XXI Congresso Nazionale SICOb Mini Gastric Bypass lopinione

XXI Congresso Nazionale SICOb Mini Gastric Bypass: l’opinione degli esperti La gestione delle complicanze. Esperienza personale e letteratura a confronto Maurizio De Luca MD Department of Surgery – Regional Hospital of Vicenza – Italy Cagliari, 25 -27 Aprile 2013

Results of Mini Gastric Bypass – Vicenza Padova Background Our Series before Mini Gastric Bypass Our Primary Surgery Sept 1993 Dec 2012 : Gastric Banding → 2400 Patients Ø 0 moratility Ø 5. 4% complication requiring reoperation Ø Mean %EWL 49% at 12 years Ø 25% of GB with %EWL < 30 (failure) APPROPRIATE BARIATRIC OPERATION – POSSIBLE ROLE OF STAGED SURGERY M DE LUCA, G Segato, L Busetto, D Asthon, F Favretti. Obesity Surgery, 18, 4, 153, 471 -472, 2008 Maurizio De Luca

Results of Mini Gastric Bypass – Vicenza Padova Background Our Series before Mini Gastric Bypass Our Remedial Surgery from Dec 1995 to January 2011 Duodenal Switch (DS) → 155 Patients (F/M 98/57) §open/VLS 41/114 VLS from Jan 2001 § 0, 7% mortality (1 case for malignant hypertermia) § 16. 7% post-op surgical complication (fistula, bleeding, internal hernia) § 5. 5% post-op medical complication (non fatal PE, pneumoniae, ARDS, MI) § 3% surgical revisions (diarrhea, low protein, excess WL, poor WL) § 12. 5% metabolic complication requiring rehospitalization arthralgia, peripheral edema, vomiting, diarrhea, nutrients deficiences § 39% of patients proctitis, alitosis, acid sweating § 75% EWL 13 years follow up §Comorbidities resolution 94% hyperlipemia, 91% Type II Diabetes ADJUSTABLE GASTRIC BANDING WITH DUODENAL SWITCH (BANDINARO): SEQUENTIAL TREATMENT IN A FAILED RESTRICTIVE PROCEDURE (LAPAROSCOPIC PRELIMINARY EXPERIENCE) DE LUCA M, Segato G, Busetto L, Ceoloni A, Banzato O, Enzi G, Favretti F Obesity Surgery, 16, 4, 2006, 400. Maurizio De Luca

Results of Mini Gastric Bypass : Vicenza Hospital /Padova University Series Antrophometric Data • April 2011 – December 2012 (20 months experience) • 42 Patients (F/M 26/16) • Primary Surgery /Remedial Surgery for Band Failure 4/38 • Age 39. 7 ± 10 (19 -62) • Weight kg 138. 7 ± 26. 8 (93 -182) • BMI 45. 6 ± 8. 1 (35 -61) • Lap/Open 42/0 • Skin-to Skin Time 110 ± 4. 65 (85 -190) No published data Maurizio De Luca

Results of Mini Gastric Bypass - Technical Details ØPerformed by Laparoscopy (4 -5 Trocar) Ø 20 -30 ml Gastric pouch (vertical gastrectomy) ØGastro-jejunal anastomosis with a stoma diameter of 1. 5 -2 cm ØL-L anastomosis ØAntireflux Stitches ØOmega Loop 220 cm ØAntecolic anastomosis One Anastomosis Gastric Bypass: a simple, safe and efficient surgical procedure for treating morbid obesity M Garcia Caballero and M Carbajo Nutricion Hospitalaria, XIX, (6) 372 -375, 2004 Maurizio De Luca

Results of Mini Gastric Bypass as Remedial Surgery Weight Loss (38 Pts) Kg months Maurizio De Luca

Results of Mini Gastric Bypass as Remedial Surgery Weight Loss (38 Pts) % EWL months Maurizio De Luca

Results of Mini Gastric Bypass (42 Pts) Comorbidities Diabetes 12 obese Pts DM 2 Ø 3 years, ØHg. A 1 c > 7. 5% ØFailure previous medical treatment Complete Remission: 9 pts (75%) Improvement: 12 pts (100%) Mean Follow-up: 13. 1 months (± 2. 3) Dyslipidemia 11 obese Pts with hypercolesterolemia and/or hypertrygliceridemia Complete remission 10 pts (90. 1%) Mean Follow-up: 12. 4 months (± 1. 9) Maurizio De Luca

Results of Mini Gastric Bypass (42 Pts) Comorbidities §OSAS 5 pts Complete resolution 100% §Sonnolence 7 pts Complete resolution 100% §Hypertension 19 pts Complete resolution 78% Partial resolution 10% §Hyperuricemia 3 pts Complete resolution 100% §Fatty liver 10 pts Improvement 90% Ultrasound at 0 and 12 months Maurizio De Luca

Results of Mini Gastric Bypass – Vicenza Padova Series Nutritional Deficiences Iron Calcium Zinc Vitamin. D Vitamin A Vitamin K Protein Dolen K et al. A clinical and nutritional comparison of biliopancreatic diversion with and without duodenal switch. Ann Surg 2004; 240 -51 Slater GH, Serum fat-soluble vitamin deficiency and abnormal calcium metabolism after malabsorptive bariatric surgery. J Gastrointestinal Surg 2004; 8: 48 -65 APPROPRIATE BARIATRIC OPERATION – POSSIBLE ROLE OF STAGED SURGERY M DE LUCA, G Segato, L Busetto, D Asthon, F Favretti. Obesity Surgery, 18, 4, 153, 471 -472, 2008 Maurizio De Luca

Results of Mini Gastric Bypass – Vicenza /Padova Series Complication of MGB Primary MGB 4 Pts Revisional 38 Pts Short Term Complications § Leakage 0 4. 7% § Bleeding 0 2. 3% § Major atelectasis § Deep vein thrombosis § Death 0 0 0 Long Term Complications (0 redo) § Stomal Ulcer § Bile Reflux § Excessive Weight Loss (malnutrition) § Bowel obstruction 0 0 2. 3% 0 0 Omega loop abdominal, intraluminal, thoracic § Total Redo Surgery (1 Pts 1° day post-op) Not published data 2. 3% Maurizio De Luca

Results of Mini Gastric Bypass – Vicenza /Padova Series Side Effects of MGB Primary MGB 4 Pts Revisional 38 Pts § Asthenia § Diarrhea § Bloating § Epigastralgia § Vomiting 0 2. 3% 0 7. 7% 2. 3% 4. 7% 2. 3% § Major metabolic consequences 0 0 <0. 001 <0. 05 <0. 01 Not published data Maurizio De Luca

Results of Mini Gastric Bypass - Literature Complication of MGB Primary MGB 923 Pts Revisional 77 Pts Short Term Complications (6 redo) § Leakage 2. 7% 0. 4% 11% 3. 8% <0. 001 § Bleeding 1. 6% 6. 4% <0. 68 § Major atelectasis § Deep vein thrombosis § Death 0. 21% 0 1. 29% 0% 0 <0. 09 <0. 77 Long Term Complications (7 redo) § Stomal Ulcer § Bile Reflux § Excessive Weight Loss (malnutrition) § Bowel obstruction 0. 69% 0. 65% 0 0, 4% 0 5. 2% 0 0 <0. 03 <0. 102 <0. 001 <0. 562 Gastrojejunostomy, gastric tube, gastric remnant abdominal, intraluminal, thoracic ONE THOUSANDS CONSECUTIVE MINI-GASTRIC BYPASS. SHORT AND LONG TERM OUTCOME Noun R, Skaff J, Riachi E Obesity Surg, 22, 697 -703, 2012 Maurizio De Luca

Results of Mini Gastric Bypass - Literature Complication of MGB Primary/Revisional MGB 1126 Pts Short Term Complications § Leakage 1. 4% 0. 9% § Bleeding 0. 3% § Gastric Perforation § Death 1 pulmonary thromboembolism/ 1 gastric wall necrosis 0. 1% Long Term Complications § Stomal Ulcer § Gastrojejunal stenosis 0. 8% 0. 4% Total Redo Surgery 1. 3% Gastrojejunostomy, gastric tube, gastric remnant abdominal, intraluminal, thoracic BYPASS GASTRICO LAPAROSCOPICO DE UNA SOLA ANASTOMOSIS (BAGUA) ASISTIDOCON BRAZO ROBOTICO: TECNICA Y RESULTATOS EN 1126 PACIENTES Caballero MAC, De Solorzano JO, Garcia-Lanza C Cirurgia Endoscopica, 9, 1, 6 -13, 2008 Maurizio De Luca

Maurizio De Luca

Lee GBP vs MGP: 10 year results - Complication Lee WJ et al. Laparoscopic Roux en Y Gastric Bypass vs Mini Gastric Bypass for the treatment of Morbid Obesity: a 10 Years experience Obesity Surgery 22: 1827 -1834, 2012 Maurizio De Luca

Lee GBP vs MGP: 10 year results Weight Loss Lee WJ et al. Laparoscopic Roux en Y Gastric Bypass vs Mini Gastric Bypass for the treatment of Morbid Obesity: a 10 Years experience Obesity Surgery 22: 1827 -1834, 2012 Maurizio De Luca

Lee GBP vs MGP: 10 year results Lee WJ et al. Laparoscopic Roux en Y Gastric Bypass vs Mini Gastric Bypass for the treatment of Morbid Obesity: a 10 Years experience Obesity Surgery 22: 1827 -1834, 2012 Maurizio De Luca

Results of Mini Gastric Bypass – Conclusion 1 v Less Surgery compared to GBP and BPD v Quicker Surgery compared to GBP and BPD v Low peri-operative complications compared to GBP and BPD v Long Term Weight Loss as BPD (75% EWL at 10 yrs) v Remission /improvement of Diabetes in 85 -90 % of cases v Remission of hyperlipidemia in 85 -95% of cases v Absence of some BPD side effects (like diarrhea, hemorrhoids, proctitis etc. ) v Reduction of metabolic consequences of BPD (protein malnutrition) Maurizio De Luca

Results of Mini Gastric Bypass – Conclusion 2 v In our series first choice operation is Gastric Banding (72% of Pts) v First option for Bile Reflux Obese Pts is GBP v First option for Diabetic or Hyperlipemic Obese Pts is MGB v First option as remedial surgery is MGB v Current studiies show that MGB is an effective, low-risk and low-failure bariatric procedure v MGB can be revised in GBP or reversed if necessary Maurizio De Luca

Results of Mini Gastric Bypass Thank You for your attention Maurizio De Luca