1. 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

2. 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.

3. 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)

4. 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, y FU, endoscopy, no CA in gastric remnant
Br J Surg 1983 Sep; 70 (9): 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

5. 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)

6. 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 May-Jun;5(3): 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%

12. 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
40 pts after previous sleeve gastrectomy or banding (18,2%)
91 pts as primary procedure(81.8%)

13. 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)
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

14. 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

15. 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

16. 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

17. 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

18. Weight loss results Preop (mean + SD) 1 year (mean + SD) LSG weight Kg
± 17.01
96.94 ± 16.55
p<0.01
LSG BMI
48.84 ± 14.20
33.93 ± 4.93
MGB weight Kg
± 19.01
86.58 ± 14.7
MGB BMI
48.40 ± 5.21
30.60 ± 4.68
LSG
MGB
Preop (n 100)
Weight (Kg)
± 19.01 NS
BMI operation
48.84 ± 14.20
1 year postop (n 50)
Weight
P<0.05
%EWL
75.08 ± 18.56
2 years results ???
BMI
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

19. 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.….

20. Thank you