Intro to Mini-Gastric Bypass (Dr Rutledge) Why? + MGB v Sleeve
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- The document outlines the schedule and topics for a full day of lectures on mini-gastric bypass (MGB) surgery given by Dr. Rutledge. The schedule includes comparisons of MGB to other procedures, the future of bariatric surgery and why MGB should be learned, and technical aspects of performing MGB surgery. - Dr. Rutledge will give two presentations comparing MGB to sleeve gastrectomy and discussing the future of bariatric surgery and why MGB is growing internationally.
Intro to Mini-Gastric Bypass (Dr Rutledge) Why? + MGB v Sleeve
- 2. Dr Rutledge; A Full Day of MGB • 9:15 (15 minutes): Comparison of safety and effectiveness Mini-gastric bypass vs Sleeve Gastrectomy • 10:30 (15 min) The Future of Bariatric Surgery, Why Learn the MGB? • 11:30 (15 min) + 11:45 (15 min) Key Lecture: MGB 4 Keys: • 16:00 (15 min) MGB: Surgical Technique: Technical Errors and Prevention: •
- 3. Dr Rutledge, 2 Presentations Session A4, 9-11am Standard + Nonstandard Bariatric Surgery • 9:15 (15 minutes): Comparison of safety and effectiveness Mini-gastric bypass vs Sleeve Gastrectomy • 10:30 (15 min) The Future of Bariatric Surgery, Why Learn the MGB? With Permission? Do Both Together, Now?
- 4. Lecture From Dr. Rutledge in Kazakhstan!
- 5. Batyrs (warriors) considered it an honor to die in battle The Military valor of Kazakh warriors was praised for centuries.
- 6. Kazakhstan!
- 8. Who is this Man? Who are We? The Golden Warrior, also known as Zolotoi Chelovek (Russian) or Altan Adam (Kazakh), is a statue of a Scythian warrior . TELL ME WHAT THIS MEANS!
- 9. “The Kazakhs are descendants of the Turkic and medieval Mongol tribes”
- 10. Who are You?
- 11. Batyrs (warriors) considered it an honor to die in battle The Military valor of Kazakh warriors was praised for centuries.
- 12. Who are You? Who are We? “In My Heart & My Soul, I am a Surgeon.” Sooner or Later All of Us Will Die. What Will You Live For?
- 13. Who are You? Who are We? “In My Heart & My Soul, I am a Surgeon.” • What does it mean to be a Kazakh warrior? • What does it mean to be “Heart & Soul” a surgeon? • It means COMMITMENT. • An Unwavering Commitment to Our Patient's Health • It means valor, we Kazakh warriors & we surgeons should be committed to our patients
- 14. Who are You? Who are We? “In My Heart & My Soul, I am a Surgeon.” Let us fight for the best for our patients. Join Me!
- 15. Some Presentations are Quiet and Gentle Not Me. I am Rutledge! I am here to challenge you! To Make You Laugh (and Cry) Wake Up!
- 16. The Future of “Bariatric Surgery” Why Learn the MGB? The Answer is “Thin Diabetics” and so much more.
- 17. The World is Changing The MGB is Growing All Around the World In Spite of American Surgeons Fighting the MGB America is NOT Always Right!
- 18. Introduction: • 20 years of the MGB & • Growing adoption • Position Paper of the IFSO • Some Bariatric surgeons STILL fear MGB • Misplaced Fears of Billroth II, “Bile Reflux” & Gastric cancer; Surgeons who have FORGOTTEN GENERAL SURGERY TRAINING!
- 19. MGB = Antrectomy w Billroth II Routine General Surgery!
- 20. MGB = Routine General Surgery • MGB: Minimally Invasive Gastric Bypass • MGB Nothing more than Routine General Surgery • Partial Gastrectomy + Billroth II • Who is afraid of the Billroth II? • Not competent General, Trauma & Cancer Surgeons! • Only a few misinformed Bariatric surgeons!
- 21. Why are so many Bariatric Surgeons so wrong, so confused? Answer: Failure of the Mason Loop Gastric Bypass
- 22. Mason Loop Violation of Basic General Surgery •Mason Loop Bypass Reconstruct w Loop •Thus Mason Loop => Failure •Violation of Basic General Surgical Principles
- 23. Surgeons Must Differentiate the Errors of Old Mason Loop vs MGB? Gastro- Jejunostomy Level of EG Junction
- 24. Billroth II #1 Technique Stomach to Bowel Now and for the past 100 years: BII #1 •The Billroth II is by far the most common technique around the world for reconstructing the gastrointestinal tract following distal gastrectomy for cancer, trauma & ulcer disease. •Tens of Thousands of Billroth II General Surgery patients from all around the world have bile that flows harmlessly across their Billroth II anastomosis every day.
- 25. Widespread Confusion MGB = Billroth II Billroth II is GOOD for You General, Trauma & Oncologic Surgeons Routinely Use the Billroth II Many Bariatric Surgeons are Uninformed & Fear the Billroth II
- 26. Billroth II Good Safe Operation Makes People Healthier! Large Scale, Population Based Studies From Taiwan National Registry Published in Obesity Surgery Show Billroth II Billroth II Decreases the Risk of Stroke, Coronary Heart Disease & Diabetes & more
- 27. A Nationwide Population-Based Study Billroth II Decreased Risk of Stroke • 6,425 pts Billroth II for Ulcer • Nationwide Health Database • Matched with 25,602 Ulcer Pts NO Billroth II • Billroth II pts Lower Risk of Stroke! • Medicine (Baltimore). 2016 Apr;95(16)
- 28. A Nationwide Population-Based Study Billroth II Decreased Risk of Coronary Heart Disease. • BII for Ulcer •National Health Insurance Database • Matched with 25,602 Ulcer Pts did not receive Billroth II • Billroth II patients 20%+ Decreased Risk of Coronary Heart Disease • Obese Surgery. 2017 Jun;27(6):1604-1611
- 29. A Nationwide Population-Based Study Billroth II Decreased Risk of Diabetes by Almost 56% • National Health Insurance Database • Matched with patients did not receive Billroth II • Billroth II patients of Diabetes (adjusted hazard ratio: 0.56) • PLoS One. 2016 Nov 28;11(11)
- 30. Billroth II in Thousands of General Surgery Patients • Billroth II => • Decreases the risk of • Stroke • Coronary Heart Disease • Diabetes • General Surgeons Routinely Use the MGB
- 31. Billroth II Routinely Used Every Day in General Surgery Feared by Some Bariatric Surgeons?
- 32. Billroth II Routinely Used Every Day by Oncologic Surgeons Feared by Bariatric Surgeons?
- 33. Oncologic Surgeons Routinely Use Billroth II Every Day In Gastric CANCER!! Feared by Bariatric Surgeons?
- 34. USA Study 2018: Roux-en-Y vs Billroth II Distal Gastrectomy for Gastric Cancer • Prospective multicenter randomized controlled trial USA Gastric Cancer Surgeons and Cancer Centers • 2008 - 2014, randomly allocated to Billroth II (n = 81) & RNY (n = 81) • Outcomes Similar: RNY = Billroth II • Ann Surgery. 2018 Feb;267(2):236-242.
- 35. Roux-en-Y or Billroth II Reconstruction After Radical Distal Gastrectomy for Gastric Cancer: A Multicenter Randomized Controlled Trial. • Prospective multicenter randomized controlled trial Gastric Cancer • No difference in nutritional status & quality of life at 1 year between the 2 groups • Conclusions: “BII & RY are similar in terms of overall GI symptom score & nutritional status at 1 year after distal gastrectomy” • Ann Surgery. 2018 Feb;267(2):236-242.
- 36. Oncologic Surgeons Routinely Use Billroth II Every Day In Gastric CANCER!! Yet: Feared by Bariatric Surgeons?
- 37. Billroth II = RNY Cancer Surgeons Routinely Use Billroth II •2015 Study 7 USA Cancer Centers •500 Patients •Prospective Randomized Trial •Compared Billroth II vs. RNY “NO advantage of RNY vs Billroth II” • Tran et al. To Roux or not to Roux: a comparison between Roux-en-Y & Billroth II reconstruction following partial gastrectomy for gastric cancer. Gastric Cancer. 2015 Sept 23.
- 38. Oncologic Surgeons Routinely Use Billroth II Every Day In Gastric CANCER!! Feared by Bariatric Surgeons?
- 39. Billroth II Routinely Used Every Day in General Surgery ONLY Feared by Uninformed Bariatric Surgeons
- 40. Billroth II Routinely Used Every Day in General Surgery ONLY Feared by Uninformed Bariatric Surgeons
- 41. Billroth II is a Good Operation I have 100 more slides and references if you wish to debate this topic Routinely Used Every Day in General Surgery ONLY Feared by Uninformed Bariatric Surgeons
- 42. The “Problem” in Bariatric Surgery No GOOD Operation
- 43. The “PROBLEM” of Bariatric Surgery • In Short Widespread Errors (Again): • RNY: Stronger than LSG = Higher Complications • Sleeve: Weaker than RNY = Fewer Complications (?) • SADI: Recreating the “Deadly” BPD & Adding LSG = GERD, Barretts? Why? Fear of “Bile”
- 44. MGB vs LSG, RNY & SADI • Controlled Prospective Trials • MGB more powerful with fewer complications than RNY • MGB 2X Rx Diabetes compared to LSG and better in almost every measure • SADI: Massive Gut Bypass = 1. BPD Complications + 2. Sleeve complications: (GERD, Barrett's, Gastric & Esophageal Cancer)
- 45. RNY vs Sleeve Example Studies: RNY: Stronger/Complicated Sleeve: Weaker/Safer?
- 46. Obes Surg. 2017 Jan Roux-En-Y Gastric Bypass Vs. Sleeve Gastrectomy: Balancing the Risks of Surgery with the Benefits of Weight Loss. Lager CJ Conclusions: “Weight loss greater in RNY vs SG. Surgical complications greater after RNY”
- 47. Surg Endosc. 2017 Comparative effectiveness of Roux-en-Y gastric bypass and sleeve gastrectomy in super obese patients. Celio AC “RNY patients had greater %TWL & increased resolution of all measured comorbidities. RNY higher 30-day mortality, reoperation and readmission (p < 0.001)
- 48. JAMA. 2018 Jan Effect of Laparoscopic Sleeve Gastrectomy vs Laparoscopic Roux-en-Y Gastric Bypass on Weight Loss at 5 Years Among Patients With Morbid Obesity: Randomized Clinical Trial. Salminen P “5 year morbidity rate 19% in sleeve & 26% in RNY % excess weight loss at 5 years 49% Sleeve & 57% after RNY”
- 49. JAMA. 2018 Jan 16 Bariatric Surgery Banding, Roux-en-Y, or Sleeve Gastrectomy & All-Cause Mortality. Reges O. “Adjusted hazard ratios (HRs) Decreased Mortality Rates => 1.6 Sleeve gastrectomy (Weaker) => 2.7 RNY gastric bypass (Stronger)”
- 50. What do we need? More Power than Sleeve/More Safety Than RNY AND NOT SADI Answer: The Mini-Gastric Bypass! Routine General Surgery: Partial Gastrectomy + Billroth II
- 51. RNY vs. Sleeve Neither Very Good RNY: Power & Complications Sleeve: A Little Safer & Weaker If only we had a better operation!
- 52. We Need Better Surgery! What Can We Learn from General Surgery?
- 53. MGB = Partial Gastrectomy + Billroth II General Surgery => Rx Diabetes J Gastric Cancer. 2017 Long-term Follow-up for Type 2 Diabetes Mellitus after Gastrectomy in Non-morbidly Obese Patients with Gastric Cancer: the Legitimacy of Onco-metabolic Surgery. Lee TH Partial Gastrectomy effective in short & long- term T2D control in non-obese patients
- 54. MGB = Partial Gastrectomy + Billroth II General Surgery => Rx Diabetes J Gastric Cancer. 2017 DM post Gastrectomy Non-Obese Gastric Cancer 27% Billroth I, 47% Billroth II, 25% RNY BP Limb 15–20 cm distal Treitz (Short) Partial Gastrectomy effective in short & long- term T2D control in non-obese patients
- 55. General Surgery Answers: Sleeve vs MGB • 238 Gastric Cancer Patients Reconstruction after distal gastrectomy • #Billroth I pts (=> Sleeve) 147 • #Billroth II pts (=> MGB) 91 • 0% RNY ( 0.0% ) • Billroth II pts Highest improvement diabetes • Oncotarget. 2017 Nov, Improved glycemic control with proximal intestinal bypass and weight loss following gastrectomy in non-obese diabetic gastric cancer patients, Ali Guner
- 56. General Surgery Answers: Sleeve vs MGB • Method of reconstruction BI (Sleeve) vs. BII (MGB) • Odds ratio improvement in glycemic control @ 24 months 5.1 (p<0.001) • Billroth II (MGB) pts 5X Odds Ratio improvement in glycemic control • Oncotarget. 2017 Nov, Improved glycemic control with proximal intestinal bypass and weight loss following gastrectomy in non-obese diabetic gastric cancer patients, Ali Guner
- 57. Good Bariatric Surgery • We all know & Agree: • Sleeve, RNY & Other Operations are good • We MGB Surgeons are Not Critical of the Other Operations or Surgeons • We measure the MGB against Sleeve / RNY • The Standards we compare ourselves
- 58. Growing Number of Studies: The MGB-OAGB: in many ways Equal To or Better Than Sleeve / RNY & Any other operation A Few Studies Examples...
- 59. Two Recent Studies Meta-analysis & systematic review Sleeve vs MGB (Hint: MGB found to be superior)
- 60. •One-Anastomosis (Mini) Gastric Bypass Versus Sleeve Gastrectomy for Morbid Obesity: a Systematic Review and Meta- analysis • Dimitrios E. Magouliotis 1 & Vasiliki S. Tasiopoulou2 & Alexis A. Svokos3 & Konstantina A. Svokos4 & Eleni Sioka1 & Dimitrios Zacharoulis1 # • Springer Science+Business Media, LLC 2017
- 61. Mean Operative Time and Length of Hospital Stay • Mean operative time was similar in both groups • The length of hospital stay was greater in the LSG group
- 62. Conclusions “This meta-analysis demonstrates the superiority of MGB compared to LSG”
- 63. MGB “Best”/Good Bariatric Surgery? Example Recent Study: MGB is “Good Surgery” Obese Surgery. 2017 Sept;27(9):2479-2487 => MGB vs. Sleeve Gastrectomy <= Systematic Review & Meta-analysis, Magouliotis DE * 17 * studies *6,761* patients “This study reveals:” MGB Better “Weight loss, Remission of comorbidities, Shorter hospital stay, & Lower Mortality” “Sleeve Higher Rate GERD” => Barrett's Esophageal Cancer
- 64. “Mini-gastric bypass simpler, safer, & more effective than sleeve” Comparison of safety & effectiveness mini-gastric bypass & Laparoscopic sleeve: A meta-analysis & systematic review Wang FG, Medicine (Baltimore). 2017 Dec
- 65. “Mini-gastric bypass simpler, safer, & more effective than laparoscopic sleeve gastrectomy” Wang 2017 METHODS: A systematic literature search was performed “Mini-Gastric Bypass had a lot of advantages” 1. Higher 1-year EWL% (excess weight loss), 2. Higher 5-year EWL%, 3. Lower leak rate, 4. Higher T2DM remission rate, higher HBP remission rate, higher obstructive sleep apnea (OSA) remission rate, 5. Lower overall late complications rate, 6. Lower gastroesophageal reflux disease (GERD) rate, 7. Shorter hospital stay & 8. Lower revision rate.
- 66. Growing Number of Studies: The MGB-OAGB: in many ways Equal To or Better Than Sleeve / RNY & Any other operation
- 67. New Data (& Old) Cancer & Sleeve Gastrectomy
- 68. Cancer & Sleeve Gastrectomy (SG) OLD News & NEW News • Increased Risk: Esophageal Cancer, Gastric Cancer & other GI Cancers • SG => GERD => Barrett's => Esophageal Cancer • New Data: SG + PPI's => Hypergastrinemia => Gastric Cancer (Esophageal/Colon/GI Cancer)
- 69. Sleeve Gastrectomy => GERD Barrett's • Obese Surgery. 2017 Dec, Reflux, Sleeve Dilation, & Barrett's Esophagus after Laparoscopic Sleeve Gastrectomy: Long-Term Follow-Up, Felsenreich DM et al. • Follow-up of more than 10 years • 14% converted to RYGB for GERD • 38% of the other pts also suffered GERD • Gastroscopies Barrett's metaplasia in 15% • High incidence of Barrett's esophagus & GERD => Risk of Esophageal Cancer
- 70. NEW STUDY: Sleeve => PPI's => Gastrin => Gastric Cancer • Proton pump inhibitors & gastric cancer: a long expected side effect finally reported also in man Waldum, http://dx.doi.org/10.1136/gutjnl-2017-315629 •Long-term PPI Use => Doubled Risk for Gastric Cancer •Both Sleeve Gastrectomy & PPI's increase levels of Gastrin •Hypergastrinemia => Increase Gastric Cancer
- 71. Sleeve Gastrectomy => Increased Risk Cancer Increased Risk of Esophageal Cancer & Gastric Cancer
- 72. MGB = Billroth II Billroth II is GOOD for You General, Trauma & Oncologic Surgeons Routinely Use the Billroth II Many Bariatric Surgeons are Uninformed & Fear the Billroth II
- 73. Lack of Knowledge & Patient Outcomes • Survey Show Correlation Between Surgeon's knowledge in there areas of expertise & patient outcomes • Survey Data Showed : • Surgeons who FEAR Gastric Cancer after MGB were much less knowledgeable about Gastric Cancer, Billroth II & General Surgery than other Bariatric Surgeons • In short the More you know the Less you fear Gastric Cancer & the Billroth II
- 74. MGB = Billroth II Billroth II is GOOD for You General, Trauma & Oncologic Surgeons Routinely Use the Billroth II Many Bariatric Surgeons are Uninformed & Fear the Billroth II
- 75. •Simple •Elegant •Effective •Durable > 15 yrs •Powerful •Tailored to Patient •Reversible •Revisable
- 76. •MGB Can Be Tailored to Meet All Needs •Usual Bariatric Patient (+/- Diabetes) •Super Obese •GERD Patient •“Difficult” Patient •Borderline Patient •FUTURE PATIENTS? Non-obese Diabetics
- 77. Imagine! A Solution to Diabetes (For SEVERE DIABETICS)
- 78. Surgery Can Successfully Treat Obesity and Diabetes But Imagine Improvement or Even Cure in the Both the Obese And the ** Thin Diabetic Patient **
- 79. General Surgery Can Teach Us the Surgical Treatment of Diabetes (in “Thin” Non Morbidly Obese Patients)
- 80. •A new perspective on an old surgical method •A systematic review and meta- analysis General Surgery Billroth II on Type 2 Diabetes •Surg Obes Relat Dis. 2015
- 81. • General Surgery Studies show that • Subtotal gastrectomy for cancer or ulcers + Billroth II (BII) >> Billroth I (BI) • More effective Rx Type 2 Diabetes • BII (MGB) More Effective Rx BI (Sleeve) •Surg Obes Relat Dis. 2015
- 82. Billroth II is a Good Procedure! “May be the Ideal Rx Thin Diabetics!” Surg Obes Relat Dis. 2015
- 83. •Conclusions: BII reconstruction after subtotal gastrectomy for cancer or ulcers more effectively improved T2D than BI reconstruction. •Thus, BII provides a treatment strategy for diabetic patients and enable metabolic surgery for Non-obese patients Surg Obes Relat Dis. 2015
- 84. The Future Metabolic Surgery Lower Weight Diabetics •What is our future? •METABOLIC SURGERY •We are “Metabolic Surgeons”
- 85. The Future is HERE Metabolic Surgery Lower Weight Diabetics 2/3 MGB Surgeons are Doing METABOLIC SURGERY on thin diabetics We are “Metabolic Surgeons”
- 87. Imagine! A Solution to the Severe Deadly Complications of Diabetes Even in Thin Patients! Blindness, Stroke, Heart Attack, Kidney Failure & Gangrene & Amputation
- 88. Bariatric Surgery in Thin Diabetics It is Already here!
- 89. RESOLUTION OF DIABETES MELLITUS IN LOWER WEIGHT PATIENTS WITH MINI-GASTRIC BYPASS Rutledge Data From 2015
- 90. Dr. Robert RUTLEDGE RESOLUTION OF DIABETES MELLITUS IN LOWER WEIGHT PATIENTS WITH MINI-GASTRIC BYPASS Nationality: United States of America E-mail: drr@clos.net
- 91. Introduction •Bariatric procedures have been shown to improve the outcome of Diabetes Mellitus (DM). •The Mini-Gastric Bypass (MGB) includes both a gastric and a bypass component which has been shown to be more effective than either alone.
- 92. Introduction •Studies have shown that the MGB leads to resolution of Type II DM in up to 95% of morbidly obese patients. •Because of the risks and danger of DM and the success of the MGB in obese diabetic the MGB was offered to lower weight patients.
- 93. Methods: •6, 234 patients underwent MGB including •303 DM patients with BMI 21-35. •The MGB operations were tailored for lower weight patients •(shorter bypass length and larger gastric pouch).
- 94. Results • 68.9% of patients were female. Average age 48 + 11. • Mean preop weight 97 kg and post op was 69 kg with a • Mean weight loss of 28 kg.
- 95. Results • DM resolved in 98% and improved in the remaining patients. • 98% of patients were off all oral medications. • 15.2% were taking insulin and all were taken off the insulin by their physicians.
- 96. Conclusions: • MGB well suited Rx DM in low weight patients • Why? Gastric pouch can be larger & Bypass length shortened Weight loss can be customized. • MGB cure/improvement glucose metabolism and serum lipid composition in Low weight DM patients.
- 97. Conclusions: Rutledge's Old Data • The Mini-Gastric Bypass improves DM in 95% of obese patients and also leads to resolution or improvement of DM in lower weight patients.
- 98. New Data: January 2018 “Remedy diabetes in non-obese patients?” “From diabetes remedy to diabetes remission; could single- anastomosis gastric bypass be a safe bridge to reach target in non-obese patients?” Tarek Abouzeid Osman Abouzeid
- 99. New Data Confirms Dr Rutledge's Old Data Study: MGB as treatment for T2DM patients with body mass index (BMI) 25 - 30 kg/m2 Ain-Shams University Hospitals on 17 consecutive patients => 13/17 patients complete remission rate 76.4%.
- 100. Conclusions Sleeve safer/weaker than RNY Goal Stronger than Sleeve/Safer than RNY => Answer: MGB => More powerful than Sleeve/Safer than RNY Future: Metabolic Surgery (Thin Diabetics) Best Surgery? => Answer: MGB (Tailored to “short” BP Limb = General Surgery BP Limb Length)
- 101. Why Learn MGB: Now and in the Future (Thin Diabetics) 1. More Powerful than Sleeve 2. Safer/Easier than RNY 3. Tailored to Patient (Normal, Obese, Super Obese 4. Reversible/Revisable 5. In Expert Hands: No Stricture/ No Obstruction and No/Minimal Malabsorption
- 102. Who are You?
- 103. Who are You? Who are We? “In My Heart & My Soul, I am a Surgeon.”