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Conference report

Mini-Gastric Bypass (One-Anastomosis) Course

Mini-Gastric (One-Anastomosis) Bypass Course held Aug. 27, 2014 at the IFSO Congress, Montreal

This article was co-authored by Mervyn Deitel, MD, FASMBS (Toronto, Canada) and Kuldeepak S. Kular, MD (Bija, India)

Kuldeepak S. Kular

All the Course presenters had published recent series with the MGB operation (OAGB), and these articles can be accessed under their names via PubMed. These papers keep disclosing that MGB has excellent results. A syllabus with abstracts of these current papers was disseminated to the attendees.

Mervyn Deitel

Under the organization of Jean-Marc Chevalier, Pradeep Chowbey, Kudeepak S. Kular, Mervyn Deitel, and Wei-Jei Lee, a mini-gastric bypass (MGB/OAGB, omega-loop gastric bypass) course was held in Montreal at the IFSO Congress. 

Pradeep Chowbey

Besides the Faculty of 30 experts, there were 100 attendees, many of whom were already performing the MGB.  It is noteworthy that all those performing the MGB had previously performed other bariatric operations.

Jean-Marc Chevalier

Dr. Cesare Peraglie of Florida presented the tips and techniques, based on a 10-year personal series of 1,500 MGBs (see Figure1).  His patients had had no operative mortality, and the long-term outcome in terms of maintained excess weight loss (mean 79%) and resolution of co-morbidities was excellent.  His video showed the dissection commencing transversely just below the crow’s foot, then going proximally beside a bougie, to the left of the angle of His which resulted in no proximal leaks. His antecolic gastrojejunostomy, 180-200 cm distal to Treitz’ ligament, is constructed wide to avoid back-pressure.

Complications of the MGB were presented by David Hargroder of  Missouri, based on a personal series of 1,400 cases.  Gastroesophageal disease with the long gastric conduit was not a postoperative feature, and for the rare instance of inadequate or excess weight loss, the gastrojejunal anastomosis could be easily moved proximally or distally. 

Figure 1: MGB (one-anastomosis or omega-loop gastric bypass)

Kular presented prevention and treatment of marginal ulcer after MGB in a series of >1,000 patients. Salicylates and smoking were avoided postop, but in his practice in the Punjab (where a diet high in fruits and vegetables is consumed), whisky did not cause ulcer. Marginal ulcer after MGB is less that after RYGB.

Robert Rutledge

Hiatal hernias (HH) are generally not repaired during the MGB, as the gastrojejunal anastomosis usually reduces the cardia. The  MGB leads to >85% resolution of GERD.  If a HH is still present, Robert Rutledge recommended repair if necessary 12-18 months after the MGB.  However, when a HH contained adherent fundus, Peraglie stated that the fundus was reduced and the hernia repaired at the MGB operation.  Rutledge, the originator of the MGB in 1997, emphasized the eradication of H. pylori and the necessity for postoperative supplements, including iron, calcium – preferably dairy, multi-vits, yoghurt, fresh fruits and vegetables. Postprandial hypoglycemia was rare.  The MGB induces significant fatty food intolerance and mild steatorrhea in response to large fatty meals.

Internal hernias had not occurred in the experience of the attendees, but leak at the gastrojejunostomy or distal small bowel obstruction did occur rarely.Atul Peters presented excellent results with MGB in the super obese.  Jean-Marc Chevallier presented a study showing the excellent quality of life at 5 years after MGB.

The data from the MGB Consensus Conferences in Paris (the last being October 2013 and also reported in Bariatric News) was presented by Deitel.  The weight loss and durability of the MGB was superior to the other bariatric operations.

Mario Musella and Marco Milone of Italy presented resolution of type 2 diabetes, hypertension and other co-morbidities after MGB, finding superiority in their study compared to laparoscopic sleeve gastrectomy (LSG).  The excellent Italian multi-center outcome of 974 consecutive laparoscopic MGBs was presented by Maurizio De Luca.  

Wei-Jei Lee

The 10-year comparison of MGB and RYGB (and more recently the LSG), in terms of postoperative weight loss, complications, resolution of diabetes, elevation of GLP-1 and quality of life, was presented by Prof. Wei-Jei Lee of Taiwan; he found superiority with the MGB in each instance.  Better results were also found with the MGB in an audit comparing it with LSG and RYGB by G.S. Jammu of India. 

The technique of the Caballero OAGB since 2004 was presented by Prof. Manuel GarciaCaballero of Spain, who inserts antireflux stitches between the afferent limb and stomach. His results have also been superior to the other bariatric operations with respect to remission or cure of diabetes.  He tailors the OAGB in diabetes surgery and for BMI.  The similar Miguel A. Carbajo method was presented by Enrique Luque De Leon of Mexico.  The results of 12 years with 2,400 OAGBs found superior results over RYGB, LSG and gastric banding.  It is estimated that 15% of the MGB surgeons insert the antireflux sutures.

Deitel pointed out that there is no evidence for increased cancer after MGB. In the literature, more than 40 cases of carcinoma after RYGB were cited, in addition to a number of cases after LAGB, and two cases after the LSG.  After MGB, no cases of carcinoma in the gastric tube or esophagus have been reported. It is noted that following the thousands of vagotomy and pyloroplasty operations for peptic ulcer disease in the 1960–70s, in which some bile was always present in the lower stomach, no cases of carcinoma were reported. Furthermore, a warning is often given about carcinoma developing in the rat’s stomach when subjected to a bile preparation; however, Frantz showed that the neoplastic changes in the unique rodent stomach occur in the proximal two-thirds (which is squamous-cell), and not in the distal one-third (which is glandular like the human stomach). Long-term follow-up after Billroth II which permits bile in stomach has indeed found a decreased incidence of carcinoma, and these studies were performed before H. pylori was known or treated.  

Kular presented his comparison of MGB and LSG, in which the weight loss after MGB was greater and the complications less.  Drs. Jean Cady and Antoine Sopriani presented a large series of MGB as a rescue operation after gastric banding failure.  Techniques for conversion to MGB after failed band, LSG and other bariatric operations were presented by Jean-Marc Chevallier. He also presented a short video of the restoration of normal anatomy after MGB for very rare de-nutrition; reversal of MGB is an easy operation.  Robotics in MGB was presented by Arun Prasad of India, which showed the ease and accuracy of this method.

The technique of the Greco-Tacchino distal MGB with a larger proximal gastric conduit and a more distal gastroileostomy was presented and recently published as “Ileal Food Diversion” – which they compared to BPD.  However, their operation is easier and has had better results.  

The experts agreed that the MGB is a simple, rapid, safe operation, with excellent resolution of obesity-associated diseases, durable weight loss, a relatively short learning curve, is adjustable with BMI and, if ever necessary, easily reversible.  Because of interest in this Course and the free papers on MGB presented during the IFSO Congress, it has been decided to hold an MGB Course in Vienna at IFSO-2015 on Aug. 26.  A Bibliography of papers presented follows:

Bibliography

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