MGB Need for Standardization, Education & Recognition
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The mini-gastric bypass (MGB) is presented as a highly effective bariatric surgery option, cited to be equal to or better than sleeve gastrectomy and Roux-en-Y in treating obesity and related comorbidities, particularly type 2 diabetes. Multiple studies highlight MGB's advantages such as higher weight loss, lower complication rates, and fewer hospital stays, while also emphasizing the importance of proper technique and understanding to mitigate risks. Despite some controversies and misunderstandings within the surgical community regarding its implementation, MGB is advocated as a safe, simple, and reversible procedure when performed correctly.
MGB Need for Standardization, Education & Recognition
- 1. Is MGB the New Gold Standard ? No, But Thank You
- 2. I Am Both Proud And Humbled To Be Here With You It Is a Great Honor To See So Many Friends Bless You All And I Hope That I Can Entertain You For a Few Minutes
- 3. MGB Does Not Wish to Be the “Gold Standard” But Now the MGB Stands Fully the Equal to Any Operation Shoulder to Shoulder with you In Our Battle Against Obesity and Diabetes Join Us!
- 4. Good Bariatric Surgery • We all know and 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 • They the Standards we compare ourselves
- 5. Growing Number of Studies: The MGB: Equal To or Better Than Sleeve / RNY & Any other operation A Few Studies Examples...
- 6. 92% of ASMBS Vote Pro MGB!! in New Orleans
- 7. 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 and Billroth II reconstruction following partial gastrectomy for gastric cancer. Gastric Cancer. 2015 Sep 23.
- 8. MGB = Billroth II, Billroth II is GOOD General Surgeons Routinely Use the Billroth II Many Bariatric Surgeons are Uninformed and Fear the Billroth II
- 9. Dr Rutledge's Results Mini-Gastric Bypass
- 10. Dr Rutledge's Results Mini-Gastric Bypass
- 11. Unique Advantages of the MGB Ideal Candidates for MGB, EVERYONE? • MGB Can Be Tailored to Meet Patient Needs 1. Usual Bariatric Patient 2. Diabetic (2x more Effective) 3. Super Obese (Max Power/Effective) 4. GERD Patient 5. Difficult/Psych Patient (Reversible <60 min) 6. Severely Ill/Liver Disease (Two Stage MGB) 7. Borderline Patient (Reversible <60 min) 8. Frail/Elderly (Low Risk) 9. Young Unmarried Female (Reversible/Revisable) 10. FUTURE PATIENTS? (Non-obese Diabetics)
- 12. MGB “Best”/Good Bariatric Surgery? Example Recent Study: MGB is “Good Surgery” Obes Surg. 2017 Sep;27(9):2479-2487 => MGB vs. Sleeve Gastrectomy <= Systematic Review and 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)
- 13. “Mini-gastric bypass simpler, safer, and more effective than laparoscopic sleeve gastrectomy” • Medicine (Baltimore). 2017 Dec • Comparison of safety and effectiveness between •Laparoscopic mini-gastric bypass and Laparoscopic sleeve gastrectomy: A meta-analysis and systematic review. •Wang FG
- 14. “Mini-gastric bypass simpler, safer, and more effective than laparoscopic sleeve gastrectomy” • “Due to safe and simple process and effective outcomes • laparoscopic mini-gastric bypass has become one of the most popular procedures in some countries”
- 15. “Mini-gastric bypass simpler, safer, and more effective than laparoscopic sleeve gastrectomy” 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 hypertension 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 and 8. Lower revision rate.
- 16. Obes Surg. 2017 Nov 3. Revisional Gastric Bypass for Failed Restrictive Procedures: Comparison of Single-Anastomosis (Mini-) and Roux-en-Y Gastric Bypass. Almalki OM • 2001 - 2015, 116 patients • Failed restrictive operations • Revisional bypass surgery (R-MGB vs. R-RNY) • R-RNY significantly longer operative times than R-MGB. • R-MGB shown to be Simpler procedure with Better weight loss than R-RNY
- 17. Sleeve, RNY & Others are Good... The MGB is As Good as or Better Than ... BUT
- 18. The MGB has Been Shown to Be One of the Most Effective and Powerful Forms of Bariatric Surgery In Hundreds of Papers it Has Also Been Shown to Be a Safe and Simple Procedure BUT...
- 20. The MGB Has Great Power The MGB Surgeon Has Great Responsibility Tips and Tricks MGB: Done Well is a Simple Operation But: Surgeon Needs to Understand Anatomy & Physiology => Mechanism of Action => Technique
- 21. Need for Safety • Beware of Brave Surgeons • Need to Understand 1. How to Avoid Trouble 2. How to Get Out of Trouble
- 22. “Mini-Gastric Bypass” Done Right! (Note, If you wish to do MGB or Omega Loop etc. Of course, No Problem But,If you wish to do MGB, This is How We Do It!) Dr. Rutledge, Email: DrRutledge@gmail.com Facebook: DrRRutledge Facebook Messenger: @DrRRutledge WhatsApp: Dr Rutledge +1 (442) 234-3237 +1 (702) - 483-7133 Youtube: DrRRutledge
- 23. Widespread Confusion and Misunderstanding of the Billroth II and the MGB
- 24. The Billroth II is a good safe operation that makes people healthier While Some bariatric Surgeons Fear the Billroth II General Surgeons Routinely Use the Billroth II
- 25. The Billroth II is a good safe operation that makes people healthier Studies Show Billroth II Decreases the Risk of Stroke, Coronary Heart Disease & Diabetes and more
- 26. A Nationwide Population-Based Study Billroth II Decreased Risk of Stroke • 6,425 patients Billroth II for Ulcer • Nationwide Health Database • Matched with 25,602 Ulcer Pts who did not receive Billroth II • Billroth II patients had a lower risk of Stroke! • Medicine (Baltimore). 2016 Apr;95(16)
- 27. 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 • Obes Surg. 2017 Jun;27(6):1604-1611
- 28. A Nationwide Population-Based Study Billroth II Decreased Risk of Diabetes by Almost 50% • National Health Insurance Database • Matched with patients did not receive Billroth II • Billroth II patients of Diabetes (adjusted hazard ratio (aHR): 0.56) • PLoS One. 2016 Nov 28;11(11)
- 29. 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
- 30. General Surgery: Sleeve vs MGB vs RNY J Gastric Cancer. 2017 Jun;17(2):99-109 Nutritional Outcomes of Patients with Gastric Cancer • Comparison of Partial Gastrectomy + • Billroth I (Sleeve), Billroth II (MGB), RNY (RNY) • Regarding post-distal gastrectomy reconstruction, those who underwent Roux-en-Y had lower levels than Billroth-I and Billroth-II first to fifth years after gastrectomy, respectively (P<0.05) • CONCLUSIONS: “Patients undergoing gastrectomy with Roux- en-Y anastomosis or adjuvant chemotherapy should be monitored carefully for malnutrition”
- 31. General Surgery Data • Comparison • Gastrectomy + Billroth I (No Duodenal Exclusion) => Like Sleeve • Gastrectomy Billroth II (WITH Duodenal Exclusion) = Like MGB
- 32. Understand Advantage of Billroth II vs Billroth I, (i.e. MGB vs Sleeve) • General Surgery • 2-year Diabetes remission rate: Billroth I 39% (Sleeve No Duodenal Exclusion) Billroth II 50% (MGB WITH Duodenal Exclusion) • BII significantly increased diabetes remission • (odds ratio, * 3.2 *) in covariate-adjusted logistic regression analysis
- 33. Bariatric Studies Confirm General Surgery Studies
- 34. 5-year results of a randomized trial Sleeve gastrectomy vs Mini-gastric bypass for the treatment of type 2 diabetes Obes Surg. 2014 • Double-blind randomized trial, HbA1c > 7.5%, BMI 25 - 35 Kg/m(2) Type 2 diabetes • At 60 months • 60% MGB • 30% SG • Achieved the primary end points • MGB Twice as Effective as Sleeve
- 35. General Surgery And Randomized Controlled Trials In Bariatric Surgery Demonstrate MGB Much More Effective In Treating Diabetes Than Sleeve
- 36. MGB Excellent Outcomes in Experienced Hands Examples from Few Recent Studies
- 37. Surg Obes Relat Dis. 2018 Feb, Abu-Abeid Diabetes resolution after MGB •25% had diabetes with average glycosylated hemoglobin of 8.6 ± 1.9 g% •Average excess weight loss 1 year after surgery was 88.9 ± 27.3 • Of all diabetic patients, only 7.8% were still diabetic average glycosylated hemoglobin of 5.4 ± 0.6 • CONCLUSIONS: MGB offers excellent resolution of diabetes.
- 38. Evaluation of Weight Loss Indicators and Laparoscopic One- Anastomosis Gastric Bypass Outcomes. Sci Rep. 2018 Jan 31, Carbajo MA • Bilio-pancreatic loop length was 275 ± 24 cm • Hospital stay was 24 hours in 98% • No surgical complications arose. • Weight decreased significantly during follow-up (P < 0.001). • Greatest weight loss was observed at 12 months post surgery (69 ± 13 kg).
- 39. 15-year experience of laparoscopic single anastomosis (mini-)gastric bypass: comparison with other bariatric procedures, Alkhalifah N Surg Endosc. 2018 Jan 8, • “Mini-gastric bypass (MGB) has been validated as a safe and effective treatment for morbid obesity” • 1,731 morbidly obese patients • 30-day post-operative major complication 1.7% less than RNY & Sleeve • At postoperative 1, 5 & 10 yrs, %WL of MGB patients 33 -29% • The MGB had a higher weight loss than RNY & LSG 2-6 years after surgery. • Revision rate of MGB 4.0% Lower than RNY & LSG.
- 40. MGB Best Bariatric Surgery ? Sample Recent Study Obes Surg. 2017 Sep;27(9):2479-2487 MGB vs. Sleeve Gastrectomy for Morbid Obesity: Systematic Review and Meta-analysis Magouliotis DE Seventeen studies 6,761 patients This study reveals: “increased weight loss, remission of comorbidities, shorter mean hospital stay, and lower mortality in the MGB group” “Sleeve Higher Rate GERD”
- 41. Obes Surg. 2017 Nov 3. Revisional Gastric Bypass for Failed Restrictive Procedures: Comparison of Single-Anastomosis (Mini-) and Roux-en-Y Gastric Bypass. Almalki OM1, • May 2001 to December 2015, a total of 116 patients with • failed restrictive bariatric operations • underwent laparoscopic revisional bypass surgery (81 R-MGB and 35 R-RNY). • R-RNY had significantly longer operative times than R-MGB. • R-MGB was shown to be a simpler procedure with better weight reduction than R-RNY
- 42. Mini-Gastric Bypass Tragic/Deadly in the Wrong Hands
- 43. Example of Failed Understanding Leading to Errors in Management and Patient Harm • My Time is limited there are many examples • 1 Recent Tragic Publication • 2 years ago Kular, Rutledge and Deitel wrote a warning letter to Editor a surgical group performing an “Omega Loop” • Quoting my paper (MGB) as the technique being used...
- 44. Liver Dysfunction & Death after MGB • Obes Surg. 2018 Mar;28(3) • “Significant Liver-Related Morbidity After Bariatric Surgery and Its Reversal-a Case Series”, Eilenberg et al • Moderate - Severe Liver damage • Fatigue (90%), ascites (70%), hepatic encephalopathy (30%), and upper gastrointestinal bleeding (20%). • Elevation of transaminases, impairment of coagulation parameters, thrombocytopenia, and hypoalbuminemia were present in 70 - 100%
- 45. Example of Failed MGB Limb Understanding Leading to Errors in Management and Patient Harm • 2 yrs ago we warned that the High %Excess Weight Loss (Misjudged BP Limb) dangerous and deadly consequences • Jan 2018, 10 patients • % excess weight loss ** 111% ** • Treatment: (?) In eight patients, lengthening of the alimentary/common limb (Discuss) • One patient, liver transplant • One patient DEATH - liver failure
- 46. Mini-Gastric Bypass Tragic/Deadly in the Wrong Hands The MGB Done WRONG!
- 47. Mini-Gastric Bypass Simple, Safe, Effective Tailored, Easily Reversible The MGB Done RIGHT!
- 48. •Mini-Gastric Bypass • Anyone can do a “single anastomosis bypass” • That Does Not make it a true “Mini-Gastric Bypass” • See the Following Examples...
- 49. Recent Publications Unequivocally Demonstrate: Poor Understanding of the MGB => Bad Outcomes
- 51. French Series: RNY Experts Adopt “MGB” => * 16% * Gastro-jejunostomy Stricture Rate Reported in the “MGB” Patients
- 52. Int J Surg. 2016 Sep Sleeve gastrectomy vs Mini gastric bypass Misunderstanding & Complications: CONCLUSION: “MGB has better weight loss at one year compared to LSG” Reported “ MGB higher gastric complications. (??)” (No other study has reported stricture at the GJ anastomosis of such high rates)
- 53. Int J Surg. 2016 Sep Sleeve gastrectomy vs Mini gastric bypass Misunderstanding & Complications: At one year MGB >> Sleeve, %TWL 38 ± 8 vs. 34 ± 8 (P < 0.0001) BMI Decrease: -17 ± 5 vs. -15 ± 4 (P = 0.005) But ** Rate of stenosis higher for MGB group, ** 16.9% vs. ** 0% in Sleeve Patients (P < 0.0001).
- 54. Misunderstanding & Confusion May Harm Patients:
- 55. Management of MGB Complications: How to Do It& How NOT To Do It Rx Excessive Weight Loss
- 56. Revision Of Mini-Gastric Bypass For Excessive Weight Loss (Rutledge) How To Do It: • Excessive wt. loss and malnutrition revision in 55 patients (0.9%) • Revision Mean Op time 47 min • Major morbidity 7%, Mean length of stay 3 days & the median 2 days • RNY Revision report Patel et al "difficult, dangerous and potentially deadly" • Revision of the MGB for excess weight loss is 1. technically simple, 2. low risk procedure 3. that takes just under an hour
- 57. Surg Obes Relat Dis. 2017 Roux-en-Y gastric bypass for the treatment of severe complications after omega-loop gastric bypass •“OLGB” conversion to Roux-en-Y gastric bypass (RNY) to treat complications. •17 patients OLGB conversion to RNY. •10 patients (59%) received nutritional support PreOp •Average wt *52 kg* BMI 18 kg/m², *%EWL 149%* •41% major adverse events <90 d •Commentary: No, No, No! Do Not do a Weight Loss Surgery (RNY) for Excessive Weight Loss.
- 58. Rx Excessive Weight Loss Post MGB Experienced MGB Surgeons vs Experienced NON-MGB Surgeons • Experienced MGB Surgeon • Immediate Revision • => Major Morbidity 7% <= • Experienced NON-MGB Surgeons (More Recent Study) • TPN + RNY • => Major Morbidity 41% <=
- 59. Another Tragic Complication Death from Malnutrition After MGB
- 60. Death: 8 months after MGB Diagnosis & Management? 29 y.o. female 8 months after MGB Hypoalbuminemia, anemia, elevated LFTs & Bilirubin, Acidosis and Steatohepatitis What to Do! Patient did not respond to Medical Rx => DEATH. What is the Diagnosis? What to do? Int J Surg Case Rep. 2017
- 61. Malnutrition: Death 8 months after MGB Diagnosis & Management? 29yr F, 8 months after MGB: => Low albumin & Hgb, High LFTs & Bilirubin, Acidosis & Steatohepatitis => Diagnosis? Bypass is Too LONG Liver Failure, Malnutrition/Deficiency(s) Int J Surg Case Rep. 2017
- 62. Malnutrition: Death 8 months after MGB Diagnosis & Management? 29yr F, 8 months after MGB: => Diagnosis? Simple: Bypass is Too LONG Liver Failure, Malnutrition/Deficiency(s) => What to Do? ** Preop Education/Planning ** 1. Resuscitation, 2. Nutritional Support, 3. Early, Simple 30-60 min Revision Int J Surg Case Rep. 2017
- 63. Dr Rutledge's Advice MGB Technique • If You Do Not Understand the Basic General Surgery Principles to the MGB • My advice will not appear justified • Expertise from Band, Sleeve, RNY & BPD/Sadi • Often do not apply to the Anatomy & Physiology of the MGB • Reminders of Basic GI Surgery the MGB
- 65. Good Bariatric Surgery • We all know and 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 • They the Standards we compare ourselves
- 66. Conclusions: And A Warning • Mini-Gastric Bypass Shown to be an excellent operation Equal to or Better than Other Procedures But Only in Trained & Experienced Hands • But Many New Surgeons Do Not Know the Critical Factors to Do the MGB Correctly Resulting in Dangerous and Deadly Outcomes