Slides Azores 2 ===> File Name: MGB Background Intro.pptx: MGB/OAGB Background: MGB as Routine Surgery, MGB vs Sleeve, MGB and Billroth II, MGB and Diabetes Treatment

1. MGB Background & History
MGB = Routine General Surgery,
MGB vs Sleeve Data,
MGB Billroth II Rx Diabetes

2. MGB Background
•9:50am to 10:40am
•MGB Background
•MGB = Routine General Surgery
•Billroth II and Gastric Cancer
•MGB vs Sleeve
•MGB Billroth II Rx Diabetes

3. MGB Background
Ideal Bariatric Surgery

4.  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

5. 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

6. SUCCESS CRITERIA
"IDEAL" WEIGHT LOSS SURGERY
 21. Low Risk of 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

7. History of
MGB & Dr Rutledge

8. History of MGB & Dr Rutledge
• Dr Rutledge Trauma Surgeon Professor of Surgery 20 years
Univ of North Carolina
• 1997 Patient: Drug Dealer, Shot by his customer
• Gun Shot Wounds X 6 to Abdomen
• 9 pm Thurs Night Sept 1997 Emergency Surgery
• Injury to Stomach, Tail of Pancreas and Multiple Loops of
Small Bowel

9. History of MGB
Patient w Gun Shot Wounds
• Injury to
Stomach, Pancreas and
Multiple Loops of Small Bowel
• Rx
Distal Gastrectomy
• Distal Pancreatectomy
• Splenectomy

10. History of MGB
RX: Antrectomy, Distal Pancreatectomy Splenectomy

11. History of MGB
Reconstruction Ante-Colic Billroth II

12. 1997: Next Morning Planned Lap RNY
MGB = Standard General Surgery (Antrectomy & Billroth II)

13. Mini-Gastric Bypass =
General Surgery
“Antrectomy + Billroth II”
MGB No Such Thing!
Minimally Invasive Surgery in 1997
Gastric Bypass Billroth II Gastro-Jejunostomy
(NOT MASON LOOP!)

14. MGB = Routine, Regular, Standard
General Surgery
Partial Gastrectomy
+
Billroth II Gastro-jejunostomy

15. General Trauma & Oncologic
Surgeons
Routinely Use Billroth II
Examples in China, Korea
&Taiwan which have high risk of
Gastric Cancer

16. Gastric Cancer Rx in Korea
Billroth II used in 82%
•Study Distal Gastrectomy for Gastric Cancer
•40 patients underwent Billroth II, 82%
•9 patients underwent Roux-en-Y, 18%
• Surg Endosc. 2016Aug;30(8):3559-66. Early experience of duet laparoscopic distal gastrectomy (duet-LDG) using three
abdominal ports for gastric carcinoma: surgical technique and comparison with conventional laparoscopic distal gastrectomy.
Jeong O

17. Korean Study 2017 Treatment Choice For Gastric
Cancer Patients
• J Gastric Cancer. 2017 June
Outcomes of Patients with Gastric Cancer, Ki Hyun Kim
• 70% Billroth I, 20% Billroth II, 10% Roux-en-Y
• Billroth II Chosen 2 to 1 vs RNY for
GASTRIC CANCER by Oncologic Surgeons in **Korea**

18. Billroth II Routine use in Taiwan
•“Subtotal gastrectomy the surgical treatment for
early-stage distal gastric cancer, is usually
accompanied by highly selective vagotomy and
**Billroth II reconstruction **”
• Sci Rep. 2016 Feb10 Gastric microbiota and predicted gene functions are altered after subtotal
gastrectomy in patients with gastric cancer Tseng CH

19. Reconstruction After Distal Gastrectomy
in Japan 2017
• Various methods of reconstruction after laparoscopic distal
gastrectomy Japan (Very High Rates Gastric Cancer)
• June 2009 and December 2015, we assessed 263 consecutive patients
• Billroth I (36.1%);
• Billroth II, 165 cases (62.7%);
• Roux-en-Y, 3 cases (1.1%)
• J Laparoendosc Adv Surg Tech A. 2017 Jul, Laparoscopic Distal
Gastrectomy Takayama Y

20. Billroth II Routinely Used in China
• Clinicopathological data of 1,140 GCa patients
• May 2008 to April 2015
• 207 patients of Billroth I
•785 Billroth II
• 148 Total Gastrectomy + RNY
• ** NO RNYs for Partial Gastrectomy ** ( 0 )
• Zhonghua Wei Chang Wai Ke Za Zhi. 2015 Dec[Distal gastrectomy brings a better long-term survival for patients with distal gastric cancer compared with total
gastrectomy]. Liu Z

21. Routine Use of Billroth II in
Sichuan, People's Republic of China.
•Study nonobese T2DM patients with
Gastric cancer => routine Billroth II
•Compared obese T2DM patients undergoing
RYGB
•Glycemic control efficacy of Billroth II Rx
nonobese T2DM
•Billroth II Similar to RNY
• Arch Med Res. 2015May Comparison of Gastric Bypass Surgeries on Managing Obese and Nonobese Type 2 Diabetes Mellitus:
A Prospective Study. Zhang X

22. The Billroth II is a
Good Procedure!
When Done RIGHT
Bariatric Surgeons Need to Re-Learn their General
Surgery
The Mason Loop Gastric Bypass was Bad
Because
the Billroth II was MISUSED!!

23. MGB Mechanism of Action
NOT Band, VBG, Sleeve, RNY or BPD (SADI)

24. MGB v RNY
Restriction Obstructive vs Non Obstructive

25. Band, Sleeve & RNY: OBSTRUCTION
Block Normal Healthy Foods
•Weight Loss =>
•Increased Hunger
•Decreased Satiety
•Healthy Foods Blocked;
OBSTRUCTION
•Drive to Eat UP
•What Happens?

26. Conclusion:
MGB = Standard General Surgery,
Simple Operation
But
MANY Tricks and Traps

27. MGB = Billroth II,
Billroth II is GOOD
General Surgeons
Know How to Use the Billroth II
Bariatric Surgeons are
Often Uninformed and Fear the Billroth II

28. MGB = Billroth II,
Billroth II is GOOD
But!
The Operation Needs to Be Used Correctly
The Operation Can Be Performed Incorrectly

29. 20 Years FEAR of MGB?
Mason Loop *NOT* MGB
Mason Loop = Billroth II Done Wrong

30. Billroth II Loop Antrum: YES, Billroth II - EGJx: NO, NEVER

31. • Well Informed
General
Surgeons
=>
Routinely Use
the Billroth II
(Correctly)
• Uninformed
Bariatric
Surgeons
=>
Fear the
Billroth II

32. Billroth II = RNY
Cancer Surgeons Routinely Use Billroth II
• 2015 Study 7 USA Cancer Centers
• 500 Patients
• Prospective Randomized Trial
• Billroth II vs. RNY for Distal Gastrectomy
• “NO advantage of Roux-en-Y over Billroth II in outcomes”
•Tran et al. To Roux or not to Roux: a comparison between Roux-en-Y and Billroth II
reconstruction following partial gastrectomy for gastric cancer. Gastric Cancer. 2015 Sep 23.

33. MGB vs Sleeve

34. Dr Rutledge's Results
Mini-Gastric Bypass

35. Dr Rutledge's Results
Mini-Gastric Bypass

36. Unique Advantages of the MGB
Ideal Candidates for MGB, EVERYONE?
• MGB Can Be Tailored to
Meet Patient Needs
1. Usual Bariatric Patient
2. Diabetic
(2x more Effective)
3. Super Obese
(Max Power/Effective)
4. GERD Patient
5. Difficult/Psych Patient
(Reversible <60 min)
6. Severely Ill/Liver Disease
(Two Stage MGB)
7. Borderline Patient
(Reversible <60 min)
8. Frail/Elderly
(Low Risk)
9. Young Unmarried Female
(Reversible/Revisable)
10. FUTURE PATIENTS?
(Non-obese Diabetics)

37. MGB “Best”/Good Bariatric Surgery?
Example Recent Study: MGB is “Good Surgery”
Obes Surg. 2017 Sep;27(9):2479-2487
=> MGB vs. Sleeve Gastrectomy <=
Systematic Review and Meta-analysis, Magouliotis DE
* 17 * studies *6,761* patients
“This study reveals:”
MGB Better “Weight loss, Remission of comorbidities,
Shorter hospital stay, & Lower Mortality”
“Sleeve Higher Rate GERD” (=> Barrett's & Esophageal Cancer)

38. “MGB simpler, safer, and more effective than Sleeve”
• Medicine (Baltimore). 2017 Dec
• Comparison of safety and effectiveness between
• Mini-gastric bypass vs Sleeve gastrectomy:
A meta-analysis and systematic review.
• Wang FG

39. “Mini-gastric bypass simpler, safer, and more effective than
laparoscopic sleeve gastrectomy”
• “Due to safe and simple process and effective
outcomes
• laparoscopic mini-gastric bypass has become
one of the most popular procedures in some
countries”

40. “Mini-gastric bypass simpler, safer, and more effective than
laparoscopic sleeve gastrectomy”
METHODS:
A systematic literature search
was performed
“Mini-Gastric Bypass had a
lot of advantages”
1. Higher 1-year EWL%
(excess weight loss),
2. Higher 5-year EWL%,
3. Lower leak rate,
4. Higher T2DM remission
rate, higher hypertension
remission rate, higher
obstructive sleep apnea
(OSA) remission rate,
5. Lower overall late
complications rate,
6. Lower gastroesophageal
reflux disease (GERD) rate,
7. Shorter hospital stay and
8. Lower revision rate.

41. Obes Surg. 2017 Nov 3. Revisional Gastric Bypass for Failed Restrictive Procedures:
Comparison of Single-Anastomosis (Mini-) and Roux-en-Y Gastric Bypass. Almalki OM
• 2001 - 2015, 116 patients
• Failed restrictive operations
• Revisional bypass surgery
(R-MGB vs. R-RNY)
• R-RNY significantly longer operative times than R-MGB.
• R-MGB shown to be
Simpler procedure with
Better weight loss than R-RNY

42. Sleeve, RNY & Others are
Good...
The MGB is As Good as or
Better Than ...
BUT

43. The MGB has Been Shown to
Be One of the Most Effective
and Powerful Forms of
Bariatric Surgery
In Hundreds of Papers it Has
Also Been Shown to Be a Safe
and Simple Procedure
BUT...

45. The MGB
Has Great Power
The MGB Surgeon Has
Great Responsibility
Tips and Tricks
MGB: Done Well is a Simple Operation
But: Surgeon Needs to Understand
Anatomy & Physiology =>
Mechanism of Action => Technique

46. Need for Safety
• Beware of Brave Surgeons
• Need to Understand
1. How to Avoid Trouble
2. How to Get Out of Trouble

47. “Mini-Gastric Bypass”
Done Right!
(Note, If you wish to do MGB or Omega Loop
etc. Of course, No Problem
But,If you wish to do MGB,
This is How We Do It!)
​Dr. Rutledge,
Email: DrRutledge@gmail.com
Facebook: DrRRutledge
Facebook Messenger: @DrRRutledge
WhatsApp: Dr Rutledge +1 (442) 234-3237
+1 (702) - 483-7133
Youtube: DrRRutledge

48. Widespread
Confusion and
Misunderstanding of the
Billroth II
and the MGB

49. The Billroth II
is a good safe operation
that makes people
healthier
While Some bariatric Surgeons Fear the Billroth II
General Surgeons Routinely Use the Billroth II

50. The Billroth II
is a good safe operation
that makes people
healthier
Studies Show
Billroth II
Decreases the Risk of
Stroke, Coronary Heart Disease & Diabetes and more

51. A Nationwide Population-Based Study
Billroth II Decreased Risk of Stroke
• 6,425 patients Billroth II for Ulcer
• Nationwide Health Database
• Matched with 25,602 Ulcer Pts who did not
receive Billroth II
• Billroth II patients had a lower risk of Stroke!
• Medicine (Baltimore). 2016 Apr;95(16)

52. A Nationwide Population-Based Study
Billroth II Decreased Risk of Coronary Heart Disease.
• BII for Ulcer
•National Health Insurance Database
• Matched with 25,602 Ulcer Pts did not receive
Billroth II
• Billroth II patients 20%+ Decreased Risk of Coronary
Heart Disease
• Obes Surg. 2017 Jun;27(6):1604-1611

53. A Nationwide Population-Based Study
Billroth II Decreased Risk of Diabetes by Almost 50%
• National Health Insurance Database
• Matched with patients did not receive Billroth II
• Billroth II patients of Diabetes (adjusted hazard ratio
(aHR): 0.56)
• PLoS One. 2016 Nov 28;11(11)

54. Billroth II in Thousands of
General Surgery Patients
• Billroth II =>
• Decreases the risk of
• Stroke
• Coronary Heart Disease
• Diabetes
• General Surgeons Routinely Use the MGB

55. General Surgery Data
• Comparison
• Gastrectomy + Billroth I
(No Duodenal Exclusion) => Like Sleeve
• Gastrectomy Billroth II
(WITH Duodenal Exclusion) = Like MGB

56. Understand Advantage of
Billroth II vs Billroth I, (i.e. MGB vs
Sleeve)
• General Surgery
• 2-year Diabetes remission rate:
Billroth I 39% (Sleeve No Duodenal Exclusion)
Billroth II 50% (MGB WITH Duodenal Exclusion)
• BII significantly increased diabetes remission
• (odds ratio, * 3.2 *) in covariate-adjusted logistic
regression analysis

57. Bariatric Studies
Confirm
General Surgery Studies

58. 5-year results of a randomized trial
Sleeve gastrectomy vs Mini-gastric bypass for the treatment of type 2 diabetes
Obes Surg. 2014
• Double-blind randomized trial,
HbA1c > 7.5%, BMI 25 - 35 Kg/m(2)
Type 2 diabetes
• At 60 months
• 60% MGB
• 30% SG
• Achieved the primary end points
• MGB Twice as Effective as Sleeve

59. General Surgery And
Randomized Controlled Trials
In Bariatric Surgery
Demonstrate
MGB Much More Effective
In Treating Diabetes Than Sleeve

60. MGB Excellent Outcomes
in Experienced Hands
Examples from Few Recent
Studies

61. Surg Obes Relat Dis. 2018 Feb, Abu-Abeid
Diabetes resolution after MGB
• 25% had diabetes with average glycosylated hemoglobin of 8.6
± 1.9 g%
• Average excess weight loss 1 year after surgery was 88.9 ± 27.3
• Of all diabetic patients, only 7.8% were still diabetic average
glycosylated hemoglobin of 5.4 ± 0.6
• CONCLUSIONS: MGB offers excellent resolution of diabetes.

62. Evaluation of Weight Loss Indicators and Laparoscopic One-Anastomosis Gastric
Bypass Outcomes.
Sci Rep. 2018 Jan 31, Carbajo MA
• Bilio-pancreatic loop length was 275 ± 24 cm
• Hospital stay was 24 hours in 98%
• No surgical complications arose.
• Weight decreased significantly during follow-up
(P < 0.001).
• Greatest weight loss was observed at 12 months
post surgery (69 ± 13 kg).

63. 15-year experience of laparoscopic single anastomosis (mini-)gastric
bypass: comparison with other bariatric procedures, Alkhalifah N Surg Endosc. 2018
Jan 8,
• “Mini-gastric bypass (MGB) has been validated as a safe and effective treatment
for morbid obesity”
• 1,731 morbidly obese patients
• 30-day post-operative major complication 1.7% less than RNY & Sleeve
• At postoperative 1, 5 & 10 yrs,
%WL of MGB patients 33 -29%
• The MGB had a higher weight loss than RNY & LSG
2-6 years after surgery.
• Revision rate of MGB 4.0%
Lower than RNY & LSG.

64. MGB Best Bariatric Surgery ?
Sample Recent Study
Obes Surg. 2017 Sep;27(9):2479-2487
MGB vs. Sleeve Gastrectomy for Morbid Obesity:
Systematic Review and Meta-analysis Magouliotis DE
Seventeen studies 6,761 patients
This study reveals:
“increased weight loss, remission of comorbidities, shorter mean hospital
stay, and lower mortality in the MGB group”
“Sleeve Higher Rate GERD”

65. Obes Surg. 2017 Nov 3. Revisional Gastric Bypass for Failed Restrictive Procedures:
Comparison of Single-Anastomosis (Mini-) and Roux-en-Y Gastric Bypass. Almalki
OM1,
• May 2001 to December 2015, a total of 116 patients with
• failed restrictive bariatric operations
• underwent laparoscopic revisional bypass surgery (81 R-MGB
and 35 R-RNY).
• R-RNY had significantly longer operative times than R-MGB.
• R-MGB was shown to be a simpler procedure with better
weight reduction than R-RNY

66. Mini-Gastric Bypass
Tragic/Deadly in the
Wrong Hands

67. MGB Billroth II Rx Diabetes

68. • Simple
• Elegant
• Effective
• Durable > 15 yrs
• Powerful
• Tailored to Patient
• Reversible
• Revisable

70. Diabetes and the “Metabolic
Surgeon”
•Diabetes mellitus is reaching epidemic
proportions
•"The level of morbidity and mortality due to
diabetes and its
potential complications are enormous, and
pose significant healthcare burden"

71. Imagine 20 years of Diabetes
• 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

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

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

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

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

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

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

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

79. Imagine 20 years of Diabetes
•Imagine!
•If Diabetes could be cured or
Major Improvement
•20-30 Minutes
•1-2 days in Hospital

80. USA
Obesity / Diabetes
Epidemic Costs
$2 Trillion a Year

81. Diabetes

82. Diabetes in Italy

83. Burden of diabetes mellitus
estimated with a longitudinal
population-based study
Research Center on Public Health,
University of Milan Bicocca, Milan,
Italy

84. Italian Diabetes Study 2014

85. Imagine!
A Solution to
Diabetes
(For SEVERE DIABETICS)

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

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

88. • General Surgery Studies show that
• Subtotal gastrectomy for cancer or ulcers
+
• Billroth II (BII) >> Billroth I (BI)
• More effective Rx Type 2 Diabetes
• BII (MGB) More Effective Rx BI (Sleeve)
•Surg Obes Relat Dis. 2015

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

90. •“Conclusions: BII reconstruction after subtotal
gastrectomy for cancer or ulcers more effectively
improved T2D than BI reconstruction.”
•“Billroth II provides a treatment strategy for
diabetic patients and enable metabolic surgery
for Non-obese patients
Surg Obes Relat Dis. 2015

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

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

94. Imagine!
A Solution to
Diabetes

95. Bariatric Surgery in
Thin Diabetics
It is Already here!

96. RNY in Thin Diabetics
Bad Outcomes

99. 50% 90%