SUCCESS CRITERIA"IDEAL" WEIGHT LOSS SURGERY1. Low Risk2. Major Weight Loss3. Easily performed4. Short operative times5. Outpatient or short hospital stay6. Minimal Blood Loss7. No Need for ICU Stay8. Minimal Pain9. Very High Patient Satisfaction10. A Good "Exit Strategy"
SUCCESS CRITERIA"IDEAL" WEIGHT LOSS SURGERY11. Change Behavior & Preferences; Marked Decrease in Hunger and Increased Satiety12. Minimal Retching and Vomiting 13. Few adhesions or hernias14. Minimal impact on Heart and Lung Function15. Low Failure Rate16. Low Cost17. Short Recovery Time18. Rapid Return to Work19. Low Risk of Pulmonary Embolus20. Durable weight loss
SUCCESS CRITERIA"IDEAL" WEIGHT LOSS SURGERY21. Low Risk of Marginal Ulcer22. Fat Malabsorption; low cholesterol & CV risk 23. No Plastic Foreign Body 24. Easily Verifiable Results; > 10 years of Results25. Low Risk of Bowel Obstruction26. Based upon sound surgical principles 27. Independent confirmation of results28. Healthy life after surgery29. 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 RNY Band SG MGB1. Low Risk - + - +2. Major Weight Loss + - - ++3. Easily performed -- + + +4. Short operative times - + + +5. Short hospital stay -- + + +6. Minimal Blood Loss - + + +7. No Need for ICU Stay - + + +8. Minimal Pain - + + +9. High PatientSatisfaction - - - +10. A Good "Exit Strategy" - - - + -- +
Criteria for Success;Ideal Weight Loss Surgery RNY Band Sleeve MGB11. Decrease Hunger + - + +12. Min Vomiting + + + +13. No Internal hernias - + + +14. Min Heart/Lung - + + +15. Low Failure Rate - - - +16. Low Cost - - - +17. Short Recovery - + + +18. Return to Work - + + +19. Low Risk of PE - + + +20. Durable Weight Loss - - - +
Criteria for Success RNY Band SG MGB21. Low Risk of Ulcer - + + -22. Malabsorption of fat + - - +23. No Foreign Body + - + +24. Verifiable Results - - - ++25. Bowel Obstruction -- + + ++26. Sound Surgical + - + +27. Independent confirm - - - ++28. Healthy life - - - ++29. RCT; LEVEL I Evidence - - - ++30. Block Sweet Eater + - - ++
Epidemiology: What do we know aboutMarginal Ulcers?Marginal ulcers represent one of the most problematicpostoperative complications following Roux-en-YA marginal ulcer, or stomal ulceration, refers to thedevelopment of mucosal erosion at the gastrojejunalanastomosis, 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 thebeginning GI SurgeryMARGINAL, GASTROJEJUNAL OR PEPTIC ULCERSUBSEQUENT TO GASTROENTEROSTOMY.Erdmann JF.Ann Surg. 1921 Apr;73(4):434-40.
Marginal Ulcer has been known since thebeginning GI SurgeryTHE ROENTGEN DIAGNOSIS AND LOCALIZATIONOF MARGINAL PEPTIC ULCER.Carman RD.Cal State J Med. 1920 Nov;18(11):377-82
Marginal Ulcer has been known since thebeginning GI SurgeryRe-evaluation of the role of the pyloric antrum inmarginal peptic ulcers.SCHILLING JA, PEARSE HE.Surg Gynecol Obstet. 1948 Aug;87(2):225-34
Marginal Ulcer has been known since thebeginning GI SurgeryVagotomy 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 thebeginning GI SurgeryReview Article: The present status of the managementof marginal ulcer.BYRD BF Jr.J Tn State Med Assoc. 1953 Feb;46(2):56-8.
Marginal Ulcer has been known since thebeginning GI Surgery2,282 RYGB122 (5%) Marginal ulcers39 (32%) SurgerySurg Obes Relat Dis. 2009 May-Jun;5(3):317-22. Revisional operations for marginal ulcerafter Roux-en-Y gastric bypass. Patel RA, Brolin RE, Department of Surgery, UniversityMedical Center at Princeton, Princeton, New Jersey 08536
Marginal Ulcer Very High After RNY GastricBypass 441 RYGB 10 (12%) of RNY gastric bypass presented an "early" marginal ulcer Asymptomatic (28%) Obes Surg. 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 A et al Department of Surgery, University Hospital, University of Chile, Santiago, Chile.
Marginal Ulcer Very High After RNY GastricBypassAssociated 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%) Surg Endosc. 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 & MGBMarginal Ulcers after Roux-en-Y Gastric Bypass:Pain for the Patient…Pain for the Surgeonby Camellia Racu,January 2010Bariatric Times.2010;7(1):23–25
Marginal Ulcer after Gastric Bypass;RNY & MGBMarginal ulcers RNY ranging from 0.6 to 16%True incidence is very likely much higherCsendes prospective studyroutine postoperative endoscopic evaluation28% of marginal ulcers were asymptomaticGastric Bypass (RNY & MGB)HIGH incidence of Marginal UlcerBILE MAKES NO DIFFERENCE!!!
Incidence of perforated gastrojejunalanastomotic ulcers after RNYApril 2002 to April 2010, 1213 patients underwentlaparoscopic RYGBOperative mortality was .15%10 perforated GJA ulcers (.82%) at a mean of 13.5(6-19) monthsMorbidity and mortality rate was 30% and 10%Perforated GJA ulcers can develop in 1 of 120 Rouxen Y Gastric Bypasses & DEADLY
Marginal Ulcers:Achilles Heel of Gastric BypassManagement1. Warn Patients & Surgeon “Be Vigilant”2. Aggressive anti-H. Pylori Rx3. Aggressive use of Antacids4. Strict Avoidance of Ulcerogenic Agents(NSAIDS, Etoh, Smoking, Coffee, Soda, Nitrates)5. Encourage: Probiotics, Yogurt, Fruits VegetablesBILE 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
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 UseBillroth II