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Mini-Gastric Bypass in the United Kingdom

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Mini Gastric Bypass: initial Experience
British Obesity Metabolic Surgery Society
4 th Annual Scientific Meeting
Jan 23-25, 2013 Glasgow
SPIRE Hospital Southampton
Department of Bariatric Surgery
M Van den Bossche, I Bailey, J Kelly
J Byrne, R Sutherland*

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Mini-Gastric Bypass in the United Kingdom

  1. 1. 4th Annual Scientific Meeting Jan 23-25, 2013 GlasgowMini Gastric Bypass: initial experience SPIRE Hospital Southampton Department of Bariatric Surgery M Van den Bossche, I Bailey, J Kelly J Byrne, R Sutherland*02/02/13 1
  2. 2. 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
  3. 3. 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
  4. 4. 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
  5. 5. 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 – Braun anastomosis – Conversion to RNY (stenosis)
  6. 6. 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
  7. 7. MGB experience at 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 cohorts02/02/13 7
  8. 8. Patient characteristics ASA score ASA RNY MGB 1 5 7 2 27 18 3 19 25 4 1 2 Co-morbidity 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 41 48 (less than 3 flights of stairs) OA (on meds) 15 25 GORD 11 1502/02/13 8
  9. 9. Results 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%02/02/13 9
  10. 10. Late 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
  11. 11. Effect on medical co-morbidityResults at 12 months FU Medical RNY RNY % improved MGB MGB (n 49) % improved condition preop Last FU preop Last FU T2DM 32 8 75% 30 7 76.7% HT 23 15 34.8% 33 20 39.4% Sleep 13 7 46% 10 4 60% apnoea Asthma 15 14 6.67% 18 11 38.9% Functional 41 1 97.57% 48 4 91.% impairment OA 15 12 20% 25 18 28% GORD 11 10 9% 15 11 26.67% (4 de novo) (4 de novo) 02/02/13 11
  12. 12. Weight loss results 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 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 + 4.6802/02/13 12
  13. 13. Conclusions 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
  14. 14. Thank you

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