Biliopancreatic limb length is more important than the name of the Gastric bypass operation

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Nimeri, MBBCh, ABS, FACS, FASMBS President, Pan Arab Society of Metabolic & Bariatric Surgery

1 Biliopancreatic limb length is more important than the name of the Gastric bypass operation Abdelrahman A. Nimeri, MBBCh, ABS, FACS, FASMBS President, Pan Arab Society of Metabolic & Bariatric Surgery (PASMBS) Adjunct Associate Professor of Surgery, UAE University COM Chief, Division of General, Thoracic, & Vascular Surgery, SKMC Director, Bariatric & Metabolic Institute (BMI) Abu Dhabi, SKMC

2 LAGB 2% Revision 17% Case Mix Disclosure No disclosures OAGB MGB 2% LoopDS 0% LSG LSG 33% RYGB LAGB Revision Communications Committee RYGB 46% OAGB MGB LoopDS

3 Take Home Message Why is RYGB becoming un-popular? Is it still the Gold standard? RYGB in it s standard short BPL is a restrictive operation with very little mal-absorption and not for every patient. Best candidates (Type II DM, GERD patients) & Worst candidates (BMI >50, weight regain after restrictive bariatric surgery). If you perform BPD, DS, SADI, DJB, OAGB/MGB you need to measure the common channel. Melton GB et al Suboptimal weight loss after RYGB J Gastrointestinal Surg 2008;12(2):250-5 Bessler M et al Frequency distribution of weight loss % after RYGB and LAGB SOARD 2008:4(4): Campos Good morning et al Factors associated with weight loss after RYGB. Arch Surg 2008:143(9):877-84

4 Take Home Message OAGB/MGB is more effective than RYGB for weight loss and comorbidity resolution because it has a longer BPL. RYGB patients with weight regain is not a dead end. Length of Roux limb is less important than BPL. In weight recidivism after RYGB: the answer is in judicial lengthening of the BPL & patients with BMI>50 & failure after restriction may benefit from a longer BPL.

5 The fall of RYGB, rise of LSG & OAGB/MGB

6 Bariatric surgery numbers in the USA

7 History of bariatric surgery in the US looks like this

9 World wide 2014

10 North American USA & Canada

11 Europe

12 Asia Pacific

15 OAGB/MGB in the UAE is 13% in 2016 up from 7% Total LSG OAGB/MGB RYGB LAGB

16 Latin America

17 Why is RYGB becoming so un-popular and why are LSG and OAGB/MGB catching on? Poor long term outcomes. High incidence of complications. Ineffectiveness long term.

21 1156 patients with severe obesity comprised 3 groups: 418 patients After RYGB (surgery group), 417 patients who sought but did not undergo surgery (primarily for insurance reasons) (non-surgery group 1), and 321 patients who did not seek surgery (non-surgery group 2). We performed clinical examinations at baseline and at 2 years, 6 years, and 12 years to ascertain the presence of type 2 diabetes, hypertension, and dyslipidemia. The follow-up rate exceeded 90% at 12 years.

25 Long term FU years after RYGB in Italy 285 RYGB patients done between Mean BMI 45.3 (+5.9) kg/m2 went down to 33.5 (5.1) kg/m2 at 8 years, 33.8 (5) kg/m2 at 10 years, 30.5 (4.1) kg/m2 at 12 years & 32.6 (4.7) kg/m2 at 14 years (69% achieved BMI <35 kg/m2). Mean EWL% 66.3% (+21) at 8 years, 64.2% (+23) at 10 years, 76.7% (+21) at 12 years & 69.8% (+23) at 14 years. FU% was 91%, 84%, 72% and 63% at 8,10,12 & 14 years. Mortality 0.35%, leak 0.7%, stenosis 1%, IH 1.4%, SBO 7.3%. 60% of patients stopped taking supplements and 35.7% had nutritional deficiencies. R. Arnoux Dabadie Abstract IFSO London 2017

29 Diabetes resolution 6 years after LSG, RYGB, Medical therapy in France All patients undergoing bariatric surgery in France in 2009 & control group matched (age, gender BMI, DM) from French National Insurance. 15,650 (85% females, 10% had DM II) had bariatric surgery in Diabetes resolution after BS was 50% vs 9% medical therapy P< The main predictive for resolution were: RYGB 16.7 ( ), LSG 7.3 ( ), LAGB 4.3 ( ), No insulin 5.8 ( ), No dyslipidemia medications 1.3 ( ). DM recurrence at 6 years was least frequent with BS 1% vs 12% in control (P<0.001). RYGB 0.06 was the more effective than LSG 0.08 & LAGB J. Thereaux, A. Fagot-Campagna France Abstract IFSO London

30 5 year results of the Swiss RCT LSG vs RYGB (SM-BOSS) RCT of 217 patients LSG 107 vs RYGB 110 at 4 centers in Switzerland. Mean BMI 44+11, Age 43+5, 72% females, mean FU 5 years (95.4%). Patients with severe GERD or Hiatal hernia were excluded. Weight loss was similar at 1 year ( vs ) P=0.13, 3 years (71+23 vs ) P=0.3, 5 years ( vs 68+25) P=0.11. Weight loss after LSG at 5 years was inferior to RYGB (25+11 vs ) P Co-morbidity resolution was significantly reduced in both except GERD which was better with RYGB. QOL, number of complications and re-operations were similar. R. Peterli, M. Bueter Abstract IFSO London 2017

31 LAGB to RYGB is more effective than LAGB to LSG 192 patients LAGB to RYGB vs 283 LAGB to LSG. The baseline age and BMI were similar in both groups. At 2 years, BMI was lower in RYGB vs kg/m2 for LSG (P=0.0004), EBMIL% was lower in RYGB 57.8% vs 29.3% in LSG (P=0.0001), & %WL was lower in RYGB 23.4% vs 12.6% in LSG (P=0.001). Reoperation was higher in conversion to RYGB 7.3% vs 1.4% (P0=0022), OR time was longer in RYGB vs minutes in LSG (P<0.001), LOS was longer RYGB 3.33 vs 2.11 days (P<0.001). Readmission was similar in RYGB 7.3% vs 3.5% in LSG (P=0.087). M. Jenkins B Schwack Abstract IFSO London 2017

50% GERD from 17% at 8.5 years 100 LSG after long-term mean FU 8.5 years (%EWL) of 60%. A significant increase in GERD symptoms (50% from 17% pre op) (RR = 2.5882, 95% CI [1.6161 4.

32 50% GERD from 17% at 8.5 years 100 LSG after long-term mean FU 8.5 years (%EWL) of 60%. A significant increase in GERD symptoms (50% from 17% pre op) (RR = , 95% CI [ ], & use of PPIs, p value = ). The chance of developing de novo reflux after LSG was 47.8% (32/67). Reflux disease was present in 7 of the 26 patients who underwent a secondary Roux- en-y gastric bypass (RYGB). In 4/7 patients, GERD disappeared completely after the secondary RYGB (57.1%).

33 68% GERD from 33% at 5 years 17.2% Barretts Esophagitis 69% Follow up A total of 110 patients after LSG, GERD symptoms(68.1% versus 33.6%: P , VAS mean score3 versus 1.8: P , and PPI intake significantly increased compared with preoperative values;57.2% versus 19.1%: P ) At EGD, an upward migration of the Z line and a biliary-like esophageal reflux was found in 73.6% and 74.5% of cases, respectively.

34 14% conversion to RYGB 23% weight regain 38.4% GERD15% Barretts metaplasia De novo GERD in 45% patients 100% Follow up 10.8 years Multi-Center study (3 centers) 43/53 patients were followed, 6 patients (14.0%) were converted to RYGB due to GERD over a period of 130 months. 10/26 (38.4%) not converted to RYGB also suffered from symptomatic reflux. Gastroscopies revealed de novo hiatal hernias in 45% of the patients & Barrett s metaplasia in 15%. SG patients suffering from symptomatic reflux scored significantly higher in the RSI (p = 0.04) and significantly lower in the GIQLI (p = 0.02) questionnaire.

36 Why is RYGB becoming so un-popular and why are LSG and OAGB/MGB catching on? Poor long term outcomes. High incidence of complications. Ineffectiveness long term.

37 (1) The steep learning curve. (2)?Re routing of the small bowel (OAGB/MGB). (3) Potential known long term complications. (4) The perceived paucity of options to treat patients with weight recidivism especially when your are super obese. In contrast, (1) the short learning curve, (2) no re routing of the small bowel, (3) unknown long term complications and (4) the many options to revise a LSG to a duodenal switch or LRYGB are the reasons patients and surgeons are choosing the LSG over LRYGB.

38 Learning curve & adoption of laparoscopic colectomy less than 1/3 of colectomies 2.2% (878/38,264) for % (1175/42,166) for % (2336/44,817) for 2004 Publication of the COST Trial. 15% (7548/42,903) for % (14,610/31,888) for Ann Surg Aug;258(2): doi: /SLA.0b013e31828faa66. Growth of laparoscopic colectomy in the United States: analysis of regional and socioeconomic factors over time. Bardakcioglu O 1, Khan A, Aldridge C, Chen J.

39 Only patients with >50% EWL at 1 year postoperatively. A total of 1426 obese patients (15.8% male) after RYGB during January 2000 to 2012 (2 year FU). Weight regain was observed in 244 patients (17.1%). Preoperative BMI was similar between groups. BMI was significantly higher and percent excess weight loss was significantly lower in the Weight Regain (WR) group (P 0.001).

40 Univariate analysis found that older age, male gender, having hypertension, dyslipidemia, and insulin-treated type 2 diabetes were all factors associated with sustained weight loss. A longer duration after RYGB was associated with weight regain. Multivariate analysis revealed that younger age was a significant predictor of weight regain even after adjusting for time since RYGB.

41 Why do RYGB patients regain weight?

42 Small pouch & rapid emptying leads to better weight loss, less weight D Riccioppo I Cecconello abstract IFSO London 2017 regain and better food intolerance in RYGB 67 RYGB patients had pouch volumetry by 3D-CT, pouch emptying by 4hr Scintigraphy, food intolerance and weight loss measurement. Median FU was 47 months, median volume was 28 ml, %ret at 1,2,4 hours was 8%, 2%, 1%. There was association between V<40ml & higher emptying rates up to 2 hours (V<40 %Ret 1=6%, %Ret2=2%) P=0.009 vs (V>40 %Ret 1=44%, %Ret2=13.5%) P= Higher emptying speed at 1 hour correlated with higher weight loss (P=0.033) and less weight regain (P=0.036) (%Ret<12% vs >25%). Better food tolerance with lower %Ret 1 hour (0.003).

45 2 decades ago, if a patient was considering a surgery involving small bowel rerouting, it would have been (RYGB) or (BPD). In contrast, today, if a patient is considering a surgery that involves small bowel rerouting, this could mean any of the following bariatric surgeries: one anastomosis gastric bypass/mini gastric bypass (OAGB/MGB) BPD or BPD duodenal switch (DS) single anastomosis duodenoileostomy (SADI) single anastomosis gastroileostomy (SAGI) single anastomosis sleeve ileostomy (SASI) duodenojejunal bypass (DJB), or stomach intestinal pylorus sparing surgery (SIPS)

46 Assuming Small bowel length is 400 cm in length Approximate stomach size in ml BPD BPD/DS SADI OAGB MGB DJB RYGB Roux limb in cm NA NA NA 100 Common Channel Alimentary limb (Roux limb + CC) BPL

47 Assuming Small bowel length is 600 cm in length Approximate stomach size in ml BPD BPD/DS SADI OAGB MGB DJB RYGB Roux limb in cm NA NA NA 100 Common Channel Alimentary limb (Roux limb + CC) BPL

48 Assuming Small bowel length is 800 cm in length BPD BPD/DS SADI OAGB MGB DJB RYGB Approximate stomach size in ml Roux limb in cm NA NA NA 100 Common Channel Alimentary limb (Roux limb + CC) BPL

49 This is why you have to measure the common channel in patients undergoing any mal-absorptive surgery (BPD, BPD-DS, SADI, DJB, or OAGB/MGB) but not in RYGB with a short BPL

50 The concept of OAGB/MGB is valid & useful in: Super-obese, failure after restrictive surgery, failure after Roux-en Y gastric bypass

51 60 cm BPL 200 cm BPL

57 RCT long vs short BPL for type II DM patients 114 diabetic patients had RYGB with different BPL length: 73 had LBPL (200cm) & 41 had SBPL (84+2cm) & followed for 5 years. DM remission at 5 years was higher in LBPL 73.1% vs SBPL 55%, P<0.05), lower relapse rate (11.9% vs 32%, P<0.05) & less need for diabetic medications (P<0.05). Mixed meal test was done for 11 LBPL & 9 SBPL patients, patients with LBPL had higher GLP-1 at 45 minutes (P<0.05), higher AUC (P=0.01), lower GIP level at 15 minutes (P<0.01), lower insulin and C peptide at 30 minutes (P,0.001) compared to SBPL. M. Guimaraes MP Monteiro Abstract IFSO London 2017

58 RCT: conversion of LAGB to LBPL vs SBPL RYGB 146 patients had conversion of LAGB to RYGB with LBPL (150 cm) 73 patients vs SBPL (75 cm) 73 patients. Both groups were similar in baseline charachtaristics. At 3 years FU was 91%, total body weight loss was 24% for LBPL vs 20% for SBPL, P=0.039). Co-morbidity resolution was no different between two groups. Short term complications in 10% (6% LBPL & 4% SBPL) NS. A. Boerboom F Berends Abstract 0.158

59 RCT of 144 patients primary RYGB 70 patients with Roux/BPL vs 75/ patients with Roux/BPL 150/75 at 48 months (FU 90%). At 24 months, EWL% was better with long BPL 150 cm 84% vs 73% in short BPL 75 cm (P=0.002). EWL% was similar at 48 month 70% vs 62% (P=0.068). Type II DM was present in 33% (48 patients), complete remission was similar in both 78% vs 75% (P>0.05). Short and long term complications were similar. F. Berends I. Janssen Abstract IFSO London 2017

60 Nutritional deficiencies are unrecognized in approximately 50% of patients who undergo RYGB surgery. Routine supplements: Calcium. iron. Multivitamins. B 12 An ounce of prevention is better than a pound of cure John et al J Am Osteopath Assoc.2009;109:

61 Nutritional deficiencies 5 years after LSG 108 patients had LSG (81 females). Median EWL% 1 year 85.6% (weight loss maintained at 5 years) median EWL%74.5% Pre operative nutritional deficiencies Low Hgb 19.4%, iron 26.7%, ferritin 6% folate 2%, B12 3.1%, magnesium 34.4%, PTH elevation 3.4%. At 5 years, significantly more patients had anemia 40.1% (P=0.001), low ferritin 44% (P<0.001), low vitamin D 12.6% (P=0.07). This highlights the need for long term supplements for LSG. D. Karavias I. Kehagias abstract 0.074

62 Nutritional deficiencies 3 years after LSG 857 patients had LSG (609 females). Age 47+12, mean BMI Weight loss at 1,2,3 years was 37+14, & Kgs. Pre operative nutritional deficiencies Low Hgb 11%, low vit D 57 %, ferritin 14%, low B12 2% & PTH elevation 327%. At 3 years, significantly more patients had anemia 14% (P=0.02), low ferritin 23% (P<0.008), high PTH 16% (P value 0.008), low vitamin D 18% (P=0.005). This highlights the need for long term supplements for LSG. N. Zaeshenas Jjogensen abstract 0.071

63 Vitamin & mineral deficiencies 4 years after LSG Fit for me RCT of 150 patients after LSG standard multivitamin SMVS vs WLSO optimum (B12 400%, iron 150%, folic acid 150%). Weight, BMI, gender, iron, B12 folic acid vit D & total body weight loss were similar (28.8% for WLSO vs 28.6% for SMVS) P>0.48. At mean follow up of 4 years, vitamin B12 deficiency was lower for WLSO 14% vs 27%, ferritin 11% vs 23%, E Aarts F BeredsAbstract 0.168

66 Need for Intensive Nutrition Care After Bariatric Surgery: Is Mini Gastric Bypass at Fault? Patients at clinical nutrition ICU from 2013 to Twelve patients required enteral nutrition or parenteral nutrition (7 OAGB/MGB (58.3%), 2 underwent a RYGB, 2 had a LSG, and 1 had LAGB. OAGB led to more severe nutrition complications requiring intensive nutrition care and therefore cannot be considered a "mini" bariatric surgery. OAGB is often considered a simplified surgical technique, it obviously requires as the other standard bariatric procedures a close follow-up by experimented teams aware of its specific complications. Bétry C et al JPEN J Parenter Enteral Nutr Mar 9.

67 Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition. A 10-year study of Reversal MGB for severe and refractory malnutrition syndrome after intensive nutritional support following MGB. 26 of 2934 patients had reversal 20.9 ± 13.4 months post-mgb. At presentation, mean (BMI) 22 ± 4.4 kg/m 2, (%EWL) ± 22.5%,, & albumin serum level 25.5 ± 3.6 gr/l. At surgical exploration, 8 of 12 (66.5%) patients had a biliary limb longer than 200 cm and 9 (34.6%) had bile reflux symptoms. After a mean follow-up of 8 ± 9.7 months, all patients experienced a complete clinical and biological regression of the SRMS after the RMGB despite a mean 13.9 kg weight regain in 16 (61.5%) patients. Overall reversal morbidity was 30.8% Langenbecks Arch Surg Aug 12. doi: /s [Epub ahead of print] Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition. Genser L 1, Soprani A 2, Tabbara M 3, Siksik JM 4, Cady J 2, Carandina S 5.

68 Impact of BPL length on severe PCM requiring revisional surgery after one anastomosis (mini) gastric bypass The highest percentage of 0.51% (120/23,277) was recorded with formulae using >200 cm of BPL for some patients, and lowest rate of 0% was seen with 150 cm BPL. (survey study). J Minim Access Surg Jul 7. doi: /jmas.JMAS_198_16. [Epub ahead of print] Mahawar KK 1, Parmar C 1, Carr WRJ 1, Jennings N 1, Schroeder N 1, Small PK 1. Reply to "Key Features of an Ideal OAGB/MGB Pouch". Our study population consisted of the first patients that underwent a Mini Gastric Bypass (MGB) at our institution. At that time, we used a considerably long biliopancreatic (BP) limb ( cm), which proved to be too long for some patients in our series, and we have since then revised our technique accordingly Saarinen T, Juuti A. Obes Surg Jun;27(6):1632. doi: /s x.

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