|Year : 2015 | Volume
| Issue : 1 | Page : 11-15
Comparing the quality of life after laparoscopic roux-en-y gastric bypass and mini gastric bypass
Mohamed Ismail1, Muhammed Shereef1, Mahesh Rajagopal1, Hafiz Ansari1, KA Sidhic2
1 Department of Baiatric and Metabolic Surgery, Moulana Hospital, MES Medical College, Perinthalmanna, Malappuram, Kerala, India
2 Department of General Surgery, MES Medical College, Perinthalmanna, Malappuram, Kerala, India
|Date of Web Publication||6-Jan-2015|
Madavana, Pathaikkara PO, Perinthalmanna, Malappuram, Kerala - 679 322
Source of Support: None, Conflict of Interest: None
Objectives: The aim was to compare the quality of life after laparoscopic Roux-en-Y gastric bypass (LRYGB) and mini-gastric bypass (LMGB) in morbidly obese patients. Materials and Methods: From January 2012 to March 2014, we enrolled 40 patients who underwent LRYGB and LMGB. The mean age and body mass index (BMI) was 39 ± 4.8 years and 43.5 ± 6.5 (kg/m 2 ), respectively. Quality of life was measured by the gastrointestinal quality of life index (GIQLI), a 36 item questionnaire before and at 1-year after LRYGB and LMGB and was compared. Results: All procedures were performed laparoscopically with no conversions. The two groups were comparable in age, gender, and BMI. One year after bariatric surgery, the mean general score of GIQLI improved significantly (P = 0.001). All patients had improvement in the four domains of the questionnaire (social function, physical status, and emotional status Despite a significant difference between two groups in postoperative physical and emotional domains of GIQLI scores (P ≤ 0.05), the postoperative gastrointestinal quality of life was comparable in both the groups. Conclusion: Both LRYGB and LMGB are effective treatments for morbid obesity. Both procedures can significantly resolve obesity-related comorbidities and increase quality of life for morbidly obese patients. LMGB was shown to be a simpler and safer procedure than LRYGB with similar efficacy at the 1-year follow-up. LMGB is thus an acceptable alternative treatment to standard LRYGB for morbidly obese patients.
Keywords: Gastro intestinal quality of life index, laparoscopic Roux-en-Y gastric bypass, laparoscopic mini-gastric bypass, morbid obesity
|How to cite this article:|
Ismail M, Shereef M, Rajagopal M, Ansari H, Sidhic K A. Comparing the quality of life after laparoscopic roux-en-y gastric bypass and mini gastric bypass. J Obes Metab Res 2015;2:11-5
|How to cite this URL:|
Ismail M, Shereef M, Rajagopal M, Ansari H, Sidhic K A. Comparing the quality of life after laparoscopic roux-en-y gastric bypass and mini gastric bypass. J Obes Metab Res [serial online] 2015 [cited 2020 May 28];2:11-5. Available from: http://www.jomrjournal.org/text.asp?2015/2/1/11/148603
| Introduction|| |
During the last decades, obesity has become a major health problem worldwide. Obesity is related to various comorbidities as coronary artery disease, hypertension, diabetes, hyperlipidemia, type 2 diabetes, insulin resistance, obstructive sleep apnea, degenerative osteoarthritis, infertility, and depression. The result is a reduction in life expectancy and quality of life.  Though different methods of treatment (diet, exercise, and pharmacotherapy) have been proposed to morbid obesity, only bariatric surgery offers excellent short and long-term results. 
Laparoscopic Roux-en-Y gastric bypass (LRYGB) is currently considered the gold standard for morbid obesity and it is a restrictive and malabsorptive irreversible procedure, first reported by Wittgrove and Clark in 1994.  It is a technically demanding procedure with a long learning curve and associated with a considerable morbidity and mortality rate. 
Laparoscopic mini-gastric bypass (LMGB), a simple and effective treatment for morbid obesity, was first reported by Rutledge.  However, controversy about the relative safety of the procedure remains like the incidence of marginal ulcer and reflux esophagitis. 
The aim of this study was to compare the quality of life in obese patients after LRYGB and LMGB in 1-year follow-up period. The primary endpoint was to compare the quality of life measured by the gastrointestinal quality of life index (GIQLI), a 36 item questionnaire before and at 1-year after the procedure. 
| Materials and Methods|| |
Study design and participants
This retrospective observational study was conducted by the Department Of Surgery, Moulana Hospital, Perinthalmanna, Kerala from January 2012 to March 2014. The study group included 40 patients who were operated on between January 2012 and March 2014. Approval of the Ethical committee of the hospital was obtained for the study.
The inclusion criteria were age between 18 and 65 years and fulfillment of the Consensus in Asia-Pacific 2005. 
Exclusion criteria were previous bariatric surgery or gastric surgery, pregnancy or psychiatric illness. Informed consent obtained prior to surgery.
Patients were evaluated and followed pre and perioperatively by a multidisciplinary team (surgeons, endocrinologist, cardiologist, pulmonologist, gastroenterologist, psychologist, psychiatrist, dieticians, and anesthesiologist). Candidates for surgery were informed about the procedure, and all completed an extensive preoperative workup indicated by the multidisciplinary team.
Laparoscopic Roux-en-Y gastric bypass
Using a 5-port technique, ante-colic and ante-gastric Roux-en-Y gastric bypass (RYGB) was performed with an alimentary limb of 100-150 cm. Biliopancreatic limb was 75 cm in all cases. A side-to-side jejunojejunostomy was done using linear Endo-GIA stapler with white loads (2.5 mm staples). An omental split was done. A 20-30 cm 3 vertical gastric pouch was created over a 36-Fr (12 mm) gastric calibration tube, without leaving any posterior pouch. End-to-side gastrojejunostomy was done using absorbable surgical suture. At the end of the procedure, the methylene blue test was injected to identify possible leaks. Mesenteric and Petersen defect was sutured in all cases with nonabsorbable surgical suture. A closed suction drain was placed in the proximity of the gastrojejunostomy. Cholecystectomy was performed for all gallstones.
Laparoscopic mini-gastric bypass
LMGB was a 5-port technique similar to that described by Rutledge.  A long gastric tube was created using an Endo-GIA stapler approximately 1.5 cm to the left of the lesser curvature from the antrum to the angle of His. A loop gastroenterostomy was created using Endo-GIA stapler with the small bowel about 150-200 cm distal to the ligament of Trietz. The gastroenterostomy was then closed with two layer continuous polydioxanon suture. One closed suction drain was left in the lesser sac before closure of the wound.
All patients received perioperative prophylactic antibiotics. Low molecular weight heparin was administered subcutaneously daily. Sequential compression devices were used in the perioperative period. Early ambulation was encouraged preferably within 6 h after surgery. The nagogastric tube was removed on the 1 st postoperative day (POD) in both groups. Oral clear liquids were allowed on the 2 nd POD provided the patient had a normal gastrograffin study and good bowel movements. Patients were discharged home on the 4 th POD after ensuring adequate oral liquid intake. Drain was removed on the POD 1. Dietician met all the patients on the POD 1.
Postoperative follow-up was evaluated by the multidisciplinary team at 1, 3, 6, 12 months and every year thereafter. After the operation both groups received daily proton pump inhibitors, multivitamins and mineral supplementation for 6 months. High protein diet and regular moderate exercise were encouraged. Necessary laboratory tests were done every 3 months and additional supplementation of Vitamin B 12 , Vitamin D and Iron were given depending on the reports.
Both groups were evaluated in terms of mean operating time, hospital stay, weight loss, resolution of comorbidities and complications. Mean percentage excess weight loss (EWL) and mean body mass index (BMI) were calculated. Complications were defined as early (<30 days) and late (>30 days).
Quality of life was assessed before and 1-year after the operation using the GIQLI, a 36 item questionnaire.  The questionnaire contains the following four domains: Gastrointestinal symptoms (19 questions), physical function (7 questions), social functions (five questions) and emotional functions (five questions). The response to each question in scored from 0 to 4 (zero being the worst and four the best option). The maximum score is 144.
Categorical variables were described with frequencies and percentages. Quantitative variables were expressed with mean and standard deviation. Categorical variables and proportions were compared using the Chi-square test or the Fisher exact test. P < 0.05 was considered as statistically significant. All data are reported as a percentage of patients, mean ± standard deviation.
| Results|| |
A total of 40 consecutive patients operated for morbid obesity were included in the study. Twenty (50%) underwent LRYGB and 20 (50%) underwent LMGB. The patients were matched for age, gender and BMI. The demographic characteristics are listed in [Table 1].
|Table 1: Demographic data and comorbidities of patients who|
underwent bariatric surgery
Click here to view
Patient compliance during the follow-up visit for both the procedures was 100% at 3 months, 100% at 6 months and 99% at 1-year. Both groups are comparable in terms of major comorbidities such as hypertension, diabetes, dyslipidemia and obstructive sleep apnea.
All procedures were done laparoscopically with no conversion [Table 2]. The mean operating time for LRYGB group (215 min) was significantly longer than the LMGB group (154 min) (P < 0.001). There was no statistically significant difference in hospital stay between the two groups. Two major postoperative complications occurred in RYGB were bleeding from the stapler line of which one patient required relaparoscopy and cauterization of the bleeding point. The second patient was managed conservatively with blood transfusion. One patient in LMGB group also had postoperative bleeding from stapler line requiring relaparoscopy. All the minor complications were recovered with conservative treatment. One patient in LRYGB group required readmission during first 30 days due to vomiting because of severe gastritis.
Excess weight loss was significantly greater in LMGB group at 1-year (58.7 ± 16.4 vs. 64.9 ± 9.5; P = 0.025). Both groups were comparable in terms of resolution of comorbidities [Table 3].
|Table 3: Comparison of weight loss, %EWL and resolution of|
comorbidities at 1‑year
Click here to view
Quality of life assessment
Preoperative GIQLI scores were comparable in both the groups. The mean GIQLI score at 1-year after surgery was significantly higher than preoperative scores in both the groups [Table 4] [Table 5] [Table 6]. For specific gastrointestinal symptoms such as abdominal pain, fullness, bloating, belching and frequent bowel movements the GIQLI score was slightly less compared with preoperative score. However, this was comparable in both the groups. In physical and emotional domains there was significant difference between the two groups.
|Table 6: Comparison of the postoperative GIQLI for LRYGB|
and LMGB at 1‑year
Click here to view
| Discussion|| |
In our study, both LRYGB and LMGB were safe and effective bariatric procedures resulting in significant weight loss and comparable resolution of comorbidities. ,,,, LMGB is technically less complex than LRYGB, which is reflected by a lower operating time. , LMGB has the advantage of using lower ante-colic gastrointestinal anastomosis, which is easier to perform than the retro-colic or ante-colic gastrojejunal anastomosis in LRYGB. There was no significant difference in hospital stay because, as a part of our department policy otherwise healthy patients were also discharged on 4 th or 5 th POD.
The most common major complication in LMGB in our study was bleeding from staple line. Rutledge  and Lee et al.  have reported similar risk due to the long stapler line compared to that in LRYGB and suggested to reinforce the staple line with seromuscular sutures. We did not routinely practice it but before closure of the wounds ensures that the staple line is perfectly hemostatic.
At 1-year after surgery %EWL was satisfactory in both groups, but there was significant difference between the two. In our study, LMGB showed better %EWL probably because of the longer bypass loop (150-200 cm in LMGB versus 100-150 cm in LRYGB). Both groups were comparable in terms of resolution of comorbidities.
Patients after LMGB were better tolerating solid diet after 1-month of surgery but it was statistically not significant. Physical and social domains of GIQLI was better with LMGB group probably because of better % EWL compared with LRYGB.
Another concern in LMGB is whether increased bile acid in the stomach might lead to chronic gastritis and cause gastric malignancy.  In our study, this was rarely a problem as the anastomosis was placed very low in the stomach.  Only two patients in LMGB group required endoscopy due to upper gastrointestinal symptoms but significant bile reflux was not noticed in both. As suggested by Lee et al.,  application of GIQLI survey system will be a good nonintervevetional alternative to routine endoscopy in clinical practice because of good patient compliance.
Incidence of marginal ulcer in LRYGB varies from 1% to 16%.  Recent systematic review and meta-analysis by Ying et al. showed that prophylactic PPI reduces the incidence of marginal ulcer.  We routinely advice proton pumb inhibitors for first 6 months for both LRYGB and LMGB patients. Though we did not routinely do endoscopy to all patients in the study group, the incidence of marginal ulcer among symptomatic patients is 0.5% in LMGB group compared to 1% in LRYGB group. Kular et al. reported 0.6% incidence of marginal ulcer in LMGB from the Indian subcontinent. 
In our study, the GIQLI detected no difference in GIQL between LRYGB and LMGB suggesting that the incidence of biliary esophagitis, chronic gastritis and marginal ulcer are not a concern although further follow-up data are required to confirm it.
| Conclusion|| |
Both LRYGB and LMGB are effective treatments for morbid obesity. Both procedures can significantly resolve obesity-related comorbidities and increase quality of life for morbidly obese patients. LMGB was shown to be a simpler and safer procedure than LRYGB with similar efficacy at the 1-year follow-up. LMGB is thus an acceptable alternative treatment to standard LRYGB for morbidly obese patients.
| References|| |
Franco JV, Ruiz PA, Palermo M, Gagner M. A review of studies comparing three laparoscopic procedures in bariatric surgery: Sleeve gastrectomy, Roux-en-Y gastric bypass and adjustable gastric banding. Obes Surg 2011;21:1458-68.
Daskalakis M, Weiner RA. Sleeve gastrectomy as a single-stage bariatric operation: Indications and limitations. Obes Facts 2009;2 Suppl 1:8-10.
Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic gastric bypass, Roux-en-Y: Preliminary report of five cases. Obes Surg 1994;4:353-57.
Leyba JL, Aulestia SN, Llopis SN. Laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy for the treatment of morbid obesity. A prospective study of 117 patients. Obes Surg 2011;21:212-6.
Rutledge R. The mini-gastric bypass: Experience with the first 1,274 cases. Obes Surg 2001;11:276-80.
Fisher BL, Buchwald H, Clark W, Champion JK, Fox SR, MacDonald KG, et al. Mini-gastric bypass controversy. Obes Surg 2001;11:773-7.
Eypasch E, Williams JI, Wood-Dauphinee S, Ure BM, Schmülling C, Neugebauer E, et al. Gastrointestinal quality of life index: Development, validation and application of a new instrument. Br J Surg 1995;82:216-22.
Thomas GN, Schooling CM, McGhee SM, Ho SY, Cheung BM, Wat NM, et al. Metabolic syndrome increases all-cause and vascular mortality: The Hong Kong Cardiovascular Risk Factor Study. Clin Endocrinol (Oxf) 2007;66:666-71.
Wittgrove AC, Clark GW. Laparoscopic gastric bypass, Roux-en-Y- 500 patients: Technique and results, with 3-60 month follow-up. Obes Surg 2000;10:233-9.
Higa KD, Boone KB, Ho T, Davies OG. Laparoscopic Roux-en-Y gastric bypass for morbid obesity: Technique and preliminary results of our first 400 patients. Arch Surg 2000;135:1029-33.
Schauer PR, Ikramuddin S, Gourash W, Ramanathan R, Luketich J. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg 2000;232:515-29.
DeMaria EJ, Sugerman HJ, Kellum JM, Meador JG, Wolfe LG. Results of 281 consecutive total laparoscopic Roux-en-Y gastric bypasses to treat morbid obesity. Ann Surg 2002;235:640-5.
Westling A, Gustavsson S. Laparoscopic vs open Roux-en-Y gastric bypass: A prospective, randomized trial. Obes Surg 2001;11:284-92.
Dresel A, Kuhn JA, Westmoreland MV, Talaasen LJ, McCarty TM. Establishing a laparoscopic gastric bypass program. Am J Surg 2002;184:617-20.
Nguyen NT, Goldman C, Rosenquist CJ, Arango A, Cole CJ, Lee SJ, et al. Laparoscopic versus open gastric bypass: A randomized study of outcomes, quality of life, and costs. Ann Surg 2001;234:279-89.
Lee WJ, Yu PJ, Wang W, Chen TC, Wei PL, Huang MT. Laparoscopic Roux-en-Y versus mini-gastric bypass for the treatment of morbid obesity: A prospective randomized controlled clinical trial. Ann Surg 2005;242:20-8.
Moon RC, Teixeira AF, Goldbach M, Jawad MA. Management and treatment outcomes of marginal ulcers after Roux-en-Y gastric bypass at a single high volume bariatric center. Surg Obes Relat Dis 2014;10:229-34.
Wu Chao Ying V, H Kim SH, J Khan K, Farrokhyar F, D'Souza J, Gmora S, et al. Prophylactic PPI help reduce marginal ulcers after gastric bypass surgery: A systematic review and meta-analysis of cohort studies. Surg Endosc 2014;Aug 27 [PubMed] DOI 10.1007/s00464-014-3794-1.
Kular KS, Manchanda N, Rutledge R. A 6-year experience with 1,054 mini-gastric bypasses-first study from Indian subcontinent. Obes Surg 2014;24:1430-5.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]