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Erschienen in:
01.04.2014 | Letter to the Editor
Still “Controversies” about the Mini Gastric Bypass?
Erschienen in: Obesity Surgery | Ausgabe 4/2014
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We read with great interest the two extensive reviews of the controversies surrounding the mini-gastric bypass (MGB) which Mahawar and colleagues have recently published in Obesity Surgery. The first review [1] describes a number of technical aspects related to the MGB and the results from published series; the second review [2] focuses on some specific controversial issues related to the MGB, relative to published literature. Although the declared purpose of these reviews is not to take sides about the aspects surrounding the MGB, leaving the interpretation to the readers, we felt the need for some comments regarding the presentation of the findings.
1.
About gastric and esophageal bile reflux [2]
The authors cite a number of published articles about the increased concentration of bile in the stomach and/or esophagus following surgical procedures which include cholecystectomy, Billroth II gastrectomy, and finally the old Mason loop horizontal gastric bypass [3]. Although caution is claimed because there are no studies evaluating bile acid levels after MGB, it is affirmed that “it is likely for MGB patients to have higher concentration of bile in the gastric pouch and the esophagus”. This position appears to be contradictory for the following reasons. First, as reminded by the authors, there is no study evaluating bile acid concentration in the long gastric pouch and esophagus following MGB. Second, this conclusion comes from the observation of long-term complications described in interventions such as Billroth II gastrectomy or the old Mason loop gastric bypass that are definitely not the MGB [3], which has a long vertical gastric pouch to at least the crow’s foot. And finally, although in most MGB series the harmless presence of bile in the gastric pouch (but not in the esophagus) has been described, no author has thus far reported any clinical symptom or histological damage related to this presence of bile [3].
2.
About symptomatic biliary reflux [2]
The article published in 2007 by Johnson et al. [4] is often cited by MGB opponents to remind the bariatric community of all the damage this surgery can cause. It is worth noting that if 32 patients who had a previous MGB were brilliantly treated, a conclusion about the safety of MGB could not be reached for the simple reason that no denominator for those 32 patients was provided in the article. Rutledge alone had already reported MGB in 2,410 patients in 2005 [5]. That means that if we want to consider no further MGBs following 2005, the entire complication rate for MGB would be 1.32 %. This would be a very acceptable morbidity rate, when we compare an authoritative Roux-en-Y gastric bypass (RYGB) series from Higa [6] reporting a 12.8 % early complication rate and a 32.2 % late complication rate on 242 patients, or the 5.61 % early morbidity rate for the sleeve gastrectomy (LSG) reported by Hutter et al. [7] in a large multi-institutional review for the American College of Surgeons.
4.
About long-term risk for gastric/esophageal cancer [2]
If we mean a lesion presenting in the gastric pouch or in the esophagus, the authors remind us that no gastric pouch or esophageal cancer has been reported thus far in the literature in patients who underwent MGB. In this regard, Mahawar et al. [1, 2] performed a thorough review of published data about the risk of gastric/esophageal cancer following any surgical procedure which may resemble MGB. A negligible risk in all patients, except for those infected by Helicobacter pylori, was found. The point is whether there is reason to follow for cancer after a bariatric procedure that is not the MGB. Sometimes, when discussing MGB, a neutral reader may feel the need from some authors to absolutely find any link between MGB and gastric cancer. We consider the affirmation “despite some differences, there are fundamental similarities between Mason’s loop gastric bypass and MGB” [2] incorrect. Furthermore, long-term studies following Billroth II did not find an increase in cancer in the remaining stomach [10‐13], although the likely presence of H. pylori was then unknown and untreated.
5.
About ease, learning curve, and complications [2]
The authors report a series of papers comparing MGB to RYGB. Their correct conclusion is that in the short term, the main advantage provided by the MGB compared to the RYGBP was significantly related to shorter operative time, less early postoperative complications and shorter postoperative hospital stay; in the long term, the most significant advantage for MGB was a higher weight loss and resolution of diabetes, and a lesser need for revisional surgery due to internal hernias or bowel obstruction [8]. Nevertheless, in our opinion, in past years when presenting the MGB, too much emphasis has been given to technical simplicity or shorter operative time, while only recently concepts such as safety, or, in the long term, weight loss and co-morbidity resolution, are emerging [14]. Although important, we do not consider a faster or easier approach the most important criteria for selection of a specific bariatric procedure [3].
6.
About the name of the procedure [2]
In October 2013, the Second International Consensus Conference on MGB was held in Paris consisting of 35 experienced surgeons performing MGB/one-anastomosis gastric bypass (OAGB) from 13 countries. One of the goals was to reach a consensus about the name of the procedure. The conclusion was that MGB/OAGB remains the name of choice to define this operation.