(OAGB) “How do I do it” Laparoscopic One Anastomosis Gastric ByPass Concepts and results in a series of 14-years experience with 2,750 patients

7th International Congress of the Spanish Society of Obesity Surgery. Valladolid - Spain May, 2004.

Failure in Weight Loss or Weight Regain!!! Stenosis Leak Bleeding Chronic Marginal Ulcer Severe Dumping. Stenosis Leak Bleeding Obstruction Stenosis Leak Bleeding Volvulus Intussuception Internal Hernia Obstruction?? Failure in Weight Loss or Weight Regain!!! Two Anastomosis GB 12 Possible Risk Factors OAGB/BAGUA 4 Possible Risk Factors .

LAPAROSCOPIC ONE ANASTOMOSIS GASTRIC BYPASS ROBOTIC - IDRIVE ULTRA POWERED STAPLING SYSTEM (OAGB)

ONE ANASTOMOSIS GASTRIC BYPASS LAPAROSCOPIC ONE ANASTOMOSIS GASTRIC BYPASS (OAGB/BAGUA) Illustration Dr. A. Valdés

KEY STEPS OF THE PROCEDURE LAPAROSCOPIC ONE ANASTOMOSIS GASTRIC BYPASS ROBOTIC - IDRIVE ULTRA POWERED STAPLING SYSTEM (OAGB) KEY STEPS OF THE PROCEDURE 1. Bilio-Pancreatic Limb: between 200 to 350 cm average. 2. Section of Greater Omentum: in supermorbid and central obesity. 3. Hiss Angle, Fat and G-E membrane Totally Dissected. 4. Gastric Pouch: length: 15-18cm, capacity: ~ 30/40 cc. (calibrated with a 36 French tube). Total dissection of fat in the posterior gastric wall. 5. “Anti-reflux Mechanism”: afferent loop suspended at least 10 cm on the gastric pouch. 6. Gastro-Ileal Anastomosis Side to Side: ~ 2.5 cm. width. However the different series published a global complication rate ranged from 20.5 to

Post-operative X-Ray control Radiologic control at 10 years LAPAROSCOPIC ONE ANASTOMOSIS GASTRIC BYPASS ROBOTIC - IDRIVE ULTRA POWERED STAPLING SYSTEM (OAGB) Post-operative X-Ray control Radiologic control at 10 years However the different series published a global complication rate ranged from 20.5 to

RESULTS: Patient Characteristics (July 2002 to February 2016) LAPAROSCOPIC ONE ANASTOMOSIS GASTRIC BYPASS: 14-YEAR EXPERIENCE IN 2.750 PATIENTS RESULTS: Patient Characteristics (July 2002 to February 2016) Age 43 (12 - 74) Gender Female 1691 (61.5%) Male 1059 (38.5%) BMI 46 (31 - 86) EBW (kg) 65 (28 - 220) The results of the first 209 patients operated on with the technique have confirmed our hypothesis. Our patients have no clinical symptoms as well as no objective evidence of GERD (measured in the 20 first patients by endoscopy and pHmetry) and margin ulcers.

RESULTS: Patient Characteristics (July 2002 to February 2016) LAPAROSCOPIC ONE ANASTOMOSIS GASTRIC BYPASS: 14-YEAR EXPERIENCE IN 2.750 PATIENTS RESULTS: Patient Characteristics (July 2002 to February 2016) Primary Surgery 1580 (57.4%) Other Previous Open Surgery 663 (24.1%) Other Associated Procedures 432 (15.7 %) Revisional Surgery 75 (2.7%) The results of the first 209 patients operated on with the technique have confirmed our hypothesis. Our patients have no clinical symptoms as well as no objective evidence of GERD (measured in the 20 first patients by endoscopy and pHmetry) and margin ulcers.

Length of Hospital Stay LAPAROSCOPIC ONE ANASTOMOSIS GASTRIC BYPASS: 14-YEAR EXPERIENCE IN 2.750 PATIENTS Length of Hospital Stay Uncomplicated Patients 2,715 (98.8%) 1 day (15-120 h.) Patients with Major Complications 35 (1.2%) 9 days (4-32 d.) The results of the first 209 patients operated on with the technique have confirmed our hypothesis. Our patients have no clinical symptoms as well as no objective evidence of GERD (measured in the 20 first patients by endoscopy and pHmetry) and margin ulcers.

Surgical Early Major Complications LAPAROSCOPIC ONE ANASTOMOSIS GASTRIC BYPASS: 14-YEAR EXPERIENCE IN 2,750 PATIENTS Surgical Early Major Complications Intraoperative Complications (resolved by Open Surgery) 4 (0.14%) Bleeding 2 (0.072 %) Gastro-esophageal Perforation 1 (0.036 %) Incorrect Gastric Transection Immediate Postoperative Complications (resolved by Open Surgery) 6 (0.21%) Leaks Intestinal Obstruction Partial Necrosis of Excluded Stomach Immediate Postoperative Complications (resolved by Lap. Surgery) 17 (0.61%) 10 (0.36%) 3 (0.109 %) Acute Gastric Distension The results of the first 209 patients operated on with the technique have confirmed our hypothesis. Our patients have no clinical symptoms as well as no objective evidence of GERD (measured in the 20 first patients by endoscopy and pHmetry) and margin ulcers. TOTAL 25 (0.909%)

Mortality Non Surgical Early Major Complications Mortality Total LAPAROSCOPIC ONE ANASTOMOSIS GASTRIC BYPASS: 14-YEAR EXPERIENCE IN 2.750 PATIENTS Non Surgical Early Major Complications Mortality Complications Treated Conservatively Mortality Leaks 8 (0.29 %) Acute Pancreatitis 1 (0.036 %) Infected Hematoma Total 10 (0.36%) Massive Pulmonary Embolism 1 (0.036 %) Nosocomial Pneumonia (Post-reintervention) DIC-Post Band reversion Total 3 (0.109%)

Gastro-intestinal stenosis LAPAROSCOPIC ONE ANASTOMOSIS GASTRIC BYPASS: 14-YEAR EXPERIENCE IN 2,750 PATIENTS Late Complications Gastro-intestinal stenosis 9 (0.3%) Pneumatic Dilatation 7 (0.25%) Prosthesis 2 (0.072%) Anastomotic Ulcer Medical Treatment 22 (0.8%) Malnutrition Medical treatment 23 (0.83%) B1-B6 Vitamin (severe deficit) 3 (0.1%) Weight regain Revisional surgery 1 (0.03%) TOTAL 45 (1.63 %)

Endoscopic Studies at 5-Year Follow-Up LAPAROSCOPIC ONE ANASTOMOSIS GASTRIC BYPASS: 14-YEAR EXPERIENCE IN 2,750 PATIENTS Endoscopic Studies at 5-Year Follow-Up Postop. UGI endoscopic (control) studies planned for all patients completing 5-year f/u 1,900 patients completed at least 5-Year f/u - 608 (32%) underwent UGI endoscopic studies NO significant acute or chronic lesions found NO erosive esophagitis or severe alkaline reflux Findings: Stomal ulcer: 4 (0.7%) Mild / Moderate pouch gastritis: 41 (7%) H. Pylori +: 10 (1.7%)

Percent of mean (and range) LAPAROSCOPIC ONE ANASTOMOSIS GASTRIC BYPASS: 14-YEAR EXPERIENCE IN 2,750 PATIENTS Weight Loss Percent of mean (and range) EWL at: 1 year 84% (55 –112%) 2 year 88% (58 –115%) 3 year 81% (55 –103%) 4 year 79% (51 –102%) 5 year 77% (48 –100%) 10 year 12 year 70% (45–98%) 69% (43–98%)

Arterial Hypertension LAPAROSCOPIC ONE ANASTOMOSIS GASTRIC BYPASS: 14-YEAR EXPERIENCE IN 2,750 PATIENTS Severe Comorbidities - Resolution Index at Two years at Ten years Dyslipidemia 98% 86% Type II Diabetes 99% 90% Arterial Hypertension 87% Sleep apnea 100%

Distribution of Operated Patients IFSO- European Database Control Procedure Total Gastric Banding 2,521 Gastric Plication 196 Gastric Sleeve 10,233 MGB / OAGB 2,256 *OAGB Centro Carbajo 810 Gastric Bypass 12,763 Gastroplasty 4 Bilio-pancreatic Diversion -Scopinaro 179 Duodenal Switch 615 Other Bariatric Surgery 794 29,561 January 2010 – January 2016 * Incluidas en las 2,256 de MGB/OAGB

IFSO- European Database Control COMPARATIVE: OAGB vs. RYGB vs. GB vs. SG IFSO- European Database Control (January 2010-January 2016) BMI Distribution TOTAL OPERATIONS 810 TOTAL OPERATIONS 12,763 OAGB/ Dr. Carbajo RYGB TOTAL OPERATIONS 2,521 TOTAL OPERATIONS 10,233 GB SG

IFSO- European Database Control COMPARATIVE: OAGB vs. RYGB vs. GB vs. SG IFSO- European Database Control (2010-2016)

IFSO- European Database Control COMPARATIVE: OAGB vs. RYGB vs. GB vs. SG IFSO- European Database Control (January 2010 – January 2016) Hospital Stay TOTAL OPERATIONS 810 TOTAL OPERATIONS 12,763 OAGB/ Dr. Carbajo RYGB TOTAL OPERATIONS 2,521 TOTAL OPERATIONS 10,233 GB SG

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

IFSO- European Database Control COMPARATIVE: OAGB vs. RYGB vs. GB vs. SG IFSO- European Database Control (January 2010-January 2016)

IFSO- European Database Control Post-operative Complications COMPARATIVE: OAGB vs. RYGB vs. GB vs. SG IFSO- European Database Control (2010-2016) Post-operative Complications

IFSO- European Database Control COMPARATIVE: OAGB vs. RYGB vs. GB vs. SG 3 years follow-up IFSO- European Database Control Evolution of % EWL 87 64 52 32

IFSO- European Database Control COMPARATIVE: OAGB vs. RYGB vs. GB vs. SG 3 years follow-up IFSO- European Database Control Evolution of % EBMIL 92 71 59 35

European database register of IFSO Center of Excellence from Jan 2010-2016 comparative EWL study between OAGB (Dr. Carbajo) vs RYGB, SG, and GB 87% 64% 39% 21%

European database register of IFSO Center of Excellence from Jan 2010-2016 comparative EBMIL study between OAGB (Dr. Carbajo) vs RYGB, SG, and GB 108 % 72% 48% 24%

LAPAROSCOPIC ONE ANASTOMOSIS GASTRIC BYPASS: 14-YEAR EXPERIENCE IN 2,750 PATIENTS CONCLUSIONS The OAGB (BAGUA) technique in our experience does not reduce the “complexity” of the surgical procedure, but significantly reduces operative time and length of hospital stay compared to other, simple or complex techniques; it also substantially decreases both early and late complication rates. In conclusion

LAPAROSCOPIC ONE ANASTOMOSIS GASTRIC BYPASS: 14-YEAR EXPERIENCE IN 2,750 PATIENTS CONCLUSIONS Excellent results in our long-term follow- up in regards to EWL/EBMIL resolution of co-morbidities and quality of life make OAGB a safe and effective technique, comparatively with others simple/complex bariatric techniques. Furthermore, is a powerful alternative for the treatment of morbid and super-morbid obesity after a 14-year experience. In conclusion

CENTER OF EXCELLENCE FOR THE STUDY AND OBESITY SURGERY TREATMENT