The Mystery of Bile or No Bile:“Elementary My Dear Watson!” Why the two opposite studies of the MGB 1. Minimal Bile Reflux 2. Common Bile Reflux Answer:  1. Skill and knowledge of the Surgeons & 2. Propper care and education of post op patients Conclusion: Don't Do the MGB! If You Don't Know What You are Doing

1. The Mystery of Bile or No Bile:
“Elementary My Dear Watson!”
• Why the two opposite studies of the MGB
1. Minimal Bile Reflux
2. Common Bile Reflux
Answer:
1. Skill and knowledge of the Surgeons &
2. Propper care and education of post op patients
Conclusion: Don't Do the MGB!
If You Don't Know What You are Doing

2. Goals, Take Home Messages
Understand Prevention/Dx/Rx “Bile Reflux”
Bile is always present in Normal Stomach & MGB/Billroth II,
Dyspepsia is common in MGB patients (= RNY &
Sleeve):
Causes / Prevention / Treatment
1. Poor technique (MGB Done Wrong: GJ, twisted pouch etc.)
Rx Prevention
2. Gastritis/Ulcer
Rx Prevention, Antacid, Diet Rx
3. Conservative (NON-Operative) Diagnosis and Treatment of Violation Basic
Post Gastrectomy Syndrome Diet/MGB Dietary & Lifestyle Guidelines:
**Follow dietary protocol** (99% Successful)

3. New Findings

6. MGB = Safe, Near Normal vs.
SADI = “Short Bowel Syndrome”
Bowel
Length
BPL CC
%
Bypassed
MGB 6 m 1.75m 4.25m 30%
SADI 6 m 3.5m 2.5m * 60% *
MGB 8 m 1.75m 6.25m 20%
SADI 8 m 5.5m 2.5m * 70% *
Bowel length, BPL = Biliopancreatic Bypass Limb Length
CC = Common Channel

7. Standardization of the MGB
Please Do Not Do the MGB
In Your Own Way
or
Please Label It as Some Other Procedure:
Omega Loop, SAGB, OAGB or Other

8. If You Wish to
Ignore My Advice
Please Do Not Attribute Your
Outcomes to the MGB

9. Patients Will Be Harmed!
Errors & Misunderstanding of the Power of the MGB

10. Standardization of the MGB
Tragedy of
“Made Up Versions of Operations”
Without Documenting These Modifications
& Follow UP:
Lakdawalla & Many Others

11. Two Splenectomies
• The tragedy of not listening to good advice
• Recent Documentation of the risk of
Bleeding of the Short Gastrics in the Dissection
of the Left Upper Quadrant
• And
• Documentation that these Splenectomies
associated with INEXPERIENCE

12. Tragic Esophageal Perforation Following
Dissection of the Angle of HIS

16. Please ReRead Your Anatomy Books
• There is NO SUCH THING as a “Free Vascular Space”
in the area of peri-EG Junction
• Instead routinely the area is easily entered with
simple blunt dissection allowing passage from the
lesser sac into the left sub-hepatic space
• But in every 100-1000 cases such a blind (uneducated
approach) will result in a torn short gastric vessel
• => Splenic Bleeding or Splenectomy

17. Who's Afraid of the Billroth
II?
Not General, Trauma or Cancer Surgeons!

18. The Mystery of Bile or No Bile:
“Elementary My Dear Watson!”
• Why the two opposite studies of the MGB
1. Minimal Bile Reflux
2. Common Bile Reflux
Answer:
1. Skill and knowledge of the Surgeons &
2. Propper care and education of post op patients
Conclusion: Don't Do the MGB!
If You Don't Know What You are Doing

19. Poorly Trained Surgeons:
Harming Patients & MGB Reputation
• Simply:
• It is clear that the outcomes of surgeons are quite
variable
(Many good surgeons report complications & Death!)
• My Advice:
Please: Do Not Make Up Your Own Operative &
Peri-Operative Techniques
• Or If You Do: Please Do Not Label it MGB

20. Fear of Bile
• General, Trauma & Oncologic
Surgeons Do Not Fear
Billroth II & Bile

21. • Fear of Bile reflux!
• Who is afraid of bile Reflux?
• NOT GENERAL SURGEONS
• Who is afraid of bile Reflux?
• Poorly informed Bariatric Surgeons

22. 20 Years FEAR of MGB?
Mason Loop is *NOT* an MGB

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

24. Published Reports
MGB and Bile Reflux Sx
• Authors, Rheinwalt
• Rutledge
• Chevallier
• Kular
• Noun
• Peraglie
• Lee
• Haargroder
• Musella and Many More
• Countries
• USA
• Egypt
• France
• Germany
• India
• UAE
• Italy
• Spain
• Belgium Many More

25. Reported Rates of Bile Reflux Sx Require
Surgical Rx
•In every series revision for Sx bile reflux rare
•1-5% or less in every study
•Treatment is trivially easy
•Where does the fear come from?

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

27. General Surgery Studies
"Gastrectomy + Billroth
II"
Kang KC, Shin SH, Lee YJ, Heo YS.
J Korean Surg Soc. 2012 Jun;82(6):347-55.
Department of Surgery, Inha University Hospital,
Inha University School of Medicine, Incheon, Korea.

28. • 100 years of Gastrectomy and Billroth II
• with good to excellent results
• Example:
• 75 Billroth II GCa Pts, 35 month FU
• Standard General Surgery BII
Rx Diabetes
• Gastrectomy + BII (i.e. MGB)
• 22% Resolved, 85% Improved

29. Billroth II = RNY
Cancer Surgeons Routinely Use Billroth II
•2015 Study 7 USA Cancer Centers
•500 Patients
•Controlled Prospective Randomized Trial
•Compared 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.

30. •Gastric Cancer. 2016 Comparison between
Roux-en-Y and Billroth II, Tran TB
•Prospective trial, 450 Pts, 7 USA Centers
•“No advantage of RNY over Billroth II
gastrojejunostomy in perioperative outcomes.
•“Both techniques should be regarded as equally
acceptable reconstructive options following
partial gastrectomy

32. Billroth II is a
Good Procedure
When Used Correctly
Bariatric Surgeons
Need to Re-Learn their General Surgery
The Mason Loop Gastric Bypass was Bad
Because
the Billroth II was Incorrectly!!

33. MGB = Standard General Surgery
How to Perform the
Mini-Gastric Bypass
MGB = Simple Operation
But
Tricks and Traps

34. Understanding, Prevention &
Treatment Of Symptomatic
Dyspepsia & “Bile Reflux”

35. Goals, Take Home Messages
Understand Prevention/Dx/Rx “Bile Reflux”
Bile is always present in Normal Stomach & MGB/Billroth II,
Dyspepsia is common in MGB patients (= RNY &
Sleeve):
Causes / Prevention / Treatment
1. Poor technique (MGB Done Wrong: GJ, twisted pouch etc.)
Rx Prevention
2. Gastritis/Ulcer
Rx Prevention, Antacid, Diet Rx
3. Conservative (NON-Operative) Diagnosis and Treatment of Violation Basic
Post Gastrectomy Syndrome Diet/MGB Dietary & Lifestyle Guidelines:
**Follow dietary protocol** (99% Successful)

36. Background:
• The Billroth II is by far
the most common technique around the world
reconstructing the gastrointestinal tract following
distal gastrectomy for cancer, trauma & ulcers
• Thousands of Billroth II General Surgery patients
from all around the world have
bile that flows harmlessly across their Billroth II
anastomosis every day.

37. Who's Afraid of the Billroth
II?
Not General, Trauma or Cancer Surgeons!

38. Bile Reflux, Rare
in MGB High Volume Surgeons
•DrRutledge's study confirms others
reporting on a large cohort MGB patients
•Prevention, frequency and management of
dyspepsia (often erroneously labeled bile as
reflux symptoms)

39. Methods:
•In a series of 6,023 patients undergoing
MGB, dyspepsia/”bile reflux” was managed
non-surgically in the vast majority (99%)
•Symptomatic dyspepsia/”bile reflux”
unresponsive to medical therapy occurred
in 4 patients over a period of 15 years.

40. Methods
•Cause & prevention of surgical errors that
=> Dyspepsia, Bile Reflux Gastritis
• 2. Differences between Bile, Bile reflux and
Gastritis/Esophagitis
• 3. Conservative Rx (99%) Surgery (<1%)

41. Methods
•Conservative Rx (99%+):
Non-surgical treatment of dyspepsia
(so called “bile reflux”)
•Surgical Rx: Braun Entero-enterostomy
treatment post MGB symptomatic
dyspepsia/”bile reflux” unresponsive to
medical therapy.

42. Results:
•6,023 patients underwent MGB.
•Dyspepsia common (7.3% in the first year)
similar to that reported in RNY gastric
bypass. Successful Rx Diet + Lifestyle
•Dyspepsia was managed per conservative
protocol and resolved symptoms routinely.

43. Initial Diagnosis of Dyspepsia
• MGB Dyspepsia
• (Nausea, Midepigastric Pain, Vomiting, Bile
Vomiting/Aspiration, Gastritis, Esophagitis,
etc.):
• NOT Automatically BILE!!!

44. Common Anatomic Errors at MGB Surgery
Short Pouch
Twisted Pouch
Bird's Beak Pouch
Narrow Pouch
Pouch Stricture
Dissection of EGJ
BP Limb too long
Strictures G-J
Kinked/Tight G-J
Reversed BP Limb
Ischemic & Foreign
Body Gastro-J

45. Anatomic Errors at Surgery:
Prevention => Do the Surgery Right!!
•Short Pouch **
•Twisted Pouch **
•Candy Cane **
•Narrow Pouch **
•Pouch Stricture **
•BP Limb too long **
•Strictured G-J **
•Kinked G-J **
•Reversed BP Limb**
•Ischemic FB GJ
DX/RX => Send me the video, Re-explore, Revise

46. Initial Diagnosis of Dyspepsia
•Non-surgical Rx Protocol for MGB Dyspepsia
(Nausea, Midepigastric Pain, Vomiting, Bile
Vomiting/Aspiration, Gastritis, Esophagitis,
etc.)
•1. Think First: Anatomic/Surgical Errors
Especially common “new surgeons” Sleeve,
RNY, Young surgeons.

47. Treatment Of Symptomatic “Bile Reflux” Dyspepsia
NOT Surgical Errors
• Underlying Differential Dx:
• Bile Reflux occurs in every patient all day, day in and day out.
• Most Common Sources of Dyspepsia
• Gastritis, erosion, ulcer (Acid peptic) smoking etc.
• Obstruction, partial, complete, intermittent, diet related
• Bacterial overgrowth (Rare)
• Dumping Syndrome (early/late) very common

48. Diagnostic/Rx Process: 1 Week Diet Hx
Detailed History & Timing
• All Foods, medications,
supplements, activities and
symptoms Logged carefully
• Rx: Diet & Lifestyle Changes:
• Optimize Diet, Supplements,
Medications
• Discontinue: Alcohol, Smoking,
NSAIDs, Steroids, “Herbs” etc.
• Encourage 6 small feeds/d
healthy diet,upright after
eating
• Rx gut microbiome: Plain
Yogurt:1-2 tsps 3-6 x / Day
• Exercise & Moderate Sun
Exposure
• Success Rate 99+%

49. Rx Lifestyle & Diet Plan
• Simple Diet & Lifestyle Changes: Rx gut microbiome: Plain Yogurt /
Curd / Fermented Dairy:1-2 tsps 3-6 x / Day.
• Stop smoking, NSAIDs, Iron, “Supplements”, Vitamins & Medications
• Before Meals, Stay upright after eating, Small meals, Limit fatty foods,
• Avoid problem (junk) foods: soda, candy, fried foods, caffeinated and
carbonated drinks, chocolate, citrus juices, vinegar dressings & mint,
etc.
• Limit or avoid alcohol, Eat slowly, small amounts, chew thoroughly and
rest between bites,
• Keep head up for 30-90 minutes post meals, relax for 30-90 minutes
after meals.

50. Common Misunderstanding:
MGB, Billroth II & Bile Reflux
• Every MGB/Billroth II Patient Can Have
Bile Reflux + Vomiting at Any Time!
• Simple: Swallow a cork=>
Distal Obstruction=> Bile reflux
• In real life: Eat a plate of noodles @ 10pm Dinner=>
Bile Reflux vomiting and aspiration that night
• Simple Rx: No Large Bulky Meal Late Before Bed
or Ever with MGB

51. Bile in MGB & Billroth II is Painless:
When Does Bile Hurt?
•Bile and dyspepsia
•No ulcer or gastritis + Bile => No Pain
•Ulcer or Gastritis + Bile => Pain
•Ulcer = in RNY = in MGB approximately 5%
•Dyspepsia in MGB => Rx Ulcer
•(Surgical Technique Cause of Ulcer/Gastritis)

52. Surgical Technique Cause of Ulcer/Gastritis
Prevention of Marginal Ulcer
•Why MGB ulcers => Lateral Aspect of the G-J
•Reason: Big bulky ischemic mass tissue
With mass of titanium staples as foreign bodies
from the poor surgical technique on the lateral
aspect of the GJ
•Prevention: Non-ischemic GJ w minimal Foreign
Bodies

53. Technical Errors
=> Symptoms
Dysphagia, Bile Reflux Gastritis, Marginal
Ulcer

54. Post Op Complication of MGB
Technical Errors
• 39 year old male “OAGB” 1 year
• Pre Op 163 kg, BMI 57. BP limb was 200 cm.
• Lost 63 kg BMI 35
• 4 months severe abdominal pain, colicky & episodes of
hypoglycemia.
• No Rx effective, CT Negative
• Diagnostic laparoscopy

55. Error Flipped/Reversed MGB(?)
=> Severe Symptoms
Common Channel
Misplaced
in Left Gutter
BP Limb
Misplaced

56. Marginal Ulcers
Gastritis &
Bile Gastritis
Technical Errors
Posterior Gastrotomy, Ischemic Bridge
Foriegn Bodies

57. Violation of Basic General Surgery
Staple Line
Ischemic
Bridge

58. Staple Line, Ischemic Bridge, Suture Line
Staple Line
Ischemic
Bridge
Suture Line

59. Staple Line, Ischemic Bridge, Suture Line
Staple Line
Ischemic
Bridge
Suture Line

60. Violating Basic General
Surgical Principles
Anatomic Failure
Creating Increased Risk
Bile Reflux Gastritis &
Marginal Ulcer

61. MGB Gastro-Jejunal Anastomosis
Done Wrong
Staple Line
Ischemic
Bridge
Small
Anastomosis

62. MGB Gastro-Jejunal Anastomosis
Done Wrong
Staple Line
Ischemic
Bridge
Small
Anastomosis

63. MGB Gastro-Jejunal Anastomosis
Done Wrong
Staple Line
Ischemic
Bridge
Small
Anastomosis

64. MGB Gastro-Jejunal Anastomosis
Done Wrong
Staple Line
Ischemic
Bridge
Small
Anastomosis

65. “Good” General Surgery MGB
Staple Line
NO Ischemic
Bridge
Large
Anastomosis

66. “Good” General Surgery MGB
Staple Line
NO Ischemic
Bridge
Large
Anastomosis

67. “Good” General Surgery MGB
Staple Line
NO Ischemic
Bridge
Large
Anastomosis

68. Everted Anastmosis:
Removal of Mass of Ischemic Foriegn Body from Lumen
Healthy Tissue

69. Surgical Technique Cause of Ulcer/Gastritis
Prevention of Marginal Ulcer
• Why MGB ulcers => Lateral
Aspect of the G-J
• Reason: Big bulky ischemic
mass tissue
With mass of titanium staples as
foreign bodies from the poor
surgical technique on the lateral
aspect of the GJ
• Prevention: Non-ischemic GJ w
minimal Foreign Bodies

70. MGB Dyspepsia/Bile Reflux
Conservative Rx
Successful >99%

71. Results
•Significant dyspepsia/bile reflux
unresponsive to protocol management
occurred in 4 patients 1 to 8 years after
MGB.
•Each of the 4 patients underwent sub 60
minute Braun entero-enterostomy with
rapid resolution of symptoms.

72. Conclusion:
•Dyspepsia + Bile is commonly present in the
MGB, dyspepsia is common in patients who
violate simple diet and lifestyle guidelines.
•Only a very small number of patients will
present with dyspepsia/”bile reflux”
unresponsive to medical management
protocol.

73. Goals, Take Home Messages
Bile is always present in Normal Stomach & MGB/Billroth II,
Dyspepsia is common in MGB patients (=RNY/Sleeve):
Causes / Prevention / Treatment
1. Poor technique (MGB Done Wrong: GJ, twisted pouch etc.)
Rx Prevention
2. Gastritis/Ulcer
Rx prevention, Antacid, Diet Rx
3. Violation Basic Post Gastrectomy Syndrome Diet/MGB Dietary
& Lifestyle Guidelines: **Follow dietary protocol**

74. Conclusions
•In rare cases short simple revision of the
MGB by adding a laparoscopic Braun
Entero-enterostomy rapidly resolves
symptoms.
•Revision of the MGB is easily performed but
usually unnecessary.
•MGB patients Do Not Need a RNY

75. Confusion About MGB
“Malabsorption”
vs
Fatty Food Intolerance
• Hint
• Its the BP Limb Length!

76. • Bowel resection: What We Already Know
• < 1/3 Normal bowel function (= MGB)
• > 1/2-2/3 “Dire Consequences” (= BPD / SADI)
i.e. “Short Bowel Syndrome” Sx (Diarrhea etc.)
• Haymond H E. Massive resection of the small intestine. Surg Gynecol Obstet.
(1935);51:693–705.

77. Simple General Surgery Truth
Short Bypass Safer
Longer Bypass
More Dangerous
If Your MGB Patient has: Diarrhea, Low Protein,
Fatigue & Peripheral Edema
The BP Limb is too Long

78. Bowel
Length
BPL CC
%
Bypassed
MGB 6 m 1.75m 4.25m 30%
SADI 6 m 3.5m 2.5m * 60% *
MGB 8 m 1.75m 6.25m 20%
SADI 8 m 5.5m 2.5m * 70% *
Bowel length, BPL = Biliopancreatic Bypass Limb Length
CC = Common Channel

79. MGB Offers Patients & Surgeon
Opportunity to Tailor Op
•1. MGB can be done with short, ultra-short,
medium, long or any length of
Biliopanceratic limb length
•Studies show
risk major deficiency/malnutrition
200 cm bypass => ~1%
150 cm bypass => 0.1% risk