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OAGB outcomes

OAGB – the long-term outcomes from 1,200 procedures

Patients lost a mean of ∼15–20 kg in the first month and ∼30–40 kg in the first trimester
Severe metabolic comorbidities such as type II diabetes mellitus, insulin resistance, hypertension, and sleep apnoea either totally resolved or substantially improved, most from the first day after surgery

Laparoscopic one-anastomosis gastric bypass (OAGB) is a safe and effective procedure, that reduces difficulty, operating time and early and late complications associated roux-en-Y gastric bypass, according to the authors of a study from the Centre of Excellence for the Study and Treatment of Obesity and Diabetes, Valladolid, Spain. They also note that long-term weight loss, resolution of comorbidities, and degree of satisfaction “are similar to results obtained with more aggressive and complex techniques. It is currently a robust and powerful alternative in bariatric surgery.”

The paper, ‘Laparoscopic One-Anastomosis Gastric Bypass: Technique, Results, and Long-Term Follow-Up in 1200 Patients’, published in Obesity Surgery, sought to evaluate experience and long-term follow-up (FU) in a large cohort of patients with morbid obesity who underwent laparoscopic OAGB at a single institution. The retrospective review of a prospectively maintained database included 1,200 consecutive patients from July 2002 to October 2008, and included follow up from six to 12 years.

Outcomes

There were 744 female (62 %) and 456 male (38 %) patients with a mean age of 43 years (range, 12–74). Mean pre-operative BMI46 (range, 33–86) and mean preoperative excess weight was 65kg (range, 34–220). The cohort included 697 patients (58 %) with no previous or simultaneous abdominal operations (subgroup 1). Another 273 (23 %) had had prior open abdominal operations and thus required adhesiolysis of variable complexity, and a total of 203 (17 %) had abdominal operations performed simultaneously, particularly gallbladder removal and/or hiatal or ventral hernia repairs (subgroup 2). Finally, in 27 (2 %), laparoscopic OAGB was performed as a revision of other (failed) bariatric procedures (subgroup 3) including previous laparoscopic gastric bands (n=13), as well as open vertical banded gastroplasties (n=14).

Intraoperative complications requiring conversion to an open approach occurred in four patients (0.3 %). Early major complications requiring reoperations occurred in 16 patients (1.3 %) and included intra-abdominal bleeding (9), leaks (3), and early small bowel obstruction (2). Late complications included 6 stomal stenosis (0.5 %) 6 (0.5 %) anastomotic or marginal ulcers (MU).

The 30-day readmission rate was 0.8 % (10 patients). Late readmissions were required in 13 patients (1 %) for stomal stenosis (6), GI bleeding due to MU (5), and malnourishment (2). Two patients died in this series (0.16 %); both had super-obesity, multiple comorbidities and risk factors. One suffered a pulmonary thromboembolism 3 days after BS (without warning symptoms or additional postoperative complications). The other suffered gastric wall necrosis, was re-operated on, and developed refractory nosocomial pneumonia. Both deaths occurred during the initial part of the series, and there were no other casualties in >1000 patients operated on thereafter.

Pre-operative nutritional deficits were found in some patients including iron (∼10 %), vitamin D (∼15 %), and calcium (∼4 %). After OAGB, a few patients developed excessive weight loss and/or nutrient deficits (usually within the first 2–3 postoperative years). A total of 14 patients (1.2 %) required further treatment for hypoalbuminemia; all received high-protein enteral supplements and pancreatic enzymes. Iron deficiency was rather common, especially in fertile women with copious menstrual bleeding and up to one third required oral supplements beyond the expected time for intestinal adaptation, and 15 patients (1.3 %) required parenteral iron.

Among liposoluble vitamins, vitamin D insufficiency was present in more than half of patients at three years and one third in the long term; this required continuous supplementation in ∼20 % of them. Longer supplementation was also needed for vitamins A and K in ∼3 and 0.5 %, respectively.

Patients lost a mean of ∼15–20 kg in the first month and ∼30–40 kg in the first trimester. The number and percentage of patients followed up at each time interval are included; only from 13 % (at 6 years) to 30 % (at 12 years) of the cumulative number of patients were lost for follow-up. Substantial weight loss was documented for most patients; through time, there was a slight weight increase in a few, which was not clinically relevant. Therefore, the authors stated that excess weight loss was maintained in most of these patients and according to Reinhold’s classification their results ranged from good (EWL >50 %) to excellent (EWL >75 %), and a long-term successful treatment (EWL >50 %) was achieved in almost all patients.

Severe metabolic comorbidities such as type II diabetes mellitus, insulin resistance, hypertension, and sleep apnoea either totally resolved or substantially improved, most from the first day after surgery (Table 1). Remission was also demonstrated in most patients for other metabolic conditions like hyperlipidaemia and liver steatosis when the first biochemical tests were ordered at the 3rd postoperative month. Interestingly, 53 % of patients had gastroesophageal reflux disease (GERD) of some degree before surgery, and all were relieved after the operation.

Table 1: Outcomes of one-anastomosis gastric bypass (OAGB) on comorbid conditions in 1200 morbidly obese patients

“We call again on the various bariatric teams that are performing the original MGB or our modified version, the OAGB, to aid in the dissemination and acceptance of this procedure by presenting and publishing their experiences and standardising the name (to MGB/OAGB), in order for all of us to be recognized as a whole,” the authors write. “Now that many of its controversies are being surpassed and the bariatric surgical community is accepting the procedure as a rational alternative in the bariatric repertoire, we should make all efforts in order to conciliate in regard to the name, avoid new disagreements, and work towards making MGB/OAGB mainstream in obesity and metabolic surgery.”

“Concerns regarding bile reflux and its potential consequences currently seem unsubstantiated but await studies with even longer-term outcomes,” the authors conclude. “So far, development of subsequent cancer has not been reported. Long-term substantial EWL, remission of comorbidities through its metabolic benefits, and degree of satisfaction are similar to the best results obtained with more aggressive and complex operations. OAGB is a safe and effective powerful alternative which is slowly (but surely) becoming mainstream in bariatric surgery.”

The article was edited from the original article, under the Creative Commons license.

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