Safe and Effective Treatment of Diabetes

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Safe and Effective Treatment of Obesity & Diabetes: Failure of the Band, Sleeve & RNY vs Success of the Mini-Gastric Bypass

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Safe and Effective Treatment of Diabetes

  1. 1. Failure of Sleeve, Band & RNY.Power of Mini-Gastric Bypass.&Successful Treatment ofObesity & Diabetes!
  2. 2. Medscape Medical News: Bypass Surgery forDiabetes With Nonmorbid Obesity? MaybeMarlene Busko: Jun 04, 2013• "In a new report, RNY bypass in mildly tomoderately obese patients withuncontrolled diabetes had better short-term glucose control and weight loss thantheir peers who received medications andlifestyle advice."• JAMA. 2013 Jun 5;309(21):2240-9. Roux-en-Y gastric bypass vs intensive medicalmanagement for the control of type 2 diabetes, hypertension, and hyperlipidemia: theDiabetes Surgery Study randomized clinical trial. Ikramuddin S, Korner J, Lee WJ,Connett JE, Inabnet WB, Billington CJ, Thomas AJ, Leslie DB, Chong K, Jeffery RW,Ahmed L, Vella A, Chuang LM, Bessler M, Sarr MG, Swain JM, Laqua P, Jensen MD,Bantle JP. Department of Surgery, School of Public Health, University of Minnesota,Minneapolis, MN 55455, USA. ikram001@umn.edu
  3. 3. Medscape Medical News: Bypass Surgery forDiabetes With Nonmorbid Obesity? MaybeMarlene Busko: Jun 04, 2013• Not metioned in the abstract:• There were 22 serious complications in 60RNY gastric-bypass patients (36%);• 2 most serious complications Anastomoticleaks (3.3%)• 1 patient suffered anoxic brain injury.• RNY patients were also more likely tohave other Complications such asnutritional deficiencies.
  4. 4. Obesity surgery-diabetes study shows pros andcons By LINDSEY TANNER | Associated Press –Tue, Jun 4, 2013• "About a third of the 60 RNYs developedserious problems within a year of theoperation"• "That rate is similar to whats been seen inprevious studies of RNY Bypass"• "for the most serious complications —infections, intestinal blockages andbleeding — the rate was 6 percent"
  5. 5. Obesity surgery-diabetes study shows pros andcons By LINDSEY TANNER | Associated Press –Tue, Jun 4, 2013• The most dangerous complicationoccurred in one patient when stomachcontents leaked from the surgery site,leading to an overwhelming infection, legamputation and brain injury.• Lead author Dr. Sayeed Ikramuddin, anobesity surgeon at the University ofMinnesota, called that case "a fluke."
  6. 6. Obesity surgery-diabetes study shows pros andcons By LINDSEY TANNER | Associated Press –Tue, Jun 4, 2013• RNY pts lost nearly 60 lbs• 75% lowered sugar levels to normal ornear normal levels• JAMA editorial says such devastatingcomplications are rare, but that• "the frequency and severity ofcomplications ... is problematic"
  7. 7. Medscape Medical News: Bypass Surgery forDiabetes With Nonmorbid Obesity? MaybeMarlene Busko: Jun 04, 2013• Not metioned in the abstract:• 22 serious complications in 60 RNYs(36%);• 2 most serious complications Anastomoticleaks (3.3%)• 1 patient suffered anoxic brain injury.• RNY patients were also more likely tohave other Complications such asnutritional deficiencies.
  8. 8. We Must Ask For Betterthan:36% Serious Complications3% Leak RateA case of brain damage and LegAmputation is NOT"a fluke"Only 75% normal or improvement
  9. 9. Expert Judgment andLatest Data onWeight Loss SurgeryProceduresBand, Sleeve,RNY andMini-Gastric Bypass
  10. 10. A CLARION CALL FOR BETTERBARIATRIC SURGERY• RNY and VBG FAIL to cut costs orLengthen Life in VA Studies• Bariatric Surgery; A History ofComplications & Failure• We Need Better Bariatric Surgery• We Simpler, Safer, More Powerful, MoreDurable and Revisable and Reversible• We Need the MGB
  11. 11. Primary Objectives• Obesity and Diabetes are GrowingProblems in India• Surgery Can Successfully Treat Obesityand diabetes in Both the Thin and ObeseDiabetic Patient• The Band, the Sleeve and the RNY arefailed forms of Bariatric Surgery• The Mini-Gastric Bypass is Both Very Safeand Very Effective Over the Short andLong Term
  12. 12. Obesity and Diabetes are GrowingProblems in India
  13. 13. India the worlds with largest number of diabetics
  14. 14. Obesity and Diabetes are GrowingProblems in India
  15. 15. Surgery Can Successfully TreatObesity and Diabetes inBoth the Thin and ObeseDiabetic Patient
  16. 16. Surgery Can Successfully Treat Obesity andDiabetes in Both the Thin and ObeseDiabetic Patient• 2011: Lee et al. MGB vs SLEEVE• 12 mos prospective study 60 T2DMpatients• Matched for DM duration, type of DMtreatment, and glycemic control• Results• T2DM resolved 93% MGB (p = 0.02)• Weight loss fasting glucose, Hgba1c waistcircumfrence all worse in SG
  17. 17. RNYBypass Surgery for Diabetes WithNonmorbid Obesity? Maybe Jun 04, 2013• 12-months, 28 participants (49%) RNY group and 11(19%) in the lifestyle-medical management groupachieved the primary end points• BUT• 22 (36%) serious complications in the RNY group• 2 most serious complications were anastomotic leak3.3%!!,• 1 patient suffered anoxic brain injury.• Patients who underwent surgery were also more likely tohave nonserious adverse events such as nutritionaldeficiencies.• JAMA. 2013 Jun 5;309(21):Roux-en-Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, andhyperlipidemia: the Diabetes Surgery Study randomized clinical trial. Ikramuddin S, Department of Surgery, School of Public Health, University ofMinnesota, Minneapolis, MN 55455, USA. ikram001@umn.edu
  18. 18. The Band,the Sleeve and the RNY areFailed forms of Bariatric Surgery
  19. 19. RNY Bypass Surgery for Diabetes WithNonmorbid Obesity? Maybe Jun 04, 2013• After 12-months, 28 participants (49%) in the gastricbypass group and 11 (19%) in the lifestyle-medicalmanagement group achieved the primary end points• BUT• 37% serious complications in the RNY group• 2 most serious complications were anastomotic leak3.3%!!,• 1 patient suffered anoxic brain injury.• Patients who underwent surgery were also more likely tohave nonserious adverse events such as nutritionaldeficiencies.• 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
  20. 20. The Mini-Gastric Bypass isBoth Very Safe andVery EffectiveOver the Short and Long Term
  21. 21. Primary Objectives• Obesity and Diabetes are Growing Problems inIndia• Surgery Can Successfully Treat Obesity anddiabetes in Both the Thin and Obese DiabeticPatient• The Band, the Sleeve and the RNY are failedforms of Bariatric Surgery• The Mini-Gastric Bypass is Both Very Safe andVery Effective Over the Short and Long Term
  22. 22. The Band, the Sleeve and theRNY are Failed forms of BariatricSurgeryPublished DataExpert Opinion
  23. 23. SUCCESS CRITERIA"IDEAL" WEIGHT LOSSSURGERYSAFETY & EFFICACYSAFETY & EFFICACY
  24. 24. SUCCESS CRITERIA"IDEAL" WEIGHT LOSS SURGERY• 1. Low Risk (SAFETY)• 2. Major Weight Loss (EFFICACY)• 3. Easily performed• 4. Short operative times (SAFETY)• 5. Outpatient or short hospital stay (SAFETY)• 6. Minimal Blood Loss (SAFETY)• 7. No Need for ICU Stay (SAFETY)• 8. Minimal Pain• 9. Very High Patient Satisfaction• 10. A Good "Exit Strategy" (SAFETY)
  25. 25. SUCCESS CRITERIA"IDEAL" WEIGHT LOSS SURGERY• 11. Change Behavior & Preferences;Marked Decrease in Hunger and Increased Satiety• 12. Minimal Retching and Vomiting• 13. Few adhesions or hernias (SAFETY)• 14. Minimal impact on Heart and Lung Function (SAFETY)• 15. Low Failure Rate (EFFICACY)• 16. Low Cost• 17. Short Recovery Time• 18. Rapid Return to Work• 19. Low Risk of Pulmonary Embolus (SAFETY)• 20. Durable weight loss (EFFICACY)
  26. 26. SUCCESS CRITERIA"IDEAL" WEIGHT LOSS SURGERY• 21. Low Risk of Ulcer (SAFETY)• 22. Fat Malabsorption; low cholesterol & CV risk (EFFICACY)• 23. No Plastic Foreign Body (SAFETY)• 24. Easily Verifiable Results; > 10 years of Results(EFFICACY)• 25. Low Risk of Bowel Obstruction (SAFETY)• 26. Based upon sound surgical principles (SAFETY)• 27. Independent confirmation of results (EFFICACY)• 28. Healthy life after surgery (SAFETY)• 29. Supported by LEVEL I Evidence; RCT (ControlledProspective Randomized Trial) (EFFICACY)• 30. Block “Sweet Eater” Failures (EFFICACY)
  27. 27. Summary: Band, Sleeve & RNY• In Short:• Band: Now fading = Very Safe/NOT VeryEffective at 5 yrs• Sleeve: Popular = Not very Safe/FadingEffectiveness• RNY: By Every Measure Most DangerousBariatric Surgery & Effectiveness "Issues"
  28. 28. Summary: Band, Sleeve & RNY•Published Data•Expert Opinion
  29. 29. 28,000 Patients• Ann Surg. 2011 Sep;254(3):410-20First report from the• American College of Surgeons• Bariatric Surgery Center Network28,000 PatientsHutter MM, Schirmer BD, Jones DB, KoCY, Cohen ME, Merkow RP, Nguyen NT.Department of Surgery, Massachusetts GeneralHospital, Boston, MA 02114, USA.mhutter@partners.org
  30. 30. BandSleeveRNY
  31. 31. BandSleeveRNY
  32. 32. BandSleeveRNY
  33. 33. Published Data:ACS Study 28,000 pts: Conclusions• Lap Band: Very Safe but 5 year Failure• Sleeve: More Dangerous than Band andfollowing Bands track to 5 yr failure• RNY: More effective but studies clearlyshow long term weight regain andrecurrence of Diabetes• RNY: Clearly the most dangerous BariatricSurgery (Remember 36% seriouscomplications and 3.3% Leak rate)
  34. 34. In Short-Published Data:ACS Study 28,000 pts: Conclusions• Lap Band: Safe but Fails• Sleeve: Danger >> Band + 5 yr failure• RNY; More effective but Most dangerous• Needed: Safety and Effectiveness• Mini-Gastric Bypass
  35. 35. Sleeve Gastrectomy Failure:• Sleeve gastrectomy and the risk of leak: asystematic analysis of 4,888 patients.• “Risk of leak is low at 2.4%." !!• Surg Endosc. 2012 Jun;26(6):1509-15. Epub 2011 Dec17. Aurora AR, Khaitan L, Saber AA. Department ofSurgery, University Hospitals Case Medical Center,Cleveland, Ohio
  36. 36. What do the Experts Say?
  37. 37. Survey Results• As part of a Pre-Conference survey for the• MGB/OAB Consensus Conference• Asked Expert Surgeons to Judge 4 weight lossprocedures.• This is a report Expert Judgment of the Band,the Sleeve, RNY and the MGB
  38. 38. 12. Your Opinion about the LAP BAND• LAP BAND is good, short simple surgery,maybe the best form of WLS, I use it often7.1%• LAP BAND is OK it is an acceptablealternative and I use it sometimes 46.4%• LAP BAND is a Bad operation and shouldnot be used 46.4%
  39. 39. 13. Your Opinion about theSLEEVE• SLEEVE is Good, short simple surgery,maybe the best form of WLS, I use it often32.1%• SLEEVE is OK it is an acceptablealternative and I use it sometimes 53.6%• SLEEVE is a Bad operation and shouldnot be used 14.3%
  40. 40. 14. Your Opinion about the RNY• RNY is Good, maybe the best form ofWLS, I use it often 42.9%• RNY is OK it is an acceptable alternativeand I use it sometimes 50.0%• RNY is a Bad operation and should not beused 7.1%
  41. 41. 15. Your Opinion about the Mini-Bypass /One Anastomosis Bypass• MGB is good, short simple surgery, maybethe best form of WLS, I use it often 67.9%• MGB is OK it is an acceptable alternativeand I use it sometimes 28.6%• MGB is a Bad operation and should not beused 3.6%
  42. 42. MGB: Fewest NegativeJudgments• 46.4% said the Band was a bad operation• 14.3%, 7.1% and 3.6% said the Sleeve, the RNYand the MGB were bad operations and shouldnot be done.• By this measure experts judged the band theleast favorable operation and the MGB the bestchoice.
  43. 43. MGB: Most Often Judged Best• These experts judged the MGB most often to bea "good, short simple surgery, maybe the bestform of WLS, I use it often" in 67.9% of cases ascompared to• 7.1%, 32.1% and 42.9% for the band, the sleeveand the RNY respectively.• In these experts opinion the MGB is by far thebest judged form of weight loss surgery.
  44. 44. Frequency of NegativeJudgment
  45. 45. Frequency of Choice as"Best" form of Surgery
  46. 46. Judgment of the Band
  47. 47. Judgment of the Sleeve
  48. 48. Judgment of the RNY
  49. 49. Judgment of the MGB/OABHighest Good / Lowest Bad
  50. 50. Success: Mini-Gastric BypassSimplicity, Power & Safety
  51. 51. Failed Sleeve Converted to RNY; Sept 2012Less 24 months!• Failed Sleeve:• Weight loss• Diabetes Rx• SEVERE Reflux symptoms.• Time to Failure less than 24 months.• 30% for "Severe Reflux"!!!!• Indications and Mid-Term Results of Conversion from Sleeve Gastrectomy to Roux-en-Y Gastric Bypass. Authors Gautier T, et al. Obes Surg. 2012 Sep 23. Départementde Chirurgie Digestive, Caen University Hospital, Caen Cedex, France,gautier.tho@gmail.com.
  52. 52. Why the Band and Sleeve FailRestrictive Procedures and Sweetand "Liquid Calories"
  53. 53. Band, Sleeve vsthe Neuro-Humoral Drive to Eat• Restrictive Procedures• MAKE SWEET EATERS:• Mechanical Block ofNormal Healthy Foods• Weight Loss: Honeymoon 2 years• Then Failure Weight Regain• GE Reflux(Risk of Esophageal Cancer)
  54. 54. Band & SleeveBlock Normal Healthy Foods• Weight Loss =>• Increased Hunger• Decreased Satiety• Healthy Foods Blocked• Drive to Eat UP• What Happens?
  55. 55. Band & Sleeve;Block Intake Normal Healthy FoodSleeve Band
  56. 56. Restrictive Procedures• Successfully BlockNormal Healthy DietBut• They DO NOT BLOCK ...
  57. 57. Pathologic Dietary ChoicesCalories:Ice Cream 200g/540 cal,2 Milky-way Bars, 1,000 cal2 L Bottle Coke 830 calTotal: 2,370 cal
  58. 58. Diet InducedIncreased Hunger
  59. 59. Summary• Most Diets &Restrictive Procedures (Band/Sleeve)Will Fail• Attempts to OverrideNeuro-Humoral Hunger SystemRoutinly Fails• R.P.s Force Patients into PathologicalDietary Choices• MAKE SWEET EATERS!
  60. 60. Primary Objectives• Obesity and Diabetes are Growing Problems inIndia• Surgery Can Successfully Treat Obesity anddiabetes in Both the Thin and Obese DiabeticPatient• The Band, the Sleeve and the RNY are failedforms of Bariatric Surgery• The Mini-Gastric Bypass is Both Very Safe andVery Effective Over the Short and Long Term
  61. 61. SOLUTION?
  62. 62. Diet InducedIncreased Hunger
  63. 63. Mini-Gastric BypassThe Mongoose!
  64. 64. Mini-Gastric Bypass• BlocksNeuro-Humoral HungerSystem• Short, Simple, Durable,30 minute Surgery that:• Decreases Hunger &Increases SatietyThe MongooseHe is a Little Bit Ugly, No?
  65. 65. One Thousand Consecutive Mini-gastric Bypass:Short- And Long-term Outcome (Noun)• 1,000 patients who underwent MGB• Operative time and length of stay for MGB• 89 min• 1.8 days• Short-term complications 2.7%• Obes Surg. 2012 May;22(5):697-703. One thousand consecutive mini-gastric bypass: short- andlong-term outcome. Noun et al, Department of Digestive Surgery, Hôtel-Dieu de France Hospitaland University Saint Joseph Medical School, Naccache, Achrafieh, BP 166830 Beirut, Lebanon.rnoun@wise.net.lb
  66. 66. One Thousand Consecutive Mini-gastric Bypass:Short- And Long-term Outcome (Noun)• 0.5% Leaks• Four (0.4%) patients, severe bile reflux Rx bystapled latero-lateral jejunojejunostomy (Braun).• Excessive weight loss occurred in four patientseasily revised.• Percent excess weight loss (EWL) of 73%occurred at 18 months• Obes Surg. 2012 May;22(5):697-703. One thousand consecutive mini-gastric bypass: short- and long-termoutcome. Noun et al, Department of Digestive Surgery, Hôtel-Dieu de France Hospital and University SaintJoseph Medical School, Naccache, Achrafieh, BP 166830 Beirut, Lebanon. rnoun@wise.net.lb
  67. 67. 9 Year MGB Follow UpEfficacy & Safety• Excess weight loss and mean BMI 5 years after LMGBwas 72.1% and 27.1• Of the 1322 patients, 23 (1.7%) reop surgery during afollow-up of 9 years.• The most common cause of revision was excess wt lossin 9, followed by inadequate weight loss in 8, and bilereflux in 3.• No internal hernia or ileus during the follow-up period.• Conclusion: MGB Excellent Durable Long Term Safe (NoHernia/Bowel Obstruction)• Surg Obes Relat Dis. 2011 Jul-Aug;7(4):486-91.Revisional surgery for laparoscopic minigastric bypass. Lee WJ,Department of Surgery, Min-Sheng General Hospital, National Taiwan University, Taipei, Taiwan.wjlee_obessurg_tw@yahoo.com.tw
  68. 68. RNY Doubles the need forhospitalisation• In California from 1995 to 2004,• 60,077 patients underwent RYGB-11,659 in 2004 alone.• The rate of hospitalization in the yearfollowing RYGB was more thandouble the rate in the year precedingRYGB• (19.3% vs 7.9%, P<.001).• Hospitalization before and after gastric bypass surgery. Zingmond DS, McGory ML,Ko CY. JAMA. 2005 Oct 19;294(15):1918-24.
  69. 69. MGB Decreases the HospitalizationAfter Surgery• The rate of hospitalization after MGB• Declined from 17% the year before to11% the year after and 2/3 of theseadmisions were unrelated to MGB• Hospitalization before and after mini-gastric bypass surgery.Rutledge R. Int J Surg. 2007 Feb;5(1):35-40. Epub 2006 Aug 10
  70. 70. 2011: Lee et al. MGB vs SLEEVE• 12 mos prospective study 60 T2DMpatients• Matched for DM duration, type of DMtreatment, and glycemic control• Results• T2DM resolved 47% SG and 93% GBP (p= 0.02)• Weight loss fasting glucose, Hgba1c waistcircumfrence all worse in SG
  71. 71. 2011: Lee et al. RYGB vs SLEEVE(Efficacy)• Controlled Prospective Trial: SG is onlyHALF as effective as MGB in inducingremission of T2DM50% 90%
  72. 72. Mini-Gastric Bypass Decreases HungerSurvey 2,783 Pts
  73. 73. What Do the Experts Say?Survey of 102 surgeons answereddetailed survey online.Surgeons from 6 Continents and 23countries.The group reported on apast years experience with over 39,000cases, Very experienced surgeons.
  74. 74. Over 100 Surgeons from Around the World:
  75. 75. Both Kular and Rutledge, Op Time < 40 min
  76. 76. Risk ofEsophagealCancer?
  77. 77. 30% Reflux &EsophagealCancer?
  78. 78. LeaksSurg Obes Relat Dis. 2008 Jul-Aug;4(4):528-33.Laparoscopic sleeve gastrectomy:
  79. 79. Leak Rate• Leak Rate in New Multicenter trial• 3.3%!!• Roux-en-Y gastric bypass vs intensive medical management for the controlof type 2 diabetes, hypertension, and hyperlipidemia: the Diabetes SurgeryStudy randomized clinical trial.• Ikramuddin S, Korner J, Lee WJ, Connett JE, Inabnet WB, Billington CJ,Thomas AJ, Leslie DB, Chong K, Jeffery RW, Ahmed L, Vella A, ChuangLM, Bessler M, Sarr MG, Swain JM, Laqua P, Jensen MD, Bantle JP.• JAMA. 2013 Jun 5;309(21):2240-9.
  80. 80. Band/SleeveRoad to FailureInitial Weight LossReturn of HungerEat Normal FoodsObstructionAcid Reflux/CancerEat Liquid CaloriesWeightRegain
  81. 81. Expert Opinion In Summary• Restrictive Procedures Fail (Band Sleeve)• Starting at 2-5 Years• Restrictive Procedures Push Patients towardsLiquid Calories• (Can a Sleeve stop Coke!)(Can a Sleeve stop Coke!)• Weight Regain is Common• Acid Reflux 30%+• Acid Reflux = Esophageal Cancer
  82. 82. Why is the MGB So Much Betterthan the Sleeve
  83. 83. 2006: Rubino et al.Duodenal exclusion• “This study shows that bypassing Duodenumdirectly ameliorates type 2 diabetes,• independently of effects on food intake, bodyweight, malabsorption, or nutrient delivery to thehindgut.”• The Mechanism of Diabetes Control After Gastrointestinal Bypass Surgery Reveals a Role of the Proximal SmallIntestine in the Pathophysiology of Type 2 Diabetes. Rubino, Francesco, MD; Forgione, Antonello, MD;Cummings, David E MD; Vix, Michel MD; Gnuli, Donatella MD; Mingrone, Geltrude MD; Castagneto, Marco, MD(S); Marescaux, Jacques MD, FRCS Annals of Surgery; 244 (5): 741-749, November 2006
  84. 84. Outcome after gastrectomy in gastriccancer patients with type 2 diabetes• 403 gastric cancer patients with T2DM• BMI % Reduction• Duodenal Bypass:• No Bypass 7.6%• Bypass 11.4%• Jong Won Kim, etal, Gangnam Severance Hospital, Yonsei UniversityCollege of Medicine, Seoul 135-720, South Korea, World J Gastroenterol.2012 January 7; 18(1): 49–54.
  85. 85. Bile Acids: Critical HormonalFactors in glucose homeostasis• Decrease in the bile acid pool results indecreases in hemoglobin A1c, glucoselevels and improved insulin sensitivity.• Duodenal bypass improve the success inthe resolution of diabetes.• Combined procedures include duodenalbypass which leads to decrease in bileacid pool.
  86. 86. The Mini-Gastric BypassExcellent Operation with Results Reported onThousands of Patients Over the Past 10-15 years• Survey Shows:• Short, Simple, Effective, Durable,• 30 min Operation with 1 day HospitalStay• Lower Leak rate than Sleeve or RNY• Best Weight Loss• Easily Reversible, Revisable
  87. 87. Primary Objectives• Obesity and Diabetes are Growing Problems inIndia• Surgery Can Successfully Treat Obesity anddiabetes in Both the Thin and Obese DiabeticPatient• The Band, the Sleeve and the RNY are failedforms of Bariatric Surgery• The Mini-Gastric Bypass is Both Very Safe andVery Effective Over the Short and Long Term
  88. 88. Conclusions• Sleeve: popular now; RelativelyDangerous and shows Bands signs of5 year failure and new onset GERD in30%• MGB short simple reversible and revisableoperation may be up to twice as effectiveas Sleeve and has excellent long termdurability
  89. 89. Marginal Ulcer has been known since thebeginning GI Surgery MARGINAL, GASTROJEJUNAL OR PEPTIC ULCERSUBSEQUENT TO GASTROENTEROSTOMY. Erdmann JF. Ann Surg. 1921 Apr;73(4):434-40.
  90. 90. UNINFORMED FEAR BILLROTH IIEDUCATED USE BILLROTH II• 1. Gastric Cancer Declining Rapidly, > 50%• 2. Gastric Cancer Cause:Environmental Factors / Easily PreventedDiet, Lifestyle changes and Rx of H. Pylori(Avoid Etoh, smoking, processed & saltedmeats and foods, seek high intake of fruits andvegetables)
  91. 91. UNINFORMED FEAR BILLROTH IIEDUCATED USE BILLROTH II• 3. Some studies Slight Increased Risk ofgastric cancer after 20 – 30 years (RR 1.5):But: BII to Rx Ulcer =>Ulcer => Increased Risk• (Worried? Rx H Pylori, Eat healthy etc.)• 4. Many Large Studies: No Increased RiskThousands of patients followed for Decades
  92. 92. UNINFORMED FEAR BILLROTH IIEDUCATED USE BILLROTH II• 5. Endoscopic screening of Billroth II patientsis Not Recommended. Why? Low Risk!• 6. General, Trauma and Oncologic surgeonsroutinely use the Billroth II (Thousands ofpublications)• 7. 2007 ~16,000 BII procedures wereperformed in the USA
  93. 93. Marginal Ulcers:Achilles Heel of Gastric Bypass Management 1. Warn Patients & Surgeon “Be Vigilant” 2. Aggressive anti-H. Pylori Rx 3. Aggressive use of Antacids 4. Strict Avoidance of Ulcerogenic Agents(NSAIDS, Etoh, Smoking, Coffee, Soda, Nitrates) 5. Encourage: Probiotics, Yogurt, Fruits Vegetables BILE MAKES NO DIFFERENCE!!!

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