percentage showed a similar development with a significant difference over time, and a strong correlation could be found between liver fat percentage and HOMA2-IR (p<0.001); QUICKI (p<0.001); AST (p<0.001); ALT (p<0.001); and TG (p<0.001) in both groups.

Glucose significantly decreased in both groups until one year. Insulin was significantly higher in RYGB post-operatively, although no group and time interaction could be found.

“Given the potential for worsening fibrosis following bariatric surgery, patients should be monitored closely and continue to undergo through hepatological workup, including non-invasive testing for fibrosis or, even liver biopsy. More research in this field, including histopathological data, is needed to define clinical relevance of these findings on hepatic outcome in terms of deterioration of non-alcoholic steatohepatitis and fibrosis and to characterise patients at risk,” the authors conclude. “In both groups, improved outcome in terms of insulin resistance and sensitivity could be found in correlation to higher WL and lower liver fat percentage, respectively.”

The article was edited from the original article, under the Creative Commons license. To access the article, please click here



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Excellent New Habits after Bariatric Surgery

 

After Bariatric Surgery, you will begin to look around your kitchen with new eyes, and as you make your weekly grocery list, there will be so many things you will no longer want to buy. Don’t worry – it will get easier as the days go by and soon, you will have some healthy new habits to add years to your life, but how can you speed those new habits along, helping make sure you see and enjoy the results of weight loss surgery long term?

4-good-habits-post-bariatric-surgery

New Habits after Bariatric Surgery

Here are some quick kitchen tips for those of you who want to make your kitchen weight loss friendly after Bariatric surgery and help speed those new habits along. Don’t be discouraged if you make a mistake. It took a lifetime to learn all of these unhealthy eating habits, so don’t be too hard on yourself! Every day is a clean slate and a fresh start on your road toward a healthy weight and proper nutritional habits.

 

Buy Bottled Water after Weight Loss Surgery

While you may have wonderfully tasting well or tap water that runs into your glass for free, you are probably willing to admit that you aren’t drinking the required number of glasses per day. After Bariatric surgery, it is highly recommended that you purchase bottled water and store it in the refrigerator or another cool location.

You will find that using purchasing bottled water will motivate you, and help you keep track of your daily water intake goals. You may be able to get your family involved with a little competitive cross referencing with the other water drinkers in your home. Do not mistake distilled water for healthy bottled water, which is not nearly as healthy and beneficial for your body.

 

Boiled Eggs after Bariatric Surgery

After weight loss surgery, you will have to follow a very specific diet until your stomach has healed and you are no longer on a liquid, puree or soft food regimen. Once you have been approved for regular food, you will be looking for high protein recipes that meet the needs of your new lifestyle. Breakfast can be especially difficult since you no longer need to eat toast, biscuits, sugary sweet cereal or greasy pork bacon and sausage.

However, what you can have are protein rich eggs. Most nutritionists will tell you that eating at least one hard boiled egg each morning for breakfast will increase your energy levels by 70 percent. This is because protein is fuel for the body and eggs are a fast, affordable and easy source. Make a new habit of keep a small container of hard boiled eggs in the refrigerator. You will find that this is a fast and convenient breakfast that you will learn to appreciate. Sprinkle some paprika on them for a bit of flavor if you do not like them plain, as this spice is a great source of vitamin E.

 

Individual Sweeteners Packets for Bariatric Patients

After Bariatric surgery, you will no longer be able to enjoy sugary sweet drinks and treats. You can, however, have artificial sugar. If one of your old habits included drinking sweet iced tea, Kool-aid or coffee with sugar, you should consider purchasing artificial sweeteners in individual packets. While drinks won’t taste nearly as sweet, you will find that over time, you can train your taste buds to enjoy less.

Another great benefit of pre-measured packets is you can see exactly how many calories you are drinking and how much progress you’ve made. Also, these pre-measured packets can be carried in a purse or pocket, making it easy to maintain your new habit wherever you go.

Zipper Seal Bags for Weight Loss Surgery Patients

After you have undergone Bariatric surgery, portion control becomes an important issue and plastic zipper seal bags can be a huge help in the storing and cooking process. While you can save significantly by buying in bulk, you should re-package all meat and food items into zipper seal bags that contain only enough for the number and size of the meals you will need.

Not only will you avoid over-eating and later raiding the fridge for leftovers, you will also find that packages used to make one dinner meal might stretch much further now. It won’t take long before you are hooked on buying and using these household helpers.

 

What are some other items to help build new habits after Bariatric surgery?

 



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