Understanding the Mechanism of Action of the Mini-Gastric Bypass
Download as PPTX, PDF1 like671 views
1. The document discusses the mechanism of action and misunderstandings of the Mini-Gastric Bypass (MGB) procedure. 2. It notes that many surgeons do not fully understand the MGB and its distinction from other procedures like Roux-en-Y gastric bypass, leading to complications. 3. The presentation aims to explain the MGB mechanism, which involves non-obstructive food restriction and intolerance as well as changes in diet, due to post-gastrectomy syndrome effects from the Billroth II limb configuration.
Understanding the Mechanism of Action of the Mini-Gastric Bypass
- 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 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 6761 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”
- 7. Understanding the Obvious If Not an MGB Expert, Do Not do the MGB! • First: If you do not understand an operation (MGB) • Do Not Use the Operation!! • In Short: This Presentation in Summary: 1. Widespread and Persistent Misunderstanding of MGB 2. Often Leading to Complications and Even Death 3. Needed: * Standardization of MGB, ** Education and *** Recognition of Knowledgeable and Skilled Surgeons
- 8. Needed: Standardization of MGB and Recognition of Surgeons Knowledgeable and Skilled in its use * Standardize, ** Educate, *** Recognize The Best in MGB Please Join The Board of Governors! MGBReviewCorp.com
- 9. Invitation to Join the Board of Governors of the MGB Review Corp I invite you to join the Board of Governors of the MGB Review Corporation For Excellence in the MGB! 1. Complete the MGB Review Corporation Information Form https://www.surveymonkey.com/r/MRCReviewCorp 2.Join the Facebook Page and Group: MGBReviewCorp https://www.Facebook.com/MGBReviewCorp/ https://www.Facebook.com/groups/MGBReviewCorp Please join us to initiate your participation in the group process Email, Call or Message for more information or to give advice and your opinions: Email: DrR@clos.net, Facebook: DrRRutledge Facebook Messenger: @DrRRutledge, Phone: 702-483-7133 or 702-714-0011 or What's App: Dr Rutledge
- 10. Confusion By Surgeons Who Do Not Understand the MGB How Often Have Surgeons And Continue to Be Wrong About the Mini-Gastric Bypass?
- 11. Confusion By Surgeons Who Do Not Understand the MGB Some Examples of MGB Confusion 1. The Pouch is Too Big & Pts Will Not Loose Weight 2. Short Gastric Pouch (MGB = Old Mason Loop) 3. Dissection EG Junction and crural Repair 4. MGB with a “Ring” 5. Irrational Fear of Bile Reflux 6. Confused About Risk Gastric Cancer 7. Fear of Malnutrition 8. Management of MGB Complications And More...
- 12. 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
- 13. Bariatric Surgeons Forget History of GI Surgery What have we learned from 100 years of GI Surgery?
- 14. 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 • …
- 15. 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**)
- 16. Polya Type Gastro-Jejunostomy (HELLO; MGB Not RNY) NOTE: Large Wide Open Gastro- jejunostomy
- 17. 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, Barretts – Roux-en-Y: (Highest Risk Complications) Weight regain, – BPD / Duodenal Switch / SADI: Malnutrition, Deficiencies, Diarrhea, Foul Smelling Gas
- 18. Understanding 1. Dumping Syndrome & 2. Post Gastrectomy Syndrome 3. Mini-Gastric Bypass Good Dumping / Bad Dumping Aversive Conditioning
- 19. 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
- 20. 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!
- 21. Why the Band/Sleeve/RNY Fail All OBSTRUCTIVE Restrictive Procedures Stricture: Block “Healthy Foods” Induce Intake of Sweets, "Liquid Calories" & “Junk Food”
- 22. 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
- 23. 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?
- 24. Band, Sleeve, RNY Block Normal Healthy Foods • Weight Loss => • Increased Hunger • Decreased Satiety • Healthy Foods Blocked • Drive to Eat Increased • What Happens?
- 25. 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
- 26. 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
- 27. Dumping and Effectiveness in Sleeve • Obes Surg. 2015 The Effect of Roux-en-Y Gastric Bypass and Sleeve Gastrectomy Surgery on Dietary Intake, Food Preferences, and Gastrointestinal Symptoms, El Labban • Gastroenterol Res Pract. 2016, Risk of Dumping Syndrome after Sleeve Gastrectomy and Roux-en-Y Gastric Bypass Ramadan M. RYGB, especially with larger gastrojejunal anastomosis, are more prone to developing DS following surgery than patients undergoing LSG • Obes Surg. 2012 Dumping symptoms and incidence of hypoglycaemia after provocation test at 6 and 12 months after laparoscopic sleeve gastrectomy. Papamargaritis D “Symptoms suggestive of dumping syndrome were recorded in 40 % of patients at 6 months and in 33 % at 12 months postoperatively.” • Obes Surg. 2012 Symptoms suggestive of dumping syndrome after provocation in patients after laparoscopic sleeve gastrectomy Tzovaras “SG 9 patients (29%) experienced definite dumping and other 5 patients (16%) symptoms suggestive of dumping syndrome”
- 28. What Make'e The MGB So Good? Hint: It's the Surgical Technique It's the Billroth II BP Limb Not Lap Band, Sleeve, RNY
- 29. Mini-Gastric Bypass Decreases Hunger Dr Rutledge's Survey 2,783 Pts
- 30. What About the MGB Re: Restriction withouth Obstruction Secondary to Post Gastrectomy Syndrome
- 31. 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
- 32. Post Gastrectomy Syndrome •Rapid Gastric Emptying •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.
- 33. 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
- 34. 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 • ...