Prof. Dr. Toygar Toydemir
He received the title of Professor of General Surgery in 2020. Dr. Toydemir, who has extensive experience in reflux and obesity surgery, continues his work in these fields. You can read the rest of our article about Mini Gastric Bypass prices, treatment process, and post-treatment precautions.
Read More Make an AppointmentMini Gastric Bypass (MGB), also known as Single Anastomosis Gastric Bypass (OAGB), is an effective surgical method in the fight against obesity. This procedure aims to achieve weight loss by both reducing the stomach volume and bypassing a section of the intestines. The stomach is turned into a narrow tube, and a new connection is made to the intestines to reduce nutrient absorption. In this way, an early feeling of fullness occurs, and calorie intake is restricted. MGB stands out with its low complication rates and effective weight loss results. However, careful follow-up is required for potential issues such as anemia and ulcers after the procedure.
Mini Gastric Bypass (MGB) is a significant milestone in the evolution of obesity surgery. Looking at the history of bariatric surgery, it is seen that surgical interventions in the gastrointestinal system to achieve weight loss date back to the 1950s. During that period, methods such as jejunoileal bypass aimed to achieve weight loss by bypassing large sections of the intestines. However, as these methods were associated with serious malnutrition, liver failure, and other complications, safer alternatives became necessary.
In 1966, Dr. Edward E. Mason from the University of Iowa changed the direction of bariatric surgery by developing the concept of gastric bypass. Dr. Mason’s method involved creating a small stomach pouch so that food would use less of the stomach, thereby limiting absorption. This technique laid the foundation for today’s modern bariatric procedures.
In 1997, Dr. Robert Rutledge introduced the Mini Gastric Bypass as a simpler and faster alternative to the traditional Roux-en-Y Gastric Bypass (RYGB) procedure. MGB, which can be performed with shorter surgical time and lower complication risk, involves creating a narrow tube along the greater curvature of the stomach and attaching it about 200 cm down the jejunum. However, concerns especially focused on bile reflux and its potential long-term effects initially limited the widespread acceptance of this method.
In the early 2000s, surgeons in Europe and Asia began to adopt and modify MGB. In 2002, Spanish surgeon Dr. Miguel A. Carbajo introduced the One Anastomosis Gastric Bypass (OAGB) method by adding afferent limbs to reduce the risk of bile reflux. This modification improved the safety profile of the procedure and facilitated its international acceptance.
Today, accumulating scientific data shows that MGB/OAGB is an effective option in the fight against obesity and related metabolic disorders. However, careful patient selection and long-term follow-up are essential for sustaining success.
Mini Gastric Bypass (MGB) surgery is a proven effective method in the fight against obesity and is suitable for individuals who meet certain criteria. Primarily, this surgery is considered for patients with severe obesity. Those with a Body Mass Index (BMI) of 40 kg/m² or higher are strong candidates for the procedure. This group is classified as morbidly obese, and MGB can provide both weight loss and improvements in obesity-related complications.
Individuals with a BMI of 35 kg/m² or higher who have one of the obesity-related diseases such as type 2 diabetes, hypertension, dyslipidemia, or obstructive sleep apnea are also eligible for surgery. In these patients, MGB aims not only for weight loss but also for remission or improvement of the associated conditions. MGB may also be considered for those with a BMI of 30–35 kg/m² who have serious metabolic disorders like uncontrolled type 2 diabetes or non-alcoholic fatty liver disease after a multidisciplinary evaluation.
MGB can be an appropriate option for patients who have not achieved successful weight loss through lifestyle changes, pharmacotherapy, or previous bariatric procedures. Particularly in cases where sufficient results were not obtained from previous bariatric interventions, MGB offers an effective alternative as revision surgery.
Factors such as age, mental health, nutritional status, and the patient’s potential for postoperative compliance should be carefully assessed during the patient selection process. The success of the surgery depends on the patient’s adherence to the necessary lifestyle changes and medical follow-up after the operation. Psychological and nutritional assessments should be performed preoperatively, and an individualized care plan should be created.
Mini Gastric Bypass (MGB) is an effective surgical method for the treatment of obesity and related diseases. However, this procedure is not suitable for everyone, and certain situations constitute absolute or relative contraindications for surgery.
Severe Gastroesophageal Reflux Disease (GERD):
Patients with severe GERD, particularly those with Los Angeles grade C or D esophagitis, are not suitable candidates for MGB. Anatomical changes made by this procedure can increase bile reflux, potentially causing worsening esophagitis or serious complications such as Barrett’s esophagus.
Barrett’s Esophagus and Enteric Metaplasia:
Because of increased bile reflux after MGB, Barrett’s esophagus or enteric metaplasia carries a risk of progressing to cancer. Therefore, surgery is not recommended in these cases.
Crohn’s Disease:
Crohn’s disease can increase the risk of active inflammation in the intestines, leading to complications after MGB. Therefore, this disease is considered a contraindication for MGB.
Severe Cardiovascular Diseases:
Serious cardiovascular issues, such as heart failure or uncontrolled coronary artery disease, can increase the risks of surgery and question its safety.
Active Peptic Ulcer Disease:
If peptic ulcers are active, the surgical changes may hinder the healing of the ulcers, so they should first be controlled through medical treatment.
Uncontrolled Psychiatric Disorders:
Poorly controlled psychiatric conditions can lead to compliance issues and complications after surgery.
Coagulopathy Issues:
Bleeding disorders can lead to serious complications during surgery and should be carefully evaluated.
Pregnancy:
Bariatric surgery is not recommended during pregnancy; patients planning pregnancy after the operation are advised to wait 12–18 months.
Active Cancer Diagnosis:
Surgery is not recommended in patients with active cancer. Cancer treatment should be completed first.
Previous Extensive Abdominal Surgeries:
Patients who have undergone previous extensive abdominal surgeries should be evaluated in detail due to the risk of adhesions.
Mini Gastric Bypass surgery begins with placing the patient in a supine position. Stabilizing the patient is crucial for maintaining stability during surgery and preventing pressure sores. To create a workspace in the abdominal cavity, pneumoperitoneum (inflating the abdominal cavity with carbon dioxide gas up to a certain pressure) is performed using carbon dioxide insufflation.
Port Placement:
Usually, five trocars are used for laparoscopic surgery:
Optic Trocar: Placed in the supraumbilical region for the laparoscope.
Right Midclavicular Trocar: Used for instruments handled by the surgeon’s right hand.
Left Midclavicular Trocar: Used for instruments handled by the surgeon’s left hand.
Right Subcostal Trocar: For retracting the liver.
Left Anterior Axillary Trocar: For placing auxiliary instruments.
Creating the Gastric Pouch:
A window is opened at the greater curvature of the stomach, working between the second and third vascular pedicles in this region. From here, a stapler cut is made toward the angle of His. This procedure forms a narrow gastric tube approximately 15–18 cm in length and 50–150 mL in volume. This new stomach pouch is the main factor that restricts food intake.
Gastrojejunostomy:
The new stomach pouch is connected to a loop of the jejunum. A loop of the jejunum is usually anastomosed with the gastric pouch about 150–200 cm from the ligament of Treitz (where the small intestine begins), often via the antecolic method. A side-to-side anastomosis is created with a linear stapler, and this connection is secured with absorbable sutures.
Nutrient Deficiencies:
Because MGB changes the structure of the stomach and intestines, problems may arise in the absorption of some nutrients.
Iron Deficiency Anemia: Bypassing the duodenum reduces iron absorption, leading to fatigue, weakness, and other symptoms of anemia. Regular blood tests and iron supplementation are recommended.
Vitamin B12 Deficiency: When the stomach is reduced, intrinsic factor production decreases, leading to problems with B12 absorption. B12 deficiency is usually addressed via sublingual or injectable forms.
Calcium and Vitamin D Deficiency: Changes in absorption can increase the risk of osteoporosis. Calcium and vitamin D supplementation is crucial.
After surgery, the rapid passage of stomach contents into the intestines can cause dumping syndrome.
Early Dumping: Occurring immediately after a meal, with symptoms such as nausea, diarrhea, and tachycardia.
Late Dumping: Occurring a few hours after a meal, with symptoms of hypoglycemia. This condition can be managed with small, low-sugar meals.
Gastrointestinal Complications:
Anastomotic Leak: A leak at the stomach-intestine junction can lead to peritonitis and may require urgent surgical intervention.
Anastomotic Stricture: Scar tissue formation at the connection site can cause difficulty swallowing; endoscopic treatment may be necessary.
Marginal Ulcers: Patients who smoke or use NSAIDs are at increased risk of ulcer formation.
Biliary and Intestinal Complications:
Gallstones: Rapid weight loss can increase the risk of gallstones.
Bowel Obstruction: Internal hernias or adhesions may require surgical intervention.
Psychological Effects and GERD:
Lifestyle changes after surgery can cause psychological challenges, making continuous support and an appropriate diet plan important. Additionally, some patients may experience increased reflux symptoms.
Mini Gastric Bypass (MGB) is a surgical method noted for its high success rates in weight loss and treating obesity-related diseases. Postoperative weight loss rates are quite impressive; large-scale studies show that patients lose around 80% of their excess weight in the first year and maintain this success in the long term. At five years, patients retain 50–60% of their excess weight loss. Similar results have been reported in Turkey, where patients lose 60–70% of their excess weight in the first 12–18 months and maintain this success over the long term.
It is known that MGB not only promotes weight loss but also contributes to improvements in obesity-related conditions. Particularly noteworthy is the 80–90% remission rate for type 2 diabetes, demonstrating the remarkable efficacy of this procedure. Significant improvements are also seen in serious health problems such as hypertension and hyperlipidemia. However, the success of MGB is directly related to the surgeon’s experience and the patient’s compliance with lifestyle changes. Experienced surgeons minimize complication rates and achieve better outcomes.
As with any surgical intervention, MGB also carries risks of complications. The most commonly observed issues include marginal ulcers (2.7%) and anemia (7%). However, the overall mortality rate is as low as 0.10%, which supports the reliability of the procedure.
Mini Gastric Bypass (MGB) surgery requires a comprehensive preparation process. This process is planned to increase surgical success, reduce complication risk, and accelerate recovery. The steps that must be taken before surgery include:
Patients undergo a thorough medical evaluation before surgery. Physical examination, medical history review, and laboratory tests are used to assess overall health status. Blood tests analyze liver and kidney functions, blood sugar levels, and nutritional status. If necessary, abdominal ultrasound or CT scans are used for a detailed examination of the abdominal region. Cardiopulmonary evaluations and sleep apnea tests help determine surgical risks. In addition, gastroscopy is recommended to rule out stomach diseases.
Developing healthy lifestyle habits before surgery is important. Quitting smoking speeds up wound healing and reduces infection risks. Regular physical activity improves surgical outcomes and overall health levels. Avoiding alcohol and caffeine can reduce postoperative complications.
A preoperative diet shrinks the liver, making the surgery easier. Typically, a low-calorie diet is used, and a clear liquid diet is adopted a few days before surgery. This preparation minimizes possible difficulties during surgery.
Psychological support is crucial for preparing for the surgery. Adequate guidance is provided for adapting to lifestyle changes and managing emotional eating behaviors.
Informing patients about the surgical procedure is part of the informed consent process. The risks, benefits, and postoperative process are explained in detail.
Postoperative care following Mini Gastric Bypass (MGB) is crucial for both the patient’s physical recovery and long-term weight loss success. The first step after surgery is adhering to a strict diet program. Starting with a liquid diet, the patient gradually transitions to full liquids, puréed foods, and soft foods. After about six weeks, patients move on to a normal diet that is high in protein, low in sugar, and low in fat. Eating slowly, chewing thoroughly, and avoiding fluid intake during meals make it easier for the digestive system to adapt.
Because of changes in nutrient absorption, vitamin and mineral supplementation is required for life. Multivitamins, vitamin B12, iron, calcium, and vitamin D supplements are recommended to prevent deficiencies. Regular blood tests are important for tailoring these needs to the individual.
Physical activity is an essential part of the postoperative process. Patients should begin with short walks early on and gradually increase the duration and intensity of exercises. A total of 150 minutes of moderate aerobic activity per week combined with resistance training prevents muscle loss.
Regular medical follow-up appointments are held to assess the weight loss process and identify possible complications. Conditions like vitamin deficiencies, dumping syndrome, or digestive problems should be managed by a specialized team.
How does mini gastric bypass differ from Roux-en-Y?
Mini gastric bypass (MGB) and Roux-en-Y gastric bypass (RYGB) are bariatric surgeries aimed at promoting weight loss by reducing stomach size and altering the digestive system, but they differ significantly in complexity and outcomes. MGB involves creating a narrow stomach tube and connecting it directly to the small intestine, resulting in shorter operation time and lower complication risk. RYGB, on the other hand, creates a small stomach pouch and reroutes the small intestine in a Y shape, making it more complex and carrying a higher risk of complications. Studies show that MGB achieves greater long-term weight loss, with patients losing 69% of their excess body weight after one year and 73% at five years, while RYGB patients lose 74% after one year and 60% after five years. Both methods effectively improve conditions such as metabolic syndrome and type 2 diabetes, but MGB’s simpler structure offers similar or better results with a lower risk profile. However, MGB carries a risk of bile reflux, which can lead to ulcers and esophageal damage, potentially requiring revision surgery.
How long does the weight loss process last after surgery?
After mini gastric bypass surgery, patients generally lose 70–80% of their excess body weight within the first year. This loss can reach 80–90% by the end of the second year. According to long-term studies, patients can maintain 50–60% of their excess body weight loss at the five-year mark. However, this process can vary from person to person based on adherence to dietary guidelines, physical activity, and overall health status.
Are vitamin deficiencies more common after mini gastric bypass?
Vitamin deficiencies are common after mini gastric bypass surgery. According to studies, long-term deficiency rates are around 35.8% for vitamin D, 16.5% for vitamin E, 13.4% for vitamin A, 9.6% for vitamin K, and 8.5% for vitamin B12. Tiamine (vitamin B1) deficiency is also prevalent postoperatively and can lead to neurological problems. These deficiencies stem from reduced nutrient absorption caused by surgical intervention. Regular follow-up and appropriate supplementation are crucial to prevent health problems stemming from these deficiencies.
How is the intestine rearranged in this method?
In a mini gastric bypass operation, a large portion of the stomach is cut to create a small, tube-shaped stomach pouch, typically holding about 120–150 mL. This new pouch is then connected directly to a section of the small intestine, bypassing about 1.5–2 meters of the digestive tract. This arrangement not only reduces the volume of the stomach but also decreases the absorption of nutrients, thereby promoting weight loss.
Who is not eligible for mini gastric bypass?
Mini gastric bypass surgery is not suitable for individuals with serious cardiovascular diseases such as heart and vascular conditions, active cancers, portal hypertension such as cirrhosis, Crohn’s disease, untreated psychiatric disorders, alcohol and drug dependencies, mental capacity limitations, and serious health issues unrelated to obesity. Additionally, smoking may be unsuitable due to the increased risk of marginal ulcers in these patients. Severe esophagitis or Barrett’s esophagus typically poses another obstacle to this surgery.
References
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