Dr Rutledge Use of the Mini-Gastric Bypass for "Thin" Diabetics

The Worldwide Epidemic Diabetes
What Can Be Done?
for Highest Risk, Highest Cost
Obese & Non-Obese Diabetics
Dr Rutledge
Email me! DrR@CLOS.net

Imagine 20 years of Diabetes
• Blindness
• Heart Attack
• Stroke
• Death
• Renal Failure
• Amputation

The Worldwide Epidemic Diabetes
What Can Be Done?
Save Lives, Save Resources, Save Money:
** The Mini-Gastric Bypass? **
for High Risk Obese & Non-Obese Diabetics

Objectives
1. Diabetes Epidemic
2. Human, Resource & Monetary Costs
3. Trick * Small Group * Highest Cost, Highest Risk Patients
4. Diabetes & Anatomy (Duodenal Exclusion => Rx Diabetes)
5. Animal, General Surgery, Billroth II => Rx Diabetes
6. MGB = General Surgery-Billroth II => Rx Diabetes
7. Surgery = 10 yr Cost Benefit (Surgery vs No-Surgery)
The Future of Bariatric (Metabolic) Surgery
8. MGB can be Tailored; Useful for all types of patients
NEW NEWS! Especially “Thin” Diabetics

Diabetes Epidemic
Things You Already Know:
Cause(s)
Prevention & Treatment

Human, Resource &
Monetary Costs
Tremendous Human Suffering
Resources Use, Beds, Drugs, etc.
Money (Pesonal, Local, Healthcare & National)

* Small Group * Highest
Cost, Highest Risk
Patients
What Can Be Done?
The Trick
Highest Cost Subgoup,
Highest Risk...

Cost Care of the Diabetic
• Hospital inpatient care (43%)
• Medications (18%),
• Other anti-diabetic agents &
diabetes supplies (12%),
• Dr office visits (9%)
• Nursing Home (8%)

Diabetes & Anatomy
(Duodenal Exclusion =>
Rx Diabetes)
Anatomical Rx Diabetes!
Really!

100 yr old General Surgery
Billroth II => Rx Diabetes!
100 year old General Surgery for Ulcers
Treats Diabetes!

MGB = General Surgery-Billroth II
=> Rx Diabetes

MGB Surgery =
10 yr Cost Benefit
(MGB Surgery vs No-Surgery)
Average Cost 1 year Diabetic in USA ($17,000 USD)
10 years ($170,000 USD)
Mini-Gastric Bypass (30 min surgery, 1 day Hospital, $17,000)
Cost Savings for AVERAGE PATIENT
= $153,000
Human Suffering, Hospital Beds, Healthcare, National

The Future of Bariatric
(Metabolic) Surgery

Imagine!
If Diabetes
10 year Remission
(75%) or
Major Improvement
20-30 Minutes Surgery
1-2 days in Hospital

MGB can be Tailored;
Useful for all types of patients
NEW NEWS!
Especially “Thin” Diabetics
MGB Surgery for the Sickest of the Sick Diabetics
75% ++ Remission of Diabetes
Cost Savings >> USD $100,000.00+ / pt / 10years
Huge Resource Savings (Hosp Beds etc.)
Untold Human Suffering

Pakistan and diabetes
A country on the edge
• Rising burden of diabetes
• Environmental and emotional changes.
Main contributors:
• Sedentary lifestyle including internet and TV usage,
• Caloric rich diets leading to increasing obesity
• National Diabetes Survey of Pakistan prevalence
diabetes 26% Pakistan
• Human resources and evidence based solutions
are enough to call multi stake holders to ACT NOW
Diabetes Res Clin Pract. 2018 Nov 10 Pakistan and diabetes-A country on the edge.
Basit A

USA Diabetes Epidemic Costs
2017:
Total cost diabetes $327 billion,
$237 billion Medical Costs
$90 billion reduced productivity
Patient: $17,000 /year
Costs increased 26% (2012-2017)

“Substantial financial burden
diabetes imposes on society,
in addition to intangible costs
from pain and suffering,
resources from care provided
by non paid caregivers”

Diabetes Mellitus in Pakistan
• Pakistan is a developing country with
limited resources and diverse economic
social patterns.
• Pakistan has high prevalence of diabetes
and its complication, which is a huge
challenge to the existing health care
system.
• The major contributing risk factors are
urbanization and change in lifestyle

The “Trick”
The Sickest of the Sick
• Small Group (Few Percent)
• The Sickest of the Sick
• >> 50%
– Human Costs (Suffering Disability)
– Healthcare Resourses
– Societal Costs
• The Sickest of the Sick
• Attack This Group!
• We Have the Tools!

Diabetes: The Sickest of the Sick
2-5% Patients => 50% Costs
• Costs associated with
diabetes-related Complications
• Higher than all the remaining
costs of managing diabetes

National Rx Diabetes
First Line Rx:
• Lifestyle
• Diet
• Exercise
• Physician Care
• Medications, etc...
• NOT Surgery

Insufficient physical activity
• Prevalence of insufficient physical activity
2016 was more than twice as high in high-
income countries (37%)
• Low-income countries (16%)
• Insufficient activity increased over time
• Worldwide trends in insufficient physical activity from 2001 to 2016:
a pooled analysis of 358 population-based surveys with 1·9 million
participants

China Study (**Potential**)
Improved Care => Decreased Costs
• T2D in China ¥621 billion
• HbA1c reductions from 8.0% to 7.0%
Improvements Rx =>
estimated savings of ¥106 billion
• Savings from reduced costs Rx diabetes
complications
Value Health Reg Issues. 2018 Assessing the Burden of Type 2 Diabetes in
China Considering the Current Status-Quo Management and Implications of
Improved Management Using a Modeling Approach, Foos V

Intensive Diet weight Loss
=> Rx Diabetes
• 1 year intensive weight management
? 12mo remission T2 diabetes.
• => Avg Weight loss of >15 kg 24% intervention group &
none in the control group
• Diabetes remission 46% in intervention group
vs 4% controls
• at 12 months, almost 50% remission DM,
• off DM drugs.
• Remission of type 2 diabetes is a practical target for
primary care.
• Primary care-led weight management for remission of type 2 diabetes
(DiRECT): an open-label, cluster-randomized trial, Published:December
05, 2017

T2DM: Complications = Costs
• 1 complication => 6X more expensive
$1,400 vs $248 without complications
• 2 & 3+ complications => (7X & 12X)
$1,700 & $3,000
• Highest Costs Complications: diabetic foot,
stroke, Ischemic heart disease & diabetic
nephropathy
• Duration & Mortality => Increased Costs
• BMJ Open. 2018 Nov 1;How do type 2 diabetes mellitus (T2DM)-related
complications and socioeconomic factors impact direct medical costs? A
cross-sectional study in rural Southeast China. Wu H

Conclusions
• Diabetes mellitus is reaching epidemic
proportions in India.
• "The level of morbidity and mortality due
to diabetes and its
potential complications are enormous,
and pose significant healthcare burden"

• Rx #
• Finger sticks 29,200 sticks
• 1 med 4/d 29,200 tabs
• 2 meds 6tabs/d 43,800 tabs
• Insulin 2/d 14,600 injections

• Imagine!
• If Diabetes could be “cured” or
Major Improvement
• 20-30 Minutes
• 1-2 days in Hospital

Sickest Most Expensive Diabetics:
= Opportunity
•Complications significantly aggravated
expenditures on T2DM.
•Proper management diabetic
complications are urgently needed to
reduce the growing economic burden of
diabetes.

Imagine!
A Solution to
Diabetes
(For SEVERE DIABETICS
with Complications Risk)

Best Treatment of Diabetes
Surgery! (Duodenal Bypass)
• (FOR SOME PATIENTS)
• Data from
1. Animal Studies
2. General Surgery
3. Bariatric Surgery

Imagine!
Diabetes as Surgical Disease
Like Gall Stones!
Like Appendicitis
In Some “Cureable” (?)
In Many Remission and/or
Long Term Improvement

Animal Models Confirm
Duodenal Bypass Improves Effectiveness
• “This study shows that
• bypassing Duodenum
• Improves T2D,
• independently of
• food intake,
body weight,
malabsorption, or
nutrient delivery”
• The Mechanism of Diabetes Control After Gastrointestinal Bypass Surgery Reveals a Role of the Proximal Small Intestine
in the Pathophysiology of Type 2 Diabetes. Rubino,); Marescaux, Jacques MD, FRCS Annals of Surgery; 244 (5): 741-
749, November 2006

General Surgery Data
Confirms Animal Models
Duodenal Exclusion =>
High Rates of Rx of Diabetes

General Surgery
"Effect of Gastrectomy For
Stomach Cancer on
Type 2 Diabetes Mellitus"
Kang KC, Shin SH, Lee YJ, Heo YS.
J Korean Surg Soc. 2012 Jun;82(6):347-55.
Department of Surgery, Inha University Hospital, Inha University School
of Medicine, Incheon, Korea.

Surgery Can Successfully Treat
Obesity and Diabetes
But Imagine Improvement or
Even Cure in the
Both the Obese
And the Non-Obese
”Thin” Diabetic Patient

Simple, Old, Time Tested,
General Surgical Procedure Treats Diabetes

The Billroth II
=
Routine
General
Surgery

The Billroth II is Good
General Surgery Studies
• Billroth II is Associated with a
Decreased Risk of Stroke and CV
Disease:
A Nationwide Population-Based Study
• Duodenal exclusion
Decreases Lipid (Chol) and Rx Diabetes
• 6,425 pts BII for PUD
• Stroke / CVD 20% lower in pts in BII
• Subtotal Gastrectomy With Billroth II Anastomosis Is Associated With a Low Risk of Ischemic Stroke in Peptic
Ulcer Disease Patients: A Nationwide Population-Based Study. Chen CH 2016 Apr;95

MGB = Partial Gastrectomy + Billroth II
General Surgery => Rx Diabetes
J Gastric Cancer. 2017
Long-term Follow-up for Type 2 Diabetes
Mellitus after Gastrectomy in
Non-morbidly Obese
Patients with Gastric Cancer: the Legitimacy
of Onco-metabolic Surgery.
Lee TH
Partial Gastrectomy effective in short &
long-term T2D control in non-obese patients

MGB = Partial Gastrectomy + Billroth II
General Surgery => Rx Diabetes
J Gastric Cancer. 2017
DM post Gastrectomy Non-Obese Gastric Cancer
27% Billroth I, 47% Billroth II, 25% RNY
BP Limb 15–20 cm distal Treitz (Short)
Partial Gastrectomy effective in short & long-
term T2D control in non-obese patients

General Surgery Can Teach Us
Bariatric Surgery
• A new perspective on
an old surgical method
• A systematic review and meta-
analysis General Surgery
Billroth II on Type 2 Diabetes
• Surg Obes Relat Dis. 2015

Systematic review and meta-analysis of
Billroth II postoperative Diabetes
• General Surgery Studies show that
• Subtotal gastrectomy for cancer or ulcers
+
• Billroth II (BII) .vs Billroth I (BI)
• More effective Rx Type 2 Diabetes
• BII (MGB) More Effective Rx BI (Sleeve)
•Surg Obes Relat Dis. 2015

Billroth II
is a Good Procedure!
“May be the Ideal Rx
Thin Diabetics!”

Billroth II (MGB) =
Rx Thin Diabetics
• Conclusions: BII reconstruction after
subtotal gastrectomy for cancer or ulcers
more effectively improved T2D than BI
reconstruction.
• Thus, BII provides a treatment strategy for
diabetic patients and enable metabolic
surgery for Non-obese patients
Surg Obes Relat Dis. 2015

Billroth II
Mini-Gastric Bypass

Mini-Gastric Bypass
Operative Procedure
1. “Standard Gen Surgery”
Antrectomy & Gastro-jejunostomy
2. Collis Gastroplasty
Non Obstructive Restriction
3. Ante-colic Billroth II Loop
Gastro jejunostomy
Tailor Bypass to Patient

Mini-Gastric Bypass
• Simple
• Elegant
• Effective
• Durable > 15 yrs
• Powerful
• Tailored to Patient
• Reversible
• Revisable

Dr Rutledge's Results
Mini-Gastric Bypass
• MGB: Tailored to Fit the Patient &
Surgeon
• Very High levels of patient satisfaction
• General Surgery Data & Controlled Trial:
MGB Twice as effective as Sleeve
Rx Diabetes
• Resolution Diabetes 85%-90%+
• Decreased Hunger, Chol, BP, cRP,
Enforced Mediterranean Diet

The Future
Metabolic Surgery
Lower Weight Diabetics
•What is our future?
•METABOLIC SURGERY
•We are “Metabolic Surgeons”

The Future
is HERE
Metabolic Surgery
Lower Weight Diabetics
2/3 MGB Surgeons are Doing
METABOLIC SURGERY
on thin diabetics
We are “Metabolic Surgeons”

The Future is Here for MGB
2/3 of MGB Surgeons

Imagine!
A Solution to the
Severe Deadly
Complications of Diabetes
Even in Thin Patients!
Blindness, Stroke, Heart Attack,
Kidney Failure &
Gangrene & Amputation

Bariatric Surgery in
Thin Diabetics
It is Already here!
Example:
Egyptian Study

MGB => 76% Remission of
Diabetes in Non-Obese
• Study from Egypt
• HbA1c, FPG (fasting plasma glucose),
and 2-hours postprandial glucose (2-H
PPG) were 9.9%, 176 mg/dl & 310
• 18 months 5.8%, 93 mg/dl & 156 mg/dl,
with 13/17 patients became off-treatment
(complete remission rate 76%).
• Asian J Surg. 2018 Jun 2. From diabetes remedy to diabetes remission;
could single-anastomosis gastric bypass be a safe bridge to reach target in
non-obese patients? Osman Abouzeid

MGB => 76% Remission of
Diabetes in Non-Obese
• Study from Egypt, BMI 25-30
• HbA1c 9.9% to 5.8% (Remission 76%)
• MGB efficient metabolic procedure
=> Rx Type 2 Diabetes
• “Opens new horizons to change the
concept of treatment from diabetes
remedy to diabetes remission”
• Asian J Surg. 2018 Jun 2. From diabetes remedy to diabetes remission;
could single-anastomosis gastric bypass be a safe bridge to reach target in
non-obese patients? Osman Abouzeid

Antrectomy & Billroth II = MGB

One Last “Trick”?
Pakistan spends 0.9% of its GDP on health
Pakistan’s citizens rely heavily on private
healthcare, which they avail primarily through
out-of-pocket payments.

One Last Trick:
Government Healthcare vs Private Healthcare
•Mobilizing the Consumer
•How wealthy is Pakistan's middle class?
The Friday Times
•Pakistan's 'middle-class' future
•Analysing the middle-class | Business
Recorder

One Last Trick:
•KARACHI: The country’s middle class is
experiencing a rapid growth, which is
evident from the rising demand for
consumer durables, education and health,
according to the State Bank of Pakistan
(SBP)

One Last Trick:
•“Several indicators show rising consumer
demand in the country.
... an increase in the sale of consumer
durables (automobiles and electronic
goods) and a sharp growth in fuel
consumption,” said the SBP.

One Last Trick:
Average cost of a Pakistani car (excluding
taxes) is Rs750,000
($5,387 USD)

Pakistan Choice
1. Present System: Coming Epidemic
of Diabetes
2. Massive Increase Government
Spending
3. Utilization of Private Sector /
Consumer Funding of Some
Diabetic Treatments?
4. Combination?

FIRST
Dr Rutledge's
Remarkable
MGB Results

Dr Rutledge's Results
Mini-Gastric Bypass
• In 6,000+ patients
• Over almost 20 years
• < 5% complications
• Mean 36 minute op time
• Median 1 day hospital stay
• 10-15 year follow up
(Talk to 10+ Year MGB Patients on Facebook)
• Controlled prospective trials
(2X better than Sleeve)
• Reversible and Revisable < 30 minutes

Outcomes of Mini-Gastric Bypass in
472 Diabetic Patients
• Egyptian Study: 472 diabetic patients
• BMI decreased from 47 to 30
• HbA1c from 9.6 to 5.7
• Diabetes remission was achieved by 84%
• “MGB can be an excellent treatment of
diabetes and obesity”
• Obes Surg. 2017 Nov; Outcomes of One Anastomosis Gastric Bypass in
472 Diabetic Patients Taha O

Outcomes of Mini-Gastric Bypass in
1,520 Diabetic Patients
• Egyptian Study: 1,520 pts
• Mean weight 79 kg at 3-year follow-up
• 0.8% required reoperation
• Obes Surg. 2017 Aug, Outcomes of Omega Loop Gastric Bypass, 6-Years
Experience of 1,520 Cases. Taha O

Antrectomy & Billroth II & MGB

Objectives
1. Diabetes Epidemic
2. Human, Resource & Monetary Costs
3. * Small Group * Highest Cost, Highest Risk Patients
4. Diabetes & Anatomy (Duodenal Exclusion => Rx Diabetes)
5. General Surgery, Billroth II => Rx Diabetes
6. MGB = General Surgery-Billroth II => Rx Diabetes
7. Surgery = 10 yr Cost Benefit (Surgery vs No-Surgery)
The Future of Bariatric (Metabolic) Surgery
8. MGB can be Tailored; Useful for all types of patients
Especially “Thin” Diabetics

Cost of Diabetes Care
• Medical costs $13,700/yr
• 10 years $130,000
• Mini-Gastric Bypass Surgery
Cost $13,000
• Savings $117,000.00

Dr Rutledge Use of the Mini-Gastric Bypass for "Thin" Diabetics

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Dr Rutledge Use of the Mini-Gastric Bypass for "Thin" Diabetics

Similar to Dr Rutledge Use of the Mini-Gastric Bypass for "Thin" Diabetics (20)

More from Dr. Robert Rutledge

More from Dr. Robert Rutledge (20)

Recently uploaded

Recently uploaded (20)

Dr Rutledge Use of the Mini-Gastric Bypass for "Thin" Diabetics