Marginal Ulcer after Gastric Bypass; RNY & MGB
Marginal ulcers RNY ranging from 0.6 to 16%
True incidence is very likely much higher
Csendes prospective study routine postoperative endoscopic evaluation
28% of marginal ulcers were asymptomatic
Gastric Bypass (RNY & MGB)HIGH incidence of Marginal Ulcer
BILE MAKES NO DIFFERENCE!!!
Understant what is obesity and Bariatric Surgery, what are the risk factors and how to overcome on the it. For more information visit at http://gisurgery.info
Understant what is obesity and Bariatric Surgery, what are the risk factors and how to overcome on the it. For more information visit at http://gisurgery.info
Carcinoma esophagus is the common cause for dysphagia for solids. These patients usually present too late to do any definitive curative surgical procedure.
colorectal cancer, epidemiology, risk factors, sign and symptom,
pathophysiology, complications, assessment and diagnostic findings, medical and nursing interventions
Bariatric surgery is gaining popularity worldwide. The number of surgeries has increased by almost 10 times in the last decade and almost 14000 bariatric surgery were performed last year in India.
Breast Conserving Surgery in Hyderabad | Breast Cancer Treatment in HyderabadYashodaHospitals
Breast-conserving Surgery is also known as lumpectomy or partial lumpectomy, it is a procedure to remove the cancer from the breast and some normal tissue. BCS involves only the part of the breast that has cancer to be removed. BCS is a good option for many women with early-stage cancers. Usually after BCS, radiation therapy is given to destroy cancer cells that may not have been removed during surgery. In some cases, chemotherapy and radiation are both given after BCS.
Who is BCS recommended for?
Not all women with breast cancer are candidates for BCS. However, speak to a doctor to find out whether BCS is an option for you.
BCS might be a good option for the below reason:
1. If the tumor is small and localized.
2. If you are eligible for radiation therapy
3. Do not have inflammatory breast cancer
4. Are not pregnant or, if pregnant, will not need radiation therapy immediately.
5. Do not have a mutation linked to breast cancer.
6. Do not have serious connective tissue diseases such as scleroderma or lupus.
Soft tissue sarcomas, treatment (surgical, radiation, chemotherapy)Joseph A. Di Como MD
A PowerPoint presentation for medical professionals regarding soft tissue sarcomas, likely most helpful to surgical residents and medical students. Gist tumors, liposarcomas, retroperitoneal sarcomas extremity, breast sarcoma and vascular sarcomas
Master of Surgery thesis by Dr Sanjoy Sanyal in JIPMER Pondicherry India, under guidance of Dr R. B. Mehta.
Shows some causative factors of recurrent inguinal hernia following Bassini-type of repair, and illustrates some steps of repair of recurrent inguinal hernias without using prosthetic materials.
Recurrent Hernia: A surgical challenge
Following slides show Pathology and Pathophysiology of Recurrences
Especially following previous Bassini-type of Inguinal Hernia repair
Recurrences are classified as Medial / Lateral depending on their relation to Inferior Epigastric Artery
Last few slides show repair techniques without using prosthetic material
The Americal Association for the Surgery of Trauma - guidelines for intestinal injury- grading and a brief description of duodenal injury and few Most common Questions
Safe Laparoscopic Cholecystectomy Techniques that are discussed here are based on current literature and Evidence Based Medicine guidelines and reviews.
Carcinoma esophagus is the common cause for dysphagia for solids. These patients usually present too late to do any definitive curative surgical procedure.
colorectal cancer, epidemiology, risk factors, sign and symptom,
pathophysiology, complications, assessment and diagnostic findings, medical and nursing interventions
Bariatric surgery is gaining popularity worldwide. The number of surgeries has increased by almost 10 times in the last decade and almost 14000 bariatric surgery were performed last year in India.
Breast Conserving Surgery in Hyderabad | Breast Cancer Treatment in HyderabadYashodaHospitals
Breast-conserving Surgery is also known as lumpectomy or partial lumpectomy, it is a procedure to remove the cancer from the breast and some normal tissue. BCS involves only the part of the breast that has cancer to be removed. BCS is a good option for many women with early-stage cancers. Usually after BCS, radiation therapy is given to destroy cancer cells that may not have been removed during surgery. In some cases, chemotherapy and radiation are both given after BCS.
Who is BCS recommended for?
Not all women with breast cancer are candidates for BCS. However, speak to a doctor to find out whether BCS is an option for you.
BCS might be a good option for the below reason:
1. If the tumor is small and localized.
2. If you are eligible for radiation therapy
3. Do not have inflammatory breast cancer
4. Are not pregnant or, if pregnant, will not need radiation therapy immediately.
5. Do not have a mutation linked to breast cancer.
6. Do not have serious connective tissue diseases such as scleroderma or lupus.
Soft tissue sarcomas, treatment (surgical, radiation, chemotherapy)Joseph A. Di Como MD
A PowerPoint presentation for medical professionals regarding soft tissue sarcomas, likely most helpful to surgical residents and medical students. Gist tumors, liposarcomas, retroperitoneal sarcomas extremity, breast sarcoma and vascular sarcomas
Master of Surgery thesis by Dr Sanjoy Sanyal in JIPMER Pondicherry India, under guidance of Dr R. B. Mehta.
Shows some causative factors of recurrent inguinal hernia following Bassini-type of repair, and illustrates some steps of repair of recurrent inguinal hernias without using prosthetic materials.
Recurrent Hernia: A surgical challenge
Following slides show Pathology and Pathophysiology of Recurrences
Especially following previous Bassini-type of Inguinal Hernia repair
Recurrences are classified as Medial / Lateral depending on their relation to Inferior Epigastric Artery
Last few slides show repair techniques without using prosthetic material
The Americal Association for the Surgery of Trauma - guidelines for intestinal injury- grading and a brief description of duodenal injury and few Most common Questions
Safe Laparoscopic Cholecystectomy Techniques that are discussed here are based on current literature and Evidence Based Medicine guidelines and reviews.
Fear of Gastric Cancer \ Bile Reflux
Rational vs. Reptilian Brain Decision Making
Fear of Gastric Cancer \ Bile Reflux
Rational vs. Reptilian Brain Decision Making
Rational Data Analysis vs.Irrational FEAR Gastric Cancer
1. Gastric Cancer Declining Rapidly
2. GC Environmental Causes; Easily Prevented
3. Some studies show Small Increased Risk Probably from Ulcers / H. Pylori
4. Many large studies: NO increased risk
5. Endoscopic Screening: Not Recommended
6. General, Trauma & Oncologic Surgeons Use Billroth II
Presentation; Discussion of Herd Behaviour is Erroneous Human Decision Making; PROACT Decision Making Tool; 30 Point Multi-Dimensional assessment tool; Selection of the Best Bariatric Surgey; Discussion of the Lack of Risk of Gastric Cancer and the Billroth II
Surgeons' Confusion &Misunderstanding the MGB:Bile, Bile Reflux, Bile Reflu...Dr. Robert Rutledge
Surgeons' Confusion &Misunderstanding the MGB:Bile, Bile Reflux, Bile Reflux Gastritis, Acid Peptic Gastritis & Marginal Ulcer Following Billroth II / MGB; Correct Management of Dyspepsia
Comparison of Revision in Roux-en-Y vs Mini-Gastric BypassDr. Robert Rutledge
Comparison of Revision in
Roux-en-Y vs
Mini-Gastric Bypass
Dr K S Kular
Kular Medical Education & Research Society
Kular Group of Institutes
drkskular@gmail.com
www.kularhospital.com
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
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
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.
Understanding Weight Loss After Bariatric SurgeryUnderstanding the Bilio-Pancreatic Limb Length
Statistics, Random Distribution and Too Little or Too Much of a Good Thing
The Billroth II is a good safe operation
Routinely used daily by General, Trauma and Cancer Surgeons Around the world
Studies show surgeons who are more fearful of Billroth II and cancer are the least knowledgeable about the scientific data on the Billroth II and Gastric Cancer
3. SUCCESS CRITERIA
"IDEAL" WEIGHT LOSS SURGERY
1. Low Risk
2. Major Weight Loss
3. Easily performed
4. Short operative times
5. Outpatient or short hospital stay
6. Minimal Blood Loss
7. No Need for ICU Stay
8. Minimal Pain
9. Very High Patient Satisfaction
10. A Good "Exit Strategy"
4. SUCCESS CRITERIA
"IDEAL" WEIGHT LOSS SURGERY
11. Change Behavior & Preferences; Marked Decrease in
Hunger and Increased Satiety
12. Minimal Retching and Vomiting
13. Few adhesions or hernias
14. Minimal impact on Heart and Lung Function
15. Low Failure Rate
16. Low Cost
17. Short Recovery Time
18. Rapid Return to Work
19. Low Risk of Pulmonary Embolus
20. Durable weight loss
5. SUCCESS CRITERIA
"IDEAL" WEIGHT LOSS SURGERY
21. Low Risk of Marginal Ulcer
22. Fat Malabsorption; low cholesterol & CV risk
23. No Plastic Foreign Body
24. Easily Verifiable Results; > 10 years of Results
25. Low Risk of Bowel Obstruction
26. Based upon sound surgical principles
27. Independent confirmation of results
28. Healthy life after surgery
29. Supported by LEVEL I Evidence; RCT (Controlled
Prospective Randomized Trial)
30. Block “Sweet Eater” Failures
11. Epidemiology: What do we know about
Marginal Ulcers?
Marginal ulcers represent one of the most problematic
postoperative complications following Roux-en-Y
A marginal ulcer, or stomal ulceration, refers to the
development of mucosal erosion at the gastrojejunal
anastomosis, typically on the jejunal side.
incidence of marginal ulcers is 0.6 to 16 %
The true incidence is very likely much higher
12. Marginal Ulcer has been known since the
beginning GI Surgery
MARGINAL, GASTROJEJUNAL OR PEPTIC ULCER
SUBSEQUENT TO GASTROENTEROSTOMY.
Erdmann JF.
Ann Surg. 1921 Apr;73(4):434-40.
13. Marginal Ulcer has been known since the
beginning GI Surgery
THE ROENTGEN DIAGNOSIS AND LOCALIZATION
OF MARGINAL PEPTIC ULCER.
Carman RD.
Cal State J Med. 1920 Nov;18(11):377-82
14. Marginal Ulcer has been known since the
beginning GI Surgery
Re-evaluation of the role of the pyloric antrum in
marginal peptic ulcers.
SCHILLING JA, PEARSE HE.
Surg Gynecol Obstet. 1948 Aug;87(2):225-34
15. Marginal Ulcer has been known since the
beginning GI Surgery
Vagotomy as a treatment for marginal ulcer.
CRILE G Jr, BROWN GM Jr.
Gastroenterology. 1951 Jan;17(1):14-9
16. Marginal Ulcer has been known since the
beginning GI Surgery
Review Article: The present status of the management
of marginal ulcer.
BYRD BF Jr.
J Tn State Med Assoc. 1953 Feb;46(2):56-8.
17. Marginal Ulcer has been known since the
beginning GI Surgery
2,282 RYGB
122 (5%) Marginal ulcers
39 (32%) Surgery
Surg Obes Relat Dis. 2009 May-Jun;5(3):317-22. Revisional operations for marginal ulcer
after Roux-en-Y gastric bypass. Patel RA, Brolin RE, Department of Surgery, University
Medical Center at Princeton, Princeton, New Jersey 08536
18. Marginal Ulcer Very High After RNY Gastric
Bypass
441 RYGB
10 (12%) of RNY gastric bypass presented an "early"
marginal ulcer
Asymptomatic (28%)
Obes Surg. 2009 Feb;19(2):135 Incidence of marginal ulcer 1 month and 1 to 2 years after
gastric bypass: a prospective consecutive endoscopic evaluation of 442 patients with morbid
obesity. Csendes A et al Department of Surgery, University Hospital, University of Chile,
Santiago, Chile.
19. Marginal Ulcer Very High After RNY Gastric
Bypass
Associated with H. Pylori
260 RYGB
7% of RNY gastric bypass marginal ulcer
H. pylori infection, (treated), was twice as common
marginal ulceration (32%) as among those who did not
(12%)
Surg Endosc. 2007 Jul;21(7):1090-4. Marginal ulceration after laparoscopic gastric bypass:
an analysis of predisposing factors in 260 patients. Rasmussen JJ, Department of Surgery,
University of California, Davis, 2221 Stockton Boulevard, Sacramento, CA 95817, USA
20. Marginal Ulcer after Gastric Bypass;
Both RNY & MGB
Marginal Ulcers after Roux-en-Y Gastric Bypass:
Pain for the Patient…Pain for the Surgeon
by Camellia Racu,
January 2010
Bariatric Times.
2010;7(1):23–25
22. Marginal Ulcer after Gastric Bypass;
RNY & MGB
Marginal ulcers RNY ranging from 0.6 to 16%
True incidence is very likely much higher
Csendes prospective study
routine postoperative endoscopic evaluation
28% of marginal ulcers were asymptomatic
Gastric Bypass (RNY & MGB)
HIGH incidence of Marginal Ulcer
BILE MAKES NO DIFFERENCE!!!
23. Incidence of perforated gastrojejunal
anastomotic ulcers after RNY
April 2002 to April 2010, 1213 patients underwent
laparoscopic RYGB
Operative mortality was .15%
10 perforated GJA ulcers (.82%) at a mean of 13.5
(6-19) months
Morbidity and mortality rate was 30% and 10%
Perforated GJA ulcers can develop in 1 of 120 Roux
en Y Gastric Bypasses & DEADLY
24. Marginal Ulcers:
Achilles Heel of Gastric Bypass
Management
1. Warn Patients & Surgeon “Be Vigilant”
2. Aggressive anti-H. Pylori Rx
3. Aggressive use of Antacids
4. Strict Avoidance of Ulcerogenic Agents
(NSAIDS, Etoh, Smoking, Coffee, Soda, Nitrates)
5. Encourage: Probiotics, Yogurt, Fruits Vegetables
BILE MAKES NO DIFFERENCE!!!
25. CONCLUSIONS:
Best Choice: Mini-Gastric Bypass
•Choice of Obesity Surgery
•Objectives “Ideal” Weight Loss Surgery
•RNY, Band, Sleeve, MGB
•MGB Best meets all objectives/success criteria
•Beware of Marginal Ulcer in RNY & MGB
•Rational Decision Making:
Best Choice; Mini-Gastric Bypass