LAUSR

I have been asked to review the paper entitled “One Anastomosis (Mini) Gastric Bypass is now an Established Bariatric Procedure: A Systematic Review of 12,807 patients,” by xyz et al [1]. Yes, the procedure has been endorsed by IFSO recently, which is contrary to current practices in North America, ASMBS has decided not to endorse the procedure, even though it has reviewed the same literature and body of evidence [2]. A decision based on unknown incidence of bile gastritis and its effects long-term, late occurrences of lifethreatening marginal ulcers, and inadequate nutritional longterm data. Roux-en-Y gastric bypass have been performed, in fact, in response to ill problems created by a loop gastroenterostomy years ago, and the souvenir of this does not appeal to many surgeons in USA, nor in Canada, an experience that is lacking on other parts of the World, except perhaps in Scandinavia. Better weight loss results can be achieved with longer biliopancreatic (BP) limbs, also possible to with Roux-en-Y gastric bypass, but without bile gastritis; hence, an SAGB would be improved! The paper makes strong points from data collected from six papers with 5 years or more of follow-up. Well, the paper by Jammu and Sharma is a retrospective comparison of sleeve gastrectomies, RYGB and SAGB [3]. The hypoproteinemia is reported at 13% in SAGB, and no other data is given about minerals and vitamins. The nutritional follow-up is not thorough and is not limited about the occurrence of an anemia or “malnutrition”; important details are still missing. Peraglie paper has only 88 patients which are > 60 years old, with no nutritional data [4]. Malabsorption should be used with caution in older patients due to lesser adaptation capacity. Chevalier’s manuscript of a series of up to 7 years is limited to two patients with malnutrition (over 1000!) and no data on any nutritional variables [5]. Kular et al. manuscript of 6 years data from 1054 patients reports 68 patients with anemia and nothing else nutritionally [6]. Musella et al. have 974 patients with minimal nutritional data (stated only 5% of irondeficiency anemia) [7]. Lee et al. study is a randomized study comparing RYGB at 10 years, 10 had malnutrition out of 1163 patients with SAGB [8]. One has to conclude that there is little evidence presented on the incidence of mineral, fatty acid, vitamin, and total protein deficiencies. It is surprising that IFSO has endorsed this concept without any scientific studies on nutrition after this procedure, pretty much like accepting the BPD or DS without any nutritional studies! More than 25 years ago, Scopinaro had published a paper entitled “Why the operation I prefer is Biliopancreatic Diversion (BPD)” [9]. BPD was to improve Roux-en-Y gastric bypass, by increasing malabsorption by making the use of the distal 250 cm of bowel with an associated needed larger gastric pouch size, or what he called an ad hoc stomach, an “eye-ball” stomach. A parallel can be made with single anastomosis gastric bypass (SAGB), a gastric pouch that is 2/3 of a sleeve, two or three times a normal Roux-en-Y gastric pouch, and connected to a loop of intestine 200 cm distal to the ligament of Treitz, which, on many patients, is on average 300 cm from the ileocecal valve. It has been advocated to use a BP limb of 300 cm (on average a distal limb of 200 cm), in patients with BMI > 60 kg/m. This is reminiscent of a very distal gastric bypass with an associated high rate of malnutrition and hypoproteinemia; several will need reversals. With time, it has been determined that standard BPD have dumping syndromes from the lack of any valve (pylorus in this instance), increased marginal ulcerations, malnutrition and severe hypoproteinemia, diarrhea and micronutrient deficiencies, hepatic failures, and BADASS, which are now encountered in SAGB. Is SAGB a new mini-Scopinaro? Most probably, especially with BP limb of 200 cm and above, so much so, that now several surgeon advocates have * Michel Gagner [email protected]