The clinical audit summarizes the results of 1,107 bariatric surgery cases performed between 2007-2014. It finds that the mini-gastric bypass (MGB) procedure has the best outcomes in terms of excess weight loss, resolution of comorbidities like diabetes and hypertension, and lowest rates of complications and mortality. Specifically, MGB achieved 92.18% excess weight loss, resolved 94.37% of diabetes cases, and had 0% mortality. In comparison, laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RNY) had lower success rates. Based on these findings, the audit recommends MGB as the procedure of choice for treating morbid obesity.

1. CLINICAL AUDIT
January 2007 to March 2014
For Effective and Safe
BARIATRIC & METABOLIC PROCEDURE
Dr. G. S. Jammu
MS, FAIS
Director cum Chief Bariatric Surgeon
JAMMU HOSPITAL, JALANDHAR (PUNJAB) INDIA
Email : drgsjammu@gmail.com • www.jammuhospital.com

2. Disclosures
Dr. G. S. Jammu
MS, FAIS
Director cum Chief Bariatric Surgeon
No Disclosure

3. Introduction
Obesity is complex disease, its epidemic is increasing not only
in developed countries but also in developing countries like
India. Obesity leads to many diseases like T2D, hypertension,
sleep apnea and fatty liver disease.
Bray, G.A. 1999. “Nutrition and obesity: Prevention and treatment”, Journal of Nutrition
Metabolic Cardiovascular Disease 9: 21-32.

4. Introduction
 In 2013, 13% people were obese world wide. India is the
third most obese country with figures as high as 30 million.
 In India problem is associated with under nutrition and the
significant proportion of overweight and obese people now
coexist. (Popkin, 2002).
• Lancet Journal
• Popkin, 2002

5. Objectives
Primary
To formulate safe & effective surgical policy for bariatric and
metabolic procedures.
Secondary
To analyze the post operative complications developed in
respective procedures by comparing LSG, RNY and MGB in
bariatric surgery.

6. Material and Methods
Audit is based on retrospective study carried out at a
single centre Jammu Hospital Jalandhar, India
from Jan 2007 to March 2014
by a Medical Audit Committee
• Bariatric Surgeon
• Physician
• Anesthetist
• Bariatric Counselor
• Nutritionist

7. A Inclusion Criteria for complication part :
All 1,107 cases (87 months period).
B Inclusion Criteria for EWL & resolution of comorbidities
part :
Cases with mean follow-up of 53.5 months (Max. 87
months and Min. 20 months)
Material and Methods

8. A Data Collection
(Complication Part)
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Sample size : 1107 cases
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Female : 63.0% (697) Male : 37.0% (410)
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Mean Age : 46.5 Years (18-72 Years) Mean BMI : 42 (30-72)
------------------------------------------------------------------------------------------
T2D : 48.6% (538) HTN : 47.7% (528) Dyslipidemia : 42.7% (473)
------------------------------------------------------------------------------------------
LSG : 339 (30.6%) RNY : 295 (26.5%) MGB : 473 (42.7%)
------------------------------------------------------------------------------------------
Mean Surgery Time (Mins.) :
MGB : 57.5 (42-75) RNY : 160.5 (123-198) LSG : 60 (45-75)
------------------------------------------------------------------------------------------

9. Comorbidities
T2D : 29.0% (118)
HTN : 30.7% (125)
Dyslipidemia : 28.5% (116)
B Data Collection
EWL & Resolution of Comorbidities
( Mean follow-up of 53.5 months)
Types of Surgeries
LSG : 97 (23.83%)
RNY : 143 (35.13%)
MGB : 167 (41.03%)
Total sample size : 407 cases

10. 1. Complications
a. Life threatening Complications
b. Non Life threatening Complications
2. Benefits
EWL & Resolution of Comorbidities
Observations

11.  Prevalence of Iron, folate & Vitamin B12 deficiency anemia after laparoscopic Roux-en-y gastric bypass. Vargas-Rulz AG,
Hernonlez Rivera G, Herrera MI, Obes Surgery 2008 Mar. 18 (3), 288-93
 Nutritional Deficiencies following Bariatric Surgery: What Have We Learned? Richard D. Bloomberg, MD, FRCSC; Amy
Fleishman, MS, RD, CDN; Jennifer E. Nalle, RN, MS, FNP; Daniel M. Herron, MD, FACS; Subhash Kini, MD, FRCS
 After gastric bypass surgery : Managing medical & surgical disorder : Macronutrient & Micronutrient disorders. Bikram
Bal, MD, Timothy R. Koch, MD, Frederick C Fineli, MD, JD, Michael G.Sars, MD. CME Released 5/11/2010.
Complication External
Bleeding
Internal
Bleeding
Leaks Pulmonary
Embolism
& DVT
Respiratory
Failure
Persistent
vomiting
Anaemia Mortality Hypo
Albumin-
emia
LSG 1.42 0.44 0.71 1.33 3.56 2.14
RNY 0.625 0.625 0.625 4.05 0.625
Standard
RNY
1.9
-----------
Distal
RNY
14.0
MGB 1 0.5 4.52 13.1
Observations
Life Threatening Complications

12. Complication External
Bleeding
Internal
Bleeding
Leaks Pulmonary
Embolism
& DVT
Respiratory
Failure
Persistent
vomiting
Anaemia Mortality Hypo
Albumin-
emia
LSG 1.42 0.44 0.71 1.33 3.56 2.14
RNY 0.625 0.625 0.625 4.05 0.625
Standard
RNY
1.9
-----------
Distal
RNY
14.0
MGB 1 0.5 4.52 13.1
Observations
Life Threatening Complications
 Prevalence of Iron, folate & Vitamin B12 deficiency anemia after laparoscopic Roux-en-y gastric bypass. Vargas-Rulz AG,
Hernonlez Rivera G, Herrera MI, Obes Surgery 2008 Mar. 18 (3), 288-93
 Nutritional Deficiencies following Bariatric Surgery: What Have We Learned? Richard D. Bloomberg, MD, FRCSC; Amy
Fleishman, MS, RD, CDN; Jennifer E. Nalle, RN, MS, FNP; Daniel M. Herron, MD, FACS; Subhash Kini, MD, FRCS
 After gastric bypass surgery : Managing medical & surgical disorder : Macronutrient & Micronutrient disorders. Bikram
Bal, MD, Timothy R. Koch, MD, Frederick C Fineli, MD, JD, Michael G.Sars, MD. CME Released 5/11/2010.

13. Hypoalbuminemia in MGB
 The high incidence of hypoalbuminemia was noticed in longer bypass
more than 230 cm.
 In all the cases in which length of bypass was 200 cm or less, the
incidence of hypalbuminemia was not seen.
 Except in one patient who had 200 cm bypass and hypoalbuminemia
was 3.0 g/dl. This patient was suffering from diabetic nephropathy. To
control the falling albumin levels in this patient we had to pay special
attention on his nutrition part and it was seen once patient started having
protein rich diet his level improved.

14. Step 1
• Nutritional Supplementation
• In patients with Albumin Level between 2.6-3.5 g/dl
Step 2
• Reversal of Bypass
• In patients with persistant Albumin Levels below 2.5 g/dl with ankle
oedema
Management of
Hypoalbuminemia in MGB

15. Management of
Hypoalbuminemia in MGB
 1 case of hypoalbuminemia had to be reversed.
 All other cases of mild hypoalbuminemia responded to good nutritional
supplementation in the form of high protein diet and did not require any
intervention.
 Now in all our patients the length of bypass is 200 cm and no
hypoalbuminemia is found in these patients.

16. Management of Hypoalbuminemia
in Distal RNY
 Revision Surgery is difficult, long and cumbersome.
 Reversal requires revision of two anastamosis.

17. Complication Nausea Dumping Internal
Hernia
Constipation Hair Loss GERD Weight
Regain
Less of
Excess
weight loss
Gall Stone
Formation
LSG 8 2.23 8 9.82 14 13.39 4.46
RNY 4.29 2.73 2.34 2.73 8 1.56 8 6.25 7.03
MGB 7.81 5.93 1.87 10 0.625 8.75
 Predictors of gallstone formation after bariatric surgery : a multivariate analysis of risk factor
compassing gastric bypass, gastric banding & sleeve gastrectomy. LIVK, Pulido N, Fajnwaks P,
Szomstein S, Rosenthal R, Sury Endasc. 2008 Dec 5.
 Bile reflux after Roux-en-Y gastric bypass; an unrecognized cause of postoperative pain. Swartz DE,
Modley E, Felix EL, Sury Obes, Retat DA. 2009 Jan-Feb; 5(1):27-30.
Observations
Non-Life Threatening Complications

18. Complication Nausea Dumping Internal
Hernia
Constipation Hair Loss GERD Weight
Regain
Less of
Excess
weight loss
Gall Stone
Formation
LSG 8 2.23 8 9.82 14 13.39 4.46
RNY 4.29 2.73 2.34 2.73 8 1.56 8 6.25 7.03
MGB 7.81 5.93 1.87 10 0.625 8.75
 Predictors of gallstone formation after bariatric surgery : a multivariate analysis of risk factor
compassing gastric bypass, gastric banding & sleeve gastrectomy. LIVK, Pulido N, Fajnwaks P,
Szomstein S, Rosenthal R, Sury Endasc. 2008 Dec 5.
 Bile reflux after Roux-en-Y gastric bypass; an unrecognized cause of postoperative pain. Swartz DE,
Modley E, Felix EL, Sury Obes, Retat DA. 2009 Jan-Feb; 5(1):27-30.
Observations
Non-Life Threatening Complications

19. LSG RNY MGB
Excess Weight Loss 53.57 72.26 92.18
Dyslipidemia 55.80 75 93.43
T2D 59.37 76.17 94.37
Hypertension 45.98 72.65 84.06
EWL & Resolution of Comorbidities
 Bariatric surgery and diabetes remission : sleeve gastrectomy or mini gastric bypass ? Marco Milone,
Matteo Nicola Dario Di Minno, Maddalena Leongito, Paola Maietta, Paolo Bianco, Caterina Taffuri, Dario
Gaudioso, Roberta Lupoli, Silvia Savastano, Francesco Milone, and Mario Musella J Gastroenterol. Oct
21, 2013; 19(39): 6590–6597.
 The laparoscopic mini-gastric bypass: the Italian experience: outcomes from 974 consecutive cases in a
multicenter review. Musella M1, Susa A, Greco F, De Luca M, Manno E, Di Stefano C, Milone M, Bonfanti
R, Segato G, Antonino A, Piazza L. Surg. Endosc. 2014 Jan 28(1), 156-63

20. LSG RNY MGB
Excess Weight Loss 53.57 72.26 92.18
Dyslipidemia 55.80 75 93.43
T2D 59.37 76.17 94.37
Hypertension 45.98 72.65 84.06
EWL & Resolution of Comorbidities
 Bariatric surgery and diabetes remission : sleeve gastrectomy or mini gastric bypass ? Marco Milone,
Matteo Nicola Dario Di Minno, Maddalena Leongito, Paola Maietta, Paolo Bianco, Caterina Taffuri, Dario
Gaudioso, Roberta Lupoli, Silvia Savastano, Francesco Milone, and Mario Musella J Gastroenterol. Oct
21, 2013; 19(39): 6590–6597.
 The laparoscopic mini-gastric bypass: the Italian experience: outcomes from 974 consecutive cases in a
multicenter review. Musella M1, Susa A, Greco F, De Luca M, Manno E, Di Stefano C, Milone M, Bonfanti
R, Segato G, Antonino A, Piazza L. Surg. Endosc. 2014 Jan 28(1), 156-63

21. Summary
Audit indicted that …
 Mortality rate was 2.14 % in cases with LSG and 0.625 % in RNY
and NIL in MGB.
 Leaks were highest in LSG (1.42 %) followed by RNY (0.625 %) and NIL
in MGB.
 Persistent vomiting was in LSG only.
 Weight regain was 14 % in LSG and 8 % in RNY but Nil in MGB.
 Hypoalbuminemia was minimal in LSG, 1.9% in Standard RNY, 14% in
Distal RNY and 13.1% in MGB.
 Resolution of Comorbidities like Dyslipidemia, T2D, Hypertension,
Excess Weight Loss was maximum in MGB

22.  Obesity surgery results depending on technique performed; Long term outcome. Grecia JA,
Martinez M, Ella M, Agculella V, Royo P, Jimenez A, Bielsa MA, Arribas D, Obes Sury. 2008 Nov 12
Benefits Excess weight loss Mortality Weight regain Hypertension T2D resolved Dyslipidemia
LSG
53.57 2.14 14 45.98 59.37 55.80
RNY
72.26 0.625 8 72.65 76.17 75
MGB 92.18 0 0 84.06 94.37 93.43
So, Why MGB ?

23.  Obesity surgery results depending on technique performed; Long term outcome. Grecia JA,
Martinez M, Ella M, Agculella V, Royo P, Jimenez A, Bielsa MA, Arribas D, Obes Sury. 2008 Nov 12
Benefits Excess weight loss Mortality Weight regain Hypertension T2D resolved Dyslipidemia
LSG
53.57 2.14 14 45.98 59.37 55.80
RNY
72.26 0.625 8 72.65 76.17 75
MGB 92.18 0 0 84.06 94.37 93.43
So, Why MGB ?

24. 0
50
100
150
200
250
2007 2008 2009 2010 2011 2012 2013
LSG RNY MGB
Transition of bariatric procedures
at our Centre

25. Conclusions
• On the basis of audit we concluded that MGB which is a
combination of sleeve and bypass is technically more easy to
perform in minimum time period comparative to LSG and RNY.
• Above all mortality rate was zero in MGB.
• EWL and resolution of comorbidities was highly significant in
our audit which simply makes MGB the simplest and most
effective procedure.

26. Policy
On the basis of this audit we suggest MGB is the procedure of
choice in patients with morbid obesity, who are compliant in taking
their vitamins, calcium and iron supplements.
LSG maybe done in non-compliant patients and who are ready to
accept weight regain.
RNY and MGB both procedures act on the same principle of
restriction and malabsorption but MGB supersedes RNY in its
technique, efficacy, reversibility and revisibility.