A longer biliopancreatic limb in Roux-en-YGB improves weight loss in the first years after surgery: results of a randomized controlled trial

Abdelrahman Nimeri, Chairman of the IFSO Communication Committee, presents the Journal Club with Frits Berends, Bariatric and Metabolic surgeon at Erasmus MC (The Netherlands).

Dr. Berends talks about the Elegance Trial, a RCT intended to answer the question: does longer biliopancreatic (BP) limb improve weight loss in Roux-en-Y Gastric Bypass (RYGB) surgery? The trial started in 2011 following the hindgut theory, according to which a series of mechanisms (anorectic, incretin effect, ileal brake) are triggered when food and bile acids land more distally in the gut.

RYGB design is the same as in 1977. Dr. Berend wonders whether there might be something we can change in the technique to improve the results. BP length has been studied but nowadays there is not much scientific evidence on its more appropriate length. According to this background Dr. Berends and his team decided to randomize patients into two groups comparing short BP limb (75 cm, 74 patients) versus long BP limb (150 cm, 67 patients). The excess weight loss (EWL) difference in 2 years’ time was then registered. Patients were blinded to the treatment.

Results were favorable to long BP initially: 48 months after surgery 72% EWL was found in long BP limb and 64% in short BP limb.

The significance in total body weight loss disappeared 4 years after surgery. Glycemic control was excellent in both groups.

The authors concluded that BP limb of 150 cm has a significantly better weight loss, with no other differences regarding the associated comorbidities. Berends suggests considering a long limb for RYGB, and even points to a major lengthening up to 200 cm in the future, although further research is needed.

After the speech Dr. Nimeri and Dr. Berends discuss the main points and communicate with the audience through the following quick poll questions:

- Do you prefer SG or RYGB?

- When would you perform a RYGB?

- If you perform RYGB how long do you usually make your BP-limb?

- Do you feel that a a longer BP-limb improves weight loss and maybe other outcomes as well?