Do you prefer RYGB or OAGB?

Present by : Amir Ashrafi MD

One of the most acceptable procedures in bariatric

surgery is laparoscopic gastric bypass. Laparoscopic

Roux-en-Y gastric bypass (RYGB) is a common

technique used in bariatric surgery. Recently, one

anastomosis gastric bypass (OAGB) has been suggested

as a simple, fast, and effective technique for obesity

treatment.

While there are no absolute contraindications to

bariatric surgery, relative contraindications do exist.

These include severe heart failure, unstable

coronary artery disease, end-stage lung disease,

active cancer treatment, portal hypertension,

drug/alcohol dependency, and impaired intellectual

capacity. Furthermore, since these procedures are

performed under general anesthesia, any

contraindication to receiving general anesthesia

would also be a contraindication for these surgeries.

Evaluation of cardiac status and cardiac risk

preoperatively is one of the essential elements in

promoting safety in any surgical patient, but

especially in morbidly obese patients. Obesity

is associated with multiple comorbidities including

diabetes, obstructive sleep apnea, dyslipidemia,

and hypertension. All of these conditions can

potentially contribute to severe cardiovascular

events such as heart failure, arrhythmias, and

sudden cardiac death.

Bariatric patients should undergo cardiac risk assessment with a

validated risk calculator , such as the Revised Cardiac Risk

Index, and assessment of functional capacity. Based upon the

results, patients should be referred to a cardiologist or primary

care provider for additional testing when appropriate.

Referral to a cardiologist should also be considered for patients

with recent myocardial infarction, unstable angina,

decompensated heart failure, high-grade arrhythmias, or

hemodynamically significant valvular heart disease.

Because of its significant cardiovascular benefits and very low

risk profile, bariatric surgery should be considered even in

patients with significant cardiac disease and/or risk.

The incidence of obstructive sleep apnea

(OSA) in the morbidly obese population is

quoted at anywhere from 71% to 95%

depending on the patient’s BMI.

The gold standard for evaluation is nocturnal

polysomnography (PSG). During PSG, the number

of apneic episodes can be quantitated. The apnea-

hypopnea index (AHI) indicates the abscess of

sleep apnea if less than 5, mild OSA for 5–15,

moderate OSA for >15, and severe OSA if >30.

However, ordering PSG routinely for every bariatric

patient is not cost-effective or appropriate.

Weight loss associated with RYGB significantly improves the

symptoms of sleep apnea and is effective in discontinuation

in the clinical use of CPAP therapy. Improvement of

obstructive sleep apnea symptoms occur as early as 1

month postoperatively.

Bile reflux is the most notoriously controversial disadvantage

of MGB/OAGB. Prejudice arose from Mason’s loop gastric

bypass, after which bilious vomiting and subsequent gastritis

and esophagitis were reported in 70% of patients. This

may occur in the old Mason’s gastric bypass with a small,

high gastric pouch and alkaline reflux esophagitis due to a

loop adjacent to the esophagus. However, there is a great

difference between the Mason’s procedure and MGB, with

anastomosis in the latter being made on a long, narrow

gastric pouch far from the esophagus.

Chevallier et al. evaluated bile reflux by endoscopic biopsies

in MGB/OAGB patients. The authors registered, as a sign of

bile reflux, foveolar dysplasia only in 17.1% of patients at 2

years and 4.6% at 4 years, with no dysplasia or metaplasia.

Bile reflux, if present, is not symptomatic in all patients.

Symptoms (heartburn, dyspepsia, bilious vomiting) can be

successfully treated pharmacologically in most cases. Bile

reflux rarely needs surgical revision.

A total of 122 obese patients (22 males) who had undergone RYGB or

OAGB surgery were included. The Sydney bile reflux index showed no

statistically significant difference between RYGB and OAGB groups.

Similarly, no statistically significant difference was found in the self-

reported history of bile reflux-related symptoms, bile reflux markers in

endoscopy, and postoperative complications between groups. OAGB and

RYGB appear to be equal with respect to postoperative complications,

bile reflux frequency, bile reflux index, and the Sydney system score.

Our results suggest that RYGB might be the

procedure of choice in morbidly obese patients with

BE requiring surgical treatment for GE reflux

disease.

Our preliminary data showed that LRYGB is a suitable

treatment option for obese patients with BE, demonstrated

by 36 % regression rate of this premalignant disease.

Although BE persisted in the remaining patients, no

progression to dysplasia was observed. A larger number of

patients and longer follow-up are needed for more definitive

conclusions.

We recommend LRYGB as an effective combined bariatric

and anti-reflux surgical procedure for patients with severe

obesity and BE. In short-term follow-up, LRYGB achieved

endoscopic and histologic regression to normal mucosa in a

substantial number of the patients in our series.

Although previously unreported after RYGB, bile

reflux can be an important possible cause of chronic

pain. Bile reflux, however, responds favorably to

alimentary limb lengthening to 100 cm and was not

been seen in patients with an alimentary limb length

>62 cm.

Bile reflux gastritis of the remnant stomach is a new

consideration for chronic abdominal pain months to

years following RYGB. Hepatobiliary scintigraphy

imaging and endoscopic biopsy are highly

suggestive. RG is safe and effective treatment.

Previous laparotomy is a significant risk factor for developing

the complications that are related to the entering the

abdominal cavity during the laparoscopy procedure.

Complications are gastrointestinal lesions, blood vessel

lesions and the impossibility of entering the abdominal

cavity. The number of complications in the open technique of

laparoscopy is significantly higher than that in the technique

of closed laparoscopy, but this technique is applied in 90% of

patient cases with previous laparotomy.

Our experience allows us to insert Veres needle in

the umbilical region for pneumoperitoneum creating

and apply the technique of closed laparoscopy in all

patients as well as those with previous laparotomy.

Why did not we find adhesions at the very

umbilicus? Supposedly, due to the poor

vascularization of the umbilicus the adhesions are

not formed, and therefore it is an appropriate place

for the entrance into the abdominal cavity with the

Veres needle and trocar

There were no significant differences in operative time, blood

loss, number of lymph nodes removed, or conversion rate

between the groups. The rate of inadvertent enterotomy was

significantly higher in the previous abdominal surgery group

than in the not having previous abdominal surgery group,

and the postoperative recovery time was significantly longer

in the previous abdominal surgery group than in the not

having previous abdominal surgery group. Ileus was more

frequent in the previous abdominal surgery group than in the

not having previous abdominal surgery group .

Laparoscopic colorectal surgery in patients with a history of

abdominal surgery exhibited acceptable short- and long-term

outcomes. Patients with a history of previous abdominal

surgery had relatively higher rate of conversion to open

surgery as well as higher incidences of prolonged

postoperative ileus and wound complications compared to

patients without such history.

OAGB was associated with shorter mean operative time.

The length of hospital stay was comparable between the two

procedures. The incidence of leaks, marginal ulcer, dumping,

bowel obstruction, revisions and mortality was similar

between the two approaches. The incidence of malnutrition

was increased in patients treated with OAGB, while the

incidence of internal hernia and bowel obstruction was

greater in the RYGB group. In addition, the percentage

excess weight loss at 1, 2 and 5 years post-operatively was

greater for the OAGB group. The rate of type 2 diabetes

remission was greater in the OAGB group. The rate of

hypertension and dyslipidemia remission was also similar

between OAGB and RYGB.

OAGB is not inferior to RYGB regarding weight loss and metabolic

improvement at 2 years. Higher incidences of diarrhea, steatorrhea, and

nutritional adverse events were observed with a 200 cm biliopancreatic

limb OAGB, suggesting a mal absorptive effect.

TWL, malnutrition, and comorbidity remission 3 years postoperatively were

comparable. Gastroesophageal reflux was less frequent after RYGB (p =

0.0729), whereas shorter operation times (p < 0.0001), less frequent

stenosis (p < 0.0001), and dumping syndrome (p = 0.0018) were found in

OAGB-MGB. Further RCTs are required.

Surgical intervention for biliary reflux was more prevalent in

the OAGB group. Surgical intervention for internal herniation

was more prevalent in the RYGB group.

At 3-year follow-up, total protein and albumin values were

similar between arms while prealbumin deficit was more

frequent after OAGB than after RYGB. The rate of type 2

diabetes (87.5% in OAGB and 92% in RYGB), arterial

hypertension (51.6% in OAGB and 58.3% in RYGB), and

dyslipidemia (69.7% in OAGB and 78.6% in RYGB)

remission was not significantly different between the two

groups.

THE END