Revisional Surgery After 925 OAGB[One Anastomosis Gastric Bypass] Operations Retrospective Cohort Study of the UK MGB/OAGB Collaborative Group.
Revisional Surgery After 925 OAGB[One Anastomosis Gastric Bypass] Operations Retrospective Cohort Study of the UK MGB/OAGB Collaborative Group.
Background: One anastomosis Gastric Bypass/Mini Gastric Bypass (OAGB/MGB) is a new operation
 that provides comparable outcomes to the common bariatric procedures. Revisional surgery is
 still needed after a number of OAGB/MGB procedures. The aim of this study is to report the
 causes and management of these revisions.

 Methods: From 2010 -2018, 925 OAGB/MGB operations were performed at 7 bariatric units across
 the United Kingdom and included in this retrospective cohort study. The data was
 retrospectively collected and analysed. The primary end point was identification of the
 causes and management of revisions. Follow up ranged from 6 months to 3 years.

 Results: Twenty-two patients (2.3%) required revisional surgery after OAGB/MGB. Five patients
 (0.5%) developed severe diarrhoea managed by shortening the bilio-pancreatic limb (BPL) to
 150cm. Four patients (0.4%) developed afferent loop syndrome and bile reflux was reported in
 another 3 (0.3%) cases; all were managed by either conversion to Roux en Y Gastric Bypass
 (RYGB) or a Braun anastomosis. Postoperative bleeding was controlled laparoscopically in 3
 patients (0.3%). Liver decompensation was reported in 2 patients (0.2%) was treated by
 shortening the BPL in one patient and a reversal to normal anatomy in another. The liver
 failure resolved in both patients. Other indications for revision included two gastro-jejunal
 stenosis (0.2%), one perforated ulcer (0.1%), one patient (0.1%) with excessive weight loss
 and one case (0.1%) of protein malnutrition. None of the 22 patients undergoing revisional
 surgery after OAGB/MBG died. Lost to follow up rate was 0.2%.

 Conclusion: Complications requiring revisional surgery after OAGB/MGB are uncommon (2.3%) and
 the majority can be managed by bilio-pancreatic limb shortening, the addition of a Braun
 side-to-side anastomosis or conversion to RYGB. Bilio-pancreatic limb length of 200 cm or
 more resulted in serious complications of liver failure, protein malnutrition, excessive
 weight loss and diarrhoea.
The UK OAGB/MGB collaborative group of 12 consultant bariatric surgeons was founded in 2017
 and the data of 925 OAGB/MGB procedures were retrospectively collected and analysed in this
 cohort study. The treatment pathway is the SAME at each NHS centre. The indications for
 referral, consultations, and follow up after surgery are similar. This is agreed bariatric
 practice governed by British Obesity and Metabolic Surgery Society's [BOMSS] guidance.

 The patients' age, BMI, presence of T2DM, comorbidities, Gastro-oesophageal reflux and hiatus
 hernia, Barrett's oesophagus, family history of upper gastro-intestinal cancer, and the
 patient choice were the main factors to influence the decision to the procedure type. Each
 centre is offering Roux en Y Gastric Bypass (RYGB), Laparoscopic Sleeve Gastrectomy (LSG),
 MGB/OAGB and Adjustable Gastric Band (AGB). The allocation of the procedure is finalised
 after mutual agreement between the patient and the surgeon taking in consideration the above
 factors and patient's choice. The data was retrospectively collected by the surgical team at
 each institution and sent to the lead of the collaborative group. The follow up is conducted
 by clinical visits, blood tests and radiology [ultrasound, computed tomography ] when needed.

 The procedures were performed between September 2010 and May 2018. A long gastric pouch of
 average 15cm was constructed over a 34-36F bougie using laparoscopic staplers. The start
 point of stapling is at the crow's foot. The omentum was only divided in selected cases such
 as male patients with a very high Body Mass Index (BMI). After identifying the
 duodeno-jejunal junction, a BPL ranging from 150-300 cm was measured. The end-side /side-side
 gastro-jejunostomy was made using a combined hand-sewn /stapled technique. Use of drains and
 closure of Petersen's space varied between different surgeons. The patients were discharged
 after 2-3 nights. The follow up was ranged from 6 months to 3 years. In the UK the NHS and
 private practice are following National Institute of Clinical Excellence [NICE] guidelines in
 management and post operative follow up. Thus there is very strict follow up for two years
 after the operation. The patients are seen two weeks after the primary surgery at which
 clinical examination, dietary assessment and baseline post operative blood test is performed.
 Then the patients are seen one month after that, then 3 monthly period for the initial year,
 and 6 monthly for the last year. During all these visits, clinical, dietary and routine
 biochemical assessments were conducted. For patients who developed complications, a different
 and longer pathway of follow up is adopted until they recover and then, discharged to their
 general practitioners (GPs). The paper was written to comply with STROCSS guidelines
 (www.strocssguideline.com).
Inclusion Criteria:

 1. They have a BMI of 40 kg/m2 or more, or between 35 kg/m2 and 40 kg/m2 and other
 significant disease (for example, type 2 diabetes or high blood pressure) that could
 be improved if they lost weight.

 2. All appropriate non-surgical measures have been tried but the person has not achieved
 or maintained adequate, clinically beneficial weight loss.

 3. The person has been receiving or will receive intensive management in a tier 3
 service.

 4. The person is generally fit for anaesthesia and surgery.

 5. The person commits to the need for long-term follow-up.

 6. Age 18-71 years -

 Exclusion Criteria:

 1. Less than 18 or more than 71 years of age

 2. Not fit for bariatric surgery

 3. Psychiatric illness -