O.174: Mini-Gastric Bypass as primary procedure in Super-Obesity – early results from Germany K.Rheinwalt, S. Kolec, A. Plamper IFSO 2013, 18th World Congress, Istanbul Dept. for Bariatric and Metabolic Surgery St. Franziskus Hospital Cologne Germany

Role of Mini-Gastric Bypass in Germany - History Germany: still underdeveloped in bariatrics German population: high body weight and high BMI Banding for a long period predominant procedure Bypass-procedures: introduced with delay Sleeve: very popular (43,7% 2012) (easier to perform in higher BMI by less experienced surgeons, reimbursement = as RYGB) still widespread fear of Gastric Cancer after BII-reconstruction K. Rheinwalt 2013

Role of Mini-Gastric Bypass in Germany – situation today Biggest published series by R. Weiner (Frankfurt) with about 176 cases from 2001 to 2007 (indications: hepatomegalie, high risk, Jehovians, pt.’s wish)* Operation time 20 minutes shorter* In this series: ~10 % transformed to RYGB for pouchitis in postoperative endoscopy (even if not symptomatic)* MGB still mostly abandoned as primary procedure 2005 until now: ~300 MGBs performed among cases (~1%) Since 2012 new interest as REDO especially after sleeve K. Rheinwalt 2013 *Weiner RA (Editor): Adipositaschirurgie. Chapter Ein-Anastomosen-Magenbypass Elsevier, München

Only 100 MGBs in the National German Survey Study of Bariatric Surgery K. Rheinwalt 2013

Why MGB? – own motivation visiting Prof. Chevallier in Paris 2009 promising results in the literature since 1997 ¹²³⁴⁵⁶⁷⁸⁹ complications (leaks, acid reflux) and weight regain with sleeves (own observations and literature)* risk of RYGB in Super-Obesity operations together with Dr. Rutledge ¹Chakhtoura G; Primary results of Laparoscopic Mini-Gastric Bypass in a French Obesity-Surgery Specialized University Hospital. Obes Surg 2008 (18): ²Lomanto D, Lee WJ et al; Bariatric Surgery in Asia in the Last 5 Years. Obes Surg 2012;22 (3): ³Garcia-Caballero M, Carbajo M. One anastomosis gastric bypass: a simple, safe and efficient procedure for treating morbid obesity. Nutr Hosp 2004 XIX(6): ⁴Noun R et al. One Thousand Consecutive Mini-Gastric Bypasses: Short- and Long-term Outcome. Obes Surg ): ⁵Rutledge R. The Mini-Gastric Bypass: Experience with the first cases. Obes Surg 2011 (11): ⁶Rutledge R, Walsh W. Continued excellent results with the mini-gastric bypass: six-year study in 2410 patients. Obes Surg. 2005;15: ⁷Rutledge R Consecutive Mini-Gastric Bypasses: 15 years later. Obes Surg. 2012; 22: 1323 (presented at XVII World Congress of IFSO in New Delhi ⁸Lee WJ et al. Laparoscopic Roux-en-Y versus mini-gastric bypass for the treatment of morbid obesity. Ann Surg. 2005;242:20-8 ⁹Lee WJ et al. Laparoscopic Roux-en-Y vs. Mini-gastric Bypass for the Treatment of Morbid Obesity: a 10-Year Experience. Obes Surg 2012(22): *Himpens J et al. Long-term results of laparoscopic sleeve gastrectomy for obesity. Ann Surg 2010; 252:

Start of own « MGB – program » in which patients for MGB? K. Rheinwalt 2013

Good indications for MGB: Super-Obesity (BMI > 50) ¹ ² ³ REDOs, especially following sleeves ⁴ ⁵ ⁶ ⁷ High-risk-patients (shorter operation times)⁸ Instead of sleeves as one or two step procedures (BPD-DS) ??? ¹Peraglie C. Laparoscopic mini-gastric bypass (LMGB) in the super-super obese: outcomes in 16 patients. Obes Surg (9): ²Choban PS,Flancbaum L.The effect of Roux limb lengths on outcome after Roux-en-Y gastric ypass: a prospective randomized clinical trial. Obes Surg 2002;12(4):540-5 ³Noun R et al. One thousand consecutive mini-gastric bypass: short- and long-term outcome. Obes Surg 2012;22: ⁴Chevallier JM. Oral Presentation. 21 Redos after LSG. 1 st Mini-Gastric Bypass Consensus Conference. Paris, Oct 2012 ⁵Kular KS. Oral Presentation. 7 Redos after LSG. 1 st Mini-Gastric Bypass Consensus Conference. Paris, Oct 2012 ⁶Plamper A, Rheinwalt K. Revisional Surgery after sleeve gastrectomy - Pro Omega-Loop Gastric Bypass. Oral Presentation. 7 th Frankfurter Meeting Nov 2012 ⁷Weiner RA, Theodoridou S, Weiner S. Failure of Laparoscopic Sleeve Gastrectomy – Further Procedure? Obes Facts 2011;4(suppl 1):42-46 ⁸Weiner RA (Editor): Adipositaschirurgie. Chapter Ein-Anastomosen-Magenbypass Elsevier, München, p K. Rheinwalt 2013

Own indication pattern until 2011 BMI < 50 BMI > 50 K. Rheinwalt 2013

BMI<50 BMI BMI > 60 Our Indication Pattern since 11 / 2011 No reflux reflux K. Rheinwalt 2013

Own technique Modified «Rutledge-technique» (no anti-reflux stitches) 5 trocars Surgeon on the right side of the patient, 1 assistant btw. legs Modification: 1st measuring BP-limb and transitory fixation stitch to greater curvature plus metal-clip-marking of the alim. limb Only then VERY LONG and NARROW gastric pouch (30 French cal. tube) Linearly stapled anastomosis to the distal posterior wall Ventrally closed with 2 layer running suture 2-0 Routine methylene blue testing and drainage K. Rheinwalt 2013

Bypass-length depending on BMI:¹ ² ³ BMI < 50BMI BMI > cm250 cm300 cm … … … … ¹Choban PS, Flancbaum L. The effect of Roux limb lengths on outcome after Roux –en-Y gastric bypass: a prospective randomized clinical trial. Obes Surg 2002;12(4):540-5 ²Rutledge R. Association of bypass limb length and one year weight loss in 4114 Mini-Gastric Bypass patients. Abstract-No.: 262. IFSO Hamburg ³Lee WJ et al. Laparoscopic mini-gastric bypass: experience with tailored bypass limb according to body weight. Obes Surg 2008; 18(3):294-9 K. Rheinwalt 2013

261 Bariatric Operations from 6/2011 to 8/2013 (197 f, 64 m, 139,7kg, BMI 48,7, 30d-mortality=0) K. Rheinwalt 2013

Among 100 MGBs: K. Rheinwalt primary MGBs for BMI > primary MGBs with BMI < 50 (for high risk, hepatomegaly, patient wish) 10 REDO-MGBs after sleeve-resections / gastric banding

Mean values for 65 primary MGBs for Super-Obesity K. Rheinwalt 2013 Age: 42,2 years (21 to 64) Weight:158,3 kg (120 to 213) BMI:55,5 kg/m² (50,2 to 65,5) Bypass length:260,2 cm (120 to 350) Length of operation: 79,2 min (45 to 160) Hospital stay:4,4 days (3 to 12) Mortality:0,0

Complications K. Rheinwalt 2013 Intraoperatively: 3 / 65 2 x oversewing of micro-leakages after methylene blue testing switch to RYGB for mesentery being too short for Omega-loop (pt. not counted in MGB-group) Postoperatively: 6 / 65 1 Re-laparoscopy for incarcerated trocar site hernia (drain channel) 1 transformation to RYGB for dysphagia (success only after Psychotherapy) 1 conservatively treated leakage (staple line of the pouch) 1 conservatively treated hemorrhage in the gallbladder bed after simultaneous cholecystectomy 1 pneumonia 2 cardiac arrhythmias

Postoperative Follow-up K. Rheinwalt 2013 MGB > 50 kg/m² (n=65) MGB < 50 kg/m² (n=25) all primary MGBs (n=90) all primary RYGBs (n= 77) Sleeve (n=36) Age42,2 y (21-64) 49,6 y (28-65) 44,2 y (21-65) 41,6 y (23-58) 44,6 y (19-64) BMI (kg/m²)55,5 (50,2-65,5) 47,2 (40,3-49,9) 53,1 (40,3-65,5) 45,9 (38,6-64,3) 55,4 (41,6-75,9) n after 6 months Weight loss after 6 months (kg) (min.-max.) 41,5 (25,0-62,4) 33,1 (16,5-43,4) 39,8 (16,5-62,4) 35,8 (19,2-51,6) 35 (10,0-64,0) EWL after 6 months (%) (min.-max.) 47,2 (27,7-62,4) 51,7 (28,4-74,2) 48,6 (27,7-74,2) 59,76 (35,8-95,8) 44,0 (15,3-64,8) n after 12 months Weight loss after 12 months (kg) (min.-max.) 55,9 (36,9-68,5) 45,5 (36,5-56,4) 51,6 (36,5-68,5) 46,5 (31,0-62,0) 40,7 (14,0-74,5) EWL after 12 months (min.-max.) 67,4 (52,0-79,8) 75,7 (50,2-96,4) 70,8 (50,2-96,4) 75,6 (45,4-104,3) 53,9 (21,4-84,87)

Summary MGB represents ~1% of bariatric procedures in Germany still widespread fears of bile reflux and cancer risks Advantages rather obvious in super-obesity, high risk and REDOs after sleeve Alternative to sleeve as primary procedure independent from BMI? our early results in 65 super-obese pts. confirm international favorable results RYGB remains standard procedure at least for BMI<50 more RCTs MGB vs. RYGB rewarded K. Rheinwalt 2013

Thank you! ? K. Rheinwalt 2013