Mini Gastric Bypass: initial experience Israeli Forum Of Obesity Surgery Meeting March 04 , 2016 Jerusalem Mini Gastric Bypass: initial experience Barzilai University Medical Center Department General & Vascular Surgery Advanced Laparoscopic and Bariatric Surgery Unit Dukhno Oleg. Melnik Idit. Yoffe Boris* 05/07/2018

Introduction in MGB Dr Robert Rutledge Pioneer 15 year experience 7000 cases Excellent results Long term FU Mini Gastric Bypass is a combination of Collis plasty Billroth 2 The Mini Gastric Bypass was conceived and pioneered by Dr Robert Rutledge some 15 years ago . Over 15 years he has carried out more than 7000 procedures with excellent resuts. His operation is nothing more than a combination of a very long Collis plasty and a Billroth 2 type gastro jejunal anastomosis. That type of anastomosis was first introduced by Theodore Billroth in 1885 and is still widely used today by cancer surgeons, trauma surgeons and general surgeons.

Fears and Controversy MGB is going to be endorsed by ASMBS or ACS and MGB is clearly on the rise throughout the world. Fears Cancer Bile reflux Marginal ulcer Why we started??? 1- As second part for failed sleeve (weight regain/ stenosis) Looking for alternative better procedures (YOFFE.BENADO) It is true that untill this day the MGB has not been endorsed by the leadership of the big American societies. When introduced MGB received al lot of criticism and many surgeons feared this operation would be tainted by the same problems as happened to the Mason Ito gastric bypass, an operation that was discredited in the 80’s: increased risk of cancer, bile reflux symptoms and marginal or stomal ulcer. (insert picture of Mason Ito bypass)

Risk of cancer Bariatric surgeons fear Billroth 2 anastomosis Cancer surgeons choose Billroth 2 Hundreds of thousands of people with Billroth 2. If CA is such a big risk shouldn’t gastroenterologists be screening these people? NO There is no recommendation to do endoscopic screening after Billroth 2 The risk is LOW: endoscopy screening is not rewarding Mayo clinic, 338 B2 patients, 25years FU, 5635 person-years. Only 2 cancers detected in >5000 pat-years of FU Schafer et al Risk of gastric cancer after treatment of benign ulcer disease. N Engl J. Med 1983: Nov 17; 309 1000 patients, 22-30 y FU, endoscopy, no CA in gastric remnant Br J Surg 1983 Sep; 70 (9): 552-4 Risk of gastric cancer after B2 resection for duodenal ulcer. Fisher AB It would appear that bariatric surgeons fear the Billroth 2 looped anastomosis yet cancer surgeon use the Billroth 2 operation. Every year thousands of Billroth 2 operation are performed in the US. (16000 in 2007) Many papers have been published detailing the safety of Billroth 2 and proving that there is no increased risk of cancer after this type of surgery

Bile reflux Major problem with Mason bypass Risk with MGB is real Anastomosis too close to oesophagus Risk with MGB is real Gastric tube has to be LONG First staple firing well into gastric antrum Anastomosis lies at level of the pylorus RNY surgeons tend to make gastric pouch not long enough Can usually be treated medically Surgical intervention Braun anastomosis Conversion to RNY (stenosis) Braun anastomosis Bile reflux was a debilitating problem with the Mason Ito bypass. With MGB as with any operastion there are some tricks and also some traps. If the gastric pouch is too short and/or there is an anastomotic stenosis then there is a high risk of bile reflux. If the gastric pouch is long and the anastomosis is wide then there will be no reflux. (insert picture of Braun anastomosis and of Mason Ito bypass)

Marginal ulcer Marginal ulcer is the Achilles heel of all gastric bypass operations: it has been known since the beginning of GI surgery It is not just a problem for MGB. Risk factors: tabac, nsaid, ischaemia, foreign body, alcohol, H pylori, poor diet Both RNY & MGB Incidence: 0.6% to 12% True incidence likely higher 28% of marginal ulcers can be asymptomatic (Csendes prospective study) Bile makes no difference Marginal ulcer in RNY 2282 patients 122 (5%) marginal ulcers 39 (32%) requiring surgery Surg Obes Relat. Dis. 2009 May-Jun;5(3):317-22 Revisional operations for marginal ulcer after RNY gastric bypass Patel RA, Brolin RE Marginal ulcers can occur with any type of gastro-enteric anastomosis. Marginal ulcers are seen both in MGB and RNY. Smoking, NSAIDS, ischaemia at the anastomosis and H Pylori are all known to be risk factors. Csendes from Santiago showed that the incidence of stomal ulcer after RNY can be as high as 12%. Brolin reported an incidence of 5% after RNY with a re-operation rate of 32%

Selection criteria's were usual There were 131 patient( till today) 89 women and 42 men BMI-range 38-62 Average weight 120 (98-210) Average operative time 51 min (38-100min) Period of time 2013-2016 40 pts after previous sleeve gastrectomy or banding (18,2%) 91 pts as primary procedure(81.8%)

MGB experience at Barzilai University Medical Center Oct 2013 – Jan 2016 2 cohorts of 100 patients: LSG vs. MGB (single anastomosis gastric bypass) Data collection (local database with or without national registry??) Follow-up: standard 3 monthly, 6 month, 12 mnt,18 month. 24 Reasonable matched not randomized LSG (N:100) MGB (N:100) Age 46.7 (18 – 65) 52.0 (24 – 71) Gender M/F 29\71 28/ 72 Weight (Kg) 124.53 + 16.53 125.46 + 19.75 To evaluate the MGB we decided to compare 2 cohorts of patients: one consisting of LSG and another of MGB’s All data were collected prospectively The follow-up was identical for both groups and the cohorts were well matched with regard to funding, age, gender and operative weight. Only 2 patients were lost to FU in each cohort 12 months after surgery. FU rate at 24 months: 70% for משרוולים 90% מעוקבים 05/07/2018

Patient characteristics ASA score Co-morbidity ASA LSG MGB 1 15 12 2 41 37 3 19 25 4 Medical Morbidity LSG (N 100) MGB (N 100) NIDDM 28 36 HTN 23 41 SAS 18 Asthma 15 Functional impairment (less than 3 flights of stairs) 71 73 Previous surgery 40 GERD 11 16 The MGB group contained a larger number ASA3 patients The co-morbidity was fairly similar in both groups. 05/07/2018

Results Mortality: 0% both groups Hospital stay: Med 2 days (MGB: 3,43 // LSG: 2,93) Early complications Complication LSG (n 100) MGB (n 100) Intraperitoneal bleed 4(CLAVIEN 3 a-b) 1(clavien 3B) GI endoluminal bleed 2 (RTT: endoscopy + laparoscopy) Anastomotic |sleeve leak 4 1(no need for additional surgery) Aspiration pneumonia 2 (ARDS) 1 Pneumonia 1 (AB) TROCAR SITE problems 1( port site infection) Anastomotic\sleeve stenosis 8 (dilatation) some of them for same patients Complication rate 7% 5,2% Mortality was 0 in both groups and the length of stay identical. There were complications in both groups.. We had 5 early and 3 late complications in the RNY group. Explain them….. There were 2 early and 4 late complications in the MGB group. Explain them…. 05/07/2018

Late complications MGB 4 dysphagia / food intolerance:(Normal endoscopy with swallow) 4 marginal ulcer and bile reflux??: well treated PPI and 1 with intention to convert to RNY > 12 months postop (heavy smoker) 1 protein malnutrition: intention to convert to proximal RNY > 12 months postop ?? Reoperation rate: ( bleeding 2/100) Early experience No internal hernia

Effect on medical co-morbidity Results at 12 months FU Medical condition LSG preop Last FU % improved MGB MGB (n 49) NIDDM 32 8 70% 36 3 90.7% HTN 23 15 34.8% 41 20 52.4% SAS 5 58’2% 18 4 60% Asthma ???? ????? Functional impairment 71 97.57% 73 91.% OA 12 20% 25 28% REFLUX SYMPTOMS ??? de novo) !!!! Both operations have beneficial effects on co-morbidities. While the 6 month data suggested that the MGB would have a significantly better effect on T2DM the 12 month data showed identical results. The functional improvement is impressive in both groups. The effect of both bypasses on pre-existing reflux symptoms is not as strong as one would have expected. In both groups 4 patients developed de novo symptoms requiring daily PPI’s 05/07/2018

Weight loss results Preop (mean + SD) 1 year (mean + SD) LSG weight Kg 126.01 ± 17.01 96.94 ± 16.55 p<0.01 LSG BMI 48.84 ± 14.20 33.93 ± 4.93 MGB weight Kg 124.62 ± 19.01 86.58 ± 14.7 MGB BMI 48.40 ± 5.21 30.60 ± 4.68 LSG MGB Preop (n 100) Weight (Kg) 126.01 + 17.01 124.62 ± 19.01 NS BMI operation 48.84 ± 14.20 48.40 + 5.21 1 year postop (n 50) Weight 96.94 + 16.55 86.58 + 14.70 P<0.05 %EWL 75.08 ± 18.56 67.69 + 15.32 2 years results ??? BMI 33.93 + 4.93 30.60 + 4.68 After 12 months the RNY group have lost on average 40Kg and their BMI has dropped 15 points The MGB patients on the other hand have lost on average 48Kg and have dropped 17 BMI points When we compare both groups we see that the MGB patients achieve 75% loss of Excess Weight while the RNY group achieves significantly less at 63% 05/07/2018

Conclusions Mini Gastric Bypass Safe and easy procedure Complications similar to LSG , but treated more easily. Beware of “tricks” and “traps” Medical benefits better than LSG and similar to RNY Weight loss probably better than RNY Valid alternative for LSG and RNY In conclusion I would like to say that MGB appears to be a safe, simple and easy to perform procedure with complications similar to the RNY. Just like with any other procedure there are certain tricks and traps one has to be aware of. The effects on co-morbidity are similar to the RNY. We did see a better weight loss with the MGB group. Our data are identical to the literature on MGB and support the claim that MGB is a valid alternative for the RNY.….

Thank you