Comparison of Revision in Roux-en-Y vs Mini-Gastric Bypass

Comparison of Revision inComparison of Revision in
Roux-en-Y vsRoux-en-Y vs
Mini-Gastric BypassMini-Gastric Bypass
Dr K S Kular
Kular Medical Education & Research Society
Kular Group of Institutes
drkskular@gmail.com
www.kularhospital.com

Complications
after
Bariatric
Surgery
Successful
Bariatric
Surgery

Objectives
1. Basics of RNY Gastric Bypass; Restrictive, Technically
Demanding, Dangerous, SBO
2. Revision of RNY; Reasons, Techniques Difficullt, Doubles
Risk of Complications
3. Basics of MGB; Malabsorbtive, Technically Simple, Low
Risk, Very Effective
4. Revision of MGB; Reasons, Techniques Simple, Low Risk
of Complications (0-2%)

1. Primary Roux en Y Gastric Bypass
The Basics
1. Primarily Restrictive ( Restrictive 95%/ Fat Malabsorptive 5% )
2. Technically Demanding (500 cases Learning Curve)
3. One of Most Dangerous Bariatric Surgery
(Complications/Leak)
4. Unique, Common, Deadly, Complication; SBO 10%
5. Moderately High Weight Regain / Failure Rate

RNY is the MOST Dangerous Form of Bariatric
Surgery
By Every measure, in Every study RNY
Highest Death Rate, Highest Leak Rate Highest Early
Complications Highest Major Complication Rate Highest
Bleeding Rate, Highest Re-operation Rate Highest PE Rate....
RNY is the most dangerous form of Bariatric Surgery
References 25-100 Studies

Medical Truth:
Randomized Controlled Trials
The Randomized Controlled Trial,
Considered
The ''Gold Standard''
For Studies Of Medical Truth

Example: Recent Controlled Prospective
Randomized Trial RNY JAMA 2013
Some of the Best Hospitals in the World
Controlled Prospective Randomized Trial in Relatively
Healthy Pts
12 months ONLY 44% normal HgbA1c levels
37% serious complications
3.3% Leaks
1 patient suffered anoxic brain injury and leg
amputation.

Revision of RNY
• Reasons: Inadequate/Excess Weight Loss/Weight
Regain/Other
• Techniques: Narrow GJ, Narrow Pouch, Lengthen
Roux Limb, Convert to Sleeve, Band to Pouch, Convert
to BPD, Limb-o-plasty (Gagner)
• Doubles Risk of Leak and Complications (20-40%)

Techniques of Revision of RNY
Narrow GJ
Narrow Pouch
Lengthen Roux Limb
Convert to Sleeve
Band to Pouch
Convert to BPD
Limb-o-plasty (Gagner)

Revision of RNY
Bloody, I Cannot See What They are Doing

Complications after RNY and revision RNY
Early complications were recorded in
37 pts (10.2%) after RNY
24 pts (22.2%) after Revision RNY p<0.01
Reoperation
12 pts (3.3%) after RNY
9 pts (8.3%) after Revision p=0.03
Revision 2 X Complications & Leak Rate
Obes Surg. 2011 Jun;21(6):692-8. Are laparoscopic gastric bypass after gastroplasty and primary laparoscopic gastric
bypass similar in terms of results? Cadière GB, Himpens

Example:
Increased Leaks in RNY Revisions
8 leaks (0.95%) after RNY
5 leaks (4.20%) after Revision
Revision 4 X Leak Rate
Surg Obes Relat Dis. 2013 Treatment of gastric Leaks after Roux-en-Y gastric bypass: a paradigm shift.Brolin
RE, Lin JM. Department of Surgery, University Medical Center at Princeton, Princeton, New Jersey 08844,
USA.rbrolin@njbariatricspc.com

Revision of Lap Band to RNY
Revisional weight loss surgery after
failed laparoscopic gastric banding
Surg Endosc. 2013 Jul 12. Tran TT et al. Division of Minimally
Invasive/Bariatric Surgery, Department of Surgery, Penn State Milton S.
Hershey Medical Center, Hershey, PA, USA

Revisions of Failed Lap Band
Lap Band to RNY
Early complications occurred in
11 patients (18 %)
4 Anastomotic leaks (6%)
20% late complications requiring surgery
1 in 5 Required Reoperation
There was one death (1.6%)

11% Leak Rate Revising RNY
46 pts revision surgery
Leaks increased after revision (11% vs 1.2%)
1 out of every 10 pts
There was a 24% (13/55) 90-day readmission rate. 1 out of
every 4 pts
Revision 5 X leak Rate
Am J Surg. 2009 Mar;197(3):391-6. Should bariatric revisional surgery be avoided secondary to
increased morbidity and mortality? Hallowell PT, Case Western Reserve University, School
of Medicine, Cleveland,

Revision of VBG to RNY
Weight regain secondary to VBG
RYGB group had a 43.5% complication rate and 1 mortality.
Complications following RYGB include: incisional hernia
(13%), anastomotic leak (8.7%), respiratory failure
(8.7%), fistula (8.7%), and perforation (4.35%).
Revision 40% Complication Rate 9% Leaks
J Obes. 2013;2013: Endoscopic revision (StomaphyX) versus formal surgical revision (gastric bypass) for failed vertical band gastroplasty. Bolton J, Gill RS, Al-Jahdali
A, Byrns S, Shi X, Birch DW, Karmali S. Department of Surgery, University of Alberta, Edmonton, AB, Canada T6G 2B7.

Pouch resizing for Roux-en-Y
6 patients (30%) developed complications
Acute abdomen due to volvulus of the small bowel
in 1,
Intra-abdominal abscess in 3
Pulmonary embolus in 2.
Revision 30% Complications
Surg Obes Relat Dis. 2013 Mar-Apr;9(2):260-7.Gastric pouch resizing for Roux-en-Y gastric bypass failure in patients
with a dilated pouch. Iannelli A, Schneck AS, Hébuterne X, Gugenheim J.

Review of RNY Revision 13 studies
Major Complications after
Primary RNY 10-25%
Revision RNY 10-40+%
Successful weight loss after
Primary RNY 68-82%
Revision RNY 5-40%

Revision of MGB
Easy and Safe;
IF You Follow the Rules

Basics of MGB
Restrictive w Major Fat Malabsorption
Technically Straight forward
Low Risk (Complications/Leak)
SBO reported as 0-0.3%
Very High Weight Loss Rare Regain
Experience with >12,000 MGB Bile Reflux rare and easily Rx
Fear of Gastric Cancer unfounded by surgeons uninformed on the
medical literature (Hot Dog is more dangerous)

MGB Very Effective & Very Safe
MGB Series
Rutledge U.S.A. 6,000 + (16 yr + FU)
Cady France 2000 +
Peraglie U.S.A. 2000 +
Carbajo Spain 2000 +
Noun Lebanon 1000
Lee Taiwan 1000 + (RCT, 10 yr+ FU)
Kular India 1000+
Garcia-Caballero Spain 1000 +
Musella et al. Italy 1000
Others (i.e. Chevallier Paris 700,
Tacchino Rome 500, etc.)

MGB One of the Most Effective & Safest
MGB Series
Findings in all series are the same:
1. Short operation, low risk of short and long term
complications
2. Excellent short and long term weight loss
75-100% EWL, (Better than BPD)
3. Revisable and Reversible
4. Minimal Risk of Bile Reflux in Knowledgeable Hands

One Thousand Consecutive Mini-gastric Bypass:
Short- And Long-term Outcome
1,000 patients who underwent MGB from November 2005 to January
2011
Operative time and length of stay for primary vs. revisional MGB were
89 ± 12.8 min vs. 144 ± 15 min (p < 0.01) and
1.85 ± 0.8 day vs. 2.35 ± 1.89 day (p < 0.01)
Short-term complications 2.7%
Obes Surg. 2012 May;22(5):697-703. One thousand consecutive mini-gastric bypass: short- and long-term outcome. Noun et al,
Department of Digestive Surgery, Hôtel-Dieu de France Hospital and University Saint Joseph Medical School, Bd Alfred Naccache,
Achrafieh, BP 166830 Beirut, Lebanon. rnoun@wise.net.lb

Five (0.5%) patients presented with leak from the gastic tube but
none had anastomotic leakage.
Four (0.4%) patients, all revisions with severe bile reflux Rx by
stapled latero-lateral jejunojejunostomy (Braun).
Excessive weight loss occurred in four patients easily revised.
Percent excess weight loss (EWL) of 72.5% occurred at 18 months.
Obes Surg. 2012 May;22(5):697-703. One thousand consecutive mini-gastric bypass: short- and long-term outcome.
Noun et al, Department of Digestive Surgery, Hôtel-Dieu de France Hospital and University Saint Joseph Medical
School, Bd Alfred Naccache, Achrafieh, BP 166830 Beirut, Lebanon. rnoun@wise.net.lb

The 50% EWL was achieved for 95% of patients at 18 months and for
89.8% at 60 months.
MGB is an effective, relatively low-risk, and
low-failure bariatric procedure.
In addition, it can be easily revised, converted,
or reversed.
Obes Surg. 2012 May;22(5):697-703. One thousand consecutive mini-gastric bypass: short-
and long-term outcome. Noun et al, Department of Digestive Surgery, Hôtel-Dieu de
France Hospital and University Saint Joseph Medical School, Bd Alfred Naccache,
Achrafieh, BP 166830 Beirut, Lebanon. rnoun@wise.net.lb

Controlled Prospective Randomized Trial
Lee WJ, Yu P-J, Wang W, Chen TC, Wei PL, Huang MT. Laparoscopic Roux-en-Y versus Mini-Gastric Bypass for the
treatment of Morbid Obesity. Ann Surg 2005 ; 242 : 20-28
RYG Bypass Mini Bypass
Op time (mns) 205 148
Early complications 20% 7.5%
Late complications 7.5% 7.5 %
EWL at one year 58.7% 64.9%
EWL at two years 60% 64.4%

Randomized Controlled Prospective Trials
MGB MUCH Superior to RNY Rx Diabetes
MGB vs RNY Rx Diabetes, Two Controlled Prospective Randomized
Trials
Ikramuddin S, et al. Roux-en-Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and
hyperlipidemia: the Diabetes Surgery Study randomized clinical trial. JAMA. 2013 Jun
Lee WJ, et al. Gastric bypass vs sleeve gastrectomy for type 2 diabetes mellitus: a randomized controlled trial. Arch Surg. 2011 Feb
Resolution of Diabetes at 12 months
Sleeve 47%
RNY 44%
MGB 93%

Revision of MGB
• Reasons:
Inadequate/Excess Weight Loss/Weight Regain/Other
• Techniques Easy
Stay away for the gastric pouch
Steps
1. Divide the Gastro Jejunostomy
2. Advance or shorten the bypass

MGB Revision 40-50 minutes
Pouch
Anastomosis
Bowel Loop

Lysis of Adhesions (No Bleeding)

Divided Pouch
Note Location Re: a RNY Dissection

Revision of MGB
Pouch
Anastomosis
Bowel Loop

Advance or Retreat the Bowel
Stapled GastroJejunostomy

Staple Closeure of Gastro-Jejunostomy

Completed Revision of MGB
47 minutes No Bleeding

Revisional surgery for laparoscopic
Mini-gastric bypass (Dr. Lee)
1,322 patients followed for 9 years
ONLY ** 2% ** required revision
Revision Bile reflux ONLY 3 pts 0.2%
All revision procedures performed lap
No major complications. 0.0%
Surg Obes Relat Dis. 2011 Jul-Aug;7(4):486-91. Revisional surgery for laparoscopic minigastric bypass.
Lee WJ, Lee YC, Ser KH, Chen SC, Chen JC, Su YH. Department of Surgery, Min-Sheng General Hospital, National Taiwan
University, Taipei, Taiwan.

Revisional surgery for
Mini-gastric bypass
1,322 pts 9 yrs
ONLY ** 2% ** revisions
No major complications. 0.0%
Surg Obes Relat Dis. 2011 Jul-Aug;7(4):486-91. Revisional surgery for laparoscopic minigastric bypass. Lee WJ, Lee
YC, Ser KH, Chen SC, Chen JC, Su YH. Department of Surgery, Min-Sheng General Hospital, National Taiwan
University, Taipei, Taiwan.

Revisional surgery for laparoscopic
Mini-gastric bypass
1,322 MGBs revision surgery was to
RNY in 11 (0.8%)
Sleeve in 10 (0.8%)
Normal in 2 (0.15%)
No major complications 0.0%
Surg Obes Relat Dis. 2011 Jul-Aug;7(4):486-91. Revisional surgery for laparoscopic minigastric bypass. Lee WJ,
Lee YC, Ser KH, Chen SC, Chen JC, Su YH. Department of Surgery, Min-Sheng General Hospital, National
Taiwan University, Taipei, Taiwan.

REVISION MINI-GASTRIC BYPASS (MGB) FOR
INADEQUATE WEIGHT LOSS
Rutledge USA, IFSO 2011
65 Revision Patients
%EWL Initial 56%; After revision 84%
Major Complications 1.5%
Late complications: 3 patients sustained Excess Weight
Loss.

Review of MGB Revision
Primary MGB 2-5%
Revision MGB 0-5+%
Primary MGB 76-97%
Revision MGB +35-40%

Conclusions
1. Basics of RNY;
Restrictive,
Technically Demanding,
Dangerous, + SBO
2. Basics of MGB;
Malabsorbtive,
Technically Simple,
Low Risk

Conclusions
1. Revision of RNY;
Rarely done
Techniques Difficullt,
Doubles Risk of Complications (15-43%)
2. Revision of MGB;
Rarely needed,
Techniques Simple,
Low Risk of Complications (0-2%)
Very Effective

Surgery Can Successfully Treat Obesity and Diabetes in Both
Thin and Obese Diabetic Patients
• 2013: Kular
Hospital
• 6 year study
T2DM patients
• Results:
• Type 2 Diabetes
resolved
• 98% of MGB

MGB More Effective than BPD
Dr Tacchino MGB vs BPD
Weight Loss and Diabetes Resolution Following Mini-
Gastric Bypass and Bilio-Pancreatic Diversion. Tacchino R.,
Rutledge R., Università Cattolica del Sacro Cuore, Rome, Italy
408 pts Jan 2007 to Dec 2009
36 months follow-up
Mini-Gastric Bypass (n = 164) initial BMI 46.4±9.6 or
Bilio-Pancreatic Diversion (n = 244) initial BMI 46.9±7
(Tacchino’s perferred Operation)

RESULTS:
Mean BMI at two years was 28.5±3.9 kg/m2 and at three
years 27.4±4.5 kg/m2 after MGB
BMI at two years 32.7± 6.04 kg/ m2 and at three years
33.6±5.1 kg/m2 after BPD
One year resolution of diabetes was accomplished in:
100% in MGB group
95% in BPD group.

Tacchino’s conclusions:
“Both MGB and BPD resluted in excellent weight loss,
excellent resolution of co-morbities with low risk of long
term complications.
The MGB was associated with greater weight loss than
BPD.
Improvements in other cardiovascular risk factors and
quality of life were similar after both procedures.”

Unfounded FEAR Gastric Cancer
Billroth II Makes No Significant Difference
• 1. Gastric Cancer Declining Rapidly
• 2. GC Environmental Causes; Easily Prevented
• 3. Some studies show Small Increased Risk
Probably from Ulcers / H. Pylori
• 4. Many large studies: NO increased risk
• 5. Endoscopic Screening: Not Recommended
• 6. General, Trauma & Oncologic Surgeons Use Billroth II

Best Rx for Diabetes
5 Objectives
1. Consider Band/Sleeve/RNY/MGB
2. Best Rx DM Requires
Gastric Procedure + Duodenal Bypass
3. Eliminates Band/Sleeve; Choice RNY vs MGB
4. RNY Most Technically Difficult Dangerous &
Deadly form of Bariatric Surgery
5. Data MGB One of the Most Effective & Safest
Rx for DM

Objective 1:
Consider Band/Sleeve/RNY/MGB

Objective 2:
Best Treatment of Diabetes Includes
Data from
General Surgery,
Bariatric Reports,
Animal Studies

Objective 2:
Animal Models Confirm
Duodenal Bypass Improves Effectiveness
“This study shows that
bypassing Duodenum
Improves T2D,
independently of
food intake, body weight, malabsorption, or
nutrient delivery”
The Mechanism of Diabetes Control After Gastrointestinal Bypass Surgery Reveals a Role of the Proximal
Small Intestine in the Pathophysiology of Type 2 Diabetes. Rubino,); Marescaux, Jacques MD, FRCS
Annals of Surgery; 244 (5): 741-749, November 2006

Objective 2: Billroth I vs Billroth II
Gastrectomy vs Gastrectomy + Bypass
Primary Gastric Procedure (PGP)
Vs
Combined Gastric + Bypass (CGB)
Which Leads to Greater Weight Loss?
Which Leads to Greater Resolution of Diabetes?
General Surgery Answer:

Bariatric Surgeons Should Not Forget Their General
Surgery Training
GS for Gastric Disease (Ca/Ulcer)
Gastrectomy ALONE 50%
Gastrectomy + Duodenal Bypass 75%
Rx T2D MUST Include
Duodenal Bypass for
BEST short and long term Efficacy
G.O. OUTPERFORMS G+D
G.O.=Gastric Only vs
G+D=Gastric + Duodenal

Outcome after gastrectomy in gastric cancer
patients with type 2 diabetes
• 403 gastric cancer patients with T2DM
• BMI % Reduction
• Duodenal Bypass:
• BI: No Bypass 7.6%
• BII: Bypass 11.4%
• ** 50% Improvement **
• Jong Won Kim, etal, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 135-
720, South Korea, World J Gastroenterol. 2012 January 7; 18(1): 49–54.

Objective 2:
Gastrectomy For
Stomach Cancer on
Type 2 Diabetes Mellitus
Kang KC, Shin SH, Lee YJ, Heo YS.
J Korean Surg Soc. 2012 Jun;82(6):347-55.
Department of Surgery, Inha University Hospital, Inha University School of
Medicine, Incheon, Korea.

Objective 2: Gastrectomy for stomach
cancer on type 2 diabetes (Kang)
75 GCa Pts, 35 month FU
BI vs BII Rx DM
Gastrectomy ALONE (i.e. Sleeve)
0% Resolved, 45% improved
Gastrectomy + BII (i.e. MGB)
22% Resolved, 85% Improved

Objective 2:
J Gastrointest Surg. 2012Jan;16(1):45-51
Gastrointestinal metabolic surgery for the
treatment of diabetic patients: a multi-
institutional international study.
Lee WJ, Hur KY, Lakadawala M, Kasama K, Wong
SK, Lee YC.

Gastrointestinal metabolic surgery for the treatment of
diabetic patients (Lakadawala)
200 patients,
Gastric Bypass vs Sleeve gastrectomy
Remission of T2DM
“Gastric Bypass pts (Gastric + Bypass)
lost more weight & higher diabetes remission Sleeve pts“
Bypass pts mix of MGB/RNY
(per Dr. Lee)

Objective 2: MGB vs Sleeve
Mini-Gastric bypass
vs Sleeve Gastrectomy
for type 2 diabetes mellitus: a
Randomized Controlled TrialRandomized Controlled Trial
Lee WJ, Chong K, Ser KH, Lee YC, Chen SC, Chen JC, Tsai MH, Chuang
LM. Arch Surg. 2011 Feb

Objective 2: Lee MGB vs Sleeve
Randomized Controlled Trial
Randomized controlled trial
60 moderately obese patients (body mass index >25 and
<35)
Outcome was remission of T2DM (fasting glucose <126
mg/dL and HbA(1c) <6.5% without glycemic therapy)
All completed the 12-month follow-up

Lee MGB vs Sleeve
Remission of Diabetes
** 93% ** Mini-gastric bypass
** 47% ** Sleeve gastrectomy
(P = .02)

Lee MGB vs Sleeve
Mini-gastric bypass
lost more weight,
achieved a lower waist circumference, and
Lower glucose, HbA(1c), and
blood lipid levels than
the sleeve gastrectomy group

Effectiveness of Bariatric Procedures
Gastric + Duodenal Bypass
Outperforms Gastric Alone
G.O. Band Poor
G.O. Sleeve Med High
G+D RNY High
G+D MGB High - Highest
Conclusions
Band & Sleeve
Less Effective than
RNY & MGB

Objective 3: Best Rx DM
This Excludes Band/Sleeve
Need for Gastric Procedure +Bypass
Eliminates Band/Sleeve;
Leaves Choice RNY vs MGB

Objective 4:
RNY is the most
Technically Difficult,
Dangerous & Deadly
form of Bariatric
Surgery
100s Refs
One Recent Example

RNY: Long learning curve of
500 cases
RNY technically challenging
2,281 cases 1999 - 2011
Complications Stabilized after *500* cases
Mortality rate .43%,
main causes of death PE & Leaks (.14% each)
Op time & Complications significantly reduced after a
long learning curve of 500 cases
Surg Obes Relat Dis. 2013 Feb 11. Overcoming the learning curve of laparoscopic Roux-en-Y gastric bypass: A 12-
year experience. El-Kadre L, Tinoco AC, Tinoco RC, Aguiar L, Santos T. Department of Surgery, São José do
Avaí Hospital, Itaperuna, Rio de Janeiro, Brazil.

Lap RNY Gastric Bypass
Med Coll Va.
Postoperative Complications L-RNY
Leak 4.5%
SBO 2%
PE 1%
Death 0.7%
Ann Surg. 2004 May; 239(5): 698–703. Multivariate Analysis of Risk Factors for
Death Following Gastric Bypass for Treatment of Morbid Obesity, Adolfo Z.
Fernandez, Jr, MD et al.

RNY Bypass Surgery for Diabetes With Nonmorbid
Obesity? Maybe Jun 04, 2013
Controlled Prospective Rndomized 12-months, 49% RNY pts vs 19%
lifestyle pts met primary end points
BUT
37% serious complications in the RNY group
2 most serious complications were anastomotic leak 3.3%!!,
1 patient suffered anoxic brain injury.
Patients who underwent surgery were also more likely to have
nonserious adverse events such as nutritional deficiencies.
JAMA. 2013 Jun 5;309(21):Roux-en-Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the
Diabetes Surgery Study randomized clinical trial. Ikramuddin S, Department of Surgery, School of Public Health, University of Minnesota, Minneapolis, MN 55455,
USA. ikram001@umn.edu

RNY Bypass Surgery for Diabetes
Controlled Prospective Randomized Trial
Normal HgbA1C level range from 4.5 to 6
Only 44% RNY pts HgbA1c < 6 (Cure)
BUT
37% serious complications in the RNY group
3.3% anastomotic leaks
1 patient suffered anoxic brain injury and amputation
JAMA. 2013 Jun 5;309(21):Roux-en-Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the Diabetes
Surgery Study randomized clinical trial. Ikramuddin S, Department of Surgery, School of Public Health, University of Minnesota, Minneapolis, MN 55455, USA.
ikram001@umn.edu

1 yr RNY
Did Not
Reach
Normal
HgbA1c
JAMA. 2013 Jun 5;309(21):Roux-en-Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the Diabetes
Surgery Study randomized clinical trial. Ikramuddin S, Department of Surgery, School of Public Health, University of Minnesota, Minneapolis, MN 55455, USA.
ikram001@umn.edu

First report from the
American College of Surgeons
Bariatric Surgery Center Network
28,000 Patients
Ann Surg. 2011 Sep;254(3):410-20
Hutter MM, Schirmer BD, Jones DB, Ko CY, Cohen ME, Merkow
RP, Nguyen NT.
Department of Surgery, Massachusetts General Hospital, Boston, MA
02114, USA.

American College of Surgeons Bariatric Surgery
Center Network
Outcome SG N (%) RNY N (%)
Conv to Open 9 (0.10) 207 (1.43)
30-day Mortality 1 (0.11) 21 (0.14)
1-Year Mortality 2 (0.21) 49 (0.34)
Readmission 51 (5.4) 937 (6.47)
Reoperation 28 (2.97) 728 (5.02)
First report from the American College of Surgeons Bariatric Surgery Center Network28,000 Patients

Center Network
Outcome LSG N (%) RNY N (%)
Coma 0 2 (0.01)
Stroke 0 5 (0.03)
Cardiac Arrest 0 13 (0.09)
Myocard Infarct 0 9 (0.06)
DVT 1 (0.11) 21 (0.14)
Pneumonia 3 (0.32) 58 (0.40)

Center Network
Outcome SG N (%) RNY N (%)
Intubation 3 (0.3) 59 (0.41)
Ventilator (> 48 hrs) 0 55 (0.38)
Acute Renal Failure 0 22 (0.15)
UTI 5 (0.5) 104 (0.7)
Wound Dehiscence 0 27 (0.19)
Septic Shock 0 21 (0.14)

Objective 5:
MGB One of the Most Effective & Safest
Best Rx for DM

Laparoscopic Roux-en-y Vs. Mini-gastric Bypass For The
Treatment Of Morbid Obesity: A 10-year Experience.
Obes Surg. 2012 Dec;22(12):1827-34. Laparoscopic
Roux-en-Y Vs. mini-gastric bypass for the
treatment of morbid obesity: a 10-year experience.
Lee WJ, Ser KH, Lee YC, Tsou JJ, Chen SC, Chen JC.
Department of Surgery, Min-Sheng General Hospital, National Taiwan University, No. 168, Chin Kuo Road, Tauoyan,
Taiwan, Republic of China. wjlee_obessurg_tw@yahoo.com.tw

October 2001 and September 2010, 1,657 patients who received
gastric bypass surgery (1,163 for LMGB and 494 for LRYGB)
Surgical time was significantly longer for LRYGB (159.2 vs. 115.3
min for LMGB, p<0.001).
The major complication rate was higher for LRYGB (3.2 vs. 1.8%, p
=0.07).
5 years after surgery, the mean BMI was lower in LMGB than
LRYGB (27.7 vs. 29.2, p<0.05) and
LMGB also had a higher excess weight loss than LRYGB (72.9 vs.
60.1%, p<0.05).
Late revision rate was LRYGB 3.6% and MGB 2.8%

CONCLUSIONS:
This study demonstrates that MGB
can be regarded as a SIMPLER and
SAFER alternative to RNY with
similar or BETTER efficacy at a 10-
year experience.

Conclusions: MGB Best Rx for DM
1. Band/Sleeve/RNY/MGB
2. Animal, Gen Surg and Bariatric Data:
Best Rx = Gastric + Duodenal Bypass
3. Excludes Band/Sleeve
4. RNY Unquestionably the Most Dangerous form of
Bariatric Surgery
5. Numerous studies show MGB short safe and highly
effective; Best Choice

Bariatric Surgery Rx Type 2 Diabetes
Bariatric Surgery Has Been shown to Successfully
Treat Type 2 Diabetes Mellitus
Unfortunately Failure of Bariatric Procedures Rx of
T2D is reported
Operations to be considered: Band/Sleeve/RNY
vs MGB

Bariatric Surgeons Should Not Forget Their General
Surgery Training
• Bariatric Surgeons should Learn from
General Surgery
• General Surgery and T2D
• Results of General Surgery for Gastric
Disease
• Cancer / Ulcer

Laparoscopic Mini Gastric Bypass
Cesare Peraglie MD FACS FASCRS
CLOS-Florida: Heart of Florida Regional Medical Center.
Davenport, Florida
drperaglie@gmail.com
SECO 2012
BARCELONA SPAIN

Laparoscopic-Mini Gastric Bypass: HOFRMC
•Over 1000 Laparoscopic MGB’s have been performed at HOFRMC since 2005.
•TYPICAL DEMOGRAPHICS: AGE: 45 (14-72), BMI: 45 (30-75), ~27% DIABETIC, ~50% HTN, ~31%
PREVIOUS ABDOMINAL SURGERY
•OUTCOMES
OP-TIME: 62Min. (37-186), Conversion to open: 0
LOS: 1 DAY or less (88%), 2 DAY (10%), 3 DAY (~2%), 4+ DAY
(<1%)
Re-admission: 5% (23 hour obs. PONV in all but one) / 0.8%
90 day
Leak: 0.3%
MORTALITY: 0 (HOSPITAL), 0 (PERI-OP:90D)

Every Testbook in General Surgery
Warns of SBO after RNY

RNY Causes Bowel Obstruction and Death
• My family member had
RNY=>SBO=>
Death
• RNY SBO 2-16%
• NO Other Bariatric Surgery
Has Such High Rate of
Bowel Obstruction

Some RNY Surgeons Never See Bowel Obstruction
after RNY
How Can this Be?
Poor Follow Up
Makes Good Results
RNY SBO 2-16%

RNY Surgeons Leave SBO to be
Cleaned Up by General Surgeons
Every
General Surgeon
is Now Taught
To Look For,
Be Vigilant and
Fear
Bowel Obstruction
After RNY
Gastric Bypass

Poor Follow Up
Makes Good Results
My Family Member
Who DIED
From Small Bowel Obstruction After RNY
Was Operated Upon by a
GENERAL Surgeon not a Bariatric Surgeon!
Her RNY Surgeon Does Not Know of her Death or her
Bowel Obstruction

Mini-Gastric Bypass
By Every Important Measure the
Best Choice for Rx Type 2 DM
Compared to RNY: Efficacy/Safety
One of the Highest Efficacy of Rx T2D
Highest Safety
Lowest Death Rate
Lowest Leak Rate
Lowest Early Complication Rate
Lowest Major Complication Rate
Lowest Bleeding Rate
Lowest Re-operation Rate
Lowest PE Rate
By Every Measure and in Every Study

Patient Satisfaction
Kular Hospital Community Hospital No Advertisement: Offer
Sleeve, RNY or MGB
Patients are followed
Sleeve pts frequently complain of N/V and referr fewer pats for
operation
RNY Less satisfaction poor referral discouraged
MGB high satisfied and refer many patients
NOW 90% of cases are MGB

India Turns to the Sleeve
Band has come and gone
Many RNY programs
Centers across India turning to sleeve for the same
reasond

Selecting an Operative Procedure
Safety and Effectiveness
Personal Experience, Animal Models, Expert Judgment,
Published Data and Controlled Prospective Randomized
Trials all show:
MGB is More Effective than Sleeve RNY
MGB is Safer than SleeveRNY

Mini-Gastric Bypass:
Excellent Results from Multiple
Surgeons

6,385 Consecutive Mini-Gastric Bypasses:
16 Years Later (Rutledge)
6,385 patients who underwent MGB from September 1997 to June
2011
Mean operative time 41 minutes and
median length of stay 1 day
Early complications occurred in 4.9%.
44 (0.7%) patients had anastomotic leaks.
Three (0.05%) patients presented with dypepsia/bile reflux not
responsive to medical therapy and were successfully treated by
Braun side-to-side jejuno-jejunostomy.

6,385 Consecutive Mini-Gastric Bypasses:
16 Years Later (Rutledge)
Gastritis/dyspepsia/marginal ulcer was the most serious long term
complication; routinely treated medically.
Excessive weight loss occurred in 1% of patients; treated by take
down of the bypass.
Mean % excess weight loss (EWL) of 78%.
10 year weight regain was mean 4.9%. >50% EWL was achieved for
95% of patients at 18 months and for 92% at 60 months.
6% of patient had inadequate weight loss or significant weight regain
were treated by revision, (addition of ~2 meters to the bypass).

Remember!
All Medical and Surgery Can Fail!
Bariatric Surgery Procedures are Known to Fail
Therefore
ALWAYS CHOOSE
Operation that Can Be Revised Safely!!
NEVER CHOOSE
Operation Revision is Dangerous!

Revision of MGB: Easily Done Rarely Needed
Revisional Surgery For Laparoscopic
Mini-Gastric Bypass
Wei-Jei Lee, M.D., Ph.D. , Yi-Chih Lee, Ph.D., Kong-
Han Ser, M.D., Shu-Chun Chen, R.N.,
Jung-Chien Chen, M.D., Yen-How Su, M.D.
Surgery for Obesity and Related Diseases
Volume 7, Issue 4 , Pages 486-491, July 2011

Revision of MGB: Easily Done Rarely Needed
January 2001 to December 2009, 1322 patients
excess weight loss and mean body mass index at 5 years after
LMGB was 72.1% and 27.1 ± 4.6 kg/m2.
Of the 1322 patients, 23 (1.7%) had undergone revision surgery
during a follow-up of 9 years.
The causes of revision
Malnutrition (Excess Weight Loss) in 9 cases
Inadequate weight loss in 8
Intractable bile reflux 3 out of 1,322 cases,
No patients had surgery for Internal hernia

FIRST International Consensus Conference on
Mini-Gastric Bypass
Paris in October 2012.

The IFSO-EC Mini-Gastric Bypass
Postgraduate Course in Barcelona in April 2012
was a notable success
• As you may know we had a great slate of presenters included such
experts and leaders included
• Prof Jean-Marc Chevallier, France, Prof Roberto Tacchino,Italy, Prof.
Dr. Manuel Garcia-Caballero, Spain, Dr. Jean Mouiel,France, Dr. Rui
Ribeiro, Dr. Cesare Peraglie, M.D., F.A.C.S., USA, Dr. Mario Musella
and Dr. K S Kular M.S. from India; and others.
https://www.surveymonkey.com/s/CCVote
Or Email DrR@clos.net

IFSO – EC Mini-Gastric Bypass Post Grad Course,
April Barcelona
The countries represented included France, Italy,
Germany, Spain, the United Kingdom, the Czech
Republic, Portugal, Egypt, United Arab Emirates, the
Netherlands and India.
We were pleased that the room was near full,
enthusiastic and educational.
As a follow up, the Society of MGB Surgeons is seeking
to survey the present opinions of surgeons about the
MGB and the other bariatric procedures.

Society of MGB Surgeons
MGB / OAGB Survey Respondents
https://www.surveymonkey.com/s/IFSO-MGB-ConsensusConference

Society of MGB Surgeons:
Rename the Mini-Gastric Bypass?

Society of MGB Surgeons MGB Post Graduate Course
MGB / OAGB Survey Respondents
20-30% of All Bariatric Surgery in France
is Mini-Gastric Bypass
IFSO-EC 18+ MGB Surgeons, 16,000+ MGB
procedures Performed
Society of MGB Surgeons
MGB Survey Respondents
23 MGB Surgeons, 19,000 MGBs,
100 surgeons, 300,000 Bariatric Procedures /
year

Irrational Illogical Thinking
Decision-Making Errors
• Confirmation Bias
(favor information that confirms preconceptions)
• Herd Behavior
(group think override rational)
• “Reptilian Brain”
Amygdala is part "impulsive," primitive system that
triggers emotional override rational thinking
https://www.surveymonkey.com/s/IFSO-MGB-ConsensusConference Or Email DrR@clos.net

PRIMITIVE RESPONSE SYSTEMS
MODIFY RISK ASSESSMENT

THE REPTILIAN BRAIN:
EMOTION & DECISION MAKING
• Rational Logical Thinking:
Frontal Lobe
• Amygdala
Interferes with the Frontal lobe
• Primitive, Impulsive
• Irrational decision-making

IRRATIONAL ILLOGICAL THINKING
CONFIRMATION BIAS
• Contrary Evidence =>
Maintains or strengthens
present beliefs
• Overconfidence
in present beliefs
• Poor Decision Making
• Especially Present in
Organizations, Military, Political & Social Groups

REPTILIAN BRAIN POOR DECISIONS
FEAR LEADS TO JUDGMENT ERRORS
• Errors in Risk Assessment
• Death Airplane Crash
• Death Car Crash
• 1 in 10,000 patient / 20 years risk of
gastric cancer
• Bowel Obstruction from internal
hernia +16% in 15 months!

Surgeons Who Fear Gastric Cancer =
Don't Know Much About Gastric Cancer
• Surgeons who say MGB = Bad, Because of the “Risk of Cancer”
• Don't know the Risk of Cancer in the General Population
• Don't know the risk of gastric cancer in Billroth II
• Don't Fear the Risk of Bowel Obstruction from internal hernia
+16% in 5 years
• Don't Fear Esophageal Cancer after Band & Sleeve

Surgeons Who Fear Gastric Cancer =
Don't Know Much About Gastric Cancer
I have recently reviewed the literature on gastric cancer and am very knowledgeable about
the risk of gastric cancer

Question Answer
H. Pylori Treatment Normalizes Risk of Gastric
Cancer in Ulcer Patients.
Agree 100%
The association between H pylori infection and
the development of gastric cancer is well
established
Agree 100%
Gastric cancer can be prevented by treating H.
Pylori, eating a diet of fresh fruit and vegetables
and avoiding smoking, alcohol and nitrates in
preserved foods
Agree 100%

Question Answer
There are many large scale studies that show no
increased risk of gastric cancer after Billroth II:
Disagree 60% !!!
Unoperated Gastric Ulcer patients have double the risk
for Gastric Cancer
Agree 100%
There are some studies showing a slight increased risk
of gastric cancer 20-30 years after Billroth II. But these
patients had the Billroth II overwhelmingly for Ulcer
Disease &
Ulcer and Gastric Cancer have a common etiology; H.
Pylori.
Agree 100%

(Un) Popularity of the MGB
• Confusion:
MGB Not Old Mason Loop Gastric Bypass
• MGB = Antrectomy and BII
• Old Mason Loop =
Total Gastrectomy + BII

PR: STATE THE PROBLEM
• Obesity Epidemic
• History of Failure of Bariatric Surgical
Procedures
• Selecting the “Ideal / BEST”
Bariatric Surgical Procedure

Sleeve Consensus Meeting?
19 surgeons have shared their data and consensus has
been sought on specific points related to sleeve only
Mean 12% acid reflux
Many showing 20% reflux
Many showing 40 % weight loss failure
( < 50 % EWL )

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"
O: OBJECTIVES, SUCCESS CRITERIA

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

21. Low Risk of Ulcer
22. Fat Malabsorbtion; 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

MINI-GASTRIC BYPASS
• The Mini-Gastric Bypass
1997 – 2011 ; >6,000 pts,
10 yr Data; Multiple Centers,
R.C.Trials
• Vertical Gastric Tube
(Collis Gastroplasty)
• Gastric Bypass
(Billroth II Gastro-jejunostomy)

MINI-GASTRIC BYPASS
BASED SOUND SURGICAL PRACTICE
• Billroth II Performed
over 100 years
• 16,000 Billroth II’s
USA in 2007
• Operation of choice:
Trauma, Ulcers, Cancer
Stomach etc.

STATISTICAL ILLITERACY;
"MANY DOCTORS MISUNDERSTAND MEDICAL LITERATURE"
• Example:
“In the absence of a Roux limb,
the long-term effects of chronic alkaline reflux are unknown.”
• REALLY? Rational vs. Reptilian Brain thinking
• Billroth II >100 years and >1,450 papers on Billroth II
Collins BJ, Miyashita T, Schweitzer M, Magnuson T, Harmon JW.,
Gastric Bypass; Why Roux-en-Y? A Review of Experimental Data,
Arch Surg. 2007; 142(10):1000-1003.

STATISTICAL ILLITERACY;
"MANY DOCTORS MISUNDERSTAND MEDICAL LITERATURE"
• Example:
“In the absence of a Roux limb,
the long-term effects of chronic alkaline reflux are unknown.”
Collins BJ, Miyashita T, Schweitzer M, Magnuson T, Harmon JW.,
Gastric Bypass; Why Roux-en-Y? A Review of Experimental Data,
Arch Surg. 2007; 142(10):1000-1003.

GASTRIC CANCER
RAPIDLY DECLINING
• The incidence of gastric cancer
in the United States has
• Decreased four-fold since
1930
• Approximately 7 cases per
100,000 people.

BARIATRIC SURGEONS FEAR BILLROTH II;
CANCER SURGEONS CHOOSE BILLROTH II
• 1,490 articles on performance of the Billroth II
• General/Trauma/Oncologic surgeons commonly use the
Billroth II
• Over 16,000 Billroth II operation
performed in USA 2007
• While Bariatric Surgeons Fear the Billroth II General
Surgeons use the Billroth II routinely

BARIATRIC SURGEONS FEAR BILLROTH II
WHAT IS MAGNITUDE OF THE PROBLEM
• Mayo Clinic Study (Example)
• 338 Billroth II patients
• Followed 25-years
• 5,635 person-years
• Only 2 Cancers in 5,000+ pt years of Follow Up
• Schafer et al, Risk of gastric carcinoma after treatment for benign ulcer disease. N
Engl J Med. 1983 Nov 17;309

MAGNITUDE OF THE PROBLEM
• Population based study, 338 Billroth II pts
• Followed 25-years
• Only 2 Cancers Found in 5,000 years
• Predicted 2.6 cancers (relative risk 0.8)
Schafer et al, Risk of gastric carcinoma after treatment for benign ulcer disease. N Engl J Med. 1983 Nov 17;309

MAGNITUDE OF THE PROBLEM
• 338 Billroth II pts, Followed 25-years
• Only 2 Cancers in 5,000 pt years follow up
• RATE of Gastric Cancer is Declining
• 24 - 50% Expected Decrease from 1983
• Future risk ~1 patient / 5,000 pt years

ULCERS INCREASE RISK CANCER
• Meta-analysis:
7 studies Small increased risk
5 studies No Increased Risk
• Studies with increased Risk; Flawed
• Billroth II = Surgery Rx Ulcers
• ULCERS increase risk of Gastric Cancer!
• Ulcers and Gastric Cancer Common Etiology
=H. Pylori=

ULCERS INCREASE RISK CANCER
•3,078 gastric cancer vs. 89,082 controls
•Ulcer increases risk gastric cancer
=(relative risk 1.53)=
•Same as Increased Risk reported Billroth II
•Many other studies confirm these findings:
•Ulcer Increases Risk Gastric Cancer
•Ulcers & Gastric Cancer:
•Common Etiology =H. Pylori=

GASTROENTEROLOGISTS IGNORE BILLROTH II
• Hundreds of thousands of people with Billroth II’s
• If cancer IS SUCH A BIG RISK…
• Shouldn’t gastroenterologists be looking for these people,
screening them with endoscopy?
• No, there is no recommendation for BII follow up screening;
Why? THE RISK IS LOW
• 63,000 yrs Follow up 23 cancers = Gen Pop.

RISK OF GASTRIC CANCER AFTER
BILLROTH II IS LOW
• Follow-up study of 1000 patients
• 22-30 year follow-up
• 196 endoscopy and biopsy No Cancer of the gastric
remnant seen
• Endoscopic screening will be “unrewarding”
• Br J Surg. 1983 Sep;70(9):552-4. Risk of gastric cancer after Billroth II resection for
duodenal ulcer. Fischer AB

WHAT CAUSES GASTRIC CANCER?
ITS NOT BILLROTH II
• Diets rich in fried, salted, smoked or preserved foods increased cancer
risk in many studies.
• Foods contain nitrites and these chemicals can be converted to more
harmful compounds (carcinogens) by bacteria in the stomach.
• Diets high in fruit and vegetables protects against Cancer
• Stomach cancer is much more common in smokers and in those with
heavy alcohol intake.
• H. Pylori, No H. Pylori No Cancer

DIET AND CANCER PREVENTION
• Avoid ETOH, Tobacco,
Processed & Preserved
Meats, Salt
• RX H. Pylori,
• Eat Fruits and Veggies,
Yogurt and
• Drink Green Tea
•
Gonzalez CA, Cancer Research, Institut Català d'Oncologia, Av. Gran Via s/n, km
2.7, 08907 L'Hospitalet, Barcelona, Spain.

Which Is More DeadlyWhich Is More Deadly
A Hot Dog Or A Billroth II?A Hot Dog Or A Billroth II?

Which Is More Deadly A Hot Dog Or A Billroth II?
Processed meats
(Bacon, sausage, hot dogs, sandwich meat, packaged ham,
pepperoni, salami, etc.)
Shown to be associated with gastric cancer.
An increase intake of 100 g of processed meat per day
Increases the risk of Gastric Cancer by 3.5 times
= Natl Cancer Inst. 2006 Mar 1;98(5):345-54. Meat intake and risk of stomach and esophageal adenocarcinoma within
the European Prospective Investigation Into Cancer and Nutrition (EPIC).
= J Natl Cancer Inst. 2006 2;98(15):1078 "Processed meat consumption and stomach cancer risk: a meta-analysis" The
Karolinska Institutet
(Hint: A Hot Dog weight 3.7 oz = 100 g = INCREASED RISK 3.5!)

Which is more deadly a Hot Dog or a
Billroth II?
AA BB

Which is more deadly a Hot Dog or a Billroth II?

Which Do Bariatric Surgeons Fear More?
A Hot Dog or a Billroth II?
AA BB

UNINFORMED FEAR BILLROTH II
EDUCATED USE BILLROTH II
• 1. Gastric Cancer Declining Rapidly, > 50%
• 2. Gastric Cancer Cause:
Environmental Factors / Easily Prevented
Diet, Lifestyle changes and Rx of H. Pylori
(Avoid Etoh, smoking, processed & salted meats and
foods, seek high intake of fruits and vegetables)

• 3. Some studies Slight Increased Risk of gastric cancer
after 20 – 30 years (RR 1.5):
But: BII was performed to Rx Ulcer =>
Ulcer => Increased Risk
• (Worried? Rx H Pylori, Eat healthy etc.)
• 4. Many Large Studies: No Increased Risk
Thousands of patients followed for Decades

• 5. Endoscopic screening of Billroth II patients is Not
Recommended. Why? Low Risk!
• 6. General, Trauma and Oncologic surgeons routinely
use the Billroth II (Thousands of publications)
• 7. 2007 ~16,000 BII procedures were performed in the
USA

• 8. Billroth II and the Mini-Gastric Bypass
Excellent, Safe and Effective
• 9. FEAR Gastric Cancer?
Avoid ETOH, Tobacco, Processed & Preserved Meats,
Rx H. Pylori,
Eat Fruits and Veggies, Yogurt and Drink Green Tea
• A Billroth II probably makes NO difference

T: TRADEOFFS
• Rational Review of the Data vs.
Fear Gastric Cancer / Bile Reflux
• Rational Thinking vs. Reptilian Brain

T: TRADEOFFS: Rational Data Analysis vs.
Irrational FEAR Gastric Cancer
• 1. Gastric Cancer Declining Rapidly
• 2. GC Environmental Causes; Easily Prevented
• 3. Some studies show Small Increased Risk
Probably from Ulcers / H. Pylori
• 4. Many large studies: NO increased risk
• 5. Endoscopic Screening: Not Recommended
• 6. General, Trauma & Oncologic Surgeons Use Billroth II

T: TRADEOFFS
FEAR OF GASTRIC CANCER
• FEAR gastric cancer?
• Avoid: Alcohol, Tobacco, Processed & Preserved
Meats
Rx: H. Pylori,
Eat Fruits & Veggies, Yogurt and
Drink Green Tea
• Billroth II Probably Makes NO DifferenceBillroth II Probably Makes NO Difference

T: TRADEOFFS
A Billroth II Probably
Makes No Difference

T: TRADEOFFS
A Billroth II Probably Makes No
Difference

Expert Opinions: "May be the Best Operation, I
Use It Frequently"
Good, maybe the best form of WLS, I use it often?
May I beg your indulgence: Please consider giving us your learned opinion:
https://www.surveymonkey.com/s/IFSO-MGB-ConsensusConference Or Email DrR@clos.net

Expert Opinion:
Operation Judged Short and Simple

Expert Opinion:
Failure is "VERY RARE"

Experts Who Once Used the Band and Now Have
Stopped Using the Band (38%)

Expert Opinions:
Patients Routinely Get Major Weight Loss

Expert Opinions:
Patients RARELY Regain Their Weight

Expert Opinion:
Patients RARELY Suffer Long Term Complications

MGB Experts (>100 MGBs):
Patients RARELY Suffer Long Term Complications

Expert Opinions:
Procedure Advocates Reporting "No Leaks"

Expert Opinions:
Procedure Advocates Reporting a Leak

Expert Opinion:
Revision is Relatively Easy

CONCLUSIONS: PR.O.A.C.T.
Rational Choice: Mini-Gastric Bypass
• Pr: Choice of Obesity Surgery
• O: Objectives “Ideal” Weight Loss Surgery
• A: RNY, Band, Sleeve, MGB
• C: MGB meets almost all objectives/success criteria
• T: Fear of Bile Reflux & Gastric Cancer
Not Supported by the Data
• Rational Decision Making: Best Choice;
Mini-Gastric Bypass

WHY CRITICS ONLY CARE FOR MGB?
• Why do Critics only care about the
Mini-Gastric Bypass?
• 100,000’s of people already have and are living with and
are getting the Billroth II every day
• Why haven’t concerned bariatric surgeons stepped
forward to stop all general, trauma and oncologic
surgeons from performing this Billroth II surgery?

•Why do Critics only care about the
•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?
•Why don’t they write letters to the editor calling for the
Billroth II to be declared a operation non-grata?

• Why do Critics only care about the
• Why haven’t concerned bariatric surgeons stepped
forward to national funding for lifetime endoscopic
screening of Billroth II patients to find dreaded gastric
cancers?
• It seems odd doesn’t it?
• There is a simple reason

• There is a simple reason
• The critics of the MGB do not do those things because
they are ...
• Such actions are Not supported by the data
• The Billroth II and the MGB are both good operations
• Published data Does Not support the critics misreading of
the medical literature

THE TIDE BEGINS TO TURN
TO THE MINI-GASTRIC BYPASS
• “Not too long ago, the bariatric community questioned the role of the
mini-gastric bypass and its appropriateness as a durable operation for
obesity.”
• The experience of Lee et al. with a large cohort suggests some
answers.”
• Michel M. Murr, M.D.
• “The Journal continues to commit to open, spirited, and balanced
discussions that are supported by data and withstand the test of
common sense.”
• Editorial: Revisional surgery for laparoscopic mini-gastric bypass.
Lee WJ, Surg Obes Relat Dis. 2011 Jul-Aug;7(4):486-91

Mini-Gastric Bypass:
9 YEARS LATER! OUT PERFORMS RNY
• New results of the MGB:
• “1,322 patients, 23 (1.7%) had revision
Follow-up of 9 years.”
• Excess weight loss 72.1%
• No patient had surgery for internal hernia
Revisional surgery for laparoscopic mini-gastric bypass.
Lee WJ, Surg Obes Relat Dis. 2011 Jul-Aug;7(4):486-91

Patient Survey:
MGB OUT-PERFORMS BAND & RNY
• Follow up survey of bariatric surgery results in 1,500
patients’ friends, family and acquaintances
• Patient Reported Success in Friends Family:
36% RNY,
24% Band and
93% MGB

EXAMPLE FEAR & DECISION MAKING
SBO VS. GASTRIC CANCER
• Which is more Deadly?
• Gastric Cancer or Small
Bowel Obstruction?
• Which is more
fearsome?

11+ RNY STUDIES INTERNAL HERNIA BOWEL
OBSTRUCTION
• 1 - 16% Internal Hernia /Small Bowel Obstruction
• Follow Up 1-10 years (only 7% at 10 years)
• Note: Dead patients cannot return for follow up
• =15/18 patients, ReOp, failed closure USA=

DEATH AFTER
SMALL BOWEL OBSTRUCTION
• 877 patients who underwent 1,007 operations for
SBO from 1961 to 1995
• Risk of bowel obstruction increases over time
• 52 Deaths 6% Death Rate
• Ann Surg. 2000 April; 231(4), Complications and Death After Surgical Treatment of
Small Bowel Obstruction A 35-Year Institutional Experience Fevang et.al.,
Department of Surgery, University Hospital, University of Bergen, Norway

FEAR AND DECISION MAKING
• Which is more Deadly?
• Gastric Cancer or
Small Bowel
Obstruction?
• Which is more
fearsome?

FEAR AND DECISION MAKING
• 1,000 RNYs, Estimate 20% SBO => 200 operations for
SBO in 5-10 years (? How many more for 20 years?)

FEAR?
• 1,000 RNYs, 20% SBO => 200 operations for SBO in
5-10 years (? How many for 20 years?)
• 6% Death Rate => 12 dead before the end of 10 years
from SBO

FEAR?
from SBO
• 1,000 MGBs After 20 years possibly increased risk of
cancer of 1 / 1,000

FEAR?
from SBO
cancer of 1/1,000
• Deaths at 10 years from Gastric Cancer 0.0

FEAR?
• 1,000 RNYs, 20% SBO => 200 operations for SBO in 5-10
years (? How many for 20 years?)
from SBO
cancer of 1/1,000
• Death at 10 years from Gastric Cancer 0.0
• Death SBO 12/10 years, Deaths Gastric Cancer 10-20
years 0-1

WHICH DO YOU FEAR?
• 1,000 RNYs = 200 SBO operations
• Death from RNY SBO 12 deaths / 10 years
• 1,000 MGB’s 0-1 Gastric Cancer @ 20 yrs
• Deaths Gastric Cancer 10-20 years 0-1?

FOLLOW UP EFFECT
• Unbiased Population based studies => Poor Results of RNY
• Positive Results of RNY reported from RNY centers
• Suffer from “Follow Up Effect”
• Patient Returns to clinic doing well: Greeted Warmly with Great Joy
• Patient Returns to clinic doing poorly: Greeted with anger and disapproval
• Successful pt => Good Follow Up / Failed pt tacitly sent away
• Now; Center reports excellent results; (30%) follow up
• Weight Regain, Band Erosion, Death
• Not Seen, Not Reported

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