Mechanism of Action of MGB
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The mini-gastric bypass (MGB) is distinct from the Roux-en-Y gastric bypass and operates on a non-obstructive restriction mechanism, leading to fat intolerance and minimal malabsorption. It is associated with lower complication rates and more effective outcomes compared to other bariatric procedures like RNY. Understanding MGB's mechanism is crucial for its effective application, emphasizing its unique surgical technique and dietary implications.
Mechanism of Action of MGB
- 1. Understanding the Mechanism of Action of the Mini-Gastric Bypass
- 2. The MGB is NOT the “Single Anastomosis Bypass” • The crital component of the MGB IS NOT the single anastomosis • Error in Naming Demonstrates • Misunderstanding the MGB
- 3. MGB Criticisms by year 2000 American Surgeons • Dr Rutledge did not take out the gallbladder • MGB was not retro colic/ retro gastric • The MGB = Old Mason GBP and All would suffer Bile Reflux Esophagitis • Billroth II causes cancer • The Pouch and the Gastro-j were too big and the patients would not lose weight • DrR used Email!, DrR had a website
- 4. Almost 20 Years Later Surgeons Still Misunderstand the MGB • The MGB is NOT a “RNY with One Less Anastomosis” • You Cannot Understand the Anatomy of the MGB (Surgical Technique) • Unless you understand the MGB Mechanism of Action
- 5. The Name • Misunderstanding: MGB is Nothing more than RNY with One Less Anastomosis • **Wrong** • This erroneous thinking lead to the renaming of the MGB to • “Single Anastomosis Bypass” • Lets Explain the misunderstanding • MGB - RNY are not the same
- 6. MGB Anatomy = Mechanism of Action 1. Non-Obstructive Restriction 2. Fatty Food Intolerance => Change preferences in Food 3. Fatty Food Malabsorption to High Fat Meal 4. Post Gastrectomy Syndrome Understanding Good Dumping/Bad Dumping 5. Post-Gastrectomy Syndrome Diet
- 7. OBSTRUCTIVE Restrictive Procedures (RNY) • Mechanism of Action & Failure • Restriction / OBSTRUCTION • Weight Loss induced by High Grade Narrowing (Stricture) = Obstruction Nausea & Vomiting w Normal Healthy Food (i.e. Broccoli, Sandwich, Apple etc.) => Vomiting • Induces “Pathologic Eating” (i.e. Coca Cola, Soda, “Soft Calories”, Candy, Ice Cream, etc.) => Failure: Weight Regain
- 8. The MGB: Summary of Dog and Human Studies Demonstrating the Difference and Advantages • MGB Non-Obstructive = 75% Decrease in Food Intake • MGB BP Limb length = Best length 1. Shorter than BPD & 2. Longer than RNY ~ 30% BP Limb => Fatty Food Intolerance & Malabsorption to large fatty meals • Billroth II with Wide Anastomosis CRITICAL for effectiveness
- 9. The MGB: Summary of Dog and Human Studies Demonstrating the Difference and Advantages • Unless you understand the MGB Mechanism of Action YOU WILL NOT “DO THE MGB RIGHT” • MGB => Induces the Well Know and Understood “Post Gastrectomy Snydrome” • MGB Pts Can eat But BUT NOT sweets, liquid calories, junk food or Fatty Foods • Post Gastrectomy Syndrome Diet
- 10. End Here! Two Choices 1. Research Documenting MGB Mechanism of Action 2. MGB Surgical Technique
- 11. Summary: RNY vs MGB • RNY ** Highest Rate of Complications (Band/Sleeve/MGB) ** Most Difficult to Revise ** Not Easily Tailored to Patient Factors ** Obstructive Restriction => Liquid Calories => Failure (Weight Regain) ** Internal Hernia • MGB ** Easier lower risk complications ** More Powerful than Band/Sleeve/RNY ** Easily revised ** Easily tailored to patient factors (Thin diabetic) ** NON-Obstructive Restriction ++ Fatty Food Intolerance ** Low Risk Internal Hernia
- 12. Summary: RNY vs MGB • Roux-en-Y Gastric Bypass • Highest Rate of Complications (Band/Sleeve/MGB), • Most Difficult to Perform/Revise, • Not Easily Tailored to Patient Factors, • ** Obstructive Restriction (Pathologic Eating) => Liquid Calories => Failure (Weight Regain) • Internal hernia/SBO Death
- 13. Summary: RNY vs MGB (Only in Well Trained Hands) • MGB: Lower risk complications (Published Paper & Prospective Trials) • More Powerful than Band/Sleeve/RNY • Easily Performed/Revised, • Easily tailored to patient factors (Thin diabetic), • ** NON-Obstructive Restriction ++ Fatty Food Intolerance Forces Patient => Mediterranean Diet • ** Low Risk Internal Hernia SBO
- 14. Surgical Procedures Rx Obesity / Diabetes • 2 Mechanisms of Action & History of Failure • Primary Restriction / OBSTRUCTION – Vertical Banded Gastroplasty – Lap Band – Sleeve – Roux-en-Y • Malabsorption – BPD / Duodenal Switch / SADI
- 15. Bariatric Surgical Procedures Problems – Vertical Banded Gastroplasty: (Abandoned) Failed Weight Regain – Lap Band: (Abandoned) Failed Weight Regain – Sleeve: (Worrisome New Data) Failed Weight Regain vs GE Reflux – Roux-en-Y: (Highest Complications Risk) Weight regain, – BPD / Duodenal Switch / SADI: Malnutrition, Deficiencies, Diarrhea, Foul Smelling Gas
- 16. OBSTRUCTIVE Restrictive Procedures (RNY) • Mechanism of Action & Failure • Restriction / OBSTRUCTION • Weight Loss induced by High Grade Narrowing (Stricture) = Obstruction Normal Healthy Food (i.e. Broccoli, Sandwich, Apple etc.) => Vomiting • Induces “Pathologic Eating” (i.e. Coca Cola, Soda, “Soft Calories”, Candy, Ice Cream, etc.) => Failure: Weight Regain
- 17. What is Roux-en-Y Gastric Bypass? Restriction + Duodenal Exclusion • Roux-en-Y Gastric Bypass both (?) • OBSTRUCTIVE Restriction • Minimal => Fatty Food Intolerance => Fat Malabsorption
- 18. OBSTRUCTIVE Restrictive Procedures • Block Normal Healthy Diet But • They DO NOT BLOCK ... Liquid / Soft Calories and “Junk Food”
- 19. “The contribution of Malabsorption to the reduction in net energy absorption after long-limb Roux-en-Y gastric bypass” Elizabeth A Odstrcil, et al October 2010 vol. 92 no. 4 704-713
- 20. The contribution of Malabsorption to the reduction in net energy absorption after long-limb Roux-en-Y gastric bypass • Results: • RNY: • No significant effect on • Protein or Carbohydrate absorption • “The contribution of Malabsorption to the reduction in net energy absorption after long-limb Roux-en-Y gastric bypass”, Elizabeth A Odstrcil, et al. Am J Clin Nutr October 2010 vol. 92 no. 4 704-713
- 21. RNY Mechanism = Obstructive Restriction • 5 months after bypass, • Malabsorption 124 kcal/d • Obstructive Restriction of food intake reduced energy absorption by 2,062 kcal/d • Restriction ALMOST 20 times more important than Malabsorption • The contribution of Malabsorption to the reduction in net energy absorption after long-limb Roux-en-Y gastric bypass, Elizabeth A Odstrcil, et al. Am J Clin Nutr October 2010 vol. 92 no. 4 704-713
- 22. RNY = Obstructive Restriction • 14 months after RNY bypass Caloric intake increasing!! • Restriction of food intake reduced energy absorption by 1,418 kcal/d • 14 months RNY Restriction Already Beginning to Fail • The contribution of Malabsorption to the reduction in net energy absorption after long-limb Roux-en-Y gastric bypass, Elizabeth A Odstrcil, et al. Am J Clin Nutr October 2010 vol. 92 no. 4 704-713
- 23. RNY OBSTRUCTIVE Restriction • RNY: Is Primarily a “Restrictive Procedure” based upon • Small Pouch and “Tight” Gastro- jejunostomy • Study Shows: RNY Early signs of RNY caloric restriction failure • The contribution of Malabsorption to the reduction in net energy absorption after long- limb Roux-en-Y gastric bypass, Elizabeth A Odstrcil, et al. Am J Clin Nutr October 2010 vol. 92 no. 4 704-713
- 24. Bariatric Surgeons Forget History of GI Surgery What have we learned from 100 years of GI Surgery?
- 25. MGB = Post Gastrectomy => (Sweets + Fatty Food) Intolerance • It’s Just General Surgery! • For over 75 years • Sweet + Fatty food intolerance common “Post Gastrectomy Syndrome” • More common & Greater degree with • Billroth II >> Billroth I • EVERSON TC. Experimental comparison of protein and fat assimilation after Billroth II, Billroth I, and segmental types of subtotal gastrectomy. Surgery. 1954 Sep;36(3):525-37 • MACLEAN LD, PERRY JF, KELLY WD, MOSSER DG, MANNICK A, WANGENSTEEN OH. Nutrition following subtotal gastrectomy of four types (Billroth I and II, segmental, and tubular resections). Surgery. 1954 May;35(5):705-18 • WOLLAEGER EE, WAUGH JM, POWER MH. Fat-assimilating capacity of the gastrointestinal tract after partial gastrectomy with gastroduodenostomy (Billroth I anastomosis). Gastroenterology. 1963 Jan;44:25-32 • …
- 26. 100 Years of GI Surgery: Sweets + Fatty Food Intolerance Gastric Operations: • What do we know: Sweets/Fatty Food Intolerance • “Rare after gastro-jejunostomy or vagotomy alone. • “Rare after RNY, Billroth I • “Especially Common after Polya type Billroth II • (**Butler, 1961**)
- 27. Polya Type Gastro-Jejunostomy (HELLO; MGB Not RNY) NOTE: Large Wide Open Gastro- jejunostomy
- 28. Bariatric Surgical Procedures Problems – Vertical Banded Gastroplasty: (Abandoned) Failed Weight Regain – Lap Band: (Abandoned) Failed Weight Regain – Sleeve: (Worrisome New Data) Failed Weight Regain & GE Reflux – Roux-en-Y: (Highest Risk Complications) Weight regain, – BPD / Duodenal Switch / SADI: Malnutrition, Deficiencies, Diarrhea, Foul Smelling Gas
- 29. OBSTRUCTIVE Restrictive Procedures: Mechanism of Action & Failure • Mechanism of Action & Failure • Restriction / OBSTRUCTION • Weight Loss induced by High Grade Narrowing (Stricture) = Obstruction of Normal Healthy Food (i.e. Broccoli, Sandwich, Apple etc.) => Vomiting • Induces “Pathologic Eating” (i.e. Coca Cola, Soda, “Soft Calories”, Candy, Ice Cream, etc.) => Failure: Weight Regain
- 30. Selecting an Operative Procedure Safety and Effectiveness Personal Experience, Animal Models, Expert Judgment, Published Data and Controlled Prospective Randomized Trials all show: MGB is More Effective than Sleeve RNY MGB is Safer than Sleeve RNY BUT ONLY IN WELL TRAINED HANDS!
- 31. Why the Band/Sleeve/RNY Fail All OBSTRUCTIVE Restrictive Procedures Stricture: Block “Healthy Foods” Induce Intake of Sweets, "Liquid Calories" & “Junk Food”
- 32. Pathologic Dietary Choices Calories: Ice Cream 200g/540 cal, 2 Milky-way Bars, 1,000 cal 2 L Bottle Coke 830 cal Total: 2,370 cal
- 33. Band/Sleeve/RNY Create Sweet/Junk Food Eaters • All OBSTRUCTIVE Restrictive Procedures (Including RNY) MAKE SWEET EATERS: • Mechanical Block of Normal Healthy Foods • Early Weight Loss: Honeymoon +/- 2 years • Then Failure Weight Regain • Why is there a growing chorus in favor of “Banding” the RNY?
- 34. Band, Sleeve, RNY Block Normal Healthy Foods • Weight Loss => • Increased Hunger • Decreased Satiety • Healthy Foods Blocked • Drive to Eat Increased • What Happens?
- 35. What About the MGB Re: Restriction & Obstruction
- 36. Mini-Gastric Bypass (MGB): Surgical Rx of Obesity / Diabetes 1. NON-Obstructive Restriction 2. Fatty Food Intolerance w 3. Minimal Malabsorption 4. Decreased Hunger Enforced Healthy Mediterranean Diet
- 37. Mini-Gastric Bypass Decreases Hunger Dr Rutledge's Survey 2,783 Pts
- 38. Post Gastrectomy Symptoms • Metabolic aberrations • Dumping syndrome • 1. Loss of stomach volume and • 2. Loss of Pyloric sphincter >> Rapid Gastric Emptying into small bowel • 2 types – Early – Late
- 39. Early Dumping syndrome • Onset in 15 to 30 min • Rapid shift extracellular fluid into SB (rapid passage and hyperosmolarity) >> acute distension >> Autonomic Sx • Most Common *** B II reconstruction *** • GI Sxs : N/V, Fullness, Cramping & Diarrhea • CVS : palpitation, tachycardia, diaphoresis
- 40. Late Dumping syndrome • Carbohydrate load in diet to the stomach • >> rapid gastric emptying pass to SB • >> hyperglycemia • >> insulin over shoot • >> cathecholamines stimulation • Sx: Mild to severe weakness, sweating, and dizziness
- 41. Post-Gastrectomy Diet • Relax at mealtimes,Eat 6 small meals/d avoid overloading the stomach. • Small bites & chew well • Limit fluids 4 oz (1/2 cup) w mealtimes. Prevent rapid gastric emptying • Drink liquids 30-45 min before eating and 1 hour after eating, rather than with meals.
- 42. Post-Gastrectomy Diet • Rest/lie down 15 minutes after meals slow rapid gastric emptying • Avoid sweets and sugars. Aggravate dumping syndrome. • Avoid very hot / cold foods or liquids, may increase dumping symptoms
- 43. Post-Gastrectomy Diet • Post Gastrectomy => Intolerance to certain foods: Especially Sweets, Acidic, Fatty foods. • Gas and bloating may occur • Avoid foods that are known to cause gas, symptoms • STOP eating as soon as start to feel full
- 44. Post-Gastrectomy Diet • Avoid tight fitting clothing frequent bending • Elevate Head bed - 6 inches • Limit caffeine (coffee, tea & cola drinks). • Limit fatty foods • Beware acidic foods (vinegar, hot peppers) • Avoid foods natural laxatives (caffeine, prunes and others)
- 45. Post-Gastrectomy Diet • Avoid spearmint and peppermint • Avoid carbonated beverages • Limit or avoid alcohol • Sit up after eating and remain in a sitting position for 60-90 min after eating • Do not eat for 2 hours before bedtime • Eat a variety of foods to assure adequate vitamins, minerals & protein • Multivitamin calcium, iron, B vitamins(?)
- 46. Post-Gastrectomy Diet • Beware lactose intolerance (the inability to digest milk sugar) • Can Lead to Gas Bloat Diarrhea etc
- 47. Understanding 1. Dumping Syndrome & 2. Post Gastrectomy Syndrome 3. Mini-Gastric Bypass Good Dumping / Bad Dumping Aversive Conditioning
- 48. Understanding 1. Dumping Syndrome & 2. Post Gastrectomy Syndrome 3. Mini-Gastric Bypass Good Dumping / Bad Dumping Aversive Conditioning
- 49. Post Gastrectomy Symptoms • Metabolic aberrations • Dumping syndrome • 1. Loss of stomach volume and • 2. Loss of Pyloric sphincter >> Rapid Gastric Emptying into small bowel • 2 types – Early – Late
- 50. Early Dumping syndrome • Onset in 15 to 30 min • Rapid shift extracellular fluid into SB (rapid passage and hyperosmolarity) >> acute distension >> Autonomic Sx • Most Common *** B II reconstruction *** • GI Sxs : N/V, Fullness, Cramping & Diarrhea • CVS : palpitation, tachycardia, diaphoresis
- 51. Late Dumping syndrome • Carbohydrate load in diet to the stomach • >> rapid gastric emptying pass to SB • >> hyperglycemia • >> insulin over shoot • >> cathecholamines stimulation • Sx: Mild to severe weakness, sweating, and dizziness
- 52. Understanding 1. Dumping Syndrome & 2. Post Gastrectomy Syndrome 3. Mini-Gastric Bypass Good Dumping / Bad Dumping Aversive Conditioning
- 53. Post Gastrectomy Syndrome •This syndrome is characterized by a lowered tolerance for large meals, rapid emptying of food into the small intestine or “dumping,” abdominal cramping pain, diarrhea, lightheadedness after eating as well as increased heart rate and sharp drops in blood sugar levels.
- 54. Post Gastrectomy Syndrome •In the "early" dumping syndrome, symptoms occur approximately one-half hour after eating whereas in the “late” dumping syndrome they appear two to four hours after eating.
- 55. Post Gastrectomy Syndrome •The Bulk Food component draws water into the intestinal lumen causing sudden fluid shifts in the early dumping whereas late dumping is caused by a reactive hypoglycemia.
- 56. Post Gastrectomy Syndrome (PGS) MGB Diet PGS Diet • 6 small feeds • Avoid Sweets, Fats • Avoid High Fat, Fried Food • More Fresh Fruit Vegs • More Dairy (xLactose) • Minimal Liquids • ... • 6 small feeds • Avoid Sweets, Fats • Avoid High Fat, Fried Food • More Fresh Fruit Vegs • More Dairy (xLactose) • Minimal Liquids • ...
- 57. What Make'e The MGB So Good? Hint: It's the Surgical Technique It's the Billroth II Not Lap Band, Sleeve, RNY
- 58. MGB: Mechanism of Action • I. Large Gastric Pouch+Wide GJ: Non-Obstructive Restriction Rapid gastric emptying: => Post Gastrectomy Syndrome Type I and II Dumping (Good/Bad) • II. Moderate Bilio-Pancreatic Bypass (Not Massive BPD/SADI bypass) Fatty food intolerance Fat Malabsorption to HIGH fatty meals
- 59. Remember your General Surgery “Post-Gastrectomy Syndrome Diet” • Eat 6-8 small meals per day • Don’t drink w meals • Avoid: = Fried foods, High fat luncheon meats such as bologna or salami, Hot dogs, sausage, bacon = Sugar, sweets, Honey, syrup, Sorbitol, xylitol
- 60. MGB => Restriction WITHOUT Obstruction • Gastric Pouch+Wide GJ: Unique • No Obstruction • Easily eat small meals • Rapid Gastric Emptying Dumps food into distal jejunum • Leads to Aversive Conditioning to Sugar, sweets, fatty foods bulky meals Dumping type I & II • NO RNY Neo-Gastric Pouch
- 61. MGB: Restriction WITHOUT Obstruction Dr Rutledge's Survey 3,223 patients • Gastric Pouch: Unique: (Not Band/Sleeve/RNY) • No Obstruction • Rapid Gastric Emptying Dumps food into mid-jejunum • En-Forced Mediterranean Diet • Increased Intake Fresh Fruit and Vegetables, Cereals and Fiber, Yogurt, Lean meats & fish • Decreased Intake Soda (Coke) Fried Foods, Greasy Meals & “Junk Foods”
- 62. aversive conditioning noun, Psychology, Psychiatry. a type of behavior conditioning in which noxious stimuli are associated with undesirable or unwanted behavior that is to be modified or abolished, as the use of nausea-inducing drugs in the treatment of alcoholism.
- 63. MGB: Aversive Conditioning Avoid Sweets, Fatty Foods, Large Meals... MGB => behavior conditioning noxious stimuli (Nausea etc.) with undesirable or unwanted behavior (Sweets, Fatty Food, Large Meals etc...) to be modified or abolished (Dumping I or II)
- 64. MGB => Restriction WITHOUT Obstruction • Gastric Pouch+Wide GJ: Unique • No Obstruction • Easily eat small meals • Rapid Gastric Emptying Dumps food into distal jejunum • Leads to Aversive Conditioning to Sugar, sweets, fatty foods bulky meals Dumping type I & II • NO RNY Neo-Gastric Pouch
- 65. MGB: Restriction WITHOUT Obstruction Dr Rutledge's Survey 3,223 patients • Gastric Pouch: Unique: (Not Band/Sleeve/RNY) • No Obstruction • Rapid Gastric Emptying Dumps food into mid-jejunum • En-Forced Mediterranean Diet • Increased Intake Fresh Fruit and Vegetables, Cereals and Fiber, Yogurt, Lean meats & fish • Decreased Intake Soda (Coke) Fried Foods, Greasy Meals & “Junk Foods”
- 66. Summary: RNY vs MGB • Roux-en-Y Gastric Bypass • Highest Rate of Complications (Band/Sleeve/MGB), • Most Difficult to Perform/Revise, • Not Easily Tailored to Patient Factors, • ** Obstructive Restriction (Pathologic Eating) => Liquid Calories => Failure (Weight Regain) • Internal hernia/SBO Death
- 67. Summary: RNY vs MGB (Only in Well Trained Hands) • MGB: Lower risk complications (Published Paper & Prospective Trials) • More Powerful than Band/Sleeve/RNY • Easily Performed/Revised, • Easily tailored to patient factors (Thin diabetic), • **NON-Obstructive Restriction ++ Fatty Food Intolerance Forces Patient => Mediterranean Diet • ** Low Risk Internal Hernia SBO
- 68. Other Problems with RNY
- 69. MGB: BPLimb + Post Gastrectomy Syndrome • Dog Study 1950, Rapid Gastric Emptying into Small Bowel • Antrectomy and Billroth II Bilio-Pancreatic Limb Bypass Bowel Bypass 5% No effect Bowel Bypass 15% No Effect Bowel Bypass 30% ++Fatty food intolerance, +Fat Malabsorption • ~30% Bypass = MGB
- 70. Best Rx DM Gastric Procedure + Duodenal Bypass This Excludes Band/Sleeve • Need for Gastric Procedure + Bypass • Eliminates Band/Sleeve; • Leaves Choice RNY vs MGB
- 71. Why Consider MGB? Long Term Failure of Band / RNY • 6 yr study 29,820 BCBS plan members. • "Laparoscopic RNY and Lap Band both Fail to reduce overall health care costs in the long term." • Impact of Bariatric Surgery on Health Care Costs of Obese Persons, A 6-Year Follow-up of Surgical and Comparison Cohorts Using Health Plan Data Jonathan P. Weiner, et al. JAMA Surg. 2013;148(6)
- 72. Band & RNY fail to reduce health care costs Health care Costs of RNY and Band RNY Ban d
- 73. RNY the MOST Dangerous Form of Bariatric Surgery • By Every measure, in Every study RNY • Highest Death Rate, Highest Leak Rate Highest Early Complications, Highest Major Complication Rate, Highest Bleeding Rate, Highest Re-operation Rate, Highest PE Rate.... • RNY is the most dangerous form of Bariatric Surgery • References 100+ Studies MGBGuidelines.com
- 74. RNY: Long learning curve 500 cases • RNY technically challenging 2,281 cases 1999 - 2011 • Complications Stabilized after *500* cases • Mortality rate .43%, main causes of death PE & Leaks (.14% each) • Op time & Complications significantly reduced after a long learning curve of 500 cases • Surg Obes Relat Dis. 2013 Feb 11. Overcoming the learning curve of laparoscopic Roux-en-Y gastric bypass: A 12-year experience. El-Kadre L, Tinoco AC, Tinoco RC, Aguiar L, Santos T. Department of Surgery, São José do Avaí Hospital, Itaperuna, Rio de Janeiro, Brazil.
- 75. The RNY is the most Technically Difficult, Dangerous form of Bariatric Surgery >100 Refs Here is One Recent Example
- 76. RNY Bypass Surgery for Diabetes With Non-morbid Obesity? Maybe Jun 04, 2013 • Controlled Prospective Randomized 12-months, 49% RNY pts vs 19% lifestyle pts met primary end points • BUT • 37% serious complications in the RNY group • 2 most serious complications were anastomotic leak 3.3%!!, • 1 patient suffered anoxic brain injury & amputation! • Patients who underwent surgery were also more likely to have non- serious adverse events such as nutritional deficiencies. • JAMA. 2013 Jun 5;309(21):Roux-en-Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the Diabetes Surgery Study randomized clinical trial. Ikramuddin S, Department of Surgery, School of Public Health, University of Minnesota, Minneapolis, MN 55455, USA. ikram001@umn.edu
- 77. RNY Bypass Surgery for Diabetes Controlled Prospective Randomized Trial • Normal HgbA1C level range from 4.5 to 6 • Only 44% RNY pts HgbA1c < 6 (Cure) • BUT • 37% serious complications in the RNY group • 3.3% anastomotic leaks • 1 patient suffered anoxic brain injury. • JAMA. 2013 Jun 5;309(21):Roux-en-Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the Diabetes Surgery Study randomized clinical trial. Ikramuddin S, Department of Surgery, School of Public Health, University of Minnesota, Minneapolis, MN 55455, USA. ikram001@umn.edu
- 78. Controlled Prospective Randomized Trial Lee WJ, Yu P-J, Wang W, Chen TC, Wei PL, Huang MT. Laparoscopic Roux-en-Y versus Mini-Gastric Bypass for the treatment of Morbid Obesity. Ann Surg 2005 ; 242 : 20-28 RYG Bypass Mini Bypass Op time (mns) 205 148 Early complications 20% 7.5% Late complications 7.5% 7.5 % EWL at one year 58.7% 64.9% EWL at two years 60% 64.4%
- 79. MGB: Summary • Obstructive: Band, VBG, Sleeve, RNY: Likely to Fail • Malabsorption: BPD, Switch, SADI Deficiencies and Malnutrition • MGB Non-Obstructive Restriction Post Gastrectomy Syndrome Physiology Fatty Food Intolerance Enforced Mediterranean Diet
- 80. More Detailed References on the Mini-Gastric Bypass
- 81. MGB One of the Most Effective & Safest Best Rx for Obesity & DM
- 82. Objective 5: MGB One of the Most Effective & Safest • MGB Series • Rutledge U.S.A. 6,000 + (16 yr + FU) • Lee Taiwan 1000 + (RCT, 10 yr+ FU) • Noun Lebanon 1000 • Kular India 1000+ • Cady France 2000 + • Peraglie U.S.A. 2000 + • Carbajo Spain 2000 + • Garcia-Caballero Spain 1000 + • Musella et al. Italy 1000 • Others (i.e. Chevallier Paris , Tacchino Rome etc.)
- 83. MGB One of the Most Effective & Safest • MGB Series • Findings in all series are the same: • Short operation, low risk of short and long term complications • Excellent short and long term weight loss 75-100% EWL, Better than BPD) • Revisable and Reversible • Minimal Risk of Bile Reflux in Knowledgeable Hands
- 84. One Thousand Consecutive Mini-gastric Bypass: Short- And Long-term Outcome • 1,000 patients who underwent MGB from November 2005 to January 2011 • Operative time and length of stay for primary vs. revisional MGB were • 89 ± 12.8 min vs. 144 ± 15 min (p < 0.01) and • l.85 ± 0.8 day vs. 2.35 ± 1.89 day (p < 0.01) • Short-term complications 2.7% for primary vs. 11.6% for revision MGB (p < 0.01) • Obes Surg. 2012 May;22(5):697-703. One thousand consecutive mini-gastric bypass: short- and long-term outcome. Noun et al, Department of Digestive Surgery, Hôtel-Dieu de France Hospital and University Saint Joseph Medical School, Bd Alfred Naccache, Achrafieh, BP 166830 Beirut, Lebanon. rnoun@wise.net.lb
- 85. One Thousand Consecutive Mini-gastric Bypass: Short- And Long-term Outcome • Five (0.5%) patients presented with leakage from the gastric tube but none had anastomotic leakage. • Four (0.4%) patients, all revisions with severe bile reflux Rx by stapled latero-lateral jejunojejunostomy (Braun). • Excessive weight loss occurred in four patients easily revised. • Percent excess weight loss (EWL) of 72.5% occurred at 18 months. • Obes Surg. 2012 May;22(5):697-703. One thousand consecutive mini-gastric bypass: short- and long-term outcome. Noun et al, Department of Digestive Surgery, Hôtel-Dieu de France Hospital and University Saint Joseph Medical School, Bd Alfred Naccache, Achrafieh, BP 166830 Beirut, Lebanon. rnoun@wise.net.lb
- 86. One Thousand Consecutive Mini-gastric Bypass: Short- And Long-term Outcome • The 50% EWL was achieved for 95% of patients at 18 months and for 89.8% at 60 months. • MGB is an effective, relatively low-risk, and low-failure bariatric procedure. • In addition, it can be easily revised, converted, or reversed. • Obes Surg. 2012 May;22(5):697-703. One thousand consecutive mini-gastric bypass: short- and long-term outcome. Noun et al, Department of Digestive Surgery, Hôtel-Dieu de France Hospital and University Saint Joseph Medical School, Bd Alfred Naccache, Achrafieh, BP 166830 Beirut, Lebanon. rnoun@wise.net.lb
- 87. Laparoscopic Roux-en-y Vs. Mini-gastric Bypass For The Treatment Of Morbid Obesity: A 10-year Experience. • Obes Surg. 2012 Dec;22(12):1827-34. Laparoscopic Roux-en-Y Vs. mini-gastric bypass for the treatment of morbid obesity: a 10-year experience. • Lee WJ, Ser KH, Lee YC, Tsou JJ, Chen SC, Chen JC. • Department of Surgery, Min-Sheng General Hospital, National Taiwan University, No. 168, Chin Kuo Road, Tauoyan, Taiwan, Republic of China. wjlee_obessurg_tw@yahoo.com.tw
- 88. Laparoscopic Roux-en-y Vs. Mini-gastric Bypass For The Treatment Of Morbid Obesity: A 10-year Experience. • October 2001 and September 2010, 1,657 patients who received gastric bypass surgery (1,163 for LMGB and 494 for LRYGB) • Surgical time was significantly longer for LRYGB (159.2 vs. 115.3 min for LMGB, p < 0.001). • The major complication rate was higher for LRYGB (3.2 vs. 1.8%, p = 0.07). • 5 years after surgery, the mean BMI was lower in LMGB than LRYGB (27.7 vs. 29.2, p < 0.05) and • LMGB also had a higher excess weight loss than LRYGB (72.9 vs. 60.1%, p < 0.05). • Late revision rate was LRYGB 3.6% and MGB 2.8%
- 89. Laparoscopic Roux-en-y Vs. Mini-gastric Bypass For The Treatment Of Morbid Obesity: A 10-year Experience. • CONCLUSIONS: • This study demonstrates that MGB can be regarded as a SIMPLER and SAFER alternative to RNY with similar or BETTER efficacy at a 10- year experience.
- 90. MGB Can Successfully Treat Obesity and Diabetes in Both Thin and Obese Diabetic Patients 2013: Kular Hospital 6 year study T2DM patients Results: Type 2 Diabetes resolved 98% of MGB
- 91. MGB More Effective than BPD Dr Tacchino MGB vs BPD • Weight Loss and Diabetes Resolution Following Mini- Gastric Bypass and Bilio-Pancreatic Diversion. Tacchino R., Rutledge R., Università Cattolica del Sacro Cuore, Rome, Italy • 408 pts Jan 2007 to Dec 2009 • 36 months follow-up • Mini-Gastric Bypass (n = 164) initial BMI 46.4±9.6 or • Bilio-Pancreatic Diversion (n = 244) initial BMI 46.9±7 (Tacchino’s preferred Operation)
- 92. MGB More Effective than BPD Dr Tacchino MGB vs BPD • RESULTS: • Mean BMI at two years was 28.5±3.9 kg/m2 and at three years 27.4±4.5 kg/m2 after MGB • BMI at two years 32.7± 6.04 kg/ m2 and at three years 33.6±5.1 kg/m2 after BPD • One year resolution of diabetes was accomplished in: • 100% in MGB group • 95% in BPD group.
- 93. MGB More Effective than BPD Dr Tacchino MGB vs BPD • Tacchino’s conclusions: • “Both MGB and BPD resulted in excellent weight loss, excellent resolution of co-morbities with low risk of long term complications. • The MGB was associated with greater weight loss than BPD. • Improvements in other cardiovascular risk factors and quality of life were similar after both procedures.”
- 94. RNY & Small Bowel Obstruction
- 96. Every Text book in General Surgery Warns of SBO after RNY
- 97. RNY Causes Bowel Obstruction and Death MGB surgeon’s family member had RNY => SBO => Death RNY SBO 2-16% NO Other Bariatric Surgery Has Such High Rate of Bowel Obstruction
- 98. Selecting an Operative Procedure Safety and Effectiveness Personal Experience, Animal Models, Expert Judgment, Published Data and Controlled Prospective Randomized Trials all show: MGB is More Effective than Sleeve RNY MGB is Safer than SleeveRNY
- 99. Conclusions: MGB MUCH Better than RNY • 1. RNY v MGB • 2. Animal, Gen Surg and Bariatric Data: Best Rx = Gastric + Duodenal Bypass • 3. Excludes Band/Sleeve • 4. RNY Unquestionably the HIGH Risk • 5. Numerous studies show MGB short safe and highly effective; Better than RNY • Best Choice
- 100. End Section
- 101. Opinion Among BPD Surgeons • Length of the Common Channel is the Critical Factor for Fat Malabsorption & weight loss • We review Animal studies and MGB results that suggest this is not the case • Am J Surg. 2005 May;189(5):536-40, Common channel length predicts outcomes of biliopancreatic diversion alone and with the duodenal switch surgery, McConnell DB, O'rourke RW, Deveney CW
- 102. NUTRIENT ABSORPTION in the SMALL INTESTINE: Remember the Basics • Duodenum and Upper Jejunum: most minerals • Jejunum and Upper Ileum: carbohydrates, amino acids, water-soluble vitamins • Jejunum: absorbs most of lipids and fat-soluble vitamins • Terminal Ileum: Bile,Vit B12
- 103. Fat absorption and the Length of Billroth II Afferent Limb • Experiment • Question: Increase length of afferent limb associated with increased fat Malabsorption • Animals underwent a 50% distal gastrectomy with an antecolic • Polya-type Billroth II anastomosis
- 105. Fat absorption and the Billroth II Afferent loop • 50% distal gastrectomy with an antecolic • Polya-type Billroth II anastomosis • Afferent limb of • 30cm, 60cm, 90cm
- 106. Fat absorption and the Billroth II Afferent Limb: RESULTS • PreOp: Fecal excretion on a 127 Gm. diet 2.4% of the ingested fat. • Similar results in dogs and in humans • Animals with BII + 30cm afferent limbs • Able to digest and absorb the dietary fat without any apparent difficulty
- 107. Fat absorption and the Billroth II Afferent loop • Average fecal excretion diet was 2.4% of the ingested fat. • Longer Loops steatorrhea increased • 30 cm. limb fecal fat 2.4% (No Change) • 60 cm. limb fecal fat excretion 10.2% • 90 cm. limb 28.2%
- 108. MGB Billroth II RNY
- 109. Fat absorption and the Billroth II Afferent loop • Average fecal excretion Pre Op 2.4% of ingested fat • Longer Limb increased steatorrhea • 30 cm. limb fecal fat 2.4% (No Change) • 60 cm. limb fecal fat excretion 10.2% • 90 cm. limb 28.2%
- 110. Fat MAL-absorption and the Billroth II Afferent LIMB • Afferent limb most important factor post gastrectomy steatorrhea, “LENGTH” • Animals with short afferent loops NO significant steatorrhea. • As the length of the afferent limb increased, a concomitant and dramatic rise in fecal fat excretion was noted.
- 111. Fat MAL-absorption and the Billroth II Afferent loop • Malabsorption is NOT due to bypass of the upper jejunum ALONE • Kremen’s Study: • Over half the jejunum can be bypassed without producing steatorrhea.
- 112. An Experimental Evaluation of the Nutritional Importance of Proximal and Distal Small Intestine • Arnold J. Kremen, et al. Ann Surg. 1954 September; 140(3): 439–447
- 113. Kremen, et al. • “Experimental studies in dogs reveal that animals can bypass • 50 to 70 per cent of their small intestine • and maintain a near normal nutritional status”
- 114. Experimental Evaluation of the Nutritional Importance of Proximal and Distal Small Intestine • Study showed that • Bypass of major lengths of the proximal small intestine, • Weight is well maintained • No great interference with fat absorption • NOTE: Contradiction with Prior Study
- 115. Experimental Evaluation of the Nutritional Importance of Proximal and Distal Small Intestine • 50 - 70% of the small bowel bypassed • Proximal and distal ends were exteriorized as a cutaneous stoma. • Intestinal continuity was re- established by end-to-end anastomosis
- 118. 50% of Jejunum Bypassed: No Weight Loss!
- 119. Massive bypass = No Effect • The small intestine in adults is a long and narrow tube about 7 meters (23 feet) long • 50% Bypass = 11.5 ft (3.5 meters) • Minimal Weight Loss!
- 120. 70% Bowel Bypassed Minimal Weight Loss
- 121. Massive bypass = Little Effects! • The small intestine in adults is a long and narrow tube about 7 meters (23 feet) long • 70% Bypass = 16 ft (5 meters) • 5% weight loss
- 122. 70% Bypass = Little Effect • Group IV animals, which were similar to Group I except that 70% instead of 50% of proximal small bowel removed from intestinal continuity, • Lost about five per cent of their preoperative weight and then stabilized at this level.
- 123. Transit Time & Fat Absorption • 50-70% Bypass • Made Little Difference in • Transit Time or • Fat Absorption NOT affected
- 124. Experimental Evaluation of the Nutritional Importance of Proximal and Distal Small Intestine • CONCLUSIONS • The proximal 50 to 70 per cent of the small intestine can be removed with no apparent ill effects. • Weight is maintained, and protein and fat absorption are not significantly altered. • Arnold J. Kremen, John H. Linner, and Charles H. Nelson
- 125. Bypass of Jejunum; Experimental Results: No Fat Malabsorption or Major Fat Malabsorption • 2 Studies; 2 Different Findings • Massive Small Bowel Bypass => Minimal Effects • Moderate Small Bowel Bypass =>Major Effects • What is the Difference?
- 126. It’s the Billroth II
- 127. Billroth II + Moderate Bypass = Fatty Food Intolerance + Mild Fat Malabsorption and Good Weight Loss
- 128. RNY • Primarily Restrictive • Minor fat Malabsorption • No Malabsorption of Protein or Carbohydrate • Restriction begins to fade early