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Mgb Done Wrong v2

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Mini-Gastric Bypass Shown to be an excellent operation
But Many New Surgeons Do Not Know the Critical Factors to Do the MGB Correctly
One Critical Success Factor:
LONG Gastric Pouch

Published in: Health & Medicine
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Mgb Done Wrong v2

  1. 1. Mini-Gastric Bypass Done WRONGWRONG Dr. RutledgeDr. Rutledge
  2. 2. Mini-Gastric Bypass • Anyone can do a “singleAnyone can do a “single anastomosis gastric bypass”anastomosis gastric bypass” • That Does Not mean theyThat Does Not mean they can/are doing the truecan/are doing the true “Mini-Gastric Bypass” (MGB)“Mini-Gastric Bypass” (MGB) • See the Following Example...See the Following Example...
  3. 3. No No No This is NOT an Mini-Gastric BypassThis is NOT an Mini-Gastric Bypass
  4. 4. Edward E. Mason, MD, PhD NOT Mini-Gastric BypassNOT Mini-Gastric Bypass NOTNOT Mini-GastricMini-Gastric BypassBypass
  5. 5. Surgeons are Foolish Confusing Old Mason Loop w MGBConfusing Old Mason Loop w MGB Gastro-Gastro- JejunostomyJejunostomy
  6. 6. MGB Gastro-Jejunostomy at the Level of the Transverse Colon Bowel LoopBowel Loop Gastro-Gastro- JejunostomyJejunostomy Gastric PouchGastric Pouch
  7. 7. For Example: Bird's Beak Defect Short PouchShort Pouch Bird's Beak DefectBird's Beak Defect
  8. 8. Wrong This is Not an MGB! Short PouchShort Pouch Old Mason Loop Bypass Error!Old Mason Loop Bypass Error!
  9. 9. Mini-Gastric Bypass Done Right LONGLONG Gastric PouchGastric Pouch
  10. 10. Surgeons Need to Understand Basic General Surgery • Misunderstanding BasicsMisunderstanding Basics of General Surgeryof General Surgery • Difference betweenDifference between Total/Subtotal GastrectomyTotal/Subtotal Gastrectomy Vs.Vs. Distal Gastrectomy/AntrectomyDistal Gastrectomy/Antrectomy
  11. 11. Distal Gastrectomy/Antrectomy • Understand AnatomyUnderstand Anatomy • EsophagusEsophagus • BodyBody • AntrumAntrum • Antrectomy + Billroth IIAntrectomy + Billroth II = Routine General= Routine General SurgerySurgery
  12. 12. Distal Gastrectomy + Billroth II = Routine General Surgery
  13. 13. MGB = Antrectomy w Billroth II Routine General Surgery!
  14. 14. Total/Subtotal Gastrectomy
  15. 15. Total/Subtotal Gastrectomy Basic General Surgery:Basic General Surgery: Total/Subtotal GastrectomyTotal/Subtotal Gastrectomy Never Reconstruct with Loop Billroth IINever Reconstruct with Loop Billroth II Only RNYOnly RNY
  16. 16. Mason Loop Violation of Basic General Surgery • Basic General SurgeryBasic General Surgery • Total/Subtotal GastrectomyTotal/Subtotal Gastrectomy NEVER Reconstruct wNEVER Reconstruct w Loop!Loop! • Mason Loop BypassMason Loop Bypass Reconstruct w LoopReconstruct w Loop • Thus Mason Loop =>Thus Mason Loop => FailureFailure • Violation of Basic GeneralViolation of Basic General Surgical PrinciplesSurgical Principles
  17. 17. Mason Loop Violation of Basic General Surgery • Mason Loop BypassMason Loop Bypass Reconstruct w LoopReconstruct w Loop • Thus Mason LoopThus Mason Loop => Failure=> Failure • Violation of BasicViolation of Basic General SurgicalGeneral Surgical PrinciplesPrinciples
  18. 18. Total/Subtotal Gastrectomy • Basic General SurgeryBasic General Surgery • NEVER ReconstructNEVER Reconstruct w Billroth IIw Billroth II • NEVER ReconstructNEVER Reconstruct w Billroth IIw Billroth II • NEVER ReconstructNEVER Reconstruct w Billroth IIw Billroth II • NEVER ReconstructNEVER Reconstruct w Billroth IIw Billroth II
  19. 19. MGB Gastric Pouch • Mini-Gastric BypassMini-Gastric Bypass Shown to be an excellentShown to be an excellent operationoperation • But Many New Surgeons DoBut Many New Surgeons Do Not Know the Critical FactorsNot Know the Critical Factors to Do the MGB Correctlyto Do the MGB Correctly • One Critical Success Factor:One Critical Success Factor: • LONG Gastric PouchLONG Gastric Pouch
  20. 20. What should be ideal length of pouch? • This question shows theThis question shows the surgeon has not understandsurgeon has not understand the teachings of Generalthe teachings of General Surgery HistorySurgery History • The Answer to Creation of theThe Answer to Creation of the pouch is Simple...pouch is Simple...
  21. 21. MGB Gastric Pouch • General Surgery:General Surgery: • Acceptable:Acceptable: Antrectomy/Distal GastrectomyAntrectomy/Distal Gastrectomy + Billroth II Loop+ Billroth II Loop • Never Acceptable:Never Acceptable: Total/Subtotal GastrectomyTotal/Subtotal Gastrectomy + Billroth II Loop+ Billroth II Loop
  22. 22. MGB Gastric Pouch • General Surgery:General Surgery: • Acceptable:Acceptable: Antrectomy/Distal GastrectomyAntrectomy/Distal Gastrectomy + Billroth II Loop+ Billroth II Loop • NEVER Acceptable!!!NEVER Acceptable!!! Total/Subtotal GastrectomyTotal/Subtotal Gastrectomy + Billroth II Loop+ Billroth II Loop
  23. 23. MGB Gastric Pouch • Acceptable:Acceptable: Antrectomy/DistalAntrectomy/Distal GastrectomyGastrectomy + Billroth II Loop+ Billroth II Loop • Not AcceptableNot Acceptable Total/SubtotalTotal/Subtotal GastrectomyGastrectomy + Billroth II Loop+ Billroth II Loop
  24. 24. MGB Pouch • EG JunctionEG Junction • Pouch fromPouch from EGJ to AntrumEGJ to Antrum • Crow's FootCrow's Foot • AntrumAntrum
  25. 25. MGB Pouch • EG JunctionEG Junction • Pouch fromPouch from EGJ to AntrumEGJ to Antrum • Crow's FootCrow's Foot • AntrumAntrum
  26. 26. MGB Pouch • EG JunctionEG Junction • Pouch fromPouch from EGJ to AntrumEGJ to Antrum • Crow's FootCrow's Foot • AntrumAntrum
  27. 27. MGB Pouch • EG JunctionEG Junction • Pouch fromPouch from EGJ to AntrumEGJ to Antrum • Crow's FootCrow's Foot • AntrumAntrum
  28. 28. MGB Gastric Pouch Length • How Long is the MGBHow Long is the MGB Pouch?Pouch? • Wrong AnswerWrong Answer Not in CentimetersNot in Centimeters • Answer: FromAnswer: From EG JunctionEG Junction to Beyondto Beyond thethe Crow's FootCrow's Foot into theinto the AntrumAntrum • The MGB Gastro-The MGB Gastro- Jejunostomy should lieJejunostomy should lie at the level of theat the level of the Transverse ColonTransverse Colon
  29. 29. Creation of the MGB Pouch • Details atDetails at https://mgbguidelines.wordpress.com/gastric-pouch-creation/https://mgbguidelines.wordpress.com/gastric-pouch-creation/ • Creation of the Gastric PouchCreation of the Gastric Pouch (Band/Sleeve/RNY)(Band/Sleeve/RNY) • Bougie of size 28 to 36 F can be used toBougie of size 28 to 36 F can be used to fashion the pouchfashion the pouch • Understanding MGB Anatomy & PhysiologyUnderstanding MGB Anatomy & Physiology • MGB NOT ObstructiveMGB NOT Obstructive • No Tight Pouch (The MGB is not a Sleeve)No Tight Pouch (The MGB is not a Sleeve) • Pouch Diameter and Length are Not CriticalPouch Diameter and Length are Not Critical • MGB Pouch Size:MGB Pouch Size: • Pouch Diameter = Esophagus;Pouch Diameter = Esophagus;
  30. 30. Creation of the MGB Pouch • Details atDetails at https://mgbguidelines.wordpress.com/gastric-pouch-creation/https://mgbguidelines.wordpress.com/gastric-pouch-creation/ • Pouch Length = Allow GJ at the greater curve of thePouch Length = Allow GJ at the greater curve of the stomachstomach • Start the Gastric Pouch (Long Pouch) at or beyondStart the Gastric Pouch (Long Pouch) at or beyond Crow’s Foot (junction of body and antrum of theCrow’s Foot (junction of body and antrum of the stomach.stomach. • Beware a Twist in the Pouch)Beware a Twist in the Pouch) • Avoid Bleeding Along Staple Line; (Very SlowAvoid Bleeding Along Staple Line; (Very Slow Application of Stapler, use compression)Application of Stapler, use compression) • Management of EG junction; MGB vs Sleeve (DOManagement of EG junction; MGB vs Sleeve (DO NOT go near the EG junction)NOT go near the EG junction) • Management of the gastric fundus; (Leaving someManagement of the gastric fundus; (Leaving some fundus is acceptable)fundus is acceptable) • Never dissect the EG junctionNever dissect the EG junction
  31. 31. Creation of the MGB Pouch • Details atDetails at https://mgbguidelines.wordpress.com/gastric-pouch-creation/https://mgbguidelines.wordpress.com/gastric-pouch-creation/ • Never dissect the EG junctionNever dissect the EG junction • Never attempt to visualize the diaphragmatic curaNever attempt to visualize the diaphragmatic cura • Always stay lateral to the EG junctionAlways stay lateral to the EG junction • Leaving some of the fundus behind in the MGB isLeaving some of the fundus behind in the MGB is always acceptablealways acceptable • Reminder: The MGB is NOT a Sleeve, The MGB isReminder: The MGB is NOT a Sleeve, The MGB is NOT a RNYNOT a RNY • Complete division of the stomach in NOT critical inComplete division of the stomach in NOT critical in the MGBthe MGB
  32. 32. MGB Part 1: Creation of the Gastric Pouch • Youtube.com VideosYoutube.com Videos • http://www.youtube.com/watchhttp://www.youtube.com/watch ?v=1B45TUAimJE?v=1B45TUAimJE • Technique of Mini-GastricTechnique of Mini-Gastric Bypass; Tips and TricksBypass; Tips and Tricks
  33. 33. Conclusions • Mini-Gastric BypassMini-Gastric Bypass Shown to be an excellentShown to be an excellent operationoperation • But Many New Surgeons DoBut Many New Surgeons Do Not Know the Critical FactorsNot Know the Critical Factors to Do the MGB Correctlyto Do the MGB Correctly • One Critical Success Factor:One Critical Success Factor: • LONG Gastric PouchLONG Gastric Pouch

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