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FIRST INTERNATIONAL
MINI-GASTRIC BYPASS /
ONE ANASTOMOSIS BYPASS
CONSENSUS CONFERENCE

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  1. 1. Namaste, Gday, Guten tag, Konichiwa, Ciao, Olá e bem-vindos, Ni Xao, Sawadeeka, Bonjour, Buenos dias, Ciao, Howdy!PROGRAM:FIRST INTERNATIONALMINI-GASTRIC BYPASS /ONE ANASTOMOSIS BYPASSCONSENSUS CONFERENCEParis Oct18-20 2012Thursday, October 18, 2012 at 8:00 AMFriday, October 19, 2012 at 12:00 PM (PDT)Paris Paris Charles de Gaulle Airport Marriott HotelAllée du Verger, 95700 Roissy-en-France, FranceIn addition Live Surgery Demonstration on Saturday Oct 20Clinique Geoffroy Saint Hilaire - Paris , 59 Rue Geoffroy-Saint-Hilaire 75005 Paris, France, 01 44 08 40 00Dr Rutledge & Dr Chiche, Two Operating Rooms 6 - 8 MGB,3 Visitors in OR,Video Transmission Conference Room 25 Surgeons, (Contact DrR@clos.net for special invitation)
  2. 2. Welcome • Honorary Meeting Chairman: Jean Mouiel, MD Pr of Surgery Obesity Center Nice France • Chairman of the Meeting: Pr Jean-Marc Chevallier, chirurgie digestive , coelioscopie et de lobésité, président de la soffco, hôpital européen georges pompidou, 20 rue leblanc, 75908 paris cedex 15, France • International Co-Chairman; Prof M. Garciacaballero, Full Professor Surgery, University Malaga, Medical Faculty, Malaga, 29080, Spain, gcaballe@uma.es • International Co-Chairman; Dr. K S Kular M.S., Director, Dept of Bariatric Surgery, Kular Hospital & College of Nursing, Bija, Ludhiana, Punjab , India - 141412 • Goals Listen to Short Data/Presentations Discuss Pros and Cons of Issues Vote on Consensus of the Group Record the Results • Meeting Process Several short presentations by leaders in the field. Chairman opens the discussion. Moderator roams the floor to seek both discussion and consensus. Recorder makes a written record of the discussion and voting also guiding the discussion to come to decisions by the group.Meeting Chairmen, Moderators and Recorders • SECTION I: Bariatric Today: Surgery Choices and Outcomes • Section Chairman: Roberto Tacchino • Moderator: Dr. Narwaria • Recorder: Dr. Jan Apers • SECTION II: MGB Results with Large Series • Section Chairman: Dr. Shashank Shah/Dr Bhandari • Moderator: Emilio Manno • Recorder: Karl Rheinwalt • SECION III: MGB/OAB Best Practice; Technical Performance • Section Chairman & Moderator: Pr Jean-Marc Chevallier • Recorder: Mario Musella • Thursday Video Techniques Lunch 1 • Section Chairman: Michael Van den Bossche • Moderator: Pr Jean-Marc Chevallier • Recorder: Jan Apers
  3. 3. Thursday Afternoon : • SECTION IV: MGB Advantages, Long Term Studies & Other Topics • Section Chairman: Prof. M. Garciacaballero • Moderator: Kamal Mahawar • Recorder: Philippe CostilFriday Morning: MGB; Experts Experience; TIPS and Tricks, Complications and Risks • SECTION V: Beginning The Consensus Conference Final Statement • Section Chairman: Jean Mouiel, MD • Moderator: Michal Cierny • Recorder: Dr. Rui Ribeiro • Video Techniques Lunch II • Section Chairman: Dr. C Peraglie • Moderator: Mario Musella • Recorder: Dr. Karl Rheinwalt • SECTION VI: The End: The Final Consensus Conference Voting Statements & Planning for the Future • Section Chairman: Dr. Roberto Tacchino • Moderator: Dr. Rutledge • Recorder: KS KularSATURDAY MORNING Oct 20 2012SECTION VII: Live MGB Surgery with Cady, ChiChe, Guerolt & RutledgeMonday Morning Oct 22, Live Surgery in Lisbon Portugal w Dr. Rui Riberio/Dr Rutledge
  4. 4. Table of Contents WelcomeFacultyProgram OutlineUpdated 10/12/12: Brief ProgramSaturday Oct 12, 2012; Live Interactive Case Demonstrations of Mini- Gastric BypassFull ProgramEsophageal Cancer & GE Reflux: Brief ReviewRutledge Version of Mini-Gastric Bypass: Tools, Tips, Techniques; Special needs for the Surgery (Instruments, etc.)ReferencesMini-Gastric Bypass ReferencesSleeve Gastrectomy Quickly Leads to New Onset GE Reflux & Weight RegainMeeting Survey
  5. 5. Faculty  Name: Title Institution: City/Town: Country:  Jean Mouiel, MD Pr of Surgery Obesity Center NICE FRANCE  Mario Musella Associate Professor of Surgery Naples "Federico II" University - Medical School Naples ITALY  Philippe COSTIL NEUILLY SUR SEINE FRANCE  Jan Apers drs. MCL Leeuwarden Leeuwarden Netherlands  Roberto Tacchino MD Catholic University Rome Italy  Atul N.C Peters DR. Fortis Hospital, Shalimar Bagh New Delhi INDIA  Rui Ribeiro Dr. Centro Hospitalar de Lisboa Central Lisboa Portugal  Michael Van den Bossche MD FRCS Spire Southampton Hospital Castel UK  Michal Cierny Dr., PhD Breclav Hospital Breclav Czech Republic  M. Garciacaballero Full Professor Surgery University Malaga Malaga Spain  Karl Rheinwalt Dr. Dept.for Bariatric Surgery, St. Franziskus-Hospital Cologne Germany  Emilio Manno MD Ospedale Cardarelli Naples Italy  Francesco Greco MD, PhD Clinica Castelli Bergamo  Maurizio De Luca MD Vicenza Regional Hospital Vicenza Italy  Martin Kox Prof hon., Dr, Chef de service département chir viscerale Centre Hospitalier Emile Mayrisch L -Esch-Alzette Luxembourg  Nicolas Cardin Dr Centre Hospitalier de Douai Douai France  Kamal Mahawar Mr. Sunderland Royal Hospital Sunderland United Kingdom  Dr. Robert Rutledge, CLOS, Las Vegas, Nevada, USA 5
  6. 6. Program Outline: Thursday morning, Oct 18 SECTION I: Bariatric Today: Surgery Choices and Outcomes SECTION II: MGB Results with Large Series SECION III: MGB/OAB Best Practice; Technical Performance Thursday Video Techniques Lunch 1 Thursday Afternoon : SECTION IV: MGB Advantages, Long Term Studies & Other Topics Friday Morning : MGB; Experts Experience; TIPS and Tricks ,Complications and Risks SECTION V: Beginning The Consensus Conference Final Statement Video Techniques Lunch II SECTION VI: The End: The Final Consensus Conference VotingStatements & Planning for the Future SATURDAY MORNING Oct 20 2012 SECTION VII: Live MGB Surgery with Cady, ChiChe, Guerolt &Rutledge Monday Morning Oct 22, Live Surgery in Lisbon Portugal w Dr. RuiRiberio/Dr Rutledge 6
  7. 7. Updated 10/12/12: Brief ProgramOct 18: Thursday Morning :Survey Hand Out, Voting Questionnaire for Consensus Instructions Time Presenter Subject 9:00 Jean Mouiel Introduction: Honorary Chairman 9:10 JM Chevallier Chairman First International Mini-Gastric Bypass / One Anastomosis Consensus Conference: ; Welcome, Charge to the Meeting; Listen, Learn, Discuss, Vote, Plan,SECTION I: Bariatric Today: Surgery Choices and Outcomes======= Special Guest Presentations: ============== The Story of Transition from “Non-MGB” to MGB Surgeon ======= Time Presenter Subject 9:20 Prof hon., Dr Martin Kox, Head Of Service Department Visceral Surgery, Centre Hospitalier Emile Mayrisch, L -Esch-Alzette, Luxembourg. Personal Reflections; History of Peptic Ulcer Surgery 9:30 M Narwaria; Past President Obesity Surg Soc India ; My Journey to the MGB / MGB in India 9:40 JM Chevallier, President Obesity Surg Soc France; What I know about MGB: 7 years experience 9:50 R Rutledge International Survey Bariatric Surgeons, Reflux & Esophageal cancer after Sleeve & Band 10:00 Opening Questions, Present Status; Meeting Goals & Future PlansSECTION II: MGB Results with Large Series Time Presenter Subject 10:10 R Tacchino My Experience with MGB in Italy 10:20 K Kular My Experience with MGB in India 10:30 M Garciacabaello My Experience with OAB in Spain 10:40 C Peraglie My Experience with MGB in USA 10:50 JP Chevallier My Experience with MGB in France 11:00 J Cady My Experience with MGB in France 11:10 R Rutledge My Experience with MGB; 15 years and 6,000 Patients Later 11:20 MGB Results: Questions and Answers and Votes from FloorSECION III: MGB/OAB Best Practice; Technical Performance Time Presenter Subject 11:30 M Musella MGB in Italy; Technical Performance Issues in MGB 11:40 C Peraglie Best Practices; Critical Technical Performance Issues in MGB 11:50 R Ribeiro MGB in Portugal Tech Issues in MGB Gastric Pouch 12:00 Jan Apers Dutch MGB, Tech Issues in MGB; Bypass & Leaks 12:10 J Cady MGB as Rescue for Failed Band 7
  8. 8. 12:20 Directed Discussion: Agreements and Controversies Technical Performance of MGB/OAB==========================================================Thursday Video Techniques Lunch 1 Garciacaballero 5 min video; 5 MGB Tips Peraglie 5 min video; 5 MGB Tips Kular 5 min video; 5 MGB Tips Videos Questions and Answers and Votes from Floor==========================================================Thursday afternoon :==========================================================SECTION IV: MGB Advantages, Long Term Studies & OtherTopics 13:30 Sandeep Aggarwal MGB vs Other Surgery 13:40 K Mahawar, MGB Review of Literature on MGB 13:50 Maurizio De Luca Italian Experience with Band, RNY, Sleeve & MGB 14:00 K S Kular: MGB vs Sleeve; Report on 200 Sleeves 14:10 R Tacchino: MGB and BPD; compare and contrast 14:20 A Peters: MGB vs. RYGB 14:30 M Bhandari GERD Band& Sleeve vs. RNY & MGB 14:40 Questions and Answers and Votes from Floor 14:50 Emilio Manno MGB Complications and Management (Leaks) 15:00 M Van den Bossche; MGB in UK; GE Reflux; Band, Sleeve, RNY & MGB 15:10 Dr Cierny My experience with MGB in Czech Republic 15:20 Dr S Shah Minimal Risk of Gastric Cancer after Billroth II, Processed Meat is Much More Dangerous 15:30 Dr. Weiner Bile Reflux following Mini-Gastric Bypass (Omega Loop) 15:40 Questions, Answers and Votes from the Floor Directed Discussion: Agreements and Controversies Panel: Chevalier, Garciacaballero, Tacchino, Kular, Peraglie, Nawaria, Weiner 16:00 Dr Rutledge; Failure of Restrictive Procedures: Coca-Cola & Ice Cream Beat Band & Sleeve 16:10 Questions and Answers and Votes from Floor==========================================================Friday Morning :MGB; Experts Experience; TIPS and Tricks , Complications and Risks==========================================================SECTION V: Beginning The Consensus Conference Final Statement 8
  9. 9. 9:00 K S Kular: Safety, Safety, Safety; Choosing the MGB 9:10 Garciacaballero; An Experts View, OAB Advantages & Advice 9:20 R Tacchino; An Experts View, MGB Advantages 9:30 Dr Narwaria An Experts View, Advice to the New MGBer 9:40 Dr Peraglie; Marginal Ulcers: An Experts View 9:50 Karl-Peter Rheinwalt My Advice on Becoming a New MGB Program 10:00 Questions and Answers and Votes from Floor 11:00 R Rutledge: Renaming the MGB/OAB; Survey Results, Discussion and Voting 1. Survey Results on Renaming the MGB 2. Keep MGB name and OAB name? 3. Create a New Name for both (BII Bypass, Omega Bypass, Sleeve Bypass 4. Some combination? 5. The MGB is a Bad name 6. The MGB is a Good Name 7. Relation between MGB and OAB (Friends, Brothers or enemies?) 8. Consensus Voting 9. Suggestions: 10. Class Name Single Anastomosis Bypass / Omega Bypass or other (include MGB AND OAB) 11. Two Sub-groups of SAB/OLB Class: 12. MGB = Type I SAB 13. OAB = Type II SAB 11:10 Questions & Voting========================================================Video Techniques Lunch II Tacchino 5 min video; 5 MGB Tips Chevallier 5 min video; 5 MGB Tips Rutledge 5 min video; Revision of MGB (Hint, Its Easy)========================================================SECTION VI: The End: The Final Consensus ConferenceVoting Statements & Planning for the Future 13:00 Creation of the Consensus Statement; Review of Survey and Voting Results So Far Dr Rutledge 13:10 Questions and Answers and FINAL Votes from Floor 13:20 Pr Tacchino: Band, Sleeve, RNY & MGB Outcomes: Consensus Statement 13:30 M Nawaria Critical Factors in Performance of MGB: Consensus Statement 13:40 Questions and Answers and FINAL Votes from Floor 14:00 Garciacaballero: The Future; Liberté, égalité, fraternité, "Liberty, equality, fraternity 14:10 Discussion and Voting 15:00 Dr. Rutledge, IFSO, IFSO-EC, ASMBS Meeting Financial Report 15:10 Voting CONSENSUS : QUESTIONS AND ANSWERS 16:00 Society of MGB/OAB Surgeons; Open Discussion and Voting, Organization and Mutual Aide 18:00 Additional Videos (TBA), Topics from the Floor 9
  10. 10. ==============================================================SATURDAY MORNING Oct 20 2012SECTION VII: Live MGB Surgery withDr’s Cady, ChiChe, Guerolt & RutledgeLive Interactive Surgery DemonstrationParis on Saturday October 20, 2012Clinique Geoffroy Saint Hilaire - Paris59 Rue Geoffroy-Saint-Hilaire 75005 Paris, France, 01 44 08 40 00Dr Cady, Guerolt, Rutledge & Chiche, Two Operating Rooms 6 - 8 MGB 3 Visitors in OR, Video Transmission ConferenceRoom 25 Surgeons, (Contact DrR@clos.net for special invitation), Possible Dinner Meeting to FollowLive Interactive Surgery DemonstrationLisbon Portugal Monday October 22, 2012Monday Morning Oct 22, Live Surgery in Lisbon Portugal w Dr. Rui Riberio/Dr Rutledge,(Contact DrR@clos.net for special invitation) 10
  11. 11. Saturday Oct 12, 2012Live Interactive Case Demonstrations of Mini-Gastric Bypass Live case demonstrations of Mini-Gastric Bypass procedures. To Be Held at Clinique Geoffroy Saint-Hilaire ( OnFacebook: http://www.facebook.com/pages/Clinique-Geoffroy-Saint-Hilaire/135267789853994 ) We have arranged a worldrenowned and clinically expert team to demonstrate the technical performance details of the Mini-Gastric Bypass in Paris onSaturday Oct 20, 2012. For the main operators on Saturday Dr Jean CADY: Medical Doctor, Member of French National Academy of Surgery, and Member on French Society ofBariatric Surgery. Laparoscopic surgeon, Bariatric surgeon, Colo-Rectal surgeon. Dr Renaud Chiche: Medical Doctor, Member on French Society of Bariatric Surgery. Laparoscopic surgeon, Bariatricsurgeon, Colo-Rectal surgeon. The space is limited to 20 surgeons and sign up is required at Sign-Up: http://satlivemgb.eventbrite.com/ 3-day Consensus Conference and Education Course on Mini-Gastric Bypass: The increasing role of Mini-Gastric Bypass(MGB) in the treatment of morbid obesity we feel dictates the need for greater acquaintance with this type of surgery. Inaddition to the 2 day consensus conference we have arranged for a total of 20 surgeons observe and interactive display of liveMGB surgeons with international MGB experts. We believe that all surgeons will find the laparoscopic bariatric mini-trainingprogram to be of value with respect to future professional orientations. Many surgeons have started performing MGBs, andour goal was to pass on some of the experience with the thousands of prior MGB’s performed by these experts. The most useful parts of the course will include discussion of the identification and treatment of complications, the useof new instrumentation, and surgical demonstrations (live interactive). We believe that the participants will very likely notepresentation of novel knowledge by all participants. The 2-day MGB course offers participants high-quality novel knowledgeand excellent training quality, and we predict, significant impact on the quality of their patient care and on their personalcareer. The influence of clinical demonstrations, on the confidence and skills of surgeons, when treating patients with newersurgical techniques, even when they have the requisite skills is enormous. Studies show that surgeons who receive aninteractive clinical demonstration prior to treating their patients were more confident of their skills and the details of theirperformance and as a result their performance improved. Clinical demonstrations are difficult to arrange and manage, they are time consuming, but they are time well spent.We are proud to offer an addition to the didactic teaching and discussion of the First International Consensus Conference onthe Mini-Gastric Bypass / One Anastomosis Bypass. Sign-Up: http://satlivemgb.eventbrite.com/ A Live Interactive Demonstration of Mini-Gastric Bypass Surgery to a limited audience of interested surgeons. Weknow that surgeons who observe live demonstrations indicate higher scores for its helpfulness in performance of all the stagesof surgical techniques, when compared to those who had observed a videotaped demonstration. The Clinic: Geoffroy Saint-Hilaire private hospital Located in the heart of the oldest district of Paris, the Geoffroy Saint-Hilaire private hospital allies the strength of agroup and the tradition of the excellence. Geoffroy Saint Hilaire private hospital is a multidisciplinary establishment having 196beds and places dedicated. This clinic includes an intensive care unit for medical and surgical cares and provides all moderntechnologies and services. Sign-Up: http://satlivemgb.eventbrite.com/ Our Commitment to Excellence in Patient Safety as well as Surgeon Education Please know that we are committed to the highest levels of patient safety and are committed to the patient’s outcomesfrom live case demonstrations of the Mini-Gastric Bypass procedures. 11
  12. 12. Updated 10/12/12: Full Program==============================================================Oct 18: Thursday Morning:Survey Hand Out, Voting Questionnaire for Consensus Instructions 12
  13. 13. Time Presenter Subject9:00 Jean Mouiel Introduction: Honorary Chairman9:10 JM Chevallier Chairman First International Mini-Gastric Bypass / One AnastomosisConsensus Conference: ; Welcome, Charge to the Meeting; Listen, Learn, Discuss, Vote, Plan, Objectives: 1. Why Are We Here: MGB Excellent Therapy Not Widely Recognized 2. Create a Report of MGB Series: MGB Excellence Best Practices Treatment for Obesity/Metabolic Disease 3. Technical Details of Best Performance of MGB 4. Plan for Support, Adoption and Improvement of MGB around the World==============================================================SECTION I: Bariatric Today: Surgery Choices and Outcomes======= Special Guest Presentations: ============== The Story of Transition from “Non-MGB” to MGB Surgeon =======Time Presenter Subject9:20 Prof hon., Dr Martin Kox, Head Of Service Department Visceral Surgery, Centre Hospitalier EmileMayrisch, L -Esch-Alzette, Luxembourg. Personal Reflections; History of Peptic Ulcer Surgery Objectives History of General Surgery History of the Treatment of Ulcer Disease Vagotomy and Antrectomy for over 100 years What Happens When Bariatric Surgeons forget They are General Surgeons9:30 M Narwaria; Past President Obesity Surg Soc India ; My Journey to the MGB / MGB in India 1. Who Am I: Successful International leader in Bariatric Surgery? 2. Initial Skepticism of MGB 3. Initial Results with MGB 4. Insights into the Mind of an MGB Skeptic9:40 JM Chevallier, President Obesity Surg Soc France; What I know about MGB: 7 years experience 1. Who Am I: Successful International leader in Bariatric Surgery? 2. Initial Skepticism of MGB 3. Initial Results with MGB 4. Insights into the Mind of an MGB Skeptic9:50 R Rutledge; International Survey Bariatric Surgeons, Reflux & Esophageal cancer after Sleeve & Band 1. Survey of 112 Bariatric Surgeons from 23 Countries Around the World 2. In Short Band is not very good, 1/3 to ½ of surgeons have abandoned the Band 3. Sleeve and Band => Acid GE Reflux => 2 X Increased risk Esophageal Cancer 4. By Almost Every Measure MGB Outperforms the Band, the Sleeve and the RNY10:00 Opening Questions, Present Status; Meeting Goals & Future Plans 1. Limitations of Band, Sleeve & RNY 2. Ideal Bariatric Surgery (measures of Success) 3. Results of MGB 4. Recommendations for Type of Bariatric Surgery 1. Why Should Successful Bariatric Surgeons Choose MGB 2. Skepticism of MGB 3. Results of MGB 4. Response to MGB Skeptics 13
  14. 14. ==============================================================SECTION II: MGB Results with Large SeriesTime Presenter Subject10:10 R Tacchino My Experience with MGB in Italy10:20 K Kular My Experience with MGB in India10:30 M Garciacabaello My Experience with OAB in Spain10:40 C Peraglie My Experience with MGB in USA10:50 JP Chevallier My Experience with MGB in France11:00 J Cady My Experience with MGB in France11:10 R Rutledge My Experience with MGB; 15 years and 6,000 Patients Later11:20 MGB Results: Questions and Answers and Votes from Floor MGB vs Other Choices for Obese Patients MGB vs Band MGB vs Sleeve MGB vs RNY==============================================================SECION III: MGB/OAB Best Practice; Technical PerformanceTime Presenter Subject11:30 M Musella MGB in Italy; Technical Performance Issues in MGB 1. Caliber & Length of sleeve 2. Length of Bypass 3. Anastomosis (handsewn, mechanical, side to side, end to side,linear stapler, circular stapler, Reinforcement ofthe staple gastric sleeve line, Reinforcement of the gastric remnant staple line, (seamguard, peri strip, fibrin glue, othersealant…) Closure of the stapler access (single layer, double layer, mechanical continuous suture, manual continuous suture,mechanical interrupted stitches, manual interrupted stitches…) 4. Only ONE WAY or Multiple Equally Good Ways to Perform MGB11:40 C Peraglie Best Practices; Critical Technical Performance Issues in MGB 1. Caliber & Length of sleeve 2. Length of Bypass 3. Anastomosis (handsewn, mechanical, side to side, end to side,linear stapler, circular stapler, Reinforcement ofthe staple gastric sleeve line, Reinforcement of the gastric remnant staple line, (seamguard, peri strip, fibrin glue, othersealant…) Closure of the stapler access (single layer, double layer, mechanical continuous suture, manual continuous suture,mechanical interrupted stitches, manual interrupted stitches…) 4. Only ONE WAY or Multiple Equally Good Ways to Perform MGB11:50 R Ribeiro MGB in Portugal Tech Issues in MGB Gastric PouchThe Gastric Pouch Time 8 min 1. Surgeon/Patient Position, Ports Position/Placement, 2. Location of pouch initiation, Skeletonization of lesser curve, 3. Creation of the pouch: Use of the staple gun, Covidien/Ethicon: Pros & Cons, Location and angle of first staple cartridge Cartridge selection: White/Blue/Gold/Green, Delays: Before and During Staple Gun Firing 4. Wisdom of Old Men: 14
  15. 15. Fear “Thickness”, Fear The Tube/Bougie/NG tube Fear the Angle of His12:00 Jan Apers Dutch MGB, Tech Issues in MGB; Bypass & Leaks 1. Dutch Experience with MGB 2. Running the Bowel, Distance of the bypass, Tailoring the length bypass 3. Leaks after MGB 4. Managing Leaks12:10 J Cady MGB as Rescue for Failed Band 1. Band is Good choice? 2. Failure Rate (Weight Regain, Reflux) and Leak Rate 3. FU Band and MGB, complications and Weight Loss 4. Band vs MGB; 50% vs 90% Success12:20 Directed Discussion: Agreements and Controversies Technical Performance of MGB/OAB Panel: Chevalier, Garciacaballero, Tacchino, Kular, Peraglie, Nawaria, Weiner==============================================================Thursday Video Techniques Lunch 1 Garciacaballero 5 min video; 5 MGB Tips Peraglie 5 min video; 5 MGB Tips Kular 5 min video; 5 MGB Tips Videos Questions and Answers and Votes from Floor==============================================================Thursday afternoon :==========================================================SECTION IV: MGB Advantages, Long Term Studies & OtherTopics13:30 Sandeep Aggarwal MGB vs Other Surgery 1. Band vs MGB 2. BPD vs MGB 3. RNY vs MGB 4. Sleeve vs MGB13:40 K Mahawar, MGB Review of Literature on MGB 1. Review of MGB Publications 2. MGB Advantages 3. MGB Disadvantages 4. MGB: Conclusions from the medical Literature13:50 Maurizio De Luca Italian Experience with Band, RNY, Sleeve & MGB 1. MGB: Excess Weight Loss 2. MGB Op Time 3. Weight Regain 4. MGB: Reflux and Esophageal Cancer 15
  16. 16. 14:00 K S Kular: MGB vs Sleeve; Report on 200 Sleeves 1. Sleeve is Good choice for Many 2. Failure Rate (Weight Regain, Reflux) and Leak Rate 3. 3 yr FU Sleeve and MGB, Pouch Dilation and Weight Loss 4. Lee; Sleeve vs MGB, 50% vs 90% Success14:10 R Tacchino: MGB and BPD; compare and contrast 1. BPD is Good choice for Many 2. Failure Rate (Weight Regain, Reflux) and Leak Rate 3. 3 yr FU BPD and MGB, Pouch Dilation and Weight Loss 4. BPD, Band, Sleeve, MGB My Advice and Perspective14:20 A Peters: MGB vs. RYGB 1. RNY is Good choice for Many 2. Failure Rate (Weight Regain, Reflux) and Leak Rate 3. FU RNY and MGB, Bowel Obstruction and Weight Regain 4. RNY, BPD, Band, Sleeve, MGB My Advice and Perspective14:30 M Bhandari GERD Band& Sleeve vs. RNY & MGB I. Esophageal Cancer, Deadly and Increasing Worldwide II. GE Reflux Primary Cause of Esophageal Cancer III. Band & Sleeve CAUSE GE Reflux in 30% of Patients! IV. RNY & MGB Resolve GE Reflux in 80%+ V. Band and Sleeve May Be PreCancerous Lesions VI. Band and Sleeve Drs Need to Warn Patients of this Deadly Risk14:40 Questions and Answers and Votes from Floor14:50 Emilio Manno MGB Complications and Management (Leaks) 1. Italian Experience of MGB 2. Anemia 3. Ulcer 4. Inadequate / Excess Weight Loss / Other Complications15:00 M Van den Bossche; MGB in UK; GE Reflux; Band, Sleeve, RNY & MGB 1. UK Experience of MGB 2. Anemia 3. Ulcer 4. Inadequate / Excess Weight Loss / Other Complications15:10 Dr Cierny My experience with MGB in Czech Republic 1. Ulcer after MGB vs RNY 2. PreOp and Post Op Management Prevention 3. Treatment of Gastritis / Ulcer 4. No Smoking, NSAIDs, Rx H.Pylori, Anti-Acids (PPI’s, H2 Blockers), Bismuth subsalicylate, Yogurt, No Smoking!!,Soda, Coffee, Etoh, Green Tea, Meat, Hand washing, Careful food prep, Safe water source15:20 Dr S Shah Minimal Risk of Gastric Cancer after Billroth II, Processed Meat is MuchMore Dangerous 1. Gastric Cancer Declining; Esophageal Cancer Rising 2. BII in Few Studies Assoc with Gastric Ca But these are Ulcer Pts (H. Pylori) 3. Bile Reflux Rare and Easily treated while maintaining Weight Loss 4. GE Reflux Doubles the Risk of Esophageal Ca; Warn Patients 16
  17. 17. 15:30 Dr. Weiner Bile Reflux following Mini-Gastric Bypass (Omega Loop) 1. Bile Reflux Ulcer after MGB vs RNY 2. PreOp and Post Op Management / Prevention 3. Treatment of Gastritis / Ulcer 4. No Smoking, NSAIDs, Rx H.Pylori, Anti-Acids (PPI’s, H2 Blockers), Bismuth subsalicylate, Yogurt, No Smoking!!, Soda, Coffee, Etoh, Green Tea, Meat, Hand washing, Careful food prep, Safe water source, *** Endoscopy ***, *** Surgery Revision *** 15:40 Questions, Answers and Votes from the Floor Directed Discussion: Agreements and Controversies Panel: Chevalier, Garciacaballero, Tacchino, Kular, Peraglie, Nawaria, Weiner 1. Long Term Outcome of Band, Sleeve, RNY, BPDLong Term MGB Outcomes 3. Band, Sleeve, RNY, BPD vs. MGB Recommendations Always Choose MGB (Rutledge Doctrine) Always Choose Band, Sleeve, RNY, BPD Tailored Approach When to choose Band, Sleeve, RNY, BPD When to choose MGB 4. BPD vs. MGB Need for Further Study 16:00 Dr Rutledge; Failure of Restrictive Procedures: Coca-Cola & Ice Cream Beat Band & Sleeve 1. Bariatrics: A History of Failure, A Cautionary Tale 2. Remember the History of the Lap Band 3. Enthusiasm, Tempered Support, Early Concerns, Failure 4. Humans are POOR Decision makers 16:10 Questions and Answers and Votes from Floor Time: 1 hourReview of Survey Questions & VotingExpert Judgment & Voting: Outcome Band, Sleeve, RNY, BPDExpert Judgment & Voting: Outcome MGBBand, Sleeve, RNY, BPD vs. MGB === Consensus Recommendations === Always Choose MGB (Rutledge Doctrine) Never Choose MGB (ASMBS Doctrine) Tailored Approach === Consensus Recommendations === When to choose Band, Sleeve, RNY, BPD When to choose MGB Friday Morning: MGB; Experts Experience; TIPS and Tricks , Complications and Risks ========================================================== SECTION V: Beginning The Consensus Conference Final Statement 9:00 K S Kular: Safety, Safety, Safety; Choosing the MGB9:10 Garciacaballero; An Experts View, OAB Advantages & Advice 17
  18. 18. 1. My Consideration of OAB 2. My Patients, My Results of OAB 3. FIVE Core Advantages of OAB 4. Advice from My Experience9:20 R Tacchino; An Experts View, MGB Advantages 1. My Consideration of MGB 2. My Patients, My Results of MGB 3. Complications and Outcomes 4. Advice from My Experience9:30 Dr Narwaria An Experts View, Advice to the New MGBer 1. Why Should Successful Bariatric Surgeons Choose MGB 2. Criticism by Colleagues of MGB 3. Results of MGB / Results of Sleeve, Band and RNY 4. Response to MGB Skeptics/Critics9:40 Dr Peraglie; Marginal Ulcers: An Experts View9:50 Karl-Peter Rheinwalt My Advice on Becoming a New MGB Program 1. Why face Criticism to Offer the MGB 2. My Decision to Choose MGB 3. The Story of the Struggle to Offer MGB 4. Advice from My Experience10:00 Questions and Answers and Votes from Floor11:00 R Rutledge: Renaming the MGB/OAB; Survey Results, Discussion and Voting 1. Survey Results on Renaming the MGB 2. Keep MGB name and OAB name? 3. Create a New Name for both (BII Bypass, Omega Bypass, Sleeve Bypass 4. Some combination? 5. The MGB is a Bad name 6. The MGB is a Good Name 7. Relation between MGB and OAB (Friends, Brothers or enemies?) 8. Consensus Voting 9. Suggestions: 10. Class Name Single Anastomosis Bypass / Omega Bypass or other (include MGB AND OAB) 11. Two Sub-groups of SAB/OLB Class: 12. MGB = Type I SAB 13. OAB = Type II SAB11:10 Questions & Voting 1. Consensus Judgment of Experts and Conference on the MGB 1. Patient / Surgeons Advantages of MGB 2. Consensus Judgment of Experts and Conference on the 3. MOST Critical Advantages 4. Consensus Judgment of Experts and Conference on the Dangers of MGBVideo Techniques Lunch II Tacchino 5 min video; 5 MGB Tips 18
  19. 19. Chevallier 5 min video; 5 MGB Tips Rutledge 5 min video; Revision of MGB (Hint, Its Easy)========================================================SECTION VI: The End: The Final Consensus Conference VotingStatements & Planning for the Future============================================================== 13:00 Creation of the Consensus Statement; Review of Survey and Voting Results Review of Survey and Voting Results So Far Dr Rutledge Report on Survey of 100 Bariatric Surgeons from 23 countries and 39,000 cases In Short: Band is Less than Sleeve is less than RNY is Less than MGB Band and Sleeve: Cause Esophageal Reflux and Esophageal Cancer Conclusions the Experts Tell Us in the Survey 13:10 Questions and Answers and FINAL Votes from Floor 13:20 Pr Tacchino: Band, Sleeve, RNY & MGB Outcomes: Consensus Statement PreOp Factors Operative Factors: Gastric Sleeve Bypass Gastro-J Anesthesia Early Post Op Management Management Leaks Long Term Management 13:30 M Nawaria Critical Factors in Performance of MGB: Consensus Statement 13:40 Questions and Answers and FINAL Votes from Floor Consensus Statement Expert Judgment of Band, Sleeve, RNY Consensus Statement Expert Judgment of Band, Sleeve, Esophageal Cancer Consensus Statement Expert Judgment of MGB 14:00 Garciacaballero: The Future; Liberté, égalité, fraternité, "Liberty, equality, fraternity 14:10 Discussion and Voting "Liberty, equality, fraternity (brotherhood)" Time 8 min Organization and Mutual Support Consensus Statement Volunteer Proctors and Surgeon Resources Direct and Remote technical advice Research Support Collaborative Study Database Repeat Meeting Next Year (Garciacaballero) 15:00 Dr. Rutledge, IFSO, IFSO-EC, ASMBS Meeting Financial Report 15:10 Voting CONSENSUS : QUESTIONS AND ANSWERS Suggestions for organizing and supporting present surgeons and inviting new surgeons Vote on consensus statement Who will volunteer to help new surgeons Direct and Remote technical advice 19
  20. 20. Research Support Collaborative Study Database Meet again Next Year? Location? Timing Research Support 16:00 Society of MGB/OAB Surgeons; Open Discussion and Voting, Organization and Mutual Aide IFSO 2013 Istanbul Turkey, 1 Day Interest Group Submit Abstracts (Rutledge will help) IFSO-EC Invited to Present at the "Bariatric Club" Interest Group at IFSO-EC 2013? Other suggestions (French, English, Italian, German, Spanish, Indian Society meetings) IFSO Turkey IFSO-EC Bariatric Club Organize 1 day Post Grad Course at IFSO-EC 2013 MGB Presentations at French, English, Italian, German, Spanish, Indian Society meetings? Society of MGB/OAB Surgeons; Open Discussion and Voting Organization and Mutual Aide==============================================================TBA SECTION VII: Live Surgery withLive Surgery Demonstration on Saturday Oct 20Clinique Geoffroy Saint Hilaire - Paris59 Rue Geoffroy-Saint-Hilaire 75005 Paris, France01 44 08 40 00Dr Rutledge & Dr ChicheTwo Operating Rooms 6 - 8 MGB3 Visitors in OR, Video Transmission Conference Room 25 Surgeons(Contact DrR@clos.net for special invitation)Possible Dinner Meeting to Follow 20
  21. 21. Esophageal Cancer & GE Reflux: Brief Review The United States has experienced an alarming and unexplained increase in the incidence of esophageal adenocarcinoma(EAC) since the 1970s. Esophageal adenocarcinoma is the fastest growing cancer in the western world. A dramatic rise in oneof the deadliest types of cancers may be linked to the increasing rates of acid reflux and gastrointestinal disorders. Cancers ofthe esophagus and stomach are among the deadliest of all cancers with more than 80% of those affected dying within fiveyears.Although cancers of the stomach (gastric cancer) have been steadily declining over the last 50 years, studies show theincidence of a cancer affecting the esophagus (esophageal adenocarcinoma) has risen by about 600% over the past fewdecades. In the report, published in CA: A Cancer Journal for Clinicians, researchers reviewed studies on cancers located wherethe stomach ends and esophagus begins, referred to as the gastroesophageal junction (GEJ). The major risk factors for this type of cancer are gastroesophageal reflux disease (GERD) and its associated conditions,such as Barretts esophagus. In Barretts esophagus, precancerous changes are present. Other associated risk factors includealcohol and tobacco use, obesity, and eating a diet low in fruits and vegetables. Studies have shown that the part of the esophagus closest to the stomach is more exposed to concentrated gastric acidand a variety of agents that may contribute to the increased risk of cancer in this region. Despite advances in screening methods for this type of cancer, researchers say more research is needed to find newways to prevent the disease and detect it early. Major risk factors for this cancer are Gastroesophageal Reflux Disease (GERD) and Barretts esophagus. In one study frequent acid reflux (≥1 time/week) accounted for the greatest single risk factor of Esophageal Cancer36% 1. GE Reflux => Esophageal Cancer 2. Sleeve => Reflux 3. Band => Reflux 4. Esophageal Cancer in Band and Sleeve 5. Sleeve & Band => GE Reflux => Esophageal Cancer Clin Gastroenterol Hepatol. 2012 May;10(5):475-80.e1. Epub 2012 Jan 13. Erosive reflux disease increases risk foresophageal adenocarcinoma, compared with nonerosive reflux. Erichsen R, Robertson D, Farkas DK, Pedersen L, Pohl H, BaronJA, Sørensen HT. Source Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark. re@dce.au.dk In the study cohort, 26,194 of the patients over 3/4 (77%) had erosive reflux disease and37 subsequently developed esophageal adenocarcinoma after amean follow-up time of ONLY 7.4 years.Their absolute risk after 10 years was 0.24% (0.15%-0.32%).The incidence of cancer among patients with erosive reflux disease wassignificantly greater than that expected for the general populationOver Twice as high (standardized incidence ratio, 2.2; 95% CI, 1.6-3.0). 21
  22. 22. Often a pillow, doughnut or soft sand bag is placed byRutledge Version of Mini- the head Gastric Bypass: Tools, EndoTracheal tube placement and Vital signs assessed Then and only then the patient is replaced to flat Tips, Techniques; Special supine and the patient is prepped and draped in the usual needs for the Surgery fashion (Instruments, etc.) The surgeon stands on the patients Right Usually requiring a STEP Stool========== The Camera is immobilized by a self retaining cameraFirst: Warning NO anticoagulants, NSAIDs holder and one assistant is on the patients Left side========== Only two scrub forPATIENT POSITIONING: the caseThe patient is The Surgeon looks across the table from patients rightsupine (not lithotomy) to left to a screen at the head of the patient located 45The table will be inclined to MAXIMUM Trendelenburg degreesposition and Full tilt to the Left Side UP between the patients head and the patients left armThe requires a simple but very important patient This means that this are must be kept free of IV polesimmobilization on the table to ensure patient safety and and anesthesia paraphernaliamake sure the ==========large patient does not move during the operation BOUGIEBoth arms are out at 90 degrees the knees Weare use 24 - 32 French (NO Larger, No smaller)"broken to an angle of 45 degrees and two Large pillows In a pinch we can use Ewald Tubeare placed Or Gastroenterologist Red Weighted Dilating Bougiebeneath the knees NO 36-38 BougiesThe Heels are padded ==========SCDs are applied INSTRUMENTSand then most importantly The instruments need are simple but should be of high3 Three LARGE Leather or Polyester Straps (Seat Belts) quality.are applied to the legs The Mayo stand should containAt the upper thigh 1 scalpel of any typethe lower thigh Veress needleand mid tibia 5 Ports in totalThen to reassure all of the anesthesia, Of the 5 ports;nursing and other attendants 4 ports are 12mm ports (not 10 or 11mm) 12 mm portswith all of the team watching that can accept theThe table is slowly and carefully moved to MAXIMUM stapler (12 mm) as well as the 5 mm operatingReverse instruments.Trendelenburg and Full Tilt Left side up Of the 5 ports the remaining port is a single 5mm portAny adjustments are made Three separate 5 mm 22
  23. 23. graspers of excellent quality, at least 2 should be Locking to make a 12mm incision 1 and 1/2 palm widths below theGraspers xiphi sternumOne of the 3 three, This may vary slightly with patient size but is5 mm graspers should ideally have longer jaws to allow a remarkably constantfirm safe The 12 mm "Camera port" is used to enter the abdomenlocked grip on the intestine The surgeonIn case of emergency there should be two good quality usesneedle drivers (in most cases not needed, but should be the camera to briefly explore the abdomen and note theon the back location of thetable) Veress needle and the Veress is removed under directStapler, Ideally Covidien 60 mm blue or Purple although visionJohnson Can be used as backup The final 4 ports are now placedNo other Open Surgery instruments on the back table The locations are as follows:Skin closure is with 1 (one) single staple in each port 1, One 5 mm port several cm medial to the left axillaryand for this we need a single pair of Adsons forceps with line 2-3 finger breadths below the costal marginteeth and 1, One 12 mm port left mid-clavicular line 2-3 fingercommercial staple gun breadths belowNo suction is on the table the costal marginWe use the Harmonic scalpel if possible 1, One 12 mm port Midline 2-3 finger breadths below theNo sutures open. xiphi sternumbut have 3-O 1, One 12 mm port Right mid-clavicular line 2-3 fingerVicryl on sh needle available if necessary, breadths belowDo Not Open the costal margin=========================== Total 5 PortsA brief summary of the procedure may be of interest In roughly a "Diamond" patternThe surgeons approaches the patient in flat supine 1 Midline 1 and 1/2 palms below xiphi sternum (theposition from the patients left side. Primary But not only,"The abdomen is examined and the location of the left Camera Port")lateral extent of the rectus sheath 1 Left Anterior Axillary Line 5 mm grasper / retractor portapproximately 4-5 finger breadths below the left costal 1 Right Mid-clavicular line port, used for stapler andmargin is camera atestimated. several points during the case for only a few momentsWith 2 Primary Surgeons Working Portsthe "go ahead" (Right Hand and Left hand)from anesthesia a 5 mm incision is made and the Veress Left hand = Midline Portneedle is Right hand = Patientsadvanced into the abdominal cavity and insufflated. Left Mid clavicular Line portThe surgeon Patientmoves is now, with approval of anesthesia,to the patients right side and after insufflation the scalpel tilted to Maximum Reverse Trendelenburg and left side upis used Warning poor anesthesia can lead to hypotension 23
  24. 24. Anesthesia must be prepared and educated as tothe Attention turned to the Left Gutterplanned revers Trendelenburg positioning and Retract the omentum medially and Identify Ligament ofdrug use so to avoid hypotension when tilting the patient TreitzPoor anesthesia Run the bowel 2 m= No surgery Count to 60Now the steps in brief for the operation ==========The left hand grasper elevates the left lobe of the Grasp and lock the loop of bowel with larger 5mmliver and the harmonic is used to dissect the lesser curve atraumatic lockingof the grasperstomach at the junction of the body and the Antrum 5-10 Gastrotomy with harmonicminutes Change camera to R Lateral portStapler is passed via the Left Hand Working port into Enterotomythe abdomen and the stomach pouch creation is under Pass 60 mm Covidien Stapler in via the "Camera" portway Fire to form GJUsing the Left Hand working port or the Right side port Manipulate 24-30 mm bougie across the anastomosissecond stapler is fired Change camera back to camera port and pass 60 mmSurgeon staplerand anesthesia now discuss Bougie placement in via the Right lateral portThe bougie is advanced and retracted under direct vision Close the GJ========== Case overSurgeon Op time 35 minutesand anesthesia agree on bougie movement commands:AdvanceRetractTap Tap (A very tiny rapid in and out motion that aids inbougie identification)Now all staplers fired from the Right hand Working port3-5 staples to EG JunctionWARNING FEAR THE EG JUNCTIONStay lateral to EG JunctionOnly fools and Sleeve surgeons dissect near the EGJunction. It is not necessary for MGB and it is dangerousWith division of 80-95% of the stomach the area lateralto EGJ is visualizedIf necessary the short gastrics are divided under directvision with careful and meticulous dissectionCase Mantra "NO BLEEDING"The division of the stomach and creation of the pouch iscompletedOp time 15-20 minutes========== 24
  25. 25. ReferencesMini-Gastric Bypass ReferencesObes Surg. 2012 Sep 11. [Epub ahead of print] with laparoscopic mini-gastric bypass (LMGBP) and laparoscopicLaparoscopic Roux-en-Y Vs. Mini-gastric Bypass for the sleeve gastrectomy (LSG). Three patients with genetic diagnosisTreatment of Morbid Obesity: a 10-Year Experience. Lee of PWS and body mass index (BMI) greater than 40 kg/m(2) wereWJ, Ser KH, Lee YC, Tsou JJ, Chen SC, Chen JC. referred for bariatric surgery. All of them had completed 2-yearDepartment of Surgery, Min-Sheng General Hospital, National postoperative follow-up. Body weight, BMI, and ghrelin levelsTaiwan University, No. 168, Chin Kuo Road, Tauoyan, Taiwan, were recorded before and after surgery. They were two femalesRepublic of China, wjlee_obessurg_tw@yahoo.com.tw. and one male. Their age ranged from 15 to 23 years old, and theBACKGROUND: mean BMI was 46.7 kg/m(2) (range 44-50). Two patientsLaparoscopic Roux-en-Y gastric bypass (LRYGB) is considered the underwent LSG and one patient underwent LMGBP. After agold standard for the treatment of morbid obesity but is median follow-up of 33 months (range 24-36 months), meantechnically challenging and results in significant perioperative weight loss and percentage of excessive weight loss at 2 yearscomplications. While laparoscopic mini-gastric bypass (LMGB) has were 32.5 kg (24.9-38.3 kg) and 63.2 % (range 50.5-86.2 %),been reported to be a simple and effective treatment for morbid respectively. The mean fasting active ghrelin level decreased fromobesity, controversy exists. Long-term follow-up data from a large 1,134.2 pg/ml preoperatively to 519.8 pg/ml 1 year after surgery.number of patients comparing LMGB to LRYGB are lacking. No major complication was observed. Iron deficiency anemia wasMETHODS: observed in the patient who underwent LMGBP. SignificantBetween October 2001 and September 2010, 1,657 reduction of body weight and level of serum ghrelin can bepatients who received gastric bypass surgery (1,163 for achieved with minimal morbidity by LSG or LMGBP in patientsLMGB and 494 for LRYGB) for their morbid obesity were with PWS.recruited from our comprehensive obesity surgery center. Patientswho received revision surgeries were excluded. Minimum follow- 22923339up was 1 year (mean 5.6 years, from 1 to 10 years). Theoperative time, estimated blood loss, length of hospital stay, andoperative complications were assessed. Late complication, 3.changes in body weight loss, BMI, quality of life, and Obes Surg. 2012 May;22(5):697-703.comorbidities were determined at follow-up. Changes in quality of One thousand consecutive mini-gastric bypass: short- and long-life were assessed using the Gastrointestinal Quality of Life Index. term outcome.RESULTS: Noun R, Skaff J, Riachi E, Daher R, Antoun NA, Nasr M.There was no difference in preoperative clinical parameters Department of Digestive Surgery, Hôtel-Dieu de France Hospitalbetween the two groups. and University Saint Joseph Medical School, Bd Alfred Naccache,Surgical time was significantly longer for LRYGB (159.2 Achrafieh, BP 166830 Beirut, Lebanon. rnoun@wise.net.lbvs. 115.3 min for LMGB, p < 0.001). There is growing evidence that mini-gastric bypass (MGB) is aThe major complication rate was borderline higher for safe and effective procedure. Operative outcome and long-termLRYGB (3.2 vs. 1.8 %, p = 0.07). follow-up of a consecutive cohort of patients who underwent MGBAt 5 years after surgery, the mean BMI was lower in LMGB are reported. The data on 1,000 patients who underwent MGBthan LRYGB (27.7 vs. 29.2, p < 0.05) and from November 2005 to January 2011 at an academic institutionLMGB also had a higher excess weight loss than LRYGB were reviewed. Mean age was 33.15 ± 10.17 years (range, 14-(72.9 vs. 60.1 %, p < 0.05). 72), preoperative BMI was 42.5 ± 6.3 kg/m(2) (range, 26-75),Postoperative gastrointestinal quality of life increased significantly mean preoperative weight was 121.6 ± 23.8 kg (range, 71-240),after operation in both groups without any significant difference and 663 were women. Operative time and length of stay forat 5 years. Obesity-related clinical parameters improved in both primary vs. revisional MGB were 89 ± 12.8 min vs. 144 ± 15 mingroups without significant difference, but LMGB had a lower (p < 0.01) and l.85 ± 0.8 day vs. 2.35 ± 1.89 day (p < 0.01). Nohemoglobin level than LRYGB. deaths occurred within 30 days of surgery. Short-termLate revision rate was similar between LRYGB and LMGB (3.6 vs. complications occurred in 2.7% for primary vs. 11.6% for2.8 %, p = 0.385). revisionnal MGB (p < 0.01). Five (0.5%) patients presented withCONCLUSIONS: leakage from the gastric tube but none had anastomotic leakage.This study demonstrates that LMGBP can be regarded as Four (0.4%) patients, all with revisional MGB, presented witha simpler and safer alternative to LRYGB with similar severe bile reflux and were cured by stapling the afferent loopefficacy at a 10-year experience. and by a latero-lateral jejunojejunostomy. Excessive weight loss occurred in four patients; two were reversed and two were23011462 converted to sleeve gastrectomy. Maximal percent excess weight loss (EWL) of 72.5% occurred at 18 months. Weight regain subsequently occurred with a mean variation of -3.9% EWL at 60 2. months. The 50% EWL was achieved for 95% of patients at 18Obes Surg. 2012 Aug 26. [Epub ahead of print] months and for 89.8% at 60 months. MGB is an effective,Ghrelin Level and Weight Loss After Laparoscopic Sleeve relatively low-risk, and low-failure bariatric procedure. In addition,Gastrectomy and Gastric Mini-Bypass for Prader-Willi Syndrome in it can be easily revised, converted, or reversed.Chinese.Fong AK, Wong SK, Lam CC, Ng EK. 22411569Division of Upper GI Surgery, Department of Surgery, Prince of 4.Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Diabetes Technol Ther. 2012 Apr;14(4):365-72. Epub 2011 DecChina. 16.Prader-Willi syndrome (PWS) is a chromosomal disorder Role of bariatric-metabolic surgery in the treatment of obese typecharacterized by the presence of hyperghrelinemia, hyperphagia, 2 diabetes with body mass index <35 kg/m2: a literature review.and obesity. The optimal treatment for PWS patient remains Reis CE, Alvarez-Leite JI, Bressan J, Alfenas RC.controversial. Here, we present our experience of treating PWS School of Health Sciences, University of Brasília, Brasília, Brazil. 25
  26. 26. caioedureis@gmail.comBariatric surgery has been used to treat type 2 diabetes mellitus 22105765(T2DM); however, its efficacy is still debatable. This literature 6.review analyzed articles that evaluated the effects of bariatric Obes Surg. 2012 Mar;22(3):502-6.surgery in treatment of T2DM in obese patients with a body mass Bariatric surgery in Asia in the last 5 years (2005-2009).index (BMI) of <35 kg/m(2). A paired t test was applied for the Lomanto D, Lee WJ, Goel R, Lee JJ, Shabbir A, So JB, Huang CK,analysis of pre- and postintervention mean BMI, fasting plasma Chowbey P, Lakdawala M, Sutedja B, Wong SK,Kitano S, Chin KF,glucose (FPG), and glycosylated hemoglobin (A1c) values. A Dineros HC, Wong A, Cheng A, Pasupathy S, Lee SK,significant (P<0.001) reduction in BMI (from 29.95±0.51 kg/m(2) Pongchairerks P, Giang TB.to 24.83±0.44 kg/m(2)), FPG (from 207.86±8.51 mg/dL to Department of Surgery, Minimally Invasive Surgical Centre,113.54±4.93 mg/dL), and A1c (from 8.89±0.15% to National University Hospital, 5 Lower Kent Ridge Road, 119074,6.35±0.18%) was observed in 29 articles (n=675). T2DM Singapore, Singapore.resolution (A1c <7% without antidiabetes medication) was Erratum inachieved in 84.0% (n=567) of the subjects. T2DM remission, • Obes Surg. 2012 Feb;22(2):345. Fah, Chin Kin [corrected tocontrol, and improvement were observed in 55.41%, 28.59%, Chin, Kin-Fah].and 14.37%, respectively. Only 1.63% (n=11) of the subjects Obesity is a major public health concern around the world,presented similar or worse glycemic control after the surgery. including Asia. Bariatric surgery has grown in popularity toT2DM remission (A1c <6% without antidiabetes medication) was combat this rising trend. An e-mail questionnaire survey was senthigher after mini-gastric bypass(72.22%) and laparoscopic/Roux- to all the representative Asia-Pacific Metabolic and Bariatricen-Y gastric bypass (70.43%). According to the Foregut and Surgery Society (APMBSS) members of 12 leading Asian countriesHindgut Hypotheses, T2DM results from the imbalance between to provide bariatric surgery data for the last 5 years (2005-2009).the incretins and diabetogenic signals. The procedures that The data provided by representative members were discussed atremove the proximal intestine and do ileal transposition the 6th International APMBSS Congress held at Singaporecontribute to the increase of glucagon-like peptide-1 levels and between 21st and 23rd October 2010. Eleven nations exceptimprovement of insulin sensitivity. These findings provide China responded. Between 2005 and 2009, a total of 6,598preliminary evidence of the benefits of bariatric-metabolic surgery bariatric procedures were performed on 2,445 men and 4,153on glycemic control of T2DM obese subjects with a BMI of women with a mean age of 35.5 years (range, 18-69years) and<35 kg/m(2). However, more clinical trials are needed to mean BMI of 44.27 kg/m(2) (range, 31.4-73 kg/m(2)) by 155investigate the metabolic effects of bariatric surgery in T2DM practicing surgeons. Almost all of the operations were performedremission on pre-obese and obese class I patients. laparoscopically (99.8%). For combined years 2005-2009, the four most commonly performed procedures were laparoscopic22176155 adjustable gastric banding (LAGB, 35.9%), laparoscopic standard 5. Roux-en-Y gastric bypass (LRYGB, 24.3%), laparoscopic sleeveUpdates Surg. 2011 Dec;63(4):239-42. Epub 2011 Nov 22. gastrectomy (LSG, 19.5%), and laparoscopic mini gastric bypassLaparoscopic mini-gastric bypass: short-term single-institute (15.4%). Comparing the 5-year trend from 2004 to 2009, theexperience. absolute numbers of bariatric surgery procedures in AsiaPiazza L, Ferrara F, Leanza S, Coco D, Sarvà S, Bellia A, Di Stefano increased from 381 to 2,091, an increase of 5.5 times. LSGC, Basile F, Biondi A. increased from 1% to 24.8% and LRYGB from 12% to 27.7%, aGeneral and Emergency Surgery Department, Garibaldi Hospital, relative increase of 24.8 and 2.3 times, whereas LAGB and miniCatania, Italy, lpiazza267@gmail.com. gastric bypass decreased from 44.6% to 35.6% and 41.7% toThe elevated variety of procedures proposed for surgical 6.7%, respectively. The absolute growth rate of bariatric surgerytreatment of obesity in the last few years suggests the necessity in Asia over the last 5 years was 449%.to find an ideal operation. Laparoscopic mini-gastric bypass(LMGB) was developed to obtain better results with lesser 22033767morbidity and mortality. LMGB was introduced by Rutledge, in 7.1997, and it consists of a long lesser-curvature tube with a Obes Surg. 2011 Nov;21(11):1758-65.terminolateral gastroenterostomy 180 cm distal to the Treitz ESR1, FTO, and UCP2 genes interact with bariatric surgeryligament. From July 1995 to May 2011 we have performed 552 affecting weight loss and glycemic control in severely obesebariatric operations, among them we have operated 197 patients.laparoscopic mini-gastric bypass (Fig. 1). There were 147 female Liou TH, Chen HH, Wang W, Wu SF, Lee YC, Yang WS, Lee WJ.(75%) and 50 male (25%) with the mean age of 37.9 years Department of Physical Medicine and Rehabilitation, Shuang Ho(range 20-55) and the mean BMI of 52.9 kg/m(2). All procedures Hospital, Taipei Medical University, Taipei, Taiwan.were completed laparoscopically, without conversion and the Erratum inmean operative time was 120 min (range from 90 to 170 min). • Obes Surg. 2012 Jan;22(1):194.The average postoperative stay was 5.0 days. We report one case BACKGROUND:of mortality for pulmonary septic complications. Major Significant variability in weight loss and glycemic control has beencomplications were two cases of pulmonary embolism (treated in observed in obese patients receiving bariatric surgery. GeneticICU), six cases of melena on seventh postoperative day and three factors may play a role in the different outcomes.cases of anastomotic ulcers resolved with high doses of PPI. We METHODS:registered a significant reduction of BMI and percentage of Five hundred and twenty severely obese patients with body massexcess weight after surgery with a significant improvement in index (BMI) ≥35 were recruited. Among them, 149 and 371obesity-related comorbidities including blood pressure, subjects received laparoscopic adjustable gastric banding (LAGB)hyperglycemia, blood lipid, uric acid, and liver function. An ideal and laparoscopic mini-gastric bypass (LMGB), respectively. Allweight loss operation should be effective, easy to perform and individuals were genotyped for five obesity-related singlesafe. Laparoscopic Roux-en-Y GastricBypass is actually the "gold- nucleotide polymorphisms on ESR1, FTO, PPARγ, and UCP2 genesstandard" technique but LMGB seems to be an attractive to explore how these genes affect weight loss and glycemicalternative: shorter operative time, with less morbidity and control after bariatric surgery at the 6th month.mortality, easier to teach and to perform. Another advantage RESULTS:could be the presence of a single anastomosis alone reducing the Obese patients with risk genotypes on rs660339-UCP2 hadpossibility of leaks. greater decrease in BMI after LAGB compared to patients with 26
  27. 27. non-risk genotypes (-7.5 vs. -6 U, p = 0.02). In contrast, after including laparoscopic adjustable gastric banding(LAGB, n=201),LMGB, obese patients with risk genotypes on either rs712221- laparoscopic mini gastricbypass(LMGB, n=13), and laparoscopicESR1 or rs9939609-FTO had significant decreases in BMI (risk vs. sleeve gastrectomy(LSG, n=5). Clinical data were analyzednon-risk genotype, -12.5 vs. -10.0 U on rs712221, p = 0.02 and - retrospectively.12.1 vs. -10.6 U on rs9939609, p = 0.04) and a significant RESULTS:amelioration in HbA1c levels (p = 0.038 for rs712221 and The mean body mass index(BMI) of patients who received LAGBp < 0.0001 for rs9939609). The synergic effect of ESR1 and FTO was 37.9 kg/m(2), and decreased to 32.4 kg/m(2) at 6 monthsgenes on HbA1c amelioration was greater (-1.54%, p for trend and to 29.7 kg/m(2) at 12 months. In 43 patients who had<0.001) than any of these genes alone in obese patients concurrent T2DM, 11(25.6%) showed clinical partialreceiving LMGB. remission(CPR) and 16(37.2%) clinical complete remission (CCR).CONCLUSIONS: Postoperative complications occurred in 26 patients(12.9%). TheThe genetic variants in the ESR, FTO, and UCP2 genes may be mean BMI of patients undergoing LMGB was 34.7 kg/m(2), andconsidered as a screening tool prior to bariatric surgery to help decreased to 31.6 kg/m(2) at 6 months and 26.9 kg/m(2) at 12clinicians predict weight loss or glycemic control outcomes for months after surgery. Ten patients had T2DM before operation, ofseverely obese patients. whom 2(20.0%) had CPR and 7(70.0%) CCR postoperatively. Postoperative complications occurred in 2 patients(15.4%). The21720911 mean BMI of patients who underwent LSG was 43.8 kg/m(2), and 8. was reduced to 38.1 kg/m(2) at 6 months and 34.3 kg/m(2) at 12Obes Rev. 2011 Aug;12(8):602-21. doi: 10.1111/j.1467- months after operation. Three patients were diagnosed with789X.2011.00866.x. Epub 2011 Mar 28. T2DM before operation. One patient (33.3%) had CPR andBariatric surgery: a systematic review and network meta-analysis 1(33.3%) reached CCR after operation. There was 1(20.0%)of randomized trials. patient who developed complication. No perioperative deathPadwal R, Klarenbach S, Wiebe N, Birch D, Karmali S, Manns B, occurred.Hazel M, Sharma AM, Tonelli M.Department of Medicine, University of Alberta, Edmonton, CONCLUSION:Alberta, Canada. Laparoscopic gastrointestinal surgery may result in satisfactoryThe clinical efficacy and safety of bariatric surgery trials were weight loss and clinical remission of T2DM with fewsystematically reviewed. MEDLINE, EMBASE, CENTRAL were complications.searched to February 2009. A basic PubCrawler alert was run untilMarch 2010. Trial registries, HTA websites and systematic reviews 21365507were searched. Manufacturers were contacted. Randomized trialscomparing bariatric surgeries and/or standard care were selected. [PubMed - in process]Evidence-based items potentially indicating risk of bias were Publication Typesassessed. Network meta-analysis was performed using Bayesian 10.techniques. Of 1838 citations, 31 RCTs involving 2619 patients World J Surg. 2011 Mar;35(3):631-6.(mean age 30-48 y; mean BMI levels 42-58 kg/m(2) ) met Laparoscopic mini-gastric bypass for type 2 diabetes: theeligibility criteria. As compared with standard care, differences in preliminary report.BMI levels from baseline at year 1 (15 trials; 1103 participants) Kim Z, Hur KY.were as follows: jejunoileal bypass [MD: -11.4 kg/m(2) ], mini- Department of Surgery, Soonchunhyang University College ofgastric bypass [-11.3 kg/m(2) ], biliopancreatic diversion [-11.2 Medicine, Soonchunhyang University Hospital, Hannam-dong,kg/m(2) ], sleeve gastrectomy [-10.1 kg/m(2) ], Roux-en-Y Yongsan-gu, Seoul 140-743, Korea.gastric bypass[-9.0 kg/m(2) ], horizontal gastroplasty [-5.0 BACKGROUND:kg/m(2) ], vertical banded gastroplasty [-6.4 kg/m(2) ], and Type 2 diabetes mellitus (T2DM) has become an epidemic healthadjustable gastric banding [-2.4 kg/m(2) ]. Bariatric surgery problem worldwide. Compared to Western countries, in Asia,appears efficacious compared to standard care in reducing BMI. T2DM occurs in patients with a lower body mass index (BMI) dueWeight losses are greatest with diversionary procedures, to central obesity and decreased pancreatic β-cell function. Theintermediate with diversionary/restrictive procedures, and lowest efficacy of laparoscopic mini-gastric bypass(LMGB) in obesewith those that are purely restrictive. Compared with Roux-en-Y patients with T2DM has been proven by numerous studies.gastric bypass, adjustable gastric banding has lower weight loss Treatment outcomes of LMGB for non-obese T2DM patients areefficacy, but also leads to fewer serious adverse effects. also estimated to be excellent. The aim of the present pilot study© 2011 The Authors. obesity reviews © 2011 International was to evaluate the efficacy and safety of LMBG in non-obeseAssociation for the Study of Obesity. T2DM patients (BMI 25-30 kg/m(2)). METHODS:21438991 Ten consecutive patients underwent LMGB at our hospital fromGrant Support August 2009 to October 2009. Preoperative data including 9. glycosylated hemoglobin (HbA1c), fasting plasma glucose (FPG),Zhonghua Wei Chang Wai Ke Za Zhi. 2011 Feb;14(2):128-31. and 2 h postprandial glucose (2-h PPG) were compared with data[Outcomes after laparoscopic surgery for 219 patients with collected at 1, 3, and 6 postoperative months.obesity]. RESULTS:[Article in Chinese] All procedures were completed laparoscopically. Mean age of theDing D, Chen DL, Hu XG, Ke CW, Yin K, Zheng CZ. patients was 46.9 years, mean BMI was 27.2 kg/m(2), meanDepartment of Minimally Invasive Surgery, Changhai Hospital, The operative time was 150.5 min, and mean postoperative hospitalSecond Military Medical University, Shanghai 200433, China. stay was 5.3 days. Neither mortality nor major complicationsOBJECTIVE: occurred. Mean preoperative glycosylated hemoglobin (HbA1c),To evaluate the outcomes after laparoscopic gastrointestinal fasting plasma glucose (FPG), 2-h PPG, and C-peptide level weresurgery for patients with obesity and type 2 diabetes 9.7%, 222 mg/dl, 343 mg/dl, and 2.78 ng/ml, respectively. At themellitus(T2DM). sixth postoperative month, HbA1c, FPG, 2-h PPG, and C-peptideMETHODS: level measured 6.7%, 144 mg/dl, 203 mg/dl, and 2.18 ng/ml.From June 2003 to June 2010, 219 patients underwent CONCLUSIONS:laparoscopic gastrointestinal surgery for obesity and T2DM, This preliminary study demonstrated the resolution of 27
  28. 28. hyperglycemia in 70% of non-obese T2DM patients (BMI 25-30 bypass (LMGB) or adjustable gastric banding (LAGB) withkg/m(2)). Although long-term follow-up data are required, early complete clinical data at baseline and at two years were enrolledoperative outcomes were satisfactory in terms of glycemic control for analysis. Decision Tree, Logistic Regression and Discriminantand safety of the procedure. analysis technologies were used to predict weight loss. Overall classification capability of the designed diagnostic models was21165621 evaluated by the misclassification costs. 11. RESULTS:Obes Surg. 2011 Aug;21(8):1209-19. Two hundred fifty-one patients consisting of 68 men and 183Reasons and outcomes of reoperative bariatric surgery for failed women was studied; with mean age 33 years. Mean +/- SDand complicated procedures (excluding adjustable gastric weight loss at 2 year was 74.5 +/- 16.4 kg. During two years ofbanding). follow up, two-hundred and five (81.7%) patients had successfulPatel S, Szomstein S, Rosenthal RJ. weight reduction while 46 (18.3%) were failed to reduce bodyBariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, weight. Operation methods, alanine transaminase (ALT),FL 33331, USA. aspartate transaminase (AST), white blood cell counts (WBC),BACKGROUND: insulin and hemoglobin A1c (HbA1c) levels were the predictiveThe rise of bariatric surgery has lead to an increasing number of factors for successful weight reduction.reoperations for failed bariatric procedures. The reasons and CONCLUSION:types of these operations are varied in nature and remain to be Decision tree model was a better classification models thandefined. traditional logistic regression and discriminant analysis in view ofMETHODS: predictive accuracies.A retrospective review of a prospectively collected database wasconducted to identify patients who underwent laparoscopic 20214230revisional surgery for non-gastric banding-related bariatricprocedures between 2001 and 2008. 13.RESULTS: J Chir (Paris). 2009 Feb;146(1):60-4.Of 384 secondary bariatric operations, 151 reoperative [Laparoscopic mini-gastric bypass].procedures were performed. Twenty-six vertical banded [Article in French]gastroplasties (17.2%), 2 mini-gastric bypasses (1.3%), 2 non- Chevallier JM, Chakhtoura G, Zinzindohoué F.divided bypasses (1.3%), 1 distal Roux-en-Y gastric bypass Service de chirurgie digestive, hôpital Européen Georges-(RYGBP; 0.7%), and 2 sleeve gastrectomies (1.3%) were Pompidou, Paris. jean-marc.chevallier@egp.aphp.frconverted to RYGBP. Three RYGBP (2%) and four jejunoilealbypass procedures (2.6%) were reversed secondary to 19446695malnutrition. One jejunoileal bypass (0.7%) and one 14.biliopancreatic diversion (0.7%) underwent sleeve gastrectomies. Surg Obes Relat Dis. 2009 May-Jun;5(3):383-6. Epub 2009 JanThree pre-anastomotic rings were removed due to erosion (2%). 18.Eleven pouch trimmings (7.3%), 16 redo gastrojejunostomies Laparoscopic conversion of distal mini-gastric bypass to proximal(10.6%), 5 redo jejunojejunostomies (3.3%), 36 remnant Roux-en-Y gastric bypass for malnutrition: case report and reviewgastrectomies (23.8%), and 2 gastrogastric fistula takedowns of the literature.(1.3%) were performed for pouch enlargements, strictures, and Dang H, Arias E, Szomstein S, Rosenthal R.gastrogastric fistulas. Thirty-six patients (23.8%) underwent a Bariatric and Metabolic Institute, Section of Minimally Invasivecombination of these procedures. The major morbidity (13.2%) and Endoscopic Surgery, Cleveland Clinic Florida, Weston, Florida,was related to leaks. Other complications included wound USA.infection, intra-abdominal abscess formation, and trocar sitehernias. The mortality rate was 2%. 19356992CONCLUSIONS: 15.Reoperative bariatric surgery is a complex and growing field in Obes Surg. 2008 Sep;18(9):1126-9. Epub 2008 Jun 25.bariatric surgery. The indications for surgical reoperation can vary Laparoscopic mini-gastric bypass (LMGB) in the super-superdepending on the procedure and reason for intervention. obese: outcomes in 16 patients.Laparoscopy appears to be a feasible approach. Though safe, Peraglie C.morbidity and mortality are significantly higher than in primary The Centers of Laparoscopic Obesity Surgery-Florida, Heart ofbariatric procedures. Florida Regional Medical Center, 40124 Highway 27, Davenport, FL, USA. drp@clos.net20676940 BACKGROUND: 12. The ideal management of the super-super obese patient (SSO) isHepatogastroenterology. 2009 Nov-Dec;56(96):1745-9. unclear and controversy exists as to the choice of procedure asObesity and the decision tree: predictors of sustained weight loss well as the risk for increased morbidity and mortality. I presentafter bariatric surgery. my experience of laparoscopic mini-gastric bypass (LMGB) in 16Lee YC, Lee WJ, Lin YC, Liew PL, Lee CK, Lin SC, Lee TS. SSO patients with early follow-up results.Department of International Business, Ching-Yun University, METHODS:Zhongli City, Taiwan. lyc6115@ms61.hinet.net Review of a prospectively maintained database was performed.BACKGROUND/AIMS: All the patients underwent LMGB by a single surgeon (CP). DataBariatric surgery is the only long-lasting effective treatment to collected included demographics, operative time, length of stay,reduce body weight in morbid obesity. Previous literature in using complications, and weight loss. Follow-up data was obtained atdata mining techniques to predict weight loss in obese patients office visits in addition to periodic telephone interviews and e-who have undergone bariatric surgery is limited. This study used mails. All office follow-up and review of correspondence frominitial evaluations before bariatric surgery and data mining Primary Care Physicians (PCP) was managed by the operatingtechniques to predict weight outcomes in morbidly obese patients surgeon.seeking surgical treatment. RESULTS:METHODOLOGY: Sixteen patients were identified as being SSO and comprise the251 morbidly obese patients undergoing laparoscopic mini-gastric study group. There were 14 women and two men. Average age 28
  29. 29. was 40 years (27-61). Average weight and BMI were 166 (150- Obes Surg. 2007 Nov;17(11):1482-6.193) and 62.4 (60-73), respectively. All procedures were Mini-gastric bypass by mini-laparotomy: a cost-effectiveperformed laparoscopically by a single surgeon with no alternative in the laparoscopic era.conversion to open. Average operative time was 78 min (41-147 Noun R, Riachi E, Zeidan S, Abboud B, Chalhoub V, Yazigi A.min) and hospital stay was 1.2 days. Intraoperative complications Department of Digestive Surgery, Hôtel-Dieu de France Hospital,included a liver laceration in one patient and an enterotomy in Beirut, Lebanon. rnoun@wise.net.lbanother. Both were managed laparoscopically. No patients BACKGROUND:required readmission to the hospital, and there were no major Laparoscopic mini-gastric bypass (MGB) is being increasinglycomplications or deaths. Weight loss showed a consistent performed worldwide. Results of MGB by mini-laparotomyincrease over the follow-up period with 2 year results of 72 KG (minilap MGB) are hereby reported.lost or 65% EWL. METHODS:CONCLUSION: 126 patients undergoing minilap MGB from October 2004 toLaparoscopic mini-gastric bypass (MGB) is a technically simple October 2006, were reviewed at an academic institution.and safe procedure in SSO patients. LMGB has the advantages of RESULTS:being a single stage procedure, being easily reversible and Mean age was 35 +/- 11.4 years (range 15-72), preoperative BMIrevisable in a laparoscopic procedure and does not sacrifice was 44 +/- 6.9 kg/m2 (range 35-61.8) and 80 (63.4%) wereportions of the stomach or implant foreign materials. Weight loss women. Co-morbidities were present in 42 (33.3%). Operativeappears favorable in the short term; however, information time was 144 +/- 15.8 minutes (range 120-160) and length ofregarding long-term weight loss, durability, and safety profile in hospital stay was 3.32 +/- 0.62 days (range 2-18). There was nothis population will require a greater number of patients and hospital mortality, and the in-hospital complication rate was 4.7%.longer follow up. No anastomotic leakage occurred, and the incidence of wound sepsis was 2.3%. The mean total cost of the procedure was 340818575943 +/- 547 USD (range 2967-6876). Five patients (3.9%) developed 16. incisional hernias and 3 (2.3%) marginal ulcers. BMI at 6 monthsObes Surg. 2008 Sep;18(9):1130-3. Epub 2008 Jun 20. was 33.0 +/- 3.1 kg/m2 (range 26.8-43.5, P < 0.001) comparedPrimary results of laparoscopic mini-gastric bypass in a French with preoperative value. At 1 year, mean excess weight loss wasobesity-surgery specialized university hospital. 68.4% and comorbidities resolved in 85%.Chakhtoura G, Zinzindohoué F, Ghanem Y, Ruseykin I, Dutranoy CONCLUSION:JC, Chevallier JM. Minilap MGB is a simple, safe, effective and low-cost gastricAssistance Publique-Hôpitaux de Paris, University Paris 5, Paris, bypass. It represents an attractive cost-effective alternative toFrance. laparoscopic MGB.BACKGROUND:Since 2002, we have performed 350 laparoscopic Roux-en-Y 18219775gastric bypasses (LRYGB). We decided to evaluate thelaparoscopic mini-gastric bypass (LMGB), an operation reported 18.as effective, yet simpler than LRYGB. It consisted of a long lesser Obes Surg. 2008 Mar;18(3):294-9. Epub 2008 Jan 12.curvature tube with a terminolateral gastroenterostomy, 200 cm Laparoscopic mini-gastric bypass: experience with tailored bypassdistal to the Treitz ligament. limb according to body weight.METHODS: Lee WJ, Wang W, Lee YC, Huang MT, Ser KH, Chen JC.From October 2006 to November 2007, 100 patients (23 men and Department of Surgery, Min-Sheng General Hospital, National77 women) underwent LMGB. The mean age was 40.9 +/- 11.5 Taiwan University, Taipei, Taiwan, Republic of China.years (17.5-62.4), the preoperative mean body weight was 131 wjlee_obessurg_tw@yahoo.com.tw+/- 23.1 kg (82-203) and the mean BMI was 46.9 +/- 7.4 BACKGROUND:kg/m(2) (32.8-72.4). Twenty-four patients had prior restrictive Gastric bypass surgery is an effective and long-lasting treatmentprocedure: 20 LAGB of which nine were already removed and four of morbidly obese patients. However, the bypass limb may needVBG (two laparoscopic and two by open surgery). In preoperative to be tailored in morbidly obese patients with a wide range ofgastric endoscopy Helicobacter pylorii was present in 26 patients obesity. The aim of the present study was to report clinical resultand eradicated. of tailored bypass limb in a group of patients receivingRESULTS: laparoscopic mini-gastric bypass surgery.All procedures were completed laparoscopically by six different METHODS:surgeons. Mean operative time was 129 +/- 37 min. There was From Jan 2002 to Dec 2006, laparoscopic mini-gastric bypass wasno death. Seven patients (7%) presented major early performed in 644 patients [469 women, 175 men: mean age 30.5complications: three reoperations for incarcerated herniation of +/- 8.1 years; mean body mass index (BMI) 43.1 +/- 6.0] in oursmall bowel in the trocar wound, one peritonitis due to a department. The gastric bypass limb was tailored according to thetraumatic injury of the biliary limb, one perianastomotic abscess, preoperative BMI. The clinical data and outcomes were analyzed.one intraabdominal bleeding requiring splenectomy, and one All the clinical data were prospectively collected and stored.endoscopic haemostasis for anastomotic bleeding. One patient RESULTS:presented anastomotic stenosis that required endoscopic Two hundred eighty-six patients belonged to lower BMI (BMI <dilatation 2 months postoperatively. Mean BMI at 3 months was 40; mean 36.0), 286 patients moderate BMI (BMI 40-50; mean38.7 kg/m(2) (31.2-60.9) and at 6 months 35.1 (23.6-53.0). Nine 43.2), and 72 patients higher BMI (BMI > 50; mean 55.4). Allpatients complained of diarrhea that resolved 3 months procedures were completed laparoscopically. Mean operative timepostoperatively and, significantly, only two patients complained of was 130 min, and mean hospital stay was 5.0 days. Twenty-threebiliary reflux. minor early complications (4.3%) and 13 major complicationsCONCLUSION: (2.0%) were encountered, with one death occurred (0.016%).Pending long-term evaluation, LMBG seems a good alternative to There was no significant difference in operation time andLRYGB, giving the same results with a more simple and complication rate between the groups. The mean bypass limb wasreproductible technique. 150 cm for the lower BMI group, 250 cm for moderate BMI group, and 350 cm for the higher BMI group. The mean BMI reduction 218566866 years after surgery was 10.7, 15.5, and 23.3 for the lower, 17. moderate, and higher BMI group. The weight loss curves and 29

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