1. Selection of the “Best” Bariatric surgery Procedure The Mini-Gastric Bypass

4. 2 Years Cardiac Surgery National Institutes of Health National Heart Lung Blood Institute

5. 20 years University of NC; Professor of Surgery, Associate Chief of Staff, Director of Section Medical Informatics, Director North Carolina Trauma Registry

7. Experience: Trauma Surgery, Director NC Trauma Registry

8. Peptic Ulcer Surgery; Vagotomy & Pyloroplasty; Antrectomy & Billroth II

9. Bariatric Surgery 33 years: Open RNY & Vertical Banded Gastroplasty

10. 1997 one first surgeons laparoscopic RNY

13. USA 001-702-714-0011 DrR@clos.net

14. Personal Visit: Dr. Rutledge Visiting Professor: France, Turkey, Austria & India, Upcoming visits Greece, Istanbul, United KingdomCzech Republic, Italy, Germany, UAE, Pakistan,

15. Please Use the Knowledge of Others Before You Start;Experience; over 14 years, over 6,000 patients

17. Hands On Surgery (with approval) Scrub in on cases Assist and Participate in MGB Surgery

18. This Fall and Next Year

19. Bija India, Dr Rutledge & Dr Kular

22. 1867Dr. Gross; Gross Clinic 1875

24. History of Failure of Bariatric Surgical Procedures

26. The Gastric Sleeve:Not as Bad as the BandNot as Dangerous as the RNY

27. SUCCESS CRITERIA"IDEAL" WEIGHT LOSS SURGERY 1. Low Risk 2. Major Weight Loss 3. Easily performed 4. Short operative times 5. Outpatient or short hospital stay 6. Minimal Blood Loss 7. No Need for ICU Stay 8. Minimal Pain 9. Very High Patient Satisfaction 10. A Good "Exit Strategy"

28. SUCCESS CRITERIA"IDEAL" WEIGHT LOSS SURGERY 11. Change Behavior & Preferences; Marked Decrease in Hunger and Increased Satiety 12. Minimal Retching and Vomiting 13. Few adhesions or hernias 14. Minimal impact on Heart and Lung Function 15. Low Failure Rate 16. Low Cost 17. Short Recovery Time 18. Rapid Return to Work 19. Low Risk of Pulmonary Embolus 20. Durable weight loss

29. SUCCESS CRITERIA"IDEAL" WEIGHT LOSS SURGERY 21. Low Risk of Ulcer 22. Fat Malabsorption; low cholesterol & CV risk 23. No Plastic Foreign Body 24. Easily Verifiable Results; > 10 years of Results 25. Low Risk of Bowel Obstruction 26. Based upon sound surgical principles 27. Independent confirmation of results 28. Healthy life after surgery 29. Supported by LEVEL I Evidence; RCT (Controlled Prospective Randomized Trial) 30. Block “Sweet Eater” Failures

31. Band

32. Sleeve

34. Vertical Gastric Tube(Collis Gastroplasty)

36. 16,000 Billroth II’sUSA in 2007

38. Criteria for Success; Ideal Weight Loss Surgery

39. Criteria for Success

40. Marginal Ulcer after Gastric Bypass; RNY & MGB Marginal Ulcers after Roux-en-Y Gastric Bypass: Pain for the Patient…Pain for the Surgeon January 2010 by Camellia Racu, Bariatric Times. 2010;7(1):23–25

41. Marginal Ulcer after Gastric Bypass; RNY & MGB

42. Marginal Ulcer after Gastric Bypass; RNY & MGB Marginal ulcers RNYranging from 0.6 to 16% True incidence is very likely much higher Csendesprospective study routine postoperative endoscopic evaluation 28% of marginal ulcers were asymptomatic Gastric Bypass (RNY & MGB)HIGH incidence of Marginal Ulcer BILE MAKES NO DIFFERENCE!!!

43. Incidence of perforated gastrojejunal anastomotic ulcers after RNY April 2002 to April 2010, 1213 patients underwent laparoscopic RYGB Operative mortality was .15% 10 perforated GJA ulcers (.82%) at a mean of 13.5 (6-19) months Morbidity and mortality rate was 30% and 10% Perforated GJA ulcers can develop in 1 of 120 Roux en Y Gastric Bypasses & DEADLY

44. Marginal Ulcers: Achilles Heel of Gastric Bypass Management 1. Warn Patients & Surgeon “Be Vigilant” 2. Aggressive anti-H. Pylori Rx 3. Aggressive use of Antacids 4. Strict Avoidance of Ulcerogenic Agents(NSAIDS, Etoh, Smoking, Coffee, Soda, Nitrates) 5. Encourage: Probiotics, Yogurt, Fruits Vegetables BILE MAKES NO DIFFERENCE!!!

46. Objectives “Ideal” Weight Loss Surgery

47. RNY, Band, Sleeve, MGB

48. MGB Best meets all objectives/success criteria

49. Beware of Marginal Ulcer

51. 100,000’s of people already have and are living with and are getting the Billroth II every day

53. Why haven’t concerned bariatric surgeons stepped forward to start a fund to help suffering Billroth II patients get needed conversions of their surgery to Roux-en-Y?

55. Why haven’t concerned bariatric surgeons stepped forward to national funding for lifetime endoscopic screening of Billroth II patients to find dreaded gastric cancers?

56. It seems odd doesn’t it?

58. The critics of the MGB do not do those things because they are ridiculous

59. Such actions are Not supported by the data

60. The Billroth II and the MGB are both good operations

63. 2. GC Environmental Causes; Easily Prevented

64. 3. Some studies show Small Increased RiskProbably from Ulcers / H. Pylori

65. 4. Many large studies: NO increased risk

66. 5. Endoscopic Screening: Not Recommended

67. 6. General, Trauma & Oncologic Surgeons Use Billroth II