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.

Greater weight loss with the omega loop bypass compared to the Roux-en-Y gastric bypass: a comparative study

BACKGROUND

Despite similar initial results on weight loss and metabolic control, with a better feasibility than the Roux-en-Y gastric bypass (RYGBP), the omega loop bypass (OLB) remains controversial. The aim of this study was to compare the short-term outcomes of the laparoscopic OLB versus the RYGBP in terms of weight loss, metabolic control, and safety.

METHODS

Two groups of consecutive patients who underwent laparoscopic gastric bypass surgery were selected: 20 OLB patients and 61 RYGBP patients. Patients were matched for age, gender, and initial body mass index (BMI). Data concerning weight loss, metabolic outcomes, and complications were collected prospectively.

RESULTS

Mean duration of the surgical procedure was shorter in the OLB group (105 vs. 152 min in the RYGBP group; p < 0.001). Mean excess BMI loss percent (EBL%) at 6 months and at 1 year was greater in the OLB group (76.3 vs. 60.0%, p = 0.001, and 89.0 vs. 71.0%, p = 0.002, respectively). After adjustment for age, sex, initial BMI, and history of previous bariatric surgery, the OLB procedure was still associated with a significantly greater 1-year EBL%. Diabetes improvement at 6 months was similar between both groups. The early and late complication rates were not statistically different. There were three anastomotic ulcers in the OLB group, in smokers, over 60 years old, who were not taking proton pump inhibitor medication.

CONCLUSIONS

In this short-term study, we observed a greater weight loss with OLB and similar efficiency on metabolic control compared to RYGBP. Long-term evaluation is necessary to confirm these outcomes.

Predictive factors of type 2 diabetes remission 1 year after bariatric surgery: impact of surgical techniques

Type 2 diabetes (T2D) remission after bariatric procedures has been highlighted in many retrospective and some recent prospective studies. However, in the most recent prospective study, more than 50 % of patients did not reach T2D remission at 1 year. Our aim was to identify baseline positive predictors for T2D remission at 1 year after bariatric surgery and to build a preoperative predictive score. We analysed the data concerning 161 obese operated on between June 2007 and December 2010. Among them, 46 were diabetic and were included in the study-11 laparoscopic adjustable gastric banding (LAGB), 26 Roux-en-Y gastric bypass (RYGB) and 9 sleeve gastrectomy (SG). We compared anthropometric and metabolic features during 1 year of follow-up. A receiver operating characteristic analysis was performed to predict T2D remission. RYGB and SG were similarly efficient for body weight loss and more efficient than LAGB; 62.8 % of patients presented with T2DM remission at 1 year, with no significant difference according to the surgical procedure. A 1-year body mass index (BMI) <35 kg m(-2) was predictive of T2DM remission whatever the procedure. The preoperative predictive factors of diabetes remission were baseline BMI ≤50 kg m(-2), duration of type 2 diabetes ≤4 years, glycated haemoglobin ≤7.1 %, fasting glucose <1.14 g/l and absence of insulin therapy. A short duration of diabetes and good preoperative glycaemic control increase the rate of T2DM remission 1 year after surgery. Preoperative metabolic data could be of greater importance than the choice of bariatric procedure.

High resolution esophageal manometry evaluation in symptomatic patients after gastric banding for morbid obesity

BACKGROUND

Dysphagia and vomiting are frequent after laparoscopic gastric banding (LAGB). These symptoms could be secondary to esophageal motility disorders. Our aim was to assess esophageal motility and clearance in symptomatic LAGB patients using high resolution manometry (HRM).

METHODS

Twenty-two LAGB patients with esophageal symptoms (dysphagia, vomiting, and regurgitations) were included. Esophageal motility was studied using HRM (ManoScan®, Sierra Systems) and classified according to the Chicago classification.

RESULTS

The median delay between surgery and manometry evaluation was 6.3 years (range 1-10). Manometric data were considered as normal in only 2 patients. Achalasia was diagnosed in 3 cases, functional EGJ obstruction in 15, hypotensive peristalsis in 2. During swallowing pan-esophageal pressurization was observed in 6 patients, hiatal hernia pressurization in 7 and gastric pouch pressurization in 2. The intra-bolus pressure was elevated in 18 patients. LAGB was deflated in 6 patients and removed in 12. In 2 patients with unchanged symptoms after LAGB removal motility disorders persisted (1 achalasia, 1 functional EGJ obstruction).

CONCLUSION

In symptomatic LAGB patients, esophageal dysmotility is frequent. High resolution manometry allows the assessment of esophageal clearance and provides guidance for the choice of treatment.

[Laparoscopic cholecystectomy. The first 30 cases in Bamako]

INTRODUCTION

The authors report the results of their short series of the laparoscopic cholecystectomy in the new center of coeliochirurgie of Bamako to Mali (West Africa).

MATERIAL AND METHOD

It is about a retrospective study over one 21 month period. All the patients carrying lithiasis symptomatic profited from this new technique in the service of surgery "A" of the hospital of the Point G Bamako.

RESULTS

30 patients were operated, that is to say 19 women and 11 men. The laparoscopic cholecystectomy accounted for 16,04% of the laparoscopic activity of the service for the same period. The pain of the hypochondre right was the reason for consultation for 96,7% of the cases (20 patients), and a defense of the hypochondre right was raised in 46,7% of the cases. The diagnosis of lithiasis vésiculaire was posed with echography in 100% of the cases. A standard hemoglobinopathy AS or SS was associated in 16,7% of the cases. The laparoscopic cholecystectomy was easy in 60% of the cases. Epiploïc adhérnces and grèles were the major per difficulty operational. Haemorrhages of the bed vésiculaire were noted among 3 patients. A patient is deceased continuations of embolism in post operational immediate. The duration of the operational act was on average of 76 min. The average duration of the hospital stay was 3,5 days. The cost of the laparoscopic cholecystectomy was lower than that of the conventional cholecystectomy in the service.

CONCLUSION

This study of the first 30 cases proved the feasibility and the reliability of the laparoscopic cholecystectomy under the conditions of developing country. The unquestionable benefit for the patient and the hospital forecasts of a beautiful future for this new procedure.

[Colonic diverticulosis and laparoscopy. Analysis of a series of 60 cases]

AIM

This is a retrospective analysis of a series of 60 cases diverticular disease.

MATERIAL AND METHOD

From May 1991 to April 1999, 60 laparoscopic colorectal resections were performed for diverticulitis.

RESULTS

Conversion to a classical procedure was necessary in 3 patients (5%). There was no mortality and 9 postoperative complications (3 reoperations). The mean length of hospital stay was 9 days, and 6.3 days for patients in whom surgery was performed after January 1998.

CONCLUSION

Laparoscopic surgery for diverticular disease is associated with acceptable morbidity and mortality rates and a short median postoperative stay.

[Heller's esocardiomyotomy without anti-reflux procedure by the laparoscopic approach. Analysis of a series of 27 cases]

From November 1992 to June 1996, 27 laparoscopic Heller's myotomies without antireflux procedure were performed. One mucosal tear occurred and was treated by open surgery. There was no mortality; one case of sepsis with a good outcome was observed on the converted patient. The mean length of hospital stay was 5.5 days. The immediate functional result was good in all cases. Postoperative esophageal manometry showed a significant reduction of the LES pressure, and post-operative pHmonitoring showed one case of reflux. The long term functional result was good in 81% of cases, moderate in 19% (slight reflux in 3 cases and dysphagia in 2 cases). No failure and no reoperation occurred in this series. This procedure has been applied to all patients with achalasia since December 1992.

Laparoscopic colo-rectal surgery: analysis of 113 cases

BACKGROUND/AIMS

The aim of the study is to relate our five years experience with laparoscopic colorectal surgery.

MATERIALS AND METHODS

One hundred-thirteen procedures were performed between October 1990 and February 1996, 7% of which were performed as emergencies. Elective indications (93%) included 45 cancers, 31 cases of diverticulosis, 18 cases of benign tumor, and 11 other reasons. Procedures performed were sigmoidectomy (61 cases), rectal resection (12 cases), segmental colectomy (15 cases), right hemicolectomy (14 cases) and restoration of continuity following a Hartmann's procedure (5 cases) and miscellaneous (6 cases).

RESULTS

Operative complications occurred in 14% of the cases. The conversion rate to laparotomy was 6%. Post operative complications occurred in 14% of the patients. Reoperation was performed in 7% of the cases and overall mortality was 1.7%. Mean length of hospital stay was 9.6 days. Long-term oncology results demonstrated no recurrence for DUKES stage A disease followed-up from 5 to 65 months, and 2 recurrence on 11 DUKES B or C. All DUKES D patients died in an average of 17 months. No abdominal wall metastases were seen during the follow-up period in 45 patients with cancer who were treated.

CONCLUSIONS

Laparoscopic colo-rectal surgery is technically feasible and has an acceptable complication rate. The best indications are treatment of benign disorders, principally excision of polyps and treatment of uncomplicated diverticulosis. This is also a good approach to treat degenerated polyps (DUKES A). The procedure should be assessed in curative excision of DUKES B or C disease.

Laparoscopic surgery for duodenal ulcer: first results of a multicentre study applying a personal procedure

Between January 1991 and February 1995 data were gathered on 136 patients operated on in 14 surgical centres. All patients underwent posterior truncal vagotomy (PTV) and anterior linear gastrectomy (ALG) for chronic duodenal ulcer. Recurrence and repeated bleeding were the main indications for surgery. An antireflux technique was simultaneously carried out in 17 patients, while 13 underwent cholecystectomy. There were no peroperative complications or deaths, and the mean duration of operation was 65 (range 25-180) min. Immediate postoperative morbidity rate was 2.9 per cent, with a mean hospital stay of 3.1 (range 2-13) days. A total of 131 patients were evaluated between 6 and 33 (mean 25) months after operation. Of these, 126 (96.2 per cent) were graded as Visick I or II. Four (3.0 per cent) were Visick III, and one patient (0.8 per cent) was considered Visick IV. Gastric function studies were performed in 45 patients before and after operation, with a maximum acid output reduction of 83 per cent 3 months after the operation. Laparoscopic PTV with ALG constitutes a simple, efficient, rapid and safe method in the treatment of patients with chronic duodenal ulcer.

Laparoscopic Nissen-Rossetti fundoplication. First results

From January 1992 to July 1994, 148 patients with symptomatic gastroesophageal reflux and/or hiatal hernia underwent Nissen-Rossetti fundoplication by a laparoscopic approach. There was no conversion and no postoperative death. The main intraoperative complications were hemorrhage (n = 12), pleural opening (n = 5), and gastric perforation (seromuscular effraction) (n = 1). Laparoscopic reoperation was necessary in two patients as a result of bleeding, and there were two cases of food impaction. The median hospital stay was 4.9 days; 117 patients were observed for follow-up for 3-31 months (median 6.2 months). Eleven cases of dysphagia extending beyond 2 months have been observed. In five of those cases, endoscopic dilatation provided effective treatment of dysphagia and in four others, a further laparoscopic intervention enabled a cure to be obtained. Eighty-four percent are satisfied with their decision to have the operation. The laparoscopic Nissen-Rossetti fundoplication can be carried out safely and effectively with positive results similar to those obtained with the open procedure and with all of the advantages of the minimally invasive approach.

Radio-anatomic study of the carotid axis with regard to the implantation of microsurgical vascular anastomoses

The authors report a radio-anatomic study of the carotid axis in the context of the implantation of microsurgical vascular anastomoses. The information derived from 36 dissections and 50 arteriographic studies suggests the preferential use of the superior thyroid, facial and lingual branches. Section and turning-down of the external carotid and direct end-to-side implantation on the common carotid could provide fall-back solutions when the collaterals are slender. Because of anatomic variations and frequent atheromatous lesions, arteriographic study before implantation appears essential.

[Tubular grafts of the inferior vena cava for portacaval shunts. Principle, technic and preliminary clinical results]

A technique for performance of portocaval shunt operations using tubular inferior vena cava grafts is proposed. The aim of this method is to avoid prosthetic or venous interposition with their risk of thrombosis. It is based on results of cadaver experimental studies and a clinical case. Different possible grafts are described, including useful sizes, advantages and inconveniences and clinical indications. Two types are selected: that resected from left surface of subhepatic vena cava for portocaval anastomosis and that obtained from anterior surface of infrarenal vena cava for mesentericocaval anastomosis.

Tubular colonic duplications. A case report and literature review

Tubular colonic duplication is a rare abnormality. The authors report here on a patient with rather nonspecific symptoms, whose abnormality was only discovered at operation. The good results obtained by a simple operative treatment of such forms contrast with the difficulties arising in clinical and radiological diagnosis. The characteristics of tubular colonic duplication are pointed out, which set it apart from all other types of duplication.

[Marion's calibrated latero-lateral portacaval anastomosis: a truncular shunt maintaining hepatopetal portal blood flow?]

The authors report the hemodynamic study of 22 cases of calibrated side-to-side portacaval shunts performed in patients with liver cirrhosis. In all patients, hepatopetal portal blood flow was present before the operation. According to the data obtained by scintiangiography and angiography, hepatopetal portal flow was maintained in 70 p. 100 of the patients immediately after the operation. After one year there was a discrepancy between the results of scintiangiography and those of conventional angiography: while portal flow seemed to be hepatopetal on the scintigraphy in 11 of controlled patients, it decreased or disappeared on the angiography in 6 other controlled patients. These results are comparable to those of selective shunts and suggest that the calibrated side-to-side portacaval shunt is a valuable procedure in maintaining hepatopetal portal flow. A controlled trial would be useful to assess the place of this operation in the treatment of portal hypertension due to cirrhosis.

Anatomical and experimental study of the ductus venosus

The authors report an anatomical study of the ductus venosus in the stillborn fetus based on resin-corrosion casts and angiography. Study in adult material was done by dissection. In the first part of this paper the classical anatomy of the ductus venosus is described and an anomalous case of a hepatic parenchymal bridge between the left and caudate lobes of the liver is reported. In the second part of this paper study of patency and dilation of the ligamentum venosum to a diameter exceeding 10 mm in adult cadavers is presented. A brief study of portal flow demonstrated that an increase in flow of 30% can be obtained by experimental induction of patency. A patent ligamentum venosum was grafted onto the abdominal aorta in the rabbit. The transplanted segment was fully patent and competent immediately after grafting, but showed thrombosis when the animal was sacrified two months after the operation. In the opinion of the authors, it may be possible to use the patent ductus venosus in man once the problems of long term resistance and patency have been solved. The latter problems are currently under investigation in our laboratory.

[A new concept of dressing: silastic foam]

The authors report their experience, still short, of a new type of dressing based upon Silastic foam used in general surgery. They emphasise the considerable progress achieved in the everyday care of their patients with easy to manage dressings and the virtual disappearance of pain. This has transformed the patients' existence and has made early physiotherapy possible in certain of them. The simplicity of use of this dressing leads to savings in time and cost and if the patient is cooperative the possibility of widespread use at home by the patient himself. The properties of this foam form the basis for a wide range of indications going beyond general surgery, with applications in ENT, dermatology, rehabilitation centres, etc. Results are satisfactory in 90% of cases, the only failures being due to a failure to obey the basic principles of care: doubtful indication (inadequate disinfection of wounds), neglect of concomitant pathology (diabetes, nutritional state) or lack of patient cooperation.

[Tubular gastrostomy]

Development and generalization of the use of mechanical suturing apparatuses has led to re-evaluation of tubular gastrostomy. Use of the 1AG clamp ensures gastric tubulization under good safety conditions (quality of the suture and absence of opening of the gastric tube). The choice of location of the tube depends upon the size of the stomach. The main indication is for feeding gastrostomies of long duration, particularly cases with irreversible lesions of the esophagus or in the ENT sphere. The quality of the apparatus and the facility with which it can be employed has transformed survival in these patients. A further possible indication is in acute necrotic pancreatitis, its use suppressing complications of classical gastrostomies (Fontan type) (gastric fistulae, disinsertions, difficulties with the apparatus). The only inconvenience of this procedure, minimal in regard to the benefits obtained, is the need for surgical closure.

[Rupture of the left subclavian artery associated with fracture of the 1st rib]

Treatment in a case of partial rupture of the subclavicular artery, provoking subacute ischemia of the upper limb and associated with a fracture of the first rib, was by sternoclavicular disinsertion and resection-suture. The importance of systematic investigation of possible subclavicular lesions in patients with fractured first ribs is emphasized, both during the initial and follow-up examinations. The presence of a fracture of this type has little influence on the classical surgical attitude adapted, apart from the possible need for resection of the first rib.

[Present role of Hartmann's operation. Apropos of 50 cases]

Of 50 Hartmann's operation conducted, 22 (including 19 for sigmoid diverticulitis) were for non-neoplastic lesions. Emergency surgery was necessary for lesions complicated by perforation, abscess, or occlusion in 34 cases, the indications for operation being local and general conditions, where immediate re-establishment of colorectal continuity was not possible, in the other 16 patients. Overall mortality was 22 p. cent, being much higher in cancer cases (32 p. cent) than in those with sigmoiditis (52 p. cent). Postoperative morbidity was marked, and was dominated by parietal complications and those due to the colostomy, and by thromboembolic complications particularly in the sigmoiditis cases. Secondary re-establishment of intestinal continuity was possible in 19 patients (6 cancers and 13 benign lesions) with a single postoperative death. Whereas the employ of Hartmann's operation in cancer would appear to be justified only in urgent complicated cases it is certainly a valid procedure in the acute phase of sigmoid diverticulitis, where its mortality is relatively low. Current mechanical suturing techniques, by facilitating secondary re-establishment of continuity, reduce the classical inconveniences of Hartmann's operation, suggesting its wider use for the emergency treatment of complicated lesions of the colon.

[Radio-anatomic and microangiographic study of pulmonary systemic vascularization]

The systemic pulmonary vascularization of 26 subjects was studied by a microangiographic technique after total body injection by micropaque. By our microangiographic technique was observed an average of 2 bronchial arteries per subject whereas by dissection we found an average of 2,5. We also noticed in 80% of our subjects a right intercosto-bronchial trunk, in 15% a right bronchial artery, in 30% a common trunk for both left and right bronchial arteries, and an average of 1.2 left bronchial arteries per subject. Besides microangiography revealed: 1) Numerous and variable aspects of systemic intra-pulmonary vascularisation except for the trifurcation of the right bronchial artery. 2) The importance of the arterial network in the submucosa of segmental and subsegmental bronchi. 3) The vascular supply of the visceral pleura by bronchial vessels.