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
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.
Understanding Weight Loss After Bariatric SurgeryUnderstanding the Bilio-Pancreatic Limb Length
Statistics, Random Distribution and Too Little or Too Much of a Good Thing
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.
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.
Understanding Weight Loss After Bariatric SurgeryUnderstanding the Bilio-Pancreatic Limb Length
Statistics, Random Distribution and Too Little or Too Much of a Good Thing
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.
Safe and Effective Treatment of Obesity & Diabetes:Failure of the Band, Sleeve & RNYvsSuccess of the Mini-Gastric Bypass
Medical News: Bypass Surgery for Diabetes w Nonmorbid Obesity? Marlene Busko: Jun 04, 2013
BUT: Not metioned in the abstract:
22 serious complications in 60 RNY patients (36%);
2 most serious complications Anastomotic leaks (3.3%)
1 patient suffered anoxic brain injury.
RNY pts more likely to have Complications
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
PREVENTIONandTreatment of Sleeve Gastrectomy Leaks
Dr Rutledge
Where does it occur?
ONE PLACE!
This is “Tiger Country” – remember that!
Managing ComplicationsFIRST Prevent Complications
Managing LeaksFirst Prevent Leaks!!
Examples of ComplacencySleeve Gastrectomy Leak
“Sleeve Gastrectomy & Risk of Leak: Systematic Analysis of 4,888 Patients”
“Risk of leak is low at 2.4%"
Surg Endosc. 2012 Jun;26(6):1509-15. Epub 2011 Dec 17. Aurora AR, Khaitan L, Saber AA. Department of Surgery, University Hospitals Case Medical Center, Cleveland, Ohio
Five Year Outcome Sleeve Gastrectomy Mini-Gastric Bypass From a Community Hos...Dr. Robert Rutledge
Five Year Outcome Sleeve Gastrectomy Mini-Gastric Bypass From a Community Hospital in Punjab, India
Dr K S Kular
Kular Medical Education & Research Society
Kular Group of Institutes
drkskular@gmail.com
www.kularhospital.com
Sleeve
MGB
Kular Hospital
Sleeve v MGB (Hint: MGB Better)
Weight Loss Raw Data, Weight Loss Excluding SG Revisions v Age Wt matched MGBs, Resolution of Co-Morbidities, Patient Satisfaction, Dyspepsia/Bile Reflux
Conclusions
The Mini-Gastric Bypass: Best Treatment Type 2 Diabetes Mellitus
Dr K S Kular
Kular Medical Education & Research Society ,
Kular Group of Institutes ,
drkskular@gmail.com
www.kularhospital.com
Why Consider the MGB?
With the Band/Sleeve/RNY available
Why even consider the Mini-Gastric Bypass?
6 yr study 29,820 BCBS plan members.
"Laparoscopic RNY and Lap Band both Fail to reduce overall health care costs in the long term."
Impact of Bariatric Surgery on Health Care Costs of Obese Persons, A 6-Year Follow-up of Surgical and Comparison Cohorts Using Health Plan Data Jonathan P. Weiner, et al. JAMA Surg. 2013;148(6)
Mini Gastric Bypass: initial Experience
British Obesity Metabolic Surgery Society
4 th Annual Scientific Meeting
Jan 23-25, 2013 Glasgow
SPIRE Hospital Southampton
Department of Bariatric Surgery
M Van den Bossche, I Bailey, J Kelly
J Byrne, R Sutherland*
Safe and Effective Treatment of Obesity & Diabetes:Failure of the Band, Sleeve & RNYvsSuccess of the Mini-Gastric Bypass
Medical News: Bypass Surgery for Diabetes w Nonmorbid Obesity? Marlene Busko: Jun 04, 2013
BUT: Not metioned in the abstract:
22 serious complications in 60 RNY patients (36%);
2 most serious complications Anastomotic leaks (3.3%)
1 patient suffered anoxic brain injury.
RNY pts more likely to have Complications
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
PREVENTIONandTreatment of Sleeve Gastrectomy Leaks
Dr Rutledge
Where does it occur?
ONE PLACE!
This is “Tiger Country” – remember that!
Managing ComplicationsFIRST Prevent Complications
Managing LeaksFirst Prevent Leaks!!
Examples of ComplacencySleeve Gastrectomy Leak
“Sleeve Gastrectomy & Risk of Leak: Systematic Analysis of 4,888 Patients”
“Risk of leak is low at 2.4%"
Surg Endosc. 2012 Jun;26(6):1509-15. Epub 2011 Dec 17. Aurora AR, Khaitan L, Saber AA. Department of Surgery, University Hospitals Case Medical Center, Cleveland, Ohio
Five Year Outcome Sleeve Gastrectomy Mini-Gastric Bypass From a Community Hos...Dr. Robert Rutledge
Five Year Outcome Sleeve Gastrectomy Mini-Gastric Bypass From a Community Hospital in Punjab, India
Dr K S Kular
Kular Medical Education & Research Society
Kular Group of Institutes
drkskular@gmail.com
www.kularhospital.com
Sleeve
MGB
Kular Hospital
Sleeve v MGB (Hint: MGB Better)
Weight Loss Raw Data, Weight Loss Excluding SG Revisions v Age Wt matched MGBs, Resolution of Co-Morbidities, Patient Satisfaction, Dyspepsia/Bile Reflux
Conclusions
The Mini-Gastric Bypass: Best Treatment Type 2 Diabetes Mellitus
Dr K S Kular
Kular Medical Education & Research Society ,
Kular Group of Institutes ,
drkskular@gmail.com
www.kularhospital.com
Why Consider the MGB?
With the Band/Sleeve/RNY available
Why even consider the Mini-Gastric Bypass?
6 yr study 29,820 BCBS plan members.
"Laparoscopic RNY and Lap Band both Fail to reduce overall health care costs in the long term."
Impact of Bariatric Surgery on Health Care Costs of Obese Persons, A 6-Year Follow-up of Surgical and Comparison Cohorts Using Health Plan Data Jonathan P. Weiner, et al. JAMA Surg. 2013;148(6)
Mini Gastric Bypass: initial Experience
British Obesity Metabolic Surgery Society
4 th Annual Scientific Meeting
Jan 23-25, 2013 Glasgow
SPIRE Hospital Southampton
Department of Bariatric Surgery
M Van den Bossche, I Bailey, J Kelly
J Byrne, R Sutherland*
MGB Need for Standardization, Education & Recognition
DrR Rutledge MGB MRC Course Schedule Day One Introduction
1
9-9:50
Introduction
Welcome Goals
Welcome MGB Review Corporation Bronze Certification Course
Outline of Introduction
I. One Sentence Overview: Obesity & diabetes Growing Epidemic
II. Present forms of “Gold Standard” forms of Bariatric Surgery FAR from Perfect/adequate Solutions
III. Sleeve/RNY/Band/Distal Bypasses (BPD, SADI etc) All with Minor, Moderate, Serious & Deadly Complications
IV. MGB “Uniformly & Repeatedly, Around the World In Studies by “Experts”…
The MGB is Equal to or Better than Other Comparable forms of Bariatric Surgery”
V. But!
Despite numerous articles by MGB Experts showing Excellent Results
Growing Number of Articles of Non-Expert MGB Surgeons with Serious & Deadly Complications.
VI. Goals of the MGB Review Corporation
Rally MGB Experts (Collecting Expert MGB Surgeons to Leadership and Recognition)
Collaborate of Standardizing the MGB (Rutledge Technique)
Educate Interested/New MGB Surgeons (Bronze Certification) Course + Successful Completion of 300 question Exam (or Board of Governors Membership Approval)
Document Surgical Technique (Silver Certification) video Review of MGB Case Performance 5 + Cases
Document Excellence in Outcomes (Gold Certification) 20+ Consecutive Case Review with Contact Info and Permission
Recognition as a Leader to Teach MGB (Platinum/Diamond Certification)
VI. Goal Improved Patient Care and Recognition of MGB Surgeons of Excellence
MGB vs Sleeve, Meta-analysis
MGB BII Rx Diabetes
Sleeve/RNY/Band/Dbs (Distal Bypasses, BPD, SADI etc.)
Sleeve: Devastating Leak, Irreversible, => Failure, Weight Regain, GERD, Barrett’s & Esophageal Cancer
Popularity rise similar to the VBG and Lap Band
RNY: Complexity, Difficult to Revise, Failure, Bowel Obstruction, Late Severe Dangerous Hypoglycemia
Distal Bypasses; Malnutrition etc
Dr Rutledge the Mini-Gastric Bypass
https://www.facebook.com/DrRutledge
Understanding the Mechanism of Action of the Mini-Gastric Bypass
127 slides
MGB Anatomy =Mechanism of Action
1. Non-Obstructive Restriction
2. Fatty Food Intolerance => Change preferences in Food
3. Fatty Food Malabsorption to High Fat Meal
4. Post Gastrectomy Syndrome Understanding Good Dumping/Bad Dumping
5. Post-Gastrectomy Syndrome Diet
MGB is Great Look at the Data
MGB widespread persistent Confusion
Fear of Malnutrition
Need MGB Standardization Education Recognition of MGB Surgeons of Excellence
Surgeons' Confusion &Misunderstanding the MGB:Bile, Bile Reflux, Bile Reflu...Dr. Robert Rutledge
Surgeons' Confusion &Misunderstanding the MGB:Bile, Bile Reflux, Bile Reflux Gastritis, Acid Peptic Gastritis & Marginal Ulcer Following Billroth II / MGB; Correct Management of Dyspepsia
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
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
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
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
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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
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
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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.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
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.
Are There Any Natural Remedies To Treat Syphilis.pdf
Prevent & Treat Bile Reflux
1. 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
2. Goals, Take Home Messages
Understand Prevention/Dx/Rx “Bile Reflux”
Bile is always present in Normal Stomach & MGB/Billroth II,
Dyspepsia is common in MGB patients (= RNY &
Sleeve):
Causes / Prevention / Treatment
1. Poor technique (MGB Done Wrong: GJ, twisted pouch etc.)
Rx Prevention
2. Gastritis/Ulcer
Rx Prevention, Antacid, Diet Rx
3. Conservative (NON-Operative) Diagnosis and Treatment of Violation Basic
Post Gastrectomy Syndrome Diet/MGB Dietary & Lifestyle Guidelines:
**Follow dietary protocol** (99% Successful)
6. MGB = Safe, Near Normal vs.
SADI = “Short Bowel Syndrome”
Bowel
Length
BPL CC
%
Bypassed
MGB 6 m 1.75m 4.25m 30%
SADI 6 m 3.5m 2.5m * 60% *
MGB 8 m 1.75m 6.25m 20%
SADI 8 m 5.5m 2.5m * 70% *
Bowel length, BPL = Biliopancreatic Bypass Limb Length
CC = Common Channel
7. Standardization of the MGB
Please Do Not Do the MGB
In Your Own Way
or
Please Label It as Some Other Procedure:
Omega Loop, SAGB, OAGB or Other
8. If You Wish to
Ignore My Advice
Please Do Not Attribute Your
Outcomes to the MGB
9. Patients Will Be Harmed!
Errors & Misunderstanding of the Power of the MGB
10. Standardization of the MGB
Tragedy of
“Made Up Versions of Operations”
Without Documenting These Modifications
& Follow UP:
Lakdawalla & Many Others
11. Two Splenectomies
• The tragedy of not listening to good advice
• Recent Documentation of the risk of
Bleeding of the Short Gastrics in the Dissection
of the Left Upper Quadrant
• And
• Documentation that these Splenectomies
associated with INEXPERIENCE
16. Please ReRead Your Anatomy Books
• There is NO SUCH THING as a “Free Vascular Space”
in the area of peri-EG Junction
• Instead routinely the area is easily entered with
simple blunt dissection allowing passage from the
lesser sac into the left sub-hepatic space
• But in every 100-1000 cases such a blind (uneducated
approach) will result in a torn short gastric vessel
• => Splenic Bleeding or Splenectomy
17. Who's Afraid of the Billroth
II?
Not General, Trauma or Cancer Surgeons!
18. 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
19. Poorly Trained Surgeons:
Harming Patients & MGB Reputation
• Simply:
• It is clear that the outcomes of surgeons are quite
variable
(Many good surgeons report complications & Death!)
• My Advice:
Please: Do Not Make Up Your Own Operative &
Peri-Operative Techniques
• Or If You Do: Please Do Not Label it MGB
20. Fear of Bile
• General, Trauma & Oncologic
Surgeons Do Not Fear
Billroth II & Bile
21. • Fear of Bile reflux!
• Who is afraid of bile Reflux?
• NOT GENERAL SURGEONS
• Who is afraid of bile Reflux?
• Poorly informed Bariatric Surgeons
24. Published Reports
MGB and Bile Reflux Sx
• Authors, Rheinwalt
• Rutledge
• Chevallier
• Kular
• Noun
• Peraglie
• Lee
• Haargroder
• Musella and Many More
• Countries
• USA
• Egypt
• France
• Germany
• India
• UAE
• Italy
• Spain
• Belgium Many More
25. Reported Rates of Bile Reflux Sx Require
Surgical Rx
•In every series revision for Sx bile reflux rare
•1-5% or less in every study
•Treatment is trivially easy
•Where does the fear come from?
27. General Surgery Studies
"Gastrectomy + Billroth
II"
Kang KC, Shin SH, Lee YJ, Heo YS.
J Korean Surg Soc. 2012 Jun;82(6):347-55.
Department of Surgery, Inha University Hospital,
Inha University School of Medicine, Incheon, Korea.
28. • 100 years of Gastrectomy and Billroth II
• with good to excellent results
• Example:
• 75 Billroth II GCa Pts, 35 month FU
• Standard General Surgery BII
Rx Diabetes
• Gastrectomy + BII (i.e. MGB)
• 22% Resolved, 85% Improved
29. Billroth II = RNY
Cancer Surgeons Routinely Use Billroth II
•2015 Study 7 USA Cancer Centers
•500 Patients
•Controlled Prospective Randomized Trial
•Compared Billroth II vs. RNY for Distal Gastrectomy
•“NO advantage of Roux-en-Y over Billroth II in outcomes”
•Tran et al. To Roux or not to Roux: a comparison between Roux-en-Y and Billroth II
reconstruction following partial gastrectomy for gastric cancer. Gastric Cancer. 2015 Sep
23.
30. •Gastric Cancer. 2016 Comparison between
Roux-en-Y and Billroth II, Tran TB
•Prospective trial, 450 Pts, 7 USA Centers
•“No advantage of RNY over Billroth II
gastrojejunostomy in perioperative outcomes.
•“Both techniques should be regarded as equally
acceptable reconstructive options following
partial gastrectomy
31.
32. Billroth II is a
Good Procedure
When Used Correctly
Bariatric Surgeons
Need to Re-Learn their General Surgery
The Mason Loop Gastric Bypass was Bad
Because
the Billroth II was Incorrectly!!
33. MGB = Standard General Surgery
How to Perform the
Mini-Gastric Bypass
MGB = Simple Operation
But
Tricks and Traps
35. Goals, Take Home Messages
Understand Prevention/Dx/Rx “Bile Reflux”
Bile is always present in Normal Stomach & MGB/Billroth II,
Dyspepsia is common in MGB patients (= RNY &
Sleeve):
Causes / Prevention / Treatment
1. Poor technique (MGB Done Wrong: GJ, twisted pouch etc.)
Rx Prevention
2. Gastritis/Ulcer
Rx Prevention, Antacid, Diet Rx
3. Conservative (NON-Operative) Diagnosis and Treatment of Violation Basic
Post Gastrectomy Syndrome Diet/MGB Dietary & Lifestyle Guidelines:
**Follow dietary protocol** (99% Successful)
36. Background:
• The Billroth II is by far
the most common technique around the world
reconstructing the gastrointestinal tract following
distal gastrectomy for cancer, trauma & ulcers
• Thousands of Billroth II General Surgery patients
from all around the world have
bile that flows harmlessly across their Billroth II
anastomosis every day.
37. Who's Afraid of the Billroth
II?
Not General, Trauma or Cancer Surgeons!
38. Bile Reflux, Rare
in MGB High Volume Surgeons
•DrRutledge's study confirms others
reporting on a large cohort MGB patients
•Prevention, frequency and management of
dyspepsia (often erroneously labeled bile as
reflux symptoms)
39. Methods:
•In a series of 6,023 patients undergoing
MGB, dyspepsia/”bile reflux” was managed
non-surgically in the vast majority (99%)
•Symptomatic dyspepsia/”bile reflux”
unresponsive to medical therapy occurred
in 4 patients over a period of 15 years.
40. Methods
•Cause & prevention of surgical errors that
=> Dyspepsia, Bile Reflux Gastritis
• 2. Differences between Bile, Bile reflux and
Gastritis/Esophagitis
• 3. Conservative Rx (99%) Surgery (<1%)
41. Methods
•Conservative Rx (99%+):
Non-surgical treatment of dyspepsia
(so called “bile reflux”)
•Surgical Rx: Braun Entero-enterostomy
treatment post MGB symptomatic
dyspepsia/”bile reflux” unresponsive to
medical therapy.
42. Results:
•6,023 patients underwent MGB.
•Dyspepsia common (7.3% in the first year)
similar to that reported in RNY gastric
bypass. Successful Rx Diet + Lifestyle
•Dyspepsia was managed per conservative
protocol and resolved symptoms routinely.
43. Initial Diagnosis of Dyspepsia
• MGB Dyspepsia
• (Nausea, Midepigastric Pain, Vomiting, Bile
Vomiting/Aspiration, Gastritis, Esophagitis,
etc.):
• NOT Automatically BILE!!!
44. Common Anatomic Errors at MGB Surgery
Short Pouch
Twisted Pouch
Bird's Beak Pouch
Narrow Pouch
Pouch Stricture
Dissection of EGJ
BP Limb too long
Strictures G-J
Kinked/Tight G-J
Reversed BP Limb
Ischemic & Foreign
Body Gastro-J
45. Anatomic Errors at Surgery:
Prevention => Do the Surgery Right!!
•Short Pouch **
•Twisted Pouch **
•Candy Cane **
•Narrow Pouch **
•Pouch Stricture **
•BP Limb too long **
•Strictured G-J **
•Kinked G-J **
•Reversed BP Limb**
•Ischemic FB GJ
DX/RX => Send me the video, Re-explore, Revise
46. Initial Diagnosis of Dyspepsia
•Non-surgical Rx Protocol for MGB Dyspepsia
(Nausea, Midepigastric Pain, Vomiting, Bile
Vomiting/Aspiration, Gastritis, Esophagitis,
etc.)
•1. Think First: Anatomic/Surgical Errors
Especially common “new surgeons” Sleeve,
RNY, Young surgeons.
47. Treatment Of Symptomatic “Bile Reflux” Dyspepsia
NOT Surgical Errors
• Underlying Differential Dx:
• Bile Reflux occurs in every patient all day, day in and day out.
• Most Common Sources of Dyspepsia
• Gastritis, erosion, ulcer (Acid peptic) smoking etc.
• Obstruction, partial, complete, intermittent, diet related
• Bacterial overgrowth (Rare)
• Dumping Syndrome (early/late) very common
48. Diagnostic/Rx Process: 1 Week Diet Hx
Detailed History & Timing
• All Foods, medications,
supplements, activities and
symptoms Logged carefully
• Rx: Diet & Lifestyle Changes:
• Optimize Diet, Supplements,
Medications
• Discontinue: Alcohol, Smoking,
NSAIDs, Steroids, “Herbs” etc.
• Encourage 6 small feeds/d
healthy diet,upright after
eating
• Rx gut microbiome: Plain
Yogurt:1-2 tsps 3-6 x / Day
• Exercise & Moderate Sun
Exposure
• Success Rate 99+%
49. 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.
50. Common Misunderstanding:
MGB, Billroth II & Bile Reflux
• Every MGB/Billroth II Patient Can Have
Bile Reflux + Vomiting at Any Time!
• Simple: Swallow a cork=>
Distal Obstruction=> Bile reflux
• In real life: Eat a plate of noodles @ 10pm Dinner=>
Bile Reflux vomiting and aspiration that night
• Simple Rx: No Large Bulky Meal Late Before Bed
or Ever with MGB
51. Bile in MGB & Billroth II is Painless:
When Does Bile Hurt?
•Bile and dyspepsia
•No ulcer or gastritis + Bile => No Pain
•Ulcer or Gastritis + Bile => Pain
•Ulcer = in RNY = in MGB approximately 5%
•Dyspepsia in MGB => Rx Ulcer
•(Surgical Technique Cause of Ulcer/Gastritis)
52. Surgical Technique Cause of Ulcer/Gastritis
Prevention of Marginal Ulcer
•Why MGB ulcers => Lateral Aspect of the G-J
•Reason: Big bulky ischemic mass tissue
With mass of titanium staples as foreign bodies
from the poor surgical technique on the lateral
aspect of the GJ
•Prevention: Non-ischemic GJ w minimal Foreign
Bodies
54. Post Op Complication of MGB
Technical Errors
• 39 year old male “OAGB” 1 year
• Pre Op 163 kg, BMI 57. BP limb was 200 cm.
• Lost 63 kg BMI 35
• 4 months severe abdominal pain, colicky & episodes of
hypoglycemia.
• No Rx effective, CT Negative
• Diagnostic laparoscopy
69. Surgical Technique Cause of Ulcer/Gastritis
Prevention of Marginal Ulcer
• Why MGB ulcers => Lateral
Aspect of the G-J
• Reason: Big bulky ischemic
mass tissue
With mass of titanium staples as
foreign bodies from the poor
surgical technique on the lateral
aspect of the GJ
• Prevention: Non-ischemic GJ w
minimal Foreign Bodies
71. Results
•Significant dyspepsia/bile reflux
unresponsive to protocol management
occurred in 4 patients 1 to 8 years after
MGB.
•Each of the 4 patients underwent sub 60
minute Braun entero-enterostomy with
rapid resolution of symptoms.
72. Conclusion:
•Dyspepsia + Bile is commonly present in the
MGB, dyspepsia is common in patients who
violate simple diet and lifestyle guidelines.
•Only a very small number of patients will
present with dyspepsia/”bile reflux”
unresponsive to medical management
protocol.
73. Goals, Take Home Messages
Bile is always present in Normal Stomach & MGB/Billroth II,
Dyspepsia is common in MGB patients (=RNY/Sleeve):
Causes / Prevention / Treatment
1. Poor technique (MGB Done Wrong: GJ, twisted pouch etc.)
Rx Prevention
2. Gastritis/Ulcer
Rx prevention, Antacid, Diet Rx
3. Violation Basic Post Gastrectomy Syndrome Diet/MGB Dietary
& Lifestyle Guidelines: **Follow dietary protocol**
74. Conclusions
•In rare cases short simple revision of the
MGB by adding a laparoscopic Braun
Entero-enterostomy rapidly resolves
symptoms.
•Revision of the MGB is easily performed but
usually unnecessary.
•MGB patients Do Not Need a RNY
76. • Bowel resection: What We Already Know
• < 1/3 Normal bowel function (= MGB)
• > 1/2-2/3 “Dire Consequences” (= BPD / SADI)
i.e. “Short Bowel Syndrome” Sx (Diarrhea etc.)
• Haymond H E. Massive resection of the small intestine. Surg Gynecol Obstet.
(1935);51:693–705.
77. Simple General Surgery Truth
Short Bypass Safer
Longer Bypass
More Dangerous
If Your MGB Patient has: Diarrhea, Low Protein,
Fatigue & Peripheral Edema
The BP Limb is too Long
78. Bowel
Length
BPL CC
%
Bypassed
MGB 6 m 1.75m 4.25m 30%
SADI 6 m 3.5m 2.5m * 60% *
MGB 8 m 1.75m 6.25m 20%
SADI 8 m 5.5m 2.5m * 70% *
Bowel length, BPL = Biliopancreatic Bypass Limb Length
CC = Common Channel
79. MGB Offers Patients & Surgeon
Opportunity to Tailor Op
•1. MGB can be done with short, ultra-short,
medium, long or any length of
Biliopanceratic limb length
•Studies show
risk major deficiency/malnutrition
200 cm bypass => ~1%
150 cm bypass => 0.1% risk