Cognitive BiasErrors in Medical Decision Making Why 20 Year Wait for the Mini-Gastric Bypass

1. MGB-OAGB
Different
and
Better!

2. Cognitive Bias
Errors in Medical Decision
Making
Why 20 Year Wait for the
Mini-Gastric Bypass
Why American Surgeons Supported
the “Lap-Band” and Opposed the MGB
Cognitive Bias International Bariatric
Surgery & the MGB-OAGB
Nelson Mandela
Revolutionary Leader ...
Served 27 yrs Prison

3. Errors in Medical
Decision Making
Why 20 Year Wait for
the Mini-Gastric
Bypass Thomas Edison
Inventor of lightbulb 1879.

4. Errors in Medical Decision
Making:
America the
Lap Band vs MGB
Why 20 Year Wait for the Mini-
Gastric Bypass
Cognitive Biases
What can we learn from the
Lap Band Experience Muhammad Ali; Champion
known for his fight against the
Vietnam War

5. OVERCONFIDENCE
•Overconfident judgment by clinicians is one
example of many cognitive biases that may
influence reasoning and medical decision
making.
•This bias has been well demonstrated in the
psychology literature, where it appears as a
common in surgeons

6. Confirmation Bias &
The Joint Commission
Events reported to The Joint Commission,
cognitive biases have been identified
contributors to sentinel events
i.e. wrong site surgeries => confirmation bias)

7. Confirmation bias
•Confirmation bias - Wikipedia
•The tendency to
search for, interpret, favor, and
recall information in a way that
•Confirms one's preexisting beliefs or
hypotheses.

8. Cognitive biases in health care
©The Joint Commission, Division of Health Care
Improvement
•Cognitive biases are increasingly recognized
as contributors to patient safety events.
•Cognitive biases are
flaws or distortions in judgment and
decision-making

9. Cognitive Bias
Flawed Human Decision Making
Why did it take
20 years for surgeons to adopt the MGB-OAGB
While Surgeons Happily Offered the Lap Band?

10. The Tragedy of the Lap Band
the New York State Experience (USA)
• SPARCS administrative database was used to identify
Lap Band placement from 2004 to 2010
• Patients w band placement subsequent removal/revision
between 2004 and 2013
• During a 7-year period, there were
19,221 Lap Band placements &
6,567 revisions or removal

11. The Tragedy of the Lap Band
the New York State Experience (USA)
• During 7-years
• 19,221 Lap Band
• 6,567 revisions or removal
• Revision rate 34%
(1 out of 3 in 7 years!)
• 29% complications w revision!
1 out 3
0
5
10
15
20
25
30
35
40
1995 2000 2005 2010 2015 2020
Pubmed Publication Count for “Lap Band”
Popularity Followed By Failure & Abandonment

12. The Tragedy of the Lap Band
the New York State Experience (USA)
•Revision rate 34%
(1 out of 3 in 7 years)
•29% had complications w revision
(1 out 3)
•Lap Band is a FAILURE

13. During the Previous 20 years
ASMBS Dictated USA Insurance Coverage of
Bariatric Surgery
• The lap band operation was first
approved by the Food and Drug
Administration in 2001, it
seemed like a safe option for
weight loss surgery
• 20 yrs the Lap Band approved
& endorsed by
American Bariatric Surgeons April 15, 1947, Jackie Robinson
becomes the first Black American
in USA Baseball

14. The OAGB by Carbajo
and the MGB
Rutledge
Short simple low risk &
effective operations
Ignored & Rejected by
American Surgeons

15. During the Previous 20 years
ASMBS Dictated USA Insurance Coverage of
Bariatric Surgery
• The MGB-OAGB operations
opposed actively since the first
1,200 patients were presented by
Dr Rutledge
•20 yrs the Lap Band approved &
endorsed by
American Bariatric Surgeons
The MGB Opposed Singer-songwriter
Bob Dylan

16. The Mini-Gastric Bypass Story
•For 20 Years Surgeons Around the World
•Led by American Surgeons and the ASMBS
•Attacked the MGB
•In spite of data from thousands of patients
from around the world including controlled
prospective randomized trials

17. Cognitive Bias
• Humans (Physicians) Believe they are good decision makers
They are not
Cognitive Biases and Heuristics in Medical Decision Making
A Critical Review Using a Systematic Search
213 studies analyzed
19 types of cognitive biases,
68% of surgeons showed confirmation bias

18. Overconfidence in Clinical Decision Making
• The American Journal of Medicine (2008) Vol 121 (5A), S24–
S29
•SOLUTIONS AND CONCLUSIONS
•Overconfidence often occurs when
determining a course of action.
•Overconfidence is associated in particular
with confirmation bias

19. Confirmation Bias
•Confirmation bias,
•The tendency to search
interpret, favor &
recall information in a way that
•Confirms preexisting beliefs or hypotheses

20. Confirmation Bias
Cognitive Bias
• In 2000 when Dr Rutledge
presented 1,200 MGB patients
• The Billroth II connection was
assessed using preexisting
beliefs (Mason Loop)
• Confirmation Bias => Loops Fail
• MGB => Fail <= Bile Reflux
• “Confirms one's preexisting
beliefs”

21. Surgeons were/are “Foolish”
Confusing Old Mason Loop w MGB
Gastro-
Jejunostomy

22. Surgeons Fought & Opposed the
MGB-OAGB
Surgeons Advocated the Lap Band
American Surgeons were/are
Wrong!

23. Abandonment of the Band
Why is No One Talking About the “Lap Band”
0
5
10
15
20
25
30
35
40
1995 2000 2005 2010 2015 2020
Pubmed Publication Count for “Lap Band”
Popularity Followed By Failure & Abandonment

24. American Surgeons
20 Years Opposing the MGB
During the Same Time Period
10 Years Offering the Failed Lap Band
to Patients

25. 20 Yrs American Bariatric History
Surgeons Support Lap Band & Oppose MGB
-20
-10
0
10
20
30
40
50
60
70
2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020
0
5
10
15
20
25
30
2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020
# of Publications: MGB vs Lap Band
(* 2018 Predicted *)
Lap Band MGB Linear (Lap Band) Linear (MGB)
Lap Band
MGB

26. The MGB-OAGB
“No Longer Investigational”
•For more than 20 years we,
•the world’s MGB-OAGB surgeons,
•have fought together to provide our
patients with,
•what we believed,
•was one of the very best forms of the
•surgical treatment for obesity, diabetes
and metabolic disease.

27. The MGB-OAGB
“No Longer Investigational”
•We should remember the courage and fortitude
that each of us has put forward to get to the
present day.
•In the face of criticism, we stood fast,
as bothers and sisters in arms.
•We have seen the lap band come and go as well
as other changes...

28. MGB-OAGB No Longer “Investigational”
BUT WE ARE NOT DONE
•The 20 year effort to have the MGB-OAGB
approved and recognized is now nearly over
•(United States of America?)
•But MGB-OAGB Surgeon Experts/Leaders
I say ”Our Job is Not Done!”

29. The Tragedy of the MGB
DONE WRONG!
•MGB is a short simple operation when the
surgeon follows the technique
•Unfortunately we have seen numerous and
varied complications and death
• MGB done wrong

30. Example: New MGB Surgeons =>
Complications
• Int J Surg. 2016 Sep, Laparoscopic sleeve gastrectomy versus
laparoscopic mini gastric bypass: One year outcomes. Kansou G
•=> *G-J Stricture 17%* <=
• Department of General, Digestive and Metabolic Surgery, La Cavale
Blanche University Hospital, Brest, France

31. The Tragedy of the MGB
DONE WRONG!
•Malnutrition and Hypoalbuminemia
•Bile Reflux
•Excessive Weight Loss
•Gastro-jejeunal stricture
•Steatorrhea
•Marginal Ulcer
•Liver Failure and Many More...

32. The Tragedy of the MGB DONE WRONG!
CAN BE PREVENTED
Understand the Pre/Intra/Post Op Rx Prevention / Treatment
• Malnutrition and
Hypoalbuminemia
• Bile Reflux
• Excessive Weight Loss
• Gastro-jejeunal stricture
• Steatorrhea
• Marginal Ulcer
• Liver Failure
• Prevent shorter BP Limb, Treatment Rapid
Recognition & Revision
• Long Gastric Pouch
• Dietary Modification
• Large diameter Gastro-jejeunal anastomosis
• Shorter BP Limb & dietary modification
• Avoid ischemic GJ anastomotic closure
• Shorter BP Limb, staged MGB or Rapid recognition
and reversal

33. Confusion By Surgeons Who Do Not
Understand the MGB
How Often
Surgeons Have Been
And
Continue to Be Wrong
About the Mini-Gastric Bypass?

34. Just Some... Examples of Confusion
• The Pouch is Too Big & Pts Will Not Loose Weight
Short Gastric Pouch
• Dissection EG Junction and Cural Repair
MGB with a “Ring”
• Irrational Fear of Bile Reflux
• Confused About Risk Gastric Cancer
• Fear of Malnutrition
• Management of MGB Complications
And More...

35. Recently Surgeons Have
“Discovered” Malnutrition after the MGB!
• Impact of biliopancreatic limb length on severe protein‒calorie
malnutrition requiring revision Mahawar K J Minim Access Surg.
2017
• Severe fatal protein malnutrition after mini-gastric bypass
surgery: Case report Motamedi M., Int J Surg Case Rep. 2017
• Laparoscopic reversal of mini-gastric bypass to original anatomy
for severe postoperative malnutrition. Genser L Langenbecks
Arch Surg. 2017
• Laparoscopic conversion mini-gastric bypass to proximal RnY for
malnutrition: case report Rosenthal R Surg Obes Relat Dis. 2009

36. Need:
Documented Misunderstanding of the
MGB Surgery for 20 Years and
Documented Death and Complications
to MGB patients in Non-Expert MGB
Surgeons Hands

37. In short:
We experts in the creation,
performance and provision of the true
MGB-OAGB believe that the
MGB-OAGB needs
Standardization, Education &
Recognition of
Surgeons of Excellence

38. We MGB-OAGB Surgeon Experts
Standardize the best practices of the
MGB-OAGB
Educate other interested surgeons &
Recognize MGB-OAGB Surgeons of
Excellence

39. "Those who Cannot
Remember the past are
Condemned to repeat it"
Santayana

40. MGB-OAGB
Past & Future
•Past: 20 Years ago the First MGB was performed
•Present: 2018 IFSO deemed the MGB-OAGB “Non-
Investigational”
•Future: There is Clear Need for
Standardization
Education
Recognition of MGB-OAGB Surgeons of Excellence

42. The MGB-OAGB
“No Longer Investigational”
•At this moment, we stand at
the end of one long road, in victory,
the MGB-OAGB is recognized,
•but also we stand at the
beginning of another long road,
a road to unify, to teach and
educate “new” surgeons to
protect our patients &
assure that they are given the best care.

43. This new road demands
further hard work and sacrifice.
But that is alright with us,
that is what we were made for,
we few, we happy few,
we band of brothers and sisters.

44. The MGB-OAGB
“No Longer Investigational”

45. MGB-OAGB
Different
and
Better!