MINI GASTRIC BY-PASS IN ITALY MULTICENTRE REVIEW M. Musella Università degli Studi di Napoli “Federico II” Dipartimento di Scienze Biomediche Avanzate Chirurgia Generale M. Musella - SICOB - Cagliari 04/13

Mini Gastric Bypass in Italy Che intervento è? E’ lecito eseguirlo? E’ vantaggioso eseguirlo? Quali risultati? M. Musella - SICOB - Cagliari 04/13

Mini Gastric Bypass in Italy M. Musella - SICOB - Cagliari 04/13

12-14 cm long gastric pouch M. Musella - SICOB - Cagliari 04/13 Mini Gastric Bypass in Italy

M. Musella - SICOB - Cagliari 04/13 Mini Gastric Bypass in Italy

M. Musella - SICOB - Cagliari 04/13 Mini Gastric Bypass in Italy

M. Musella - SICOB - Cagliari 04/13 Mini Gastric Bypass in Italy – 220 cm from Treitz ligament

M. Musella - SICOB - Cagliari 04/13 Mini Gastric Bypass in Italy

Che intervento è? E’ lecito eseguirlo? E’ vantaggioso eseguirlo? Quali risultati? M. Musella - SICOB - Cagliari 04/13

2001 Mini Gastric Bypass in Italy

2005 M. Musella - SICOB - Cagliari 04/13 Mini Gastric Bypass in Italy

2005 M. Musella - SICOB - Cagliari 04/13 Mini Gastric Bypass in Italy

2005 M. Musella - SICOB - Cagliari 04/13 Mini Gastric Bypass in Italy

2008 M. Musella - SICOB - Cagliari 04/13 Mini Gastric Bypass in Italy

2011 M. Musella - SICOB - Cagliari 04/13 Mini Gastric Bypass in Italy

2011 M. Musella - SICOB - Cagliari 04/13 Mini Gastric Bypass in Italy

2012 M. Musella - SICOB - Cagliari 04/13 Mini Gastric Bypass in Italy

2012 M. Musella - SICOB - Cagliari 04/13 Mini Gastric Bypass in Italy

Biliary Gastritis Achloridria Mucosal chronic inflammation Nitrosoderivate activation Gastric stump cancer M. Musella - SICOB - Cagliari 04/13

Mini Gastric Bypass in Italy M. Musella - SICOB - Cagliari 04/13

Mini Gastric Bypass in Italy Biliary Gastritis Rutledge 2005 (2475 pts.)0.2% Carbajo 2005 (209 pts.)0%* Chevallier 2008 (100 pts.)2.0% Noun 2012(1000 pts)0%-5.1%** Lee 2012 (1163 pts.)3.7%*** M. Musella - SICOB - Cagliari 04/13

Mini Gastric Bypass in Italy Biliary Gastritis Johnson WH, Fernanadez AZ, Farrell TM, Macdonald KG, Grant JP, McMahon RL, Pryor AD, Wolfe LG, DeMaria EJ.(2007) Surgical revision of loop ("mini") gastric bypass procedure: multicenter review of complications and conversions to Roux-en-Y gastric bypass. Surg Obes Relat Dis Jan-Feb;3(1): M. Musella - SICOB - Cagliari 04/13

Mini Gastric Bypass in Italy Gastric stump cancer Caygill CP, Hill MJ, Kirkham JS, Northfield TC (1986) Mortality from gastric cancer following gastric surgery for peptic ulcer. Lancet 1(8487): Viste A, Bjørnestad E, Opheim P, Skarstein A, Thunold J, Hartveit F, Eide GE, Eide TJ, Søreide O (1986) Risk of carcinoma following gastric operations for benign disease. A historical cohort study of 3470 patients. Lancet 2(8505): Lundegårdh G, Adami HO, Helmick C, Zack M, Meirik O (1988) Stomach cancer after partial gastrectomy for benign ulcer disease. N Engl J Med 319: M. Musella - SICOB - Cagliari 04/13

Mini Gastric Bypass in Italy Gastric stump cancer Fischer AB, Graem N, Jensen OM. Risk of gastric cancer after Billroth II resection for duodenal ulcer (1983) Br J Surg 70: Tokudome S, Kono S, Ikeda M, Kuratsune M, Sano C, Inokuchi K, Kodama Y, Ichimiya H, Nakayama F, Kaibara N, et al. (1984) A prospective study on primary gastric stump cancer following partial gastrectomy for benign gastroduodenal diseases. Cancer Res 44: M. Musella - SICOB - Cagliari 04/13

Mini Gastric Bypass in Italy Gastric stump cancer M. Musella - SICOB - Cagliari 04/13

Mini Gastric Bypass in Italy Gastric stump cancer M. Musella - SICOB - Cagliari 04/13

Mini Gastric Bypass in Italy Gastric stump cancer M. Musella - SICOB - Cagliari 04/13 Bassily R, Smallwood RA, Crotty B. (2000) Risk of gastric cancer is not increased after partial gastrectomy. J Gastroenterol Hepatol. Jul;15(7): The records of a total of 569 patients who had a partial gastrectomy for peptic ulcer disease at Repatriation General Hospital, Heidelberg, between 1957 and 1976 were reviewed. Duration of follow up was 17.3 years (range 1-41 years). The expected number of cancers in this population was 6.5. Assuming all survivors were free of gastric cancer, the standardized incidence ratio was 1.39 (95% confidence intervals , P=0.313). The risk of gastric cancer was not increased after partial gastrectomy in this Australian population.

Mini Gastric Bypass in Italy Esophago Gastric cancer M. Musella - SICOB - Cagliari 04/13

Mini Gastric Bypass in Italy Esophago Gastric cancer 33 esophagogastric cancers (ca) 4 ca (12.1%) following a loop bypass (not better described) 3 ca located in the excluded stomach 1 ca located in the gastric pouch following a 1980 surgery 15 ca (45.4%) following restrictive procedures (LAGB, SG, VBG) 14 ca (42.4%) following RYGBP (5 located in the excluded stomach) M. Musella - SICOB - Cagliari 04/13

Mini Gastric Bypass in Italy M. Musella - SICOB - Cagliari 04/13 Che intervento è? E’ lecito eseguirlo? E’ vantaggioso eseguirlo? Quali risultati?

Mini Gastric Bypass in Italy M. Musella - SICOB - Cagliari 04/13

Mini Gastric Bypass in Italy M. Musella - SICOB - Cagliari 04/13 Che intervento è? E’ lecito eseguirlo? E’ vantaggioso eseguirlo? Quali risultati?

Dal 11/07/2006 al 31/12/2012 abbiamo valutato i risultati ottenuti dall’esecuzione del Mini Gastric Bypass laparoscopico, per la cura dell’obesità e di alcune comorbilità associate ad essa, eseguiti nei seguenti centri : CentersPatients Musella 52 Piazza 380 Greco 70 Susa 406 De Luca 45 Manno 21 M. Musella - SICOB - Cagliari 04/13 Mini Gastric Bypass in Italy

Sono stati eseguiti un totale di 974 interventi 475 pazienti maschi (28%) 499 pazienti femmine (71,69%) BMI medio = 48 ± 4,579 Età media della popolazione = 39,45 anni M. Musella - SICOB - Cagliari 04/13 Mini Gastric Bypass in Italy

Main Preoperative Parameters M. Musella - SICOB - Cagliari 04/13 Mini Gastric Bypass in Italy

Calibre of the bougie : 42 fr (380 patients) 40 fr (70 patients) 36 fr (524 patients) Loop lenght : ± 23.2 cm M. Musella - SICOB - Cagliari 04/13

Size of the blue cartdrige linear stapler (gastrojejunal anastomosis): 30 mm(70 patients) 45 mm(451 patients) 60 mm (453 patients) Stapler holes closure method: Double layer running 2-0 suture(573 patients) Single layer running 2-0 suture(21 patients) Interrupted 2-0 stitches(380 patients) Reinforcement of the suture line: Fibrin sealant (52 patients) Oversewing(45 patients) M. Musella - SICOB - Cagliari 04/13

In 451 patients an anti-biliary reflux mechanism was provided. All 974 patients were checked by an intraoperative methylene blue test at the end of the procedure M. Musella - SICOB - Cagliari 04/13 Mini Gastric Bypass in Italy

TOTALE PAZIENTI DECEDUTI 2/974= 0,2% PAZIENTI DECEDUTI PER COMPLICANZE NON RELATIVE ALLA PROCEDURA 1/974=0,1% Trombo-embolia polmonare 3 casi (0,3%) di cui 1 decesso (25%) Infarto del miocardio0 casi Ischemia cerebrale1 caso (0,1%) Insufficienza renale acuta0 casi PAZIENTI DECEDUTI PER COMPLICANZE RELATIVE ALLA PROCEDURA: 1/974=0,1% LEAK ANASTOMOSI = 3 casi (0,3%) di cui 1 decesso (33%) LEAK TUBULO GASTRICO= 5 casi (0,5%) LEAK MONCONE GASTRICO= 2 casi (0,2%) BLEEDING=25 casi (2,5%) EMORRAGIE DIGESTIVE=9 casi (0,9%) M. Musella - SICOB - Cagliari 04/13

Peri-operative complications M. Musella - SICOB - Cagliari 04/13 Mini Gastric Bypass in Italy

Follow up outcome M. Musella - SICOB - Cagliari 04/13

Follow up complication rate M. Musella - SICOB - Cagliari 04/13

Mini Gastric Bypass in Italy Conclusioni 1. E’ un intervento eseguibile senza rischi per il paziente 2. E’ un intervento vantaggioso per il paziente… 3. E’ un intervento che ha dimostrato una efficacia sovrapponibile e in alcuni parametri anche superiore al RYGBP

M. Musella - SICOB - Cagliari 04/13 Mini Gastric Bypass in Italy Mail to:

M. Musella - SICOB - Cagliari 04/13 Mini Gastric Bypass in Italy Il giorno 17/apr/2013, alle ore 09.46, Dr Rutledge ha scritto: Looks Great! May I advertise it, Please? Translation: 10:30 to 11:30 SESSION III MINIGASTRIC BYPASS: OPINION OF EXPERTS Chairman: C. Giardiello (Caserta) Moderators: L. Square (Catania), A. Susa (Rovigo)