The document discusses malabsorption following Roux-en-Y gastric bypass surgery. It examines the differences between restriction and malabsorption in energy absorption after this procedure. The key findings from a 2010 study are:
1) Early after surgery, restriction from reduced food intake reduced energy absorption by over 16 times more than malabsorption
2) At 14 months, restriction still reduced energy absorption more than malabsorption, though the effect of restriction was beginning to fail
3) Malabsorption alone only accounted for a 6-11% reduction in calorie absorption after Roux-en-Y gastric bypass.
Rivision surgery after laparoscopic sleeve gastrectomyIbrahim Abunohaiah
Revision Surgery After Laparoscopic Sleeve Gastrectomy
Introduction to bariatric surgery
When to Revise a Weight Loss Surgery?
Options for redo surgery.
Laparoscopic Roux-en-Y gastric Bypass.
Rivision surgery after laparoscopic sleeve gastrectomyIbrahim Abunohaiah
Revision Surgery After Laparoscopic Sleeve Gastrectomy
Introduction to bariatric surgery
When to Revise a Weight Loss Surgery?
Options for redo surgery.
Laparoscopic Roux-en-Y gastric Bypass.
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.
Golden steps to perform laparoscopic sleeve gastrectomyDeep Goel
Laparoscopic sleeve gastrectomy is one of the popular procedure performed in morbidly obese patients to achieve significant weight loss upto 80%. We are explaining golden tips to perform safer sleeve gastrectomy surgery from surgeons perspective.
enteral nutrition, nutrition, nutrition after surgery, nutrition of debilitated patient, nutrition of patient who cant take orally, post operative care, surgical nutrition, total parentral nutrition
Understant what is obesity and Bariatric Surgery, what are the risk factors and how to overcome on the it. For more information visit at http://gisurgery.info
Fear of Cancer, General Surgeons Use the Billroth II, Bariatric Surgeons FE...Dr. Robert Rutledge
Irrational Fears of CancerGeneral Surgeons Use the Billroth IIBariatric Surgeons FEAR the Billroth II (Mini-Bypass)
Irrational Fear of Gastric Cancer:CHOOSING THE BEST WEIGHT LOSS SURGERY, R Rutledge MD, www.CLOS.net, Email: DrR@clos.net. http://www.slideshare.net/DrRRMD/fear-g-ca-02-0214v2
GASTRIC VS. COMBINED GASTRO-INTESTINAL PROCEDURES FOR CONTROL OF OBESITYDr. Robert Rutledge
GASTRIC VS. COMBINED GASTRO-INTESTINAL PROCEDURES FOR CONTROL OF OBESITY
1. Bariatric surgery history is replete with failed Primary Gastric Procedures for obesity,
2. Physiologically it is easy to see how an excess of 2, 000 calories a day can be ingested as liquid/soft calories (Coke and Cake) thus “Beating” the operations’ “gastric restriction” Band/Sleeve.
3. Studies in Gastric Cancer patients show that Combined Gastro-Intestinal Procedures outperform Primary Gastric Procedures
4. Primary Gastric Procedures can be predicted to fail even following initial success (see Lap Band(r))
Sleeve Gastrectomy and Lap band Appear likely to Lead to Esophageal CancerDr. Robert Rutledge
It appears that Sleeve and Band surgeons Should warn their patients of the Long term risk of GERD and Increased Risk of Esophageal cancer and Institute appropriate follow up planning.
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.
Golden steps to perform laparoscopic sleeve gastrectomyDeep Goel
Laparoscopic sleeve gastrectomy is one of the popular procedure performed in morbidly obese patients to achieve significant weight loss upto 80%. We are explaining golden tips to perform safer sleeve gastrectomy surgery from surgeons perspective.
enteral nutrition, nutrition, nutrition after surgery, nutrition of debilitated patient, nutrition of patient who cant take orally, post operative care, surgical nutrition, total parentral nutrition
Understant what is obesity and Bariatric Surgery, what are the risk factors and how to overcome on the it. For more information visit at http://gisurgery.info
Fear of Cancer, General Surgeons Use the Billroth II, Bariatric Surgeons FE...Dr. Robert Rutledge
Irrational Fears of CancerGeneral Surgeons Use the Billroth IIBariatric Surgeons FEAR the Billroth II (Mini-Bypass)
Irrational Fear of Gastric Cancer:CHOOSING THE BEST WEIGHT LOSS SURGERY, R Rutledge MD, www.CLOS.net, Email: DrR@clos.net. http://www.slideshare.net/DrRRMD/fear-g-ca-02-0214v2
GASTRIC VS. COMBINED GASTRO-INTESTINAL PROCEDURES FOR CONTROL OF OBESITYDr. Robert Rutledge
GASTRIC VS. COMBINED GASTRO-INTESTINAL PROCEDURES FOR CONTROL OF OBESITY
1. Bariatric surgery history is replete with failed Primary Gastric Procedures for obesity,
2. Physiologically it is easy to see how an excess of 2, 000 calories a day can be ingested as liquid/soft calories (Coke and Cake) thus “Beating” the operations’ “gastric restriction” Band/Sleeve.
3. Studies in Gastric Cancer patients show that Combined Gastro-Intestinal Procedures outperform Primary Gastric Procedures
4. Primary Gastric Procedures can be predicted to fail even following initial success (see Lap Band(r))
Sleeve Gastrectomy and Lap band Appear likely to Lead to Esophageal CancerDr. Robert Rutledge
It appears that Sleeve and Band surgeons Should warn their patients of the Long term risk of GERD and Increased Risk of Esophageal cancer and Institute appropriate follow up planning.
Fear & Confusion about the Risk of Cancer after Bariatric SurgeryDr. Robert Rutledge
Esophageal Cancer from
Fear & Confusion about the Risk of Cancer after Bariatric Surgery
Sleeve & Band vs Risk of Gastric Cancer after Mini-Gastric Bypass
Dr Rutledge
The Centers for Laparoscopic Obesity Surgery, www.CLOS.net www.MiniBypass.net Email: DrR@clos.net
Critics of the Mini-Gastric Bypass were Wrong
MGB Results
In Short
By every measure
In every study
By Every Author
MGB Equal to or Better Than any other form of Bariatric Surgery
Critics Wrong
In Short:
Bariatric Surgeons who are well educated in the Basics of General Surgery
Choose the Mini-Gastric Bypass
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
The contribution of malabsorption to the reduction in net energy absorption after long-limb Roux-en-Y gastric bypass
The contribution of malabsorption to the reduction in net energy absorption after long-limb Roux-en-Y gastric bypass
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
Let me to you ,how to loss weight fastest ,healthy weight loss and best weight loss program
fastest weight loss,healthy weight loss,best weight loss program
This presentation was delivered at Puri on 10th january 2015
on the occasion of annual Rotary District Conference along with IMA Puri. It highlights on metabolic syndrome and its surgical solution.
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 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
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
Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
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This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
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Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
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2. What is Roux-en-Y Gastric Bypass?
• Roux-en-Y Gastric
Bypass both (?)
• Restrictive
• Malabsorptive (?)
Components
3. Malabsorption vs. Restriction after
long-limb RNY gastric bypass
• Roux-en-Y gastric bypass (RNY)
restricts food intake
• when the Roux limb is elongated to
150 cm
• IS the RNY malabsorptive?
• Measure calorie reduction after RNY
• Restriction vs Malabsorption
• The contribution of malabsorption to the reduction in net energy absorption after long-limb Roux-en-Y gastric
bypass, Elizabeth A Odstrcil, et al. Am J Clin Nutr October 2010 vol. 92 no. 4 704-7
4. “The contribution of
malabsorption to the reduction in
net energy absorption after
long-limb
Roux-en-Y gastric bypass”
Elizabeth A Odstrcil, Juan G Martinez, Carol A Santa Ana,
Beiqi Xue, Reva E Schneider, Karen J Steffer, Jack L
Porter, John Asplin, Joseph A Kuhn, and John S Fordtran
Am J Clin Nutr October 2010 vol. 92 no. 4 704-713
5. The contribution of malabsorption to the reduction in net
energy absorption after long-limb Roux-en-Y gastric bypass
• Results:
• RNY:
• No significant effect on
• Protein or Carbohydrate
absorption
• “The contribution of malabsorption to the reduction in net energy
absorption after long-limb Roux-en-Y gastric bypass”, Elizabeth A
Odstrcil, et al. Am J Clin Nutr October 2010 vol. 92 no. 4 704-713
6. RNY Malabsorption vs. Restriction
• 5 months after bypass,
• Malabsorption reduced absorption by
124 kcal/d
• Restriction of food intake reduced energy
absorption by 2,062 kcal/d
• Restriction 16 times more important than
Malabsorption
• The contribution of malabsorption to the reduction in net energy absorption
after long-limb Roux-en-Y gastric bypass, Elizabeth A Odstrcil, et al. Am J
Clin Nutr October 2010 vol. 92 no. 4 704-713
7. RNY Malabsorption vs. Restriction
• 14 months after bypass,
• Malabsorption reduced absorption of
combustible energy by 172 kcal/d
• vs
• Restriction of food intake reduced energy
absorption by 1,418 kcal/d
• (Why: Restriction Beginning to Fail)
• The contribution of malabsorption to the reduction in net energy absorption after long-limb Roux-en-Y gastric bypass, Elizabeth A Odstrcil,
et al. Am J Clin Nutr October 2010 vol. 92 no. 4 704-713
9. RNY Malabsorption vs. Restriction
• Malabsorption ONLY
6%-11% reduction in calories
• RNY: Is Primarily a
“Restrictive Procedure”
• Study Shows: Early signs of
RNY caloric failure
• The contribution of malabsorption to the reduction in net energy absorption after long-
limb Roux-en-Y gastric bypass, Elizabeth A Odstrcil, et al. Am J Clin Nutr October
2010 vol. 92 no. 4 704-713
10. The contribution of malabsorption to the reduction in net
energy absorption after long-limb Roux-en-Y gastric bypass
• Dietary intake and net intestinal absorption of
fat, protein, and carbohydrate were measured
• Calculated the total reduction in fat, protein,
carbohydrate, and calories after RYGB
• Extent to which these reductions were due to
restriction or malabsorption
• The contribution of malabsorption to the reduction in net energy absorption after long-
limb Roux-en-Y gastric bypass, Elizabeth A Odstrcil, et al. Am J Clin Nutr October
2010 vol. 92 no. 4 704-713
11. The contribution of malabsorption to the reduction in net
energy absorption after long-limb Roux-en-Y gastric bypass
• Fat absorption and malabsorption
• Average fat intake was
• 156 g/d before bypass,
• 50 g/d 5 mo after bypass, and
• 82 g/d 14 mo after bypass.
• The contribution of malabsorption to the reduction in net energy absorption
after long-limb Roux-en-Y gastric bypass, Elizabeth A Odstrcil, et al. Am J
Clin Nutr October 2010 vol. 92 no. 4 704-713
12.
13. Correlation between the length of jejunum in the
biliopancreatic (BP) limb and the reduction in fat absorption
14. Bile Acid Depletion:
Fat Malabsorption &
Treatment of Diabetes
Most Bariatric surgeons
DO NOT
Understand Bile/Bile Acids
15. Bile Acids: Not Just for Fat
Absorption
• Bile Acids Needed for Fat
absorption
(Decreased Bile Acids =>
Decreased Fat Absorption)
• Studies show that bile acids
also play a large role in
glucose homeostasis
16. Bile Acids: Not Just Detergents
Bile Acids as Hormones
• Bile acids as hormones act on several
Critical receptors:
• Farnesoid X receptor (FXR) and
• Pregnane X receptor (PXR),
• Constitutive androstane receptor (CAR),
• G-protein-coupled receptor TGR5.
• Bile acids AS HORMONES regulate
Cholesterol, Glucose, and
metabolism/energy homeostasis
17. What Most Bariatric Surgeons
Do Not Understand
• Bile Acids Critical to Fat and Glucose
Control in the Body
• Decreased Bile Acids =>
Decreased Fat absorption
Lowered Blood Glucose Levels
• MGB (Billroth II) =>
Decreased Bile Acids
• RNY does NOT Affect Bile Acid Pool
18. Study of long-limb Roux-en-Y gastric bypass
• Results: RNY does not cause bile
acid malabsorption
• Fecal bile acid excretion average
• Before: 0.8 g/d
• Post Op 5 mo: 0.5 g/d
• Post Op 14 mo: 0.7 g/d
• Decreased Bile Acids Rx Diabetes
• RNY Does Not Cause Loss of Bile
19. Bile Acid Sequestration Reduces Glucose
Levels by Increasing Metabolic Clearance
• Bile acid sequestrants (BAS) reduce
plasma glucose levels in type II
diabetics
• BAS induced plasma glucose
lowering by increasing metabolic
clearance rate of glucose in
peripheral tissues
• RNY Does Not Cause Loss of Bile
• MGB Does Cause Bile Acid Losses
21. Post Gastrectomy Steatorrhea
• For over 75 years authors have noted that
• Fat Malabsorption/Steatorrhea common
post gastrectomy syndrome in some
patients
• More common & Greater degree with
• Billroth II >> Billroth I
• EVERSON TC. Experimental comparison of protein and fat assimilation after Billroth II, Billroth I, and segmental
types of subtotal gastrectomy. Surgery. 1954 Sep;36(3):525-37
• MACLEAN LD, PERRY JF, KELLY WD, MOSSER DG, MANNICK A, WANGENSTEEN OH. Nutrition following
subtotal gastrectomy of four types (Billroth I and II, segmental, and tubular resections). Surgery. 1954
May;35(5):705-18
• WOLLAEGER EE, WAUGH JM, POWER MH. Fat-assimilating capacity of the gastrointestinal tract after partial
gastrectomy with gastroduodenostomy (Billroth I anastomosis). Gastroenterology. 1963 Jan;44:25-32
• …
22. 100 Years of GI Surgery: Steatorrhea
following Gastric Operations:
• What do we know:
• Rare after gastro-jejunostomy or vagotomy
alone.
• Rare after Billroth I
• Especially Common after Polya gastrectomy
with BII.
• (Butler, 1961)
24. Opinion Among BPD Surgeons
• Length of the Common Channel is
the Critical Factor for Fat
malabsorption & weight loss
• We review Animal studies and
MGB results that suggest this is
not the case
• Am J Surg. 2005 May;189(5):536-40, Common channel length predicts outcomes of
biliopancreatic diversion alone and with the duodenal switch surgery, McConnell DB, O'rourke
RW, Deveney CW
25. NUTRIENT ABSORPTION in the SMALL
INTESTINE: Remember the Basics
• Duodenum and Upper Jejunum:
most minerals
• Jejunum and Upper Ileum:
carbohydrates, amino acids,
water-soluble vitamins
• Jejunum: absorbs most of lipids
and fat-soluble vitamins
• Terminal Ileum: Bile,Vit B12
26. Fat absorption and the
Length of Billroth II Afferent Limb
• Experiment
• Question: Increase length of
afferent limb associated with
increased fat malabsorption
• Animals underwent a 50% distal
gastrectomy with an antecolic
• Polya-type Billroth II anastomosis
27.
28. Fat absorption and the
Billroth II Afferent loop
• 50% distal
gastrectomy with
an antecolic
• Polya-type Billroth
II anastomosis
• Afferent limb of
• 30cm, 60cm, 90cm
29. Fat absorption and the
Billroth II Afferent Limb: RESULTS
• PreOp: Fecal excretion on a 127 Gm. diet
2.4% of the ingested fat.
• Similar results in dogs and in humans
• Animals with BII + 30cm afferent limbs
• Able to digest and absorb the dietary fat
without any apparent difficulty
30. Fat absorption and the
Billroth II Afferent loop
• Average fecal excretion diet was
2.4% of the ingested fat.
• Longer Loops steatorrhea increased
• 30 cm. limb fecal fat 2.4% (No Change)
• 60 cm. limb fecal fat excretion 10.2%
• 90 cm. limb 28.2%
31. Fat Malabsorption
Billroth II (MGB) vs RNY
0
5
10
15
20
25
30
0 20 40 60 80 100
Bypass Limb Length
FatLost(%)
MGB
Billroth II
RNY
32. Fat absorption and the
Billroth II Afferent loop
• Average fecal excretion Pre Op
2.4% of ingested fat
• Longer Limb increased steatorrhea
• 30 cm. limb fecal fat 2.4% (No Change)
• 60 cm. limb fecal fat excretion 10.2%
• 90 cm. limb 28.2%
33. Fat MAL-absorption and the
Billroth II Afferent LIMB
• Afferent limb most important factor post
gastrectomy steatorrhea, “LENGTH”
• Animals with short afferent loops NO
significant steatorrhea.
• As the length of the afferent limb
increased, a concomitant and dramatic
rise in fecal fat excretion was noted.
34. Fat MAL-absorption and the
Billroth II Afferent loop
• Malabsorption is NOT due to
bypass of the upper jejunum
ALONE
• Kremen’s Study:
• Over half the jejunum can be
bypassed without producing
steatorrhea.
35. An Experimental Evaluation of the
Nutritional Importance of
Proximal and Distal Small
Intestine
• Arnold J. Kremen, et al.
Ann Surg. 1954 September; 140(3): 439–447
36. Kremen, et al.
• “Experimental studies in dogs
reveal that animals can bypass
• 50 to 70 per cent of their
small intestine
• and maintain a near normal
nutritional status”
37. Experimental Evaluation of the Nutritional
Importance of Proximal and Distal Small Intestine
• Study showed that
• Bypass of major lengths of the
proximal small intestine,
• Weight is well maintained
• No great interference with fat
absorption
• NOTE:
Contradiction with Prior Study
38. Experimental Evaluation of the Nutritional
Importance of Proximal and Distal Small Intestine
• 50 - 70% of the small bowel
bypassed
• Proximal and distal ends were
exteriorized as a cutaneous
stoma.
• Intestinal continuity was re-
established by end-to-end
anastomosis
42. Massive bypass = No Effect
• The small intestine in adults is a
long and narrow tube about
7 meters (23 feet) long
• 50% Bypass = 11.5 ft (3.5 meters)
• Minimal Weight Loss!
44. Massive bypass = Little Effects!
• The small intestine in adults is
a long and narrow tube about
7 meters (23 feet) long
• 70% Bypass = 16 ft (5 meters)
• 5% weight loss
45. 70% Bypass = Little Effect
• Group IV animals, which were
similar to Group I except that 70%
instead of 50% of proximal small
bowel removed from intestinal
continuity,
• Lost about five per cent of their
preoperative weight and then
stabilized at this level.
46. Transit Time & Fat Absorption
• 50-70% Bypass
• Made Little Difference in
• Transit Time or
• Fat Absorption NOT affected
47. Experimental Evaluation of the Nutritional
Importance of Proximal and Distal Small Intestine
• CONCLUSIONS
• The proximal 50 to 70 per cent of the small
intestine can be removed with no apparent ill
effects.
• Weight is maintained, and protein and fat
absorption are not significantly altered.
• Arnold J. Kremen, John H. Linner, and Charles H. Nelson
48. Bypass of Jejunum; Experimental Results:
No Fat Malbsorption or Major Fat
Malabsorption
• 2 Studies; 2 Different Findings
• Massive Small Bowel Bypass
=> Minimal Effects
• Moderate Small Bowel Bypass
=>Major Effects
• What is the Difference?