Kular To Tailor or Not to TailorMost Important to UNDERSTAND: BP Limb Length and Outcomes

To Tailor or Not to Tailor
Most Important to UNDERSTAND: BP Limb Length and Outcomes
1. BP Limb Length “Roughly” Predicts Wt Loss (Rutledge)
2. Simple: More BP Limb => More Weight Loss
3. More Weight Loss =>
Increase Risk of Excessive Weight Loss (i.e. BPD SADI etc...)
4. MGB gives Choice (Patient & Surgeon)
5. OK, Don't Tailor => Less Wt Loss & Lower Risk Malnutrition
6. In Skilled Hands: Excellent Wt Loss & Low Risk of Excessive Wt Loss
MGB in others => Can be Dangerous & Deadly
7. Surgeon MUST understand Easy Rapid Rx excessive Wt Loss
8. NEED: Standardization, Education & Recognition

Understanding Weight Loss After
Bariatric Surgery
Statistics, Random Distribution and
Too Little or Too Much of a Good Thing

Topics & Objectives
1. MGB is an Excellent Procedure: Look at the Data
2. MGB: Widespread, Persistent Confusion (examples)
i.e. BP Limb Length Does Not Predict Weight Loss (Wrong)
i.e. Fear of MGB Malnutrition (MGB rates similar to RNY)
i.e. Mismanagement of MGB Malnutrition
(Don't Do Weight Loss Surgery for Malnurition)
3. Need MGB Standardization, Education, Recognition of MGB
Surgeons of Excellence

Confusion By Surgeons
Who Do Not Understand the MGB
?? MGB Best Bariatric Surgery ??
In Hundreds of Articles of MGB
In Every Study, By Every Measure
the MGB is Equal to or
(More Often) Better Than
Any Comparable Bariatric Surgery
(Including Randomized Controlled Prospective Trials)

Understanding the Obvious
• First: If you do not understand an operation (MGB)
• Do Not Use the Operation!!
• In Short: This Presentation in Summary:
1. Widespread and Persistent Misunderstanding of MGB
2. Often Leading to Complications and Even Death
3. Needed: * Standardization of MGB, ** Education and
*** Recognition of Knowledgeable and Skilled Surgeons

Needed: Standardization of MGB and
Recognition of Surgeons Knowledgeable
and Skilled in its use
* Standardize, ** Educate, *** Recognize
The Best in MGB
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Email: DrR@clos.net, Facebook: DrRRutledge
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Phone: 702-483-7133 or 702-714-0011 or What's App: Dr Rutledge

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

Understand the MGB
Some Examples of MGB Confusion
1. The Pouch is Too Big & Pts Will Not Loose Weight
2. Short Gastric Pouch (MGB = Old Mason Loop)
3. Dissection EG Junction and crural Repair
4. MGB with a “Ring”
5. Irrational Fear of Bile Reflux
6. Confused About Risk Gastric Cancer
7. Fear of Malnutrition
8. Management of MGB Complications
And More...

Bowel Bypass Limb Length &
Weight Loss
• Recently the confusion about
Bowel Bypass Limb Length and
Weight Loss
• Many Studies of RNY => No advantage of BP Limb
length Re: Weight Loss
• Surgeon Advocate MGB 150 cm bypass only. Why?
150 cm => Less Malnutrition (Correct)
150 cm => Equal Weight Loss (Wrong)

Summary (In Short)
1. BP Limb/Weight Loss, 2. Malnutrition & MGB, 3. Rx Excessive Wt Loss
1. BP Limb and Weight Loss
(Hint: Longer Bypass = More Weight Loss)
2. Malnutrition and MGB
(Hint: Uncommon and Easily Managed and
MGB Unique: Surgeon/Patient can choose
More Power or Lower Risk of Excess Wt Loss)
3. Management of Excess Weight Loss after MGB
(Hint: Easy, immediate 30-60 minute revision
NOT RNY!)

1. BP Limb and Weight Loss
(Hint: Longer Bypass =
More Weight Loss)

Dr Rutledge's Study
BP Limb Length & Weight Loss
4,000+ patients
Longer bypass => More Weight Loss

Linear Regression Line (R2=0.39)

BP Limb & Weight Loss: Conclusions
• Largest reported study of bypass length and weight loss after gastric bypass.
• Prior negative studies with small sample sizes may have suffered from a Type II error.
• (Small sample => No Diff)
• Preop weight & limb length significantly associated w weight loss
• Every additional foot of bowel bypassed is associated with a
mean increase in the expected one year weight loss.

Dr Rutledge's Study
Very Simple Conclusions
1. Longer bypass = More Weight Loss
2. Longer bypass = More Power (Mean XsWL)
3. More Power =>
Increased Risk of Excess Weight Loss
(Small)

2. Malnutrition and MGB
(Hint: Uncommon and Easily Managed
and
MGB Unique: Surgeon/Patient can
Choose
More Power or Lower Risk of
Excess Wt Loss)

Understand the MGB
Fear of Malnutrition
Management of MGB Complications
Focus

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

Recently Surgeons Have
“Discovered” Fear Malnutrition after the MGB!
1. Shows Evidence of Deep Misunderstanding of:
2. Of the MGB (Uncommon & Easily Managed)
3. Of the RNY (Has Similar Risk of Malnutrition)
4. Of the SADI BPD etc (MUCH Worse malnutrition)
5. But MOST Important;
Misunderstanding of Simple Statistics
(Mean & Std. Deviation, Simple)

Fear of Malnutrition in the MGB
One Example:
• 12 pts TPN nutrition
• 7 "one-anastomosis gastric bypass" (OAGB)
or "mini gastric bypass,"
“This case series suggests that OAGB could
over expose subjects to severe nutrition
complications”
JPEN J Parenter Enteral Nutr. 2017 Need for Intensive Nutrition Care
After Bariatric Surgery. Bétry C

Fear of MGB Malnutrition
Shows Ignorance of Large Scale
MGB Series Studies

Evidence of Deep Misunderstanding of the MGB
What Do large Scale Series of MGB Report?
Two Examples
All Large Scale MGB Series are the Same:
Malnutrition after MGB:
Risk LOW & Treatment Easy **
(** If Surgeon Knows What to Do **)

Malnutrition Post MGB
Deep Misunderstanding of MGB
• Obes Surg. 2016
Laparoscopic Conversion of (Mini) Gastric Bypass Complications
• 49 Conversions of 2,382 Cases
= 2%
• 58% Conversions for Malnutrition
= 1% MGB => Revision for Malnutrition

Malnutrition Post MGB
Deep Misunderstanding of MGB
• Surg Obes Relat Dis. 2015
Mini-gastric bypass: long-term results,
Chevallier J M
• Malnutrition Required Revision
= 1.6%

Fear of Malnutrition?
MGB Malnutrition Rate: 4 / 1,000 MGBs
• MGB Malnutrition requiring revision
• Total survey data
• 101 Surgeons (Many NOT Doing Standard MGB)
• 36,952 Patients
• *Malnutrition Rate 0.4%* (138 pts)
• Severe protein‒calorie malnutrition requiring revisional
surgery after one anastomosis (mini) gastric bypass, Mahawar J
Minim Access Surg. 2017

Fear of Malnutrition?
MGB Malnutrition Rate: 4 / 1,000 MGBs
MGB Malnutrition requiring revision
101 Surgeons (Many NOT Doing Standard MGB),
36,952 Patients, *Malnutrition Rate 0.4%* (138 pts)
5-10 Times LOWER Than RNY, 50-100 Times Lower than SADI
Mahwar 2017

Fear of MGB Malnutrition
Little Recognition of Other Studies
Comparison RNY vs MGB
Risk of Malnutrition

RNY vs MGB
Evidence of Deep Misunderstanding of the
RNY, Malnutrition, Revision Data
RNY has Malnutrition/Revision Rates
Roughly Equal to MGB

Pubmed Searches:
A Simple Test
• PUBMED:
Search “roux-en-y gastric bypass”
=> 11,834 Articles
•Search “Roux-en-y gastric bypass”
+ “Malnutrition”
=> 481 articles
4% of All RNY Articles are on Malnutrition

Pubmed Searches:
A Simple Test
•Search “roux-en-y gastric bypass”
=> 11,834 Articles
•Search “Roux-en-y gastric bypass”
+ “Deficiency”
=> 514 articles
4% of All RNY Articles are on Deficiency

RNY Malnutrition
Sample Articles (There are > 400 More...)
1. Revisional surgery for severe protein-calorie malnutrition after Roux-
en-Y gastric bypass: Ceneviva R, Surg Obes Relat Dis. 2016
2. Endoscopic reversal of gastric bypass for severe malnutrition after
Roux-en-Y gastric bypass surgery. Ngamruengphong S, Gastrointest
Endosc. 2015
3. Risk of Malnutrition, Trace Metal, and Vitamin Deficiency Post Roux-
en-Y Gastric Bypass, Billeter A, Obes Surg. 2015
4. Malnutrition-induced myopathy following Roux-en-Y gastric bypass.
Hsia A, Muscle Nerve. 2001
+ 400 more...

RNY Malnutrition
Requiring “Feeding Tube”
• 3,487 pts
139 (3.9%) required a *Feeding Tube*
• Refractory malnutrition was the indication after RnY bypass
• Department of Surgery, University of Virginia Health System,
Charlottesville, Virginia
• Surg Obes Relat Dis. 2016 Feeding tube placement for
malnutrition
Charles EJ
•

Malnutrition and RNY
Reversal of Roux-en-Y
• 2017 IFSO President Himpens
• RNY side effects => reversal
•Dumping, hypoglycemia, Malnutrition, severe
diarrhea and excessive nausea and vomiting
• Obes Surg. 2017 Medium-Term Outcomes after Reversal of
Roux-en-Y Gastric Bypass. Arman G, Himpens J

Roux-en-Y gastric bypass reversal:
A Systematic Review
• 35 articles
• Malnutrition was the most common
indication for reversal
• Followed by severe dumping syndrome
(9.4%), postprandial hypoglycemia (8.5%),
and excessive weight loss (8.5%)
• Surg Obes Relat Dis. 2016 Roux-en-Y gastric bypass reversal, Shoar S

RNY Most Common Indication for TPN
J Parenter Enteral Nutr. 2017
• 54 pts (6.3%) had TPN post bariatric surgery.
• The most common procedure was
• Roux-en-Y gastric bypass (72%),
• Malnutrition the most common indication (57%).
• Weight at TPN 72 kg
• JPEN J Parenter Enteral Nutr. 2017 Home Parenteral Nutrition
in Bariatric Surgery- Malnutrition. Mundi M

Study Sleeve and RNY
Same Decrease in PreAlbumin
• Continuous decrease in prealbumin
•Mild protein depletion
38% of RNY
52% of Sleeve
• “RNY & Sleeve comparable effects in risk of micro-
nutrient and protein deficiencies”
• Obes Surg. 2016 Micro-nutrient and Protein Deficiencies After Gastric Bypass
and Sleeve Gastrectomy

Excessive Weight Loss Following Roux-en-Y
Obes Surg. 2016 Management of Excessive Weight Loss Following Roux-en-Y
• RNY Pts successfully reversed to normal
anatomy after evaluation, management,
and treatment by multidisciplinary team.
• Lowest BMI (kg/m(2)) was 14.2
• Obes Surg. 2016 Management of Excessive Weight Loss
Following Roux-en-Y Akusoba

SADI
Obes Surg. 2017 SADI: A Systematic Review
1/3
One out of 3 found to have
Malnutrition

SADI
A Systematic Review of Efficacy and Safety
• 12 studies including 581 SADI
• %EWL
70% @ 1 year
85% @ 2 years
• Malnutrition in up to
* 34% * of patients
• Obes Surg. 2017 Single Anastomosis Duodeno-Ileal Switch
(SADI): A Systematic Review of Efficacy and Safety.

But MOST Important
Evidence of Deep Misunderstanding
of
Simple Statistics
(Mean & Std. Deviation, Simple)

Simple Statistics Suggest Risk of
Malnutrition
• RNY/MGB/BPD,SADI
• Est. Mean %XsWtLoss = 72/78/82% (Roughly)
• Standard Deviation: 23/23/24%
• If we assume 120% Excess Weight Loss is
indicative of Malnutrition
• Mean + S.D. => Easy EXPECTED Malnutrition
• Expected Rate from Simple Statistics
for Band/Sleeve/RNY/MGB/BPB,SADI

RNY: Risk of Malnutrition/Excess Weight Loss
1. RNY Mean Excess Wt Loss: =
72% ** (Powerful)
2. Standard Deviation (S.D.) =
23%
3. Malnutrition/eXcessWL (MXWL)
= Loss of 120% XBL
4. RNY: Risk Malnutrition/eXcess
WL (MXWL) =
1.8% (Moderate Risk)

MGB (2M bypass): Risk of
Malnutrition/Excess Weight Loss
1. MGB (2M bypass) Mean
Excess Wt Loss: = 78% **
(More Powerful Surgery)
24%
= Loss of 120% XBL
4. MGB (2M bypass): Risk
Malnutrition/eXcess WL
(MXWL) = 3% (Higher Risk)
5. BUT MGB Can Be Tailored!

BPD/SADI etc: Risk of Malnutrition/Excess
Weight Loss
1. BPD/SADI etc Mean Excess Wt
Loss: = 82% ** (Very Powerful)
24%
= Loss of 120% XBL
4. BPD/SADI etc: Risk
(MXWL) = **6% (Highest Risk)

MGB: Unique
Offers the Surgeons Choice:
Choose More Power or Safety
The Surgeon, Family and Patient
Can choose an operation that
matches their situation

Simple Example of Expert Use of MGB
BP Limb Titration
•Power: BP Limb Length 200cm =
Excess Weight Loss ~ 1/100 patients
•Conservative: BP Limb Length 150cm =
Excess Weight Loss ~ 1/1,000 patients
•How to Use this Knowledge...

BP Limb Titration
• Patient: 50 y.o diabetic, Glucose 400mg, 400 units
Insulin, Blind in one eye losing site in the other.
Gangrene in two toes, s/p MI time 2, CVA and recent
TIA... Physician predict risk of impending death!
• Discuss options with the Pt & Family
• Might Choose Greater Power:
BP Limb Length 200cm =
Risk Excess Weight Loss ~ 1/100 patients

BP Limb Titration
• Patient: Young Female BMI 40 possible poor follow
up otherwise good health. + Vegetarian
• Discuss options with the Pt & Family
• Might Choose Conservative:
BP Limb Length 150cm =
Excess Weight Loss ~ 1/1,000 patients

•MGB Uniquely Qualified to Allow Patient and Surgeon
to Address Power & Surgery Risk
Modulating Risk of Malnutrition/Excess Weight Loss
Study Demonstrates Power and Risk of
Malnutrition/Excess Weight Loss
MGB Allows patient and surgeon to titrate operative
choices based upon preferences and secondarily to
easily address post op excess weight loss or
malnutrition

MGB Titrate Operative Choices
(1.5 vs 2.0 BP Limb)
• Similar this survey MGB surgeons have reported on
rates of Post Op Malnutrition and excess weight loss
requiring re-operation:
• Results: Risk of Malnutrition/Excess Weight Loss
• MGB BP Limb of 2 meters eXcess WL
requiring revision surgery 1%
• MGB BP Limb of 1.5 meters eXcess WL
requiring revision surgery 0.1%

MGB: Patient and Surgeon Choice
MGB with BP Limb of 2 meters for Maximal
weight Loss and approximately 1-3% risk of
excess weight loss
Or
MGB with BP Limb of 1.5 meters for Less
weight Loss and approximately 0.1% risk of
excess weight loss

Choosing Weight Loss Surgery (RNY) for
Malnutrition/Excess Weight Loss after MGB
17 patients underwent OLGB (MGB) conversion to
RYGB
Almost Half, 41%, developed major Complications
“The conversion of MGB to RNY is associated with
high morbidity”
Opinion: Do not Do Weight Loss Surgery for
Malnutrition/Deficiency After MGB
Surg Obes Relat Dis. 2017 Roux-en-Y gastric bypass for the treatment of severe complications after omega-
loop gastric bypass Poghosyan

Management of MGB
Excess Weight Loss
• Immediate Assess Nutritional Status/Resuscitation +
Early Surgical Revision (Do Not Delay)
• Classify Malnutrition/Deficiencies:
90% Severe/Sick:
Rx: Divide GJ + Gastro-gastrostomy (Op Time 30-60 min)
10% Mild:
Rx: Divide GJ + Shorten Bypass (Op Time 30-60 min)
• (Warning: Not RNY! Don't Do Weight Loss Surgery
for Excess Weight Loss/Malnutrition)

A More Detailed Explanation
Simple Statistics
Expected Weight Loss
vs
Risk Malnutrition

First: Patients Do Not Experience
MEAN Weight Loss!
• Many surgeons use the MEAN (Average)
to Judge the result
(i.e. Mean %Excess Weight Loss)
• While the MEAN is useful...
• It is like
looking at only one end of the Elephant
• And Sometimes it is the WRONG End

Problems with the MEAN
Patients
Do Not Lose
a Mean
Amount of
Weight

Weight and Metabolic Outcomes 12 Years
after *RNY* Gastric Bypass
• The mean unadjusted change from
baseline in body weight in the surgery
group was −46.8 kg
• (95% confidence interval, −48.0 to −45.5)
• 5% of RNY Pts lose > 100 lbs
• NEJM 2017

Mean % Weight
Loss
Some Sustained
Massive Weight
Loss
i.e. 300 lb/136 kg pt

Understanding Weight Loss
• It is Not Enough to Know the MEAN
weight loss
• You must understand the
SCATTER
• The Standard Deviation (Std. Dev., S.D.)

Understanding Weight Loss
1. First Simple Things
2. Then We'll Study Statistics
3. In Short:
Fear of Malnutrition
is Simple Lack of Basic Knowledge

Dr Rutledge's Study
4,000+ Patient Study
1. Longer bypass = More Weight Loss
2. Longer bypass = More Power (MeanXsWL)
3. More Power = Increased Risk of Excess Weight Loss
4. MGB is Unique “Tailored Operation”

Dr Rutledge's Study
4,000+ patients
1. Shorter bypass = Less Weight Loss
2. Shorter bypass = Less Power (Mean XsWL)
3. Less Power = Decreased Risk of Excess Weight Loss
4. MGB is Unique “Tailored Operation”

Conclusions
• More Bypass = More Weight Loss /
Increased Risk of Excess Weight Loss
• MGB is UNIQUE;
Surgeon, patient, family => Tailored Surgery
• Measuring the common channel / entire
bowel = NO improvement in Accuracy
(Std.Dev.)

The Goal of Weight Loss Surgery
Weight Loss

The Goal of Weight Loss Surgery:
Weight Loss, Of Course
But Not Too Much and
Not Too Little

Bariatric Weight Loss Surgery
• A History of Failure
• Jejuno-ileal Bypass
• Horizontal Gastroplasty
• Vertical Banded Gastroplasty
• Lap Band
• ? Sleeve/RNY/BPD etc.?

Judgment of Success or Failure
•Many Factors might be used to
judge the success or failure of
Weight Loss Surgery

Weight Loss
Because of Convenience and
Publications
For this presentation I will use:
% Excess Weight Loss (Imperfect)

Data Collection
Review of published series
Survey of participating Surgeons
For the purpose of this study Data Collection
Operation Type, %Excess weight loss
(Mean and Standard Deviation)

Reminders
Some
Basics:
Simple Statistics
1. Mean
2. Standard Deviation

Explanation: Mean
Mean = Power/Effectiveness of a Group of
results calculated average of the
measurements:
a calculated "central" value of a set of numbers.
To calculate: Just add up all the Measurements,
then divide by how many Measurements there
are.

Explanation: Standard Deviation
 Standard deviation is a number used to tell how
measurements for a group are spread out from the
average (mean), or expected value.
 A small standard deviation means that most of the
Measurements are very close to the average
(accurate)
 A high standard deviation means that the
Measurements are spread out (inaccurate)

“Normal Distribution”
A normal distribution, a bell
curve
Blue = Accurate Small SD
Red = Inaccurate Large SD
All normal distributions
look like a symmetric, bell-
shaped curve

Bell Shaped Curve Normal Distribution
• Red Powerful
Mean = 2.0
• Blue Weak
Mean = 0.4
• Red Accurate
SD = 0.5
• Blue Inaccurate
SD = 1.0

Mean, Normal Distribution, Standard Deviation

Percent XsWtLoss, SD = Accuracy
All Roughly the same!
Mean S.D.
Band 45% + 23%
Sleeve 58% + 24%
RNY 72% + 23%
MGB 78% + 22%
BPD/SADI82% + 24%

Review Survey/Review Percent XsWtLoss
Mean = Power, SD = Accuracy
Mean S.D.
Band 45% + 23%
Sleeve 58% + 24%
RNY 72% + 23%
MGB 78% + 22%
BPD/DS/SADI 82% + 24%

Survey/Review Percent XsWtLoss
Mean = Power, SD = Accuracy
Mean S.D.
Band 45% + 23%
Sleeve 58% + 24%
RNY 72% + 23%
MGB 78% + 22% Unique
BPD/SADI82% + 24%
MGB Can be Made
More or Less
Powerful based
upon Surgeon,
Patient and Family
preference by
modifying BP Limb
Length

Percent XsWtLoss, SD = Accuracy
All Roughly the same!
Mean S.D.
Band 45% + 23%
Sleeve 58% + 24%
RNY 72% + 23%
MGB 78% + 22%
BPD/SADI 82% + 24%
What Does this Mean?
It means all forms of Bariatric
Surgery vary in POWER
(Band<Sleeve<RNY<MGB<BPD-SADI)
But
All are roughly
Equally Inaccurate

Explanation of Weight and Malnutrition
1.Power of Bariatric Surgery = Mean
Excess Wt Loss
2. Accuracy = Std.Dev., “Spread” of the
Patients Weight Loss around the mean

1. To Explain malnutrition and Excess
Weight Loss
2. For this study
3. Define Malnutrition/eXcess WL (MXWL)
=
Loss of 120% of Excess Body Weight
(XsBW)

1.Then we can calculate
Risk of Malnutrition/eXcess WL (MXWL) for
each bariatric operation
2.Example;
Preop 300lbs XsWL 125% => 108 lbs
Preop 136kg XsWL 125% => 48.8kg

Calculating Risk of Malnutrition/Excess Weight Loss
1. Power of Bariatric Surgery = Mean Excess Wt Loss
2. Accuracy = Std.Dev., “Spread” of the Patients Weight
Loss around the mean
3. If we define Malnutrition/eXcess WL (MXWL) =
Loss of 120% of Excess Body Weight (XBW)
4.Then we can calculate risk of Malnutrition/eXcess WL
(MXWL) for each bariatric operation
5.Example; Preop 300lbs XsWL 125% => 108 lbs
Preop 136kg XsWL 125% => 48.8kg

Example: SADI
High Power (Mean)
+ 25% Standard Deviation
=>
Increased Risk Malnutrition
Simple:
More Powerful Surgery
=>
More Risk of Malnutrition

SADI-XWL-Mean: Mean Excess Weight Loss
Almost 10% Excess Weight Loss (7.5%)
SADI/BPD
Mean XsWL: 84%

Lap Band:
**VERY LOW** Risk of Malnutrition
1. Lap Band Mean Excess Wt
Loss: = 45% ** (WEAK)
23% (Usual)
= Loss of 120% XBL
4. Band: Risk
(MXWL) = 0.06% Very Low!

Sleeve:
1. Sleeve Mean Excess Wt Loss:
= 58% ** (Power Moderate)
24%
= Loss of 120% XBL
4. Sleeve: Risk
(MXWL) = 0.5% (Low Risk)

•Op Est. Risk Xs Wt Loss
• Band 0.06%
• Sleeve 0.5%
• RNY 1.8%
• MGB (2M bypass) 3%
• BPD/SADI 6%
Two Important Points to Note:
1.MGB with 2 meter (6 foot
Bypass)
2.BPD/SADI etc
NO More Accurate
than other operations that
DO NOT MEASURE THE
COMMON CHANNEL

1. The Power (Mean XWL)
varies by procedure (B<S<R<M<Bpd)
Std.Dev. stays roughly the same
(B=S=R=M=Bpd)
2. Greater power => INCREASED
Risk Malnutrition/Excess Weight
Loss
(B 0.06%<S 0.5%<R 1.8%<M 3%<Bpd 6%)
Two Important Points to Note:
1.MGB with 2 meter
(6 foot Bypass)
2.BPD/SADI etc
NO More Accurate
than other operations that
DO NOT MEASURE THE
COMMON CHANNEL

ASSOCIATION OF BYPASS LIMB
LENGTH AND ONE YEAR WEIGHT
LOSS IN 4,114 MINI-GASTRIC BYPASS
PATIENTS
Dr Rutledge, Know this Since 2011
Poster Number: P.185,
Your Presentation takes place: Date: 01.09.2011,
Session: P8 / GASTRIC BYPASS / 16.00-17.00

BP Limb & Weight Loss: Results
• Weight loss following MGB followed a logarithmic
decline though the end of the first year and then
leveled off.
• Bypass limb length varied from
0.5 - 3 meters.
• Weight loss Increases as
Bypass limb length Increase

BP Limb & Weight Loss: Results
• A multivariate regression model using bypass
length and Preop weight improved the predictive
value of the model,
• Wt Loss = 13.04 + Bypass*6.98 +
Pre Op Wt * 0.25
• (Fig. 2, p<0.0001, r2= 0.38)

The Myth of the Common Channel

Myth of the Common Channel
Measuring the Common Channel will improve
the outcomes (accuracy of weight loss)
following bariatric surgery
1.No supporting evidence
2.This study shows procedures/surgeons using
the common channel DO NOT improve weight
loss accuracy

Preliminary Conclusions
1. Bariatric Operation based on published reports and
survey data are more or less powerful
Band < Sleeve < RNY < MGB < = BPD/SADI etc
2. All Bariatric Procedures studied are roughly equally
accurate/inaccurate
3. Measuring the Common Channel as part of bypass
operation does NOT appear to improve or affect
Accuracy of Bariatric Procedures

•Obes Surg. 2016 Mar;26(3):701-3. doi:
10.1007/s11695-015-2017-8.
•Laparoscopic Conversion of One
Anastomosis Gastric Bypass to Roux-en-Y
Gastric Bypass for Chronic Bile Reflux.
•Facchiano E1, Leuratti L2, Veltri M2,
Lucchese M2.

• Abstract
• BACKGROUND:
• One anastomosis gastric bypass (OAGB) demonstrated similar results to traditional Roux-en-Y procedures. A possible concern
is how to manage a chronic bile reflux when medical therapy results ineffective. Revision of the gastro-jejunal anastomosis,
obtaining a Roux-en-Y reconstruction, has already been proposed, but technical details have not been elucidated yet. This video
shows how to revise a 200-cm OAGB to treat chronic bile reflux, by converting the procedure to Roux-en-Y, having a short
gastric pouch and a long efferent limb.
• METHODS:
• A 51-year-old patient complained of recurrent heartburns 2 months after OAGB. A gastroscopy witnessed the presence of a 6-cm
long gastric pouch with pouchitis and bile reflux in esophagus. Specific medications were ineffective. He underwent a revisional
laparoscopic procedure. The efferent limb was measured and consisted of 650 cm. The afferent limb was then divided next to the
previous gastro-jejunal anastomosis and a jejuno-jejunal anastomosis was performed distally at 70 cm on the alimentary limb.
• RESULTS:
• Total operative time was 50 min. The postoperative stay was uneventful and the patient was discharged in postoperative day four.
At 6 months follow-up he is still free of medications without symptoms.
• CONCLUSIONS:
• The ideal scenario for the presented technique is the finding of a long efferent limb, in order to fashion a Roux-en-Y limb without
the risk of postoperative malabsorption. To reach this goal, we suggest the measurement of the whole small bowel intra-
operatively, in order to assess the length of the common channel left in place.

Kular To Tailor or Not to TailorMost Important to UNDERSTAND: BP Limb Length and Outcomes

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