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Mini Gastric Bypass: initial experienceMini Gastric Bypass: initial experience

SPIRE Hospital Southampton

Department of Bariatric SurgeryM Van den Bossche, I Bailey, J Kelly

J Byrne, R Sutherland*

4th Annual Scientific MeetingJan 23-25, 2013 Glasgow

Introduction in MGB Dr Robert Rutledge

– Pioneer– 15 year experience– 7000 cases– Excellent results– Long term FU

Mini Gastric Bypass is a combination of

•Collis plasty

•Billroth 2

Mini Gastric Bypass is a combination of

•Collis plasty

•Billroth 2

Fears and Controversy

MGB not endorsed by ASMBS or ACS but MGB is clearly on the rise throughout the world.

Fears– Cancer

– Bile reflux

– Marginal ulcer

Are those fears supported by data and evidence?– The literature suggests NOT

Risk of cancer

Bariatric surgeons fear Billroth 2 anastomosis Cancer surgeons choose Billroth 2 Hundreds of thousands of people with Billroth 2.

– If CA is such a big risk shouldn’t gastroenterologists be screening these people?

– NO There is no recommendation to do endoscopic screening after Billroth 2

The risk is LOW: endoscopy screening is not rewarding

– Mayo clinic, 338 B2 patients, 25years FU, 5635 person-years. Only 2 cancers detected in >5000 pat-years of FU

• Schafer et al Risk of gastric cancer after treatment of benign ulcer disease. N Engl J. Med 1983: Nov 17; 309

– 1000 patients, 22-30 y FU, endoscopy, no CA in gastric remnant• Br J Surg 1983 Sep; 70 (9): 552-4 Risk of gastric cancer after B2 resection for

duodenal ulcer. Fisher AB

Bile reflux Major problem with Mason Ito bypass

– Anastomosis too close to oesophagus Risk with MGB is real Gastric tube has to be LONG

– First staple firing well into gastric antrum

– Anastomosis lies at level of the pylorus

– RNY surgeons tend to make gastric pouch not long enough Can usually be treated medically Surgical intervention

– Braun anastomosis

– Conversion to RNY (stenosis)

Braun anastomosisBraun anastomosis

Marginal ulcer Marginal ulcer is the Achilles heel of all gastric bypass operations:

it has been known since the beginning of GI surgery It is not just a problem for MGB. Risk factors: tobacco,nsaid,ischaemia, foreign body, alcohol, H

pylori, poor diet Both RNY & MGB

– Incidence: 0.6% to 12%– True incidence likely higher– 28% of marginal ulcers can be asymptomatic (Csendes prospective

study) Bile makes no difference Marginal ulcer in RNY

– 2282 patients– 122 (5%) marginal ulcers– 39 (32%) requiring surgery

• Surg Obes Relat. Dis. 2009 May-Jun;5(3):317-22 Revisional operations for marginal ulcer after RNY gastric bypass Patel RA, Brolin RE

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MGB experience atMGB experience at SPIRE Southampton Hospital SPIRE Southampton Hospital

Oct 2010 – Jan 2012 2 cohorts of 52 patients: RNY vs. MGB Prospective data collection (NBSR and local database) Follow-up: standard 3 monthly Well matched

RNY (N:52) MGB (N:52)

Age 49.5 (31 – 63) 51.0 (24 – 71)

Gender M/F 22/30 23/ 29

Weight (Kg) 134.53 + 16.53 135.46 + 19.75

FU rate at 12 months: 96% for both cohorts

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Patient characteristicsPatient characteristics ASA score

Co-morbidity

ASA RNY MGB

1 5 7

2 27 18

3 19 25

4 1 2

Medical Morbidity RNY (N 52) MGB (N 52)

T2DM 32 (5 Insulin) 30 (3 Insulin)

HT 23 33

Sleep apnoea 13 10

Asthma 15 18

Functional impairment(less than 3 flights of stairs)

41 48

OA (on meds) 15 25

GORD 11 15

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ResultsResults Mortality: 0% both groups Hospital stay: Med 2 days (MGB: 2-9 // RNY: 2-12) Early complications

Complication RNY (n 52) MGB (n 52)

Intraperitoneal bleed 3 (1 RTT, 2 transfusion)

GI endoluminal bleed 1 (RTT: endoscopy + laparoscopy)

Anastomotic leak 1 (RTT: leak not identified)

Aspiration pneumonia 1 (ARDS)

Pneumonia 1 (AB)

Cardiac event 1

Anastomotic stenosis 3 (dilatation) 3 (dilatation)

Complication rate 15% 11.5%

Late complications MGBLate complications MGB

1 dysphagia / food intolerance: converted to normal anatomy at 6 months

1 marginal ulcer and ?bile reflux: converted to RNY (elsewhere) > 12 months postop (heavy smoker)

1 protein malnutrition: converted to proximal RNY > 12 months postop

Reoperation rate: 5.7% (3/52)– Early experience– Learning curve

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Effect on medical co-morbidityEffect on medical co-morbidity

Results at 12 months FU

MedicalMedical

conditioncondition

RNY

preop

RNY

Last FU

% improved MGB

preop

MGB (n 49)

Last FU

% improved

T2DM 32 8 75% 30 7 76.7%

HT 23 15 34.8% 33 20 39.4%

Sleep

apnoea

13 7 46% 10 4 60%

Asthma 15 14 6.67% 18 11 38.9%

Functional impairment

41 1 97.57% 48 4 91.%

OA 15 12 20% 25 18 28%

GORD 11 10(4 de novo)

9% 15 11(4 de novo)

26.67%

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Weight loss resultsWeight loss results

RNY MGB

Preop (n 52) Weight (Kg) 136.01 + 17.01 134.62 ± 19.01 NS

BMI operation 48.84 ± 14.20 48.40 + 5.21 NS

1 year postop (n 50) Weight 96.94 + 16.55 86.58 + 14.70 P<0.05

%EWL 63.08 ± 18.56 75.69 + 15.32 P<0.05

BMI 33.93 + 4.93 31.60 + 4.68

Preop (mean + SD) 1 year (mean + SD)

RNY weight Kg 136.01 ± 17.01 96.94 ± 16.55 p<0.01

RNY BMI 48.84 ± 14.20 33.93 ± 4.93 p<0.01

MGB weight Kg 134.62 ± 19.01 86.58 ± 14.7 p<0.01

MGB BMI 48.40 ± 5.21 31.60 ± 4.68 p<0.01

ConclusionsConclusions

Mini Gastric Bypass– Safe and easy procedure– Complications similar to RNY– Beware of “tricks” and “traps”– Medical benefits similar to RNY– Weight loss probably better than RNY– Valid alternative for RNY

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