The scientific name for this procedure is Billroth II operation (Gastrojejunostomy intestinal anastomosis) and the official name is mini gastric bypass or MGB. This operation is quickly gaining notoriety as being one of the safest and most effective forms of bariatric surgery, and it has been gaining proponents in large numbers worldwide since it was conceived in the United States 16 years ago by Dr. Robert Rutledge, as a modification of the standard Billroth II procedure. In October of 2012, Dr. Rutledge and Jean-Marc Chevallier, the president of SOFCO, the French Bariatric Surgery Organization, led the International Mini Gastric Bypass Conference. The conference was held in Paris and incorporated 55 experts. Its success was clear and led to a follow-up conference in October of 2013, which was also held in Paris and involved 35 surgeons specializing in MGB hailing from 13 different countries, many of which who operated at the professional level. Many of the professionals who attended these conferences had reported experience using other forms of bariatric surgery including RYGB Roux-en-Y gastric bypass, sleeve gastrectomy or SG and GB or gastric banding.
There are two components created by this laparoscopic operation. The first is that the gastric pouch has less curvature and is thereby more restrictive. The second is a jejunal bypass which is 200 cm or longer and features a single antecolic gastro-jejunostomy anastomosis, leading to a significant reduction in fat absorption.
The stomach’s lesser curvature is identified, and stapler divided. The lesser curvature is identified where the body and the antrum meet and the stapler division is created at a right angle from this lesser curvature, then upwards parallel to it. The surgeon divides the stomach laterally toward the gastroesophageal junction. Unlike when it comes to the sleeve gastrectomy operation, the cardia is avoided explicitly.
When creating the 200 cm long malabsorptive jejunal bypass, the surgeon turns their attention to the left gutter, retracting the omentum medially so that they may identify the Treitz ligament. They run the bowel 200 cm distal to this ligament, at which point the gastric sleeve’s distal tip is anastomosed antecolic to the jejunum end to side.
The mini gastric bypass surgery has shown itself to be quite effective in resolving gastro-esophageal reflux disease or GERD. Surgeons believe this is because it resolves obesity in the patient as well as creating traction reducing cardia in the abdomen.
Some of the surgeons who engage in the mini gastric bypass surgery vary the actual length of the bypass. In people who are very tall or especially obese, the surgeon may opt for 250 cm or more rather than the traditional 200 cm distal to the Treitz ligament. A group in Italy has performed this surgery with 600 cm and more depending on the patient. Different modifications of this surgery have had different results, and it was found that placing the GJ between 200 cm and 300 cm proximal to the body’s ileocecal valve would be ideal in maintaining an adequate level of nutrition.
A Spanish technique has been developed, which was prevented by Flores hailing from Mexico. In this technique, they constructed an antireflux valve on the GJ’s afferent side. They place sutures along the afferent limb and the sleeve in order to inhibit the possibility of reflex. More than 80 percent of all attendees of the conference said that they used the Rutledge method and Rutledge measurements, whereas 10 percent used the Carbajo method presented by Mexico, and 5 percent utilized the Tacchino method involving the 300 cm common limb.
Should it become necessary, it is possible for the MGB operation to be modified if there is inadequate weight loss or an excess amount of weight loss. This involves only moving the anastomosis either proximally or distally. There is a physician in India, Bhanderi, who constructs a sleeve in a much longer length. Prasad, a physician in India, uses robotics in order to perform this operation.
Discussion on Survey Findings
Before the conference, a questionnaire was provided by SurveyMonkey. The results of the survey yielded the following information, that was based on carefully recorded data; especially necessary, since the MGB had been met with heavy skepticism in the past. The average BMI before the operation was 46.1, and the average hospital stay was only 3.2 days. In 91.4 percent of patients, diabetes had resolved itself within one year.
There was evidence of preoperative GE reflux found in 15.3 ±14.2% and then postoperatively in only 4.7 ±14.2%. This led the experts to the opinion that GERD is improved by MGB. Surgery to revise the MGB has only been necessary for 3.2% of that 0.4% for bile reflux. Braun entero-enterostomy was rarely needed. In a small 1.4 ±1.8% (range 0-5) ulcers occurred; a number less than those after RYGB. There have been nearly no postoperative ulcers occurring in Spain and India.
The %EWL was: one year at 75.8, two years at 85.0, three years at 78.0, four years at 75.0, five years at 70.2, longer 70.0. In 14.2 ±25.1% there was a failure to lose less than 50% of excess weight in 5 years. There has been a 0.2% operative 30-day mortality rate translating to 33 deaths.
A surgeon from Taiwan, Wei-Jei Lee, described a comparison that he made over ten years between the RYGB and the MGB surgeries. He believed that MGB was safer and simpler and that it produced better results when it came to diabetes reduction, GLP-1 elevation and long term weight loss.
In the early stages of the mini gastric bypass surgery, there were high prejudices by surgeons who had been performing longer procedures with greater difficulty. Surgeons all over the world who are performing the mini gastric bypass operation, however, are finding that they are receiving the same results like these other operations. The attendees of the MGB conferences are finding that this operation is technically simple, rapid, effective and safe. The operation also offers a single antecolic anastomosis that is in easy view, the absence of any leaking issues and a bypassed length that can be modified based on the BMI of the patient. This procedure processes patients with durable weight loss that can be reversed or revised as needed.