The Long Magenstrasse in the Treatment of Super Obese Patients (Results over 5 Years after Surgery)

doi:10.4236/ss.2013.410092

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Surgical Science, 2013, 4, 469-473

http://dx.doi.org/10.4236/ss.2013.410092 Published Online October 2013 (http://www.scirp.org/journal/ss)

The Long Magenstrasse in the Treatment of Super Obese

Patients (Resu lts ov er 5 Years after Surgery )

Giovanni Berbiglia1, Mario Martinotti2*, Gian Matteo Carena1, Elena Palamarciuc1,

Marina Fariseo1, Carlo Vassallo1

1Chirurgia II, Istituto Clinico “Città di Pavia”, Pavia, Italy

2Dipartimento di Chirurgia Generale, “Istituti Ospitalieri”, Cremona, Italy

Email: *[email protected]

Received July 24, 2013; revised August 22, 2013; accepted August 30, 2013

cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: The considerable increase in Obesity and especially the increase in super obese patients (Body Mass In-

dex—BMI ≥ 50 Kg/m2) who require surgery lead doctors to search for surgery techniques which give good results in

terms of a consistent and stable weight loss associated with low morbidity and good quality of life. The Long Magen-

strasse (LM) intervention, born from combining two properly modified surgical procedures (Selective Vagotomy with

pyloric divulsion and Mangestrasse & Mill by Johnston) seems to have these characteristics according to our experience

after operating on 660 patients. Methods: From October 2003 to October 2008 we treated 186 patients with LM. One

hundred and sixty-two patients were regularly present to the annual follow-up, but 24 patients didn’t turn up, therefore,

they were contacted by phone. On average, surgery lasted approximately 80 minutes (range: 50 - 90 minutes). Thirty

patients were super obese with an average BMI of 57.4 Kg/m2; 156 patients were grade II and III obese with an average

BMI of 40.7 Kg/m2. Results: The average BMI of the 30 super obese patients decreased from 57.4 Kg/m2 to 35.9

Kg/m2 one year after surgery, to 35.6, 5 years after surgery and it has remained stable until now. In the 156 patients

suffering from II and III grade obesity, the average BMI decreased from 40.7 Kg/m2 to 27.8 Kg/m2 one year after sur-

gery and it has remained stable until now. Out of all super obese diabetic patients, only one has partially maintained

his/her therapy. Patients have reported a decreased appetite since the very first days of post-operative period with an

early sense of satiety which is unchanged until today. Conclusions: A consistent and stable weight loss over 5 years

after surgery even in Super Obese patients, a decrease in appetite with an early sense of satiety, a re-equilibrium of the

metabolic syndrome in particular of Diabetes Mellitus, allow to classify LM among those surgical treatments with a

mixed mechanism of action: both restrictive and functional, in particular, entero-hormonal and gastric neurosecretory.

Keywords: Super Obesity; Bariatric Surgery; Magenstrasse and Mill; Sleeve Gastrectomy; Gastric Partition; Gastric

Bypass

1. Introduction

When performing Sleeve Gastrectomy (SG), each sur-

geon chooses the measures that he/she considers the most

suitable ones: from 3 to 8 cm distant from the pylorus with

conservation or non-conservation of the antrum, a calibra-

tion bougie ranging between 32 and 50 Fr. resulting in

great variability in results especially over time [1, 2].

Whereas, in the LM the surgical technique is very pre-

cise and its results are absolutely reproducible [3,4].

The suture-section stretches from the angle of His up

to 2 - 3 cm from the pylorus on a calibration bougie of 36

Fr., in this way the stomach appears uniformly tubular at

the level of the small curvature (food tract). The rest of

the stomach (corpus and fundus) is excluded from food

transit while still producing gastric juices which flow

into the 3 cm dimension prepyloric “Mill” (secretory

pathway).

Without distal pouch, which could experience dilation

over time, gastric conservation allows surgeons to stretch

the suture-section up to 2 - 3 cm from the pylorus. In

order to ease the transit of food bolus, a pyloric divulsion

is carried out resulting in good gastric drainage which

reduces the possibility of gastro-oesophageal reflux.

Another consequence of the long suture-section is se-

lective vagotomy that determines a consistent reduction

in gastric secretion (20% - 30%) [5] which is, anyway,

*Corresponding author.

G. BERBIGLIA ET AL.

470

proportional to the amount of food eaten (surgery restric-

tive aspect).

Differently from SG where corpus and fundus are re-

moved, in the LM technique, despite being present, they

are not transited by food, therefore, there are no stimuli

to the production of ghrelin as it happens in gastric

banding or in the traditional BPD (Biliopancreatic Diver-

sion) [6,7].

Another positive datum of LM is the physiological

transit of food through the duodenum-jejunum without

the “dumping syndrome” which is instead frequent in

those techniques implying a direct gastro jejunal transit.

During a gastroscopy, where each part of the stomach

can be studied, a biliary reflux inside the “Mill” has

never been noticed, probably thanks to a simple pyloric

divulsion instead of a real surgical pyloroplasty.

2. Materials and Methods

In October 2003 we started using LM for treating great

obese patients; until December 2012, 660 patients were

operated on with this procedure.

All patients underwent a pre-operative internistic-die-

tological screening with possible respiratory rehabilita-

tion more or less protracted over time until reaching an

Apnea/Hypopnea Index (AHI) inferior to 5.

From October 2003 to October 2008 we treated with

LM 186 patients, 147 women (79%) and 39 men (21%)

with an average age of 39 (range: 16 - 62) and an average

BMI of 45 Kg/m2.

Thirty patients were super obese with an average BMI

of 57.4 Kg/m2; 156 patients were II and III grade obese

with an average BMI of 40.7 Kg/m2 (Table 1).

Out of these 30 super obese patients, 21 were women

and 9 were men with an average age of 39 (range 16 -

54); 16% suffered from Pickwick syndrome, 36% from

dyslipidemia 16% was affected by hyperuricemia and

34% by arterial hypertension.

The average time of intervention with “open” surgery

with median or left subcostal laparotomy lasted 80 min-

utes; in the other cases surgery was performed with

videolaparoscopy or hand-assisted videolaparoscopy.

The pylorus divulsion was digitoclastic in “open” sur-

gery or hand-assisted videolaparoscopic, pneumatic-en-

doscopic in case of videolaparoscopic procedure.

All patients underwent heparin prophylaxis and an

Table 1. Subjects baseline characteristics before Long Ma-

genstrasse.

Obese (n. 156) Superobese (n. 30)

Men/Women (N) 70/116 (156) 8/22 (30)

Age 40.6 ± 9.5 39.3 ± 9.8

Weight (Kg) 105 ± 15 (86 - 133.5) 159 ± 29.4 (125 - 250)

BMI (kg/m2) 40.7 ± 4.1 (35.3 - 48.4) 57.4 ± 6 (50 - 74)

elastic compressive bandage was applied to those sub-

jects suffering from varicose veins in the lower limbs.

The follow up of the patients who underwent surgery

is as follows: 3 months, 6 months, 1 year after surgery

and then each year until now.

One hundred and sixty-two patients were regularly

present to the annual follow up, 24 patients didn’t turn up,

therefore, they were contacted by phone.

3. Results

In the 30 super obese patients operated on over 5 years

ago the average BMI shifted from a preoperative value of

57.4 Kg/m2 (range 50 - 74) to 38.3 Kg/m2 one year after

surgery, to 35.65 years after surgery and to a current

value of to 35.9 Kg/m2 (range 23 - 54) with an average

%EWL (Percentage of Excess Weight Loss) of 60.16

(range 34 - 97) (Figures 1 and 2).

In the 156 II and III grade obese patients the average

BMI decreased from a preoperative level of 40.7 Kg/m2

(range 35.3 - 48.4) to 26.6 Kg/m2 after one year from

surgery, to 26.7 Kg/m2 5 years after surgery and to 27.8

Kg/m2 (range 19.6 - 35.8) with an average % EWL of

69.4 (Figures 3 and 4, Table 2).

Figure 1. Average BMI (Body Mass Index) in super obese

patients with relative primary standard deviation before

surgery, 1 year after surgery, 5 years after surgery and

today (patients operated on from 5 to 10 years ago).

Figure 2. Average % EWL (Percentage of Excess Weight

Loss) of super obese patients with relative standard devia-

tion 1 year after surgery, 5 years after surgery and today

(patients operated on from 5 to 10 years ago).

G. BERBIGLIA ET AL. 471

Figure 3. Average BMI (Body Mass Index) of II and III

grade obese patients with relative standard deviation, 1

year after surgery, 5 years after surgery and today (patients

operated on from 5 to 10 years ago).

Figure 4. Average %EWL (Percentage of Excess Weit

Table 2. Follow-up over 5 years.

Obese (n. 156) Super Obese (n. 30)

Loss) of II and III grade obese patients with relative stan-

dard deviation, 1 year after surgery, 5 years after surgery

and today (patients operated on from 5 to 10 years).

Weight (Kg) 71. 99.8 ± 12.0 (49 - 94)3 ± 24.8 (56 - 182)

BMI (kg/m2) 27. 8.7 ± 3.8 (19.6 - 35.8)35.9 ± 7.5 (23 - 42)

From a nutritional point of view there is similar be-

f parathormones over

tim

of 5 super obese patients suffering from type 2

he results about other comor-

ago. Av-

Before Operation Current

viour between super obese and II and III grade obese

patients: no deficiency of the main elements (Table 3).

Some cases of occasional folic acid and vitamin B12 oral

supplementation for 1 - 2 months.

No alterations in the values o

Out

abetes, only one is still under a low hypoglycaemic

therapy; the other 4 are not following any therapy over 5

years after the operation.

In super obese patients, t

dities of the metabolic disease refer to recoveries from

OSAS (Obstructive Sleep Apnea Syndrome) in 90% of

cases, from high blood pressure in 65%, from dyslipide-

mia in 80% and hyperuricemia in 85% of cases.

Table 3. N. 186 patients operated on over 5 years

erage nutritional levels before and after Long Magenstrasse.

Iron (g/dl) µ74.81 78.24

Ca (mg/dl) 8.98 8.91

V) 43

it. B12 (pg/ml14.12 21.36

olic Acid (ng/ml)5.94 4.90

Total Proteins 7.30 6.90

Among perioperative complications we report a suture

rated on before October 2008

l cases the dumping syndrome was absent.

4. Discussion

edure has a mixed type mechanism of

4.1. Conservation and Gastric Restriction

l stom-

tion stretches from the angle of His up

de-

hiscence at antral level which was resolved with an

urgent surgical revision.

In the 186 patients ope

e most frequent complication, which generally ap-

peared 6 - 12 months after surgery, is, generally, the

postprandial, and never the nocturnal, gastro-oesophageal

reflux (9% of patients who underwent surgery), probably

due to a recovered pyloric tone; the treatment is endo-

scopic and consists in a pneumatic dilation of the pylo-

rus.

In al

LM surgical proc

action given by the combination of a gastric restriction,

entero-hormonal effects, a change in motility, gastric

secretion and, obviously, in eating habits.

Differently from S.G., where measures of residua

ach are not standardized and each surgeon can choose a

distance from the pylorus ranging from 3 to 8 cm and a

calibration bougie ranging from 32 to 50 Fr. with great

variability in the results especially over time, in the LM,

the technique requires specific measures with reproduci-

ble results.

The suture-sec

2 - 3 cm from the pylorus with a calibration bougie of

36 Fr. resulting, this way, in a uniformly tubular stomach

at the small curvature (food tract). The rest of the stom-

ach (corpus and fundus) is excluded from food transit

while still producing gastric juices which flow into the 3

cm dimension prepyloric “Mill” (secretory pathway).

In order to stop the bolus from descending the duo

m and reaching back the excluded stomach, a pyloric

divulsion is fundamental because it resolves the pyloric

spasm secondary to the vagal nervous interruption;

therefore, the food bolus transits easily also thanks to the

lack of a prepyloric “pouch” which requires an effective

emptying pump.

G. BERBIGLIA ET AL.

472

This maneuver consisting in the interruption of the

fib

y take place

er from night

LM is a 20% - 30% reduc-

tio

c juices

ervation acts favorably on the production

e through

4.2. Mechanism of Actions of Hormones

in has not

alysis of the results has underlined

istics of LM are:

nality, though re-

yloric region remains uniform over

tim

e of a

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