Laparoscopic Roux-en-Y versus mini-gastric bypass for the treatment of morbid obesity: a prospective randomized controlled clinical trial

Clinical practice guidelines of the European Association for Endoscopic Surgery (EAES) on bariatric surgery: update 2020 endorsed by IFSO-EC, EASO and ESPCOP

BACKGROUND

Surgery for obesity and metabolic diseases has been evolved in the light of new scientific evidence, long-term outcomes and accumulated experience. EAES has sponsored an update of previous guidelines on bariatric surgery.

METHODS

A multidisciplinary group of bariatric surgeons, obesity physicians, nutritional experts, psychologists, anesthetists and a patient representative comprised the guideline development panel. Development and reporting conformed to GRADE guidelines and AGREE II standards.

RESULTS

Systematic review of databases, record selection, data extraction and synthesis, evidence appraisal and evidence-to-decision frameworks were developed for 42 key questions in the domains Indication; Preoperative work-up; Perioperative management; Non-bypass, bypass and one-anastomosis procedures; Revisional surgery; Postoperative care; and Investigational procedures. A total of 36 recommendations and position statements were formed through a modified Delphi procedure.

CONCLUSION

This document summarizes the latest evidence on bariatric surgery through state-of-the art guideline development, aiming to facilitate evidence-based clinical decisions.

Randomized Controlled Trial of One Anastomosis Gastric Bypass Versus Roux-En-Y Gastric Bypass for Obesity: Comparison of the YOMEGA and Taiwan Studies

BACKGROUND

The YOMEGA study (Y-study) was a randomized trial comparing one anastomosis gastric bypass (OAGB) and Roux-en-Y gastric bypass (RYGB). Here, we aim to compare the Y-study and our pioneer trial from Taiwan (T-study).

METHODS

Data from the Y-study and the T-study were collected and compared.

RESULTS

The Y-study recruited 234 patients with a mean body mass index (BMI) of 43.9 and age of 43.5 years. The T-study recruited 80 patients with a similar mean BMI of 44.3 and mean age of 31.4 years. The studies had similar findings including (1) OAGB is easier and possibly safer procedure than RYGB. Both studies showed that OAGB had a shorter operation time than RYGB, but a lower surgical complication rate was only demonstrated in T-study. (2) Both procedures have similar weight loss but OAGB features better glycemic control than RYGB. Weight loss at 2 years after surgery was similar between two procedures, but OAGB reduced HbA1c to a greater degree than RYGB at 2 years in Y-study (- 2.3% vs. - 1.3%; p = 0.025). The resolution of the metabolic syndrome was 100% for both groups in the T-study. (3) OAGB carried a higher risk of malnutrition. OAGB had more malabsorptive problems with a lower hemoglobin level than RYGB at 2 years after surgery. Adverse malnutrition events occurred in nine (7.8%) OAGB patients in the Y-study. Four (3.4%) patients of OAGB received revision surgery in Y-study but none in T-study. (4) Bile reflux was noted in OAGB patients but did not influence quality of life or revision rate. Y-study found that bile in the gastric pouch was present in 16% of patients in the OAGB group versus none in the RYGB, but no inter-group difference in quality of life was detected. There was a trend for RYGB patients to experience more abdominal pain than OAGB.

CONCLUSIONS

Both studies showed that OAGB is a technically easier procedure and features better glycemic control than RYGB, but has a mal-absorptive effect. However, the bile reflux and abdominal pain controversies persisted.

Missing Something? Comparisons of Effectiveness and Outcomes of Bariatric Surgery Procedures and Their Preferred Reporting: Refining the Evidence Base

Comparisons of effectiveness of bariatric surgery (BS) procedures encompass weight loss, metabolic/clinical outcomes, and improvements or worsening of comorbidities. Post-operative physical activity (PA) and diet influence such outcomes but are frequently not included in comparisons of effectiveness. We assessed the value and necessity of including post-operative PA/diet data when comparing effectiveness of BS. Including post-operative PA/diet data has significant benefits for BS and patients. The paper proposes an explicit preferred reporting system (Preferred REporting of post-operative PHYsical activity and Diet data in comparisons of BS effectiveness: PRE-PHYD Bariatric). Including post-operative PA/diet data could result in more accurate appraisals of effectiveness of BS procedures. This could translate into better 'individualized' BS by achieving a better 'fit' between patient and procedure.

One Anastomosis Gastric Bypass Versus Roux-en-Y Gastric Bypass for Morbid Obesity: an Updated Meta-Analysis

INTRODUCTION

We aim to review the available literature on morbidly obese patients treated with one anastomosis gastric bypass (OAGB) or Roux-en-Y gastric bypass (RYGB) in order to compare the clinical outcomes of the two methods.

METHODS

A literature search was performed in PubMed, Cochrane Library, and Scopus, in accordance with the PRISMA guidelines.

RESULTS

Sixteen studies were included in the qualitative analysis, and 11 studies were included in the quantitative analysis (meta-analysis), incorporating 12,445 patients. OAGB was associated with shorter mean operative time. The length of hospital stay was comparable between the two procedures. The incidence of leaks, marginal ulcer, dumping, bowel obstruction, revisions, and mortality was similar between the two approaches. The incidence of malnutrition was increased in patients treated with OAGB, while the incidence of internal hernia and bowel obstruction was greater in the RYGB group. In addition, the OAGB was associated with greater % excess weight loss (%EWL) at 1, 2, and 5 years postoperatively. The rate of diabetes remission was greater in the OAGB group. Nonetheless, the rate of hypertension and dyslipidemia remission was similar between OAGB and RYGB.

CONCLUSION

The present meta-analysis is the best currently available evidence on the topic and demonstrates the superiority of OAGB compared with RYGB, in terms of weight loss and diabetes remission. However, the OAGB was associated with a significantly higher incidence of malnutrition, thus indicating the significant malabsorptive traits of this operation.

Long-term consequences of one anastomosis gastric bypass on esogastric mucosa in a preclinical rat model

Although bariatric surgery is proven to sustain weight loss in morbidly obese patients, long-term adverse effects have yet to be fully characterized. This study compared the long-term consequences of two common forms of bariatric surgery: one-anastomosis gastric bypass (OAGB) and Roux-en-Y Gastric Bypass (RYGB) in a preclinical rat model. We evaluated the influence of biliopancreatic limb (BPL) length, malabsorption, and bile acid (BA) reflux on esogastric mucosa. After 30 weeks of follow-up, Wistar rats operated on RYGB, OAGB with a short BPL (15 cm, OAGB-15), or a long BPL (35 cm, OAGB-35), and unoperated rats exhibit no cases of esogastric cancer, metaplasia, dysplasia, or Barrett’s esophagus. Compared to RYGB, OAGB-35 rats presented higher rate of esophagitis, fundic gastritis and perianastomotic foveolar hyperplasia. OAGB-35 rats also revealed the greatest weight loss and malabsorption. On the contrary, BA concentrations were the highest in the residual gastric pouch of OAGB-15 rats. Yet, no association could be established between the esogastric lesions and malabsorption, weight loss, or gastric bile acid concentrations. In conclusion, RYGB results in a better long-term outcome than OAGB, as chronic signs of biliary reflux or reactional gastritis were reported post-OAGB even after reducing the BPL length in a preclinical rat model.

Standardization of Bariatric Metabolic Procedures: World Consensus Meeting Statement

BACKGROUND

Standardization of the key measurements of a procedure's finished anatomic configuration strengthens surgical practice, research, and patient outcomes. A consensus meeting was organized to define standard versions of 25 bariatric metabolic procedures.

METHODS

A panel of experts in bariatric metabolic surgery from multiple continents was invited to present technique descriptions and outcomes for 4 classic, or conventional, and 21 variant and emerging procedures. Expert panel and audience discussion was followed by electronic voting on proposed standard dimensions and volumes for each procedure's key anatomic alterations. Consensus was defined as ≥ 70% agreement.

RESULTS

The Bariatric Metabolic Surgery Standardization World Consensus Meeting (BMSS-WOCOM) was convened March 22-24, 2018, in New Delhi, India. Discussion confirmed heterogeneity in procedure measurements in the literature. A set of anatomic measurements to serve as the standard version of each procedure was proposed. After two voting rounds, 22/25 (88.0%) configurations posed for consideration as procedure standards achieved voting consensus by the expert panel, 1 did not attain consensus, and 2 were not voted on. All configurations were voted on by ≥ 50% of 50 expert panelists. The Consensus Statement was developed from scientific evidence collated from presenters' slides and a separate literature review, meeting video, and transcripts. Review and input was provided by consensus panel members.

CONCLUSIONS

Standard versions of the finished anatomic configurations of 22 surgical procedures were established by expert consensus. The BMSS process was undertaken as a first step in developing evidence-based standard bariatric metabolic surgical procedures with the aim of improving consistency in surgery, data collection, comparison of procedures, and outcome reporting.

Multidisciplinary Management of Leaks After One-Anastomosis Gastric Bypass in a Single-Center Series of 2780 Consecutive Patients

PURPOSE

Few data exist in the literature concerning leaks after one-anastomosis gastric bypass (OAGB). Our aim was to describe the incidence, presentation, and management of leaks after OAGB.

SETTING

A private clinic in France.

METHODS

Between May 2010 and December 2017, 2780 consecutive patients underwent OAGB. A retrospective chart review was performed on the 46 patients (1.7%) who experienced postoperative leaks.

RESULTS

Leaks arose from the anastomosis in 6 cases (13%) and from the gastric pouch in 27 cases (59%), while the remaining 13 patients (28%) had leaks from an undetermined origin. Management followed a standardized algorithm taking into consideration the clinical situation and findings on an oral contrast computed tomography (CT) scan. All patients were treated by fasting, total parenteral nutrition, and antimicrobial therapy. Nine patients (20%) could be managed by medical treatment only, 13 patients (28%) underwent laparoscopic management (washout and drainage plus T-tube placement in 5 cases or conversion to Roux-en-Y gastric bypass (RYGB) in one case). The remaining 23 patients (50%) were managed by percutaneous drainage and/or endoscopy. No mortality was observed; the major morbidity rate was 20%. The median length of a hospital stay was 17 days (5-80).

CONCLUSION

Management of leaks after OAGB depends on clinical conditions and presence, size, and location of an abscess and/or a fistula. If endoscopy and interventional radiology are available, reoperation can be avoided in most patients. In most leaks at the gastrojejunal anastomosis, inserting a T-tube in the leak orifice avoids the necessity for conversion to RYGB.

Mini/One Anastomosis Gastric Bypass Versus Roux-en-Y Gastric Bypass as a Second Step Procedure After Sleeve Gastrectomy-a Retrospective Cohort Study

BACKGROUND

Whether one anastomosis gastric bypass (OAGB) or Roux-en-Y gastric bypass (RYGB) is a better revisional bariatric surgery (RBS) after sleeve gastrectomy (SG) is still under debate. The aim is to compare short-term outcomes of RYGB and OAGB as a RBS after SG, pertaining to their effects on weight loss, resolution of comorbidities, and complications.

METHODS

We performed a single-center analysis of 55 patients (n = 34 OAGB, n = 21 RYGB). Indications for revisional surgery included weight regain/loss failure (67%) and intractable gastroesophageal reflux disease (33%). Data were collected up to 1-year follow-up (FU) and included time of revisional surgery, operation time, weight, body mass index, excess weight loss, and total weight loss (TWL), both in percent, complications and resolution of comorbidities.

RESULTS

Operation time was 79 ± 36 (OAGB-MGB) and 98 ± 24 min (RYGB) (p = 0.03). In the first 30 postoperative days, three patients in the RYGB group, and no patient in the OAGB group, had postoperative complications. FU was 100%. Minor complication rates at 12 months were 33.3% (RYGB) and 35.3% (OAGB). At 12 months, mean % TWL was 10.3 ± 7.6% (RYGB) and 15.8 ± 7.8% (OAGB) (p = 0.0132).

CONCLUSIONS

OAGB after failed SG was found to be a quicker procedure with less perioperative complications. At 1-year FU, no significant differences were seen between RYGB and OAGB regarding readmission and minor complications. Still long-term FU including the risk of malnutrition is needed to have a complete evaluation of OAGB as a RBS for the future.

Efficiency and risks of one-anastomosis gastric bypass

The single-anastomosis gastric bypass has been proposed as a simpler and efficient weight loss reducing surgery. Postoperative outcomes are comparable to those of contemporary popular procedures. There are, however, controversies regarding the efficiency and risks of one-anastomosis gastric bypass (OAGB). The purpose of this review is to define the role of OAGB in metabolic surgery via its operative outcomes. A review of English language literature was performed using the PubMed database, basing the search on the following keywords: “one-anastomosis gastric bypass” AND “outcomes”. A total of 238 articles were considered for review. Following thorough screening and selection criteria, 7 articles were considered sufficient for assessment. The nature of the available evidence of this technique poses a challenge to OAGB in its establishment as a standard of care procedure. The anatomical configuration following surgery, as well as the metabolic implications of its hypo-absorptive nature, raises controversial and ongoing concerns that are yet to be addressed. Hence, prospective studies with long-term follow-up (>5 years) can bypass these concerns and allow the progression of the clinical practice of OAGB.

The learning curve of one anastomosis gastric bypass and its impact as a preceding procedure to Roux-en Y gastric bypass: initial experience of one hundred and five consecutive cases

Background

The aim of this study was to assess the learning curve of one anastomosis gastric bypass (OAGB-MGB) at the start of a low volume bariatric unit and analyze its impact as a preceding procedure to Roux-en Y gastric bypass (RYGB).

Methods

From January 2014 to December 2017, all patients who underwent bariatric surgeries in our teaching hospital that were performed by the same surgeon were enrolled. The first 47 patients who underwent OAGB-MGB were assigned to group A. RYGB has been offered as a treatment option since July 2016; thereafter, 26 patients who underwent OAGB-MGB and 32 patients who underwent RYGB at the same time interval were assigned to group B and group C, respectively. Baseline characteristics, perioperative outcomes and percentage of total weight loss (%TWL) up to 12 months postoperatively were collected and analyzed between groups.

Results

Compared to the patients in group C, those in groups A and B were older (39.4 yrs. and 42.2 yrs., respectively, vs. 34.2 yrs.; p = 0.021) and predominantly male (48.9 and 73.1%, respectively vs. 40.6%; p = 0.04), and they had a higher body mass index (41.8 kg/m² and 43.3 kg/m², respectively vs. 37.7 kg/m²; p = 0.002) and a higher incidence of hypertension (44.7 and 61.5%, respectively vs. 21.9%; p = 0.008). In addition, the operation time was significantly reduced (118.2 min and 115.8 min, respectively vs. 153.1 min; p <  0.001), and the length of stay was shortened (3.0 days and 2.9 days, respectively vs. 3.4 days; p = 0.002) in groups B and C compared to group A. No mortality, conversion or leakage was reported throughout the study period. The 30-day complication rate was decreased in group C compared to groups A and B (0% vs. 6.4 and 7.7%, respectively; p = 0.307). The %TWL at the 12-month follow-up was 36.3, 30.9 and 28.3% for groups A, B and C, respectively (p <  0.001).

Conclusion

Our study verified the early emergence of a learning curve effect for OAGB-MGB, and the proficiency acquired can be transferred to subsequent practice for RYGB in terms of acceptable operation time and length of stay without an increase in complications.

Weight loss after one-anastomosis/mini-gastric bypass - The impact of biliopancreatic limb: A retrospective cohort study

Background

One-anastomosis/mini-gastric bypass (OAGB/MGB), as a popular bariatric surgery method, has many advantages; however, the biliopancreatic limb length (BPL) in this surgery is under debate. The aim of the study was to evaluate the effect of BPL on weight-loss outcome after OAGB/MGB.

Materials and Methods

A retrospective cohort study was performed on 653 patients who underwent OAGB/MGB with adjusted BPL based on preoperative body mass index (BMI) and patient's age, between 2010 and 2015 with 12-month follow-ups. Weight-loss outcomes and complications were analyzed in these patients, considering BPL.

Results

Weight, age, sex, and type 2 diabetes mellitus were the most contributory predictors as independent predictors of 12-month excess weight loss, respectively, and BPL was the least contributory predictor.

Conclusion

Tailoring BPL in OAGB/MGB based on patient's age and preoperative BMI seems to have acceptable results.

Outcomes After Metabolic Surgery in Asians-a Meta-analysis

BACKGROUND

Obesity and type 2 diabetes mellitus (T2DM) are now increasingly epidemic in Asia. As obesity and T2DM have different disease patterns in Asians compared to Westerners, outcomes after metabolic surgery may differ. The aim of this meta-analysis was to gather the current available evidence on the outcomes after metabolic surgery in Asians.

METHODS

A literature search was conducted in September 2017. Four outcome measures were examined: (1) % excess weight loss (EWL), (2) post-intervention body mass index (BMI), (3) T2DM resolution or improvement, and (4) hypertension resolution.

RESULTS

Thirteen publications with a total of 1052 patients were analyzed, of which nine were randomized controlled trials, and four were case-matched studies. All the studies had a minimum follow-up duration of at least 1 year. % EWL was significantly higher in those who have undergone Roux-en-Y gastric bypass (RYGB) (SMD 0.53, 95% CI 0.12 to 0.94) versus sleeve gastrectomy (SG). T2DM resolution/improvement was favorable in those who have undergone RYGB (pooled OR 1.39, 95% CI 0.53 to 3.67) versus SG, although not statistically significant. Hypertension resolution was not significantly different between patients who have undergone SG versus RYGB (pooled OR 0.96, 95% CI 0.44 to 2.11).

CONCLUSION

RYGB results in better weight loss compared to SG in Asians, but the rate of T2DM resolution/improvement and improvement of hypertension appears to be similar. In Asian patients without symptoms of gastro-esophageal reflux disease in whom metabolic surgery is performed mainly for T2DM and metabolic syndrome, SG may be the surgery of choice.

Short- and Mid-term Outcomes of 527 One Anastomosis Gastric Bypass/Mini-Gastric Bypass (OAGB/MGB) Operations: Retrospective Study

BACKGROUND

One anastomosis gastric bypass/mini-gastric bypass (OAGB/MGB) is considered an alternative option in metabolic and bariatric surgery. The aim of this study was to evaluate the safety, efficacy and postoperative challenges of OAGB/MGB as a new procedure.

METHODS

We performed 519 primary MGBs and 8 additional second-stage MGBs during 2014-2018. The data were collected from patients' notes as well as the surgeons' prospective data sheets. Two senior surgeons performed the operations. The ultimate primary measures were assessment of the safety and management of the complications. The secondary outcomes were excess weight loss and resolution of the comorbidities.

RESULTS

The type 2 diabetes mellitus (T2DM) remission rate was 83% and 70% over 1 and 3 years, respectively (HBA1C < 6.5%). Weight loss was 28-152 kg (SD 23.11). Excess weight loss ranged from 41 to 125%. Hypertension resolution was 61%, 58% and 58% in the first, second and third years, respectively. Ninety-nine per cent of sleep apnoea patients improved symptomatically and went off the continuous positive airway pressure (CPAP) machine. Two (0.37%) patients developed diarrhoea, cured by shortening the afferent biliopancreatic limb (BPL). Eight (1.5%) stomal ulcers were reported. Two patients (0.37%) developed deranged liver function, revised by shortening the BPL in one patient and a reversal in the second patient. The mean follow-up was 2.5 years. Mortality was zero.

CONCLUSIONS

This is the largest UK OAGB/MGB study to date showing safety and acceptable results for metabolic syndrome and obesity problems. OAGB/MGB revisional options are rectifying the morbidity and no mortality.

Prospective randomized controlled trial comparing the efficacy and safety of Roux-en-Y gastric bypass and one-anastomosis gastric bypass (the RYSA trial): trial protocol and interim analysis

INTRODUCTION

There is a lack of prospective studies comparing Roux-en-Y gastric bypass (RYGB) and one-anastomosis gastric bypass (OAGB). Also, the effects of bariatric surgery and weight loss need a deeper understanding through metabolic studies. We describe the trial protocol and interim analysis of a prospective randomized controlled study comparing RYGB and OAGB: the RYSA trial.

MATERIALS AND METHODS

In total, 120 bariatric patients will be randomized between RYGB and OAGB in two academic centers. All patients will be followed up for 10 years with analysis and measurements of weight, comorbidities, blood tests, body composition and questionnaires. Extensive metabolic analyses (mixed meal tests, energy expenditure, biopsies of muscle and subcutaneous fat, urine, saliva and fecal samples) will be carried out in the Obesity Research Unit, University of Helsinki, for all patients treated at the Helsinki University Hospital (80 patients) at baseline, 6 months and 12 months. Bile reflux will be studied for the OAGB group at the Helsinki University Hospital at 6 months with gastroscopy and scintigraphy.

RESULTS

At an interim analysis at 3 months (half-way) through recruitment (30 RYGB and 30 OAGB patients) there have been no deaths and no intensive care unit admittances. One patient in both groups required additional gastroscopy, with anastomosis dilatation in the RYGB group but with no additional intervention in the OAGB group.

CONCLUSION

The trial can be safely carried out. Recruitment is estimated to be complete by the end of 2019.

TRIAL REGISTRATION

Clinical Trials Identifier NCT02882685. Registered on August 30th 2016.

LSG vs MGB-OAGB-3 Year Follow-up Data: a Randomised Control Trial

AIM

The objective of this study is to compare 3-year follow-up results of one anastomosis gastric bypass (MGB-OAGB) and laparoscopic sleeve gastrectomy (LSG) in terms of weight loss, complications, resolution of comorbidities and quality of life.

MATERIALS AND METHODS

A prospective randomised study of results between 100 LSG patients and 101 MGB-OAGB patients was done from 2012 to 2015. The results were compared regarding operative outcomes, percentage of excess weight loss (%EWL), complications, resolution of comorbidities and quality of life (BAROS score) at 3 years follow-up.

RESULTS

Follow-up was achieved in 93 MGB-OAGB vs 92 LSG patients for 3-year period. The average %EWL for MGB-OAGB vs LSG was 66.48 vs 61.15% at the end of 3 years respectively, which was statistically insignificant. Diabetes remission was seen in 89.13% of MGB-OAGB patients and 81.82% of LSG patients. Remission of hypertension was seen in 74% of MGB-OAGB patients and 72.22% of LSG patients. Bariatric analysis reporting and outcome system (BAROS) with comorbidity in LSG patients and MGB-OAGB patients was 6.03 and 6.96 respectively, whereas in patients without comorbidity, BAROS score was 3.86 in LSG group and 4.34 in MGB-OAGB group.

CONCLUSIONS

In our study, at 36 months follow up, there was no significant difference between LSG and MGB-OAGB in %EWL and remission of HTN. Type 2 diabetes mellitus (T2DM) remission rates were higher after MGB-OAGB as compared to LSG but the difference was statistically insignificant. MGB-OAGB patients with comorbidities have a better quality of life and BAROS score compared to LSG patients.

Results of The Comparative Study of 200 Cases: One Anastomosis Gastric Bypass vs Roux-en-Y Gastric Bypass

INTRODUCTION

Obesity has experienced worldwide increase and surgery has become the treatment that has achieved the best results. Several techniques have been described; the most popular are vertical gastrectomy (GV) and the Roux-en-Y gastric bypass (RYGB). However, mini-gastric bypass/one anastomosis gastric bypass (MGB/OAGB) has gained popularity due to its simplicity and good results.

OBJECTIVE

To comparatively evaluate the results of MGB/OAGB with those of RYGB with 1-year follow-up.

METHODS

The paper presents a comparative case and control study of 100 patients that underwent MGB/OAGB surgery and another 100 with RYGB surgery, operated between 2008 and 2016. Patients were not submitted to revision surgery and had the following pre-operative variables: age 40.46 ± 12.4 vs. 39.43 ± 10.33 years; sex 64 and 54 women, 36 and 46 men; BMI 44.8 ± 12.06 and 45.29 ± 8.82 kg/m²; 50 and 54 cases with comorbidities, respectively, these being non-significant differences.

RESULTS

The surgical time was 69.01 ± 4.62 (OAGB) vs. 88.98 ± 3.44 min; the time of hospitalization was 2 days, reaching a BMI of 27.7 ± 7.85 and 29 ± 4.52 kg/m², with an excess weight loss 1 year after surgery of 89.4 vs. 85.9%, respectively. The morbidity rates are 9% for OAGB and 11% for the RYGB. There was a comorbidity resolution of 84.4 and 83.7% respectively, without mortality.

CONCLUSIONS

The results show the benefits of both techniques, OAGB being the easiest to perform and with less surgical time.

Mini Gastric Bypass-One Anastomosis Gastric Bypass (MGB-OAGB)-IFSO Position Statement

PREAMBLE

The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) has played an integral role in educating both the metabolic surgical and the medical community at large about the role of innovative and new surgical and/or endoscopic interventions in treating adiposity-based chronic diseases.The mini gastric bypass is also known as the one anastomosis gastric bypass. The IFSO has agreed that the standard nomenclature should be the mini gastric bypass-one anastomosis gastric bypass (MGB-OAGB). The IFSO commissioned a task force (Appendix 1) to determine if MGB-OAGB is an effective and safe procedure and if it should be considered a surgical option for the treatment of obesity and metabolic diseases.The following position statement is issued by the IFSO MGB-OAGB task force and approved by the IFSO Scientific Committee and Executive Board. This statement is based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence. It will be reviewed in 2 years.

Measuring the small bowel length may decrease the incidence of malnutrition after laparoscopic one-anastomosis gastric bypass with tailored bypass limb

BACKGROUND

Laparoscopic one (single)-anastomosis gastric bypass (OAGB) is an effective and durable treatment for morbidly obese patients. However, the ideal length of the small bowel bypass remains controversial.

OBJECTIVES

The study aimed to report the clinical results of using a tailored bypass based on the total length of the small bowel.

SETTING

Academic medical center.

METHODS

Since 2005, we have performed OAGB with tailored limb according to preoperative body mass index. From July 2014, we modified our technique, measuring the whole small bowel length to keep the common channel at least 400-cm long. Data from 470 patients treated with the new technique (Group II) were compared with those of a matched group treated with tailored bypass only (Group I). The preoperative clinical data and outcomes were analyzed. All clinical data were prospectively collected and stored.

RESULTS

Both groups had similar clinical profiles at baseline. All procedures were completed laparoscopically. Group II had a significant longer operation time (161.9 versus 122.6 min; P < .001), but shorter hospital stay (2.9 versus 5.3 d; P < .001) and lower complication rate (.2% versus 1.5%; P = .002) than Group I. One year after surgery, the mean body mass index (27.4 versus 26.8 kg/m²; P = .244), percent total weight loss (32.0% versus 34.0%; P = .877), and diabetes remission rate (84.7% versus 84.1%; P = .876) were comparable between the 2 groups. However, Group II patients had a significantly lower incidence of anemia (5.9% versus 11.1%; P < .001), secondary hyperparathyroidism (21.7% versus 33.8%; P < .001) and hypoalbuminemia (1.5% versus 2.8%; P < .001) than did Group I.

CONCLUSION

Routine measurement of the whole bowel length to keep the common channel at least 400-cm long may reduce the incidence of malnutrition after OAGB with tailored limb bypass, without compromising efficacy in weight loss and diabetes resolution.

Fitobezoar posterior a mini bypass gástrico por laparoscopia

Introducción. La miniderivación (mini-bypass) gástrica por laparoscopia es un procedimiento bariátrico que recientemente ha cobrado popularidad. Las alteraciones del tubo digestivo generadas por estos procedimientos pueden ocasionar diversas complicaciones, algunas raras, como los bezoares. Caso clínico. Se presenta el caso de una mujer de 52 años de edad con antecedentes de diabetes mellitus y obesidad, que fue tratada con una miniderivación gástrica por laparoscopia. Nueve meses después del procedimiento, presentó dolor en el epigastrio, intolerancia a los alimentos y vómito, por lo cual se dio tratamiento sintomático sin obtener mejoría. Se practicó una endoscopia de vías digestivas altas, cuyo hallazgo fue un bezoar de coco que obstruía parcialmente la anastomosis. El bezoar se trituró y se extrajo por endoscopia. Discusión. Los pacientes con antecedentes de cirugía bariátrica tienen mayor riesgo de presentar bezoares por la modificación del tubo digestivo. Estos pacientes presentan frecuentemente síntomas de dispepsia, por lo que la sintomatología inespecífica puede confundirse o subestimarse. Se debe considerar practicar una endoscopia en todos aquellos con antecedentes de cirugía bariátrica que presenten vómito persistente después de ingerir alimentos o síntomas de obstrucción gástrica.

OAGB vs BGBP: A retrospective comparative study of a cohort of patients who had bariatric surgery in 2012 at one centre by a single surgeon

Two modifications of Roux-en-Y gastric bypass (RYGB), one anastomosis gastric bypass (OAGB) and Roux-en-Y banded gastric bypass (BGBP), are gaining popularity in use because the OAGB is reported to be a simpler operation, and the BGBP is reported to have sustained weight loss compared to standard RYGB. A retrospective review and analysis of data comparing outcomes up to 5 years after BGBP and OAGB from a prospectively maintained database of all bariatric metabolic operations in 2012 was performed. Eighty-two patients underwent a BGBP and 90 an OAGB. The average age and body mass index were 44.12 and 43.97 and 43.57 and 45.79 in the BGBP and OAGB groups, respectively. Postoperative nutrient deficiencies were similar in both groups but were more prominent in the OAGB group. The % excess body weight loss (%EBWL) was 78% and 71.5% at 5 years in the OAGB and BGBP groups, respectively. The % total weight loss (%TWL) was also higher in OAGB compared to the BGBP group, 34.72% and 30.49%, respectively. Resolution of type 2 diabetes (T2DM) was significantly higher in the OAGB group, 79.16%, than in the BGBP group, 71.42%. The resolution of dyslipidaemia and hypertension were similar in both groups, but sleep apnoea resolution was higher in OAGB group. Both operations produced excellent weight loss in the intermediate term. The %EBWL and resolution of T2DM were significantly higher after the OAGB operation at the expense of increased incidence of nutrient deficiencies and hypoproteinemia. Quality of life improvement and patient satisfaction were high after both operations. Long-term follow up and multicentre prospective studies are needed to confirm these intermediate outcomes.

Retrospective cohort study of 925 OAGB procedures. The UK MGB/OAGB collaborative group

BACKGROUND

Mini-One Anastomosis Gastric Bypass is a new operation that provides comparable outcomes to the common bariatric procedures. Revisional surgery is still needed after a number of MGB-OAGB procedures. The aim of this study is to report the causes and management of these revisions.

METHODS

From 2010 to 2018, 925 MGB-OAGB operations were performed at 7 bariatric units across the United Kingdom and included in this retrospective cohort study. The data was retrospectively collected and analysed. The primary end point was the identification of the causes and management of revisions. Follow up ranged from 6 months to 3 years.

RESULTS

Twenty-two patients [2.3%] required revisional surgery after MGB-OAGB. Five patients [0.5%] developed severe diarrhoea managed by shortening the bilio-pancreatic limb to 150 cm. Four patients [0.4%] developed afferent loop syndrome and bile reflux was reported in another 3 [0.3%] cases; all were managed by either conversion to Roux en Y Gastric Bypass or a Braun anastomosis. Postoperative bleeding was controlled laparoscopically in 3 patients [0.3%]. Liver decompensation that was reported in 2 patients [0.2%] was treated by shortening the BPL in one patient and a reversal to normal anatomy in another. The liver failure resolved in both patients. Other indications for revision included two gastro-jejunal stenosis [0.2%], one perforated ulcer [0.1%], one patient [0.1%] with excessive weight loss and one case [0.1%] of protein malnutrition. None of the 22 patients undergoing revisional surgery after MGB-OAGB died. Lost to follow up rate was 0.2%.

CONCLUSION

Complications requiring revisional surgery after MGB-OAGB are uncommon [2.3%] and the majority can be managed by bilio-pancreatic limb shortening, the addition of a Braun side-to-side anastomosis or conversion to RYGB. Bilio-pancreatic limb length of 200 cm or more resulted in serious complications of liver failure, protein malnutrition, excessive weight loss and diarrhoea.

Outcomes of Long Pouch Gastric Bypass (LPGB): 4-Year Experience in Primary and Revision Cases

BACKGROUND

One of the most important complications of the one anastomosis gastric bypass (OAGB) is enterobilio acid reflux (EBAR). We report the concept of the long pouch Roux-en-Y gastric bypass (LPRYGB) meaning a Roux-en-Y with a long pouch and a 100-cm alimentary limb to avoid EBAR, with a long biliopancreatic limb to increase metabolic effects.

METHODS

A total of 300 LPRYGB cases in a 4-year period, with a 90% follow-up rate, were analysed. Anthropometric, technical feasibility, morbidity, weight loss and comorbidity outcomes were analysed.

RESULTS

The percentage total weight loss (%TWL) was 30.5% at 4 years of follow-up (32.3% in primary and 28.3% in revisions). Six intra-operative (2%) and 28 postoperative complications (9.3%) were seen. Out of this 28 complications, 11 (3.6%) were late complications. Reoperations were performed in 15 patients (5.0%). Clinically relevant EBAR was present in 3 cases only (1%) 4 years after the operation.

CONCLUSIONS

The LPRYGB combines the main advantages of the OAGB (light restriction and moderate malabsorption) with the anti-reflux effect from the Roux-en-Y diversion.

The long term microbiota and metabolic status in patients with colorectal cancer after curative colon surgery

Whether there are subsequent changes of metabolic profiles and microbiota status after partial colectomy remains unknown. We evaluated and compared long-term effects of microbiota status and metabolic profiles in early colorectal cancer (CRC) patients after curative colectomy to the controls. In this cross-sectional study, we analyzed metabolic syndrome occurrence in 165 patients after curative partial colectomy with right hemicolectomy (RH) or low anterior resection (LAR) and 333 age-sex matched controls. Fecal samples from some of those with RH, LAR, and controls were analyzed by next-generation sequencing method. The occurrences of metabolic syndrome were significantly higher in patients after RH, but not LAR, when compared with the controls over the long term (> 5 years) follow-up (P = 0.020). Compared with control group, RH group showed lower bacterial diversity (P = 0.007), whereas LAR group showed significantly higher bacterial diversity at the genera level (P = 0.016). Compared with the control group, the principal component analysis revealed significant differences in bacterial genera abundance after RH and LAR (P < 0.001). Furthermore, the Firmicutes to Bacteroidetes ratio was significantly lower in the RH group than the control group (22.0% versus 49.4%, P < 0.05). In conclusion, early CRC patients after RH but not LAR were associated with a higher occurrence of metabolic syndrome than the controls during long-term follow-up. In parallel with metabolic change, patients with RH showed dysbiosis with a tendency to decreased richness and a significant decrease in the diversity of gut microbiota.

Liver transplantation for bariatric surgery-related liver failure: a systematic review of a rare condition

BACKGROUND

Protein malnutrition and bacterial overgrowth occurring after bariatric surgery (BS) might cause severe liver failure (LF) needing liver transplantation (LT).

OBJECTIVES

To evaluate indications and outcomes of LT for BS-related LF.

SETTING

University hospital in France.

METHODS

The EMBASE, MEDLINE, and COCHRANE central databases were systematically searched according to the PRISMA criteria from inception up through December 2017 for articles describing LT for LF after BS.

RESULTS

Fourteen studies reporting 36 patients listed for LT, of which 32 underwent the procedure, were retained. The types of previously performed BS included jejunoileal bypass (n = 16), bilio-pancreatic diversion according to Scopinaro (n = 14) or with duodenal switch (n = 3), bilio-intestinal bypass (n = 1), long-limb Roux-en-Y gastric bypass (n = 1), and single anastomosis omega gastric bypass (n = 1). Liver failure developed a median of 20 months after BS (mean ± SD: 105 ± 121 mo; range, 5-300 mo). This interval of time was significantly shorter after biliopancreatic diversion than jejunoileal bypass (mean ± SD: 22 ± 21 mo versus 269 ± 27 mo; P = .0001). Four patients (11.1%) died while on the waiting list for LT, and 4 more (12.5%) died after LT. Morbidity and liver retransplantation were reported in 8 (25%) and 2 (6.2%) patients, respectively. Twenty-one patients (65.6%) had their BS procedure reversed (1 patient before, 15 patients during, and 5 patients after LT, respectively). Biopsy-proven steatosis recurrence after LT was reported in 6 patients (18.7%), 4 of whom did not have BS reversal.

CONCLUSIONS

Severe LF occurring after BS, although rare, might require LT. When indicated, LT is effective at restoring liver function, even when BS reversal is performed synchronously.

Lipid profile change after bariatric surgeries: laparoscopic gastric plication versus mini gastric bypass

INTRODUCTION

Bariatric surgeries are known to have profound effects on lipid profile. Laparoscopic gastric plication (LGP) has been shown to have a comparable effect on weight loss rather than Roux-en-Y gastric bypass (RYGB) and mini gastric bypass (MGB). But the post-operative effect on lipid profile is not well-compared. We aimed to compare post-operative lipid profile change after LGP and MGB.

METHODS

In a retrospective analysis, we reviewed 91 patients for at least 12 months. Patients were assigned to undergo either LGP (71 patients) or MGB (20 patients). Preoperative and postoperative visits were accomplished and weight, BMI, fasting blood glucose (FBG) and lipid profile including triglyceride (TG), and total cholesterol (TC) levels were repeatedly measured. Follow up rate for the first year was 100%.

RESULTS

LGP significantly decreased both TG and TC levels in each follow up (all p values < .05). The same trends were observed in BMI reduction, total body weight loss percentage, and FBG. When comparing either TC or TG level between LGP and MGB, there was just one statistically significant result in TG reduction at 6 months (p value = .042) while MGB showed more reduction. All other variables in different follow up visits were not significantly different between two techniques.

CONCLUSIONS

LGP would result in lipid profile improvement lasting at least for one year. Lipid-lowering effect seems to be similar between LGP and MGB. This lipid-lowering property and weight reduction might be indicative that LGP is an alternative for RYGB and MGB in selective patients.

Efficacy and safety of one anastomosis gastric bypass versus Roux-en-Y gastric bypass for obesity (YOMEGA): a multicentre, randomised, open-label, non-inferiority trial

BACKGROUND

One anastomosis gastric bypass (OAGB) is increasingly used in the treatment of morbid obesity. However, the efficacy and safety outcomes of this procedure remain debated. We report the results of a randomised trial (YOMEGA) comparing the outcomes of OAGB versus standard Roux-en-Y gastric bypass (RYGB).

METHODS

This prospective, multicentre, randomised non-inferiority trial, was held in nine obesity centres in France. Patients were eligible for inclusion if their body-mass index (BMI) was 40 kg/m² or higher, or 35 kg/m² or higher with the presence of at least one comorbidity (type 2 diabetes, high blood pressure, obstructive sleep apnoea, dyslipidaemia, or arthritis), and were aged 18-65 years. Key exclusion criteria were a history of oesophagitis, Barrett's oesophagus, severe gastro-oesophageal reflux disease resistant to proton-pump inhibitors, and previous bariatric surgery. Participants were randomly assigned (1:1) to OAGB or RYGB, stratified by centre with blocks of variable size; the study was open-label, with no masking required. RYGB consisted of a 150 cm alimentary limb and a 50 cm biliary limb and OAGB of a single gastrojejunal anastomosis with a 200 cm biliopancreatic limb. The primary endpoint was percentage excess BMI loss at 2 years. The primary endpoint was assessed in the per-protocol population and safety was assessed in all randomised participants. This study is registered with ClinicalTrials.gov, number NCT02139813, and is now completed.

FINDINGS

From May 13, 2014, to March 2, 2016, of 261 patients screened for eligibility, 253 (97%) were randomly assigned to OAGB (n=129) or RYGB (n=124). Five patients did not undergo their assigned surgery, and after undergoing their surgery 14 were excluded from the per-protocol analysis (seven due to pregnancy, two deaths, one withdrawal, and four revisions from OAGB to RYGB) In the per-protocol population (n=117 OAGB, n=117 RYGB), mean age was 43·5 years (SD 10·8), mean BMI was 43·9 kg/m² (SD 5·6), 176 (75%) of 234 participants were female, and 58 (27%) of 211 with available data had type 2 diabetes. After 2 years, mean percentage excess BMI loss was -87·9% (SD 23·6) in the OAGB group and -85·8% (SD 23·1) in the RYGB group, confirming non-inferiority of OAGB (mean difference -3·3%, 95% CI -9·1 to 2·6). 66 serious adverse events associated with surgery were reported (24 in the RYGB group vs 42 in the OAGB group; p=0·042), of which nine (21·4%) in the OAGB group were nutritional complications versus none in the RYGB group (p=0·0034).

INTERPRETATION

OAGB is not inferior to RYGB regarding weight loss and metabolic improvement at 2 years. Higher incidences of diarrhoea, steatorrhoea, and nutritional adverse events were observed with a 200 cm biliopancreatic limb OAGB, suggesting a malabsorptive effect.

FUNDING

French Ministry of Health.

Protein deficiency after gastric bypass: The role of common limb length in revision surgery

BACKGROUND

Bariatric surgery, especially the gastric bypass procedure, is an effective therapy for morbid obesity, but may reduce protein absorption and induce protein deficiency (PD). A recent study reported an issue about common limb length for PD.

OBJECTIVE

This study aimed to examine the prevalence of PD after gastric bypass surgery and investigate the role of common limb length in PD-related revision surgery.

SETTING

Hospital-based bariatric center.

METHODS

From 2001 to 2016, 2397 patients with morbid obesity who underwent bariatric/metabolic surgery with 1-year follow-up were recruited. Serum albumin and total protein were measured before and 1 year after surgery. Medical records of patients who underwent revision surgery due to PD were reviewed.

RESULTS

The overall prevalence of PD was .5% preoperatively. The prevalence of PD increased to 2.0% at 1 year after surgery. The incidence was highest in one-anastomosis gastric bypass (2.8%) followed by Roux-en-Y gastric bypass (1.8%). Until the end of follow-up, all 19 patients who underwent revision surgery for intractable PD had a relatively short common limb length of <400 cm. After elongation of the common limb length to >400 cm in revision surgery, PD improved in all patients.

CONCLUSIONS

A subset of patients can develop PD after gastric bypass surgery when the common limb length is <400 cm. In patients with intractable PD after gastric bypass surgery, revision surgery for elongation of common limb length to >400 cm is mandatory to avoid PD-related complications.

Initial outcomes of one anastomosis gastric bypass at a single institution

INTRODUCTION

One anastomosis gastric bypass (OAGB) is an emerging bariatric procedure, which has been reported to be safe and effective. This study aims to evaluate the short-term outcome of OAGB and its midterm effects on weight loss and remission of type 2 diabetes mellitus (T2DM).

MATERIALS AND METHODS

A retrospective review of patients who had undergone OAGB between January 2013 and January 2017 in King Abdulaziz University Hospital, Jeddah, Saudi Arabia, is presented here. Patients' perioperative characteristics, biochemical profile (fasting blood glucose, HbA1c and iron profile) and details on subsequent weight loss in terms of body mass index (BMI) and excess weight loss percentage (EWL%) along with early and late postoperative complications were evaluated.

RESULTS

Out of the 47 patients who underwent OAGB, 42 were included in this study and completed the 2-year follow-up. Average operative time was 107±21.3 minutes and average length of hospital stay was 2.5±0.53 days. Mean preoperative BMI was 47.6±9.1 kg/m², and at 1 and 2 years of follow-up, it was 30.5±7.4 and 27.1±5.1, respectively. No mortality, anastomotic leak or bleeding were reported. Most common midterm complication was iron deficiency anemia (n=7/42). Remission of T2DM at 6 months was 80%. Patients with preoperative T2DM for less than 10 years showed better remission (P<0.001).

CONCLUSION

Our analysis suggests that OAGB is a safe and effective weight loss procedure that carries low perioperative risk and acceptable nutritional complications in the midterm, with a notable remission of T2DM. Preoperative duration of T2DM plays a major role in achieving remission after OAGB.

Cecal volvulus following mini gastric bypass: A case report and review of literature

•

Cecal volvulus is one of the differential diagnosis of post Mini-gastric bypass acute intestinal obstruction. and pain.

•

Urgent intervention in acute presentation post gastric bypass is the key to saving the patient life and lower morbidity.

•

Conversion of Mini-gastric bypass to Roux-en-Y gastric bypass in any complication surgery is recommended when feasible.

Introduction: With the rising worldwide obesity epidemic, bariatric surgeries are gaining popularity as the most effective modality for achieving long term results in weight loss and reducing its metabolic sequels.

Case presentation: A 36-year-old female presented with a sudden onset of severe abdominal pain for 6 h. The patient underwent Mini gastric bypass (MGB) 2 years prior to presentation. Computed tomography (CT) scan revealed a 14-cm dilatation of the cecum occupying the left upper quadrant of the abdomen with the swirling appearance of the mesentery. These findings were confirmed through emergency exploratory laparotomy to be cecal volvulus. a right hemicolectomy and conversion of MGB to a conventional Roux-en-Y gastric bypass.

Discussion: a modification of the classical gastric bypass surgery the MGB considered by its advocates to be a safer, simpler, and more effective option. However, serious complications can take place especially in the early learning curve of the procedure.

Conclusions

We present a unexpected acute in top of chronic cecal volvulus in patient two years post MGB. The uncommon serious complication should be considered one of the differential diagnosis of acute surgical abdomen in those patients.

Revisional Gastric Bypass for Failed Restrictive Procedures: Comparison of Single-Anastomosis (Mini-) and Roux-en-Y Gastric Bypass

BACKGROUND

Ten to 50% of patients who received restrictive bariatric operations may require reoperation for unsatisfactory weight loss or weight regain. Failed restrictive procedures are usually managed with conversion to another bariatric procedure with a favor of conversion to laparoscopic gastric bypass. Our aim is to evaluate two different bypass techniques, laparoscopic RY gastric bypass (RYGB) versus single-anastomosis (mini-) gastric bypass (SAGB) as a revision option (R-RYGB and R-SAGB) for failed restrictive bariatric operations.

MATERIAL AND METHODS

From May 2001 to December 2015, a total of 116 patients with failed restrictive bariatric operations underwent laparoscopic revisional bypass surgery (81 R-SAGB and 35 R-RYGB). Among them, 81 were failed after vertical banded gastroplasty (VBG) and 35 were after adjustable gastric band (AGB). The demographic data, surgical parameters, and outcomes were studied.

RESULTS

The average age at revision surgery was 35.7 years (range 22-56), and the average body mass index (BMI) before reoperation was 37.2 kg/m² (29.0-51.8). Revision surgery was performed after 58.8 months from the primary surgery on average (14-180 months). The main reasons for the revisions were weight regain (50.9%), inadequate weight loss (31%), and intolerance (18.1%). All of the procedures were completed laparoscopically as one-stage procedure. R-RYGB had significantly longer operative times than R-SAGB. Major complication occurred in 12 (10%) patients without significant difference between R-SAGB group and R-RYGB group. At 1 year follow-up, weight loss was better in R-SAGB than R-RYGB (76.8 vs. 32.9% EWL; p = 0.001). At 5 year follow-up, a significantly lower hemoglobin level was found in R-SAGB group (p = 0.03).

CONCLUSION

Both SAGB and RYGB are acceptable options for revising a restrictive type of bariatric procedures with equal safety profile. R-SAGB was shown to be a simpler procedure with better weight reduction than R-RYGB but anemia is a considerable complication at long-term follow-up.

A New Physiologic Mouse Model of One Anastomosis Gastric Bypass

BACKGROUND

One anastomosis gastric bypass (OAGB) is a modern metabolic operation that has been demonstrated to be a rapid, safe, and effective procedure. As for other bariatric operations, the mechanisms and long-term effects of this procedure remain largely unknown and are difficult to address in human studies. Here, we present a new physiologic mouse model for mechanistic and long-term investigations.

METHODS

Six-week-old C57Bl/6 mice were fed a high-fat diet for 12 weeks and scheduled for OAGB or sham operation. Mice were observed for 2 weeks after the operation, and weight and metabolic condition were monitored.

RESULTS

Six mice were used to adapt the surgical technique. Afterwards, another 7 mice were scheduled for OAGB without further complications. The newly established OAGB procedure resulted in significant weight loss and improvement of glucose metabolism 2 weeks after the operation.

CONCLUSIONS

The operation presented here is an easy-to-learn and physiologic mouse model of OAGB that can be used for further studies in mice.

Significant Liver-Related Morbidity After Bariatric Surgery and Its Reversal-a Case Series

Background

Nonalcoholic fatty liver disease (NAFLD) occurs in up to 80% of patients with obesity. Current data suggest an improvement of NAFLD after established bariatric procedures.

Objectives

This study investigated liver function impairment after Roux-en-Y gastric bypass (RYGB) and one-anastomosis gastric bypass (OAGB).

Setting

University Hospital, Bariatric Surgery Unit

Methods

In this single-center case series, consecutive in- and outpatients after bariatric surgery who presented with severe liver dysfunction from March 2014 to February 2017 were included and followed until March 2017.

Results

In total, 10 patients (m:f = 2:8; median age 48 years, range 22–66 years) were included. Liver dysfunction occurred after a median postoperative time of 15 months (range 2–88 months). Median %excess weight loss at that time was 110.6% (range 85.2–155.5%). Liver steatosis/fibrosis occurred in 70%, cirrhosis in 30% of patients, and led to fatigue (90%), ascites (70%), hepatic encephalopathy (30%), and upper gastrointestinal bleeding (20%). Elevation of transaminases, impairment of coagulation parameters, thrombocytopenia, and hypoalbuminemia were present in 70, 80, 70, and 100%, respectively. In eight patients, lengthening of the alimentary/common limb led to an improvement or complete remission of symptoms. In one patient, liver transplantation was required, one patient deceased due to septic shock and decompensated liver disease.

Conclusions

Severe liver dysfunction may also occur after bariatric procedures such as OAGB and RYGB. A comprehensive, meticulous follow-up for early identification of postoperative liver impairment should be aspired. Bypass length reduction led to a fast improvement in all patients.

Bile Gastritis Following Laparoscopic Single Anastomosis Gastric Bypass: Pilot Study to Assess Significance of Bilirubin Level in Gastric Aspirate

INTRODUCTION

Laparoscopic single anastomosis gastric bypass (SAGB) is increasingly performed for morbidly obese patients.

AIM OF WORK

This pilot study aims primarily at evaluating the incidence of bile gastritis after SAGB. The occurrence of reflux oesophagitis and reflux symptoms were also assessed.

PATIENTS AND METHODS

This study included 20 patients having no reflux symptoms. All patients underwent a SAGB as a primary bariatric procedure by a single surgeon. Patients included consented to have an upper GI endoscopy done at 6 months postoperatively. Gastric aspirate was sent for bilirubin level assessment. Gastric and esophageal biopsies were submitted for histopathology and campylobacter-like organism (CLO) test.

RESULTS

In our study, the rate of bile gastritis was 30%. In 18 patients, the level of bilirubin in gastric aspirate seems to be related to the degree of mucosal inflammation. The remaining two patients had microscopic moderate to severe gastritis with normal aspirate bilirubin level. Two patients with bilirubin level in aspirate more than 20 mg/dl had severe oesophagitis, gastritis with erosions, and metaplasia. Relationship between bilirubin level and histopathological findings of gastric biopsy examination was statistically significant with a P value of 0.001.

CONCLUSION

The incidence of bile gastritis in this cohort is higher than reported in the literature, and this may be worrying. The correlation between endoscopic findings and patients' symptoms is poor. Bilirubin level and pH in aspirate might be useful tools to confirm alkaline reflux. Its level might help to choose candidates for revision surgery after SAGB. This needs further validation with larger sample size.