The MGB2i is described as having a lower risk profile than other bariatric procedures due to its use of hand sewing instead of staples, which aims to eliminate staple line leaks and bleeding. It also adds a gastrojejunostomy to the anterior

1. The
Mini-Gastric
Bypass (2i)
Recognize Most Common Complications of Bariatric Surgery
Minimal Modification of the MGB
1. Decrease Risk Bleeding & Leaks
2. Decrease in Operative Time & Resource Utilization
3. Decrease Risk of Reflux

2. The MGB2i
Lower Risk & More Power

3. Most Common Complications Bariatric Surgery

4. Philosophy of the MGB/MGB2i
• Remove Resivoir Fuction of the Stomach/Covert to Extention of
the Esophagus (Collis Gastroplasty)
• Avoid the EG junction, leave the fundus
• Extend the Length of the Gastric Pouch 30-50%
• Decrease the ischemia of the lateral GJ anastomosis,
(marginal ulcer/perforation)
• Increased GJ outlet (Dumping)
• Decrease/eliminate staple line bleed/leak
• Easy revision/reversal
• Easily tailored: from normal weight diabetic to super super obese

5. The Mini-Gastric Bypass
**NOT** Mason Gastric Bypass
• Of course anyone is entitled to perform any surgery they
see fit
• But some surgeons have performed an operation that they
claim is a “Mini-Gastric Bypass”
• Do not understand the
Anatomy & Physiology of the
• Basic GI Surgery the MGB Not
Failed Mason Loop Gastric Bypass

6. https://mgbguidelines.wordpress.com/gastric-pouch-creation/
•Edward E. Mason, MD, PhD
NOT a Mini-Gastric Bypass
• This is Not a
Mini-Gastric
Bypass

7. Fear of Malnutrition &
Excess Weight Loss
• Death from Malnutrition with Zero Food Intake:
=> Requires 2 - 4 Months! With some food: 3 - 6 months!
• Simple Takeaway #1: IF Loose to Much => Revision!
• We need Patient & Surgeon Education
• Signs & Sx of malnutrition: Weak, edema ...
• Rx: Revision, short simple 30 min surgery

8. MGB2i
Distal Greater Curvature Gastro-Jejunostomy

9. Gastro-Jejunostomy Site vs Reflux
• Mason Loop
• Some “Non-MGB” SAGB
Surgeons
• MGB
• MGB2

10. MGB Pouch (Original Technique)
• EG Junction
• Crow’s Foot
• MGB-OT
Gastro-jejunostomy

11. MGB2i =>
1/3 - 1/2 Longer Gastric Pouch
EG Junction
“Bad” Short
MGB Pouch
Crow’s Foot
MGB-OT DrR
GJ Site
Additional
Length of
the Pouch

12. MGB2i
Anterior Gastric Plication

13. Complications of Gastric Plication
• Loss of restriction & weight regain
• Plication breakdown (Ischemia Poor Blood Supply)
• GE Reflux/Persistent heartburn
(Narrowing/Stricture Fundus)
• Gastric wall herniation (Ischemia / perforation)
• Gastric intussusception
• Gastric ulcers (Chronic Ischemia)

14. MGB2i vs Gastric Plication
MGB2i RX Complications of Gastric Plication
• Classical Gastric Plication
• Loss of restriction & weight regain
• Plication breakdown (Ischemia Poor
Blood Supply)
• GE Reflux/Persistent heartburn
(Narrowing/Stricture Fundus)
• Gastric wall herniation (Ischemia /
perforation)
• Gastric intussusception
• Gastric ulcers (Ischemia)
• MGB2i Modifications
Loss of restriction & weight regain:
+2 Meter Gastric Bypass
• Plication breakdown (Ischemia Poor Blood Supply)
No Devascularization of Greater Curve
• GE Reflux/Persistent heartburn
(Narrowing/Stricture Fundus)
Loose Fundus & Gastro-J => Low Pressure
• Gastric wall herniation (Ischemia / perforation)
No devascualrization of the plicated stomach
• Gastric intussusception
Downward traction on the stoamch pouch + GJ
• Gastric ulcers (Ischemia)
No devascualrization

16. MGB -OT vs. MGB2i
Medial vs. Lateral Approach of Staplegun
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

17. MGB -OT vs. MGB2i
Medial vs. Lateral Approach of Staplegun
MGB2i
Lateral
Approach of
Staple-gun
Narrow
Afferent
Limb GJ
Outlet

18. POD 1 Leak Test
• Esophagus
• EG Junction
• Proximal Gastric Pouch

19. 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

20. POD 1 Leak Test
• Esophagus
• EG Junction
• Proximal Gastric Pouch
• Midpoint of the Gastric Pouch
• Junction of the Body/Antrum
• Edema Gastro-jejunostomy
• Efferent Limb
• Antrum + Plicated Pylorus

21. POD 1 Leak Test
• Esophagus
• EG Junction
• Proximal Gastric Pouch
• Midpoint of the Gastric Pouch
• Junction of the Body/Antrum
• Edema Gastro-jejunostomy
• Efferent Limb
• Antrum + Plicated Pylorus

23. Background Knowledge
• MGB Superb short & long term procedure
• Early Complications:
All Bariatric Surgery: Leak & Bleeding
• Staples: Superb tools, but Imperfect (Leak/Bleeding)
• Most modern Bariatric surgery face
Risk of bleeding & leak reported in rates of 0.1 to 5%

24. Gastric Plication: Pro/Con (Good/Not Perfect)
Twelve year experience of laparoscopic gastric plication
Mohammad Talebpour
• 800 cases, EWL 70% after 24 months
• 55% after 5 years following surgery.
• Mean Op time 72 min (49–152) minutes
• Mean hosp stay 72 hours
• Cost: $2,000.00 < band & sleeve
$2,500.00 < RNY
• Complications: Weight regain 31% @12 yrs
• 1% re-operation leak, obstruction, intra-abdominal
bleeding and vomiting

25. Gastric Plication: Issues Pro/Con
• Pro: *Short op time & hosp stay, *Moderate weight loss
• *Low Cost $2,000 - $2,500 less
• Con: Complications: Weight regain; leak, obstruction,
intra-abdominal bleeding & vomiting (ischemic plication)
• Con 2: Moderate Effectiveness +
Usual Complications++ (Leak/Bleeding etc.)
• Why: ischemia of the plicated stomach

26. Gastric Plication: Issues Pro/Con
Ischemia/Necrosis of the plicated stomach
• Con: Complications: Weight regain; leak, obstruction,
intra-abdominal bleeding and vomiting
• Con 2: The most common side effects reported by
patients include:
Vomiting, severe nausea & abdominal pain
which can last for a week or more
• Why: Ischemia/Necrosis of the plicated stomach

27. Mini-Gastric Bypass
• Almost “Perfect” Operation
• Short Simple Effective Reversible Revisable
• Can be Tailored to Patient’s Needs
• BUT: Like most bariatric procedures
• Has small but significant rates of leak & bleeding

28. The Simple Theory of the MGB 2
Stapless MGB
• No/Minimal Staple Line Leak or Bleeding
• How: Anterior Plication of the
Stomach Pouch: No Cutting No Staples
• Avoid the limitations/complications of Plication
• How:
• 1. Do not devascularize the gastric tissue and
• 2. Add the MGB bypass to increase the power of the
operation & decompress the stomach pouch to avoid
subsequent dilation/weight regain

29. Short-term Outcome of Single-Anastomosis Plication Ileal Bypass
(SAPI) Springer, December 2020Obesity Surgery
• Many Good Men & Women have had similar ideas:
i.e. The SAPI procedure involved
• plication of the greater curvature of the stomach in two
rows
• then performing a stapled side-to-side anastomosis
between an ileal loop and the gastric antrum.

30. Nothing New Under the Sun
SAGI PGP
• Many authors have led similar/same
procedure(s)
• Our own concern was the lateral
devascularization of the greater
curvature and the reported
ischmia, pain, necrosis and
perforations reported in
Plication Series
Single Anastomosis Gastro Ileal Bypass with Pyloric and Gastric Plication (SAGI PGP): A New Innovative Bariatric Operation
Ferman Faris Mohammed1* and Rafil Abdel Alwahab Aldaaod2

31. Failed AnteriorGastric Plication
S. A. Brethauer et al. / Surgery for Obesity and Related Diseases xx (2010)
• Laparoscopic gastric plication for treatment of severe obesity
• Stacy A. Brethauer, M.D.,*, Jason L. Harris, Ph.D.b
• , Matthew Kroh, M.D., Philip R. Schauer, M.D., Bariatric and Metabolic
Institute, Cleveland Clinic, Cleveland, Ohio
• Ethicon, Endo-Surgery, Cincinnati, Ohio
• Received May 6, 2010; accepted September 22, 2010

32. Diagram Plication procedure.
Failed LC “lesser curvature” (?); GC greater curvature;
Greater Curve Plication “Lesser” Curve” Anterior Plication

33. Diagram Plication procedure.
Failed LC “lesser curvature” (?); GC greater curvature;
Greater Curve Plication “Lesser Curve” Anterior Plication

34. Greater Weight Loss with Lateral Plication

35. Diagram Plication procedure.
Failed LC “lesser curvature” (?); GC greater curvature;
Reason Failure: Obviously
Less Gastric Narrowing/Larger Gastric Pouch
Greater Curve Plication
Smaller Pouch Size
“Lesser” Curve” Anterior Plication
Bigger Pouch Size

36. Plication Problems
MGB2 Modifications of other Plications
• => Anterior Plication => Weight Loss Failure
Ans: Narrowed Pouch + Added Tailored MGB Gastric Bypass
• => Plication => Nausea, Vomitting, Ischemia, Performation, Leak
• Ans: Anterior Plication, spare the fundus, maintain lateral gastroepiploic
& short gastric blood supply + no stragulation of the plication
• => Staple Line Leak & Bleeding
(Many/most surgeons oversew the staple lines)
• Ans: All steps are Hand Sewn, No Staples

37. Post Op MGB 2
• Large Gastric Fundus
• Narrow Gastric Tube
• Gastro-Jejunostomy
• Antrum
• Distal BP Limb

38. Mini Gastric Bypass 2
Large Gastric Fundus

40. Planned Location of the Gastrojejunostomy
Greater
Curvature
Lesser
Curvature &
Crow’s Foot
Antrum

41. Gastro-Jejunostomy

42. Bougie Passed Across
the Gastro-Jejunostomy

43. Bougie Passed Across
the Gastro-Jejunostomy

44. Distal Bilio-Pancreatic Limb

45. MGB2 Gastro-Jejunostomy

46. Completed MGB2

47. Completed Mini-Gastric Bypass 2

48. Gastric Body

49. Prior Failed Lap Band

50. Completed MGB2

51. Scar & Distorted Gastric Anatomy from
Prior Lap Band

52. Scar & Distorted Gastric Anatomy from
Prior Lap Band

56. Gastric
Pouch
Greater
Curvature
Free Space
Gastro-
Jejunostomy

57. Gastric
Pouch
Greater
Curvature
Free Space
Gastro-

58. Gastric
Pouch
Greater
Curvature

59. Gastric
Pouch
Greater
Curvature

60. Gastric
Pouch Greater
Curvature

61. Gastric
Pouch
Greater
Curvature

62. Gastric
Pouch
Free Space
Gastro-
Jejunostomy

63. Gastric Pouch

67. Antral Plication

68. Antral Plication

69. Antral Plication

70. Antral Plication

71. MGB2

72. Mini-Gastric Bypass 2

73. Distended Pouch: Leak Test

74. The Mini-Gastric Bypass 2, (MGB2)
Antrum
Neo-Gastric
Pouch
Proximal
BP Limb
Distal
BP Limb
Vascular
Greater
Curvature