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*

1. 4th Annual Scientific Meeting
Jan 23-25, 2013 Glasgow
Mini 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. 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. 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. 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. 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. 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. 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 cohorts
02/02/13 7

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 15
02/02/13 8

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. 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. Effect on medical co-morbidity
Results 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. 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 + 4.68
02/02/13 12

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. Thank you