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New procedure

Surgeon combines mini gastric bypass and sleeve

Operation intends to replicate metabolic effects of both procedures
Researchers now recruiting patients into study to measure safety and efficacy
Professor Bekavac-Beslin

A Croatian surgeon has developed a new procedure which aims to combine the metabolic benefits of the mini gastric bypass and the sleeve gastrectomy.

Professor Miroslav Bekavac-Bešlin, of University Hospital Sestre Milosrdnice, Croatia, says that the operation, which he calls the MGB+PSG, for mini gastric bypass plus proximal sleeve gastrectomy, intends to replicate both the reduced levels of ghrelin seen after sleeve gastrectomy, and the increased levels of incretin seen after mini gastric bypass.

“A combination of both procedures might provide a better control in two separate endocrine hormonal systems which are important for the control of glucose and weight loss after the bariatric procedure,” he told in an email.

Unlike a conventional mini gastric bypass, the resected portion of the stomach is removed from the patient, and the majority of the blood flow to the lesser curvature of the stomach is retained.

“Duodenogastric reflux is reduced, the possibility of tumor development is also reduced after removal of the fundus and corpus and if necessary this procedure may be converted to Billroth I procedure,” said Bekavac-Bešlin.

The procedure has so far been carried out without complications in two patients, and Bekavac-Bešlin and colleagues are currently preparing a study to establish its safety and efficacy.

The first procedure took place on March 1, on a female patient with a BMI of 39.6. After ten days, she had lost 6kg, and reported having no sensation of hunger. The second patient was operated on April 4.

Figure 1


Bekavac-Bešlin describes the procedure as follows:

Figure 2

“The MGB+PSG procedure is performed laparoscopically with trocar positioning identical as for sleeve gastrectomy. The gastrocolic ligament is opened with an ultrasonic knife at the greater curvature of the stomach; this permits exploration of the posterior wall of the gastric body in the zone of stapler resection at the gastric body adjacent to the antrum. The pes anserinus (crow’s foot) is the marking on the lesser curvature.

Gastric resection is performed with a green loading of the 60mm stapler. The resection line goes from the greater curvature next to the antrum, towards the lesser curvature; two 60mm loadings are used. The resection line is proximally to the pes anserinus which is preserved (Figure 1, Line 1).

Gastric resection follows in the same manner as sleeve resection: a 34 calibration probe is inserted into the stomach and placed next to the lesser curvature; the stomach is then resected parallel to this probe with a stapler to the Angle of His (Figure 1, Line 2); caution must be taken not to place the resection line too close to the oesophagus. The stapler loading can be either green or blue and the stapler length is 60 mm.

The greater curvature is dissected with an ultrasonic knife and the resected part of the stomach (Figure 1, Item 3) is placed in a bag and prepared for extraction. Another possibility is to dissect the greater curvature to the level of the left crus of the diaphragm with an ultrasonic knife and then do the resection of gastric body in the manner of sleeve resection.

At this stage of the procedure we have a gastric stump ready for anastomosis with the small intestine. The first portion of the small intestine from the Treitz’ ligament is mobilised, usually measured at about 200cm and an antecolic isoperistaltic gastroenteroanastomosis is formed (Figure 2) with a linear 45mm stapler with blue loading accompanied by a running one-layered suture of the stapler opening.”


Bekavac-Bešlin is currently working with Assistant Professor Fuad Pašić of Tuzla University Hospital in Bosnia & Herzegovina to recruit patients to a study examining the outcomes of the procedure. The study will compare a group of patients who will receive the new operation to two other groups: one will receive mini gastric bypass on its own, while the other will receive sleeve gastrectomy on its own. The researchers hope to include 30 patients in each group.

The follow-up will last for five years, and will capture patients’ anthropometric measurements, as well as their standard biochemistry, Hb1Ac, cholesterol, triglycerides, TNF-A, IL-6, CRP, C-peptide, adrenalin, noradrenalin, ghrelin, leptin, adiponectine, incretins, and 24-hour urine cortisol.

“We realize that an ideal bariatric procedure does not exist,” said Bekavac-Bešlin. “This fact gives us the right to take two recognised and efficient procedures and try to get the best of them, and expect that our morbidly obese patients will have the greatest benefit.”

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