Mgb mechanism of action

Understanding the
Mechanism of Action of
the Mini-Gastric Bypass

The MGB is NOT
the
“Single Anastomosis Bypass”
• The crital component of the MGB
IS NOT the single anastomosis
• Error in Naming Demonstrates
• Misunderstanding the MGB

MGB Criticisms by
2000 American Surgeons
• I did not take out the gallbladder
• It was not retro colic/ retro gastric
• The MGB = Old Mason GBP and
All would suffer Bile Reflux Esophagitis
• Billroth II causes cancer
• The Pouch and the Gastro-j were too big
and the patients would not lose weight
• I used Email!, I had a website

Almost 20 Years Later
Surgeons Still Misunderstand
the MGB
• The MGB is NOT a
RNY with One Less Anastomosis
• You Cannot Understand the Anatomy of
the MGB (Surgical Technique)
• Unless you understand the
Mechanism of Action

The Name
• Misunderstanding:
MGB is Nothing more than RNY with
One Less Anastomosis
• **Wrong**
• This erroneous thinking lead to the
renaming of the MGB to
• Single Anastomosis Bypass
• Lets Explain the misunderstanding
• MGB - RNY are not the same

The MGB: Summary of Dog and Human Studies
Demonstrating the Difference and Advantages
• MGB Non-Obstructive 75% Decrease in
Food Intake
• BP Limb length Best length shorter than
BPD and longer than RNY
~ 30% BP Limb => Fatty Food Intolerance
and Malabsorption to large fatty meals
• Billroth II with Wide Anastomosis
CRITICAL for effectiveness
• Dozens of Studies of General Surgery ...

The MGB: Summary of Dog and Human Studies
Demonstrating the Difference and Advantages
• Unless you understand the
MGB Mechanism of Action
YOU WILL NOT DO THE MGB RIGHT
• MGB => Induces the Well Know and
Understood “Post Gastrectomy Snydrome”
• MGB Pts Can eat
BUT NOT sweets, liquid calories, junk
food or Fatty Foods
• Post Gastrectomy Syndrome Diet

End Here!
Two Choices
1. Research Documenting MGB
Mechanism of Action
2. MGB Surgical Technique

Summary: RNY vs MGB
• RNY ** Highest Rate of Complications (Band/Sleeve/MGB)
** Most Difficult to Revise
** Not Easily Tailored to Patient Factors
** Obstructive Restriction => Liquid Calories => Failure
(Weight Regain)
** Internal Hernia
• MGB ** Easier lower risk complications
** More Powerful than Band/Sleeve/RNY
** Easily revised
** Easily tailored to patient factors (Thin diabetic)
** NON-Obstructive Restriction ++ Fatty Food Intolerance
** Low Risk Internal Hernia

Summary: RNY vs MGB
• Roux-en-Y Gastric Bypass
• Highest Rate of Complications
(Band/Sleeve/MGB),
• Most Difficult to Perform/Revise,
• Not Easily Tailored to Patient Factors,
• ** Obstructive Restriction (Pathologic Eating)
=> Liquid Calories
=> Failure (Weight Regain)
• Internal hernia/SBO Death

Summary: RNY vs MGB
(Only in Well Trained Hands)
• MGB: Lower risk complications
(Published Paper & Prospective Trials)
• More Powerful than Band/Sleeve/RNY
• Easily Performed/Revised,
• Easily tailored to patient factors
(Thin diabetic),
• **NON-Obstructive Restriction
++ Fatty Food Intolerance
Forces Patient => Mediterranean Diet
• ** Low Risk Internal Hernia SBO

Surgical Procedures
Rx Obesity / Diabetes
• 2 Mechanisms of Action &
History of Failure
• Restriction / OBSTRUCTION
– Vertical Banded Gastroplasty
– Lap Band
– Sleeve
– Roux-en-Y
• Malabsorption
– BPD / Duodenal Switch / SADI

Bariatric Surgical Procedures
Problems
– Vertical Banded Gastroplasty: (Abandoned)
Failed Weight Regain
– Lap Band: (Abandoned)
– Sleeve: (Worrisome New Data)
Failed Weight Regain vs Failed GE Reflux
– Roux-en-Y: (Highest Complications Risk)
Weight regain,
– BPD / Duodenal Switch / SADI: Malnutrition,
Deficiencies, Diarrhea, Foul Smelling Gas

OBSTRUCTIVE Restrictive
Procedures (RNY)
• Mechanism of Action & Failure
• Weight Loss induced by
High Grade Narrowing (Stricture) = Obstruction
Normal Healthy Food
(i.e. Broccoli, Sandwich, Apple etc.) => Vomiting
• Induces “Pathologic Eating”
(i.e. Coca Cola, Soda, “Soft Calories”, Candy,
Ice Cream, etc.)
=> Failure: Weight Regain

What is Roux-en-Y Gastric Bypass?
Restriction + Duodenal Exclusion
• Roux-en-Y Gastric Bypass
both (?)
• OBSTRUCTIVE
Restriction
• Minimal
=> Fatty Food Intolerance
=> Fat Malabsorption

OBSTRUCTIVE Restrictive
Procedures
• Successfully Block
Normal Healthy Diet
But
• They DO NOT BLOCK ...
Liquid / Soft Calories
and “Junk Food”

“The contribution of
Malabsorption to the reduction in
net energy absorption after
long-limb
Roux-en-Y gastric bypass”
Elizabeth A Odstrcil, et al
October 2010 vol. 92 no. 4 704-713

The contribution of Malabsorption to the reduction in net
energy absorption after long-limb Roux-en-Y gastric bypass
• Results:
• RNY:
• No significant effect on
• Protein or Carbohydrate
absorption
• “The contribution of Malabsorption to the reduction in net energy
absorption after long-limb Roux-en-Y gastric bypass”, Elizabeth A
Odstrcil, et al. Am J Clin Nutr October 2010 vol. 92 no. 4 704-713

RNY Mechanism =
Obstructive Restriction
• 5 months after bypass,
• Malabsorption 124 kcal/d
• Obstructive Restriction of food intake
reduced energy absorption by 2,062 kcal/d
• Restriction ALMOST 20 times more
important than Malabsorption
• The contribution of Malabsorption to the reduction in net energy absorption
after long-limb Roux-en-Y gastric bypass, Elizabeth A Odstrcil, et al. Am J
Clin Nutr October 2010 vol. 92 no. 4 704-713

RNY = Obstructive Restriction
• 14 months after bypass caloric intake
increasing!!
• Restriction of food intake reduced
energy absorption by 1,418 kcal/d
• Restriction Already Beginning to Fail
• The contribution of Malabsorption to the reduction in net energy absorption after long-limb Roux-en-Y gastric bypass, Elizabeth A Odstrcil,
et al. Am J Clin Nutr October 2010 vol. 92 no. 4 704-713

RNY OBSTRUCTIVE Restriction
• RNY: Is Primarily a
“Restrictive Procedure”
based upon
• Small Pouch and “Tight” Gastro-
jejunostomy
• Study Shows: RNY Early signs of
RNY caloric restriction failure
• The contribution of Malabsorption to the reduction in net energy absorption after long-
limb Roux-en-Y gastric bypass, Elizabeth A Odstrcil, et al. Am J Clin Nutr October
2010 vol. 92 no. 4 704-713

Bariatric Surgeons Forget
History of GI Surgery
What have we learned from
100 years of GI Surgery?

MGB = Post Gastrectomy
=> Sweets + Fatty Food Intolerance
• It’s Just General Surgery!
• For over 75 years
• Sweet + Fatty food intolerance common
“Post Gastrectomy Syndrome”
• More common & Greater degree with
• Billroth II >> Billroth I
• EVERSON TC. Experimental comparison of protein and fat assimilation after Billroth II, Billroth I,
and segmental types of subtotal gastrectomy. Surgery. 1954 Sep;36(3):525-37
• MACLEAN LD, PERRY JF, KELLY WD, MOSSER DG, MANNICK A, WANGENSTEEN OH.
Nutrition following subtotal gastrectomy of four types (Billroth I and II, segmental, and tubular
resections). Surgery. 1954 May;35(5):705-18
• WOLLAEGER EE, WAUGH JM, POWER MH. Fat-assimilating capacity of the gastrointestinal
tract after partial gastrectomy with gastroduodenostomy (Billroth I anastomosis).
Gastroenterology. 1963 Jan;44:25-32
• …

100 Years of GI Surgery:
Sweets + Fatty Food Intolerance Gastric Operations:
• What do we know:
Sweets/Fatty Food Intolerance
• “Rare after gastro-jejunostomy or
vagotomy alone.
• “Rare after RNY, Billroth I
• “Especially Common after
Polya type Billroth II
• (**Butler, 1961**)

Polya Type Gastro-Jejunostomy
(HELLO; MGB Not RNY)
NOTE:
Large
Wide Open
Gastro-
jejunostom
y

Bariatric Surgical Procedures
Problems
– Vertical Banded Gastroplasty: (Abandoned)
– Lap Band: (Abandoned)
– Sleeve: (Worrisome New Data)
Failed Weight Regain vs Failed GE Reflux
– Roux-en-Y: (Highest Risk Complications)
Weight regain,
– BPD / Duodenal Switch / SADI: Malnutrition,
Deficiencies, Diarrhea, Foul Smelling Gas

OBSTRUCTIVE Restrictive Procedures:
Mechanism of Action & Failure
• Mechanism of Action & Failure
• Weight Loss induced by
High Grade Narrowing (Stricture) =
Obstruction of Normal Healthy Food
(i.e. Broccoli, Sandwich, Apple etc.) => Vomiting
• Induces “Pathologic Eating” (i.e. Coca Cola,
Soda, “Soft Calories”, Candy, Ice Cream, etc.)
=> Failure: Weight Regain

Selecting an Operative Procedure
Safety and Effectiveness
Personal Experience, Animal Models, Expert Judgment,
Published Data and Controlled Prospective Randomized
Trials all show:
MGB is More Effective than Sleeve RNY
MGB is Safer than Sleeve RNY
BUT ONLY IN
WELL TRAINED HANDS!

Why the Band/Sleeve/RNY
Fail
All OBSTRUCTIVE Restrictive Procedures
Stricture: Block “Healthy Foods”
Induce Intake of Sweets,
"Liquid Calories" &
“Junk Food”

Pathologic Dietary Choices
Calories:
Ice Cream 200g/540 cal,
2 Milky-way Bars, 1,000 cal
2 L Bottle Coke 830 cal
Total: 2,370 cal

RNY Creates Sweet/Junk Food Eaters
• All OBSTRUCTIVE Restrictive Procedures
(Including RNY) MAKE SWEET EATERS:
• Mechanical Block of
Normal Healthy Foods
• Early Weight Loss: Honeymoon +/- 2 years
• Then Failure Weight Regain
• Why is there a growing chorus in favor of
“Banding” the RNY?

Band, Sleeve, RNY
Block Normal Healthy Foods
• Weight Loss =>
• Increased Hunger
• Decreased Satiety
• Healthy Foods Blocked
• Drive to Eat Increased
• What Happens?

What About the MGB
Re: Restriction & Obstruction

Mini-Gastric Bypass (MGB):
Surgical Rx of Obesity / Diabetes
1. NON-Obstructive Restriction
2. Fatty Food Intolerance w
3. Minimal Malabsorption
4. Decreased Hunger
Enforced Healthy Mediterranean Diet

Mini-Gastric Bypass Decreases Hunger
Dr Rutledge's Survey 2,783 Pts

Post Gastrectomy Symptoms
• Metabolic aberrations
• Dumping syndrome
• 1. Loss of stomach volume and
• 2. Loss of Pyloric sphincter >>
Rapid Gastric Emptying into small bowel
• 2 types
– Early
– Late

Early Dumping syndrome
• Onset in 15 to 30 min
• Rapid shift extracellular fluid into SB
(rapid passage and hyperosmolarity)
>> acute distension >> Autonomic Sx
• Most Common *** B II reconstruction ***
• GI Sxs : N/V, Fullness, Cramping & Diarrhea
• CVS : palpitation, tachycardia, diaphoresis

Late Dumping syndrome
• Carbohydrate load in diet to the stomach
• >> rapid gastric emptying pass to SB
• >> hyperglycemia
• >> insulin over shoot
• >> cathecholamines stimulation
• Sx: Mild to severe
weakness, sweating, and dizziness

Post-Gastrectomy Diet
• Relax at mealtimes,Eat 6 small meals/d
avoid overloading the stomach.
• Small bites & chew well
• Limit fluids 4 oz (1/2 cup) w mealtimes.
Prevent rapid gastric emptying
• Drink liquids 30-45 min before eating
and 1 hour after eating, rather than with
meals.

• Rest/lie down 15 minutes after
meals slow rapid gastric emptying
• Avoid sweets and sugars.
Aggravate dumping syndrome.
• Avoid very hot / cold foods or
liquids, may increase dumping
symptoms

• Post Gastrectomy => Intolerance to
certain foods:
Especially Sweets, Acidic, Fatty
foods.
• Gas and bloating may occur
• Avoid foods that are known to cause
gas, symptoms
• STOP eating as soon as start to feel
full

• Avoid tight fitting clothing
frequent bending
• Elevate Head bed - 6 inches
• Limit caffeine (coffee, tea & cola drinks).
• Limit fatty foods
• Beware acidic foods (vinegar, hot peppers)
• Avoid foods natural laxatives
(caffeine, prunes and others)

• Avoid spearmint and peppermint
• Avoid carbonated beverages
• Limit or avoid alcohol
• Sit up after eating and remain in a sitting
position for 60-90 min after eating
• Do not eat for 2 hours before bedtime
• Eat a variety of foods to assure adequate
vitamins, minerals & protein
• Multivitamin calcium, iron, B vitamins(?)

• Beware lactose intolerance
(the inability to digest milk sugar)
• Can Lead to Gas Bloat Diarrhea etc

Understanding
1. Dumping Syndrome &
2. Post Gastrectomy Syndrome
3. Mini-Gastric Bypass
Good Dumping / Bad Dumping
Aversive Conditioning

Post Gastrectomy Syndrome
•This syndrome is characterized by a
lowered tolerance for large meals,
rapid emptying of food into the small
intestine or “dumping,” abdominal
cramping pain, diarrhea,
lightheadedness after eating as well
as increased heart rate and sharp
drops in blood sugar levels.

•In the "early" dumping syndrome,
symptoms occur approximately
one-half hour after eating
whereas in the “late” dumping
syndrome they appear two to four
hours after eating.

•The Bulk Food component draws
water into the intestinal lumen
causing sudden fluid shifts in the
early dumping whereas late
dumping is caused by a reactive
hypoglycemia.

MGB Diet PGS Diet
• 6 small feeds
• Avoid Sweets, Fats
• Avoid High Fat,
Fried Food
• More Fresh Fruit
Vegs
• More Dairy
(xLactose)
• Minimal Liquids
• ...
• 6 small feeds
• Avoid Sweets, Fats
• Avoid High Fat,
Fried Food
• More Fresh Fruit
Vegs
• More Dairy
(xLactose)
• Minimal Liquids
• ...

What Make'e
The MGB
So Good?
Hint:
It's the Surgical Technique
It's the Billroth II
Not Lap Band, Sleeve, RNY

MGB: Mechanism of Action
• I. Large Gastric Pouch+Wide GJ:
Non-Obstructive Restriction
Rapid gastric emptying:
=> Post Gastrectomy Syndrome
Type I and II Dumping (Good/Bad)
• II. Moderate Bilio-Pancreatic Bypass
(Not Massive BPD/SADI bypass)
Fatty food intolerance
Fat Malabsorption to HIGH fatty meals

Remember your General Surgery
“Post-Gastrectomy Syndrome Diet”
• Eat 6-8 small meals per day
• Don’t drink w meals
• Avoid:
= Fried foods, High fat luncheon meats
such as bologna or salami, Hot dogs,
sausage, bacon
= Sugar, sweets, Honey, syrup, Sorbitol,
xylitol

MGB =>
Restriction WITHOUT Obstruction
• Gastric Pouch+Wide GJ: Unique
• No Obstruction
• Easily eat small meals
• Rapid Gastric Emptying
Dumps food into distal jejunum
• Leads to Aversive Conditioning to
Sugar, sweets, fatty foods bulky meals
Dumping type I & II
• NO RNY Neo-Gastric Pouch

MGB: Restriction WITHOUT Obstruction
Dr Rutledge's Survey 3,223 patients
• Gastric Pouch: Unique: (Not Band/Sleeve/RNY)
• No Obstruction
• Rapid Gastric Emptying
Dumps food into mid-jejunum
• En-Forced Mediterranean Diet
• Increased Intake Fresh Fruit and Vegetables,
Cereals and Fiber, Yogurt, Lean meats & fish
• Decreased Intake Soda (Coke) Fried Foods,
Greasy Meals & “Junk Foods”

aversive conditioning
noun, Psychology, Psychiatry.
a type of behavior conditioning in which
noxious stimuli are associated with
undesirable or unwanted behavior that is
to be modified or abolished,
as the use of nausea-inducing drugs in
the treatment of alcoholism.

MGB: Aversive Conditioning
Avoid Sweets, Fatty Foods, Large Meals...
MGB =>
behavior conditioning
noxious stimuli (Nausea etc.) with
undesirable or unwanted behavior
(Sweets, Fatty Food, Large Meals etc...)
to be modified or abolished
(Dumping I or II)

MGB: BPLimb + Post
Gastrectomy Syndrome
• Dog Study 1950, Rapid Gastric Emptying
into Small Bowel
• Antrectomy and Billroth II
Bilio-Pancreatic Limb Bypass
Bowel Bypass 5% No effect
Bowel Bypass 15% No Effect
Bowel Bypass 30% ++Fatty food
intolerance, +Fat Malabsorption
• ~30% Bypass = MGB

Best Rx DM
Gastric Procedure + Duodenal Bypass
This Excludes Band/Sleeve
• Need for
Gastric Procedure + Bypass
• Eliminates Band/Sleeve;
• Leaves Choice RNY vs MGB

Why Consider MGB?
Long Term Failure of Band / RNY
• 6 yr study 29,820 BCBS plan members.
• "Laparoscopic RNY and Lap Band both Fail to
reduce overall health care costs in the long
term."
• Impact of Bariatric Surgery on Health Care Costs of Obese Persons, A 6-Year Follow-up
of Surgical and Comparison Cohorts Using Health Plan Data Jonathan P. Weiner, et al. JAMA Surg.
2013;148(6)

Band & RNY fail to reduce health care costs
Health care Costs of RNY and Band
RNY
Ban
d

RNY the MOST Dangerous
Form of Bariatric Surgery
• By Every measure, in Every study RNY
• Highest Death Rate, Highest Leak Rate Highest
Early Complications, Highest Major Complication Rate,
Highest Bleeding Rate, Highest Re-operation Rate,
Highest PE Rate....
• RNY is the most dangerous form of Bariatric
Surgery
• References 100+ Studies MGBGuidelines.com

RNY: Long learning curve
500 cases
• RNY technically challenging
2,281 cases 1999 - 2011
• Complications Stabilized after *500* cases
• Mortality rate .43%,
main causes of death PE & Leaks (.14% each)
• Op time & Complications significantly reduced after a
long learning curve of 500 cases
• Surg Obes Relat Dis. 2013 Feb 11. Overcoming the learning curve of laparoscopic Roux-en-Y gastric bypass: A
12-year experience. El-Kadre L, Tinoco AC, Tinoco RC, Aguiar L, Santos T. Department of Surgery, São José do
Avaí Hospital, Itaperuna, Rio de Janeiro, Brazil.

The RNY
is the most Technically
Difficult, Dangerous
form of Bariatric
Surgery
>100 Refs
Here is One Recent
Example

RNY Bypass Surgery for Diabetes With Non-morbid
Obesity? Maybe Jun 04, 2013
• Controlled Prospective Randomized 12-months, 49% RNY pts vs
19% lifestyle pts met primary end points
• BUT
• 37% serious complications in the RNY group
• 2 most serious complications were anastomotic leak 3.3%!!,
• 1 patient suffered anoxic brain injury & amputation!
• Patients who underwent surgery were also more likely to have non-
serious adverse events such as nutritional deficiencies.
• JAMA. 2013 Jun 5;309(21):Roux-en-Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the
Diabetes Surgery Study randomized clinical trial. Ikramuddin S, Department of Surgery, School of Public Health, University of Minnesota, Minneapolis, MN 55455,
USA. ikram001@umn.edu

RNY Bypass Surgery for Diabetes
Controlled Prospective Randomized Trial
• Normal HgbA1C level range from 4.5 to 6
• Only 44% RNY pts HgbA1c < 6 (Cure)
• BUT
• 37% serious complications in the RNY group
• 3.3% anastomotic leaks
• 1 patient suffered anoxic brain injury.
• JAMA. 2013 Jun 5;309(21):Roux-en-Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia:
the Diabetes Surgery Study randomized clinical trial. Ikramuddin S, Department of Surgery, School of Public Health, University of Minnesota, Minneapolis, MN 55455,
USA. ikram001@umn.edu

Controlled Prospective Randomized Trial
Lee WJ, Yu P-J, Wang W, Chen TC, Wei PL, Huang MT. Laparoscopic Roux-en-Y versus Mini-Gastric Bypass
for the treatment of Morbid Obesity. Ann Surg 2005 ; 242 : 20-28
RYG Bypass Mini Bypass
Op time (mns) 205 148
Early complications 20% 7.5%
Late complications 7.5% 7.5 %
EWL at one year 58.7% 64.9%
EWL at two years 60% 64.4%

MGB: Summary
• Obstructive: Band, VBG, Sleeve, RNY:
Likely to Fail
• Malabsorption: BPD, Switch, SADI
Deficiencies and Malnutrition
• MGB
Non-Obstructive Restriction
Post Gastrectomy Syndrome Physiology
Fatty Food Intolerance
Enforced Mediterranean Diet

More Detailed References on
the Mini-Gastric Bypass

MGB One of the Most Effective & Safest
Best Rx for Obesity & DM

Objective 5:
• MGB Series
• Rutledge U.S.A. 6,000 + (16 yr + FU)
• Lee Taiwan 1000 + (RCT, 10 yr+ FU)
• Noun Lebanon 1000
• Kular India 1000+
• Cady France 2000 +
• Peraglie U.S.A. 2000 +
• Carbajo Spain 2000 +
• Garcia-Caballero Spain 1000 +
• Musella et al. Italy 1000
• Others (i.e. Chevallier Paris , Tacchino Rome etc.)

• MGB Series
• Findings in all series are the same:
• Short operation, low risk of short and long term
complications
• Excellent short and long term weight loss 75-100%
EWL, Better than BPD)
• Revisable and Reversible
• Minimal Risk of Bile Reflux in Knowledgeable Hands

One Thousand Consecutive Mini-gastric Bypass:
Short- And Long-term Outcome
• 1,000 patients who underwent MGB from November 2005 to
January 2011
• Operative time and length of stay for primary vs. revisional MGB
were
• 89 ± 12.8 min vs. 144 ± 15 min (p < 0.01) and
• l.85 ± 0.8 day vs. 2.35 ± 1.89 day (p < 0.01)
• Short-term complications 2.7% for primary vs. 11.6% for revision
MGB (p < 0.01)
• Obes Surg. 2012 May;22(5):697-703. One thousand consecutive mini-gastric bypass: short- and long-term outcome. Noun et al,
Department of Digestive Surgery, Hôtel-Dieu de France Hospital and University Saint Joseph Medical School, Bd Alfred Naccache,
Achrafieh, BP 166830 Beirut, Lebanon. rnoun@wise.net.lb

• Five (0.5%) patients presented with leakage from the gastric tube
but none had anastomotic leakage.
• Four (0.4%) patients, all revisions with severe bile reflux Rx by
stapled latero-lateral jejunojejunostomy (Braun).
• Excessive weight loss occurred in four patients easily revised.
• Percent excess weight loss (EWL) of 72.5% occurred at 18
months.
• Obes Surg. 2012 May;22(5):697-703. One thousand consecutive mini-gastric bypass: short- and long-term
outcome. Noun et al, Department of Digestive Surgery, Hôtel-Dieu de France Hospital and University Saint
Joseph Medical School, Bd Alfred Naccache, Achrafieh, BP 166830 Beirut, Lebanon. rnoun@wise.net.lb

• The 50% EWL was achieved for 95% of patients at 18 months and
for 89.8% at 60 months.
• MGB is an effective, relatively low-risk, and low-failure bariatric
procedure.
• In addition, it can be easily revised, converted, or reversed.
• Obes Surg. 2012 May;22(5):697-703. One thousand consecutive mini-gastric bypass:
short- and long-term outcome. Noun et al, Department of Digestive Surgery, Hôtel-Dieu
de France Hospital and University Saint Joseph Medical School, Bd Alfred Naccache,
Achrafieh, BP 166830 Beirut, Lebanon. rnoun@wise.net.lb

Laparoscopic Roux-en-y Vs. Mini-gastric Bypass For The
Treatment Of Morbid Obesity: A 10-year Experience.
• Obes Surg. 2012 Dec;22(12):1827-34. Laparoscopic Roux-en-Y
Vs. mini-gastric bypass for the treatment of morbid obesity: a
10-year experience.
• Lee WJ, Ser KH, Lee YC, Tsou JJ, Chen SC, Chen JC.
• Department of Surgery, Min-Sheng General Hospital, National
Taiwan University, No. 168, Chin Kuo Road, Tauoyan, Taiwan,
Republic of China. wjlee_obessurg_tw@yahoo.com.tw

• October 2001 and September 2010, 1,657 patients who received
gastric bypass surgery (1,163 for LMGB and 494 for LRYGB)
• Surgical time was significantly longer for LRYGB (159.2 vs. 115.3
min for LMGB, p < 0.001).
• The major complication rate was higher for LRYGB (3.2 vs. 1.8%,
p = 0.07).
• 5 years after surgery, the mean BMI was lower in LMGB than
LRYGB (27.7 vs. 29.2, p < 0.05) and
• LMGB also had a higher excess weight loss than LRYGB (72.9
vs. 60.1%, p < 0.05).
• Late revision rate was LRYGB 3.6% and MGB 2.8%

• CONCLUSIONS:
• This study demonstrates that MGB
can be regarded as a SIMPLER and
SAFER alternative to RNY with
similar or BETTER efficacy at a 10-
year experience.

MGB Can Successfully Treat Obesity and Diabetes in Both
Thin and Obese Diabetic Patients
2013: Kular
Hospital
6 year study T2DM
patients
Results:
Type 2 Diabetes
resolved
98% of MGB

MGB More Effective than BPD
Dr Tacchino MGB vs BPD
• Weight Loss and Diabetes Resolution Following Mini-
Gastric Bypass and Bilio-Pancreatic Diversion. Tacchino R.,
Rutledge R., Università Cattolica del Sacro Cuore, Rome, Italy
• 408 pts Jan 2007 to Dec 2009
• 36 months follow-up
• Mini-Gastric Bypass (n = 164) initial BMI 46.4±9.6 or
• Bilio-Pancreatic Diversion (n = 244) initial BMI 46.9±7
(Tacchino’s preferred Operation)

• RESULTS:
• Mean BMI at two years was 28.5±3.9 kg/m2 and at three
years 27.4±4.5 kg/m2 after MGB
• BMI at two years 32.7± 6.04 kg/ m2 and at three years
33.6±5.1 kg/m2 after BPD
• One year resolution of diabetes was accomplished in:
• 100% in MGB group
• 95% in BPD group.

• Tacchino’s conclusions:
• “Both MGB and BPD resulted in excellent weight loss,
excellent resolution of co-morbities with low risk of long
term complications.
• The MGB was associated with greater weight loss than
BPD.
• Improvements in other cardiovascular risk factors and
quality of life were similar after both procedures.”

Every Text book in General Surgery
Warns of SBO after RNY

RNY Causes Bowel Obstruction and Death
MGB surgeon’s family
member had
RNY => SBO => Death
RNY SBO 2-16%
NO Other Bariatric Surgery
Has Such High Rate of
Bowel Obstruction

Selecting an Operative Procedure
Safety and Effectiveness
Personal Experience, Animal Models, Expert Judgment,
Published Data and Controlled Prospective Randomized
Trials all show:
MGB is More Effective than Sleeve RNY
MGB is Safer than SleeveRNY

Conclusions: MGB MUCH Better than RNY
• 1. RNY v MGB
• 2. Animal, Gen Surg and Bariatric Data:
Best Rx = Gastric + Duodenal Bypass
• 3. Excludes Band/Sleeve
• 4. RNY Unquestionably the HIGH Risk
• 5. Numerous studies show MGB short safe and
highly effective; Better than RNY
• Best Choice

Opinion Among BPD Surgeons
• Length of the Common Channel
is the Critical Factor for Fat
Malabsorption & weight loss
• We review Animal studies and
MGB results that suggest this is
not the case
• Am J Surg. 2005 May;189(5):536-40, Common channel length predicts outcomes of
biliopancreatic diversion alone and with the duodenal switch surgery, McConnell DB, O'rourke
RW, Deveney CW

NUTRIENT ABSORPTION in the SMALL
INTESTINE: Remember the Basics
• Duodenum and Upper Jejunum:
most minerals
• Jejunum and Upper Ileum:
carbohydrates, amino acids,
water-soluble vitamins
• Jejunum: absorbs most of lipids
and fat-soluble vitamins
• Terminal Ileum: Bile,Vit B12

Fat absorption and the
Length of Billroth II Afferent Limb
• Experiment
• Question: Increase length of
afferent limb associated with
increased fat Malabsorption
• Animals underwent a 50% distal
gastrectomy with an antecolic
• Polya-type Billroth II anastomosis

Billroth II Afferent loop
• 50% distal
gastrectomy with
an antecolic
• Polya-type Billroth
II anastomosis
• Afferent limb of
• 30cm, 60cm, 90cm

Billroth II Afferent Limb: RESULTS
• PreOp: Fecal excretion on a 127 Gm. diet
2.4% of the ingested fat.
• Similar results in dogs and in humans
• Animals with BII + 30cm afferent limbs
• Able to digest and absorb the dietary fat
without any apparent difficulty

• Average fecal excretion diet was
2.4% of the ingested fat.
• Longer Loops steatorrhea increased
• 30 cm. limb fecal fat 2.4% (No Change)
• 60 cm. limb fecal fat excretion 10.2%
• 90 cm. limb 28.2%

• Average fecal excretion Pre Op
2.4% of ingested fat
• Longer Limb increased steatorrhea
• 30 cm. limb fecal fat 2.4% (No Change)
• 60 cm. limb fecal fat excretion 10.2%
• 90 cm. limb 28.2%

Fat MAL-absorption and the
Billroth II Afferent LIMB
• Afferent limb most important factor post
gastrectomy steatorrhea, “LENGTH”
• Animals with short afferent loops NO
significant steatorrhea.
• As the length of the afferent limb
increased, a concomitant and dramatic
rise in fecal fat excretion was noted.

Fat MAL-absorption and the
• Malabsorption is NOT due to
bypass of the upper jejunum
ALONE
• Kremen’s Study:
• Over half the jejunum can be
bypassed without producing
steatorrhea.

An Experimental Evaluation of the
Nutritional Importance of
Proximal and Distal Small
Intestine
• Arnold J. Kremen, et al.
Ann Surg. 1954 September; 140(3): 439–447

Kremen, et al.
• “Experimental studies in dogs
reveal that animals can bypass
• 50 to 70 per cent of their
small intestine
• and maintain a near normal
nutritional status”

Experimental Evaluation of the Nutritional
Importance of Proximal and Distal Small Intestine
• Study showed that
• Bypass of major lengths of the
proximal small intestine,
• Weight is well maintained
• No great interference with fat
absorption
• NOTE:
Contradiction with Prior Study

• 50 - 70% of the small bowel
bypassed
• Proximal and distal ends were
exteriorized as a cutaneous
stoma.
• Intestinal continuity was re-
established by end-to-end
anastomosis

50% of Jejunum Bypassed:
No Weight Loss!

Massive bypass = No Effect
• The small intestine in adults is a
long and narrow tube about
7 meters (23 feet) long
• 50% Bypass = 11.5 ft (3.5 meters)
• Minimal Weight Loss!

70% Bowel Bypassed
Minimal Weight Loss

Massive bypass = Little Effects!
• The small intestine in adults is
a long and narrow tube about
7 meters (23 feet) long
• 70% Bypass = 16 ft (5 meters)
• 5% weight loss

70% Bypass = Little Effect
• Group IV animals, which were
similar to Group I except that 70%
instead of 50% of proximal small
bowel removed from intestinal
continuity,
• Lost about five per cent of their
preoperative weight and then
stabilized at this level.

Transit Time & Fat Absorption
• 50-70% Bypass
• Made Little Difference in
• Transit Time or
• Fat Absorption NOT affected

• CONCLUSIONS
• The proximal 50 to 70 per cent of the small
intestine can be removed with no apparent ill
effects.
• Weight is maintained, and protein and fat
absorption are not significantly altered.
• Arnold J. Kremen, John H. Linner, and Charles H. Nelson

Bypass of Jejunum; Experimental Results:
No Fat Malabsorption or Major Fat
Malabsorption
• 2 Studies; 2 Different Findings
• Massive Small Bowel Bypass
=> Minimal Effects
• Moderate Small Bowel Bypass
=>Major Effects
• What is the Difference?

Billroth II + Moderate Bypass
=
Fatty Food Intolerance +
Mild Fat Malabsorption and
Good Weight Loss

RNY
• Primarily Restrictive
• Minor fat Malabsorption
• No Malabsorption of Protein or
Carbohydrate
• Restriction begins to fade early

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