One Anastomosis Gastric Bypass and Mini Gastric Bypass

Anatomy and Physiology

Anatomy of the Stomach

Located in the upper abdomen, below the diaphragm, and to the left of the midline, the stomach is positioned between the esophagus and the duodenum of the small intestine and comprises 5 regions:

• The cardia is the entry point for food from the esophagus into the stomach, lying just distal to the gastroesophageal junction.
• The fundus is a dome-shaped region above and to the left of the cardia.
• The body is the largest portion of the stomach that connects to the fundus; the body of the stomach lies below the fundus and abuts the left diaphragm.
• The antrum is the lower part of the stomach connecting to the stomach body which holds partially digested food until it is ready to move into the small intestine.
• The pylorus is the funnel-shaped region connecting the stomach to the duodenum. The pyloric antrum connects to the stomach's body, leading to the narrower pyloric canal, which further connects to the duodenum. The smooth muscle pyloric sphincter regulates stomach emptying.

The stomach's lesser curvature lies beneath the medial segments of the liver and includes the incisura angularis, or angular incisure, which is identified as the junction of the vertical and horizontal axes of the lesser curvature; this marks the transition of the body to antrum. The greater curvature is the long left lateral border of the stomach from the fundus to the pylorus, which is connected to the greater omentum. The left border of the intraabdominal esophagus and the fundus meet at an acute angle termed the "angle of His." Posterior to the stomach lies the lesser sac, which is a potential space anterior to the pancreas and bordered by the splenic artery, spleen, left kidney, and transverse mesocolon.

The stomach wall has 5 layers:

• The mucosa is the innermost layer where nearly all stomach cancers originate, comprised of 3 parts.
  • An epithelial layer that contains glands and multiple cell types, including: 
    • Surface mucous cells: These cells secrete mucus to protect the gastric epithelium from acidic and enzymatic damage
    • Mucous neck cells: These cells produce mucus that lubricates and protects the gastric lining
    • Parietal cells: These cells secrete hydrochloric acid (HCl) and intrinsic factor, essential for the absorption of vitamin B12
    • Chief cells: These cells produce pepsinogen, the inactive form of the enzyme pepsin, which aids in protein digestion
    • Enteroendocrine cells: These cells release hormones such as gastrin, somatostatin, and histamine, which regulate gastric acid secretion and other digestive functions.
  • The lamina propria is a layer of connective tissue.
  • The muscularis mucosa is a thin layer of muscle.
• The submucosa is a supporting layer beneath the mucosa.
• The muscularis propria is a thick muscle layer that moves and mixes the stomach contents through peristalsis.
• The subserosa is a layer of connective tissue containing blood vessels, lymphatics, and nerves. 
• The serosa is the outermost wrapping layer of the stomach.

In its relaxed state, the stomach's mucosa and submucosa form folds known as rugae. 

Vascular Supply

The arterial blood supply to the stomach includes:

• Celiac trunk: This originates from the abdominal aorta with 3 major branches: the left gastric, common hepatic, and splenic arteries.
• Common hepatic artery: gives off the gastroduodenal artery, which runs behind the first portion of the duodenum.
• Left gastric artery: This artery arises from the celiac trunk to run along the superior portion of the stomach's lesser curvature and anastomose with the right gastric artery
• Right gastric artery: This artery originates from the proper hepatic artery to run along the inferior portion of the stomach's lesser curvature and anastomose with the left gastric artery.
• Left gastroepiploic artery: This artery arises from the splenic artery to run along the superior portion of the stomach's greater curvature, and anastomose with the right gastroepiploic artery. This is the principal blood supply to the stomach after sleeve gastrectomy. The left gastroepiploic artery gives off many posterior branches, which should remain uninterrupted during the dissection of the stomach's posterior surface.
• Right gastroepiploic artery: This artery arises from the gastroduodenal artery to travel along the inferior portion of the stomach's greater curvature and anastomose with the left gastroepiploic artery.
• Short gastric arteries: These are usually comprised of 3 to 5 arteries originating from the splenic and left gastroepiploic arteries to supply the stomach's greater curvature. These arteries are contained in the gastrosplenic ligament and go to the gastric fundus.

Venous Drainage

• The veins of the stomach share names with the arteries.
• The right and left gastric veins drain directly into the hepatic portal vein, whereas the short gastric veins and the gastroepiploic veins drain into the superior mesenteric vein.

Ligamentous Attachments

The following ligaments are attached to the stomach to anchor it in place:

• Gastrocolic ligament: This portion of the greater omentum connects the stomach's greater curvature to the transverse colon, forms part of the anterior wall of the lesser sac, and contains the gastroepiploic vessels.
• Gastrosplenic ligament: This portion of the greater omentum connects the stomach's greater curvature to the splenic hilum and contains the left gastroepiploic and short gastric arteries.
• Gastrohepatic ligament: This peritoneal attachment connects the medial liver to the stomach's lesser curvature, forms part of the anterior wall of the lesser sac, and contains the right and left gastric arteries. A replaced left hepatic artery may also be included here.
• Gastrophrenic ligament: This peritoneal attachment connects the left hemidiaphragm to the superior portion of the stomach.

Innervation

The stomach receives innervation from both the sympathetic and parasympathetic nervous systems and local enteric neurons:

• Parasympathetic innervation: The main parasympathetic input to the stomach comes from the vagus nerve (cranial nerve X). Vagal fibers innervate the stomach's smooth muscle layers and glands, stimulating secretion and motility. Parasympathetic stimulation increases gastric activity, including the secretion of gastric juices and peristaltic contractions.
• Sympathetic innervation: Sympathetic fibers reach the stomach via the greater splanchnic nerve and its branches, originating from the T6-T9 spinal cord segments. Sympathetic stimulation inhibits gastric activity, including secretion and motility, and causes vasoconstriction in the gastric vasculature.
• Enteric nervous system: This intrinsic nervous system of the stomach controls local reflexes and regulates functions such as peristalsis, secretion, and blood flow within the stomach independently of the central nervous system. The enteric nervous system consists of a complex network of neurons located within the walls of the gastrointestinal tract.
• Sensory innervation: Sensory fibers, including those from the vagus nerve, convey information about distension, chemical composition, and other stimuli within the stomach to the central nervous system. These sensory inputs are crucial in regulating appetite, triggering reflexes, and coordinating digestive processes.

Physiology of OAGB/MGB

The OAGB/MGB procedure induces weight loss and metabolic changes through several physiological mechanisms:

• Restriction: The small gastric pouch limits the volume of food intake. This restriction helps patients feel full with less food, reducing overall caloric consumption.
• Malabsorption: By bypassing a substantial portion of the small intestine, the procedure reduces the length of the intestinal tract available for nutrient absorption. This malabsorptive component decreases the absorption of calories, fats, and other nutrients, contributing to weight loss.
• Hormonal changes: The altered gastrointestinal anatomy affects the secretion of gut hormones, particularly those involved in hunger and satiety. Key hormones affected by bariatric surgery include ghrelin, glucagon-like peptide-1 (GLP-1), peptide YY (PYY), and insulin. Levels of ghrelin (a hunger-stimulating hormone) typically decrease after the procedure, leading to reduced appetite. There is an increase in hormones like PYY and GLP-1, which enhance satiety, improve insulin sensitivity, and reduce blood glucose levels, aiding in the resolution of type 2 diabetes mellitus in many patients. Rapid improvements in insulin sensitivity and beta-cell function occur independent of weight loss. 
• Dumping syndrome: The rapid emptying of food into the small intestine can lead to "dumping syndrome," characterized by symptoms such as nausea, abdominal cramping, and diarrhea after consuming high-sugar or high-fat foods. This side effect further discourages the intake of calorie-dense foods, contributing to weight loss.
• Bile reflux: This is a potential complication unique to OAGB/MGB. Bile from the small intestine can enter the gastric pouch and esophagus, causing irritation and discomfort. However, variations in the surgical technique, such as those introduced by Dr Miguel Carbajo, aim to minimize this risk by adjusting the anastomosis configuration.

Indications

Bariatric surgery is advised for individuals with Class I, Class II, and Class III obesity when conventional methods such as lifestyle changes and pharmacotherapy have failed to achieve adequate weight loss and metabolic improvements. A thorough evaluation by a multidisciplinary team—including physicians, dietitians, psychologists, and surgeons—is essential to assess individual risks and benefits, ensuring comprehensive preoperative and postoperative care. Additionally, bariatric surgery is increasingly used as a bridging procedure to prepare patients for other surgeries, including transplant, cardiac, orthopedic, and hernia surgeries. The 2022 guidelines from the American Society for Metabolic and Bariatric Surgery and the International Federation for the Surgery of Obesity and Metabolic Disorders provide updated criteria for considering metabolic and bariatric surgery.[5][10] These guidelines include:

Obesity

• Bariatric surgery is recommended for individuals with a BMI >35 kg/m², regardless of the presence, absence, or severity of comorbidities, and for patients with type 2 diabetes (T2DM) and BMI >30 kg/m².
• Bariatric surgery should be considered in individuals with a BMI of 30 to 34.9 kg/m² who have not achieved significant weight loss or comorbidity improvement with nonsurgical interventions such as diet, exercise, behavioral therapy, or pharmacotherapy. 
• Note that patients of Asian descent qualify for surgery at lower BMI thresholds.

Obesity-Related Comorbidities

• Type 2 diabetes: Bariatric surgery has been shown to result in significant improvements or remission of T2DM in obese individuals, making it a viable option for patients with uncontrolled diabetes.[11][12]
• Hypertension: Bariatric surgery can lead to substantial reductions in blood pressure, making it an effective treatment option for obese individuals with hypertension.[12][13]
• Dyslipidemia: Bariatric surgery has been associated with improved lipid profiles, including reductions in total cholesterol, low-density lipoprotein cholesterol, and triglyceride levels.[12][14]
• Obstructive sleep apnea: Bariatric surgery may improve or resolve symptoms of obstructive sleep apnea, including snoring, daytime sleepiness, and apnea-hypopnea index scores.[12]
• Gastroesophageal reflux disease: Bariatric surgery may alleviate symptoms of gastroesophageal reflux disease by reducing gastric acid production and promoting weight loss.[12][14]
• Cardiovascular disease: This includes, but is not limited to, coronary artery disease, heart failure, and atrial fibrillation.
• Steatotic liver disease: This includes metabolic dysfunction-associated steatotic liver disease (MASLD; formerly nonalcoholic liver disease or NAFLD) and metabolic dysfunction-associated steatohepatitis (MASH; formerly nonalcoholic steatohepatitis or NASH).
• Asthma
• Chronic kidney disease
• Polycystic ovarian syndrome 
• Infertility
• Bone and joint diseases

Other Considerations

Medical clearance: Before undergoing bariatric surgery, patients should undergo a thorough medical evaluation and obtain clearance from their healthcare provider to ensure they are suitable candidates for anesthesia and surgery.

Psychological evaluation: Patients should undergo a psychological evaluation to assess their readiness for surgery, ability to adhere to long-term postoperative dietary and lifestyle changes, and potential risk of postoperative psychological complications.[15]

Contraindications

While highly effective for weight loss and metabolic improvements, the OAGB/MGB procedure is associated with various potential complications that must be carefully considered in the preoperative and postoperative phases. They include:

Absolute contraindications

• Unacceptable surgical risk (eg, left ventricular ejection fraction <10%) 
• Decompensated liver cirrhosis 
• Uncontrolled or unmonitored psychopathological conditions
• Uncontrolled or unmonitored eating disorder 
• Active drug dependency [16][17]

Relative contraindications

• Wound healing disorders
• Active smoking
• Significant and chronic steroid use
• Significant and chronic nonsteroidal anti-inflammatory use

Specific contraindications for OAGB/MGB

• Primary short gut (total small intestine length <350 cm) or secondary short gut syndrome (following resection)
• Crohn disease

Equipment

Equipment for an OAGB/MGB varies by surgeon preference but generally includes:

• Laparoscopic tower equipped with a high-definition camera, light source, and insufflation system
• Nathanson liver retractor
• Trocars (typically 5-mm and 12-mm trocars are used)
• Laparoscopic staplers
• Energy devices
• Suturing instruments
• Nasogastric tube and bougie
• Hemoclips or stapling reinforcement materials
• Suction and irrigation
• Bariatric surgical instruments. Longer laparoscopic instruments are required to accommodate the larger abdominal cavity in obese patients. These include laparoscopic scissors, graspers, retractors, and dissectors.

Personnel

An OAGB/MGB operation requires the following personnel:

Surgical Team

• Surgeon, either standing on the right or between the patient's legs
• Camera assistant, standing to the right or left of the patient
• Surgical technician or operating room nurse, standing to the left of the patient

Anesthesia Team

• Anesthesiologist
• Anesthesia assistant

Operating Room Staff

• Circulating or operating room nurse

Preparation

Preparation for OAGB/MGB is crucial to ensure optimal surgical outcomes and patient safety. Preoperative preparation includes dietary restrictions, medication management, and a comprehensive preoperative evaluation.

Dietary Restrictions

Patients are typically required to adhere to nil per os status before the procedure, as per enhanced recovery after surgery protocols, to reduce the risk of aspiration and facilitate a smoother recovery. Some institutions recommend a clear liquid diet 7 to 10 days before surgery. This dietary regimen aims to shrink the liver, which is particularly important in obese individuals to improve visualization and access to the stomach during the procedure.

Medication Management

A multidisciplinary team, including surgeons, anesthesiologists, and the patient’s primary care clinician, must carefully coordinate the management of blood thinners and other maintenance medications. Blood thinners may need to be temporarily discontinued or adjusted to minimize the risk of bleeding during surgery. At the same time, other medications may be continued or modified based on individual patient needs.

Preoperative Evaluation

A thorough preoperative evaluation is essential. This may include an upper gastrointestinal series or esophagogastroduodenoscopy to assess the anatomy of the esophagus, stomach, and duodenum, ensuring that there are no underlying conditions that could complicate the surgery. Identifying and treating Helicobacter pylori infection before the operation is critical, as untreated infection can increase the risk of marginal ulcers postoperatively. Clearing the infection reduces this risk and contributes to better long-term outcomes.

Technique or Treatment

The OAGB/MGB is a bariatric procedure that has evolved since its first performance in 1997 by Dr Robert Rutledge in the United States. The procedure involves creating a gastric pouch by horizontally dividing the stomach below the most distal branches of the anterior and posterior vagal trunks, followed by a vertical division that avoids the angle of His. This gastric pouch is then anastomosed to a loop of jejunum approximately 200 cm distal to the ligament of Treitz. The specific design of the gastric pouch in OAGB/MGB aims to ensure an unobstructed pathway for food from the upper inlet to the outlet. This anatomical modification rapidly empties gastric contents into the midjejunum, leading to postgastrectomy syndrome physiology. Patients may experience discomfort with the intake of sweet and liquid calories and develop an intolerance to fatty foods, leading to a natural avoidance of high-calorie and high-fat foods in favor of smaller, lower-fat, and lower-sugar meals.

The OAGB/MGB procedure is based on 2 primary principles: creating a moderately sized gastric pouch (restrictive component) and constructing a loop gastrojejunostomy that bypasses the proximal small bowel (malabsorptive component). Notably, terms such as OAGB, MGB, single anastomosis gastric bypass, and omega loop gastric bypass are often used interchangeably in clinical practice. However, these procedures are not the same, with slight variations in technique depending on the surgeon and institution. For example, Rutledge's original technique involves an end-to-side gastrojejunostomy, while a popular method developed by Carbajo employs a side-to-side gastrojejunostomy. Today, OAGB/MGB generally refers to a long, narrow gastric tube extending at or below the crow's foot of the lesser curve, a common feature across these variations. The following describes the classical OAGB/MGB technique as developed by Rutledge.[9]

Operative Technique

Anesthesia and patient positioning: The patient is anesthetized using general anesthesia with endotracheal intubation. The patient is typically positioned supine on the operating table, and a Foley catheter is inserted preoperatively. To prevent deep vein thrombosis, thromboembolism-deterrent stockings and sequential compression devices are applied. The surgeon stands on the patient's right side, with the camera operator on the right and the assistant on the left. The patient's head is elevated with a 45-degree tilt toward the right.

Port positioning: The procedure begins with the placement of five laparoscopic ports:

• One 12-mm port is placed subxiphoid, approximately 2 cm below the xiphoid process.
• Two 12-mm ports are positioned 2 cm below the right and left subcostal margins at the midclavicular line.
• One 12-mm port is located 18 cm below the xiphoid process.
• A 5-mm port is inserted at the left anterior axillary line below the costal margin.

Creation of lesser omental window and antral division: Upon entering the abdomen, a diagnostic laparoscopy is performed to evaluate the small bowel, liver, and other abdominal structures for abnormalities. The liver is retracted, often using a Nathanson retractor, to allow adequate visualization. Dissection begins approximately 3 to 4 cm proximal to the pylorus at the "crow's foot," where a 2 to 4 cm window is created, entering the lesser sac. Care is taken to maintain hemostasis and preserve the neurovascular branches from the left gastric artery and vein while dividing the antrum at a right angle to its longitudinal axis with a linear stapler. The initial vertical firing should not transect more than 60% of the antrum's width.

Creation of the gastric pouch: The linear stapler is then fired vertically towards the angle of His, perpendicular to the axis of the initial antral division, and parallel to the lesser curvature until reaching the tip of the pouch. A 36 Fr bougie is often used to guide this process. The resulting pouch is typically 15 to 18 cm long with a 50 to 150 mL capacity. Care is taken to preserve the angle of His, ensuring that a minimum cuff of approximately 1 cm is left from the angle. The staple line of the gastric pouch and the excluded stomach can be reinforced with a 3-0 polydioxanone continuous suture, with careful attention to maintaining hemostasis.

Gastrotomy: A gastrotomy is made on the anterior side of the gastric pouch, parallel to the horizontal staple line, and midway between the inferior angles of the pouch.

Bowel measurement and enterotomy: The duodenojejunal flexure is identified at the Ligament of Treitz, and 150 to 200 cm of the small bowel is measured from this point. An enterotomy is created at the antimesenteric border of the selected jejunal loop.

Gastrojejunostomy: An isoperistaltic, antecolic, end-to-side gastrojejunostomy is performed using a 45 mm blue cartridge stapler under no tension. During this step, any intraluminal or staple line bleeding is identified and controlled.

Closure: The gastrojejunostomy is closed using absorbable sutures in a hand-sewn, extramucosal fashion. The anastomosis is returned to its natural position, ensuring adequate hemostasis.

Leak test and drain placement: Before skin closure, a leak test is performed to assess the integrity of the anastomosis. The patient is placed in the Trendelenburg position, and the gastric pouch and anastomosis are submerged in normal saline. At the same time, an endoscope is passed through the gastrojejunostomy and insufflated with air. The absence of bubbles in the saline confirms an intact anastomosis. Alternatively, methylene blue dye can be used for this test, though it is less commonly employed. A drain may be placed between the gastric pouch and the bypassed stomach, though this practice is increasingly uncommon. All ports are removed and closed under direct vision.

Postoperative care: Postoperative care protocols have shifted towards early recovery and minimization of complications. Patients can often begin clear fluids as early as postoperative day 1, reflecting modern recovery practices. The use of a postoperative upper gastrointestinal study before initiating an oral diet varies by institution and surgeon preference. Some surgeons still routinely perform this study to confirm anastomotic integrity, while others rely on clinical assessments, especially if the patient remains asymptomatic. Using a methylene blue challenge 48 hours post-surgery has also become less common

Complications

OAGB/MGB, while generally considered a safe and effective bariatric procedure, is associated with various complications that can occur in the early and late postoperative periods. Early complications of OAGB/MGB include anastomotic leaks, hemorrhage from anastomoses or staple lines, bowel obstruction, and deep vein thrombosis/pulmonary embolism. Anastomotic leaks, though rare, can be life-threatening and often manifest 24 to 72 hours after surgery. Hemorrhage from anastomoses or staple lines may require transfusion, while bowel obstruction can result from various causes, including technical errors or early postoperative bowel obstructions.

In the late postoperative period, complications such as internal herniation, marginal ulcers, stricture at the gastrojejunal anastomosis, gastro-gastric fistulas, micronutrient deficiency, gallstone formation, and dumping syndrome may occur. Internal herniation, particularly through a potential mesenteric space between the small bowel and transverse colon, can lead to bowel strangulation and necessitates laparoscopic intervention for the reduction and closure of defects. Strictures at the gastrojejunal anastomosis can impede the passage of food and require endoscopic dilation or surgical revision.[18]

Additionally, patients with OAGB/MGB are at risk of developing micronutrient deficiencies due to malabsorption, necessitating lifelong vitamin/mineral supplementation. Gallstone formation is common due to rapid weight loss, and careful management, including laparoscopic cholecystectomy with on-table cholangiography, may be required. Dumping syndrome is a complication characterized by a range of postprandial symptoms that occur due to the rapid passage of food into the small intestine. Patients may experience nausea, vomiting, abdominal cramping, diarrhea, dizziness, and lightheadedness shortly after eating, particularly after consuming foods high in sugars or fats. This may require dietary modifications and behavioral interventions.[19]

Clinical Significance

OAGB/MGB has gained recognition as a highly effective surgical option for managing obesity and its related comorbidities. Clinical study results have consistently reported substantial weight loss following the procedure, with patients typically achieving an excess body weight loss (EBWL) ranging from 60% to 80% within 12 to 24 months postoperatively. Results from a study by Rutledge and Walsh (2005) reported an average EBWL of 74% at 12 months, which was sustained over 5 years, demonstrating the long-term effectiveness of OAGB/MGB in maintaining weight loss.[20]

Metabolic improvements following OAGB/MGB are also significant. A meta-analysis from 2014 found that OAGB/MGB resulted in T2DM remission rates of approximately 80%, with notable reductions in hemoglobin A1c levels and a decrease in the need for diabetic medications.[21] Hypertension remission was observed in 65% of patients, and dyslipidemia improved in over 70%, highlighting the procedure's effectiveness in addressing multiple obesity-related comorbidities.[9][21][22]

Moreover, OAGB/MGB's impact on hormonal regulation, particularly concerning appetite control, is noteworthy. While the precise mechanisms are still being elucidated, OAGB/MGB has been associated with alterations in gut hormones such as ghrelin, cholecystokinin, GLP-1, PYY, and amylin.[23][24][25] These hormonal changes contribute to reduced appetite, increased satiety, and improved glucose metabolism, ultimately supporting long-term weight loss and metabolic health.

Compared to RYGB, OAGB/MGB offers similar, if not superior, outcomes regarding weight loss and metabolic improvements. Results from a 2014 comparative study demonstrated that patients undergoing OAGB/MGB achieved a slightly higher EBWL (72% vs 68%) at 24 months compared to those undergoing RYGB.[26] Furthermore, the same study's results reported a T2DM remission rate of 84% in the OAGB/MGB group versus 78% in the RYGB group.

OAGB/MGB also has a relatively lower complication rate and shorter operative time than RYGB. OAGB/MGB is reported to have a shorter operative time (mean of 85 minutes vs 120 minutes for RYGB) and a lower incidence of postoperative complications such as anastomotic leaks (0.5% vs 1.2% in RYGB).[27] Additionally, the simplicity of the OAGB/MGB procedure, with only 1 anastomosis, contributes to its safety profile and lower risk of complications such as internal hernias. These findings underscore the clinical significance of OAGB/MGB as a safe and effective bariatric procedure that offers robust weight loss, significant metabolic improvements, and a favorable complication profile compared to other bariatric surgeries.

Enhancing Healthcare Team Outcomes

Caring for patients undergoing OAGB/MGB requires a coordinated effort from an interprofessional healthcare team comprising physicians, advanced practitioners, nurses, pharmacists, and other health professionals. Each team member is crucial in ensuring patient-centered care, optimizing outcomes, promoting patient safety, and enhancing team performance related to this complex surgical procedure.[28] Physicians and surgeons are responsible for assessing patient eligibility for OAGB/MGB, determining surgical approaches, and overseeing perioperative care. Nurses provide comprehensive preoperative education, support patients through the surgical process, and manage postoperative recovery. Pharmacists contribute by reviewing medication regimens, ensuring appropriate prophylaxis against postoperative complications, and monitoring for drug interactions. Other health professionals, such as nutritionists and psychologists, offer specialized interventions to address dietary and mental health concerns before and after surgery.[29]

Nutritionists work closely with patients throughout the process to develop personalized nutrition plans tailored to their unique needs and dietary requirements. Preoperative nutritional counseling aims to optimize patients' nutritional status, promote weight loss, and mitigate potential risks associated with surgery. Postoperatively, nutritionists continue to support patients in adapting to dietary changes, ensuring adequate nutrient intake, and fostering long-term adherence to dietary recommendations to achieve optimal health outcomes.[28][30] Psychologists also play a crucial role in the multidisciplinary care team, addressing the psychological and behavioral aspects of obesity and bariatric surgery. They provide comprehensive psychosocial assessments, evaluating patients' mental health status, coping strategies, and readiness for surgery. Psychologists offer preoperative counseling and support to help patients navigate the emotional and psychological challenges associated with weight loss surgery, including body image concerns, lifestyle changes, and relationship dynamics. Additionally, they assist patients in developing effective coping mechanisms, managing stressors, and addressing any underlying psychological factors that may impact surgical outcomes and long-term success.[31]

Interprofessional communication facilitates seamless care transitions and ensures that all team members are informed and aligned with the patient's treatment plan. Regular team meetings allow for collaborative decision-making, review of patient progress, and adjustment of care plans as needed. Strategies are developed collectively to address any challenges or complications during the perioperative period, promoting proactive management and patient safety. In this collaborative approach, all interprofessional healthcare team members work synergistically to ensure holistic patient care and support throughout the OAGB/MGB surgical process. By leveraging their unique expertise and perspectives, nutritionists and psychologists contribute to the comprehensive management of patients, addressing both the physical and psychological aspects of obesity and bariatric surgery. Through effective communication, coordination, and teamwork, the multidisciplinary team strives to optimize patient outcomes, enhance patient satisfaction, and improve the overall quality of care in managing obesity and related conditions.