Mini Loop Gastric Bypass: Is It a Safe Alternative?
Mini Loop Gastric Bypass: Is It a Safe Alternative?
Abstract & Commentary
By Nicole R. Basa, MD, and Amir Mehran, MD, FACS, Dr. Basa is a Fellow at UCLA, and Dr. Mehran is Assistant Clinical Professor of Surgery, Director, Bariatric Surgery, Section for Minimally Invasive and Bariatric Surgery, Department of Surgery, UCLA. Drs. Basa and Mehran report no financial relationships relevant to this field of study.
Re-popularized by Robert Rutledge, MD, in the late 1990's, the mini-loop gastric bypass (MLGB) has gained increasing attention in both the surgical and lay literature. The procedure is similar to the Billroth II gastrectomy, where a loop of jejunum is anastomosed to a smaller stomach pouch. In contrast to the conventional Roux-en-Y gastric bypass, the loop is not divided and a jejunojejunostomy anastomosis is not performed. The secretions from the in-situ stomach and duodenum, therefore, flow past the gastrojejunostomy, potentially causing an increased rate of bile reflux gastritis, marginal ulceration, and the possible future development of gastroesophageal carcinoma.
In Mason and colleagues' series of loop gastric bypass patients from the 1960's and 70's, the incidence of bilious vomiting and gastritis was as high as 70%.1 Subsequently, the Roux-en-Y gastric bypass (LRYGB) became more popular, as it eliminated this side effect. MLGB proponents, however, believe that by creating the gastrojejunostomy at a more dependent portion of the gastric pouch, the incidence of dyspepsia and ulcers secondary to bile reflux is reduced to around 5%.2
There is a paucity of independent literature regarding this procedure. Most recently, Lee and colleagues3 have performed a limited, randomized, controlled trial comparing 40 laparoscopic LRYGBs to 40 laparoscopic MLGBs. The duration of surgery was longer for the LRYGB compared to the MLGB [(205 min vs 148 min (P < 0.05)], as was the length of hospital stay [(6.9 ± 2.8 days vs 5.5 ± 1.4 days (P < 0.05)]. Lee et al also reported a higher postoperative complication rate for the LRYGB group (20%) compared to the MLGB segment (7.5%). Weight loss and quality of life results, however, were similar between the 2 groups at 2 years. This article was criticized for having an inadequate number of patients to demonstrate a true significance, and the LRYGB results were not comparable to other published reports in the literature.4 Longer operative time and hospital stay may reflect the surgical inexperience of the surgeons performing the LRYGB, resulting in a technical bias towards the MLGB.4
One recent article by Johnson and colleagues5 combines the experience of 5 academic institutions in North Carolina and Virginia that have seen a high volume of complications resulting from MLGB. This review countered the conclusions made by the MLGB group regarding a lower morbidity and reoperative rate than the RYGB. A total of 32 patients had been seen, with 65% of them requiring a conversion to RYGB. Three patients had anastomotic leaks, and 20 had intractable bile reflux gastritis. Johnson et al raised concerns about the unknown denominator (total number of patients), concerned that if 5 institutions in one segment of the country treated several MLGB complications, there may be many more unreported ones elsewhere, as MLGBs are performed at specialized centers throughout the country.
Commentary
MLGB has also received unwanted publicity in the lay press. A 2005 Wall Street Journal (WSJ) article calls Dr. Rutledge a "doctor-entrepreneur."6 Since MLGB is not covered by most insurance companies, patients are responsible for all of the costs. Mini-gastric bypass programs have been established throughout the country, including at hospitals in Florida, Michigan, North Carolina, California, Missouri, Arkansas and, most recently, Las Vegas. According to the WSJ, surgeons who perform MLGB are trained by Dr. Rutledge and pay a portion of their fees to him for each surgery that they do.
Finally, MLGB is not considered a mainstream bariatric procedure by the American Society for Bariatric Surgery (ASBS), which has excluded it from the Resolutions adopted by its members in 2003 (Bylaws, Article 1, Section 2.2). The ASBS describes the need for more objective, evidence-based data on MLGB before it can be accepted as a safe bariatric procedure.
To determine the safety and effectiveness of MLGB, a large randomized trial comparing MLGB to RYGB is undoubtedly needed. The self-report of a practice's data can be fraught with bias and may be criticized by opponents to the procedure. Johnson et al have proposed the creation of a national registry to track complications, as well as the need for revisional surgery after MLGB or other non-traditional operations.3 Until then, the debate about MLGB will continue. Further maturation and honest reporting of MLGB data is needed prior to making any definitive conclusions about the merits or dangers of this procedure.
References
1. Mason EE, Ito C. Gastric bypass in obesity. Surg Clin North Am. 1967;47:1345-1351.
2. Rutledge R, Walsh TR. Continued excellent results with the mini-gastric bypass: Six-year study in 2410 patients. Obes Surg. 2005;15:1304-1308.
3. Lee WJ, et al. Laparoscopic Roux-en-Y versus mini-gastric bypass for the treatment of morbid obesity. Ann Surg. 2005;242:20-28.
4. Livingston EH. Is laparoscopic Roux-en-Y gastric bypass superior to mini-gastric bypass for the treatment of morbid obesity? Nat Clin Pract Gastroenterol Hepatol. 2006;3:16-17.
5. Johnson WH, et al. Surgical revision of loop ("mini") gastric bypass procedure: Multicenter review of complications and conversions to Roux-en-Y gastric bypass. Surg Obesity Relat Dis. 2007;3:37-41.
6. Staple Diet: A doctor's version of obesity surgery raises some bile — in surging field, "minigastric," is simpler and quicker, but critics see safety risk — burning "like battery acid." Wallstreet Journal. Jan 14, 2005.
Re-popularized by Robert Rutledge, MD, in the late 1990's, the mini-loop gastric bypass (MLGB) has gained increasing attention in both the surgical and lay literature.Subscribe Now for Access
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