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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 1
| Issue : 1 | Page : 42-48 |
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Outcomes of 75 consecutive cases of laparoscopic one-anastomosis gastric bypass: A prospective study
Dhananjay Pandey1, Lokesh Yadav2, Kona S Lakshmi3, Ramalingam Trivikraman4
1 Institute of Minimal Access, Bariatric & Robotic Surgery, Max Super Speciality Hospital, Vaishali, Delhi NCR, India
2 Department of GI surgery, CKS Hospital, Jaipur, Rajasthan, India
3 Department of Minimal Access, GI & Bariatric Surgery, Yashoda Hospital, Somajiguda, Hyderabad, Telangana, India
4 Department of Surgical Gastroenterology, Baby Memorial Hospital, Kozhikode, Kerala, India
| Date of Submission | 24-Dec-2021 |
| Date of Acceptance | 22-Mar-2022 |
| Date of Web Publication | 07-Apr-2022 |
Correspondence Address:
Dr. Lokesh Yadav
Department of GI Surgery, CKS Hospital, 98A, Sikar Road, VKI, Jaipur, Rajasthan - 302013
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jbs.jbs_13_21
Background: Obesity is increasing at an alarming rate in India along with rest of the world. In the National Family and Health survey - IV conducted in 2015-16; 31.3% women and 26.6% men in urban area were obese or over weight. Bariatric surgery has long been introduced for weight control and is well established measure and superior to other weight control measures. Procedures like laparoscopic Roux en Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are more commonly performed than Laparoscopic One Anastomosis Gastric Bypass (LOAGB). Although sufficient data has accumulated in literature regarding the safety and efficacy of LOAGB, some of standard textbooks still mention it as an experimental procedure and not the mainstream procedure. Aims and Objective: The present study was conducted with objective to find out changes in pre-operative and post-operative status of diabetes mellitus, hypertension, dyslipidemia, obstructive sleep apnoea, osteoarthritis, GERD and quality of life after laparoscopic one anastomosis gastric bypass along with its safety and efficacy in Indian population. Material and Methods: The study was conducted at a tertiary care bariatric surgical centre and included 75 consecutive individual operated between January 2016 to December 2017 who underwent Laparoscopic One Anastomosis Gastric Bypass and followed prospectively for minimum 1 year (mean 18 months) and statistical analysis was done using SPSS 21 software. Result: One Anastomosis Gastric Bypass was completed laparoscopically in all the patients without need for conversion to an open procedure. The overall complication with Laparoscopic One Anastomosis Gastric Bypass was 1.3% without any mortality. Mean percentage of excess weight loss (% EWL) achieved was 72.73. 93.9 % patients with diabetes, 67.43% patients with hypertension, 87.1% patient with hyperlipidemia, all the patient with obstructive sleep apnoea and osteoarthritis of knee showed improvement in their disease status. None of the patient showed worsening of gastroesophageal reflux or development of new symptoms of gastro esophageal reflux. All patients had improvement in their quality of life as seen in the improvement of their SF 36 scores. Conclusion: Laparoscopic One Anastomosis Gastric Bypass is a safe and effective bariatric procedure. The post procedure improvement in diabetes, hypertension, hyperlipidemia, obstructive sleep apnoea, osteoarthritis of knee and quality of life is significant in Indian context.
Keywords: Bariatric surgery, metabolic surgery, obesity, one-anastomosis gastric bypass
How to cite this article:
Pandey D, Yadav L, Lakshmi KS, Trivikraman R. Outcomes of 75 consecutive cases of laparoscopic one-anastomosis gastric bypass: A prospective study. J Bariatr Surg 2022;1:42-8 |
How to cite this URL:
Pandey D, Yadav L, Lakshmi KS, Trivikraman R. Outcomes of 75 consecutive cases of laparoscopic one-anastomosis gastric bypass: A prospective study. J Bariatr Surg [serial online] 2022 [cited 2023 Sep 29];1:42-8. Available from: http://www.jbsonline.org/text.asp?2022/1/1/42/342732 |
| Introduction | |  |
Obesity is a modern pandemic and one of the greatest public health challenges of the 21st century. According to the World Health Organization 2016 data, 39% of adults aged 18 years and over 39% of men and 40% of women were overweight worldwide.[1] In India, the obese population has doubled in the past decade. In the National Family and Health survey-IV conducted in 2015–2016; 31.3% of women and 26.6% of men in urban areas were obese or overweight.[2] India is ranked on 3rd position in global rank of obesity in women and 5th in men.[3] At present, it is being considered the second most common cause of preventable death, next to smoking.
Although bariatric surgery has long been established as the most effective solution for long-term weight loss, one-anastomosis gastric bypass (OAGB) is relatively new procedure among the armamentarium of bariatric surgeon that was introduced by Dr. R. Rutledge in 1997.[4] Advantages of laparoscopic OAGB (LOAGB) are one less anastomosis hence lower risk of anastomotic leakage, shorter operative time, very little incidence of internal herniation, shorter learning curve, ease of reversibility, and fewer complication.[5] Improvement in quality of life (QOL) is great in majority. The results following surgery are also comparable to the current gold standard procedure Laparoscopic Roux-en-Y Gastric Bypass (LRYGB).
Although sufficient data has accumulated in the literature regarding the safety and efficacy of LOAGB, some of standard textbooks still mention it as an experimental procedure and do not consider it a mainstream procedure. The present study was conducted with objective to find out changes in the pre-and postoperative status of diabetes mellitus (DM), hypertension, dyslipidemia, obstructive sleep apnea (OSA), osteoarthritis, gastroesophageal reflux disease (GERD), and QOL after OAGB along with its safety and efficacy in the Indian population.
| Methods | | |
This prospective study was conducted at the Department of Minimal Access, Bariatric and Surgical Gastroenterology at a tertiary health care center in south-central India. Approval of ethical committee was sought before the study. The study included all individuals who willfully consented to participate in the study and were fit for surgery after preoperative assessment in the form of the general physical and medical workup, cardiopulmonary evaluation, psychological, and nutritional evaluation. The International Federation for the Surgery of Obesity and Metabolic Disorders-Asian Pacific Chapter consensus criteria 2011 for bariatric surgery was used for patient selection and all patients underwent LOABG from January 2016 to December 2017.[6] Upper gastrointestinal (GI) endoscopy was done in all our patients undergoing bariatric surgery. However, it was done selectively postoperatively on basis of symptoms.
Individuals who underwent LOAGB after other bariatric procedures (i.e., laparoscopic sleeve gastrectomy); patients having diabetes secondary to a specific disease (i.e., maturity-onset diabetes of the young or type 1 diabetes, after total/partial pancreatectomy); patient with secondary hypertension, genetic causes of dyslipidemia, osteoarthritis secondary to trauma, and GERD secondary to known pathology were excluded from this study.
The technique used for LOAGB was a 5-port technique near similar to that described by Rutledge et al.[4] Location of the ports was as follows: 12-mm camera port in the midline, supraumbilical; 13-mm working port in the right midclavicular line, 3–4 fingerbreadths below the costal margin; 13-mm midline working port, 2 fingerbreadths below and right to the xiphisternum; 5-mm liver retraction port, 2 fingerbreadths below the left costal margin just to the left of xiphisternum; and 5-mm assistant port in the left anterior axillary line, 2 fingerbreadths below the costal margin [Figure 1]. Dissection was started at lesser curvature by opening of lesser sac [Figure 2]. The first stapler (Endo GIA) was fired approximately 1.5–2 cm distal to incisura angularis on lesser curvature [Figure 3]. Dissection done near hiatus and adhesions were released from the posterior surface of the stomach if present before firing of last stapler [Figure 4]. Endo staplers were fired over a 34-French bougie to create a long gastric sleeve or pouch. This bougie was just used as a guide with no relation to calibration of the size of the pouch. Stomach pouch was at least around twice the size of the bougie. Approximately 100 ml pouch volume was made [Figure 5]. A loop antecolic gastrojejunostomy was done with the small bowel about 150–200 cm distal to the ligament of Treitz with an Endo-GIA stapler [Figure 6]. Over sewing of gastrojejunostomy was done with 2-0 Vicryl Suture [Figure 7]. All patients underwent methylene blue leak test. One abdominal drain was left near the anastomosis. | Figure 1: Port placement for laparoscopic one-anastomosis gastric bypass
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 | Figure 6: Antecolic gastrojejunostomy at 150–200 cm from the ligament of Treitz
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Main characteristics regarding the demographics variable were recorded. The preoperative presence of type 2 DM, hypertension, dyslipidemia, preoperative medication usage, dose, number of agents, and preoperative biochemical characteristics such as fasting glucose, PP glucose, glycosylated hemoglobin (HbA1c), fasting plasma lipid (total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides) was noted. The presence of other obesity-related conditions such as osteoarthritis and OSA was noted. Sleep apnea study was performed when indicated. Assessment for gastroesophageal reflux was done clinically (as recent consensus definition made it as clinical diagnosis). QOL was calculated using Short Form 36 (SF-36) questionnaire.
Intraoperative findings such as the duration of surgery, any intraoperative complication, and conversion to open surgery were noted. Postoperative complications such as anastomotic/staple line bleeding or leak, malnutrition, marginal ulcer, dumping, etc., were noted. The average duration of hospital stay and the perioperative (30 days) mortality was noted. Patients were followed-up at 1, 3, 6, and 12 months after operation and every 6 months thereafter.
Comparisons were made in this study between the periods immediately before surgery and 1 year after surgery by noting similar characteristics as described above in the preoperative period. Weight loss was expressed in terms of percentage of excess body weight. The American Diabetes Association 2016 criteria were used to define remission and improvement.[7] Diabetes was considered in remission when HbA1c <6.5% or fasting blood glucose (≤110 mg/dL) without the use of any antidiabetic medications and improved if patients still required oral medication at lower dosages and HbA1c was decreased from the previous level. The American Heart Association guidelines 2014 and the European Atherosclerotic Society Guidelines 2016 were used for defining remission and improvement of hypertension and dyslipidemias, respectively.[8],[9] OSA was considered in remission when postoperative sleep study demonstrates no apneic/hypopneic episode and improved when apnea–hypopnea index decreased in comparison to baseline. Osteoarthritis of the knee was considered improved when patient dose not required medicine or required a lower dose of previous medicine. Improvement or worsening in GERD was assessed clinically.
Analysis of this data was done with the help of SPSS software 22 and statistical test applied was Student's t-test, Chi-square test with 95% confidence interval (P < 0.05).
| Results | | |
A total of 75 individuals (41 male, 34 female) underwent LOAGB during the study. The mean age of the study group was 43.04 ± 9.92 years. The mean body mass index (BMI) of patients before surgery was 46.67 ± 5.81 and the BMI at a mean follow-up of 1 year was 29.41 ± 4.54 (P < 0.05). The mean percentage of excess weight loss was observed to 72.73 ± 13.98.
The mean duration of surgery in this series was 80.84 ± 8.85 min and the mean duration of hospital stay was 3.07 ± 0.58 days. There were no intraoperative complications, no conversion to open surgery, and the 30-day mortality was nil. The overall postoperative complication rate was 1.3%. None of the patients required an intervention or reoperation due to postoperative complications. The key intraoperative variables observed are given in [Table 1]. | Table 1: Key intraoperative and postoperative results studied with laparoscopic one-anastomosis gastric bypass
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Impact on comorbidities
Observation revealed that diabetes status improved overall in 93.9% of patients with remission in their diabetes status seen in 32.7% (stopped using any antidiabetic treatment as complete normalization of blood sugar levels) of patients and improvement in 61.2% of patients as shown by decreased medication requirement and reduction of HbA1c. The mean FBS and HbA1c levels and oral hypoglycemic agents' medication were significantly lower at 1-year postsurgery when compared to the presurgery period (P < 0.05). It was observed that of four patients, who used 3 OHA in the preoperative period, 75% were free of OHA and 25% had reduced to a single OHA. Of 31 patients who used 2 OHA in the preoperative period, 77.4% were reduced to using a single OHA and 16.1% were free of any medication.
A total of 67.43% of patient showed overall improvement in hypertensive status after 1 year of LOAGB, as remission was seen in 6.97% of (no longer required medication) patients. Fourteen of the 43 patients who used two antihypertensive medications in the preoperative period, 57.1% reduced to using single medication and 14.3% stopped using any hypertensive medication. Twenty-five of the 43 patients who used single antihypertensive medication in the preoperative period, of those 12% stopped using antihypertensive medication. The number of antihypertensive medications used by 32.55% of patients remained unchanged. There was a statistically significant decrease in the antihypertensive medication postsurgery (P < 0.05).
It was observed that 87.1% of patients initially with their abnormal fasting plasma lipid profiles showed overall improvement in their fasting plasma lipid profile after 1 year of LOAGB. Among these, remission was seen in 58.9% of patients and improvement in 28.2% of patients.
Sleep study was done selectively when the diagnosis of sleep apnea was suspected. Of 12 patients (16%) who underwent sleep study, all had OSA. Among these patients, 50% had remission and 50% improved in the follow-up period.
Of 75 patients, 21 patients had knee pain. Among them, 57.1% had stopped medication for knee pain and 42.9% decreased dose in the postoperative follow-up period.
Two of 75 patients with preoperative diagnosis of GERD underwent LOAGB both of which showed stable disease in the postoperative period. None of the operated cases have shown new development of GERD. The key comorbidities assessed at 1 year are given in [Table 2]. | Table 2: Summary of effect of laparoscopic one-anastomosis gastric bypass on comorbidities at 1-year follow-up
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Impact on quality of life
It was observed that the mean SF-36 for physical health, mental health, and total SF-36 was significantly more in the postoperative follow-up at 1-year period than compared to the preoperative period (P < 0.05) as shown in [Figure 8]. | Figure 8: Mean physical, mental, and total Short Form 36 scores compared preoperatively and after 1 year of laparoscopic one-anastomosis gastric bypass
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| Discussion | | |
After its introduction by Dr. R. Rutledge, the controversies related to Mini-Gastric Bypass (OAGB/Omega-Loop Gastric Bypass/Single Anastomosis Gastric Bypass) never seemed to cease. The LOAGB came in existence as it overcomes the limitations of the RYGB such as technical complexity and demanding learning curve, internal hernia, gastrojejunal stricture, late weight regain, and difficulty in reversing and revising;[10],[11],[12] these are the factors that also led to the development of the gastric band and sleeve gastrectomy.
The advantage of the LOAGB comes from the fact that it has both restrictive and malabsorptive components. Studies showed that a bariatric operation which includes a gastric and intestinal component outperforms purely gastric restrictive procedures such as the band and sleeve gastrectomy.[5],[13] LOAGB takes less time to perform, has a shorter learning curve and is associated with fewer major complications hence this operation has gained proponents worldwide, particularly increasing in the past years in Asia.[14]
One of the unique advantages of LOAGB is reversal is possible, it has an “Exit Strategy.”[15] Reversal is a simple procedure involving division of the gastrojejunostomy and creation of gastro-gastrostomy. The other advantage of this procedure is tailoring the bypass limb according to the BMI. It allows weight reduction that can be balanced against the risk of resulting micronutrient deficiencies. In a study by Lee et al., better results were suggested with using a bypass limb of 150 cm in those with BMI below 40 and increasing bypass limb by 10 cm with every increase BMI category related to obesity instead of using a fixed 200 cm limb for all patients.[16]
Previous studies with large cohort report overall complication rate of LOAGB was <5%, much lower than the overall complication rate of 17% of bariatric surgeries recently reported17. Furthermore, studies with LOAGB surgeries with more than 1000 cases, reported mortality of 0.2%, lower than the average 0.31% death rate of bariatric surgeries.[17] Rutledge and Walsh reported one death from myocardial infarction and another death from a perforated colon (2/2410).[18]
The main perioperative complications related to this procedure are bleeding and anastomotic leakage. In the present study, there were no intraoperative complications, and 30-day mortality was nil. The present study also revealed a low overall complication rate of 1.3% in the form of postoperative bleed. Most bleeding can be stopped spontaneously or requires blood transfusion as in our case. Most of leaks can be identified intraoperatively by methylene blue leak test and can be managed with suture closure. In a large retrospective analysis by Genser et al.,[19] leak rate was 1.5% (35/2321 patients). Most of leaks were diagnosed intraoperatively (27/35). Leaks which were undiagnosed intraoperatively (8/35) were symptomatic (intra-abdominal abscess or collections) and were diagnosed by upper GI contrast series or by computed tomography with oral water-soluble contrast. Preferred management for staple line leak in a hemodynamically stable patient is retrievable self-expanding metallic stents; very rarely patient may require a reexploration, either open or laparoscopic. The present study did not show any anastomotic leak.
Diabetes is the most common comorbidity, which resolves after bariatric surgery. In fact, the resolution or improvement was so significant that it lead to a recommendation by various diabetes federations that metabolic surgery should be considered for diabetic patients with a BMI >35 kg/m2 and it might be considered a nonprimary option for diabetic patients with BMI 30–35 kg/m2 with uncontrolled sugars. It also motivated research into the resolution of other comorbidities. As shown in results, it was observed that after 1 year of LOAGB the blood sugar control of the patients, improved overall in 93.9% of patients with remission in their diabetes status seen in 32.7% of patients and improvement in 61.2% of patients. The mean FBS and HbA1c were significantly lower at 1-year postsurgery when compared to the presurgery period (P < 0.05). There was a statistically significant decrease in the OHA medication postsurgery (P < 0.05).
Resolution of diabetes was also shown in various randomized clinical trials comparing best medical therapy and bariatric surgery. Although different criteria were used for defining remission and most of the studies do not differentiate between remission and improvement, still significant improvement was noted in diabetes status following LOAGB at different time intervals.
Bariatric surgery purely done for diabetes resolution is also not uncommon. In the present study, one patient with BMI of 33.6 kg/m2 was on 90 units of insulin per day along with high dose of oral hypoglycemic agents, for whom LOAGB was done for diabetes remission. He showed marked improvement in diabetes status with significant decrease in insulin requirement.
Etiology of hypertension is multifactorial and resolution of hypertension after bariatric surgery is gradual and less documented when compared to diabetes. In the present study, it was observed that 67% of patient showed overall improvement in hypertensive status after 1 year of LOAGB, as remission was seen in 6.97% of patients and hypertension status improved in 60.46% of patients. There was a statistically significant decrease in the antihypertensive medication postsurgery (P < 0.05). Studies from Rutledge et al. reported a higher resolution or improvement in hypertension of 80%, whereas Milone et al. showed only 33.3% of remission in hypertensive status after LOAGB.[20]
Improvement in dyslipidemia or hyperlipidemia after bariatric surgery is often related to weight loss. In the present study, it was observed that 87.1% of patients initially with their abnormal fasting plasma lipid profiles showed overall improvement in their fasting plasma lipid profile after 1 year of LOAGB, among them remission was seen in 58.9% of patients. Milone et al. in their study showed that 75 participants with hypercholesterolemia/hypertriglyceridemia at baseline, 38 (50.6%) normalized lipid profile at 1-year assessment.[20] Kular et al. reported an improvement in hyperlipidemia in 91% of patients in their study.[21] Rutledge and Walsh reported resolution or improvement of hypercholesterolemia in 89% of patients.[18]
The postoperative course may be complicated when the patients have preexisting OSA. No guidelines exist about the necessity of sleep study before bariatric surgery and protocols can vary from center to center. At our center, selective patients underwent sleep study when the diagnosis of sleep apnea was suspected. In the present study, 12 patients (16%) underwent sleep study. It was observed that of 12 patients who underwent sleep study, all had OSA. Among these patients, 50% had remission and 50% improved in the follow-up period. In a recent study from All India Institute of Medical Sciences by Priyadarshini et al., 19 (70%) patients of 26 patients having OSA were improved at the mean follow-up of 5.2 ± 2.5 months after bariatric surgery.[22] Improvement in OSA was noted in 87% and 92% in the study of Rutledge and Kular, respectively.[18],[21] In their meta-analysis of 342 patients, Greenburg et al. showed pooled baseline apnea–hypopnea index of 54.7 events/hour (95% CI, 49.0–60.3) was reduced by 38.2 events/hour (95% CI, 31.9–44.4) to a final value of 15.8 events/hour (95% CI, 12.6–19.0).[23] Although the improvement was significant, the author concluded that the patient should continue treatment of OSA to avoid its complications.
Knee pain or osteoarthritis of the knee can be age-related, traumatic, or may be associated with excess weight gain. The pain perception can vary from person to person and studies regarding the effect of LOAGB on osteoarthritis of the knee are scarce. In a study by Rishi et al., significant reduction in pain, stiffness, and activity of daily living was noted after 3 and 6 months postoperatively.[24] Improvement of knee pain after bariatric surgery was also reported in various studies using validated questionnaire regarding the severity of knee pain and impairment of daily activity and QOL.[25] In the present study, improvement in osteoarthritis was accessed by requirement of analgesic medications for the same complaint. It was observed that of 21 patients who had knee pain, 57.1% had stopped medication for knee pain and 42.9% decreased dose in the postoperative follow-up period.
Scope of bariatric surgery is not limited to weight reduction; the improvement in QOL is one of the major achievements of bariatric surgery. Studies comparing QOL before and after bariatric surgery are scarce in the literature. Lee et al. and Bruzzi M. et al. using the GI Quality-of-Life Index showed that postoperative QOL of the LOAGB group was significantly higher than preoperative score.[5],[26] The SF-36 questionnaire is one of the most commonly used indexes to assess the overall QOL of an individual and was used in our study. It was observed in the present study that the mean SF-36 for physical health, mental health, and total SF-36 was significantly more in the postoperative follow-up at 1-year period than compared to the preoperative period (P < 0.05).
The late complications of LOAGB include marginal ulcer, malabsorption leading to iron deficiency anemia, hypoproteinemia, and steatorrhea, and bile reflux. The incidence of marginal ulcers in various series is 1%–6% which is similar to the LRYGB.[27] The incidence of significant malabsorption varies in different series from 0.5% to 5%.[27],[28] Routine follow-up is necessary for the patient's lifetime and in the event of excess weight loss or a specific deficiency, treatment such as extra supplements may be instituted. In some cases (0.5%–1% in Dr. Rutledge's series), significant specific or nonspecific excess weight loss and deficiencies have been treated by reversal of the LOAGB.[18]
Internal hernia has been widely recognized in RYGB but in an experience of more than 16,000 LOAGBs, no internal hernias had been experienced.[28] As is seen with all forms of weight loss surgery, the incidence of cholelithiasis can occur after LOAGB. The presence of bile in endoscopy usually does not lead to any symptoms and GERD remains a clinical diagnosis and we usually do LRYGB in cases of symptomatic GERD; however, two patients with mild symptoms of GERD and diagnosis of small hiatal hernia opted of LOAGB and no worsening of symptoms has been noticed in follow-up. None of the operated patients developed new-onset of GERD symptoms. A concern to the LOAGB has been the potential development of gastroesophageal cancer from bile reflux. Data show that Billroth II gastrectomy is not associated with increased cancer rates.[27] After LOAGB, no carcinoma of the gastric channel or esophagus has been reported.[29] Late complication was beyond scope of this study as the follow-up period was limited. We will publish an update of this study with long-term results in future.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2]
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