[Laparoscopic mini-gastric bypass: an effective option for the treatment of morbid obesity]

IFSO Update Position Statement on One Anastomosis Gastric Bypass (OAGB)

The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued a position statement on the role of one anastomosis gastric bypass (OAGB) in the field of bariatric/metabolic surgery in 2018 De Luca et al. (Obes Surg. 28(5):1188-206, 2018). This position statement was issued by the IFSO OAGB task force and approved by the IFSO Scientific Committee and IFSO Executive Board. In 2018, the OAGB task force recognized the necessity to update the position statement in the following 2 years since additional high-quality data could emerge. The updated IFSO position statement on OAGB was issued also in response to inquiries to the IFSO by society members, universities, hospitals, physicians, insurances, patients, policy makers, and media. The IFSO position statement on OAGB has been reviewed within 2 years according to the availability of additional scientific evidence. The recommendation of the statement is derived from peer-reviewed scientific literature and available knowledge. The IFSO update position statement on OAGB will again be reviewed in 2 years provided additional high-quality studies emerge.

Bariatric Surgery After Previous Antireflux Surgery Without Takedown of the Previous Fundoplication: a Prospective Study

BACKGROUND

The increased prevalence of reflux disease in obese patients, combined with widespread availability of laparoscopic antireflux surgery, has increased the likelihood that more patients will seek bariatric surgery having previously undergone fundoplication.

OBJECTIVES

This study examined our series of laparoscopic bariatric surgery after previous antireflux surgery without takedown of the previous fundoplication. We discuss our results, our technique and the tips and tricks to avoid complication after this procedure.

SETTING

Private practice.

METHODS

We operated on patients suffering from obesity who had already undergone laparoscopic Nissen. The patients were eligible for bariatric surgery according to the French National Institute of Health's criteria for bariatric surgery. The pre-operative assessment involved gastroscopy with biopsies looking for Helicobacter pylori, oesophago-gastroduodenoscopy, investigation for sleep apnoea syndrome and a full laboratory assessment. The patients took part in their choice of surgery.

RESULTS

The patients' post-operative course was uncomplicated. No patients had symptoms of gastro-esophageal reflux late after surgery and good gastrointestinal comfort was achieved (no pain, no reflux). All of the patients were satisfied. Length of stay was 3 to 5 days. All patients exhibited significant weight loss.

CONCLUSION

Bariatric surgery is possible after fundoplication without taking down the fundoplication. It appears to be a viable alternative in patients seeking weight loss surgery after fundoplication, which is currently assumed contraindicated.

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.

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.

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.

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.

One anastomosis gastric bypass versus Roux-en-Y gastric bypass for morbid obesity: a meta-analysis

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. A literature search was performed in PubMed, Cochrane library and Scopus, in accordance with the PRISMA guidelines. Twelve studies met the inclusion criteria (7452 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 percentage excess weight loss at 1, 2 and 5 years post-operatively was greater for the OAGB group. The rate of type 2 diabetes remission was greater in the OAGB group. The rate of hypertension and dyslipidemia remission was also similar between OAGB and RYGB. Randomized controlled trials, comparing RYGB to OAGB, are necessary to further assess their clinical outcomes.

One-Anastomosis Gastric Bypass Versus Sleeve Gastrectomy for Morbid Obesity: a Systematic Review and Meta-analysis

We aim to review the available literature on obese patients treated with one-anastomosis gastric bypass (OAGB) or laparoscopic sleeve gastrectomy (LSG), in order to compare the clinical outcomes and intraoperative parameters of the two methods. A systematic literature search was performed in PubMed, Cochrane Library, and Scopus databases, in accordance with the PRISMA guidelines. Seventeen studies met the inclusion criteria incorporating 6761 patients. This study reveals increased weight loss, remission of comorbidities, shorter mean hospital stay, and lower mortality in the OAGB group. The incidence of leaks and intra-abdominal bleeding was similar between the two approaches. Well-designed, randomized controlled studies, comparing LSG to OAGB, are necessary to further assess their clinical outcomes.

Conversional Weight Loss Surgery: an Australian Experience of Converting Laparoscopic Adjustable Gastric Bands to Laparoscopic Sleeve Gastrectomy

BACKGROUND

Bariatric surgery is the most effective treatment for severe obesity, capable of producing more than 50% excess weight loss at 10-year follow-up (James Clin Dermatol 1; 22:276-80; O'Brien Br J Surg 2; 102:611-17; Buchwald et al. Metab Syndr 3; 347-56). The success of bariatric surgery extends far beyond weight loss, with up to 80-90% of patients having improvement or resolution of many of their weight-related co-morbidities including type II diabetes mellitus and hypertension (Puzziferri et al. JAMA 4; 312:934-42; Buchwald et al. Am J Med 5; 122:248-56). However, there is a paucity of data regarding conversional bariatric surgery.

OBJECTIVE

This study aims to explore the efficacy, safety and feasibility of conversional surgery.

SETTING

This study represents the largest Australasian series focusing on conversional bariatric surgery. The study was conducted in the Norwest Private Hospital and Hospital for Specialist Surgery (HSS), both private Hospitals in Sydney, Australia.

METHODS

Data was collected prospectively at regular intervals for more than 12 months from 1 January 2012 to 1st November 2015 for all patients requiring a laparoscopic sleeve gastrectomy (LSG) as secondary procedure after prior laparoscopic adjustable gastric band (LAGB). Excess weight loss (EWL), percentage total body weight loss (TWL) and excess BMI loss (EBMIL) as well as any complications were recorded.

RESULTS

There were low rates of morbidity (1.1%) and no mortality at 12-month follow-up. Satisfactory EWL of 60% (95% CI: 56.6-63.4%), EBMIL of 60.1% (95% CI: 48.8-71.4%) and 16% TWL was achieved at 12-month follow-up.

CONCLUSION

We therefore conclude that sleeve gastrectomy is a safe and valid option for conversional bariatric surgery following LAGB.

Resectional One Anastomosis Gastric Bypass/Mini Gastric Bypass as a Novel Option for Revision of Restrictive Procedures: Preliminary Results

BACKGROUND

Revisional surgery is becoming a common and challenging practice in bariatric centers. The aim of this study was to evaluate resectional one anastomosis gastric bypass/mini gastric bypass (R-OAGB/MGB) as a revisional procedure.

METHODS

From January 2016 to February 2017, data on 21 consecutive patients undergoing R-OAGB/MGB for weight loss failure after primary restrictive procedures were prospectively collected and analysed.

RESULTS

Mean age was 39 ± 12 years (18-65), and 11 (52.3%) were women. The mean operative time was 96.4 ± 20.9 min (range, 122-80), and the mean postoperative stay was 47.8 ± 7.4 hours (range, 36-73). There were no deaths and no procedure-related complications. The mean body mass index (BMI) decreased from 42.9 ± 6.5 at the time of R-OAGB/MGB to 28.5 ± 4 at the 12-month follow-up. At that time point, the mean percentage of BMI loss (%EBL) and the mean percentage of total body weight loss (%TWL) reached 81.6 ± 0.17% and 35 ± 0.01%, respectively.

CONCLUSION

R-OAGB/MGB was technically straightforward, effective, and safe in this at-surgical risk population. R-OAGB/MGB should be added to the armamentarium of revisional bariatric procedures considering its technical aspects and the potential advantage on weight loss.

Controversy surrounding 'mini' gastric bypass

Mini gastric bypass is a modification of Mason loop gastric bypass with a longer lesser curvature-based pouch. Though it has been around for more than 15 years, its uptake by the bariatric community has been relatively slow, and the procedure has been mired in controversy right from its early days. Lately, there seems to be a surge in the interest in this procedure, and there is now published experience with more than 5,000 procedures globally. This review examines the major controversial aspects of this procedure against the available scientific literature. Surgeons performing this procedure need to be aware of these controversies and counsel their patients appropriately.

"Mini" gastric bypass: systematic review of a controversial procedure

Mini gastric bypass is being explored by many bariatric surgeons as a standalone bariatric procedure. Several surgeons from different parts of the world have now published their extensive experience with this procedure. It appears to be an effective bariatric procedure with acceptable weight loss, co-morbidity resolution, and complication rates in the short and medium term. Its proponents claim that it is safer and easier than the gold standard Roux-en-Y gastric bypass. However, concerns with regard to symptomatic gastric or oesophageal biliary reflux requiring revisional surgery and long-term risk of gastric and oesophageal cancers persist. This paper reviews the published experience to date with this procedure and examines the surrounding controversy.

Efficacy and safety of laparoscopic mini gastric bypass. A systematic review

BACKGROUND

Laparoscopic mini-gastric bypass (LMGB) is a relatively new bariatric procedure; published studies are accumulating in various settings. The objective of this study was to summarize the available evidence about the efficacy and safety of LMGB.

METHODS

A systematic search in the literature was performed , and PubMed and reference lists were scrutinized (end-of-search date: July 15, 2013). For the assessment of the eligible articles, the Newcastle-Ottawa quality assessment scale was used.

RESULTS

Ten eligible studies were included in this study, reporting data on 4,899 patients. According to all included studies, LMGB induced substantial weight and body mass index reduction, as well as substantial excess weight loss. Moreover, resolution or improvement in all major associated medical illnesses and improvement in overall Gastrointestinal Quality of Life Index score were recorded. Major bleeding and anastomotic ulcer were the most commonly reported complications. Readmission rate ranged from 0%- 11%, whereas the rate of revision operations ranged from .3%- 6%. The latter were conducted due to a variety of medical reasons such as inadequate or excessive weight loss, malnutrition, and upper gastrointestinal bleeding. Finally, the mortality rate ranged between 0% and .5% among primary LMGB procedures.

CONCLUSION

LMGB represents an effective bariatric procedure; its safety and minimal postoperative morbidity seem remarkable. Randomized comparative studies seem mandatory for the further evaluation of LMGB.

Laparoscopic omega-loop gastric bypass for the conversion of failed sleeve gastrectomy: early experience

OBJECTIVES

Despite the initial effectiveness of sleeve gastrectomy (SG), some patients who undergo this purely restrictive technique have inadequate weight loss or renewed weight gain and persistent obesity-related co-morbidities with their potentially lethal complications. In such patients, the conversion of SG by the addition of a malabsorptive technique may then be necessary.

PATIENTS AND METHODS

Conversion of SG to a mini gastric bypass (MGBP) was evaluated for failure of weight loss. An ante-colic end-to-side stapled gastro-jejunal anastomosis was performed laparoscopically, connecting the long narrow gastric tube to the jejunum at a point 200cm downstream from the ligament of Treitz.

RESULTS

Between October 2006 and February 2012, 651 laparoscopic MGBP were performed for morbid obesity. Twenty-three of these patients (3.5%) had previously undergone SG. The conversion from SG to MGPB was performed laparoscopically in 19 of the 23 patients (81%) at a mean interval of 26.3months (8.2-63.7). The 30-day postoperative mortality rate was zero and the morbidity rate was 9.5%. The mean BMI before MGBP was 44±7.7kg (35.8-55.4). Conversion of SG to MGBP resulted in additional weight loss, achieving a mean BMI of 39.9 with a 26.8% loss of excess BMI (EBL) at 3months, mean BMI of 36.5 with 37.2% EBL at 12months, mean BMI of 36.2 with 48.6% EBL at 18months, and mean BMI of 35.7 with EBL of 51.6% at 24months. The overall mean EBL was 57.3±19.5% (range: 25-82%) at 42.3months (range 16.7-60.8months).

CONCLUSION

Conversion of SG to MGBP is feasible, safe and effective, and results in significant additional weight loss. Definitive results at 2 and 5years are awaited for the long-term procedure validation.

One thousand consecutive mini-gastric bypass: short- and long-term outcome

There is growing evidence that mini-gastric bypass (MGB) is a safe and effective procedure. Operative outcome and long-term follow-up of a consecutive cohort of patients who underwent MGB are reported. The data on 1,000 patients who underwent MGB from November 2005 to January 2011 at an academic institution were reviewed. Mean age was 33.15 ± 10.17 years (range, 14-72), preoperative BMI was 42.5 ± 6.3 kg/m(2) (range, 26-75), mean preoperative weight was 121.6 ± 23.8 kg (range, 71-240), and 663 were women. Operative time and length of stay for primary vs. revisional MGB were 89 ± 12.8 min vs. 144 ± 15 min (p < 0.01) and l.85 ± 0.8 day vs. 2.35 ± 1.89 day (p < 0.01). No deaths occurred within 30 days of surgery. Short-term complications occurred in 2.7% for primary vs. 11.6% for revisionnal MGB (p < 0.01). Five (0.5%) patients presented with leakage from the gastric tube but none had anastomotic leakage. Four (0.4%) patients, all with revisional MGB, presented with severe bile reflux and were cured by stapling the afferent loop and by a latero-lateral jejunojejunostomy. Excessive weight loss occurred in four patients; two were reversed and two were converted to sleeve gastrectomy. Maximal percent excess weight loss (EWL) of 72.5% occurred at 18 months. Weight regain subsequently occurred with a mean variation of -3.9% EWL at 60 months. The 50% EWL was achieved for 95% of patients at 18 months and for 89.8% at 60 months. MGB is an effective, relatively low-risk, and low-failure bariatric procedure. In addition, it can be easily revised, converted, or reversed.

Two important criteria for reducing the risk of postoperative ulcers at the gastrojejunostomy site after gastric bypass: patient compliance and type of gastric bypass

BACKGROUND

Ulcers at the gastrojejunostomy site are a common problem after gastric surgery. Their postoperative development seems to be associated with Helicobacter pylori-related gastritis or abuse of nicotine, alcohol or non-steroidal anti-inflammatory drugs (NSAIDs), but is also dependent on the choice of surgical method (Roux-en-Y or B-II gastric bypass).

PATIENTS AND METHODS

This study evaluated the follow-up of 1,908 patients over a period of 5 years (January 2006-December 2010). In 1,861 cases, we performed a Roux-en-Y gastric bypass, and in 47 cases a B-II gastric bypass.

RESULTS

All patients (n = 407) with symptoms such as dysphagia, reflux, nausea, vomiting or epigastric pain underwent gastroscopy. In 52 cases, ulcers were found at the gastrojejunostomy site. Of these patients, 39 (75%; p < 0.0001) had consumed alcohol, nicotine or NSAIDs; in 14 patients (27%; p < 0.0001) we detected H. pylorirelated gastritis. A total of 2.4% of the patients after Roux-en-Y gastric bypass (45/1,861) and 14.9% of the patients after B-II gastric bypass (7/47) developed ulcers at the gastroenteral junction. The difference is clearly significant (Fisher's exact test, p = 0.0002). Furthermore, there were significant differences regarding the recurrence rate: 86% of the B-II gastric bypass group and 13.3% of the Roux-en-Y gastric bypass group needed to be treated several times.

CONCLUSIONS

Every patient needs to be informed preoperatively that there is a markedly increased risk of ulcers at the gastroenteral junction, particularly if the patient cannot avoid potential risk factors (nicotine, alcohol, NSAIDs). Preoperative gastroscopy with H. pylori testing and subsequent eradication can also reduce the risk of ulcers. An increased incidence of peptic ulcers after B-II gastric bypass was noted. All of these patients were converted to Roux-en-Y.