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Obesity IGINAL CONTRIBUTIONSThe First Consensus Statement on One Anastomosis/Mini Gastric Bypass(OAGB/MGB) Using a Modified Delphi ApproachKamal K. Mahawar 1 & Jacques Himpens 2 & Scott A. Shikora 3 & Jean-Marc Chevallier 4 & Mufazzal Lakdawala 5 &Maurizio De Luca 6 & Rudolf Weiner 7 & Ali Khammas 8 & Kuldeepak Singh Kular 9 & Mario Musella 10 & Gerhard Prager 11 &Mohammad Khalid Mirza 12 & Miguel Carbajo 13 & Lilian Kow 14 & Wei-Jei Lee 15 & Peter K. Small 1# Springer Science Business Media, LLC, part of Springer Nature 2017AbstractBackground An increasing number of surgeons worldwide are now performing one anastomosis/mini gastric bypass(OAGB/MGB). Lack of a published consensus amongst experts may be hindering progress and affecting outcomes. This paperreports results from the first modified Delphi consensus building exercise on this procedure.Methods A committee of 16 recognised opinion-makers in bariatric surgery with special interest in OAGB/MGB was constituted. The committee invited 101 OAGB/MGB experts from 39 countries to vote on 55 statements in areas of controversy orvariation associated with this procedure. An agreement amongst 70.0% of the experts was considered to indicate a consensus.Results A consensus was achieved for 48 of the 55 proposed statements after two rounds of voting. There was no consensus forseven statements. Remarkably, 100.0% of the experts felt that OAGB/MGB was an Bacceptable mainstream surgical option and96.0% felt that it could no longer be regarded as a new or experimental procedure. Approximately 96.0 and 91.0% of the expertsfelt that OAGB/MGB did not increase the risk of gastric and oesophageal cancers, respectively. Approximately 94.0% of theexperts felt that the construction of the gastric pouch should start in the horizontal portion of the lesser curvature. There was aconsensus of 82, 84, and 85% for routinely supplementing iron, vitamin B12, and vitamin D, respectively.Conclusion OAGB/MGB experts achieved consensus on a number of aspects concerning this procedure but several areas ofdisagreements persist emphasising the need for more studies in the future.Keywords Mini gastric bypass . One anastomosis gastric bypass . Single anastomosis gastric bypass . Omega loop gastric bypass .Loop gastric bypass . Gastric bypass . Consensus statement . Delphi approach* Kamal K. Mahawarkamal mahawar@hotmail.com8Rashid Hospital, Dubai, United Arab Emirates9Kular College and Hospitals Pvt. Ltd., Bija, Ludhiana, Punjab, India10Advanced Biomedical Sciences Department, Federico II University,Naples, Italy1Bariatric Unit, Department of General Surgery, Sunderland RoyalHospital, Sunderland SR4 7TP, UK2St. Pierre University Hospital, Brussels, Belgium113Medical University of Vienna, Vienna, AustriaBrigham and Women’s Hospital, Harvard Medical School,Boston, MA, USA12King Fahad University Hospital, Khobar, Saudi Arabia4Université Paris 5, Paris, France135Digestive Health Institute, Mumbai, IndiaCentre of Excellence for the Study and Treatment of Obesity andDiabetes, Valladolid, Spain6Montebelluna Treviso Hospital, Treviso, Italy14Adelaide Bariatric Centre, Adelaide, Australia7Clinic Obesity Surgery, Sana-Klinikum Offenbach,Offenbach, Germany15Min-Sheng General Hospital, Taoyuan City, Taiwan
OBES SURGAbbreviationsOAGB/MGBIFSORYGBGERDOne Anastomosis (Mini) Gastric BypassInternational Federation for the Surgery ofObesity and Metabolic DisordersRoux-en-Y Gastric BypassGastro-Esophageal Reflux DiseaseIntroductionOne anastomosis/mini gastric bypass (OAGB/MGB) is beingperformed by an increasing number of surgeons worldwidewith several thousand cases [1–4] now documented in thepublished scientific literature. At the same time, there is considerable variation amongst surgeons with regard to a numberof peri-operative practices [5]. This survey of 210 OAGB/MGB surgeons from 39 countries with a cumulative experience of 68,442 procedures revealed considerable variations inpractice. For example, surgeons described no less than 55different absolute and 59 relative contraindications to this procedure in their practice. Rather more worryingly, a large number of surgeons did not routinely recommend iron, vitamin D,and vitamin B12 supplementation after this procedure. Giventhat these supplementations are now routine and supported byvarious nutritional guidelines [6, 7] after Roux-en-Y gastricbypass (RYGB), one fails to understand the rationale behindthese practices with a procedure that is associated with ahigher incidence of severe protein-calorie malnutrition [8].There were further significant variations with regard to thelength of the bilio-pancreatic limb used with only 35.0% ofthe surgeons using a fixed length. There was also lack ofconsistency regarding approach to patients with hiatus hernia.This variation in practice is probably because there is arelative lack of studies on various peri-operative practicesconcerning this procedure. The unfortunate controversy surrounding this procedure [9] has probably further hindered itswidespread adoption and detailed scientific investigation.Developing a systematic evidence base for all of the differentaspects of this procedure will not be easy and likely to takesome time. While we wait for that to happen, a consensusamongst experts can be useful to guide newer surgeons. Atthe same time, surgeons need to be aware that expert opinioncan only be regarded as level 1V evidence and needs to beconfirmed in future studies. There is currently no publishedconsensus amongst experts concerning various aspects ofOAGB/MGB.Modified Delphi protocol is a recognised strategy for consensus building amongst experts [10]. This technique has beenused widely in various walks of life including biomedicaldisciplines as well as bariatric surgery [11]. It allows expertsto share and modify their opinion anonymously and removesthe possibility of some loud voices determining the groupthinking. It further allows experts to change their views without any loss of face that can happen in open face-to-facesetting. The aim of this exercise was to develop consensusamongst OAGB/MGB experts on a range of practices andprinciples concerning this procedure following a modifiedDelphi protocol.MethodsWe constituted a committee of 16 recognised opinion-makersin bariatric surgery with a special interest in this procedure tooversee the consensus building exercise (Table 1). The committee invited 101 expert OAGB/MGB surgeons from aroundthe world (Table 2) to take part in the consensus buildingexercise. The experts had to meet following criteria forinclusion.1. Nomination by either a member of the OAGB/MGBConsensus Building Committee or President of a nationalbariatric society affiliated to International Federation forthe Surgery of Obesity and Metabolic Disorders (IFSO)2. Self-confirmation of OAGB/MGB expert status3. Working knowledge of English language4. Participation in both rounds of voting as per the modifiedDelphi protocolThe committee drafted 55 statements for experts to vote on.The members of the committee also voted as experts. Noattempt was made to examine individual responses. An agreement amongst 70.0% of the experts was used to define consensus. This cut-off has been used in previous consensus papers published in the field of bariatric surgery [12]. Expertswere encouraged to provide justification for their choices. Thecommittee invited a second round of votes from experts onstatements with 75.0% consensus after the first round. Thecumulative results of the first-round exercise were shared withexperts prior to the second-round voting. The exercise wasconcluded after two rounds as the committee felt a saturationpoint had been reached.ResultsA total of 101 experts from 39 countries voted on 55 statements proposed by the consensus building committee. With 9experts, India had the highest number of OAGB/MGB expertsin the world followed by the United Kingdom (8), France (8),Mexico (8), and Italy (7).Table 3 summarises detailed results of first- and secondround votes on each of the 55 statements. A consensus of 75.0% was reached for 38 statements and a consensus of70.0–75.0% was reached for another 7 statements, after the
OBES SURGTable 1 Members of OAGB/MGB Consensus Building Committee (inalphabetical order)NameCountryMiguel CarbajoSpainJean-Marc ChevallierFranceMohammad Khalid MirzaMaurizio De LucaKingdom of Saudi ArabiaItalyJacques HimpensBelgiumAli KhammasLilian KowUnited Arab EmiratesAustraliaKuldeepak Singh KularMufazzal LakdawalaIndiaIndiaWei-Jei LeeTaiwanKamal MahawarUnited KingdomMario MusellaGerhard PragerScott Alan ShikoraItalyAustriaUnited States of AmericaPeter SmallUnited KingdomRudolf WeinerGermanyfirst round. There was no consensus on 10 statements after thefirst round.The committee decided to vote on statements with 75.0%consensus in the second round. After the second round, aconsensus of 70.0% was achieved for all but 7 statements.Expert Disagreement with the Committee StatementsOut of the 48 statements where consensus was achieved, experts agreed with 46 of the statements proposed by the committee. Two statements where a consensus of disagreementwas reached have been clearly identified in Table 3. Theseare as follows.(i) One anastomosis/mini gastric bypass (OAGB/MGB) isnot a malabsorptive bariatric procedure (disagreed by82.0% of the experts).(ii) The standard length of the bilio-pancreatic limb shouldbe 150 cm for all patients (disagreed by 82.0% of theexperts).but a consensus was achieved after the second round are asfollows.(i) OAGB/MGB is an acceptable surgical option for suitablepatients with large hiatus hernia ( 4.0 cm) (75.25%agreed).(ii) OAGB/MGB is an acceptable surgical option in suitablepatients with Child-Pugh class A cirrhosis of the liverwithout portal hypertension (75.25% agreed).(iii) Surgeons should avoid going too close to the angle ofHis to avoid leaks in this area (77.23% agreed).No Consensus AchievedEven after two rounds of voting, there was no consensus on 7statements. These have been clearly identified in Table 3 andare as follows.(i) One anastomosis/mini gastric bypass (OAGB/MGB)largely works similar to an RYGB in its mechanism ofaction (65.35% disagreed).(ii) OAGB/MGB is an acceptable surgical option for suitable patients with severe gastro-oesophageal reflux disease (GERD) requiring daily medication (69.31%agreed).(iii) OAGB/MGB is the preferred surgical option for suitable patients with severe psychiatric disorders becauseof the ease of reversibility (54.46% agreed).(iv) OAGB/MGB is not recommended for patients withBarrett’s oesophagus (66.34% agreed).(v) Routine crural approximation is unnecessary for patientswith a hiatus hernia (63.37% agreed).(vi) Patients should be advised routine prophylaxis for gallstones with ursodeoxycholic acid for at least 6 months(64.36% disagreed).(vii) Patients developing symptomatic GERD unresponsiveto maximal medical therapy after OAGB/MGB can beoffered surgical correction in the form of a Braun’sanastomosis between afferent and efferent limbs(66.34% disagreed).Change in Position in Second RoundDiscussionFor each of the 17 statements that went for second-roundvoting, the majority (irrespective of whether it was to agreeor disagree) increased indicating the willingness of experts tomove towards a consensus. After the second round, there wasa consensus on 48 statements as opposed to 45 statementswhere a consensus was achieved after the first round. Threestatements where there was no consensus after the first roundOne anastomosis/mini gastric bypass is an attractive primaryas well as revisional bariatric procedure [1]. At the same time,there are multiple areas of controversy and variation. There isinsufficient evidence at the present time to allow us to draw arobust conclusion on these aspects of this procedure. Thoughexpert opinion is graded as the lowest level of scientific evidence, it is often the only available evidence to inform clinical
OBES SURGTable 2One anastomosis/mini gastric bypass experts (in alphabetical order)SerialnumberNameInstitutionCountry1.Richard AbittanRichard Abittan Bariatric Center, CasablancaMorocco2.3.Mohamed M AbouzeidSami Salem AhmedAin Shams UniversityIstishari Hospital, AmmanEgyptJordan4.Recep AktimurIstanbul Aydin UniversityTurkey5.Ali AlhamdaniWhittington HospitalUnited Kingdom6.7.Haider A AlshurafaMustafa AllouchPrince Sultan Military Medical CityNini Hospital, TripoliSaudi ArabiaLebanon8.9.Priscila AntozziArturo Valdés AlvarezCentro de Cirugias Especiales Dres AntozziChristus Muguerza SaltilloArgentinaMexico10.Basil J AmmoriSalford Royal HospitalUnited Kingdom11.12.Jan ApersAlberto ArangoFranciscus Gasthuis, RotterdamKennedy HospitalNetherlandsColombia13.14.Raymond ArnouxSarfaraz BaigPolyclinique de Bordeaux TonduBelle Vue Clinic, KolkataFranceIndia15.16.17.Ramana BalasubramanianMohit BhandariJean BiaginiMedica Gamma Hospital, KolkataMohak Bariatrics and Robotics, IndoreSt. Joseph ile BlanchetMehrdad BohlooliMichael Van den BoscheWilliam BraunMatthieu BruzziClinique de la Sauvegarde, LyonJam Hospital, TehranSpire Southampton HospitalWeight and Metabolic Solutions AustraliaHôpital Européen Georges-PompidouFranceIranUnited KingdomAustraliaFrance23.24.25.Francisco J CamposMiguel A CarbajoWilliam CarrSecretaría de Salud CDMXMexicoCenter of Excellence for the Study and Treatment of Obesity and Diabetes SpainSunderland Royal HospitalUnited Kingdom26.27.28.Suleyman CetinkunarJean-Marc ChevallierMichal ČiernyAdana Numune Training and Research HospitalUniversité Paris 5Břeclav HospitalTurkeyFranceCzech Republic29.30.Jérome DargentMaurizio De LucaPolyclinique Lyon-NordMontebelluna Treviso HospitalFranceItaly31.Shamsi ElhasaniPrincess Royal University Hospital, KentUnited oes EmousJorge EsmeralMarcelo FageMohamad Hayssam ElfawalOlivier FercocqMiguel Flores de la TorreMarc AMRM FocquetVincent FreringFrank GarciaFrancesco GrecoJavit Kuri GuintoYasser HamzaDavid E HargroderMedical Center LeeuwardenCIMA HospitalGrupo Bariatrico OesteMakassed General HospitalClinique du TerEquipo Multidisciplinario BAdios a Las Obesidad KOMC AZ St. Elisabeth Ziekenhuis, ZottegemClinique SauvegardeUcom Grupo Integral, CAIstituto Ospedaliero Fondazione Poliambulanza BresciaHospital Privado Santa LuciaAlexandria Faculty of MedicineMercy Hospital Carthage45.46.47.Jacques HimpensGeorge HopkinsGurvinder S JammuSt. Pierre University Hospital, BrusselsRoyal Brisbane and Women’s HospitalJammu Hospital, Jalandhar, PunjabNetherlandsCosta uelaItalyMexicoEgyptUnited States ofAmericaBelgiumAustraliaIndia
OBES SURGTable 2 Anne JuutiEwoud H JutteHelsinki University Central HospitalMedisch Centrum LeeuwardenFinlandNetherlands50.Mohammad KermansaraviIran University of Medical SciencesIran51.52.Ali KhammasThomas KöstlerRashid HospitalSpital Limmattal, ZürichUnited Arab EmiratesSwitzerland53.54.Lilian KowJon KristinssonAdelaide Bariatric CentreOslo University Hospital, AkerAustraliaNorway55.Kuldeepak Singh KularKular College and Hospitals Pvt. Ltd.India56.Mufazzal LakdawalaDigestive Health Institute, MumbaiIndia57.58.Ming-Hsien LeeWei-Jei LeeChina Medical University Hospital, TaiwanMin-Sheng General HospitalTaiwanTaiwan59.Tomasz LewandowskiCentre of General, Bariatric and Oncological Surgery BPro Medica Ełk, Poland60.61.Ricardo Belda LozanoRoger Charles LucianiHospital TorrecárdenasCentre Hospitalier Mutualiste Les Portes du SudSpainFrance62.63.Kamal MahawarTarek MahdySunderland Royal HospitalMansoura Faculty of MedicineUnited KingdomUnited Arab Emirates64.Angeles Pedregal Hospital, Mexico CityMexico65.66.Diana Gabriela MaldonadoPintadoEmilio MannoRami MickerBariatric and Metabolic Unit Cardarelli Hospital, NaplesClínica del CountryItalyColombia67.68.69.Mohammad Khalid MirzaFernando MontufarMario MusellaSaudi ArabiaGuatemalaItaly70.71.72.73.74.Mahendra NarwariaSalvador Navarrete AulestiaBrigitte ObermayerTaryel OmarovOral B OspanovKing Fahad University HospitalClínica de Cirugia Bariatrica en GuatemalaAdvanced Biomedical Sciences Department Federico II University NaplesAsian Bariatrics Pvt. Ltd., AhmedabadClínica Santa SofíaGöttlicher Heiland Krankenhaus, WienAzerbaijan Medical UniversityAstana Medical n75.76.77.M Mahir OzmenChetan ParmarRaul Vazquez PelcastreLiv Hospital AnkaraWhittington Hospital, LondonHigh Specialty Regional Hospital of Yucatan PeninsulaTurkeyUnited 0.91.Luigi PiazzaArun PrasadGerhard PragerMarco RaffaelliAsnat RazielKarl Peter RheinwaltRui RibeiroNasser SakranVladimir SamoylovKong-Han SerGeorge SkroubisPeter K SmallJose Sergio Verboonen SoteloScott A ShikoraSICOBApollo Hospital. New DelhiMedical University of ViennaUniversità Cattolica del Sacro CuoreAssuta Medical CenterSt. Franziskus Hospital, CologneClinica de Santo António, LisboaEmek Medical Center, AfulaRoad Hospital Station Voronezh-1 JSCMin-Sheng General HospitalUniversity of PatrasSunderland Royal HospitalObesity Goodbye CenterBrigham and Women’s Hospital92.93.Antonio SusaOsama TahaIstituto Clinico San Rocco, BresciaBariatric Center, raelRussiaTaiwanGreeceUnited KingdomMexicoUnited States ofAmericaItalyEgypt
OBES SURGTable 2 .Om TantiaMurat UstunILS Hospital, Salt Lake, KolkataIstanbul Bariatric CenterIndiaTurkey96.Villy VågeHelse BergenNorway97.98.Ramon VilallongaRudolf WeinerCentro Médico TeknonClinic Obesity Surgery, Sana-Klinikum OffenbachSpainGermany99.100.Monica Vera ZallesJosé Ayala ZavaletaCentro Medico FoianiniHospital Regional de Alta Especialidad de OaxacaBoliviaMexico101.Khalil ZayadinAmman Surgical HospitalJordanpractice. A consensus amongst experts using a robust methodology can help drive up clinical standards. At the sametime, it is important to make a distinction between a clinicalguideline which is necessarily a synthesis of available evidence and a consensus statement which is an attempt to getexperts to agree on the correct choice, often in areas with noclear scientific evidence.A recent attempt at understanding objections to OAGB/MGB [13] revealed that approximately 51.0 and 45.0% ofsurgeons who do not perform this procedure cite an increasedrisk of gastric and oesophageal cancer respectively as one ofthe contributory factors. It is especially interesting because nota single case of a gastric pouch or oesophageal cancer has yetbeen reported in published scientific literature after this procedure. Critics would, of course, argue that since it is a newerprocedure and the vast majority have only been performedover the last decade, we need to see longer follow-up studiesto be absolutely certain. At the same time, one has to recognisethat it will probably never be practicable to design an adequatestudy with either of these cancers as an endpoint. The opinionof experts hence matters in such situations and can often settleprotracted debates. In our consensus building exercise, 96.0and 91.0% of the experts felt that OAGB/MGB does not increase the risk of gastric cancers and oesophageal cancers,respectively. This issue has been investigated in some detailin the past [9], and the conclusion was that there is lack ofconvincing data from human studies to label bile as a carcinogen for either gastric or oesophageal cancers but authorsacknowledge that this is a controversial topic.Young age, symptomsofGERD,hiatushernia,andvegetarianfood habitsareoftenused asrelativeorabsolutecontraindicationsby OAGB/MGB surgeons [5]. There was a consensus of 95.0%amongst experts that OAGB/MGB is an acceptable surgical option for suitable young adults in this exercise. Similarly, thoughthere is a definite incidence and prevalence of GERD afterOAGB/MGB, the exact number is currently a matter of debate,and studies specifically conducting a detailed risk versus benefitevaluation of such patient selection strategies in comparison withother procedures such as RYGB are currently lacking.Notwithstanding the relative scarcity of such studies, there wasa consensus amongst experts in this study that OAGB/MGB is anacceptable option for suitable patients with a hiatus hernia, including even those with a large hiatus hernia of 4.0 cm.Similarly, though there was no consensus on patients with severeGERD requiring daily medication, there was 86.0% consensusthat OAGB/MGB was Ban acceptable surgical option for suitablepatients with mild to moderate GERD . There was a further79.0% consensus that OAGB/MGB was an acceptable surgicaloption for vegetarian patients.As expected, 94.0% of the experts felt that construction of thepouch should start in the horizontal portion of the lesser curvatureof the gastric pouch [14]. Remarkably, however, 81.0% of theexperts felt that the routine use of the anti-reflux technique aspopularised by Carbajo et al. [15] was not strictly necessary.Once again, comparative studies evaluating the role of this technique are lacking and must be regarded as an important area forfuture investigation. Similarly, 82.0% of the experts felt that theroutine closure of Petersen’s space was unnecessary probablyreflecting the previously stated position of many experts [16] butwith an increasing number of reports of Petersen’s hernia after einthefuture.RYGB is traditionally classified as a combined restrictiveand malabsorptive procedure. But we now know that malabsorption contributes only approximately 11.0% to total caloriedeficit in the early period after RYGB and possibly even lowerin the long term [18]. Such studies do not exist for OAGB/MGB but it is nevertheless interesting that 82.0% of the experts disagreed with the statement Bone anastomosis/mini gastric bypass (OAGB/MGB) is not a malabsorptive bariatricprocedure . Similarly, 82.0% of the experts disagreed withthe statement, BThe standard length of the bilio-pancreaticlimb should be 150 cm for all patients . Future studies needto address the contribution of malabsorption to total caloriedeficit after OAGB/MGB and efficacy of a standard biliopancreatic limb of 150 cm. Majority of the experts agreed thatit was acceptable to use a bilio-pancreatic limb of up to 200 cmwith this procedure in various clinical settings with Bcarefulmonitoring .
.9.8.6.7.5.4.3.OAGB/MGB is an acceptable surgical option for suitable young adults.OAGB/MGB is an acceptable surgical option for suitable elderly patients( 70.0 years of age).OAGB/MGB is an acceptable surgical option for suitable patients with severegastro-oesophageal reflux disease (GERD) requiring daily medication.OAGB/MGB is the preferred surgical option for suitable patients with severepsychiatric disorders because of the ease of reversibility.OAGB/MGB is an acceptable surgical option for suitable patients with mildto moderate GERD.OAGB/MGB is an acceptable surgical option for suitable patients with largehiatus hernia ( 4.0 cm).OAGB/MGB is an acceptable surgical option for suitable patients with mildto moderate hiatus hernia ( 4.0 cm).OAGB/MGB is not recommended for patients with Barrett’s oesophagus.OAGB/MGB is not recommended for patients with Crohn’s disease.Smokers should be advised to cease smoking prior to OAGB/MGB as thereis a higher risk of marginal ulcer and other complications in smokers.OAGB/MGB is an acceptable surgical option in vegetarian patients.OAGB/MGB is an acceptable surgical option in suitable patients with Child-Pughclass A cirrhosis of the liver without portal hypertension.All OAGB/MGB patients should undergo a routine preoperative uppergastro-intestinal endoscopy.All OAGB/MGB patients should undergo a routine preoperative ultrasoundscan of the abdomen.All OAGB/MGB patients should undergo a preoperative screening, followedby eradication if needed, for Helicobacter pylori.Construction of OAGB/MGB pouch should start in the horizontal portionof the lesser curvature of the stomach to make it as long as possible.Routine use of staple-line reinforcement is unnecessary.Routine use of anti-reflux sutures or technique is unnecessary.Surgeons may choose to use an oro-gastric tube to size the pouch.Surgeons should avoid going too close to the angle of His to avoid leaks in this area.The routine crural approximation is unnecessary for patients with a hiatus hernia.One anastomosis/mini gastric bypass (OAGB/MGB) largely works similar to aRoux-en-Y gastric bypass (RYGB) in its mechanism of action.One anastomosis/mini gastric bypass (OAGB/MGB) is not a malabsorptivebariatric procedure (experts disagreed).OAGB/MGB is an acceptable mainstream surgical option for suitable patientsseeking bariatric or metabolic surgery.Surgeons performing OAGB/MGB do not need to take approval from institutionalreview boards.OAGB/MGB can no longer be regarded as a new or experimental procedure.1.2.StatementsConsensus statement voting resultsSerial no.Table 3Agree 86.14% (n 87)Agree 73.27% (n 74)Agree 95.05% (n 96)Agree 66.34% (n 67)Agree 55.45% (n 56)Agree 94.06% (n 95)Agree 83.17% (n 84)Agree 73.27% (n 74)Agree 75.25% (n 76)Agree 79.21% (n 80)Agree 67.33% (n 68)Agree 60.4% (n 61)Agree 79.21% (n 80)Agree 98.02% (n 99)Agree 89.11% (n 90)Agree 66.34% (n 67)Agree 86.14% (n 87)Agree 50.5% (n 51)Agree 63.37% (n 64)NAAgree 81.19% (n 82)NAAgree 77.23% (n 78)Agree 63.37% (n 64)NANANANAConsensusConsensusConsensusConsensusNo nsusConsensusNo consensusConsensusConsensusAgree 66.34% (n 67)NANANAAgree 75.25% (n 76)ConsensusConsensusNAAgree 75.25% (n 76)ConsensusNo consensusAgree 54.46% (n 55)NANo consensusAgree 69.31% (n NAAgree 85.15% (n 86)Agree 96.04% (n 97)Agree 95.05% (n 96)Agree 70.3% (n 71)NANAConsensusNo consensusDisagree 65.35% (n 66)NAFinaloutcomeSecond-round, experts’agreeing % (n 101)Agree 75.25% (n 76)Agree 100.0% (n 101)Disagree 82.18% (n 83)Disagree 52.48% (n 53)First-round, experts’ agreeing% (n 101)OBES SURG
50.51.4948.46.47.45.43.44.41.42.40.Patients developing symptomatic GERD unresponsive to maximal medicaltherapy after OAGB/MGB can be offered surgical correction in the form of aconversion to RYGB.Patients developing symptomatic GERD unresponsive to maximal medical therapyafter OAGB/MGB can be offered surgical correction in the form of a Braun’sanastomosis between afferent and efferent limbs.Some patients develop protein-calorie malnutrition after OAGB/MGB.Patients developing protein-calorie malnutrition after OAGB/MGB can be offereda reversal of the procedure if appropriate.Routine postoperative use of nasogastric tubes is unnecessary.Routine postoperative contrast study to check for leaks prior to allowing oralintake is unnecessary.Patients should be advised marginal ulcer prophylaxis using a proton pumpinhibitor for at least a duration of 6 months.Patients should be advised a routine multivitamin supplement containing suitableamounts of zinc and copper, daily for the rest of their life.Patients should be advised routine iron supplements for the rest of their life.Patients should be advised routine vitamin D and calcium supplements forthe rest of their life.Patients should be advised routine vitamin B12 supplements for the rest of their life.Patients should be advised routine prophylaxis for gallstones with ursodeoxycholicacid for at least 6 months.Patients should be advised annual screening for anaemia and secondaryhyperparathyroidism for the rest of their life.Patients should be advised annual bariatric follow-up for the rest of their life.Some patients experience GERD after OAGB/MGB.37.38.39.An intraoperative leak test is recommended.Routine placement of surgical drains is unnecessary.35.36.34.33.32.30.31.29.The standard length of the bilio-pancreatic limb should be 150 cm for all patients(experts disagreed).It is not necessary to measure the total small bowel length.It is acceptable to routinely use a standard bilio-pancreatic limb length of up to200 cm with careful monitoring.It is acceptable to use a bilio-pancreatic limb of up to 200 cm for superobesepatients with careful monitoring.It is acceptable to use a bilio-pancreatic limb of up to 200 cm for patients seekingrevisions from previous gastric bands or sleeves, with careful monitoring.Routine closure of Petersen’s space is unnecessary.If an oro-gastric tube is used, it is acceptable to use tubes of sizes rangingfrom 32 to 40 Fr.Routine division of the greater omentum is unnecessary.27.28.StatementsSerial no.Table 3 (continued)NAAgree 90.10% (n 91)Agree 89.11% (n 90)Disagree 55.45% (n 56)Agree 91.09% (n 92)Agree 95.05% (n 96)Agree 89.11% (n 90)ConsensusConsensusNo consensusDisagree 66.34% (n usNo susFinaloutcomeNANANANAAgree 84.16% (n 85)Disagree 64.36% (n 65)Agree 71.29% (n 72)Disagree 55.45% (n 56)Agree 94.06% (n 95)Agree 82.18% (n 83)NANAAgree 88.12% (n 89)Agree 85.15% (n 86.0%)Agree 72.28% (n 73)Agree 85.15% (n 86)Agree 88.12% (n 89)Agree 71.29% (72.0%)Agree 92.08% (n 93)Agree 75.00% (n 75)NAAgree 78.22% (n 79)Agree 82.18% (n 83)Agree 93.07% (n 94)Agree 72.28% (n 73)NANAAgree 79.21% (n 80)NANANANASecond-round, experts’agreeing % (n 101)Agree 75.25% (n 76)Agree 76.24% (n 77)Agree 70.3% (n 71)Agree 78.22% (n 79)Disagree 82.18% (n 83)Agree 81.19% (n 82)Agree 95.05% (n 96)First-round, experts’ agreeing% (n 101)OBES SURG
12. Alberto Arango Kennedy Hospital Colombia 13. Raymond Arnoux Polyclinique de Bordeaux Tondu France 14. Sarfaraz Baig Belle Vue Clinic, Kolkata India 15. Ramana Balasubramanian Medica Gamma Hospital, Kolkata India 16. Mohit Bhandari Mohak Bariatrics and Robotics, Indore India 17. Jean Biagini St. Joseph Hospital Lebanon 18.
