Mini Gastric (Omega Loop) Bypass Studies

Laparoscopic mini-gastric bypass in patients age 60 and older.

Surgical Endoscopy

January 2016, Volume 30, Issue 1, pp 38-43

Cesare Peraglie MD FACS FASCRS

Background

Bariatric surgery in patients over age 60 was previously not considered, due to higher risk. The author presents a study of patients ≥60 years who underwent laparoscopic mini-gastric bypass (LMGB), to evaluate outcomes with follow-up to 6 years.

Methods

From 2007–2013, a prospectively maintained database was reviewed and patients ≥60 years were identified. Demographics evaluated included age, sex, weight, BMI, comorbidities, operative time, complications, length of stay (LOS) and %EWL up to 72 months.

Results

From 2007–2013, a total of 758 LMGBs were performed by one surgeon (CP). Eighty-eight (12 %) were ≥60 years old, with 62 % female. Mean age of this cohort at operation was 64 (60–74), and mean weight and BMI were 118 kg (78–171) and 43 kg/m2 (33–61), respectively. Comorbidities were present in all patients, and one-third had previous abdominal operations. All patients underwent LMGB, without conversion to open. Mean operative time was 70 min (43–173). Only one patient required overnight ICU admission. Average LOS was 1.2 days (1–3). Overall complication rate was 4.5 % (all minor); there were no major complications. Readmission rate was 1.2 % (one patient). There was no surgical-related mortality. Follow-up to 90 days was 89 %, but steadily declined to 42 % at 6 years (72 months). The %EWL was 72 % at 72 months.

Conclusion

LMGB can be safely performed with good weight loss in patients ≥60 years old, despite numerous comorbidities and previous abdominal operations.

Efficacy of Bariatric Surgery in Type 2 Diabetes Mellitus Remission: the Role of Mini Gastric Bypass/One Anastomosis Gastric Bypass and Sleeve Gastrectomy at 1 Year of Follow-up. A European surveyA 7-Year Clinical

Obesity Surgery

May 2016, Volume 26, Issue 5, pp 933-940

Musella et al.

Background

A retrospective study was undertaken to define the efficacy of both mini gastric bypass or one anastomosis gastric bypass (MGB/OAGB) and sleeve gastrectomy (SG) in type 2 diabetes mellitus (T2DM) remission in morbidly obese patients (pts).

Methods

Eight European centers were involved in this survey. T2DM was preoperatively diagnosed in 313/3252 pts (9.62 %). In 175/313 patients, 55.9 % underwent MGB/OAGB, while in 138/313 patients, 44.1 % received SG between January 2006 and December 2014.

Results

Two hundred six out of 313 (63.7 %) pts reached 1 year of follow-up. The mean body mass index (BMI) for MGB/OAGB pts was 33.1 ± 6.6, and the mean BMI for SG pts was 35.9 ± 5.9 (p < 0.001). Eighty-two out of 96 (85.4 %) MGB/OAGB pts vs. 67/110 (60.9 %) SG pts are in remission (p  < 0.001). No correlation was found in the % change vs. baseline values for hemoglobin A1c (HbA1c) and fasting plasma glucose (FPG) in relation to BMI reduction, for both MGB/OAGB or SG (ΔFPG 0.7 and ΔHbA1c 0.4 for MGB/OAGB; ΔFPG 0.7 and ΔHbA1c 0.1 for SG). At multivariate analysis, high baseline HbA1c [odds ratio (OR) = 0.623, 95 % confidence interval (CI) 0.419–0.925, p = 0.01], preoperative consumption of insulin or oral antidiabetic agents (OR = 0.256, 95 % CI 0.137–0.478, p = <0.001), and T2DM duration >10 years (OR = 0.752, 95 % CI 0.512–0.976, p = 0.01) were negative predictors whereas MGB/OAGB resulted as a positive predictor (OR = 3.888, 95 % CI 1.654–9.143, p = 0.002) of diabetes remission.

Conclusions

A significant BMI decrease and T2DM remission unrelated from weight loss were recorded for both procedures if compared to baseline values. At univariate and multivariate analyses, MGB/OAGB seems to outperform significantly SG. Four independent variables able to influence T2DM remission at 12 months have been identified.

Audit of 1107 Cases Comparing Sleeve Gastrectomy, Roux-En-Y Gastric Bypass, and Mini-Gastric Bypass, to Determine an Effective and Safe Bariatric and Metabolic Procedure

Obesity Surgery

May 2016, Volume 26, Issue 5, pp 926-932

Gurvinder S. Jammu , Rajni Sharma

Background

The epidemic of obesity is engulfing developed as well as developing countries like India. We present our 7-year experience with laparoscopic sleeve gastrectomy (LSG), Roux-en-Y gastric bypass (RYGB), and mini-gastric bypass (MGB) to determine an effective and safe bariatric and metabolic procedure.

Methods

The study is an analysis of a prospectively collected bariatric database of 473 MGBs, 339 LSGs, and 295 RYGBs.

Results

Mortality rate was 2.1 % in LSG, 0.3 % in RYGB, and 0 % in MGB. Leaks were highest in LSG (1.5 %), followed by RYGB (0.3 %), and zero in MGB. Bile reflux was seen in <1 % in the MGB series. Persistent vomiting was seen only in LSG. Weight regain was 14.2 % in LSG, 8.5 % in RYGB, but 0 % in MGB. Hypoalbuminemia was minimal in LSG, 2.0 % in RYGB, and 13.1 % in MGB (in earlier patients where bypass was >250 cm). The following resolution of comorbidities: dyslipidemia, type 2 diabetes (T2D), hypertension, and percent excess weight loss (%EWL) was maximum in MGB. GERD was maximum in LSG (9.8 %), followed by RYGB (1.7 %), and minimal in MGB (0.6 %).

Conclusions

RYGB and MGB act on the principle of restriction and malabsorption, but MGB superseded RYGB in its technical ease, efficacy, revisibility, and reversibility. Mortality was zero in MGB. %EWL and resolution of comorbidities were highly significant in MGB. Based on this audit, we suggest that MGB is the effective and safe procedure for patients who are compliant in taking their supplements. LSG may be done in non-compliant patients and those ready to accept weight regain.

One Thousand Single Anastomosis (Omega Loop) Gastric Bypasses to Treat Morbid Obesity in a 7-Year Period: Outcomes Show Few Complications and Good Efficacy.

Obes Surg. 2015 Jan 14. [Epub ahead of print]

Chevallier JM1, Arman GA, Guenzi M, Rau C, Bruzzi M, Beaupel N, Zinzindohoué F, Berger A

BACKGROUND:

A short-term randomized controlled trial shows that the one anastomosis gastric bypass (OAGB) is a safe and effective alternative to the Roux-en-Y gastric bypass (RYGB).

OBJECTIVE:

The aim of this study is to evaluate the OAGB at our University Hospital between 2006 and 2013.

PATIENTS:

One thousand patients have undergone an OAGB. Data were collected on all consecutive patients. The mean follow-up period was 31 months (SD, 26.3; range, 12-82.9), and complete follow-up was available in 126 of 175 patients (72 %) at 5 years after surgery.

RESULTS:

Mortality rate was 0.2 %. Overall morbidity was 5.5 %; 34 required reoperations: i.e., 6 leaks, 5 obstructions, 5 incisional hernias, 7 biliary refluxes, 2 perforated ulcers, 2 bleeds, 2 abscesses, and 1 anastomotic stricture. Four patients were reoperated for weight regain. Overall rate of marginal ulcers was 2 % (n = 20), all in heavy smokers. Conversion from an OAGB to a RYGB was required in nine cases (0.9 %): seven for intractable biliary reflux, two for a marginal ulcer. At 5 years, percent excess body mass index loss was 71.6 ± 27 %. One hundred patients with type-2 diabetes, with a mean preoperative HbA1C of 7.7 ± 1.9 %, were followed for >2 years; the total resolution rate was 85.7 %.

CONCLUSION:

This study confirms that the OAGB is an effective procedure for morbid obesity with comparable outcomes to RYGB; in addition, it seems to be safer with lower morbidity. Its technical simplicity represents a real advantage and makes it an option that should be considered by all bariatric surgeons.

REMISSION OF TYPE 2 DIABETES MELLITUS AFTER OMEGA LOOP GASTRIC BYPASS FOR MORBID OBESITY

Surgical endoscopy, 2015. Jan 1. [Epub ahead of print]

Guenzi Martino, Arman Gustavo, Rau Cédric, Cordun Cristiana, Moszkowicz David, Voron Thibault, Chevallier Jean-Marc.

BACKGROUND:

Roux-en-Y gastric bypass (RYGBP) is a validated technique for the treatment of morbid obesity and results in a significant rate of remission of type 2 diabetes (T2D). Omega gastric bypass (OGBP) is an effective and simpler alternative for weight loss, but its effect on T2D is unclear.

METHODS:

Between December 2006 and September 2012, 804 laparoscopic OGBPs were carried out in our centre. Among these, 100 (12.4 %) patients had T2D at the time of the intervention. Remission of T2D was defined by a glycated haemoglobin (HbA1c) level of <6 % without concomitant treatment.

RESULTS:

Postoperative follow-up was completed by 81 patients (mean age: 49 ± 11 years; mean weight at surgery: 133 ± 29 kg; mean body mass index (BMI): 47 ± 9 kg/m2). Mean preoperative HbA1c was 8 ± 2 g/dL. Before OGBP, seven patients (9 %) had received no oral hypoglycaemic treatment, 30 (37 %) had received monotherapy, 26 (32 %) bitherapy, six (7 %) tritherapy and 12 (15 %) patients had used insulin. Over a mean follow-up of 26 months (range 1-75), mean weight decreased to 94 ± 23 kg and mean BMI to 35 kg/m2. Seventy-one (88 %) patients had complete remission of T2D and the other 10 (12 %) had reduced their treatment. Seven patients (58 %) initially treated with insulin no longer required this treatment. Mean time to remission of T2D for patients receiving one or more oral therapies versus insulin was 6.9 versus 17.9 months.

CONCLUSIONS:

OMBP is effective treatment for obesity in terms of weight loss and remission of T2D.

Single anastomosis or mini-gastric bypass: long-term results and quality of life after a 5-year follow-up.

Surg Obes Relat Dis. 2014 Sep 16.  [Epub ahead of print]

Bruzzi M1, Rau C2, Voron T2, Guenzi M2, Berger A2, Chevallier JM2.

BACKGROUND:

Laparoscopic mini-gastric bypass (LMGB) is an alternative to the laparoscopic Roux-en-Y gastric bypass (LRYGB), which is considered to be the gold standard in the treatment of morbid obesity.

OBJECTIVES:

Present 5-year results of 175 patients who had undergone a LMGB between October 2006 and October 2008.

SETTING:

University public hospital, France.

METHODS:

Complete follow-up was available in 126 of 175 patients (72%) who had LMGB. Mortality, morbidity, weight loss, co-morbidities, and quality of life were assessed. Weight loss was determined as a change in body mass index (BMI) and percent excess BMI loss (%EBMIL). Quality of life in the treatment group was analyzed using the Gastrointestinal Quality of Life Index (GIQLI) and was compared with a retrospectively case matched preoperative control group.

RESULTS:

There were no deaths. Thirteen patients (10.3%) developed major complications. Marginal ulcers occurred in 4% of patients. Incapacitating biliary reflux developed in 2 (1.6%) who required conversion into RYGB. Gastric pouch dilation occurred in 4 patients (3.2%) and inadequate weight loss with severe malnutrition in 2 (1.6%). At 5 years, mean BMI was 31±6 kg/m2 and mean %EBMIL was 71.5%±26.5%. Postoperative GIQLI score of the treatment group was significantly higher than preoperative score of the control group (110.3±17.4 versus 92.5±15.9, P<.001). Social, psychological, and physical functions were increased significantly. No significant differences were found in gastroesophageal reflux or diarrhea symptoms between the 2 groups. Long-term follow-up showed an improvement in all co-morbidities.

CONCLUSIONS:

At 5 years, LMGB was safe, effective, and provided interesting quality of life results.

15 years of the mini-gastric bypass

Presenting the outcomes at the IFSO meeting in New Delhi, Dr Robert Rutledge, Nevada, said that these results add to the growing evidence that MGB is a safe and effective procedure with many of the features of an ideal bariatric surgery.

From September 1997 to June 2011, 6,385 patients underwent MGB, with the mean pre-operative weight (+/- standard deviation) was 143 +/-31kg, BMI 47+/-7; 83% of the patients were female.

Outcomes

The mean operative time was 41 minutes and median length of stay was one day. Early complications occurred in 4.9% of the patients; 44 patients (0.7%) had anastomotic leaks. Three patients (0.05%) presented with dypepsia/bile reflux that was not responsive to medical therapy and were successfully treated by Braun side-to-side jejuno-jejunostomy. Gastritis/dyspepsia/marginal ulcer was the most serious long term complication; routinely treated medically.

Three deaths (0.05%) occurred within 30 days of surgery. The most recent death was in 2004.

Weight loss

Excessive weight loss occurred in 1% of patients; treated by take down of the bypass. The mean percent excess weight loss was 78% and the ten-year weight regain, 4.9%. At 18 months, 95% of patients achieved >50% EWL and 92% at 60 months.

Inadequate weight loss or significant weight regain was found in 6% of patients and these patients subsequently underwent a revision (addition of ~2 meters to the bypass). Rutledge said that these reported outcomes are comparable to other large, long term MGB series reported in the literature.

Comparable procedures

In addition, Rutledge also presented the preliminary results from an IFSO Varianational Committee on New Procedures Survey that interviewed over 118 surgeons from 30 countries and who shared their career experience from over 39,000 bariatric cases.

The surgeons were asked their expert opinion on laparoscopic gastric banding, sleeve gastrectomy, Roux-en-Y gastric bypass (RNY) and MGB.

Asked whether weight gain was common after each procedure, all experts agreed that weight gain was common after banding, 42% said weight gain was common after sleeve, 39% said weight gain was common after RNY bypass and only 9% said weight gain was common after MGB.

When asked the converse question regarding major weight loss, 10% said major weight loss was common after banding, 78% said it was common after sleeve, 84% said it was common after bypass and 90% said it was common after MGB.

Over 90% said that banding presented a risk of post operative acid reflux, 60% said the sleeve presented a risk of post op acid reflux, but only 5% said RNY bypass presented a risk of reflux, while 10% said MGB presented a risk of reflux. This is important because extensive data show that acid reflux can lead to oesophageal cancer.

Finally, when asked about the ease of revision surgery, 30% agreed that banding revision was easy, 52% agreed that sleeve revision was easy, 22% agreed that bypass revision was easy, while 90% said MGB agreed that sleeve revision was easy.

“These 15 year data confirm other studies showing that the MGB is comparable, and in some instances preferable, to more common procedures such as banding, RNY bypass and sleeve,” concluded Rutledge. “In spite of initial scepticism, MGB is a safe and effective procedure and can be easily revised, converted or reversed.”

LAPAROSCOPIC MINI-GASTRIC BYPASS IN PATIENTS 60 YEARS OF AGE AND OLDER
Presented at IFSO (International Federation for the Surgery of Obesity and Metabolic Disorders): Hamburg, Germany: September 2011

Peraglie C.P.1

1Heart of Florida Regional Medical Center, Surgery, Davenport, United States
 

Background: Bariatric surgery in patients over the age of 60 was previously not considered an option due to a presumed higher risk. I present in the following study a group of patients 60 years and older who underwent Laparoscopic Mini Gastric Bypass (LMGB) with the aim to evaluate operative outcomes with respect to morbidity mortality and weight loss at 1 year follow up. Methods: From 2007-10, a prospectively maintained database was reviewed and patients 60 years of age and older were identified. Demographics evaluated included age sex, weight, BMI, co-morbidities, op time, complications, LOS, and %EWL at 1, 6,and 12 months.
 

Results: From 2007-10 a total of 556 LMGB were performed by a single surgeon (CP). 57(10.3 %) were patients over 60 years. There were 62%F and 38%M. Average age was 63 years(60-72), average weight and BMI were 121 kg (77-171) and 43 kg/m2 ( 35-61 ) respectively. Co-morbidities were present in the majority of patients with an incidence of 46% for diabetes, 79% hypertension and 49% dyslipidemia. In addition, 17.5% of patients had CAD (Coronary artery disease) with 10.5% having stents and 10.5% on anticoagulation with plavix or coumadin. 32% had previous abdominal surgery including cholecystectomy, ventral hernia repair with and without mesh, colon resection, hysterectomy, abdominoplasty and appendectomy. All patients had LMGB without conversion. Average op-time was 65 minutes (43-120). Only 1 patient required an overnight ICU admission. Average LOS was 1.2 days (1-3). The overall complication rate was 7% and there were no major complications. Readmission rate was 1 patient (1.7%). F/U at 1,3, 6, and 12 months post operatively was 100%, 96%, 88% and 80% respectively.
There was no surgical or procedure related mortality within the entire study group or time period. In total, one patient, however, expired at 1 year post-op due to newly diagnosed anaplastic carcinoma of the thyroid.. %EWL at 1,6 and 12 months was 18%, 51%, and 65% respectively. At the end of one year, 69% were off medications for diabetes, 51% for hypertension and 46% for dislipidemia.
 

Conclusions: LMGB can be safely performed in patients 60 years of age and older despite numerous co-morbid conditions as well as previous abdominal procedures.

ROLE OF MINI GASTRIC BYPASS AS A SINGLE STAGE PROCEDURE IN SUPER-SUPER OBESE PATIENTS
Kular K.S.1, Manchanda N.1
1Kular College of Nursing & Hospital, Dept. of Bariatric Surgery, Ludhiana, India
Background: Controversy continues to exist as far as the ideal management of the super- super obese (SSO) patients is concerned. A two stage procedure in the form of Laparoscopic Sleeve Gastrectomy (LSG) followed by Laparoscopic Roux-en-Y Gastric Bypass (LRYGBP) has been suggested by many. We present the results of a study of Laparoscopic Mini Gastric Bypass (LMGBP), as a single stage procedure in 42 super-super obese patients.
 

Methods: A prospective data base of 42 SSO patients (with BMI above 60 kg/sq m) who underwent LMGBP was accessed. Data regarding the demographics, operative time, hospital stay, complications and weight loss was collected. Follow up was done for a minimum of one year. Average age was 36 years. Average weight and BMI were 168 kg and 63.2 kg/ sq m respectively.
 

Results: All procedures were performed laparoscopically with no conversion to open. Average operative time was 84 mins. Hospital stay was 2.5 days. Intraoperative complications included a liver laceration in two patients and a short gastric artery bleed in one patient, all managed intra operatively. There were no deaths. Excess weight loss at 1 year was 63.4%.

Conclusion: LMGBP shows good results for weight loss in super super obese patients with a significantly low complication rate. LMGBP can be considered as an effective single stage procedure in the SSO patients. Long term results are awaited.
 

Revisional surgery for laparoscopic minigastric bypass

Surgery for Obesity and Related Diseases: Volume 7, Issue 4 , Pages 486-491, July 2011

Background:Laparoscopic minigastric bypass (LMGB), a sleeved gastric tube with Billroth II anastomosis, has been proposed as an alternative to laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity. However, the data regarding revision surgery after LMGB during long-term follow-up is not clear.

Methods: From January 2001 to December 2009, 1322 patients (996 women and 326 men, mean age 31.6 ± 9.1 years, mean body mass index 40.2 ± 7.4 kg/m2), who were enrolled in a surgically supervised weight loss program and had undergone LMGB were included. All the patients received regular yearly follow-up, and all the clinical data were prospectively collected and stored. The reasons and type of surgery for revision surgery were identified and analyzed.

Results: The excess weight loss and mean body mass index at 5 years after LMGB was 72.1% and 27.1 ± 4.6 kg/m2. Of the 1322 patients, 23 (1.7%) had undergone revision surgery during a follow-up of 9 years. The estimated accumulated revision rate of 9 years was 2.69% for LMGB. The most common cause of revision was malnutrition in 9 (39.1%), followed by inadequate weight loss in 8 (34.7%), and intractable bile reflux and dissatisfaction each in 3 (13.0%). The type of revision surgery was LRYGB in 11 (47.8%), sleeve gastrectomy in 10 (43.5%), and conversion to a normal anatomic state in 2 (8.6%). All the revision procedures were performed using a laparoscopic approach, without major complications. Two patients underwent repeat second revision surgery to duodenal switch and biliopancreatic diversion each in 1 patient. All patients had satisfactory results after revision surgery. No patients had undergone revision surgery for internal hernia or ileus during the follow-up period.

Conclusion:  LMGB resulted in significant and sustained weight loss with an acceptably low revision rate at long-term follow-up. Revision surgery after LMGB can be performed using a laparoscopic approach with a low risk.

Keywords: Morbid obesity, Laparoscopy, Minigastric bypass, Revision

Gastric Bypass vs Sleeve Gastrectomy for Type 2 Diabetes Mellitus:A Randomized Controlled Trial

Wei-Jei Lee, MD, PhD; Keong Chong, MD; Kong-Han Ser, MD; Yi-Chih Lee, PhD; Shu-Chun Chen, RN; Jung-Chien Chen, MD; Ming-Han Tsai, MD; Lee-Ming Chuang, MD

Arch Surg. 2011;146(2):143-148. doi:10.1001/archsurg.2010.326

Objectives  To determine the efficacies of 2 weight-reducing operations on diabetic control and the role of duodenum exclusion.

Design  Double-blind randomized controlled trial.

Setting  Department of Surgery of the Min-Sheng General Hospital, National Taiwan University.

Patients  We studied 60 moderately obese patients (body mass index >25 and <35) aged >30 to <60 years who had poorly controlled type 2 diabetes mellitus (T2DM) (hemoglobin A1c [HbA1c] >7.5%) after conventional treatment (>6 months) from September 1, 2007, through June 30, 2008. Patients and observers were masked during the follow-up, which ended in 2009, 1 year after final enrollment.

Interventions  Gastric bypass with duodenum exclusion (n = 30) vs sleeve gastrectomy without duodenum exclusion (n = 30).

Main Outcome Measures  The primary outcome was remission of T2DM (fasting glucose <126 mg/dL and HbA1c <6.5% without glycemic therapy). Secondary measures included weight and metabolic syndrome. Analysis was by intention to treat.

Results  Of the 60 patients enrolled, all completed the 12-month follow-up. Remission of T2DM was achieved by 28 (93%) in the gastric bypass group and 14 (47%) in the sleeve gastrectomy group (P = .02). Participants assigned to gastric bypass had lost more weight, achieved a lower waist circumference, and had lower glucose, HbA1c, and blood lipid levels than the sleeve gastrectomy group. No serious complications occurred in either group.

Conclusions  Participants randomized to gastric bypass were more likely to achieve remission of T2DM. Duodenum exclusion plays a role in T2DM treatment and should be assessed.

Trial Registration  clinicaltrials.gov Identifier: NCT00540462 (http://www.clinicaltrials.gov).

Primary Results of Laparoscopic Mini-Gastric Bypass in a French Obesity-Surgery Specialized University Hospital
Ghassan Chakhtoura & Franck Zinzindohoué & Yassine Ghanem & Ivan Ruseykin & Jean-Christophe Dutranoy & Jean-Marc Chevallier

OBES SURG (2008) 18:1130–1133

Received: 1 May 2008 / Accepted: 23 May 2008 / Published online: 20 June 2008 # Springer Science + Business Media, LLC 2008

Abstract: Background Since 2002, we have performed 350 laparo- scopic Roux-en-Y gastric bypasses (LRYGB). We decided to evaluate the laparoscopic mini-gastric bypass (LMGB), an operation reported as effective, yet simpler than LRYGB. It consisted of a long lesser curvature tube with a terminolateral gastroenterostomy, 200 cm distal to the Treitz ligament. Methods: From October 2006 to November 2007, 100 patients (23 men and 77 women) underwent LMGB. The mean    age    was    40.9 ± 11.5    years    (17.5–62.4),    the    preoperative mean body weight was 131±23.1 kg (82–203) and the mean BMI    was    46.9 ± 7.4    kg/m2    (32.8–72.4).    Twenty-four    patients had prior restrictive procedure: 20 LAGB of which nine were already removed and four VBG (two laparoscopic and two by open surgery). In preoperative gastric endoscopy Helicobacter pylorii was present in 26 patients and eradicated.

Results: All procedures were completed laparoscopically by six different surgeons. Mean operative time was 129±37 min. There was no death. Seven patients (7%) presented major early complications: three re-operations for incarcerated herniation of small bowel in the trocar wound, one peritonitis due to a traumatic injury of the biliary limb, one perianas- tomotic abscess, one intra-abdominal bleeding requiring splenectomy, and one endoscopic hemostasis for anastomotic bleeding. One patient presented anastomotic stenosis that required endoscopic dilatation 2 months post-operatively. Mean BMI at 3 months was 38.7 kg/m2 (31.2–60.9) and at 6 months 35.1 (23.6–53.0). Nine patients complained of diarrhea that resolved 3 months postoperatively and, signifi- cantly, only two patients complained of biliary reflux.

Conclusion: Pending long-term evaluation, LMBG seems a good alternative to LRYGB, giving the same results with a more simple and reproductible technique.

COMMENTS: LMGB is far from gaining general consensus so, what’s wrong with LMGB?
Not its low leakage rate. We haven’t noted any in our series (the postoperative peritonitis that we encountered was due to a traumatic jejunal injury away from the anastomosis). This is also true for other LMGB pub- lished series [5–9]. These low rates can probably be explained by a good blood supply of the gastric pouch and of the uninterrupted jejunal loop.
Not its simplicity. With only one anastomosis to do, we have gained 30 min in our operating time compared to LRYGB. And everybody knows that the enteroenteros- tomy can bring many complications such as leakage, kinking, internal hernias. Although our mean operative time seems longer than in other series, it can be due to the fact that 24% of our patients had prior restrictive procedures and that four out of six surgeons are senior residents. To note is our very conservative approach regarding postoperative realimentation; with growing experience, we are beginning to feed the patients on the third postoperative day resulting in 2-days shorter hospitalizations.
Surely not its effect on weight loss. With %EWL of 51% and 63% at 6 months and 1 year, we have equivalent figures as other LMGB series and this effect seems to be long-lasting [9].
Neither its anastomotic ulcer rate. Our 1% rate is lower than the usual 2% to 8% rate observed in other mini- bypass series. This may be due to our systematic pre- operative search and eradication of H. Pylori, our small gastric pouch meaning less acid secretion and our recommendation for lifelong proton pomp inhibitor usage. Even more, biliary presence at the site of the anastomosis in LMGB could hamper the ulcerogenic effect of acid.

Nor its good digestive tolerance. Lee’s 2005 clinical trial found no difference in digestive well-being between LMGB and LRYGB; our 2% clinical reflux rate com-pares positively with the 3% rate of clinical reflux that he described in both LMGB and LRYGB [7]. We plan next to undergo systematic search for esophageal biliary reflux after LMGB via impedencemetry, which is a more accurate method for assessing biliary reflux than the classic pHmetry that Carbajo used in his patients [8].
Is it an increased gastric cancer risk? This is probably the main issue. In rats, the pancreatico-duodenal reflux alone or in combination with bile reflux produced gastric adenocarcinoma whereas no carcinomas were found in animals with bile reflux alone [10]. If this is true in humans, is the effect of pancreatic juice still the same 2 m beyond the duodenum? Results of very long- term follow-up of human series after partial gastrecto- my show contradictory results: while some found no increase of gastric carcinomas after Billroth II anastomosis [11, 12], others state the contrary [13, 14]. Some even pretend that diversion of the enteric reflux from the gastric remnant with a Roux loop may yield pre- cancerous changes [15]. In a 1990 meta-analysis of 22 literature report on the risk of gastric cancer after remote peptic ulcer surgery, no statistical difference was found between the surgical techniques [16], and the LMGB is different from a Billroth II partial gastrectomy with a smaller gastric volume and a longer alimentary limb. Noteworthy is that in these retrospective studies, the role of H. pylori—a major risk factor or gastric cancer—is not taken into account. So, by sticking to the facts, we can repeat after Kondo that “the relationship between duodenogastric reflux and gastric cancer has not yet been defined from human data and that the question whether the incidence of gastric stump carcinoma is higher than that of gastric carcinoma in general is still unanswered.

Continued Excellent Results with the Mini-Gastric Bypass: Six-Year Study in 2,410 Patients

Obesity Surgery, 15, 1304-1308
Robert Rutledge, MD, FACS; Thomas R. Walsh, MD, FACS, CPE
The Centers of Excellence for Laparoscopic Obesity Surgery (CELOS), Las Vegas, NV, USA

Background: There is a growing body of evidence showing that the Mini-Gastric Bypass (MGB) is a safe and effective alternative to other bariatric surgical operations. This study reports on the results of a consecutive cohort of patients undergoing the MGB.
Methods: A prospective database was used to con-tinuously assess the results in 2,410 MGB patients treated from September 1997 to February 2004.
Results:The average operative time was 37.5 minutes, and the median length of stay was 1 day. The 30-day mortality and complication rates were 0.08% and 5.9% respectively. The leak rate was 1.08%. Average weight loss at 1 year was 59 kg (80% of excess body weight). The most frequent long-term complications were dys- pepsia and ulcers (5.6%) and iron deficiency anemia (4.9 %.) Excessive weight loss with malnutrition occurred in 1.1%. Weight loss was well maintained over 5 years, with <5% patients regaining more than 10 kg.
Conclusions: Overall, the MGB is very safe initially and in the long-term. It has reliable weight loss and complications similar to other forms of gastric bypass.

Laparoscopic Roux-en-Y Versus Mini-Gastric Bypass for the Treatment of Morbid Obesity: A Prospective Randomized Controlled Clinical Trial

Ann Surg 2005;242:pp 20 –28

Wei-Jei Lee, MD, PhD,* Po-Jui Yu, RN,† Weu Wang, MD,* Tai-Chi Chen, MD,* Po-Li Wei, MD,* and Ming-Te Huang, MD*

Objectives: This prospective, randomized trial compared the safe- ty and effectiveness of laparoscopic Roux-en-Y gastric bypass (LRYGBP) and laparoscopic mini-gastric bypass (LMGBP) in the treatment of morbid obesity.
Summary Background Data: LRYGBP has been the gold standard for the treatment of morbid obesity. While LMGBP has been reported to be a simple and effective treatment, data from a ran- domized trial are lacking.
Methods: Eighty patients who met the NIH criteria were recruited and randomized to receive either LRYGBP (n &#x10fc03; 40) or LMGBP (n &#x10fc03; 40). The minimum postoperative follow-up was 2 years (mean, 31.3 months). Perioperative data were assessed. Late complication, excess weight loss, BMI, quality of life, and comorbidities were determined. Changes in quality of life were assessed using the Gastro-Intestinal Quality of Life Index (GIQLI).
Results: There was one conversion (2.5%) in the LRYGBP group. Operation time was shorter in LMGBP group (205 versus 148, P &#x10fc01; 0.05). There was no mortality in each group. The operative morbid- ity rate was higher in the LRYGBP group (20% versus 7.5%, P &#x10fc01; 0.05). The late complications rate was the same in the 2 groups (7.5%) with no reoperation. The percentage of excess weight loss was 58.7% and 60.0% at 1 and 2 years, respectively, in the LPYGBP group, and 64.9% and 64.4% in the LMGBP group. The residual excess weight &#x10fc01;50% at 2 years postoperatively was achieved in 75% of patients in the LRYGBP group and 95% in the LMGBP group (P &#x10fc01; 0.05). A significant improvement of obesity-related clinical parameters and complete resolution of metabolic syndrome in both groups were noted. Both gastrointestinal quality of life increased significantly without any significant difference between the groups.
Conclusion: Both LRYGBP and LMGBP are effective for morbid obesity with similar results for resolution of metabolic syndrome and improvement of quality of life. LMGBP is a simpler and safer procedure that has no disadvantage compared with LRYGBP at 2 years of follow-up.