PARASTOMAL HERNIA : An ostomy is an artificial opening through the abdominal wall for the intestine or ureter in order to discharge feces or urine. Hernias that are associated with colostomies, ileostomies, jejunostomies or urostomies, where viscus penetrates the abdominal wall are called as paraostomal hernias
DIGITAL RECTAL EXAMINATION- Skill Lab- OSCE
#digitalrectalexamination #surgicaleducator #babysurgeon #skilllab #osce
Subscription Link: http://youtube.com/c/surgicaleducator...
Surgical Educator Android App link: https://play.google.com/store/apps/de...
Dear viewers,
• Greetings from “Surgical Educator”
• Today I am uploading one more video on Skill Lab procedure for your OSCE exam.
• In this episode, I am talking about the DRE- Digital Rectal Examination , the skill which should be mastered by all medical students.
• I hope you can master the skill by watching this video and can do all the steps in the correct sequence.
• You can enjoy all my videos in the following link:
• youtube.com/c/surgicaleducator
• Thank you for watching the video.
PARASTOMAL HERNIA : An ostomy is an artificial opening through the abdominal wall for the intestine or ureter in order to discharge feces or urine. Hernias that are associated with colostomies, ileostomies, jejunostomies or urostomies, where viscus penetrates the abdominal wall are called as paraostomal hernias
DIGITAL RECTAL EXAMINATION- Skill Lab- OSCE
#digitalrectalexamination #surgicaleducator #babysurgeon #skilllab #osce
Subscription Link: http://youtube.com/c/surgicaleducator...
Surgical Educator Android App link: https://play.google.com/store/apps/de...
Dear viewers,
• Greetings from “Surgical Educator”
• Today I am uploading one more video on Skill Lab procedure for your OSCE exam.
• In this episode, I am talking about the DRE- Digital Rectal Examination , the skill which should be mastered by all medical students.
• I hope you can master the skill by watching this video and can do all the steps in the correct sequence.
• You can enjoy all my videos in the following link:
• youtube.com/c/surgicaleducator
• Thank you for watching the video.
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
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.
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
Mini-Gastric BypassShown to be an excellent operation
But Many New Surgeons Do Not Know the Critical Factors to Do the MGB Correctly
One Critical Success Factor:
LONG Gastric Pouch
Gastric bypass surgery makes the stomach smaller and causes food to bypass part of the small intestine. You will feel filled more quickly than when your stomach was its original size. This reduces the quantity of food you can eat at one time. Bypassing part of the intestine reduces how much food and nutrients are absorbed. This leads to weight loss
Anatomy of the stomach
Brief history of gastric surgery
Indications of Gastrectomy
The different types of gastrectomies.
The various reconstructions following a gastrectomy
Post Gastrectomy syndromes
Mini-Gastric Bypass Done Right: A Description of the Surgical TechniqueDr. Robert Rutledge
Mini-Gastric Bypass Done Right:
A Description of the Surgical Technique
Authors: Dr.Rutledge, Dr.K.S.Kular and Dr.Manchanda.
This chapter discusses the technique of Mini-Gastric Bypass (MGB). The title of the chapter is Mini-Gastric Bypass Done Right.The surgical technique is selected to indicate our opinion that many surgeons and physicians have been and remain confused about the performance of the MGB as created and taught be Dr Rutledge.
Explicitly, the Mini-Gastric Bypass(MGB) which will be discussed in this article is NOT a so called Single Anastomosis Bypass, its not the Omega Loop Bypass nor the SAGB nor the SADI and especially it is definitely not the Old Mason Loop Gastric Bypass. These misnomers and other surgeon and patient misunderstandings and confusion has led to problems with this otherwise it is a simple procedure.
The Mini-Gastric Bypass is reported and described as a simple technique yet as the following examples will show it can be both tragic and occasionally deadly when used by surgeons with inadequate understanding of the procedure and its technique.
The Mini-Gastric Bypass is an analogue of two routine straightforward general surgical principles, the Collis Gastroplasty and the Antrectomy and Billroth II. Although the foundational principles of the MGB are relatively simple and straightforward it has been shown that many surgeons are confused about the details of the procedure, leading in some cases to tragic and deadly results in the wrong hands.
Weight loss surgery - is it the right choice? By TruweightTruweight
If you think that you are too busy to follow a healthy way to lose weight then you need to at least consider the risks associated with Weight Loss Surgeries and their side effects.
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
Prediction of Weight Loss Following The Mini-Gastric Bypass: Multivariate Regression Modeling
Robert Rutledge, K Kular, N. Manchanda CLOS Center For Laparoscopic Obesity Surgery, MGB Review Corp
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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1. The MGB
Technique and Physiology
Tips and Tricks
MGB: Done Well is a Simple Operation
But: Need to Understand
Anatomy & Physiology =>
Mechanism of Action => Technique
2. Need for Safety
• Beware of Brave Surgeons
• Need to Understand
1. How to Avoid Trouble
2. How to Get Out of Trouble
4. MGB Part 1: Creation of the Gastric Pouch
• Creation of the Gastric Pouch (Band/Sleeve/RNY)
• Bougie of size 28 to 36 F can be used to fashion the pouch
• Understanding MGB Anatomy & Physiology
• MGB NOT Obstructive
• No Tight Pouch (The MGB is not a Sleeve)
• Pouch Diameter and Length are Not Critical
• MGB Pouch Size:
• Pouch Diameter = Esophagus;
• Pouch Length = Allow GJ at the greater curve of the stomach
• Start the Gastric Pouch (Long Pouch) at or beyond Crow’s Foot (junction of body and antrum of the stomach.
• Beware a Twist in the Pouch)
• Avoid Bleeding Along Staple Line; (Very Slow Application of Stapler, use compression)
• Management of EG junction; MGB vs Sleeve (DO NOT go near the EG junction)
• Management of the gastric fundus; (Leaving some fundus is acceptable)
• Never dissect the EG junction
• Never attempt to visualize the diaphragmatic cura
• Always stay lateral to the EG junction
• Leaving some of the fundus behind in the MGB is always acceptable
• Reminder: The MGB is NOT a Sleeve, The MGB is NOT a RNY
• Complete division of the stomach in NOT critical in the MGB
5. Management of Hiatal Hernia in
Patients WITH or WITHOUT GERD
• Do Nothing!!
• Do Not Dissect the Hiatus,
• Do Not Repair the Crua.
•Reminder the MGB is not a sleeve.
•In cases of a large hiatal hernia
•Reduce the stomach into the abdomen and
•Complete the usual MGB pouch.
•MGB leads to greater than 85% resolution of GERD (Rutledge),
•further treatment is rarely needed
•Additional procedure can be performed in 12-18 months when the
patient is healthier and smaller if necessary (RareNever needed).
6. Bilio-Pancreatic Bypass
•Never Divide the omentum;
•Retract the omentum medially
•Run the small bowel hand over hand with atraumatic bowel clamps
•Estimate distance of each hand to hand movement
•Estimate Measure the length of the bowel;
•Understand that accurately measuring the bowel length is a “FOOL’S ERRAND”
•Understand that bowel length varies moment to moment, hour to hour and day to day.
•Understand that any and ALL bowel length measurements are inherently imprecise
and thus weight loss is as unpredictable with MGB as with Band, Sleeve and RNY.
•Because of lack of precision always be conservative in creating the bilio-pancreatic
limb.
•Warning the MGB can be the most powerful form of Bariatric Surgery
•Measure the length of the grasper tip (usually between 1.5 and 3 cm)
•Run the bowel length approximately 60 steps of 3 cm (1.2 inches) =>
•Creating Bilio-pancreatic limb length of 180 cm
7. Bilio-Pancreatic Limb
Length
•Recognize risk of long Bilio-Pancreatic Limb Length and Excess Weight
Loss/Malnutrition
•Understand management of Excess Weight Loss (Rapid 30-60 min Revision)
•Recommendations to MGB Surgeons with
•MGB Experience of Less Than 250 Cases
•MI 30-60 180 cm (count 60 3 cm/1.2 inch steps)
•BMI 60-80 200-250 cm (65-80 3 cm/1.2 inch steps)
•Elderly (Age > 60) Decrease limb length by 20%
•Vegetarians Decrease limb length by 20%
•Frail/Fragile patient Decrease limb length by 20%
•First 200 MGB’s (New MGB surgeon) Decrease limb length by 20%
8. Gastro-Jejunostomy
• Possibly the most IMPORTANT step in MGB
• After Identifying the Site for the GJ Move Loop to left upper quadrant
• Confirm at least 1-2 meters more distal bowel
• (It is unnecessary to run the entire small bowel)
• Carefully expose tip of gastric pouch; Make sure it is not twisted
• Create gastrotomy ANTERIOR to the staple line 1 cm from first staples at the start of the pouch
• Create jejunotomy on anti-mesenteric border at 180 cm Bilio-pancreatic limb
• Dilate the jejunotomy with the Anvil of the 60-mm blue staple cartridge
• then remove the anvil and place the staple cartridge into the bowel
• Thread the bowel all the way onto the cartridge
• Grasp the gastric pouch at the gastrotomy and advance the anvil into the gastrotomy
• Now stop
• The surgery is almost over; Take your time
• Critical Factors in Gastro-Jejunostomy
• Several features in positioning the staple cartridge, the gastric pouch and the bowel must be exactly
aligned for a successful surgery. Simply proceeding slowly and carefully will result in a good
outcome.
9. Gastro-Jejunostomy
• Critical Factors:
• Both the gastric pouch and the bowel edges must meet at exactly the junction of the cartridge and the anvil of the staple gun
• No twist in either the bowel or the gastric pouch
• Large visible area of bowel anteriorly (should not be too close to the bowel mesentary)
• Gastric pouch staple line should NOT cross the staple cartridge/anvil longitudinally (keep the gastric pouch staple line out of the jaws
of the stapler and several millimeters away from the anastomosis)
• There should be visible space on the posterior gastric wall between the lateral gastric staple line and the staple cartridge and anvil
(avoid ischemic island)
• Take time No tension on the bowel
• Gastric mesentary not in the staple line
• Carefully and slowly evaluate the placement of the gastric pouch, the bowel and the staple gun
• Do not proceed until each is perfectly placed
• Then close the stapler and begin a very very slow firing of the staple gun, use compression to avoid bleeding.
• Using extra time Slowly is the watchword
• This staple line MUST NOT BLEED
• This achieved simply by the surgeon’s patience and direct pressure
• The stapled GJ is completed and the stapler removed
• Now the GJ should lie perfectly with the sweep of the bowel from the patient’s left to right and the GJ located at the level of the greater
curvature of the stomach or the transverse colon.
• If it is not perfect do not proceed but stop and consider dividing the GJ and performing another GJ 10-15 cm distal to the failed
anastomosis.
• Do not leave an imperfect GJ.
10. Gastro-Jejunostomy
Closeure
•All that is left is a minor closure of a 1-2 cm defect of the GJ.
•The Diameter of the Gastro-Jejunostomy in the MGB (Large)
•A few comments stapled or hand sewn closure is acceptable but do not forget 100
years of GI and general surgery science and experience.
•One or two layers NEVER MORE.
•The anastomosis heals by diffusion of oxygen blood cells into the spaces between the
sutures. This means there must me 1-3 mm between sutures and the suture should
NOT strangulate the tissue.
•Leak Testing
•For the first 150 cases test the anastomosis with air and methylene blue for
demonstration of technical errors. After the first 150 cases if the surgeons still finds
leaks with air or methylene blue he/she should consider retraining for laparoscopic
surgey with another more experienced surgeon.
•End of Operation
•Do not inject Marcaine in the Port Sites (It does not help post op pain)
•Inspect the Gastro-jejunostomy, the gastric pouch and the EG junction
•No Drains
11. And More...
•Post Op
•Post Op Orders
•Discharge Instructions
•MGB Diet
•Supplements
•Follow Up
•Follow Up Blood Tests
•Dx Leak Protocol
•Rx Leak Protocol
19. Misunderstanding of the MGB Surgery
Death and Complications to MGB patients
MGB Center/Surgeon of Excellence Program
Why, What is the Need:
=> 20 Years of Documented MGB Excellence
And
=> 20 Years of Documented
Misunderstanding of the MGB
including Death and Complications to MGB
patients
in the Hands of “Non-Expert” MGB Surgeons
20. Int J Surg. 2016 Sep
Sleeve gastrectomy vs Mini gastric bypass
Misunderstanding & Complications:
CONCLUSION:
“MGB seems to have better weight loss at one year
compared to LSG with
“ MGB higher gastric complications. (??)”
(No other study has reported stricture at the GJ
anastomosis of such high rates)
21. Tragic Report of "Omega-Loop" Bypass with
100% Excess Weight Loss Resulting in Liver
Failure and Death...
Misunderstanding & Complications:
22. A Tragic Report of "Omega-Loop" Bypass with 100% Excess
Weight Loss Resulting in Liver Failure and Death...
Need for Standardization, Education and Recognition prevent
more harm
Misunderstanding & Complications:
CONCLUSION:
“MGB seems to have better weight loss at one year
compared to LSG with
“ MGB higher gastric complications. (??)”
(No other study has reported stricture at the GJ
anastomosis of such high rates)
23. Int J Surg. 2016 Sep
Sleeve gastrectomy vs Mini gastric bypass
Misunderstanding & Complications:
At one year MGB >> Sleeve,
%TWL 38 ± 8 vs. 34 ± 8 (P < 0.0001)
BMI Decrease: -17 ± 5 vs. -15 ± 4 (P = 0.005)
But
** Rate of stenosis higher for MGB group,
** 16.9% vs.
** 0% in Sleeve Patients (P < 0.0001).
24. The Mini-Gastric Bypass:
Standardization, Education & Recognition
MGB Center/Surgeon of Excellence Program
Why, What is the Need:
=> 20 Years of Documented MGB Excellence
And
=> 20 Years of Documented
Misunderstanding of the MGB
including Death and Complications to MGB
patients
in the Hands of “Non-Expert” MGB Surgeons
25. The MGB Certificates of Excellence:
Standardization, Education & Recognition
Recognition
=> Certified MGB Certificates Recognized
Facebook
Web page
Twitter
Youtube
Dr Rutleddge and
Members of the MGB Board of Governors
OVER 100,00 Followers
JOIN US
26. The MGB Certificates of Excellence:
Standardization, Education & Recognition
MGB Center/Surgeon of Excellence Program
Standardization
=> Expert Group => MGB Guidelines
Education
=> Teaching and Certification
Knowledge: Bronze Certificate
Technical Skill: Silver Certificate
Outcomes: Gold Certificate
Teacher: Platinum Certificate
27. Death: 8 months after MGB
Diagnosis & Management?
29 y.o. female 8 months after MGB
Hypoalbuminemia, anemia, elevated liver
enzymes and direct bilirubinemia,
metabolic acidosis and Steatohepatitis
What to Do!
Patient did not respond to Medical Rx and
DEATH.
Do you know what to do?
Int J Surg Case Rep. 2017
28. Malnutrition: Death 8 months after MGB
Diagnosis & Management?
29yr F, 8 months after MGB:
=> Low albumin & Hgb,
High LFTs & Bilirubin,
Acidosis & Steatohepatitis
=> Diagnosis? Simple:
Bypass is Too LONG
Liver Failure,
Malnutrition/Deficiency(s)
Int J Surg Case Rep. 2017
29. Malnutrition: Death 8 months after MGB
Diagnosis & Management?
29yr F, 8 months after MGB:
=> Diagnosis? Simple: Bypass is Too LONG
Liver Failure, Malnutrition/Deficiency(s)
=> What to Do?
Preop Education/Planning
Resuscitation,
Nutritional Support,
Early, Simple 30-60 min Revision
Int J Surg Case Rep. 2017
30. JPEN J Parenter Enteral Nutr. 2017
"Nutrition Deficiencies in Mini Gastric Bypass
Patients: Where Do We Stand Today?"
Bétry C, Disse E, Chambrier C, Laville M, Robert M.
Do You Know What to Do?
JPEN J Parenter Enteral Nutr. 2017
Nutrition Deficiencies in Mini Gastric Bypass Patients.
Athanasiou A, Markakis C, Spartalis E.
31. Surg Obes Relat Dis. 2016
Conversion of
OAGB/MGB to Roux-en-Y for
Bile reflux gastritis after failed
Braun jejunojejunostomy.
Nimeri A
Do You Know What to Do?
32. A Comparison of SADI Patients
Single anastomosis sleeve ileal (SASI) bypass
Int J Surg. 2016 Efficacy of single anastomosis
sleeve ileal (SASI) bypass for type-2 diabetic
morbid obese patients, Mahdy T1
10% postoperative complications. Pulmonary
embolism, Postoperative bleeding, Leak & one
complete obstruction at the gastro-ileal
anastomosis.
6 months postoperative, Marginal ulcer,
12 months after surgery, another patient (2%) was
re-operated for excessive weight loss.
35. https://mgbguidelines.wordpress.com/gastric-pouch-creation/
Dr Rutledge's Advice
MGB Technique
• If You Do Not Understand the Basic
General Surgery Principles
• My advice will not appear justified
• Expertise from Band, Sleeve, RNY
& BPD/Sadi
• Often do not apply to the Anatomy
& Physiology of the MGB
• Reminders of Basic GI Surgery the
MGB
36. https://mgbguidelines.wordpress.com/gastric-pouch-creation/
The Mini-Gastric Bypass
• Of course anyone is entitled to
perform any surgery they see fit
• But some surgeons have performed
an operation that they claim is a
“Mini-Gastric Bypass”
• Do not understand the
Anatomy & Physiology of the
• Basic GI Surgery the MGB and
Failed Mason Loop Gastric Bypass
37. https://mgbguidelines.wordpress.com/gastric-pouch-creation/
The Mini-Gastric Bypass
Do Not Understand Appropriate use Billroth II
• Some surgeons Do not understand Basic
General Surgical Principles
• Appropriate use Billroth II
• Yes => Antrectomy & Billroth II
• No => Total/Subtotal Gastrectomy & Billroth II
• Need to Understand Why
• Anatomy & Physiology of proper use of Billroth
II
• i.e. Failed Mason Loop Gastric Bypass
40. https://mgbguidelines.wordpress.com/gastric-pouch-creation/
•
The Mini-Gastric Bypass
Do Not Understand Failed Mason Loop vs
MGB
• Critics of MGB as well as certain
surgeons performing what they call
“MGB?”
• Do not understand the
Anatomy & Physiology of the MGB
• Difference between MGB and the
Failed Mason Loop Gastric Bypass
• Have not learned the lessons of General
surgery and when and to use Billroth II
65. MGB Gastric Pouch Length
Pouch Volume
• How Long is the MGB
Pouch?
• Wrong Question
Not in Centimeters
• Answer: From
EG Junction to Beyond the
Crow's Foot into the
Antrum
• The MGB Gastro-
Jejunostomy should lie at
the level of the Transverse
Colon
66. https://mgbguidelines.wordpress.com/gastric-pouch-creation/
•
Creation of the MGB Pouch
• Creation of the Gastric Pouch
(Band/Sleeve/RNY)
• Bougie of size 28 to 36 F can be used to
fashion the pouch
• Understanding MGB Anatomy & Physiology
• MGB NOT Obstructive
• No Tight Pouch (The MGB is not a Sleeve)
• Pouch Diameter and Length are Not Critical
• MGB Pouch Size:
• Pouch Diameter = Esophagus;
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•
Creation of the MGB Pouch
• Creation of the Gastric Pouch
(Band/Sleeve/RNY)
• Creation of the MGB gastric pouch
should be Simple
• but there are several differences
between the MGB pouch and the
• Gastric pouch created in the Sleeve,
RNY and the dissection recommended
for the Lap Band
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•
Creation of the MGB Pouch
• Never dissect the EG junction
• Never attempt to visualize the diaphragmatic cura
• Always stay lateral to the EG junction
• Leaving some of the fundus behind in the MGB is
always acceptable
• Reminder: The MGB is NOT a Sleeve, The MGB is
NOT a RNY
• Complete division of the stomach in NOT critical in the
MGB
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•
MGB: Gastric Pouch
• Beware a Twist in the Pouch
• Avoid Bleeding Along Staple Line; (Very Slow
Application of Stapler, use compression)
• Management of EG junction; MGB vs Sleeve
(DO NOT go near the EG junction)
• Management of the gastric fundus; (Leaving
some fundus is acceptable)
• Never dissect the EG junction
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•
Management of Hiatal
Hernia
• In cases of a large hiatal hernia
• Reduce the stomach into the abdomen and
• Complete the usual MGB pouch.
• MGB leads to greater than 85% resolution of
GERD (Rutledge),
• Further treatment is rarely needed
• Additional procedure can be performed in 12-18
months when the patient is healthier and smaller if
necessary (RareNever needed).
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•
Bilio-Pancreatic Bypass 2
• Understand that accurately measuring the
bowel length is a “FOOL’S ERRAND”
• Understand that bowel length varies moment
to moment, hour to hour and day to day.
• Understand that any and ALL bowel length
measurements are inherently imprecise and
thus weight loss is as unpredictable with MGB
as with Band, Sleeve and RNY.
• Because of lack of precision always be
conservative in creating the bilio-pancreatic
limb.
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•
Bilio-Pancreatic Limb
Length
• Create gastrotomy ANTERIOR to the staple
line 1 cm from first staples at the start of the
pouch
• Create jejunotomy on anti-mesenteric border
at 180 cm Bilio-pancreatic limb
• Dilate the jejunotomy with the Anvil of the 60-
mm blue staple cartridge
• then remove the anvil and place the staple
cartridge into the bowel
• Thread the bowel all the way onto the
cartridge
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•
Gastro-Jejunostomy 1b
• Create gastrotomy ANTERIOR to the staple
line 1 cm from first staples at the start of
the pouch
• Create jejunotomy on anti-mesenteric
border at 150-200 cm Bilio-pancreatic limb
• Dilate the jejunotomy with the Anvil of the
60-mm blue staple cartridge
• then remove the anvil and place the staple
cartridge into the bowel
• Thread the bowel all the way onto the
cartridge
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•
Gastro-Jejunostomy 2a
• Grasp the gastric pouch at the gastrotomy and
advance the anvil into the gastrotomy
• Now stop
• The surgery is almost over; Take your time
• Critical Factors in Gastro-Jejunostomy
• Several features in positioning the staple
cartridge, the gastric pouch and the bowel
must be exactly aligned for a successful
surgery. Simply proceeding slowly and
carefully will result in a good outcome.
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•
Gastro-Jejunostomy 2c
• Gastric pouch staple line should NOT cross
the staple cartridge/anvil longitudinally (keep
the gastric pouch staple line out of the jaws of
the stapler and several millimeters away from
the anastomosis)
• There should be visible space on the posterior
gastric wall between the lateral gastric staple
line and the staple cartridge and anvil (avoid
ischemic island)
• Take time No tension on the bowel
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•
Gastro-Jejunostomy
• Gastric mesentary not in the staple line
• Carefully and slowly evaluate the placement of
the gastric pouch, the bowel and the staple
gun
• Do not proceed until each is perfectly placed
• Then close the stapler and begin a very very
slow firing of the staple gun, use compression
to avoid bleeding.
• Using extra time Slowly is the watchword
• This staple line MUST NOT BLEED
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•
Gastro-Jejunostomy
• This staple line MUST NOT BLEED
• This achieved simply by the surgeon’s
patience and direct pressure
• The stapled GJ is completed and the stapler
removed
• Now the GJ should lie perfectly with the sweep
of the bowel from the patient’s left to right and
the GJ located at the level of the greater
curvature of the stomach or the transverse
colon.