MGB, the Billroth II as Ideal Bariatric Surgery Dubai

1. Different & Better
MGB-OAGB

2. I Humbly
Thank You
for Kind Invitation
My Brothers &
Colleagues

4. MGB Citations / Year
0
10
20
30
40
50
60
2000 2003 2006 2009 2012 2015 2018

5. Why Are We Here?

6. Mini-Gastric Bypass
The Mini-Gastric Bypass is Being Done
Now Let it Be Done Well
Dr Rutledge
Email: DrR@clos.net
Join Us!

7. Now Popular MGB
is Being Done
Without Understanding
Leading to
Deaths & Complications

8. • History of DrR & MGB
• MGB = Billroth II, Billroth II is GOOD
• MGB = General Surgery, How to
• The Future of Bariatric (Metabolic) Surgery
• Diabetes in Epidemic
• The Mini-Gastric Bypass can be Tailored;
Useful for all types of patients
Especially “Thin” Diabetics

9. Standardization, Education & Recognition
Excellence in Delivering the Mini-Gastric Bypass

10. MGB Growing Fast
Good News / Bad News
Why are we here?
I. Why MGB?
Answer: 1. MGB More Effective & Lower risk,
2. Revision of Failed Sleeve
3. BUT MOST Important: Diabetes
II. If You DO MGB why Learn MGB?
Answer: MGB => Complications / Deadly
in unskilled hands (Examples?)
MGB => Not Hard to Learn,
BUT you must LEARN IT!

11. The Mini-Gastric Bypass
• 1. Simple Powerful & Easily Performed
• 2. Dangerous:
Do not understand the operation
• 3. NEED:
Standardization, Education & Recognition

12. SUCCESS CRITERIA
"IDEAL" WEIGHT LOSS SURGERY
Survey of 400 patients

13. 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

14. 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

15. 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

16. Summary Selection of
Best Surgery for Each Patient
Safety,
Few/Rare Complications,
Effective,
Durable,
Easily Reversible Revisable
Tailored to Thin, Overweight, Obese & Super
Obese

17. Growing Number of Studies:
The MGB-OAGB:
in many ways Equal To or Better Than
Sleeve / RNY & Any other operation
A Few Studies
Examples...

18. Two Recent Studies
Meta-analysis & systematic
review
Sleeve vs MGB
(Hint: MGB found to be superior)

19. MGB “Best”/Good Bariatric Surgery?
Example Recent Study: MGB is “Good Surgery”
Obese Surgery. 2017 Sept;27(9):2479-2487
=> MGB vs. Sleeve Gastrectomy <=
Systematic Review & 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

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

21. “Mini-gastric bypass simpler, safer, & more effective than
laparoscopic sleeve gastrectomy” Wang 2017
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
HBP 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 &
8. Lower revision rate.

22. Growing Number of Studies:
The MGB-OAGB:
in many ways
Equal To or Better Than
Sleeve / RNY & Any other operation

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

24. History of
Dr Rutledge &
MGB

26. • Injury to
Stomach, Pancreas and
Multiple Loops of Small
Bowel
• Rx
Distal Gastrectomy
• Distal Pancreatectomy
• Splenectomy

29. 1997 Next Morning Planned Lap RNY
MGB = Standard General Surgery (Antrectomy & Billroth II)

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

31. 20 Years FEAR of MGB?
Mason Loop *NOT* MGB

32. Mini-Gastric Bypass
Operative Procedure
1. “Standard Gen Surgery”
Antrectomy & Gastro-jejunostomy
2. Collis Gastroplasty
Non Obstructive Restriction
3. Antecolic Billroth II Loop
Gastro jejunostomy
Tailor Bypass to Patient

33. Its Just General Surgery

34. Mini-Gastric Bypass (MGB) Survey:
153 Surgeons, 75,000+ MGBs

35. Expert Opinion:
Operation Judged Short and Simple

36. Expert Opinion:
Failure is "VERY RARE"

37. Expert Opinions:
Patients RARELY Regain Their Weight

38. Expert Opinions:
Surgeons Reporting "No Leaks"

39. Expert Opinion:
Revision is Relatively Easy
NOTE: Reversal of Sleeve => IMPOSSIBLE

40. All Operations Are Good for 5 Years
•Jejuno-ileal Bypass
•Vertical Banded Gastroplasty
•BPD
•Lap Band
•Sleeve...
•SADI (Single Anastomosis BPD)

41. Sleeve & Sleeve+ Operations
•Sleeve
•Single anastomosis
Sleeve ileal (SASI)
•SADI, SIPS
•S+Operations

42. Sleeve => GERD => Long Term PPIs
• Surg Obes Relat Dis. 2017
•“Do sleeve gastrectomy and gastric bypass
influence treatment with proton pump
inhibitors 4 years after surgery?”
A nationwide cohort
•French National Health Insurance Data
• PPI use 4 years after Sleeve = *73%*

43. Fear of MGB? Fear PPI's!

44. Fear of MGB? Fear PPI's!
• FRACTURES — The labels of all prescription PPIs include a warning about
an increased risk of fractures with long-term use.7
• Mechanism – Reduced gastric acidity might interfere with calcium
absorption.
• Clinical Studies – A meta-analysis of 18 trials involving a total of 244,109
fracture cases found that PPI use was associated with
increase in the risk of hip (RR 1.3), spine (RR 1.6), and
any-site fractures (RR 1.3).

45. Fear of MGB? Fear PPI's!
• HYPOMAGNESEMIA AND QT PROLONGATION —
Hypomagnesemia has occurred rarely with prolonged PPI use
and is usually accompanied by hypokalemia and
hypocalcemia.11 QT interval prolongation and torsades de
pointes (TdP) associated with severe PPI-induced
hypomagnesemia have been reported.12-14 TdP has also been
reported in patients taking a PPI concomitantly with drugs that
directly prolong the QT interval.

46. Fear of MGB? Fear PPI's!
•KIDNEY DISEASE — Use of PPIs has been
associated with acute interstitial nephritis
and subsequent progression to chronic
kidney disease (CKD).19
•Recent observational studies have reported
an increased risk of CKD in long-term PPI
users.

47. Fear of MGB? Fear PPI's!
•VITAMIN B12 DEFICIENCY — Decreased
absorption and subsequent deficiency of
vitamin B12 can occur with chronic use of
PPIs and/or H2RAs, particularly with high
doses and use in elderly patients.23
•Mechanism – Release of vitamin B12 from
dietary protein is dependent on gastric acid.

48. Fear of MGB? Fear PPI's!
• IRON DEFICIENCY — PPIs inhibit iron absorption decrease acid production
• Clinical Studies – A recent case-control study of 77,046 patients with newly diagnosed
iron deficiency and 383,314 controls found that those taking a PPI or an H2RA for ≥2
years had an increased risk of iron deficiency
• COMMUNITY-ACQUIRED PNEUMONIA (CAP) — Use of PPIs has been associated with an
increase in the risk of CAP, but the results of studies are conflicting.
• Mechanism – The mechanism by which PPIs increase the risk of CAP is presumed to be
reduced gastric acidity might promote bacterial colonization in the upper GI tract.

49. Fear of MGB? Fear PPI's!
• CDI — Recent studies of an association between PPI use and an increased risk of
Clostridium difficile infection (CDI)
• Pooled analysis of 50 studies showed a significant associated risk of incident CDI among
PPI users, especially in general ward patients. J Hosp Infect. 2018
• Fifty-six studies (40 case-control and 16 cohort) involving 356,683 patients
World J Gastroenterol. 2017
“PPI use is associated with an increased risk for development of CDI”
• Mechanism – PPIs increase CDI C. difficile colonization
• Predictors of Mortality Among a National Cohort of Veterans With Recurrent Clostridium
difficile Infection. PPIs one of the most powerful prediction of DEATH from CDI!
• PPIs; odds ratio [OR], 3.9, ...

50. Fear of MGB? Fear PPI's!
• DEMENTIA — PPI use has been associated with cognitive decline
• Mechanism – PPIs can reduce vitamin B12 levels, Animal studies PPI use can enhance
beta-amyloid production in the brain.33
• Clinical Studies – A prospective cohort study including 73,679 patients ≥75 years old
without dementia who were followed for 7 years PPI users more likely to develop
dementia (HR 1.44)
• ALL-CAUSE MORTALITY — Study in US veterans followed for >5 years, compared to use of
H2RAs,
PPI's associated with an increased risk of death (HR 1.25).
Duration of PPI use and use also associated with an increased risk of all-cause mortality.

51. Fear of MGB? Fear PPI's!
• Influence of proton pump inhibitors on clinical outcomes in coronary
heart disease patients receiving aspirin and clopidogrel: A meta-
analysis.
• Hu W, et al. 2018
• meta-analysis included 33,492 patients in 4 randomized controlled
trials and 8 controlled observational studies
• use of PPIs increased the rates of major adverse cardiovascular
events, stent thrombosis, and revascularization.

52. Fear of MGB? Fear PPI's!
• Eur J Gastroenterol Hepatol. 2018 Adverse outcomes of long-term use
of proton pump inhibitors: a systematic review and meta-analysis.
• Odds of community-acquired
• pneumonia, hip fracture, and colorectal cancer were
• 67% [odds ratio (OR)=1.67;
• 95% confidence interval (CI): 1.04-2.67],
• 42% (OR=1.42; 95% CI: 1.33-1.53), and
• 55% (OR=1.55; 95% CI: 0.88-2.73)
• higher in patients with long-term PPIs

53. Fear of MGB? Fear PPI's!
• Gastric Cancer: (GC) CONCLUSION:
• Long-term use of PPIs was associated with an increased GC
• Gut. 2018 Long-term proton pump inhibitors and risk of gastric cancer
development after treatment for Helicobacter pylori: a population-
based study Cheung K
• 63,397 eligible subjects, 153 (0.24%) developed GC during a median
follow-up of 7.6 years.
PPIs use was associated with an increased GC risk (HR 2.4, while H2RA
was not (HR 0.7)

54. Fear of MGB? Fear PPI's!
•63,397 pts, 153 (0.24%) Gastric Cancers
median follow-up of 7.6 years.
•Long-term PPIs use was associated with a
2.4-fold increase in gastric cancer
•The risk of gastric cancer increases with the
dose and duration of PPIs use.

55. Mini-Gastric Bypass (MGB) Survey:
122 Surgeons, 75,000+ MGBs

56. Zero (0%) Gastric/Esophageal Cancers
122 Surgeons, 75,000+ MGBs

57. Fear of MGB? Fear PPI's!
• 63,397 pts, 153 (0.24%) Gastric Cancers
7.6 years follow-up (PPI/No PPI)
• 122 MGB Surgeons, 75,000+ MGBs,
Zero (0%) Gastric/Esophageal Cancers
• PPI's more cancers than MGB

58. Sleeve => GERD => PPIs => Cancer++
•GERD sx & esophageal lesions after sleeve
gastrectomy; Surg Obes Relat Dis. 2018
•University of Rome, Rome, Italy
•GERD symptoms & PPI's in 70% and 64% of pts
•5 yrs Post Sleeve 2/3 Pts on PPIs
(=> PPIs => Cancer++)

59. In Short: MGB very Successful/Safe
• MGB Very Safe
• Very Low Risk
• Sleeve: Very Likely to Need Long Term
PPIs...
• Long Term PPIs => osteoporosis/fracture,
Kidney damage, infection (pneumonia & C.Diff),
rhabdomyolysis, deficiencies (B12, Mg & Fe)
• + Gastric & Esophageal Cancer

60. MGB = Billroth II
Billroth II is GOOD for You
General, Trauma & Oncologic Surgeons
Routinely Use the Billroth II
Many Bariatric Surgeons are
Uninformed & Fear the Billroth II

61. Widespread
Confusion &
Misunderstanding of
the
Billroth II & the MGB

62. 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

63. 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 & more

64. 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
• Matched Billroth II patients had a lower risk of Stroke!
• Medicine (Baltimore). 2016 Apr;95(16)

65. 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
• Obese Surgery. 2017 Jun;27(6):1604-1611

66. A Nationwide Population-Based Study
Billroth II Decreased Risk of Diabetes by Almost 56%
• 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)

67. 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

68. Billroth II
Routinely Used Every Day in
General Surgery
Feared by Some Bariatric Surgeons?

69. Billroth II
Routinely Used Every Day
by Oncologic Surgeons
Feared by Bariatric Surgeons?

70. Oncologic Surgeons
Routinely Use Billroth II
Every Day
In Gastric CANCER!!
Feared by Bariatric Surgeons?

71. Roux-en-Y or Billroth II Reconstruction After Radical Distal
Gastrectomy for Gastric Cancer: A Multicenter Randomized
Controlled Trial.
• Prospective multicenter randomized controlled trial
Gastric Cancer
• 2008 - 2014, randomly allocated to
Billroth II (n = 81) & RNY (n = 81)
• Outcomes Similar
• Ann Surgery. 2018 Feb;267(2):236-242.

72. Roux-en-Y or Billroth II Reconstruction After Radical Distal
Gastrectomy for Gastric Cancer: A Multicenter Randomized
Controlled Trial.
• Prospective multicenter randomized controlled trial Gastric
Cancer
• No difference in nutritional status &
quality of life at 1 year between the 2 groups
• Conclusions:
“BII & RY are similar in terms of overall GI symptom score &
nutritional status at 1 year after distal gastrectomy”
• Ann Surgery. 2018 Feb;267(2):236-242.

73. Oncologic Surgeons
Routinely Use Billroth II
Every Day
In Gastric CANCER!!
Feared by Bariatric Surgeons?

74. 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 & Billroth II
reconstruction following partial gastrectomy for gastric cancer. Gastric Cancer. 2015 Sept
23.

75. Oncologic Surgeons:
Routinely Use Billroth II
Every Day
In Gastric CANCER Patients!!
Feared by Bariatric Surgeons

76. Billroth II
Routinely Used Every Day in
General Surgery
Feared by Uninformed
Bariatric Surgeons

77. FIRST
Dr Rutledge's
Remarkable
MGB Results

78. Dr Rutledge's Results
Mini-Gastric Bypass

79. Dr Rutledge's Results
Mini-Gastric Bypass

80. Mini-Gastric Bypass
Operative Procedure
1. “Standard Gen Surgery”
Antrectomy & Gastro-jejunostomy
2. Collis Gastroplasty
Non Obstructive Restriction
3. Ante-colic Billroth II Loop
Gastro jejunostomy
Tailor Bypass to Patient

81. Billroth II Loop Antrum: YES, EGJx: NO, NEVER

82. • Well Informed
General
Surgeons
=>
Routinely Use
the Billroth II
• Uninformed
Bariatric
Surgeons
=>
Fear the
Billroth II

83. Population Based National Data:
Billroth II => Good Safe Operation
Makes people healthier!
Billroth II
Decreases the Risk of
Stroke, Coronary Heart Disease & Diabetes...

84. A Nationwide Population-Based Study
Billroth II Decreased Risk of Stroke
• 6,425 patients Billroth II for Ulcer
• Taiwan 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)

85. A Nationwide Population-Based Study
Billroth II Decreased Risk of Coronary Heart Disease.
• Patients w BII for Ulcer
• Taiwan 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

86. 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 Risk of Diabetes
(adjusted hazard ratio 0.56)
• PLoS One. 2016 Nov 28;11(11)