Peter K. Small

“Mini” Gastric Bypass: Systematic Review of a Controversial Procedure

Mini gastric bypass is being explored by many bariatric surgeons as a standalone bariatric procedure. Several surgeons from different parts of the world have now published their extensive experience with this procedure. It appears to be an effective bariatric procedure with acceptable weight loss, co-morbidity resolution, and complication rates in the short and medium term. Its proponents claim that it is safer and easier than the gold standard Roux-en-Y gastric bypass. However, concerns with regard to symptomatic gastric or oesophageal biliary reflux requiring revisional surgery and long-term risk of gastric and oesophageal cancers persist. This paper reviews the published experience to date with this procedure and examines the surrounding controversy.

Weight Loss Decreases Excess Pancreatic Triacylglycerol Specifically in Type 2 Diabetes

OBJECTIVE This study determined whether the decrease in pancreatic triacylglycerol during weight loss in type 2 diabetes mellitus (T2DM) is simply reflective of whole-body fat or specific to diabetes and associated with the simultaneous recovery of insulin secretory function. RESEARCH DESIGN AND METHODS Individuals listed for gastric bypass surgery who had T2DM or normal glucose tolerance (NGT) matched for age, weight, and sex were studied before and 8 weeks after surgery. Pancreas and liver triacylglycerol were quantified using in-phase, out-of-phase MRI. Also measured were the first-phase insulin response to a stepped intravenous glucose infusion, hepatic insulin sensitivity, and glycemic and incretin responses to a semisolid test meal. RESULTS Weight loss after surgery was similar (NGT: 12.8 ± 0.8% and T2DM: 13.6 ± 0.7%) as was the change in fat mass (56.7 ± 3.3 to 45.4 ± 2.3 vs. 56.6 ± 2.4 to 43.0 ± 2.4 kg). Pancreatic triacylglycerol did not change in NGT (5.1 ± 0.2 to 5.5 ± 0.4%) but decreased in the group with T2DM (6.6 ± 0.5 to 5.4 ± 0.4%; P = 0.007). First-phase insulin response to a stepped intravenous glucose infusion did not change in NGT (0.24 [0.13–0.46] to 0.23 [0.19–0.37] nmol ⋅ min−1 ⋅ m−2) but normalized in T2DM (0.08 [−0.01 to –0.10] to 0.22 [0.07–0.30]) nmol ⋅ min−1 ⋅ m−2 at week 8 (P = 0.005). No differential effect of incretin secretion was observed after gastric bypass, with more rapid glucose absorption bringing about equivalently enhanced glucagon-like peptide 1 secretion in the two groups. CONCLUSIONS The fall in intrapancreatic triacylglycerol in T2DM, which occurs during weight loss, is associated with the condition itself rather than decreased total body fat.

Simultaneous Sleeve Gastrectomy and Hiatus Hernia Repair: a Systematic Review

Sleeve gastrectomy can exacerbate gastro-oesophageal reflux disease in some patients and cause de novo reflux in others. Some surgeons believe Roux-en-Y gastric bypass is the best bariatric surgical procedure for obese patients with hiatus hernia. Others believe that even patients with hiatus hernia can also be safely offered sleeve gastrectomy if combined with a simultaneous hiatus hernia repair. Still, others will offer these patients sleeve gastrectomy without any attempt to diagnose or repair hiatus hernia repair. The effectiveness of concurrent hiatal hernia repair in reducing the incidence of postoperative reflux after sleeve gastrectomy is unclear. This review systematically investigates the results and techniques of simultaneous sleeve gastrectomy and hiatus hernia repair for the treatment of obesity in accordance with PRISMA guidelines.

Sleeve gastrectomy and gastro-oesophageal reflux disease: a complex relationship.

Sleeve gastrectomy is rapidly becoming popular as a standalone bariatric operation. At the same time, there are valid concerns regarding its long-term durability and postoperative gastro-oesophageal reflux disease. Though gastric bypass remains the gold standard bariatric operation, it is not suitable for all patients. Sleeve gastrectomy is sometimes the only viable option. Patients with inflammatory bowel disease, liver cirrhosis, significant intra-abdominal adhesions involving small bowel and those reluctant to undergo gastric bypass could fall in this category. It is widely recognised that some patients report worsening of their gastro-oesophageal reflux disease after sleeve gastrectomy. Still, others develop de novo reflux. This review examines if it is possible to identify these patients prior to surgery and thus prevent postoperative gastro-oesophageal reflux disease after sleeve gastrectomy.

A retrospective comparison of early results of conversion of failed gastric banding to sleeve gastrectomy or gastric bypass

BACKGROUND Laparoscopic adjustable gastric banding (LAGB) is associated with high long-term failure rates requiring conversion to alternative procedures. Operative conversion to laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric (LRYGB) bypass is associated with higher complication rates than primary procedures. OBJECTIVES To compare results for converting failed LAGB to LSG versus LRYGB. SETTING University Hospital, United Kingdom, National Health Service. METHODS All patients undergoing conversion of LAGB to LRYGB and LSG from July 2006 to September 2012 were included. A retrospective analysis of our prospectively maintained database was performed to identify differences in death rates, complication rates, length of hospital stay, and weight loss. Within this study LRYGB was the preferred choice for conversion and LSG was only considered in the presence of significant intraabdominal adhesions, because of patient choice, or in patients with contraindications to LRYGB. RESULTS Eighty-nine patients with failed LAGB underwent conversional surgery within this period. Of these, 64 patients underwent conversion to LRYGB and 25 underwent conversion to LSG. There was no statistical difference in percentage of excess weight loss at 1 or 2 years after conversional surgery to LSG or LRYGB. Conversion to LRYGB was carried out as a single procedure in 51/64 (80%) compared with 10/25 (40%) for conversion to LSG (P = .003). One postoperative complication occurred requiring reoperation after conversion to LRYGB. CONCLUSION There was no difference in complication rates, hospital stay, and early weight loss when converting failed LAGB to LRYGB or LSG. Both procedures are appropriate for conversion from LAGB, although a staged approach is often needed, especially for LSG.

Revisional Roux-en-Y Gastric Bypass and Sleeve Gastrectomy: a Systematic Review of Comparative Outcomes with Respective Primary Procedures

Though primary bariatric surgery is now firmly established as the first-line treatment for morbid obesity, this is not the case with revisional bariatric surgery. Despite proven benefits and patient demand, revisional bariatric surgery continues to attract controversy. Even though it is widely believed to be riskier and less effective than primary bariatric surgery, there is currently no systematic review in literature addressing this point. This review aims to establish outcomes after revisional bariatric surgery in comparison with those after primary bariatric surgery. Since Roux-en-Y gastric bypass or sleeve gastrectomy is currently the commonest anatomy achieved after revisional bariatric surgery, this review focuses on the outcome of revisional Roux-en-Y gastric bypass and revisional sleeve gastrectomy in comparison with respective primary procedures.

Current status of mini-gastric bypass

Mini-gastric bypass (MGP) is a promising bariatric procedure. Tens of thousands of this procedure have been performed throughout the world since Rutledge performed the first procedure in the United States of America in 1997. Several thousands of these have even been documented in the published scientific literature. Despite a proven track record over nearly two decades, this operation continues to polarise the bariatric community. A large number of surgeons across the world have strong objections to this procedure and do not perform it. The risk of symptomatic (bile) reflux, marginal ulceration, severe malnutrition, and long-term risk of gastric and oesophageal cancers are some of the commonly voiced concerns. Despite these expressed fears, several advantages such as technical simplicity, shorter learning curve, ease of revision and reversal, non-inferior weight loss and comorbidity resolution outcomes have prompted some surgeons to advocate a wider adoption of this procedure. This review examines the current status of these controversial aspects in the light of the published academic literature in English.

An Evidence-Based Algorithm for the Management of Marginal Ulcers following Roux-en-Y Gastric Bypass

As the demand for obesity surgery grows, Roux-en-Y gastric bypass remains the most commonly performed procedure associated with low complication rates and good long-term co-morbidity resolution and weight loss. Marginal ulcers remain a cause of significant morbidity in medium and long term and are reported in every large series of this operation. Marginal ulceration is a complex problem with unclear aetiology and lack of clear consensus on its prevention and management. A clearer understanding of the available evidence regarding the prevention and treatment of marginal ulcers is needed to improve patient care. We propose an algorithm for management of patients with marginal ulcers based on the best available evidence in the literature.

Reversal of Type 2 diabetes after bariatric surgery is determined by the degree of achieved weight loss in both short‐ and long‐duration diabetes

To define the impact of duration of diabetes and extent of weight loss on the reversibility of Type 2 diabetes after bariatric surgery.

The First Consensus Statement on One Anastomosis/Mini Gastric Bypass (OAGB/MGB) Using a Modified Delphi Approach

BackgroundAn increasing number of surgeons worldwide are now performing one anastomosis/mini gastric bypass (OAGB/MGB). Lack of a published consensus amongst experts may be hindering progress and affecting outcomes. This paper reports results from the first modified Delphi consensus building exercise on this procedure.MethodsA committee of 16 recognised opinion-makers in bariatric surgery with special interest in OAGB/MGB was constituted. The committee invited 101 OAGB/MGB experts from 39 countries to vote on 55 statements in areas of controversy or variation associated with this procedure. An agreement amongst ≥ 70.0% of the experts was considered to indicate a consensus.ResultsA consensus was achieved for 48 of the 55 proposed statements after two rounds of voting. There was no consensus for seven statements. Remarkably, 100.0% of the experts felt that OAGB/MGB was an “acceptable mainstream surgical option” and 96.0% felt that it could no longer be regarded as a new or experimental procedure. Approximately 96.0 and 91.0% of the experts felt that OAGB/MGB did not increase the risk of gastric and oesophageal cancers, respectively. Approximately 94.0% of the experts felt that the construction of the gastric pouch should start in the horizontal portion of the lesser curvature. There was a consensus of 82, 84, and 85% for routinely supplementing iron, vitamin B12, and vitamin D, respectively.ConclusionOAGB/MGB experts achieved consensus on a number of aspects concerning this procedure but several areas of disagreements persist emphasising the need for more studies in the future.