1. O.174: Mini-Gastric Bypass as primary procedure in Super-Obesity – early results from Germany K.Rheinwalt, S. Kolec, A. Plamper IFSO 2013, 18th World Congress, Istanbul 30.8.2013 Dept. for Bariatric and Metabolic Surgery St. Franziskus Hospital Cologne Germany

2. Role of Mini-Gastric Bypass in Germany - History Germany: still underdeveloped in bariatrics German population: high body weight and high BMI Banding for a long period predominant procedure Bypass-procedures: introduced with delay Sleeve: very popular (43,7% 2012) (easier to perform in higher BMI by less experienced surgeons, reimbursement = as RYGB) still widespread fear of Gastric Cancer after BII-reconstruction K. Rheinwalt 2013

3. Role of Mini-Gastric Bypass in Germany – situation today Biggest published series by R. Weiner (Frankfurt) with about 176 cases from 2001 to 2007 (indications: hepatomegalie, high risk, Jehovians, pt.’s wish)* Operation time 20 minutes shorter* In this series: ~10 % transformed to RYGB for pouchitis in postoperative endoscopy (even if not symptomatic)* MGB still mostly abandoned as primary procedure 2005 until now: ~300 MGBs performed among 29.000 cases (~1%) Since 2012 new interest as REDO especially after sleeve K. Rheinwalt 2013 *Weiner RA (Editor): Adipositaschirurgie. Chapter 7.3.1 Ein-Anastomosen-Magenbypass. 2010 Elsevier, München. 82-83

4. Only 100 MGBs in the National German Survey Study of Bariatric Surgery 2007 - 2012 K. Rheinwalt 2013

5. Why MGB? – own motivation visiting Prof. Chevallier in Paris 2009 promising results in the literature since 1997 ¹²³⁴⁵⁶⁷⁸⁹ complications (leaks, acid reflux) and weight regain with sleeves (own observations and literature)* risk of RYGB in Super-Obesity operations together with Dr. Rutledge ¹Chakhtoura G; Primary results of Laparoscopic Mini-Gastric Bypass in a French Obesity-Surgery Specialized University Hospital. Obes Surg 2008 (18):1130- 33 ²Lomanto D, Lee WJ et al; Bariatric Surgery in Asia in the Last 5 Years. Obes Surg 2012;22 (3):502-506 ³Garcia-Caballero M, Carbajo M. One anastomosis gastric bypass: a simple, safe and efficient procedure for treating morbid obesity. Nutr Hosp 2004 XIX(6):372-75 ⁴Noun R et al. One Thousand Consecutive Mini-Gastric Bypasses: Short- and Long-term Outcome. Obes Surg 2012522):697-703 ⁵Rutledge R. The Mini-Gastric Bypass: Experience with the first 1.274 cases. Obes Surg 2011 (11):276-280 ⁶Rutledge R, Walsh W. Continued excellent results with the mini-gastric bypass: six-year study in 2410 patients. Obes Surg. 2005;15:1304-8 ⁷Rutledge R. 6385 Consecutive Mini-Gastric Bypasses: 15 years later. Obes Surg. 2012; 22: 1323 (presented at XVII World Congress of IFSO in New Delhi ⁸Lee WJ et al. Laparoscopic Roux-en-Y versus mini-gastric bypass for the treatment of morbid obesity. Ann Surg. 2005;242:20-8 ⁹Lee WJ et al. Laparoscopic Roux-en-Y vs. Mini-gastric Bypass for the Treatment of Morbid Obesity: a 10-Year Experience. Obes Surg 2012(22):1827-34 *Himpens J et al. Long-term results of laparoscopic sleeve gastrectomy for obesity. Ann Surg 2010; 252:319-324

6. Start of own « MGB – program » in 2011 - which patients for MGB? K. Rheinwalt 2013

7. Good indications for MGB: Super-Obesity (BMI > 50) ¹ ² ³ REDOs, especially following sleeves ⁴ ⁵ ⁶ ⁷ High-risk-patients (shorter operation times)⁸ Instead of sleeves as one or two step procedures (BPD-DS) ??? ¹Peraglie C. Laparoscopic mini-gastric bypass (LMGB) in the super-super obese: outcomes in 16 patients. Obes Surg 2008 18(9):1126-9. ²Choban PS,Flancbaum L.The effect of Roux limb lengths on outcome after Roux-en-Y gastric ypass: a prospective randomized clinical trial. Obes Surg 2002;12(4):540-5 ³Noun R et al. One thousand consecutive mini-gastric bypass: short- and long-term outcome. Obes Surg 2012;22:697-703 ⁴Chevallier JM. Oral Presentation. 21 Redos after LSG. 1 st Mini-Gastric Bypass Consensus Conference. Paris, Oct 2012 ⁵Kular KS. Oral Presentation. 7 Redos after LSG. 1 st Mini-Gastric Bypass Consensus Conference. Paris, Oct 2012 ⁶Plamper A, Rheinwalt K. Revisional Surgery after sleeve gastrectomy - Pro Omega-Loop Gastric Bypass. Oral Presentation. 7 th Frankfurter Meeting Nov 2012 ⁷Weiner RA, Theodoridou S, Weiner S. Failure of Laparoscopic Sleeve Gastrectomy – Further Procedure? Obes Facts 2011;4(suppl 1):42-46 ⁸Weiner RA (Editor): Adipositaschirurgie. Chapter 7.3.1 Ein-Anastomosen-Magenbypass. 2010 Elsevier, München, p. 82-83 K. Rheinwalt 2013

8. Own indication pattern until 2011 BMI < 50 BMI > 50 K. Rheinwalt 2013

9. BMI<50 BMI 50 - 60 BMI > 60 Our Indication Pattern since 11 / 2011 No reflux reflux K. Rheinwalt 2013

10. Own technique Modified «Rutledge-technique» (no anti-reflux stitches) 5 trocars Surgeon on the right side of the patient, 1 assistant btw. legs Modification: 1st measuring BP-limb and transitory fixation stitch to greater curvature plus metal-clip-marking of the alim. limb Only then VERY LONG and NARROW gastric pouch (30 French cal. tube) Linearly stapled anastomosis to the distal posterior wall Ventrally closed with 2 layer running suture 2-0 Routine methylene blue testing and drainage K. Rheinwalt 2013

11. Bypass-length depending on BMI:¹ ² ³ BMI < 50BMI 50 - 60BMI > 60 200 cm250 cm300 cm … … … … ¹Choban PS, Flancbaum L. The effect of Roux limb lengths on outcome after Roux –en-Y gastric bypass: a prospective randomized clinical trial. Obes Surg 2002;12(4):540-5 ²Rutledge R. Association of bypass limb length and one year weight loss in 4114 Mini-Gastric Bypass patients. Abstract-No.: 262. IFSO Hamburg 1.9.2011 ³Lee WJ et al. Laparoscopic mini-gastric bypass: experience with tailored bypass limb according to body weight. Obes Surg 2008; 18(3):294-9 K. Rheinwalt 2013

12. 261 Bariatric Operations from 6/2011 to 8/2013 (197 f, 64 m, 139,7kg, BMI 48,7, 30d-mortality=0) K. Rheinwalt 2013

13. Among 100 MGBs: K. Rheinwalt 2013 65 primary MGBs for BMI > 50 25 primary MGBs with BMI < 50 (for high risk, hepatomegaly, patient wish) 10 REDO-MGBs after sleeve-resections / gastric banding

14. Mean values for 65 primary MGBs for Super-Obesity K. Rheinwalt 2013 Age: 42,2 years (21 to 64) Weight:158,3 kg (120 to 213) BMI:55,5 kg/m² (50,2 to 65,5) Bypass length:260,2 cm (120 to 350) Length of operation: 79,2 min (45 to 160) Hospital stay:4,4 days (3 to 12) Mortality:0,0

15. Complications K. Rheinwalt 2013 Intraoperatively: 3 / 65 2 x oversewing of micro-leakages after methylene blue testing switch to RYGB for mesentery being too short for Omega-loop (pt. not counted in MGB-group) Postoperatively: 6 / 65 1 Re-laparoscopy for incarcerated trocar site hernia (drain channel) 1 transformation to RYGB for dysphagia (success only after Psychotherapy) 1 conservatively treated leakage (staple line of the pouch) 1 conservatively treated hemorrhage in the gallbladder bed after simultaneous cholecystectomy 1 pneumonia 2 cardiac arrhythmias

16. Postoperative Follow-up K. Rheinwalt 2013 MGB > 50 kg/m² (n=65) MGB < 50 kg/m² (n=25) all primary MGBs (n=90) all primary RYGBs (n= 77) Sleeve (n=36) Age42,2 y (21-64) 49,6 y (28-65) 44,2 y (21-65) 41,6 y (23-58) 44,6 y (19-64) BMI (kg/m²)55,5 (50,2-65,5) 47,2 (40,3-49,9) 53,1 (40,3-65,5) 45,9 (38,6-64,3) 55,4 (41,6-75,9) n after 6 months2812403723 Weight loss after 6 months (kg) (min.-max.) 41,5 (25,0-62,4) 33,1 (16,5-43,4) 39,8 (16,5-62,4) 35,8 (19,2-51,6) 35 (10,0-64,0) EWL after 6 months (%) (min.-max.) 47,2 (27,7-62,4) 51,7 (28,4-74,2) 48,6 (27,7-74,2) 59,76 (35,8-95,8) 44,0 (15,3-64,8) n after 12 months 1410242821 Weight loss after 12 months (kg) (min.-max.) 55,9 (36,9-68,5) 45,5 (36,5-56,4) 51,6 (36,5-68,5) 46,5 (31,0-62,0) 40,7 (14,0-74,5) EWL after 12 months (min.-max.) 67,4 (52,0-79,8) 75,7 (50,2-96,4) 70,8 (50,2-96,4) 75,6 (45,4-104,3) 53,9 (21,4-84,87)

17. Summary MGB represents ~1% of bariatric procedures in Germany still widespread fears of bile reflux and cancer risks Advantages rather obvious in super-obesity, high risk and REDOs after sleeve Alternative to sleeve as primary procedure independent from BMI? our early results in 65 super-obese pts. confirm international favorable results RYGB remains standard procedure at least for BMI<50 more RCTs MGB vs. RYGB rewarded K. Rheinwalt 2013

18. Thank you! ? K. Rheinwalt 2013