Bypass Gástrico de Una Anastomosis (OAGB/BAGUA): una cirugía metabólica segura y muy eficaz.

¿Qué tipo de patología queremos tratar y controlar? La obesidad es una Enfermedad Metabólica Inflamatoria Crónica. Alto riesgo cardiovascular. Progresiva e incapacitante. Controlable pero incurable y de fatales consecuencias para la salud y la vida.

¿Cuáles son los objetivos de una cirugía metabólica "ideal"? Erradicar o controlar el sobrepeso a largo plazo (> 10 años). Resolver, mejorar o controlar las comorbilidades graves y el riesgo cardiovascular a largo plazo (> 10 años). Mejorar la calidad de vida y evitar una muerte prematura. Integrar a los pacientes a su vida personal, social y familiar.

Which must be the principles and criteria of an ¨IDEAL METABOLIC¨ procedure?: Evidence Must be safe Must eliminate and control all the associated co-morbidities To loose and keep the weight lost in life time term. Minimum incidence of postoperative and long-term complication To maintain a good quiality of life Easy to reproduce Short time in surgery No more than 24/48hrs in hospital bed Easily management of mal-absortion Do not need any kind of prosthetic supplies. To be easily checked and debated in data bases. To be done in a continuous and follow-up program. Minimum blood lost Do not need ICU Minimum post-surgery pain. Patient feels grateful with it. As easily reversible as reviewed by laparoscopic approach. That does not produce nausea or vomiting Fast recovery and aloud the patient to walk at the next day. Aloud the patient returning to work in a week. Minimum risk of PTE Minimum risk of gastro-jejunostomy ulcers The process must be guided by a distinguished Center of Excellence or by The European Accreditation Council of the International Federation of Obesity Surgery Societies. Columnas iguales

¿Qué procedimientos metabólicos podemos utilizar?: Evidencias Endoscópicos: Balón, POSE, Endobarrier, Gastroplastia endoscópica... No existen evidencias de eficacia real. Quirúrgicos: 1.- Cirugías simples (restrictivas) --- BG, GVA, PG, GV. ** Resultados buenos (50-65% EIMCP) a corto plazo. Fracaso a largo plazo (< 50% EIMCP a 10 años) 2.- Cirugías complejas: --- BGYR estándar **Resultados buenos (50-65% EIMCP) a corto y medio plazo. No se mantienen resultados [> del 50% pacientes ( ̴50-65% EIMCP a 10 años)] --- CD-DB. *Resultados excelentes a largo plazo (> 75% EIMCP > 10 años) ** Altos índices de morbimortalidad y complicaciones a largo plazo. --- OAGB/BAGUA *Resultados excelentes a largo plazo (> 75% EIMCP > 10 años). ** Menor índice de morbimortalidad y complicaciones a largo plazo.

Disminuir los riesgos postquirúrgicos del Bypass Gástrico Estenosis Fuga Sangrado Úlcera Marginal Crónica Dumping severo. Estenosis Fuga Sangrado Hernia interna Obstrucción Estenosis Fuga Sangrado Vólvulo Intususcepción Obstrucción?? REGANANCIA DE PESO Dos Anastomosis 12 Posibles Factores de Riesgo Una Anastomosis 4 Posibles Factores de Riesgo

   Carbajo M, Garcia-Caballero M, Toledano M, Osorio D, Garacia-Lanza C, Carmona JA. One-anastomosis gastric bypass by laparoscopy: results of the first 209 patients. Obes Surg 2005;15:398-404. Rutledge R. Hospitalization before and after mini-gastric bypass surgery. Int J Surg 2007;5:35-40. Piazza L, Ferrara F, Leanza S, Coco D, Sarvà S, Bellia A, Di Stefano C, Basile F, Biondi A. Laparoscopic mini-gastric bypass: short-term single-institute experience. Updates Surg 2011;63:239-42. Lee WJ, Ser KH, Lee YC, Tsou JJ, Chen SC, Chen JC. Laparoscopic Roux-en-Y vs. mini-gastric bypass for the treatment of morbid obesity: a 10-year experience. Obes Surg 2012;22:1827-34. Musella M, Sousa A, Greco F, De Luca, Manno E, Di Stefano C, Milone M, Bonfanto R, Segato G, Antonino A, Piazzo L. The laparoscopic mini-gastric bypass: The Italian experience: outcomes from 974 consecutive cases in a multi-center review. Surg Endosc 2014;28:156-63. Musella M, Milone M. Still “controversies” about the mini gastric bypass? Obes Surg 2014;24”:643-4. Kim MJ, Hur KY. Short-term outcomes of laparoscopic single anastomosis gastric bypass (LSAGB) for the treatment of type 2 diabetes in lower BMI (<30 kg/m(2)) patients. Obes Surg 2014;24:1044-51. Lee WJ, Chong K, Lin YH, Wei JH, Chen SC. Laparoscopic sleeve gastrectomy versus single anastomosis (mini-) gastric bypass for the treatment of type 2 diabetes mellitus: 5-year results of a randomized trial and study of incretin effect. Obes Surg 2014;24:1552-62. Kular KS, Manchanda N, Rutledge R.  Analysis of the five-year outcomes of sleeve gastrectomy and mini gastric bypass: A report from the Indian sub-continent. Obes Surg 2014;24:1724-8.  Georgiadou D, Sergentanis TN, Nixon A, Diamantis T, Tsigris C, Psaltopoulou T. Efficacy and safety of laparoscopic mini-gastric bypass. A systematic review. Surg Obes Relat Dis 2014;10:984-91. Musella M. Milone M, Gaudioso D, Bianco P, Palumbo R, Bellini M, Milone F. A decade of bariatric surgery. What have we learned? Outcome in 520 patients from a single institution. Int J Surg 2014;12 Suppl 1:S183-8. Garciacaballero M, Reyes-Ortiz A, Garcia M, Martinez-Moreno JM, Toval JA, Garcia A, Minquez A, Osorio D, Mata JM, Miralles F. Changes of body composition in patients with BMI 23-50 after tailored one anastomosis gastric bypass (BAGUA): influence of diabetes and metabolic syndrome. Obes Surg 2014;24:2040-7. Carbajo MA, Jimenez JM, Castro MJ, Ortiz-Solorzano J, Arango A. Outcomes and weight loss, fasting blood glucose and glycosylated hemoglobin in a sample of 415 obese patients, included in the database of the European Accreditation Council for Excellence Centers for Bariatric Surgery with Laparoscopic One Anastomosis Gastric Bypass. Nutr Hosp 2014;30:1032-8. Carbajo MA, Vazquez-Pelcastre, Aparicio-Ponce R, Luque de Lyon E, Jimenez JM, Ortiz-Solarzano J, Castro MJ. 12-year old adolescent with super morbid Luque-de Leon, E.,Carbajo MA, Conversion of one-anastomosis gastric bypass (OAGB) is rarely needed if standard operative techniques are performed. Obes Surg 2016:26: 1588-91. Carbajo MA, Fong-Hirales A, Luque-de-Leon E, Molina-Lopez JF, Ortiz-de-Solorzano J. Weigth loos and improvement of lipid profiles in morbidly obeses patients after laparoscopic one-anatomosis gastric bypass: 2-years follow-up. Surgical Endoscopic. DOI 10.1007/s00464-016-4990-y. Carbajo MA, Luque-de-Leon E. Differentiating mini-gastric bypass/one-anastomosis gastric bypass from the single-anastomosis duodenoileal bypass procedures. Surg Obes relat Dis 2016:12; 933-4 Musella M, Apers J, Rheinwalt K, Ribeiro R, Manno E, Greco F, Milone M, Di Stefano C, Guler S, Van Lessen IM, Guerra A, Maglio MN, Bonfanti R, Novotna R, Coretti G, Piazza L. Efficacy of bariatric surgery in type 2 diabetes mellitus remission: the role of mini gastric bypass/one anastomosis gastric bypass and sleeve gastrectomy at 1 year of follow-up. A European survey. Obes Surg 2015 Sep 4 [Epub ahead of print].obesity, treated with laparoscopic one anastomosis gastric bypass (LOAGB/BAGUA): A case report after 5-year follow-up. Nutr Hosp 2015;31:2327-32. Carbajo MA, Luque-de-Leon E, Jiminez JM, Ortiz-de-Solorzano J, Perez-Miranda M, Castro-Alija M. Laparoscopic one-anastomosis gastric bypass: technique, results, and long-term follow-up in 1200 patients. Obes Surg Online First 25 Oct 2016 doi:10.1007/s11695-016-2428-1. Jammu GS, Sharma R. An eight-year experience with 189 type 2 diabetic patients after mini-gastric bypass. Integrative Obesity and Diabetes. 2016;2(4);246–9. doi: 10.15761/IOD.1000154. References ok

Weight loss, weight regain, and convertions to Roux-en-Y gastric bypass: 10-year results of laparoscopic sleeve gastrectomy Felsenreich DM, Langer FB, et al Surg Obes Relat Dis,2016 feb s1550 53 patients with complete 10-year-follow-up 36% were converted for weight reganain or reflux at a median of 36 months a mean percent excess weight loss of 53 ± 25% was achieved by only 32 patients ok CONCLUSION: Within a long-term follow-up of 10 years o more after SG, a high incidence of both significant weigth regain (59% of patients) and intractable reflux was observed, leading to conversion

Peri- and postoperative complication rate LSG 46133 pts (13.7 % mean) Mortality LSG 152 pts (0.3%)

Gastroesophageal reflux disease and Barrett’s esophagus after laparoscopic sleeve gastrectomy: a possible, underestimated long-term complication Alfredo Genco, M.D., Emanuele Soricelli, M.D. Giovanni Casella, M.D., Ph.D., Roberta Maselli, M.D., Lidia Castagneto-Gissey, M.D., Nicola Di Lorenzo, M.D., Nicola Basso, M.D. A significant increase in the incidence and in the severity of erosive esophagitis (EE) was evidenced, whereas nondysplastic Barrett’s esophagus (BE) was newly diagnosed in 19/110 patients (17.2%). No significant correlations were found between GERD symptoms and endoscopic findings.

Laparoscopic Roux-en-Y gastric bypass: 10-year follow-up K. Higa, T. Ho. F. Tercero, T. Yunus, K. Bone SOARD, 2011; 7: 516-525 242 patients *Follow up (rate 26% at 10 years) *Average %EWL at 10 years after surgery was 57,1% ± 33,9% *1 of 4 patients had inadequate weight loss (Biron’s definition) *33.2% failed to achieve an EWL of <50% *35% of the patients had ≥ 1 complication during follow-up - Internal Hernia rate was 16% - Gastro-yeyunal stenosis rate was 4.9% - Marginal ulcer rate was 4.5% *Only 18% remained nutritionally intact during follow-up 33% at 2 years 7% at 10 years ok CONCLUSION: “Althought our goal has been to improve the health and quality of life of our patients, MEASUREMENTS OF SUCCESS REMAIN NEBULOUS”

Early and late complication rate LRYGBP 81/770 pts (10.5 %)

>20.000 observed cases

Mortality rate LRYGBP (0.22%) Reoperation rate LRYGBP (2.5%) Perioperative complication rate (6.9%)

CONCLUSION: Higher level of execess weigth loos are archived. Long-Term outcomes after biliopancreatic diversion with and without duodenal switch: 2-,5-, and 10 year data Sethi M, Chau E, et al. Surg Obes Relat Dis. 2016;9 S1550 *100 patients. Mean follow 8.2 years (range 1-15 yr) active follow up 72% EWL 68% AT 10-15 years. 37% of patients developed long term complications requiring surgery CONCLUSION: Higher level of execess weigth loos are archived. Although nutricional deficiencies and post operative complications are common.

Complications following the MGB/OAGB: an Italian multi institutional study of 2678 cases with 10 years of follow up “Federico II” University - Naples - Italy Advanced Biomedical Sciences Department Results Operative time: 86.59±36.45 minutes for primary procedures and 109.3±24.81 minutes for revisional/redo surgeries Conversion rate to open surgery: 20/2678 pts (0.7%) Mean hospital stay: 4.16±1.10 days Mortality rate: 3/2678 pts (0.1%) Intraoperative complications: 14/2678 pts (0.5%) Early complications: 84/2678 pts (3.1%) Late complications: 72/683 pts (10.5%)

Conclusions If we consider the long-term results of the changes in body weight and resolution of obesity-related comorbidities at 1, 3 and 5 years, our series shows a satisfactory comparison with published papers. The concept of a logarithmic decline in weight loss appears to be confirmed at 5 years in our series, whereas both T2DM and hypertension remission is maintained at 5 years (84.8% and 87.5%, respectively). In conclusion, in our opinion, the most important criteria in the selection of a bariatric procedure remain safety and efficacy in the resolution of both weight loss and comorbidities during the long term rather than a faster or easier approach.

Methods: Initial 1200 patients submitted to laparoscopic OAGB between 2002 and 2008 were analyzed after a 6–12-year FU. There were 744 female (62 %) and 456 male (38 %) patients with a mean age was 43 years (12–74). Mean preoperative BMI was 46 kg/m2 (range, 33–86) and mean preoperative EW was 65 kg (range, 34–220). There were 697 (58 %) without previous or simultaneous abdominal operations, 273 (23 %) with previous, 203 (17 %) with simultaneous, and 27 (2 %) performed as revisions.

%EWL y BMI. Evidences: Pérdida de peso en el 1 mes: 15 a 20 kg Primer trimestre: 30 a 40 kg Clasificación de Reinhold´s: Buena a Excelente

Distribución de los procedimientos quirúrgicos EAC-BS 2017

IFSO- European Database Control Intra-operative Complications COMPARATIVE: OAGB vs. RYGB vs. GB vs. SG IFSO- European Database Control (Since January 2010) Intra-operative Complications Bleeding Liver Failure Injury splenic Other Gastrointestinal perforation vascular Deaths % TOTAL OPERATIONS 938 TOTAL OPERATIONS 14161 OAGB RYGB TOTAL OPERATIONS 2542 TOTAL OPERATIONS 16225 GB SG

IFSO- European Database Control Post-operative Complications COMPARATIVE: OAGB vs. RYGB vs. GB vs. SG IFSO- European Database Control (Since January 2010) Post-operative Complications

IFSO- European Database Control General Complications COMPARATIVE: OAGB vs. RYGB vs. GB vs. SG IFSO- European Database Control (Since January 2010) General Complications 0.56% 4.06% TOTAL OPERATIONS 938 TOTAL OPERATIONS 14161 OAGB RYGB 3.96% 4.29% TOTAL OPERATIONS 2542 TOTAL OPERATIONS 16225 GB SG

European database register of IFSO Center of Excellence from Jan 2010-2016 comparative EWL study between OAGB vs RYGB, SG, and GB: Evidence 86,54% 63,75% 39,29% 20,56%

European database register of IFSO Center of Excellence from Jan 2010-2016 comparative EBMIL study between OAGB vs RYGB, SG, and GB: Evidence 107,86% 71,88% 47,82% 23,65%

OAGB-BAGUA CONCLUSIONES A LO LARGO DE CASI 30 AÑOS NUESTRA EXPERIENCIA HA SIDO QUE EL PERFIL METABÓLICO DE TODAS LAS TÉCNICAS RESTRICTIVAS (incluyendo la GV), FRACASA A MEDIO Y LARGO PLAZO, POR LO QUE LAS HEMOS ABANDONADO. EL BGYR FUNCIONA BIEN A CORTO Y MEDIO PLAZO, PERO NOS DEFRAUDÓ SU ALTO NIVEL DE COMPLICACIONES Y SU POBRE PERFIL METABÓLICO A LARGO PLAZO, POR LO QUE TAMBIÉN LO ABANDONAMOS.

OAGB-BAGUA CONCLUSIONES 3. COMENZAMOS A DISEÑAR EL OAGB-BAGUA EN 2002 Y CON 3.000 CASOS ACTUALES PODEMOS AFIRMAR SU EXCELENTE PERFIL METABÓLICO A LARGO PLAZO, ESCASAS COMPLICACIONES, CONTROL DEL PESO Y COMORBILIDADES, SOBRE TODO EN LA DIABETES TIPO II 4. NO EXISTE NADA IDEAL, PERO EL OAGB-BAGUA REPRESENTA ACTUALMENTE UNA EXCELENTE ALTERNATIVA EN CIRUGIA BARIATRICA Y METABOLICA.

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