MINI GASTRIC BY-PASS IN ITALY
MULTICENTRE REVIEW 2006-2012
Università degli Studi di Napoli “Federico II”
Dipartimento di Scienze Biomediche Avanzate
Chirurgia Generale
M. Musella
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
 Che intervento è?
 E’ lecito eseguirlo?
 E’ vantaggioso eseguirlo?
 Quali risultati?
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
12-14 cm long gastric pouch
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
200 – 220 cm from Treitz ligament
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
200 – 220 cm from Treitz ligament
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
 Che intervento è?
 E’ lecito eseguirlo?
 E’ vantaggioso eseguirlo?
 Quali risultati?
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
2001
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
2005
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
2005
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
2005
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
2008
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
2011
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
2011
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
2012
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
2012
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
 Biliary Gastritis
 Achloridria
 Mucosal chronic
inflammation
 Nitrosoderivate activation
 Gastric stump cancer
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
Biliary Gastritis





Rutledge 2005 (2475 pts.)
Carbajo 2005 (209 pts.)
Chevallier 2008 (100 pts.)
Noun 2012 (1000 pts)
Lee 2012 (1163 pts.)
0.2%
0%*
2.0%
0%-5.1%**
3.7%***
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
Biliary Gastritis
Johnson WH, Fernanadez AZ, Farrell TM, Macdonald KG,
Grant JP, McMahon RL, Pryor AD, Wolfe LG, DeMaria
EJ.(2007) Surgical revision of loop ("mini") gastric bypass
procedure: multicenter review of complications and
conversions to Roux-en-Y gastric bypass. Surg Obes Relat
Dis. 2007 Jan-Feb;3(1):37-41.
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
Gastric stump cancer
Caygill CP, Hill MJ, Kirkham JS, Northfield TC (1986) Mortality
from gastric cancer following gastric surgery for peptic ulcer. Lancet
1(8487):929-31.
Viste A, Bjørnestad E, Opheim P, Skarstein A, Thunold J, Hartveit F,
Eide GE, Eide TJ, Søreide O (1986) Risk of carcinoma following
gastric operations for benign disease. A historical cohort study of
3470 patients. Lancet 2(8505):502-5.
Lundegårdh G, Adami HO, Helmick C, Zack M, Meirik O (1988)
Stomach cancer after partial gastrectomy for benign ulcer disease. N
Engl J Med 319:195-200.
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
Gastric stump cancer
 Fischer AB, Graem N, Jensen OM. Risk of gastric cancer after
Billroth II resection for duodenal ulcer (1983) Br J Surg 70:552-4.
 Tokudome S, Kono S, Ikeda M, Kuratsune M, Sano C, Inokuchi K,
Kodama Y, Ichimiya H, Nakayama F, Kaibara N, et al. (1984) A
prospective study on primary gastric stump cancer following partial
gastrectomy for benign gastroduodenal diseases. Cancer Res
44:2208-12.
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
Gastric stump cancer
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
Gastric stump cancer
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
Gastric stump cancer
Bassily R, Smallwood RA, Crotty B. (2000)
Risk of gastric cancer is not increased after partial
gastrectomy. J Gastroenterol Hepatol. Jul;15(7):762-5.
The records of a total of 569 patients who had a partial gastrectomy
for peptic ulcer disease at Repatriation General Hospital,
Heidelberg, between 1957 and 1976 were reviewed.
Duration of follow up was 17.3 years (range 1-41 years). The expected
number of cancers in this population was 6.5. Assuming all survivors
were free of gastric cancer, the standardized incidence ratio was 1.39
(95% confidence intervals 0.64-2.65, P=0.313).
The risk of gastric cancer was not increased after partial gastrectomy
in this Australian population.
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
Esophago Gastric cancer
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
Esophago Gastric cancer





33 esophagogastric cancers (ca)
4 ca (12.1%) following a loop bypass (not better described)
3 ca located in the excluded stomach
1 ca located in the gastric pouch following a 1980 surgery
15 ca (45.4%) following restrictive procedures (LAGB, SG,
VBG)
 14 ca (42.4%) following RYGBP (5 located in the excluded
stomach)
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
 Che intervento è?
 E’ lecito eseguirlo?
 E’ vantaggioso eseguirlo?
 Quali risultati?
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
M. Musella - SICOB - Cagliari 04/13
M. Musella - SICOB - Cagliari 04/13
M. Musella - SICOB - Cagliari 04/13
M. Musella - SICOB - Cagliari 04/13
M. Musella - SICOB - Cagliari 04/13
M. Musella - SICOB - Cagliari 04/13
M. Musella - SICOB - Cagliari 04/13
M. Musella - SICOB - Cagliari 04/13
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
 Che intervento è?
 E’ lecito eseguirlo?
 E’ vantaggioso eseguirlo?
 Quali risultati?
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
Dal 11/07/2006 al 31/12/2012 abbiamo valutato i risultati
ottenuti dall’esecuzione del Mini Gastric Bypass
laparoscopico, per la cura dell’obesità e di alcune
comorbilità associate ad essa, eseguiti nei seguenti centri :
Centers
Patients
Musella
52
Piazza
380
Greco
70
Susa
406
De Luca
45
Manno
21
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
Sono stati eseguiti un totale di 974 interventi
475 pazienti maschi
499 pazienti femmine
(28%)
(71,69%)
BMI medio =
48 ± 4,579
Età media della popolazione =
39,45 anni
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
Main Preoperative Parameters
Pts Number (%)
Hypertensive Pts (%)
Diabetic Pts (%)
BMI < 30
2 (0.2)
0
2 (100)
30<BMI<35
54 (5.5)
13 (24.0)
30 (55.5)
35<BMI<40
192 (19.7)
38 (19.7)
38 (19.7)
40<BMI<50
416 (42.7)
90 (21.6)
53 (12.7)
50<BMI<60
257 (26.3)
116 (45.1)
89 (34.6)
53 (5.4)
34 (64.1)
12 (22.6)
974 (100)
291 (29.8)
224* (22.9)
BMI > 60
Total
M. Musella - SICOB - Cagliari 04/13
Calibre of the bougie :
• 42 fr
(380 patients)
• 40 fr
(70 patients)
• 36 fr
(524 patients)
Loop lenght :
224.6 ± 23.2 cm
M. Musella - SICOB - Cagliari 04/13
Size of the blue cartdrige linear stapler (gastrojejunal anastomosis):
• 30 mm
(70 patients)
• 45 mm
(451 patients)
• 60 mm
(453 patients)
Stapler holes closure method:
• Double layer running 2-0 suture
(573 patients)
• Single layer running 2-0 suture
(21 patients)
• Interrupted 2-0 stitches
(380 patients)
Reinforcement of the suture line:
• Fibrin sealant
(52 patients)
• Oversewing
(45 patients)
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
In 451 patients an anti-biliary reflux mechanism was provided.
All 974 patients were checked by an intraoperative methylene
blue test at the end of the procedure
M. Musella - SICOB - Cagliari 04/13
TOTALE PAZIENTI DECEDUTI
• 2/974
=
0,2%
PAZIENTI DECEDUTI PER COMPLICANZE NON RELATIVE ALLA PROCEDURA
• 1/974
=
0,1%
•Trombo-embolia polmonare
•Infarto del miocardio
•Ischemia cerebrale
•Insufficienza renale acuta
3 casi (0,3%) di cui 1 decesso (25%)
0 casi
1 caso (0,1%)
0 casi
PAZIENTI DECEDUTI PER COMPLICANZE RELATIVE ALLA PROCEDURA:
• 1/974
=
0,1%
LEAK ANASTOMOSI =
3 casi (0,3%) di cui 1 decesso (33%)
LEAK TUBULO GASTRICO=
5 casi (0,5%)
LEAK MONCONE GASTRICO=
2 casi (0,2%)
BLEEDING=
25 casi (2,5%)
EMORRAGIE DIGESTIVE=
9 casi (0,9%)
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
Peri-operative complications
Pts Number (%)
Pts/Days from Surgery
Surgical
revisions/Complications
(%)
3*/974 (0.3)
2*/1d; 1/15d
-
Stroke
1/974 (0.1)
1/20d
-
Respiratory distress
1/974 (0.1)
1/1d
-
GJ Anastomosis leak
3*/974 (0.3)
1*/1d; 1/2d; 1/5d
1/3
Gastric pouch leak
5/974 (0.5)
4/2d; 1/3d
5/5
Gastric remnant leak
2/974 (0.2)
1/2d; 1/12d
0/2
Abdominal bleeding
25/974 (2.5)
25/1d
9/25
GI bleeding
9/974 (0.9)
5/3d; 3/5d; 1/9d
1/9
Gastric perforation
2/974 (0.2)
2/1d
2/2
Jejunal perforation
3/974 (0.3)
3/2d
2/2
Total
54/974 (5.5)
PE
M. Musella - SICOB - Cagliari 04/13
20/48 (41.6)
Follow up outcome
12 months
36 months
60 months
Pts in follow up/Pts
operated
795/974 (81.0%)
510/974 (52.3%)
201/974 (20.6%)
Weight (Kg)
91.5 ± 18.5
79.1 ± 8.55
81.7 ± 23.15
BMI
31.88 ± 4.91
27.5 ± 2.12
28 ± 2.25
EWL%
70.12 ± 8.35
81.5 ± 4.95
77 ± 5.14
diabetes pts in
remission/ diabetes pts
in follow up
175/201 (87.0%)
160/186 (86.0%)
87/103 (84.4%)
hypertensive pts
healed/ hypertensive
pts in follow up
172/190 (90.5%)
132/155 (85.1%)
84/96 (87.5%)
M. Musella - SICOB - Cagliari 04/13
Follow up complication rate
Pts Number (%)
Surgical revisions/Complications (%)
Gastric pouch enlargment
4/974 (0.4)
0/4
Trocar hernia
1/974 (0.1)
1/1
EWL > 100%
1/974 (0.1)
1/1
Weight regain
2/974 (0.2)
1/2
Anastomotic ulcers
14/974 (1.4)
4/14
Biliary gastritis
8/974 (0.8)
0/8
Iron deficiency anemia
44/974 (4.5)
-
Total
74/974 (7.5)
7/30 (23.3)
M. Musella - SICOB - Cagliari 04/13
Present study
Rutledge(2)
Noun(8)
Carbajo(4)
Chevallier(5)
Lee(16)
Operative time*
9551.6
37.5
8912.8
93.0^
12937
115.324.6
Conversion rate
1.2%
0.17%
-
0.9%
-
0.1%
Mortality
0.2%
0.08%
-
0.9%
-
0.17%
Short term complications (STC)
5.5%
5.9%
2.7%^
4.4%
7%
8.5%
STC requiring surgical repair
2.0%
1.16%
0.2%^
1.4%
6%
1.8%
Long term complications (LTC)
7.4%°
11.6%°
4.1%^
8.1%°
4%
2.8%
LTC requiring surgical repair
0.7%
1.1%
3.4%^
-
-
2.8%
EWL% at 1 year
70.1±8.35
80
69.9±23.1
75
63±14
64.9±9.5(3)
EWL% at 3 years
81.5±4.95
80
72.2±22
-
-
-
EWL% at 5 years
77±5.14
80
68.6±21.9
-
-
72.9±19.3
-
-
93%(17)
-
-
-
T2DM resolution at 1 year
87%
T2DM resolution at 3 years
86%
83%
85%
M. Musella - SICOB - Cagliari 04/13
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
Conclusioni
1. E’ un intervento eseguibile senza rischi per il paziente
2. E’ un intervento vantaggioso per il paziente…
3. E’ un intervento che ha dimostrato una efficacia
sovrapponibile e in alcuni parametri anche superiore al
RYGBP
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
Mail to:
[email protected]
M. Musella - SICOB - Cagliari 04/13
Mini Gastric Bypass in Italy 2006-2012
Il giorno 17/apr/2013, alle ore 09.46, Dr Rutledge ha scritto:
Looks Great!
May I advertise it, Please?
Translation:
10:30 to 11:30 SESSION III MINIGASTRIC BYPASS: OPINION OF EXPERTS
Chairman: C. Giardiello (Caserta)
Moderators: L. Square (Catania), A. Susa (Rovigo)
M. Musella - SICOB - Cagliari 04/13