Marginal ulcer gastric bypass


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Marginal ulcer gastric bypass

  1. 1. Marginal Ulcer & Gastric Bypass<br />
  2. 2.
  3. 3. Dr Rutledge: Training & Background<br /><ul><li>Undergrad/Medical School; Teacher Dr. Lester Dragstedt Pioneer / Inventor of the Highly Controversial Vagotomy and Pyloroplasty
  4. 4. 2 Years Cardiac Surgery National Institutes of Health National Heart Lung Blood Institute
  5. 5. 20 years University of NC; Professor of Surgery, Associate Chief of Staff, Director of Section Medical Informatics, Director North Carolina Trauma Registry
  6. 6. Author of 93 papers and articles</li></li></ul><li>Dr Rutledge: Training & Background<br /><ul><li>Specialty: Trauma, Critical Care, Medical Informatics and Bariatric Surgery (1978-1998 20 years University NC)
  7. 7. Experience: Trauma Surgery, Director NC Trauma Registry
  8. 8. Peptic Ulcer Surgery; Vagotomy & Pyloroplasty; Antrectomy & Billroth II
  9. 9. Bariatric Surgery 33 years: Open RNY & Vertical Banded Gastroplasty
  10. 10. 1997 one first surgeons laparoscopic RNY
  11. 11. Mini-Gastric Bypass; 14 years, over 6,000 cases</li></li></ul><li>CONSIDERING THE MGB?MGB IS A SUPERB SURGERY BUT…WARNING: “THERE ARE “TRICKS AND TRAPS”<br />Dr. Rutledge<br />USA 001-702-714-0011<br />
  12. 12. OFFER A SAFE & SUCCESSFUL MGB PROGRAM<br /><ul><li>Call / Email: Anytime question or advice on any clinical, technical or patient MGB question
  13. 13. USA 001-702-714-0011
  14. 14. Personal Visit: Dr. Rutledge Visiting Professor: France, Turkey, Austria & India, Upcoming visits Greece, Istanbul, United KingdomCzech Republic, Italy, Germany, UAE, Pakistan,
  15. 15. Please Use the Knowledge of Others Before You Start;Experience; over 14 years, over 6,000 patients
  16. 16. USA 001-702-714-0011</li></li></ul><li>UPCOMING “HANDS ON” MGB IN INDIA“TRICKS AND TRAPS” TRAINING PROGRAM<br /><ul><li>Didactic Sessions Talk with the Leading World Experts
  17. 17. Hands On Surgery (with approval) Scrub in on cases Assist and Participate in MGB Surgery
  18. 18. This Fall and Next Year
  19. 19. Bija India, Dr Rutledge & Dr Kular
  20. 20. USA 001-702-714-0011</li></li></ul><li>Problem Definition:Bariatric Surgery: A HISTORY OF FAILURE<br />
  21. 21. The Gastric Sleeve:Not as Bad as the BandNot as Dangerous as the RNY<br />
  22. 22. SUCCESS CRITERIA"IDEAL" WEIGHT LOSS SURGERY<br />1.  Low Risk<br />2. Major Weight Loss<br />3. Easily performed<br />4. Short operative times<br />5. Outpatient or short hospital stay<br />6. Minimal Blood Loss<br />7. No Need for ICU Stay<br />8. Minimal Pain<br />9. Very High Patient Satisfaction<br />10. A Good "Exit Strategy" <br />
  23. 23. SUCCESS CRITERIA"IDEAL" WEIGHT LOSS SURGERY<br />11. Change Behavior & Preferences; Marked Decrease in Hunger and Increased Satiety<br />12. Minimal Retching and Vomiting <br />13. Few adhesions or hernias<br />14. Minimal impact on Heart and Lung Function<br />15. Low Failure Rate<br />16. Low Cost<br />17. Short Recovery Time<br />18. Rapid Return to Work<br />19. Low Risk of Pulmonary Embolus<br />20. Durable weight loss<br />
  24. 24. SUCCESS CRITERIA"IDEAL" WEIGHT LOSS SURGERY<br />21. Low Risk of Marginal Ulcer<br />22. Fat Malabsorption; low cholesterol & CV risk <br />23. No Plastic Foreign Body <br />24. Easily Verifiable Results; > 10 years of Results<br />25. Low Risk of Bowel Obstruction<br />26. Based upon sound surgical principles <br />27. Independent confirmation of results<br />28. Healthy life after surgery<br />29. Supported by LEVEL I Evidence; RCT (Controlled Prospective Randomized Trial)<br />30. Block “Sweet Eater” Failures<br />
  25. 25. MINI-GASTRIC BYPASS <br /><ul><li>The Mini-Gastric Bypass1997 – 2011 ; >6,000 pts,10 yr Data; Multiple Centers,R.C.Trials
  26. 26. Vertical Gastric Tube(Collis Gastroplasty)
  27. 27. Gastric Bypass(Billroth II Gastro-jejunostomy)</li></li></ul><li>MINI-GASTRIC BYPASSBASED SOUND SURGICAL PRACTICE <br /><ul><li>Billroth II Performed over 100 years
  28. 28. 16,000 Billroth II’sUSA in 2007
  29. 29. Operation of choice: Trauma, Ulcers, Cancer Stomach etc.</li></li></ul><li>Criteria for Success; Ideal Weight Loss Surgery<br />
  30. 30. Criteria for Success; Ideal Weight Loss Surgery<br />
  31. 31. Criteria for Success<br />
  32. 32. Epidemiology: What do we know about Marginal Ulcers?<br />Marginal ulcers represent one of the most problematic postoperative complications following Roux-en-Y <br />A marginal ulcer, or stomal ulceration, refers to the development of mucosal erosion at the gastrojejunal anastomosis, typically on the jejunal side.<br />incidence of marginal ulcers is 0.6 to 16 %<br />The true incidence is very likely much higher<br />
  33. 33. Marginal Ulcer has been known since the beginning GI Surgery<br />MARGINAL, GASTROJEJUNAL OR PEPTIC ULCER SUBSEQUENT TO GASTROENTEROSTOMY.<br />Erdmann JF.<br />Ann Surg. 1921Apr;73(4):434-40. <br />
  34. 34. Marginal Ulcer has been known since the beginning GI Surgery<br />THE ROENTGEN DIAGNOSIS AND LOCALIZATION OF MARGINAL PEPTIC ULCER.<br />Carman RD.<br />Cal State J Med. 1920 Nov;18(11):377-82<br />
  35. 35. Marginal Ulcer has been known since the beginning GI Surgery<br />Re-evaluation of the role of the pyloric antrum in marginal peptic ulcers.<br />SCHILLING JA, PEARSE HE.<br />SurgGynecol Obstet. 1948 Aug;87(2):225-34<br />
  36. 36. Marginal Ulcer has been known since the beginning GI Surgery<br />Vagotomy as a treatment for marginal ulcer.<br />CRILE G Jr, BROWN GM Jr.<br />Gastroenterology. 1951 Jan;17(1):14-9<br />
  37. 37. Marginal Ulcer has been known since the beginning GI Surgery<br />Review Article: The present status of the management of marginal ulcer.<br />BYRD BF Jr.<br />J Tn State Med Assoc. 1953 Feb;46(2):56-8.<br />
  38. 38. Marginal Ulcer has been known since the beginning GI Surgery<br />2,282 RYGB<br />122 (5%)Marginal ulcers <br />39 (32%) Surgery<br />SurgObesRelat Dis. 2009 May-Jun;5(3):317-22. Revisionaloperations for marginal ulcer after Roux-en-Y gastric bypass. Patel RA, Brolin RE, Department of Surgery, University Medical Center at Princeton, Princeton, New Jersey 08536<br />
  39. 39. Marginal Ulcer Very High After RNY Gastric Bypass<br />441 RYGB<br />10 (12%)of RNY gastric bypass presented an "early" marginal ulcer<br />Asymptomatic (28%)<br />ObesSurg. 2009 Feb;19(2):135 Incidence of marginal ulcer 1 month and 1 to 2 years after gastric bypass: a prospective consecutive endoscopic evaluation of 442 patients with morbid obesity. Csendes Aet al Department of Surgery, University Hospital, University of Chile, Santiago, Chile.<br />
  40. 40. Marginal Ulcer Very High After RNY Gastric BypassAssociated with H. Pylori<br />260 RYGB<br />7%of RNY gastric bypass marginal ulcer<br />H. pylori infection, (treated), was twice as common marginal ulceration (32%) as among those who did not (12%)<br />SurgEndosc. 2007 Jul;21(7):1090-4. Marginal ulceration after laparoscopic gastric bypass: an analysis of predisposing factors in 260 patients. Rasmussen JJ, Department of Surgery, University of California, Davis, 2221 Stockton Boulevard, Sacramento, CA 95817, USA<br />
  41. 41. Marginal Ulcer after Gastric Bypass; Both RNY & MGB<br />Marginal Ulcers after Roux-en-Y Gastric Bypass: Pain for the Patient…Pain for the Surgeon<br />by Camellia Racu, <br />January 2010<br />Bariatric Times. <br />2010;7(1):23–25<br />
  42. 42. Marginal Ulcer after Gastric Bypass; RNY <br />
  43. 43. Marginal Ulcer after Gastric Bypass; RNY & MGB<br />Marginal ulcers RNYranging from 0.6 to 16%<br />True incidence is very likely much higher<br />Csendesprospective study routine postoperative endoscopic evaluation<br />28% of marginal ulcers were asymptomatic<br />Gastric Bypass (RNY & MGB)HIGH incidence of Marginal Ulcer<br />BILE MAKES NO DIFFERENCE!!!<br />
  44. 44. Incidence of perforated gastrojejunal anastomotic ulcers after RNY<br />April 2002 to April 2010, 1213 patients underwent laparoscopic RYGB<br />Operative mortality was .15%<br />10 perforated GJA ulcers (.82%) at a mean of 13.5 (6-19) months<br />Morbidity and mortality rate was 30% and 10%<br />Perforated GJA ulcers can develop in 1 of 120 Roux en Y Gastric Bypasses & DEADLY<br />
  45. 45. Marginal Ulcers: Achilles Heel of Gastric Bypass<br />Management<br />1. Warn Patients & Surgeon “Be Vigilant”<br />2. Aggressive anti-H. Pylori Rx<br />3. Aggressive use of Antacids<br />4. Strict Avoidance of Ulcerogenic Agents(NSAIDS, Etoh, Smoking, Coffee, Soda, Nitrates)<br />5. Encourage: Probiotics, Yogurt, Fruits Vegetables<br />BILE MAKES NO DIFFERENCE!!!<br />
  46. 46. CONCLUSIONS: Best Choice: Mini-Gastric Bypass<br /><ul><li>Choice of Obesity Surgery
  47. 47. Objectives “Ideal” Weight Loss Surgery
  48. 48. RNY, Band, Sleeve, MGB
  49. 49. MGB Best meets all objectives/success criteria
  50. 50. Beware of Marginal Ulcer in RNY & MGB
  51. 51. Rational Decision Making: Best Choice; Mini-Gastric Bypass</li></li></ul><li>WHY CRITICS ONLY WORRY ABOUT THE MINI-GASTRIC BYPASS?<br /><ul><li>Why do Critics only care about the Mini-Gastric Bypass?
  52. 52. 100,000’s of people already have and are living with and are getting the Billroth II every day
  53. 53. Why haven’t concerned bariatric surgeons stepped forward to stop all general, trauma and oncologic surgeons from performing this Billroth II surgery?</li></li></ul><li>WHY CRITICS ONLY WORRY ABOUT THE MINI-GASTRIC BYPASS?<br /><ul><li>Why do Critics only care about the Mini-Gastric Bypass?
  54. 54. Why haven’t concerned bariatric surgeons stepped forward to start a fund to help suffering Billroth II patients get needed conversions of their surgery to Roux-en-Y?
  55. 55. Why don’t they write letters to the editor calling for the Billroth II to be declared a operation non-grata?</li></li></ul><li>WHY CRITICS ONLY WORRY ABOUT THE MINI-GASTRIC BYPASS?<br /><ul><li>Why do Critics only care about the Mini-Gastric Bypass?
  56. 56. Why haven’t concerned bariatric surgeons stepped forward to national funding for lifetime endoscopic screening of Billroth II patients to find dreaded gastric cancers?
  57. 57. It seems odd doesn’t it?
  58. 58. There is a simple reason</li></li></ul><li>WHY CRITICS ONLY WORRY ABOUT THE MINI-GASTRIC BYPASS?<br /><ul><li>There is a simple reason
  59. 59. The critics of the MGB do not do those things because they are ridiculous
  60. 60. Such actions are Not supported by the data
  61. 61. The Billroth II and the MGB are both good operations
  62. 62. Published data Does Not support the critics misreading of the medical literature</li></li></ul><li>CRITICS OF THE MINI-GASTRIC BYPASSSHOULD BE EMBARRASSED<br />
  63. 63. Rational Data Analysis vs.Irrational FEAR Gastric Cancer<br /><ul><li>1. Gastric Cancer Declining Rapidly
  64. 64. 2. GC Environmental Causes; Easily Prevented
  65. 65. 3. Some studies show Small Increased RiskProbably from Ulcers / H. Pylori
  66. 66. 4. Many large studies: NO increased risk
  67. 67. 5. Endoscopic Screening: Not Recommended
  68. 68. 6. General, Trauma & Oncologic Surgeons Use Billroth II</li>