Common Complication, Errors & Misunderstandings in the MGB:Prevention & Treatment

1. Common Complication, Errors & Misunderstandings in
the MGB:
Prevention & Treatment
2:10pm to 3 :20pm (012)

2. Final Lecture:
Everything About the MGB
Common Errors & Misunderstandings in the MGB
Dx/Rx MGB Excess weight loss,
Malnutrition Prevention,
Management Protocol,
Revision & Techniques & Understanding
Use & Value of the Mini-Gastroplasty

3. The Mini-Gastric Bypass is
Both Very Safe and
Very Effective
Over the Short and Long Term

4. Bilio-Pancreatic Limb
Tailoring the MGB

5. Bilio-Pancreatic Limb in MGB
Understanding how to perform

7. UNIQUE POWER of MGB;
Tailor to Patient and Surgeon's Desires
UNDERSTANDING BP Limb Length Optional Decision of Surgeon
and Patient
Longer BP Limb => Greater Weight Loss
Risk of Excess Weight Loss 1%
Shorter BP Limb => Less Weight Loss
Risk of Excess Weight Loss 0.1%

13. Start Pouch Below the Crow's Foot (Long Pouch)
Avoid “Bird's Beak” Deformity
Loose Pouch (Non Obstructive)
Avoid the EG junction
No Twist in the Pouch
Never dissect the hiatus for Hiatal Hernia or GERD

14. MGB Has Great Power!
(Conservative BP Limb length)
Length of the gut is constantly changing
% Bypass / Common Channel
NOT Better than Standard 150-200cm
Care in performance of GJ
WIDE GJ 3-5 cm (Not a RNY GJ)
Avoid Lateral Pouch Staple Line

15. The Mini-Gastric Bypass
Short & Long Term Risks and Benefits

16. The Mini-Gastric Bypass:
Complications
Risk, Identification & Management
“Mini-gastric bypass is a simpler, safer, and more
effective bariatric procedure than laparoscopic sleeve
gastrectomy“
Medicine (Baltimore). 2017 Dec; Comparison of safety and effectiveness between laparoscopic mini-
gastric bypass and laparoscopic sleeve gastrectomy:
A meta-analysis and systematic review.
Wang FG, Yu ZP, Yan WM, Yan M, Song MM

17. MGB Better than Sleeve
A meta-analysis and systematic review
“Mini-gastric bypass is a simpler, safer, and more effective bariatric procedure
than laparoscopic sleeve gastrectomy“
Medicine (Baltimore). 2017 Dec; Comparison of safety and effectiveness between
laparoscopic mini-gastric bypass and laparoscopic sleeve gastrectomy:
A meta-analysis and systematic review.
Wang FG, Yu ZP, Yan WM, Yan M, Song MM

18. MGB vs sleeve gastrectomy for type 2 diabetes:
Prospective randomized controlled trial.
Remission of T2DM was achieved by
93% MGB vs. 47% in sleeve gastrectomy group
(P = .02).
MGB lost more weight, achieved a lower waist circumference, and had lower glucose,
HbA(1c), and blood lipid levels than the sleeve gastrectomy group.
No serious complications occurred in either group.

19. MGB vs Sleeve
A meta-analysis and systematic review
“Patients receiving mini-gastric bypass had a lot of advantageous indexes than patients
receiving sleeve gastrectomy,
such as higher 1-year EWL% (excess weight loss),
higher 5-year EWL%, higher T2DM remission rate, higher hypertension remission rate,
higher obstructive sleep apnea (OSA) remission rate,
Lower leakage rate,
Lower overall late complications rate,
Lower gastroesophageal reflux disease (GERD) rate,
Shorter hospital stay and
Lower revision rate.”
Medicine (Baltimore). 2017 Dec; Comparison of safety and effectiveness between laparoscopic mini-gastric bypass and laparoscopic sleeve
gastrectomy: A meta-analysis and systematic review. Wang FG, Yu ZP, Yan WM, Yan M, Song MM

20. 15-year experience of (mini-) gastric bypass: comparison
with other bariatric procedures.
WJ Lee; Surg Endosc. 2018
The 30-day post-operative major complication occurred in
1.7% of MGB, 2.0% RNY & 1.4% Sleeve
MGB had a higher weight loss
LSG had a lower remission rates comparing to MGB and LRYGB.
15 yr Revision rate MGB 4%: Lower than 5% RnY & 5.2% in Sleeve
CONCLUSION:
MGB is an effective procedure for treating morbid obesity and metabolic
disorders, which results in sustained weight loss and a high resolution of
comorbidities.

21. Rutledge Outcomes and Complications After Mini-Gastric
Bypass
6,185 consecutive patients
85% females with a mean age of 39 years
The mean operating time was 42 minutes
Median Hospital Stay 1 day

22. Mini-Gastric Bypass outperforms RNY
as measured by Length of Stay
A shorter Length of Stay (LOS) usually is associated with a better outcome.
Length of Stay is often an indicator of more efficient and effective care.
Shorter LOS means that the patient is able to return home earlier, providing the
opportunity to recuperate in a familiar surrounding free from potential
complications that result from the hospital environment.

23. Comparison the LOS in MGB vs RNY in
Three Large National Databases
Results: Analysis of LOS for RNY was recently published. (Wolfe et al); Wolfe reported on review of LOS analyses:
1. Nationwide Inpatient Sample (NIS), an AHRQ data source on 7 million RNY's;
2. Bariatric Outcomes Longitudinal Database (BOLD) data over 250,000 RNY's,
3. University Health System Consortium (UHC), 113 academic medical centers and 254 affiliated hospitals (90% of the
nation's non-profit academic medical centers)

24. MGB v RNY
Nationwide Inpatient Sample (NIS)
median LOS 2.7 d, less than 1% had 1 day LOS
Bariatric Outcomes Longitudinal Database (BOLD)
mean LOS 2.4 d, < 1% had 1 day LOS;
University Health Consortium database only 8.3% in leading US hospitals had a LOS of 1 d or less.
“Given these data only a small minority of RNY patients could safely meet 1 day LOS goal.”
MGB: **median LOS was 1 day**, mean of 1.2 days.

25. Analysis of Complications After Mini-Gastric Bypass
31.6% of patients reported a complication:
Minor in 22.7%,
Moderate in 3.7%,
Severe -> Hospitalization in 5.2%

26. MGB: Most Frequent Complications
5%:
Dyspepsia/Ulcer/Gastritis (? Not Bile ?)
Anemia
2%:
Gas-Cramps,
Nausea/Vomiting,

27. Less Frequent MGB Complications
1%:
Diarrhea,
Leak,
Dehydration,
Regained Weight,
Hernia,
Minor Bleeding
Less Than 1%
Renal Stones, Gall Bladder Removal, Stricture,
Minor Eating-Complaints, Malnutrition, Re-Exploration,
Poor Wt Loss, Hair Loss,
Low Ca., Pneumonia-Minor, Perforated Ulcer, Hypoglycemia,
Thiamine Deficiency, Potassium Deficiency, Revision, Gout.

28. Management of MGB Complications:
How to &
How NOT To
Excessive Weight Loss

29. Revision Of Mini-Gastric Bypass For Excess Weight Loss
(Rutledge)
Excessive wt. loss and malnutrition revision in 55 patients (0.9%)
Revision Operative time 47 min
No mortality, major morbidity was 7%, mean length of stay 3 days and the
median was 2 days
RNY Revision report Patel, et al "difficult, dangerous and potentially deadly"
Revision of the MGB for excess weight loss is
technically simple, low risk procedure that takes just under an hour

30. Surg Obes Relat Dis. 2017
Roux-en-Y gastric bypass for the treatment of severe complications after
omega-loop gastric bypass
OLGB conversion to Roux-en-Y gastric bypass (RYGB) to treat complications.
Seventeen patients underwent OLGB conversion to RYGB.
Before conversion, 10 patients (58.8%) received nutritional support for
undernutrition
Average weight 52 kg, BMI 18 kg/m², %EWL 149%
41% major adverse events <90 d
Commentary: No, No, No! Do Not do a Weight Loss Surgery (RNY) for
Excessive Weight Loss.

31. Rx Excessive Weight Loss Post MGB
Experienced MGB Surgeons vs Experiened NON-MGB Surgeons
Experienced MGB Surgeon
Immediate Revision
=> Major Morbidity 7% <=
Experienced NON-MGB Surgeons
(More Recent Study)
TPN + RNY
=> Major Morbidity 41% <=

32. Common/Important Complications
• Anemia
• Complications of staple line & anastomosis
• Leak, Bleeding, Stenosis
• Protein-calorie malnutrition (Excessive Wt Loss)

33. MGB Complications and Management
Survey of 250 MGB/Non MGB Surgeons

37. Anemia
Confusion and Mismanagement
Often see aggesive encouragement of oral iron
supplements (can cause dyspepsia d constipation)
with limited effectiveness
Fall back to IV iron use
Ignore the primary problem

38. Anemia
Confusion and Mismanagement
The primary problem
Anemia almost never occurs in Men
The Primary Cause is:
Menstrual Blood Loss
Primary Rx => Decrease Menstrual Blood Loss

39. Complications of staple line and anastomoses following
laparoscopic bariatric surgery
Gianfranco Silecchia and Angelo Iossa, Ann Gastroenterol. 2018 Jan-Feb; 31(1): 56–64

40. Many Other Examples of Failed Understanding Leading to
Errors in Mangement and Patient Harm
Time is limited
1 Recent Tragic Example
2 years ago Kular, Rutledge and Deitel wrote a warning letter to Editor
a surgical group perfoming an “Omega Loop”
Quoting my paper as the technque being used (prager)

41. Many Other Examples of Failed Understanding Leading to
Errors in Mangement and Patient Harm
We warned that the very high %Excess Weight Loss of their cases (Misjudging BP Limb) would lead to
dangerous and deadly consequences
Jan 2018 they reported on 10 patients Median %excess weight loss at that time was 110.6%
Treatment: (?) In eight patients, lengthening of the alimentary/common limb
In one patient, liver transplantation was required, one patient DEATH due to liver failure

42. Understanding the Obvious
• First: If you do not understand an operation (MGB)
• Do Not Use the Operation
• In Short This Presentation in Summary:
• Widespread and Persistent Misunderstanding of MGB
• Often Leading to Complications and Even Death
• Needed: Standardization of MGB and Recognition of
Surgeons Knowledgeable and Skilled in its use

43. Confusion By Surgeons Who Do Not
Understand the MGB
Some Examples of Confusion
The Pouch is Too Big & Pts Will Not Loose Weight
Short Gastric Pouch (MGB = OldMason Loop)
Dissection EG Junction and crural Repair
MGB with a “Ring”
Irrational Fear of Bile Reflux
Confused About Risk Gastric Cancer
Fear of Malnutrition
Management of MGB Complications
And More...

44. Needed: Standardization of MGB and Recognition of Surgeons
Knowledgeable and Skilled in its use
Standardize, Educate, Recognize
The Best in MGB
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MGBReviewCorp.com