The Mini-Gastric BypassDr Rutledge, DrR@CLOS.netFour Stories for Four Radical Ideas 20 minutes, 4 topics 5 minutes each 1. (Mis)Understanding the  MGB Mechanism of action 2. MGB Paradox (Good MGB/Bad MGB) 3. MGB: BP Limb Length 4. MGB-OT to the new MGB2i

1. The Mini-Gastric Bypass
Dr Rutledge, DrR@CLOS.net
Four Stories for Four Radical Ideas
20 minutes, 4 topics
5 minutes each

2. Four Stories for Four Radical Ideas
(Some Controversy?)
1. (Mis)Understanding the
MGB Mechanism of action
2. MGB Paradox (Good MGB/Bad MGB)
3. MGB: BP Limb Length
4. MGB-OT to the new MGB2i

3. 1. (Mis)Understanding the MGB
Mechanism of action
It’s **NOT** a Sleeve

4. 1. (Mis)Understanding the MGB
Mechanism of action
• The MGB is Nothing more than:
Collis Gastroplasty
Billroth II (Polya) + Bypass 200 cm Jejunum
• Mechanism of Action is
Non obstructive elimination of the reservoir
function of the stomach (NOT, Band, Sleeve or VBG)
Dumping (Type 1 & 2)
Fatty Food intolerance/malabsorption

5. MGB: Nothing More than General Surgery
Critics usually are not clear on Non-Obstructive MB-Original Technique:
Collis Gastroplasty Billroth II (Polya) MGB-OT

6. What do we want? Rapid gastric emptying!
Prevention delayed gastric emptying after Whipple: Network meta-analysis randomized trials 2021
Learning from RCTs
• B-II a lower incidence of DGE &
shorter op time.
Metaanalysis of RCTs 2021
•Billroth II
•Speeds Gastric Emptying
•Goal of MGB!
Billroth II w Braun Entero-enterostomy

7. MGB-OT Mechanism of Action
1. Non obstructive elimination of the
reservoir function of the stomach
(MGB: NOT like the Band, Sleeve or VBG)
2. Dumping (Type 1 & 2)
3. Fatty Food intolerance/fat malabsorption
200 cm jejunal bypass

8. 2. MGB Paradox (Good MGB/Bad MGB)
•The MGB Paradox?
•Some Surgeons Report Excellent Results:
- Rutledge & many others
•Some Surgeons Report Bad Results:
- Yomega French Study,
- 2021 Australia 10% reop for Reflux!!

9. •Excellent Results: Rutledge & Others
with MGB - Original Technique
vs.
Occasional Worldwide Reports of:
Poor Weight Loss/Excess Weight Loss,
Bile Reflux, Leaks & Death

10. Good MGB Example Dr Lee
•Failed restrictive bariatric operations underwent
revision surgery
•for weight regain (51%), inadequate weight loss (31%)
•Follow Up
•Weight loss was better for MGB vs RYGB
•(77% vs. 32% EWL; p = 0.001).

11. MGB: Bile Reflux?
Expected(?) Complication
vs
Surgical Technique/Post Op Diet/Lifestyle
Bile reflux reported in
0.3% vs 35%???

12. Yomega Trial: Questions
Higher diarrhea OAGB 20% vs. RYGB 7%
Higher steatorrhea OAGB: 11 g vs. RYGB: 7g
19% gastritis & 10% esophagitis OAGB vs. 6% & 3% RYGB
Bad Outcomes? => Bad Surgeons/Technical Errors?
MGB?
20%/10% Gastritis/Esophagitis
20% Diarrhea/Steatorrhea (What does that tell you?)

13. Sample MGB Done Wrong
Severely Twisted Gastric Pouch
Causes:
Bile Reflux
Nausea
Vomiting
Excessive Weight
Loss
Ischemic
Marginal Ulcer

14. MGB Paradox: Good MGB vs Bad MGB
Possible Explanaintions:
1. The surgical Procedure Itself is Flawed
2. The Surgeon’s Technique
3. Post Op Management

15. Sample Error in Creating the Gastric Pouch
“TWISTED” Pouch
• How the MGB Gastric Pouch ...
• Should NOT Lie: WRONG
• NOT Like a Normal Stomach
• Medial = Lesser Curvature
• 180 Deg Twist
9 O'clock to 3 o'clock
• Lateral = Neo-Greater Curvature
Twist

16. Technical Errors
=> Bad Outcomes

17. 3: BP Limb Length: Two Topics
•3A. Longer BP Limb => More Wt Loss
•3B. It’s ** SIBO ** NOT BP Limb Length
Malnutrition & Death after
BPD/MGB/SADI etc.

18. 3A. Longer BP Limb
=> More Wt Loss
Reminder!
Eat More Fat => Gain More Weight
Eat, Digest & Absorb Less Fat =>
Lose MORE Weight

19. “Impairment of fat absorption with Billroth II
Afferent loop length vs fat absorption“
“An experiment ...
increased afferent limb length
predictably increased fat malabsorption”

20. “Normal” Fecal excretion 2.4% ingested fat
Similar results both in animals & humans
“afferent loop lengthens steatorrhea increases”
fecal fat excretion Normal ~2%
30 cm 2.4%
60 cm 10%
90 cm 28%
• Ergo: Longer BP Limb (Afferent) => Greater Fat/Weight Loss

21. Dosage of MGB
Uniquely
Can Be
Titrated to Effect

22. Kular 10 yr Follow Up
BP Limb Length %EWL 9 years
y = 0.002x - 0.06
R2
= 0.7
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
100 150 200 250 300 350
BP Limb Length vs %EWL

23. 3B. Malnutrition & Death
Post BPD/MGB/SADI etc.
It’s ** SIBO **
**NOT BP Limb Length**

24. *Small Bowel Length, *Short Bowel
Syndrome & *MGB Limb Lengths
• Small Bowel Length (Taccino) 690cm (23ft)*
• Short Bowel Syndrome; Bowel Needed to Live
Independently: 60cm (2ft) small bowel
(if some colon remains)
• MGB Bowel Bypassed: 200cm (6ft)
• Residual post MGB, Avg Distal Bowel 490cm (16ft)

25. Those who do not remember the past,
are condemned to repeat it!
“It is probable that this complication is
more important than the 9 recorded cases”
Delay Dx: “The diagnosis usually only after
months or years of disability”
Steatorrhea common
Malnutrition, edema hypoproteinemia

26. Those who do not remember the past,
are condemned to repeat it!
“It is probable that this complication is
more important than the 9 recorded cases”
Delay Dx: “The diagnosis usually only after
months or years of disability”
Steatorrhea common
Malnutrition, edema hypoproteinemia

27. Those who do not remember the past,
are condemned to repeat it!
Medical Rx with “tetracycline, ... chloramphenicol,
and possibly other antibiotics...
“Definitive therapy...
early surgical correction”
Thomas Starzl 1961 &
Echoed by Dr Rutledge from 1997-2022

28. Malnutrition/Diarrhea etc. Post MGB
It Is SIBO / Is Not BP Limb Length
• Proximal 6 feet of jejunum major site of fat absorption
• SIBO interferes with Lipid absorption => Steatorrhea, malnutrition
• SIBO jejunal microbiota altered
• ALTERED Gut microbiome in patients with SIBO.
Dysbiosis in the mucosa-associated gut microbiome
DX & RX of SIBO

29. 4. Mini-Gastric Bypass (2i)

30. 4. Mini-Gastric Bypass (2i)
True to Billroth II General SurgeryMGB Anatomy & Physiology
1. Decrease Risk Bleeding & Leaks
2. Decrease Op Time & Resource Utilization
3. Decrease Risk of Reflux

31. 4. MGB-OT to the new MGB2i
Complications of Bariatric Surgery
• Death ~0.1%, Major complications 4%
• Most Common Serious Complications
Bleeding, leaks & stenosis
• Expert Panel: Leak rate 1% - 3%,
>10% in revisions.
• Anastomotic leak increases
morbidity -> 61% & mortality -> 15%.

32. Most Common Complications Bariatric Surgery

33. MGB/MGB2i: 8 Step Philosophy
1. Remove Reservoir Function of the Stomach/Convert to Extension of the
Esophagus (Collis Gastroplasty)
2. Avoid the EG junction (sling & clasp), leave the fundus
3. Extend the Length of the Gastric Pouch 30-50% (Rx Reflux)
4. Improve Blood Supply of GJ anastomosis (lateral blood supply),
(=> Decrease stricture, reflux, marginal ulcer/perforation)
5. Increased GJ outlet (Dumping)
6. Decrease staple line bleed/leak
7. Easy revision/reversal
8. Easily tailored: from thin normal weight diabetic to super super obese

34. Gastro-Jejunostomy Site => Reflux
•Mason Loop
•Some “Non-MGB”
SAGB Surgeons
•MGB
•MGB2i Gastro-jejunostomy

35. MGB -OT vs. MGB2i
Medial (MGB-OT) vs. Lateral (MGB2i) of Staple-gun
MGB-OT
(Original
Technique)
Medial
Approach of
Staple-gun
MGB-OT
(Original Technique)
Medial Approach of
Staple-gun
MGB2i
Lateral Approach
of Staple-gun
MGB2i
Lateral
Approach of
Staple-gun

36. MGB2i Upper GI
POD 1 Leak Test
•Esophagus
•EG Junction
•Proximal Gastric
Pouch

37. MGB2i, POD 1 Leak Test
•Esophagus
•EG Junction
•Proximal Gastric Pouch
•Midpoint of the Gastric Pouch
•Junction of the Body/Antrum
•Gastro-jejunostomy
•Efferent Limb

38. Summary:
Four Stories for Four Seasons
1. (Mis)Understanding the MGB Mechanism
of action
•2. MGB Paradox (Good MGB/Bad MGB)
•3. BP Limb Length
•4. MGB-OT to the new MGB2i
- Fini -