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MGB (Mini-Gastric Bypass) v Sleeve Gastrectomy

The document discusses the mini-gastric bypass (MGB) as a potentially superior surgical option for weight loss compared to sleeve gastrectomy (SG), highlighting higher healthcare costs and complications associated with SG, particularly nausea, vomiting, and gastroesophageal reflux disease (GERD). It cites numerous studies indicating that patients undergoing SG often face increased risks of severe complications, including long-term esophageal issues and higher hospitalization rates. The document emphasizes the need for careful consideration of surgical options in bariatric surgery due to the associated health risks.

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https://mgbguidelines.wordpress.com/gastric-pouch-creation/ Mini-Gastric Bypass: Why Choose the MGB “We Need a Better Surgery” Dr. Rutledge Email DrR@clos.net
Failed Bariatric Surgery •Total health-care costs were higher for patients with normal Blood sugar levels or those with prediabetes •Who were given Bariatric Surgery!!!
Bariatric Surgery Patients Do Worse! •Lancet Diabetes Endocrinol. 2015 Nov;3(11):855-65. •Health-care costs over 15 years after bariatric surgery for patients with different baseline glucose status: results from the Swedish Obese Subjects study.
Bariatric Surgery Patients Do Worse! •Swedish Obese Subjects (SOS) study is a prospective study of adults who had bariatric surgery and contemporaneously matched controls who were treated conventionally •Data for inpatient and outpatient visits from the Swedish National Patient Register. We followed up the sample linked to register data for up to 15 years •we followed up 4,030 patients (2,836 who were euglycaemic; 591 who had prediabetes; 603 who had diabetes •Swedish Obese Subjects study.
Bariatric Surgery Patients Do Worse! •Compared with the No Surgery group, we noted •greater inpatient costs in the surgery group for the •euglycaemic ($50,000 vs $25,000 p<0·0001) •prediabetes ($58,000 vs $32,000 p<0·0001), •diabetes ($61,000 vs $47,000 p<0·0001) •Surgery Patients Did Worse •Total health-care costs were higher in the surgery group (x for diabetics) •Swedish Obese Subjects study.
Bariatric Surgery Patients Do Worse! •INTERPRETATION: •“Total health-care costs were higher for patients with euglycaemia or prediabetes in the surgery group than in the conventional treatment group” •Swedish Obese Subjects study. 2015
https://mgbguidelines.wordpress.com/gastric-pouch-creation/ Mini-Gastric Bypass: Excellent Rx GERD & Confusion by Sleeve/RNY Surgeons Sleeve: High Rates of GERD & Confusion by Sleeve surgeons Dr. Rutledge Email DrR@clos.net
Considering the MGB “In Every Study, By Every Measure the MGB is Equal to or Better than any other Surgery”
https://mgbguidelines.wordpress.com/gastric-pouch-creation/ •Mini-Gastric Bypass Confusion & Mistakes • Anyone can do a “single anastomosis gastric bypass” • That “Does Not” mean doing the true “Mini-Gastric Bypass” (MGB) • Doing the MGB Wrong has led to Many Complications: Examples ... • This Course “Doing the MGB Right”
Reminders of the Basics of General Surgery Sleeve is NOT New Performed in 1940 Has been Abandoned 1950 Surgical Rx Hiatal Hernia “Alone” (Hill/Allison Repairs) Has been Abandoned
The Sleeve is NOT New •As early as 1940, O.H. Wangensteen performed longitudinal gastric resection to excise acid-producing body of the stomach •Wangensteen OH. Aseptic gastric resection. SGO. 1940;70:59–70
History of Ulcer Surgery •K. Schwarz’s discovery of the concept of “no ulcers without acids” in 1910 •O.H. Wangensteen who Devised longitudinal gastric resection (Sleeve) •Parietal cells, (HCL) most dense lengthwise along the greater curvature •Wangensteen performed the first experiments of longitudinal resection along the greater gastric curvature to reduce acidity of gastric juice in 1940
History of Ulcer Surgery •Wangensteen applied this technique in 90 patients with duodenal ulcers and reported initially Positive Results •Evolution and evaluation of an acceptable operation for peptic ulcer. WANGENSTEEN OH Am J Gastroenterol. 1953 Sep; 20(9):611-26 • Abandoned, after performing further animal experiments in 1957 •The acid response of the stomach after test meals was many-fold higher in animals spitting up
The Sleeve is NOT New He concluded that his “tubular gastric resection” should be viewed with caution and he stopped using the technique Abandoned Segmental gastric resection: an acceptable operation for peptic ulcer; tubular resection unacceptable. WANGENSTEEN OH Surgery. 1957 Apr; 41(4):686-90.
The Sleeve is Very Popular (Now?) Remember the Lap Band Vertical Banded Gastroplasty
A Modest Proposal •My Opinion: •Sleeve = Failed VBG •(Vertical Banded Gastroplasty) •and the ** VBG has been abandoned! **
Sleeve = VBG Sleeve Gastrectomy = 1. Irreversible Stomach only operation, 2. Makes Eating Usual Foods Difficult Because of a ... 3. Partial Blockage (Obstruction) in the stomach 4. Patients Complain of Frequent Nausea and Vomiting with MANY "Normal Foods" (i.e. Broccoli, Sandwich, Apple) 5. N&V with "Normal" Food Encourages "Junk" foods like Potato Chips, Coke, Soda, Sweets, Ice Cream, etc. 6. Initially moderate to good weight loss 7. followed by high rates of weight regain and 8. ~1/3 of patients with moderate to severe GERD often requiring surgery and Long Term Risk of Esophageal Cancer. Failed VBG Vertical Banded Gastroplasty = 1. Irreversible Stomach only operation, 2. Makes Eating Usual Foods Difficult Because of a ... 3. Partial Blockage (Obstruction) in the stomach 4. Patients Complain of Frequent Nausea and Vomiting with MANY "Normal Foods" (i.e. Broccoli, Sandwich, Apple) 5. N&V with "Normal" Food Encourages "Junk" foods like Potato Chips, Coke, Soda, Sweets, Ice Cream, etc. 6. Initially moderate to good weight loss 7. followed by high rates of weight regain and 8. ~1/3 of patients with moderate to severe GERD often requiring surgery and Long Term Risk of Esophageal Cancer.
Sleeve = VBG Abandoned Sleeve Gastrectomy = 1. Irreversible Stomach only operation, 2. Makes Eating Usual Foods Difficult Because of a ... 3. Partial Blockage (Obstruction) in the stomach 4. Patients Complain of Frequent Nausea and Vomiting with MANY "Normal Foods" (i.e. Broccoli, Sandwich, Apple) 5. N&V with "Normal" Food Encourages "Junk" foods like Potato Chips, Coke, Soda, Sweets, Ice Cream, etc. 6. Initially moderate to good weight loss 7. followed by high rates of weight regain often requiring revision 8. ~1/3 of patients with moderate to severe GERD often requiring revision surgery and Long Term Risk of Esophageal Cancer.
GERD and Anatomy of the Lower Esophageal Sphincter
Anatomy and Physiology of the Esophago-Gastric junction
Anatomy and Physiology of the Esophago-Gastric junction
If You Get a Sleeve You're Gonna Vomit
Sleeve Gastrectomy Creates HIGH Pressure System • Study HIGH intragastric pressure after water swallows in patients after SG (77 %) often w/o upper GI symptoms • Gastric dysrhythmia cause of vomiting induced by retrograde gastric electrical ectopic locus •Obes Surg. 2016 Oct;26, High-resolution Impedance Manometry after Sleeve Gastrectomy: Increased Intragastric Pressure and Reflux are Frequent Events, Mion F, Tolone S et.al.
Sleeve N&V + GERD Obes Surg. 2016 Oct;26 • Manometry Showed: • Reflux episodes frequent after Sleeve (52%): • Significantly associated with gastroesophageal reflux (GER) symptoms and • Ineffective esophageal motility i.e. N&V
Abnormal Gastric Pacemaking After Sleeve Gastrectomy Gastric myoelectrical activity (GMA) vomiting Gastric dysrhythmia precedes vomiting major pattern of dysrhythmia immediately before vomiting also noticed immediately after vomiting
Abnormal Gastric Pacemaking After Sleeve Gastrectomy Sleeve gastrectomy (LSG) includes excision of the normal gastric pacemaker, which induces electrical dysrhythmias impacting on post-operative symptoms and recovery High-resolution (HR) electrical mapping before and after Sleeve Patterns of Abnormal Gastric Pacemaking After Sleeve Gastrectomy Defined by Laparoscopic High-Resolution Electrical Mapping. Obes Surg. 2017 Aug;27(8):1929-1937
Abnormal Gastric Pacemaking After Sleeve Gastrectomy  All Sleeves developed abnormalities either a  Ectopic pacemaker with retrograde propagation (50%) or Bioelectrical quiescence (50%)  Resection of the gastric pacemaker resulted in aberrant distal ectopic pacemaking or bioelectrical quiescence.  Ectopic pacemaking can persist long after LSG, inducing chronic dysmotility.
Anatomy and Physiology of the Esophago-Gastric junction
Post Sleeve Manometry • Heartburn and regurgitation • Deteriorated in 11% & 28% patients • Patients developed • Decreased LES length and • Weakened LES pressure after LSG.
Sleeve Gastrectomy Vomiting Google Search Results Sleeve Gastrectomy & Vomiting Items: 1 to 20 of **540** Articles in PUBMED
Sleeve Gastrectomy = Vomiting •352 patients; Dysphagia Endoscopy **23%** •1 out of every 4 Sleeves! => Endoscoped for dysphagia (N&V) •Nath A, Yewale S, Tran T, Brebbia JS, Shope TR, Koch TR. Dysphagia after vertical sleeve gastrectomy: Evaluation of risk factors and assessment of endoscopic intervention. World Journal of Gastroenterology. 2016;22(47):10371-10379. doi:10.3748/wjg.v22.i47.10371.
The hidden endoscopic burden of sleeve gastrectomy •Another Study 211 patients sleeve gastrectomy over a 34-month period. •17% of all sleeve gastrectomy patients required post-operative endoscopy •2% of sleeve gastrectomy patients encountered a post-operative staple line leak •Equivalent cost of €159,898, €373/case
Repeated Belching After Sleeve Gastrectomy •Belching occurred significantly more often after LSG, •Total number of gastric belches increased from 30 ± 12 before to **60** ± 38/24 h •Esophageal acid exposure increased significantly, from 4 ± 2.9 % before to 13 ± 10.5 % after LSG (p = 0.01) •Burgerhart JS, van de Meeberg PC, Mauritz FA, et al. Increased Belching After Sleeve Gastrectomy. Obesity Surgery. 2016;26:132-137
Sleeve Gastrectomy You are likely to need to go back into the Hospital in the first year after your surgery!!! •1 out of every 10 Sleeve patients will be back in the hospital in the first year!! •"just over one-third of patients visited the ED (33.9%)" •There were 14,080 SG between 2011 and 2013 •One in every ten of these visits resulted in readmission (9.5%), with •12.5% of Sleeve patients admitted to the Hospital within their first year after SG surgery!!
Sleeve Gastrectomy You are likely to need to go back into the Hospital in the first year after your surgery!!! •ED visits for abdominal pain (n = 1029; 11.14%), vomiting (n = 237; 2.57%), dehydration (n = 224; 2.43%), and syncope (n = 206; 2.23%) were attributed to surgery. •Overall 1-year readmission rates after SG are greater than 1 in ten (12.5%) •1 out of every 10 Sleeve patients will be back in the hospital in the first year!! •Sleeve Gastrectomy: the first 3 Years: evaluation of emergency department visits, readmissions, and reoperations for 14,080 patients in New York State. •https://www.ncbi.nlm.nih.gov/pubmed/28840343
Sleeve => N&V •In another Sleeve study •30% of Readmissions Nausea & Vomiting •"Given the progressive increase in the proportion of bariatric patients undergoing SG, hospital programs that aim to •**decrease readmissions after bariatric surgery need to focus on •**prevention and control of postoperative nausea and dehydration" •https://www.ncbi.nlm.nih.gov/pubmed/27067353
Proximal Leakage After Laparoscopic Sleeve Gastrectomy •Obes Surg. 2017 Aug 24. •Proximal Leakage After Laparoscopic Sleeve Gastrectomy: an Analysis of Preoperative and Operative Predictors on 1,738 Consecutive Procedures. •And 3 chances out of 100 you will have a leak •Proximal leakage was observed in 45 patients out of 1738 (2.6%). •No correlation was found between leakage and the preoperative variables analyzed.
Google Search of Pubmed Database for Complications of Sleeve Scary!
Wernicke's & Sleeve Gastrectomy •Wernicke's & Sleeve Gastrectomy Search results PUBMED •Items: 1 to 20 of **29** •Wernicke’s encephalopathy after sleeve gastrectomy: Literature review •(Note: Zero (0) Cases of Wernicke's with MGB
Mesenteric ischaemia Sleeve Gastrectomy •Search results PUBMED •Items: 1 to 20 of **68** •Portal Vein Thrombosis due to Prothrombin Gene Mutation following Sleeve Gastrectomy Murad Baba, Jordan Fakhoury, Amer Syed Case Rep Gastrointest Med. 2015; 2015: 816914 •Portomesenteric Vein Thrombosis, Bowel Gangrene, and Bilateral Pulmonary Artery Embolism Two Weeks after Laparoscopic Sleeve Gastrectomy Case Rep Surg. 2015; 2015: •(Note: Zero (0) Cases of Mesenteric Ischemia with MGB
GERD, Esophagitis, Barrett's and Esophageal Cancer
From Rats to Man Sleeve Causes Reflux, Esophagitis Barrett's and Esophageal cancer
Rats •Association between sleeve gastrectomy (SG) and gastroesophageal reflux disease •Rats who underwent SG had significantly increased reflux severity, compared with sham (21.1% versus 0%, P = .02), respectively •CONCLUSIONS: •SG is independently associated with histopathologic changes consistent with severe esophagitis in an animal model
Gastroesophageal reflux disease & Barrett's esophagus after laparoscopic sleeve gastrectomy • Surg Obes Relat Dis. 2017 Apr;13(4):568-574. • Gastroesophageal reflux disease and Barrett's esophagus after laparoscopic sleeve gastrectomy: a possible, underestimated long-term complication. • Genco A
Gastroesophageal reflux disease & Barrett's esophagus after laparoscopic sleeve gastrectomy •At a mean 58 months, • GERD symptoms 68% vs 34%: P<.0001, • Visual Analog Scale mean 3 vs 1.8: P = .018, • PPI intake significantly increased compared with preoperative values 57% vs 19%: P<.0001
Gastroesophageal reflux disease & Barrett's esophagus after laparoscopic sleeve gastrectomy • At EGD, upward migration of the "Z" line • esophageal reflux was found in 75% of cases. • A significant increase in the incidence and in the severity of erosive esophagitis (EE) • Barrett's esophagus (BE) newly diagnosed in 17% • Lifetime Endoscopic surveillance after SG should be advocated irrespective of GERD sx
Sleeve Gastrectomy Reflux & Barrett's Esophagus • Obes Surg. 2017 Jun 8. • Reflux, Sleeve Dilation, and Barrett's Esophagus after Laparoscopic Sleeve Gastrectomy: Long-Term Follow-Up. •Felsenreich DM1, Kefurt R1, Schermann M2, Beckerhinn P3, Kristo I1, Krebs M4, Prager G5, Langer FB1
Sleeve Gastrectomy Reflux & Barrett's Esophagus • 24-h pH metries, manometries, gastroscopies, and questionnaires focusing on reflux (GIQLI, RSI) in SG patients with a • Follow-up of more than 10 years who did not suffer from symptomatic reflux or hiatal hernia preoperatively.
Sleeve Gastrectomy Reflux & Barrett's Esophagus • 14% were converted to RYGB due to intractable reflux • Gastroscopies revealed • De novo hiatal hernias in 45% • Barrett's metaplasia in 15%.
Gastroesophageal reflux before and after sleeve gastrectomy •Surg Obes Relat Dis. 2014 Jul-Aug; • Evaluation of gastroesophageal reflux before and after sleeve gastrectomy using symptom scoring, scintigraphy, and endoscopy. • Sharma A1, Aggarwal S2, Ahuja V3, Bal C4.
Gastroesophageal reflux before and after sleeve gastrectomy • Radionuclide scintigraphy revealed a significant rise of GERD from 6% to 78% in the postoperative period (p<0.001). • UGIE showed a rise in incidence of esophagitis from 19% to 25%
Gastroesophageal reflux disease symptoms and erosive esophagitis •Surg Endosc. 2013 Apr;27(4) •Increase in gastroesophageal reflux disease symptoms and erosive esophagitis 1 year after laparoscopic sleeve gastrectomy among obese adults. •Tai CM1, Huang CK, Lee YC, Chang CY, Lee CT, Lin JT.
Gastroesophageal reflux disease symptoms and erosive esophagitis •Significant increase in the prevalence of GERD symptoms (12 vs. 47%) • •Erosive Esophagitis (17 vs. 67%) after LSG (P < 0.001). • Hiatal hernias increased significantly (6 vs. 27%; P < 0.001)
MGB and GERD • Tolone Study •After MGB surgery, none of the patients reported de novo heartburn or regurgitation. •At endoscopic follow-up 1 year after surgery, •esophagitis was absent in all patients and no biliary gastritis or presence of bile was recorded
MGB and GERD • Tolone Study •MGB Manometric features and patterns did not change significantly after surgery •Intragastric pressures (IGP) diminished statistically (from a median of 15 to 9.5, p<0.01) •MGB is a Low Pressure System
MGB = Low Pressure Sleeve = HIGH Pressure => GERD • Tolone Study •Intragastric pressures (IGP) diminished statistically (from a median of 15 to 9.5, p<0.01) •MGB is a Low Pressure System •In contrast, SG induced significant elevation IGP (from 15 to 19, P < 0.01) •Sleeve is a HIGH Pressure System
Reflux Events MGB vs Sleeve Tolone Study • MGB => A dramatic decrease in the number of reflux events (from a median of 41 to 7; P < 0.01) MGB MGB Low Pressure = Less Reflux •SG +> significant increase in esophageal acid exposure & number of reflux episodes (from 33 to 53; P <0.01) •Sleeve is HIGH Pressure = More Reflux
Esophageal adenocarcinoma after Sleeve • Int J Surg Case Rep. 2017; 32: 47–50. • Esophageal adenocarcinoma five years after laparoscopic sleeve gastrectomy. A case report • Fernando Gabriel Wright
Esophageal adenocarcinoma after Sleeve • Int J Surg Case Rep. 2017; 32: 47–50. • Esophageal adenocarcinoma five years after laparoscopic sleeve gastrectomy. A case report • Fernando Gabriel Wright
Esophageal Cancer After Sleeve • Shortcoming of LSG in the long-term follow-up and this is the Frequent onset of de novo GERD • Significant increase of GERD and hiatal hernia post sleeve, • Also an increase in revisional surgeries associated with refractory reflux post Sleeve
Esophageal Cancer After Sleeve •48-Year-old man that underwent a laparoscopic sleeve gastrectomy •Routine preoperative evaluation included an upper gastrointestinal series and EGD, which showed no reflux or hiatal hernia, no esophagitis or Barrett́ s esophagus. •Helicobacter pylori was negative. •15 months after the operation, he complained of new onset of typical GERD symptoms. He was put on proton pump inhibitors (PPI) •4 years later (fifth postoperative year) dysphagia to solids and a 10 kg weight loss. Endoscopy adenocarcinoma of the esophagus
Esophageal Cancer After Sleeve •In a prospective randomized trial that compared LSG with gastric banding, Himpens et al. found development of de novo reflux symptoms in 21.5% of the LSG cohort at one-year follow-up •Braghetto et al. analized 231 patients without reflux symptoms, esophagitis or Barrett, who underwent a LSG. In the follow-up, GERD symptoms were found in 23.2%, erosive esophagitis in 15.5%, and Barrett’s esophagus (intestinal metaplasia) in 1.2%
Esophageal Cancer After Sleeve •two other cases of esophageal adenocarcinoma after LSG have been published. •Scheepers et al. described the case of a 57-year-old woman who was submitted for a LSG and was diagnosed with esophageal adenocarcinoma four months after bariatric surgery [15]. •In another case reported by Sohn et al., a 44-year-old woman who underwent LSG developed an adenocarcinoma of the gastroesophageal junction 2.5 years after surgery [16]
GERD & Bariatric Surgery  GERD, Barrett's, Esophageal Cancer  Hx of General Surgery, Forgotten Allison, Hill Repairs (Failure Abandoned)  Rx with Nissen, Results of Nissen  GERD in Bariatric Surgery Band & Sleeve CAUSE GERD Sleeve Surgeons Failed Rx??  RNY Rx GERD  MGB Excellent Rx GERD Understanding Why?
Systematic review: Laparoscopic Nissen fundoplication for gastroesophageal reflux disease Laparoscopic Nissen fundoplication (LF) for gastroesophageal reflux disease (GERD). 10 years after LF, 36% reported heartburn & 29% reported regurgitation. The proportion using PPIs increased, from 9% in year 1 to 18% at 10 years.
A randomized controlled trial of laparoscopic Nissen fundoplication versus proton pump inhibitors for the treatment of patients with chronic gastroesophageal reflux disease (GERD): 3-year outcomes. •Surg Endosc. 2011 Aug;25(8):2547-54.
RCT; Nissen vs PPIs •A randomized controlled trial (RCT) gastroesophageal reflux disease (GERD) •1. who were stable and symptomatically controlled with long-term medical therapy to •compare •ongoing medical therapy with •laparoscopic Nissen fundoplication (LNF).
Nissen vs PPIs: No difference •GERD Sx or Acid exposure on 24-h pH monitoring •There were six treatment failures (12%) in the surgical group and eight treatment failures (16%) in the medical group by 3 years.
RCT: CONCLUSIONS: For patients whose GERD symptoms are stable and controlled with PPI, Medical therapy Nissen are equally effective
Use of proton pump inhibitors after anti-reflux surgery: a nationwide register-based follow-up study •Jan 28, 2014 - •Lødrup A(1), Pottegård A(2), Hallas J(2),
Denmark Nationwide health care registry study •PPI use after Anti-reflux surgery (ARS) in the general Danish population using nationwide health care registries. •A nationwide retrospective follow- up study of all patients aged ≥18 and undergoing first-time ARS in Denmark during 1996–2010
Denmark Nationwide health care registry study • Female gender, high age, recent ARS, previous use of PPI & use of NSAIDs drugs or antiplatelet therapy significantly increased the risk of PPI use (Nissen failure).
Long term failure of Nissen •3465 patients ARS •5, 10 & 15-year risks of New PPI Rx = 57%, 72% & *83%*, respectively •5, 10 & 15-year risks Long-term PPI use = 30%, 41% and *57%*
Nissen Failure • Conclusions Risk of PPI use after Nissen high! • More than 50% of patients became long-term PPI users • Patients should be made aware that long-term PPI therapy is often necessary after Nissen.
Majority of Gastro-Esophageal Reflux Disease Patients Continue to Use Proton Pump Inhibitors After Anti-reflux Surgery (Nissen) A Madan et al. Aliment Pharmacol Ther 2006 Mar 01
Nissen Failure 80% Rx PPIs •Nissen fundoplication at our institution over a period of over 3 years were asked to complete a questionnaire •80% patients were still taking anti-reflux medications including proton pump inhibitors
Rx GERD with Nissen Very Questionable Results
MGB Rx GERD
Survey 3,000 MGB Patients • 64% of MGB patients taking antacid medications for GERD preop (PPIs, H2Blockers or Antacids) • Post MGB resolution of GERD Sx with discontinuation of medications 81%
MGB Rx GERD Equal to or Better Than Nissen • How Does it Work?
MGB Rx GERD Mechanism of Action 1. Reduction of Acid Production 2. Weight loss 3. Downward traction on the stomach 4. *Creation of LOW Pressure System*
MGB Rx GERD Mechanism of Action 1. Reduction of Acid Production 2. Weight loss 3. Downward traction on the stomach 4. *Creation of LOW Pressure System*
Conclusions • GERD common serious problem in Bariatric patients • Nissen “gold standard” poor results + = simply taking PPI's • Dr Rutledge MGB Series: 80% success Rx GERD • Understand WHY! • MGB Good to Excellent Rx GERD
Post-op malnutrition Vitamin and mineral deficiencies after Sleeve Gastrectomy: A huge challenge Thought that deficiencies mostly occurred in procedures with a malabsorptive component, like the RNY, MGB or the BPD The risk for deficiencies after sleeve gastrectomy was considered low. 3 Studies show that sleeve deficiencies occur almost as much.3,4 Research by Capoccia et al. showed that following laparoscopic sleeve gastrectomy a significant proportion of patients developed vitamin B12 and folate deficiency.4
Deficiencies in Sleeve •Dr. Aarts iron deficiency 43% Sleeve patients •In 26% of patients had significantly low B12, folate, iron and vitamin D levels in sleeve gastrectomy patients.3 •“There is no doubt that the levels of nutritional deficiencies after sleeve are higher than those reported in the literature.” •“In our series, 28% of patients were anemic, but the literature states only a few percent of anemia cases per year. •This is incorrect, nutritional deficiency rates after sleeve gastrectomy are grossly under reported.
Malnutrition MGB •You Can Get Malnourished After MGB •But •Usually it is not a Poor Diet •It usually means that the Bypass is Too Long and Needs revision •In skilled hands this occurs in 0.1 to 1% of patients •For 99%-99.9% of MGB Patients the Recommended Diet for MGB is... •Practically every system in the human body benefits from the "Mediterranean diet"
MGB vs Sleeve, Meta-analysis  Mini-Gastric Bypass/One-Anastomosis Gastric Bypass Versus Sleeve Gastrectomy  for Morbid Obesity: a Systematic Review and Meta-analysis  Seventeen studies met the inclusion criteria incorporating 6,761 patients.  In this study  MGB study patients were older, and heavier than comparable Sleeve patients
MGB vs Sleeve, Meta-analysis In spite of MGB patients being older and heavier…This study reveals MGB => MGB better weight loss vs Sleeve => MGB better remission of comorbidities vs Sleeve (i.e. Diabetes Mellitus), => MGB Shorter hospital stay vs Sleeve => MGB Significantly lower death rate in the MGB than Sleeve! Mini-Gastric Bypass/One-anastomosis gastric bypass (MGB) is a safe, feasible and effective bariatric procedure
Sleeve is a Poor Treatment of Diabetes MGB is an Excellent Treatment of Diabetes
Sleeve Diabetes Remission Rates at 7yrs (28%) • Ann Surg. 2017 Jul 24. Individualized Metabolic Surgery Score: Procedure Selection Based on Diabetes Severity. •At median postoperative follow-up of 7 years (range 5-12) •Diabetes remission (HbA1C <6.5% off medications) •49% after RYGB and •28% after SG (P < 0.001)
Sleeve Rx Diabetes •Ann Surg. 2016 Oct;264(4):674-81.Can Sleeve Gastrectomy "Cure" Diabetes? Long-term Metabolic Effects of Sleeve Gastrectomy in Patients With Type 2 Diabetes. • long-term metabolic effects of laparoscopic sleeve gastrectomy •Complete remission (HbA1c <6% off medications) in 11% •"cure" (continuous complete remission for ≥5 years) was achieved in 3%
RCT Sleeve vs MGB 5 yrs • At 60 months, •18 MGB pts (60%) •9 Sleeve pts (30%) •Achieved the primary end points •HbA1c ≤6.5% without glycemic therapy.
Considering the MGB “In Every Study, By Every Measure the MGB is Equal to or Better than any other Surgery”

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MGB (Mini-Gastric Bypass) v Sleeve Gastrectomy

  • 1.
    https://mgbguidelines.wordpress.com/gastric-pouch-creation/ Mini-Gastric Bypass: Why Choosethe MGB “We Need a Better Surgery” Dr. Rutledge Email DrR@clos.net
  • 2.
    Failed Bariatric Surgery •Totalhealth-care costs were higher for patients with normal Blood sugar levels or those with prediabetes •Who were given Bariatric Surgery!!!
  • 3.
    Bariatric Surgery Patients DoWorse! •Lancet Diabetes Endocrinol. 2015 Nov;3(11):855-65. •Health-care costs over 15 years after bariatric surgery for patients with different baseline glucose status: results from the Swedish Obese Subjects study.
  • 4.
    Bariatric Surgery Patients DoWorse! •Swedish Obese Subjects (SOS) study is a prospective study of adults who had bariatric surgery and contemporaneously matched controls who were treated conventionally •Data for inpatient and outpatient visits from the Swedish National Patient Register. We followed up the sample linked to register data for up to 15 years •we followed up 4,030 patients (2,836 who were euglycaemic; 591 who had prediabetes; 603 who had diabetes •Swedish Obese Subjects study.
  • 5.
    Bariatric Surgery Patients DoWorse! •Compared with the No Surgery group, we noted •greater inpatient costs in the surgery group for the •euglycaemic ($50,000 vs $25,000 p<0·0001) •prediabetes ($58,000 vs $32,000 p<0·0001), •diabetes ($61,000 vs $47,000 p<0·0001) •Surgery Patients Did Worse •Total health-care costs were higher in the surgery group (x for diabetics) •Swedish Obese Subjects study.
  • 6.
    Bariatric Surgery Patients DoWorse! •INTERPRETATION: •“Total health-care costs were higher for patients with euglycaemia or prediabetes in the surgery group than in the conventional treatment group” •Swedish Obese Subjects study. 2015
  • 7.
    https://mgbguidelines.wordpress.com/gastric-pouch-creation/ Mini-Gastric Bypass: Excellent RxGERD & Confusion by Sleeve/RNY Surgeons Sleeve: High Rates of GERD & Confusion by Sleeve surgeons Dr. Rutledge Email DrR@clos.net
  • 8.
    Considering the MGB “InEvery Study, By Every Measure the MGB is Equal to or Better than any other Surgery”
  • 9.
    https://mgbguidelines.wordpress.com/gastric-pouch-creation/ •Mini-Gastric Bypass Confusion &Mistakes • Anyone can do a “single anastomosis gastric bypass” • That “Does Not” mean doing the true “Mini-Gastric Bypass” (MGB) • Doing the MGB Wrong has led to Many Complications: Examples ... • This Course “Doing the MGB Right”
  • 10.
    Reminders of theBasics of General Surgery Sleeve is NOT New Performed in 1940 Has been Abandoned 1950 Surgical Rx Hiatal Hernia “Alone” (Hill/Allison Repairs) Has been Abandoned
  • 11.
    The Sleeve isNOT New •As early as 1940, O.H. Wangensteen performed longitudinal gastric resection to excise acid-producing body of the stomach •Wangensteen OH. Aseptic gastric resection. SGO. 1940;70:59–70
  • 12.
    History of UlcerSurgery •K. Schwarz’s discovery of the concept of “no ulcers without acids” in 1910 •O.H. Wangensteen who Devised longitudinal gastric resection (Sleeve) •Parietal cells, (HCL) most dense lengthwise along the greater curvature •Wangensteen performed the first experiments of longitudinal resection along the greater gastric curvature to reduce acidity of gastric juice in 1940
  • 13.
    History of UlcerSurgery •Wangensteen applied this technique in 90 patients with duodenal ulcers and reported initially Positive Results •Evolution and evaluation of an acceptable operation for peptic ulcer. WANGENSTEEN OH Am J Gastroenterol. 1953 Sep; 20(9):611-26 • Abandoned, after performing further animal experiments in 1957 •The acid response of the stomach after test meals was many-fold higher in animals spitting up
  • 14.
    The Sleeve isNOT New He concluded that his “tubular gastric resection” should be viewed with caution and he stopped using the technique Abandoned Segmental gastric resection: an acceptable operation for peptic ulcer; tubular resection unacceptable. WANGENSTEEN OH Surgery. 1957 Apr; 41(4):686-90.
  • 15.
    The Sleeve isVery Popular (Now?) Remember the Lap Band Vertical Banded Gastroplasty
  • 16.
    A Modest Proposal •MyOpinion: •Sleeve = Failed VBG •(Vertical Banded Gastroplasty) •and the ** VBG has been abandoned! **
  • 17.
    Sleeve = VBG SleeveGastrectomy = 1. Irreversible Stomach only operation, 2. Makes Eating Usual Foods Difficult Because of a ... 3. Partial Blockage (Obstruction) in the stomach 4. Patients Complain of Frequent Nausea and Vomiting with MANY "Normal Foods" (i.e. Broccoli, Sandwich, Apple) 5. N&V with "Normal" Food Encourages "Junk" foods like Potato Chips, Coke, Soda, Sweets, Ice Cream, etc. 6. Initially moderate to good weight loss 7. followed by high rates of weight regain and 8. ~1/3 of patients with moderate to severe GERD often requiring surgery and Long Term Risk of Esophageal Cancer. Failed VBG Vertical Banded Gastroplasty = 1. Irreversible Stomach only operation, 2. Makes Eating Usual Foods Difficult Because of a ... 3. Partial Blockage (Obstruction) in the stomach 4. Patients Complain of Frequent Nausea and Vomiting with MANY "Normal Foods" (i.e. Broccoli, Sandwich, Apple) 5. N&V with "Normal" Food Encourages "Junk" foods like Potato Chips, Coke, Soda, Sweets, Ice Cream, etc. 6. Initially moderate to good weight loss 7. followed by high rates of weight regain and 8. ~1/3 of patients with moderate to severe GERD often requiring surgery and Long Term Risk of Esophageal Cancer.
  • 18.
    Sleeve = VBGAbandoned Sleeve Gastrectomy = 1. Irreversible Stomach only operation, 2. Makes Eating Usual Foods Difficult Because of a ... 3. Partial Blockage (Obstruction) in the stomach 4. Patients Complain of Frequent Nausea and Vomiting with MANY "Normal Foods" (i.e. Broccoli, Sandwich, Apple) 5. N&V with "Normal" Food Encourages "Junk" foods like Potato Chips, Coke, Soda, Sweets, Ice Cream, etc. 6. Initially moderate to good weight loss 7. followed by high rates of weight regain often requiring revision 8. ~1/3 of patients with moderate to severe GERD often requiring revision surgery and Long Term Risk of Esophageal Cancer.
  • 19.
    GERD and Anatomyof the Lower Esophageal Sphincter
  • 20.
    Anatomy and Physiologyof the Esophago-Gastric junction
  • 21.
    Anatomy and Physiologyof the Esophago-Gastric junction
  • 22.
    If You Geta Sleeve You're Gonna Vomit
  • 23.
    Sleeve Gastrectomy Creates HIGHPressure System • Study HIGH intragastric pressure after water swallows in patients after SG (77 %) often w/o upper GI symptoms • Gastric dysrhythmia cause of vomiting induced by retrograde gastric electrical ectopic locus •Obes Surg. 2016 Oct;26, High-resolution Impedance Manometry after Sleeve Gastrectomy: Increased Intragastric Pressure and Reflux are Frequent Events, Mion F, Tolone S et.al.
  • 24.
    Sleeve N&V +GERD Obes Surg. 2016 Oct;26 • Manometry Showed: • Reflux episodes frequent after Sleeve (52%): • Significantly associated with gastroesophageal reflux (GER) symptoms and • Ineffective esophageal motility i.e. N&V
  • 25.
    Abnormal Gastric Pacemaking AfterSleeve Gastrectomy Gastric myoelectrical activity (GMA) vomiting Gastric dysrhythmia precedes vomiting major pattern of dysrhythmia immediately before vomiting also noticed immediately after vomiting
  • 26.
    Abnormal Gastric Pacemaking AfterSleeve Gastrectomy Sleeve gastrectomy (LSG) includes excision of the normal gastric pacemaker, which induces electrical dysrhythmias impacting on post-operative symptoms and recovery High-resolution (HR) electrical mapping before and after Sleeve Patterns of Abnormal Gastric Pacemaking After Sleeve Gastrectomy Defined by Laparoscopic High-Resolution Electrical Mapping. Obes Surg. 2017 Aug;27(8):1929-1937
  • 27.
    Abnormal Gastric Pacemaking AfterSleeve Gastrectomy  All Sleeves developed abnormalities either a  Ectopic pacemaker with retrograde propagation (50%) or Bioelectrical quiescence (50%)  Resection of the gastric pacemaker resulted in aberrant distal ectopic pacemaking or bioelectrical quiescence.  Ectopic pacemaking can persist long after LSG, inducing chronic dysmotility.
  • 28.
    Anatomy and Physiologyof the Esophago-Gastric junction
  • 29.
    Post Sleeve Manometry •Heartburn and regurgitation • Deteriorated in 11% & 28% patients • Patients developed • Decreased LES length and • Weakened LES pressure after LSG.
  • 30.
    Sleeve Gastrectomy Vomiting GoogleSearch Results Sleeve Gastrectomy & Vomiting Items: 1 to 20 of **540** Articles in PUBMED
  • 31.
    Sleeve Gastrectomy =Vomiting •352 patients; Dysphagia Endoscopy **23%** •1 out of every 4 Sleeves! => Endoscoped for dysphagia (N&V) •Nath A, Yewale S, Tran T, Brebbia JS, Shope TR, Koch TR. Dysphagia after vertical sleeve gastrectomy: Evaluation of risk factors and assessment of endoscopic intervention. World Journal of Gastroenterology. 2016;22(47):10371-10379. doi:10.3748/wjg.v22.i47.10371.
  • 32.
    The hidden endoscopic burdenof sleeve gastrectomy •Another Study 211 patients sleeve gastrectomy over a 34-month period. •17% of all sleeve gastrectomy patients required post-operative endoscopy •2% of sleeve gastrectomy patients encountered a post-operative staple line leak •Equivalent cost of €159,898, €373/case
  • 33.
    Repeated Belching After SleeveGastrectomy •Belching occurred significantly more often after LSG, •Total number of gastric belches increased from 30 ± 12 before to **60** ± 38/24 h •Esophageal acid exposure increased significantly, from 4 ± 2.9 % before to 13 ± 10.5 % after LSG (p = 0.01) •Burgerhart JS, van de Meeberg PC, Mauritz FA, et al. Increased Belching After Sleeve Gastrectomy. Obesity Surgery. 2016;26:132-137
  • 34.
    Sleeve Gastrectomy Youare likely to need to go back into the Hospital in the first year after your surgery!!! •1 out of every 10 Sleeve patients will be back in the hospital in the first year!! •"just over one-third of patients visited the ED (33.9%)" •There were 14,080 SG between 2011 and 2013 •One in every ten of these visits resulted in readmission (9.5%), with •12.5% of Sleeve patients admitted to the Hospital within their first year after SG surgery!!
  • 35.
    Sleeve Gastrectomy Youare likely to need to go back into the Hospital in the first year after your surgery!!! •ED visits for abdominal pain (n = 1029; 11.14%), vomiting (n = 237; 2.57%), dehydration (n = 224; 2.43%), and syncope (n = 206; 2.23%) were attributed to surgery. •Overall 1-year readmission rates after SG are greater than 1 in ten (12.5%) •1 out of every 10 Sleeve patients will be back in the hospital in the first year!! •Sleeve Gastrectomy: the first 3 Years: evaluation of emergency department visits, readmissions, and reoperations for 14,080 patients in New York State. •https://www.ncbi.nlm.nih.gov/pubmed/28840343
  • 36.
    Sleeve => N&V •Inanother Sleeve study •30% of Readmissions Nausea & Vomiting •"Given the progressive increase in the proportion of bariatric patients undergoing SG, hospital programs that aim to •**decrease readmissions after bariatric surgery need to focus on •**prevention and control of postoperative nausea and dehydration" •https://www.ncbi.nlm.nih.gov/pubmed/27067353
  • 37.
    Proximal Leakage After LaparoscopicSleeve Gastrectomy •Obes Surg. 2017 Aug 24. •Proximal Leakage After Laparoscopic Sleeve Gastrectomy: an Analysis of Preoperative and Operative Predictors on 1,738 Consecutive Procedures. •And 3 chances out of 100 you will have a leak •Proximal leakage was observed in 45 patients out of 1738 (2.6%). •No correlation was found between leakage and the preoperative variables analyzed.
  • 38.
    Google Search ofPubmed Database for Complications of Sleeve Scary!
  • 39.
    Wernicke's & SleeveGastrectomy •Wernicke's & Sleeve Gastrectomy Search results PUBMED •Items: 1 to 20 of **29** •Wernicke’s encephalopathy after sleeve gastrectomy: Literature review •(Note: Zero (0) Cases of Wernicke's with MGB
  • 40.
    Mesenteric ischaemia Sleeve Gastrectomy •Searchresults PUBMED •Items: 1 to 20 of **68** •Portal Vein Thrombosis due to Prothrombin Gene Mutation following Sleeve Gastrectomy Murad Baba, Jordan Fakhoury, Amer Syed Case Rep Gastrointest Med. 2015; 2015: 816914 •Portomesenteric Vein Thrombosis, Bowel Gangrene, and Bilateral Pulmonary Artery Embolism Two Weeks after Laparoscopic Sleeve Gastrectomy Case Rep Surg. 2015; 2015: •(Note: Zero (0) Cases of Mesenteric Ischemia with MGB
  • 41.
  • 42.
    From Rats toMan Sleeve Causes Reflux, Esophagitis Barrett's and Esophageal cancer
  • 43.
    Rats •Association between sleevegastrectomy (SG) and gastroesophageal reflux disease •Rats who underwent SG had significantly increased reflux severity, compared with sham (21.1% versus 0%, P = .02), respectively •CONCLUSIONS: •SG is independently associated with histopathologic changes consistent with severe esophagitis in an animal model
  • 44.
    Gastroesophageal reflux disease& Barrett's esophagus after laparoscopic sleeve gastrectomy • Surg Obes Relat Dis. 2017 Apr;13(4):568-574. • Gastroesophageal reflux disease and Barrett's esophagus after laparoscopic sleeve gastrectomy: a possible, underestimated long-term complication. • Genco A
  • 45.
    Gastroesophageal reflux disease& Barrett's esophagus after laparoscopic sleeve gastrectomy •At a mean 58 months, • GERD symptoms 68% vs 34%: P<.0001, • Visual Analog Scale mean 3 vs 1.8: P = .018, • PPI intake significantly increased compared with preoperative values 57% vs 19%: P<.0001
  • 46.
    Gastroesophageal reflux disease& Barrett's esophagus after laparoscopic sleeve gastrectomy • At EGD, upward migration of the "Z" line • esophageal reflux was found in 75% of cases. • A significant increase in the incidence and in the severity of erosive esophagitis (EE) • Barrett's esophagus (BE) newly diagnosed in 17% • Lifetime Endoscopic surveillance after SG should be advocated irrespective of GERD sx
  • 47.
    Sleeve Gastrectomy Reflux &Barrett's Esophagus • Obes Surg. 2017 Jun 8. • Reflux, Sleeve Dilation, and Barrett's Esophagus after Laparoscopic Sleeve Gastrectomy: Long-Term Follow-Up. •Felsenreich DM1, Kefurt R1, Schermann M2, Beckerhinn P3, Kristo I1, Krebs M4, Prager G5, Langer FB1
  • 48.
    Sleeve Gastrectomy Reflux &Barrett's Esophagus • 24-h pH metries, manometries, gastroscopies, and questionnaires focusing on reflux (GIQLI, RSI) in SG patients with a • Follow-up of more than 10 years who did not suffer from symptomatic reflux or hiatal hernia preoperatively.
  • 49.
    Sleeve Gastrectomy Reflux &Barrett's Esophagus • 14% were converted to RYGB due to intractable reflux • Gastroscopies revealed • De novo hiatal hernias in 45% • Barrett's metaplasia in 15%.
  • 50.
    Gastroesophageal reflux before andafter sleeve gastrectomy •Surg Obes Relat Dis. 2014 Jul-Aug; • Evaluation of gastroesophageal reflux before and after sleeve gastrectomy using symptom scoring, scintigraphy, and endoscopy. • Sharma A1, Aggarwal S2, Ahuja V3, Bal C4.
  • 51.
    Gastroesophageal reflux before andafter sleeve gastrectomy • Radionuclide scintigraphy revealed a significant rise of GERD from 6% to 78% in the postoperative period (p<0.001). • UGIE showed a rise in incidence of esophagitis from 19% to 25%
  • 52.
    Gastroesophageal reflux disease symptomsand erosive esophagitis •Surg Endosc. 2013 Apr;27(4) •Increase in gastroesophageal reflux disease symptoms and erosive esophagitis 1 year after laparoscopic sleeve gastrectomy among obese adults. •Tai CM1, Huang CK, Lee YC, Chang CY, Lee CT, Lin JT.
  • 53.
    Gastroesophageal reflux disease symptomsand erosive esophagitis •Significant increase in the prevalence of GERD symptoms (12 vs. 47%) • •Erosive Esophagitis (17 vs. 67%) after LSG (P < 0.001). • Hiatal hernias increased significantly (6 vs. 27%; P < 0.001)
  • 54.
    MGB and GERD •Tolone Study •After MGB surgery, none of the patients reported de novo heartburn or regurgitation. •At endoscopic follow-up 1 year after surgery, •esophagitis was absent in all patients and no biliary gastritis or presence of bile was recorded
  • 55.
    MGB and GERD •Tolone Study •MGB Manometric features and patterns did not change significantly after surgery •Intragastric pressures (IGP) diminished statistically (from a median of 15 to 9.5, p<0.01) •MGB is a Low Pressure System
  • 56.
    MGB = LowPressure Sleeve = HIGH Pressure => GERD • Tolone Study •Intragastric pressures (IGP) diminished statistically (from a median of 15 to 9.5, p<0.01) •MGB is a Low Pressure System •In contrast, SG induced significant elevation IGP (from 15 to 19, P < 0.01) •Sleeve is a HIGH Pressure System
  • 57.
    Reflux Events MGBvs Sleeve Tolone Study • MGB => A dramatic decrease in the number of reflux events (from a median of 41 to 7; P < 0.01) MGB MGB Low Pressure = Less Reflux •SG +> significant increase in esophageal acid exposure & number of reflux episodes (from 33 to 53; P <0.01) •Sleeve is HIGH Pressure = More Reflux
  • 58.
    Esophageal adenocarcinoma after Sleeve •Int J Surg Case Rep. 2017; 32: 47–50. • Esophageal adenocarcinoma five years after laparoscopic sleeve gastrectomy. A case report • Fernando Gabriel Wright
  • 59.
    Esophageal adenocarcinoma after Sleeve •Int J Surg Case Rep. 2017; 32: 47–50. • Esophageal adenocarcinoma five years after laparoscopic sleeve gastrectomy. A case report • Fernando Gabriel Wright
  • 60.
    Esophageal Cancer After Sleeve •Shortcoming of LSG in the long-term follow-up and this is the Frequent onset of de novo GERD • Significant increase of GERD and hiatal hernia post sleeve, • Also an increase in revisional surgeries associated with refractory reflux post Sleeve
  • 61.
    Esophageal Cancer After Sleeve •48-Year-oldman that underwent a laparoscopic sleeve gastrectomy •Routine preoperative evaluation included an upper gastrointestinal series and EGD, which showed no reflux or hiatal hernia, no esophagitis or Barrett́ s esophagus. •Helicobacter pylori was negative. •15 months after the operation, he complained of new onset of typical GERD symptoms. He was put on proton pump inhibitors (PPI) •4 years later (fifth postoperative year) dysphagia to solids and a 10 kg weight loss. Endoscopy adenocarcinoma of the esophagus
  • 62.
    Esophageal Cancer After Sleeve •Ina prospective randomized trial that compared LSG with gastric banding, Himpens et al. found development of de novo reflux symptoms in 21.5% of the LSG cohort at one-year follow-up •Braghetto et al. analized 231 patients without reflux symptoms, esophagitis or Barrett, who underwent a LSG. In the follow-up, GERD symptoms were found in 23.2%, erosive esophagitis in 15.5%, and Barrett’s esophagus (intestinal metaplasia) in 1.2%
  • 63.
    Esophageal Cancer After Sleeve •twoother cases of esophageal adenocarcinoma after LSG have been published. •Scheepers et al. described the case of a 57-year-old woman who was submitted for a LSG and was diagnosed with esophageal adenocarcinoma four months after bariatric surgery [15]. •In another case reported by Sohn et al., a 44-year-old woman who underwent LSG developed an adenocarcinoma of the gastroesophageal junction 2.5 years after surgery [16]
  • 64.
    GERD & BariatricSurgery  GERD, Barrett's, Esophageal Cancer  Hx of General Surgery, Forgotten Allison, Hill Repairs (Failure Abandoned)  Rx with Nissen, Results of Nissen  GERD in Bariatric Surgery Band & Sleeve CAUSE GERD Sleeve Surgeons Failed Rx??  RNY Rx GERD  MGB Excellent Rx GERD Understanding Why?
  • 65.
    Systematic review: LaparoscopicNissen fundoplication for gastroesophageal reflux disease Laparoscopic Nissen fundoplication (LF) for gastroesophageal reflux disease (GERD). 10 years after LF, 36% reported heartburn & 29% reported regurgitation. The proportion using PPIs increased, from 9% in year 1 to 18% at 10 years.
  • 66.
    A randomized controlledtrial of laparoscopic Nissen fundoplication versus proton pump inhibitors for the treatment of patients with chronic gastroesophageal reflux disease (GERD): 3-year outcomes. •Surg Endosc. 2011 Aug;25(8):2547-54.
  • 67.
    RCT; Nissen vsPPIs •A randomized controlled trial (RCT) gastroesophageal reflux disease (GERD) •1. who were stable and symptomatically controlled with long-term medical therapy to •compare •ongoing medical therapy with •laparoscopic Nissen fundoplication (LNF).
  • 68.
    Nissen vs PPIs:No difference •GERD Sx or Acid exposure on 24-h pH monitoring •There were six treatment failures (12%) in the surgical group and eight treatment failures (16%) in the medical group by 3 years.
  • 69.
    RCT: CONCLUSIONS: For patientswhose GERD symptoms are stable and controlled with PPI, Medical therapy Nissen are equally effective
  • 70.
    Use of protonpump inhibitors after anti-reflux surgery: a nationwide register-based follow-up study •Jan 28, 2014 - •Lødrup A(1), Pottegård A(2), Hallas J(2),
  • 71.
    Denmark Nationwide health careregistry study •PPI use after Anti-reflux surgery (ARS) in the general Danish population using nationwide health care registries. •A nationwide retrospective follow- up study of all patients aged ≥18 and undergoing first-time ARS in Denmark during 1996–2010
  • 72.
    Denmark Nationwide health careregistry study • Female gender, high age, recent ARS, previous use of PPI & use of NSAIDs drugs or antiplatelet therapy significantly increased the risk of PPI use (Nissen failure).
  • 73.
    Long term failureof Nissen •3465 patients ARS •5, 10 & 15-year risks of New PPI Rx = 57%, 72% & *83%*, respectively •5, 10 & 15-year risks Long-term PPI use = 30%, 41% and *57%*
  • 74.
    Nissen Failure • ConclusionsRisk of PPI use after Nissen high! • More than 50% of patients became long-term PPI users • Patients should be made aware that long-term PPI therapy is often necessary after Nissen.
  • 75.
    Majority of Gastro-Esophageal RefluxDisease Patients Continue to Use Proton Pump Inhibitors After Anti-reflux Surgery (Nissen) A Madan et al. Aliment Pharmacol Ther 2006 Mar 01
  • 76.
    Nissen Failure 80%Rx PPIs •Nissen fundoplication at our institution over a period of over 3 years were asked to complete a questionnaire •80% patients were still taking anti-reflux medications including proton pump inhibitors
  • 77.
    Rx GERD withNissen Very Questionable Results
  • 78.
  • 79.
    Survey 3,000 MGBPatients • 64% of MGB patients taking antacid medications for GERD preop (PPIs, H2Blockers or Antacids) • Post MGB resolution of GERD Sx with discontinuation of medications 81%
  • 80.
    MGB Rx GERD Equalto or Better Than Nissen • How Does it Work?
  • 81.
    MGB Rx GERD Mechanismof Action 1. Reduction of Acid Production 2. Weight loss 3. Downward traction on the stomach 4. *Creation of LOW Pressure System*
  • 82.
    MGB Rx GERD Mechanismof Action 1. Reduction of Acid Production 2. Weight loss 3. Downward traction on the stomach 4. *Creation of LOW Pressure System*
  • 83.
    Conclusions • GERD commonserious problem in Bariatric patients • Nissen “gold standard” poor results + = simply taking PPI's • Dr Rutledge MGB Series: 80% success Rx GERD • Understand WHY! • MGB Good to Excellent Rx GERD
  • 84.
    Post-op malnutrition Vitamin andmineral deficiencies after Sleeve Gastrectomy: A huge challenge Thought that deficiencies mostly occurred in procedures with a malabsorptive component, like the RNY, MGB or the BPD The risk for deficiencies after sleeve gastrectomy was considered low. 3 Studies show that sleeve deficiencies occur almost as much.3,4 Research by Capoccia et al. showed that following laparoscopic sleeve gastrectomy a significant proportion of patients developed vitamin B12 and folate deficiency.4
  • 85.
    Deficiencies in Sleeve •Dr.Aarts iron deficiency 43% Sleeve patients •In 26% of patients had significantly low B12, folate, iron and vitamin D levels in sleeve gastrectomy patients.3 •“There is no doubt that the levels of nutritional deficiencies after sleeve are higher than those reported in the literature.” •“In our series, 28% of patients were anemic, but the literature states only a few percent of anemia cases per year. •This is incorrect, nutritional deficiency rates after sleeve gastrectomy are grossly under reported.
  • 86.
    Malnutrition MGB •You CanGet Malnourished After MGB •But •Usually it is not a Poor Diet •It usually means that the Bypass is Too Long and Needs revision •In skilled hands this occurs in 0.1 to 1% of patients •For 99%-99.9% of MGB Patients the Recommended Diet for MGB is... •Practically every system in the human body benefits from the "Mediterranean diet"
  • 87.
    MGB vs Sleeve,Meta-analysis  Mini-Gastric Bypass/One-Anastomosis Gastric Bypass Versus Sleeve Gastrectomy  for Morbid Obesity: a Systematic Review and Meta-analysis  Seventeen studies met the inclusion criteria incorporating 6,761 patients.  In this study  MGB study patients were older, and heavier than comparable Sleeve patients
  • 88.
    MGB vs Sleeve,Meta-analysis In spite of MGB patients being older and heavier…This study reveals MGB => MGB better weight loss vs Sleeve => MGB better remission of comorbidities vs Sleeve (i.e. Diabetes Mellitus), => MGB Shorter hospital stay vs Sleeve => MGB Significantly lower death rate in the MGB than Sleeve! Mini-Gastric Bypass/One-anastomosis gastric bypass (MGB) is a safe, feasible and effective bariatric procedure
  • 89.
    Sleeve is aPoor Treatment of Diabetes MGB is an Excellent Treatment of Diabetes
  • 90.
    Sleeve Diabetes RemissionRates at 7yrs (28%) • Ann Surg. 2017 Jul 24. Individualized Metabolic Surgery Score: Procedure Selection Based on Diabetes Severity. •At median postoperative follow-up of 7 years (range 5-12) •Diabetes remission (HbA1C <6.5% off medications) •49% after RYGB and •28% after SG (P < 0.001)
  • 91.
    Sleeve Rx Diabetes •AnnSurg. 2016 Oct;264(4):674-81.Can Sleeve Gastrectomy "Cure" Diabetes? Long-term Metabolic Effects of Sleeve Gastrectomy in Patients With Type 2 Diabetes. • long-term metabolic effects of laparoscopic sleeve gastrectomy •Complete remission (HbA1c <6% off medications) in 11% •"cure" (continuous complete remission for ≥5 years) was achieved in 3%
  • 92.
    RCT Sleeve vsMGB 5 yrs • At 60 months, •18 MGB pts (60%) •9 Sleeve pts (30%) •Achieved the primary end points •HbA1c ≤6.5% without glycemic therapy.
  • 93.
    Considering the MGB “InEvery Study, By Every Measure the MGB is Equal to or Better than any other Surgery”