Morality Clinical Trial
Official title:
Revisional Surgery After 925 OAGB Operations Retrospective Cohort Study of the United Kingdom MGB[Mini Gastric Bypass]/OAGB Collaborative Group.
Background: One anastomosis Gastric Bypass/Mini Gastric Bypass (OAGB/MGB) is a new operation
that provides comparable outcomes to the common bariatric procedures. Revisional surgery is
still needed after a number of OAGB/MGB procedures. The aim of this study is to report the
causes and management of these revisions.
Methods: From 2010 -2018, 925 OAGB/MGB operations were performed at 7 bariatric units across
the United Kingdom and included in this retrospective cohort study. The data was
retrospectively collected and analysed. The primary end point was identification of the
causes and management of revisions. Follow up ranged from 6 months to 3 years.
Results: Twenty-two patients (2.3%) required revisional surgery after OAGB/MGB. Five patients
(0.5%) developed severe diarrhoea managed by shortening the bilio-pancreatic limb (BPL) to
150cm. Four patients (0.4%) developed afferent loop syndrome and bile reflux was reported in
another 3 (0.3%) cases; all were managed by either conversion to Roux en Y Gastric Bypass
(RYGB) or a Braun anastomosis. Postoperative bleeding was controlled laparoscopically in 3
patients (0.3%). Liver decompensation was reported in 2 patients (0.2%) was treated by
shortening the BPL in one patient and a reversal to normal anatomy in another. The liver
failure resolved in both patients. Other indications for revision included two gastro-jejunal
stenosis (0.2%), one perforated ulcer (0.1%), one patient (0.1%) with excessive weight loss
and one case (0.1%) of protein malnutrition. None of the 22 patients undergoing revisional
surgery after OAGB/MBG died. Lost to follow up rate was 0.2%.
Conclusion: Complications requiring revisional surgery after OAGB/MGB are uncommon (2.3%) and
the majority can be managed by bilio-pancreatic limb shortening, the addition of a Braun
side-to-side anastomosis or conversion to RYGB. Bilio-pancreatic limb length of 200 cm or
more resulted in serious complications of liver failure, protein malnutrition, excessive
weight loss and diarrhoea.
The UK OAGB/MGB collaborative group of 12 consultant bariatric surgeons was founded in 2017
and the data of 925 OAGB/MGB procedures were retrospectively collected and analysed in this
cohort study. The treatment pathway is the SAME at each NHS centre. The indications for
referral, consultations, and follow up after surgery are similar. This is agreed bariatric
practice governed by British Obesity and Metabolic Surgery Society's [BOMSS] guidance.
The patients' age, BMI, presence of T2DM, comorbidities, Gastro-oesophageal reflux and hiatus
hernia, Barrett's oesophagus, family history of upper gastro-intestinal cancer, and the
patient choice were the main factors to influence the decision to the procedure type. Each
centre is offering Roux en Y Gastric Bypass (RYGB), Laparoscopic Sleeve Gastrectomy (LSG),
MGB/OAGB and Adjustable Gastric Band (AGB). The allocation of the procedure is finalised
after mutual agreement between the patient and the surgeon taking in consideration the above
factors and patient's choice. The data was retrospectively collected by the surgical team at
each institution and sent to the lead of the collaborative group. The follow up is conducted
by clinical visits, blood tests and radiology [ultrasound, computed tomography ] when needed.
The procedures were performed between September 2010 and May 2018. A long gastric pouch of
average 15cm was constructed over a 34-36F bougie using laparoscopic staplers. The start
point of stapling is at the crow's foot. The omentum was only divided in selected cases such
as male patients with a very high Body Mass Index (BMI). After identifying the
duodeno-jejunal junction, a BPL ranging from 150-300 cm was measured. The end-side /side-side
gastro-jejunostomy was made using a combined hand-sewn /stapled technique. Use of drains and
closure of Petersen's space varied between different surgeons. The patients were discharged
after 2-3 nights. The follow up was ranged from 6 months to 3 years. In the UK the NHS and
private practice are following National Institute of Clinical Excellence [NICE] guidelines in
management and post operative follow up. Thus there is very strict follow up for two years
after the operation. The patients are seen two weeks after the primary surgery at which
clinical examination, dietary assessment and baseline post operative blood test is performed.
Then the patients are seen one month after that, then 3 monthly period for the initial year,
and 6 monthly for the last year. During all these visits, clinical, dietary and routine
biochemical assessments were conducted. For patients who developed complications, a different
and longer pathway of follow up is adopted until they recover and then, discharged to their
general practitioners (GPs). The paper was written to comply with STROCSS guidelines
(www.strocssguideline.com).
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