This document provides guidance on performing the mini-gastric bypass (MGB) technique. It emphasizes that surgeons must understand the anatomy and physiology of the MGB to avoid complications. Key steps include creating a long gastric pouch, placing the gastrojejunostomy at the level of the transverse colon, and being conservative when measuring the biliopancreatic limb length. Surgeons are warned against confusing the MGB with other procedures or violating principles of general surgery. Understanding the distinctions between total/subtotal gastrectomy and distal gastrectomy/antrectomy is emphasized.
Recent Update on Management of Ulcerative ColitisDr Amit Dangi
Recent update on the surgical and medical management of ulcerative colitis, including various controversies regarding IPAA and recent medical management incorporating the role of biologicals
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.
Recent Update on Management of Ulcerative ColitisDr Amit Dangi
Recent update on the surgical and medical management of ulcerative colitis, including various controversies regarding IPAA and recent medical management incorporating the role of biologicals
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.
PowerPoint presentation on Choledochal Cysts, also known as biliary cyst, uploaded by Dr. Vaskar Humagain, first presented in 31st December, 2013. This presentation contains all the information about Choledochal Cysts, the original and revised Todani classification of choledochal cysts, pathogenesis, other associated congenital anomalies, clinical features in infant and adult, management of choledochal cysts. Comments are highly welcome :)
EUS Guided Interventions for Pancreatobiliary TumoursJarrod Lee
Endoscopic Ultrasound (EUS) has advanced rapidly in recent years, and has evolved from a primarily diagnostic tool, to one that has an increasing role in interventions. We review the latest roles of EUS guided interventions for pancreas and bile duct tumours.
The lecture was the plenary lecture at the Philippines National Endoscopy Conference 2014
We review the most important articles above the differents Precut techiques: Fistulotomy, Papillotomy and Transpancreatic Sphincterotomy. The techique is safe and effective. And a brief comment about my experience in Fistulotomy, "No Post ERCP Pancreatitis because No touch the papilllary orifice"
Sleeve gastrectomy surgery is the best option for weight loss.Dr.Ramesh is an icon in the field of medical science. He has a lot of experience in the field of surgery.
Knowledge of the basic principles of bowel resection, anastomosis, and the stoma formation, will allow the gynecologist to competently manage many scenarios in which malignancies involve the bowel and require resection for restoration of bowel continuity. In patients with ramified pelvic tumours, a colorectal surgeon may be required as portion of the multidisciplinary approach to ensure complete removal of the cancer (Alves et al., 2004).
The type of the intestinal anastomosis one performs depends on personnel preference but irrespective of the technique availed, principles that ensure a successful outcome include: good vascular supply to segments being specifically approximated, no distal obstruction, and a tension free repair. There are certain bowel disorders like bloating, colic pain etc (Sreeremya, 2018).
Comparison of Revision in Roux-en-Y vs Mini-Gastric BypassDr. Robert Rutledge
Comparison of Revision in
Roux-en-Y vs
Mini-Gastric Bypass
Dr K S Kular
Kular Medical Education & Research Society
Kular Group of Institutes
drkskular@gmail.com
www.kularhospital.com
Artery first approach For Pancreatic Head tumours by Dr Harsh Shah (www.gastr...Dr Harsh Shah
Artery first approach to Pancreatic head tumour. There are various approaches as described in this presentation. Pros & Cons of all approaches are discussed.
PowerPoint presentation on Choledochal Cysts, also known as biliary cyst, uploaded by Dr. Vaskar Humagain, first presented in 31st December, 2013. This presentation contains all the information about Choledochal Cysts, the original and revised Todani classification of choledochal cysts, pathogenesis, other associated congenital anomalies, clinical features in infant and adult, management of choledochal cysts. Comments are highly welcome :)
EUS Guided Interventions for Pancreatobiliary TumoursJarrod Lee
Endoscopic Ultrasound (EUS) has advanced rapidly in recent years, and has evolved from a primarily diagnostic tool, to one that has an increasing role in interventions. We review the latest roles of EUS guided interventions for pancreas and bile duct tumours.
The lecture was the plenary lecture at the Philippines National Endoscopy Conference 2014
We review the most important articles above the differents Precut techiques: Fistulotomy, Papillotomy and Transpancreatic Sphincterotomy. The techique is safe and effective. And a brief comment about my experience in Fistulotomy, "No Post ERCP Pancreatitis because No touch the papilllary orifice"
Sleeve gastrectomy surgery is the best option for weight loss.Dr.Ramesh is an icon in the field of medical science. He has a lot of experience in the field of surgery.
Knowledge of the basic principles of bowel resection, anastomosis, and the stoma formation, will allow the gynecologist to competently manage many scenarios in which malignancies involve the bowel and require resection for restoration of bowel continuity. In patients with ramified pelvic tumours, a colorectal surgeon may be required as portion of the multidisciplinary approach to ensure complete removal of the cancer (Alves et al., 2004).
The type of the intestinal anastomosis one performs depends on personnel preference but irrespective of the technique availed, principles that ensure a successful outcome include: good vascular supply to segments being specifically approximated, no distal obstruction, and a tension free repair. There are certain bowel disorders like bloating, colic pain etc (Sreeremya, 2018).
Comparison of Revision in Roux-en-Y vs Mini-Gastric BypassDr. Robert Rutledge
Comparison of Revision in
Roux-en-Y vs
Mini-Gastric Bypass
Dr K S Kular
Kular Medical Education & Research Society
Kular Group of Institutes
drkskular@gmail.com
www.kularhospital.com
Artery first approach For Pancreatic Head tumours by Dr Harsh Shah (www.gastr...Dr Harsh Shah
Artery first approach to Pancreatic head tumour. There are various approaches as described in this presentation. Pros & Cons of all approaches are discussed.
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.
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
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
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
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
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
Health Education on prevention of hypertensionRadhika kulvi
Hypertension is a chronic condition of concern due to its role in the causation of coronary heart diseases. Hypertension is a worldwide epidemic and important risk factor for coronary artery disease, stroke and renal diseases. Blood pressure is the force exerted by the blood against the walls of the blood vessels and is sufficient to maintain tissue perfusion during activity and rest. Hypertension is sustained elevation of BP. In adults, HTN exists when systolic blood pressure is equal to or greater than 140mmHg or diastolic BP is equal to or greater than 90mmHg. The
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
Nursing Care of Client With Acute And Chronic Renal Failure.ppt
Mgb technique (the Rutledge Technique)
1. The MGB
Technique and Physiology
Tips and Tricks
Simple Operation Done Well
Need to Understand
Anatomy & Physiology!!
2. Need for Safety
• Beware of Brave Surgeons
• Need to Understand
1. How to Avoid Trouble
2. How to Get Out of Trouble
Dr. Rutledge is an Excellent
Advisor, Listen to Him!
He Has Made So Many Mistakes
3. 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
4. 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).
5. 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
6. 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%
7. 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.
8. 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.
9. 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
10. And More...
•Post Op
•Post Op Orders
•Discharge Instructions
•MGB Diet
•Supplements
•Follow Up
•Follow Up Blood Tests
•Dx Leak Protocol
•Rx Leak Protocol
18. Int J Surg Case Rep. 2017; Death
8 months after mini gastric bypass
29 y.o. female 8 month after MGB
Hypoalbuminemia, anemia, elevated liver
enzymes and direct bilirubinemia,
metabolic acidosis and Steatohepatitis
They Did Not Know What to Do!
Patient did not respond to medical care
and died.
Do you know what to do?
19. 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.
20. 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?
21. 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.
24. 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
25. 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
26. 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
29. 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
55. 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;
57. https://mgbguidelines.wordpress.com/gastric-pouch-creation/
•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
58. https://mgbguidelines.wordpress.com/gastric-pouch-creation/
•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
60. https://mgbguidelines.wordpress.com/gastric-pouch-creation/
•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 1
• 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
• 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 2b
• 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)
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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.
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•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.
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•Gastro-Jejunostomy Closeure
• 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