Mini-Gastric BypassShown to be an excellent operation But Many New Surgeons Do Not Know the Critical Factors to Do the MGB Correctly One Critical Success Factor: LONG Gastric Pouch

1. Mini-Gastric Bypass
Done WRONGWRONG
Dr. RutledgeDr. Rutledge

2. Mini-Gastric Bypass
• Anyone can do a “singleAnyone can do a “single
anastomosis gastric bypass”anastomosis gastric bypass”
• That Does Not mean theyThat Does Not mean they
can/are doing the truecan/are doing the true
“Mini-Gastric Bypass” (MGB)“Mini-Gastric Bypass” (MGB)
• See the Following Example...See the Following Example...

3. No No No
This is NOT an Mini-Gastric BypassThis is NOT an Mini-Gastric Bypass

4. Edward E. Mason, MD, PhD
NOT Mini-Gastric BypassNOT Mini-Gastric Bypass
NOTNOT
Mini-GastricMini-Gastric
BypassBypass

5. Surgeons are Foolish
Confusing Old Mason Loop w MGBConfusing Old Mason Loop w MGB
Gastro-Gastro-
JejunostomyJejunostomy

6. MGB Gastro-Jejunostomy
at the Level of the Transverse Colon
Bowel LoopBowel Loop
Gastro-Gastro-
JejunostomyJejunostomy
Gastric PouchGastric Pouch

7. For Example:
Bird's Beak Defect
Short PouchShort Pouch
Bird's Beak DefectBird's Beak Defect

8. Wrong
This is Not an MGB!
Short PouchShort Pouch
Old Mason Loop Bypass Error!Old Mason Loop Bypass Error!

9. Mini-Gastric Bypass
Done Right
LONGLONG Gastric PouchGastric Pouch

10. Surgeons Need to Understand
Basic General Surgery
• Misunderstanding BasicsMisunderstanding Basics
of General Surgeryof General Surgery
• Difference betweenDifference between
Total/Subtotal GastrectomyTotal/Subtotal Gastrectomy
Vs.Vs.
Distal Gastrectomy/AntrectomyDistal Gastrectomy/Antrectomy

11. Distal Gastrectomy/Antrectomy
• Understand AnatomyUnderstand Anatomy
• EsophagusEsophagus
• BodyBody
• AntrumAntrum
• Antrectomy + Billroth IIAntrectomy + Billroth II
= Routine General= Routine General
SurgerySurgery

12. Distal Gastrectomy + Billroth II
= Routine General Surgery

13. MGB = Antrectomy w Billroth II
Routine General Surgery!

14. Total/Subtotal Gastrectomy

15. Total/Subtotal Gastrectomy
Basic General Surgery:Basic General Surgery:
Total/Subtotal GastrectomyTotal/Subtotal Gastrectomy
Never Reconstruct with Loop Billroth IINever Reconstruct with Loop Billroth II
Only RNYOnly RNY

16. Mason Loop
Violation of Basic General Surgery
• Basic General SurgeryBasic General Surgery
• Total/Subtotal GastrectomyTotal/Subtotal Gastrectomy
NEVER Reconstruct wNEVER Reconstruct w
Loop!Loop!
• Mason Loop BypassMason Loop Bypass
Reconstruct w LoopReconstruct w Loop
• Thus Mason Loop =>Thus Mason Loop =>
FailureFailure
• Violation of Basic GeneralViolation of Basic General
Surgical PrinciplesSurgical Principles

17. Mason Loop
Violation of Basic General Surgery
• Mason Loop BypassMason Loop Bypass
Reconstruct w LoopReconstruct w Loop
• Thus Mason LoopThus Mason Loop
=> Failure=> Failure
• Violation of BasicViolation of Basic
General SurgicalGeneral Surgical
PrinciplesPrinciples

18. Total/Subtotal Gastrectomy
• Basic General SurgeryBasic General Surgery
• NEVER ReconstructNEVER Reconstruct
w Billroth IIw Billroth II
• NEVER ReconstructNEVER Reconstruct
w Billroth IIw Billroth II
• NEVER ReconstructNEVER Reconstruct
w Billroth IIw Billroth II
• NEVER ReconstructNEVER Reconstruct
w Billroth IIw Billroth II

19. MGB Gastric Pouch
• Mini-Gastric BypassMini-Gastric Bypass
Shown to be an excellentShown to be an excellent
operationoperation
• But Many New Surgeons DoBut Many New Surgeons Do
Not Know the Critical FactorsNot Know the Critical Factors
to Do the MGB Correctlyto Do the MGB Correctly
• One Critical Success Factor:One Critical Success Factor:
• LONG Gastric PouchLONG Gastric Pouch

20. What should be ideal length of pouch?
• This question shows theThis question shows the
surgeon has not understandsurgeon has not understand
the teachings of Generalthe teachings of General
Surgery HistorySurgery History
• The Answer to Creation of theThe Answer to Creation of the
pouch is Simple...pouch is Simple...

21. MGB Gastric Pouch
• General Surgery:General Surgery:
• Acceptable:Acceptable:
Antrectomy/Distal GastrectomyAntrectomy/Distal Gastrectomy
+ Billroth II Loop+ Billroth II Loop
• Never Acceptable:Never Acceptable:
Total/Subtotal GastrectomyTotal/Subtotal Gastrectomy
+ Billroth II Loop+ Billroth II Loop

22. MGB Gastric Pouch
• General Surgery:General Surgery:
• Acceptable:Acceptable:
Antrectomy/Distal GastrectomyAntrectomy/Distal Gastrectomy
+ Billroth II Loop+ Billroth II Loop
• NEVER Acceptable!!!NEVER Acceptable!!!
Total/Subtotal GastrectomyTotal/Subtotal Gastrectomy
+ Billroth II Loop+ Billroth II Loop

23. MGB Gastric Pouch
• Acceptable:Acceptable:
Antrectomy/DistalAntrectomy/Distal
GastrectomyGastrectomy
+ Billroth II Loop+ Billroth II Loop
• Not AcceptableNot Acceptable
Total/SubtotalTotal/Subtotal
GastrectomyGastrectomy
+ Billroth II Loop+ Billroth II Loop

24. MGB Pouch
• EG JunctionEG Junction
• Pouch fromPouch from
EGJ to AntrumEGJ to Antrum
• Crow's FootCrow's Foot
• AntrumAntrum

25. MGB Pouch
• EG JunctionEG Junction
• Pouch fromPouch from
EGJ to AntrumEGJ to Antrum
• Crow's FootCrow's Foot
• AntrumAntrum

26. MGB Pouch
• EG JunctionEG Junction
• Pouch fromPouch from
EGJ to AntrumEGJ to Antrum
• Crow's FootCrow's Foot
• AntrumAntrum

27. MGB Pouch
• EG JunctionEG Junction
• Pouch fromPouch from
EGJ to AntrumEGJ to Antrum
• Crow's FootCrow's Foot
• AntrumAntrum

28. MGB Gastric Pouch Length
• How Long is the MGBHow Long is the MGB
Pouch?Pouch?
• Wrong AnswerWrong Answer
Not in CentimetersNot in Centimeters
• Answer: FromAnswer: From
EG JunctionEG Junction to Beyondto Beyond
thethe Crow's FootCrow's Foot into theinto the
AntrumAntrum
• The MGB Gastro-The MGB Gastro-
Jejunostomy should lieJejunostomy should lie
at the level of theat the level of the
Transverse ColonTransverse Colon

29. Creation of the MGB Pouch
• Details atDetails at
https://mgbguidelines.wordpress.com/gastric-pouch-creation/https://mgbguidelines.wordpress.com/gastric-pouch-creation/
• Creation of the Gastric PouchCreation of the Gastric Pouch
(Band/Sleeve/RNY)(Band/Sleeve/RNY)
• Bougie of size 28 to 36 F can be used toBougie of size 28 to 36 F can be used to
fashion the pouchfashion the pouch
• Understanding MGB Anatomy & PhysiologyUnderstanding MGB Anatomy & Physiology
• MGB NOT ObstructiveMGB NOT Obstructive
• No Tight Pouch (The MGB is not a Sleeve)No Tight Pouch (The MGB is not a Sleeve)
• Pouch Diameter and Length are Not CriticalPouch Diameter and Length are Not Critical
• MGB Pouch Size:MGB Pouch Size:
• Pouch Diameter = Esophagus;Pouch Diameter = Esophagus;

30. Creation of the MGB Pouch
• Details atDetails at
https://mgbguidelines.wordpress.com/gastric-pouch-creation/https://mgbguidelines.wordpress.com/gastric-pouch-creation/
• Pouch Length = Allow GJ at the greater curve of thePouch Length = Allow GJ at the greater curve of the
stomachstomach
• Start the Gastric Pouch (Long Pouch) at or beyondStart the Gastric Pouch (Long Pouch) at or beyond
Crow’s Foot (junction of body and antrum of theCrow’s Foot (junction of body and antrum of the
stomach.stomach.
• Beware a Twist in the Pouch)Beware a Twist in the Pouch)
• Avoid Bleeding Along Staple Line; (Very SlowAvoid Bleeding Along Staple Line; (Very Slow
Application of Stapler, use compression)Application of Stapler, use compression)
• Management of EG junction; MGB vs Sleeve (DOManagement of EG junction; MGB vs Sleeve (DO
NOT go near the EG junction)NOT go near the EG junction)
• Management of the gastric fundus; (Leaving someManagement of the gastric fundus; (Leaving some
fundus is acceptable)fundus is acceptable)
• Never dissect the EG junctionNever dissect the EG junction

31. Creation of the MGB Pouch
• Details atDetails at
https://mgbguidelines.wordpress.com/gastric-pouch-creation/https://mgbguidelines.wordpress.com/gastric-pouch-creation/
• Never dissect the EG junctionNever dissect the EG junction
• Never attempt to visualize the diaphragmatic curaNever attempt to visualize the diaphragmatic cura
• Always stay lateral to the EG junctionAlways stay lateral to the EG junction
• Leaving some of the fundus behind in the MGB isLeaving some of the fundus behind in the MGB is
always acceptablealways acceptable
• Reminder: The MGB is NOT a Sleeve, The MGB isReminder: The MGB is NOT a Sleeve, The MGB is
NOT a RNYNOT a RNY
• Complete division of the stomach in NOT critical inComplete division of the stomach in NOT critical in
the MGBthe MGB

32. MGB Part 1:
Creation of the Gastric Pouch
• Youtube.com VideosYoutube.com Videos
• http://www.youtube.com/watchhttp://www.youtube.com/watch
?v=1B45TUAimJE?v=1B45TUAimJE
• Technique of Mini-GastricTechnique of Mini-Gastric
Bypass; Tips and TricksBypass; Tips and Tricks

33. Conclusions
• Mini-Gastric BypassMini-Gastric Bypass
Shown to be an excellentShown to be an excellent
operationoperation
• But Many New Surgeons DoBut Many New Surgeons Do
Not Know the Critical FactorsNot Know the Critical Factors
to Do the MGB Correctlyto Do the MGB Correctly
• One Critical Success Factor:One Critical Success Factor:
• LONG Gastric PouchLONG Gastric Pouch