gastric bypass procedures: forget the name, remember the
TRANSCRIPT
Biliopancreatic limb length is more important
than the name of the Gastric bypass operation
Abdelrahman A Nimeri MBBCh ABS FACS FASMBS
President Pan Arab Society of Metabolic amp Bariatric Surgery (PASMBS)
Adjunct Associate Professor of Surgery UAE University COM
Chief Division of General Thoracic amp Vascular Surgery SKMC
Director Bariatric amp Metabolic Institute (BMI) Abu Dhabi SKMC
Communications
Committee
Case Mix DisclosureNo disclosures
LSG33
RYGB46
LAGB2
Revision17
OAGB MGB2
LoopDS0 LSG
RYGB
LAGB
Revision
OAGB MGB
LoopDS
Take Home Message
Melton GB et al Suboptimal weight loss after RYGB J Gastrointestinal Surg 200812(2)250-5
Bessler M et al Frequency distribution of weight loss after RYGB and LAGB SOARD 20084(4)486-91
Campos Good morning et al Factors associated with weight loss after RYGB Arch Surg 2008143(9)877-84
Why is RYGB becoming un-popular Is it still the Gold standard
RYGB in itrsquos standard short BPL is a restrictive operation with
very little mal-absorption and not for every patient
Best candidates (Type II DM GERD patients) amp Worst candidates
(BMI gt50 weight regain after restrictive bariatric surgery)
If you perform BPD DS SADI DJB OAGBMGB you need to
measure the common channel
Take Home Message
OAGBMGB is more effective than RYGB for weight loss and co-
morbidity resolution because it has a longer BPL
RYGB patients with weight regain is not a dead end
Length of Roux limb is less important than BPL
In weight recidivism after RYGB the answer is in judicial
lengthening of the BPL amp patients with BMIgt50 amp failure after
restriction may benefit from a longer BPL
The fall of RYGB rise of LSG amp OAGBMGB
bull Bariatric surgery numbers in the USA 2011-2016
History of bariatric surgery in the US looks like this
World wide 2014
North American USA amp Canada
Europe
Asia Pacific
3224 3223
4366 4438
423262 274
468254 170 131 222220 230
381840
4196 4033
5386
6403
2013 2014 2015 2016
OAGBMGB in the UAE is
13 in 2016 up from 7 2015Total
LSG
OAGBMGB
RYGBLAGB
Latin America
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull 1156 patients with severe obesity comprised 3 groups 418
patients After RYGB (surgery group) 417 patients who
sought but did not undergo surgery (primarily for insurance
reasons) (non-surgery group 1) and 321 patients who did not
seek surgery (non-surgery group 2)
bull We performed clinical examinations at baseline and at 2
years 6 years and 12 years to ascertain the presence of type
2 diabetes hypertension and dyslipidemia
bull The follow-up rate exceeded 90 at 12 years
Long term FU 10-15 years after RYGB in Italy
bull 285 RYGB patients done between 2000-2006
bull Mean BMI 453 (+59) kgm2 went down to 335 (51) kgm2 at 8 years 338 (5) kgm2 at 10 years 305 (41) kgm2 at 12 years amp 326 (47) kgm2 at 14 years (69 achieved BMI lt35 kgm2)
bull Mean EWL 663 (+21) at 8 years 642 (+23) at 10 years 767 (+21) at 12 years amp 698 (+23) at 14 years
bull FU was 91 84 72 and 63 at 81012 amp 14 years
bull Mortality 035 leak 07 stenosis 1 IH 14 SBO 73
bull 60 of patients stopped taking supplements and 357 had nutritional deficiencies
R Arnoux Dabadie Abstract 0115 IFSO London 2017
376
1369
265
2037
Diabetes resolution 6 years after LSG RYGB Medical therapy in France
bull All patients undergoing bariatric surgery in France in 2009 amp control group matched (age gender BMI DM) from French National Insurance
bull 15650 (85 females 10 had DM II) had bariatric surgery in 2009
bull Diabetes resolution after BS was 50 vs 9 medical therapy Plt0001
bull The main predictive for resolution were RYGB 167 (13-214) LSG 73 (56-96) LAGB 43 (33-56) No insulin 58 (46-74) No dyslipidemia medications 13 (11-16)
bull DM recurrence at 6 years was least frequent with BS 1 vs 12 in control (Plt0001)
bull RYGB 006 was the more effective than LSG 008 amp LAGB 016
J Thereaux A Fagot-Campagna France Abstract 0004 IFSO London
5 year results of the Swiss RCT LSG vs RYGB (SM-BOSS)
bull RCT of 217 patients LSG 107 vs RYGB 110 at 4 centers in Switzerland
bull Mean BMI 44+11 Age 43+5 72 females mean FU 5 years (954)
bull Patients with severe GERD or Hiatal hernia were excluded
bull Weight loss was similar at 1 year (723+22 vs 766+20) P=013 3 years (71+23 vs 734+23) P=03 5 years (622+27 vs 68+25) P=011
bull Weight loss after LSG at 5 years was inferior to RYGB (25+11 vs 286+10) P+002 Co-morbidity resolution was significantly reduced in both except GERD which was better with RYGB
bull QOL number of complications and re-operations were similar
R Peterli M Bueter Abstract 0005 IFSO London 2017
LAGB to RYGB is more effective than LAGB to LSG
bull 192 patients LAGB to RYGB vs 283 LAGB to LSG
bull The baseline age and BMI were similar in both groups
bull At 2 years BMI was lower in RYGB 3293 vs 3834 kgm2 for LSG (P=00004) EBMIL was lower in RYGB 578 vs 293 in LSG (P=00001) amp WL was lower in RYGB 234 vs 126 in LSG (P=0001)
bull Reoperation was higher in conversion to RYGB 73 vs 14 (P0=0022) OR time was longer in RYGB 1201 vs 1155 minutes in LSG (Plt0001) LOS was longer RYGB 333 vs 211 days (Plt0001)
bull Readmission was similar in RYGB 73 vs 35 in LSG (P=0087)M Jenkins B Schwack Abstract 0160 IFSO London 2017
50 GERD from 17 at 85 years
bull 100 LSG after long-term mean FU 85 years (EWL) of 60
bull A significant increase in GERD symptoms (50 from 17 pre op) (RR
= 25882 95 CI [16161ndash 41452] amp use of PPIs p value = 00001)
bull The chance of developing de novo reflux after LSG was 478 (3267)
Reflux disease was present in 7 of the 26 patients who underwent a secondary
Roux- en-Y gastric bypass (RYGB)
bull In 47 patients GERD disappeared completely after the secondary
RYGB (571)
68 GERD from 33 at 5 years
172 Barretts Esophagitis
69 Follow up
bull A total of 110 patients after LSG GERD symptoms(681 versus 336 P
00001 VAS mean score3 versus 18 P 1frasl4 018 and PPI intake significantly
increased compared with preoperative values572 versus 191 P 00001)
bull At EGD an upward migration of the ldquoZrdquo line and a biliary-like esophageal reflux
was found in 736 and 745 of cases respectively
bull Multi-Center study (3 centers) 4353 patients were followed 6 patients (140)
were converted to RYGB due to GERD over a period of 130 months
bull 1026 (384) not converted to RYGB also suffered from symptomatic reflux
bull Gastroscopies revealed de novo hiatal hernias in 45 of the patients amp Barrettrsquos
metaplasia in 15 SG patients suffering from symptomatic reflux scored
significantly higher in the RSI (p = 004) and significantly lower in the GIQLI (p
= 002) questionnaire
14 conversion to RYGB 23 weight regain
De novo GERD in 45 patients
100 Follow up 108 years384 GERD15 Barretts metaplasia
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull (1) The steep learning curve
bull (2) Re routing of the small bowel (OAGBMGB)
bull (3) Potential known long term complications
bull (4) The perceived paucity of options to treat patients with weight
recidivism especially when your are super obese
bull In contrast (1) the short learning curve (2) no re routing of the small
bowel (3) unknown long term complications and (4) the many
options to revise a LSG to a duodenal switch or LRYGB are the reasons
patients and surgeons are choosing the LSG over LRYGB
Learning curve amp adoption of laparoscopic colectomy
less than 13 of colectomies
bull 22 (87838264) for 1996
bull 27 (117542166) for 2000
bull 5 (233644817) for 2004 Publication of the COST Trial
bull 15 (754842903) for 2008
bull 314 (1461031888) for 2009Ann Surg 2013 Aug258(2)270-4 doi 101097SLA0b013e31828faa66
Growth of laparoscopic colectomy in the United States analysis of regional
and socioeconomic factors over time
Bardakcioglu O1 Khan A Aldridge C Chen J
bull A total of 1426 obese patients (158 male) after RYGB during January 2000
to 2012 (2 year FU)
bull Weight regain was observed in 244 patients (171) Preoperative BMI
was similar between groups
bull BMI was significantly higher and percent excess weight loss was
significantly lower in the Weight Regain (WR) group (P 0001)
Only patients with gt50 EWL
at 1 year postoperatively
bull Univariate analysis found that older age male gender having
hypertension dyslipidemia and insulin-treated type 2 diabetes were all
factors associated with sustained weight loss
bull A longer duration after RYGB was associated with weight regain
Multivariate analysis revealed that younger age was a significant predictor
of weight regain even after adjusting for time since RYGB
Why do RYGB patients regain weight
Small pouch amp rapid emptying leads to better weight loss less weight
regain and better food intolerance in RYGB
bull 67 RYGB patients had pouch volumetry by 3D-CT pouch emptying by 4hr Scintigraphy food intolerance and weight loss measurement
bull Median FU was 47 months median volume was 28 ml ret at 124 hours was 8 2 1
bull There was association between Vlt40ml amp higher emptying rates up to 2 hours (Vlt40 Ret 1=6 Ret2=2) P=0009 vs (Vgt40 Ret 1=44 Ret2=135) P=0045
bull Higher emptying speed at 1 hour correlated with higher weight loss (P=0033) and less weight regain (P=0036) (Retlt12 vs gt25)
bull Better food tolerance with lower Ret 1 hour (0003)
D Riccioppo I Cecconello abstract 0110 IFSO London 2017
2 decades ago if a patient was considering a surgery involving
small bowel rerouting it would have been (RYGB) or (BPD)
In contrast today if a patient is considering a surgery that
involves small bowel rerouting this could mean any of the
following bariatric surgeries
one anastomosis gastric bypassmini gastric bypass (OAGBMGB)
BPD or BPD duodenal switch (DS)
single anastomosis duodenoileostomy (SADI)
single anastomosis gastroileostomy (SAGI)
single anastomosis sleeve ileostomy (SASI)
duodenojejunal bypass (DJB) or
stomach intestinal pylorus sparing surgery (SIPS)
Assuming Small bowel
length is 400 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 200 150 250
Alimentary limb (Roux
limb + CC)
250 250 250 200 150 350
BPL 150 150 150 200 250 50
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
Communications
Committee
Case Mix DisclosureNo disclosures
LSG33
RYGB46
LAGB2
Revision17
OAGB MGB2
LoopDS0 LSG
RYGB
LAGB
Revision
OAGB MGB
LoopDS
Take Home Message
Melton GB et al Suboptimal weight loss after RYGB J Gastrointestinal Surg 200812(2)250-5
Bessler M et al Frequency distribution of weight loss after RYGB and LAGB SOARD 20084(4)486-91
Campos Good morning et al Factors associated with weight loss after RYGB Arch Surg 2008143(9)877-84
Why is RYGB becoming un-popular Is it still the Gold standard
RYGB in itrsquos standard short BPL is a restrictive operation with
very little mal-absorption and not for every patient
Best candidates (Type II DM GERD patients) amp Worst candidates
(BMI gt50 weight regain after restrictive bariatric surgery)
If you perform BPD DS SADI DJB OAGBMGB you need to
measure the common channel
Take Home Message
OAGBMGB is more effective than RYGB for weight loss and co-
morbidity resolution because it has a longer BPL
RYGB patients with weight regain is not a dead end
Length of Roux limb is less important than BPL
In weight recidivism after RYGB the answer is in judicial
lengthening of the BPL amp patients with BMIgt50 amp failure after
restriction may benefit from a longer BPL
The fall of RYGB rise of LSG amp OAGBMGB
bull Bariatric surgery numbers in the USA 2011-2016
History of bariatric surgery in the US looks like this
World wide 2014
North American USA amp Canada
Europe
Asia Pacific
3224 3223
4366 4438
423262 274
468254 170 131 222220 230
381840
4196 4033
5386
6403
2013 2014 2015 2016
OAGBMGB in the UAE is
13 in 2016 up from 7 2015Total
LSG
OAGBMGB
RYGBLAGB
Latin America
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull 1156 patients with severe obesity comprised 3 groups 418
patients After RYGB (surgery group) 417 patients who
sought but did not undergo surgery (primarily for insurance
reasons) (non-surgery group 1) and 321 patients who did not
seek surgery (non-surgery group 2)
bull We performed clinical examinations at baseline and at 2
years 6 years and 12 years to ascertain the presence of type
2 diabetes hypertension and dyslipidemia
bull The follow-up rate exceeded 90 at 12 years
Long term FU 10-15 years after RYGB in Italy
bull 285 RYGB patients done between 2000-2006
bull Mean BMI 453 (+59) kgm2 went down to 335 (51) kgm2 at 8 years 338 (5) kgm2 at 10 years 305 (41) kgm2 at 12 years amp 326 (47) kgm2 at 14 years (69 achieved BMI lt35 kgm2)
bull Mean EWL 663 (+21) at 8 years 642 (+23) at 10 years 767 (+21) at 12 years amp 698 (+23) at 14 years
bull FU was 91 84 72 and 63 at 81012 amp 14 years
bull Mortality 035 leak 07 stenosis 1 IH 14 SBO 73
bull 60 of patients stopped taking supplements and 357 had nutritional deficiencies
R Arnoux Dabadie Abstract 0115 IFSO London 2017
376
1369
265
2037
Diabetes resolution 6 years after LSG RYGB Medical therapy in France
bull All patients undergoing bariatric surgery in France in 2009 amp control group matched (age gender BMI DM) from French National Insurance
bull 15650 (85 females 10 had DM II) had bariatric surgery in 2009
bull Diabetes resolution after BS was 50 vs 9 medical therapy Plt0001
bull The main predictive for resolution were RYGB 167 (13-214) LSG 73 (56-96) LAGB 43 (33-56) No insulin 58 (46-74) No dyslipidemia medications 13 (11-16)
bull DM recurrence at 6 years was least frequent with BS 1 vs 12 in control (Plt0001)
bull RYGB 006 was the more effective than LSG 008 amp LAGB 016
J Thereaux A Fagot-Campagna France Abstract 0004 IFSO London
5 year results of the Swiss RCT LSG vs RYGB (SM-BOSS)
bull RCT of 217 patients LSG 107 vs RYGB 110 at 4 centers in Switzerland
bull Mean BMI 44+11 Age 43+5 72 females mean FU 5 years (954)
bull Patients with severe GERD or Hiatal hernia were excluded
bull Weight loss was similar at 1 year (723+22 vs 766+20) P=013 3 years (71+23 vs 734+23) P=03 5 years (622+27 vs 68+25) P=011
bull Weight loss after LSG at 5 years was inferior to RYGB (25+11 vs 286+10) P+002 Co-morbidity resolution was significantly reduced in both except GERD which was better with RYGB
bull QOL number of complications and re-operations were similar
R Peterli M Bueter Abstract 0005 IFSO London 2017
LAGB to RYGB is more effective than LAGB to LSG
bull 192 patients LAGB to RYGB vs 283 LAGB to LSG
bull The baseline age and BMI were similar in both groups
bull At 2 years BMI was lower in RYGB 3293 vs 3834 kgm2 for LSG (P=00004) EBMIL was lower in RYGB 578 vs 293 in LSG (P=00001) amp WL was lower in RYGB 234 vs 126 in LSG (P=0001)
bull Reoperation was higher in conversion to RYGB 73 vs 14 (P0=0022) OR time was longer in RYGB 1201 vs 1155 minutes in LSG (Plt0001) LOS was longer RYGB 333 vs 211 days (Plt0001)
bull Readmission was similar in RYGB 73 vs 35 in LSG (P=0087)M Jenkins B Schwack Abstract 0160 IFSO London 2017
50 GERD from 17 at 85 years
bull 100 LSG after long-term mean FU 85 years (EWL) of 60
bull A significant increase in GERD symptoms (50 from 17 pre op) (RR
= 25882 95 CI [16161ndash 41452] amp use of PPIs p value = 00001)
bull The chance of developing de novo reflux after LSG was 478 (3267)
Reflux disease was present in 7 of the 26 patients who underwent a secondary
Roux- en-Y gastric bypass (RYGB)
bull In 47 patients GERD disappeared completely after the secondary
RYGB (571)
68 GERD from 33 at 5 years
172 Barretts Esophagitis
69 Follow up
bull A total of 110 patients after LSG GERD symptoms(681 versus 336 P
00001 VAS mean score3 versus 18 P 1frasl4 018 and PPI intake significantly
increased compared with preoperative values572 versus 191 P 00001)
bull At EGD an upward migration of the ldquoZrdquo line and a biliary-like esophageal reflux
was found in 736 and 745 of cases respectively
bull Multi-Center study (3 centers) 4353 patients were followed 6 patients (140)
were converted to RYGB due to GERD over a period of 130 months
bull 1026 (384) not converted to RYGB also suffered from symptomatic reflux
bull Gastroscopies revealed de novo hiatal hernias in 45 of the patients amp Barrettrsquos
metaplasia in 15 SG patients suffering from symptomatic reflux scored
significantly higher in the RSI (p = 004) and significantly lower in the GIQLI (p
= 002) questionnaire
14 conversion to RYGB 23 weight regain
De novo GERD in 45 patients
100 Follow up 108 years384 GERD15 Barretts metaplasia
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull (1) The steep learning curve
bull (2) Re routing of the small bowel (OAGBMGB)
bull (3) Potential known long term complications
bull (4) The perceived paucity of options to treat patients with weight
recidivism especially when your are super obese
bull In contrast (1) the short learning curve (2) no re routing of the small
bowel (3) unknown long term complications and (4) the many
options to revise a LSG to a duodenal switch or LRYGB are the reasons
patients and surgeons are choosing the LSG over LRYGB
Learning curve amp adoption of laparoscopic colectomy
less than 13 of colectomies
bull 22 (87838264) for 1996
bull 27 (117542166) for 2000
bull 5 (233644817) for 2004 Publication of the COST Trial
bull 15 (754842903) for 2008
bull 314 (1461031888) for 2009Ann Surg 2013 Aug258(2)270-4 doi 101097SLA0b013e31828faa66
Growth of laparoscopic colectomy in the United States analysis of regional
and socioeconomic factors over time
Bardakcioglu O1 Khan A Aldridge C Chen J
bull A total of 1426 obese patients (158 male) after RYGB during January 2000
to 2012 (2 year FU)
bull Weight regain was observed in 244 patients (171) Preoperative BMI
was similar between groups
bull BMI was significantly higher and percent excess weight loss was
significantly lower in the Weight Regain (WR) group (P 0001)
Only patients with gt50 EWL
at 1 year postoperatively
bull Univariate analysis found that older age male gender having
hypertension dyslipidemia and insulin-treated type 2 diabetes were all
factors associated with sustained weight loss
bull A longer duration after RYGB was associated with weight regain
Multivariate analysis revealed that younger age was a significant predictor
of weight regain even after adjusting for time since RYGB
Why do RYGB patients regain weight
Small pouch amp rapid emptying leads to better weight loss less weight
regain and better food intolerance in RYGB
bull 67 RYGB patients had pouch volumetry by 3D-CT pouch emptying by 4hr Scintigraphy food intolerance and weight loss measurement
bull Median FU was 47 months median volume was 28 ml ret at 124 hours was 8 2 1
bull There was association between Vlt40ml amp higher emptying rates up to 2 hours (Vlt40 Ret 1=6 Ret2=2) P=0009 vs (Vgt40 Ret 1=44 Ret2=135) P=0045
bull Higher emptying speed at 1 hour correlated with higher weight loss (P=0033) and less weight regain (P=0036) (Retlt12 vs gt25)
bull Better food tolerance with lower Ret 1 hour (0003)
D Riccioppo I Cecconello abstract 0110 IFSO London 2017
2 decades ago if a patient was considering a surgery involving
small bowel rerouting it would have been (RYGB) or (BPD)
In contrast today if a patient is considering a surgery that
involves small bowel rerouting this could mean any of the
following bariatric surgeries
one anastomosis gastric bypassmini gastric bypass (OAGBMGB)
BPD or BPD duodenal switch (DS)
single anastomosis duodenoileostomy (SADI)
single anastomosis gastroileostomy (SAGI)
single anastomosis sleeve ileostomy (SASI)
duodenojejunal bypass (DJB) or
stomach intestinal pylorus sparing surgery (SIPS)
Assuming Small bowel
length is 400 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 200 150 250
Alimentary limb (Roux
limb + CC)
250 250 250 200 150 350
BPL 150 150 150 200 250 50
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
Take Home Message
Melton GB et al Suboptimal weight loss after RYGB J Gastrointestinal Surg 200812(2)250-5
Bessler M et al Frequency distribution of weight loss after RYGB and LAGB SOARD 20084(4)486-91
Campos Good morning et al Factors associated with weight loss after RYGB Arch Surg 2008143(9)877-84
Why is RYGB becoming un-popular Is it still the Gold standard
RYGB in itrsquos standard short BPL is a restrictive operation with
very little mal-absorption and not for every patient
Best candidates (Type II DM GERD patients) amp Worst candidates
(BMI gt50 weight regain after restrictive bariatric surgery)
If you perform BPD DS SADI DJB OAGBMGB you need to
measure the common channel
Take Home Message
OAGBMGB is more effective than RYGB for weight loss and co-
morbidity resolution because it has a longer BPL
RYGB patients with weight regain is not a dead end
Length of Roux limb is less important than BPL
In weight recidivism after RYGB the answer is in judicial
lengthening of the BPL amp patients with BMIgt50 amp failure after
restriction may benefit from a longer BPL
The fall of RYGB rise of LSG amp OAGBMGB
bull Bariatric surgery numbers in the USA 2011-2016
History of bariatric surgery in the US looks like this
World wide 2014
North American USA amp Canada
Europe
Asia Pacific
3224 3223
4366 4438
423262 274
468254 170 131 222220 230
381840
4196 4033
5386
6403
2013 2014 2015 2016
OAGBMGB in the UAE is
13 in 2016 up from 7 2015Total
LSG
OAGBMGB
RYGBLAGB
Latin America
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull 1156 patients with severe obesity comprised 3 groups 418
patients After RYGB (surgery group) 417 patients who
sought but did not undergo surgery (primarily for insurance
reasons) (non-surgery group 1) and 321 patients who did not
seek surgery (non-surgery group 2)
bull We performed clinical examinations at baseline and at 2
years 6 years and 12 years to ascertain the presence of type
2 diabetes hypertension and dyslipidemia
bull The follow-up rate exceeded 90 at 12 years
Long term FU 10-15 years after RYGB in Italy
bull 285 RYGB patients done between 2000-2006
bull Mean BMI 453 (+59) kgm2 went down to 335 (51) kgm2 at 8 years 338 (5) kgm2 at 10 years 305 (41) kgm2 at 12 years amp 326 (47) kgm2 at 14 years (69 achieved BMI lt35 kgm2)
bull Mean EWL 663 (+21) at 8 years 642 (+23) at 10 years 767 (+21) at 12 years amp 698 (+23) at 14 years
bull FU was 91 84 72 and 63 at 81012 amp 14 years
bull Mortality 035 leak 07 stenosis 1 IH 14 SBO 73
bull 60 of patients stopped taking supplements and 357 had nutritional deficiencies
R Arnoux Dabadie Abstract 0115 IFSO London 2017
376
1369
265
2037
Diabetes resolution 6 years after LSG RYGB Medical therapy in France
bull All patients undergoing bariatric surgery in France in 2009 amp control group matched (age gender BMI DM) from French National Insurance
bull 15650 (85 females 10 had DM II) had bariatric surgery in 2009
bull Diabetes resolution after BS was 50 vs 9 medical therapy Plt0001
bull The main predictive for resolution were RYGB 167 (13-214) LSG 73 (56-96) LAGB 43 (33-56) No insulin 58 (46-74) No dyslipidemia medications 13 (11-16)
bull DM recurrence at 6 years was least frequent with BS 1 vs 12 in control (Plt0001)
bull RYGB 006 was the more effective than LSG 008 amp LAGB 016
J Thereaux A Fagot-Campagna France Abstract 0004 IFSO London
5 year results of the Swiss RCT LSG vs RYGB (SM-BOSS)
bull RCT of 217 patients LSG 107 vs RYGB 110 at 4 centers in Switzerland
bull Mean BMI 44+11 Age 43+5 72 females mean FU 5 years (954)
bull Patients with severe GERD or Hiatal hernia were excluded
bull Weight loss was similar at 1 year (723+22 vs 766+20) P=013 3 years (71+23 vs 734+23) P=03 5 years (622+27 vs 68+25) P=011
bull Weight loss after LSG at 5 years was inferior to RYGB (25+11 vs 286+10) P+002 Co-morbidity resolution was significantly reduced in both except GERD which was better with RYGB
bull QOL number of complications and re-operations were similar
R Peterli M Bueter Abstract 0005 IFSO London 2017
LAGB to RYGB is more effective than LAGB to LSG
bull 192 patients LAGB to RYGB vs 283 LAGB to LSG
bull The baseline age and BMI were similar in both groups
bull At 2 years BMI was lower in RYGB 3293 vs 3834 kgm2 for LSG (P=00004) EBMIL was lower in RYGB 578 vs 293 in LSG (P=00001) amp WL was lower in RYGB 234 vs 126 in LSG (P=0001)
bull Reoperation was higher in conversion to RYGB 73 vs 14 (P0=0022) OR time was longer in RYGB 1201 vs 1155 minutes in LSG (Plt0001) LOS was longer RYGB 333 vs 211 days (Plt0001)
bull Readmission was similar in RYGB 73 vs 35 in LSG (P=0087)M Jenkins B Schwack Abstract 0160 IFSO London 2017
50 GERD from 17 at 85 years
bull 100 LSG after long-term mean FU 85 years (EWL) of 60
bull A significant increase in GERD symptoms (50 from 17 pre op) (RR
= 25882 95 CI [16161ndash 41452] amp use of PPIs p value = 00001)
bull The chance of developing de novo reflux after LSG was 478 (3267)
Reflux disease was present in 7 of the 26 patients who underwent a secondary
Roux- en-Y gastric bypass (RYGB)
bull In 47 patients GERD disappeared completely after the secondary
RYGB (571)
68 GERD from 33 at 5 years
172 Barretts Esophagitis
69 Follow up
bull A total of 110 patients after LSG GERD symptoms(681 versus 336 P
00001 VAS mean score3 versus 18 P 1frasl4 018 and PPI intake significantly
increased compared with preoperative values572 versus 191 P 00001)
bull At EGD an upward migration of the ldquoZrdquo line and a biliary-like esophageal reflux
was found in 736 and 745 of cases respectively
bull Multi-Center study (3 centers) 4353 patients were followed 6 patients (140)
were converted to RYGB due to GERD over a period of 130 months
bull 1026 (384) not converted to RYGB also suffered from symptomatic reflux
bull Gastroscopies revealed de novo hiatal hernias in 45 of the patients amp Barrettrsquos
metaplasia in 15 SG patients suffering from symptomatic reflux scored
significantly higher in the RSI (p = 004) and significantly lower in the GIQLI (p
= 002) questionnaire
14 conversion to RYGB 23 weight regain
De novo GERD in 45 patients
100 Follow up 108 years384 GERD15 Barretts metaplasia
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull (1) The steep learning curve
bull (2) Re routing of the small bowel (OAGBMGB)
bull (3) Potential known long term complications
bull (4) The perceived paucity of options to treat patients with weight
recidivism especially when your are super obese
bull In contrast (1) the short learning curve (2) no re routing of the small
bowel (3) unknown long term complications and (4) the many
options to revise a LSG to a duodenal switch or LRYGB are the reasons
patients and surgeons are choosing the LSG over LRYGB
Learning curve amp adoption of laparoscopic colectomy
less than 13 of colectomies
bull 22 (87838264) for 1996
bull 27 (117542166) for 2000
bull 5 (233644817) for 2004 Publication of the COST Trial
bull 15 (754842903) for 2008
bull 314 (1461031888) for 2009Ann Surg 2013 Aug258(2)270-4 doi 101097SLA0b013e31828faa66
Growth of laparoscopic colectomy in the United States analysis of regional
and socioeconomic factors over time
Bardakcioglu O1 Khan A Aldridge C Chen J
bull A total of 1426 obese patients (158 male) after RYGB during January 2000
to 2012 (2 year FU)
bull Weight regain was observed in 244 patients (171) Preoperative BMI
was similar between groups
bull BMI was significantly higher and percent excess weight loss was
significantly lower in the Weight Regain (WR) group (P 0001)
Only patients with gt50 EWL
at 1 year postoperatively
bull Univariate analysis found that older age male gender having
hypertension dyslipidemia and insulin-treated type 2 diabetes were all
factors associated with sustained weight loss
bull A longer duration after RYGB was associated with weight regain
Multivariate analysis revealed that younger age was a significant predictor
of weight regain even after adjusting for time since RYGB
Why do RYGB patients regain weight
Small pouch amp rapid emptying leads to better weight loss less weight
regain and better food intolerance in RYGB
bull 67 RYGB patients had pouch volumetry by 3D-CT pouch emptying by 4hr Scintigraphy food intolerance and weight loss measurement
bull Median FU was 47 months median volume was 28 ml ret at 124 hours was 8 2 1
bull There was association between Vlt40ml amp higher emptying rates up to 2 hours (Vlt40 Ret 1=6 Ret2=2) P=0009 vs (Vgt40 Ret 1=44 Ret2=135) P=0045
bull Higher emptying speed at 1 hour correlated with higher weight loss (P=0033) and less weight regain (P=0036) (Retlt12 vs gt25)
bull Better food tolerance with lower Ret 1 hour (0003)
D Riccioppo I Cecconello abstract 0110 IFSO London 2017
2 decades ago if a patient was considering a surgery involving
small bowel rerouting it would have been (RYGB) or (BPD)
In contrast today if a patient is considering a surgery that
involves small bowel rerouting this could mean any of the
following bariatric surgeries
one anastomosis gastric bypassmini gastric bypass (OAGBMGB)
BPD or BPD duodenal switch (DS)
single anastomosis duodenoileostomy (SADI)
single anastomosis gastroileostomy (SAGI)
single anastomosis sleeve ileostomy (SASI)
duodenojejunal bypass (DJB) or
stomach intestinal pylorus sparing surgery (SIPS)
Assuming Small bowel
length is 400 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 200 150 250
Alimentary limb (Roux
limb + CC)
250 250 250 200 150 350
BPL 150 150 150 200 250 50
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
Take Home Message
OAGBMGB is more effective than RYGB for weight loss and co-
morbidity resolution because it has a longer BPL
RYGB patients with weight regain is not a dead end
Length of Roux limb is less important than BPL
In weight recidivism after RYGB the answer is in judicial
lengthening of the BPL amp patients with BMIgt50 amp failure after
restriction may benefit from a longer BPL
The fall of RYGB rise of LSG amp OAGBMGB
bull Bariatric surgery numbers in the USA 2011-2016
History of bariatric surgery in the US looks like this
World wide 2014
North American USA amp Canada
Europe
Asia Pacific
3224 3223
4366 4438
423262 274
468254 170 131 222220 230
381840
4196 4033
5386
6403
2013 2014 2015 2016
OAGBMGB in the UAE is
13 in 2016 up from 7 2015Total
LSG
OAGBMGB
RYGBLAGB
Latin America
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull 1156 patients with severe obesity comprised 3 groups 418
patients After RYGB (surgery group) 417 patients who
sought but did not undergo surgery (primarily for insurance
reasons) (non-surgery group 1) and 321 patients who did not
seek surgery (non-surgery group 2)
bull We performed clinical examinations at baseline and at 2
years 6 years and 12 years to ascertain the presence of type
2 diabetes hypertension and dyslipidemia
bull The follow-up rate exceeded 90 at 12 years
Long term FU 10-15 years after RYGB in Italy
bull 285 RYGB patients done between 2000-2006
bull Mean BMI 453 (+59) kgm2 went down to 335 (51) kgm2 at 8 years 338 (5) kgm2 at 10 years 305 (41) kgm2 at 12 years amp 326 (47) kgm2 at 14 years (69 achieved BMI lt35 kgm2)
bull Mean EWL 663 (+21) at 8 years 642 (+23) at 10 years 767 (+21) at 12 years amp 698 (+23) at 14 years
bull FU was 91 84 72 and 63 at 81012 amp 14 years
bull Mortality 035 leak 07 stenosis 1 IH 14 SBO 73
bull 60 of patients stopped taking supplements and 357 had nutritional deficiencies
R Arnoux Dabadie Abstract 0115 IFSO London 2017
376
1369
265
2037
Diabetes resolution 6 years after LSG RYGB Medical therapy in France
bull All patients undergoing bariatric surgery in France in 2009 amp control group matched (age gender BMI DM) from French National Insurance
bull 15650 (85 females 10 had DM II) had bariatric surgery in 2009
bull Diabetes resolution after BS was 50 vs 9 medical therapy Plt0001
bull The main predictive for resolution were RYGB 167 (13-214) LSG 73 (56-96) LAGB 43 (33-56) No insulin 58 (46-74) No dyslipidemia medications 13 (11-16)
bull DM recurrence at 6 years was least frequent with BS 1 vs 12 in control (Plt0001)
bull RYGB 006 was the more effective than LSG 008 amp LAGB 016
J Thereaux A Fagot-Campagna France Abstract 0004 IFSO London
5 year results of the Swiss RCT LSG vs RYGB (SM-BOSS)
bull RCT of 217 patients LSG 107 vs RYGB 110 at 4 centers in Switzerland
bull Mean BMI 44+11 Age 43+5 72 females mean FU 5 years (954)
bull Patients with severe GERD or Hiatal hernia were excluded
bull Weight loss was similar at 1 year (723+22 vs 766+20) P=013 3 years (71+23 vs 734+23) P=03 5 years (622+27 vs 68+25) P=011
bull Weight loss after LSG at 5 years was inferior to RYGB (25+11 vs 286+10) P+002 Co-morbidity resolution was significantly reduced in both except GERD which was better with RYGB
bull QOL number of complications and re-operations were similar
R Peterli M Bueter Abstract 0005 IFSO London 2017
LAGB to RYGB is more effective than LAGB to LSG
bull 192 patients LAGB to RYGB vs 283 LAGB to LSG
bull The baseline age and BMI were similar in both groups
bull At 2 years BMI was lower in RYGB 3293 vs 3834 kgm2 for LSG (P=00004) EBMIL was lower in RYGB 578 vs 293 in LSG (P=00001) amp WL was lower in RYGB 234 vs 126 in LSG (P=0001)
bull Reoperation was higher in conversion to RYGB 73 vs 14 (P0=0022) OR time was longer in RYGB 1201 vs 1155 minutes in LSG (Plt0001) LOS was longer RYGB 333 vs 211 days (Plt0001)
bull Readmission was similar in RYGB 73 vs 35 in LSG (P=0087)M Jenkins B Schwack Abstract 0160 IFSO London 2017
50 GERD from 17 at 85 years
bull 100 LSG after long-term mean FU 85 years (EWL) of 60
bull A significant increase in GERD symptoms (50 from 17 pre op) (RR
= 25882 95 CI [16161ndash 41452] amp use of PPIs p value = 00001)
bull The chance of developing de novo reflux after LSG was 478 (3267)
Reflux disease was present in 7 of the 26 patients who underwent a secondary
Roux- en-Y gastric bypass (RYGB)
bull In 47 patients GERD disappeared completely after the secondary
RYGB (571)
68 GERD from 33 at 5 years
172 Barretts Esophagitis
69 Follow up
bull A total of 110 patients after LSG GERD symptoms(681 versus 336 P
00001 VAS mean score3 versus 18 P 1frasl4 018 and PPI intake significantly
increased compared with preoperative values572 versus 191 P 00001)
bull At EGD an upward migration of the ldquoZrdquo line and a biliary-like esophageal reflux
was found in 736 and 745 of cases respectively
bull Multi-Center study (3 centers) 4353 patients were followed 6 patients (140)
were converted to RYGB due to GERD over a period of 130 months
bull 1026 (384) not converted to RYGB also suffered from symptomatic reflux
bull Gastroscopies revealed de novo hiatal hernias in 45 of the patients amp Barrettrsquos
metaplasia in 15 SG patients suffering from symptomatic reflux scored
significantly higher in the RSI (p = 004) and significantly lower in the GIQLI (p
= 002) questionnaire
14 conversion to RYGB 23 weight regain
De novo GERD in 45 patients
100 Follow up 108 years384 GERD15 Barretts metaplasia
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull (1) The steep learning curve
bull (2) Re routing of the small bowel (OAGBMGB)
bull (3) Potential known long term complications
bull (4) The perceived paucity of options to treat patients with weight
recidivism especially when your are super obese
bull In contrast (1) the short learning curve (2) no re routing of the small
bowel (3) unknown long term complications and (4) the many
options to revise a LSG to a duodenal switch or LRYGB are the reasons
patients and surgeons are choosing the LSG over LRYGB
Learning curve amp adoption of laparoscopic colectomy
less than 13 of colectomies
bull 22 (87838264) for 1996
bull 27 (117542166) for 2000
bull 5 (233644817) for 2004 Publication of the COST Trial
bull 15 (754842903) for 2008
bull 314 (1461031888) for 2009Ann Surg 2013 Aug258(2)270-4 doi 101097SLA0b013e31828faa66
Growth of laparoscopic colectomy in the United States analysis of regional
and socioeconomic factors over time
Bardakcioglu O1 Khan A Aldridge C Chen J
bull A total of 1426 obese patients (158 male) after RYGB during January 2000
to 2012 (2 year FU)
bull Weight regain was observed in 244 patients (171) Preoperative BMI
was similar between groups
bull BMI was significantly higher and percent excess weight loss was
significantly lower in the Weight Regain (WR) group (P 0001)
Only patients with gt50 EWL
at 1 year postoperatively
bull Univariate analysis found that older age male gender having
hypertension dyslipidemia and insulin-treated type 2 diabetes were all
factors associated with sustained weight loss
bull A longer duration after RYGB was associated with weight regain
Multivariate analysis revealed that younger age was a significant predictor
of weight regain even after adjusting for time since RYGB
Why do RYGB patients regain weight
Small pouch amp rapid emptying leads to better weight loss less weight
regain and better food intolerance in RYGB
bull 67 RYGB patients had pouch volumetry by 3D-CT pouch emptying by 4hr Scintigraphy food intolerance and weight loss measurement
bull Median FU was 47 months median volume was 28 ml ret at 124 hours was 8 2 1
bull There was association between Vlt40ml amp higher emptying rates up to 2 hours (Vlt40 Ret 1=6 Ret2=2) P=0009 vs (Vgt40 Ret 1=44 Ret2=135) P=0045
bull Higher emptying speed at 1 hour correlated with higher weight loss (P=0033) and less weight regain (P=0036) (Retlt12 vs gt25)
bull Better food tolerance with lower Ret 1 hour (0003)
D Riccioppo I Cecconello abstract 0110 IFSO London 2017
2 decades ago if a patient was considering a surgery involving
small bowel rerouting it would have been (RYGB) or (BPD)
In contrast today if a patient is considering a surgery that
involves small bowel rerouting this could mean any of the
following bariatric surgeries
one anastomosis gastric bypassmini gastric bypass (OAGBMGB)
BPD or BPD duodenal switch (DS)
single anastomosis duodenoileostomy (SADI)
single anastomosis gastroileostomy (SAGI)
single anastomosis sleeve ileostomy (SASI)
duodenojejunal bypass (DJB) or
stomach intestinal pylorus sparing surgery (SIPS)
Assuming Small bowel
length is 400 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 200 150 250
Alimentary limb (Roux
limb + CC)
250 250 250 200 150 350
BPL 150 150 150 200 250 50
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
The fall of RYGB rise of LSG amp OAGBMGB
bull Bariatric surgery numbers in the USA 2011-2016
History of bariatric surgery in the US looks like this
World wide 2014
North American USA amp Canada
Europe
Asia Pacific
3224 3223
4366 4438
423262 274
468254 170 131 222220 230
381840
4196 4033
5386
6403
2013 2014 2015 2016
OAGBMGB in the UAE is
13 in 2016 up from 7 2015Total
LSG
OAGBMGB
RYGBLAGB
Latin America
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull 1156 patients with severe obesity comprised 3 groups 418
patients After RYGB (surgery group) 417 patients who
sought but did not undergo surgery (primarily for insurance
reasons) (non-surgery group 1) and 321 patients who did not
seek surgery (non-surgery group 2)
bull We performed clinical examinations at baseline and at 2
years 6 years and 12 years to ascertain the presence of type
2 diabetes hypertension and dyslipidemia
bull The follow-up rate exceeded 90 at 12 years
Long term FU 10-15 years after RYGB in Italy
bull 285 RYGB patients done between 2000-2006
bull Mean BMI 453 (+59) kgm2 went down to 335 (51) kgm2 at 8 years 338 (5) kgm2 at 10 years 305 (41) kgm2 at 12 years amp 326 (47) kgm2 at 14 years (69 achieved BMI lt35 kgm2)
bull Mean EWL 663 (+21) at 8 years 642 (+23) at 10 years 767 (+21) at 12 years amp 698 (+23) at 14 years
bull FU was 91 84 72 and 63 at 81012 amp 14 years
bull Mortality 035 leak 07 stenosis 1 IH 14 SBO 73
bull 60 of patients stopped taking supplements and 357 had nutritional deficiencies
R Arnoux Dabadie Abstract 0115 IFSO London 2017
376
1369
265
2037
Diabetes resolution 6 years after LSG RYGB Medical therapy in France
bull All patients undergoing bariatric surgery in France in 2009 amp control group matched (age gender BMI DM) from French National Insurance
bull 15650 (85 females 10 had DM II) had bariatric surgery in 2009
bull Diabetes resolution after BS was 50 vs 9 medical therapy Plt0001
bull The main predictive for resolution were RYGB 167 (13-214) LSG 73 (56-96) LAGB 43 (33-56) No insulin 58 (46-74) No dyslipidemia medications 13 (11-16)
bull DM recurrence at 6 years was least frequent with BS 1 vs 12 in control (Plt0001)
bull RYGB 006 was the more effective than LSG 008 amp LAGB 016
J Thereaux A Fagot-Campagna France Abstract 0004 IFSO London
5 year results of the Swiss RCT LSG vs RYGB (SM-BOSS)
bull RCT of 217 patients LSG 107 vs RYGB 110 at 4 centers in Switzerland
bull Mean BMI 44+11 Age 43+5 72 females mean FU 5 years (954)
bull Patients with severe GERD or Hiatal hernia were excluded
bull Weight loss was similar at 1 year (723+22 vs 766+20) P=013 3 years (71+23 vs 734+23) P=03 5 years (622+27 vs 68+25) P=011
bull Weight loss after LSG at 5 years was inferior to RYGB (25+11 vs 286+10) P+002 Co-morbidity resolution was significantly reduced in both except GERD which was better with RYGB
bull QOL number of complications and re-operations were similar
R Peterli M Bueter Abstract 0005 IFSO London 2017
LAGB to RYGB is more effective than LAGB to LSG
bull 192 patients LAGB to RYGB vs 283 LAGB to LSG
bull The baseline age and BMI were similar in both groups
bull At 2 years BMI was lower in RYGB 3293 vs 3834 kgm2 for LSG (P=00004) EBMIL was lower in RYGB 578 vs 293 in LSG (P=00001) amp WL was lower in RYGB 234 vs 126 in LSG (P=0001)
bull Reoperation was higher in conversion to RYGB 73 vs 14 (P0=0022) OR time was longer in RYGB 1201 vs 1155 minutes in LSG (Plt0001) LOS was longer RYGB 333 vs 211 days (Plt0001)
bull Readmission was similar in RYGB 73 vs 35 in LSG (P=0087)M Jenkins B Schwack Abstract 0160 IFSO London 2017
50 GERD from 17 at 85 years
bull 100 LSG after long-term mean FU 85 years (EWL) of 60
bull A significant increase in GERD symptoms (50 from 17 pre op) (RR
= 25882 95 CI [16161ndash 41452] amp use of PPIs p value = 00001)
bull The chance of developing de novo reflux after LSG was 478 (3267)
Reflux disease was present in 7 of the 26 patients who underwent a secondary
Roux- en-Y gastric bypass (RYGB)
bull In 47 patients GERD disappeared completely after the secondary
RYGB (571)
68 GERD from 33 at 5 years
172 Barretts Esophagitis
69 Follow up
bull A total of 110 patients after LSG GERD symptoms(681 versus 336 P
00001 VAS mean score3 versus 18 P 1frasl4 018 and PPI intake significantly
increased compared with preoperative values572 versus 191 P 00001)
bull At EGD an upward migration of the ldquoZrdquo line and a biliary-like esophageal reflux
was found in 736 and 745 of cases respectively
bull Multi-Center study (3 centers) 4353 patients were followed 6 patients (140)
were converted to RYGB due to GERD over a period of 130 months
bull 1026 (384) not converted to RYGB also suffered from symptomatic reflux
bull Gastroscopies revealed de novo hiatal hernias in 45 of the patients amp Barrettrsquos
metaplasia in 15 SG patients suffering from symptomatic reflux scored
significantly higher in the RSI (p = 004) and significantly lower in the GIQLI (p
= 002) questionnaire
14 conversion to RYGB 23 weight regain
De novo GERD in 45 patients
100 Follow up 108 years384 GERD15 Barretts metaplasia
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull (1) The steep learning curve
bull (2) Re routing of the small bowel (OAGBMGB)
bull (3) Potential known long term complications
bull (4) The perceived paucity of options to treat patients with weight
recidivism especially when your are super obese
bull In contrast (1) the short learning curve (2) no re routing of the small
bowel (3) unknown long term complications and (4) the many
options to revise a LSG to a duodenal switch or LRYGB are the reasons
patients and surgeons are choosing the LSG over LRYGB
Learning curve amp adoption of laparoscopic colectomy
less than 13 of colectomies
bull 22 (87838264) for 1996
bull 27 (117542166) for 2000
bull 5 (233644817) for 2004 Publication of the COST Trial
bull 15 (754842903) for 2008
bull 314 (1461031888) for 2009Ann Surg 2013 Aug258(2)270-4 doi 101097SLA0b013e31828faa66
Growth of laparoscopic colectomy in the United States analysis of regional
and socioeconomic factors over time
Bardakcioglu O1 Khan A Aldridge C Chen J
bull A total of 1426 obese patients (158 male) after RYGB during January 2000
to 2012 (2 year FU)
bull Weight regain was observed in 244 patients (171) Preoperative BMI
was similar between groups
bull BMI was significantly higher and percent excess weight loss was
significantly lower in the Weight Regain (WR) group (P 0001)
Only patients with gt50 EWL
at 1 year postoperatively
bull Univariate analysis found that older age male gender having
hypertension dyslipidemia and insulin-treated type 2 diabetes were all
factors associated with sustained weight loss
bull A longer duration after RYGB was associated with weight regain
Multivariate analysis revealed that younger age was a significant predictor
of weight regain even after adjusting for time since RYGB
Why do RYGB patients regain weight
Small pouch amp rapid emptying leads to better weight loss less weight
regain and better food intolerance in RYGB
bull 67 RYGB patients had pouch volumetry by 3D-CT pouch emptying by 4hr Scintigraphy food intolerance and weight loss measurement
bull Median FU was 47 months median volume was 28 ml ret at 124 hours was 8 2 1
bull There was association between Vlt40ml amp higher emptying rates up to 2 hours (Vlt40 Ret 1=6 Ret2=2) P=0009 vs (Vgt40 Ret 1=44 Ret2=135) P=0045
bull Higher emptying speed at 1 hour correlated with higher weight loss (P=0033) and less weight regain (P=0036) (Retlt12 vs gt25)
bull Better food tolerance with lower Ret 1 hour (0003)
D Riccioppo I Cecconello abstract 0110 IFSO London 2017
2 decades ago if a patient was considering a surgery involving
small bowel rerouting it would have been (RYGB) or (BPD)
In contrast today if a patient is considering a surgery that
involves small bowel rerouting this could mean any of the
following bariatric surgeries
one anastomosis gastric bypassmini gastric bypass (OAGBMGB)
BPD or BPD duodenal switch (DS)
single anastomosis duodenoileostomy (SADI)
single anastomosis gastroileostomy (SAGI)
single anastomosis sleeve ileostomy (SASI)
duodenojejunal bypass (DJB) or
stomach intestinal pylorus sparing surgery (SIPS)
Assuming Small bowel
length is 400 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 200 150 250
Alimentary limb (Roux
limb + CC)
250 250 250 200 150 350
BPL 150 150 150 200 250 50
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
bull Bariatric surgery numbers in the USA 2011-2016
History of bariatric surgery in the US looks like this
World wide 2014
North American USA amp Canada
Europe
Asia Pacific
3224 3223
4366 4438
423262 274
468254 170 131 222220 230
381840
4196 4033
5386
6403
2013 2014 2015 2016
OAGBMGB in the UAE is
13 in 2016 up from 7 2015Total
LSG
OAGBMGB
RYGBLAGB
Latin America
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull 1156 patients with severe obesity comprised 3 groups 418
patients After RYGB (surgery group) 417 patients who
sought but did not undergo surgery (primarily for insurance
reasons) (non-surgery group 1) and 321 patients who did not
seek surgery (non-surgery group 2)
bull We performed clinical examinations at baseline and at 2
years 6 years and 12 years to ascertain the presence of type
2 diabetes hypertension and dyslipidemia
bull The follow-up rate exceeded 90 at 12 years
Long term FU 10-15 years after RYGB in Italy
bull 285 RYGB patients done between 2000-2006
bull Mean BMI 453 (+59) kgm2 went down to 335 (51) kgm2 at 8 years 338 (5) kgm2 at 10 years 305 (41) kgm2 at 12 years amp 326 (47) kgm2 at 14 years (69 achieved BMI lt35 kgm2)
bull Mean EWL 663 (+21) at 8 years 642 (+23) at 10 years 767 (+21) at 12 years amp 698 (+23) at 14 years
bull FU was 91 84 72 and 63 at 81012 amp 14 years
bull Mortality 035 leak 07 stenosis 1 IH 14 SBO 73
bull 60 of patients stopped taking supplements and 357 had nutritional deficiencies
R Arnoux Dabadie Abstract 0115 IFSO London 2017
376
1369
265
2037
Diabetes resolution 6 years after LSG RYGB Medical therapy in France
bull All patients undergoing bariatric surgery in France in 2009 amp control group matched (age gender BMI DM) from French National Insurance
bull 15650 (85 females 10 had DM II) had bariatric surgery in 2009
bull Diabetes resolution after BS was 50 vs 9 medical therapy Plt0001
bull The main predictive for resolution were RYGB 167 (13-214) LSG 73 (56-96) LAGB 43 (33-56) No insulin 58 (46-74) No dyslipidemia medications 13 (11-16)
bull DM recurrence at 6 years was least frequent with BS 1 vs 12 in control (Plt0001)
bull RYGB 006 was the more effective than LSG 008 amp LAGB 016
J Thereaux A Fagot-Campagna France Abstract 0004 IFSO London
5 year results of the Swiss RCT LSG vs RYGB (SM-BOSS)
bull RCT of 217 patients LSG 107 vs RYGB 110 at 4 centers in Switzerland
bull Mean BMI 44+11 Age 43+5 72 females mean FU 5 years (954)
bull Patients with severe GERD or Hiatal hernia were excluded
bull Weight loss was similar at 1 year (723+22 vs 766+20) P=013 3 years (71+23 vs 734+23) P=03 5 years (622+27 vs 68+25) P=011
bull Weight loss after LSG at 5 years was inferior to RYGB (25+11 vs 286+10) P+002 Co-morbidity resolution was significantly reduced in both except GERD which was better with RYGB
bull QOL number of complications and re-operations were similar
R Peterli M Bueter Abstract 0005 IFSO London 2017
LAGB to RYGB is more effective than LAGB to LSG
bull 192 patients LAGB to RYGB vs 283 LAGB to LSG
bull The baseline age and BMI were similar in both groups
bull At 2 years BMI was lower in RYGB 3293 vs 3834 kgm2 for LSG (P=00004) EBMIL was lower in RYGB 578 vs 293 in LSG (P=00001) amp WL was lower in RYGB 234 vs 126 in LSG (P=0001)
bull Reoperation was higher in conversion to RYGB 73 vs 14 (P0=0022) OR time was longer in RYGB 1201 vs 1155 minutes in LSG (Plt0001) LOS was longer RYGB 333 vs 211 days (Plt0001)
bull Readmission was similar in RYGB 73 vs 35 in LSG (P=0087)M Jenkins B Schwack Abstract 0160 IFSO London 2017
50 GERD from 17 at 85 years
bull 100 LSG after long-term mean FU 85 years (EWL) of 60
bull A significant increase in GERD symptoms (50 from 17 pre op) (RR
= 25882 95 CI [16161ndash 41452] amp use of PPIs p value = 00001)
bull The chance of developing de novo reflux after LSG was 478 (3267)
Reflux disease was present in 7 of the 26 patients who underwent a secondary
Roux- en-Y gastric bypass (RYGB)
bull In 47 patients GERD disappeared completely after the secondary
RYGB (571)
68 GERD from 33 at 5 years
172 Barretts Esophagitis
69 Follow up
bull A total of 110 patients after LSG GERD symptoms(681 versus 336 P
00001 VAS mean score3 versus 18 P 1frasl4 018 and PPI intake significantly
increased compared with preoperative values572 versus 191 P 00001)
bull At EGD an upward migration of the ldquoZrdquo line and a biliary-like esophageal reflux
was found in 736 and 745 of cases respectively
bull Multi-Center study (3 centers) 4353 patients were followed 6 patients (140)
were converted to RYGB due to GERD over a period of 130 months
bull 1026 (384) not converted to RYGB also suffered from symptomatic reflux
bull Gastroscopies revealed de novo hiatal hernias in 45 of the patients amp Barrettrsquos
metaplasia in 15 SG patients suffering from symptomatic reflux scored
significantly higher in the RSI (p = 004) and significantly lower in the GIQLI (p
= 002) questionnaire
14 conversion to RYGB 23 weight regain
De novo GERD in 45 patients
100 Follow up 108 years384 GERD15 Barretts metaplasia
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull (1) The steep learning curve
bull (2) Re routing of the small bowel (OAGBMGB)
bull (3) Potential known long term complications
bull (4) The perceived paucity of options to treat patients with weight
recidivism especially when your are super obese
bull In contrast (1) the short learning curve (2) no re routing of the small
bowel (3) unknown long term complications and (4) the many
options to revise a LSG to a duodenal switch or LRYGB are the reasons
patients and surgeons are choosing the LSG over LRYGB
Learning curve amp adoption of laparoscopic colectomy
less than 13 of colectomies
bull 22 (87838264) for 1996
bull 27 (117542166) for 2000
bull 5 (233644817) for 2004 Publication of the COST Trial
bull 15 (754842903) for 2008
bull 314 (1461031888) for 2009Ann Surg 2013 Aug258(2)270-4 doi 101097SLA0b013e31828faa66
Growth of laparoscopic colectomy in the United States analysis of regional
and socioeconomic factors over time
Bardakcioglu O1 Khan A Aldridge C Chen J
bull A total of 1426 obese patients (158 male) after RYGB during January 2000
to 2012 (2 year FU)
bull Weight regain was observed in 244 patients (171) Preoperative BMI
was similar between groups
bull BMI was significantly higher and percent excess weight loss was
significantly lower in the Weight Regain (WR) group (P 0001)
Only patients with gt50 EWL
at 1 year postoperatively
bull Univariate analysis found that older age male gender having
hypertension dyslipidemia and insulin-treated type 2 diabetes were all
factors associated with sustained weight loss
bull A longer duration after RYGB was associated with weight regain
Multivariate analysis revealed that younger age was a significant predictor
of weight regain even after adjusting for time since RYGB
Why do RYGB patients regain weight
Small pouch amp rapid emptying leads to better weight loss less weight
regain and better food intolerance in RYGB
bull 67 RYGB patients had pouch volumetry by 3D-CT pouch emptying by 4hr Scintigraphy food intolerance and weight loss measurement
bull Median FU was 47 months median volume was 28 ml ret at 124 hours was 8 2 1
bull There was association between Vlt40ml amp higher emptying rates up to 2 hours (Vlt40 Ret 1=6 Ret2=2) P=0009 vs (Vgt40 Ret 1=44 Ret2=135) P=0045
bull Higher emptying speed at 1 hour correlated with higher weight loss (P=0033) and less weight regain (P=0036) (Retlt12 vs gt25)
bull Better food tolerance with lower Ret 1 hour (0003)
D Riccioppo I Cecconello abstract 0110 IFSO London 2017
2 decades ago if a patient was considering a surgery involving
small bowel rerouting it would have been (RYGB) or (BPD)
In contrast today if a patient is considering a surgery that
involves small bowel rerouting this could mean any of the
following bariatric surgeries
one anastomosis gastric bypassmini gastric bypass (OAGBMGB)
BPD or BPD duodenal switch (DS)
single anastomosis duodenoileostomy (SADI)
single anastomosis gastroileostomy (SAGI)
single anastomosis sleeve ileostomy (SASI)
duodenojejunal bypass (DJB) or
stomach intestinal pylorus sparing surgery (SIPS)
Assuming Small bowel
length is 400 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 200 150 250
Alimentary limb (Roux
limb + CC)
250 250 250 200 150 350
BPL 150 150 150 200 250 50
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
History of bariatric surgery in the US looks like this
World wide 2014
North American USA amp Canada
Europe
Asia Pacific
3224 3223
4366 4438
423262 274
468254 170 131 222220 230
381840
4196 4033
5386
6403
2013 2014 2015 2016
OAGBMGB in the UAE is
13 in 2016 up from 7 2015Total
LSG
OAGBMGB
RYGBLAGB
Latin America
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull 1156 patients with severe obesity comprised 3 groups 418
patients After RYGB (surgery group) 417 patients who
sought but did not undergo surgery (primarily for insurance
reasons) (non-surgery group 1) and 321 patients who did not
seek surgery (non-surgery group 2)
bull We performed clinical examinations at baseline and at 2
years 6 years and 12 years to ascertain the presence of type
2 diabetes hypertension and dyslipidemia
bull The follow-up rate exceeded 90 at 12 years
Long term FU 10-15 years after RYGB in Italy
bull 285 RYGB patients done between 2000-2006
bull Mean BMI 453 (+59) kgm2 went down to 335 (51) kgm2 at 8 years 338 (5) kgm2 at 10 years 305 (41) kgm2 at 12 years amp 326 (47) kgm2 at 14 years (69 achieved BMI lt35 kgm2)
bull Mean EWL 663 (+21) at 8 years 642 (+23) at 10 years 767 (+21) at 12 years amp 698 (+23) at 14 years
bull FU was 91 84 72 and 63 at 81012 amp 14 years
bull Mortality 035 leak 07 stenosis 1 IH 14 SBO 73
bull 60 of patients stopped taking supplements and 357 had nutritional deficiencies
R Arnoux Dabadie Abstract 0115 IFSO London 2017
376
1369
265
2037
Diabetes resolution 6 years after LSG RYGB Medical therapy in France
bull All patients undergoing bariatric surgery in France in 2009 amp control group matched (age gender BMI DM) from French National Insurance
bull 15650 (85 females 10 had DM II) had bariatric surgery in 2009
bull Diabetes resolution after BS was 50 vs 9 medical therapy Plt0001
bull The main predictive for resolution were RYGB 167 (13-214) LSG 73 (56-96) LAGB 43 (33-56) No insulin 58 (46-74) No dyslipidemia medications 13 (11-16)
bull DM recurrence at 6 years was least frequent with BS 1 vs 12 in control (Plt0001)
bull RYGB 006 was the more effective than LSG 008 amp LAGB 016
J Thereaux A Fagot-Campagna France Abstract 0004 IFSO London
5 year results of the Swiss RCT LSG vs RYGB (SM-BOSS)
bull RCT of 217 patients LSG 107 vs RYGB 110 at 4 centers in Switzerland
bull Mean BMI 44+11 Age 43+5 72 females mean FU 5 years (954)
bull Patients with severe GERD or Hiatal hernia were excluded
bull Weight loss was similar at 1 year (723+22 vs 766+20) P=013 3 years (71+23 vs 734+23) P=03 5 years (622+27 vs 68+25) P=011
bull Weight loss after LSG at 5 years was inferior to RYGB (25+11 vs 286+10) P+002 Co-morbidity resolution was significantly reduced in both except GERD which was better with RYGB
bull QOL number of complications and re-operations were similar
R Peterli M Bueter Abstract 0005 IFSO London 2017
LAGB to RYGB is more effective than LAGB to LSG
bull 192 patients LAGB to RYGB vs 283 LAGB to LSG
bull The baseline age and BMI were similar in both groups
bull At 2 years BMI was lower in RYGB 3293 vs 3834 kgm2 for LSG (P=00004) EBMIL was lower in RYGB 578 vs 293 in LSG (P=00001) amp WL was lower in RYGB 234 vs 126 in LSG (P=0001)
bull Reoperation was higher in conversion to RYGB 73 vs 14 (P0=0022) OR time was longer in RYGB 1201 vs 1155 minutes in LSG (Plt0001) LOS was longer RYGB 333 vs 211 days (Plt0001)
bull Readmission was similar in RYGB 73 vs 35 in LSG (P=0087)M Jenkins B Schwack Abstract 0160 IFSO London 2017
50 GERD from 17 at 85 years
bull 100 LSG after long-term mean FU 85 years (EWL) of 60
bull A significant increase in GERD symptoms (50 from 17 pre op) (RR
= 25882 95 CI [16161ndash 41452] amp use of PPIs p value = 00001)
bull The chance of developing de novo reflux after LSG was 478 (3267)
Reflux disease was present in 7 of the 26 patients who underwent a secondary
Roux- en-Y gastric bypass (RYGB)
bull In 47 patients GERD disappeared completely after the secondary
RYGB (571)
68 GERD from 33 at 5 years
172 Barretts Esophagitis
69 Follow up
bull A total of 110 patients after LSG GERD symptoms(681 versus 336 P
00001 VAS mean score3 versus 18 P 1frasl4 018 and PPI intake significantly
increased compared with preoperative values572 versus 191 P 00001)
bull At EGD an upward migration of the ldquoZrdquo line and a biliary-like esophageal reflux
was found in 736 and 745 of cases respectively
bull Multi-Center study (3 centers) 4353 patients were followed 6 patients (140)
were converted to RYGB due to GERD over a period of 130 months
bull 1026 (384) not converted to RYGB also suffered from symptomatic reflux
bull Gastroscopies revealed de novo hiatal hernias in 45 of the patients amp Barrettrsquos
metaplasia in 15 SG patients suffering from symptomatic reflux scored
significantly higher in the RSI (p = 004) and significantly lower in the GIQLI (p
= 002) questionnaire
14 conversion to RYGB 23 weight regain
De novo GERD in 45 patients
100 Follow up 108 years384 GERD15 Barretts metaplasia
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull (1) The steep learning curve
bull (2) Re routing of the small bowel (OAGBMGB)
bull (3) Potential known long term complications
bull (4) The perceived paucity of options to treat patients with weight
recidivism especially when your are super obese
bull In contrast (1) the short learning curve (2) no re routing of the small
bowel (3) unknown long term complications and (4) the many
options to revise a LSG to a duodenal switch or LRYGB are the reasons
patients and surgeons are choosing the LSG over LRYGB
Learning curve amp adoption of laparoscopic colectomy
less than 13 of colectomies
bull 22 (87838264) for 1996
bull 27 (117542166) for 2000
bull 5 (233644817) for 2004 Publication of the COST Trial
bull 15 (754842903) for 2008
bull 314 (1461031888) for 2009Ann Surg 2013 Aug258(2)270-4 doi 101097SLA0b013e31828faa66
Growth of laparoscopic colectomy in the United States analysis of regional
and socioeconomic factors over time
Bardakcioglu O1 Khan A Aldridge C Chen J
bull A total of 1426 obese patients (158 male) after RYGB during January 2000
to 2012 (2 year FU)
bull Weight regain was observed in 244 patients (171) Preoperative BMI
was similar between groups
bull BMI was significantly higher and percent excess weight loss was
significantly lower in the Weight Regain (WR) group (P 0001)
Only patients with gt50 EWL
at 1 year postoperatively
bull Univariate analysis found that older age male gender having
hypertension dyslipidemia and insulin-treated type 2 diabetes were all
factors associated with sustained weight loss
bull A longer duration after RYGB was associated with weight regain
Multivariate analysis revealed that younger age was a significant predictor
of weight regain even after adjusting for time since RYGB
Why do RYGB patients regain weight
Small pouch amp rapid emptying leads to better weight loss less weight
regain and better food intolerance in RYGB
bull 67 RYGB patients had pouch volumetry by 3D-CT pouch emptying by 4hr Scintigraphy food intolerance and weight loss measurement
bull Median FU was 47 months median volume was 28 ml ret at 124 hours was 8 2 1
bull There was association between Vlt40ml amp higher emptying rates up to 2 hours (Vlt40 Ret 1=6 Ret2=2) P=0009 vs (Vgt40 Ret 1=44 Ret2=135) P=0045
bull Higher emptying speed at 1 hour correlated with higher weight loss (P=0033) and less weight regain (P=0036) (Retlt12 vs gt25)
bull Better food tolerance with lower Ret 1 hour (0003)
D Riccioppo I Cecconello abstract 0110 IFSO London 2017
2 decades ago if a patient was considering a surgery involving
small bowel rerouting it would have been (RYGB) or (BPD)
In contrast today if a patient is considering a surgery that
involves small bowel rerouting this could mean any of the
following bariatric surgeries
one anastomosis gastric bypassmini gastric bypass (OAGBMGB)
BPD or BPD duodenal switch (DS)
single anastomosis duodenoileostomy (SADI)
single anastomosis gastroileostomy (SAGI)
single anastomosis sleeve ileostomy (SASI)
duodenojejunal bypass (DJB) or
stomach intestinal pylorus sparing surgery (SIPS)
Assuming Small bowel
length is 400 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 200 150 250
Alimentary limb (Roux
limb + CC)
250 250 250 200 150 350
BPL 150 150 150 200 250 50
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
World wide 2014
North American USA amp Canada
Europe
Asia Pacific
3224 3223
4366 4438
423262 274
468254 170 131 222220 230
381840
4196 4033
5386
6403
2013 2014 2015 2016
OAGBMGB in the UAE is
13 in 2016 up from 7 2015Total
LSG
OAGBMGB
RYGBLAGB
Latin America
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull 1156 patients with severe obesity comprised 3 groups 418
patients After RYGB (surgery group) 417 patients who
sought but did not undergo surgery (primarily for insurance
reasons) (non-surgery group 1) and 321 patients who did not
seek surgery (non-surgery group 2)
bull We performed clinical examinations at baseline and at 2
years 6 years and 12 years to ascertain the presence of type
2 diabetes hypertension and dyslipidemia
bull The follow-up rate exceeded 90 at 12 years
Long term FU 10-15 years after RYGB in Italy
bull 285 RYGB patients done between 2000-2006
bull Mean BMI 453 (+59) kgm2 went down to 335 (51) kgm2 at 8 years 338 (5) kgm2 at 10 years 305 (41) kgm2 at 12 years amp 326 (47) kgm2 at 14 years (69 achieved BMI lt35 kgm2)
bull Mean EWL 663 (+21) at 8 years 642 (+23) at 10 years 767 (+21) at 12 years amp 698 (+23) at 14 years
bull FU was 91 84 72 and 63 at 81012 amp 14 years
bull Mortality 035 leak 07 stenosis 1 IH 14 SBO 73
bull 60 of patients stopped taking supplements and 357 had nutritional deficiencies
R Arnoux Dabadie Abstract 0115 IFSO London 2017
376
1369
265
2037
Diabetes resolution 6 years after LSG RYGB Medical therapy in France
bull All patients undergoing bariatric surgery in France in 2009 amp control group matched (age gender BMI DM) from French National Insurance
bull 15650 (85 females 10 had DM II) had bariatric surgery in 2009
bull Diabetes resolution after BS was 50 vs 9 medical therapy Plt0001
bull The main predictive for resolution were RYGB 167 (13-214) LSG 73 (56-96) LAGB 43 (33-56) No insulin 58 (46-74) No dyslipidemia medications 13 (11-16)
bull DM recurrence at 6 years was least frequent with BS 1 vs 12 in control (Plt0001)
bull RYGB 006 was the more effective than LSG 008 amp LAGB 016
J Thereaux A Fagot-Campagna France Abstract 0004 IFSO London
5 year results of the Swiss RCT LSG vs RYGB (SM-BOSS)
bull RCT of 217 patients LSG 107 vs RYGB 110 at 4 centers in Switzerland
bull Mean BMI 44+11 Age 43+5 72 females mean FU 5 years (954)
bull Patients with severe GERD or Hiatal hernia were excluded
bull Weight loss was similar at 1 year (723+22 vs 766+20) P=013 3 years (71+23 vs 734+23) P=03 5 years (622+27 vs 68+25) P=011
bull Weight loss after LSG at 5 years was inferior to RYGB (25+11 vs 286+10) P+002 Co-morbidity resolution was significantly reduced in both except GERD which was better with RYGB
bull QOL number of complications and re-operations were similar
R Peterli M Bueter Abstract 0005 IFSO London 2017
LAGB to RYGB is more effective than LAGB to LSG
bull 192 patients LAGB to RYGB vs 283 LAGB to LSG
bull The baseline age and BMI were similar in both groups
bull At 2 years BMI was lower in RYGB 3293 vs 3834 kgm2 for LSG (P=00004) EBMIL was lower in RYGB 578 vs 293 in LSG (P=00001) amp WL was lower in RYGB 234 vs 126 in LSG (P=0001)
bull Reoperation was higher in conversion to RYGB 73 vs 14 (P0=0022) OR time was longer in RYGB 1201 vs 1155 minutes in LSG (Plt0001) LOS was longer RYGB 333 vs 211 days (Plt0001)
bull Readmission was similar in RYGB 73 vs 35 in LSG (P=0087)M Jenkins B Schwack Abstract 0160 IFSO London 2017
50 GERD from 17 at 85 years
bull 100 LSG after long-term mean FU 85 years (EWL) of 60
bull A significant increase in GERD symptoms (50 from 17 pre op) (RR
= 25882 95 CI [16161ndash 41452] amp use of PPIs p value = 00001)
bull The chance of developing de novo reflux after LSG was 478 (3267)
Reflux disease was present in 7 of the 26 patients who underwent a secondary
Roux- en-Y gastric bypass (RYGB)
bull In 47 patients GERD disappeared completely after the secondary
RYGB (571)
68 GERD from 33 at 5 years
172 Barretts Esophagitis
69 Follow up
bull A total of 110 patients after LSG GERD symptoms(681 versus 336 P
00001 VAS mean score3 versus 18 P 1frasl4 018 and PPI intake significantly
increased compared with preoperative values572 versus 191 P 00001)
bull At EGD an upward migration of the ldquoZrdquo line and a biliary-like esophageal reflux
was found in 736 and 745 of cases respectively
bull Multi-Center study (3 centers) 4353 patients were followed 6 patients (140)
were converted to RYGB due to GERD over a period of 130 months
bull 1026 (384) not converted to RYGB also suffered from symptomatic reflux
bull Gastroscopies revealed de novo hiatal hernias in 45 of the patients amp Barrettrsquos
metaplasia in 15 SG patients suffering from symptomatic reflux scored
significantly higher in the RSI (p = 004) and significantly lower in the GIQLI (p
= 002) questionnaire
14 conversion to RYGB 23 weight regain
De novo GERD in 45 patients
100 Follow up 108 years384 GERD15 Barretts metaplasia
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull (1) The steep learning curve
bull (2) Re routing of the small bowel (OAGBMGB)
bull (3) Potential known long term complications
bull (4) The perceived paucity of options to treat patients with weight
recidivism especially when your are super obese
bull In contrast (1) the short learning curve (2) no re routing of the small
bowel (3) unknown long term complications and (4) the many
options to revise a LSG to a duodenal switch or LRYGB are the reasons
patients and surgeons are choosing the LSG over LRYGB
Learning curve amp adoption of laparoscopic colectomy
less than 13 of colectomies
bull 22 (87838264) for 1996
bull 27 (117542166) for 2000
bull 5 (233644817) for 2004 Publication of the COST Trial
bull 15 (754842903) for 2008
bull 314 (1461031888) for 2009Ann Surg 2013 Aug258(2)270-4 doi 101097SLA0b013e31828faa66
Growth of laparoscopic colectomy in the United States analysis of regional
and socioeconomic factors over time
Bardakcioglu O1 Khan A Aldridge C Chen J
bull A total of 1426 obese patients (158 male) after RYGB during January 2000
to 2012 (2 year FU)
bull Weight regain was observed in 244 patients (171) Preoperative BMI
was similar between groups
bull BMI was significantly higher and percent excess weight loss was
significantly lower in the Weight Regain (WR) group (P 0001)
Only patients with gt50 EWL
at 1 year postoperatively
bull Univariate analysis found that older age male gender having
hypertension dyslipidemia and insulin-treated type 2 diabetes were all
factors associated with sustained weight loss
bull A longer duration after RYGB was associated with weight regain
Multivariate analysis revealed that younger age was a significant predictor
of weight regain even after adjusting for time since RYGB
Why do RYGB patients regain weight
Small pouch amp rapid emptying leads to better weight loss less weight
regain and better food intolerance in RYGB
bull 67 RYGB patients had pouch volumetry by 3D-CT pouch emptying by 4hr Scintigraphy food intolerance and weight loss measurement
bull Median FU was 47 months median volume was 28 ml ret at 124 hours was 8 2 1
bull There was association between Vlt40ml amp higher emptying rates up to 2 hours (Vlt40 Ret 1=6 Ret2=2) P=0009 vs (Vgt40 Ret 1=44 Ret2=135) P=0045
bull Higher emptying speed at 1 hour correlated with higher weight loss (P=0033) and less weight regain (P=0036) (Retlt12 vs gt25)
bull Better food tolerance with lower Ret 1 hour (0003)
D Riccioppo I Cecconello abstract 0110 IFSO London 2017
2 decades ago if a patient was considering a surgery involving
small bowel rerouting it would have been (RYGB) or (BPD)
In contrast today if a patient is considering a surgery that
involves small bowel rerouting this could mean any of the
following bariatric surgeries
one anastomosis gastric bypassmini gastric bypass (OAGBMGB)
BPD or BPD duodenal switch (DS)
single anastomosis duodenoileostomy (SADI)
single anastomosis gastroileostomy (SAGI)
single anastomosis sleeve ileostomy (SASI)
duodenojejunal bypass (DJB) or
stomach intestinal pylorus sparing surgery (SIPS)
Assuming Small bowel
length is 400 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 200 150 250
Alimentary limb (Roux
limb + CC)
250 250 250 200 150 350
BPL 150 150 150 200 250 50
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
North American USA amp Canada
Europe
Asia Pacific
3224 3223
4366 4438
423262 274
468254 170 131 222220 230
381840
4196 4033
5386
6403
2013 2014 2015 2016
OAGBMGB in the UAE is
13 in 2016 up from 7 2015Total
LSG
OAGBMGB
RYGBLAGB
Latin America
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull 1156 patients with severe obesity comprised 3 groups 418
patients After RYGB (surgery group) 417 patients who
sought but did not undergo surgery (primarily for insurance
reasons) (non-surgery group 1) and 321 patients who did not
seek surgery (non-surgery group 2)
bull We performed clinical examinations at baseline and at 2
years 6 years and 12 years to ascertain the presence of type
2 diabetes hypertension and dyslipidemia
bull The follow-up rate exceeded 90 at 12 years
Long term FU 10-15 years after RYGB in Italy
bull 285 RYGB patients done between 2000-2006
bull Mean BMI 453 (+59) kgm2 went down to 335 (51) kgm2 at 8 years 338 (5) kgm2 at 10 years 305 (41) kgm2 at 12 years amp 326 (47) kgm2 at 14 years (69 achieved BMI lt35 kgm2)
bull Mean EWL 663 (+21) at 8 years 642 (+23) at 10 years 767 (+21) at 12 years amp 698 (+23) at 14 years
bull FU was 91 84 72 and 63 at 81012 amp 14 years
bull Mortality 035 leak 07 stenosis 1 IH 14 SBO 73
bull 60 of patients stopped taking supplements and 357 had nutritional deficiencies
R Arnoux Dabadie Abstract 0115 IFSO London 2017
376
1369
265
2037
Diabetes resolution 6 years after LSG RYGB Medical therapy in France
bull All patients undergoing bariatric surgery in France in 2009 amp control group matched (age gender BMI DM) from French National Insurance
bull 15650 (85 females 10 had DM II) had bariatric surgery in 2009
bull Diabetes resolution after BS was 50 vs 9 medical therapy Plt0001
bull The main predictive for resolution were RYGB 167 (13-214) LSG 73 (56-96) LAGB 43 (33-56) No insulin 58 (46-74) No dyslipidemia medications 13 (11-16)
bull DM recurrence at 6 years was least frequent with BS 1 vs 12 in control (Plt0001)
bull RYGB 006 was the more effective than LSG 008 amp LAGB 016
J Thereaux A Fagot-Campagna France Abstract 0004 IFSO London
5 year results of the Swiss RCT LSG vs RYGB (SM-BOSS)
bull RCT of 217 patients LSG 107 vs RYGB 110 at 4 centers in Switzerland
bull Mean BMI 44+11 Age 43+5 72 females mean FU 5 years (954)
bull Patients with severe GERD or Hiatal hernia were excluded
bull Weight loss was similar at 1 year (723+22 vs 766+20) P=013 3 years (71+23 vs 734+23) P=03 5 years (622+27 vs 68+25) P=011
bull Weight loss after LSG at 5 years was inferior to RYGB (25+11 vs 286+10) P+002 Co-morbidity resolution was significantly reduced in both except GERD which was better with RYGB
bull QOL number of complications and re-operations were similar
R Peterli M Bueter Abstract 0005 IFSO London 2017
LAGB to RYGB is more effective than LAGB to LSG
bull 192 patients LAGB to RYGB vs 283 LAGB to LSG
bull The baseline age and BMI were similar in both groups
bull At 2 years BMI was lower in RYGB 3293 vs 3834 kgm2 for LSG (P=00004) EBMIL was lower in RYGB 578 vs 293 in LSG (P=00001) amp WL was lower in RYGB 234 vs 126 in LSG (P=0001)
bull Reoperation was higher in conversion to RYGB 73 vs 14 (P0=0022) OR time was longer in RYGB 1201 vs 1155 minutes in LSG (Plt0001) LOS was longer RYGB 333 vs 211 days (Plt0001)
bull Readmission was similar in RYGB 73 vs 35 in LSG (P=0087)M Jenkins B Schwack Abstract 0160 IFSO London 2017
50 GERD from 17 at 85 years
bull 100 LSG after long-term mean FU 85 years (EWL) of 60
bull A significant increase in GERD symptoms (50 from 17 pre op) (RR
= 25882 95 CI [16161ndash 41452] amp use of PPIs p value = 00001)
bull The chance of developing de novo reflux after LSG was 478 (3267)
Reflux disease was present in 7 of the 26 patients who underwent a secondary
Roux- en-Y gastric bypass (RYGB)
bull In 47 patients GERD disappeared completely after the secondary
RYGB (571)
68 GERD from 33 at 5 years
172 Barretts Esophagitis
69 Follow up
bull A total of 110 patients after LSG GERD symptoms(681 versus 336 P
00001 VAS mean score3 versus 18 P 1frasl4 018 and PPI intake significantly
increased compared with preoperative values572 versus 191 P 00001)
bull At EGD an upward migration of the ldquoZrdquo line and a biliary-like esophageal reflux
was found in 736 and 745 of cases respectively
bull Multi-Center study (3 centers) 4353 patients were followed 6 patients (140)
were converted to RYGB due to GERD over a period of 130 months
bull 1026 (384) not converted to RYGB also suffered from symptomatic reflux
bull Gastroscopies revealed de novo hiatal hernias in 45 of the patients amp Barrettrsquos
metaplasia in 15 SG patients suffering from symptomatic reflux scored
significantly higher in the RSI (p = 004) and significantly lower in the GIQLI (p
= 002) questionnaire
14 conversion to RYGB 23 weight regain
De novo GERD in 45 patients
100 Follow up 108 years384 GERD15 Barretts metaplasia
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull (1) The steep learning curve
bull (2) Re routing of the small bowel (OAGBMGB)
bull (3) Potential known long term complications
bull (4) The perceived paucity of options to treat patients with weight
recidivism especially when your are super obese
bull In contrast (1) the short learning curve (2) no re routing of the small
bowel (3) unknown long term complications and (4) the many
options to revise a LSG to a duodenal switch or LRYGB are the reasons
patients and surgeons are choosing the LSG over LRYGB
Learning curve amp adoption of laparoscopic colectomy
less than 13 of colectomies
bull 22 (87838264) for 1996
bull 27 (117542166) for 2000
bull 5 (233644817) for 2004 Publication of the COST Trial
bull 15 (754842903) for 2008
bull 314 (1461031888) for 2009Ann Surg 2013 Aug258(2)270-4 doi 101097SLA0b013e31828faa66
Growth of laparoscopic colectomy in the United States analysis of regional
and socioeconomic factors over time
Bardakcioglu O1 Khan A Aldridge C Chen J
bull A total of 1426 obese patients (158 male) after RYGB during January 2000
to 2012 (2 year FU)
bull Weight regain was observed in 244 patients (171) Preoperative BMI
was similar between groups
bull BMI was significantly higher and percent excess weight loss was
significantly lower in the Weight Regain (WR) group (P 0001)
Only patients with gt50 EWL
at 1 year postoperatively
bull Univariate analysis found that older age male gender having
hypertension dyslipidemia and insulin-treated type 2 diabetes were all
factors associated with sustained weight loss
bull A longer duration after RYGB was associated with weight regain
Multivariate analysis revealed that younger age was a significant predictor
of weight regain even after adjusting for time since RYGB
Why do RYGB patients regain weight
Small pouch amp rapid emptying leads to better weight loss less weight
regain and better food intolerance in RYGB
bull 67 RYGB patients had pouch volumetry by 3D-CT pouch emptying by 4hr Scintigraphy food intolerance and weight loss measurement
bull Median FU was 47 months median volume was 28 ml ret at 124 hours was 8 2 1
bull There was association between Vlt40ml amp higher emptying rates up to 2 hours (Vlt40 Ret 1=6 Ret2=2) P=0009 vs (Vgt40 Ret 1=44 Ret2=135) P=0045
bull Higher emptying speed at 1 hour correlated with higher weight loss (P=0033) and less weight regain (P=0036) (Retlt12 vs gt25)
bull Better food tolerance with lower Ret 1 hour (0003)
D Riccioppo I Cecconello abstract 0110 IFSO London 2017
2 decades ago if a patient was considering a surgery involving
small bowel rerouting it would have been (RYGB) or (BPD)
In contrast today if a patient is considering a surgery that
involves small bowel rerouting this could mean any of the
following bariatric surgeries
one anastomosis gastric bypassmini gastric bypass (OAGBMGB)
BPD or BPD duodenal switch (DS)
single anastomosis duodenoileostomy (SADI)
single anastomosis gastroileostomy (SAGI)
single anastomosis sleeve ileostomy (SASI)
duodenojejunal bypass (DJB) or
stomach intestinal pylorus sparing surgery (SIPS)
Assuming Small bowel
length is 400 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 200 150 250
Alimentary limb (Roux
limb + CC)
250 250 250 200 150 350
BPL 150 150 150 200 250 50
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
Europe
Asia Pacific
3224 3223
4366 4438
423262 274
468254 170 131 222220 230
381840
4196 4033
5386
6403
2013 2014 2015 2016
OAGBMGB in the UAE is
13 in 2016 up from 7 2015Total
LSG
OAGBMGB
RYGBLAGB
Latin America
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull 1156 patients with severe obesity comprised 3 groups 418
patients After RYGB (surgery group) 417 patients who
sought but did not undergo surgery (primarily for insurance
reasons) (non-surgery group 1) and 321 patients who did not
seek surgery (non-surgery group 2)
bull We performed clinical examinations at baseline and at 2
years 6 years and 12 years to ascertain the presence of type
2 diabetes hypertension and dyslipidemia
bull The follow-up rate exceeded 90 at 12 years
Long term FU 10-15 years after RYGB in Italy
bull 285 RYGB patients done between 2000-2006
bull Mean BMI 453 (+59) kgm2 went down to 335 (51) kgm2 at 8 years 338 (5) kgm2 at 10 years 305 (41) kgm2 at 12 years amp 326 (47) kgm2 at 14 years (69 achieved BMI lt35 kgm2)
bull Mean EWL 663 (+21) at 8 years 642 (+23) at 10 years 767 (+21) at 12 years amp 698 (+23) at 14 years
bull FU was 91 84 72 and 63 at 81012 amp 14 years
bull Mortality 035 leak 07 stenosis 1 IH 14 SBO 73
bull 60 of patients stopped taking supplements and 357 had nutritional deficiencies
R Arnoux Dabadie Abstract 0115 IFSO London 2017
376
1369
265
2037
Diabetes resolution 6 years after LSG RYGB Medical therapy in France
bull All patients undergoing bariatric surgery in France in 2009 amp control group matched (age gender BMI DM) from French National Insurance
bull 15650 (85 females 10 had DM II) had bariatric surgery in 2009
bull Diabetes resolution after BS was 50 vs 9 medical therapy Plt0001
bull The main predictive for resolution were RYGB 167 (13-214) LSG 73 (56-96) LAGB 43 (33-56) No insulin 58 (46-74) No dyslipidemia medications 13 (11-16)
bull DM recurrence at 6 years was least frequent with BS 1 vs 12 in control (Plt0001)
bull RYGB 006 was the more effective than LSG 008 amp LAGB 016
J Thereaux A Fagot-Campagna France Abstract 0004 IFSO London
5 year results of the Swiss RCT LSG vs RYGB (SM-BOSS)
bull RCT of 217 patients LSG 107 vs RYGB 110 at 4 centers in Switzerland
bull Mean BMI 44+11 Age 43+5 72 females mean FU 5 years (954)
bull Patients with severe GERD or Hiatal hernia were excluded
bull Weight loss was similar at 1 year (723+22 vs 766+20) P=013 3 years (71+23 vs 734+23) P=03 5 years (622+27 vs 68+25) P=011
bull Weight loss after LSG at 5 years was inferior to RYGB (25+11 vs 286+10) P+002 Co-morbidity resolution was significantly reduced in both except GERD which was better with RYGB
bull QOL number of complications and re-operations were similar
R Peterli M Bueter Abstract 0005 IFSO London 2017
LAGB to RYGB is more effective than LAGB to LSG
bull 192 patients LAGB to RYGB vs 283 LAGB to LSG
bull The baseline age and BMI were similar in both groups
bull At 2 years BMI was lower in RYGB 3293 vs 3834 kgm2 for LSG (P=00004) EBMIL was lower in RYGB 578 vs 293 in LSG (P=00001) amp WL was lower in RYGB 234 vs 126 in LSG (P=0001)
bull Reoperation was higher in conversion to RYGB 73 vs 14 (P0=0022) OR time was longer in RYGB 1201 vs 1155 minutes in LSG (Plt0001) LOS was longer RYGB 333 vs 211 days (Plt0001)
bull Readmission was similar in RYGB 73 vs 35 in LSG (P=0087)M Jenkins B Schwack Abstract 0160 IFSO London 2017
50 GERD from 17 at 85 years
bull 100 LSG after long-term mean FU 85 years (EWL) of 60
bull A significant increase in GERD symptoms (50 from 17 pre op) (RR
= 25882 95 CI [16161ndash 41452] amp use of PPIs p value = 00001)
bull The chance of developing de novo reflux after LSG was 478 (3267)
Reflux disease was present in 7 of the 26 patients who underwent a secondary
Roux- en-Y gastric bypass (RYGB)
bull In 47 patients GERD disappeared completely after the secondary
RYGB (571)
68 GERD from 33 at 5 years
172 Barretts Esophagitis
69 Follow up
bull A total of 110 patients after LSG GERD symptoms(681 versus 336 P
00001 VAS mean score3 versus 18 P 1frasl4 018 and PPI intake significantly
increased compared with preoperative values572 versus 191 P 00001)
bull At EGD an upward migration of the ldquoZrdquo line and a biliary-like esophageal reflux
was found in 736 and 745 of cases respectively
bull Multi-Center study (3 centers) 4353 patients were followed 6 patients (140)
were converted to RYGB due to GERD over a period of 130 months
bull 1026 (384) not converted to RYGB also suffered from symptomatic reflux
bull Gastroscopies revealed de novo hiatal hernias in 45 of the patients amp Barrettrsquos
metaplasia in 15 SG patients suffering from symptomatic reflux scored
significantly higher in the RSI (p = 004) and significantly lower in the GIQLI (p
= 002) questionnaire
14 conversion to RYGB 23 weight regain
De novo GERD in 45 patients
100 Follow up 108 years384 GERD15 Barretts metaplasia
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull (1) The steep learning curve
bull (2) Re routing of the small bowel (OAGBMGB)
bull (3) Potential known long term complications
bull (4) The perceived paucity of options to treat patients with weight
recidivism especially when your are super obese
bull In contrast (1) the short learning curve (2) no re routing of the small
bowel (3) unknown long term complications and (4) the many
options to revise a LSG to a duodenal switch or LRYGB are the reasons
patients and surgeons are choosing the LSG over LRYGB
Learning curve amp adoption of laparoscopic colectomy
less than 13 of colectomies
bull 22 (87838264) for 1996
bull 27 (117542166) for 2000
bull 5 (233644817) for 2004 Publication of the COST Trial
bull 15 (754842903) for 2008
bull 314 (1461031888) for 2009Ann Surg 2013 Aug258(2)270-4 doi 101097SLA0b013e31828faa66
Growth of laparoscopic colectomy in the United States analysis of regional
and socioeconomic factors over time
Bardakcioglu O1 Khan A Aldridge C Chen J
bull A total of 1426 obese patients (158 male) after RYGB during January 2000
to 2012 (2 year FU)
bull Weight regain was observed in 244 patients (171) Preoperative BMI
was similar between groups
bull BMI was significantly higher and percent excess weight loss was
significantly lower in the Weight Regain (WR) group (P 0001)
Only patients with gt50 EWL
at 1 year postoperatively
bull Univariate analysis found that older age male gender having
hypertension dyslipidemia and insulin-treated type 2 diabetes were all
factors associated with sustained weight loss
bull A longer duration after RYGB was associated with weight regain
Multivariate analysis revealed that younger age was a significant predictor
of weight regain even after adjusting for time since RYGB
Why do RYGB patients regain weight
Small pouch amp rapid emptying leads to better weight loss less weight
regain and better food intolerance in RYGB
bull 67 RYGB patients had pouch volumetry by 3D-CT pouch emptying by 4hr Scintigraphy food intolerance and weight loss measurement
bull Median FU was 47 months median volume was 28 ml ret at 124 hours was 8 2 1
bull There was association between Vlt40ml amp higher emptying rates up to 2 hours (Vlt40 Ret 1=6 Ret2=2) P=0009 vs (Vgt40 Ret 1=44 Ret2=135) P=0045
bull Higher emptying speed at 1 hour correlated with higher weight loss (P=0033) and less weight regain (P=0036) (Retlt12 vs gt25)
bull Better food tolerance with lower Ret 1 hour (0003)
D Riccioppo I Cecconello abstract 0110 IFSO London 2017
2 decades ago if a patient was considering a surgery involving
small bowel rerouting it would have been (RYGB) or (BPD)
In contrast today if a patient is considering a surgery that
involves small bowel rerouting this could mean any of the
following bariatric surgeries
one anastomosis gastric bypassmini gastric bypass (OAGBMGB)
BPD or BPD duodenal switch (DS)
single anastomosis duodenoileostomy (SADI)
single anastomosis gastroileostomy (SAGI)
single anastomosis sleeve ileostomy (SASI)
duodenojejunal bypass (DJB) or
stomach intestinal pylorus sparing surgery (SIPS)
Assuming Small bowel
length is 400 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 200 150 250
Alimentary limb (Roux
limb + CC)
250 250 250 200 150 350
BPL 150 150 150 200 250 50
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
Asia Pacific
3224 3223
4366 4438
423262 274
468254 170 131 222220 230
381840
4196 4033
5386
6403
2013 2014 2015 2016
OAGBMGB in the UAE is
13 in 2016 up from 7 2015Total
LSG
OAGBMGB
RYGBLAGB
Latin America
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull 1156 patients with severe obesity comprised 3 groups 418
patients After RYGB (surgery group) 417 patients who
sought but did not undergo surgery (primarily for insurance
reasons) (non-surgery group 1) and 321 patients who did not
seek surgery (non-surgery group 2)
bull We performed clinical examinations at baseline and at 2
years 6 years and 12 years to ascertain the presence of type
2 diabetes hypertension and dyslipidemia
bull The follow-up rate exceeded 90 at 12 years
Long term FU 10-15 years after RYGB in Italy
bull 285 RYGB patients done between 2000-2006
bull Mean BMI 453 (+59) kgm2 went down to 335 (51) kgm2 at 8 years 338 (5) kgm2 at 10 years 305 (41) kgm2 at 12 years amp 326 (47) kgm2 at 14 years (69 achieved BMI lt35 kgm2)
bull Mean EWL 663 (+21) at 8 years 642 (+23) at 10 years 767 (+21) at 12 years amp 698 (+23) at 14 years
bull FU was 91 84 72 and 63 at 81012 amp 14 years
bull Mortality 035 leak 07 stenosis 1 IH 14 SBO 73
bull 60 of patients stopped taking supplements and 357 had nutritional deficiencies
R Arnoux Dabadie Abstract 0115 IFSO London 2017
376
1369
265
2037
Diabetes resolution 6 years after LSG RYGB Medical therapy in France
bull All patients undergoing bariatric surgery in France in 2009 amp control group matched (age gender BMI DM) from French National Insurance
bull 15650 (85 females 10 had DM II) had bariatric surgery in 2009
bull Diabetes resolution after BS was 50 vs 9 medical therapy Plt0001
bull The main predictive for resolution were RYGB 167 (13-214) LSG 73 (56-96) LAGB 43 (33-56) No insulin 58 (46-74) No dyslipidemia medications 13 (11-16)
bull DM recurrence at 6 years was least frequent with BS 1 vs 12 in control (Plt0001)
bull RYGB 006 was the more effective than LSG 008 amp LAGB 016
J Thereaux A Fagot-Campagna France Abstract 0004 IFSO London
5 year results of the Swiss RCT LSG vs RYGB (SM-BOSS)
bull RCT of 217 patients LSG 107 vs RYGB 110 at 4 centers in Switzerland
bull Mean BMI 44+11 Age 43+5 72 females mean FU 5 years (954)
bull Patients with severe GERD or Hiatal hernia were excluded
bull Weight loss was similar at 1 year (723+22 vs 766+20) P=013 3 years (71+23 vs 734+23) P=03 5 years (622+27 vs 68+25) P=011
bull Weight loss after LSG at 5 years was inferior to RYGB (25+11 vs 286+10) P+002 Co-morbidity resolution was significantly reduced in both except GERD which was better with RYGB
bull QOL number of complications and re-operations were similar
R Peterli M Bueter Abstract 0005 IFSO London 2017
LAGB to RYGB is more effective than LAGB to LSG
bull 192 patients LAGB to RYGB vs 283 LAGB to LSG
bull The baseline age and BMI were similar in both groups
bull At 2 years BMI was lower in RYGB 3293 vs 3834 kgm2 for LSG (P=00004) EBMIL was lower in RYGB 578 vs 293 in LSG (P=00001) amp WL was lower in RYGB 234 vs 126 in LSG (P=0001)
bull Reoperation was higher in conversion to RYGB 73 vs 14 (P0=0022) OR time was longer in RYGB 1201 vs 1155 minutes in LSG (Plt0001) LOS was longer RYGB 333 vs 211 days (Plt0001)
bull Readmission was similar in RYGB 73 vs 35 in LSG (P=0087)M Jenkins B Schwack Abstract 0160 IFSO London 2017
50 GERD from 17 at 85 years
bull 100 LSG after long-term mean FU 85 years (EWL) of 60
bull A significant increase in GERD symptoms (50 from 17 pre op) (RR
= 25882 95 CI [16161ndash 41452] amp use of PPIs p value = 00001)
bull The chance of developing de novo reflux after LSG was 478 (3267)
Reflux disease was present in 7 of the 26 patients who underwent a secondary
Roux- en-Y gastric bypass (RYGB)
bull In 47 patients GERD disappeared completely after the secondary
RYGB (571)
68 GERD from 33 at 5 years
172 Barretts Esophagitis
69 Follow up
bull A total of 110 patients after LSG GERD symptoms(681 versus 336 P
00001 VAS mean score3 versus 18 P 1frasl4 018 and PPI intake significantly
increased compared with preoperative values572 versus 191 P 00001)
bull At EGD an upward migration of the ldquoZrdquo line and a biliary-like esophageal reflux
was found in 736 and 745 of cases respectively
bull Multi-Center study (3 centers) 4353 patients were followed 6 patients (140)
were converted to RYGB due to GERD over a period of 130 months
bull 1026 (384) not converted to RYGB also suffered from symptomatic reflux
bull Gastroscopies revealed de novo hiatal hernias in 45 of the patients amp Barrettrsquos
metaplasia in 15 SG patients suffering from symptomatic reflux scored
significantly higher in the RSI (p = 004) and significantly lower in the GIQLI (p
= 002) questionnaire
14 conversion to RYGB 23 weight regain
De novo GERD in 45 patients
100 Follow up 108 years384 GERD15 Barretts metaplasia
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull (1) The steep learning curve
bull (2) Re routing of the small bowel (OAGBMGB)
bull (3) Potential known long term complications
bull (4) The perceived paucity of options to treat patients with weight
recidivism especially when your are super obese
bull In contrast (1) the short learning curve (2) no re routing of the small
bowel (3) unknown long term complications and (4) the many
options to revise a LSG to a duodenal switch or LRYGB are the reasons
patients and surgeons are choosing the LSG over LRYGB
Learning curve amp adoption of laparoscopic colectomy
less than 13 of colectomies
bull 22 (87838264) for 1996
bull 27 (117542166) for 2000
bull 5 (233644817) for 2004 Publication of the COST Trial
bull 15 (754842903) for 2008
bull 314 (1461031888) for 2009Ann Surg 2013 Aug258(2)270-4 doi 101097SLA0b013e31828faa66
Growth of laparoscopic colectomy in the United States analysis of regional
and socioeconomic factors over time
Bardakcioglu O1 Khan A Aldridge C Chen J
bull A total of 1426 obese patients (158 male) after RYGB during January 2000
to 2012 (2 year FU)
bull Weight regain was observed in 244 patients (171) Preoperative BMI
was similar between groups
bull BMI was significantly higher and percent excess weight loss was
significantly lower in the Weight Regain (WR) group (P 0001)
Only patients with gt50 EWL
at 1 year postoperatively
bull Univariate analysis found that older age male gender having
hypertension dyslipidemia and insulin-treated type 2 diabetes were all
factors associated with sustained weight loss
bull A longer duration after RYGB was associated with weight regain
Multivariate analysis revealed that younger age was a significant predictor
of weight regain even after adjusting for time since RYGB
Why do RYGB patients regain weight
Small pouch amp rapid emptying leads to better weight loss less weight
regain and better food intolerance in RYGB
bull 67 RYGB patients had pouch volumetry by 3D-CT pouch emptying by 4hr Scintigraphy food intolerance and weight loss measurement
bull Median FU was 47 months median volume was 28 ml ret at 124 hours was 8 2 1
bull There was association between Vlt40ml amp higher emptying rates up to 2 hours (Vlt40 Ret 1=6 Ret2=2) P=0009 vs (Vgt40 Ret 1=44 Ret2=135) P=0045
bull Higher emptying speed at 1 hour correlated with higher weight loss (P=0033) and less weight regain (P=0036) (Retlt12 vs gt25)
bull Better food tolerance with lower Ret 1 hour (0003)
D Riccioppo I Cecconello abstract 0110 IFSO London 2017
2 decades ago if a patient was considering a surgery involving
small bowel rerouting it would have been (RYGB) or (BPD)
In contrast today if a patient is considering a surgery that
involves small bowel rerouting this could mean any of the
following bariatric surgeries
one anastomosis gastric bypassmini gastric bypass (OAGBMGB)
BPD or BPD duodenal switch (DS)
single anastomosis duodenoileostomy (SADI)
single anastomosis gastroileostomy (SAGI)
single anastomosis sleeve ileostomy (SASI)
duodenojejunal bypass (DJB) or
stomach intestinal pylorus sparing surgery (SIPS)
Assuming Small bowel
length is 400 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 200 150 250
Alimentary limb (Roux
limb + CC)
250 250 250 200 150 350
BPL 150 150 150 200 250 50
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
3224 3223
4366 4438
423262 274
468254 170 131 222220 230
381840
4196 4033
5386
6403
2013 2014 2015 2016
OAGBMGB in the UAE is
13 in 2016 up from 7 2015Total
LSG
OAGBMGB
RYGBLAGB
Latin America
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull 1156 patients with severe obesity comprised 3 groups 418
patients After RYGB (surgery group) 417 patients who
sought but did not undergo surgery (primarily for insurance
reasons) (non-surgery group 1) and 321 patients who did not
seek surgery (non-surgery group 2)
bull We performed clinical examinations at baseline and at 2
years 6 years and 12 years to ascertain the presence of type
2 diabetes hypertension and dyslipidemia
bull The follow-up rate exceeded 90 at 12 years
Long term FU 10-15 years after RYGB in Italy
bull 285 RYGB patients done between 2000-2006
bull Mean BMI 453 (+59) kgm2 went down to 335 (51) kgm2 at 8 years 338 (5) kgm2 at 10 years 305 (41) kgm2 at 12 years amp 326 (47) kgm2 at 14 years (69 achieved BMI lt35 kgm2)
bull Mean EWL 663 (+21) at 8 years 642 (+23) at 10 years 767 (+21) at 12 years amp 698 (+23) at 14 years
bull FU was 91 84 72 and 63 at 81012 amp 14 years
bull Mortality 035 leak 07 stenosis 1 IH 14 SBO 73
bull 60 of patients stopped taking supplements and 357 had nutritional deficiencies
R Arnoux Dabadie Abstract 0115 IFSO London 2017
376
1369
265
2037
Diabetes resolution 6 years after LSG RYGB Medical therapy in France
bull All patients undergoing bariatric surgery in France in 2009 amp control group matched (age gender BMI DM) from French National Insurance
bull 15650 (85 females 10 had DM II) had bariatric surgery in 2009
bull Diabetes resolution after BS was 50 vs 9 medical therapy Plt0001
bull The main predictive for resolution were RYGB 167 (13-214) LSG 73 (56-96) LAGB 43 (33-56) No insulin 58 (46-74) No dyslipidemia medications 13 (11-16)
bull DM recurrence at 6 years was least frequent with BS 1 vs 12 in control (Plt0001)
bull RYGB 006 was the more effective than LSG 008 amp LAGB 016
J Thereaux A Fagot-Campagna France Abstract 0004 IFSO London
5 year results of the Swiss RCT LSG vs RYGB (SM-BOSS)
bull RCT of 217 patients LSG 107 vs RYGB 110 at 4 centers in Switzerland
bull Mean BMI 44+11 Age 43+5 72 females mean FU 5 years (954)
bull Patients with severe GERD or Hiatal hernia were excluded
bull Weight loss was similar at 1 year (723+22 vs 766+20) P=013 3 years (71+23 vs 734+23) P=03 5 years (622+27 vs 68+25) P=011
bull Weight loss after LSG at 5 years was inferior to RYGB (25+11 vs 286+10) P+002 Co-morbidity resolution was significantly reduced in both except GERD which was better with RYGB
bull QOL number of complications and re-operations were similar
R Peterli M Bueter Abstract 0005 IFSO London 2017
LAGB to RYGB is more effective than LAGB to LSG
bull 192 patients LAGB to RYGB vs 283 LAGB to LSG
bull The baseline age and BMI were similar in both groups
bull At 2 years BMI was lower in RYGB 3293 vs 3834 kgm2 for LSG (P=00004) EBMIL was lower in RYGB 578 vs 293 in LSG (P=00001) amp WL was lower in RYGB 234 vs 126 in LSG (P=0001)
bull Reoperation was higher in conversion to RYGB 73 vs 14 (P0=0022) OR time was longer in RYGB 1201 vs 1155 minutes in LSG (Plt0001) LOS was longer RYGB 333 vs 211 days (Plt0001)
bull Readmission was similar in RYGB 73 vs 35 in LSG (P=0087)M Jenkins B Schwack Abstract 0160 IFSO London 2017
50 GERD from 17 at 85 years
bull 100 LSG after long-term mean FU 85 years (EWL) of 60
bull A significant increase in GERD symptoms (50 from 17 pre op) (RR
= 25882 95 CI [16161ndash 41452] amp use of PPIs p value = 00001)
bull The chance of developing de novo reflux after LSG was 478 (3267)
Reflux disease was present in 7 of the 26 patients who underwent a secondary
Roux- en-Y gastric bypass (RYGB)
bull In 47 patients GERD disappeared completely after the secondary
RYGB (571)
68 GERD from 33 at 5 years
172 Barretts Esophagitis
69 Follow up
bull A total of 110 patients after LSG GERD symptoms(681 versus 336 P
00001 VAS mean score3 versus 18 P 1frasl4 018 and PPI intake significantly
increased compared with preoperative values572 versus 191 P 00001)
bull At EGD an upward migration of the ldquoZrdquo line and a biliary-like esophageal reflux
was found in 736 and 745 of cases respectively
bull Multi-Center study (3 centers) 4353 patients were followed 6 patients (140)
were converted to RYGB due to GERD over a period of 130 months
bull 1026 (384) not converted to RYGB also suffered from symptomatic reflux
bull Gastroscopies revealed de novo hiatal hernias in 45 of the patients amp Barrettrsquos
metaplasia in 15 SG patients suffering from symptomatic reflux scored
significantly higher in the RSI (p = 004) and significantly lower in the GIQLI (p
= 002) questionnaire
14 conversion to RYGB 23 weight regain
De novo GERD in 45 patients
100 Follow up 108 years384 GERD15 Barretts metaplasia
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull (1) The steep learning curve
bull (2) Re routing of the small bowel (OAGBMGB)
bull (3) Potential known long term complications
bull (4) The perceived paucity of options to treat patients with weight
recidivism especially when your are super obese
bull In contrast (1) the short learning curve (2) no re routing of the small
bowel (3) unknown long term complications and (4) the many
options to revise a LSG to a duodenal switch or LRYGB are the reasons
patients and surgeons are choosing the LSG over LRYGB
Learning curve amp adoption of laparoscopic colectomy
less than 13 of colectomies
bull 22 (87838264) for 1996
bull 27 (117542166) for 2000
bull 5 (233644817) for 2004 Publication of the COST Trial
bull 15 (754842903) for 2008
bull 314 (1461031888) for 2009Ann Surg 2013 Aug258(2)270-4 doi 101097SLA0b013e31828faa66
Growth of laparoscopic colectomy in the United States analysis of regional
and socioeconomic factors over time
Bardakcioglu O1 Khan A Aldridge C Chen J
bull A total of 1426 obese patients (158 male) after RYGB during January 2000
to 2012 (2 year FU)
bull Weight regain was observed in 244 patients (171) Preoperative BMI
was similar between groups
bull BMI was significantly higher and percent excess weight loss was
significantly lower in the Weight Regain (WR) group (P 0001)
Only patients with gt50 EWL
at 1 year postoperatively
bull Univariate analysis found that older age male gender having
hypertension dyslipidemia and insulin-treated type 2 diabetes were all
factors associated with sustained weight loss
bull A longer duration after RYGB was associated with weight regain
Multivariate analysis revealed that younger age was a significant predictor
of weight regain even after adjusting for time since RYGB
Why do RYGB patients regain weight
Small pouch amp rapid emptying leads to better weight loss less weight
regain and better food intolerance in RYGB
bull 67 RYGB patients had pouch volumetry by 3D-CT pouch emptying by 4hr Scintigraphy food intolerance and weight loss measurement
bull Median FU was 47 months median volume was 28 ml ret at 124 hours was 8 2 1
bull There was association between Vlt40ml amp higher emptying rates up to 2 hours (Vlt40 Ret 1=6 Ret2=2) P=0009 vs (Vgt40 Ret 1=44 Ret2=135) P=0045
bull Higher emptying speed at 1 hour correlated with higher weight loss (P=0033) and less weight regain (P=0036) (Retlt12 vs gt25)
bull Better food tolerance with lower Ret 1 hour (0003)
D Riccioppo I Cecconello abstract 0110 IFSO London 2017
2 decades ago if a patient was considering a surgery involving
small bowel rerouting it would have been (RYGB) or (BPD)
In contrast today if a patient is considering a surgery that
involves small bowel rerouting this could mean any of the
following bariatric surgeries
one anastomosis gastric bypassmini gastric bypass (OAGBMGB)
BPD or BPD duodenal switch (DS)
single anastomosis duodenoileostomy (SADI)
single anastomosis gastroileostomy (SAGI)
single anastomosis sleeve ileostomy (SASI)
duodenojejunal bypass (DJB) or
stomach intestinal pylorus sparing surgery (SIPS)
Assuming Small bowel
length is 400 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 200 150 250
Alimentary limb (Roux
limb + CC)
250 250 250 200 150 350
BPL 150 150 150 200 250 50
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
Latin America
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull 1156 patients with severe obesity comprised 3 groups 418
patients After RYGB (surgery group) 417 patients who
sought but did not undergo surgery (primarily for insurance
reasons) (non-surgery group 1) and 321 patients who did not
seek surgery (non-surgery group 2)
bull We performed clinical examinations at baseline and at 2
years 6 years and 12 years to ascertain the presence of type
2 diabetes hypertension and dyslipidemia
bull The follow-up rate exceeded 90 at 12 years
Long term FU 10-15 years after RYGB in Italy
bull 285 RYGB patients done between 2000-2006
bull Mean BMI 453 (+59) kgm2 went down to 335 (51) kgm2 at 8 years 338 (5) kgm2 at 10 years 305 (41) kgm2 at 12 years amp 326 (47) kgm2 at 14 years (69 achieved BMI lt35 kgm2)
bull Mean EWL 663 (+21) at 8 years 642 (+23) at 10 years 767 (+21) at 12 years amp 698 (+23) at 14 years
bull FU was 91 84 72 and 63 at 81012 amp 14 years
bull Mortality 035 leak 07 stenosis 1 IH 14 SBO 73
bull 60 of patients stopped taking supplements and 357 had nutritional deficiencies
R Arnoux Dabadie Abstract 0115 IFSO London 2017
376
1369
265
2037
Diabetes resolution 6 years after LSG RYGB Medical therapy in France
bull All patients undergoing bariatric surgery in France in 2009 amp control group matched (age gender BMI DM) from French National Insurance
bull 15650 (85 females 10 had DM II) had bariatric surgery in 2009
bull Diabetes resolution after BS was 50 vs 9 medical therapy Plt0001
bull The main predictive for resolution were RYGB 167 (13-214) LSG 73 (56-96) LAGB 43 (33-56) No insulin 58 (46-74) No dyslipidemia medications 13 (11-16)
bull DM recurrence at 6 years was least frequent with BS 1 vs 12 in control (Plt0001)
bull RYGB 006 was the more effective than LSG 008 amp LAGB 016
J Thereaux A Fagot-Campagna France Abstract 0004 IFSO London
5 year results of the Swiss RCT LSG vs RYGB (SM-BOSS)
bull RCT of 217 patients LSG 107 vs RYGB 110 at 4 centers in Switzerland
bull Mean BMI 44+11 Age 43+5 72 females mean FU 5 years (954)
bull Patients with severe GERD or Hiatal hernia were excluded
bull Weight loss was similar at 1 year (723+22 vs 766+20) P=013 3 years (71+23 vs 734+23) P=03 5 years (622+27 vs 68+25) P=011
bull Weight loss after LSG at 5 years was inferior to RYGB (25+11 vs 286+10) P+002 Co-morbidity resolution was significantly reduced in both except GERD which was better with RYGB
bull QOL number of complications and re-operations were similar
R Peterli M Bueter Abstract 0005 IFSO London 2017
LAGB to RYGB is more effective than LAGB to LSG
bull 192 patients LAGB to RYGB vs 283 LAGB to LSG
bull The baseline age and BMI were similar in both groups
bull At 2 years BMI was lower in RYGB 3293 vs 3834 kgm2 for LSG (P=00004) EBMIL was lower in RYGB 578 vs 293 in LSG (P=00001) amp WL was lower in RYGB 234 vs 126 in LSG (P=0001)
bull Reoperation was higher in conversion to RYGB 73 vs 14 (P0=0022) OR time was longer in RYGB 1201 vs 1155 minutes in LSG (Plt0001) LOS was longer RYGB 333 vs 211 days (Plt0001)
bull Readmission was similar in RYGB 73 vs 35 in LSG (P=0087)M Jenkins B Schwack Abstract 0160 IFSO London 2017
50 GERD from 17 at 85 years
bull 100 LSG after long-term mean FU 85 years (EWL) of 60
bull A significant increase in GERD symptoms (50 from 17 pre op) (RR
= 25882 95 CI [16161ndash 41452] amp use of PPIs p value = 00001)
bull The chance of developing de novo reflux after LSG was 478 (3267)
Reflux disease was present in 7 of the 26 patients who underwent a secondary
Roux- en-Y gastric bypass (RYGB)
bull In 47 patients GERD disappeared completely after the secondary
RYGB (571)
68 GERD from 33 at 5 years
172 Barretts Esophagitis
69 Follow up
bull A total of 110 patients after LSG GERD symptoms(681 versus 336 P
00001 VAS mean score3 versus 18 P 1frasl4 018 and PPI intake significantly
increased compared with preoperative values572 versus 191 P 00001)
bull At EGD an upward migration of the ldquoZrdquo line and a biliary-like esophageal reflux
was found in 736 and 745 of cases respectively
bull Multi-Center study (3 centers) 4353 patients were followed 6 patients (140)
were converted to RYGB due to GERD over a period of 130 months
bull 1026 (384) not converted to RYGB also suffered from symptomatic reflux
bull Gastroscopies revealed de novo hiatal hernias in 45 of the patients amp Barrettrsquos
metaplasia in 15 SG patients suffering from symptomatic reflux scored
significantly higher in the RSI (p = 004) and significantly lower in the GIQLI (p
= 002) questionnaire
14 conversion to RYGB 23 weight regain
De novo GERD in 45 patients
100 Follow up 108 years384 GERD15 Barretts metaplasia
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull (1) The steep learning curve
bull (2) Re routing of the small bowel (OAGBMGB)
bull (3) Potential known long term complications
bull (4) The perceived paucity of options to treat patients with weight
recidivism especially when your are super obese
bull In contrast (1) the short learning curve (2) no re routing of the small
bowel (3) unknown long term complications and (4) the many
options to revise a LSG to a duodenal switch or LRYGB are the reasons
patients and surgeons are choosing the LSG over LRYGB
Learning curve amp adoption of laparoscopic colectomy
less than 13 of colectomies
bull 22 (87838264) for 1996
bull 27 (117542166) for 2000
bull 5 (233644817) for 2004 Publication of the COST Trial
bull 15 (754842903) for 2008
bull 314 (1461031888) for 2009Ann Surg 2013 Aug258(2)270-4 doi 101097SLA0b013e31828faa66
Growth of laparoscopic colectomy in the United States analysis of regional
and socioeconomic factors over time
Bardakcioglu O1 Khan A Aldridge C Chen J
bull A total of 1426 obese patients (158 male) after RYGB during January 2000
to 2012 (2 year FU)
bull Weight regain was observed in 244 patients (171) Preoperative BMI
was similar between groups
bull BMI was significantly higher and percent excess weight loss was
significantly lower in the Weight Regain (WR) group (P 0001)
Only patients with gt50 EWL
at 1 year postoperatively
bull Univariate analysis found that older age male gender having
hypertension dyslipidemia and insulin-treated type 2 diabetes were all
factors associated with sustained weight loss
bull A longer duration after RYGB was associated with weight regain
Multivariate analysis revealed that younger age was a significant predictor
of weight regain even after adjusting for time since RYGB
Why do RYGB patients regain weight
Small pouch amp rapid emptying leads to better weight loss less weight
regain and better food intolerance in RYGB
bull 67 RYGB patients had pouch volumetry by 3D-CT pouch emptying by 4hr Scintigraphy food intolerance and weight loss measurement
bull Median FU was 47 months median volume was 28 ml ret at 124 hours was 8 2 1
bull There was association between Vlt40ml amp higher emptying rates up to 2 hours (Vlt40 Ret 1=6 Ret2=2) P=0009 vs (Vgt40 Ret 1=44 Ret2=135) P=0045
bull Higher emptying speed at 1 hour correlated with higher weight loss (P=0033) and less weight regain (P=0036) (Retlt12 vs gt25)
bull Better food tolerance with lower Ret 1 hour (0003)
D Riccioppo I Cecconello abstract 0110 IFSO London 2017
2 decades ago if a patient was considering a surgery involving
small bowel rerouting it would have been (RYGB) or (BPD)
In contrast today if a patient is considering a surgery that
involves small bowel rerouting this could mean any of the
following bariatric surgeries
one anastomosis gastric bypassmini gastric bypass (OAGBMGB)
BPD or BPD duodenal switch (DS)
single anastomosis duodenoileostomy (SADI)
single anastomosis gastroileostomy (SAGI)
single anastomosis sleeve ileostomy (SASI)
duodenojejunal bypass (DJB) or
stomach intestinal pylorus sparing surgery (SIPS)
Assuming Small bowel
length is 400 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 200 150 250
Alimentary limb (Roux
limb + CC)
250 250 250 200 150 350
BPL 150 150 150 200 250 50
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull 1156 patients with severe obesity comprised 3 groups 418
patients After RYGB (surgery group) 417 patients who
sought but did not undergo surgery (primarily for insurance
reasons) (non-surgery group 1) and 321 patients who did not
seek surgery (non-surgery group 2)
bull We performed clinical examinations at baseline and at 2
years 6 years and 12 years to ascertain the presence of type
2 diabetes hypertension and dyslipidemia
bull The follow-up rate exceeded 90 at 12 years
Long term FU 10-15 years after RYGB in Italy
bull 285 RYGB patients done between 2000-2006
bull Mean BMI 453 (+59) kgm2 went down to 335 (51) kgm2 at 8 years 338 (5) kgm2 at 10 years 305 (41) kgm2 at 12 years amp 326 (47) kgm2 at 14 years (69 achieved BMI lt35 kgm2)
bull Mean EWL 663 (+21) at 8 years 642 (+23) at 10 years 767 (+21) at 12 years amp 698 (+23) at 14 years
bull FU was 91 84 72 and 63 at 81012 amp 14 years
bull Mortality 035 leak 07 stenosis 1 IH 14 SBO 73
bull 60 of patients stopped taking supplements and 357 had nutritional deficiencies
R Arnoux Dabadie Abstract 0115 IFSO London 2017
376
1369
265
2037
Diabetes resolution 6 years after LSG RYGB Medical therapy in France
bull All patients undergoing bariatric surgery in France in 2009 amp control group matched (age gender BMI DM) from French National Insurance
bull 15650 (85 females 10 had DM II) had bariatric surgery in 2009
bull Diabetes resolution after BS was 50 vs 9 medical therapy Plt0001
bull The main predictive for resolution were RYGB 167 (13-214) LSG 73 (56-96) LAGB 43 (33-56) No insulin 58 (46-74) No dyslipidemia medications 13 (11-16)
bull DM recurrence at 6 years was least frequent with BS 1 vs 12 in control (Plt0001)
bull RYGB 006 was the more effective than LSG 008 amp LAGB 016
J Thereaux A Fagot-Campagna France Abstract 0004 IFSO London
5 year results of the Swiss RCT LSG vs RYGB (SM-BOSS)
bull RCT of 217 patients LSG 107 vs RYGB 110 at 4 centers in Switzerland
bull Mean BMI 44+11 Age 43+5 72 females mean FU 5 years (954)
bull Patients with severe GERD or Hiatal hernia were excluded
bull Weight loss was similar at 1 year (723+22 vs 766+20) P=013 3 years (71+23 vs 734+23) P=03 5 years (622+27 vs 68+25) P=011
bull Weight loss after LSG at 5 years was inferior to RYGB (25+11 vs 286+10) P+002 Co-morbidity resolution was significantly reduced in both except GERD which was better with RYGB
bull QOL number of complications and re-operations were similar
R Peterli M Bueter Abstract 0005 IFSO London 2017
LAGB to RYGB is more effective than LAGB to LSG
bull 192 patients LAGB to RYGB vs 283 LAGB to LSG
bull The baseline age and BMI were similar in both groups
bull At 2 years BMI was lower in RYGB 3293 vs 3834 kgm2 for LSG (P=00004) EBMIL was lower in RYGB 578 vs 293 in LSG (P=00001) amp WL was lower in RYGB 234 vs 126 in LSG (P=0001)
bull Reoperation was higher in conversion to RYGB 73 vs 14 (P0=0022) OR time was longer in RYGB 1201 vs 1155 minutes in LSG (Plt0001) LOS was longer RYGB 333 vs 211 days (Plt0001)
bull Readmission was similar in RYGB 73 vs 35 in LSG (P=0087)M Jenkins B Schwack Abstract 0160 IFSO London 2017
50 GERD from 17 at 85 years
bull 100 LSG after long-term mean FU 85 years (EWL) of 60
bull A significant increase in GERD symptoms (50 from 17 pre op) (RR
= 25882 95 CI [16161ndash 41452] amp use of PPIs p value = 00001)
bull The chance of developing de novo reflux after LSG was 478 (3267)
Reflux disease was present in 7 of the 26 patients who underwent a secondary
Roux- en-Y gastric bypass (RYGB)
bull In 47 patients GERD disappeared completely after the secondary
RYGB (571)
68 GERD from 33 at 5 years
172 Barretts Esophagitis
69 Follow up
bull A total of 110 patients after LSG GERD symptoms(681 versus 336 P
00001 VAS mean score3 versus 18 P 1frasl4 018 and PPI intake significantly
increased compared with preoperative values572 versus 191 P 00001)
bull At EGD an upward migration of the ldquoZrdquo line and a biliary-like esophageal reflux
was found in 736 and 745 of cases respectively
bull Multi-Center study (3 centers) 4353 patients were followed 6 patients (140)
were converted to RYGB due to GERD over a period of 130 months
bull 1026 (384) not converted to RYGB also suffered from symptomatic reflux
bull Gastroscopies revealed de novo hiatal hernias in 45 of the patients amp Barrettrsquos
metaplasia in 15 SG patients suffering from symptomatic reflux scored
significantly higher in the RSI (p = 004) and significantly lower in the GIQLI (p
= 002) questionnaire
14 conversion to RYGB 23 weight regain
De novo GERD in 45 patients
100 Follow up 108 years384 GERD15 Barretts metaplasia
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull (1) The steep learning curve
bull (2) Re routing of the small bowel (OAGBMGB)
bull (3) Potential known long term complications
bull (4) The perceived paucity of options to treat patients with weight
recidivism especially when your are super obese
bull In contrast (1) the short learning curve (2) no re routing of the small
bowel (3) unknown long term complications and (4) the many
options to revise a LSG to a duodenal switch or LRYGB are the reasons
patients and surgeons are choosing the LSG over LRYGB
Learning curve amp adoption of laparoscopic colectomy
less than 13 of colectomies
bull 22 (87838264) for 1996
bull 27 (117542166) for 2000
bull 5 (233644817) for 2004 Publication of the COST Trial
bull 15 (754842903) for 2008
bull 314 (1461031888) for 2009Ann Surg 2013 Aug258(2)270-4 doi 101097SLA0b013e31828faa66
Growth of laparoscopic colectomy in the United States analysis of regional
and socioeconomic factors over time
Bardakcioglu O1 Khan A Aldridge C Chen J
bull A total of 1426 obese patients (158 male) after RYGB during January 2000
to 2012 (2 year FU)
bull Weight regain was observed in 244 patients (171) Preoperative BMI
was similar between groups
bull BMI was significantly higher and percent excess weight loss was
significantly lower in the Weight Regain (WR) group (P 0001)
Only patients with gt50 EWL
at 1 year postoperatively
bull Univariate analysis found that older age male gender having
hypertension dyslipidemia and insulin-treated type 2 diabetes were all
factors associated with sustained weight loss
bull A longer duration after RYGB was associated with weight regain
Multivariate analysis revealed that younger age was a significant predictor
of weight regain even after adjusting for time since RYGB
Why do RYGB patients regain weight
Small pouch amp rapid emptying leads to better weight loss less weight
regain and better food intolerance in RYGB
bull 67 RYGB patients had pouch volumetry by 3D-CT pouch emptying by 4hr Scintigraphy food intolerance and weight loss measurement
bull Median FU was 47 months median volume was 28 ml ret at 124 hours was 8 2 1
bull There was association between Vlt40ml amp higher emptying rates up to 2 hours (Vlt40 Ret 1=6 Ret2=2) P=0009 vs (Vgt40 Ret 1=44 Ret2=135) P=0045
bull Higher emptying speed at 1 hour correlated with higher weight loss (P=0033) and less weight regain (P=0036) (Retlt12 vs gt25)
bull Better food tolerance with lower Ret 1 hour (0003)
D Riccioppo I Cecconello abstract 0110 IFSO London 2017
2 decades ago if a patient was considering a surgery involving
small bowel rerouting it would have been (RYGB) or (BPD)
In contrast today if a patient is considering a surgery that
involves small bowel rerouting this could mean any of the
following bariatric surgeries
one anastomosis gastric bypassmini gastric bypass (OAGBMGB)
BPD or BPD duodenal switch (DS)
single anastomosis duodenoileostomy (SADI)
single anastomosis gastroileostomy (SAGI)
single anastomosis sleeve ileostomy (SASI)
duodenojejunal bypass (DJB) or
stomach intestinal pylorus sparing surgery (SIPS)
Assuming Small bowel
length is 400 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 200 150 250
Alimentary limb (Roux
limb + CC)
250 250 250 200 150 350
BPL 150 150 150 200 250 50
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
bull 1156 patients with severe obesity comprised 3 groups 418
patients After RYGB (surgery group) 417 patients who
sought but did not undergo surgery (primarily for insurance
reasons) (non-surgery group 1) and 321 patients who did not
seek surgery (non-surgery group 2)
bull We performed clinical examinations at baseline and at 2
years 6 years and 12 years to ascertain the presence of type
2 diabetes hypertension and dyslipidemia
bull The follow-up rate exceeded 90 at 12 years
Long term FU 10-15 years after RYGB in Italy
bull 285 RYGB patients done between 2000-2006
bull Mean BMI 453 (+59) kgm2 went down to 335 (51) kgm2 at 8 years 338 (5) kgm2 at 10 years 305 (41) kgm2 at 12 years amp 326 (47) kgm2 at 14 years (69 achieved BMI lt35 kgm2)
bull Mean EWL 663 (+21) at 8 years 642 (+23) at 10 years 767 (+21) at 12 years amp 698 (+23) at 14 years
bull FU was 91 84 72 and 63 at 81012 amp 14 years
bull Mortality 035 leak 07 stenosis 1 IH 14 SBO 73
bull 60 of patients stopped taking supplements and 357 had nutritional deficiencies
R Arnoux Dabadie Abstract 0115 IFSO London 2017
376
1369
265
2037
Diabetes resolution 6 years after LSG RYGB Medical therapy in France
bull All patients undergoing bariatric surgery in France in 2009 amp control group matched (age gender BMI DM) from French National Insurance
bull 15650 (85 females 10 had DM II) had bariatric surgery in 2009
bull Diabetes resolution after BS was 50 vs 9 medical therapy Plt0001
bull The main predictive for resolution were RYGB 167 (13-214) LSG 73 (56-96) LAGB 43 (33-56) No insulin 58 (46-74) No dyslipidemia medications 13 (11-16)
bull DM recurrence at 6 years was least frequent with BS 1 vs 12 in control (Plt0001)
bull RYGB 006 was the more effective than LSG 008 amp LAGB 016
J Thereaux A Fagot-Campagna France Abstract 0004 IFSO London
5 year results of the Swiss RCT LSG vs RYGB (SM-BOSS)
bull RCT of 217 patients LSG 107 vs RYGB 110 at 4 centers in Switzerland
bull Mean BMI 44+11 Age 43+5 72 females mean FU 5 years (954)
bull Patients with severe GERD or Hiatal hernia were excluded
bull Weight loss was similar at 1 year (723+22 vs 766+20) P=013 3 years (71+23 vs 734+23) P=03 5 years (622+27 vs 68+25) P=011
bull Weight loss after LSG at 5 years was inferior to RYGB (25+11 vs 286+10) P+002 Co-morbidity resolution was significantly reduced in both except GERD which was better with RYGB
bull QOL number of complications and re-operations were similar
R Peterli M Bueter Abstract 0005 IFSO London 2017
LAGB to RYGB is more effective than LAGB to LSG
bull 192 patients LAGB to RYGB vs 283 LAGB to LSG
bull The baseline age and BMI were similar in both groups
bull At 2 years BMI was lower in RYGB 3293 vs 3834 kgm2 for LSG (P=00004) EBMIL was lower in RYGB 578 vs 293 in LSG (P=00001) amp WL was lower in RYGB 234 vs 126 in LSG (P=0001)
bull Reoperation was higher in conversion to RYGB 73 vs 14 (P0=0022) OR time was longer in RYGB 1201 vs 1155 minutes in LSG (Plt0001) LOS was longer RYGB 333 vs 211 days (Plt0001)
bull Readmission was similar in RYGB 73 vs 35 in LSG (P=0087)M Jenkins B Schwack Abstract 0160 IFSO London 2017
50 GERD from 17 at 85 years
bull 100 LSG after long-term mean FU 85 years (EWL) of 60
bull A significant increase in GERD symptoms (50 from 17 pre op) (RR
= 25882 95 CI [16161ndash 41452] amp use of PPIs p value = 00001)
bull The chance of developing de novo reflux after LSG was 478 (3267)
Reflux disease was present in 7 of the 26 patients who underwent a secondary
Roux- en-Y gastric bypass (RYGB)
bull In 47 patients GERD disappeared completely after the secondary
RYGB (571)
68 GERD from 33 at 5 years
172 Barretts Esophagitis
69 Follow up
bull A total of 110 patients after LSG GERD symptoms(681 versus 336 P
00001 VAS mean score3 versus 18 P 1frasl4 018 and PPI intake significantly
increased compared with preoperative values572 versus 191 P 00001)
bull At EGD an upward migration of the ldquoZrdquo line and a biliary-like esophageal reflux
was found in 736 and 745 of cases respectively
bull Multi-Center study (3 centers) 4353 patients were followed 6 patients (140)
were converted to RYGB due to GERD over a period of 130 months
bull 1026 (384) not converted to RYGB also suffered from symptomatic reflux
bull Gastroscopies revealed de novo hiatal hernias in 45 of the patients amp Barrettrsquos
metaplasia in 15 SG patients suffering from symptomatic reflux scored
significantly higher in the RSI (p = 004) and significantly lower in the GIQLI (p
= 002) questionnaire
14 conversion to RYGB 23 weight regain
De novo GERD in 45 patients
100 Follow up 108 years384 GERD15 Barretts metaplasia
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull (1) The steep learning curve
bull (2) Re routing of the small bowel (OAGBMGB)
bull (3) Potential known long term complications
bull (4) The perceived paucity of options to treat patients with weight
recidivism especially when your are super obese
bull In contrast (1) the short learning curve (2) no re routing of the small
bowel (3) unknown long term complications and (4) the many
options to revise a LSG to a duodenal switch or LRYGB are the reasons
patients and surgeons are choosing the LSG over LRYGB
Learning curve amp adoption of laparoscopic colectomy
less than 13 of colectomies
bull 22 (87838264) for 1996
bull 27 (117542166) for 2000
bull 5 (233644817) for 2004 Publication of the COST Trial
bull 15 (754842903) for 2008
bull 314 (1461031888) for 2009Ann Surg 2013 Aug258(2)270-4 doi 101097SLA0b013e31828faa66
Growth of laparoscopic colectomy in the United States analysis of regional
and socioeconomic factors over time
Bardakcioglu O1 Khan A Aldridge C Chen J
bull A total of 1426 obese patients (158 male) after RYGB during January 2000
to 2012 (2 year FU)
bull Weight regain was observed in 244 patients (171) Preoperative BMI
was similar between groups
bull BMI was significantly higher and percent excess weight loss was
significantly lower in the Weight Regain (WR) group (P 0001)
Only patients with gt50 EWL
at 1 year postoperatively
bull Univariate analysis found that older age male gender having
hypertension dyslipidemia and insulin-treated type 2 diabetes were all
factors associated with sustained weight loss
bull A longer duration after RYGB was associated with weight regain
Multivariate analysis revealed that younger age was a significant predictor
of weight regain even after adjusting for time since RYGB
Why do RYGB patients regain weight
Small pouch amp rapid emptying leads to better weight loss less weight
regain and better food intolerance in RYGB
bull 67 RYGB patients had pouch volumetry by 3D-CT pouch emptying by 4hr Scintigraphy food intolerance and weight loss measurement
bull Median FU was 47 months median volume was 28 ml ret at 124 hours was 8 2 1
bull There was association between Vlt40ml amp higher emptying rates up to 2 hours (Vlt40 Ret 1=6 Ret2=2) P=0009 vs (Vgt40 Ret 1=44 Ret2=135) P=0045
bull Higher emptying speed at 1 hour correlated with higher weight loss (P=0033) and less weight regain (P=0036) (Retlt12 vs gt25)
bull Better food tolerance with lower Ret 1 hour (0003)
D Riccioppo I Cecconello abstract 0110 IFSO London 2017
2 decades ago if a patient was considering a surgery involving
small bowel rerouting it would have been (RYGB) or (BPD)
In contrast today if a patient is considering a surgery that
involves small bowel rerouting this could mean any of the
following bariatric surgeries
one anastomosis gastric bypassmini gastric bypass (OAGBMGB)
BPD or BPD duodenal switch (DS)
single anastomosis duodenoileostomy (SADI)
single anastomosis gastroileostomy (SAGI)
single anastomosis sleeve ileostomy (SASI)
duodenojejunal bypass (DJB) or
stomach intestinal pylorus sparing surgery (SIPS)
Assuming Small bowel
length is 400 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 200 150 250
Alimentary limb (Roux
limb + CC)
250 250 250 200 150 350
BPL 150 150 150 200 250 50
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
Long term FU 10-15 years after RYGB in Italy
bull 285 RYGB patients done between 2000-2006
bull Mean BMI 453 (+59) kgm2 went down to 335 (51) kgm2 at 8 years 338 (5) kgm2 at 10 years 305 (41) kgm2 at 12 years amp 326 (47) kgm2 at 14 years (69 achieved BMI lt35 kgm2)
bull Mean EWL 663 (+21) at 8 years 642 (+23) at 10 years 767 (+21) at 12 years amp 698 (+23) at 14 years
bull FU was 91 84 72 and 63 at 81012 amp 14 years
bull Mortality 035 leak 07 stenosis 1 IH 14 SBO 73
bull 60 of patients stopped taking supplements and 357 had nutritional deficiencies
R Arnoux Dabadie Abstract 0115 IFSO London 2017
376
1369
265
2037
Diabetes resolution 6 years after LSG RYGB Medical therapy in France
bull All patients undergoing bariatric surgery in France in 2009 amp control group matched (age gender BMI DM) from French National Insurance
bull 15650 (85 females 10 had DM II) had bariatric surgery in 2009
bull Diabetes resolution after BS was 50 vs 9 medical therapy Plt0001
bull The main predictive for resolution were RYGB 167 (13-214) LSG 73 (56-96) LAGB 43 (33-56) No insulin 58 (46-74) No dyslipidemia medications 13 (11-16)
bull DM recurrence at 6 years was least frequent with BS 1 vs 12 in control (Plt0001)
bull RYGB 006 was the more effective than LSG 008 amp LAGB 016
J Thereaux A Fagot-Campagna France Abstract 0004 IFSO London
5 year results of the Swiss RCT LSG vs RYGB (SM-BOSS)
bull RCT of 217 patients LSG 107 vs RYGB 110 at 4 centers in Switzerland
bull Mean BMI 44+11 Age 43+5 72 females mean FU 5 years (954)
bull Patients with severe GERD or Hiatal hernia were excluded
bull Weight loss was similar at 1 year (723+22 vs 766+20) P=013 3 years (71+23 vs 734+23) P=03 5 years (622+27 vs 68+25) P=011
bull Weight loss after LSG at 5 years was inferior to RYGB (25+11 vs 286+10) P+002 Co-morbidity resolution was significantly reduced in both except GERD which was better with RYGB
bull QOL number of complications and re-operations were similar
R Peterli M Bueter Abstract 0005 IFSO London 2017
LAGB to RYGB is more effective than LAGB to LSG
bull 192 patients LAGB to RYGB vs 283 LAGB to LSG
bull The baseline age and BMI were similar in both groups
bull At 2 years BMI was lower in RYGB 3293 vs 3834 kgm2 for LSG (P=00004) EBMIL was lower in RYGB 578 vs 293 in LSG (P=00001) amp WL was lower in RYGB 234 vs 126 in LSG (P=0001)
bull Reoperation was higher in conversion to RYGB 73 vs 14 (P0=0022) OR time was longer in RYGB 1201 vs 1155 minutes in LSG (Plt0001) LOS was longer RYGB 333 vs 211 days (Plt0001)
bull Readmission was similar in RYGB 73 vs 35 in LSG (P=0087)M Jenkins B Schwack Abstract 0160 IFSO London 2017
50 GERD from 17 at 85 years
bull 100 LSG after long-term mean FU 85 years (EWL) of 60
bull A significant increase in GERD symptoms (50 from 17 pre op) (RR
= 25882 95 CI [16161ndash 41452] amp use of PPIs p value = 00001)
bull The chance of developing de novo reflux after LSG was 478 (3267)
Reflux disease was present in 7 of the 26 patients who underwent a secondary
Roux- en-Y gastric bypass (RYGB)
bull In 47 patients GERD disappeared completely after the secondary
RYGB (571)
68 GERD from 33 at 5 years
172 Barretts Esophagitis
69 Follow up
bull A total of 110 patients after LSG GERD symptoms(681 versus 336 P
00001 VAS mean score3 versus 18 P 1frasl4 018 and PPI intake significantly
increased compared with preoperative values572 versus 191 P 00001)
bull At EGD an upward migration of the ldquoZrdquo line and a biliary-like esophageal reflux
was found in 736 and 745 of cases respectively
bull Multi-Center study (3 centers) 4353 patients were followed 6 patients (140)
were converted to RYGB due to GERD over a period of 130 months
bull 1026 (384) not converted to RYGB also suffered from symptomatic reflux
bull Gastroscopies revealed de novo hiatal hernias in 45 of the patients amp Barrettrsquos
metaplasia in 15 SG patients suffering from symptomatic reflux scored
significantly higher in the RSI (p = 004) and significantly lower in the GIQLI (p
= 002) questionnaire
14 conversion to RYGB 23 weight regain
De novo GERD in 45 patients
100 Follow up 108 years384 GERD15 Barretts metaplasia
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull (1) The steep learning curve
bull (2) Re routing of the small bowel (OAGBMGB)
bull (3) Potential known long term complications
bull (4) The perceived paucity of options to treat patients with weight
recidivism especially when your are super obese
bull In contrast (1) the short learning curve (2) no re routing of the small
bowel (3) unknown long term complications and (4) the many
options to revise a LSG to a duodenal switch or LRYGB are the reasons
patients and surgeons are choosing the LSG over LRYGB
Learning curve amp adoption of laparoscopic colectomy
less than 13 of colectomies
bull 22 (87838264) for 1996
bull 27 (117542166) for 2000
bull 5 (233644817) for 2004 Publication of the COST Trial
bull 15 (754842903) for 2008
bull 314 (1461031888) for 2009Ann Surg 2013 Aug258(2)270-4 doi 101097SLA0b013e31828faa66
Growth of laparoscopic colectomy in the United States analysis of regional
and socioeconomic factors over time
Bardakcioglu O1 Khan A Aldridge C Chen J
bull A total of 1426 obese patients (158 male) after RYGB during January 2000
to 2012 (2 year FU)
bull Weight regain was observed in 244 patients (171) Preoperative BMI
was similar between groups
bull BMI was significantly higher and percent excess weight loss was
significantly lower in the Weight Regain (WR) group (P 0001)
Only patients with gt50 EWL
at 1 year postoperatively
bull Univariate analysis found that older age male gender having
hypertension dyslipidemia and insulin-treated type 2 diabetes were all
factors associated with sustained weight loss
bull A longer duration after RYGB was associated with weight regain
Multivariate analysis revealed that younger age was a significant predictor
of weight regain even after adjusting for time since RYGB
Why do RYGB patients regain weight
Small pouch amp rapid emptying leads to better weight loss less weight
regain and better food intolerance in RYGB
bull 67 RYGB patients had pouch volumetry by 3D-CT pouch emptying by 4hr Scintigraphy food intolerance and weight loss measurement
bull Median FU was 47 months median volume was 28 ml ret at 124 hours was 8 2 1
bull There was association between Vlt40ml amp higher emptying rates up to 2 hours (Vlt40 Ret 1=6 Ret2=2) P=0009 vs (Vgt40 Ret 1=44 Ret2=135) P=0045
bull Higher emptying speed at 1 hour correlated with higher weight loss (P=0033) and less weight regain (P=0036) (Retlt12 vs gt25)
bull Better food tolerance with lower Ret 1 hour (0003)
D Riccioppo I Cecconello abstract 0110 IFSO London 2017
2 decades ago if a patient was considering a surgery involving
small bowel rerouting it would have been (RYGB) or (BPD)
In contrast today if a patient is considering a surgery that
involves small bowel rerouting this could mean any of the
following bariatric surgeries
one anastomosis gastric bypassmini gastric bypass (OAGBMGB)
BPD or BPD duodenal switch (DS)
single anastomosis duodenoileostomy (SADI)
single anastomosis gastroileostomy (SAGI)
single anastomosis sleeve ileostomy (SASI)
duodenojejunal bypass (DJB) or
stomach intestinal pylorus sparing surgery (SIPS)
Assuming Small bowel
length is 400 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 200 150 250
Alimentary limb (Roux
limb + CC)
250 250 250 200 150 350
BPL 150 150 150 200 250 50
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
376
1369
265
2037
Diabetes resolution 6 years after LSG RYGB Medical therapy in France
bull All patients undergoing bariatric surgery in France in 2009 amp control group matched (age gender BMI DM) from French National Insurance
bull 15650 (85 females 10 had DM II) had bariatric surgery in 2009
bull Diabetes resolution after BS was 50 vs 9 medical therapy Plt0001
bull The main predictive for resolution were RYGB 167 (13-214) LSG 73 (56-96) LAGB 43 (33-56) No insulin 58 (46-74) No dyslipidemia medications 13 (11-16)
bull DM recurrence at 6 years was least frequent with BS 1 vs 12 in control (Plt0001)
bull RYGB 006 was the more effective than LSG 008 amp LAGB 016
J Thereaux A Fagot-Campagna France Abstract 0004 IFSO London
5 year results of the Swiss RCT LSG vs RYGB (SM-BOSS)
bull RCT of 217 patients LSG 107 vs RYGB 110 at 4 centers in Switzerland
bull Mean BMI 44+11 Age 43+5 72 females mean FU 5 years (954)
bull Patients with severe GERD or Hiatal hernia were excluded
bull Weight loss was similar at 1 year (723+22 vs 766+20) P=013 3 years (71+23 vs 734+23) P=03 5 years (622+27 vs 68+25) P=011
bull Weight loss after LSG at 5 years was inferior to RYGB (25+11 vs 286+10) P+002 Co-morbidity resolution was significantly reduced in both except GERD which was better with RYGB
bull QOL number of complications and re-operations were similar
R Peterli M Bueter Abstract 0005 IFSO London 2017
LAGB to RYGB is more effective than LAGB to LSG
bull 192 patients LAGB to RYGB vs 283 LAGB to LSG
bull The baseline age and BMI were similar in both groups
bull At 2 years BMI was lower in RYGB 3293 vs 3834 kgm2 for LSG (P=00004) EBMIL was lower in RYGB 578 vs 293 in LSG (P=00001) amp WL was lower in RYGB 234 vs 126 in LSG (P=0001)
bull Reoperation was higher in conversion to RYGB 73 vs 14 (P0=0022) OR time was longer in RYGB 1201 vs 1155 minutes in LSG (Plt0001) LOS was longer RYGB 333 vs 211 days (Plt0001)
bull Readmission was similar in RYGB 73 vs 35 in LSG (P=0087)M Jenkins B Schwack Abstract 0160 IFSO London 2017
50 GERD from 17 at 85 years
bull 100 LSG after long-term mean FU 85 years (EWL) of 60
bull A significant increase in GERD symptoms (50 from 17 pre op) (RR
= 25882 95 CI [16161ndash 41452] amp use of PPIs p value = 00001)
bull The chance of developing de novo reflux after LSG was 478 (3267)
Reflux disease was present in 7 of the 26 patients who underwent a secondary
Roux- en-Y gastric bypass (RYGB)
bull In 47 patients GERD disappeared completely after the secondary
RYGB (571)
68 GERD from 33 at 5 years
172 Barretts Esophagitis
69 Follow up
bull A total of 110 patients after LSG GERD symptoms(681 versus 336 P
00001 VAS mean score3 versus 18 P 1frasl4 018 and PPI intake significantly
increased compared with preoperative values572 versus 191 P 00001)
bull At EGD an upward migration of the ldquoZrdquo line and a biliary-like esophageal reflux
was found in 736 and 745 of cases respectively
bull Multi-Center study (3 centers) 4353 patients were followed 6 patients (140)
were converted to RYGB due to GERD over a period of 130 months
bull 1026 (384) not converted to RYGB also suffered from symptomatic reflux
bull Gastroscopies revealed de novo hiatal hernias in 45 of the patients amp Barrettrsquos
metaplasia in 15 SG patients suffering from symptomatic reflux scored
significantly higher in the RSI (p = 004) and significantly lower in the GIQLI (p
= 002) questionnaire
14 conversion to RYGB 23 weight regain
De novo GERD in 45 patients
100 Follow up 108 years384 GERD15 Barretts metaplasia
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull (1) The steep learning curve
bull (2) Re routing of the small bowel (OAGBMGB)
bull (3) Potential known long term complications
bull (4) The perceived paucity of options to treat patients with weight
recidivism especially when your are super obese
bull In contrast (1) the short learning curve (2) no re routing of the small
bowel (3) unknown long term complications and (4) the many
options to revise a LSG to a duodenal switch or LRYGB are the reasons
patients and surgeons are choosing the LSG over LRYGB
Learning curve amp adoption of laparoscopic colectomy
less than 13 of colectomies
bull 22 (87838264) for 1996
bull 27 (117542166) for 2000
bull 5 (233644817) for 2004 Publication of the COST Trial
bull 15 (754842903) for 2008
bull 314 (1461031888) for 2009Ann Surg 2013 Aug258(2)270-4 doi 101097SLA0b013e31828faa66
Growth of laparoscopic colectomy in the United States analysis of regional
and socioeconomic factors over time
Bardakcioglu O1 Khan A Aldridge C Chen J
bull A total of 1426 obese patients (158 male) after RYGB during January 2000
to 2012 (2 year FU)
bull Weight regain was observed in 244 patients (171) Preoperative BMI
was similar between groups
bull BMI was significantly higher and percent excess weight loss was
significantly lower in the Weight Regain (WR) group (P 0001)
Only patients with gt50 EWL
at 1 year postoperatively
bull Univariate analysis found that older age male gender having
hypertension dyslipidemia and insulin-treated type 2 diabetes were all
factors associated with sustained weight loss
bull A longer duration after RYGB was associated with weight regain
Multivariate analysis revealed that younger age was a significant predictor
of weight regain even after adjusting for time since RYGB
Why do RYGB patients regain weight
Small pouch amp rapid emptying leads to better weight loss less weight
regain and better food intolerance in RYGB
bull 67 RYGB patients had pouch volumetry by 3D-CT pouch emptying by 4hr Scintigraphy food intolerance and weight loss measurement
bull Median FU was 47 months median volume was 28 ml ret at 124 hours was 8 2 1
bull There was association between Vlt40ml amp higher emptying rates up to 2 hours (Vlt40 Ret 1=6 Ret2=2) P=0009 vs (Vgt40 Ret 1=44 Ret2=135) P=0045
bull Higher emptying speed at 1 hour correlated with higher weight loss (P=0033) and less weight regain (P=0036) (Retlt12 vs gt25)
bull Better food tolerance with lower Ret 1 hour (0003)
D Riccioppo I Cecconello abstract 0110 IFSO London 2017
2 decades ago if a patient was considering a surgery involving
small bowel rerouting it would have been (RYGB) or (BPD)
In contrast today if a patient is considering a surgery that
involves small bowel rerouting this could mean any of the
following bariatric surgeries
one anastomosis gastric bypassmini gastric bypass (OAGBMGB)
BPD or BPD duodenal switch (DS)
single anastomosis duodenoileostomy (SADI)
single anastomosis gastroileostomy (SAGI)
single anastomosis sleeve ileostomy (SASI)
duodenojejunal bypass (DJB) or
stomach intestinal pylorus sparing surgery (SIPS)
Assuming Small bowel
length is 400 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 200 150 250
Alimentary limb (Roux
limb + CC)
250 250 250 200 150 350
BPL 150 150 150 200 250 50
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
Diabetes resolution 6 years after LSG RYGB Medical therapy in France
bull All patients undergoing bariatric surgery in France in 2009 amp control group matched (age gender BMI DM) from French National Insurance
bull 15650 (85 females 10 had DM II) had bariatric surgery in 2009
bull Diabetes resolution after BS was 50 vs 9 medical therapy Plt0001
bull The main predictive for resolution were RYGB 167 (13-214) LSG 73 (56-96) LAGB 43 (33-56) No insulin 58 (46-74) No dyslipidemia medications 13 (11-16)
bull DM recurrence at 6 years was least frequent with BS 1 vs 12 in control (Plt0001)
bull RYGB 006 was the more effective than LSG 008 amp LAGB 016
J Thereaux A Fagot-Campagna France Abstract 0004 IFSO London
5 year results of the Swiss RCT LSG vs RYGB (SM-BOSS)
bull RCT of 217 patients LSG 107 vs RYGB 110 at 4 centers in Switzerland
bull Mean BMI 44+11 Age 43+5 72 females mean FU 5 years (954)
bull Patients with severe GERD or Hiatal hernia were excluded
bull Weight loss was similar at 1 year (723+22 vs 766+20) P=013 3 years (71+23 vs 734+23) P=03 5 years (622+27 vs 68+25) P=011
bull Weight loss after LSG at 5 years was inferior to RYGB (25+11 vs 286+10) P+002 Co-morbidity resolution was significantly reduced in both except GERD which was better with RYGB
bull QOL number of complications and re-operations were similar
R Peterli M Bueter Abstract 0005 IFSO London 2017
LAGB to RYGB is more effective than LAGB to LSG
bull 192 patients LAGB to RYGB vs 283 LAGB to LSG
bull The baseline age and BMI were similar in both groups
bull At 2 years BMI was lower in RYGB 3293 vs 3834 kgm2 for LSG (P=00004) EBMIL was lower in RYGB 578 vs 293 in LSG (P=00001) amp WL was lower in RYGB 234 vs 126 in LSG (P=0001)
bull Reoperation was higher in conversion to RYGB 73 vs 14 (P0=0022) OR time was longer in RYGB 1201 vs 1155 minutes in LSG (Plt0001) LOS was longer RYGB 333 vs 211 days (Plt0001)
bull Readmission was similar in RYGB 73 vs 35 in LSG (P=0087)M Jenkins B Schwack Abstract 0160 IFSO London 2017
50 GERD from 17 at 85 years
bull 100 LSG after long-term mean FU 85 years (EWL) of 60
bull A significant increase in GERD symptoms (50 from 17 pre op) (RR
= 25882 95 CI [16161ndash 41452] amp use of PPIs p value = 00001)
bull The chance of developing de novo reflux after LSG was 478 (3267)
Reflux disease was present in 7 of the 26 patients who underwent a secondary
Roux- en-Y gastric bypass (RYGB)
bull In 47 patients GERD disappeared completely after the secondary
RYGB (571)
68 GERD from 33 at 5 years
172 Barretts Esophagitis
69 Follow up
bull A total of 110 patients after LSG GERD symptoms(681 versus 336 P
00001 VAS mean score3 versus 18 P 1frasl4 018 and PPI intake significantly
increased compared with preoperative values572 versus 191 P 00001)
bull At EGD an upward migration of the ldquoZrdquo line and a biliary-like esophageal reflux
was found in 736 and 745 of cases respectively
bull Multi-Center study (3 centers) 4353 patients were followed 6 patients (140)
were converted to RYGB due to GERD over a period of 130 months
bull 1026 (384) not converted to RYGB also suffered from symptomatic reflux
bull Gastroscopies revealed de novo hiatal hernias in 45 of the patients amp Barrettrsquos
metaplasia in 15 SG patients suffering from symptomatic reflux scored
significantly higher in the RSI (p = 004) and significantly lower in the GIQLI (p
= 002) questionnaire
14 conversion to RYGB 23 weight regain
De novo GERD in 45 patients
100 Follow up 108 years384 GERD15 Barretts metaplasia
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull (1) The steep learning curve
bull (2) Re routing of the small bowel (OAGBMGB)
bull (3) Potential known long term complications
bull (4) The perceived paucity of options to treat patients with weight
recidivism especially when your are super obese
bull In contrast (1) the short learning curve (2) no re routing of the small
bowel (3) unknown long term complications and (4) the many
options to revise a LSG to a duodenal switch or LRYGB are the reasons
patients and surgeons are choosing the LSG over LRYGB
Learning curve amp adoption of laparoscopic colectomy
less than 13 of colectomies
bull 22 (87838264) for 1996
bull 27 (117542166) for 2000
bull 5 (233644817) for 2004 Publication of the COST Trial
bull 15 (754842903) for 2008
bull 314 (1461031888) for 2009Ann Surg 2013 Aug258(2)270-4 doi 101097SLA0b013e31828faa66
Growth of laparoscopic colectomy in the United States analysis of regional
and socioeconomic factors over time
Bardakcioglu O1 Khan A Aldridge C Chen J
bull A total of 1426 obese patients (158 male) after RYGB during January 2000
to 2012 (2 year FU)
bull Weight regain was observed in 244 patients (171) Preoperative BMI
was similar between groups
bull BMI was significantly higher and percent excess weight loss was
significantly lower in the Weight Regain (WR) group (P 0001)
Only patients with gt50 EWL
at 1 year postoperatively
bull Univariate analysis found that older age male gender having
hypertension dyslipidemia and insulin-treated type 2 diabetes were all
factors associated with sustained weight loss
bull A longer duration after RYGB was associated with weight regain
Multivariate analysis revealed that younger age was a significant predictor
of weight regain even after adjusting for time since RYGB
Why do RYGB patients regain weight
Small pouch amp rapid emptying leads to better weight loss less weight
regain and better food intolerance in RYGB
bull 67 RYGB patients had pouch volumetry by 3D-CT pouch emptying by 4hr Scintigraphy food intolerance and weight loss measurement
bull Median FU was 47 months median volume was 28 ml ret at 124 hours was 8 2 1
bull There was association between Vlt40ml amp higher emptying rates up to 2 hours (Vlt40 Ret 1=6 Ret2=2) P=0009 vs (Vgt40 Ret 1=44 Ret2=135) P=0045
bull Higher emptying speed at 1 hour correlated with higher weight loss (P=0033) and less weight regain (P=0036) (Retlt12 vs gt25)
bull Better food tolerance with lower Ret 1 hour (0003)
D Riccioppo I Cecconello abstract 0110 IFSO London 2017
2 decades ago if a patient was considering a surgery involving
small bowel rerouting it would have been (RYGB) or (BPD)
In contrast today if a patient is considering a surgery that
involves small bowel rerouting this could mean any of the
following bariatric surgeries
one anastomosis gastric bypassmini gastric bypass (OAGBMGB)
BPD or BPD duodenal switch (DS)
single anastomosis duodenoileostomy (SADI)
single anastomosis gastroileostomy (SAGI)
single anastomosis sleeve ileostomy (SASI)
duodenojejunal bypass (DJB) or
stomach intestinal pylorus sparing surgery (SIPS)
Assuming Small bowel
length is 400 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 200 150 250
Alimentary limb (Roux
limb + CC)
250 250 250 200 150 350
BPL 150 150 150 200 250 50
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
5 year results of the Swiss RCT LSG vs RYGB (SM-BOSS)
bull RCT of 217 patients LSG 107 vs RYGB 110 at 4 centers in Switzerland
bull Mean BMI 44+11 Age 43+5 72 females mean FU 5 years (954)
bull Patients with severe GERD or Hiatal hernia were excluded
bull Weight loss was similar at 1 year (723+22 vs 766+20) P=013 3 years (71+23 vs 734+23) P=03 5 years (622+27 vs 68+25) P=011
bull Weight loss after LSG at 5 years was inferior to RYGB (25+11 vs 286+10) P+002 Co-morbidity resolution was significantly reduced in both except GERD which was better with RYGB
bull QOL number of complications and re-operations were similar
R Peterli M Bueter Abstract 0005 IFSO London 2017
LAGB to RYGB is more effective than LAGB to LSG
bull 192 patients LAGB to RYGB vs 283 LAGB to LSG
bull The baseline age and BMI were similar in both groups
bull At 2 years BMI was lower in RYGB 3293 vs 3834 kgm2 for LSG (P=00004) EBMIL was lower in RYGB 578 vs 293 in LSG (P=00001) amp WL was lower in RYGB 234 vs 126 in LSG (P=0001)
bull Reoperation was higher in conversion to RYGB 73 vs 14 (P0=0022) OR time was longer in RYGB 1201 vs 1155 minutes in LSG (Plt0001) LOS was longer RYGB 333 vs 211 days (Plt0001)
bull Readmission was similar in RYGB 73 vs 35 in LSG (P=0087)M Jenkins B Schwack Abstract 0160 IFSO London 2017
50 GERD from 17 at 85 years
bull 100 LSG after long-term mean FU 85 years (EWL) of 60
bull A significant increase in GERD symptoms (50 from 17 pre op) (RR
= 25882 95 CI [16161ndash 41452] amp use of PPIs p value = 00001)
bull The chance of developing de novo reflux after LSG was 478 (3267)
Reflux disease was present in 7 of the 26 patients who underwent a secondary
Roux- en-Y gastric bypass (RYGB)
bull In 47 patients GERD disappeared completely after the secondary
RYGB (571)
68 GERD from 33 at 5 years
172 Barretts Esophagitis
69 Follow up
bull A total of 110 patients after LSG GERD symptoms(681 versus 336 P
00001 VAS mean score3 versus 18 P 1frasl4 018 and PPI intake significantly
increased compared with preoperative values572 versus 191 P 00001)
bull At EGD an upward migration of the ldquoZrdquo line and a biliary-like esophageal reflux
was found in 736 and 745 of cases respectively
bull Multi-Center study (3 centers) 4353 patients were followed 6 patients (140)
were converted to RYGB due to GERD over a period of 130 months
bull 1026 (384) not converted to RYGB also suffered from symptomatic reflux
bull Gastroscopies revealed de novo hiatal hernias in 45 of the patients amp Barrettrsquos
metaplasia in 15 SG patients suffering from symptomatic reflux scored
significantly higher in the RSI (p = 004) and significantly lower in the GIQLI (p
= 002) questionnaire
14 conversion to RYGB 23 weight regain
De novo GERD in 45 patients
100 Follow up 108 years384 GERD15 Barretts metaplasia
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull (1) The steep learning curve
bull (2) Re routing of the small bowel (OAGBMGB)
bull (3) Potential known long term complications
bull (4) The perceived paucity of options to treat patients with weight
recidivism especially when your are super obese
bull In contrast (1) the short learning curve (2) no re routing of the small
bowel (3) unknown long term complications and (4) the many
options to revise a LSG to a duodenal switch or LRYGB are the reasons
patients and surgeons are choosing the LSG over LRYGB
Learning curve amp adoption of laparoscopic colectomy
less than 13 of colectomies
bull 22 (87838264) for 1996
bull 27 (117542166) for 2000
bull 5 (233644817) for 2004 Publication of the COST Trial
bull 15 (754842903) for 2008
bull 314 (1461031888) for 2009Ann Surg 2013 Aug258(2)270-4 doi 101097SLA0b013e31828faa66
Growth of laparoscopic colectomy in the United States analysis of regional
and socioeconomic factors over time
Bardakcioglu O1 Khan A Aldridge C Chen J
bull A total of 1426 obese patients (158 male) after RYGB during January 2000
to 2012 (2 year FU)
bull Weight regain was observed in 244 patients (171) Preoperative BMI
was similar between groups
bull BMI was significantly higher and percent excess weight loss was
significantly lower in the Weight Regain (WR) group (P 0001)
Only patients with gt50 EWL
at 1 year postoperatively
bull Univariate analysis found that older age male gender having
hypertension dyslipidemia and insulin-treated type 2 diabetes were all
factors associated with sustained weight loss
bull A longer duration after RYGB was associated with weight regain
Multivariate analysis revealed that younger age was a significant predictor
of weight regain even after adjusting for time since RYGB
Why do RYGB patients regain weight
Small pouch amp rapid emptying leads to better weight loss less weight
regain and better food intolerance in RYGB
bull 67 RYGB patients had pouch volumetry by 3D-CT pouch emptying by 4hr Scintigraphy food intolerance and weight loss measurement
bull Median FU was 47 months median volume was 28 ml ret at 124 hours was 8 2 1
bull There was association between Vlt40ml amp higher emptying rates up to 2 hours (Vlt40 Ret 1=6 Ret2=2) P=0009 vs (Vgt40 Ret 1=44 Ret2=135) P=0045
bull Higher emptying speed at 1 hour correlated with higher weight loss (P=0033) and less weight regain (P=0036) (Retlt12 vs gt25)
bull Better food tolerance with lower Ret 1 hour (0003)
D Riccioppo I Cecconello abstract 0110 IFSO London 2017
2 decades ago if a patient was considering a surgery involving
small bowel rerouting it would have been (RYGB) or (BPD)
In contrast today if a patient is considering a surgery that
involves small bowel rerouting this could mean any of the
following bariatric surgeries
one anastomosis gastric bypassmini gastric bypass (OAGBMGB)
BPD or BPD duodenal switch (DS)
single anastomosis duodenoileostomy (SADI)
single anastomosis gastroileostomy (SAGI)
single anastomosis sleeve ileostomy (SASI)
duodenojejunal bypass (DJB) or
stomach intestinal pylorus sparing surgery (SIPS)
Assuming Small bowel
length is 400 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 200 150 250
Alimentary limb (Roux
limb + CC)
250 250 250 200 150 350
BPL 150 150 150 200 250 50
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
LAGB to RYGB is more effective than LAGB to LSG
bull 192 patients LAGB to RYGB vs 283 LAGB to LSG
bull The baseline age and BMI were similar in both groups
bull At 2 years BMI was lower in RYGB 3293 vs 3834 kgm2 for LSG (P=00004) EBMIL was lower in RYGB 578 vs 293 in LSG (P=00001) amp WL was lower in RYGB 234 vs 126 in LSG (P=0001)
bull Reoperation was higher in conversion to RYGB 73 vs 14 (P0=0022) OR time was longer in RYGB 1201 vs 1155 minutes in LSG (Plt0001) LOS was longer RYGB 333 vs 211 days (Plt0001)
bull Readmission was similar in RYGB 73 vs 35 in LSG (P=0087)M Jenkins B Schwack Abstract 0160 IFSO London 2017
50 GERD from 17 at 85 years
bull 100 LSG after long-term mean FU 85 years (EWL) of 60
bull A significant increase in GERD symptoms (50 from 17 pre op) (RR
= 25882 95 CI [16161ndash 41452] amp use of PPIs p value = 00001)
bull The chance of developing de novo reflux after LSG was 478 (3267)
Reflux disease was present in 7 of the 26 patients who underwent a secondary
Roux- en-Y gastric bypass (RYGB)
bull In 47 patients GERD disappeared completely after the secondary
RYGB (571)
68 GERD from 33 at 5 years
172 Barretts Esophagitis
69 Follow up
bull A total of 110 patients after LSG GERD symptoms(681 versus 336 P
00001 VAS mean score3 versus 18 P 1frasl4 018 and PPI intake significantly
increased compared with preoperative values572 versus 191 P 00001)
bull At EGD an upward migration of the ldquoZrdquo line and a biliary-like esophageal reflux
was found in 736 and 745 of cases respectively
bull Multi-Center study (3 centers) 4353 patients were followed 6 patients (140)
were converted to RYGB due to GERD over a period of 130 months
bull 1026 (384) not converted to RYGB also suffered from symptomatic reflux
bull Gastroscopies revealed de novo hiatal hernias in 45 of the patients amp Barrettrsquos
metaplasia in 15 SG patients suffering from symptomatic reflux scored
significantly higher in the RSI (p = 004) and significantly lower in the GIQLI (p
= 002) questionnaire
14 conversion to RYGB 23 weight regain
De novo GERD in 45 patients
100 Follow up 108 years384 GERD15 Barretts metaplasia
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull (1) The steep learning curve
bull (2) Re routing of the small bowel (OAGBMGB)
bull (3) Potential known long term complications
bull (4) The perceived paucity of options to treat patients with weight
recidivism especially when your are super obese
bull In contrast (1) the short learning curve (2) no re routing of the small
bowel (3) unknown long term complications and (4) the many
options to revise a LSG to a duodenal switch or LRYGB are the reasons
patients and surgeons are choosing the LSG over LRYGB
Learning curve amp adoption of laparoscopic colectomy
less than 13 of colectomies
bull 22 (87838264) for 1996
bull 27 (117542166) for 2000
bull 5 (233644817) for 2004 Publication of the COST Trial
bull 15 (754842903) for 2008
bull 314 (1461031888) for 2009Ann Surg 2013 Aug258(2)270-4 doi 101097SLA0b013e31828faa66
Growth of laparoscopic colectomy in the United States analysis of regional
and socioeconomic factors over time
Bardakcioglu O1 Khan A Aldridge C Chen J
bull A total of 1426 obese patients (158 male) after RYGB during January 2000
to 2012 (2 year FU)
bull Weight regain was observed in 244 patients (171) Preoperative BMI
was similar between groups
bull BMI was significantly higher and percent excess weight loss was
significantly lower in the Weight Regain (WR) group (P 0001)
Only patients with gt50 EWL
at 1 year postoperatively
bull Univariate analysis found that older age male gender having
hypertension dyslipidemia and insulin-treated type 2 diabetes were all
factors associated with sustained weight loss
bull A longer duration after RYGB was associated with weight regain
Multivariate analysis revealed that younger age was a significant predictor
of weight regain even after adjusting for time since RYGB
Why do RYGB patients regain weight
Small pouch amp rapid emptying leads to better weight loss less weight
regain and better food intolerance in RYGB
bull 67 RYGB patients had pouch volumetry by 3D-CT pouch emptying by 4hr Scintigraphy food intolerance and weight loss measurement
bull Median FU was 47 months median volume was 28 ml ret at 124 hours was 8 2 1
bull There was association between Vlt40ml amp higher emptying rates up to 2 hours (Vlt40 Ret 1=6 Ret2=2) P=0009 vs (Vgt40 Ret 1=44 Ret2=135) P=0045
bull Higher emptying speed at 1 hour correlated with higher weight loss (P=0033) and less weight regain (P=0036) (Retlt12 vs gt25)
bull Better food tolerance with lower Ret 1 hour (0003)
D Riccioppo I Cecconello abstract 0110 IFSO London 2017
2 decades ago if a patient was considering a surgery involving
small bowel rerouting it would have been (RYGB) or (BPD)
In contrast today if a patient is considering a surgery that
involves small bowel rerouting this could mean any of the
following bariatric surgeries
one anastomosis gastric bypassmini gastric bypass (OAGBMGB)
BPD or BPD duodenal switch (DS)
single anastomosis duodenoileostomy (SADI)
single anastomosis gastroileostomy (SAGI)
single anastomosis sleeve ileostomy (SASI)
duodenojejunal bypass (DJB) or
stomach intestinal pylorus sparing surgery (SIPS)
Assuming Small bowel
length is 400 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 200 150 250
Alimentary limb (Roux
limb + CC)
250 250 250 200 150 350
BPL 150 150 150 200 250 50
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
50 GERD from 17 at 85 years
bull 100 LSG after long-term mean FU 85 years (EWL) of 60
bull A significant increase in GERD symptoms (50 from 17 pre op) (RR
= 25882 95 CI [16161ndash 41452] amp use of PPIs p value = 00001)
bull The chance of developing de novo reflux after LSG was 478 (3267)
Reflux disease was present in 7 of the 26 patients who underwent a secondary
Roux- en-Y gastric bypass (RYGB)
bull In 47 patients GERD disappeared completely after the secondary
RYGB (571)
68 GERD from 33 at 5 years
172 Barretts Esophagitis
69 Follow up
bull A total of 110 patients after LSG GERD symptoms(681 versus 336 P
00001 VAS mean score3 versus 18 P 1frasl4 018 and PPI intake significantly
increased compared with preoperative values572 versus 191 P 00001)
bull At EGD an upward migration of the ldquoZrdquo line and a biliary-like esophageal reflux
was found in 736 and 745 of cases respectively
bull Multi-Center study (3 centers) 4353 patients were followed 6 patients (140)
were converted to RYGB due to GERD over a period of 130 months
bull 1026 (384) not converted to RYGB also suffered from symptomatic reflux
bull Gastroscopies revealed de novo hiatal hernias in 45 of the patients amp Barrettrsquos
metaplasia in 15 SG patients suffering from symptomatic reflux scored
significantly higher in the RSI (p = 004) and significantly lower in the GIQLI (p
= 002) questionnaire
14 conversion to RYGB 23 weight regain
De novo GERD in 45 patients
100 Follow up 108 years384 GERD15 Barretts metaplasia
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull (1) The steep learning curve
bull (2) Re routing of the small bowel (OAGBMGB)
bull (3) Potential known long term complications
bull (4) The perceived paucity of options to treat patients with weight
recidivism especially when your are super obese
bull In contrast (1) the short learning curve (2) no re routing of the small
bowel (3) unknown long term complications and (4) the many
options to revise a LSG to a duodenal switch or LRYGB are the reasons
patients and surgeons are choosing the LSG over LRYGB
Learning curve amp adoption of laparoscopic colectomy
less than 13 of colectomies
bull 22 (87838264) for 1996
bull 27 (117542166) for 2000
bull 5 (233644817) for 2004 Publication of the COST Trial
bull 15 (754842903) for 2008
bull 314 (1461031888) for 2009Ann Surg 2013 Aug258(2)270-4 doi 101097SLA0b013e31828faa66
Growth of laparoscopic colectomy in the United States analysis of regional
and socioeconomic factors over time
Bardakcioglu O1 Khan A Aldridge C Chen J
bull A total of 1426 obese patients (158 male) after RYGB during January 2000
to 2012 (2 year FU)
bull Weight regain was observed in 244 patients (171) Preoperative BMI
was similar between groups
bull BMI was significantly higher and percent excess weight loss was
significantly lower in the Weight Regain (WR) group (P 0001)
Only patients with gt50 EWL
at 1 year postoperatively
bull Univariate analysis found that older age male gender having
hypertension dyslipidemia and insulin-treated type 2 diabetes were all
factors associated with sustained weight loss
bull A longer duration after RYGB was associated with weight regain
Multivariate analysis revealed that younger age was a significant predictor
of weight regain even after adjusting for time since RYGB
Why do RYGB patients regain weight
Small pouch amp rapid emptying leads to better weight loss less weight
regain and better food intolerance in RYGB
bull 67 RYGB patients had pouch volumetry by 3D-CT pouch emptying by 4hr Scintigraphy food intolerance and weight loss measurement
bull Median FU was 47 months median volume was 28 ml ret at 124 hours was 8 2 1
bull There was association between Vlt40ml amp higher emptying rates up to 2 hours (Vlt40 Ret 1=6 Ret2=2) P=0009 vs (Vgt40 Ret 1=44 Ret2=135) P=0045
bull Higher emptying speed at 1 hour correlated with higher weight loss (P=0033) and less weight regain (P=0036) (Retlt12 vs gt25)
bull Better food tolerance with lower Ret 1 hour (0003)
D Riccioppo I Cecconello abstract 0110 IFSO London 2017
2 decades ago if a patient was considering a surgery involving
small bowel rerouting it would have been (RYGB) or (BPD)
In contrast today if a patient is considering a surgery that
involves small bowel rerouting this could mean any of the
following bariatric surgeries
one anastomosis gastric bypassmini gastric bypass (OAGBMGB)
BPD or BPD duodenal switch (DS)
single anastomosis duodenoileostomy (SADI)
single anastomosis gastroileostomy (SAGI)
single anastomosis sleeve ileostomy (SASI)
duodenojejunal bypass (DJB) or
stomach intestinal pylorus sparing surgery (SIPS)
Assuming Small bowel
length is 400 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 200 150 250
Alimentary limb (Roux
limb + CC)
250 250 250 200 150 350
BPL 150 150 150 200 250 50
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
68 GERD from 33 at 5 years
172 Barretts Esophagitis
69 Follow up
bull A total of 110 patients after LSG GERD symptoms(681 versus 336 P
00001 VAS mean score3 versus 18 P 1frasl4 018 and PPI intake significantly
increased compared with preoperative values572 versus 191 P 00001)
bull At EGD an upward migration of the ldquoZrdquo line and a biliary-like esophageal reflux
was found in 736 and 745 of cases respectively
bull Multi-Center study (3 centers) 4353 patients were followed 6 patients (140)
were converted to RYGB due to GERD over a period of 130 months
bull 1026 (384) not converted to RYGB also suffered from symptomatic reflux
bull Gastroscopies revealed de novo hiatal hernias in 45 of the patients amp Barrettrsquos
metaplasia in 15 SG patients suffering from symptomatic reflux scored
significantly higher in the RSI (p = 004) and significantly lower in the GIQLI (p
= 002) questionnaire
14 conversion to RYGB 23 weight regain
De novo GERD in 45 patients
100 Follow up 108 years384 GERD15 Barretts metaplasia
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull (1) The steep learning curve
bull (2) Re routing of the small bowel (OAGBMGB)
bull (3) Potential known long term complications
bull (4) The perceived paucity of options to treat patients with weight
recidivism especially when your are super obese
bull In contrast (1) the short learning curve (2) no re routing of the small
bowel (3) unknown long term complications and (4) the many
options to revise a LSG to a duodenal switch or LRYGB are the reasons
patients and surgeons are choosing the LSG over LRYGB
Learning curve amp adoption of laparoscopic colectomy
less than 13 of colectomies
bull 22 (87838264) for 1996
bull 27 (117542166) for 2000
bull 5 (233644817) for 2004 Publication of the COST Trial
bull 15 (754842903) for 2008
bull 314 (1461031888) for 2009Ann Surg 2013 Aug258(2)270-4 doi 101097SLA0b013e31828faa66
Growth of laparoscopic colectomy in the United States analysis of regional
and socioeconomic factors over time
Bardakcioglu O1 Khan A Aldridge C Chen J
bull A total of 1426 obese patients (158 male) after RYGB during January 2000
to 2012 (2 year FU)
bull Weight regain was observed in 244 patients (171) Preoperative BMI
was similar between groups
bull BMI was significantly higher and percent excess weight loss was
significantly lower in the Weight Regain (WR) group (P 0001)
Only patients with gt50 EWL
at 1 year postoperatively
bull Univariate analysis found that older age male gender having
hypertension dyslipidemia and insulin-treated type 2 diabetes were all
factors associated with sustained weight loss
bull A longer duration after RYGB was associated with weight regain
Multivariate analysis revealed that younger age was a significant predictor
of weight regain even after adjusting for time since RYGB
Why do RYGB patients regain weight
Small pouch amp rapid emptying leads to better weight loss less weight
regain and better food intolerance in RYGB
bull 67 RYGB patients had pouch volumetry by 3D-CT pouch emptying by 4hr Scintigraphy food intolerance and weight loss measurement
bull Median FU was 47 months median volume was 28 ml ret at 124 hours was 8 2 1
bull There was association between Vlt40ml amp higher emptying rates up to 2 hours (Vlt40 Ret 1=6 Ret2=2) P=0009 vs (Vgt40 Ret 1=44 Ret2=135) P=0045
bull Higher emptying speed at 1 hour correlated with higher weight loss (P=0033) and less weight regain (P=0036) (Retlt12 vs gt25)
bull Better food tolerance with lower Ret 1 hour (0003)
D Riccioppo I Cecconello abstract 0110 IFSO London 2017
2 decades ago if a patient was considering a surgery involving
small bowel rerouting it would have been (RYGB) or (BPD)
In contrast today if a patient is considering a surgery that
involves small bowel rerouting this could mean any of the
following bariatric surgeries
one anastomosis gastric bypassmini gastric bypass (OAGBMGB)
BPD or BPD duodenal switch (DS)
single anastomosis duodenoileostomy (SADI)
single anastomosis gastroileostomy (SAGI)
single anastomosis sleeve ileostomy (SASI)
duodenojejunal bypass (DJB) or
stomach intestinal pylorus sparing surgery (SIPS)
Assuming Small bowel
length is 400 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 200 150 250
Alimentary limb (Roux
limb + CC)
250 250 250 200 150 350
BPL 150 150 150 200 250 50
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
bull Multi-Center study (3 centers) 4353 patients were followed 6 patients (140)
were converted to RYGB due to GERD over a period of 130 months
bull 1026 (384) not converted to RYGB also suffered from symptomatic reflux
bull Gastroscopies revealed de novo hiatal hernias in 45 of the patients amp Barrettrsquos
metaplasia in 15 SG patients suffering from symptomatic reflux scored
significantly higher in the RSI (p = 004) and significantly lower in the GIQLI (p
= 002) questionnaire
14 conversion to RYGB 23 weight regain
De novo GERD in 45 patients
100 Follow up 108 years384 GERD15 Barretts metaplasia
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull (1) The steep learning curve
bull (2) Re routing of the small bowel (OAGBMGB)
bull (3) Potential known long term complications
bull (4) The perceived paucity of options to treat patients with weight
recidivism especially when your are super obese
bull In contrast (1) the short learning curve (2) no re routing of the small
bowel (3) unknown long term complications and (4) the many
options to revise a LSG to a duodenal switch or LRYGB are the reasons
patients and surgeons are choosing the LSG over LRYGB
Learning curve amp adoption of laparoscopic colectomy
less than 13 of colectomies
bull 22 (87838264) for 1996
bull 27 (117542166) for 2000
bull 5 (233644817) for 2004 Publication of the COST Trial
bull 15 (754842903) for 2008
bull 314 (1461031888) for 2009Ann Surg 2013 Aug258(2)270-4 doi 101097SLA0b013e31828faa66
Growth of laparoscopic colectomy in the United States analysis of regional
and socioeconomic factors over time
Bardakcioglu O1 Khan A Aldridge C Chen J
bull A total of 1426 obese patients (158 male) after RYGB during January 2000
to 2012 (2 year FU)
bull Weight regain was observed in 244 patients (171) Preoperative BMI
was similar between groups
bull BMI was significantly higher and percent excess weight loss was
significantly lower in the Weight Regain (WR) group (P 0001)
Only patients with gt50 EWL
at 1 year postoperatively
bull Univariate analysis found that older age male gender having
hypertension dyslipidemia and insulin-treated type 2 diabetes were all
factors associated with sustained weight loss
bull A longer duration after RYGB was associated with weight regain
Multivariate analysis revealed that younger age was a significant predictor
of weight regain even after adjusting for time since RYGB
Why do RYGB patients regain weight
Small pouch amp rapid emptying leads to better weight loss less weight
regain and better food intolerance in RYGB
bull 67 RYGB patients had pouch volumetry by 3D-CT pouch emptying by 4hr Scintigraphy food intolerance and weight loss measurement
bull Median FU was 47 months median volume was 28 ml ret at 124 hours was 8 2 1
bull There was association between Vlt40ml amp higher emptying rates up to 2 hours (Vlt40 Ret 1=6 Ret2=2) P=0009 vs (Vgt40 Ret 1=44 Ret2=135) P=0045
bull Higher emptying speed at 1 hour correlated with higher weight loss (P=0033) and less weight regain (P=0036) (Retlt12 vs gt25)
bull Better food tolerance with lower Ret 1 hour (0003)
D Riccioppo I Cecconello abstract 0110 IFSO London 2017
2 decades ago if a patient was considering a surgery involving
small bowel rerouting it would have been (RYGB) or (BPD)
In contrast today if a patient is considering a surgery that
involves small bowel rerouting this could mean any of the
following bariatric surgeries
one anastomosis gastric bypassmini gastric bypass (OAGBMGB)
BPD or BPD duodenal switch (DS)
single anastomosis duodenoileostomy (SADI)
single anastomosis gastroileostomy (SAGI)
single anastomosis sleeve ileostomy (SASI)
duodenojejunal bypass (DJB) or
stomach intestinal pylorus sparing surgery (SIPS)
Assuming Small bowel
length is 400 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 200 150 250
Alimentary limb (Roux
limb + CC)
250 250 250 200 150 350
BPL 150 150 150 200 250 50
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
bull Poor long term outcomes
bull High incidence of complications
bull Ineffectiveness long term
Why is RYGB becoming so un-popular and why
are LSG and OAGBMGB catching on
bull (1) The steep learning curve
bull (2) Re routing of the small bowel (OAGBMGB)
bull (3) Potential known long term complications
bull (4) The perceived paucity of options to treat patients with weight
recidivism especially when your are super obese
bull In contrast (1) the short learning curve (2) no re routing of the small
bowel (3) unknown long term complications and (4) the many
options to revise a LSG to a duodenal switch or LRYGB are the reasons
patients and surgeons are choosing the LSG over LRYGB
Learning curve amp adoption of laparoscopic colectomy
less than 13 of colectomies
bull 22 (87838264) for 1996
bull 27 (117542166) for 2000
bull 5 (233644817) for 2004 Publication of the COST Trial
bull 15 (754842903) for 2008
bull 314 (1461031888) for 2009Ann Surg 2013 Aug258(2)270-4 doi 101097SLA0b013e31828faa66
Growth of laparoscopic colectomy in the United States analysis of regional
and socioeconomic factors over time
Bardakcioglu O1 Khan A Aldridge C Chen J
bull A total of 1426 obese patients (158 male) after RYGB during January 2000
to 2012 (2 year FU)
bull Weight regain was observed in 244 patients (171) Preoperative BMI
was similar between groups
bull BMI was significantly higher and percent excess weight loss was
significantly lower in the Weight Regain (WR) group (P 0001)
Only patients with gt50 EWL
at 1 year postoperatively
bull Univariate analysis found that older age male gender having
hypertension dyslipidemia and insulin-treated type 2 diabetes were all
factors associated with sustained weight loss
bull A longer duration after RYGB was associated with weight regain
Multivariate analysis revealed that younger age was a significant predictor
of weight regain even after adjusting for time since RYGB
Why do RYGB patients regain weight
Small pouch amp rapid emptying leads to better weight loss less weight
regain and better food intolerance in RYGB
bull 67 RYGB patients had pouch volumetry by 3D-CT pouch emptying by 4hr Scintigraphy food intolerance and weight loss measurement
bull Median FU was 47 months median volume was 28 ml ret at 124 hours was 8 2 1
bull There was association between Vlt40ml amp higher emptying rates up to 2 hours (Vlt40 Ret 1=6 Ret2=2) P=0009 vs (Vgt40 Ret 1=44 Ret2=135) P=0045
bull Higher emptying speed at 1 hour correlated with higher weight loss (P=0033) and less weight regain (P=0036) (Retlt12 vs gt25)
bull Better food tolerance with lower Ret 1 hour (0003)
D Riccioppo I Cecconello abstract 0110 IFSO London 2017
2 decades ago if a patient was considering a surgery involving
small bowel rerouting it would have been (RYGB) or (BPD)
In contrast today if a patient is considering a surgery that
involves small bowel rerouting this could mean any of the
following bariatric surgeries
one anastomosis gastric bypassmini gastric bypass (OAGBMGB)
BPD or BPD duodenal switch (DS)
single anastomosis duodenoileostomy (SADI)
single anastomosis gastroileostomy (SAGI)
single anastomosis sleeve ileostomy (SASI)
duodenojejunal bypass (DJB) or
stomach intestinal pylorus sparing surgery (SIPS)
Assuming Small bowel
length is 400 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 200 150 250
Alimentary limb (Roux
limb + CC)
250 250 250 200 150 350
BPL 150 150 150 200 250 50
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
bull (1) The steep learning curve
bull (2) Re routing of the small bowel (OAGBMGB)
bull (3) Potential known long term complications
bull (4) The perceived paucity of options to treat patients with weight
recidivism especially when your are super obese
bull In contrast (1) the short learning curve (2) no re routing of the small
bowel (3) unknown long term complications and (4) the many
options to revise a LSG to a duodenal switch or LRYGB are the reasons
patients and surgeons are choosing the LSG over LRYGB
Learning curve amp adoption of laparoscopic colectomy
less than 13 of colectomies
bull 22 (87838264) for 1996
bull 27 (117542166) for 2000
bull 5 (233644817) for 2004 Publication of the COST Trial
bull 15 (754842903) for 2008
bull 314 (1461031888) for 2009Ann Surg 2013 Aug258(2)270-4 doi 101097SLA0b013e31828faa66
Growth of laparoscopic colectomy in the United States analysis of regional
and socioeconomic factors over time
Bardakcioglu O1 Khan A Aldridge C Chen J
bull A total of 1426 obese patients (158 male) after RYGB during January 2000
to 2012 (2 year FU)
bull Weight regain was observed in 244 patients (171) Preoperative BMI
was similar between groups
bull BMI was significantly higher and percent excess weight loss was
significantly lower in the Weight Regain (WR) group (P 0001)
Only patients with gt50 EWL
at 1 year postoperatively
bull Univariate analysis found that older age male gender having
hypertension dyslipidemia and insulin-treated type 2 diabetes were all
factors associated with sustained weight loss
bull A longer duration after RYGB was associated with weight regain
Multivariate analysis revealed that younger age was a significant predictor
of weight regain even after adjusting for time since RYGB
Why do RYGB patients regain weight
Small pouch amp rapid emptying leads to better weight loss less weight
regain and better food intolerance in RYGB
bull 67 RYGB patients had pouch volumetry by 3D-CT pouch emptying by 4hr Scintigraphy food intolerance and weight loss measurement
bull Median FU was 47 months median volume was 28 ml ret at 124 hours was 8 2 1
bull There was association between Vlt40ml amp higher emptying rates up to 2 hours (Vlt40 Ret 1=6 Ret2=2) P=0009 vs (Vgt40 Ret 1=44 Ret2=135) P=0045
bull Higher emptying speed at 1 hour correlated with higher weight loss (P=0033) and less weight regain (P=0036) (Retlt12 vs gt25)
bull Better food tolerance with lower Ret 1 hour (0003)
D Riccioppo I Cecconello abstract 0110 IFSO London 2017
2 decades ago if a patient was considering a surgery involving
small bowel rerouting it would have been (RYGB) or (BPD)
In contrast today if a patient is considering a surgery that
involves small bowel rerouting this could mean any of the
following bariatric surgeries
one anastomosis gastric bypassmini gastric bypass (OAGBMGB)
BPD or BPD duodenal switch (DS)
single anastomosis duodenoileostomy (SADI)
single anastomosis gastroileostomy (SAGI)
single anastomosis sleeve ileostomy (SASI)
duodenojejunal bypass (DJB) or
stomach intestinal pylorus sparing surgery (SIPS)
Assuming Small bowel
length is 400 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 200 150 250
Alimentary limb (Roux
limb + CC)
250 250 250 200 150 350
BPL 150 150 150 200 250 50
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
Learning curve amp adoption of laparoscopic colectomy
less than 13 of colectomies
bull 22 (87838264) for 1996
bull 27 (117542166) for 2000
bull 5 (233644817) for 2004 Publication of the COST Trial
bull 15 (754842903) for 2008
bull 314 (1461031888) for 2009Ann Surg 2013 Aug258(2)270-4 doi 101097SLA0b013e31828faa66
Growth of laparoscopic colectomy in the United States analysis of regional
and socioeconomic factors over time
Bardakcioglu O1 Khan A Aldridge C Chen J
bull A total of 1426 obese patients (158 male) after RYGB during January 2000
to 2012 (2 year FU)
bull Weight regain was observed in 244 patients (171) Preoperative BMI
was similar between groups
bull BMI was significantly higher and percent excess weight loss was
significantly lower in the Weight Regain (WR) group (P 0001)
Only patients with gt50 EWL
at 1 year postoperatively
bull Univariate analysis found that older age male gender having
hypertension dyslipidemia and insulin-treated type 2 diabetes were all
factors associated with sustained weight loss
bull A longer duration after RYGB was associated with weight regain
Multivariate analysis revealed that younger age was a significant predictor
of weight regain even after adjusting for time since RYGB
Why do RYGB patients regain weight
Small pouch amp rapid emptying leads to better weight loss less weight
regain and better food intolerance in RYGB
bull 67 RYGB patients had pouch volumetry by 3D-CT pouch emptying by 4hr Scintigraphy food intolerance and weight loss measurement
bull Median FU was 47 months median volume was 28 ml ret at 124 hours was 8 2 1
bull There was association between Vlt40ml amp higher emptying rates up to 2 hours (Vlt40 Ret 1=6 Ret2=2) P=0009 vs (Vgt40 Ret 1=44 Ret2=135) P=0045
bull Higher emptying speed at 1 hour correlated with higher weight loss (P=0033) and less weight regain (P=0036) (Retlt12 vs gt25)
bull Better food tolerance with lower Ret 1 hour (0003)
D Riccioppo I Cecconello abstract 0110 IFSO London 2017
2 decades ago if a patient was considering a surgery involving
small bowel rerouting it would have been (RYGB) or (BPD)
In contrast today if a patient is considering a surgery that
involves small bowel rerouting this could mean any of the
following bariatric surgeries
one anastomosis gastric bypassmini gastric bypass (OAGBMGB)
BPD or BPD duodenal switch (DS)
single anastomosis duodenoileostomy (SADI)
single anastomosis gastroileostomy (SAGI)
single anastomosis sleeve ileostomy (SASI)
duodenojejunal bypass (DJB) or
stomach intestinal pylorus sparing surgery (SIPS)
Assuming Small bowel
length is 400 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 200 150 250
Alimentary limb (Roux
limb + CC)
250 250 250 200 150 350
BPL 150 150 150 200 250 50
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
bull A total of 1426 obese patients (158 male) after RYGB during January 2000
to 2012 (2 year FU)
bull Weight regain was observed in 244 patients (171) Preoperative BMI
was similar between groups
bull BMI was significantly higher and percent excess weight loss was
significantly lower in the Weight Regain (WR) group (P 0001)
Only patients with gt50 EWL
at 1 year postoperatively
bull Univariate analysis found that older age male gender having
hypertension dyslipidemia and insulin-treated type 2 diabetes were all
factors associated with sustained weight loss
bull A longer duration after RYGB was associated with weight regain
Multivariate analysis revealed that younger age was a significant predictor
of weight regain even after adjusting for time since RYGB
Why do RYGB patients regain weight
Small pouch amp rapid emptying leads to better weight loss less weight
regain and better food intolerance in RYGB
bull 67 RYGB patients had pouch volumetry by 3D-CT pouch emptying by 4hr Scintigraphy food intolerance and weight loss measurement
bull Median FU was 47 months median volume was 28 ml ret at 124 hours was 8 2 1
bull There was association between Vlt40ml amp higher emptying rates up to 2 hours (Vlt40 Ret 1=6 Ret2=2) P=0009 vs (Vgt40 Ret 1=44 Ret2=135) P=0045
bull Higher emptying speed at 1 hour correlated with higher weight loss (P=0033) and less weight regain (P=0036) (Retlt12 vs gt25)
bull Better food tolerance with lower Ret 1 hour (0003)
D Riccioppo I Cecconello abstract 0110 IFSO London 2017
2 decades ago if a patient was considering a surgery involving
small bowel rerouting it would have been (RYGB) or (BPD)
In contrast today if a patient is considering a surgery that
involves small bowel rerouting this could mean any of the
following bariatric surgeries
one anastomosis gastric bypassmini gastric bypass (OAGBMGB)
BPD or BPD duodenal switch (DS)
single anastomosis duodenoileostomy (SADI)
single anastomosis gastroileostomy (SAGI)
single anastomosis sleeve ileostomy (SASI)
duodenojejunal bypass (DJB) or
stomach intestinal pylorus sparing surgery (SIPS)
Assuming Small bowel
length is 400 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 200 150 250
Alimentary limb (Roux
limb + CC)
250 250 250 200 150 350
BPL 150 150 150 200 250 50
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
bull Univariate analysis found that older age male gender having
hypertension dyslipidemia and insulin-treated type 2 diabetes were all
factors associated with sustained weight loss
bull A longer duration after RYGB was associated with weight regain
Multivariate analysis revealed that younger age was a significant predictor
of weight regain even after adjusting for time since RYGB
Why do RYGB patients regain weight
Small pouch amp rapid emptying leads to better weight loss less weight
regain and better food intolerance in RYGB
bull 67 RYGB patients had pouch volumetry by 3D-CT pouch emptying by 4hr Scintigraphy food intolerance and weight loss measurement
bull Median FU was 47 months median volume was 28 ml ret at 124 hours was 8 2 1
bull There was association between Vlt40ml amp higher emptying rates up to 2 hours (Vlt40 Ret 1=6 Ret2=2) P=0009 vs (Vgt40 Ret 1=44 Ret2=135) P=0045
bull Higher emptying speed at 1 hour correlated with higher weight loss (P=0033) and less weight regain (P=0036) (Retlt12 vs gt25)
bull Better food tolerance with lower Ret 1 hour (0003)
D Riccioppo I Cecconello abstract 0110 IFSO London 2017
2 decades ago if a patient was considering a surgery involving
small bowel rerouting it would have been (RYGB) or (BPD)
In contrast today if a patient is considering a surgery that
involves small bowel rerouting this could mean any of the
following bariatric surgeries
one anastomosis gastric bypassmini gastric bypass (OAGBMGB)
BPD or BPD duodenal switch (DS)
single anastomosis duodenoileostomy (SADI)
single anastomosis gastroileostomy (SAGI)
single anastomosis sleeve ileostomy (SASI)
duodenojejunal bypass (DJB) or
stomach intestinal pylorus sparing surgery (SIPS)
Assuming Small bowel
length is 400 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 200 150 250
Alimentary limb (Roux
limb + CC)
250 250 250 200 150 350
BPL 150 150 150 200 250 50
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
Why do RYGB patients regain weight
Small pouch amp rapid emptying leads to better weight loss less weight
regain and better food intolerance in RYGB
bull 67 RYGB patients had pouch volumetry by 3D-CT pouch emptying by 4hr Scintigraphy food intolerance and weight loss measurement
bull Median FU was 47 months median volume was 28 ml ret at 124 hours was 8 2 1
bull There was association between Vlt40ml amp higher emptying rates up to 2 hours (Vlt40 Ret 1=6 Ret2=2) P=0009 vs (Vgt40 Ret 1=44 Ret2=135) P=0045
bull Higher emptying speed at 1 hour correlated with higher weight loss (P=0033) and less weight regain (P=0036) (Retlt12 vs gt25)
bull Better food tolerance with lower Ret 1 hour (0003)
D Riccioppo I Cecconello abstract 0110 IFSO London 2017
2 decades ago if a patient was considering a surgery involving
small bowel rerouting it would have been (RYGB) or (BPD)
In contrast today if a patient is considering a surgery that
involves small bowel rerouting this could mean any of the
following bariatric surgeries
one anastomosis gastric bypassmini gastric bypass (OAGBMGB)
BPD or BPD duodenal switch (DS)
single anastomosis duodenoileostomy (SADI)
single anastomosis gastroileostomy (SAGI)
single anastomosis sleeve ileostomy (SASI)
duodenojejunal bypass (DJB) or
stomach intestinal pylorus sparing surgery (SIPS)
Assuming Small bowel
length is 400 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 200 150 250
Alimentary limb (Roux
limb + CC)
250 250 250 200 150 350
BPL 150 150 150 200 250 50
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
Small pouch amp rapid emptying leads to better weight loss less weight
regain and better food intolerance in RYGB
bull 67 RYGB patients had pouch volumetry by 3D-CT pouch emptying by 4hr Scintigraphy food intolerance and weight loss measurement
bull Median FU was 47 months median volume was 28 ml ret at 124 hours was 8 2 1
bull There was association between Vlt40ml amp higher emptying rates up to 2 hours (Vlt40 Ret 1=6 Ret2=2) P=0009 vs (Vgt40 Ret 1=44 Ret2=135) P=0045
bull Higher emptying speed at 1 hour correlated with higher weight loss (P=0033) and less weight regain (P=0036) (Retlt12 vs gt25)
bull Better food tolerance with lower Ret 1 hour (0003)
D Riccioppo I Cecconello abstract 0110 IFSO London 2017
2 decades ago if a patient was considering a surgery involving
small bowel rerouting it would have been (RYGB) or (BPD)
In contrast today if a patient is considering a surgery that
involves small bowel rerouting this could mean any of the
following bariatric surgeries
one anastomosis gastric bypassmini gastric bypass (OAGBMGB)
BPD or BPD duodenal switch (DS)
single anastomosis duodenoileostomy (SADI)
single anastomosis gastroileostomy (SAGI)
single anastomosis sleeve ileostomy (SASI)
duodenojejunal bypass (DJB) or
stomach intestinal pylorus sparing surgery (SIPS)
Assuming Small bowel
length is 400 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 200 150 250
Alimentary limb (Roux
limb + CC)
250 250 250 200 150 350
BPL 150 150 150 200 250 50
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
2 decades ago if a patient was considering a surgery involving
small bowel rerouting it would have been (RYGB) or (BPD)
In contrast today if a patient is considering a surgery that
involves small bowel rerouting this could mean any of the
following bariatric surgeries
one anastomosis gastric bypassmini gastric bypass (OAGBMGB)
BPD or BPD duodenal switch (DS)
single anastomosis duodenoileostomy (SADI)
single anastomosis gastroileostomy (SAGI)
single anastomosis sleeve ileostomy (SASI)
duodenojejunal bypass (DJB) or
stomach intestinal pylorus sparing surgery (SIPS)
Assuming Small bowel
length is 400 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 200 150 250
Alimentary limb (Roux
limb + CC)
250 250 250 200 150 350
BPL 150 150 150 200 250 50
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
Assuming Small bowel
length is 400 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 200 150 250
Alimentary limb (Roux
limb + CC)
250 250 250 200 150 350
BPL 150 150 150 200 250 50
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
Assuming Small bowel
length is 600 cm in
length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 400 350 450
Alimentary limb (Roux
limb + CC)
250 250 250 400 350 550
BPL 350 350 350 200 250 50
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
Assuming Small bowel
length is 800 cm in length
BPD BPDDS SADI OAGB
MGB
DJB RYGB
Approximate stomach
size in ml
250-400 150 150 120 150 30
Roux limb in cm 200 150 NA NA NA 100
Common Channel 50 100 250 600 550 650
Alimentary limb (Roux
limb + CC)
250 250 250 600 550 750
BPL 550 550 550 200 250 50
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
This is why you have to measure the
common channel in patients undergoing any
mal-absorptive surgery (BPD BPD-DS
SADI DJB or OAGBMGB) but not in
RYGB with a short BPL
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
The concept of OAGBMGB is valid amp useful in
Super-obese failure after restrictive surgery
failure after Roux-en Y gastric bypass
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
200 cm BPL60 cm BPL
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
RCT long vs short BPL for type II DM patients
bull 114 diabetic patients had RYGB with different BPL length 73 had
LBPL (200cm) amp 41 had SBPL (84+2cm) amp followed for 5 years
bull DM remission at 5 years was higher in LBPL 731 vs SBPL 55
Plt005) lower relapse rate (119 vs 32 Plt005) amp less need for
diabetic medications (Plt005)
bull Mixed meal test was done for 11 LBPL amp 9 SBPL patients patients
with LBPL had higher GLP-1 at 45 minutes (Plt005) higher AUC
(P=001) lower GIP level at 15 minutes (Plt001) lower insulin and
C peptide at 30 minutes (P0001) compared to SBPL
M Guimaraes MP Monteiro Abstract 0144 IFSO London 2017
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
RCT conversion of LAGB to LBPL vs SBPL RYGB
bull 146 patients had conversion of LAGB to RYGB with LBPL (150 cm)
73 patients vs SBPL (75 cm) 73 patients
bull Both groups were similar in baseline charachtaristics
bull At 3 years FU was 91 total body weight loss was 24 for LBPL
vs 20 for SBPL P=0039)
bull Co-morbidity resolution was no different between two groups
bull Short term complications in 10 (6 LBPL amp 4 SBPL) NS
A Boerboom F Berends Abstract 0158
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
bull RCT of 144 patients primary RYGB 70 patients with RouxBPL vs 75150 74 patients with RouxBPL 15075 at 48 months (FU 90)
bull At 24 months EWL was better with long BPL 150 cm 84 vs 73 in short BPL 75 cm (P=0002)
bull EWL was similar at 48 month 70 vs 62 (P=0068)
bull Type II DM was present in 33 (48 patients) complete remission was similar in both 78 vs 75 (Pgt005)
bull Short and long term complications were similar
F Berends I Janssen Abstract 0006 IFSO London 2017
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
An ounce of prevention is better than a pound of cure
Nutritional deficiencies are unrecognized in approximately
50 of patients who undergo RYGB surgery
John et al J Am Osteopath Assoc2009109601-604
Routine supplements
ndash Calciumndash iron
ndash Multivitaminsndash B12
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
Nutritional deficiencies 5 years after LSG
bull 108 patients had LSG 2005-2011 (81 females)
bull Median EWL 1 year 856 (weight loss maintained at 5 years) median EWL745
bull Pre operative nutritional deficiencies Low Hgb 194 iron 267 ferritin 6 folate 2 B12 31 magnesium 344 PTH elevation 34
bull At 5 years significantly more patients had anemia 401 (P=0001) low ferritin 44 (Plt0001) low vitamin D 126 (P=007)
bull This highlights the need for long term supplements for LSG D Karavias I Kehagias abstract 0074
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
Nutritional deficiencies 3 years after LSG
bull 857 patients had LSG 2010-2013 (609 females)
bull Age 47+12 mean BMI 43+7
bull Weight loss at 123 years was 37+14 35+15 amp 33+14 Kgs
bull Pre operative nutritional deficiencies Low Hgb 11 low vit D 57 ferritin 14 low B12 2 amp PTH elevation 327
bull At 3 years significantly more patients had anemia 14 (P=002) low ferritin 23 (Plt0008) high PTH 16 (P value 0008) low vitamin D 18 (P=0005)
bull This highlights the need for long term supplements for LSG
N Zaeshenas Jjogensen abstract 0071
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
Vitamin amp mineral deficiencies 4 years after LSG rdquoFit for merdquo
bull RCT of 150 patients after LSG standard multivitamin SMVS vs
WLSO optimum (B12 400 iron 150 folic acid 150)
bull Weight BMI gender iron B12 folic acid vit D amp total body
weight loss were similar (288 for WLSO vs 286 for SMVS)
Pgt048
bull At mean follow up of 4 years vitamin B12 deficiency was lower
for WLSO 14 vs 27 ferritin 11 vs 23
E Aarts F BeredsAbstract 0168
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
bullPatients at clinical nutrition ICU from 2013 to 2015
bullTwelve patients required enteral nutrition or parenteral nutrition (7
OAGBMGB (583) 2 underwent a RYGB 2 had a LSG and 1 had LAGB
bullOAGB led to more severe nutrition complications requiring intensive nutrition
care and therefore cannot be considered a mini bariatric surgery
bullOAGB is often considered a simplified surgical technique it obviously requires
as the other standard bariatric procedures a close follow-up by experimented
teams aware of its specific complications
Beacutetry C et al JPEN J Parenter Enteral Nutr 2016 Mar 9
Need for Intensive Nutrition Care After Bariatric Surgery Is Mini Gastric Bypass at Fault
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
bull A 10-year study of Reversal MGB for severe and refractory malnutrition
syndrome after intensive nutritional support following MGB
bull 26 of 2934 patients had reversal 209 plusmn 134 months post-MGB At
presentation mean (BMI) 22 plusmn 44 kgm2 (EWL) 1036 plusmn 225 amp
albumin serum level 255 plusmn 36 grL
bull At surgical exploration 8 of 12 (665) patients had a biliary limb longer
than 200 cm and 9 (346) had bile reflux symptoms
bull After a mean follow-up of 8 plusmn 97 months all patients experienced a complete
clinical and biological regression of the SRMS after the RMGB despite a
mean 139 kg weight regain in 16 (615) patients Overall reversal
morbidity was 308
Langenbecks Arch Surg 2017 Aug 12 doi 101007s00423-017-1615-4 [Epub ahead of print]
Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition
Genser L1 Soprani A2 Tabbara M3 Siksik JM4 Cady J2 Carandina S5
Laparoscopic reversal of mini-gastric bypass to original
anatomy for severe postoperative malnutrition
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
J Minim Access Surg 2017 Jul 7 doi 104103jmasJMAS_198_16 [Epub ahead of print]
Mahawar KK1 Parmar C1 Carr WRJ1 Jennings N1 Schroeder N1 Small PK1
Impact of BPL length on severe PCM requiring revisional
surgery after one anastomosis (mini) gastric bypass
The highest percentage of 051 (12023277) was recorded with formulae using gt200
cm of BPL for some patients and lowest rate of 0 was seen with 150 cm
BPL (survey study)
Our study population consisted of the first patients that underwent a Mini Gastric Bypass
(MGB) at our institution At that time we used a considerably long biliopancreatic
(BP) limb (250ndash275 cm) which proved to be too long for some patients in our series
and we have since then revised our technique accordingly
Saarinen T Juuti A Obes Surg 2017 Jun27(6)1632 doi 101007s11695-017-2674-x
Reply to Key Features of an Ideal OAGBMGB Pouch
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
70
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
71Please Join our Facebook or Telegram groups
Pan Arab Society for Metabolic amp Bariatric Surgery
