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Mal Fobi’s Corner

Mini gastric bypass - what is in a name?

...21 years later, the MGB is still at the center of an ongoing controversy in the field

The mini gastric bypass (MGB) is a bariatric metabolic procedure that is currently gaining a lot of attention. This operation was first performed in 1997 by its inventor who, in 2001, presented and published his rationale, technique, and comparatively good outcomes with the procedure in more than 1,000 cases with excellent follow-up. He stated clearly in his first publication that he was describing a minimally invasive gastric bypass operation because it was technically easier, required less time in the operating room, was less prone to internal hernias, easily amenable to revision and reversal, and provided good weight loss and metabolic effects. These claims have been validated by many who have published outcomes with follow up to 15 years.   

The article was authored by Mathias A. L. (MAL) Fobi - MD FACS, FICS, FACN, a clinical professor of surgery at SAIMS JIO University and the Director of clinical Research and Training at Mohak Bariatric and Robotic Surgery Center in Indore, India. He was the Medical Director and Chief Surgeon at the Center for Surgical treatment of Obesity in Los Angeles from 1979 to 2016. He is a past President of the California chapter of the ASMBS, past President of the ASMBS Foundation, past President of IFSO and past Chair of the Board of Trustees of IFSO

However, 21 years later, the MGB is still at the center of an ongoing controversy in the field. Those who perform and advocate the MGB see no complications and find very little wrong with offering this operation for most patients who are candidates for weight-loss surgery. Those who have not used it, and/or are against it, have only horror stories to tell about the operation. The truth is somewhere in the middle.

The MGB controversy takes me back to the late 1970s, when I was denied privileges to perform the gastric bypass procedure at prestigious hospitals in Los Angeles; their credentialing committees denied my request instinctively because of the word “bypass.” They did not see the word “gastric” in front of the “bypass,” and I was informed that “that shunt operation should not be done because it causes diarrhoea, enteritis, kidney stones, liver failure, electrolyte abnormalities, and death.” The phrase, “bypass for obesity,” conjured the memory of the jejunoileal bypass (JIB), an excellent weight-loss procedure that unfortunately was associated with serious long-term complications. At the time, I recognized the ignorance in these decisions to deny me operating privileges for the gastric bypass. I rewrote my requests, asking instead for the privilege to perform “a limiting proximal gastric pouch with a Roux-en-Y gastro-jejunostomy to treat morbid obesity.” This request was granted, and patients came to my centre requesting the limiting gastric pouch.

The above experience engendered the development of the Fobi Pouch procedure. When I began performing the vertical banded gastroplasty in 1981, it was called the “uptown pouch” and the Roux-en-Y gastric bypass was called the “downtown pouch”. Accordingly, when we undertook the prospective study comparing the gastroplasty to the gastric bypass, the randomized ballots were labelled “uptown” and “downtown”. When, eventually, I described the banded gastric bypass (BGBP), which evolved from revising the banded gastroplasty to a gastric bypass with the band/ring in place and the gastroenterostomy below the band/ring, the operation was called the Fobi Pouch rather than the banded gastric bypass. —A name is a word or set of words by which a person or thing is known, addressed, or referred to.

Innovations in bariatric surgery have mostly been serendipitous. None has taken the prescribed route of in vitro, then animal, and then human trials prior to launching. The JIB was introduced based on the observation that weight loss resulted from a short-gut syndrome that resulted from small bowel resection for various reasons. The JIB was an iatrogenic short-gut syndrome that was reversible. Similarly the gastric bypass was based on the observation that a small stomach that resulted from gastric resection for either cancer or ulcer disease caused weight loss due to decreased caloric intake.

The biliopancreatic diversion (BPD) was introduced as a hybrid of the gastric bypass and JIB. The adjustable gastric banding procedure evolved from the perception at the time that the effect of the gastric bypass was due to the restrictiveness of the pouch. The vertical banded gastroplasty was introduced based on the same perception. The banded gastric bypass was introduced based on observations that patients who were revised from banded gastroplasty to a Roux-en-Y gastric bypass with the gastroenterostomy distal to the band/ring, resulted in better weight loss and maintenance. The duodenal switch (DS) was introduced to minimize complications from the BPD. It decreased dumping, enhanced restriction, minimized the incidence of ulcers, and now we know it also enhanced the ghrelin effect of the BPD. Single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI), a procedure with a single anastomosis and longer common limb, was introduced to simplify the BPD-DS and decrease the incidence of diarrhoea and protein deficiency. The sleeve gastrectomy (SG) was introduced as a first-stage procedure for the difficult laparoscopic BPD-DS, and later, was proposed as a stand-alone operation. The single-anastomosis gastro-ileal bypass (SAGI), a hybrid of the MGB and the SADI, was introduced as a strong metabolic operation, easy to perform, yet with a fixed common limb to prevent protein deficiency. The single-anastomosis sleeve with ileal bypass (SASI) was introduced to enhance the incretin effects of the SG while decreasing the iron, B12, and calcium deficiency effects by keeping the duodeno-jejunal axis in continuity. It also provides for endoscopic access to all of the upper gastrointestinal tract.

The innovator or proponent of each of the above listed procedures named the procedures. Kremen named the JIB; Mason, the Roux-en-Y gastric bypass; Fobi, the BGBP; Scopinaro, the BPD; Hess, the BPD-DS; Gagner, the SG; Torres, the SADI; De Luca, the SAGI; Mahdy, the SASI, and the list goes on. For some strange reason bariatric surgeons are having a problem accepting the name, MGB, introduced by its innovator, Rutledge, who described it as a “minimally invasive gastric bypass,” in short, the MGB. Some call it the one-anastomosis gastric bypass (OAGB); some, the single-anastomosis gastric bypass (SAGB);  and others, the omega loop gastric bypass (OLGB). This controversy has gone to the extent that the two main bariatric journals will not publish papers with the name MGB. Why? A rose by any other name smells just as sweet.

The MGB by any other name is an effective metabolic operation with complications just as all other bariatric procedures have complications. History is replete with dedicated doctors who were ridiculed and shunned for ideas that seemed radical or nonsensical to their peers, but who may have been simply ahead of their time. Those who suffered such ill treatment changed medical history, often at great cost to themselves. Like many other great inventions, the MGB is evolving. It underwent ridicule and strong opposition, and now, hopefully acceptance. Ultimately it will take its rightful place in the armamentarium of bariatric metabolic procedures.

What is in a name? Maybe using the descriptive phrase of the procedure, “mono anastomosis gastric bypass,” will make the acronym “MGB” acceptable.

It is important to note the relative contraindications that should be associated with appropriate application of the MGB: (1) Bile reflux esophagitis—Do not perform the MGB in patients with symptomatic GERD, endoscopic esophagitis, or in patients with large hiatal hernias; (2) Barretts Esophagus/cancer—Do not perform the MGB in patients younger than 40. (It takes 30+ years for cancer from esophagitis due to bile reflux.); (3) Protein caloric malnutrition—Keep the biliopancreatic limb in the MGB <200 cm; if in doubt, measure all limb lengths to make sure the common limb is >400 cm.

When the Food and Drug Administration (FDA) delays approval of new effective treatments wanting absolute proof that they will cause no harm, doctors cry foul play because patients are deprived of effective therapy. Devices, but not surgical procedures are approved by the FDA. Surgery is approved by the standard of care based on acceptance in the surgical field of practice. Delayed acceptance of the MGB with a BP limb <200 cm but >150 cm and a common limb >400 cm in patients with no symptomatic GERD or endoscopic esophagitis or radiologic or endoscopic large hiatal hernia deprives a subset of patients a treatment procedure that by all standards is superior to the two procedures (SG and RYGBP) most commonly performed for treatment of obesity worldwide.

What is in a name?

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