Robert Rutledge

Continued Excellent Results with the Mini-Gastric Bypass: Six-Year Study in 2,410 Patients

Background: There is a growing body of evidence showing that the Mini-Gastric Bypass (MGB) is a safe and effective alternative to other bariatric surgical operations. This study reports on the results of a consecutive cohort of patients undergoing the MGB. Methods: A prospective database was used to continuously assess the results in 2,410 MGB patients treated from September 1997 to February 2004. Results:The average operative time was 37.5 minutes, and the median length of stay was 1 day. The 30-day mortality and complication rates were 0.08% and 5.9% respectively. The leak rate was 1.08%. Average weight loss at 1 year was 59 kg (80% of excess body weight). The most frequent long-term complications were dyspepsia and ulcers (5.6%) and iron deficiency anemia (4.9%.) Excessive weight loss with malnutrition occurred in 1.1%. Weight loss was well maintained over 5 years, with <5% patients regaining more than 10 kg. Conclusions: Overall, the MGB is very safe initially and in the long-term. It has reliable weight loss and complications similar to other forms of gastric bypass.

Revision of Failed Gastric Banding to Mini-Gastric Bypass

Background: Although laparoscopic adjustable gastric banding (LAGB) has been found to be a generally successful weight loss operation, there are reports of occasional LAGB failure. The results of rescue procedures for these patients are important. The mini-gastric bypass (MGB) is a safe and effective alternative to other bariatric surgical procedures. We report the results of conversion of 3 failed LAGB procedures to MGB. Methods: In a series of 2,595 patients who underwent MGB, 3 had previously undergone an LAGB that failed to sustain weight loss. Results: Average operative time was 54 minutes in LAGB conversions to MGB (compared to 37.5 minutes in primary MGB), and length of stay was 1 day. There were no complications in the patients converted MGB. The weight loss in converted MGB patients was similar to the weight loss in primary MGB patients, with a mean weight loss at 1 year of 60 kg (79% of excess weight) Conclusion: Conversion of failed LAGB to MGB was a safe procedure that added ∼20 minutes to the short MGB operating time. Patient satisfaction was high, recovery was rapid, and weight loss was very good.

Naming the Mini-Gastric Bypass

To the Editor: I am pleased to comment on the suggestions to rename the operation which I named the “Mini-Gastric Bypass” in 1997. Publications from around the world demonstrate that my initially good results are confirmed. This is particularly rewarding given the early criticism attended to the mini-gastric bypass (MGB) in its early years. Critics said that the pouch was too big, the anastomosis too large, and there would be devastating and unmanageable bile reflux gastritis and that there be no weight loss. They were incorrect. Carbajo and Caballero modified the MGB adding an “antireflux” technique and called their version the “One-Anastomosis Gastric Bypass (OAGB)”. Others have suggested the Omega Loop Gastric Bypass which is a suitable name, but has its own limitations. The long-used names MGB and OAGB thus stand, and the use of Single Anastomosis Gastric Bypass (SAGB) is similar to OAGB and is likely to be confused with the various SADI procedures. The MGB is restrictive while not being obstructive. In contrast to the small pouch and small gastrojejunostomy of the RYGB, the tight gastric pouch of the sleeve, and the fixed plastic of the Lap-band, the MGB uses a larger gastric pouch with a wide open gastrojejunostomy to allow rapid emptying into the jejunum. Also, in contrast to the RYGB, the MGB has a significant malabsorptive component. It induces significant fatty food intolerance, an increase in bowel movements, and mild steatorrhea in response to large fatty meals. The operation has been found to induce a “Mediterranean-type” diet postoperatively with a decrease in intake of sugar-sweetened beverages, fatty foods, processed meats, and an increase in yogurt, fresh fruits, and vegetables. I believe now that my initial findings have been well confirmed; the MGB/OAGB is a short simple operation that is safe in the short and long terms. MGB/OAGB provides one of the best and most durable weight loss of any bariatric operation; it can be easily tailored to treat the spectrum of metabolic disease from the thin diabetic to the super-super obese, and it can easily be reversed or revised.

What a Mini/One Anastomosis Gastric Bypass (MGB/OAGB) Is.

We observed with interest the video from the Italian group headed by Marcello Lucchese [1]. It is purported to show the surgical resolution of one of the complications described following the mini/one anastomosis gastric bypass (MGB/ OAGB)—intractable esophageal bile reflux. This complication is reported in large series to require revisional surgery at a rate ranging from 0.1 to 0.7 % following primary MGB/ OAGB [2–5]. We reported the Italian experience with the MGB/OAGB in 2014, describing eight patients (8/818, 0.9 %) complaining of gastric (no esophageal) bile reflux, but this drawback resolved autonomously with conservative treatment [6]. Furthermore, an endoscopy surveillance program following MGB/OAGB performed in two units from the Italian experience, including both symptomatic and asymptomatic patients, did not show any particular histologic damage [7] at 36 months. This is confirmed in another large series [8]. The surgical repair is sometimes done by creating a side-toside Braun anastomosis between the afferent and efferent limb [2] or by turning the MGB/OAGB into a Roux-en-Y gastric bypass (RYGB) [3, 4]. In this light, we consider that Dr. Lucchese has done an excellent revision, which is clear in his video. Nevertheless, it must be pointed out that Dr. Lucchese did not turn an MGB/OAGB into a RYGB. He performed a revision in which the primary surgery is incorrectly reported, possibly by the first surgeon, to be an MGB/OAGB. MGB/ OAGB technique (as described elsewhere) [4, 7, 9] strictly implies a narrow gastric tube which is tailored starting just below the crow’s foot. It must never be shorter than 12–14 cm (Fig. 1), while the gastric pouch seen in the video is 6-cm long, exposing that patient to an unavoidable esophageal bile reflux. This surgery resembles more

Laparoscopic Mini-Gastric (One-Anastomosis) Bypass Surgery

The mini-gastric bypass (MGB) consists of a long, narrow lesser curvature gastric pouch beginning below crow’s foot, extending lateral to the esophagogastric (EG) junction, with a wide anastomosis to an antecolic jejunal loop at a point about 200 cm distal to Treitz’ ligament, providing malabsorption. The operation is brief, simple and safe, has provided reliable weight loss, and is now being increasingly performed. If needed, the anastomotic site can be easily adjusted for body mass index (BMI). The technique, complications and results are reported.

Physiology of the MGB: How It Works for Long-Term Weight Loss

Obesity is increasing rapidly throughout the world, and is predicted to double by 2025. Bariatric surgery has shown promising results, but a need for a safe and more effective procedure exists. In the last decade, there have been many publications confirming that Mini-Gastric Bypass (MGB) is a safer and equally or more effective alternative to the traditional Roux-en-Y gastric bypass. MGB has shown stronger metabolic control and more durable weight loss than the traditional bariatric operations.

Understanding the Technique of MGB: Clearing the Confusion

After almost 20 years of confusion, the Mini-Gastric Bypass (MGB) still leads to errors and patient harm when inexperienced surgeons attempt to adopt it without a clear understanding of the underlying mechanism of action and the details of the anatomy of the operation. When understood by a skilled surgeon, the MGB is a simple straightforward and very powerful operation that provides the surgeon with many advantages including the ability to tailor the operation to the patient and surgeons’ goals. The misunderstanding of the MGB and the confusion with other past and present bariatric procedures have led to poor and even deadly outcomes. This chapter is designed to educate the interested surgeon on the important details, in order to understand and safely begin training to perform the MGB.

Reply to “Reviews of One Anastomosis Gastric Bypass” by K. Mahawar

Contrary to his Reply to Letters [1], Dr. Mahawar’s opening assertion [2] that he is a member of the Mini-Gastric Bypass– One-Anastomosis Gastric Bypass Club (which has >300 members) is not correct. Dr. Mahawar in two similar papers [3, 4], published in Obesity Surgery 2 months apart, concludes that MGB may carry a risk of reflux and carcinoma. Drs. Musella and Milone [5] and we [1] answered these assertions in our Reply. The Conclusion of Mahawar’s first paper [3] states BThis procedure may carry a risk of gastric and/or esophageal reflux^ and warns of Ba higher risk of cancers in the gastric tube and oesophagus in the long term – surgeons should counsel their patients appropriately .̂ The Conclusion of his second paper [4] states BSurgeons must be aware of these controversial aspects...., including the controversy surrounding risk for gastric and oesophageal cancers, to be able to counsel their patients appropriately .̂ This is after he had questioned us whether CA occurs after MGB and agreed with us that this is not a feature, especially when compared to other bariatric operations [1, 5]. It was following this, in 2015 and 2016, that he reported, based on his small experience, the fact that reflux is infrequent and carcinoma almost unknown after MGB. Our Letter to the Editor discusses his issues [2], as we explain the two operations [1]—MGB and its variant OAGB. Many of us have performed >2000 of these procedures and are at the professorial level, so that his assertion that we are Bunscientific^ [2] is offensive.

Regarding Liver Function 1 Year After Omega Loop Gastric Bypass.

The paper comparing Roux-en-Y vs omega loop gastric bypass by Prager’s group [1] found increased weight loss but worse liver function at 1 year after the omega loop gastric bypass (OLGB) in a small series. This has raised possible concern on how they are performing their OLGB. The SAGB (mini-gastric bypass or MGB) has been performed for 20 years, with >6300 MGBs by Rutledge, >2500 by Kular, 1700 MGBs by Peraglie, and 1300 MGBs by Hargroder. Postoperative liver function tests (LFTs) are routine and have shown improvement (not worsening). Good results, including LFTs, were found by Cady with 3500 MGBs and also Chevallier [2], Musella and Milone [3], Noun [4], Wei-Jei Lee in direct comparisons with RYGB [5], Kular [6], and others [7–10]. The problem may lie in how Prager’s OLGB was performed. Their biliopancreatic limb could have been too long, and the patients’ outcomes suggest that rather than 200 cm, the bypassed loop could have been 300 or 400 cm (similar to the lengths in a BPD). Where Prager called his operation OLGB, their mean %EWL of 127 ± 31 at 1 year indicates excessive weight loss. At the Experts’ Conference in Saalfelden, Austria, on March 2016, their nutritionist, B. Lötsch, described their OLGB patients as difficult to manage; they had to be encouraged to take daily protein supplements, and many experienced incipient malnutrition, diarrhea, and low serum proteins and were frequently in clinic. The explanation could be their technique could lead to a 300–400-cm bypass. It is recalled that after the old jejunoileal bypass (JIB), patients had to take pre-digested collagen capsules (3 tid) which contain lipotropic factor L-methionine (3.9 mg per capsule) and a high-protein diet to prevent negative effects on the liver [11]. If the explanation could be a bypass in their OLGB is too long, this could be dangerous (https://www.Facebook. Com/DrRutledge/videos/10156722532430532/). MGB has been shown around the world to be a safe operation, but new MGB surgeons should be conservative in their lengths.