Mini-Gastric Bypass: Best Surgery;

Presentaion; Selection of the "Best" Bariatric Surgical Procedure; Discussion of the risk of "Marginal Ulcer" in MGB and in RNY gastric bypass

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

2. Dr Rutledge: Training & Background Undergrad/Medical School; Teacher Dr. Lester Dragstedt Pioneer / Inventor of the Highly Controversial Vagotomy and Pyloroplasty 2 Years Cardiac Surgery National Institutes of Health National Heart Lung Blood Institute 20 years University of NC; Professor of Surgery , Associate Chief of Staff, Director of Section Medical Informatics, Director North Carolina Trauma Registry Author of 93 papers and articles

3. Dr Rutledge: Training & Background Specialty: Trauma, Critical Care, Medical Informatics and Bariatric Surgery (1978-1998 20 years University NC) Experience: Trauma Surgery , Director NC Trauma Registry Peptic Ulcer Surgery ; Vagotomy & Pyloroplasty; Antrectomy & Billroth II Bariatric Surgery 33 years : Open RNY & Vertical Banded Gastroplasty 1997 one first surgeons laparoscopic RNY Mini-Gastric Bypass; 14 years, over 6,000 cases

4. Dr. Rutledge USA 001-702-714-0011 [email protected] CONSIDERING THE MGB? MGB IS A SUPERB SURGERY BUT… WARNING: “ THERE ARE “TRICKS AND TRAPS ”

5. OFFER A SAFE & SUCCESSFUL MGB PROGRAM Call / Email: Anytime question or advice on any clinical, technical or patient MGB question USA 001-702-714-0011 [email protected] Personal Visit: Dr. Rutledge Visiting Professor: France, Turkey, Austria & India, Upcoming visits Greece, Istanbul, United Kingdom Czech Republic, Italy, Germany, UAE, Pakistan, Please Use the Knowledge of Others Before You Start; Experience; over 14 years, over 6,000 patients USA 001-702-714-0011 [email protected]

6. UPCOMING “HANDS ON” MGB IN INDIA “TRICKS AND TRAPS” TRAINING PROGRAM Didactic Sessions Talk with the Leading World Experts Hands On Surgery (with approval) Scrub in on cases Assist and Participate in MGB Surgery This Fall and Next Year Bija India, Dr Rutledge & Dr Kular USA 001-702-714-0011 [email protected]

7. SURGERY HISTORY OF POOR DECISIONS JOSEPH LISTER: AMERICAN SURGEONS DELAYED ADOPTION OF ANTISEPSIS 10 YEARS

8. REPTILIAN BRAIN POOR DECISION MAKING Lister published antisepsis paper: 1867 Dr. Gross; Gross Clinic 1875

9. Definition of the Problem Obesity Epidemic History of Failure of Bariatric Surgical Procedures Selecting the “Ideal / BEST” Bariatric Surgical Procedure

10. Problem Definition: Bariatric Surgery: A HISTORY OF FAILURE Procedure Assessment Jejuno-ileal Bypass (Failure) Vertical Banded Gastroplasty (Failure) Lap Band (Fail?) RNY Bypass (Fail?) BPD/DS (Fail?) Sleeve: 5% Leak, 60-80% GE Reflux, Irreversible, Weight regain (Fail?)

11. The Gastric Sleeve: Not as Bad as the Band Not as Dangerous as the RNY

12. 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" SUCCESS CRITERIA "IDEAL" WEIGHT LOSS SURGERY

13. 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

14. 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

15. Selected Bariatric Procedures RNY Band Sleeve MGB

16. 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)

17. 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.

18. Criteria for Success; Ideal Weight Loss Surgery RNY Band SG MGB 1. Low Risk - + - + 2. Major Weight Loss + - - ++ 3. Easily performed - - + + + 4. Short operative times - + + + 5. Short hospital stay - - + + + 6. Minimal Blood Loss - + + + 7. No Need for ICU Stay - + + + 8. Minimal Pain - + + + 9. High Patient Satisfaction - - - + 10. A Good "Exit Strategy" - - - + - - +

19. Criteria for Success; Ideal Weight Loss Surgery RNY Band Sleeve MGB 11. Decrease Hunger + - + + 12. Min Vomiting + + + + 13. No Internal hernias - + + + 14. Min Heart/Lung - + + + 15. Low Failure Rate - - - + 16. Low Cost - - - + 17. Short Recovery - + + + 18. Return to Work - + + + 19. Low Risk of PE - + + + 20. Durable Weight Loss - - - +

20. Criteria for Success RNY Band SG MGB 21. Low Risk of Ulcer - + + - 22. Malabsorption of fat + - - + 23. No Foreign Body + - + + 24. Verifiable Results - - - ++ 25. Bowel Obstruction - - + + ++ 26. Sound Surgical + - + + 27. Independent confirm - - - ++ 28. Healthy life - - - ++ 29. RCT; LEVEL I Evidence - - - ++ 30. Block Sweet Eater + - - ++

21. 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

22. Marginal Ulcer after Gastric Bypass; RNY & MGB

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

24. 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

25. 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!!!

26. CONCLUSIONS: Best Choice : Mini-Gastric Bypass Choice of Obesity Surgery Objectives “Ideal” Weight Loss Surgery RNY , Band, Sleeve, MGB MGB Best meets all objectives/success criteria Beware of Marginal Ulcer Rational Decision Making: Best Choice; Mini-Gastric Bypass

27. 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 ?

28. WHY CRITICS ONLY CARE FOR MGB? Why do Critics only care about the Mini-Gastric Bypass ? 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 ?

29. WHY CRITICS ONLY CARE FOR MGB? Why do Critics only care about the Mini-Gastric Bypass? 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

30. WHY CRITICS ONLY CARE FOR MGB? There is a simple reason The critics of the MGB do not do those things because they are ridiculous 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

31. CRITICS OF THE MINI-GASTRIC BYPASS SHOULD BE EMBARRASSED

32. 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