do you prefer rygb or oagb?
TRANSCRIPT
Do you prefer RYGB or OAGB?
Present by : Amir Ashrafi MD
One of the most acceptable procedures in bariatric
surgery is laparoscopic gastric bypass. Laparoscopic
Roux-en-Y gastric bypass (RYGB) is a common
technique used in bariatric surgery. Recently, one
anastomosis gastric bypass (OAGB) has been suggested
as a simple, fast, and effective technique for obesity
treatment.
While there are no absolute contraindications to
bariatric surgery, relative contraindications do exist.
These include severe heart failure, unstable
coronary artery disease, end-stage lung disease,
active cancer treatment, portal hypertension,
drug/alcohol dependency, and impaired intellectual
capacity. Furthermore, since these procedures are
performed under general anesthesia, any
contraindication to receiving general anesthesia
would also be a contraindication for these surgeries.
Evaluation of cardiac status and cardiac risk
preoperatively is one of the essential elements in
promoting safety in any surgical patient, but
especially in morbidly obese patients. Obesity
is associated with multiple comorbidities including
diabetes, obstructive sleep apnea, dyslipidemia,
and hypertension. All of these conditions can
potentially contribute to severe cardiovascular
events such as heart failure, arrhythmias, and
sudden cardiac death.
Bariatric patients should undergo cardiac risk assessment with a
validated risk calculator , such as the Revised Cardiac Risk
Index, and assessment of functional capacity. Based upon the
results, patients should be referred to a cardiologist or primary
care provider for additional testing when appropriate.
Referral to a cardiologist should also be considered for patients
with recent myocardial infarction, unstable angina,
decompensated heart failure, high-grade arrhythmias, or
hemodynamically significant valvular heart disease.
Because of its significant cardiovascular benefits and very low
risk profile, bariatric surgery should be considered even in
patients with significant cardiac disease and/or risk.
The incidence of obstructive sleep apnea
(OSA) in the morbidly obese population is
quoted at anywhere from 71% to 95%
depending on the patient’s BMI.
The gold standard for evaluation is nocturnal
polysomnography (PSG). During PSG, the number
of apneic episodes can be quantitated. The apnea-
hypopnea index (AHI) indicates the abscess of
sleep apnea if less than 5, mild OSA for 5–15,
moderate OSA for >15, and severe OSA if >30.
However, ordering PSG routinely for every bariatric
patient is not cost-effective or appropriate.
Weight loss associated with RYGB significantly improves the
symptoms of sleep apnea and is effective in discontinuation
in the clinical use of CPAP therapy. Improvement of
obstructive sleep apnea symptoms occur as early as 1
month postoperatively.
Bile reflux is the most notoriously controversial disadvantage
of MGB/OAGB. Prejudice arose from Mason’s loop gastric
bypass, after which bilious vomiting and subsequent gastritis
and esophagitis were reported in 70% of patients. This
may occur in the old Mason’s gastric bypass with a small,
high gastric pouch and alkaline reflux esophagitis due to a
loop adjacent to the esophagus. However, there is a great
difference between the Mason’s procedure and MGB, with
anastomosis in the latter being made on a long, narrow
gastric pouch far from the esophagus.
Chevallier et al. evaluated bile reflux by endoscopic biopsies
in MGB/OAGB patients. The authors registered, as a sign of
bile reflux, foveolar dysplasia only in 17.1% of patients at 2
years and 4.6% at 4 years, with no dysplasia or metaplasia.
Bile reflux, if present, is not symptomatic in all patients.
Symptoms (heartburn, dyspepsia, bilious vomiting) can be
successfully treated pharmacologically in most cases. Bile
reflux rarely needs surgical revision.
A total of 122 obese patients (22 males) who had undergone RYGB or
OAGB surgery were included. The Sydney bile reflux index showed no
statistically significant difference between RYGB and OAGB groups.
Similarly, no statistically significant difference was found in the self-
reported history of bile reflux-related symptoms, bile reflux markers in
endoscopy, and postoperative complications between groups. OAGB and
RYGB appear to be equal with respect to postoperative complications,
bile reflux frequency, bile reflux index, and the Sydney system score.
Our results suggest that RYGB might be the
procedure of choice in morbidly obese patients with
BE requiring surgical treatment for GE reflux
disease.
Our preliminary data showed that LRYGB is a suitable
treatment option for obese patients with BE, demonstrated
by 36 % regression rate of this premalignant disease.
Although BE persisted in the remaining patients, no
progression to dysplasia was observed. A larger number of
patients and longer follow-up are needed for more definitive
conclusions.
We recommend LRYGB as an effective combined bariatric
and anti-reflux surgical procedure for patients with severe
obesity and BE. In short-term follow-up, LRYGB achieved
endoscopic and histologic regression to normal mucosa in a
substantial number of the patients in our series.
Although previously unreported after RYGB, bile
reflux can be an important possible cause of chronic
pain. Bile reflux, however, responds favorably to
alimentary limb lengthening to 100 cm and was not
been seen in patients with an alimentary limb length
>62 cm.
Bile reflux gastritis of the remnant stomach is a new
consideration for chronic abdominal pain months to
years following RYGB. Hepatobiliary scintigraphy
imaging and endoscopic biopsy are highly
suggestive. RG is safe and effective treatment.
Previous laparotomy is a significant risk factor for developing
the complications that are related to the entering the
abdominal cavity during the laparoscopy procedure.
Complications are gastrointestinal lesions, blood vessel
lesions and the impossibility of entering the abdominal
cavity. The number of complications in the open technique of
laparoscopy is significantly higher than that in the technique
of closed laparoscopy, but this technique is applied in 90% of
patient cases with previous laparotomy.
Our experience allows us to insert Veres needle in
the umbilical region for pneumoperitoneum creating
and apply the technique of closed laparoscopy in all
patients as well as those with previous laparotomy.
Why did not we find adhesions at the very
umbilicus? Supposedly, due to the poor
vascularization of the umbilicus the adhesions are
not formed, and therefore it is an appropriate place
for the entrance into the abdominal cavity with the
Veres needle and trocar
There were no significant differences in operative time, blood
loss, number of lymph nodes removed, or conversion rate
between the groups. The rate of inadvertent enterotomy was
significantly higher in the previous abdominal surgery group
than in the not having previous abdominal surgery group,
and the postoperative recovery time was significantly longer
in the previous abdominal surgery group than in the not
having previous abdominal surgery group. Ileus was more
frequent in the previous abdominal surgery group than in the
not having previous abdominal surgery group .
Laparoscopic colorectal surgery in patients with a history of
abdominal surgery exhibited acceptable short- and long-term
outcomes. Patients with a history of previous abdominal
surgery had relatively higher rate of conversion to open
surgery as well as higher incidences of prolonged
postoperative ileus and wound complications compared to
patients without such history.
OAGB was associated with shorter mean operative time.
The length of hospital stay was comparable between the two
procedures. The incidence of leaks, marginal ulcer, dumping,
bowel obstruction, revisions and mortality was similar
between the two approaches. The incidence of malnutrition
was increased in patients treated with OAGB, while the
incidence of internal hernia and bowel obstruction was
greater in the RYGB group. In addition, the percentage
excess weight loss at 1, 2 and 5 years post-operatively was
greater for the OAGB group. The rate of type 2 diabetes
remission was greater in the OAGB group. The rate of
hypertension and dyslipidemia remission was also similar
between OAGB and RYGB.
OAGB is not inferior to RYGB regarding weight loss and metabolic
improvement at 2 years. Higher incidences of diarrhea, steatorrhea, and
nutritional adverse events were observed with a 200 cm biliopancreatic
limb OAGB, suggesting a mal absorptive effect.
TWL, malnutrition, and comorbidity remission 3 years postoperatively were
comparable. Gastroesophageal reflux was less frequent after RYGB (p =
0.0729), whereas shorter operation times (p < 0.0001), less frequent
stenosis (p < 0.0001), and dumping syndrome (p = 0.0018) were found in
OAGB-MGB. Further RCTs are required.
Surgical intervention for biliary reflux was more prevalent in
the OAGB group. Surgical intervention for internal herniation
was more prevalent in the RYGB group.
At 3-year follow-up, total protein and albumin values were
similar between arms while prealbumin deficit was more
frequent after OAGB than after RYGB. The rate of type 2
diabetes (87.5% in OAGB and 92% in RYGB), arterial
hypertension (51.6% in OAGB and 58.3% in RYGB), and
dyslipidemia (69.7% in OAGB and 78.6% in RYGB)
remission was not significantly different between the two
groups.
THE END