The Mini-Gastric Bypass:Best Treatment Type 2 Diabetes Mellitus

The Mini-Gastric Bypass:The Mini-Gastric Bypass:Best Treatment Type 2 Diabetes Best Treatment Type 2 Diabetes

MellitusMellitus

Dr K S KularKular Medical Education & Research Society ,

Kular Group of Institutes ,drkskular@gmail.com

www.kularhospital.com

Best Rx for Diabetes5 Objectives

1. Consider Band/Sleeve/RNY/MGB2. Best Rx DM Requires

Gastric Procedure + Duodenal Bypass3. Eliminates Band/Sleeve; Choice RNY vs MGB4. RNY Most Technically Difficult Dangerous &

Deadly form of Bariatric Surgery5. 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

Both a Gastric Procedure + Duodenal Bypass

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 IIGastrectomy vs Gastrectomy + Bypass

Primary Gastric Procedure (PGP)

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. Less Effective 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: General Surgery"Effect of 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 FUBI vs BII Rx DMGastrectomy ALONE (i.e. Sleeve)

0% Resolved, 45% improvedGastrectomy + BII (i.e. MGB)

22% Resolved, 85% Improved

Objective 2: General SurgeryJ Gastrointest Surg. 2012 Jan;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 SleeveRandomized 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 SleeveRandomized Controlled Trial

Remission of Diabetes

** 93% ** Mini-gastric bypass

** 47% ** Sleeve gastrectomy

(P = .02)

Lee MGB vs SleeveRandomized Controlled Trial

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 ProceduresGastric + Duodenal BypassOutperforms Gastric Alone

G.O. Band PoorG.O. Sleeve Med HighG+D RNY HighG+D MGB High - HighestConclusions

Band & Sleeve Less Effective than RNY & MGB

Objective 3: Best Rx DM Gastric Procedure + Duodenal Bypass

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 RefsOne Recent Example

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 RateHighest Bleeding Rate, Highest Re-operation RateHighest PE Rate....

RNY is the most dangerous form of Bariatric Surgery

References 25-100 Studies

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

BUT37% 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)

37% serious complications in the RNY group

3.3% anastomotic leaks

1 patient suffered anoxic brain injury.

1 yr RNY Did NotReachNormalHgbA1c

First report from the American College of Surgeons

Bariatric Surgery Center Network28,000 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

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)

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)

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%

Objective 5: MGB One of the Most Effective & Safest

Best Rx for DM

Objective 5:MGB One of the Most Effective & Safest

MGB SeriesRutledge U.S.A. 6,000 + (16 yr + FU)Lee Taiwan 1000 + (RCT, 10 yr+ FU)Noun Lebanon 1000Kular India 1000+Cady France 2000 +Peraglie U.S.A. 2000 +Carbajo Spain 2000 +Garcia-Caballero Spain 1000 +Musella et al. Italy 1000Otheres (i.e. Chevallier Paris , Tacchino Rome etc.)

MGB One of the Most Effective & Safest

MGB SeriesFindings in all series are the same:Short operation, low risk of short and long term

complicationsExcellent short and long term weight loss 75-100% EWL,

Better than BPD)Revisable and ReversibleMinimal 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

l.85 ± 0.8 day vs. 2.35 ± 1.89 day (p < 0.01)

Short-term complications 2.7% for primary vs. 11.6% for revisionnal MGB (p < 0.01)

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 leakage 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 patientseasily 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

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.

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 BPDDr 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.”

Randomized Controlled Prospective TrialsMGB 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%

Conclusions: MGB Best Rx for DM

1. Band/Sleeve/RNY/MGB2. Animal, Gen Surg and Bariatric Data:

Best Rx = Gastric + Duodenal Bypass3. Excludes Band/Sleeve4. RNY Unquestionably the Most Dangerous form of

Bariatric Surgery5. Numerous studies show MGB short safe and highly

effective; Best Choice

Which Is More Deadly Which 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 BBhttps://www.surveymonkey.com/s/IFSO-MGB-ConsensusConference

Or Email DrR@clos.net

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

A daily serving of processed meat Billroth II

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

AA BBhttps://www.surveymonkey.com/s/IFSO-MGB-ConsensusConference

Or Email DrR@clos.net

UNINFORMED FEAR BILLROTH IIEDUCATED 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 RiskThousands 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 BypassExcellent, 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 MeatsRx: H. Pylori, Eat Fruits & Veggies, Yogurt and Drink Green Tea

• Billroth II Probably Makes NO DifferenceBillroth II Probably Makes NO Difference

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 FASCRSCLOS-Florida: Heart of Florida Regional Medical Center.

Davenport, Floridadrperaglie@gmail.com

SECO 2012BARCELONA 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

•OUTCOMESOP-TIME: 62Min. (37-186), Conversion to open: 0LOS: 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 dayLeak: 0.3%MORTALITY: 0 (HOSPITAL), 0 (PERI-OP:90D)

RNY & Small Bowel Obstruction

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 TaughtTo Look For,

Be Vigilant and Fear

Bowel ObstructionAfter RNY

Gastric Bypass

Poor Follow UpMakes 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 BypassBy 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 ProcedureSafety and Effectiveness

Personal Experience, Animal Models, Expert Judgment, Published Data and Controlled Prospective Randomized

Trials all show:

MGB is More Effective than Sleeve \RNYMGB is Safer than Sleeve\RNY

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 DiseasesVolume 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 BypassPostgraduate 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

Society of Mini-Gastric Bypass SurgeonsIssues (To Do) List

00. ISSUES

01. FIRST PRINCIPLES

02. NAMING/RENAMING THE MINI-GASTRIC BYPASS

04. THE PRESENT SATE OF THE MGB

05. NATIONAL AND INTERNATIONAL RECOGNITION OF THE MGB

06. INTERNATIONAL MGB REGISTRY

07. MENTORING PROGRAMS FOR NEW MGB/OL SURGEONS

08. SHARING INFORMATION

09. MGB RESEARCH PLANS

10. STANDARD PRE-OP EVALUATION PROCESS

11. STANDARD PRE-OPERATIVE PERMIT

12. PREOP MANAGEMENT OF MINI-GASTRIC BYPASS

13. ANESTHESIA MANAGEMENT OF MINI-GASTRIC BYPASS

14. STANDARDIZED MGB OPERATIVE PROCEDURE

15. POST OPERATIVE MGB MANAGEMENT

16. MANAGEMENT OF MGB COMPLICATIONS

17. OTHER TOPICS (COMMITTEE’S SUGGESTIONS)

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.

https://www.surveymonkey.com/s/CCVote

Society of MGB SurgeonsMGB / OAGB Survey Respondents

https://www.surveymonkey.com/s/IFSO-MGB-ConsensusConference Or Email DrR@clos.net

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

Dr. Rutledge & Experts Around the World:We Want to Help You!

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

CONSIDERING THE MGB?

MGB IS A SUPERB SURGERY BUT…

WARNING:

“THERE ARE “TRICKS AND TRAPS”“THERE ARE “TRICKS AND TRAPS”

MGB Survey Findings

• Low VolumeLow Volume MGB Surgeons = Poorer Outcomes (Not as Bad as Sleeve or RNY)

• More Leaks• More Reflux• More Revisions• MoreMore Like the “Old Loop” Anatomy • LessLess Like Antrectomy & Billroth II Anatomy

Consensus Conference on MGB; Paris Oct 2012“TRICKS AND TRAPS” TRAINING PROGRAM

• Didactic SessionsTalk with the Leading World Experts

• Arrange for “Hands On Surgery” TrainingScrub on casesAssist and Participate in MGB Surgery

• Dr Rutledge & Dr Kular and other MGB experts World Wide

• USA 001-702-714-0011 DrR@clos.net

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

PRIMITIVE RESPONSE SYSTEMSMODIFY 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 DECISIONSFEAR 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

Agree Disagree

Know 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%

SURGERYHISTORY OF POOR DECISIONS

JOSEPH LISTER:

AMERICAN SURGEONS DELAYED ADOPTION OF ANTISEPSIS 10 YEARS

REPTILIAN BRAINPOOR DECISION MAKING

• Lister published antisepsis

paper:

• 1867

Dr. Gross; Gross Clinic 1875

(Un) Popularity of the MGB

• Confusion:MGB Not Old Mason Loop Gastric Bypass

• MGB = Antrectomy and BII

• Old Mason Loop = Total Gastrectomy + BII

PR.O.A.C.T METHODOLOGY• Pr: Define the Problem

• O: Objectives: Criteria for Success

• A: Alternatives: Available Options

• C: Consequences: Outcomes/Results

• T: Tradeoffs: Weigh Pros & Cons

• Different Systematic way to make decisions....

PR: STATE THE PROBLEM

• Obesity Epidemic

• History of Failure of Bariatric Surgical Procedures

• Selecting the “Ideal / BEST” Bariatric Surgical Procedure

PR: 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: 1-5% Leaks, 60-80% Late GE Reflux, Irreversible, High Rate Weight regain (Fail?)

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 Risk2. Major Weight Loss3. Easily performed4. Short operative times5. Outpatient or short hospital stay6. Minimal Blood Loss7. No Need for ICU Stay8. Minimal Pain9. Very High Patient Satisfaction10. A Good "Exit Strategy"

O: OBJECTIVES, SUCCESS CRITERIA"IDEAL" WEIGHT LOSS SURGERY

O: OBJECTIVES, SUCCESS CRITERIA"IDEAL" WEIGHT LOSS SURGERY11. Change Behavior & Preferences; Marked Decrease in Hunger

and Increased Satiety12. Minimal Retching and Vomiting 13. Few adhesions or hernias14. Minimal impact on Heart and Lung Function15. Low Failure Rate16. Low Cost17. Short Recovery Time18. Rapid Return to Work19. Low Risk of Pulmonary Embolus20. Durable weight loss

O: OBJECTIVES, SUCCESS CRITERIA"IDEAL" WEIGHT LOSS SURGERY

21. Low Risk of Ulcer22. Fat Malabsorbtion; low cholesterol & CV risk 23. No Plastic Foreign Body 24. Easily Verifiable Results; > 10 years of Results25. Low Risk of Bowel Obstruction26. Based upon sound surgical principles 27. Independent confirmation of results28. Healthy life after surgery29. Supported by LEVEL I Evidence; RCT (Controlled Prospective

Randomized Trial)30. Block “Sweet Eater” Failures

A: ALTERNATIVES

• RNY

• Band

• Sleeve

• MGB

MINI-GASTRIC BYPASS

• The Mini-Gastric Bypass1997 – 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 BYPASSBASED SOUND SURGICAL PRACTICE

• Billroth II Performed over 100 years

• 16,000 Billroth II’sUSA in 2007

• Operation of choice: Trauma, Ulcers, Cancer Stomach etc.

T: TRADEOFFS• Fear of Gastric Cancer \ Bile Reflux

• Rational vs. Reptilian Brain Decision Making

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 IIWHAT 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

BARIATRIC SURGEONS FEAR BILLROTH IIMAGNITUDE 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

BARIATRIC SURGEONS FEAR BILLROTH IIMAGNITUDE 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=

BARIATRIC SURGEONS FEAR BILLROTH IIGASTROENTEROLOGISTS 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.

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

Band Sleeve RNY MGB

Maybe Best Operation

Expert Opinion: Operation Judged Short and Simple

Band Sleeve RNY MGB

Short Simple Op

Expert Opinion: Failure is "VERY RARE"

Band Sleeve RNY MGB

Failure is Very Rare

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

Stopped Using the Band

Expert Opinions: Patients Routinely Get Major Weight Loss

Band Sleeve RNY MGB

Patients routinely get major weight loss

89% 89%

Expert Opinions: Patients RARELY Regain Their Weight

Band Sleeve RNY MGB

Patients RARELY Regain Their Weight

Expert Opinion: Patients RARELY Suffer Long Term Complications

Band Sleeve RNY MGB

Patients RARELY Suffer Long Term Complications

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

Band Sleeve RNY MGB

MGB Experts: Patients RARELY Suffer Long Term Complications

Expert Opinions: Procedure Advocates Reporting "No Leaks"

MGB Sleeve RNY

No Leaks %

Expert Opinions: Procedure Advocates Reporting a Leak

MGB Sleeve RNY

Surgeons WITH Leaks

Expert Opinion: Revision is Relatively Easy

Band Sleeve RNY MGB

Revision is relatively easy

RNY Band SG MGB1. 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" - - - + - - +

RNY Band Sleeve MGB11. 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 - - - +

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 + - - ++

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 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?

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

WHY CRITICS ONLY CARE FOR MGB?• 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 TURNTO 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 MAKINGSBO 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 MAKINGSBO VS. GASTRIC CANCER

FEAR AND DECISION MAKINGSBO VS. GASTRIC CANCER• 1,000 RNYs, Estimate 20% SBO => 200 operations for

SBO in 5-10 years (? How many more for 20 years?)

FEAR?SBO VS. GASTRIC CANCER• 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

• 1,000 MGBs After 20 years possibly increased risk of cancer of 1 / 1,000

• 1,000 MGBs After 20 years possibly increased risk of cancer of 1/1,000

• Deaths at 10 years from Gastric Cancer 0.0

FEAR?SBO VS. GASTRIC CANCER• 1,000 RNYs, 20% SBO => 200 operations for SBO in 5-10

years (? How many for 20 years?)

• 1,000 MGBs After 20 years possibly increased risk of 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?SBO VS. GASTRIC CANCER

• 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?

FEAR AND DECISION MAKINGSBO VS. GASTRIC CANCER

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

The Mini-Gastric Bypass:Best Treatment Type 2 Diabetes Mellitus

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procedure

chronic alkaline

small bowel

benign ulcer

decision making

bowel obstruction

billroth ii

Education

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