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GENERAL SURGERY NEWS / JULY 2021
The Roux-en-Y Gastric Bypass Is the Superior Operation
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Roux-en-Y or OneAnastomosis Gastric Bypass: Which Is the Better Bariatric Treatment? s we all get vaccinated, COVID-19 is finally coming under control. Once again, we will be able to meet in person, debate face-to-face, and settle our differences over dinner and perhaps a drink or two. That doesn’t mean, however, that our Great Debates should stop. In fact, this month we are pitting two debaters, both long-time friends of mine and, amazingly, each other, who have been arguing virtually on every online forum during the pandemic. Their debate is on what the best initial anastomotic bariatric treatment may be: the Roux-en-Y gastric bypass (RYGB) or the one-anastomosis gastric bypass (OAGB). This is not a new debate in the United States. It has been going on for more than 20 years, ever since the mini gastric bypass was first introduced. At first, it was a political battle and not based on legitimate data, but hopefully time has changed all that. Now, the debate should be over interpretation of the data; that is, interpretation of a multitude of studies performed outside the United States, because our societies have previously failed to approve the use of any form of the mini gastric bypass. Consequently, insurance companies did not reimburse it, essentially blocking legitimate studies in the United States. As you will see in this month’s debate, our two highly respected and clinically experienced surgeons practice in very different settings (university vs. private practice) and come to very different conclusions from their interpretation of the same available data. Is one right and the other wrong? Can we even answer the question up for debate or is it time to conduct our own well-structured studies in the United States to possibly put this argument to rest? I am sure our debaters will excite some of you to voice your own opinions on this subject. I would encourage you to follow up with us at General Surgery News, just as many of you have done with our previous debates like the safe cholecystectomy debate. We can only make progress by agreeing to disagree and listening to the other side’s opinions. nions. So, let the debate begin!
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Edward L. Felix, x, MD Editor, The Great Debates es General Surgeon, Pismo o Beach, Calif.
he surgical approach to obesity mana safer perioperative portfolio. In princiagement encompasses a wide specple, the one-anastomosis MGB/OAGB trum of procedures. Metabolic surgeons should be safer than the two anastomoses face a daily challenge of choosing the optiin RYGB, but the data show otherwise.5,6 mal bariatric operation without clear-cut The MGB/OAGB is falsely publicized as a guidance or a definite algorithm. This protechnically feasible operation, while in realcedure selection dilemma exists between ity, it seems to be harder to teach and reprothe Roux-en-Y gastric bypass (RYGB) and duce—both crucial features for the spread Omar the mini or one-anastomosis gastric bypass Ghanem, MD of any successful operation. Furthermore, (MGB/OAGB). Which is the better operif the MGB/OAGB is that easy and that Assistant Professor ation and why? perfect, why the emergence of the various of Surgery Interestingly, the Roux gastrojejunostomodifications of it? Although these deviaMayo Clinic my was introduced in 1977, to resolve bile tions are present in the RYGB, they are not Rochester, Minn. pouch gastritis in the previously described surgery-defining as in MGB/OAGB. loop gastrojejunostomy configuration.1 While the MGB/OAGB is marketHistologically, there were pouch and anased as the impeccable procedure and the tomotic abnormalities in 86% to 91% of the loop solution for every problem, the above characteristics configuration patients (even when an entero-enteros- pin it as an imperfect one—thus a non-endorsement tomy was added).2 While the current MGB/OAGB by the American Society of Metabolic and Bariatric adopters managed to shift attention from bile gastri- Surgeons, and a withdrawal of endorsement from the tis to the “lack” of bile esophagitis in MGB/OAGB, French National Authority of Health. The discrepthe basis of the problem of why the Roux was created ancy between adopters’ claims and the reality witis still there in the current loop configuration. nessed by the governing institutes is a projection of Could this inflammation lead to cancer? In a Japa- one fact: lack of transparency. nese study, 417 patients developed gastric stump carcinoma after Billroth II reconstruction when partial In principle, the one-anastomosis MGB/OAGB gastrectomy was performed for benign causes (time should be safer than the two anastomoses in interval, 33.9 years). Although it might not be appropriate to consider the Billroth II reconstruction itself RYGB, but the data show otherwise. This non-endorsement leads to lack of reimburseto be oncogenic, the study concludes that gastric ment by insurance companies, but most importantly, stump carcinoma “may come from gastrectomy-relatto a nonexistence of MGB/OAGB data from major ing mechanisms after gastrectomy for original benign 3 registries. Appreciatively, the short- and long-term diseases.” Bile reflux is not as benign as it is advertised, and only time will tell. Time is a test that sure- risks and outcomes of the RYGB cannot be kept ly the RYGB has passed. While a few cases of cancer secret, providing a superlative tool for advancing both have been reported after RYGB, they remain small the surgery itself and the bariatric field. Learning relative to the very high denominator of the RYGBs from the advantages and liabilities is a must. Findthat have been performed over the past four decades. ing an equilibrium between safety and efficacy is a Additionally, while MGB/OAGB surgeons con- must. Reproducibility is a must. Reimbursement is a stantly undermine pathologic bile esophagitis, 45% must. Transparency is a must. When RYGB satisfies (n=742) of the surveyed surgeons reported revising it all the above checkpoints and MGB/OAGB satisfies at least once for bile reflux.4 none, is there really a debate? One should not conSafety, a major determinant in choosing the ideal fuse enthusiasm and lobbying with realism and data. bariatric procedure, continues to be a vague matter within the MGB/OAGB community. Luck- References ily, the long-term safety of MGB/OAGB has been 1. Buchwald H, Buchwald JN. Evolution of operative procedures for the management of morbid obesity compared to RYGB in the randomized controlled 1950-2000. Obes Surg. 2002;12(5):705-717. YOMEGA trial (with several MGB/OAGB pioneers 5 on the design team). The MGB/OAGB had a seri- 2. McCarthy HB, Rucker RD Jr, Chan EK, et al. Gastritis after gastric bypass surgery. Surgery. ous complication rate of 36% (compared with 20% for 1985;98(1):68-71. RYGB) and an unforgiving 7.7% rate of malnutrition. Critics of the YOMEGA trial attributed these higher 3. Tanigawa N, Nomura E, Lee SW, et al. Current malnutrition rates to a fixed MGB/OAGB biliopanstate of gastric stump carcinoma in Japan: based on the results of a nationwide survey. World J Surg. creatic (BP) length of 200 cm used in the trial. Being 2010;34(7):1540-1547. a malabsorptive procedure, the MGB/OAGB efficacy depends on this longer BP length. Can MGB/OAGB 4. Haddad A, Bashir A, Fobi M, et al. The IFSO maintain a competitive, noninferior efficacy if the BP worldwide one anastomosis gastric bypass survey: techniques and outcomes? Obes Surg. limb is shorter or if a percentage (rather than a fixed 2021;31(4):1411-1421. segment) of the total bowel length is bypassed? Of course not. The “defective” design of a wider gastro- 5. Robert M, Espalieu P, Pelascini E, et al. Efficacy and jejunostomy, smaller reservoir, and absence of pylorus safety of one anastomosis gastric bypass versus Rouxen-Y gastric bypass for obesity (YOMEGA): a muladded to a longer BP limb is a recipe for metabolic ticentre, randomised, open-label, non-inferiority trial. deficiencies with incidences of anemia of 44%, hypoLancet. 2019;393(10178):1299-1309. albuminemia of 32%, and hypocalcemia of 19% over a period of five years, compared with 17%, 15% and 6. Bhandari M, Nautiyal HK, Kosta S, et al. Comparison of one-anastomosis gastric bypass and Roux-en-Y 8%, respectively, for RYGB.6 gastric bypass for treatment of obesity: a 5-year study. One can only hope that this humble long-term Surg Obes Relat Dis. 2019;15(12):2038-2044. MGB/OAGB safety profile is counterbalanced by
