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Presentation; Marginal ulcer gastric bypass
 

Presentation; Marginal ulcer gastric bypass

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Marginal ulceration is a known Serious complication of Roux-en-Y gastric bypass, with an incidence of approximately 1% to 16%

Marginal ulceration is a known Serious complication of Roux-en-Y gastric bypass, with an incidence of approximately 1% to 16%

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    Presentation; Marginal ulcer gastric bypass Presentation; Marginal ulcer gastric bypass Presentation Transcript

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