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Namaste, G'day, Guten tag, Konichiwa, Ciao,
                Olá e bem-vindos, Ni Xao, Sawadeeka, Bonjour,
                                      Buenos dias, Ciao, Howdy!




PROGRAM:
FIRST INTERNATIONAL
MINI-GASTRIC BYPASS /
ONE ANASTOMOSIS BYPASS
CONSENSUS CONFERENCE




Paris Oct18-20 2012
Thursday, October 18, 2012 at 8:00 AM
Friday, October 19, 2012 at 12:00 PM (PDT)
Paris Paris Charles de Gaulle Airport Marriott Hotel
Allée du Verger, 95700 Roissy-en-France, France

In addition Live Surgery Demonstration on Saturday Oct 20
Clinique Geoffroy Saint Hilaire - Paris , 59 Rue Geoffroy-Saint-Hilaire 75005 Paris, France, 01 44 08 40 00

Dr Rutledge & Dr Chiche, Two Operating Rooms 6 - 8 MGB,3 Visitors in OR,
Video Transmission Conference Room 25 Surgeons, (Contact      DrR@clos.net for special invitation)
Welcome

  •   Honorary Meeting Chairman: Jean Mouiel, MD Pr of Surgery Obesity Center Nice France
  •   Chairman of the Meeting: Pr Jean-Marc Chevallier, chirurgie digestive , coelioscopie et de l'obésité, président de la
      soffco, hôpital européen georges pompidou, 20 rue leblanc, 75908 paris cedex 15, France
  •   International Co-Chairman; Prof M. Garciacaballero, Full Professor Surgery, University Malaga, Medical Faculty,
      Malaga, 29080, Spain, gcaballe@uma.es
  •   International Co-Chairman; Dr. K S Kular M.S., Director, Dept of Bariatric Surgery, Kular Hospital & College of Nursing,
      Bija, Ludhiana, Punjab , India - 141412


  •   Goals
      Listen to Short Data/Presentations
      Discuss Pros and Cons of Issues
      Vote on Consensus of the Group
      Record the Results


  •   Meeting Process
      Several short presentations by leaders in the field.
      Chairman opens the discussion.
      Moderator roams the floor to seek both discussion and consensus.
      Recorder makes a written record of the discussion and voting also guiding the discussion to come to decisions by the
      group.


Meeting Chairmen, Moderators and Recorders
  •   SECTION I: Bariatric Today: Surgery Choices and Outcomes
  •   Section Chairman: Roberto Tacchino
  •   Moderator: Dr. Narwaria
  •   Recorder: Dr. Jan Apers

  •   SECTION II: MGB Results with Large Series
  •   Section Chairman: Dr. Shashank Shah/Dr Bhandari
  •   Moderator: Emilio Manno
  •   Recorder: Karl Rheinwalt

  •   SECION III: MGB/OAB Best Practice; Technical Performance
  •   Section Chairman & Moderator: Pr Jean-Marc Chevallier
  •   Recorder: Mario Musella

  •   Thursday Video Techniques Lunch 1
  •   Section Chairman: Michael Van den Bossche
  •   Moderator: Pr Jean-Marc Chevallier
  •   Recorder: Jan Apers
Thursday Afternoon :

    •   SECTION IV: MGB Advantages, Long Term Studies & Other Topics
    •   Section Chairman: Prof. M. Garciacaballero
    •   Moderator: Kamal Mahawar
    •   Recorder: Philippe Costil

Friday Morning: MGB; Expert's Experience; TIPS and Tricks, Complications and Risks

    •   SECTION V: Beginning The Consensus Conference Final Statement
    •   Section Chairman: Jean Mouiel, MD
    •   Moderator: Michal Cierny
    •   Recorder: Dr. Rui Ribeiro

    •   Video Techniques Lunch II
    •   Section Chairman: Dr. C Peraglie
    •   Moderator: Mario Musella
    •   Recorder: Dr. Karl Rheinwalt

    •   SECTION VI: The End: The Final Consensus Conference Voting Statements & Planning for the Future
    •   Section Chairman: Dr. Roberto Tacchino
    •   Moderator: Dr. Rutledge
    •   Recorder: KS Kular

SATURDAY MORNING Oct 20 2012
SECTION VII: Live MGB Surgery with Cady, ChiChe, Guerolt & Rutledge
Monday Morning Oct 22, Live Surgery in Lisbon Portugal w Dr. Rui Riberio/Dr Rutledge
Table of Contents
   Welcome
Faculty
Program Outline
Updated 10/12/12: Brief Program
Saturday Oct 12, 2012; Live Interactive Case Demonstrations of Mini-
   Gastric Bypass
Full Program
Esophageal Cancer & GE Reflux: Brief Review
Rutledge Version of Mini-Gastric Bypass: Tools, Tips, Techniques;
   Special needs for the Surgery (Instruments, etc.)
References
Mini-Gastric Bypass References
Sleeve Gastrectomy Quickly Leads to New Onset GE Reflux & Weight
   Regain
Meeting Survey
Faculty
     Name: Title Institution: City/Town: Country:

     Jean Mouiel, MD Pr of Surgery Obesity Center NICE FRANCE

     Mario Musella Associate Professor of Surgery Naples "Federico II" University - Medical School Naples ITALY

     Philippe COSTIL NEUILLY SUR SEINE FRANCE

     Jan Apers drs. MCL Leeuwarden Leeuwarden Netherlands

     Roberto Tacchino MD Catholic University Rome Italy

     Atul N.C Peters DR. Fortis Hospital, Shalimar Bagh New Delhi INDIA

     Rui Ribeiro Dr. Centro Hospitalar de Lisboa Central Lisboa Portugal

     Michael Van den Bossche MD FRCS Spire Southampton Hospital Castel UK

     Michal Cierny Dr., PhD Breclav Hospital Breclav Czech Republic

     M. Garciacaballero Full Professor Surgery University Malaga Malaga Spain

     Karl Rheinwalt Dr. Dept.for Bariatric Surgery, St. Franziskus-Hospital Cologne Germany

     Emilio Manno MD Ospedale Cardarelli Naples Italy

     Francesco Greco MD, PhD Clinica Castelli Bergamo

     Maurizio De Luca MD Vicenza Regional Hospital Vicenza Italy
     Martin Kox Prof hon., Dr, Chef de service département chir viscerale Centre Hospitalier Emile Mayrisch L -Esch-Alzette
  Luxembourg

     Nicolas Cardin Dr Centre Hospitalier de Douai Douai France

     Kamal Mahawar Mr. Sunderland Royal Hospital Sunderland United Kingdom

     Dr. Robert Rutledge, CLOS, Las Vegas, Nevada, USA




                                                                                                                          5
Program Outline:
   Thursday morning, Oct 18
   SECTION I: Bariatric Today: Surgery Choices and Outcomes
   SECTION II: MGB Results with Large Series
   SECION III: MGB/OAB Best Practice; Technical Performance
   Thursday Video Techniques Lunch 1
   Thursday Afternoon :
   SECTION IV: MGB Advantages, Long Term Studies & Other Topics
   Friday Morning : MGB; Expert's Experience; TIPS and Tricks ,
Complications and Risks
   SECTION V: Beginning The Consensus Conference Final Statement
   Video Techniques Lunch II
   SECTION VI: The End: The Final Consensus Conference Voting
Statements & Planning for the Future
   SATURDAY MORNING Oct 20 2012
   SECTION VII: Live MGB Surgery with Cady, ChiChe, Guerolt &
Rutledge
   Monday Morning Oct 22, Live Surgery in Lisbon Portugal w Dr. Rui
Riberio/Dr Rutledge




                                                                  6
Updated 10/12/12: Brief Program
Oct 18: Thursday Morning :
Survey Hand Out, Voting Questionnaire for Consensus Instructions
   Time    Presenter                       Subject
    9:00   Jean Mouiel                      Introduction: Honorary Chairman
    9:10   JM Chevallier                   Chairman First International Mini-Gastric Bypass / One Anastomosis
                                           Consensus Conference: ; Welcome, Charge to the Meeting; Listen,
                                           Learn, Discuss, Vote, Plan,
SECTION I: Bariatric Today: Surgery Choices and Outcomes
======= Special Guest Presentations: =======
======= The Story of Transition from “Non-MGB” to MGB Surgeon =======
   Time    Presenter                       Subject
    9:20   Prof hon., Dr Martin Kox,       Head Of Service Department Visceral Surgery, Centre Hospitalier Emile
                                           Mayrisch, L -Esch-Alzette, Luxembourg. Personal Reflections; History
                                           of Peptic Ulcer Surgery
    9:30   M Narwaria;                  Past President Obesity Surg Soc India ; My Journey to the MGB /
                                        MGB in India
    9:40   JM Chevallier,               President Obesity Surg Soc France; What I know about MGB: 7 years
                                        experience
    9:50   R Rutledge                   International Survey Bariatric Surgeons, Reflux & Esophageal cancer
                                        after Sleeve & Band
  10:00    Opening Questions, Present Status; Meeting Goals & Future Plans

SECTION II: MGB Results with Large Series
   Time    Presenter                       Subject
  10:10    R Tacchino                      My Experience    with   MGB in Italy
  10:20    K Kular                         My Experience    with   MGB in India
  10:30    M Garciacabaello                My Experience    with   OAB in Spain
  10:40    C Peraglie                      My Experience    with   MGB in USA
  10:50    JP Chevallier                   My Experience    with   MGB in France
  11:00    J Cady                          My Experience    with   MGB in France
  11:10    R Rutledge                      My Experience    with   MGB; 15 years and 6,000 Patients Later

  11:20    MGB Results: Questions and Answers and Votes from Floor


SECION III: MGB/OAB Best Practice; Technical Performance
   Time    Presenter                       Subject
  11:30    M Musella                       MGB in Italy; Technical Performance Issues in MGB
  11:40    C Peraglie                      Best Practices; Critical Technical Performance Issues in MGB
  11:50     R Ribeiro                      MGB in Portugal Tech Issues in MGB Gastric Pouch
  12:00    Jan Apers                       Dutch MGB, Tech Issues in MGB; Bypass & Leaks
  12:10    J Cady                          MGB as Rescue for Failed Band


                                                                                                                   7
12:20   Directed Discussion: Agreements and Controversies Technical Performance of MGB/OAB

==========================================================
Thursday Video Techniques Lunch 1
         Garciacaballero             5 min video; 5 MGB Tips
         Peraglie                    5 min video; 5 MGB Tips
         Kular                       5 min video; 5 MGB Tips
         Videos Questions and Answers and Votes from Floor
==========================================================

Thursday afternoon :
==========================================================

SECTION IV: MGB Advantages, Long Term Studies & Other
Topics
 13:30   Sandeep Aggarwal            MGB vs Other Surgery
 13:40   K Mahawar, MGB              Review of Literature on MGB
 13:50   Maurizio De Luca            Italian Experience with Band, RNY, Sleeve & MGB
 14:00   K S Kular:                  MGB vs Sleeve; Report on 200 Sleeves
 14:10   R Tacchino:                 MGB and BPD; compare and contrast
 14:20   A Peters:                   MGB vs. RYGB
 14:30   M Bhandari                  GERD Band& Sleeve vs. RNY & MGB
 14:40   Questions and Answers and Votes from Floor

 14:50   Emilio Manno                      MGB Complications and Management (Leaks)
 15:00   M Van den Bossche;                MGB in UK; GE Reflux; Band, Sleeve, RNY & MGB
 15:10   Dr Cierny                         My experience with MGB in Czech Republic
 15:20   Dr S Shah                         Minimal Risk of Gastric Cancer after Billroth II, Processed Meat is
                                           Much More Dangerous
 15:30   Dr. Weiner                        Bile Reflux following Mini-Gastric Bypass (Omega Loop)
 15:40   Questions, Answers and Votes from the Floor
         Directed Discussion: Agreements and Controversies
         Panel: Chevalier, Garciacaballero, Tacchino, Kular, Peraglie, Nawaria, Weiner

 16:00   Dr Rutledge;                Failure of Restrictive Procedures: Coca-Cola & Ice Cream Beat Band &
                                     Sleeve
 16:10   Questions and Answers and Votes from Floor

==========================================================

Friday Morning :
MGB; Expert's Experience; TIPS and Tricks , Complications and Risks
==========================================================
SECTION V: Beginning The Consensus Conference Final Statement
                                                                                                                 8
9:00   K S Kular:                  Safety, Safety, Safety; Choosing the MGB
   9:10   Garciacaballero;            An Experts View, OAB Advantages & Advice
   9:20   R Tacchino;                 An Experts View, MGB Advantages
   9:30   Dr Narwaria                 An Expert's View, Advice to the New MGB'er
   9:40   Dr Peraglie;                Marginal Ulcers: An Expert's View
   9:50   Karl-Peter Rheinwalt        My Advice on Becoming a New MGB Program
  10:00   Questions and Answers and Votes from Floor
  11:00   R Rutledge:                 Renaming the MGB/OAB; Survey Results, Discussion and Voting
                                               1.    Survey Results on Renaming the MGB
                                               2.    Keep MGB name and OAB name?
                                               3.    Create a New Name for both (BII Bypass, Omega Bypass, Sleeve
                                                     Bypass
                                               4.    Some combination?
                                               5.    The MGB is a Bad name
                                               6.    The MGB is a Good Name
                                               7.    Relation between MGB and OAB (Friends, Brothers or enemies?)
                                               8.    Consensus Voting
                                               9.    Suggestions:
                                               10.   Class Name Single Anastomosis Bypass / Omega Bypass or other
                                                     (include MGB AND OAB)
                                               11.   Two Sub-groups of SAB/OLB Class:
                                               12.   MGB = Type I SAB
                                               13.   OAB = Type II SAB

  11:10   Questions & Voting
========================================================

Video Techniques Lunch II
       Tacchino             5 min video; 5 MGB Tips
       Chevallier           5 min video; 5 MGB Tips
       Rutledge             5 min video; Revision of MGB (Hint, Its Easy)
========================================================

SECTION VI: The End: The Final Consensus Conference
Voting Statements & Planning for the Future
  13:00   Creation of the Consensus Statement; Review of Survey and Voting Results So Far Dr Rutledge
  13:10   Questions and Answers and FINAL Votes from Floor
  13:20   Pr Tacchino:                  Band, Sleeve, RNY & MGB Outcomes: Consensus Statement
  13:30   M Nawaria                     Critical Factors in Performance of MGB: Consensus Statement
  13:40   Questions and Answers and FINAL Votes from Floor
  14:00   Garciacaballero:               The Future; Liberté, égalité, fraternité, "Liberty, equality, fraternity
  14:10   Discussion and Voting
  15:00   Dr. Rutledge,                  IFSO, IFSO-EC, ASMBS Meeting Financial Report
  15:10   Voting CONSENSUS : QUESTIONS AND ANSWERS
  16:00   Society of MGB/OAB Surgeons; Open Discussion and Voting, Organization and Mutual Aide
  18:00   Additional Videos (TBA), Topics from the Floor



                                                                                                                    9
==============================================================

SATURDAY MORNING Oct 20 2012
SECTION VII: Live MGB Surgery with
Dr’s Cady, ChiChe, Guerolt & Rutledge

Live Interactive Surgery Demonstration
Paris on Saturday October 20, 2012
Clinique Geoffroy Saint Hilaire - Paris59 Rue Geoffroy-Saint-Hilaire 75005 Paris, France, 01 44 08 40 00
Dr Cady, Guerolt, Rutledge & Chiche, Two Operating Rooms 6 - 8 MGB 3 Visitors in OR, Video Transmission Conference
Room 25 Surgeons, (Contact DrR@clos.net for special invitation), Possible Dinner Meeting to Follow
Live Interactive Surgery Demonstration
Lisbon Portugal Monday October 22, 2012
Monday Morning Oct 22, Live Surgery in Lisbon Portugal w Dr. Rui Riberio/Dr Rutledge,
(Contact DrR@clos.net for special invitation)




                                                                                                                     10
Saturday Oct 12, 2012
Live Interactive Case Demonstrations of Mini-Gastric Bypass
       Live case demonstrations of Mini-Gastric Bypass procedures. To Be Held at Clinique Geoffroy Saint-Hilaire ( On
Facebook: http://www.facebook.com/pages/Clinique-Geoffroy-Saint-Hilaire/135267789853994 ) We have arranged a world
renowned and clinically expert team to demonstrate the technical performance details of the Mini-Gastric Bypass in Paris on
Saturday Oct 20, 2012. For the main operators on Saturday
        Dr Jean CADY: Medical Doctor, Member of French National Academy of Surgery, and Member on French Society of
Bariatric Surgery. Laparoscopic surgeon, Bariatric surgeon, Colo-Rectal surgeon.
      Dr Renaud Chiche: Medical Doctor, Member on French Society of Bariatric Surgery. Laparoscopic surgeon, Bariatric
surgeon, Colo-Rectal surgeon.
       The space is limited to 20 surgeons and sign up is required at Sign-Up: http://satlivemgb.eventbrite.com/
       3-day Consensus Conference and Education Course on Mini-Gastric Bypass: The increasing role of Mini-Gastric Bypass
(MGB) in the treatment of morbid obesity we feel dictates the need for greater acquaintance with this type of surgery. In
addition to the 2 day consensus conference we have arranged for a total of 20 surgeons observe and interactive display of live
MGB surgeons with international MGB experts. We believe that all surgeons will find the laparoscopic bariatric mini-training
program to be of value with respect to future professional orientations. Many surgeons have started performing MGB's, and
our goal was to pass on some of the experience with the thousands of prior MGB’s performed by these experts.
        The most useful parts of the course will include discussion of the identification and treatment of complications, the use
of new instrumentation, and surgical demonstrations (live interactive). We believe that the participants will very likely note
presentation of novel knowledge by all participants. The 2-day MGB course offers participants high-quality novel knowledge
and excellent training quality, and we predict, significant impact on the quality of their patient care and on their personal
career.
        The influence of clinical demonstrations, on the confidence and skills of surgeons, when treating patients with newer
surgical techniques, even when they have the requisite skills is enormous. Studies show that surgeons who receive an
interactive clinical demonstration prior to treating their patients were more confident of their skills and the details of their
performance and as a result their performance improved.
       Clinical demonstrations are difficult to arrange and manage, they are time consuming, but they are time well spent.
We are proud to offer an addition to the didactic teaching and discussion of the First International Consensus Conference on
the Mini-Gastric Bypass / One Anastomosis Bypass.
       Sign-Up: http://satlivemgb.eventbrite.com/
        A Live Interactive Demonstration of Mini-Gastric Bypass Surgery to a limited audience of interested surgeons. We
know that surgeons who observe live demonstrations indicate higher scores for its helpfulness in performance of all the stages
of surgical techniques, when compared to those who had observed a videotaped demonstration.
       The Clinic: Geoffroy Saint-Hilaire private hospital
       Located in the heart of the oldest district of Paris, the Geoffroy Saint-Hilaire private hospital allies the strength of a
group and the tradition of the excellence. Geoffroy Saint Hilaire private hospital is a multidisciplinary establishment having 196
beds and places dedicated. This clinic includes an intensive care unit for medical and surgical cares and provides all modern
technologies and services.
       Sign-Up: http://satlivemgb.eventbrite.com/
       Our Commitment to Excellence in Patient Safety as well as Surgeon Education
        Please know that we are committed to the highest levels of patient safety and are committed to the patient’s outcomes
from live case demonstrations of the Mini-Gastric Bypass procedures.




                                                                                                                                   11
Updated 10/12/12: Full Program
==============================================================
Oct 18: Thursday Morning:
Survey Hand Out, Voting Questionnaire for Consensus Instructions




                                                                   12
Time     Presenter                   Subject
9:00     Jean Mouiel                 Introduction: Honorary Chairman
9:10     JM Chevallier               Chairman First International Mini-Gastric Bypass / One Anastomosis
Consensus Conference: ; Welcome, Charge to the Meeting; Listen, Learn, Discuss, Vote, Plan,
           Objectives:
   1. Why Are We Here: MGB Excellent Therapy Not Widely Recognized
   2. Create a Report of MGB Series: MGB Excellence Best Practices Treatment for Obesity/Metabolic Disease
   3. Technical Details of Best Performance of MGB
   4. Plan for Support, Adoption and Improvement of MGB around the World

==============================================================
SECTION I: Bariatric Today: Surgery Choices and Outcomes
======= Special Guest Presentations: =======
======= The Story of Transition from “Non-MGB” to MGB Surgeon =======
Time      Presenter                    Subject
9:20      Prof hon., Dr Martin Kox,    Head Of Service Department Visceral Surgery, Centre Hospitalier Emile
Mayrisch, L -Esch-Alzette, Luxembourg. Personal Reflections; History of Peptic Ulcer Surgery
             Objectives
             History of General Surgery
             History of the Treatment of Ulcer Disease
             Vagotomy and Antrectomy for over 100 years
             What Happens When Bariatric Surgeons forget They are General Surgeons

9:30      M Narwaria; Past President Obesity Surg Soc India ; My Journey to the MGB / MGB in India
          1. Who Am I: Successful International leader in Bariatric Surgery?
          2. Initial Skepticism of MGB
          3. Initial Results with MGB
          4. Insights into the Mind of an MGB Skeptic

9:40      JM Chevallier, President Obesity Surg Soc France; What I know about MGB: 7 years experience
          1. Who Am I: Successful International leader in Bariatric Surgery?
          2. Initial Skepticism of MGB
          3. Initial Results with MGB
          4. Insights into the Mind of an MGB Skeptic

9:50     R Rutledge; International Survey Bariatric Surgeons, Reflux & Esophageal cancer after Sleeve & Band
         1. Survey of 112 Bariatric Surgeons from 23 Countries Around the World
         2. In Short Band is not very good, 1/3 to ½ of surgeons have abandoned the Band
         3. Sleeve and Band => Acid GE Reflux => 2 X Increased risk Esophageal Cancer
         4. By Almost Every Measure MGB Outperforms the Band, the Sleeve and the RNY

10:00     Opening Questions, Present Status; Meeting Goals & Future Plans
          1. Limitations of Band, Sleeve & RNY
          2. Ideal Bariatric Surgery (measures of Success)
          3. Results of MGB
          4. Recommendations for Type of Bariatric Surgery
   1. Why Should Successful Bariatric Surgeons Choose MGB
   2. Skepticism of MGB
   3. Results of MGB
   4. Response to MGB Skeptics


                                                                                                             13
==============================================================
SECTION II: MGB Results with Large Series
Time       Presenter                          Subject
10:10      R Tacchino                         My Experience    with   MGB in Italy
10:20      K Kular                            My Experience    with   MGB in India
10:30      M Garciacabaello                   My Experience    with   OAB in Spain
10:40      C Peraglie                         My Experience    with   MGB in USA
10:50      JP Chevallier                      My Experience    with   MGB in France
11:00      J Cady                             My Experience    with   MGB in France
11:10      R Rutledge                         My Experience    with   MGB; 15 years and 6,000 Patients Later

11:20      MGB   Results: Questions and Answers and Votes from Floor
           MGB   vs Other Choices for Obese Patients
           MGB   vs Band
           MGB   vs Sleeve
           MGB   vs RNY

==============================================================

SECION III: MGB/OAB Best Practice; Technical Performance
Time       Presenter                          Subject
11:30      M Musella                          MGB in Italy; Technical Performance Issues in MGB
            1. Caliber & Length of sleeve
            2. Length of Bypass
            3. Anastomosis (handsewn, mechanical, side to side, end to side,linear stapler, circular stapler, Reinforcement of
the staple gastric sleeve line, Reinforcement of the gastric remnant staple line, (seamguard, peri strip, fibrin glue, other
sealant…) Closure of the stapler access (single layer, double layer, mechanical continuous suture, manual continuous suture,
mechanical interrupted stitches, manual interrupted stitches…)
            4. Only ONE WAY or Multiple Equally Good Ways to Perform MGB

11:40      C Peraglie                         Best Practices; Critical Technical Performance Issues in MGB
            1. Caliber & Length of sleeve
            2. Length of Bypass
            3. Anastomosis (handsewn, mechanical, side to side, end to side,linear stapler, circular stapler, Reinforcement of
the staple gastric sleeve line, Reinforcement of the gastric remnant staple line, (seamguard, peri strip, fibrin glue, other
sealant…) Closure of the stapler access (single layer, double layer, mechanical continuous suture, manual continuous suture,
mechanical interrupted stitches, manual interrupted stitches…)
            4. Only ONE WAY or Multiple Equally Good Ways to Perform MGB

11:50      R Ribeiro                           MGB in Portugal Tech Issues in MGB Gastric Pouch
The Gastric Pouch
   Time 8 min
      1. Surgeon/Patient Position, Ports Position/Placement,
           2. Location of pouch initiation, Skeletonization of lesser curve,
           3. Creation of the pouch:
           Use of the staple gun, Covidien/Ethicon: Pros & Cons,
           Location and angle of first staple cartridge
           Cartridge selection: White/Blue/Gold/Green,
           Delays: Before and During Staple Gun Firing
           4. Wisdom of Old Men:

                                                                                                                             14
Fear “Thickness”,
           Fear The Tube/Bougie/NG tube
           Fear the Angle of His

12:00      Jan Apers                        Dutch MGB, Tech Issues in MGB; Bypass & Leaks
           1. Dutch Experience with MGB
           2. Running the Bowel, Distance of the bypass, Tailoring the length bypass
           3. Leaks after MGB
           4. Managing Leaks

12:10       J Cady                           MGB as Rescue for Failed Band
    1. Band is Good choice?
    2. Failure Rate (Weight Regain, Reflux) and Leak Rate
    3. FU Band and MGB, complications and Weight Loss
    4. Band vs MGB; 50% vs 90% Success

12:20     Directed Discussion: Agreements and Controversies Technical Performance of MGB/OAB
     Panel: Chevalier, Garciacaballero, Tacchino, Kular, Peraglie, Nawaria, Weiner

==============================================================
Thursday Video Techniques Lunch 1
         Garciacaballero     5 min video; 5 MGB Tips
         Peraglie            5 min video; 5 MGB Tips
         Kular               5 min video; 5 MGB Tips
         Videos Questions and Answers and Votes from Floor

==============================================================


Thursday afternoon :
==========================================================
SECTION IV: MGB Advantages, Long Term Studies & Other
Topics
13:30      Sandeep Aggarwal                 MGB vs Other Surgery
           1. Band vs MGB
           2. BPD vs MGB
           3. RNY vs MGB
           4. Sleeve vs MGB

13:40      K Mahawar, MGB                   Review of Literature on MGB
           1. Review of MGB Publications
           2. MGB Advantages
           3. MGB Disadvantages
           4. MGB: Conclusions from the medical Literature

13:50      Maurizio De Luca            Italian Experience with Band, RNY, Sleeve & MGB
           1. MGB: Excess Weight Loss
           2. MGB Op Time
           3. Weight Regain
           4. MGB: Reflux and Esophageal Cancer



                                                                                               15
14:00      K S Kular:                        MGB vs Sleeve; Report on 200 Sleeves
           1. Sleeve is Good choice for Many
           2. Failure Rate (Weight Regain, Reflux) and Leak Rate
           3. 3 yr FU Sleeve and MGB, Pouch Dilation and Weight Loss
           4. Lee; Sleeve vs MGB, 50% vs 90% Success

14:10      R Tacchino:                       MGB and BPD; compare and contrast
           1. BPD is Good choice for Many
           2. Failure Rate (Weight Regain, Reflux) and Leak Rate
           3. 3 yr FU BPD and MGB, Pouch Dilation and Weight Loss
           4. BPD, Band, Sleeve, MGB My Advice and Perspective

14:20      A Peters:                         MGB vs. RYGB
           1. RNY is Good choice for Many
           2. Failure Rate (Weight Regain, Reflux) and Leak Rate
           3. FU RNY and MGB, Bowel Obstruction and Weight Regain
           4. RNY, BPD, Band, Sleeve, MGB My Advice and Perspective

14:30      M Bhandari                        GERD Band& Sleeve vs. RNY & MGB
           I. Esophageal Cancer, Deadly and Increasing Worldwide
           II. GE Reflux Primary Cause of Esophageal Cancer
           III. Band & Sleeve CAUSE GE Reflux in 30% of Patients!
           IV. RNY & MGB Resolve GE Reflux in 80%+
           V. Band and Sleeve May Be PreCancerous Lesions
           VI. Band and Sleeve Dr's Need to Warn Patients of this Deadly Risk

14:40      Questions and Answers and Votes from Floor

14:50      Emilio Manno                      MGB Complications and Management (Leaks)
           1. Italian Experience of MGB
           2. Anemia
           3. Ulcer
           4. Inadequate / Excess Weight Loss / Other Complications

15:00      M Van den Bossche;                MGB in UK; GE Reflux; Band, Sleeve, RNY & MGB
           1. UK Experience of MGB
           2. Anemia
           3. Ulcer
           4. Inadequate / Excess Weight Loss / Other Complications

15:10      Dr Cierny                         My experience with MGB in Czech Republic
           1. Ulcer after MGB vs RNY
           2. PreOp and Post Op Management Prevention
           3. Treatment of Gastritis / Ulcer
           4. No Smoking, NSAIDs, Rx H.Pylori, Anti-Acids (PPI’s, H2 Blockers), Bismuth subsalicylate, Yogurt, No Smoking!!,
Soda, Coffee, Etoh, Green Tea, Meat, Hand washing, Careful food prep, Safe water source

15:20    Dr S Shah                           Minimal Risk of Gastric Cancer after Billroth II, Processed Meat is Much
More Dangerous
           1.   Gastric Cancer Declining; Esophageal Cancer Rising
           2.   BII in Few Studies Assoc with Gastric Ca But these are Ulcer Pts (H. Pylori)
           3.   Bile Reflux Rare and Easily treated while maintaining Weight Loss
           4.   GE Reflux Doubles the Risk of Esophageal Ca; Warn Patients

                                                                                                                          16
15:30      Dr. Weiner                         Bile Reflux following Mini-Gastric Bypass (Omega Loop)
            1. Bile Reflux Ulcer after MGB vs RNY
            2. PreOp and Post Op Management / Prevention
            3. Treatment of Gastritis / Ulcer
            4. No Smoking, NSAIDs, Rx H.Pylori, Anti-Acids (PPI’s, H2 Blockers), Bismuth subsalicylate, Yogurt, No Smoking!!,
 Soda, Coffee, Etoh, Green Tea, Meat, Hand washing, Careful food prep, Safe water source, *** Endoscopy ***, *** Surgery
 Revision ***

 15:40      Questions, Answers and Votes from the Floor
            Directed Discussion: Agreements and Controversies
             Panel: Chevalier, Garciacaballero, Tacchino, Kular, Peraglie, Nawaria, Weiner
     1. Long Term Outcome of Band, Sleeve, RNY, BPD
Long Term MGB Outcomes
   3. Band, Sleeve, RNY, BPD vs. MGB Recommendations
     Always Choose MGB (Rutledge Doctrine)
     Always Choose Band, Sleeve, RNY, BPD
     Tailored Approach
     When to choose Band, Sleeve, RNY, BPD
     When to choose MGB
   4. BPD vs. MGB Need for Further Study


 16:00      Dr Rutledge;                       Failure of Restrictive Procedures: Coca-Cola & Ice Cream Beat Band &
 Sleeve
             1.   Bariatrics: A History of Failure, A Cautionary Tale
             2.   Remember the History of the Lap Band
             3.   Enthusiasm, Tempered Support, Early Concerns, Failure
             4.   Humans are POOR Decision makers

 16:10       Questions and Answers and Votes from Floor
     Time: 1 hour
Review of Survey Questions & Voting
Expert Judgment & Voting: Outcome Band, Sleeve, RNY, BPD
Expert Judgment & Voting: Outcome MGB
Band, Sleeve, RNY, BPD vs. MGB
     === Consensus Recommendations ===
     Always Choose MGB (Rutledge Doctrine)
     Never Choose MGB (ASMBS Doctrine)
     Tailored Approach
   === Consensus Recommendations ===
     When to choose Band, Sleeve, RNY, BPD
     When to choose MGB



 Friday Morning:
 MGB; Expert's Experience; TIPS and Tricks , Complications and Risks
 ==========================================================
 SECTION V: Beginning The Consensus Conference Final Statement
 9:00      K S Kular:                       Safety, Safety, Safety; Choosing the MGB
9:10 Garciacaballero;      An Experts View, OAB Advantages & Advice

                                                                                                                           17
1. My Consideration of OAB
               2. My Patients, My Results of OAB
               3. FIVE Core Advantages of OAB
               4. Advice from My Experience

9:20 R Tacchino; An Experts View, MGB Advantages
           1. My Consideration of MGB
           2. My Patients, My Results of MGB
           3. Complications and Outcomes
           4. Advice from My Experience

9:30 Dr Narwaria An Expert's View, Advice to the New MGB'er
           1. Why Should Successful Bariatric Surgeons Choose MGB
           2. Criticism by Colleagues of MGB
           3. Results of MGB / Results of Sleeve, Band and RNY
           4. Response to MGB Skeptics/Critics

9:40           Dr Peraglie;                        Marginal Ulcers: An Expert's View

9:50 Karl-Peter    Rheinwalt     My Advice on Becoming a New MGB Program
            1.     Why face Criticism to Offer the MGB
            2.     My Decision to Choose MGB
            3.     The Story of the Struggle to Offer MGB
            4.     Advice from My Experience

10:00          Questions and Answers and Votes from Floor
11:00        R Rutledge: Renaming the MGB/OAB; Survey Results, Discussion and Voting
    1.      Survey Results on Renaming the MGB
    2.      Keep MGB name and OAB name?
    3.      Create a New Name for both (BII Bypass, Omega Bypass, Sleeve Bypass
    4.      Some combination?
    5.      The MGB is a Bad name
    6.      The MGB is a Good Name
    7.      Relation between MGB and OAB (Friends, Brothers or enemies?)
    8.      Consensus Voting
    9.      Suggestions:
    10.     Class Name Single Anastomosis Bypass / Omega Bypass or other (include MGB AND OAB)
    11.     Two Sub-groups of SAB/OLB Class:
    12.     MGB = Type I SAB
    13.     OAB = Type II SAB


11:10        Questions & Voting        1. Consensus Judgment of Experts and Conference on the MGB
       1.   Patient / Surgeons Advantages of MGB
       2.   Consensus Judgment of Experts and Conference on the
       3.   MOST Critical Advantages
       4.   Consensus Judgment of Experts and Conference on the Dangers of MGB



Video Techniques Lunch II
               Tacchino                            5 min video; 5 MGB Tips


                                                                                                    18
Chevallier           5 min video; 5 MGB Tips
       Rutledge             5 min video; Revision of MGB (Hint, Its Easy)
========================================================
SECTION VI: The End: The Final Consensus Conference Voting
Statements & Planning for the Future
==============================================================
  13:00 Creation of the Consensus Statement; Review of Survey and Voting Results Review of Survey and
        Voting Results So Far Dr Rutledge Report on Survey of 100 Bariatric Surgeons from 23 countries and 39,000
        cases
        In Short: Band is Less than Sleeve is less than RNY is Less than MGB
        Band and Sleeve: Cause Esophageal Reflux and Esophageal Cancer
        Conclusions the Experts Tell Us in the Survey

   13:10   Questions and Answers and FINAL Votes from Floor
   13:20   Pr Tacchino:                Band, Sleeve, RNY & MGB Outcomes: Consensus Statement
                                           PreOp Factors
                                           Operative Factors:
                                           Gastric Sleeve
                                           Bypass
                                           Gastro-J
                                           Anesthesia
                                           Early Post Op Management
                                           Management Leaks
                                           Long Term Management

   13:30   M Nawaria                   Critical Factors in Performance of MGB: Consensus Statement
   13:40   Questions and Answers and FINAL Votes from Floor
           Consensus Statement Expert Judgment of Band, Sleeve, RNY
           Consensus Statement Expert Judgment of Band, Sleeve, Esophageal Cancer
           Consensus Statement Expert Judgment of MGB

   14:00   Garciacaballero:                The Future; Liberté, égalité, fraternité, "Liberty, equality, fraternity
   14:10   Discussion and Voting           "Liberty, equality, fraternity (brotherhood)"
                                           Time 8 min
                                           Organization and Mutual Support
                                           Consensus Statement
                                           Volunteer Proctors and Surgeon Resources
                                           Direct and Remote technical advice
                                           Research Support
                                           Collaborative Study
                                           Database
                                           Repeat Meeting Next Year (Garciacaballero)

   15:00   Dr. Rutledge,             IFSO, IFSO-EC, ASMBS Meeting Financial Report
   15:10   Voting CONSENSUS : QUESTIONS AND ANSWERS
           Suggestions for organizing and supporting present surgeons and inviting new surgeons
           Vote on consensus statement
           Who will volunteer to help new surgeons
           Direct and Remote technical advice


                                                                                                                      19
Research Support
            Collaborative Study
            Database
            Meet again Next Year? Location? Timing
            Research Support

    16:00   Society of MGB/OAB Surgeons; Open Discussion and Voting, Organization and Mutual Aide
            IFSO 2013 Istanbul Turkey, 1 Day Interest Group
            Submit Abstracts (Rutledge will help)
            IFSO-EC Invited to Present at the "Bariatric Club"
            Interest Group at IFSO-EC 2013?
            Other suggestions (French, English, Italian, German, Spanish, Indian Society meetings)
                 IFSO Turkey
            IFSO-EC Bariatric Club
            Organize 1 day Post Grad Course at IFSO-EC 2013
            MGB Presentations at French, English, Italian, German, Spanish, Indian Society meetings?
               Society of MGB/OAB Surgeons; Open Discussion and Voting
            Organization and Mutual Aide


==============================================================
TBA SECTION VII: Live Surgery with

Live Surgery Demonstration on Saturday Oct 20
Clinique Geoffroy Saint Hilaire - Paris
59 Rue Geoffroy-Saint-Hilaire 75005 Paris, France
01 44 08 40 00

Dr Rutledge & Dr Chiche
Two Operating Rooms 6 - 8 MGB
3 Visitors in OR, Video Transmission Conference Room 25 Surgeons
(Contact DrR@clos.net for special invitation)
Possible Dinner Meeting to Follow




                                                                                                       20
Esophageal Cancer & GE Reflux: Brief Review
      The United States has experienced an alarming and unexplained increase in the incidence of esophageal adenocarcinoma
(EAC) since the 1970s. Esophageal adenocarcinoma is the fastest growing cancer in the western world. A dramatic rise in one
of the deadliest types of cancers may be linked to the increasing rates of acid reflux and gastrointestinal disorders. Cancers of
the esophagus and stomach are among the deadliest of all cancers with more than 80% of those affected dying within five
years.Although cancers of the stomach (gastric cancer) have been steadily declining over the last 50 years, studies show the
incidence of a cancer affecting the esophagus (esophageal adenocarcinoma) has risen by about 600% over the past few
decades.

     In the report, published in CA: A Cancer Journal for Clinicians, researchers reviewed studies on cancers located where
the stomach ends and esophagus begins, referred to as the gastroesophageal junction (GEJ).

     The major risk factors for this type of cancer are gastroesophageal reflux disease (GERD) and its associated conditions,
such as Barrett's esophagus. In Barrett's esophagus, precancerous changes are present. Other associated risk factors include
alcohol and tobacco use, obesity, and eating a diet low in fruits and vegetables.

     Studies have shown that the part of the esophagus closest to the stomach is more exposed to concentrated gastric acid
and a variety of agents that may contribute to the increased risk of cancer in this region.

    Despite advances in screening methods for this type of cancer, researchers say more research is needed to find new
ways to prevent the disease and detect it early.

     Major risk factors for this cancer are Gastroesophageal Reflux Disease (GERD) and Barrett's esophagus.

   In one study frequent acid reflux (≥1 time/week) accounted for the greatest single risk factor of Esophageal Cancer
36%

              1.     GE Reflux => Esophageal Cancer
              2.     Sleeve => Reflux
              3.     Band => Reflux
              4.     Esophageal Cancer in Band and Sleeve
              5.     Sleeve & Band => GE Reflux => Esophageal Cancer

     Clin Gastroenterol Hepatol. 2012 May;10(5):475-80.e1. Epub 2012 Jan 13. Erosive reflux disease increases risk for
esophageal adenocarcinoma, compared with nonerosive reflux. Erichsen R, Robertson D, Farkas DK, Pedersen L, Pohl H, Baron
JA, Sørensen HT. Source Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark. re@dce.au.dk

      In the study cohort, 26,194 of the patients over 3/4 (77%) had erosive reflux disease and
37 subsequently developed esophageal adenocarcinoma after a
mean follow-up time of ONLY 7.4 years.
Their absolute risk after 10 years was 0.24% (0.15%-0.32%).
The incidence of cancer among patients with erosive reflux disease was
significantly greater than that expected for the general population
Over Twice as high (standardized incidence ratio, 2.2; 95% CI, 1.6-3.0).




                                                                                                                              21
Often a pillow, doughnut or soft sand bag is placed by
Rutledge Version of Mini-                                  the head
  Gastric Bypass: Tools,                                   EndoTracheal tube placement and Vital signs assessed
                                                           Then and only then the patient is replaced to flat
  Tips, Techniques; Special                                supine and the patient is prepped and draped in the usual
  needs for the Surgery                                    fashion

  (Instruments, etc.)                                      The surgeon
                                                           stands on the patient's Right
                                                           Usually requiring a STEP Stool
==========                                                 The Camera is immobilized by a self retaining camera
First: Warning NO anticoagulants, NSAIDs                   holder and one assistant is on the patient's Left side
==========                                                 Only two scrub for
PATIENT POSITIONING:                                       the case
The patient is                                             The Surgeon looks across the table from patient's right
supine (not lithotomy)                                     to left to a screen at the head of the patient located 45
The table will be inclined to MAXIMUM Trendelenburg        degrees
position and Full tilt to the Left Side UP                 between the patient's head and the patient's left arm
The requires a simple but very important patient           This means that this are must be kept free of IV poles
immobilization on the table to ensure patient safety and   and anesthesia paraphernalia
make sure the                                              ==========
large patient does not move during the operation           BOUGIE
Both arms are out at 90 degrees the knees                  We
are                                                        use 24 - 32 French (NO Larger, No smaller)
"broken' to an angle of 45 degrees and two Large pillows   In a pinch we can use Ewald Tube
are placed                                                 Or Gastroenterologist Red Weighted Dilating Bougie
beneath the knees                                          NO 36-38 Bougies
The Heels are padded                                       ==========
SCDs are applied                                           INSTRUMENTS
and then most importantly                                  The instruments need are simple but should be of high
3 Three LARGE Leather or Polyester Straps (Seat Belts)     quality.
are applied to the legs                                    The Mayo stand should contain
At the upper thigh                                         1 scalpel of any type
the lower thigh                                            Veress needle
and mid tibia                                              5 Ports in total
Then to reassure all of the anesthesia,                    Of the 5 ports;
nursing and other attendants                               4 ports are 12mm ports (not 10 or 11mm) 12 mm ports
with all of the team watching                              that can accept the
The table is slowly and carefully moved to MAXIMUM         stapler (12 mm) as well as the 5 mm operating
Reverse                                                    instruments.
Trendelenburg and Full Tilt Left side up                   Of the 5 ports the remaining port is a single 5mm port
Any adjustments are made                                   Three separate 5 mm

                                                                                                                       22
graspers of excellent quality, at least 2 should be Locking      to make a 12mm incision 1 and 1/2 palm widths below the
Graspers                                                         xiphi sternum
One of the 3 three,                                              This may vary slightly with patient size but is
5 mm graspers should ideally have longer jaws to allow a         remarkably constant
firm safe                                                        The 12 mm "Camera port" is used to enter the abdomen
locked grip on the intestine                                     The surgeon
In case of emergency there should be two good quality            uses
needle drivers (in most cases not needed, but should be          the camera to briefly explore the abdomen and note the
on the back                                                      location of the
table)                                                           Veress needle and the Veress is removed under direct
Stapler, Ideally Covidien 60 mm blue or Purple although          vision
Johnson Can be used as backup                                    The final 4 ports are now placed
No other Open Surgery instruments on the back table              The locations are as follows:
Skin closure is with 1 (one) single staple in each port          1, One 5 mm port several cm medial to the left axillary
and for this we need a single pair of Adson's forceps with       line 2-3 finger breadths below the costal margin
teeth and                                                        1, One 12 mm port left mid-clavicular line 2-3 finger
commercial staple gun                                            breadths below
No suction is on the table                                       the costal margin
We use the Harmonic scalpel if possible                          1, One 12 mm port Midline 2-3 finger breadths below the
No sutures open.                                                 xiphi sternum
but have 3-O                                                     1, One 12 mm port Right mid-clavicular line 2-3 finger
Vicryl on sh needle available if necessary,                      breadths below
Do Not Open                                                      the costal margin
===========================                                      Total 5 Ports
A brief summary of the procedure may be of interest              In roughly a "Diamond" pattern
The surgeons approaches the patient in flat supine               1 Midline 1 and 1/2 palms below xiphi sternum (the
position from the patient's left side.                           Primary But not only,"
The abdomen is examined and the location of the left             Camera Port")
lateral extent of the rectus sheath                              1 Left Anterior Axillary Line 5 mm grasper / retractor port
approximately 4-5 finger breadths below the left costal          1 Right Mid-clavicular line port, used for stapler and
margin is                                                        camera at
estimated.                                                       several points during the case for only a few moments
With                                                             2 Primary Surgeon's Working Ports
the "go ahead"                                                   (Right Hand and Left hand)
from anesthesia a 5 mm incision is made and the Veress           Left hand = Midline Port
needle is                                                        Right hand = Patient's
advanced into the abdominal cavity and insufflated.              Left Mid clavicular Line port
The surgeon                                                      Patient
moves                                                            is now, with approval of anesthesia,
to the patient's right side and after insufflation the scalpel   tilted to Maximum Reverse Trendelenburg and left side up
is used                                                          Warning poor anesthesia can lead to hypotension

                                                                                                                           23
Anesthesia must be prepared and educated as tothe            Attention turned to the Left Gutter
planned revers Trendelenburg positioning and                 Retract the omentum medially and Identify Ligament of
drug use so to avoid hypotension when tilting the patient    Treitz
Poor anesthesia                                              Run the bowel 2 m
= No surgery                                                 Count to 60
Now the steps in brief for the operation                     ==========
The left hand grasper elevates the left lobe of the          Grasp and lock the loop of bowel with larger 5mm
liver and the harmonic is used to dissect the lesser curve   atraumatic locking
of the                                                       grasper
stomach at the junction of the body and the Antrum 5-10      Gastrotomy with harmonic
minutes                                                      Change camera to R Lateral port
Stapler is passed via the Left Hand Working port into        Enterotomy
the abdomen and the stomach pouch creation is under          Pass 60 mm Covidien Stapler in via the "Camera" port
way                                                          Fire to form GJ
Using the Left Hand working port or the Right side port      Manipulate 24-30 mm bougie across the anastomosis
second stapler is fired                                      Change camera back to camera port and pass 60 mm
Surgeon                                                      stapler
and anesthesia now discuss Bougie placement                  in via the Right lateral port
The bougie is advanced and retracted under direct vision     Close the GJ
==========                                                   Case over
Surgeon                                                      Op time 35 minutes
and anesthesia agree on bougie movement commands:
Advance
Retract
Tap Tap (A very tiny rapid in and out motion that aids in
bougie identification)
Now all staplers fired from the Right hand Working port
3-5 staples to EG Junction
WARNING FEAR THE EG JUNCTION
Stay lateral to EG Junction
Only fools and Sleeve surgeons dissect near the EG
Junction. It is not necessary for MGB and it is dangerous
With division of 80-95% of the stomach the area lateral
to EGJ is visualized
If necessary the short gastrics are divided under direct
vision with careful and meticulous dissection
Case Mantra "NO BLEEDING"
The division of the stomach and creation of the pouch is
completed
Op time 15-20 minutes
==========

                                                                                                                     24
References
Mini-Gastric Bypass References
Obes Surg. 2012 Sep 11. [Epub ahead of print]                            with laparoscopic mini-gastric bypass (LMGBP) and laparoscopic
Laparoscopic Roux-en-Y Vs. Mini-gastric Bypass for the                   sleeve gastrectomy (LSG). Three patients with genetic diagnosis
Treatment of Morbid Obesity: a 10-Year Experience. Lee                   of PWS and body mass index (BMI) greater than 40 kg/m(2) were
WJ, Ser KH, Lee YC, Tsou JJ, Chen SC, Chen JC.                           referred for bariatric surgery. All of them had completed 2-year
Department of Surgery, Min-Sheng General Hospital, National              postoperative follow-up. Body weight, BMI, and ghrelin levels
Taiwan University, No. 168, Chin Kuo Road, Tauoyan, Taiwan,              were recorded before and after surgery. They were two females
Republic of China, wjlee_obessurg_tw@yahoo.com.tw.                       and one male. Their age ranged from 15 to 23 years old, and the
BACKGROUND:                                                              mean BMI was 46.7 kg/m(2) (range 44-50). Two patients
Laparoscopic Roux-en-Y gastric bypass (LRYGB) is considered the          underwent LSG and one patient underwent LMGBP. After a
gold standard for the treatment of morbid obesity but is                 median follow-up of 33 months (range 24-36 months), mean
technically challenging and results in significant perioperative         weight loss and percentage of excessive weight loss at 2 years
complications. While laparoscopic mini-gastric bypass (LMGB) has         were 32.5 kg (24.9-38.3 kg) and 63.2 % (range 50.5-86.2 %),
been reported to be a simple and effective treatment for morbid          respectively. The mean fasting active ghrelin level decreased from
obesity, controversy exists. Long-term follow-up data from a large       1,134.2 pg/ml preoperatively to 519.8 pg/ml 1 year after surgery.
number of patients comparing LMGB to LRYGB are lacking.                  No major complication was observed. Iron deficiency anemia was
METHODS:                                                                 observed in the patient who underwent LMGBP. Significant
Between October 2001 and September 2010, 1,657                           reduction of body weight and level of serum ghrelin can be
patients who received gastric bypass surgery (1,163 for                  achieved with minimal morbidity by LSG or LMGBP in patients
LMGB and 494 for LRYGB) for their morbid obesity were                    with PWS.
recruited from our comprehensive obesity surgery center. Patients
who received revision surgeries were excluded. Minimum follow-           22923339
up was 1 year (mean 5.6 years, from 1 to 10 years). The
operative time, estimated blood loss, length of hospital stay, and
operative complications were assessed. Late complication,                 3.
changes in body weight loss, BMI, quality of life, and                   Obes Surg. 2012 May;22(5):697-703.
comorbidities were determined at follow-up. Changes in quality of        One thousand consecutive mini-gastric bypass: short- and long-
life were assessed using the Gastrointestinal Quality of Life Index.     term outcome.
RESULTS:                                                                 Noun R, Skaff J, Riachi E, Daher R, Antoun NA, Nasr M.
There was no difference in preoperative clinical parameters              Department of Digestive Surgery, Hôtel-Dieu de France Hospital
between the two groups.                                                  and University Saint Joseph Medical School, Bd Alfred Naccache,
Surgical time was significantly longer for LRYGB (159.2                  Achrafieh, BP 166830 Beirut, Lebanon. rnoun@wise.net.lb
vs. 115.3 min for LMGB, p < 0.001).                                      There is growing evidence that mini-gastric bypass (MGB) is a
The major complication rate was borderline higher for                    safe and effective procedure. Operative outcome and long-term
LRYGB (3.2 vs. 1.8 %, p = 0.07).                                         follow-up of a consecutive cohort of patients who underwent MGB
At 5 years after surgery, the mean BMI was lower in LMGB                 are reported. The data on 1,000 patients who underwent MGB
than LRYGB (27.7 vs. 29.2, p < 0.05) and                                 from November 2005 to January 2011 at an academic institution
LMGB also had a higher excess weight loss than LRYGB                     were reviewed. Mean age was 33.15 ± 10.17 years (range, 14-
(72.9 vs. 60.1 %, p < 0.05).                                             72), preoperative BMI was 42.5 ± 6.3 kg/m(2) (range, 26-75),
Postoperative gastrointestinal quality of life increased significantly   mean preoperative weight was 121.6 ± 23.8 kg (range, 71-240),
after operation in both groups without any significant difference        and 663 were women. Operative time and length of stay for
at 5 years. Obesity-related clinical parameters improved in both         primary vs. revisional MGB were 89 ± 12.8 min vs. 144 ± 15 min
groups without significant difference, but LMGB had a lower              (p < 0.01) and l.85 ± 0.8 day vs. 2.35 ± 1.89 day (p < 0.01). No
hemoglobin level than LRYGB.                                             deaths occurred within 30 days of surgery. Short-term
Late revision rate was similar between LRYGB and LMGB (3.6 vs.           complications occurred in 2.7% for primary vs. 11.6% for
2.8 %, p = 0.385).                                                       revisionnal MGB (p < 0.01). Five (0.5%) patients presented with
CONCLUSIONS:                                                             leakage from the gastric tube but none had anastomotic leakage.
This study demonstrates that LMGBP can be regarded as                    Four (0.4%) patients, all with revisional MGB, presented with
a simpler and safer alternative to LRYGB with similar                    severe bile reflux and were cured by stapling the afferent loop
efficacy at a 10-year experience.                                        and by a latero-lateral jejunojejunostomy. Excessive weight loss
                                                                         occurred in four patients; two were reversed and two were
23011462                                                                 converted to sleeve gastrectomy. Maximal percent excess weight
                                                                         loss (EWL) of 72.5% occurred at 18 months. Weight regain
                                                                         subsequently occurred with a mean variation of -3.9% EWL at 60
 2.                                                                      months. The 50% EWL was achieved for 95% of patients at 18
Obes Surg. 2012 Aug 26. [Epub ahead of print]                            months and for 89.8% at 60 months. MGB is an effective,
Ghrelin Level and Weight Loss After Laparoscopic Sleeve                  relatively low-risk, and low-failure bariatric procedure. In addition,
Gastrectomy and Gastric Mini-Bypass for Prader-Willi Syndrome in         it can be easily revised, converted, or reversed.
Chinese.
Fong AK, Wong SK, Lam CC, Ng EK.                                         22411569
Division of Upper GI Surgery, Department of Surgery, Prince of            4.
Wales Hospital, The Chinese University of Hong Kong, Hong Kong,          Diabetes Technol Ther. 2012 Apr;14(4):365-72. Epub 2011 Dec
China.                                                                   16.
Prader-Willi syndrome (PWS) is a chromosomal disorder                    Role of bariatric-metabolic surgery in the treatment of obese type
characterized by the presence of hyperghrelinemia, hyperphagia,          2 diabetes with body mass index <35 kg/m2: a literature review.
and obesity. The optimal treatment for PWS patient remains               Reis CE, Alvarez-Leite JI, Bressan J, Alfenas RC.
controversial. Here, we present our experience of treating PWS           School of Health Sciences, University of Brasília, Brasília, Brazil.


                                                                                                                                            25
caioedureis@gmail.com
Bariatric surgery has been used to treat type 2 diabetes mellitus      22105765
(T2DM); however, its efficacy is still debatable. This literature       6.
review analyzed articles that evaluated the effects of bariatric       Obes Surg. 2012 Mar;22(3):502-6.
surgery in treatment of T2DM in obese patients with a body mass        Bariatric surgery in Asia in the last 5 years (2005-2009).
index (BMI) of <35 kg/m(2). A paired t test was applied for the        Lomanto D, Lee WJ, Goel R, Lee JJ, Shabbir A, So JB, Huang CK,
analysis of pre- and postintervention mean BMI, fasting plasma         Chowbey P, Lakdawala M, Sutedja B, Wong SK,Kitano S, Chin KF,
glucose (FPG), and glycosylated hemoglobin (A1c) values. A             Dineros HC, Wong A, Cheng A, Pasupathy S, Lee SK,
significant (P<0.001) reduction in BMI (from 29.95±0.51 kg/m(2)        Pongchairerks P, Giang TB.
to 24.83±0.44 kg/m(2)), FPG (from 207.86±8.51 mg/dL to                 Department of Surgery, Minimally Invasive Surgical Centre,
113.54±4.93 mg/dL), and A1c (from 8.89±0.15% to                        National University Hospital, 5 Lower Kent Ridge Road, 119074,
6.35±0.18%) was observed in 29 articles (n=675). T2DM                  Singapore, Singapore.
resolution (A1c <7% without antidiabetes medication) was               Erratum in
achieved in 84.0% (n=567) of the subjects. T2DM remission,             •      Obes Surg. 2012 Feb;22(2):345. Fah, Chin Kin [corrected to
control, and improvement were observed in 55.41%, 28.59%,              Chin, Kin-Fah].
and 14.37%, respectively. Only 1.63% (n=11) of the subjects            Obesity is a major public health concern around the world,
presented similar or worse glycemic control after the surgery.         including Asia. Bariatric surgery has grown in popularity to
T2DM remission (A1c <6% without antidiabetes medication) was           combat this rising trend. An e-mail questionnaire survey was sent
higher after mini-gastric bypass(72.22%) and laparoscopic/Roux-        to all the representative Asia-Pacific Metabolic and Bariatric
en-Y gastric bypass (70.43%). According to the Foregut and             Surgery Society (APMBSS) members of 12 leading Asian countries
Hindgut Hypotheses, T2DM results from the imbalance between            to provide bariatric surgery data for the last 5 years (2005-2009).
the incretins and diabetogenic signals. The procedures that            The data provided by representative members were discussed at
remove the proximal intestine and do ileal transposition               the 6th International APMBSS Congress held at Singapore
contribute to the increase of glucagon-like peptide-1 levels and       between 21st and 23rd October 2010. Eleven nations except
improvement of insulin sensitivity. These findings provide             China responded. Between 2005 and 2009, a total of 6,598
preliminary evidence of the benefits of bariatric-metabolic surgery    bariatric procedures were performed on 2,445 men and 4,153
on glycemic control of T2DM obese subjects with a BMI of               women with a mean age of 35.5 years (range, 18-69years) and
<35 kg/m(2). However, more clinical trials are needed to               mean BMI of 44.27 kg/m(2) (range, 31.4-73 kg/m(2)) by 155
investigate the metabolic effects of bariatric surgery in T2DM         practicing surgeons. Almost all of the operations were performed
remission on pre-obese and obese class I patients.                     laparoscopically (99.8%). For combined years 2005-2009, the
                                                                       four most commonly performed procedures were laparoscopic
22176155                                                               adjustable gastric banding (LAGB, 35.9%), laparoscopic standard
 5.                                                                    Roux-en-Y gastric bypass (LRYGB, 24.3%), laparoscopic sleeve
Updates Surg. 2011 Dec;63(4):239-42. Epub 2011 Nov 22.                 gastrectomy (LSG, 19.5%), and laparoscopic mini gastric bypass
Laparoscopic mini-gastric bypass: short-term single-institute          (15.4%). Comparing the 5-year trend from 2004 to 2009, the
experience.                                                            absolute numbers of bariatric surgery procedures in Asia
Piazza L, Ferrara F, Leanza S, Coco D, Sarvà S, Bellia A, Di Stefano   increased from 381 to 2,091, an increase of 5.5 times. LSG
C, Basile F, Biondi A.                                                 increased from 1% to 24.8% and LRYGB from 12% to 27.7%, a
General and Emergency Surgery Department, Garibaldi Hospital,          relative increase of 24.8 and 2.3 times, whereas LAGB and mini
Catania, Italy, lpiazza267@gmail.com.                                  gastric bypass decreased from 44.6% to 35.6% and 41.7% to
The elevated variety of procedures proposed for surgical               6.7%, respectively. The absolute growth rate of bariatric surgery
treatment of obesity in the last few years suggests the necessity      in Asia over the last 5 years was 449%.
to find an ideal operation. Laparoscopic mini-gastric bypass
(LMGB) was developed to obtain better results with lesser              22033767
morbidity and mortality. LMGB was introduced by Rutledge, in            7.
1997, and it consists of a long lesser-curvature tube with a           Obes Surg. 2011 Nov;21(11):1758-65.
terminolateral gastroenterostomy 180 cm distal to the Treitz           ESR1, FTO, and UCP2 genes interact with bariatric surgery
ligament. From July 1995 to May 2011 we have performed 552             affecting weight loss and glycemic control in severely obese
bariatric operations, among them we have operated 197                  patients.
laparoscopic mini-gastric bypass (Fig. 1). There were 147 female       Liou TH, Chen HH, Wang W, Wu SF, Lee YC, Yang WS, Lee WJ.
(75%) and 50 male (25%) with the mean age of 37.9 years                Department of Physical Medicine and Rehabilitation, Shuang Ho
(range 20-55) and the mean BMI of 52.9 kg/m(2). All procedures         Hospital, Taipei Medical University, Taipei, Taiwan.
were completed laparoscopically, without conversion and the            Erratum in
mean operative time was 120 min (range from 90 to 170 min).            •      Obes Surg. 2012 Jan;22(1):194.
The average postoperative stay was 5.0 days. We report one case        BACKGROUND:
of mortality for pulmonary septic complications. Major                 Significant variability in weight loss and glycemic control has been
complications were two cases of pulmonary embolism (treated in         observed in obese patients receiving bariatric surgery. Genetic
ICU), six cases of melena on seventh postoperative day and three       factors may play a role in the different outcomes.
cases of anastomotic ulcers resolved with high doses of PPI. We        METHODS:
registered a significant reduction of BMI and percentage of            Five hundred and twenty severely obese patients with body mass
excess weight after surgery with a significant improvement in          index (BMI) ≥35 were recruited. Among them, 149 and 371
obesity-related comorbidities including blood pressure,                subjects received laparoscopic adjustable gastric banding (LAGB)
hyperglycemia, blood lipid, uric acid, and liver function. An ideal    and laparoscopic mini-gastric bypass (LMGB), respectively. All
weight loss operation should be effective, easy to perform and         individuals were genotyped for five obesity-related single
safe. Laparoscopic Roux-en-Y GastricBypass is actually the "gold-      nucleotide polymorphisms on ESR1, FTO, PPARγ, and UCP2 genes
standard" technique but LMGB seems to be an attractive                 to explore how these genes affect weight loss and glycemic
alternative: shorter operative time, with less morbidity and           control after bariatric surgery at the 6th month.
mortality, easier to teach and to perform. Another advantage           RESULTS:
could be the presence of a single anastomosis alone reducing the       Obese patients with risk genotypes on rs660339-UCP2 had
possibility of leaks.                                                  greater decrease in BMI after LAGB compared to patients with


                                                                                                                                        26
non-risk genotypes (-7.5 vs. -6 U, p = 0.02). In contrast, after       including laparoscopic adjustable gastric banding(LAGB, n=201),
LMGB, obese patients with risk genotypes on either rs712221-           laparoscopic mini gastricbypass(LMGB, n=13), and laparoscopic
ESR1 or rs9939609-FTO had significant decreases in BMI (risk vs.       sleeve gastrectomy(LSG, n=5). Clinical data were analyzed
non-risk genotype, -12.5 vs. -10.0 U on rs712221, p = 0.02 and -       retrospectively.
12.1 vs. -10.6 U on rs9939609, p = 0.04) and a significant             RESULTS:
amelioration in HbA1c levels (p = 0.038 for rs712221 and               The mean body mass index(BMI) of patients who received LAGB
p < 0.0001 for rs9939609). The synergic effect of ESR1 and FTO         was 37.9 kg/m(2), and decreased to 32.4 kg/m(2) at 6 months
genes on HbA1c amelioration was greater (-1.54%, p for trend           and to 29.7 kg/m(2) at 12 months. In 43 patients who had
<0.001) than any of these genes alone in obese patients                concurrent T2DM, 11(25.6%) showed clinical partial
receiving LMGB.                                                        remission(CPR) and 16(37.2%) clinical complete remission (CCR).
CONCLUSIONS:                                                           Postoperative complications occurred in 26 patients(12.9%). The
The genetic variants in the ESR, FTO, and UCP2 genes may be            mean BMI of patients undergoing LMGB was 34.7 kg/m(2), and
considered as a screening tool prior to bariatric surgery to help      decreased to 31.6 kg/m(2) at 6 months and 26.9 kg/m(2) at 12
clinicians predict weight loss or glycemic control outcomes for        months after surgery. Ten patients had T2DM before operation, of
severely obese patients.                                               whom 2(20.0%) had CPR and 7(70.0%) CCR postoperatively.
                                                                       Postoperative complications occurred in 2 patients(15.4%). The
21720911                                                               mean BMI of patients who underwent LSG was 43.8 kg/m(2), and
 8.                                                                    was reduced to 38.1 kg/m(2) at 6 months and 34.3 kg/m(2) at 12
Obes Rev. 2011 Aug;12(8):602-21. doi: 10.1111/j.1467-                  months after operation. Three patients were diagnosed with
789X.2011.00866.x. Epub 2011 Mar 28.                                   T2DM before operation. One patient (33.3%) had CPR and
Bariatric surgery: a systematic review and network meta-analysis       1(33.3%) reached CCR after operation. There was 1(20.0%)
of randomized trials.                                                  patient who developed complication. No perioperative death
Padwal R, Klarenbach S, Wiebe N, Birch D, Karmali S, Manns B,          occurred.
Hazel M, Sharma AM, Tonelli M.
Department of Medicine, University of Alberta, Edmonton,               CONCLUSION:
Alberta, Canada.                                                       Laparoscopic gastrointestinal surgery may result in satisfactory
The clinical efficacy and safety of bariatric surgery trials were      weight loss and clinical remission of T2DM with few
systematically reviewed. MEDLINE, EMBASE, CENTRAL were                 complications.
searched to February 2009. A basic PubCrawler alert was run until
March 2010. Trial registries, HTA websites and systematic reviews      21365507
were searched. Manufacturers were contacted. Randomized trials
comparing bariatric surgeries and/or standard care were selected.      [PubMed - in process]
Evidence-based items potentially indicating risk of bias were          Publication Types
assessed. Network meta-analysis was performed using Bayesian            10.
techniques. Of 1838 citations, 31 RCTs involving 2619 patients         World J Surg. 2011 Mar;35(3):631-6.
(mean age 30-48 y; mean BMI levels 42-58 kg/m(2) ) met                 Laparoscopic mini-gastric bypass for type 2 diabetes: the
eligibility criteria. As compared with standard care, differences in   preliminary report.
BMI levels from baseline at year 1 (15 trials; 1103 participants)      Kim Z, Hur KY.
were as follows: jejunoileal bypass [MD: -11.4 kg/m(2) ], mini-        Department of Surgery, Soonchunhyang University College of
gastric bypass [-11.3 kg/m(2) ], biliopancreatic diversion [-11.2      Medicine, Soonchunhyang University Hospital, Hannam-dong,
kg/m(2) ], sleeve gastrectomy [-10.1 kg/m(2) ], Roux-en-Y              Yongsan-gu, Seoul 140-743, Korea.
gastric bypass[-9.0 kg/m(2) ], horizontal gastroplasty [-5.0           BACKGROUND:
kg/m(2) ], vertical banded gastroplasty [-6.4 kg/m(2) ], and           Type 2 diabetes mellitus (T2DM) has become an epidemic health
adjustable gastric banding [-2.4 kg/m(2) ]. Bariatric surgery          problem worldwide. Compared to Western countries, in Asia,
appears efficacious compared to standard care in reducing BMI.         T2DM occurs in patients with a lower body mass index (BMI) due
Weight losses are greatest with diversionary procedures,               to central obesity and decreased pancreatic β-cell function. The
intermediate with diversionary/restrictive procedures, and lowest      efficacy of laparoscopic mini-gastric bypass(LMGB) in obese
with those that are purely restrictive. Compared with Roux-en-Y        patients with T2DM has been proven by numerous studies.
gastric bypass, adjustable gastric banding has lower weight loss       Treatment outcomes of LMGB for non-obese T2DM patients are
efficacy, but also leads to fewer serious adverse effects.             also estimated to be excellent. The aim of the present pilot study
© 2011 The Authors. obesity reviews © 2011 International               was to evaluate the efficacy and safety of LMBG in non-obese
Association for the Study of Obesity.                                  T2DM patients (BMI 25-30 kg/m(2)).
                                                                       METHODS:
21438991                                                               Ten consecutive patients underwent LMGB at our hospital from
Grant Support                                                          August 2009 to October 2009. Preoperative data including
 9.                                                                    glycosylated hemoglobin (HbA1c), fasting plasma glucose (FPG),
Zhonghua Wei Chang Wai Ke Za Zhi. 2011 Feb;14(2):128-31.               and 2 h postprandial glucose (2-h PPG) were compared with data
[Outcomes after laparoscopic surgery for 219 patients with             collected at 1, 3, and 6 postoperative months.
obesity].                                                              RESULTS:
[Article in Chinese]                                                   All procedures were completed laparoscopically. Mean age of the
Ding D, Chen DL, Hu XG, Ke CW, Yin K, Zheng CZ.                        patients was 46.9 years, mean BMI was 27.2 kg/m(2), mean
Department of Minimally Invasive Surgery, Changhai Hospital, The       operative time was 150.5 min, and mean postoperative hospital
Second Military Medical University, Shanghai 200433, China.            stay was 5.3 days. Neither mortality nor major complications
OBJECTIVE:                                                             occurred. Mean preoperative glycosylated hemoglobin (HbA1c),
To evaluate the outcomes after laparoscopic gastrointestinal           fasting plasma glucose (FPG), 2-h PPG, and C-peptide level were
surgery for patients with obesity and type 2 diabetes                  9.7%, 222 mg/dl, 343 mg/dl, and 2.78 ng/ml, respectively. At the
mellitus(T2DM).                                                        sixth postoperative month, HbA1c, FPG, 2-h PPG, and C-peptide
METHODS:                                                               level measured 6.7%, 144 mg/dl, 203 mg/dl, and 2.18 ng/ml.
From June 2003 to June 2010, 219 patients underwent                    CONCLUSIONS:
laparoscopic gastrointestinal surgery for obesity and T2DM,            This preliminary study demonstrated the resolution of


                                                                                                                                          27
hyperglycemia in 70% of non-obese T2DM patients (BMI 25-30             bypass (LMGB) or adjustable gastric banding (LAGB) with
kg/m(2)). Although long-term follow-up data are required, early        complete clinical data at baseline and at two years were enrolled
operative outcomes were satisfactory in terms of glycemic control      for analysis. Decision Tree, Logistic Regression and Discriminant
and safety of the procedure.                                           analysis technologies were used to predict weight loss. Overall
                                                                       classification capability of the designed diagnostic models was
21165621                                                               evaluated by the misclassification costs.
 11.                                                                   RESULTS:
Obes Surg. 2011 Aug;21(8):1209-19.                                     Two hundred fifty-one patients consisting of 68 men and 183
Reasons and outcomes of reoperative bariatric surgery for failed       women was studied; with mean age 33 years. Mean +/- SD
and complicated procedures (excluding adjustable gastric               weight loss at 2 year was 74.5 +/- 16.4 kg. During two years of
banding).                                                              follow up, two-hundred and five (81.7%) patients had successful
Patel S, Szomstein S, Rosenthal RJ.                                    weight reduction while 46 (18.3%) were failed to reduce body
Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston,   weight. Operation methods, alanine transaminase (ALT),
FL 33331, USA.                                                         aspartate transaminase (AST), white blood cell counts (WBC),
BACKGROUND:                                                            insulin and hemoglobin A1c (HbA1c) levels were the predictive
The rise of bariatric surgery has lead to an increasing number of      factors for successful weight reduction.
reoperations for failed bariatric procedures. The reasons and          CONCLUSION:
types of these operations are varied in nature and remain to be        Decision tree model was a better classification models than
defined.                                                               traditional logistic regression and discriminant analysis in view of
METHODS:                                                               predictive accuracies.
A retrospective review of a prospectively collected database was
conducted to identify patients who underwent laparoscopic              20214230
revisional surgery for non-gastric banding-related bariatric
procedures between 2001 and 2008.                                       13.
RESULTS:                                                               J Chir (Paris). 2009 Feb;146(1):60-4.
Of 384 secondary bariatric operations, 151 reoperative                 [Laparoscopic mini-gastric bypass].
procedures were performed. Twenty-six vertical banded                  [Article in French]
gastroplasties (17.2%), 2 mini-gastric bypasses (1.3%), 2 non-         Chevallier JM, Chakhtoura G, Zinzindohoué F.
divided bypasses (1.3%), 1 distal Roux-en-Y gastric bypass             Service de chirurgie digestive, hôpital Européen Georges-
(RYGBP; 0.7%), and 2 sleeve gastrectomies (1.3%) were                  Pompidou, Paris. jean-marc.chevallier@egp.aphp.fr
converted to RYGBP. Three RYGBP (2%) and four jejunoileal
bypass procedures (2.6%) were reversed secondary to                    19446695
malnutrition. One jejunoileal bypass (0.7%) and one                     14.
biliopancreatic diversion (0.7%) underwent sleeve gastrectomies.       Surg Obes Relat Dis. 2009 May-Jun;5(3):383-6. Epub 2009 Jan
Three pre-anastomotic rings were removed due to erosion (2%).          18.
Eleven pouch trimmings (7.3%), 16 redo gastrojejunostomies             Laparoscopic conversion of distal mini-gastric bypass to proximal
(10.6%), 5 redo jejunojejunostomies (3.3%), 36 remnant                 Roux-en-Y gastric bypass for malnutrition: case report and review
gastrectomies (23.8%), and 2 gastrogastric fistula takedowns           of the literature.
(1.3%) were performed for pouch enlargements, strictures, and          Dang H, Arias E, Szomstein S, Rosenthal R.
gastrogastric fistulas. Thirty-six patients (23.8%) underwent a        Bariatric and Metabolic Institute, Section of Minimally Invasive
combination of these procedures. The major morbidity (13.2%)           and Endoscopic Surgery, Cleveland Clinic Florida, Weston, Florida,
was related to leaks. Other complications included wound               USA.
infection, intra-abdominal abscess formation, and trocar site
hernias. The mortality rate was 2%.                                    19356992
CONCLUSIONS:                                                            15.
Reoperative bariatric surgery is a complex and growing field in        Obes Surg. 2008 Sep;18(9):1126-9. Epub 2008 Jun 25.
bariatric surgery. The indications for surgical reoperation can vary   Laparoscopic mini-gastric bypass (LMGB) in the super-super
depending on the procedure and reason for intervention.                obese: outcomes in 16 patients.
Laparoscopy appears to be a feasible approach. Though safe,            Peraglie C.
morbidity and mortality are significantly higher than in primary       The Centers of Laparoscopic Obesity Surgery-Florida, Heart of
bariatric procedures.                                                  Florida Regional Medical Center, 40124 Highway 27, Davenport,
                                                                       FL, USA. drp@clos.net
20676940                                                               BACKGROUND:
 12.                                                                   The ideal management of the super-super obese patient (SSO) is
Hepatogastroenterology. 2009 Nov-Dec;56(96):1745-9.                    unclear and controversy exists as to the choice of procedure as
Obesity and the decision tree: predictors of sustained weight loss     well as the risk for increased morbidity and mortality. I present
after bariatric surgery.                                               my experience of laparoscopic mini-gastric bypass (LMGB) in 16
Lee YC, Lee WJ, Lin YC, Liew PL, Lee CK, Lin SC, Lee TS.               SSO patients with early follow-up results.
Department of International Business, Ching-Yun University,            METHODS:
Zhongli City, Taiwan. lyc6115@ms61.hinet.net                           Review of a prospectively maintained database was performed.
BACKGROUND/AIMS:                                                       All the patients underwent LMGB by a single surgeon (CP). Data
Bariatric surgery is the only long-lasting effective treatment to      collected included demographics, operative time, length of stay,
reduce body weight in morbid obesity. Previous literature in using     complications, and weight loss. Follow-up data was obtained at
data mining techniques to predict weight loss in obese patients        office visits in addition to periodic telephone interviews and e-
who have undergone bariatric surgery is limited. This study used       mails. All office follow-up and review of correspondence from
initial evaluations before bariatric surgery and data mining           Primary Care Physicians (PCP) was managed by the operating
techniques to predict weight outcomes in morbidly obese patients       surgeon.
seeking surgical treatment.                                            RESULTS:
METHODOLOGY:                                                           Sixteen patients were identified as being SSO and comprise the
251 morbidly obese patients undergoing laparoscopic mini-gastric       study group. There were 14 women and two men. Average age


                                                                                                                                         28
was 40 years (27-61). Average weight and BMI were 166 (150-           Obes Surg. 2007 Nov;17(11):1482-6.
193) and 62.4 (60-73), respectively. All procedures were              Mini-gastric bypass by mini-laparotomy: a cost-effective
performed laparoscopically by a single surgeon with no                alternative in the laparoscopic era.
conversion to open. Average operative time was 78 min (41-147         Noun R, Riachi E, Zeidan S, Abboud B, Chalhoub V, Yazigi A.
min) and hospital stay was 1.2 days. Intraoperative complications     Department of Digestive Surgery, Hôtel-Dieu de France Hospital,
included a liver laceration in one patient and an enterotomy in       Beirut, Lebanon. rnoun@wise.net.lb
another. Both were managed laparoscopically. No patients              BACKGROUND:
required readmission to the hospital, and there were no major         Laparoscopic mini-gastric bypass (MGB) is being increasingly
complications or deaths. Weight loss showed a consistent              performed worldwide. Results of MGB by mini-laparotomy
increase over the follow-up period with 2 year results of 72 KG       (minilap MGB) are hereby reported.
lost or 65% EWL.                                                      METHODS:
CONCLUSION:                                                           126 patients undergoing minilap MGB from October 2004 to
Laparoscopic mini-gastric bypass (MGB) is a technically simple        October 2006, were reviewed at an academic institution.
and safe procedure in SSO patients. LMGB has the advantages of        RESULTS:
being a single stage procedure, being easily reversible and           Mean age was 35 +/- 11.4 years (range 15-72), preoperative BMI
revisable in a laparoscopic procedure and does not sacrifice          was 44 +/- 6.9 kg/m2 (range 35-61.8) and 80 (63.4%) were
portions of the stomach or implant foreign materials. Weight loss     women. Co-morbidities were present in 42 (33.3%). Operative
appears favorable in the short term; however, information             time was 144 +/- 15.8 minutes (range 120-160) and length of
regarding long-term weight loss, durability, and safety profile in    hospital stay was 3.32 +/- 0.62 days (range 2-18). There was no
this population will require a greater number of patients and         hospital mortality, and the in-hospital complication rate was 4.7%.
longer follow up.                                                     No anastomotic leakage occurred, and the incidence of wound
                                                                      sepsis was 2.3%. The mean total cost of the procedure was 3408
18575943                                                              +/- 547 USD (range 2967-6876). Five patients (3.9%) developed
 16.                                                                  incisional hernias and 3 (2.3%) marginal ulcers. BMI at 6 months
Obes Surg. 2008 Sep;18(9):1130-3. Epub 2008 Jun 20.                   was 33.0 +/- 3.1 kg/m2 (range 26.8-43.5, P < 0.001) compared
Primary results of laparoscopic mini-gastric bypass in a French       with preoperative value. At 1 year, mean excess weight loss was
obesity-surgery specialized university hospital.                      68.4% and comorbidities resolved in 85%.
Chakhtoura G, Zinzindohoué F, Ghanem Y, Ruseykin I, Dutranoy          CONCLUSION:
JC, Chevallier JM.                                                    Minilap MGB is a simple, safe, effective and low-cost gastric
Assistance Publique-Hôpitaux de Paris, University Paris 5, Paris,     bypass. It represents an attractive cost-effective alternative to
France.                                                               laparoscopic MGB.
BACKGROUND:
Since 2002, we have performed 350 laparoscopic Roux-en-Y              18219775
gastric bypasses (LRYGB). We decided to evaluate the
laparoscopic mini-gastric bypass (LMGB), an operation reported         18.
as effective, yet simpler than LRYGB. It consisted of a long lesser   Obes Surg. 2008 Mar;18(3):294-9. Epub 2008 Jan 12.
curvature tube with a terminolateral gastroenterostomy, 200 cm        Laparoscopic mini-gastric bypass: experience with tailored bypass
distal to the Treitz ligament.                                        limb according to body weight.
METHODS:                                                              Lee WJ, Wang W, Lee YC, Huang MT, Ser KH, Chen JC.
From October 2006 to November 2007, 100 patients (23 men and          Department of Surgery, Min-Sheng General Hospital, National
77 women) underwent LMGB. The mean age was 40.9 +/- 11.5              Taiwan University, Taipei, Taiwan, Republic of China.
years (17.5-62.4), the preoperative mean body weight was 131          wjlee_obessurg_tw@yahoo.com.tw
+/- 23.1 kg (82-203) and the mean BMI was 46.9 +/- 7.4                BACKGROUND:
kg/m(2) (32.8-72.4). Twenty-four patients had prior restrictive       Gastric bypass surgery is an effective and long-lasting treatment
procedure: 20 LAGB of which nine were already removed and four        of morbidly obese patients. However, the bypass limb may need
VBG (two laparoscopic and two by open surgery). In preoperative       to be tailored in morbidly obese patients with a wide range of
gastric endoscopy Helicobacter pylorii was present in 26 patients     obesity. The aim of the present study was to report clinical result
and eradicated.                                                       of tailored bypass limb in a group of patients receiving
RESULTS:                                                              laparoscopic mini-gastric bypass surgery.
All procedures were completed laparoscopically by six different       METHODS:
surgeons. Mean operative time was 129 +/- 37 min. There was           From Jan 2002 to Dec 2006, laparoscopic mini-gastric bypass was
no death. Seven patients (7%) presented major early                   performed in 644 patients [469 women, 175 men: mean age 30.5
complications: three reoperations for incarcerated herniation of      +/- 8.1 years; mean body mass index (BMI) 43.1 +/- 6.0] in our
small bowel in the trocar wound, one peritonitis due to a             department. The gastric bypass limb was tailored according to the
traumatic injury of the biliary limb, one perianastomotic abscess,    preoperative BMI. The clinical data and outcomes were analyzed.
one intraabdominal bleeding requiring splenectomy, and one            All the clinical data were prospectively collected and stored.
endoscopic haemostasis for anastomotic bleeding. One patient          RESULTS:
presented anastomotic stenosis that required endoscopic               Two hundred eighty-six patients belonged to lower BMI (BMI <
dilatation 2 months postoperatively. Mean BMI at 3 months was         40; mean 36.0), 286 patients moderate BMI (BMI 40-50; mean
38.7 kg/m(2) (31.2-60.9) and at 6 months 35.1 (23.6-53.0). Nine       43.2), and 72 patients higher BMI (BMI > 50; mean 55.4). All
patients complained of diarrhea that resolved 3 months                procedures were completed laparoscopically. Mean operative time
postoperatively and, significantly, only two patients complained of   was 130 min, and mean hospital stay was 5.0 days. Twenty-three
biliary reflux.                                                       minor early complications (4.3%) and 13 major complications
CONCLUSION:                                                           (2.0%) were encountered, with one death occurred (0.016%).
Pending long-term evaluation, LMBG seems a good alternative to        There was no significant difference in operation time and
LRYGB, giving the same results with a more simple and                 complication rate between the groups. The mean bypass limb was
reproductible technique.                                              150 cm for the lower BMI group, 250 cm for moderate BMI group,
                                                                      and 350 cm for the higher BMI group. The mean BMI reduction 2
18566866                                                              years after surgery was 10.7, 15.5, and 23.3 for the lower,
 17.                                                                  moderate, and higher BMI group. The weight loss curves and


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Programme

  • 1. Namaste, G'day, Guten tag, Konichiwa, Ciao, Olá e bem-vindos, Ni Xao, Sawadeeka, Bonjour, Buenos dias, Ciao, Howdy! PROGRAM: FIRST INTERNATIONAL MINI-GASTRIC BYPASS / ONE ANASTOMOSIS BYPASS CONSENSUS CONFERENCE Paris Oct18-20 2012 Thursday, October 18, 2012 at 8:00 AM Friday, October 19, 2012 at 12:00 PM (PDT) Paris Paris Charles de Gaulle Airport Marriott Hotel Allée du Verger, 95700 Roissy-en-France, France In addition Live Surgery Demonstration on Saturday Oct 20 Clinique Geoffroy Saint Hilaire - Paris , 59 Rue Geoffroy-Saint-Hilaire 75005 Paris, France, 01 44 08 40 00 Dr Rutledge & Dr Chiche, Two Operating Rooms 6 - 8 MGB,3 Visitors in OR, Video Transmission Conference Room 25 Surgeons, (Contact DrR@clos.net for special invitation)
  • 2. Welcome • Honorary Meeting Chairman: Jean Mouiel, MD Pr of Surgery Obesity Center Nice France • Chairman of the Meeting: Pr Jean-Marc Chevallier, chirurgie digestive , coelioscopie et de l'obésité, président de la soffco, hôpital européen georges pompidou, 20 rue leblanc, 75908 paris cedex 15, France • International Co-Chairman; Prof M. Garciacaballero, Full Professor Surgery, University Malaga, Medical Faculty, Malaga, 29080, Spain, gcaballe@uma.es • International Co-Chairman; Dr. K S Kular M.S., Director, Dept of Bariatric Surgery, Kular Hospital & College of Nursing, Bija, Ludhiana, Punjab , India - 141412 • Goals Listen to Short Data/Presentations Discuss Pros and Cons of Issues Vote on Consensus of the Group Record the Results • Meeting Process Several short presentations by leaders in the field. Chairman opens the discussion. Moderator roams the floor to seek both discussion and consensus. Recorder makes a written record of the discussion and voting also guiding the discussion to come to decisions by the group. Meeting Chairmen, Moderators and Recorders • SECTION I: Bariatric Today: Surgery Choices and Outcomes • Section Chairman: Roberto Tacchino • Moderator: Dr. Narwaria • Recorder: Dr. Jan Apers • SECTION II: MGB Results with Large Series • Section Chairman: Dr. Shashank Shah/Dr Bhandari • Moderator: Emilio Manno • Recorder: Karl Rheinwalt • SECION III: MGB/OAB Best Practice; Technical Performance • Section Chairman & Moderator: Pr Jean-Marc Chevallier • Recorder: Mario Musella • Thursday Video Techniques Lunch 1 • Section Chairman: Michael Van den Bossche • Moderator: Pr Jean-Marc Chevallier • Recorder: Jan Apers
  • 3. Thursday Afternoon : • SECTION IV: MGB Advantages, Long Term Studies & Other Topics • Section Chairman: Prof. M. Garciacaballero • Moderator: Kamal Mahawar • Recorder: Philippe Costil Friday Morning: MGB; Expert's Experience; TIPS and Tricks, Complications and Risks • SECTION V: Beginning The Consensus Conference Final Statement • Section Chairman: Jean Mouiel, MD • Moderator: Michal Cierny • Recorder: Dr. Rui Ribeiro • Video Techniques Lunch II • Section Chairman: Dr. C Peraglie • Moderator: Mario Musella • Recorder: Dr. Karl Rheinwalt • SECTION VI: The End: The Final Consensus Conference Voting Statements & Planning for the Future • Section Chairman: Dr. Roberto Tacchino • Moderator: Dr. Rutledge • Recorder: KS Kular SATURDAY MORNING Oct 20 2012 SECTION VII: Live MGB Surgery with Cady, ChiChe, Guerolt & Rutledge Monday Morning Oct 22, Live Surgery in Lisbon Portugal w Dr. Rui Riberio/Dr Rutledge
  • 4. Table of Contents Welcome Faculty Program Outline Updated 10/12/12: Brief Program Saturday Oct 12, 2012; Live Interactive Case Demonstrations of Mini- Gastric Bypass Full Program Esophageal Cancer & GE Reflux: Brief Review Rutledge Version of Mini-Gastric Bypass: Tools, Tips, Techniques; Special needs for the Surgery (Instruments, etc.) References Mini-Gastric Bypass References Sleeve Gastrectomy Quickly Leads to New Onset GE Reflux & Weight Regain Meeting Survey
  • 5. Faculty  Name: Title Institution: City/Town: Country:  Jean Mouiel, MD Pr of Surgery Obesity Center NICE FRANCE  Mario Musella Associate Professor of Surgery Naples "Federico II" University - Medical School Naples ITALY  Philippe COSTIL NEUILLY SUR SEINE FRANCE  Jan Apers drs. MCL Leeuwarden Leeuwarden Netherlands  Roberto Tacchino MD Catholic University Rome Italy  Atul N.C Peters DR. Fortis Hospital, Shalimar Bagh New Delhi INDIA  Rui Ribeiro Dr. Centro Hospitalar de Lisboa Central Lisboa Portugal  Michael Van den Bossche MD FRCS Spire Southampton Hospital Castel UK  Michal Cierny Dr., PhD Breclav Hospital Breclav Czech Republic  M. Garciacaballero Full Professor Surgery University Malaga Malaga Spain  Karl Rheinwalt Dr. Dept.for Bariatric Surgery, St. Franziskus-Hospital Cologne Germany  Emilio Manno MD Ospedale Cardarelli Naples Italy  Francesco Greco MD, PhD Clinica Castelli Bergamo  Maurizio De Luca MD Vicenza Regional Hospital Vicenza Italy  Martin Kox Prof hon., Dr, Chef de service département chir viscerale Centre Hospitalier Emile Mayrisch L -Esch-Alzette Luxembourg  Nicolas Cardin Dr Centre Hospitalier de Douai Douai France  Kamal Mahawar Mr. Sunderland Royal Hospital Sunderland United Kingdom  Dr. Robert Rutledge, CLOS, Las Vegas, Nevada, USA 5
  • 6. Program Outline: Thursday morning, Oct 18 SECTION I: Bariatric Today: Surgery Choices and Outcomes SECTION II: MGB Results with Large Series SECION III: MGB/OAB Best Practice; Technical Performance Thursday Video Techniques Lunch 1 Thursday Afternoon : SECTION IV: MGB Advantages, Long Term Studies & Other Topics Friday Morning : MGB; Expert's Experience; TIPS and Tricks , Complications and Risks SECTION V: Beginning The Consensus Conference Final Statement Video Techniques Lunch II SECTION VI: The End: The Final Consensus Conference Voting Statements & Planning for the Future SATURDAY MORNING Oct 20 2012 SECTION VII: Live MGB Surgery with Cady, ChiChe, Guerolt & Rutledge Monday Morning Oct 22, Live Surgery in Lisbon Portugal w Dr. Rui Riberio/Dr Rutledge 6
  • 7. Updated 10/12/12: Brief Program Oct 18: Thursday Morning : Survey Hand Out, Voting Questionnaire for Consensus Instructions Time Presenter Subject 9:00 Jean Mouiel Introduction: Honorary Chairman 9:10 JM Chevallier Chairman First International Mini-Gastric Bypass / One Anastomosis Consensus Conference: ; Welcome, Charge to the Meeting; Listen, Learn, Discuss, Vote, Plan, SECTION I: Bariatric Today: Surgery Choices and Outcomes ======= Special Guest Presentations: ======= ======= The Story of Transition from “Non-MGB” to MGB Surgeon ======= Time Presenter Subject 9:20 Prof hon., Dr Martin Kox, Head Of Service Department Visceral Surgery, Centre Hospitalier Emile Mayrisch, L -Esch-Alzette, Luxembourg. Personal Reflections; History of Peptic Ulcer Surgery 9:30 M Narwaria; Past President Obesity Surg Soc India ; My Journey to the MGB / MGB in India 9:40 JM Chevallier, President Obesity Surg Soc France; What I know about MGB: 7 years experience 9:50 R Rutledge International Survey Bariatric Surgeons, Reflux & Esophageal cancer after Sleeve & Band 10:00 Opening Questions, Present Status; Meeting Goals & Future Plans SECTION II: MGB Results with Large Series Time Presenter Subject 10:10 R Tacchino My Experience with MGB in Italy 10:20 K Kular My Experience with MGB in India 10:30 M Garciacabaello My Experience with OAB in Spain 10:40 C Peraglie My Experience with MGB in USA 10:50 JP Chevallier My Experience with MGB in France 11:00 J Cady My Experience with MGB in France 11:10 R Rutledge My Experience with MGB; 15 years and 6,000 Patients Later 11:20 MGB Results: Questions and Answers and Votes from Floor SECION III: MGB/OAB Best Practice; Technical Performance Time Presenter Subject 11:30 M Musella MGB in Italy; Technical Performance Issues in MGB 11:40 C Peraglie Best Practices; Critical Technical Performance Issues in MGB 11:50 R Ribeiro MGB in Portugal Tech Issues in MGB Gastric Pouch 12:00 Jan Apers Dutch MGB, Tech Issues in MGB; Bypass & Leaks 12:10 J Cady MGB as Rescue for Failed Band 7
  • 8. 12:20 Directed Discussion: Agreements and Controversies Technical Performance of MGB/OAB ========================================================== Thursday Video Techniques Lunch 1 Garciacaballero 5 min video; 5 MGB Tips Peraglie 5 min video; 5 MGB Tips Kular 5 min video; 5 MGB Tips Videos Questions and Answers and Votes from Floor ========================================================== Thursday afternoon : ========================================================== SECTION IV: MGB Advantages, Long Term Studies & Other Topics 13:30 Sandeep Aggarwal MGB vs Other Surgery 13:40 K Mahawar, MGB Review of Literature on MGB 13:50 Maurizio De Luca Italian Experience with Band, RNY, Sleeve & MGB 14:00 K S Kular: MGB vs Sleeve; Report on 200 Sleeves 14:10 R Tacchino: MGB and BPD; compare and contrast 14:20 A Peters: MGB vs. RYGB 14:30 M Bhandari GERD Band& Sleeve vs. RNY & MGB 14:40 Questions and Answers and Votes from Floor 14:50 Emilio Manno MGB Complications and Management (Leaks) 15:00 M Van den Bossche; MGB in UK; GE Reflux; Band, Sleeve, RNY & MGB 15:10 Dr Cierny My experience with MGB in Czech Republic 15:20 Dr S Shah Minimal Risk of Gastric Cancer after Billroth II, Processed Meat is Much More Dangerous 15:30 Dr. Weiner Bile Reflux following Mini-Gastric Bypass (Omega Loop) 15:40 Questions, Answers and Votes from the Floor Directed Discussion: Agreements and Controversies Panel: Chevalier, Garciacaballero, Tacchino, Kular, Peraglie, Nawaria, Weiner 16:00 Dr Rutledge; Failure of Restrictive Procedures: Coca-Cola & Ice Cream Beat Band & Sleeve 16:10 Questions and Answers and Votes from Floor ========================================================== Friday Morning : MGB; Expert's Experience; TIPS and Tricks , Complications and Risks ========================================================== SECTION V: Beginning The Consensus Conference Final Statement 8
  • 9. 9:00 K S Kular: Safety, Safety, Safety; Choosing the MGB 9:10 Garciacaballero; An Experts View, OAB Advantages & Advice 9:20 R Tacchino; An Experts View, MGB Advantages 9:30 Dr Narwaria An Expert's View, Advice to the New MGB'er 9:40 Dr Peraglie; Marginal Ulcers: An Expert's View 9:50 Karl-Peter Rheinwalt My Advice on Becoming a New MGB Program 10:00 Questions and Answers and Votes from Floor 11:00 R Rutledge: Renaming the MGB/OAB; Survey Results, Discussion and Voting 1. Survey Results on Renaming the MGB 2. Keep MGB name and OAB name? 3. Create a New Name for both (BII Bypass, Omega Bypass, Sleeve Bypass 4. Some combination? 5. The MGB is a Bad name 6. The MGB is a Good Name 7. Relation between MGB and OAB (Friends, Brothers or enemies?) 8. Consensus Voting 9. Suggestions: 10. Class Name Single Anastomosis Bypass / Omega Bypass or other (include MGB AND OAB) 11. Two Sub-groups of SAB/OLB Class: 12. MGB = Type I SAB 13. OAB = Type II SAB 11:10 Questions & Voting ======================================================== Video Techniques Lunch II Tacchino 5 min video; 5 MGB Tips Chevallier 5 min video; 5 MGB Tips Rutledge 5 min video; Revision of MGB (Hint, Its Easy) ======================================================== SECTION VI: The End: The Final Consensus Conference Voting Statements & Planning for the Future 13:00 Creation of the Consensus Statement; Review of Survey and Voting Results So Far Dr Rutledge 13:10 Questions and Answers and FINAL Votes from Floor 13:20 Pr Tacchino: Band, Sleeve, RNY & MGB Outcomes: Consensus Statement 13:30 M Nawaria Critical Factors in Performance of MGB: Consensus Statement 13:40 Questions and Answers and FINAL Votes from Floor 14:00 Garciacaballero: The Future; Liberté, égalité, fraternité, "Liberty, equality, fraternity 14:10 Discussion and Voting 15:00 Dr. Rutledge, IFSO, IFSO-EC, ASMBS Meeting Financial Report 15:10 Voting CONSENSUS : QUESTIONS AND ANSWERS 16:00 Society of MGB/OAB Surgeons; Open Discussion and Voting, Organization and Mutual Aide 18:00 Additional Videos (TBA), Topics from the Floor 9
  • 10. ============================================================== SATURDAY MORNING Oct 20 2012 SECTION VII: Live MGB Surgery with Dr’s Cady, ChiChe, Guerolt & Rutledge Live Interactive Surgery Demonstration Paris on Saturday October 20, 2012 Clinique Geoffroy Saint Hilaire - Paris59 Rue Geoffroy-Saint-Hilaire 75005 Paris, France, 01 44 08 40 00 Dr Cady, Guerolt, Rutledge & Chiche, Two Operating Rooms 6 - 8 MGB 3 Visitors in OR, Video Transmission Conference Room 25 Surgeons, (Contact DrR@clos.net for special invitation), Possible Dinner Meeting to Follow Live Interactive Surgery Demonstration Lisbon Portugal Monday October 22, 2012 Monday Morning Oct 22, Live Surgery in Lisbon Portugal w Dr. Rui Riberio/Dr Rutledge, (Contact DrR@clos.net for special invitation) 10
  • 11. Saturday Oct 12, 2012 Live Interactive Case Demonstrations of Mini-Gastric Bypass Live case demonstrations of Mini-Gastric Bypass procedures. To Be Held at Clinique Geoffroy Saint-Hilaire ( On Facebook: http://www.facebook.com/pages/Clinique-Geoffroy-Saint-Hilaire/135267789853994 ) We have arranged a world renowned and clinically expert team to demonstrate the technical performance details of the Mini-Gastric Bypass in Paris on Saturday Oct 20, 2012. For the main operators on Saturday Dr Jean CADY: Medical Doctor, Member of French National Academy of Surgery, and Member on French Society of Bariatric Surgery. Laparoscopic surgeon, Bariatric surgeon, Colo-Rectal surgeon. Dr Renaud Chiche: Medical Doctor, Member on French Society of Bariatric Surgery. Laparoscopic surgeon, Bariatric surgeon, Colo-Rectal surgeon. The space is limited to 20 surgeons and sign up is required at Sign-Up: http://satlivemgb.eventbrite.com/ 3-day Consensus Conference and Education Course on Mini-Gastric Bypass: The increasing role of Mini-Gastric Bypass (MGB) in the treatment of morbid obesity we feel dictates the need for greater acquaintance with this type of surgery. In addition to the 2 day consensus conference we have arranged for a total of 20 surgeons observe and interactive display of live MGB surgeons with international MGB experts. We believe that all surgeons will find the laparoscopic bariatric mini-training program to be of value with respect to future professional orientations. Many surgeons have started performing MGB's, and our goal was to pass on some of the experience with the thousands of prior MGB’s performed by these experts. The most useful parts of the course will include discussion of the identification and treatment of complications, the use of new instrumentation, and surgical demonstrations (live interactive). We believe that the participants will very likely note presentation of novel knowledge by all participants. The 2-day MGB course offers participants high-quality novel knowledge and excellent training quality, and we predict, significant impact on the quality of their patient care and on their personal career. The influence of clinical demonstrations, on the confidence and skills of surgeons, when treating patients with newer surgical techniques, even when they have the requisite skills is enormous. Studies show that surgeons who receive an interactive clinical demonstration prior to treating their patients were more confident of their skills and the details of their performance and as a result their performance improved. Clinical demonstrations are difficult to arrange and manage, they are time consuming, but they are time well spent. We are proud to offer an addition to the didactic teaching and discussion of the First International Consensus Conference on the Mini-Gastric Bypass / One Anastomosis Bypass. Sign-Up: http://satlivemgb.eventbrite.com/ A Live Interactive Demonstration of Mini-Gastric Bypass Surgery to a limited audience of interested surgeons. We know that surgeons who observe live demonstrations indicate higher scores for its helpfulness in performance of all the stages of surgical techniques, when compared to those who had observed a videotaped demonstration. The Clinic: Geoffroy Saint-Hilaire private hospital Located in the heart of the oldest district of Paris, the Geoffroy Saint-Hilaire private hospital allies the strength of a group and the tradition of the excellence. Geoffroy Saint Hilaire private hospital is a multidisciplinary establishment having 196 beds and places dedicated. This clinic includes an intensive care unit for medical and surgical cares and provides all modern technologies and services. Sign-Up: http://satlivemgb.eventbrite.com/ Our Commitment to Excellence in Patient Safety as well as Surgeon Education Please know that we are committed to the highest levels of patient safety and are committed to the patient’s outcomes from live case demonstrations of the Mini-Gastric Bypass procedures. 11
  • 12. Updated 10/12/12: Full Program ============================================================== Oct 18: Thursday Morning: Survey Hand Out, Voting Questionnaire for Consensus Instructions 12
  • 13. Time Presenter Subject 9:00 Jean Mouiel Introduction: Honorary Chairman 9:10 JM Chevallier Chairman First International Mini-Gastric Bypass / One Anastomosis Consensus Conference: ; Welcome, Charge to the Meeting; Listen, Learn, Discuss, Vote, Plan, Objectives: 1. Why Are We Here: MGB Excellent Therapy Not Widely Recognized 2. Create a Report of MGB Series: MGB Excellence Best Practices Treatment for Obesity/Metabolic Disease 3. Technical Details of Best Performance of MGB 4. Plan for Support, Adoption and Improvement of MGB around the World ============================================================== SECTION I: Bariatric Today: Surgery Choices and Outcomes ======= Special Guest Presentations: ======= ======= The Story of Transition from “Non-MGB” to MGB Surgeon ======= Time Presenter Subject 9:20 Prof hon., Dr Martin Kox, Head Of Service Department Visceral Surgery, Centre Hospitalier Emile Mayrisch, L -Esch-Alzette, Luxembourg. Personal Reflections; History of Peptic Ulcer Surgery Objectives History of General Surgery History of the Treatment of Ulcer Disease Vagotomy and Antrectomy for over 100 years What Happens When Bariatric Surgeons forget They are General Surgeons 9:30 M Narwaria; Past President Obesity Surg Soc India ; My Journey to the MGB / MGB in India 1. Who Am I: Successful International leader in Bariatric Surgery? 2. Initial Skepticism of MGB 3. Initial Results with MGB 4. Insights into the Mind of an MGB Skeptic 9:40 JM Chevallier, President Obesity Surg Soc France; What I know about MGB: 7 years experience 1. Who Am I: Successful International leader in Bariatric Surgery? 2. Initial Skepticism of MGB 3. Initial Results with MGB 4. Insights into the Mind of an MGB Skeptic 9:50 R Rutledge; International Survey Bariatric Surgeons, Reflux & Esophageal cancer after Sleeve & Band 1. Survey of 112 Bariatric Surgeons from 23 Countries Around the World 2. In Short Band is not very good, 1/3 to ½ of surgeons have abandoned the Band 3. Sleeve and Band => Acid GE Reflux => 2 X Increased risk Esophageal Cancer 4. By Almost Every Measure MGB Outperforms the Band, the Sleeve and the RNY 10:00 Opening Questions, Present Status; Meeting Goals & Future Plans 1. Limitations of Band, Sleeve & RNY 2. Ideal Bariatric Surgery (measures of Success) 3. Results of MGB 4. Recommendations for Type of Bariatric Surgery 1. Why Should Successful Bariatric Surgeons Choose MGB 2. Skepticism of MGB 3. Results of MGB 4. Response to MGB Skeptics 13
  • 14. ============================================================== SECTION II: MGB Results with Large Series Time Presenter Subject 10:10 R Tacchino My Experience with MGB in Italy 10:20 K Kular My Experience with MGB in India 10:30 M Garciacabaello My Experience with OAB in Spain 10:40 C Peraglie My Experience with MGB in USA 10:50 JP Chevallier My Experience with MGB in France 11:00 J Cady My Experience with MGB in France 11:10 R Rutledge My Experience with MGB; 15 years and 6,000 Patients Later 11:20 MGB Results: Questions and Answers and Votes from Floor MGB vs Other Choices for Obese Patients MGB vs Band MGB vs Sleeve MGB vs RNY ============================================================== SECION III: MGB/OAB Best Practice; Technical Performance Time Presenter Subject 11:30 M Musella MGB in Italy; Technical Performance Issues in MGB 1. Caliber & Length of sleeve 2. Length of Bypass 3. Anastomosis (handsewn, mechanical, side to side, end to side,linear stapler, circular stapler, Reinforcement of the staple gastric sleeve line, Reinforcement of the gastric remnant staple line, (seamguard, peri strip, fibrin glue, other sealant…) Closure of the stapler access (single layer, double layer, mechanical continuous suture, manual continuous suture, mechanical interrupted stitches, manual interrupted stitches…) 4. Only ONE WAY or Multiple Equally Good Ways to Perform MGB 11:40 C Peraglie Best Practices; Critical Technical Performance Issues in MGB 1. Caliber & Length of sleeve 2. Length of Bypass 3. Anastomosis (handsewn, mechanical, side to side, end to side,linear stapler, circular stapler, Reinforcement of the staple gastric sleeve line, Reinforcement of the gastric remnant staple line, (seamguard, peri strip, fibrin glue, other sealant…) Closure of the stapler access (single layer, double layer, mechanical continuous suture, manual continuous suture, mechanical interrupted stitches, manual interrupted stitches…) 4. Only ONE WAY or Multiple Equally Good Ways to Perform MGB 11:50 R Ribeiro MGB in Portugal Tech Issues in MGB Gastric Pouch The Gastric Pouch Time 8 min 1. Surgeon/Patient Position, Ports Position/Placement, 2. Location of pouch initiation, Skeletonization of lesser curve, 3. Creation of the pouch: Use of the staple gun, Covidien/Ethicon: Pros & Cons, Location and angle of first staple cartridge Cartridge selection: White/Blue/Gold/Green, Delays: Before and During Staple Gun Firing 4. Wisdom of Old Men: 14
  • 15. Fear “Thickness”, Fear The Tube/Bougie/NG tube Fear the Angle of His 12:00 Jan Apers Dutch MGB, Tech Issues in MGB; Bypass & Leaks 1. Dutch Experience with MGB 2. Running the Bowel, Distance of the bypass, Tailoring the length bypass 3. Leaks after MGB 4. Managing Leaks 12:10 J Cady MGB as Rescue for Failed Band 1. Band is Good choice? 2. Failure Rate (Weight Regain, Reflux) and Leak Rate 3. FU Band and MGB, complications and Weight Loss 4. Band vs MGB; 50% vs 90% Success 12:20 Directed Discussion: Agreements and Controversies Technical Performance of MGB/OAB Panel: Chevalier, Garciacaballero, Tacchino, Kular, Peraglie, Nawaria, Weiner ============================================================== Thursday Video Techniques Lunch 1 Garciacaballero 5 min video; 5 MGB Tips Peraglie 5 min video; 5 MGB Tips Kular 5 min video; 5 MGB Tips Videos Questions and Answers and Votes from Floor ============================================================== Thursday afternoon : ========================================================== SECTION IV: MGB Advantages, Long Term Studies & Other Topics 13:30 Sandeep Aggarwal MGB vs Other Surgery 1. Band vs MGB 2. BPD vs MGB 3. RNY vs MGB 4. Sleeve vs MGB 13:40 K Mahawar, MGB Review of Literature on MGB 1. Review of MGB Publications 2. MGB Advantages 3. MGB Disadvantages 4. MGB: Conclusions from the medical Literature 13:50 Maurizio De Luca Italian Experience with Band, RNY, Sleeve & MGB 1. MGB: Excess Weight Loss 2. MGB Op Time 3. Weight Regain 4. MGB: Reflux and Esophageal Cancer 15
  • 16. 14:00 K S Kular: MGB vs Sleeve; Report on 200 Sleeves 1. Sleeve is Good choice for Many 2. Failure Rate (Weight Regain, Reflux) and Leak Rate 3. 3 yr FU Sleeve and MGB, Pouch Dilation and Weight Loss 4. Lee; Sleeve vs MGB, 50% vs 90% Success 14:10 R Tacchino: MGB and BPD; compare and contrast 1. BPD is Good choice for Many 2. Failure Rate (Weight Regain, Reflux) and Leak Rate 3. 3 yr FU BPD and MGB, Pouch Dilation and Weight Loss 4. BPD, Band, Sleeve, MGB My Advice and Perspective 14:20 A Peters: MGB vs. RYGB 1. RNY is Good choice for Many 2. Failure Rate (Weight Regain, Reflux) and Leak Rate 3. FU RNY and MGB, Bowel Obstruction and Weight Regain 4. RNY, BPD, Band, Sleeve, MGB My Advice and Perspective 14:30 M Bhandari GERD Band& Sleeve vs. RNY & MGB I. Esophageal Cancer, Deadly and Increasing Worldwide II. GE Reflux Primary Cause of Esophageal Cancer III. Band & Sleeve CAUSE GE Reflux in 30% of Patients! IV. RNY & MGB Resolve GE Reflux in 80%+ V. Band and Sleeve May Be PreCancerous Lesions VI. Band and Sleeve Dr's Need to Warn Patients of this Deadly Risk 14:40 Questions and Answers and Votes from Floor 14:50 Emilio Manno MGB Complications and Management (Leaks) 1. Italian Experience of MGB 2. Anemia 3. Ulcer 4. Inadequate / Excess Weight Loss / Other Complications 15:00 M Van den Bossche; MGB in UK; GE Reflux; Band, Sleeve, RNY & MGB 1. UK Experience of MGB 2. Anemia 3. Ulcer 4. Inadequate / Excess Weight Loss / Other Complications 15:10 Dr Cierny My experience with MGB in Czech Republic 1. Ulcer after MGB vs RNY 2. PreOp and Post Op Management Prevention 3. Treatment of Gastritis / Ulcer 4. No Smoking, NSAIDs, Rx H.Pylori, Anti-Acids (PPI’s, H2 Blockers), Bismuth subsalicylate, Yogurt, No Smoking!!, Soda, Coffee, Etoh, Green Tea, Meat, Hand washing, Careful food prep, Safe water source 15:20 Dr S Shah Minimal Risk of Gastric Cancer after Billroth II, Processed Meat is Much More Dangerous 1. Gastric Cancer Declining; Esophageal Cancer Rising 2. BII in Few Studies Assoc with Gastric Ca But these are Ulcer Pts (H. Pylori) 3. Bile Reflux Rare and Easily treated while maintaining Weight Loss 4. GE Reflux Doubles the Risk of Esophageal Ca; Warn Patients 16
  • 17. 15:30 Dr. Weiner Bile Reflux following Mini-Gastric Bypass (Omega Loop) 1. Bile Reflux Ulcer after MGB vs RNY 2. PreOp and Post Op Management / Prevention 3. Treatment of Gastritis / Ulcer 4. No Smoking, NSAIDs, Rx H.Pylori, Anti-Acids (PPI’s, H2 Blockers), Bismuth subsalicylate, Yogurt, No Smoking!!, Soda, Coffee, Etoh, Green Tea, Meat, Hand washing, Careful food prep, Safe water source, *** Endoscopy ***, *** Surgery Revision *** 15:40 Questions, Answers and Votes from the Floor Directed Discussion: Agreements and Controversies Panel: Chevalier, Garciacaballero, Tacchino, Kular, Peraglie, Nawaria, Weiner 1. Long Term Outcome of Band, Sleeve, RNY, BPD Long Term MGB Outcomes 3. Band, Sleeve, RNY, BPD vs. MGB Recommendations Always Choose MGB (Rutledge Doctrine) Always Choose Band, Sleeve, RNY, BPD Tailored Approach When to choose Band, Sleeve, RNY, BPD When to choose MGB 4. BPD vs. MGB Need for Further Study 16:00 Dr Rutledge; Failure of Restrictive Procedures: Coca-Cola & Ice Cream Beat Band & Sleeve 1. Bariatrics: A History of Failure, A Cautionary Tale 2. Remember the History of the Lap Band 3. Enthusiasm, Tempered Support, Early Concerns, Failure 4. Humans are POOR Decision makers 16:10 Questions and Answers and Votes from Floor Time: 1 hour Review of Survey Questions & Voting Expert Judgment & Voting: Outcome Band, Sleeve, RNY, BPD Expert Judgment & Voting: Outcome MGB Band, Sleeve, RNY, BPD vs. MGB === Consensus Recommendations === Always Choose MGB (Rutledge Doctrine) Never Choose MGB (ASMBS Doctrine) Tailored Approach === Consensus Recommendations === When to choose Band, Sleeve, RNY, BPD When to choose MGB Friday Morning: MGB; Expert's Experience; TIPS and Tricks , Complications and Risks ========================================================== SECTION V: Beginning The Consensus Conference Final Statement 9:00 K S Kular: Safety, Safety, Safety; Choosing the MGB 9:10 Garciacaballero; An Experts View, OAB Advantages & Advice 17
  • 18. 1. My Consideration of OAB 2. My Patients, My Results of OAB 3. FIVE Core Advantages of OAB 4. Advice from My Experience 9:20 R Tacchino; An Experts View, MGB Advantages 1. My Consideration of MGB 2. My Patients, My Results of MGB 3. Complications and Outcomes 4. Advice from My Experience 9:30 Dr Narwaria An Expert's View, Advice to the New MGB'er 1. Why Should Successful Bariatric Surgeons Choose MGB 2. Criticism by Colleagues of MGB 3. Results of MGB / Results of Sleeve, Band and RNY 4. Response to MGB Skeptics/Critics 9:40 Dr Peraglie; Marginal Ulcers: An Expert's View 9:50 Karl-Peter Rheinwalt My Advice on Becoming a New MGB Program 1. Why face Criticism to Offer the MGB 2. My Decision to Choose MGB 3. The Story of the Struggle to Offer MGB 4. Advice from My Experience 10:00 Questions and Answers and Votes from Floor 11:00 R Rutledge: Renaming the MGB/OAB; Survey Results, Discussion and Voting 1. Survey Results on Renaming the MGB 2. Keep MGB name and OAB name? 3. Create a New Name for both (BII Bypass, Omega Bypass, Sleeve Bypass 4. Some combination? 5. The MGB is a Bad name 6. The MGB is a Good Name 7. Relation between MGB and OAB (Friends, Brothers or enemies?) 8. Consensus Voting 9. Suggestions: 10. Class Name Single Anastomosis Bypass / Omega Bypass or other (include MGB AND OAB) 11. Two Sub-groups of SAB/OLB Class: 12. MGB = Type I SAB 13. OAB = Type II SAB 11:10 Questions & Voting 1. Consensus Judgment of Experts and Conference on the MGB 1. Patient / Surgeons Advantages of MGB 2. Consensus Judgment of Experts and Conference on the 3. MOST Critical Advantages 4. Consensus Judgment of Experts and Conference on the Dangers of MGB Video Techniques Lunch II Tacchino 5 min video; 5 MGB Tips 18
  • 19. Chevallier 5 min video; 5 MGB Tips Rutledge 5 min video; Revision of MGB (Hint, Its Easy) ======================================================== SECTION VI: The End: The Final Consensus Conference Voting Statements & Planning for the Future ============================================================== 13:00 Creation of the Consensus Statement; Review of Survey and Voting Results Review of Survey and Voting Results So Far Dr Rutledge Report on Survey of 100 Bariatric Surgeons from 23 countries and 39,000 cases In Short: Band is Less than Sleeve is less than RNY is Less than MGB Band and Sleeve: Cause Esophageal Reflux and Esophageal Cancer Conclusions the Experts Tell Us in the Survey 13:10 Questions and Answers and FINAL Votes from Floor 13:20 Pr Tacchino: Band, Sleeve, RNY & MGB Outcomes: Consensus Statement PreOp Factors Operative Factors: Gastric Sleeve Bypass Gastro-J Anesthesia Early Post Op Management Management Leaks Long Term Management 13:30 M Nawaria Critical Factors in Performance of MGB: Consensus Statement 13:40 Questions and Answers and FINAL Votes from Floor Consensus Statement Expert Judgment of Band, Sleeve, RNY Consensus Statement Expert Judgment of Band, Sleeve, Esophageal Cancer Consensus Statement Expert Judgment of MGB 14:00 Garciacaballero: The Future; Liberté, égalité, fraternité, "Liberty, equality, fraternity 14:10 Discussion and Voting "Liberty, equality, fraternity (brotherhood)" Time 8 min Organization and Mutual Support Consensus Statement Volunteer Proctors and Surgeon Resources Direct and Remote technical advice Research Support Collaborative Study Database Repeat Meeting Next Year (Garciacaballero) 15:00 Dr. Rutledge, IFSO, IFSO-EC, ASMBS Meeting Financial Report 15:10 Voting CONSENSUS : QUESTIONS AND ANSWERS Suggestions for organizing and supporting present surgeons and inviting new surgeons Vote on consensus statement Who will volunteer to help new surgeons Direct and Remote technical advice 19
  • 20. Research Support Collaborative Study Database Meet again Next Year? Location? Timing Research Support 16:00 Society of MGB/OAB Surgeons; Open Discussion and Voting, Organization and Mutual Aide IFSO 2013 Istanbul Turkey, 1 Day Interest Group Submit Abstracts (Rutledge will help) IFSO-EC Invited to Present at the "Bariatric Club" Interest Group at IFSO-EC 2013? Other suggestions (French, English, Italian, German, Spanish, Indian Society meetings) IFSO Turkey IFSO-EC Bariatric Club Organize 1 day Post Grad Course at IFSO-EC 2013 MGB Presentations at French, English, Italian, German, Spanish, Indian Society meetings? Society of MGB/OAB Surgeons; Open Discussion and Voting Organization and Mutual Aide ============================================================== TBA SECTION VII: Live Surgery with Live Surgery Demonstration on Saturday Oct 20 Clinique Geoffroy Saint Hilaire - Paris 59 Rue Geoffroy-Saint-Hilaire 75005 Paris, France 01 44 08 40 00 Dr Rutledge & Dr Chiche Two Operating Rooms 6 - 8 MGB 3 Visitors in OR, Video Transmission Conference Room 25 Surgeons (Contact DrR@clos.net for special invitation) Possible Dinner Meeting to Follow 20
  • 21. Esophageal Cancer & GE Reflux: Brief Review The United States has experienced an alarming and unexplained increase in the incidence of esophageal adenocarcinoma (EAC) since the 1970s. Esophageal adenocarcinoma is the fastest growing cancer in the western world. A dramatic rise in one of the deadliest types of cancers may be linked to the increasing rates of acid reflux and gastrointestinal disorders. Cancers of the esophagus and stomach are among the deadliest of all cancers with more than 80% of those affected dying within five years.Although cancers of the stomach (gastric cancer) have been steadily declining over the last 50 years, studies show the incidence of a cancer affecting the esophagus (esophageal adenocarcinoma) has risen by about 600% over the past few decades. In the report, published in CA: A Cancer Journal for Clinicians, researchers reviewed studies on cancers located where the stomach ends and esophagus begins, referred to as the gastroesophageal junction (GEJ). The major risk factors for this type of cancer are gastroesophageal reflux disease (GERD) and its associated conditions, such as Barrett's esophagus. In Barrett's esophagus, precancerous changes are present. Other associated risk factors include alcohol and tobacco use, obesity, and eating a diet low in fruits and vegetables. Studies have shown that the part of the esophagus closest to the stomach is more exposed to concentrated gastric acid and a variety of agents that may contribute to the increased risk of cancer in this region. Despite advances in screening methods for this type of cancer, researchers say more research is needed to find new ways to prevent the disease and detect it early. Major risk factors for this cancer are Gastroesophageal Reflux Disease (GERD) and Barrett's esophagus. In one study frequent acid reflux (≥1 time/week) accounted for the greatest single risk factor of Esophageal Cancer 36% 1. GE Reflux => Esophageal Cancer 2. Sleeve => Reflux 3. Band => Reflux 4. Esophageal Cancer in Band and Sleeve 5. Sleeve & Band => GE Reflux => Esophageal Cancer Clin Gastroenterol Hepatol. 2012 May;10(5):475-80.e1. Epub 2012 Jan 13. Erosive reflux disease increases risk for esophageal adenocarcinoma, compared with nonerosive reflux. Erichsen R, Robertson D, Farkas DK, Pedersen L, Pohl H, Baron JA, Sørensen HT. Source Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark. re@dce.au.dk In the study cohort, 26,194 of the patients over 3/4 (77%) had erosive reflux disease and 37 subsequently developed esophageal adenocarcinoma after a mean follow-up time of ONLY 7.4 years. Their absolute risk after 10 years was 0.24% (0.15%-0.32%). The incidence of cancer among patients with erosive reflux disease was significantly greater than that expected for the general population Over Twice as high (standardized incidence ratio, 2.2; 95% CI, 1.6-3.0). 21
  • 22. Often a pillow, doughnut or soft sand bag is placed by Rutledge Version of Mini- the head Gastric Bypass: Tools, EndoTracheal tube placement and Vital signs assessed Then and only then the patient is replaced to flat Tips, Techniques; Special supine and the patient is prepped and draped in the usual needs for the Surgery fashion (Instruments, etc.) The surgeon stands on the patient's Right Usually requiring a STEP Stool ========== The Camera is immobilized by a self retaining camera First: Warning NO anticoagulants, NSAIDs holder and one assistant is on the patient's Left side ========== Only two scrub for PATIENT POSITIONING: the case The patient is The Surgeon looks across the table from patient's right supine (not lithotomy) to left to a screen at the head of the patient located 45 The table will be inclined to MAXIMUM Trendelenburg degrees position and Full tilt to the Left Side UP between the patient's head and the patient's left arm The requires a simple but very important patient This means that this are must be kept free of IV poles immobilization on the table to ensure patient safety and and anesthesia paraphernalia make sure the ========== large patient does not move during the operation BOUGIE Both arms are out at 90 degrees the knees We are use 24 - 32 French (NO Larger, No smaller) "broken' to an angle of 45 degrees and two Large pillows In a pinch we can use Ewald Tube are placed Or Gastroenterologist Red Weighted Dilating Bougie beneath the knees NO 36-38 Bougies The Heels are padded ========== SCDs are applied INSTRUMENTS and then most importantly The instruments need are simple but should be of high 3 Three LARGE Leather or Polyester Straps (Seat Belts) quality. are applied to the legs The Mayo stand should contain At the upper thigh 1 scalpel of any type the lower thigh Veress needle and mid tibia 5 Ports in total Then to reassure all of the anesthesia, Of the 5 ports; nursing and other attendants 4 ports are 12mm ports (not 10 or 11mm) 12 mm ports with all of the team watching that can accept the The table is slowly and carefully moved to MAXIMUM stapler (12 mm) as well as the 5 mm operating Reverse instruments. Trendelenburg and Full Tilt Left side up Of the 5 ports the remaining port is a single 5mm port Any adjustments are made Three separate 5 mm 22
  • 23. graspers of excellent quality, at least 2 should be Locking to make a 12mm incision 1 and 1/2 palm widths below the Graspers xiphi sternum One of the 3 three, This may vary slightly with patient size but is 5 mm graspers should ideally have longer jaws to allow a remarkably constant firm safe The 12 mm "Camera port" is used to enter the abdomen locked grip on the intestine The surgeon In case of emergency there should be two good quality uses needle drivers (in most cases not needed, but should be the camera to briefly explore the abdomen and note the on the back location of the table) Veress needle and the Veress is removed under direct Stapler, Ideally Covidien 60 mm blue or Purple although vision Johnson Can be used as backup The final 4 ports are now placed No other Open Surgery instruments on the back table The locations are as follows: Skin closure is with 1 (one) single staple in each port 1, One 5 mm port several cm medial to the left axillary and for this we need a single pair of Adson's forceps with line 2-3 finger breadths below the costal margin teeth and 1, One 12 mm port left mid-clavicular line 2-3 finger commercial staple gun breadths below No suction is on the table the costal margin We use the Harmonic scalpel if possible 1, One 12 mm port Midline 2-3 finger breadths below the No sutures open. xiphi sternum but have 3-O 1, One 12 mm port Right mid-clavicular line 2-3 finger Vicryl on sh needle available if necessary, breadths below Do Not Open the costal margin =========================== Total 5 Ports A brief summary of the procedure may be of interest In roughly a "Diamond" pattern The surgeons approaches the patient in flat supine 1 Midline 1 and 1/2 palms below xiphi sternum (the position from the patient's left side. Primary But not only," The abdomen is examined and the location of the left Camera Port") lateral extent of the rectus sheath 1 Left Anterior Axillary Line 5 mm grasper / retractor port approximately 4-5 finger breadths below the left costal 1 Right Mid-clavicular line port, used for stapler and margin is camera at estimated. several points during the case for only a few moments With 2 Primary Surgeon's Working Ports the "go ahead" (Right Hand and Left hand) from anesthesia a 5 mm incision is made and the Veress Left hand = Midline Port needle is Right hand = Patient's advanced into the abdominal cavity and insufflated. Left Mid clavicular Line port The surgeon Patient moves is now, with approval of anesthesia, to the patient's right side and after insufflation the scalpel tilted to Maximum Reverse Trendelenburg and left side up is used Warning poor anesthesia can lead to hypotension 23
  • 24. Anesthesia must be prepared and educated as tothe Attention turned to the Left Gutter planned revers Trendelenburg positioning and Retract the omentum medially and Identify Ligament of drug use so to avoid hypotension when tilting the patient Treitz Poor anesthesia Run the bowel 2 m = No surgery Count to 60 Now the steps in brief for the operation ========== The left hand grasper elevates the left lobe of the Grasp and lock the loop of bowel with larger 5mm liver and the harmonic is used to dissect the lesser curve atraumatic locking of the grasper stomach at the junction of the body and the Antrum 5-10 Gastrotomy with harmonic minutes Change camera to R Lateral port Stapler is passed via the Left Hand Working port into Enterotomy the abdomen and the stomach pouch creation is under Pass 60 mm Covidien Stapler in via the "Camera" port way Fire to form GJ Using the Left Hand working port or the Right side port Manipulate 24-30 mm bougie across the anastomosis second stapler is fired Change camera back to camera port and pass 60 mm Surgeon stapler and anesthesia now discuss Bougie placement in via the Right lateral port The bougie is advanced and retracted under direct vision Close the GJ ========== Case over Surgeon Op time 35 minutes and anesthesia agree on bougie movement commands: Advance Retract Tap Tap (A very tiny rapid in and out motion that aids in bougie identification) Now all staplers fired from the Right hand Working port 3-5 staples to EG Junction WARNING FEAR THE EG JUNCTION Stay lateral to EG Junction Only fools and Sleeve surgeons dissect near the EG Junction. It is not necessary for MGB and it is dangerous With division of 80-95% of the stomach the area lateral to EGJ is visualized If necessary the short gastrics are divided under direct vision with careful and meticulous dissection Case Mantra "NO BLEEDING" The division of the stomach and creation of the pouch is completed Op time 15-20 minutes ========== 24
  • 25. References Mini-Gastric Bypass References Obes Surg. 2012 Sep 11. [Epub ahead of print] with laparoscopic mini-gastric bypass (LMGBP) and laparoscopic Laparoscopic Roux-en-Y Vs. Mini-gastric Bypass for the sleeve gastrectomy (LSG). Three patients with genetic diagnosis Treatment of Morbid Obesity: a 10-Year Experience. Lee of PWS and body mass index (BMI) greater than 40 kg/m(2) were WJ, Ser KH, Lee YC, Tsou JJ, Chen SC, Chen JC. referred for bariatric surgery. All of them had completed 2-year Department of Surgery, Min-Sheng General Hospital, National postoperative follow-up. Body weight, BMI, and ghrelin levels Taiwan University, No. 168, Chin Kuo Road, Tauoyan, Taiwan, were recorded before and after surgery. They were two females Republic of China, wjlee_obessurg_tw@yahoo.com.tw. and one male. Their age ranged from 15 to 23 years old, and the BACKGROUND: mean BMI was 46.7 kg/m(2) (range 44-50). Two patients Laparoscopic Roux-en-Y gastric bypass (LRYGB) is considered the underwent LSG and one patient underwent LMGBP. After a gold standard for the treatment of morbid obesity but is median follow-up of 33 months (range 24-36 months), mean technically challenging and results in significant perioperative weight loss and percentage of excessive weight loss at 2 years complications. While laparoscopic mini-gastric bypass (LMGB) has were 32.5 kg (24.9-38.3 kg) and 63.2 % (range 50.5-86.2 %), been reported to be a simple and effective treatment for morbid respectively. The mean fasting active ghrelin level decreased from obesity, controversy exists. Long-term follow-up data from a large 1,134.2 pg/ml preoperatively to 519.8 pg/ml 1 year after surgery. number of patients comparing LMGB to LRYGB are lacking. No major complication was observed. Iron deficiency anemia was METHODS: observed in the patient who underwent LMGBP. Significant Between October 2001 and September 2010, 1,657 reduction of body weight and level of serum ghrelin can be patients who received gastric bypass surgery (1,163 for achieved with minimal morbidity by LSG or LMGBP in patients LMGB and 494 for LRYGB) for their morbid obesity were with PWS. recruited from our comprehensive obesity surgery center. Patients who received revision surgeries were excluded. Minimum follow- 22923339 up was 1 year (mean 5.6 years, from 1 to 10 years). The operative time, estimated blood loss, length of hospital stay, and operative complications were assessed. Late complication, 3. changes in body weight loss, BMI, quality of life, and Obes Surg. 2012 May;22(5):697-703. comorbidities were determined at follow-up. Changes in quality of One thousand consecutive mini-gastric bypass: short- and long- life were assessed using the Gastrointestinal Quality of Life Index. term outcome. RESULTS: Noun R, Skaff J, Riachi E, Daher R, Antoun NA, Nasr M. There was no difference in preoperative clinical parameters Department of Digestive Surgery, Hôtel-Dieu de France Hospital between the two groups. and University Saint Joseph Medical School, Bd Alfred Naccache, Surgical time was significantly longer for LRYGB (159.2 Achrafieh, BP 166830 Beirut, Lebanon. rnoun@wise.net.lb vs. 115.3 min for LMGB, p < 0.001). There is growing evidence that mini-gastric bypass (MGB) is a The major complication rate was borderline higher for safe and effective procedure. Operative outcome and long-term LRYGB (3.2 vs. 1.8 %, p = 0.07). follow-up of a consecutive cohort of patients who underwent MGB At 5 years after surgery, the mean BMI was lower in LMGB are reported. The data on 1,000 patients who underwent MGB than LRYGB (27.7 vs. 29.2, p < 0.05) and from November 2005 to January 2011 at an academic institution LMGB also had a higher excess weight loss than LRYGB were reviewed. Mean age was 33.15 ± 10.17 years (range, 14- (72.9 vs. 60.1 %, p < 0.05). 72), preoperative BMI was 42.5 ± 6.3 kg/m(2) (range, 26-75), Postoperative gastrointestinal quality of life increased significantly mean preoperative weight was 121.6 ± 23.8 kg (range, 71-240), after operation in both groups without any significant difference and 663 were women. Operative time and length of stay for at 5 years. Obesity-related clinical parameters improved in both primary vs. revisional MGB were 89 ± 12.8 min vs. 144 ± 15 min groups without significant difference, but LMGB had a lower (p < 0.01) and l.85 ± 0.8 day vs. 2.35 ± 1.89 day (p < 0.01). No hemoglobin level than LRYGB. deaths occurred within 30 days of surgery. Short-term Late revision rate was similar between LRYGB and LMGB (3.6 vs. complications occurred in 2.7% for primary vs. 11.6% for 2.8 %, p = 0.385). revisionnal MGB (p < 0.01). Five (0.5%) patients presented with CONCLUSIONS: leakage from the gastric tube but none had anastomotic leakage. This study demonstrates that LMGBP can be regarded as Four (0.4%) patients, all with revisional MGB, presented with a simpler and safer alternative to LRYGB with similar severe bile reflux and were cured by stapling the afferent loop efficacy at a 10-year experience. and by a latero-lateral jejunojejunostomy. Excessive weight loss occurred in four patients; two were reversed and two were 23011462 converted to sleeve gastrectomy. Maximal percent excess weight loss (EWL) of 72.5% occurred at 18 months. Weight regain subsequently occurred with a mean variation of -3.9% EWL at 60 2. months. The 50% EWL was achieved for 95% of patients at 18 Obes Surg. 2012 Aug 26. [Epub ahead of print] months and for 89.8% at 60 months. MGB is an effective, Ghrelin Level and Weight Loss After Laparoscopic Sleeve relatively low-risk, and low-failure bariatric procedure. In addition, Gastrectomy and Gastric Mini-Bypass for Prader-Willi Syndrome in it can be easily revised, converted, or reversed. Chinese. Fong AK, Wong SK, Lam CC, Ng EK. 22411569 Division of Upper GI Surgery, Department of Surgery, Prince of 4. Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Diabetes Technol Ther. 2012 Apr;14(4):365-72. Epub 2011 Dec China. 16. Prader-Willi syndrome (PWS) is a chromosomal disorder Role of bariatric-metabolic surgery in the treatment of obese type characterized by the presence of hyperghrelinemia, hyperphagia, 2 diabetes with body mass index <35 kg/m2: a literature review. and obesity. The optimal treatment for PWS patient remains Reis CE, Alvarez-Leite JI, Bressan J, Alfenas RC. controversial. Here, we present our experience of treating PWS School of Health Sciences, University of Brasília, Brasília, Brazil. 25
  • 26. caioedureis@gmail.com Bariatric surgery has been used to treat type 2 diabetes mellitus 22105765 (T2DM); however, its efficacy is still debatable. This literature 6. review analyzed articles that evaluated the effects of bariatric Obes Surg. 2012 Mar;22(3):502-6. surgery in treatment of T2DM in obese patients with a body mass Bariatric surgery in Asia in the last 5 years (2005-2009). index (BMI) of <35 kg/m(2). A paired t test was applied for the Lomanto D, Lee WJ, Goel R, Lee JJ, Shabbir A, So JB, Huang CK, analysis of pre- and postintervention mean BMI, fasting plasma Chowbey P, Lakdawala M, Sutedja B, Wong SK,Kitano S, Chin KF, glucose (FPG), and glycosylated hemoglobin (A1c) values. A Dineros HC, Wong A, Cheng A, Pasupathy S, Lee SK, significant (P<0.001) reduction in BMI (from 29.95±0.51 kg/m(2) Pongchairerks P, Giang TB. to 24.83±0.44 kg/m(2)), FPG (from 207.86±8.51 mg/dL to Department of Surgery, Minimally Invasive Surgical Centre, 113.54±4.93 mg/dL), and A1c (from 8.89±0.15% to National University Hospital, 5 Lower Kent Ridge Road, 119074, 6.35±0.18%) was observed in 29 articles (n=675). T2DM Singapore, Singapore. resolution (A1c <7% without antidiabetes medication) was Erratum in achieved in 84.0% (n=567) of the subjects. T2DM remission, • Obes Surg. 2012 Feb;22(2):345. Fah, Chin Kin [corrected to control, and improvement were observed in 55.41%, 28.59%, Chin, Kin-Fah]. and 14.37%, respectively. Only 1.63% (n=11) of the subjects Obesity is a major public health concern around the world, presented similar or worse glycemic control after the surgery. including Asia. Bariatric surgery has grown in popularity to T2DM remission (A1c <6% without antidiabetes medication) was combat this rising trend. An e-mail questionnaire survey was sent higher after mini-gastric bypass(72.22%) and laparoscopic/Roux- to all the representative Asia-Pacific Metabolic and Bariatric en-Y gastric bypass (70.43%). According to the Foregut and Surgery Society (APMBSS) members of 12 leading Asian countries Hindgut Hypotheses, T2DM results from the imbalance between to provide bariatric surgery data for the last 5 years (2005-2009). the incretins and diabetogenic signals. The procedures that The data provided by representative members were discussed at remove the proximal intestine and do ileal transposition the 6th International APMBSS Congress held at Singapore contribute to the increase of glucagon-like peptide-1 levels and between 21st and 23rd October 2010. Eleven nations except improvement of insulin sensitivity. These findings provide China responded. Between 2005 and 2009, a total of 6,598 preliminary evidence of the benefits of bariatric-metabolic surgery bariatric procedures were performed on 2,445 men and 4,153 on glycemic control of T2DM obese subjects with a BMI of women with a mean age of 35.5 years (range, 18-69years) and <35 kg/m(2). However, more clinical trials are needed to mean BMI of 44.27 kg/m(2) (range, 31.4-73 kg/m(2)) by 155 investigate the metabolic effects of bariatric surgery in T2DM practicing surgeons. Almost all of the operations were performed remission on pre-obese and obese class I patients. laparoscopically (99.8%). For combined years 2005-2009, the four most commonly performed procedures were laparoscopic 22176155 adjustable gastric banding (LAGB, 35.9%), laparoscopic standard 5. Roux-en-Y gastric bypass (LRYGB, 24.3%), laparoscopic sleeve Updates Surg. 2011 Dec;63(4):239-42. Epub 2011 Nov 22. gastrectomy (LSG, 19.5%), and laparoscopic mini gastric bypass Laparoscopic mini-gastric bypass: short-term single-institute (15.4%). Comparing the 5-year trend from 2004 to 2009, the experience. absolute numbers of bariatric surgery procedures in Asia Piazza L, Ferrara F, Leanza S, Coco D, Sarvà S, Bellia A, Di Stefano increased from 381 to 2,091, an increase of 5.5 times. LSG C, Basile F, Biondi A. increased from 1% to 24.8% and LRYGB from 12% to 27.7%, a General and Emergency Surgery Department, Garibaldi Hospital, relative increase of 24.8 and 2.3 times, whereas LAGB and mini Catania, Italy, lpiazza267@gmail.com. gastric bypass decreased from 44.6% to 35.6% and 41.7% to The elevated variety of procedures proposed for surgical 6.7%, respectively. The absolute growth rate of bariatric surgery treatment of obesity in the last few years suggests the necessity in Asia over the last 5 years was 449%. to find an ideal operation. Laparoscopic mini-gastric bypass (LMGB) was developed to obtain better results with lesser 22033767 morbidity and mortality. LMGB was introduced by Rutledge, in 7. 1997, and it consists of a long lesser-curvature tube with a Obes Surg. 2011 Nov;21(11):1758-65. terminolateral gastroenterostomy 180 cm distal to the Treitz ESR1, FTO, and UCP2 genes interact with bariatric surgery ligament. From July 1995 to May 2011 we have performed 552 affecting weight loss and glycemic control in severely obese bariatric operations, among them we have operated 197 patients. laparoscopic mini-gastric bypass (Fig. 1). There were 147 female Liou TH, Chen HH, Wang W, Wu SF, Lee YC, Yang WS, Lee WJ. (75%) and 50 male (25%) with the mean age of 37.9 years Department of Physical Medicine and Rehabilitation, Shuang Ho (range 20-55) and the mean BMI of 52.9 kg/m(2). All procedures Hospital, Taipei Medical University, Taipei, Taiwan. were completed laparoscopically, without conversion and the Erratum in mean operative time was 120 min (range from 90 to 170 min). • Obes Surg. 2012 Jan;22(1):194. The average postoperative stay was 5.0 days. We report one case BACKGROUND: of mortality for pulmonary septic complications. Major Significant variability in weight loss and glycemic control has been complications were two cases of pulmonary embolism (treated in observed in obese patients receiving bariatric surgery. Genetic ICU), six cases of melena on seventh postoperative day and three factors may play a role in the different outcomes. cases of anastomotic ulcers resolved with high doses of PPI. We METHODS: registered a significant reduction of BMI and percentage of Five hundred and twenty severely obese patients with body mass excess weight after surgery with a significant improvement in index (BMI) ≥35 were recruited. Among them, 149 and 371 obesity-related comorbidities including blood pressure, subjects received laparoscopic adjustable gastric banding (LAGB) hyperglycemia, blood lipid, uric acid, and liver function. An ideal and laparoscopic mini-gastric bypass (LMGB), respectively. All weight loss operation should be effective, easy to perform and individuals were genotyped for five obesity-related single safe. Laparoscopic Roux-en-Y GastricBypass is actually the "gold- nucleotide polymorphisms on ESR1, FTO, PPARγ, and UCP2 genes standard" technique but LMGB seems to be an attractive to explore how these genes affect weight loss and glycemic alternative: shorter operative time, with less morbidity and control after bariatric surgery at the 6th month. mortality, easier to teach and to perform. Another advantage RESULTS: could be the presence of a single anastomosis alone reducing the Obese patients with risk genotypes on rs660339-UCP2 had possibility of leaks. greater decrease in BMI after LAGB compared to patients with 26
  • 27. non-risk genotypes (-7.5 vs. -6 U, p = 0.02). In contrast, after including laparoscopic adjustable gastric banding(LAGB, n=201), LMGB, obese patients with risk genotypes on either rs712221- laparoscopic mini gastricbypass(LMGB, n=13), and laparoscopic ESR1 or rs9939609-FTO had significant decreases in BMI (risk vs. sleeve gastrectomy(LSG, n=5). Clinical data were analyzed non-risk genotype, -12.5 vs. -10.0 U on rs712221, p = 0.02 and - retrospectively. 12.1 vs. -10.6 U on rs9939609, p = 0.04) and a significant RESULTS: amelioration in HbA1c levels (p = 0.038 for rs712221 and The mean body mass index(BMI) of patients who received LAGB p < 0.0001 for rs9939609). The synergic effect of ESR1 and FTO was 37.9 kg/m(2), and decreased to 32.4 kg/m(2) at 6 months genes on HbA1c amelioration was greater (-1.54%, p for trend and to 29.7 kg/m(2) at 12 months. In 43 patients who had <0.001) than any of these genes alone in obese patients concurrent T2DM, 11(25.6%) showed clinical partial receiving LMGB. remission(CPR) and 16(37.2%) clinical complete remission (CCR). CONCLUSIONS: Postoperative complications occurred in 26 patients(12.9%). The The genetic variants in the ESR, FTO, and UCP2 genes may be mean BMI of patients undergoing LMGB was 34.7 kg/m(2), and considered as a screening tool prior to bariatric surgery to help decreased to 31.6 kg/m(2) at 6 months and 26.9 kg/m(2) at 12 clinicians predict weight loss or glycemic control outcomes for months after surgery. Ten patients had T2DM before operation, of severely obese patients. whom 2(20.0%) had CPR and 7(70.0%) CCR postoperatively. Postoperative complications occurred in 2 patients(15.4%). The 21720911 mean BMI of patients who underwent LSG was 43.8 kg/m(2), and 8. was reduced to 38.1 kg/m(2) at 6 months and 34.3 kg/m(2) at 12 Obes Rev. 2011 Aug;12(8):602-21. doi: 10.1111/j.1467- months after operation. Three patients were diagnosed with 789X.2011.00866.x. Epub 2011 Mar 28. T2DM before operation. One patient (33.3%) had CPR and Bariatric surgery: a systematic review and network meta-analysis 1(33.3%) reached CCR after operation. There was 1(20.0%) of randomized trials. patient who developed complication. No perioperative death Padwal R, Klarenbach S, Wiebe N, Birch D, Karmali S, Manns B, occurred. Hazel M, Sharma AM, Tonelli M. Department of Medicine, University of Alberta, Edmonton, CONCLUSION: Alberta, Canada. Laparoscopic gastrointestinal surgery may result in satisfactory The clinical efficacy and safety of bariatric surgery trials were weight loss and clinical remission of T2DM with few systematically reviewed. MEDLINE, EMBASE, CENTRAL were complications. searched to February 2009. A basic PubCrawler alert was run until March 2010. Trial registries, HTA websites and systematic reviews 21365507 were searched. Manufacturers were contacted. Randomized trials comparing bariatric surgeries and/or standard care were selected. [PubMed - in process] Evidence-based items potentially indicating risk of bias were Publication Types assessed. Network meta-analysis was performed using Bayesian 10. techniques. Of 1838 citations, 31 RCTs involving 2619 patients World J Surg. 2011 Mar;35(3):631-6. (mean age 30-48 y; mean BMI levels 42-58 kg/m(2) ) met Laparoscopic mini-gastric bypass for type 2 diabetes: the eligibility criteria. As compared with standard care, differences in preliminary report. BMI levels from baseline at year 1 (15 trials; 1103 participants) Kim Z, Hur KY. were as follows: jejunoileal bypass [MD: -11.4 kg/m(2) ], mini- Department of Surgery, Soonchunhyang University College of gastric bypass [-11.3 kg/m(2) ], biliopancreatic diversion [-11.2 Medicine, Soonchunhyang University Hospital, Hannam-dong, kg/m(2) ], sleeve gastrectomy [-10.1 kg/m(2) ], Roux-en-Y Yongsan-gu, Seoul 140-743, Korea. gastric bypass[-9.0 kg/m(2) ], horizontal gastroplasty [-5.0 BACKGROUND: kg/m(2) ], vertical banded gastroplasty [-6.4 kg/m(2) ], and Type 2 diabetes mellitus (T2DM) has become an epidemic health adjustable gastric banding [-2.4 kg/m(2) ]. Bariatric surgery problem worldwide. Compared to Western countries, in Asia, appears efficacious compared to standard care in reducing BMI. T2DM occurs in patients with a lower body mass index (BMI) due Weight losses are greatest with diversionary procedures, to central obesity and decreased pancreatic β-cell function. The intermediate with diversionary/restrictive procedures, and lowest efficacy of laparoscopic mini-gastric bypass(LMGB) in obese with those that are purely restrictive. Compared with Roux-en-Y patients with T2DM has been proven by numerous studies. gastric bypass, adjustable gastric banding has lower weight loss Treatment outcomes of LMGB for non-obese T2DM patients are efficacy, but also leads to fewer serious adverse effects. also estimated to be excellent. The aim of the present pilot study © 2011 The Authors. obesity reviews © 2011 International was to evaluate the efficacy and safety of LMBG in non-obese Association for the Study of Obesity. T2DM patients (BMI 25-30 kg/m(2)). METHODS: 21438991 Ten consecutive patients underwent LMGB at our hospital from Grant Support August 2009 to October 2009. Preoperative data including 9. glycosylated hemoglobin (HbA1c), fasting plasma glucose (FPG), Zhonghua Wei Chang Wai Ke Za Zhi. 2011 Feb;14(2):128-31. and 2 h postprandial glucose (2-h PPG) were compared with data [Outcomes after laparoscopic surgery for 219 patients with collected at 1, 3, and 6 postoperative months. obesity]. RESULTS: [Article in Chinese] All procedures were completed laparoscopically. Mean age of the Ding D, Chen DL, Hu XG, Ke CW, Yin K, Zheng CZ. patients was 46.9 years, mean BMI was 27.2 kg/m(2), mean Department of Minimally Invasive Surgery, Changhai Hospital, The operative time was 150.5 min, and mean postoperative hospital Second Military Medical University, Shanghai 200433, China. stay was 5.3 days. Neither mortality nor major complications OBJECTIVE: occurred. Mean preoperative glycosylated hemoglobin (HbA1c), To evaluate the outcomes after laparoscopic gastrointestinal fasting plasma glucose (FPG), 2-h PPG, and C-peptide level were surgery for patients with obesity and type 2 diabetes 9.7%, 222 mg/dl, 343 mg/dl, and 2.78 ng/ml, respectively. At the mellitus(T2DM). sixth postoperative month, HbA1c, FPG, 2-h PPG, and C-peptide METHODS: level measured 6.7%, 144 mg/dl, 203 mg/dl, and 2.18 ng/ml. From June 2003 to June 2010, 219 patients underwent CONCLUSIONS: laparoscopic gastrointestinal surgery for obesity and T2DM, This preliminary study demonstrated the resolution of 27
  • 28. hyperglycemia in 70% of non-obese T2DM patients (BMI 25-30 bypass (LMGB) or adjustable gastric banding (LAGB) with kg/m(2)). Although long-term follow-up data are required, early complete clinical data at baseline and at two years were enrolled operative outcomes were satisfactory in terms of glycemic control for analysis. Decision Tree, Logistic Regression and Discriminant and safety of the procedure. analysis technologies were used to predict weight loss. Overall classification capability of the designed diagnostic models was 21165621 evaluated by the misclassification costs. 11. RESULTS: Obes Surg. 2011 Aug;21(8):1209-19. Two hundred fifty-one patients consisting of 68 men and 183 Reasons and outcomes of reoperative bariatric surgery for failed women was studied; with mean age 33 years. Mean +/- SD and complicated procedures (excluding adjustable gastric weight loss at 2 year was 74.5 +/- 16.4 kg. During two years of banding). follow up, two-hundred and five (81.7%) patients had successful Patel S, Szomstein S, Rosenthal RJ. weight reduction while 46 (18.3%) were failed to reduce body Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, weight. Operation methods, alanine transaminase (ALT), FL 33331, USA. aspartate transaminase (AST), white blood cell counts (WBC), BACKGROUND: insulin and hemoglobin A1c (HbA1c) levels were the predictive The rise of bariatric surgery has lead to an increasing number of factors for successful weight reduction. reoperations for failed bariatric procedures. The reasons and CONCLUSION: types of these operations are varied in nature and remain to be Decision tree model was a better classification models than defined. traditional logistic regression and discriminant analysis in view of METHODS: predictive accuracies. A retrospective review of a prospectively collected database was conducted to identify patients who underwent laparoscopic 20214230 revisional surgery for non-gastric banding-related bariatric procedures between 2001 and 2008. 13. RESULTS: J Chir (Paris). 2009 Feb;146(1):60-4. Of 384 secondary bariatric operations, 151 reoperative [Laparoscopic mini-gastric bypass]. procedures were performed. Twenty-six vertical banded [Article in French] gastroplasties (17.2%), 2 mini-gastric bypasses (1.3%), 2 non- Chevallier JM, Chakhtoura G, Zinzindohoué F. divided bypasses (1.3%), 1 distal Roux-en-Y gastric bypass Service de chirurgie digestive, hôpital Européen Georges- (RYGBP; 0.7%), and 2 sleeve gastrectomies (1.3%) were Pompidou, Paris. jean-marc.chevallier@egp.aphp.fr converted to RYGBP. Three RYGBP (2%) and four jejunoileal bypass procedures (2.6%) were reversed secondary to 19446695 malnutrition. One jejunoileal bypass (0.7%) and one 14. biliopancreatic diversion (0.7%) underwent sleeve gastrectomies. Surg Obes Relat Dis. 2009 May-Jun;5(3):383-6. Epub 2009 Jan Three pre-anastomotic rings were removed due to erosion (2%). 18. Eleven pouch trimmings (7.3%), 16 redo gastrojejunostomies Laparoscopic conversion of distal mini-gastric bypass to proximal (10.6%), 5 redo jejunojejunostomies (3.3%), 36 remnant Roux-en-Y gastric bypass for malnutrition: case report and review gastrectomies (23.8%), and 2 gastrogastric fistula takedowns of the literature. (1.3%) were performed for pouch enlargements, strictures, and Dang H, Arias E, Szomstein S, Rosenthal R. gastrogastric fistulas. Thirty-six patients (23.8%) underwent a Bariatric and Metabolic Institute, Section of Minimally Invasive combination of these procedures. The major morbidity (13.2%) and Endoscopic Surgery, Cleveland Clinic Florida, Weston, Florida, was related to leaks. Other complications included wound USA. infection, intra-abdominal abscess formation, and trocar site hernias. The mortality rate was 2%. 19356992 CONCLUSIONS: 15. Reoperative bariatric surgery is a complex and growing field in Obes Surg. 2008 Sep;18(9):1126-9. Epub 2008 Jun 25. bariatric surgery. The indications for surgical reoperation can vary Laparoscopic mini-gastric bypass (LMGB) in the super-super depending on the procedure and reason for intervention. obese: outcomes in 16 patients. Laparoscopy appears to be a feasible approach. Though safe, Peraglie C. morbidity and mortality are significantly higher than in primary The Centers of Laparoscopic Obesity Surgery-Florida, Heart of bariatric procedures. Florida Regional Medical Center, 40124 Highway 27, Davenport, FL, USA. drp@clos.net 20676940 BACKGROUND: 12. The ideal management of the super-super obese patient (SSO) is Hepatogastroenterology. 2009 Nov-Dec;56(96):1745-9. unclear and controversy exists as to the choice of procedure as Obesity and the decision tree: predictors of sustained weight loss well as the risk for increased morbidity and mortality. I present after bariatric surgery. my experience of laparoscopic mini-gastric bypass (LMGB) in 16 Lee YC, Lee WJ, Lin YC, Liew PL, Lee CK, Lin SC, Lee TS. SSO patients with early follow-up results. Department of International Business, Ching-Yun University, METHODS: Zhongli City, Taiwan. lyc6115@ms61.hinet.net Review of a prospectively maintained database was performed. BACKGROUND/AIMS: All the patients underwent LMGB by a single surgeon (CP). Data Bariatric surgery is the only long-lasting effective treatment to collected included demographics, operative time, length of stay, reduce body weight in morbid obesity. Previous literature in using complications, and weight loss. Follow-up data was obtained at data mining techniques to predict weight loss in obese patients office visits in addition to periodic telephone interviews and e- who have undergone bariatric surgery is limited. This study used mails. All office follow-up and review of correspondence from initial evaluations before bariatric surgery and data mining Primary Care Physicians (PCP) was managed by the operating techniques to predict weight outcomes in morbidly obese patients surgeon. seeking surgical treatment. RESULTS: METHODOLOGY: Sixteen patients were identified as being SSO and comprise the 251 morbidly obese patients undergoing laparoscopic mini-gastric study group. There were 14 women and two men. Average age 28
  • 29. was 40 years (27-61). Average weight and BMI were 166 (150- Obes Surg. 2007 Nov;17(11):1482-6. 193) and 62.4 (60-73), respectively. All procedures were Mini-gastric bypass by mini-laparotomy: a cost-effective performed laparoscopically by a single surgeon with no alternative in the laparoscopic era. conversion to open. Average operative time was 78 min (41-147 Noun R, Riachi E, Zeidan S, Abboud B, Chalhoub V, Yazigi A. min) and hospital stay was 1.2 days. Intraoperative complications Department of Digestive Surgery, Hôtel-Dieu de France Hospital, included a liver laceration in one patient and an enterotomy in Beirut, Lebanon. rnoun@wise.net.lb another. Both were managed laparoscopically. No patients BACKGROUND: required readmission to the hospital, and there were no major Laparoscopic mini-gastric bypass (MGB) is being increasingly complications or deaths. Weight loss showed a consistent performed worldwide. Results of MGB by mini-laparotomy increase over the follow-up period with 2 year results of 72 KG (minilap MGB) are hereby reported. lost or 65% EWL. METHODS: CONCLUSION: 126 patients undergoing minilap MGB from October 2004 to Laparoscopic mini-gastric bypass (MGB) is a technically simple October 2006, were reviewed at an academic institution. and safe procedure in SSO patients. LMGB has the advantages of RESULTS: being a single stage procedure, being easily reversible and Mean age was 35 +/- 11.4 years (range 15-72), preoperative BMI revisable in a laparoscopic procedure and does not sacrifice was 44 +/- 6.9 kg/m2 (range 35-61.8) and 80 (63.4%) were portions of the stomach or implant foreign materials. Weight loss women. Co-morbidities were present in 42 (33.3%). Operative appears favorable in the short term; however, information time was 144 +/- 15.8 minutes (range 120-160) and length of regarding long-term weight loss, durability, and safety profile in hospital stay was 3.32 +/- 0.62 days (range 2-18). There was no this population will require a greater number of patients and hospital mortality, and the in-hospital complication rate was 4.7%. longer follow up. No anastomotic leakage occurred, and the incidence of wound sepsis was 2.3%. The mean total cost of the procedure was 3408 18575943 +/- 547 USD (range 2967-6876). Five patients (3.9%) developed 16. incisional hernias and 3 (2.3%) marginal ulcers. BMI at 6 months Obes Surg. 2008 Sep;18(9):1130-3. Epub 2008 Jun 20. was 33.0 +/- 3.1 kg/m2 (range 26.8-43.5, P < 0.001) compared Primary results of laparoscopic mini-gastric bypass in a French with preoperative value. At 1 year, mean excess weight loss was obesity-surgery specialized university hospital. 68.4% and comorbidities resolved in 85%. Chakhtoura G, Zinzindohoué F, Ghanem Y, Ruseykin I, Dutranoy CONCLUSION: JC, Chevallier JM. Minilap MGB is a simple, safe, effective and low-cost gastric Assistance Publique-Hôpitaux de Paris, University Paris 5, Paris, bypass. It represents an attractive cost-effective alternative to France. laparoscopic MGB. BACKGROUND: Since 2002, we have performed 350 laparoscopic Roux-en-Y 18219775 gastric bypasses (LRYGB). We decided to evaluate the laparoscopic mini-gastric bypass (LMGB), an operation reported 18. as effective, yet simpler than LRYGB. It consisted of a long lesser Obes Surg. 2008 Mar;18(3):294-9. Epub 2008 Jan 12. curvature tube with a terminolateral gastroenterostomy, 200 cm Laparoscopic mini-gastric bypass: experience with tailored bypass distal to the Treitz ligament. limb according to body weight. METHODS: Lee WJ, Wang W, Lee YC, Huang MT, Ser KH, Chen JC. From October 2006 to November 2007, 100 patients (23 men and Department of Surgery, Min-Sheng General Hospital, National 77 women) underwent LMGB. The mean age was 40.9 +/- 11.5 Taiwan University, Taipei, Taiwan, Republic of China. years (17.5-62.4), the preoperative mean body weight was 131 wjlee_obessurg_tw@yahoo.com.tw +/- 23.1 kg (82-203) and the mean BMI was 46.9 +/- 7.4 BACKGROUND: kg/m(2) (32.8-72.4). Twenty-four patients had prior restrictive Gastric bypass surgery is an effective and long-lasting treatment procedure: 20 LAGB of which nine were already removed and four of morbidly obese patients. However, the bypass limb may need VBG (two laparoscopic and two by open surgery). In preoperative to be tailored in morbidly obese patients with a wide range of gastric endoscopy Helicobacter pylorii was present in 26 patients obesity. The aim of the present study was to report clinical result and eradicated. of tailored bypass limb in a group of patients receiving RESULTS: laparoscopic mini-gastric bypass surgery. All procedures were completed laparoscopically by six different METHODS: surgeons. Mean operative time was 129 +/- 37 min. There was From Jan 2002 to Dec 2006, laparoscopic mini-gastric bypass was no death. Seven patients (7%) presented major early performed in 644 patients [469 women, 175 men: mean age 30.5 complications: three reoperations for incarcerated herniation of +/- 8.1 years; mean body mass index (BMI) 43.1 +/- 6.0] in our small bowel in the trocar wound, one peritonitis due to a department. The gastric bypass limb was tailored according to the traumatic injury of the biliary limb, one perianastomotic abscess, preoperative BMI. The clinical data and outcomes were analyzed. one intraabdominal bleeding requiring splenectomy, and one All the clinical data were prospectively collected and stored. endoscopic haemostasis for anastomotic bleeding. One patient RESULTS: presented anastomotic stenosis that required endoscopic Two hundred eighty-six patients belonged to lower BMI (BMI < dilatation 2 months postoperatively. Mean BMI at 3 months was 40; mean 36.0), 286 patients moderate BMI (BMI 40-50; mean 38.7 kg/m(2) (31.2-60.9) and at 6 months 35.1 (23.6-53.0). Nine 43.2), and 72 patients higher BMI (BMI > 50; mean 55.4). All patients complained of diarrhea that resolved 3 months procedures were completed laparoscopically. Mean operative time postoperatively and, significantly, only two patients complained of was 130 min, and mean hospital stay was 5.0 days. Twenty-three biliary reflux. minor early complications (4.3%) and 13 major complications CONCLUSION: (2.0%) were encountered, with one death occurred (0.016%). Pending long-term evaluation, LMBG seems a good alternative to There was no significant difference in operation time and LRYGB, giving the same results with a more simple and complication rate between the groups. The mean bypass limb was reproductible technique. 150 cm for the lower BMI group, 250 cm for moderate BMI group, and 350 cm for the higher BMI group. The mean BMI reduction 2 18566866 years after surgery was 10.7, 15.5, and 23.3 for the lower, 17. moderate, and higher BMI group. The weight loss curves and 29