MGB Need for Standardization, Education & Recognition DrR Rutledge MGB MRC Course Schedule Day One Introduction 1 9-9:50 Introduction Welcome Goals Welcome MGB Review Corporation Bronze Certification Course Outline of Introduction I. One Sentence Overview: Obesity & diabetes Growing Epidemic II. Present forms of “Gold Standard” forms of Bariatric Surgery FAR from Perfect/adequate Solutions III. Sleeve/RNY/Band/Distal Bypasses (BPD, SADI etc) All with Minor, Moderate, Serious & Deadly Complications IV. MGB “Uniformly & Repeatedly, Around the World In Studies by “Experts”… The MGB is Equal to or Better than Other Comparable forms of Bariatric Surgery” V. But! Despite numerous articles by MGB Experts showing Excellent Results Growing Number of Articles of Non-Expert MGB Surgeons with Serious & Deadly Complications. VI. Goals of the MGB Review Corporation Rally MGB Experts (Collecting Expert MGB Surgeons to Leadership and Recognition) Collaborate of Standardizing the MGB (Rutledge Technique) Educate Interested/New MGB Surgeons (Bronze Certification) Course + Successful Completion of 300 question Exam (or Board of Governors Membership Approval) Document Surgical Technique (Silver Certification) video Review of MGB Case Performance 5 + Cases Document Excellence in Outcomes (Gold Certification) 20+ Consecutive Case Review with Contact Info and Permission Recognition as a Leader to Teach MGB (Platinum/Diamond Certification) VI. Goal Improved Patient Care and Recognition of MGB Surgeons of Excellence MGB vs Sleeve, Meta-analysis MGB BII Rx Diabetes Sleeve/RNY/Band/Dbs (Distal Bypasses, BPD, SADI etc.) Sleeve: Devastating Leak, Irreversible, => Failure, Weight Regain, GERD, Barrett’s & Esophageal Cancer Popularity rise similar to the VBG and Lap Band RNY: Complexity, Difficult to Revise, Failure, Bowel Obstruction, Late Severe Dangerous Hypoglycemia Distal Bypasses; Malnutrition etc

1. Is MGB the New Gold Standard ?
No, But Thank You

2. I Am Both Proud And Humbled
To Be Here With You
It Is a Great Honor To See So Many Friends
Bless You All And
I Hope That I Can Entertain You For a Few Minutes

3. MGB Does Not
Wish to Be the “Gold Standard”
But
Now the MGB
Stands Fully the Equal to Any Operation
Shoulder to Shoulder with you
In Our Battle Against Obesity and Diabetes
Join Us!

4. Good Bariatric Surgery
• We all know and Agree:
• Sleeve, RNY & Other Operations are good
• We MGB Surgeons are Not Critical of the
Other Operations or Surgeons
• We measure the MGB against Sleeve / RNY
• They the Standards we compare ourselves

5. Growing Number of Studies:
The MGB:
Equal To or Better Than
Sleeve / RNY & Any other operation
A Few Studies
Examples...

6. 92% of ASMBS Vote
Pro MGB!! in New Orleans

7. Billroth II = RNY
Cancer Surgeons Routinely Use Billroth II
•2015 Study 7 USA Cancer Centers
•500 Patients
•Prospective Randomized Trial
•Compared Billroth II vs. RNY
“NO advantage of RNY vs Billroth II”
• 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.

8. MGB = Billroth II,
Billroth II is GOOD
General Surgeons Routinely Use the Billroth II
Many Bariatric Surgeons are
Uninformed and Fear the Billroth II

9. Dr Rutledge's Results
Mini-Gastric Bypass

10. Dr Rutledge's Results
Mini-Gastric Bypass

11. 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)

12. 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)

13. “Mini-gastric bypass simpler, safer, and more
effective than laparoscopic sleeve
gastrectomy”
• Medicine (Baltimore). 2017 Dec
• Comparison of safety and effectiveness
between
•Laparoscopic mini-gastric bypass and
Laparoscopic sleeve gastrectomy:
A meta-analysis and systematic review.
•Wang FG

14. “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”

15. “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.

16. 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

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

18. 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...

20. 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

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

22. “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

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

24. 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

25. 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

26. 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)

27. 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

28. 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)

29. 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

30. General Surgery: Sleeve vs MGB vs RNY
J Gastric Cancer. 2017 Jun;17(2):99-109
Nutritional Outcomes of Patients with Gastric Cancer
• Comparison of Partial Gastrectomy +
• Billroth I (Sleeve), Billroth II (MGB), RNY (RNY)
• Regarding post-distal gastrectomy reconstruction,
those who underwent Roux-en-Y had lower levels than
Billroth-I and Billroth-II
first to fifth years after gastrectomy, respectively (P<0.05)
• CONCLUSIONS: “Patients undergoing gastrectomy with Roux-
en-Y anastomosis or adjuvant chemotherapy should be
monitored carefully for malnutrition”

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

32. 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

33. Bariatric Studies
Confirm
General Surgery Studies

34. 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

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

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

37. 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.

38. 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).

39. 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.

40. 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”

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 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

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

43. Example of Failed Understanding Leading to Errors
in Management and Patient Harm
• My Time is limited there are many
examples
• 1 Recent Tragic Publication
• 2 years ago
Kular, Rutledge and Deitel
wrote a warning letter to Editor
a surgical group performing an “Omega
Loop”
• Quoting my paper (MGB) as the technique
being used...

44. Liver Dysfunction &
Death after MGB
• Obes Surg. 2018 Mar;28(3)
• “Significant Liver-Related Morbidity After Bariatric
Surgery and Its Reversal-a Case Series”, Eilenberg et al
• Moderate - Severe Liver damage
• Fatigue (90%), ascites (70%), hepatic encephalopathy
(30%), and upper gastrointestinal bleeding (20%).
• Elevation of transaminases, impairment of coagulation
parameters, thrombocytopenia, and hypoalbuminemia
were present in 70 - 100%

45. Example of Failed MGB Limb Understanding
Leading to Errors in Management and Patient
Harm
• 2 yrs ago we warned that the
High %Excess Weight Loss
(Misjudged BP Limb)
dangerous and deadly consequences
• Jan 2018, 10 patients
• % excess weight loss ** 111% **
• Treatment: (?) In eight patients, lengthening of
the alimentary/common limb (Discuss)
• One patient, liver transplant
• One patient DEATH - liver failure

46. Mini-Gastric Bypass
Tragic/Deadly in the
Wrong Hands
The MGB
Done WRONG!

47. Mini-Gastric Bypass
Simple, Safe, Effective
Tailored, Easily Reversible
The MGB
Done RIGHT!

48. •Mini-Gastric Bypass
• Anyone can do a
“single anastomosis bypass”
• That Does Not make it a true
“Mini-Gastric Bypass”
• See the Following Examples...

49. Recent Publications
Unequivocally Demonstrate:
Poor Understanding of the MGB
=> Bad Outcomes

50. Misunderstanding &
Confusion
Harm Patients:

51. French Series:
RNY Experts Adopt “MGB”
=>
* 16% * Gastro-jejunostomy
Stricture Rate Reported in
the “MGB” Patients

52. Int J Surg. 2016 Sep
Sleeve gastrectomy vs Mini gastric bypass
Misunderstanding & Complications:
CONCLUSION:
“MGB has better weight loss at one year
compared to LSG”
Reported “ MGB higher gastric complications.
(??)”
(No other study has reported stricture at the GJ
anastomosis of such high rates)

53. Int J Surg. 2016 Sep
Sleeve gastrectomy vs Mini gastric bypass
Misunderstanding & Complications:
At one year MGB >> Sleeve,
%TWL 38 ± 8 vs. 34 ± 8 (P < 0.0001)
BMI Decrease: -17 ± 5 vs. -15 ± 4 (P = 0.005)
But
** Rate of stenosis higher for MGB group,
** 16.9% vs.
** 0% in Sleeve Patients (P < 0.0001).

54. Misunderstanding &
Confusion
May Harm Patients:

55. Management of MGB
Complications:
How to Do It&
How NOT To Do It
Rx Excessive Weight Loss

56. Revision Of Mini-Gastric Bypass For
Excessive Weight Loss (Rutledge)
How To Do It:
• Excessive wt. loss and malnutrition revision
in 55 patients (0.9%)
• Revision Mean Op time 47 min
• Major morbidity 7%,
Mean length of stay 3 days & the median 2 days
• RNY Revision report Patel et al
"difficult, dangerous and potentially deadly"
• Revision of the MGB for excess weight loss is
1. technically simple, 2. low risk procedure
3. that takes just under an hour

57. Surg Obes Relat Dis. 2017
Roux-en-Y gastric bypass for the treatment of severe
complications after omega-loop gastric bypass
•“OLGB” conversion to Roux-en-Y gastric bypass (RNY)
to treat complications.
•17 patients OLGB conversion to RNY.
•10 patients (59%) received nutritional support PreOp
•Average wt *52 kg* BMI 18 kg/m², *%EWL 149%*
•41% major adverse events <90 d
•Commentary: No, No, No! Do Not do a Weight Loss
Surgery (RNY) for Excessive Weight Loss.

58. Rx Excessive Weight Loss Post MGB
Experienced MGB Surgeons vs Experienced NON-MGB
Surgeons
• Experienced MGB Surgeon
• Immediate Revision
• => Major Morbidity 7% <=
• Experienced NON-MGB Surgeons
(More Recent Study)
• TPN + RNY
• => Major Morbidity 41% <=

59. Another Tragic Complication
Death from Malnutrition After MGB

60. Death: 8 months after MGB
Diagnosis & Management?
29 y.o. female 8 months after MGB
Hypoalbuminemia, anemia, elevated LFTs &
Bilirubin, Acidosis and Steatohepatitis
What to Do!
Patient did not respond to Medical Rx
=> DEATH.
What is the Diagnosis?
What to do?
Int J Surg Case Rep. 2017

61. Malnutrition: Death 8 months after MGB
Diagnosis & Management?
29yr F, 8 months after MGB:
=> Low albumin & Hgb,
High LFTs & Bilirubin,
Acidosis & Steatohepatitis
=> Diagnosis?
Bypass is Too LONG
Liver Failure,
Malnutrition/Deficiency(s)
Int J Surg Case Rep. 2017

62. Malnutrition: Death 8 months after MGB
Diagnosis & Management?
29yr F, 8 months after MGB:
=> Diagnosis? Simple: Bypass is Too LONG
Liver Failure, Malnutrition/Deficiency(s)
=> What to Do?
** Preop Education/Planning **
1. Resuscitation,
2. Nutritional Support,
3. Early, Simple 30-60 min Revision
Int J Surg Case Rep. 2017

63. Dr Rutledge's Advice
MGB Technique
• If You Do Not Understand the Basic
General Surgery Principles to the MGB
• My advice will not appear justified
• Expertise from Band, Sleeve, RNY &
BPD/Sadi
• Often do not apply to the Anatomy &
Physiology of the MGB
• Reminders of Basic GI Surgery the MGB

65. Good Bariatric Surgery
• We all know and Agree:
• Sleeve, RNY & Other Operations are good
• We MGB Surgeons are Not Critical of the
Other Operations or Surgeons
• We measure the MGB against Sleeve / RNY
• They the Standards we compare ourselves

66. Conclusions:
And A Warning
• Mini-Gastric Bypass
Shown to be an excellent operation
Equal to or Better than Other Procedures
But Only in Trained & Experienced Hands
• But Many New Surgeons Do Not Know the Critical Factors to
Do the MGB Correctly Resulting in Dangerous and Deadly
Outcomes