Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Comparison of Revision in Roux-en-Y vs Mini-Gastric Bypass

4,668 views

Published on

Comparison of Revision in
Roux-en-Y vs
Mini-Gastric Bypass
Dr K S Kular
Kular Medical Education & Research Society
Kular Group of Institutes
drkskular@gmail.com
www.kularhospital.com

Published in: Education, Health & Medicine

Comparison of Revision in Roux-en-Y vs Mini-Gastric Bypass

  1. 1. Comparison of Revision inComparison of Revision in Roux-en-Y vsRoux-en-Y vs Mini-Gastric BypassMini-Gastric Bypass Dr K S Kular Kular Medical Education & Research Society Kular Group of Institutes drkskular@gmail.com www.kularhospital.com
  2. 2. Complications after Bariatric Surgery Successful Bariatric Surgery
  3. 3. Objectives 1. Basics of RNY Gastric Bypass; Restrictive, Technically Demanding, Dangerous, SBO 2. Revision of RNY; Reasons, Techniques Difficullt, Doubles Risk of Complications 3. Basics of MGB; Malabsorbtive, Technically Simple, Low Risk, Very Effective 4. Revision of MGB; Reasons, Techniques Simple, Low Risk of Complications (0-2%)
  4. 4. 1. Primary Roux en Y Gastric Bypass The Basics 1. Primarily Restrictive ( Restrictive 95%/ Fat Malabsorptive 5% ) 2. Technically Demanding (500 cases Learning Curve) 3. One of Most Dangerous Bariatric Surgery (Complications/Leak) 4. Unique, Common, Deadly, Complication; SBO 10% 5. Moderately High Weight Regain / Failure Rate
  5. 5. RNY is the MOST Dangerous Form of Bariatric Surgery By Every measure, in Every study RNY Highest Death Rate, Highest Leak Rate Highest Early Complications Highest Major Complication Rate Highest Bleeding Rate, Highest Re-operation Rate Highest PE Rate.... RNY is the most dangerous form of Bariatric Surgery References 25-100 Studies
  6. 6. Medical Truth: Randomized Controlled Trials The Randomized Controlled Trial, Considered The ''Gold Standard'' For Studies Of Medical Truth
  7. 7. Example: Recent Controlled Prospective Randomized Trial RNY JAMA 2013 Some of the Best Hospitals in the World Controlled Prospective Randomized Trial in Relatively Healthy Pts 12 months ONLY 44% normal HgbA1c levels 37% serious complications 3.3% Leaks 1 patient suffered anoxic brain injury and leg amputation.
  8. 8. Revision of RNY • Reasons: Inadequate/Excess Weight Loss/Weight Regain/Other • Techniques: Narrow GJ, Narrow Pouch, Lengthen Roux Limb, Convert to Sleeve, Band to Pouch, Convert to BPD, Limb-o-plasty (Gagner) • Doubles Risk of Leak and Complications (20-40%)
  9. 9. Techniques of Revision of RNY Narrow GJ Narrow Pouch Lengthen Roux Limb Convert to Sleeve Band to Pouch Convert to BPD Limb-o-plasty (Gagner)
  10. 10. Dissection Near EG Junction
  11. 11. Revision of RNY Bloody, I Cannot See What They are Doing
  12. 12. Complications after RNY and revision RNY Early complications were recorded in 37 pts (10.2%) after RNY 24 pts (22.2%) after Revision RNY p<0.01 Reoperation 12 pts (3.3%) after RNY 9 pts (8.3%) after Revision p=0.03 Revision 2 X Complications & Leak Rate Obes Surg. 2011 Jun;21(6):692-8. Are laparoscopic gastric bypass after gastroplasty and primary laparoscopic gastric bypass similar in terms of results? Cadière GB, Himpens
  13. 13. Revision of RNY Bloody, I Cannot See What They are Doing
  14. 14. Example: Increased Leaks in RNY Revisions 8 leaks (0.95%) after RNY 5 leaks (4.20%) after Revision Revision 4 X Leak Rate Surg Obes Relat Dis. 2013 Treatment of gastric Leaks after Roux-en-Y gastric bypass: a paradigm shift.Brolin RE, Lin JM. Department of Surgery, University Medical Center at Princeton, Princeton, New Jersey 08844, USA.rbrolin@njbariatricspc.com
  15. 15. Revision of RNY Bloody, I Cannot See What They are Doing
  16. 16. Revision of Lap Band to RNY Revisional weight loss surgery after failed laparoscopic gastric banding Surg Endosc. 2013 Jul 12. Tran TT et al. Division of Minimally Invasive/Bariatric Surgery, Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
  17. 17. Revisions of Failed Lap Band Lap Band to RNY Early complications occurred in 11 patients (18 %) 4 Anastomotic leaks (6%) 20% late complications requiring surgery 1 in 5 Required Reoperation There was one death (1.6%)
  18. 18. Revision of RNY Bloody, I Cannot See What They are Doing
  19. 19. 11% Leak Rate Revising RNY 46 pts revision surgery Leaks increased after revision (11% vs 1.2%) 1 out of every 10 pts There was a 24% (13/55) 90-day readmission rate. 1 out of every 4 pts Revision 5 X leak Rate Am J Surg. 2009 Mar;197(3):391-6. Should bariatric revisional surgery be avoided secondary to increased morbidity and mortality? Hallowell PT, Case Western Reserve University, School of Medicine, Cleveland,
  20. 20. Revision of RNY Dissection
  21. 21. Revision of VBG to RNY Weight regain secondary to VBG RYGB group had a 43.5% complication rate and 1 mortality. Complications following RYGB include: incisional hernia (13%), anastomotic leak (8.7%), respiratory failure (8.7%), fistula (8.7%), and perforation (4.35%). Revision 40% Complication Rate 9% Leaks J Obes. 2013;2013: Endoscopic revision (StomaphyX) versus formal surgical revision (gastric bypass) for failed vertical band gastroplasty. Bolton J, Gill RS, Al-Jahdali A, Byrns S, Shi X, Birch DW, Karmali S. Department of Surgery, University of Alberta, Edmonton, AB, Canada T6G 2B7.
  22. 22. Pouch resizing for Roux-en-Y 6 patients (30%) developed complications Acute abdomen due to volvulus of the small bowel in 1, Intra-abdominal abscess in 3 Pulmonary embolus in 2. Revision 30% Complications Surg Obes Relat Dis. 2013 Mar-Apr;9(2):260-7.Gastric pouch resizing for Roux-en-Y gastric bypass failure in patients with a dilated pouch. Iannelli A, Schneck AS, Hébuterne X, Gugenheim J.
  23. 23. Review of RNY Revision 13 studies Major Complications after Primary RNY 10-25% Major Complications after Revision RNY 10-40+% Successful weight loss after Primary RNY 68-82% Successful weight loss after Revision RNY 5-40%
  24. 24. Revision of MGB Easy and Safe; IF You Follow the Rules
  25. 25. Basics of MGB Restrictive w Major Fat Malabsorption Technically Straight forward Low Risk (Complications/Leak) SBO reported as 0-0.3% Very High Weight Loss Rare Regain Experience with >12,000 MGB Bile Reflux rare and easily Rx Fear of Gastric Cancer unfounded by surgeons uninformed on the medical literature (Hot Dog is more dangerous)
  26. 26. MGB Very Effective & Very Safe MGB Series Rutledge U.S.A. 6,000 + (16 yr + FU) Cady France 2000 + Peraglie U.S.A. 2000 + Carbajo Spain 2000 + Noun Lebanon 1000 Lee Taiwan 1000 + (RCT, 10 yr+ FU) Kular India 1000+ Garcia-Caballero Spain 1000 + Musella et al. Italy 1000 Others (i.e. Chevallier Paris 700, Tacchino Rome 500, etc.)
  27. 27. MGB One of the Most Effective & Safest MGB Series Findings in all series are the same: 1. Short operation, low risk of short and long term complications 2. Excellent short and long term weight loss 75-100% EWL, (Better than BPD) 3. Revisable and Reversible 4. Minimal Risk of Bile Reflux in Knowledgeable Hands
  28. 28. One Thousand Consecutive Mini-gastric Bypass: Short- And Long-term Outcome 1,000 patients who underwent MGB from November 2005 to January 2011 Operative time and length of stay for primary vs. revisional MGB were 89 ± 12.8 min vs. 144 ± 15 min (p < 0.01) and 1.85 ± 0.8 day vs. 2.35 ± 1.89 day (p < 0.01) Short-term complications 2.7% Obes Surg. 2012 May;22(5):697-703. One thousand consecutive mini-gastric bypass: short- and long-term outcome. Noun et al, Department of Digestive Surgery, Hôtel-Dieu de France Hospital and University Saint Joseph Medical School, Bd Alfred Naccache, Achrafieh, BP 166830 Beirut, Lebanon. rnoun@wise.net.lb
  29. 29. One Thousand Consecutive Mini-gastric Bypass: Short- And Long-term Outcome Five (0.5%) patients presented with leak from the gastic tube but none had anastomotic leakage. Four (0.4%) patients, all revisions with severe bile reflux Rx by stapled latero-lateral jejunojejunostomy (Braun). Excessive weight loss occurred in four patients easily revised. Percent excess weight loss (EWL) of 72.5% occurred at 18 months. Obes Surg. 2012 May;22(5):697-703. One thousand consecutive mini-gastric bypass: short- and long-term outcome. Noun et al, Department of Digestive Surgery, Hôtel-Dieu de France Hospital and University Saint Joseph Medical School, Bd Alfred Naccache, Achrafieh, BP 166830 Beirut, Lebanon. rnoun@wise.net.lb
  30. 30. One Thousand Consecutive Mini-gastric Bypass: Short- And Long-term Outcome The 50% EWL was achieved for 95% of patients at 18 months and for 89.8% at 60 months. MGB is an effective, relatively low-risk, and low-failure bariatric procedure. In addition, it can be easily revised, converted, or reversed. Obes Surg. 2012 May;22(5):697-703. One thousand consecutive mini-gastric bypass: short- and long-term outcome. Noun et al, Department of Digestive Surgery, Hôtel-Dieu de France Hospital and University Saint Joseph Medical School, Bd Alfred Naccache, Achrafieh, BP 166830 Beirut, Lebanon. rnoun@wise.net.lb
  31. 31. Controlled Prospective Randomized Trial Lee WJ, Yu P-J, Wang W, Chen TC, Wei PL, Huang MT. Laparoscopic Roux-en-Y versus Mini-Gastric Bypass for the treatment of Morbid Obesity. Ann Surg 2005 ; 242 : 20-28 RYG Bypass Mini Bypass Op time (mns) 205 148 Early complications 20% 7.5% Late complications 7.5% 7.5 % EWL at one year 58.7% 64.9% EWL at two years 60% 64.4%
  32. 32. Randomized Controlled Prospective Trials MGB MUCH Superior to RNY Rx Diabetes MGB vs RNY Rx Diabetes, Two Controlled Prospective Randomized Trials Ikramuddin S, et al. Roux-en-Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the Diabetes Surgery Study randomized clinical trial. JAMA. 2013 Jun Lee WJ, et al. Gastric bypass vs sleeve gastrectomy for type 2 diabetes mellitus: a randomized controlled trial. Arch Surg. 2011 Feb Resolution of Diabetes at 12 months Sleeve 47% RNY 44% MGB 93%
  33. 33. Revision of MGB • Reasons: Inadequate/Excess Weight Loss/Weight Regain/Other • Techniques Easy Stay away for the gastric pouch Steps 1. Divide the Gastro Jejunostomy 2. Advance or shorten the bypass
  34. 34. MGB Revision 40-50 minutes Pouch Anastomosis Bowel Loop
  35. 35. Lysis of Adhesions (No Bleeding)
  36. 36. Divide the Gastro-Jejunostomy
  37. 37. Divided Pouch Note Location Re: a RNY Dissection
  38. 38. Completed Revised MGB
  39. 39. Revision of MGB Pouch Anastomosis Bowel Loop
  40. 40. Divide the Gastro-Jejunostomy
  41. 41. Advance or Retreat the Bowel Stapled GastroJejunostomy
  42. 42. Staple Closeure of Gastro-Jejunostomy
  43. 43. Completed Revision of MGB 47 minutes No Bleeding
  44. 44. Completed Revision of MGB 47 minutes No Bleeding
  45. 45. Revisional surgery for laparoscopic Mini-gastric bypass (Dr. Lee) 1,322 patients followed for 9 years ONLY ** 2% ** required revision Revision Bile reflux ONLY 3 pts 0.2% All revision procedures performed lap No major complications. 0.0% Surg Obes Relat Dis. 2011 Jul-Aug;7(4):486-91. Revisional surgery for laparoscopic minigastric bypass. Lee WJ, Lee YC, Ser KH, Chen SC, Chen JC, Su YH. Department of Surgery, Min-Sheng General Hospital, National Taiwan University, Taipei, Taiwan.
  46. 46. Revisional surgery for Mini-gastric bypass 1,322 pts 9 yrs ONLY ** 2% ** revisions No major complications. 0.0% Surg Obes Relat Dis. 2011 Jul-Aug;7(4):486-91. Revisional surgery for laparoscopic minigastric bypass. Lee WJ, Lee YC, Ser KH, Chen SC, Chen JC, Su YH. Department of Surgery, Min-Sheng General Hospital, National Taiwan University, Taipei, Taiwan.
  47. 47. Revisional surgery for laparoscopic Mini-gastric bypass 1,322 MGBs revision surgery was to RNY in 11 (0.8%) Sleeve in 10 (0.8%) Normal in 2 (0.15%) No major complications 0.0% Surg Obes Relat Dis. 2011 Jul-Aug;7(4):486-91. Revisional surgery for laparoscopic minigastric bypass. Lee WJ, Lee YC, Ser KH, Chen SC, Chen JC, Su YH. Department of Surgery, Min-Sheng General Hospital, National Taiwan University, Taipei, Taiwan.
  48. 48. REVISION MINI-GASTRIC BYPASS (MGB) FOR INADEQUATE WEIGHT LOSS Rutledge USA, IFSO 2011 65 Revision Patients %EWL Initial 56%; After revision 84% Major Complications 1.5% Late complications: 3 patients sustained Excess Weight Loss.
  49. 49. Review of MGB Revision Major Complications after Primary MGB 2-5% Major Complications after Revision MGB 0-5+% Successful weight loss after Primary MGB 76-97% Successful weight loss after Revision MGB +35-40%
  50. 50. Conclusions 1. Basics of RNY; Restrictive, Technically Demanding, Dangerous, + SBO 2. Basics of MGB; Malabsorbtive, Technically Simple, Low Risk
  51. 51. Conclusions 1. Revision of RNY; Rarely done Techniques Difficullt, Doubles Risk of Complications (15-43%) 2. Revision of MGB; Rarely needed, Techniques Simple, Low Risk of Complications (0-2%) Very Effective
  52. 52. Surgery Can Successfully Treat Obesity and Diabetes in Both Thin and Obese Diabetic Patients • 2013: Kular Hospital • 6 year study T2DM patients • Results: • Type 2 Diabetes resolved • 98% of MGB
  53. 53. MGB More Effective than BPD Dr Tacchino MGB vs BPD Weight Loss and Diabetes Resolution Following Mini- Gastric Bypass and Bilio-Pancreatic Diversion. Tacchino R., Rutledge R., Università Cattolica del Sacro Cuore, Rome, Italy 408 pts Jan 2007 to Dec 2009 36 months follow-up Mini-Gastric Bypass (n = 164) initial BMI 46.4±9.6 or Bilio-Pancreatic Diversion (n = 244) initial BMI 46.9±7 (Tacchino’s perferred Operation)
  54. 54. MGB More Effective than BPD Dr Tacchino MGB vs BPD RESULTS: Mean BMI at two years was 28.5±3.9 kg/m2 and at three years 27.4±4.5 kg/m2 after MGB BMI at two years 32.7± 6.04 kg/ m2 and at three years 33.6±5.1 kg/m2 after BPD One year resolution of diabetes was accomplished in: 100% in MGB group 95% in BPD group.
  55. 55. MGB More Effective than BPD Dr Tacchino MGB vs BPD Tacchino’s conclusions: “Both MGB and BPD resluted in excellent weight loss, excellent resolution of co-morbities with low risk of long term complications. The MGB was associated with greater weight loss than BPD. Improvements in other cardiovascular risk factors and quality of life were similar after both procedures.”
  56. 56. Unfounded FEAR Gastric Cancer Billroth II Makes No Significant Difference • 1. Gastric Cancer Declining Rapidly • 2. GC Environmental Causes; Easily Prevented • 3. Some studies show Small Increased Risk Probably from Ulcers / H. Pylori • 4. Many large studies: NO increased risk • 5. Endoscopic Screening: Not Recommended • 6. General, Trauma & Oncologic Surgeons Use Billroth II
  57. 57. Best Rx for Diabetes 5 Objectives 1. Consider Band/Sleeve/RNY/MGB 2. Best Rx DM Requires Gastric Procedure + Duodenal Bypass 3. Eliminates Band/Sleeve; Choice RNY vs MGB 4. RNY Most Technically Difficult Dangerous & Deadly form of Bariatric Surgery 5. Data MGB One of the Most Effective & Safest Rx for DM
  58. 58. Objective 1: Consider Band/Sleeve/RNY/MGB
  59. 59. Objective 2: Best Treatment of Diabetes Includes Gastric Procedure + Duodenal Bypass Data from General Surgery, Bariatric Reports, Animal Studies
  60. 60. Objective 2: 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
  61. 61. Objective 2: Billroth I vs Billroth II Gastrectomy vs Gastrectomy + Bypass Primary Gastric Procedure (PGP) Vs Combined Gastric + Bypass (CGB) Which Leads to Greater Weight Loss? Which Leads to Greater Resolution of Diabetes? General Surgery Answer:
  62. 62. Bariatric Surgeons Should Not Forget Their General Surgery Training GS for Gastric Disease (Ca/Ulcer) Gastrectomy ALONE 50% Gastrectomy + Duodenal Bypass 75% Rx T2D MUST Include Duodenal Bypass for BEST short and long term Efficacy G.O. OUTPERFORMS G+D G.O.=Gastric Only vs G+D=Gastric + Duodenal
  63. 63. Outcome after gastrectomy in gastric cancer patients with type 2 diabetes • 403 gastric cancer patients with T2DM • BMI % Reduction • Duodenal Bypass: • BI: No Bypass 7.6% • BII: Bypass 11.4% • ** 50% Improvement ** • Jong Won Kim, etal, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 135- 720, South Korea, World J Gastroenterol. 2012 January 7; 18(1): 49–54.
  64. 64. Objective 2: 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.
  65. 65. Objective 2: Gastrectomy for stomach  cancer on type 2 diabetes (Kang) 75 GCa Pts, 35 month FU BI vs BII Rx DM Gastrectomy ALONE (i.e. Sleeve) 0% Resolved, 45% improved Gastrectomy + BII (i.e. MGB) 22% Resolved, 85% Improved
  66. 66. Objective 2: J Gastrointest Surg. 2012Jan;16(1):45-51 Gastrointestinal metabolic surgery for the treatment of diabetic patients: a multi- institutional international study. Lee WJ, Hur KY, Lakadawala M, Kasama K, Wong SK, Lee YC.
  67. 67. Gastrointestinal metabolic surgery for the treatment of diabetic patients (Lakadawala) 200 patients, Gastric Bypass vs Sleeve gastrectomy Remission of T2DM “Gastric Bypass pts (Gastric + Bypass) lost more weight & higher diabetes remission Sleeve pts“ Bypass pts mix of MGB/RNY (per Dr. Lee)
  68. 68. Objective 2: MGB vs Sleeve Mini-Gastric bypass vs Sleeve Gastrectomy for type 2 diabetes mellitus: a Randomized Controlled TrialRandomized Controlled Trial Lee WJ, Chong K, Ser KH, Lee YC, Chen SC, Chen JC, Tsai MH, Chuang LM. Arch Surg. 2011 Feb
  69. 69. Objective 2: Lee MGB vs Sleeve Randomized Controlled Trial Randomized controlled trial 60 moderately obese patients (body mass index >25 and <35) Outcome was remission of T2DM (fasting glucose <126 mg/dL and HbA(1c) <6.5% without glycemic therapy) All completed the 12-month follow-up
  70. 70. Lee MGB vs Sleeve Randomized Controlled Trial Remission of Diabetes ** 93% ** Mini-gastric bypass ** 47% ** Sleeve gastrectomy (P = .02)
  71. 71. Lee MGB vs Sleeve Randomized Controlled Trial Mini-gastric bypass lost more weight, achieved a lower waist circumference, and Lower glucose, HbA(1c), and blood lipid levels than the sleeve gastrectomy group
  72. 72. Effectiveness of Bariatric Procedures Gastric + Duodenal Bypass Outperforms Gastric Alone G.O. Band Poor G.O. Sleeve Med High G+D RNY High G+D MGB High - Highest Conclusions Band & Sleeve Less Effective than RNY & MGB
  73. 73. Objective 3: Best Rx DM Gastric Procedure + Duodenal Bypass This Excludes Band/Sleeve Need for Gastric Procedure +Bypass Eliminates Band/Sleeve; Leaves Choice RNY vs MGB
  74. 74. Objective 4: RNY is the most Technically Difficult, Dangerous & Deadly form of Bariatric Surgery 100s Refs One Recent Example
  75. 75. RNY: Long learning curve of 500 cases RNY technically challenging 2,281 cases 1999 - 2011 Complications Stabilized after *500* cases Mortality rate .43%, main causes of death PE & Leaks (.14% each) Op time & Complications significantly reduced after a long learning curve of 500 cases Surg Obes Relat Dis. 2013 Feb 11. Overcoming the learning curve of laparoscopic Roux-en-Y gastric bypass: A 12- year experience. El-Kadre L, Tinoco AC, Tinoco RC, Aguiar L, Santos T. Department of Surgery, São José do Avaí Hospital, Itaperuna, Rio de Janeiro, Brazil.
  76. 76. Lap RNY Gastric Bypass Med Coll Va. Postoperative Complications L-RNY Leak 4.5% SBO 2% PE 1% Death 0.7% Ann Surg. 2004 May; 239(5): 698–703. Multivariate Analysis of Risk Factors for Death Following Gastric Bypass for Treatment of Morbid Obesity, Adolfo Z. Fernandez, Jr, MD et al.
  77. 77. RNY Bypass Surgery for Diabetes With Nonmorbid Obesity? Maybe Jun 04, 2013 Controlled Prospective Rndomized 12-months, 49% RNY pts vs 19% lifestyle pts met primary end points BUT 37% serious complications in the RNY group 2 most serious complications were anastomotic leak 3.3%!!, 1 patient suffered anoxic brain injury. Patients who underwent surgery were also more likely to have nonserious adverse events such as nutritional deficiencies. JAMA. 2013 Jun 5;309(21):Roux-en-Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the Diabetes Surgery Study randomized clinical trial. Ikramuddin S, Department of Surgery, School of Public Health, University of Minnesota, Minneapolis, MN 55455, USA. ikram001@umn.edu
  78. 78. RNY Bypass Surgery for Diabetes Controlled Prospective Randomized Trial Normal HgbA1C level range from 4.5 to 6 Only 44% RNY pts HgbA1c < 6 (Cure) BUT 37% serious complications in the RNY group 3.3% anastomotic leaks 1 patient suffered anoxic brain injury and amputation JAMA. 2013 Jun 5;309(21):Roux-en-Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the Diabetes Surgery Study randomized clinical trial. Ikramuddin S, Department of Surgery, School of Public Health, University of Minnesota, Minneapolis, MN 55455, USA. ikram001@umn.edu
  79. 79. 1 yr RNY Did Not Reach Normal HgbA1c JAMA. 2013 Jun 5;309(21):Roux-en-Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the Diabetes Surgery Study randomized clinical trial. Ikramuddin S, Department of Surgery, School of Public Health, University of Minnesota, Minneapolis, MN 55455, USA. ikram001@umn.edu
  80. 80. First report from the American College of Surgeons Bariatric Surgery Center Network 28,000 Patients Ann Surg. 2011 Sep;254(3):410-20 Hutter MM, Schirmer BD, Jones DB, Ko CY, Cohen ME, Merkow RP, Nguyen NT. Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA.
  81. 81. American College of Surgeons Bariatric Surgery Center Network Outcome SG N (%) RNY N (%) Conv to Open 9 (0.10) 207 (1.43) 30-day Mortality 1 (0.11) 21 (0.14) 1-Year Mortality 2 (0.21) 49 (0.34) Readmission 51 (5.4) 937 (6.47) Reoperation 28 (2.97) 728 (5.02) First report from the American College of Surgeons Bariatric Surgery Center Network28,000 Patients
  82. 82. American College of Surgeons Bariatric Surgery Center Network Outcome LSG N (%) RNY N (%) Coma 0 2 (0.01) Stroke 0 5 (0.03) Cardiac Arrest 0 13 (0.09) Myocard Infarct 0 9 (0.06) DVT 1 (0.11) 21 (0.14) Pneumonia 3 (0.32) 58 (0.40)
  83. 83. American College of Surgeons Bariatric Surgery Center Network Outcome SG N (%) RNY N (%) Intubation 3 (0.3) 59 (0.41) Ventilator (> 48 hrs) 0 55 (0.38) Acute Renal Failure 0 22 (0.15) UTI 5 (0.5) 104 (0.7) Wound Dehiscence 0 27 (0.19) Septic Shock 0 21 (0.14)
  84. 84. Objective 5: MGB One of the Most Effective & Safest Best Rx for DM
  85. 85. Laparoscopic Roux-en-y Vs. Mini-gastric Bypass For The Treatment Of Morbid Obesity: A 10-year Experience. Obes Surg. 2012 Dec;22(12):1827-34. Laparoscopic Roux-en-Y Vs. mini-gastric bypass for the treatment of morbid obesity: a 10-year experience. Lee WJ, Ser KH, Lee YC, Tsou JJ, Chen SC, Chen JC. Department of Surgery, Min-Sheng General Hospital, National Taiwan University, No. 168, Chin Kuo Road, Tauoyan, Taiwan, Republic of China. wjlee_obessurg_tw@yahoo.com.tw
  86. 86. Laparoscopic Roux-en-y Vs. Mini-gastric Bypass For The Treatment Of Morbid Obesity: A 10-year Experience. October 2001 and September 2010, 1,657 patients who received gastric bypass surgery (1,163 for LMGB and 494 for LRYGB) Surgical time was significantly longer for LRYGB (159.2 vs. 115.3 min for LMGB, p<0.001).    The major complication rate was higher for LRYGB (3.2 vs. 1.8%, p  =0.07).  5 years after surgery, the mean BMI was lower in LMGB than LRYGB (27.7 vs. 29.2, p<0.05) and    LMGB also had a higher excess weight loss than LRYGB (72.9 vs. 60.1%, p<0.05).    Late revision rate was LRYGB 3.6% and MGB 2.8%
  87. 87. Laparoscopic Roux-en-y Vs. Mini-gastric Bypass For The Treatment Of Morbid Obesity: A 10-year Experience. CONCLUSIONS: This study demonstrates that MGB can be regarded as a SIMPLER and SAFER alternative to RNY with similar or BETTER efficacy at a 10- year experience.
  88. 88. Conclusions: MGB Best Rx for DM 1. Band/Sleeve/RNY/MGB 2. Animal, Gen Surg and Bariatric Data: Best Rx = Gastric + Duodenal Bypass 3. Excludes Band/Sleeve 4. RNY Unquestionably the Most Dangerous form of Bariatric Surgery 5. Numerous studies show MGB short safe and highly effective; Best Choice
  89. 89. Bariatric Surgery Rx Type 2 Diabetes Bariatric Surgery Has Been shown to Successfully Treat Type 2 Diabetes Mellitus Unfortunately Failure of Bariatric Procedures Rx of T2D is reported Operations to be considered: Band/Sleeve/RNY vs MGB
  90. 90. Bariatric Surgeons Should Not Forget Their General Surgery Training • Bariatric Surgeons should Learn from General Surgery • General Surgery and T2D • Results of General Surgery for Gastric Disease • Cancer / Ulcer
  91. 91. Laparoscopic Mini Gastric Bypass Cesare Peraglie MD FACS FASCRS CLOS-Florida: Heart of Florida Regional Medical Center. Davenport, Florida drperaglie@gmail.com SECO 2012 BARCELONA SPAIN
  92. 92. Laparoscopic-Mini Gastric Bypass: HOFRMC •Over 1000 Laparoscopic MGB’s have been performed at HOFRMC since 2005. •TYPICAL DEMOGRAPHICS: AGE: 45 (14-72), BMI: 45 (30-75), ~27% DIABETIC, ~50% HTN, ~31% PREVIOUS ABDOMINAL SURGERY •OUTCOMES OP-TIME: 62Min. (37-186), Conversion to open: 0 LOS: 1 DAY or less (88%), 2 DAY (10%), 3 DAY (~2%), 4+ DAY (<1%) Re-admission: 5% (23 hour obs. PONV in all but one) / 0.8% 90 day Leak: 0.3% MORTALITY: 0 (HOSPITAL), 0 (PERI-OP:90D)
  93. 93. RNY & Small Bowel Obstruction
  94. 94. Every Testbook in General Surgery Warns of SBO after RNY
  95. 95. RNY Causes Bowel Obstruction and Death • My family member had RNY=>SBO=> Death • RNY SBO 2-16% • NO Other Bariatric Surgery Has Such High Rate of Bowel Obstruction
  96. 96. Some RNY Surgeons Never See Bowel Obstruction after RNY How Can this Be? Poor Follow Up Makes Good Results RNY SBO 2-16%
  97. 97. RNY Surgeons Leave SBO to be Cleaned Up by General Surgeons Every General Surgeon is Now Taught To Look For, Be Vigilant and Fear Bowel Obstruction After RNY Gastric Bypass
  98. 98. Poor Follow Up Makes Good Results My Family Member Who DIED From Small Bowel Obstruction After RNY Was Operated Upon by a GENERAL Surgeon not a Bariatric Surgeon! Her RNY Surgeon Does Not Know of her Death or her Bowel Obstruction
  99. 99. Mini-Gastric Bypass By Every Important Measure the Best Choice for Rx Type 2 DM Compared to RNY: Efficacy/Safety One of the Highest Efficacy of Rx T2D Highest Safety Lowest Death Rate Lowest Leak Rate Lowest Early Complication Rate Lowest Major Complication Rate Lowest Bleeding Rate Lowest Re-operation Rate Lowest PE Rate By Every Measure and in Every Study
  100. 100. Lap RNY Gastric Bypass Med Coll Va. Postoperative Complications L-RNY Leak 4.5% SBO 2% PE 1% Death 0.7% Ann Surg. 2004 May; 239(5): 698–703. Multivariate Analysis of Risk Factors for Death Following Gastric Bypass for Treatment of Morbid Obesity, Adolfo Z. Fernandez, Jr, MD et al.
  101. 101. Lap RNY Gastric Bypass Med Coll Va. Postoperative Complications L-RNY Leak 4.5% SBO 2% PE 1% Death 0.7% Ann Surg. 2004 May; 239(5): 698–703. Multivariate Analysis of Risk Factors for Death Following Gastric Bypass for Treatment of Morbid Obesity, Adolfo Z. Fernandez, Jr, MD et al.
  102. 102. Patient Satisfaction Kular Hospital Community Hospital No Advertisement: Offer Sleeve, RNY or MGB Patients are followed Sleeve pts frequently complain of N/V and referr fewer pats for operation RNY Less satisfaction poor referral discouraged MGB high satisfied and refer many patients NOW 90% of cases are MGB
  103. 103. India Turns to the Sleeve Band has come and gone Many RNY programs Centers across India turning to sleeve for the same reasond
  104. 104. Selecting an Operative Procedure Safety and Effectiveness Personal Experience, Animal Models, Expert Judgment, Published Data and Controlled Prospective Randomized Trials all show: MGB is More Effective than Sleeve RNY MGB is Safer than SleeveRNY
  105. 105. Mini-Gastric Bypass: Excellent Results from Multiple Surgeons
  106. 106. 6,385 Consecutive Mini-Gastric Bypasses: 16 Years Later (Rutledge) 6,385 patients who underwent MGB from September 1997 to June 2011 Mean operative time 41 minutes and median length of stay 1 day Early complications occurred in 4.9%. 44 (0.7%) patients had anastomotic leaks. Three (0.05%) patients presented with dypepsia/bile reflux not responsive to medical therapy and were successfully treated by Braun side-to-side jejuno-jejunostomy.
  107. 107. 6,385 Consecutive Mini-Gastric Bypasses: 16 Years Later (Rutledge) Gastritis/dyspepsia/marginal ulcer was the most serious long term complication; routinely treated medically. Excessive weight loss occurred in 1% of patients; treated by take down of the bypass. Mean % excess weight loss (EWL) of 78%. 10 year weight regain was mean 4.9%. >50% EWL was achieved for 95% of patients at 18 months and for 92% at 60 months. 6% of patient had inadequate weight loss or significant weight regain were treated by revision, (addition of ~2 meters to the bypass).
  108. 108. Remember! All Medical and Surgery Can Fail! Bariatric Surgery Procedures are Known to Fail Therefore ALWAYS CHOOSE Operation that Can Be Revised Safely!! NEVER CHOOSE Operation Revision is Dangerous!
  109. 109. Revision of MGB: Easily Done Rarely Needed Revisional Surgery For Laparoscopic Mini-Gastric Bypass Wei-Jei Lee, M.D., Ph.D. , Yi-Chih Lee, Ph.D., Kong- Han Ser, M.D., Shu-Chun Chen, R.N., Jung-Chien Chen, M.D., Yen-How Su, M.D. Surgery for Obesity and Related Diseases Volume 7, Issue 4 , Pages 486-491, July 2011
  110. 110. Revision of MGB: Easily Done Rarely Needed January 2001 to December 2009, 1322 patients excess weight loss and mean body mass index at 5 years after LMGB was 72.1% and 27.1 ± 4.6 kg/m2. Of the 1322 patients, 23 (1.7%) had undergone revision surgery during a follow-up of 9 years. The causes of revision Malnutrition (Excess Weight Loss) in 9 cases Inadequate weight loss in 8 Intractable bile reflux 3 out of 1,322 cases, No patients had surgery for Internal hernia
  111. 111. FIRST International Consensus Conference on Mini-Gastric Bypass Paris in October 2012.
  112. 112. The IFSO-EC Mini-Gastric Bypass Postgraduate Course in Barcelona in April 2012 was a notable success • As you may know we had a great slate of presenters included such experts and leaders included • Prof Jean-Marc Chevallier, France, Prof Roberto Tacchino,Italy, Prof. Dr. Manuel Garcia-Caballero, Spain, Dr. Jean Mouiel,France, Dr. Rui Ribeiro, Dr. Cesare Peraglie, M.D., F.A.C.S., USA, Dr. Mario Musella and Dr. K S Kular M.S. from India; and others. https://www.surveymonkey.com/s/CCVote Or Email DrR@clos.net
  113. 113. IFSO – EC Mini-Gastric Bypass Post Grad Course, April Barcelona The countries represented included France, Italy, Germany, Spain, the United Kingdom, the Czech Republic, Portugal, Egypt, United Arab Emirates, the Netherlands and India. We were pleased that the room was near full, enthusiastic and educational. As a follow up, the Society of MGB Surgeons is seeking to survey the present opinions of surgeons about the MGB and the other bariatric procedures. https://www.surveymonkey.com/s/CCVote
  114. 114. Society of MGB Surgeons MGB / OAGB Survey Respondents https://www.surveymonkey.com/s/IFSO-MGB-ConsensusConference Or Email DrR@clos.net
  115. 115. Society of MGB Surgeons: Rename the Mini-Gastric Bypass?
  116. 116. Society of MGB Surgeons MGB Post Graduate Course MGB / OAGB Survey Respondents 20-30% of All Bariatric Surgery in France is Mini-Gastric Bypass IFSO-EC 18+ MGB Surgeons, 16,000+ MGB procedures Performed Society of MGB Surgeons MGB Survey Respondents 23 MGB Surgeons, 19,000 MGBs, 100 surgeons, 300,000 Bariatric Procedures / year
  117. 117. Irrational Illogical Thinking Decision-Making Errors • Confirmation Bias (favor information that confirms preconceptions) • Herd Behavior (group think override rational) • “Reptilian Brain” Amygdala is part "impulsive," primitive system that triggers emotional override rational thinking https://www.surveymonkey.com/s/IFSO-MGB-ConsensusConference Or Email DrR@clos.net
  118. 118. PRIMITIVE RESPONSE SYSTEMS MODIFY RISK ASSESSMENT https://www.surveymonkey.com/s/CCVote Or Email DrR@clos.net
  119. 119. THE REPTILIAN BRAIN: EMOTION & DECISION MAKING • Rational Logical Thinking: Frontal Lobe • Amygdala Interferes with the Frontal lobe • Primitive, Impulsive • Irrational decision-making https://www.surveymonkey.com/s/CCVote Or Email DrR@clos.net
  120. 120. IRRATIONAL ILLOGICAL THINKING CONFIRMATION BIAS • Contrary Evidence => Maintains or strengthens present beliefs • Overconfidence in present beliefs • Poor Decision Making • Especially Present in Organizations, Military, Political & Social Groups https://www.surveymonkey.com/s/CCVote Or Email DrR@clos.net
  121. 121. REPTILIAN BRAIN POOR DECISIONS FEAR LEADS TO JUDGMENT ERRORS • Errors in Risk Assessment • Death Airplane Crash • Death Car Crash • 1 in 10,000 patient / 20 years risk of gastric cancer • Bowel Obstruction from internal hernia +16% in 15 months! https://www.surveymonkey.com/s/CCVote Or Email DrR@clos.net
  122. 122. Surgeons Who Fear Gastric Cancer = Don't Know Much About Gastric Cancer • Surgeons who say MGB = Bad, Because of the “Risk of Cancer” • Don't know the Risk of Cancer in the General Population • Don't know the risk of gastric cancer in Billroth II • Don't Fear the Risk of Bowel Obstruction from internal hernia +16% in 5 years • Don't Fear Esophageal Cancer after Band & Sleeve
  123. 123. Surgeons Who Fear Gastric Cancer = Don't Know Much About Gastric Cancer I have recently reviewed the literature on gastric cancer and am very knowledgeable about the risk of gastric cancer
  124. 124. Question Answer H. Pylori Treatment Normalizes Risk of Gastric Cancer in Ulcer Patients. Agree 100% The association between H pylori infection and the development of gastric cancer is well established Agree 100% Gastric cancer can be prevented by treating H. Pylori, eating a diet of fresh fruit and vegetables and avoiding smoking, alcohol and nitrates in preserved foods Agree 100%
  125. 125. Question Answer There are many large scale studies that show no increased risk of gastric cancer after Billroth II: Disagree 60% !!! Unoperated Gastric Ulcer patients have double the risk for Gastric Cancer Agree 100% There are some studies showing a slight increased risk of gastric cancer 20-30 years after Billroth II. But these patients had the Billroth II overwhelmingly for Ulcer Disease & Ulcer and Gastric Cancer have a common etiology; H. Pylori. Agree 100%
  126. 126. (Un) Popularity of the MGB • Confusion: MGB Not Old Mason Loop Gastric Bypass • MGB = Antrectomy and BII • Old Mason Loop = Total Gastrectomy + BII https://www.surveymonkey.com/s/IFSO-MGB-ConsensusConference Or Email DrR@clos.net
  127. 127. PR: STATE THE PROBLEM • Obesity Epidemic • History of Failure of Bariatric Surgical Procedures • Selecting the “Ideal / BEST” Bariatric Surgical Procedure https://www.surveymonkey.com/s/IFSO-MGB-ConsensusConference Or Email DrR@clos.net
  128. 128. Sleeve Consensus Meeting? 19 surgeons have shared their data and consensus has been sought on specific points related to sleeve only Mean 12% acid reflux Many showing 20% reflux Many showing 40 % weight loss failure ( < 50 % EWL ) https://www.surveymonkey.com/s/CCVote Or Email DrR@clos.net
  129. 129. SUCCESS CRITERIA "IDEAL" WEIGHT LOSS SURGERY
  130. 130. 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" O: OBJECTIVES, SUCCESS CRITERIA "IDEAL" WEIGHT LOSS SURGERY
  131. 131. O: OBJECTIVES, 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
  132. 132. O: OBJECTIVES, SUCCESS CRITERIA "IDEAL" WEIGHT LOSS SURGERY 21. Low Risk of Ulcer 22. Fat Malabsorbtion; 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
  133. 133. MINI-GASTRIC BYPASS • The Mini-Gastric Bypass 1997 – 2011 ; >6,000 pts, 10 yr Data; Multiple Centers, R.C.Trials • Vertical Gastric Tube (Collis Gastroplasty) • Gastric Bypass (Billroth II Gastro-jejunostomy) https://www.surveymonkey.com/s/IFSO-MGB-ConsensusConference Or Email DrR@clos.net
  134. 134. MINI-GASTRIC BYPASS BASED SOUND SURGICAL PRACTICE • Billroth II Performed over 100 years • 16,000 Billroth II’s USA in 2007 • Operation of choice: Trauma, Ulcers, Cancer Stomach etc.
  135. 135. STATISTICAL ILLITERACY; "MANY DOCTORS MISUNDERSTAND MEDICAL LITERATURE" • Example: “In the absence of a Roux limb, the long-term effects of chronic alkaline reflux are unknown.” • REALLY? Rational vs. Reptilian Brain thinking • Billroth II >100 years and >1,450 papers on Billroth II Collins BJ, Miyashita T, Schweitzer M, Magnuson T, Harmon JW., Gastric Bypass; Why Roux-en-Y? A Review of Experimental Data, Arch Surg. 2007; 142(10):1000-1003.
  136. 136. STATISTICAL ILLITERACY; "MANY DOCTORS MISUNDERSTAND MEDICAL LITERATURE" • Example: “In the absence of a Roux limb, the long-term effects of chronic alkaline reflux are unknown.” Collins BJ, Miyashita T, Schweitzer M, Magnuson T, Harmon JW., Gastric Bypass; Why Roux-en-Y? A Review of Experimental Data, Arch Surg. 2007; 142(10):1000-1003.
  137. 137. GASTRIC CANCER RAPIDLY DECLINING • The incidence of gastric cancer in the United States has • Decreased four-fold since 1930 • Approximately 7 cases per 100,000 people. https://www.surveymonkey.com/s/IFSO-MGB-ConsensusConference Or Email DrR@clos.net
  138. 138. BARIATRIC SURGEONS FEAR BILLROTH II; CANCER SURGEONS CHOOSE BILLROTH II • 1,490 articles on performance of the Billroth II • General/Trauma/Oncologic surgeons commonly use the Billroth II • Over 16,000 Billroth II operation performed in USA 2007 • While Bariatric Surgeons Fear the Billroth II General Surgeons use the Billroth II routinely https://www.surveymonkey.com/s/CCVote Or Email DrR@clos.net
  139. 139. BARIATRIC SURGEONS FEAR BILLROTH II WHAT IS MAGNITUDE OF THE PROBLEM • Mayo Clinic Study (Example) • 338 Billroth II patients • Followed 25-years • 5,635 person-years • Only 2 Cancers in 5,000+ pt years of Follow Up • Schafer et al, Risk of gastric carcinoma after treatment for benign ulcer disease. N Engl J Med. 1983 Nov 17;309
  140. 140. BARIATRIC SURGEONS FEAR BILLROTH II MAGNITUDE OF THE PROBLEM • Population based study, 338 Billroth II pts • Followed 25-years • 5,635 person-years • Only 2 Cancers Found in 5,000 years • Predicted 2.6 cancers (relative risk 0.8) Schafer et al, Risk of gastric carcinoma after treatment for benign ulcer disease. N Engl J Med. 1983 Nov 17;309
  141. 141. BARIATRIC SURGEONS FEAR BILLROTH II MAGNITUDE OF THE PROBLEM • 338 Billroth II pts, Followed 25-years • 5,635 person-years • Only 2 Cancers in 5,000 pt years follow up • RATE of Gastric Cancer is Declining • 24 - 50% Expected Decrease from 1983 • Future risk ~1 patient / 5,000 pt years
  142. 142. ULCERS INCREASE RISK CANCER • Meta-analysis: 7 studies Small increased risk 5 studies No Increased Risk • Studies with increased Risk; Flawed • Billroth II = Surgery Rx Ulcers • ULCERS increase risk of Gastric Cancer! • Ulcers and Gastric Cancer Common Etiology =H. Pylori=
  143. 143. ULCERS INCREASE RISK CANCER •3,078 gastric cancer vs. 89,082 controls •Ulcer increases risk gastric cancer =(relative risk 1.53)= •Same as Increased Risk reported Billroth II •Many other studies confirm these findings: •Ulcer Increases Risk Gastric Cancer •Ulcers & Gastric Cancer: •Common Etiology =H. Pylori=
  144. 144. BARIATRIC SURGEONS FEAR BILLROTH II GASTROENTEROLOGISTS IGNORE BILLROTH II • Hundreds of thousands of people with Billroth II’s • If cancer IS SUCH A BIG RISK… • Shouldn’t gastroenterologists be looking for these people, screening them with endoscopy? • No, there is no recommendation for BII follow up screening; Why? THE RISK IS LOW • 63,000 yrs Follow up 23 cancers = Gen Pop.
  145. 145. RISK OF GASTRIC CANCER AFTER  BILLROTH II IS LOW • Follow-up study of 1000 patients • 22-30 year follow-up • 196 endoscopy and biopsy No Cancer of the gastric remnant seen • Endoscopic screening will be “unrewarding” • Br J Surg. 1983 Sep;70(9):552-4. Risk of gastric cancer after Billroth II resection for duodenal ulcer. Fischer AB
  146. 146. WHAT CAUSES GASTRIC CANCER? ITS NOT BILLROTH II • Diets rich in fried, salted, smoked or preserved foods increased cancer risk in many studies. • Foods contain nitrites and these chemicals can be converted to more harmful compounds (carcinogens) by bacteria in the stomach. • Diets high in fruit and vegetables protects against Cancer • Stomach cancer is much more common in smokers and in those with heavy alcohol intake. • H. Pylori, No H. Pylori No Cancer
  147. 147. DIET AND CANCER PREVENTION • Avoid ETOH, Tobacco, Processed & Preserved Meats, Salt • RX H. Pylori, • Eat Fruits and Veggies, Yogurt and • Drink Green Tea • Gonzalez CA, Cancer Research, Institut Català d'Oncologia, Av. Gran Via s/n, km 2.7, 08907 L'Hospitalet, Barcelona, Spain.
  148. 148. Which Is More DeadlyWhich Is More Deadly A Hot Dog Or A Billroth II?A Hot Dog Or A Billroth II?
  149. 149. Which Is More Deadly A Hot Dog Or A Billroth II? Processed meats (Bacon, sausage, hot dogs, sandwich meat, packaged ham, pepperoni, salami, etc.) Shown to be associated with gastric cancer. An increase intake of 100 g of processed meat per day Increases the risk of Gastric Cancer by 3.5 times = Natl Cancer Inst. 2006 Mar 1;98(5):345-54. Meat intake and risk of stomach and esophageal adenocarcinoma within the European Prospective Investigation Into Cancer and Nutrition (EPIC). = J Natl Cancer Inst. 2006 2;98(15):1078 "Processed meat consumption and stomach cancer risk: a meta-analysis" The Karolinska Institutet (Hint: A Hot Dog weight 3.7 oz = 100 g = INCREASED RISK 3.5!)
  150. 150. Which is more deadly a Hot Dog or a Billroth II? AA BB https://www.surveymonkey.com/s/IFSO-MGB-ConsensusConference Or Email DrR@clos.net
  151. 151. Which is more deadly a Hot Dog or a Billroth II?
  152. 152. Which Do Bariatric Surgeons Fear More? A Hot Dog or a Billroth II? AA BB https://www.surveymonkey.com/s/IFSO-MGB-ConsensusConference Or Email DrR@clos.net
  153. 153. UNINFORMED FEAR BILLROTH II EDUCATED USE BILLROTH II • 1. Gastric Cancer Declining Rapidly, > 50% • 2. Gastric Cancer Cause: Environmental Factors / Easily Prevented Diet, Lifestyle changes and Rx of H. Pylori (Avoid Etoh, smoking, processed & salted meats and foods, seek high intake of fruits and vegetables)
  154. 154. UNINFORMED FEAR BILLROTH II EDUCATED USE BILLROTH II • 3. Some studies Slight Increased Risk of gastric cancer after 20 – 30 years (RR 1.5): But: BII was performed to Rx Ulcer => Ulcer => Increased Risk • (Worried? Rx H Pylori, Eat healthy etc.) • 4. Many Large Studies: No Increased Risk Thousands of patients followed for Decades
  155. 155. UNINFORMED FEAR BILLROTH II EDUCATED USE BILLROTH II • 5. Endoscopic screening of Billroth II patients is Not Recommended. Why? Low Risk! • 6. General, Trauma and Oncologic surgeons routinely use the Billroth II (Thousands of publications) • 7. 2007 ~16,000 BII procedures were performed in the USA
  156. 156. UNINFORMED FEAR BILLROTH II EDUCATED USE BILLROTH II • 8. Billroth II and the Mini-Gastric Bypass Excellent, Safe and Effective • 9. FEAR Gastric Cancer? Avoid ETOH, Tobacco, Processed & Preserved Meats, Rx H. Pylori, Eat Fruits and Veggies, Yogurt and Drink Green Tea • A Billroth II probably makes NO difference
  157. 157. T: TRADEOFFS • Rational Review of the Data vs. Fear Gastric Cancer / Bile Reflux • Rational Thinking vs. Reptilian Brain
  158. 158. T: TRADEOFFS: 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 Risk Probably from Ulcers / H. Pylori • 4. Many large studies: NO increased risk • 5. Endoscopic Screening: Not Recommended • 6. General, Trauma & Oncologic Surgeons Use Billroth II
  159. 159. T: TRADEOFFS FEAR OF GASTRIC CANCER • FEAR gastric cancer? • Avoid: Alcohol, Tobacco, Processed & Preserved Meats Rx: H. Pylori, Eat Fruits & Veggies, Yogurt and Drink Green Tea • Billroth II Probably Makes NO DifferenceBillroth II Probably Makes NO Difference
  160. 160. T: TRADEOFFS FEAR OF GASTRIC CANCER A Billroth II Probably Makes No Difference
  161. 161. T: TRADEOFFS FEAR OF GASTRIC CANCER A Billroth II Probably Makes No Difference
  162. 162. Expert Opinions: "May be the Best Operation, I Use It Frequently" Good, maybe the best form of WLS, I use it often? May I beg your indulgence: Please consider giving us your learned opinion: https://www.surveymonkey.com/s/IFSO-MGB-ConsensusConference Or Email DrR@clos.net
  163. 163. Expert Opinion: Operation Judged Short and Simple
  164. 164. Expert Opinion: Failure is "VERY RARE"
  165. 165. Experts Who Once Used the Band and Now Have Stopped Using the Band (38%)
  166. 166. Expert Opinions: Patients Routinely Get Major Weight Loss
  167. 167. Expert Opinions: Patients RARELY Regain Their Weight
  168. 168. Expert Opinion: Patients RARELY Suffer Long Term Complications
  169. 169. MGB Experts (>100 MGBs): Patients RARELY Suffer Long Term Complications
  170. 170. Expert Opinions: Procedure Advocates Reporting "No Leaks"
  171. 171. Expert Opinions: Procedure Advocates Reporting a Leak
  172. 172. Expert Opinion: Revision is Relatively Easy
  173. 173. CONCLUSIONS: PR.O.A.C.T. Rational Choice: Mini-Gastric Bypass • Pr: Choice of Obesity Surgery • O: Objectives “Ideal” Weight Loss Surgery • A: RNY, Band, Sleeve, MGB • C: MGB meets almost all objectives/success criteria • T: Fear of Bile Reflux & Gastric Cancer Not Supported by the Data • Rational Decision Making: Best Choice; Mini-Gastric Bypass
  174. 174. WHY CRITICS ONLY CARE FOR MGB? • 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?
  175. 175. WHY CRITICS ONLY CARE FOR MGB? •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?
  176. 176. WHY CRITICS ONLY CARE FOR MGB? • 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
  177. 177. WHY CRITICS ONLY CARE FOR MGB? • There is a simple reason • The critics of the MGB do not do those things because they are ... • 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
  178. 178. THE TIDE BEGINS TO TURN TO THE MINI-GASTRIC BYPASS • “Not too long ago, the bariatric community questioned the role of the mini-gastric bypass and its appropriateness as a durable operation for obesity.” • The experience of Lee et al. with a large cohort suggests some answers.” • Michel M. Murr, M.D. • “The Journal continues to commit to open, spirited, and balanced discussions that are supported by data and withstand the test of common sense.” • Editorial: Revisional surgery for laparoscopic mini-gastric bypass. Lee WJ, Surg Obes Relat Dis. 2011 Jul-Aug;7(4):486-91
  179. 179. Mini-Gastric Bypass: 9 YEARS LATER! OUT PERFORMS RNY • New results of the MGB: • “1,322 patients, 23 (1.7%) had revision Follow-up of 9 years.” • Excess weight loss 72.1% • No patient had surgery for internal hernia Revisional surgery for laparoscopic mini-gastric bypass. Lee WJ, Surg Obes Relat Dis. 2011 Jul-Aug;7(4):486-91
  180. 180. Patient Survey: MGB OUT-PERFORMS BAND & RNY • Follow up survey of bariatric surgery results in 1,500 patients’ friends, family and acquaintances • Patient Reported Success in Friends Family: 36% RNY, 24% Band and 93% MGB
  181. 181. EXAMPLE FEAR & DECISION MAKING SBO VS. GASTRIC CANCER • Which is more Deadly? • Gastric Cancer or Small Bowel Obstruction? • Which is more fearsome?
  182. 182. 11+ RNY STUDIES INTERNAL HERNIA BOWEL OBSTRUCTION • 1 - 16% Internal Hernia /Small Bowel Obstruction • Follow Up 1-10 years (only 7% at 10 years) • Note: Dead patients cannot return for follow up • =15/18 patients, ReOp, failed closure USA=
  183. 183. DEATH AFTER SMALL BOWEL OBSTRUCTION • 877 patients who underwent 1,007 operations for SBO from 1961 to 1995 • Risk of bowel obstruction increases over time • 52 Deaths 6% Death Rate • Ann Surg. 2000 April; 231(4), Complications and Death After Surgical Treatment of Small Bowel Obstruction A 35-Year Institutional Experience Fevang et.al., Department of Surgery, University Hospital, University of Bergen, Norway
  184. 184. FEAR AND DECISION MAKING SBO VS. GASTRIC CANCER • Which is more Deadly? • Gastric Cancer or Small Bowel Obstruction? • Which is more fearsome?
  185. 185. FEAR AND DECISION MAKING SBO VS. GASTRIC CANCER • 1,000 RNYs, Estimate 20% SBO => 200 operations for SBO in 5-10 years (? How many more for 20 years?)
  186. 186. FEAR? SBO VS. GASTRIC CANCER • 1,000 RNYs, 20% SBO => 200 operations for SBO in 5-10 years (? How many for 20 years?) • 6% Death Rate => 12 dead before the end of 10 years from SBO
  187. 187. FEAR? SBO VS. GASTRIC CANCER • 1,000 RNYs, 20% SBO => 200 operations for SBO in 5-10 years (? How many for 20 years?) • 6% Death Rate => 12 dead before the end of 10 years from SBO • 1,000 MGBs After 20 years possibly increased risk of cancer of 1 / 1,000
  188. 188. FEAR? SBO VS. GASTRIC CANCER • 1,000 RNYs, 20% SBO => 200 operations for SBO in 5-10 years (? How many for 20 years?) • 6% Death Rate => 12 dead before the end of 10 years from SBO • 1,000 MGBs After 20 years possibly increased risk of cancer of 1/1,000 • Deaths at 10 years from Gastric Cancer 0.0
  189. 189. FEAR? SBO VS. GASTRIC CANCER • 1,000 RNYs, 20% SBO => 200 operations for SBO in 5-10 years (? How many for 20 years?) • 6% Death Rate => 12 dead before the end of 10 years from SBO • 1,000 MGBs After 20 years possibly increased risk of cancer of 1/1,000 • Death at 10 years from Gastric Cancer 0.0 • Death SBO 12/10 years, Deaths Gastric Cancer 10-20 years 0-1
  190. 190. WHICH DO YOU FEAR? SBO VS. GASTRIC CANCER • 1,000 RNYs = 200 SBO operations • Death from RNY SBO 12 deaths / 10 years • 1,000 MGB’s 0-1 Gastric Cancer @ 20 yrs • Deaths Gastric Cancer 10-20 years 0-1?
  191. 191. FEAR AND DECISION MAKING SBO VS. GASTRIC CANCER • Which is more Deadly? • Gastric Cancer or Small Bowel Obstruction? • Which is more fearsome?
  192. 192. FOLLOW UP EFFECT • Unbiased Population based studies => Poor Results of RNY • Positive Results of RNY reported from RNY centers • Suffer from “Follow Up Effect” • Patient Returns to clinic doing well: Greeted Warmly with Great Joy • Patient Returns to clinic doing poorly: Greeted with anger and disapproval • Successful pt => Good Follow Up / Failed pt tacitly sent away • Now; Center reports excellent results; (30%) follow up • Weight Regain, Band Erosion, Death • Not Seen, Not Reported

×