OBES SURG DOI 10.1007/s11695-014-1526-1
LETTER TO THE EDITOR
The Name of Mini Gastric Bypass Kamal K. Mahawar & William R. J. Carr & Neil Jennings & Shlok Balupuri & Peter K. Small
# Springer Science+Business Media New York 2014
Dear Editor, Recent debate following publication of Lee’s article [1] and subsequent responses [2, 3] regarding name of Rutledge’s long gastric pouch gastric bypass with a loop reconstruction also known as mini gastric bypass (MGB) is somewhat unfortunate. As the first bariatric unit within the National Health Service of United Kingdom performing this procedure, we wished the debate and discussions on this procedure were held at a different level where we actually addressed the dilemma in the minds of the surgeons and the patients rather than confuse them further. When it comes to name, even though we would have preferred to call it modified loop gastric bypass [4] emphasizing its similarities with Mason’s original loop gastric bypass, we were concerned about the confusion it would cause in the minds of surgeons and patients and hence resigned ourselves to the fact that this will be yet another misnomer scientific community will have to live with. Moreover, let us not forget that Rutledge, the inventor of this procedure, named it mini gastric bypass [5]. Increasing body of published evidence [6–8] has now satisfied most of the controversial aspects that have plagued this procedure from its early days [4]. It is now more or less settled that patients undergoing MGB rarely suffer with symptomatic biliary gastro-oesophageal reflux and, when it happens, it is probably due to the construction of a shorter pouch by surgeons in their learning curve with this procedure. Marginal ulcer rate in these patients does not seem to be higher than those undergoing Roux-en-Y gastric bypass (RYGB), a n d f i n a l l y, i t i s n o w w i d e l y r e c o g n i s e d t h a t
K. K. Mahawar (*) : W. R. J. Carr : N. Jennings : S. Balupuri : P. K. Small Bariatric Unit, Sunderland Royal Hospital, Sunderland SR4 7TP, UK e-mail: [email protected]
gastrojejunostomy leaks and marginal ulcers in these patients can be managed in much the same way as after RYGB [6–8]. However, one controversy with MGB which is still preventing its widespread adoption, despite its multiple proven advantages, is that of the theoretical concern of a higher risk of gastric and/or oesophageal cancer in these patients in the minds of some surgeons. This is a question that ultimately only time can answer, but it is worth noting that in scientific literature, there is only one published report of a cancer after MGB [9] and, even in this patient, cancer was not in the part of the stomach in contact with bile (gastric pouch). This patient developed gastric cancer in her bypassed stomach 9 years after her MGB. This is significant because tens of thousands of this procedure have now been performed all over the world with more than 6000 published cases [6–8]. It is hard to imagine that even one case of gastric or oesophageal cancer in any patient after this procedure will go unnoticed given the significant scrutiny surrounding it. This is especially significant as the two cancers both individually have an annual incidence of 1 in almost every 7–10 thousand population and the lifetime risk of each is approximately 1 in 50–100 in the general population [10, 11]. Closest surgical model of MGB is Mason’s loop gastric pouch [4]. Both procedures have loop reconstruction, and both were/are carried out for morbidly obese subjects. In fact, Mason loop gastric bypass patients should be at even higher risk as the pouch was much shorter in these patients compared to the long pouch of MGB and these patients were operated on prior to discovery of Helicobacter pylori, when the incidence of gastric cancer was higher in most parts of the world. Though it is impossible to be certain of the exact numbers of Mason’s loop bypasses that have been performed in the 1960s through the 1980s, my correspondence with senior bariatric surgeons who have lived through those times suggests that the number is in the range of 8000 or so in the USA alone. Thought this number is a pure guess, it is a guess that is
OBES SURG
significant to the debate regarding risk of gastric and oesophageal cancer in Mason’s loop gastric bypass and MGB patients. On the basis of these estimates, we could expect at least one each of gastric and oesophageal cancer in these patients every year. However, what we have seen is different. Scientific literature has a record of only one published case of cancer after Mason’s loop gastric bypass [12]. It is our view that all bariatric procedures protect against cancer [13] to varying degrees and as bariatric surgeons we prevent cancers, not cause them. MGB is an attractive surgical procedure, with multiple apparent benefits. It deserves a fair hearing. Conflict of Interest The authors declare that they have no conflict of interest.
References 1. Lee WJ, Lin YH. Single-anastomosis gastric bypass (SAGB): appraisal of clinical evidence. Obes Surg. 2014;24(10):1749–56. 2. Rutledge R. Naming the mini-gastric bypass. Obes Surg. 2014;24(12):2173. 3. Deitel M, Kular KS, Chevallier JM. Discussion of review article by Lee and Lin on mini gastric bypass (one-anastomosis gastric bypass). Obes Surg. 2014;24(12):2172. doi:10.1007/ s11695-014-1369-9.
4. Mahawar KK, Carr WR, Balupuri S, Small PK. Controversy surrounding ‘mini’ gastric bypass. Obes Surg. 2014;24(2):324–33. 5. Rutledge R. The mini-gastric bypass: experience with the first 1,274 cases. Obes Surg. 2001;11(3):276–80. 6. Mahawar KK, Jennings N, Brown J, Gupta A, Balupuri S, Small PK. “Mini” gastric bypass: systematic review of a controversial procedure. Obes Surg. 2013;23(11):1890–8. 7. Kular KS, Manchanda N, Rutledge R. A 6-year experience with 1, 054 mini-gastric bypasses-first study from Indian subcontinent. Obes Surg. 2014;24(9):1430–5. 8. Musella M, Susa A, Greco F, De Luca M, Manno E, Di Stefano C, et al. The laparoscopic mini-gastric bypass: the Italian experience: outcomes from 974 consecutive cases in a multicenter review. Surg Endosc. 2014;28(1):156–63. 9. Wu CC, Lee WJ, Ser KH, Chen JC, Tsou JJ, Chen SC, et al. Gastric cancer after mini-gastric bypass surgery: a case report and literature review. Asian J Endosc Surg. 2013;6(4):303–6. 10. Stomach Cancer Incidence Statistics. Cancer Research UK Website. http://www.cancerresearchuk.org/cancer-info/cancerstats/types/ stomach/incidence/uk-stomach-cancer-incidence-statistics. Last accessed on 9th November’ 2014. 11. Oesophageal Cancer Incidence Statistics. Cancer Research UK Website. http://www.cancerresearchuk.org/cancer-info/cancerstats/ types/oesophagus/incidence/uk-oesophageal-cancer-incidencestatistics. Last accessed on 9th November’ 2014. 12. Babor R, Booth M. Adenocarcinoma of the gastric pouch 26 years after loop gastric bypass. Obes Surg. 2006;16(7):935–8. 13. Sjöström L, Gummesson A, Sjöström CD, Narbro K, Peltonen M, Wedel H, et al. Swedish Obese Subjects Study. Effects of bariatric surgery on cancer incidence in obese patients in Sweden (Swedish Obese Subjects Study): a prospective, controlled intervention trial. Lancet Oncol. 2009;10(7):653–62.
LETTER TO THE EDITOR
The Name of Mini Gastric Bypass Kamal K. Mahawar & William R. J. Carr & Neil Jennings & Shlok Balupuri & Peter K. Small
# Springer Science+Business Media New York 2014
Dear Editor, Recent debate following publication of Lee’s article [1] and subsequent responses [2, 3] regarding name of Rutledge’s long gastric pouch gastric bypass with a loop reconstruction also known as mini gastric bypass (MGB) is somewhat unfortunate. As the first bariatric unit within the National Health Service of United Kingdom performing this procedure, we wished the debate and discussions on this procedure were held at a different level where we actually addressed the dilemma in the minds of the surgeons and the patients rather than confuse them further. When it comes to name, even though we would have preferred to call it modified loop gastric bypass [4] emphasizing its similarities with Mason’s original loop gastric bypass, we were concerned about the confusion it would cause in the minds of surgeons and patients and hence resigned ourselves to the fact that this will be yet another misnomer scientific community will have to live with. Moreover, let us not forget that Rutledge, the inventor of this procedure, named it mini gastric bypass [5]. Increasing body of published evidence [6–8] has now satisfied most of the controversial aspects that have plagued this procedure from its early days [4]. It is now more or less settled that patients undergoing MGB rarely suffer with symptomatic biliary gastro-oesophageal reflux and, when it happens, it is probably due to the construction of a shorter pouch by surgeons in their learning curve with this procedure. Marginal ulcer rate in these patients does not seem to be higher than those undergoing Roux-en-Y gastric bypass (RYGB), a n d f i n a l l y, i t i s n o w w i d e l y r e c o g n i s e d t h a t
K. K. Mahawar (*) : W. R. J. Carr : N. Jennings : S. Balupuri : P. K. Small Bariatric Unit, Sunderland Royal Hospital, Sunderland SR4 7TP, UK e-mail: [email protected]
gastrojejunostomy leaks and marginal ulcers in these patients can be managed in much the same way as after RYGB [6–8]. However, one controversy with MGB which is still preventing its widespread adoption, despite its multiple proven advantages, is that of the theoretical concern of a higher risk of gastric and/or oesophageal cancer in these patients in the minds of some surgeons. This is a question that ultimately only time can answer, but it is worth noting that in scientific literature, there is only one published report of a cancer after MGB [9] and, even in this patient, cancer was not in the part of the stomach in contact with bile (gastric pouch). This patient developed gastric cancer in her bypassed stomach 9 years after her MGB. This is significant because tens of thousands of this procedure have now been performed all over the world with more than 6000 published cases [6–8]. It is hard to imagine that even one case of gastric or oesophageal cancer in any patient after this procedure will go unnoticed given the significant scrutiny surrounding it. This is especially significant as the two cancers both individually have an annual incidence of 1 in almost every 7–10 thousand population and the lifetime risk of each is approximately 1 in 50–100 in the general population [10, 11]. Closest surgical model of MGB is Mason’s loop gastric pouch [4]. Both procedures have loop reconstruction, and both were/are carried out for morbidly obese subjects. In fact, Mason loop gastric bypass patients should be at even higher risk as the pouch was much shorter in these patients compared to the long pouch of MGB and these patients were operated on prior to discovery of Helicobacter pylori, when the incidence of gastric cancer was higher in most parts of the world. Though it is impossible to be certain of the exact numbers of Mason’s loop bypasses that have been performed in the 1960s through the 1980s, my correspondence with senior bariatric surgeons who have lived through those times suggests that the number is in the range of 8000 or so in the USA alone. Thought this number is a pure guess, it is a guess that is
OBES SURG
significant to the debate regarding risk of gastric and oesophageal cancer in Mason’s loop gastric bypass and MGB patients. On the basis of these estimates, we could expect at least one each of gastric and oesophageal cancer in these patients every year. However, what we have seen is different. Scientific literature has a record of only one published case of cancer after Mason’s loop gastric bypass [12]. It is our view that all bariatric procedures protect against cancer [13] to varying degrees and as bariatric surgeons we prevent cancers, not cause them. MGB is an attractive surgical procedure, with multiple apparent benefits. It deserves a fair hearing. Conflict of Interest The authors declare that they have no conflict of interest.
References 1. Lee WJ, Lin YH. Single-anastomosis gastric bypass (SAGB): appraisal of clinical evidence. Obes Surg. 2014;24(10):1749–56. 2. Rutledge R. Naming the mini-gastric bypass. Obes Surg. 2014;24(12):2173. 3. Deitel M, Kular KS, Chevallier JM. Discussion of review article by Lee and Lin on mini gastric bypass (one-anastomosis gastric bypass). Obes Surg. 2014;24(12):2172. doi:10.1007/ s11695-014-1369-9.
4. Mahawar KK, Carr WR, Balupuri S, Small PK. Controversy surrounding ‘mini’ gastric bypass. Obes Surg. 2014;24(2):324–33. 5. Rutledge R. The mini-gastric bypass: experience with the first 1,274 cases. Obes Surg. 2001;11(3):276–80. 6. Mahawar KK, Jennings N, Brown J, Gupta A, Balupuri S, Small PK. “Mini” gastric bypass: systematic review of a controversial procedure. Obes Surg. 2013;23(11):1890–8. 7. Kular KS, Manchanda N, Rutledge R. A 6-year experience with 1, 054 mini-gastric bypasses-first study from Indian subcontinent. Obes Surg. 2014;24(9):1430–5. 8. Musella M, Susa A, Greco F, De Luca M, Manno E, Di Stefano C, et al. The laparoscopic mini-gastric bypass: the Italian experience: outcomes from 974 consecutive cases in a multicenter review. Surg Endosc. 2014;28(1):156–63. 9. Wu CC, Lee WJ, Ser KH, Chen JC, Tsou JJ, Chen SC, et al. Gastric cancer after mini-gastric bypass surgery: a case report and literature review. Asian J Endosc Surg. 2013;6(4):303–6. 10. Stomach Cancer Incidence Statistics. Cancer Research UK Website. http://www.cancerresearchuk.org/cancer-info/cancerstats/types/ stomach/incidence/uk-stomach-cancer-incidence-statistics. Last accessed on 9th November’ 2014. 11. Oesophageal Cancer Incidence Statistics. Cancer Research UK Website. http://www.cancerresearchuk.org/cancer-info/cancerstats/ types/oesophagus/incidence/uk-oesophageal-cancer-incidencestatistics. Last accessed on 9th November’ 2014. 12. Babor R, Booth M. Adenocarcinoma of the gastric pouch 26 years after loop gastric bypass. Obes Surg. 2006;16(7):935–8. 13. Sjöström L, Gummesson A, Sjöström CD, Narbro K, Peltonen M, Wedel H, et al. Swedish Obese Subjects Study. Effects of bariatric surgery on cancer incidence in obese patients in Sweden (Swedish Obese Subjects Study): a prospective, controlled intervention trial. Lancet Oncol. 2009;10(7):653–62.
