A NOVEL LAPAROSCOPIC REVERSABLE GASTRIC BAYPASS WITHFUNDECTOMY AND ESPLORABLE STOMACH: LRYGBP (fes)

G. LESTI1, S. F. ALTORIO1, M. A. ZAPPA2, A. PORTA2

1Clinica Di Lorenzo - Avezzano - 2 Ospedale Sacra Famiglia fatebenefratelli Erba ComoINTRODUCTIONThe Roux en-y gastric bypass is the most frequently performed procedure worldwide for surgical weight loss (more than 200.000 procedures in 2013) and is regarded by many as the gold standard to which other procedures should be compared. However ,many other surgeons, especially European and Italian- myself included -have always been afraid to leave the remnant stomach in the abdomen without any real possibility of diagnosing and treating disorders of the stomach, duodenum and bile duct. In view of the above mentioned considerations, in June 2001 we designed and performed the first laparoscopic gastric bypass with fun-dectomy and exploration of the remnant stomach (LRYGBP (fse) The first idea was to create a passage between the stomach pouch and stomach remnant by form¬ing a channel about 2 cm wide which, in the early days of our experience, in 52 patients was closed with adjustable gastric banding. Since January 2007 we have replaced the adjustable gastric banding by a Gore-Tex patch measuring 1cm wide 5-7 cm long and 0.12mm thick because 6 cases presented migration of the bending into the remnant stomach or jejunum via the ana-stomosis. The second idea was the removal of the gastric fundus ;the highly important physiological reason of fundus removal ,is the presence of parietal cells se¬creting ghrelin in it .The data in the literature claim that the results of bariatric surgery depend not only on the size of the gastric pouch or the length of the alimentary or the bilio-pancreatic limb, but also on the secretion of certain hormones, such as ghrelin ,a powerful hormone produced in the gastric fundus that has been found to impact on body weight.

LAPAROSCOPIC GASTRIC BYPASS BY LESTI LAPAROSCOPIC GASTRIC BY-PASS BY LESTI

THE DRAWING SHOWS THE POSITIONING OF THE DCB, and THE POUCH OF 25-30 ml .

The alimentary limb varies between 200 to 250 cm, the biliary limb 200-250 cm depending on BMI,

LAROSCOPIC GASTRIC BY-PASS BY LESTI

COMORBIDITIES

Type 2 diabetes mellitus : 24%• Obstructive sleep apnea : 27.2%• Systemic hypertension : 51.3%• Metabolic syndrome : 21.4%• Esophageal reflux :37.6%• Gallstones : 6.8%

LAPAROSCOPIC GASTRIC BY-PASS BY LESTI

PATIENTS 454 (1/2007—12/2013)Age (years( 43.6 (27-68)

• Gender (m/ f ) 166/288• BMI ( Kg/m2 48.2 (36.3-55.7)• Weight (Kg.) 136.4 (98.3-168.5)• Excess weight (kg ) 58.2 (35.4-97.2)• °°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°

Post-operatve stay(gg,) 4.74 (3—8 )Mean operating time 152min. (108 –227)

LAPAROSCOPIC GASTRIC BY-PASS BY LESTI

Major Complications and reoperationsMortality 0

• Leaks 0• Bleeding/reoperation 1 • Ulcers 0• Stricture 0• Internal hernias/reoperations 2• MIGRATION 0LAPAROSCOPIC GASTRIC BY-PASS BY LESTI

COMORBIDITIES RESOLUTION AT 3 YEARS(278PTS)Resolution improvment Not resol

• T2 DM 72.15% 19.3% 8.2%• Hypertension 69.4% 24.6% 6%• Obstructive s.apnea 62.5% 37.5% ====• Arthritis. ===== 100% ====• Gastro-esoph. Reflux 87.3% 12.7% ====

LAPAROSCOPIC GASTRIC BY-PASS BY LESTI

COMORBIDITIES RESOLUTION AT 5 YEARS(166)

Resolution Improvment not change• T2 DM 68.5% 21.4% 10.1%• Hypertension 67.4% 26.1% 6.5%• Obstructive Syndr. 60.5% 39.5% ====• Arthrisis. ===== 100% ====• Gastro esoph. Refl. 84.8% 15.2% ====

BODY WEIGHT Pre-op:136.4 Post-op :80.5

% EWL at 1 year (414 pts) : 77.8.% % EWL at3 years (278 pts) :84.4%% EWL at5 years (166pts) :79.6% “ BMI Pre-op : 48.2 Post-op :30.7

BMI LOST : 17.5

LAPAROSCOPIC GASTRIC BYPASS BY LESTI

The x ray shows the passage of bariumdirectly to the digiunum-ileum..

Nothing passes to the remnantstomach.

The endoscope can pass to the remnant stomach with gentle pushing

On the right,the gastroscopy shows the passage(anastomosis

2.5/3cm) of food from the gastric pouch to the

intestineOn the left ,the,passage to

the remnantstomach is visible ,closedby the DCB, allowing the

passage of endoscope butnot of food

MATERIALS ANDMETHODS From June 2001 to June 2014, 505 morbidly obese patients underwent LRYGBP(fse). Since January 2007 we have replaced the adjustable gastric banding by a 1mm thick Gore-Tex band measuring 5-7 cm. ,because in the first 52 patients we had 6 cases of migration of the bending into the remnant stomach or jejunum via the anastomosis . We reported only the results of the group of 454 patients with the Gore-Tex band operated on between January 2007- December 2014. The population reviewed includes 288 females and 166 males with a mean age of 43.6 (range 27-68) and a preoperative BMI of 48.2 kg/m° range (36.7-58.3). The patients’ characteristics and existing comorbidities are reported in below tables. All patients were selected according to the criteria for bariatric surgery proposed by the National Institutes of Health (NIH) Consensus of 1991 and replicated and updated by the Italian Society of Obesity Surgery (SICOB) The patients eligible for bariatric surgery(BMI>40kg./m2 or BMI >35 kg/ m2) with obesity related comorbidities underwent evaluation by a bariatric multidisciplinary team at our center for obesity disorders.

CONCLUSIONSThe LRYGBP (fse ) performed for the first time in 2001 presents the same results in weight loss of standard but , in our opinion has some important advantages. A) The realistic possibility to perform diagnostic and therapeutic procedures for any disease of the stomach, duodenum and bile duct. Any kind of endoscopic can pass, with gentle pushing, through the hole connecting the pouch to the remnant stomach.B) The resection of the gastric fundus, which is the main source of orexigenic ghrelin, can allow more effective weight loss and exerts beneficial metabolic effects in corre¬lation with PYY and GLP-1.The fundectomy markedly reduces the level of ghrelin, and thus the sense of hunger. C) The 2.5- 3 cm wide anastomosis allows, with a rapid passage of food into the fasting jejunum ,an increased production of anorectic hormones and, with the introduction of solid foods , patients satisfaction with very few episodes of vomiting. All of this improves a good quality of life. D) Reversibility. Is it an important question in an surgical procedure which practically never leads to malnutrition problems or excessive weight loss in patients? We think that an adult or young obese or diabetic patient who has to face , sometime in his life, an oncologic or degenerative disease which require a complex therapeutic and alimentary treatment could benefit from an reversible operation. At the last, the re¬versibility is an important option for psychiatric patients. The LRYGBP(fse) can pro¬vide reversibility simply by cutting ,the Gore-Tex band laparoscopicallyAt present, we feel very confident about this procedure, which can be considered safe because we have not had any serious complications since we switched from using the adjustable gastric banding to using a 1mm thick Gore-Tex band measuring 1 x5-7 cm. The duration of the operation in recent cases has also settled at not over 2 hours.

ThanksMuch is owed in this issue to the work of A. Chronaiou and M. Tsoli ). They evaluated whether fundus re¬section in patients undergoing standard LRYGBP en-hances the efficacy of the procedure in term of weight loss, fasting glucose levels and hormonal secretions. Body weight and body mass index decreased markedly and comparably after both procedures. Fasting ghrelin de¬creased 3 months after LRYGBP, but increased at 12 months to above baseline, while after LRYGBP + fundus resection it decreased markedly and persistently .Postprandial GLP-1, PYY and insulin responses were further enhanced and postprandial glucose levels were lower after LRYGBP+ FR compared to LRYGBP. Postoperatively ghrelin changes correlated negatively with GLP-1 changes. In conclusions, the resection of the gastric fundus in patients undergoing LRYGBP was associated with persistently lower fasting ghrelin levels ;higher postprandial PYY, GLP-1 and insulin responses and lower postprandial glucose levels com¬pared to standard LRYGBP. These finding suggest that fundus resection in the setting of LRYGBP may be more effective for the management of morbid obesity and diabetes type 2.