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
Received July 24, 2013; revised August 22, 2013; accepted August 30, 2013
Copyright © 2013 Giovanni Berbiglia et al. This is an open access article distributed under the Creative Commons Attribution Li-
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.
C
opyright © 2013 SciRes. SS

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)
gh
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-
ha
f parathormones over
tim
of 5 super obese patients suffering from type 2
di
he results about other comor-
bi
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
e.
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
F
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
de
rated on before October 2008
th
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
to
de-
nu
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
pu
er from night
py
LM is a 20% - 30% reduc-
tio
c juices
pr
ervation acts favorably on the production
of
e through
en
4.2. Mechanism of Actions of Hormones
in has not
alysis of the results has underlined
th
ns
istics of LM are:
nality, though re-
du
yloric region remains uniform over
tim
e of a
go
REFERENCES
[1] A. A. Gumbin and A. Pomp,
-x
ro-muscular pyloric ring with a craft technique, could
be easily criticized, but it is very effective both as a digi-
toclastic and endoscopic pneumatic-dilator maneuver as
confirmed by the daily clinical experience.
Gastric tube peristalsis can thus regularl
shing food bolus into the duodenum and limiting oe-
sophageal reflux which would force the subject to as-
sume omeprazole for long periods of time.
Patients who underwent LM do not suff
rosis and only few cases start intermittent cycles of
therapy with omeprazole.
Another important effect of
n in the gastric exocrine secretion influenced by selec-
tive vagotomy secondary to gastric tubulization.
This reduction makes the production of gastri
oportional to the quantity of food ingested (restrictive
aspect of the LM) creating a balanced mixing at the level
of the “Mill”.
Gastric cons
“Sle
the intrinsic factor and thus on vitamin B12.
It should be noted that it is possible to explor
doscopic route also the part of the stomach excluded
from food transit.
As reported by Drazen et al. [8], although ghrel
been dosed in the considered patients, it is reasonable to
assume that it has an important role in the modulation of
appetite. After surgery, in fact, the fundus of the stomach
is excluded by the food tract and, consequently, the cells
responsible for the secretion of ghrelin are not involved
in the stimulation by the food ingested; this aspect inevi-
tably results in a reduced endocrine secretion of ghrelin
which determines an inhibition of the hormonal cascade
that promotes the sense of hunger. Afterwards, food bo-
lus, thanks to the pyloric divulsion, reaches more rapidly
the duodenum and the jejunum, site of GIP (Gastric In-
hibitory Polypeptide) and PYY (Peptide YY) synthesis.
Reinehr et al. [9] and Valderas et al. [10] showed that a
more rapid intestinal transit of the partially digested food
bolus through these intestinal tracts triggers an increase
in the secretion of GIP and PYY resulting in an early
sense of satiety due to hypothalamic stimulation. More-
over, GIP and PYY together with the quick transit of
partially digested food, stimulate iliac L cells to secrete
GLP-1 (Glucagon-Like Peptide-1), which exerts its sec-
retory effect improving insulin sensitivity and promoting
the sense of satiety.
Furthermore, the an
at, concurrently to weight loss, patients improve their
dyslipidemic pathology by remarkably reducing cardio
vascular risks.
5. Conclusio
Important character
1) Gastric conservation with functio
ced, helps maintain a good metabolic-nutritional bal-
ance over time.
2) Tubular prep
e without any possibility of dilation as it can, some-
times, happen in the SG: we believe this to be an essen-
tial characteristic to avoid weight gain over time.
Finally, we should underline the high percentag
od quality of life in terms of food “compliance”: eating
solid and varied foods.
s, M. Gagner, G. Dak
eve Gastrectomy for Morbid Obesity,” Obesity Sur-
gery, Vol. 17, No. 7, 2007, pp. 962-969.
http://dx.doi.org/10.1007/s11695-007-9151
y,
11.07.017
[2] M. Deitel, M. Gagner, A. L. Erickson and R. D. Crosb
“Third International Summit: Current Status of Sleeve
Gastrectomy,” Surgery for Obesity and Related Diseases,
Vol. 7, No. 6, 2011, pp. 749-759.
http://dx.doi.org/10.1016/j.soard.20
Carena, A.
182-3
[3] C. Vassallo, G. Berbiglia, A. Pessina, M.
Firullo, A. Griziotti, F. Ramajoli, E. Palamarciuc and M.
Fariseo, “The Super-Magenstrasse and Mill Operation
with Pyloroplasty: Preliminary Results,” Obesity Surgery,
Vol. 17, No. 8, 2007, pp. 1080-1083.
http://dx.doi.org/10.1007/s11695-007-9
ng Magen-[4] C. Vassallo, G. Berbiglia, M. Carena, “The Lo
strasse with Pyloroplasty as Functional Gastric Bypass:
6-Years Experience, 308 Operations,” Health, Vol. 2, No.
8, 2010, pp. 935-940.
http://dx.doi.org/10.4236/health.2010.28138
[5] M. Allgöwer, F. Harder, L. F. Hollender, H. J. Peiper and
h, M. P. Hendy and G.
-0311-z
J. R. Siewert, “Trattato di Gastroenterologia Chirurgica,”
Delfino Antonio, Frosinone, 1984.
[6] K. Tymitz, A. Engel, S. McDonoug
Kerlakian, “Changes in Ghrelin Levels Following Bariat-
ric Surgery: Review of the Literature,” Obesity Surgery,
Vol. 21, No. 1, 2011, pp. 125-130.
http://dx.doi.org/10.1007/s11695-010
nmühler, et [7] A. Bohdjalian, F. B. Langer, S. Shakeri-Leide
al., “Sleeve Gastrectomy as Sole and Definitive Bariatric
Procedure: 5-Year Results for Weight Loss and Ghrelin,”
Obesity Surgery, Vol. 20, No. 5, 2010, pp. 535-540.
http://dx.doi.org/10.1007/s11695-009-0066-6
[8] D. L. Drazen, T. P. Vahl, D. A. D’Alessio, “Effects of a
Fixed Meal Pattern on Ghrelin Secretion: Evidence for a
Learned Response Independent of Nutrient Status,” En-
docrinology, Vol. 147, No. 1, 2006, pp. 23-30.
http://dx.doi.org/10.1210/en.2005-0973
[9] T. Reinehr, C. L. Roth, G. H. Schernthaner, H. P. Kopp, S.
and after Surgically Induced Weight Loss,” Obesity Sur-
Kriwanek and G. Schernthaner, “Peptide YY and Gluca-
gon-Like Peptide-1 in Morbidly Obese Patients before

G. BERBIGLIA ET AL. 473
gery, Vol. 17, No. 12, 2007, pp. 1571-1577.
http://dx.doi.org/10.1007/s11695-007-9323-8
[10] J. P. Valderas, V. Irribarra, C. Boza, R. de l
Liberona, A. M. Acosta, M. Yolito and A. M
a Cruz, Y
aiz, “Medi-
.
cal and Surgical Treatments for Obesity Have Opposite
Effects on Peptide YY and Appetite: A Prospective Study
Controlled for Weight Loss,” The Journal of Clinical
Endocrinology and Metabolism, Vol. 95, No. 3, 2010, pp.
1069-1075. http://dx.doi.org/10.1210/jc.2009-0983