An Outlet for Endoscopic Access to the Remnant Does not Reduce the Effectiveness of Gastric Bypass: Long-Term Outcomes of a Modified Roux-En-Y Gastric Bypass that Allows Traditional Endoscopy of Bypassed Stomach

BACKGROUND: Roux-en-Y Gastric Bypass (RYGB) is one of the most common operation performed worldwide as treatment for severe obesity. Patients who undergo this procedure need a periodic follow-up mainly radiological, but often endoscopic, in order to state the surgical long term outcome. These patients usually have a long life expectance, with the possibility to develop several pathologies also in the anatomically excluded stomach. In 2002, it has been introduced in bariatric surgery a modified gastric bypass , the Roux-en-Y Gastric Bypass on Vertical Banded Gastroplasty (RYGB-on-VBG), where traditional endoscopic study of the gastric remnant resulted to be feasible through a small passage between gastric pouch and excluded stomach that has been leaved. In the mid-term RYGB-on-VBG obtained results in terms of weight loss and comorbidities resolution equivalent to those found after standard RYGB Aim of our study is to verify the outcomes in the long-term. METHODS: Between June 2002 and June 2010, 320 patients, with mean age 42.0±11.3 years, mean BMI 48.0±8.7 kg/m2 and mean EBW% 94.05±36.6 underwent modified RYGB via an open approach. 37.5% of the patients were superobese. Preoperative comorbidities were hypertension (p.155, 48.4%), OSAS (p.79, 24.6%) and type II DM (p. 55, 17.1%). RESULTS: Operative mortality was 0.6% (p.2) and early complications 1.9% (p.6). At 2 year of follow-up mean BMI and EWL% were 30.9±5.8 and 68.9±17.0 respectively. The average percentages of comorbidities resolution were: OSAS 90.1%; type II DM 83.5%; hypertension 47.5%; hyperlipidemia 30%. Early surgical complications were 4 (1.4%). At 8 year of follow-up, the mean BMI and EWL% were 34.0±7.7 and 63.4±18.5 respectively. Late specific complications were 8 (1.7%). For all the followed patients (95% of the patients) the modified RYGB enabled traditional endoscopic and radiologic evaluation of the gastric remnant. Our macroscopic and microscopic studies were similar to other reports where Authors performed the gastric remnant exploration backward through the alimentary limb (Double Baloon Enteroscopy), with gastritis of various degree in 97% of cases and intestinal metaplasia in 15.8% of them. CONCLUSIONS: In the long-term, an outlet for access to the remnant did not reduce the effectiveness of gastric bypass. The modified RYGB outcomes in term of weight loss, resolution of comorbidities and surgical complications are comparable to those after standard RYGB as reported in literature. Traditional endoscopy was feasible in all patients who underwent RYGB-on-VBG for morbid obesity in this series. Frequent detection of altered mucosal surface, even in patients with normal preoperative endoscopic pattern, advices for a systematic evaluation in all patients who underwent RYGB to better define the nature of the lesions and how they respond to specific medications. Standard endoscopy in patients operated with RYGB-on-VBG can be proposed as screening tool, specially in countries with high incidence of gastric cancer.