1. Marginal Ulcer & Gastric Bypass

4. 2 Years Cardiac Surgery National Institutes of Health National Heart Lung Blood Institute

5. 20 years University of NC; Professor of Surgery, Associate Chief of Staff, Director of Section Medical Informatics, Director North Carolina Trauma Registry

7. Experience: Trauma Surgery, Director NC Trauma Registry

8. Peptic Ulcer Surgery; Vagotomy & Pyloroplasty; Antrectomy & Billroth II

9. Bariatric Surgery 33 years: Open RNY & Vertical Banded Gastroplasty

10. 1997 one first surgeons laparoscopic RNY

13. USA 001-702-714-0011 DrR@clos.net

14. Personal Visit: Dr. Rutledge Visiting Professor: France, Turkey, Austria & India, Upcoming visits Greece, Istanbul, United KingdomCzech Republic, Italy, Germany, UAE, Pakistan,

15. Please Use the Knowledge of Others Before You Start;Experience; over 14 years, over 6,000 patients

17. Hands On Surgery (with approval) Scrub in on cases Assist and Participate in MGB Surgery

18. This Fall and Next Year

19. Bija India, Dr Rutledge & Dr Kular

21. The Gastric Sleeve:Not as Bad as the BandNot as Dangerous as the RNY

22. 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"

23. 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

24. 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

26. Vertical Gastric Tube(Collis Gastroplasty)

28. 16,000 Billroth II’sUSA in 2007

30. Criteria for Success; Ideal Weight Loss Surgery

31. Criteria for Success

32. 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

33. Marginal Ulcer has been known since the beginning GI Surgery MARGINAL, GASTROJEJUNAL OR PEPTIC ULCER SUBSEQUENT TO GASTROENTEROSTOMY. Erdmann JF. Ann Surg. 1921Apr;73(4):434-40.

34. 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

35. 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. SurgGynecol Obstet. 1948 Aug;87(2):225-34

36. 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

37. 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.

38. Marginal Ulcer has been known since the beginning GI Surgery 2,282 RYGB 122 (5%)Marginal ulcers 39 (32%) Surgery SurgObesRelat Dis. 2009 May-Jun;5(3):317-22. Revisionaloperations 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

39. Marginal Ulcer Very High After RNY Gastric Bypass 441 RYGB 10 (12%)of RNY gastric bypass presented an "early" marginal ulcer Asymptomatic (28%) ObesSurg. 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 Aet al Department of Surgery, University Hospital, University of Chile, Santiago, Chile.

40. Marginal Ulcer Very High After RNY Gastric BypassAssociated 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%) SurgEndosc. 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

41. 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

42. Marginal Ulcer after Gastric Bypass; RNY

43. Marginal Ulcer after Gastric Bypass; RNY & MGB Marginal ulcers RNYranging from 0.6 to 16% True incidence is very likely much higher Csendesprospective study routine postoperative endoscopic evaluation 28% of marginal ulcers were asymptomatic Gastric Bypass (RNY & MGB)HIGH incidence of Marginal Ulcer BILE MAKES NO DIFFERENCE!!!

44. 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

45. 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!!!

47. Objectives “Ideal” Weight Loss Surgery

48. RNY, Band, Sleeve, MGB

49. MGB Best meets all objectives/success criteria

50. Beware of Marginal Ulcer in RNY & MGB

52. 100,000’s of people already have and are living with and are getting the Billroth II every day

54. Why haven’t concerned bariatric surgeons stepped forward to start a fund to help suffering Billroth II patients get needed conversions of their surgery to Roux-en-Y?

56. Why haven’t concerned bariatric surgeons stepped forward to national funding for lifetime endoscopic screening of Billroth II patients to find dreaded gastric cancers?

57. It seems odd doesn’t it?

59. The critics of the MGB do not do those things because they are ridiculous

60. Such actions are Not supported by the data

61. The Billroth II and the MGB are both good operations

64. 2. GC Environmental Causes; Easily Prevented

65. 3. Some studies show Small Increased RiskProbably from Ulcers / H. Pylori

66. 4. Many large studies: NO increased risk

67. 5. Endoscopic Screening: Not Recommended

68. 6. General, Trauma & Oncologic Surgeons Use Billroth II