Surgical Revision of Loop ("Mini") GB Procedure
Abstract & Commentary
By Namir Katkhouda, MD, FACS, Professor of Surgery, Chief, Minimally Invasive Surgery, University of Southern California (USC)-Los Angeles, CA. Dr. Katkhouda is a consultant for Baxter, Ethicon, Storz, and Gore.
Synopsis: The results of this preliminary review have confirmed that MGB does require revision in some patients and that conversion to RYGB is a common form of revision.
Source: 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 Obes Relat Dis. 2007;3:37-41.
Background: The claim that the "mini"-gastric bypass (MGB) procedure, with its loop gastrojejunostomy, is safer and equally effective to the Roux-en-Y gastric bypass (RYGB) procedure has been promoted before validation. Rumors of unreported complications and the accuracy of follow up are additional concerns. This study was undertaken to identify MGB patients who require, or required, revisional surgery at 5 hospitals within the region of the United States where the MGB procedure originated to assess the claim that revision to RYGB is rarely needed.
Methods: The databases of 5 medical centers were retrospectively searched to identify patients undergoing surgical revision after a MGB procedure, all of which had been done elsewhere.
Results: A total of 32 patients were identified who presented with complications after undergoing an MGB procedure and required, or require, revisional surgery. The complications included gastrojejunostomy leak in 3, bile reflux in 20, intractable marginal ulcer in 5, malabsorption/malnutrition in 8, and weight gain in 2. Of the 32 patients, 21 required conversion to RYGB, and an additional 5 have planned revisions in the future. Also, 2 patients were treated with Braun enteroenterostomies and 4 required one or more abdominal explorations.
Conclusions: The results of this preliminary review have confirmed that MGB does require revision in some patients, and that conversion to RYGB is a common form of revision. A national registry to record the complications and the number of revisions is proposed to gain insight into the need for revision after MGB and other nontraditional bariatric procedures.
Johnson and colleagues have reviewed retrospective databases from 5 medical centers to identify patients who underwent revisions of the loop minigastric bypass. They found 32 patients who underwent a revision, with 20 patients diagnosed with bile reflux and 5 patients diagnosed with marginal ulcers. These results, according to Johnson et al, contradict the notion that the loop gastric bypass is a very safe procedure. Moreover, data was only pulled from one area of the United States, and the data from the rest of the Country is unknown. Johnson et al hypothesize that the original gastric bypass was initially made with a horizontal gastric pouch attached to a gastroenterostomy. It led to numerous marginal ulcers and severe bile reflux and, thus, was abandoned.
The current loop gastric bypass, as proposed by Rutledge13, is constructed around a vertical pouch along the lesser curvature in order to lessen bile reflux problems.
This article seems to show that these problems are still present, even if the denominator is unknown. Bile esophagitis is, on the other hand, very rare following the standard Roux-en-Y gastric bypass.
Does this mean that the loop gastric bypass should be abandoned? The answer is no because there is not enough conclusive scientific evidence that the procedure is detrimental to the patients. The corollary of this statement is that Johnson et al promoting this controversial operation should maintain a database with a long-term follow up of an acceptable number of patients, and this database should be made readily available for scientific assessment, and comparative trials should be undertaken. An effort in this direction was made recently by a publication in 2005 by a Taiwanese team of a study comparing the laparoscopic Roux en Y gastric bypass to the mini bypass in a good peer review journal. The study was criticized for its small sample size and possible bias. More comparative studies should be encouraged.
1. Gastrointestinal surgery for severe obesity. Proceedings of a National Institutes of Health Consensus Development Conference. March 25-27, Bethesda, MD. Am J Clin Nutr. 1992;55:487s-619s.
2. Buchwald H, Consensus Conference Panel. Bariatric surgery for morbid obesity: Health implications for patients, health professionals, and third-party payers. J Am Coll Surg. 2005;200:593-604.
3. DeMaria EJ, et al. Results of 281 consecutive total laparoscopic Roux-en-Y gastric bypasses to treat morbid obesity. Ann Surg. 2002;235:640-645.
4. Schauer PR, et al. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg. 2000;232:515-529.
5. Papasavas PK, et al. Outcome analysis of laparoscopic Roux-en-Y gastric bypass for morbid obesity. The first 116 cases. Surg Endosc. 2002;16:1653-1657.
6. Pories WJ, et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg. 1995;222:339-350.
7. Schauer PR, et al. Effect of laparoscopic Roux-en-Y gastric bypass on type 2 diabetes mellitus. Ann Surg. 2003;238:467-484.
8. Sjostrom L, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2004;351:2683-2693.
9. Marema RT, et al. Comparison of the benefits and complications between laparoscopic and open Roux-en-Y gastric bypass surgeries. Surg Endosc. 2005;19:525-530.
10. Nguyen NT, et al. Laparoscopic versus open gastric bypass: A randomized study of outcomes, quality of life, and costs. Ann Surg. 2001;234:279-289.
11. Jones DB, et al. Optimal management of the morbidly obese patient: SAGES appropriateness conference statement. Surg Endosc. 2004;18:1029-1037.
12. Lee WJ, et al. Laparoscopic Roux-en-Y versus mini-gastric bypass for the treatment of morbid obesity: A prospective randomized controlled trial. Ann Surg. 2005;242:20-28.
13. Rutledge R, Walsh TR. Continued excellent results with the mini-gastric bypass: Six-year study in 2,410 patients. Obes Surg. 2005;15:1304-1308.
14. Rutledge R. The mini-gastric bypass: Experience with the first 1,274 cases. Obes Surg. 2001;11:276-280.
15. 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.
16. Mason EE, Ito C. Gastric bypass in obesity. Surg Clin North Am. 1967;47:1345-1351.
17. Griffen WO Jr, et al. A prospective comparison of gastric and jejunoileal bypass procedures for morbid obesity. Ann Surg. 1977;186:500-509.
18. Fisher BL, et al. Mini-gastric bypass controversy. Obes Surg. 2001;11:773-777.
19. Wang W, et al. Short-term results of laparoscopic mini-gastric bypass. Obes Surg. 2005;15:648-654.