MGB STUDIES

15-year experience of laparoscopic single anastomosis (mini-)gastric bypass: comparison with other bariatric procedures.


Surg Endosc. 2018 Jul;32(7):3024-3031. doi: 10.1007/s00464-017-6011-1. Epub 2018 Jan 8. Alkhalifah N1,2, Lee WJ3, Hai TC1,4, Ser KH1, Chen JC1, Wu CC1. BACKGROUND: Laparoscopic single anastomosis (mini-)gastric bypass (LSAGB) has been validated as a safe and effective treatment for morbid obesity. However, data of the long-term outcome remain lacking. METHODS: Between October 2001 and December 2015, 1731 morbidly obese patients who received LSAGB as primary bariatric procedure at the Min-Sheng General Hospital were recruited. Surgical outcome, weight loss, resolution of comorbidities, and late complications were followed, then compared with groups of laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). All data derived from a prospective bariatric database and a retrospective analysis were conducted. RESULTS: The average patient age was 33.8 ± 10.4 years with a mean body mass index (BMI) of 40.4 ± 7.7 kg/m2. Of them, 70.0% were female while 30.0% were male. Mean operating time, intraoperative blood, and hospital stay of LSAGB were 124.6 ± 38.8 min, 39.5 ± 38.7 ml, and 5.0 ± 4.1 days, respectively. The 30-day post-operative major complication occurred in 30 (1.7%) of LSAGB patients, 16 (2.0%) of LRYGB, and 15 (1.4%) of LSG patients. The follow-up rates at 1, 5, and 10 years were 89.3, 52.1, and 43.6%, respectively. At postoperative 1, 5, and 10 years, the mean percentage of weight loss (%WL) of LSAGB patients were 32.7, 32.2, and 29.1%, and mean BMI became 27, 26.9, and 27 kg/m2, respectively. The LSAGB had a higher weight loss than LRYGB and LSG at 2-6 years after surgery. LSG had a lower remission rate in dyslipidemia comparing to LSAGB and LRYGB. The overall revision rate of LSAGB is 4.0% (70/1731) which was lower than the 5.1% in LRYGB and 5.2% in the LSG. CONCLUSION: LSAGB is an effective procedure for treating morbid obesity and metabolic disorders, which results in sustained weight loss and a high resolution of comorbidities.




One Anastomosis (Mini) Gastric Bypass Is Now an Established Bariatric Procedure: a Systematic Review of 12,807 Patients.


Obes Surg. 2018 Sep;28(9):2956-2967. doi: 10.1007/s11695-018-3382-x Parmar CD1, Mahawar KK2. Abstract The One Anastomosis (Mini) Gastric Bypass is rapidly gaining acceptance. This review reports cumulative results of 12,807 procedures in obese patients with a mean age of 41.18 years and BMI of 46.6 kg/m2. The overall mortality was 0.10% and the leak rate was 0.96%. The follow-up duration ranged from 6 months to 12 years. A marginal ulceration rate of 2.7% and an anaemia rate of 7.0% were reported. Approximately 2.0% of patients reported postoperative gastro-oesophageal reflux and 0.71% developed malnutrition. Excess weight loss at 6, 12, 24 and 60 months was 60.68, 72.56, 78.2 and 76.6% respectively. Type 2 diabetes mellitus and hypertension resolved in 83.7 and 66.94% respectively. We conclude that there is now sufficient evidence to include MGB-OAGB as a mainstream bariatric procedure.




One Anastomosis Gastric Bypass in Morbidly Obese Patients with BMI ≥ 50 kg/m2: a Systematic Review Comparing It with Roux-En-Y Gastric Bypass and Sleeve Gastrectomy.


Obes Surg. 2019 Jun 27. doi: 10.1007/s11695-019-04034-9. [Epub ahead of print] Parmar CD1, Bryant C2, Luque-de-Leon E3, Peraglie C4, Prasad A5, Rheinwalt K6, Musella M7. Abstract BACKGROUND: To explore the role of one anastomosis (Mini) gastric bypass (OAGB) for the super-obese patients. METHOD: Literature review was performed in March 2019 as per PRISMA guidelines. RESULTS: A total of 318 patients were identified. Mean age was 31.8 years. Mean body mass index (BMI) was 57.4 kg/m2. The mean operative time was 93.1 min with median length of stay of 4.5 days. The biliopancreatic limb (BPL) varied from 190 to 350 cm(median 280 cm). Early mortality was 0.31% with seven complications (including 1 revisional surgery). Leak rate was 0%. Mean %excess weight loss (EWL) at 12, 18-24 and 60 months was 67.7%, 71.6% and 90.75%, respectively. CONCLUSIONS: OAGB is a safe and effective option for management of super and super-super obese patients with tailoring of the BPL. Larger comparison, follow-up and randomised trials are necessary to validate these findings.




Audit of 1107 Cases Comparing Sleeve Gastrectomy, Roux-En-Y Gastric Bypass, and Mini-Gastric Bypass, to Determine an Effective and Safe Bariatric and Metabolic Procedure


Obesity Surgery May 2016, Volume 26, Issue 5, pp 926-932 Gurvinder S. Jammu , Rajni Sharma Background: The epidemic of obesity is engulfing developed as well as developing countries like India. We present our 7-year experience with laparoscopic sleeve gastrectomy (LSG), Roux-en-Y gastric bypass (RYGB), and mini-gastric bypass (MGB) to determine an effective and safe bariatric and metabolic procedure. Methods: The study is an analysis of a prospectively collected bariatric database of 473 MGBs, 339 LSGs, and 295 RYGBs. Results: Mortality rate was 2.1 % in LSG, 0.3 % in RYGB, and 0 % in MGB. Leaks were highest in LSG (1.5 %), followed by RYGB (0.3 %), and zero in MGB. Bile reflux was seen in <1 % in the MGB series. Persistent vomiting was seen only in LSG. Weight regain was 14.2 % in LSG, 8.5 % in RYGB, but 0 % in MGB. Hypoalbuminemia was minimal in LSG, 2.0 % in RYGB, and 13.1 % in MGB (in earlier patients where bypass was >250 cm). The following resolution of comorbidities: dyslipidemia, type 2 diabetes (T2D), hypertension, and percent excess weight loss (%EWL) was maximum in MGB. GERD was maximum in LSG (9.8 %), followed by RYGB (1.7 %), and minimal in MGB (0.6 %). Conclusions RYGB and MGB act on the principle of restriction and malabsorption, but MGB superseded RYGB in its technical ease, efficacy, revisibility, and reversibility. Mortality was zero in MGB. %EWL and resolution of comorbidities were highly significant in MGB. Based on this audit, we suggest that MGB is the effective and safe procedure for patients who are compliant in taking their supplements. LSG may be done in non-compliant patients and those ready to accept weight regain.




One-Anastomosis Gastric Bypass Versus Sleeve Gastrectomy for Morbid Obesity: a Systematic Review and Meta-analysis


OBES SURG (2017) 27:2479–2487 Dimitrios E. Magouliotis1 & Vasiliki S. Tasiopoulou2 & Alexis A. Svokos3 & Konstantina A. Svokos4 & Eleni Sioka1 & Dimitrios Zacharoulis1 Abstract We aim to review the available literature on obese patients treated with one-anastomosis gastric bypass (OAGB) or laparoscopic sleeve gastrectomy (LSG), in order to compare the clinical outcomes and intraoperative parameters of the two methods. A systematic literature search was performed in PubMed, Cochrane Library, and Scopus databases, in accordance with the PRISMAguidelines. Seventeen studies met the inclusion criteria incorporating 6761 patients. This study reveals increased weight loss, remission of comorbidities, shorter mean hospital stay, and lower mortality in the OAGB group.




Efficacy of Bariatric Surgery in Type 2 Diabetes Mellitus Remission: the Role of Mini Gastric Bypass/One Anastomosis Gastric Bypass and Sleeve Gastrectomy at 1 Year of Follow-up. A European survey.


Obes Surg. 2016 May;26(5):933-40. Musella M1, Apers J2, Rheinwalt K3, Ribeiro R4, Manno E5, Greco F6, Čierny M7, Milone M8, Di Stefano C9, Guler S2, Van Lessen IM3, Guerra A4, Maglio MN5, Bonfanti R6, Novotna R7, Coretti G8, Piazza L9. BACKGROUND: A retrospective study was undertaken to define the efficacy of both mini gastric bypass or one anastomosis gastric bypass (MGB/OAGB) and sleeve gastrectomy (SG) in type 2 diabetes mellitus (T2DM) remission in morbidly obese patients (pts). METHODS: Eight European centers were involved in this survey. T2DM was preoperatively diagnosed in 313/3252 pts (9.62%). In 175/313 patients, 55.9% underwent MGB/OAGB, while in 138/313 patients, 44.1% received SG between January 2006 and December 2014. RESULTS: Two hundred six out of 313 (63.7 %) pts reached 1 year of follow-up. The mean body mass index (BMI) for MGB/OAGB pts was 33.1 ± 6.6, and the mean BMI for SG pts was 35.9 ± 5.9 (p < 0.001). Eighty-two out of 96 (85.4%) MGB/OAGB pts vs. 67/110 (60.9%) SG pts are in remission (p < 0.001). No correlation was found in the % change vs. baseline values for hemoglobin A1c (HbA1c) and fasting plasma glucose (FPG) in relation to BMI reduction, for both MGB/OAGB or SG (ΔFPG 0.7 and ΔHbA1c 0.4 for MGB/OAGB; ΔFPG 0.7 and ΔHbA1c 0.1 for SG). At multivariate analysis, high baseline HbA1c [odds ratio (OR) = 0.623, 95% confidence interval (CI) 0.419-0.925, p = 0.01], preoperative consumption of insulin or oral antidiabetic agents (OR = 0.256, 95% CI 0.137-0.478, p = <0.001), and T2DM duration >10 years (OR = 0.752, 95% CI 0.512-0.976, p = 0.01) were negative predictors whereas MGB/OAGB resulted as a positive predictor (OR = 3.888, 95% CI 1.654-9.143, p = 0.002) of diabetes remission. CONCLUSIONS: A significant BMI decrease and T2DM remission unrelated from weight loss were recorded for both procedures if compared to baseline values. At univariate and multivariate analyses, MGB/OAGB seems to outperform significantly SG. Four independent variables able to influence T2DM remission at 12 months have been identified.




Complications Following the Mini/One Anastomosis Gastric Bypass (MGB/OAGB): a Multi-institutional Survey on 2678 Patients with a Mid-term (5 Years) Follow-up.


Obes Surg. 2017 Nov;27(11):2956-2967 Musella M1, Susa A2, Manno E3, De Luca M4, Greco F5, Raffaelli M6, Cristiano S7, Milone M8, Bianco P8, Vilardi A2, Damiano I3, Segato G4, Pedretti L5, Giustacchini P6, Fico D7, Veroux G9, Piazza L9. BACKGROUND: In recent years, several articles have reported considerable results with the Mini/One Anastomosis Gastric Bypass (MGB/OAGB) in terms of both weight loss and resolution of comorbidities. Despite those positive reports, some controversies still limit the widespread acceptance of this procedure. Therefore, a multicenter retrospective study, with the aim to investigate complications following this procedure, has been designed. PATIENTS AND METHODS: To report the complications rate following the MGB/OAGB and their management, and to assess the role of this approach in determining eventual complications related especially to the loop reconstruction, in the early and late postoperative periods, the clinical records of 2678 patients who underwent MGB/OAGB between 2006 and 2015 have been studied. RESULTS: Intraoperative and early complications rates were 0.5 and 3.1%, respectively. Follow-up at 5 years was 62.6%. Late complications rate was 10.1%. A statistical correlation was found for perioperative bleeding both with operative time (p < 0.001) or a learning curve of less than 50 cases (p < 0.001). A statistical correlation was found for postoperative duodenal-gastro-esophageal reflux (DGER) with a preexisting gastro-esophageal-reflux disease (GERD) or with a gastric pouch shorter than 9 cm, (p < 0.001 and p = 0.001), respectively. An excessive weight loss correlated with a biliopancreatic limb longer than 250 cm (p < 0.001). CONCLUSIONS: Our results confirm MGB/OAGB to be a reliable bariatric procedure. According to other large and long-term published series, MGB/OAGB seems to compare very favorably, in terms of complication rate, with two mainstream procedures as standard Roux-en-Y gastric bypass (RYGBP) and laparoscopic sleeve gastrectomy (LSG).




An eight-year experience with 189 Type 2 diabetic patients after mini-gastric bypass


Integrative Obesity and Diabetes: 2016. Volume 2(4): 246-249 Gurvinder S. Jammu* and Rajni Sharma*
Jammu Hospital, India
Abstract
Background: Laparoscopic mini-gastric bypass (MGB) is gaining popularity because of favorable weight loss, co-morbidity resolution, simplicity and exit strategies.
We evaluated the efficacy of the MGB in %EWL and resolution of type 2 diabetes (T2D) in different age-groups who had different durations of T2D. The successful
end-result was set at HbA1c <6.5.
Methods: The study is a retrospective analysis of prospectively-collected data on 189 T2D patients who had undergone MGB from Jan 2007 to Dec 2014. Mean
pre-operative age was 50.4 years (27-75 years). Mean duration of T2D was 12.75 years (6 months – 25 years). Mean pre-operative HbA1c was 10. 4% (6.9%-13.9%),
with mean C-peptide 6.65 (0.24-13.05).
Results: Mean EWL was >90%. For the same length of bypass, the rate of %EWL was greater in the younger age group (27-40 years). T2D resolved in 95.1% of
the patients (complete cessation of medication for T2D), with a significant improvement in the remainder. Although in a few patients with IDDM the requirement
for exogenous insulin persisted, the dose of insulin was significantly reduced. Those who had shorter duration of T2D (6 months to 5 years) showed faster remission. Conclusions: MGB was effective in both %EWL and improvement in glycemic control, thus leading to clinical resolution or improvement in T2D and its related complications. Nutritional deficiencies and gastroesophagealreflux were easily avoidable with proper technique. The simplicity, results and exit strategies make MGBa superior bariatric and metabolic procedure.




Laparoscopic mini-gastric bypass in patients age 60 and older.


Surgical Endoscopy :January 2016, Volume 30, Issue 1, pp 38-43 Cesare Peraglie MD FACS FASCRS Background Bariatric surgery in patients over age 60 was previously not considered, due to higher risk. The author presents a study of patients ≥60 years who underwent laparoscopic mini-gastric bypass (LMGB), to evaluate outcomes with follow-up to 6 years. Methods From 2007–2013, a prospectively maintained database was reviewed and patients ≥60 years were identified. Demographics evaluated included age, sex, weight, BMI, comorbidities, operative time, complications, length of stay (LOS) and %EWL up to 72 months. Results From 2007–2013, a total of 758 LMGBs were performed by one surgeon (CP). Eighty-eight (12 %) were ≥60 years old, with 62 % female. Mean age of this cohort at operation was 64 (60–74), and mean weight and BMI were 118 kg (78–171) and 43 kg/m2 (33–61), respectively. Comorbidities were present in all patients, and one-third had previous abdominal operations. All patients underwent LMGB, without conversion to open. Mean operative time was 70 min (43–173). Only one patient required overnight ICU admission. Average LOS was 1.2 days (1–3). Overall complication rate was 4.5 % (all minor); there were no major complications. Readmission rate was 1.2 % (one patient). There was no surgical-related mortality. Follow-up to 90 days was 89 %, but steadily declined to 42 % at 6 years (72 months). The %EWL was 72 % at 72 months. Conclusion LMGB can be safely performed with good weight loss in patients ≥60 years old, despite numerous comorbidities and previous abdominal operations.




Efficacy of Bariatric Surgery in Type 2 Diabetes Mellitus Remission: the Role of Mini Gastric Bypass/One Anastomosis Gastric Bypass and Sleeve Gastrectomy at 1 Year of Follow-up. A European surveyA 7-Year Clinical


Obesity Surgery: May 2016, Volume 26, Issue 5, pp 933-940 Musella et al. Background A retrospective study was undertaken to define the efficacy of both mini gastric bypass or one anastomosis gastric bypass (MGB/OAGB) and sleeve gastrectomy (SG) in type 2 diabetes mellitus (T2DM) remission in morbidly obese patients (pts). Methods Eight European centers were involved in this survey. T2DM was preoperatively diagnosed in 313/3252 pts (9.62 %). In 175/313 patients, 55.9 % underwent MGB/OAGB, while in 138/313 patients, 44.1 % received SG between January 2006 and December 2014. Results Two hundred six out of 313 (63.7 %) pts reached 1 year of follow-up. The mean body mass index (BMI) for MGB/OAGB pts was 33.1 ± 6.6, and the mean BMI for SG pts was 35.9 ± 5.9 (p < 0.001). Eighty-two out of 96 (85.4 %) MGB/OAGB pts vs. 67/110 (60.9 %) SG pts are in remission (p  < 0.001). No correlation was found in the % change vs. baseline values for hemoglobin A1c (HbA1c) and fasting plasma glucose (FPG) in relation to BMI reduction, for both MGB/OAGB or SG (ΔFPG 0.7 and ΔHbA1c 0.4 for MGB/OAGB; ΔFPG 0.7 and ΔHbA1c 0.1 for SG). At multivariate analysis, high baseline HbA1c [odds ratio (OR) = 0.623, 95 % confidence interval (CI) 0.419–0.925, p = 0.01], preoperative consumption of insulin or oral antidiabetic agents (OR = 0.256, 95 % CI 0.137–0.478, p = <0.001), and T2DM duration >10 years (OR = 0.752, 95 % CI 0.512–0.976, p = 0.01) were negative predictors whereas MGB/OAGB resulted as a positive predictor (OR = 3.888, 95 % CI 1.654–9.143, p = 0.002) of diabetes remission. Conclusion A significant BMI decrease and T2DM remission unrelated from weight loss were recorded for both procedures if compared to baseline values. At univariate and multivariate analyses, MGB/OAGB seems to outperform significantly SG. Four independent variables able to influence T2DM remission at 12 months have been identified.




Single anastomosis or mini-gastric bypass: long-term results and quality of life after a 5-year follow-up.


Surg Obes Relat Dis. 2014 Sep 16. [Epub ahead of print] Bruzzi M1, Rau C2, Voron T2, Guenzi M2, Berger A2, Chevallier JM2. BACKGROUND: Laparoscopic mini-gastric bypass (LMGB) is an alternative to the laparoscopic Roux-en-Y gastric bypass (LRYGB), which is considered to be the gold standard in the treatment of morbid obesity. OBJECTIVES: Present 5-year results of 175 patients who had undergone a LMGB between October 2006 and October 2008. METHODS: Complete follow-up was available in 126 of 175 patients (72%) who had LMGB. Mortality, morbidity, weight loss, co-morbidities, and quality of life were assessed. Weight loss was determined as a change in body mass index (BMI) and percent excess BMI loss (%EBMIL). Quality of life in the treatment group was analyzed using the Gastrointestinal Quality of Life Index (GIQLI) and was compared with a retrospectively case matched preoperative control group. RESULTS: There were no deaths. Thirteen patients (10.3%) developed major complications. Marginal ulcers occurred in 4% of patients. Incapacitating biliary reflux developed in 2 (1.6%) who required conversion into RYGB. Gastric pouch dilation occurred in 4 patients (3.2%) and inadequate weight loss with severe malnutrition in 2 (1.6%). At 5 years, mean BMI was 31±6 kg/m2 and mean %EBMIL was 71.5%±26.5%. Postoperative GIQLI score of the treatment group was significantly higher than preoperative score of the control group (110.3±17.4 versus 92.5±15.9, P<.001). Social, psychological, and physical functions were increased significantly. No significant differences were found in gastroesophageal reflux or diarrhea symptoms between the 2 groups. Long-term follow-up showed an improvement in all co-morbidities. CONCLUSIONS: At 5 years, LMGB was safe, effective, and provided interesting quality of life results.




Primary Results of Laparoscopic Mini-Gastric Bypass in a French Obesity-Surgery Specialized University Hospital


Ghassan Chakhtoura & Franck Zinzindohoué & Yassine Ghanem & Ivan Ruseykin & Jean-Christophe Dutranoy & Jean-Marc Chevallier OBES SURG (2008) 18:1130–1133 Received: 1 May 2008 / Accepted: 23 May 2008 / Published online: 20 June 2008 # Springer Science + Business Media, LLC 2008

Abstract: Background Since 2002, we have performed 350 laparo- scopic Roux-en-Y gastric bypasses (LRYGB). We decided to evaluate the laparoscopic mini-gastric bypass (LMGB), an operation reported as effective, yet simpler than LRYGB. It consisted of a long lesser curvature tube with a terminolateral gastroenterostomy, 200 cm distal to the Treitz ligament. Methods: From October 2006 to November 2007, 100 patients (23 men and 77 women) underwent LMGB. The mean age was 40.9 ± 11.5 years (17.5–62.4), the preoperative mean body weight was 131±23.1 kg (82–203) and the mean BMI was 46.9 ± 7.4 kg/m2 (32.8–72.4). Twenty-four patients had prior restrictive procedure: 20 LAGB of which nine were already removed and four VBG (two laparoscopic and two by open surgery). In preoperative gastric endoscopy Helicobacter pylorii was present in 26 patients and eradicated. Results: All procedures were completed laparoscopically by six different surgeons. Mean operative time was 129±37 min. There was no death. Seven patients (7%) presented major early complications: three re-operations for incarcerated herniation of small bowel in the trocar wound, one peritonitis due to a traumatic injury of the biliary limb, one perianas- tomotic abscess, one intra-abdominal bleeding requiring splenectomy, and one endoscopic hemostasis for anastomotic bleeding. One patient presented anastomotic stenosis that required endoscopic dilatation 2 months post-operatively. Mean BMI at 3 months was 38.7 kg/m2 (31.2–60.9) and at 6 months 35.1 (23.6–53.0). Nine patients complained of diarrhea that resolved 3 months postoperatively and, signifi- cantly, only two patients complained of biliary reflux. Conclusion: Pending long-term evaluation, LMBG seems a good alternative to LRYGB, giving the same results with a more simple and reproductible technique. COMMENTS: LMGB is far from gaining general consensus so, what’s wrong with LMGB?
Not its low leakage rate. We haven’t noted any in our series (the postoperative peritonitis that we encountered was due to a traumatic jejunal injury away from the anastomosis). This is also true for other LMGB pub- lished series [5–9]. These low rates can probably be explained by a good blood supply of the gastric pouch and of the uninterrupted jejunal loop.
Not its simplicity. With only one anastomosis to do, we have gained 30 min in our operating time compared to LRYGB. And everybody knows that the enteroenteros- tomy can bring many complications such as leakage, kinking, internal hernias. Although our mean operative time seems longer than in other series, it can be due to the fact that 24% of our patients had prior restrictive procedures and that four out of six surgeons are senior residents. To note is our very conservative approach regarding postoperative realimentation; with growing experience, we are beginning to feed the patients on the third postoperative day resulting in 2-days shorter hospitalizations.
Surely not its effect on weight loss. With %EWL of 51% and 63% at 6 months and 1 year, we have equivalent figures as other LMGB series and this effect seems to be long-lasting [9].
Neither its anastomotic ulcer rate. Our 1% rate is lower than the usual 2% to 8% rate observed in other mini- bypass series. This may be due to our systematic pre- operative search and eradication of H. Pylori, our small gastric pouch meaning less acid secretion and our recommendation for lifelong proton pomp inhibitor usage. Even more, biliary presence at the site of the anastomosis in LMGB could hamper the ulcerogenic effect of acid. Nor its good digestive tolerance. Lee’s 2005 clinical trial found no difference in digestive well-being between LMGB and LRYGB; our 2% clinical reflux rate com-pares positively with the 3% rate of clinical reflux that he described in both LMGB and LRYGB [7]. We plan next to undergo systematic search for esophageal biliary reflux after LMGB via impedencemetry, which is a more accurate method for assessing biliary reflux than the classic pHmetry that Carbajo used in his patients [8].
Is it an increased gastric cancer risk? This is probably the main issue. In rats, the pancreatico-duodenal reflux alone or in combination with bile reflux produced gastric adenocarcinoma whereas no carcinomas were found in animals with bile reflux alone [10]. If this is true in humans, is the effect of pancreatic juice still the same 2 m beyond the duodenum? Results of very long- term follow-up of human series after partial gastrecto- my show contradictory results: while some found no increase of gastric carcinomas after Billroth II anastomosis [11, 12], others state the contrary [13, 14]. Some even pretend that diversion of the enteric reflux from the gastric remnant with a Roux loop may yield pre- cancerous changes [15]. In a 1990 meta-analysis of 22 literature report on the risk of gastric cancer after remote peptic ulcer surgery, no statistical difference was found between the surgical techniques [16], and the LMGB is different from a Billroth II partial gastrectomy with a smaller gastric volume and a longer alimentary limb. Noteworthy is that in these retrospective studies, the role of H. pylori—a major risk factor or gastric cancer—is not taken into account. So, by sticking to the facts, we can repeat after Kondo that “the relationship between duodenogastric reflux and gastric cancer has not yet been defined from human data and that the question whether the incidence of gastric stump carcinoma is higher than that of gastric carcinoma in general is still unanswered.