Mini-Gastric Bypass Whats in a Name? Mini gastric bypass (MGB) - PowerPoint PPT Presentation

Mini-Gastric Bypass

What’s in a Name? • Mini gastric bypass (MGB) since 1997 • Rutledge 2001 • One-anastomosis gastric bypass (OAGB) • Garcia-Caballero in 2004 • Single-anastomosis gastric bypass (SAGB) • Lee 2014 • Omega loop gastric bypass (OLGB) • Himpens 2015

One Anastomosis Gastric Bypass • Gastric pouch 15 ± 2.5 cm • Level of the crow’s foot • Gastrojejunostomy 200 (150-300) cm from ligament of Treitz • “Larger” G-J • 1.5 to > 3 cm

Long Gastric Pouch

End-to-end vs Side-to-side

• MGB 4 th most common bariatric operation in Europe and Asia • 5-10% of bariatric operations in many countries • Annual volume up to 4000 operations per year

Bariatric Operations in 2013 Country Total AGB RYGB SG BPD/DS OAGB USA/Canada 154,276 15,523 54,420 67,021 1520 ?? France 37,300 7000 8000 18,000 300 4000 Italy 8106 2282 1733 2879 111 538 Egypt 5875 200 1300 2500 10 300 Austria 2354 115 1210 760 20 210 Turkey 3250 400 500 1500 115 200 Greece 1499 234 262 622 23 191 Spain 2425 28 1029 818 329 150 Poland 1658 209 318 913 0 140

Controversies • Bile gastritis and esophagitis • Billroth II gastrectomy • Original Mason loop gastric bypass • No formal studies of bile reflux after OAGB • ? Increased cancer risk • Bile and/or H. pylori • No published reports of such

• Bile reflux was most commonly seen complication (20 of 32 patients) • Diagnosis • Bilious vomiting or abdominal pain, bile gastritis on endoscopy • Revision • Conversion to RYGB in 14 • Braun enteroenterostomy in 2 • Plans for conversion to RYGB in 4 Johnson, SOARD , 2007

• No bile reflux in 923 primary OAGB • Bile reflux in 5.19% of 77 revision OAGB • Treatment of bile reflux • Stapling afferent limb proximal to G-J and creating Braun enteroenterostomy 70 cm distally Noun, Obes Surg , 2012

Potential Disadvantages • More malabsorption • More diarrhea • More marginal ulcers • More catastrophic gastrojejunostomy leak

Potential Advantages • Emphasis on technical simplicity and shorter OR times • ? Lower complication rate • Less internal hernia, bowel obstruction • Better weight loss • Greater resolution of co-morbidities

The Data

• Mean follow-up 11.4 months • Pre-op BMI 48.1 kg/m 2 (34.5 – 73.8) • OR time: 92.4 min (45 – 150) • Length of stay: 2.2 days (2 – 17) • Pouch with 36 French OG tube • Gastrojejunostomy 200cm from LOT

Outcomes • No leaks • No mortality • Reoperation • 1 in first 30 days • Adhesion to terminal ileum (probably unrelated) • 3 later • Perforated marginal ulcer (converted to RYGB) • Marginal ulcer (realignment of anastomosis) • Abdominal pain (adhesiolysis, crural closure)

Complications • Wound infection (1) • Self-limited GI bleeding (1) • Marginal ulcer (4)

Safety • Marginal ulcer comparable to RYGB • No internal hernias • GERD similar to VSG • “No published proof of significant bile gastroesophageal reflux after OAGB.” • ? More malabsorption than RYGB • “Unconvinced” of any increased risk of cancer

Weight Loss 100 94.8 %EWL %TWL 82.6 79.5 75 60.1 50 40.8 38.3 36.8 27.5 25 0 6 months 12 months 18 months 24 months ( n =114) ( n =65) ( n =31) ( n =6)

Takeaways • Several 1000’s published cases world-wide • Still controversial • Held to higher level of scrutiny • Excellent patient satisfaction • Excellent weight loss • Excellent co-morbidity improvement

• 8 European centers • 313 patient with T2DM • MGB in 55.9% • VSG in 44.1% • Pouch 15 ± 2.5 cm long, GJ at 195 ± 25.5 cm • 1 year F/U in 63.7% • 85.7% of those eligible for 1 yr f/u

Safety

Takeaways • OAGB has “very acceptable” risk • Similar to VSG • Outperforms VSG • Weight loss • T2DM remission • Reduction in BP

Operation LSG (339) RYGB (295) OAGB (333) Mean BMI 35 42.5 56.5 Age 23 38 46.5 Female 45.4% 71.2% 70.4% T2DM 24.5 32.5 75.9 HTN 26.5 38.3 68.7 Dyslipidemia 23.3 36.3 60.7 Complete F/ 97 (28.6%) 143 (48.5%) 167 (50.2) U • Mean F/U of 53.5 (20-87) months

Complications Procedure LSG RYGB OAGB Number performed 339 295 473 Leaks 5 1 0 Mild hypoalbuminemia (2.5-3.5) 0 6 44 Severe hypoalbuminemia (<2.5) 0 0 18 Anemia 12 14 23 GERD 32 5 3 Internal hernia 0 6 0 Dumping 0 8 28 Mortality 7 1 0 Excess weight loss < 50% 45 19 0 Weight regain 48 25 0

Comorbidity Resolution Cases LSG RYGB OAGB Total number with T2DM 23 33 62 Number with remission 13 25 59 Percentage 56.5 75.8 95.1 Total number with HTN 30 47 48 Number with remission 14 34 41 Percentage 46.7 72.3 85.4 Total number with dyslipidemia 21 50 45 Number with remission 11 37 42 Percentage 52.4 74.0 93.3

Takeaways • “OAGB is the effective and safe procedure for patients who are compliant in taking their supplements.” • “LSG may be done in non-compliant patients and those ready to accept weight regain.”

• Complete F/U in 126 of 175 (72%) • Gastric tube over 32 Fr bougie • Gastrojejunostomy 200 cm from ligament of Treitz • PPIs for 6 months

Early Complications Early mortality (< 3 months) 0 Early complications (< 3 months) 10 (7.9%) Major complications 7 (5.5%) Peri-anastomotic abscess 1 (0.8%) Peritonitis due to a traumatic injury of the afferent loop 1 (0.8%) Intra-abdominal bleeding 1 (0.8%) Port site herniation 3 (2.4%) Anastomotic stricture 1 (0.8%) Minor complications 3 (2.4%) Marginal ulcer 1 (0.8%) Deep vein thrombosis 1 (0.8%) Minor wound infection 1 (0.8%) • Reoperations in 6 (4.8%)

Late Complications • Reoperation in 6 (4.8%) • Marginal ulcer in 5 (4%) • Iron deficiency anemia in 4 (3.2%)

Outcomes • %Excess BMI Loss: 71.5% ± 26.5 • Avg BMI 47 → 31 at 5 yr • Weight regain in 4 (3.2%) • Pouch revision in 3 • Severe malnutrition in 2 (1.6%) • Revision operation being considered

Outcomes Before OAGB 60 months after OAGB P (n = 126) (n = 126) Hypertension 48 (38%) 23 (18.5%) < 0.001 Hyperlipidemia 31 (25%) 6 (5%) < 0.001 Joint pain 52 (41%) 33 (26.5%) 0.014 Type 2 diabetes • Complete T2DM remission in 82% 28 (22%) 5 (4%) < 0.001 Sleep apnea 24 (19.5%) 12 (9.5%) 0.029

• 31 published articles prior to December 2014 • 16 single-arm case studies • 15 comparison studies • LAGB vs OAGB (8) • LSG vs OAGB (6) • RYGB vs OAGB (5)

Outcomes • Operative time ≈ 50 to 90 min • Early complications (1 – 2%) • Bleeding, leak, wound infection • Late complications (2 – 8%) • Bile reflux, marginal ulcer, iron deficiency • Low mortality rate (< 1%)

Versus LAGB Remission of T2DM Post-op BMI

Versus LSG 1-Year %EWL Remission of T2DM

Versus LSG Revision Surgery Rate

Versus RYGB Operative Time Revision Surgery Rate 1-Year %EWL

Versus RYGB Remission of T2DM

Role of OAGB

Bariatric Surgery Algorithm • Patient • • Not binge Binge eating eating • T2 DM • GERD – • GERD + • T2 DM – + • • • • GERD + • GERD + • DS BPD GERD – GERD – • RYGB • OAGB • Sleeve Himpens, Surg Endo , 2015

One Anastomosis Gastric Bypass • Surge of international interest • May offer advantages over VSG and RYGB in select patients • Merits further investigation, ideally with randomized controlled trials

Thank You