Understanding the MGB & GERD

https://mgbguidelines.wordpress.com/gastric-pouch-creation/
Mini-Gastric Bypass:
Why Choose the MGB
“We Need a Better Surgery”
Dr. Rutledge
Email DrR@clos.net

Sleeve Gastrectomy Vomiting
Google Search Results
Sleeve Gastrectomy &
“Vomiting”
**540** Articles in
PUBMED

Mini-Gastric Bypass:
Excellent Rx GERD &
Confusion by Sleeve/RNY Surgeons
Sleeve: High Rates of GERD &
Confusion by Sleeve surgeons
Dr. Rutledge
Email DrR@clos.net

Considering the MGB
“In Every Study,
By Every Measure the
MGB is Equal to or
Better than
any other Surgery”

•Mini-Gastric Bypass
Confusion & Mistakes
• Anyone can do a
“single anastomosis gastric bypass”
• That “Does Not” mean doing the
true “Mini-Gastric Bypass” (MGB)
• Doing the MGB Wrong has led to
Many Complications: Examples ...
• This Course “Doing the MGB
Right”

Reminders of the Basics of
General Surgery
Sleeve is NOT New
Performed in 1940
Has been Abandoned 1950
Surgical Rx Hiatal Hernia “Alone”
(Hill/Allison Repairs)
Has been Abandoned

The Sleeve is NOT New
•As early as 1940,
O.H. Wangensteen performed
longitudinal gastric resection
to excise acid-producing body of
the stomach
•Wangensteen OH.
Aseptic gastric resection.
SGO. 1940;70:59–70

History of Ulcer Surgery:
Sleeve = Failed
•K. Schwarz’s discovery of the concept of
“no ulcers without acids” in 1910
•O.H. Wangensteen Devised
longitudinal gastric resection (Sleeve)
•Parietal cells, (HCL) most dense lengthwise along
the greater curvature
•Wangensteen performed the first experiments of
longitudinal resection along the greater gastric
curvature to reduce acidity of gastric juice in
** 1940 **

History of Ulcer Surgery:
Sleeve Abandoned
• Wangensteen applied this technique in 90 patients
with duodenal ulcers and reported initially Positive
Results
• Evolution and evaluation of an acceptable operation for
peptic ulcer. WANGENSTEEN OH
Am J Gastroenterol. 1953 Sep; 20(9):611-26
• Abandoned, after performing further animal
experiments in 1957
•The acid response of the stomach after test meals
was many-fold higher in animals spitting up

The Sleeve is NOT New
He concluded that
his “tubular gastric
resection” should be
viewed with caution
and he stopped using
the technique
Abandoned
Segmental gastric resection: an acceptable operation for peptic ulcer;
tubular resection unacceptable. WANGENSTEEN OH Surgery. 1957
Apr; 41(4):686-90.

The Sleeve is Very Popular
(Now?)
Remember!!
Lap Band = Very Popular
Abandoned!
Vertical Banded Gastroplasty
= Very Popular
Abandoned!

A Modest Proposal
• My Opinion:
• Sleeve = VBG (Failed)
•(Vertical Banded Gastroplasty)
•and
•** VBG has been abandoned! **

Sleeve = VBG
Sleeve Gastrectomy =
1. Irreversible Stomach only operation,
2. Makes Eating Usual Foods Difficult
Because of a ...
3. Partial Blockage (Obstruction) in the
stomach
4. Patients Complain of Frequent Nausea and
Vomiting with MANY "Normal Foods"
(i.e. Broccoli, Sandwich, Apple)
5. N&V with "Normal" Food Encourages
"Junk" foods like Potato Chips, Coke, Soda,
Sweets, Ice Cream, etc.
6. Initially moderate to good weight loss
7. followed by high rates of weight regain and
8. ~1/3 of patients with moderate to severe
GERD
often requiring surgery and
Long Term Risk of Esophageal Cancer.
Failed VBG Vertical Banded Gastroplasty =
1. Stomach only operation,
2. Makes Eating Usual Foods Difficult
Because of a ...
3. Partial Blockage (Obstruction) in the
stomach
4. Patients Complain of Frequent Nausea
and Vomiting with MANY "Normal Foods"
(i.e. Broccoli, Sandwich, Apple)
"Junk" foods like Potato Chips, Coke,
Soda, Sweets, Ice Cream, etc.
7. followed by high rates of weight regain and
8. ~1/3 of patients with moderate to severe
GERD often requiring surgery and

Sleeve = VBG Abandoned
Sleeve Gastrectomy =
1. Irreversible Stomach only operation,
2. Makes Eating Usual Foods Difficult Because of a ...
3. Partial Blockage (Obstruction) in the stomach
4. Patients Complain of Frequent Nausea and Vomiting
with MANY "Normal Foods" (i.e. Broccoli, Sandwich, Apple)
"Junk" foods like Potato Chips, Coke, Soda, Sweets, Ice Cream,
etc.
7. followed by high rates of weight regain often requiring revision
8. ~1/3 of patients with moderate to severe GERD
often requiring revision surgery and

GERD and Anatomy of the
Lower Esophageal
Sphincter

Anatomy and Physiology of the
Esophago-Gastric junction

If You Get a Sleeve
You're Gonna Vomit
• Anatomy and Physiology of the
Esophago-Gastric junction
Disrupted By Sleeve Gastrectomy

Sleeve Gastrectomy
Creates HIGH Pressure System
• Study HIGH intragastric pressure after
water swallows in SG
(77 %) often w/o upper GI symptoms
• Gastric dysrhythmia (cause of vomiting)
induced by retrograde gastric electrical
ectopic locus in SG
•Obes Surg. 2016 Oct;26, High-resolution Impedance Manometry
after Sleeve Gastrectomy: Increased Intragastric Pressure and
Reflux are Frequent Events, Mion F, Tolone S et.al.

Sleeve N&V + GERD
Obes Surg. 2016 Oct;26
• Manometry Showed:
• Reflux episodes frequent after Sleeve (52%):
• Significantly associated with
gastroesophageal reflux (GER)
symptoms and
• Ineffective esophageal motility i.e. N&V

Abnormal Gastric Pacemaking
After Sleeve Gastrectomy
Gastric myoelectrical
activity (GMA) vomiting
Gastric dysrhythmia
precedes vomiting
major pattern of
dysrhythmia immediately
before vomiting also
noticed immediately after
vomiting

Sleeve gastrectomy (SG)
Excision of the normal gastric pacemaker,
Induces electrical dysrhythmias impacting
on post-operative symptoms and recovery
High-resolution (HR) electrical mapping
before and after Sleeve
Patterns of Abnormal Gastric Pacemaking After Sleeve Gastrectomy
Defined by Laparoscopic High-Resolution Electrical Mapping. Obes Surg.
2017 Aug;27(8):1929-1937

 All Sleeves developed
abnormalities either a
 Ectopic pacemaker with
retrograde propagation (50%) or
Bioelectrical quiescence (50%)
 Resection of the gastric
pacemaker resulted in aberrant
distal ectopic pacemaking or
bioelectrical quiescence.
 Ectopic pacemaking can persist
long after LSG, inducing chronic
dysmotility.

Anatomy and Physiology of the Esophago-Gastric junction

Post Sleeve Manometry
• Anatomy and Physiology of the Esophago-Gastric junction
• Heartburn and regurgitation
• Deteriorated in 11% & 28% patients
• Patients developed
• Decreased LES length and
• Weakened LES pressure after LSG.

Sleeve Gastrectomy = Vomiting
•352 patients;
Endoscopy for Dysphagia
**23%**
•1 out of every 4 Sleeves! =>
Endoscoped for dysphagia
(N&V)
•Nath A, Yewale S, Tran T, Brebbia JS, Shope TR, Koch TR. Dysphagia after
vertical sleeve gastrectomy: Evaluation of risk factors and assessment of
endoscopic intervention. World Journal of Gastroenterology.
2016;22(47):10371-10379. doi:10.3748/wjg.v22.i47.10371.

The hidden endoscopic
burden of sleeve gastrectomy
•Another Study 211 patients sleeve
gastrectomy over a 34-month period.
•17% of all sleeve gastrectomy patients
required post-operative endoscopy
•2% of sleeve gastrectomy patients
encountered a post-operative staple
line leak
•Equivalent cost of €159,898

Repeated Belching After
Sleeve Gastrectomy
•Belching occurred significantly more often
after LSG,
•Total number of gastric belches increased
from 30 ± 12 before to **60** ± 38/24 h
•Esophageal acid exposure increased
significantly, from 4 ± 2.9 % before to
13 ± 10.5 % after LSG (p = 0.01)
•Burgerhart JS, van de Meeberg PC, Mauritz FA, et al. Increased
Belching After Sleeve Gastrectomy. Obesity Surgery. 2016;26:132-137

Sleeve Gastrectomy
Go to the Hospital in the first year after
your surgery!!!
•1 out of every 10 Sleeve patients will be ADMITTED in
the hospital in the first year!!
•"1/3 of patients to Emergency Dept (33.9%)"
•Study 14,080 SG between 2011 and 2013
•12.5% of Sleeve patients admitted to the Hospital within
their first year after SG surgery!!

Sleeve Gastrectomy You are likely to
need to go back into the Hospital in the
first year after your surgery!!!
•ED visits for abdominal pain (n = 1029; 11.14%),
vomiting (n = 237; 2.57%), dehydration (n = 224; 2.43%),
and syncope (n = 206; 2.23%) were attributed to surgery.
•Overall 1-year readmission rates after SG are greater
than 1 in ten (12.5%)
•1 out of every 10 Sleeve patients will be back in the
hospital in the first year!!
•Sleeve Gastrectomy: the first 3 Years: evaluation of emergency department
visits, readmissions, and reoperations for 14,080 patients in New York
State.
•https://www.ncbi.nlm.nih.gov/pubmed/28840343

Sleeve => N&V
•In another Sleeve study
•30% of Readmissions Nausea & Vomiting
•"Given the progressive increase in the
proportion of bariatric patients undergoing SG,
hospital programs that aim to
•**decrease readmissions after bariatric surgery
need to focus on
•**prevention and control of postoperative
nausea and dehydration"
•Sippey M, et al. 30-day readmissions after sleeve gastrectomy versus
Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2016

Proximal Leakage After
Laparoscopic Sleeve Gastrectomy
•Obes Surg. 2017 Aug 24. Proximal Leakage After
Laparoscopic Sleeve Gastrectomy: an Analysis of
Preoperative and Operative Predictors on 1,738
Consecutive Procedures.
•3 chances out of 100 you will have a leak
•Proximal leakage was observed in 45 patients out of
1738 (2.6%).
•No correlation was found between leakage and the
preoperative variables analyzed.

Google Search of Pubmed
Database for Complications
of Sleeve
Scary!

Wernicke's & Sleeve Gastrectomy
•Wernicke's & Sleeve Gastrectomy
Search results PUBMED
•Items: 1 to 20 of **29**
•Wernicke’s encephalopathy after
sleeve gastrectomy: Literature review
•(Note: Zero (0) Cases of Wernicke's
with MGB

Mesenteric ischaemia
Sleeve Gastrectomy
•Search results PUBMED
•Items: 1 to 20 of **68**
•Portal Vein Thrombosis due to Prothrombin Gene Mutation following
Sleeve Gastrectomy Murad Baba, Jordan Fakhoury, Amer Syed Case
Rep Gastrointest Med. 2015; 2015: 816914
•Portomesenteric Vein Thrombosis, Bowel Gangrene, and Bilateral
Pulmonary Artery Embolism Two Weeks after Laparoscopic Sleeve
Gastrectomy Case Rep Surg. 2015; 2015:
•(Note: Zero (0) Cases of Mesenteric Ischemia with MGB

GERD, Esophagitis,
Barrett's and Esophageal
Cancer

From Rats to Man
Sleeve Causes Reflux,
Esophagitis Barrett's and
Esophageal cancer

Rats
•Association between sleeve gastrectomy (SG)
and gastroesophageal reflux disease
•Rats who underwent SG had significantly
increased reflux severity, compared with sham
(21.1% versus 0%, P = .02), respectively
•CONCLUSIONS:
•SG is independently associated with
histopathologic changes consistent with severe
esophagitis in an animal model

Gastroesophageal reflux disease & Barrett's
esophagus after laparoscopic sleeve gastrectomy
• Surg Obes Relat Dis. 2017
Apr;13(4):568-574.
• Gastroesophageal reflux disease and
Barrett's esophagus after laparoscopic
sleeve gastrectomy: a possible,
underestimated long-term complication.
• Genco A

•At a mean 58 months,
• GERD symptoms
68% vs 34% preop: P<.0001,
• Visual Analog Scale mean
3 vs 1.8: P = .018,
• PPI intake significantly increased
compared with preoperative values
57% vs 19%: P<.0001

• At EGD, upward migration of the "Z" line
• esophageal reflux was found in
*** 75% of cases. ***
• A significant increase in the incidence and
in the severity of erosive esophagitis (EE)
• NEW Barrett's esophagus (BE) *** 17%***
• Lifetime Endoscopic surveillance after SG
should be advocated irrespective of GERD sx
! ! !

Sleeve Gastrectomy
Reflux & Barrett's Esophagus
• Obes Surg. 2017 Jun 8.
• Reflux, Sleeve Dilation, and Barrett's
Esophagus after Laparoscopic Sleeve
Gastrectomy: Long-Term Follow-Up.
•Felsenreich DM1, Kefurt R1, Schermann
M2, Beckerhinn P3, Kristo I1, Krebs M4,
Prager G5, Langer FB1

Sleeve Gastrectomy
• 24-h pH metries, manometries,
gastroscopies, and questionnaires
focusing on reflux (GIQLI, RSI) in SG
patients with a
• Follow-up of more than 10 years who
did not suffer from symptomatic reflux or
hiatal hernia preoperatively.

Sleeve Gastrectomy
• 14% were converted to
RYGB due to intractable reflux
• Gastroscopies revealed
• De novo hiatal hernias in 45%
• Barrett's metaplasia in 15%.

Gastroesophageal reflux before
and after sleeve gastrectomy
•Surg Obes Relat Dis. 2014 Jul-Aug;
• Evaluation of gastroesophageal reflux
before and after sleeve gastrectomy using
symptom scoring, scintigraphy, and
endoscopy.
• Sharma A1, Aggarwal S2, Ahuja V3, Bal C4.

Gastroesophageal reflux before
and after sleeve gastrectomy
• Radionuclide scintigraphy
revealed a significant rise of
GERD from 6% to 78% in the
postoperative period (p<0.001).
• UGIE showed a rise in incidence of
esophagitis from 19% to 25%

Gastroesophageal reflux disease
symptoms and erosive esophagitis
•Surg Endosc. 2013 Apr;27(4)
•Increase in gastroesophageal reflux disease
symptoms and erosive esophagitis 1 year
after laparoscopic sleeve gastrectomy
among obese adults.
•Tai CM1, Huang CK, Lee YC, Chang CY, Lee
CT, Lin JT.

Gastroesophageal reflux disease
symptoms and erosive esophagitis
•Significant increase in the prevalence
of GERD symptoms (12 vs. 47%)
•
•Erosive Esophagitis (17 vs. 67%) after
LSG (P < 0.001).
• Hiatal hernias increased significantly
(6 vs. 27%; P < 0.001)

MGB and GERD
• Tolone Study
•After MGB, none of the patients
reported de novo heartburn or
regurgitation.
•At endoscopic follow-up 1 year after
surgery,
•esophagitis was absent in all patients
and no biliary gastritis or presence of
bile was recorded

MGB and GERD
• Tolone Study
•MGB Manometric features and patterns
did not change significantly after
surgery
•Intragastric pressures (IGP) diminished
statistically (from a median of 15 to 9.5,
p<0.01)
•MGB is a Low Pressure System

MGB = Low Pressure
Sleeve = HIGH Pressure => GERD
• Tolone Study
•Intragastric pressures (IGP)
diminished statistically (from a median
of 15 to 9.5, p<0.01)
•MGB is a Low Pressure System
•In contrast, SG induced significant
elevation IGP (from 15 to 19, P < 0.01)
•Sleeve is a HIGH Pressure System

Reflux Events MGB vs Sleeve
Tolone Study
• MGB => A dramatic decrease in the
number of reflux events (from a median
of 41 to 7; P < 0.01) MGB
MGB Low Pressure = Less Reflux
•SG +> significant increase in
esophageal acid exposure & number of
reflux episodes (from 33 to 53; P <0.01)
•Sleeve is HIGH Pressure = More Reflux

Esophageal adenocarcinoma
after Sleeve
• Int J Surg Case Rep. 2017; 32:
47–50.
• Esophageal adenocarcinoma five
years after laparoscopic
sleeve gastrectomy. A case report
• Fernando Gabriel Wright

Esophageal Cancer
After Sleeve
• Shortcoming of LSG in the long-term
follow-up and this is the
Frequent onset of de novo GERD
• Significant increase of GERD and
hiatal hernia post sleeve,
• Also an increase in revisional
surgeries associated with refractory
reflux post Sleeve

Esophageal Cancer
After Sleeve
•48-Year-old man that underwent a laparoscopic
sleeve gastrectomy
•Routine preoperative evaluation included an upper
gastrointestinal series and EGD, which showed no
reflux or hiatal hernia, no esophagitis or Barrett́ s
esophagus.
•Helicobacter pylori was negative.
•15 months after the operation, he complained of new
onset of typical GERD symptoms. He was put on
proton pump inhibitors (PPI)
•4 years later (fifth postoperative year) dysphagia to
solids and a 10 kg weight loss. Endoscopy
adenocarcinoma of the esophagus

Esophageal Cancer
After Sleeve
•In a prospective randomized trial that compared LSG
with gastric banding, Himpens et al. found
development of de novo reflux symptoms in 21.5% of
the LSG cohort at one-year follow-up
•Braghetto et al. analized 231 patients without reflux
symptoms, esophagitis or Barrett, who underwent a
LSG. In the follow-up, GERD symptoms were found
in 23.2%, erosive esophagitis in 15.5%, and
•Barrett’s esophagus (intestinal metaplasia) in 1.2%

Esophageal Cancer
After Sleeve
•two other cases of esophageal adenocarcinoma
after LSG have been published.
•Scheepers et al. described the case of a 57-year-old
woman who was submitted for a LSG and was
diagnosed with esophageal adenocarcinoma four
months after bariatric surgery [15].
•In another case reported by Sohn et al., a 44-year-old
woman who underwent LSG developed an
adenocarcinoma of the gastroesophageal junction
2.5 years after surgery [16]

GERD & Bariatric Surgery
 GERD, Barrett's, Esophageal Cancer
 Hx of General Surgery, Forgotten
Allison, Hill Repairs (Failure Abandoned)
 Rx with Nissen, Results of Nissen
 GERD in Bariatric Surgery
Band & Sleeve CAUSE GERD
Sleeve Surgeons Failed Rx??
 RNY Rx GERD
 MGB Excellent Rx GERD
Understanding Why?

Systematic review: Laparoscopic Nissen
fundoplication for gastroesophageal reflux disease
Laparoscopic Nissen fundoplication (LF) for
gastroesophageal reflux disease (GERD).
10 years after LF, 36% reported heartburn &
29% reported regurgitation.
The proportion using PPIs increased, from
9% in year 1 to 18% at 10 years.

A randomized controlled trial of
laparoscopic Nissen fundoplication
versus proton pump inhibitors for the
treatment of patients with chronic
gastroesophageal reflux disease
(GERD): 3-year outcomes.
•Surg Endosc. 2011
Aug;25(8):2547-54.

RCT; Nissen vs PPIs
•A randomized controlled trial (RCT)
gastroesophageal reflux disease (GERD)
•1. who were stable and symptomatically
controlled with long-term medical therapy
to
•compare
•ongoing medical therapy with
•laparoscopic Nissen fundoplication (LNF).

Nissen vs PPIs: No difference
•GERD Sx or
Acid exposure on 24-h pH
monitoring
•There were six treatment failures
(12%) in the surgical group and
eight treatment failures (16%) in
the medical group by 3 years.

RCT: CONCLUSIONS:
For patients whose GERD
symptoms are stable and
controlled with PPI,
Medical therapy
Nissen
are equally effective

Use of proton pump
inhibitors after anti-reflux
surgery: a nationwide
register-based follow-up
study
•Jan 28, 2014 -
•Lødrup A(1), Pottegård
A(2), Hallas J(2),

Denmark Nationwide health
care registry study
•PPI use after Anti-reflux surgery
(ARS) in the general Danish
population using nationwide health
care registries.
•A nationwide retrospective follow-
up study of all patients aged ≥18
and undergoing first-time ARS in
Denmark during 1996–2010

Denmark Nationwide health
care registry study
• Female gender, high age,
recent ARS, previous use of
PPI & use of NSAIDs drugs or
antiplatelet therapy
significantly increased the risk
of PPI use (Nissen failure).

Long term failure of Nissen
•3465 patients ARS
•5, 10 & 15-year risks of
New PPI Rx =
57%, 72% & *83%*, respectively
•5, 10 & 15-year risks
Long-term PPI use =
30%, 41% and *57%*

Nissen Failure
• Conclusions Risk of PPI use after
Nissen high!
• More than 50% of patients became
long-term PPI users
• Patients should be made aware
that long-term PPI therapy is often
necessary after Nissen.

Majority of Gastro-Esophageal
Reflux Disease Patients
Continue to Use Proton Pump
Inhibitors After Anti-reflux
Surgery (Nissen)
A Madan et al. Aliment Pharmacol Ther
2006 Mar 01

Nissen Failure 80% Rx PPIs
•Nissen fundoplication at our
institution over a period of over 3
years were asked to complete a
questionnaire
•80% patients were still taking
anti-reflux medications including
proton pump inhibitors

Rx GERD with Nissen
Very Questionable Results

Survey 3,000 MGB Patients
• 64% of MGB patients taking
antacid medications for GERD
preop (PPIs, H2Blockers or
Antacids)
• Post MGB resolution of GERD
Sx with discontinuation of
medications 81%

MGB Rx GERD
Equal to or Better Than
Nissen
• How Does it Work?

MGB Rx GERD
Mechanism of Action
1. Reduction of Acid
Production
2. Weight loss
3. Downward traction on the
stomach
4. *Creation of LOW Pressure
System*

Conclusions
• GERD common serious problem
in Bariatric patients
• Nissen “gold standard” poor
results + = simply taking PPI's
• Dr Rutledge MGB Series:
80% success Rx GERD
• Understand WHY!
• MGB Good to Excellent Rx GERD

Post-op malnutrition
Vitamin and mineral deficiencies after Sleeve
Gastrectomy: A huge challenge
Thought that deficiencies mostly occurred in procedures with
a malabsorptive component, like the RNY, MGB or the BPD
The risk for deficiencies after sleeve gastrectomy was
considered low. 3
Studies show that sleeve deficiencies occur almost as
much.3,4
Research by Capoccia et al. showed that following
laparoscopic sleeve gastrectomy a significant proportion of
patients developed vitamin B12 and folate deficiency.4

Deficiencies in Sleeve
•Dr. Aarts iron deficiency 43% Sleeve patients
•In 26% of patients had significantly low B12, folate, iron
and vitamin D levels in sleeve gastrectomy patients.3
•“There is no doubt that the levels of nutritional
deficiencies after sleeve are higher than those reported
in the literature.”
•“In our series, 28% of patients were anemic, but the
literature states only a few percent of anemia cases per
year.
•This is incorrect, nutritional deficiency rates after sleeve
gastrectomy are grossly under reported.

Malnutrition MGB
•You Can Get Malnourished After MGB
•But
•Usually it is not a Poor Diet
•It usually means that the Bypass is Too Long
and Needs revision
•In skilled hands this occurs in 0.1 to 1% of
patients
•For 99%-99.9% of MGB Patients the
Recommended Diet for MGB is...
•Practically every system in the human body
benefits from the "Mediterranean diet"

MGB vs Sleeve, Meta-analysis
 Mini-Gastric Bypass/One-Anastomosis Gastric
Bypass Versus Sleeve Gastrectomy
 for Morbid Obesity: a Systematic Review and
Meta-analysis
 Seventeen studies met the inclusion criteria
incorporating 6,761 patients.
 In this study
 MGB study patients were older, and heavier
than comparable Sleeve patients

MGB vs Sleeve, Meta-analysis
In spite of MGB patients being older and
heavier…This study reveals MGB
=> MGB better weight loss vs Sleeve
=> MGB better remission of comorbidities vs
Sleeve (i.e. Diabetes Mellitus),
=> MGB Shorter hospital stay vs Sleeve
=> MGB Significantly lower death rate in the MGB
than Sleeve!
Mini-Gastric Bypass/One-anastomosis gastric
bypass (MGB) is a safe, feasible and effective
bariatric procedure

Sleeve is a Poor Treatment
of Diabetes
MGB is an Excellent
Treatment of Diabetes

Sleeve Diabetes Remission Rates
at 7yrs (28%)
• Ann Surg. 2017 Jul 24. Individualized Metabolic Surgery
Score: Procedure Selection Based on Diabetes Severity.
•At median postoperative follow-up of 7 years
(range 5-12)
•Diabetes remission
(HbA1C <6.5% off medications)
•49% after RYGB and
•28% after SG (P < 0.001)

Sleeve Rx Diabetes
•Ann Surg. 2016 Oct;264(4):674-81.Can Sleeve
Gastrectomy "Cure" Diabetes? Long-term
Metabolic Effects of Sleeve Gastrectomy in
Patients With Type 2 Diabetes.
• long-term metabolic effects of laparoscopic
sleeve gastrectomy
•Complete remission (HbA1c <6% off
medications) in 11%
•"cure" (continuous complete remission for
≥5 years) was achieved in 3%

RCT Sleeve vs MGB 5 yrs
• At 60 months,
•18 MGB pts (60%)
•9 Sleeve pts (30%)
•Achieved the primary end
points
•HbA1c ≤6.5% without glycemic
therapy.

Understanding the MGB & GERD

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Understanding the MGB & GERD