MGB Tips and Ticks
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1. The document describes the mini-gastric bypass (MGB) procedure performed by Dr. Rutledge. 2. The MGB involves creating a gastric pouch through antrectomy and gastrojejunostomy, similar to standard general surgery procedures. A Collis gastroplasty is also performed to create a non-obstructive gastric tube. 3. Dr. Rutledge's results from over 6,000 MGB patients over 20 years show very low complication rates, short operative and hospital times, and durable weight loss and diabetes resolution for over 15 years. The MGB can be tailored for different patients and is reversible.
MGB Tips and Ticks
- 1. A Few of the Fine Points and Tips Mini-Gastric Bypass Dr Rutledge Email: DrR@clos.net
- 2. Mini-Gastric Bypass Operative Procedure 1. “Standard Gen Surgery” Antrectomy & Gastro-jejunostomy 2. Collis Gastroplasty Non Obstructive Restriction 3. Antecolic Billroth II Loop Gastro jejunostomy Tailor Bypass to Patient
- 3. Mini-Gastric Bypass • Simple • Elegant • Effective • Durable > 15 yrs • Powerful • Tailored to Patient • Reversible • Revisable
- 4. Lets Do MGB Easy 30 minute Case
- 5. Dissection Lesser Curve at or just below Crow's Foot
- 6. Staple Perpendicular to the Lesser Curve
- 7. Perpendicular to Lesser Curve, Base of the Pouch
- 8. NOT a Sleeve Pouch Wide Base
- 10. 1. Avoid EG Junction 2. Cobra Head Distal Tip
- 13. Avoid EG Junction Tips Re: Gastro-Jejunostomy
- 15. Staple vs Suture (1-2 layer) Everted Anastomosis
- 16. Mini-Gastric Bypass • Simple • Elegant • Effective • Durable > 15 yrs • Powerful • Tailored to Patient • Reversible • Revisable
- 17. DrR MGB Presentation Part 1: Introduction, History of MGB; Slides 2-11 Part 2: Confusion; MGB = Standard General Surgery, Slides 12-30 Part 3: Confusion; Mechanism of Action Slides 31-42 Part 4: MGB Surgical Technique Slides 43-76
- 18. Part 1: Introduction, History of MGB
- 19. History of MGB & Dr Rutledge • Dr Rutledge Trauma Surgeon Professor of Surgery 20 years Univ of North Carolina • 1997 Patient: Illegal Drug Dealer • Gun Shot Wounds X 6 to Abdomen • 9 pm Thurs Night Sept 1997 Emergency Surgery • Injury to Stomach, Tail of Pancreas and Multiple Loops of Small Bowel
- 20. History of MGB Patient w Gun Shot Wounds 1997 • Injury to Stomach, Pancreas and Multiple Loops of Small Bowel • Rx Distal Gastrectomy • Distal Pancreatectomy • Splenectomy
- 21. History of MGB RX: Antrectomy, Distal Pancreatectomy Splenectomy
- 22. History of MGB Reconstruction Ante-Colic Billroth II
- 23. 1997 Next Morning Planned Lap RNY MGB = Standard General Surgery (MGB => Antrectomy & Billroth II)
- 24. For 20 years American Surgeons Cannot Understand This Simple Fact MGB = Standard General Surgery (MGB => Antrectomy & Billroth II)
- 25. 20 Years Later Surgeons Still Misunderstand the MGB • The MGB is NOT a RNY with One Less Anastomosis
- 26. MGB = Billroth II, Billroth II is GOOD General Surgeons Know How to Use the Billroth II Many Bariatric Surgeons are Uninformed and Fear the Billroth II
- 27. 20 Years FEAR of MGB? Mason Loop *NOT* MGB Billroth II Loop Gastro-Jejunostomy WRONG RIGHT
- 28. History of MGB Mason Loop VIOLATED Rule General Surgery Billroth II Loop: Antrum: YES, EGJx: NO, NEVER
- 29. The Billroth II is a Good Operation When Used Wisely! • Well Informed General Surgeons => Routinely Use the Billroth II • Uninformed Bariatric Surgeons => Fear the Billroth II
- 30. MGB: Easy / Not Easy Restriction via Post Gastrectomy Syndrome • Basic General Surgery • 1. Collis Gastroplasty NON-Obstructive Gastric Tube NOT Sleeve, Not Roux type Pouch • 2. Antrectomy & Billroth II NON-Obstructive Gastro-Jejunostomy MODERATE Bypass • Should be Simple But...
- 31. MGB Knowledge = Technique 1. If You Do Not Understand the Mechanism of Action and the Anatomy (Knowledge) 2. Then You Will NOT Know How to Do the Surgery (Technique)
- 32. Confusion Re: MGB • MGB is NOT Old Mason Loop Violates Basic General Surgery • MGB is NOT Like RNY or Sleeve Obstruction From Small or Narrow Pouch
- 33. Confusion Re: MGB • MGB is NOT Primarily Malabsorptive Forgetting Basic General Surgery (2 m bypass) • MGB NOT Like Jejuno-ileal Bypass, BPD, SADI Massive Gut Bypass • Misunderstanding Mechanism of Action MGB *IS* => Restriction WITHOUT Obstruction => Post Gastrectomy Syndrome => Good Dumping / Bad Dumping => ** Not ** Band / Sleeve / RNY
- 34. MGB: Easy: ifYou Know What You are Doing Disaster in the Wrong Hands
- 35. All the Details for Doing a Good MGB... 1. If You Do Not Understand the Mechanism of Action and the Anatomy (Knowledge) 2. Then You Will NOT Know How to Do the Surgery (Technique)
- 37. MGB Part 1: Creation of the Gastric Pouch •Creation of the Gastric Pouch (Band/Sleeve/RNY) •Bougie of size 28 to 36 F can be used to fashion the pouch •Understanding MGB Anatomy & Physiology •MGB NOT Obstructive •No Tight Pouch (The MGB is not a Sleeve) •Pouch Diameter and Length are Not Critical •MGB Pouch Size: •Pouch Diameter = Esophagus; •Pouch Length = Allow GJ at the greater curve of the stomach •Start the Gastric Pouch (Long Pouch) at or beyond Crow’s Foot (junction of body and antrum of the stomach. •Beware a Twist in the Pouch) •Avoid Bleeding Along Staple Line; (Very Slow Application of Stapler, use compression) •Management of EG junction; MGB vs Sleeve (DO NOT go near the EG junction) •Management of the gastric fundus; (Leaving some fundus is acceptable) •Never dissect the EG junction •Never attempt to visualize the diaphragmatic cura •Always stay lateral to the EG junction •Leaving some of the fundus behind in the MGB is always acceptable •Reminder: The MGB is NOT a Sleeve, The MGB is NOT a RNY •Complete division of the stomach in NOT critical in the MGB
- 38. Management of Hiatal Hernia in Patients WITH or WITHOUT GERD •Do Nothing!! Do Not Dissect the Hiatus, Do Not Repair the Crua. •Reminder the MGB is not a sleeve. •In cases of a large hiatal hernia •Reduce the stomach into the abdomen and •Complete the usual MGB pouch. •MGB leads to greater than 85% resolution of GERD (Rutledge), •further treatment is rarely needed •Additional procedure can be performed in 12-18 months when the patient is healthier and smaller if necessary (RareNever needed).
- 39. Part 2: Bilio-Pancreatic Bypass • Never Divide the omentum; • Retract the omentum medially • Run the small bowel hand over hand with atraumatic bowel clamps • Estimate distance of each hand to hand movement • Estimate Measure the length of the bowel; • Understand that accurately measuring the bowel length is a “FOOL’S ERRAND” • Understand that bowel length varies moment to moment, hour to hour and day to day. • Understand that any and ALL bowel length measurements are inherently imprecise and thus weight loss is as unpredictable with MGB as with Band, Sleeve and RNY. • Because of lack of precision always be conservative in creating the bilio- pancreatic limb. • Warning the MGB can be the most powerful form of Bariatric Surgery • Measure the length of the grasper tip (usually between 1.5 and 3 cm) • Run the bowel length approximately 60 steps of 3 cm (1.2 inches) => • Creating Bilio-pancreatic limb length of 180 cm
- 40. Bilio-Pancreatic Limb Length • Recognize risk of long Bilio-Pancreatic Limb Length and Excess Weight Loss/Malnutrition • Understand management of Excess Weight Loss (Rapid 30-60 min Revision) • Recommendations to MGB Surgeons with • MGB Experience of Less Than 250 Cases • MI 30-60 180 cm (count 60 3 cm/1.2 inch steps) • BMI 60-80 200-250 cm (65-80 3 cm/1.2 inch steps) • Elderly (Age > 60) Decrease limb length by 20% • Vegetarians Decrease limb length by 20% • Frail/Fragile patient Decrease limb length by 20% • First 200 MGB’s (New MGB surgeon) Decrease limb length by 20%
- 41. Gastro-Jejunostomy •Possibly the most IMPORTANT step in MGB •After Identifying the Site for the GJ Move Loop to left upper quadrant •Confirm at least 1-2 meters more distal bowel •(It is unnecessary to run the entire small bowel) •Carefully expose tip of gastric pouch; Make sure it is not twisted •Create gastrotomy ANTERIOR to the staple line 1 cm from first staples at the start of the pouch •Create jejunotomy on anti-mesenteric border at 180 cm Bilio-pancreatic limb •Dilate the jejunotomy with the Anvil of the 60-mm blue staple cartridge •then remove the anvil and place the staple cartridge into the bowel •Thread the bowel all the way onto the cartridge •Grasp the gastric pouch at the gastrotomy and advance the anvil into the gastrotomy •Now stop •The surgery is almost over; Take your time •Critical Factors in Gastro-Jejunostomy •Several features in positioning the staple cartridge, the gastric pouch and the bowel must be exactly aligned for a successful surgery. Simply proceeding slowly and carefully will result in a good outcome.
- 42. Gastro-Jejunostomy • Critical Factors: • Both the gastric pouch and the bowel edges must meet at exactly the junction of the cartridge and the anvil of the staple gun • No twist in either the bowel or the gastric pouch • Large visible area of bowel anteriorly (should not be too close to the bowel mesentary) • Gastric pouch staple line should NOT cross the staple cartridge/anvil longitudinally (keep the gastric pouch staple line out of the jaws of the stapler and several millimeters away from the anastomosis) • There should be visible space on the posterior gastric wall between the lateral gastric staple line and the staple cartridge and anvil (avoid ischemic island) • Take time No tension on the bowel • Gastric mesentary not in the staple line • Carefully and slowly evaluate the placement of the gastric pouch, the bowel and the staple gun • Do not proceed until each is perfectly placed • Then close the stapler and begin a very very slow firing of the staple gun, use compression to avoid bleeding. • Using extra time Slowly is the watchword • This staple line MUST NOT BLEED • This achieved simply by the surgeon’s patience and direct pressure • The stapled GJ is completed and the stapler removed • Now the GJ should lie perfectly with the sweep of the bowel from the patient’s left to right and the GJ located at the level of the greater curvature of the stomach or the transverse colon. • If it is not perfect do not proceed but stop and consider dividing the GJ and performing another GJ 10-15 cm distal to the failed anastomosis. • Do not leave an imperfect GJ.
- 43. Gastro-Jejunostomy Closure • All that is left is a minor closure of a 1-2 cm defect of the GJ. • The Diameter of the Gastro-Jejunostomy in the MGB (Large) • A few comments stapled or hand sewn closure is acceptable but do not forget 100 years of GI and general surgery science and experience. • One or two layers NEVER MORE. • The anastomosis heals by diffusion of oxygen blood cells into the spaces between the sutures. This means there must me 1-3 mm between sutures and the suture should NOT strangulate the tissue. • Leak Testing • For the first 150 cases test the anastomosis with air and methylene blue for demonstration of technical errors. After the first 150 cases if the surgeons still finds leaks with air or methylene blue he/she should consider retraining for laparoscopic surgery with another more experienced surgeon. • End of Operation • Do not inject Marcaine in the Port Sites (It does not help post op pain) • Inspect the Gastro-jejunostomy, the gastric pouch and the EG junction • No Drains
- 44. And More... • Post Op • Post Op Orders • Discharge Instructions • MGB Diet • Supplements • Follow Up • Follow Up Blood Tests • Dx Leak Protocol • Rx Leak Protocol
- 45. Obviously I Cannot Teach All of These Things in One Lecture
- 46. Objectives 1. History of DrRutledge & MGB (It's Just General Surgery) 2. MGB = Billroth II, Billroth II is GOOD 3. MGB = General Surgery, How to 4. The Future of Bariatric (Metabolic) Surgery 5. Diabetes Epidemic 6. The Mini-Gastric Bypass can be Tailored; Useful for all types of patients Especially * thin * Diabetics
- 48. Dr Rutledge's Results Mini-Gastric Bypass • In 6,000+ patients • Over almost 20 years • < 5% complications • Mean 36 minute op time • Median 1 day hospital stay • 10-15 year follow up (Talk to 10+ Year MGB Patients on Facebook) • Controlled prospective trials (** 2X better than Sleeve **) • Reversible and Revisable < 30 minutes
- 49. Dr Rutledge's Results Confirmed in Every Published Series • MGB: Tailored to Fit the Patient & Surgeon • Very High levels of patient satisfaction • General Surgery Data & Controlled Trial: MGB Twice as effective as Sleeve Rx Diabetes • Resolution Diabetes 85%-90%+ • Decreased Hunger, Chol, BP, cRP, Enforced Mediterranean Diet • Easily Reversible Revisable ...
- 50. Mini-Gastric Bypass Operative Procedure 1. “Standard Gen Surgery” Antrectomy & Gastro-jejunostomy 2. Collis Gastroplasty Non Obstructive Restriction 3. Antecolic Billroth II Loop Gastro jejunostomy Tailor Bypass to Patient
- 51. Mini-Gastric Bypass • Simple • Elegant • Effective • Durable > 15 yrs • Powerful • Tailored to Patient • Reversible • Revisable
- 52. Lets Do MGB Easy 30 minute Case
- 53. Dissection Lesser Curve at or just below Crow's Foot
- 54. Staple Perpendicular to the Lesser Curve
- 55. Perpendicular to Lesser Curve, Base of the Pouch
- 56. NOT a Sleeve Pouch Wide Base
- 58. 1. Avoid EG Junction 2. Cobra Head Distal Tip
- 61. Avoid EG Junction Tips Re: Gastro-Jejunostomy
- 63. Staple vs Suture (1-2 layer) Everted Anastomosis
- 64. Mini-Gastric Bypass • Simple • Elegant • Effective • Durable > 15 yrs • Powerful • Tailored to Patient • Reversible • Revisable
- 65. Ideal Candidates for MGB EVERYONE? ;-) •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
- 66. The End Finito