Resectional OAGB-MGB for the revision of restrictive procedures

Resectional One Anastomosis Gastric Bypass/Mini Gastric Bypass (R-OAGB/MGB) is a viable option for revisional bariatric procedures and could - in the future - be considered as a primary bariatric procedure considering its technical aspects and the potential advantage on weight loss, according to researchers from University Saint Joseph Medical School, Beirut, Lebanon and Poissy/Saint-Germain Medical Center, Université de Versailles/Saint-Quentin en Yvelines, Poissy, France.

The paper, ‘Resectional One Anastomosis Gastric Bypass/Mini Gastric Bypass as a Novel Option for Revision of Restrictive Procedures: Preliminary Results’, published in the Journal of Obesity, noted that revision surgery is one of the main research fields in bariatric surgery and there are many surgical options available, including those considered as an advancement and simplification of the standard biliopancreatic diversion by involving only a single anastomosis.

“Compared to OAGB/MGB, R-OAGB/MGB is a technical modification that facilitates the pouch fashioning, allows direct access to adhesions of the lesser sac, avoids complications arising from the residual stomach, and might have metabolic implication,” the authors reported. “…Also, the advantage of resection allowed direct access to severe adherences and scarring induced by the primary procedure that represents hazardous steps during revision.”

In the paper, the investigators report their preliminary experience with R-OAGB/MGB, a procedure that “starts by sleeve gastrectomy followed by an omega loop anastomosis between the transected sleeved gastric tube and the jejunum with special emphasis on operative and postoperative outcomes.”

“We believe that this technical modification facilitates the pouch fashioning considering the vast majority of bariatric surgeons who are familiar with sleeve gastrectomy.”

From January 2016 to February 2017, 21 patients (11 females, 10 males; age, 39.6±12.2) who previously had primary restrictive procedures (ten LGB, seven LSG and five LGP) were referred to the researchers for weight regain. The mean BMI at the time of the primary procedure was 45±4.8, decreased to 35±5.3 and later increased to 42.9±6.5 at the time of R-OAGB/MGB. In all patients, the previous procedure was performed by laparoscopy.

In patients with previous LSG, X-ray swallow examination detected five patients with dilated residual fundus (group A) and two patients with large remnant antrum (group B). Patients with failed LSG and chronic symptoms of reflux were excluded from the current study. All patients with previous LGP had gastric prolapse of the gastric plication.

R-OAGB/MGB technique

The R-OAGB/MGB technique is based on a 5-port approach. For patients with previous LSG, the gastric sleeve was dissected free from firm adhesion between the staple line and surrounding tissues, starting from the distal staple line and proceeding to the angle of His. For patients with previous LGP, the plicated part of the stomach was dissected free from surrounding tissues and the line of sutures was disrupted only where the first staples were placed. The first step of R-OAGB/MGB involved a calibrated (40F tube) sleeve using 4.8mm green Endo GIA reloads (Covidien) removing all the excessive and/or plicated gastric tissue along with plicature sutures.

For patients with previous LGB, the gastric band was freed from the surrounding capsule and adhesions and cut and extracted through the 15mm port. The internal fibrous tissue between the band and the stomach was removed as well to prevent stenosis of the tube at this level. The gastric greater curvature was than completely freed starting at 4cm proximal to the pylorus using LigaSure (Covidien) along with the direct release of lower sac adhesions and scarring to the left crus. A sleeve gastrectomy was than performed as described above.

The second step involved transection of the sleeved tube at its base (at least 12cm from the esophagogastric junction) and an antecolic loop end-to-side anastomosis with the jejunum (150cm distal to the ligament of Treitz for patients with BMI≤50  and 200cm for patients with BMI>50). The researchers used a hanging suture between the gastric pouch and the afferent loop to minimise reflux and a retaining suture between the lower part of the pouch and the antrum to prevent it from twisting. An intraoperative methylene blue test was then performed to exclude a leak. Increasing systolic blood pressure to 130 mm Hg while decreasing the pneumoperitoneum pressure allowed the achievement of hemostasis at the staple line by cautery or oversuturing.

Outcomes

The results revealed that the mean operative time was 96.4±20.9 minutes (range, 122–80), and the mean postoperative stay was 47.8±7.4 hours (range, 36–73). All procedures were completed laparoscopically and were uneventful, no one was admitted to the intensive care unit. There were no deaths, no procedure-related complications and no symptoms of chronic reflux or bile regurgitation reported by any of the patients.

The mean BMI decrease was 35.6±5.6, 30.6 4.6 and 28.5±4 at three, six and 12 months. At that time points, the mean ëL reached 41.7±0.1, 73.7±0.1, and 81.6±0.17%, while the mean percentage of the total body weight loss (%TWL) reached 17±0.01, 29.2±0.01 and 35±0.01% (Figure 1). Three patients with previous LGB had complete resolution of diabetes and two with previous LGP had complete resolution of hypertension.
 

Figure 1: Evolution of BMI from the primary operation through the resectional MGB

“Reflecting the study’s results, the procedure described herein was technically straightforward, effective, and safe in this at-surgical risk population,” the authors concluded. “We believe that this technical modification facilitates the pouch fashioning considering the vast majority of bariatric surgeons who are familiar with sleeve gastrectomy…However, comparative studies are needed to confirm this last issue.”