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Initial Experience with Laparoscopic Mini-gastric Bypass in Korean Obese Patients

Purpose: To report our initial experience with laparoscopic mini-gastric bypass (LMGB) in Korean obese patients. Materials and Methods: From July 2016 to February 2018, 14 male patients underwent LMGB for morbid obesity at a single institution. Five trocars were placed in a U-shape formation and 1 trocar was placed at the epigastrium as a liver retractor; a window was created between the vagal nerve and lesser curvature at the gastric angle for entering the lesser sac; a narrow gastric tube (∼100-120 ml volume) was made; a linear-stapled gastrojejunostomy was created after bypassing the jejunum 200 cm from the Treitz’ ligament; and the Petersen defect was closed to prevent internal hernia. Patient demographics, operative time, estimated blood loss, postoperative hospital stay, complications, weight loss, and resolution of comorbidities were evaluated during 1 year of follow-up. Results: All procedures were successful by laparoscopy. The average age was 29 (19-49) years; weight, 164.9 (127-250) kg; and body mass index, 51.0 (42.4-81.6) kg/m. In 1 case, nephrectomy was simultaneously performed for early renal cell carcinoma. The mean operative time was 148.8 (120-175) min. The mean postoperative hospital stay was 1.9 (1-4) days. The percentage excess weight loss at 1, 3, 6, 9, and 12 months was 16.6%, 31.0%, 41.4%, 45.4%, and 50.4%, respectively. The resolution rate of type 2 diabetes mellitus, hypertension, and dyslipidemia was 75%, 40%, and 66.7%, respectively. There was no major complication including mortality during the follow-up. Conclusion: LMGB is a technically simple, safe, and effective procedure in Korean obese patients.


INTRODUCTION
Obesity is one of the most important health issues worldwide. Recently, bariatric surgery has become the best treatment option for morbid obesity and related comorbidities, as it has been shown to be more effective than medical therapy or lifestyle modification [1][2][3]. To date, laparoscopic Roux-en-Y gastric bypass (LRYGB) is the gold standard procedure for morbid obesity among various types of surgical procedures [4]. However, LRYGB remains technically challenging and ranks as one of the most difficult laparoscopic surgeries, especially for inexperienced surgeons [4,5]. It has a highly steep learning curve and is associated with longer operating times and higher perioperative complication rates in the upward portion of the curve [6].
Laparoscopic mini-gastric bypass (LMGB) was first proposed by Rutledge in 2001 [7]. The procedure consists ligament. This procedure, similar to LRYGB, causes weight loss through both restrictive and hypoabsorptive mechanisms. There are several apparent advantages of LMGB over LRYGB. LMGB has a shorter learning curve because the side-to-side loop gastrojejunostomy in LMGB is technically easier to perform than the Roux-en-Yfashioned anastomosis in LRYGB. In addition, LMGB has a lower potential risk of internal herniation than LRYGB because the internal defect after LMGB is less than that after LRYGB. Moreover, LMGB is easier to revise or reverse than LRYGB because of the simplicity of the technique.
However, despite the several benefits of LMGB along with its equivalent effects to those of LRYGB in terms of weight loss and resolution of comorbidities, concerns related to symptomatic alkaline reflux and the risk of gastric/ esophageal cancer have prevented its adoption [8].
During the last 20 years, a number of surgeons from different countries have been able to replicate these results and ＞16,000 published cases now exist in the surgical literature [9]. We believe that there is now sufficient evidence supporting the adoption of this procedure as another surgical treatment option. However, to date, published studies on LMGB in Korean obese patients are scarce [10]. Therefore, we aimed to describe our initial experience with LMGB in Korean obese patients.

Patients
We retrospectively reviewed the prospectively collected medical records of Korean obese patients who underwent LMGB for the treatment of morbid obesity from July 2016 to       Korean patients [10]. Although this study included nonobese patients with T2DM, it nevertheless showed that  . This is consistent with previous findings showing that the %EWL was greater in the lower BMI group for each baseline BMI grouping [16,17].

Surgical techniques
Compared with other studies in patients with super obesity (BMI ≥50 kg/m 2 ), the %EWL after LMGB in the present study is higher than that after laparoscopic sleeve gastrectomy (mean 40.2%, 49.5%, and 35.6%), whereas the weight loss effect is similar to or slightly less than that of LRYGB (mean 55.0%, 55.8%, and 51.0%) [18][19][20].
In terms of the impact of LMGB on comorbidities, our study showed that 3 of 4 (75%) patients had remission of T2DM, 1 (25%) patient had improvement of T2DM, 2 of 5 (40%) patients had remission of hypertension, and 2 of 3 (66.7%) patients had remission of dyslipidemia after LMGB.
According to a systematic review published by Quan et al. It is expected that the operation time will be shorter as the number of cases increases [21]. The estimated blood loss was 50.7 (0-100) ml, similar to that in another study (mean 39.8 ml) [22]. The postoperative hospital stay was 1.9 (1-4) days, which seems shorter than that in other studies (about 2-7.1 days) [14]. In several studies, the simplified surgical processes of LMGB resulted in a shorter operative time, less blood loss, and shorter hospitalization than LRYGB [22][23][24].
In terms of safety, there were no early major com-

CONCLUSION
LMGB is a technically simple, safe, and effective procedure in Korean obese patients. It seems to result in favorable weight loss and has a high resolution rate of metabolic comorbidities in the short term; however, information about long-term weight loss, durability, and safety profile in this population will require studies with a greater number of patients and a longer follow-up period.