PROACT

The Mini-Gastric Bypass: Best Treatment Type 2 Diabetes MellitusDr K S KularKular Medical Education & Research Society ,Kular Group of Institutes ,drkskular@gmail.comwww.kularhospital.com

WHY MGB?Why Consider the MGB?With the Band/Sleeve/RNY availableWhy even consider the Mini-Gastric Bypass?

Is Bariatric Surgery Worth It?Comment on Impact of Bariatric Surgery on Health Care Costs of Obese PersonsEdward H. Livingston, MDJAMA Surg. 2013;148(6):561

Why Consider MGB?Long Term Failure of Band / RNY6 yr study 29,820 BCBS plan members. "Laparoscopic RNY and Lap Band both Fail to reduce overall health care costs in the long term."

Impact of Bariatric Surgery on Health Care Costs of Obese Persons, A 6-Year Follow-up of Surgical and Comparison Cohorts Using Health Plan Data Jonathan P. Weiner, et al. JAMA Surg. 2013;148(6)

Long-term follow-up from the Swedish Obese Subjects study reported in JAMA showed that although fewer medications were used by bariatric patients compared with controls, the bariatric patients used substantially more hospital resources.

A formal cost-effectiveness study using very high-quality data from the US Department of Veterans Affairs did not show a cost benefit for Roux-en-Y gastric bypass.

Band/RNY Failure to Demonstrate benefitAnalysis of BlueCross Blue Shield patients for 6 years failed to demonstrate a benefit for Band or RNY Coupled with findings that bariatric surgery confers little to no long-term survival benefit,4 these observations show that bariatric surgery does not provide an overall societal benefit. xxx

Band & RNY fail to reduce healthcare costsHealthcare Costs of RNY and BandRNYBand

Why Consider MGB?

Why Consider Mini-Gastric Bypass?

Best Rx for Diabetes5 Objectives1. 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 BypassData from General Surgery, Bariatric Reports, Animal Studies

Objective 2: Animal Models ConfirmDuodenal 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 + BypassPrimary Gastric Procedure (PGP)VsCombined 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 TrainingGS for Gastric Disease (Ca/Ulcer)Gastrectomy ALONE 50%Gastrectomy + Duodenal Bypass 75%Rx T2D MUST Include Duodenal Bypass for BEST short and long term EfficacyG.O. Less Effective G+D G.O.=Gastric Only vs G+D=Gastric + Duodenal

Outcome after gastrectomy in gastric cancer patients with type 2 diabetes403 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): 4954.

Objective 2: General Surgery"Effect of GastrectomyForStomachCanceron Type 2Diabetes 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: Gastrectomyforstomachcanceron type 2diabetes (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.

LeeWJ,Hur KY,Lakadawala M,Kasama K,Wong SK,LeeYC.

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

Objective 2: MGB vs SleeveMini-Gastric bypassvsSleeveGastrectomy for type 2diabetes mellitus: a RandomizedControlled Trial

LeeWJ, Chong K, Ser KH,LeeYC, Chen SC, Chen JC, Tsai MH, Chuang LM. Arch Surg. 2011 Feb

Objective 2: Lee MGB vs SleeveRandomized Controlled TrialRandomizedcontrolled trial 60 moderately obese patients (body mass index >25 and 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 FailTherefore ALWAYS CHOOSEOperation that Can Be Revised Safely!!NEVER CHOOSE Operation Revision is Dangerous!

Revision of MGB: Easily Done Rarely Needed

Revisional Surgery For Laparoscopic Mini-Gastric BypassWei-JeiLee, M.D., Ph.D. ,Yi-ChihLee, Ph.D.,Kong-HanSer, M.D.,Shu-ChunChen, R.N.,Jung-ChienChen, M.D.,Yen-HowSu, M.D.

Surgery for Obesity and Related Diseases Volume 7, Issue 4, Pages 486-491, July 2011

Revision of MGB: Easily Done Rarely NeededJanuary 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 casesInadequate 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 BypassParis in October 2012.

The IFSO-EC Mini-Gastric BypassPostgraduate Course in Barcelona in April 2012 was a notable successAs 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) List00. ISSUES01. FIRST PRINCIPLES02. NAMING/RENAMING THE MINI-GASTRIC BYPASS04. THE PRESENT SATE OF THE MGB05. NATIONAL AND INTERNATIONAL RECOGNITION OF THE MGB06. INTERNATIONAL MGB REGISTRY07. MENTORING PROGRAMS FOR NEW MGB/OL SURGEONS08. SHARING INFORMATION09. MGB RESEARCH PLANS10. STANDARD PRE-OP EVALUATION PROCESS11. STANDARD PRE-OPERATIVE PERMIT12. PREOP MANAGEMENT OF MINI-GASTRIC BYPASS13. ANESTHESIA MANAGEMENT OF MINI-GASTRIC BYPASS14. STANDARDIZED MGB OPERATIVE PROCEDURE15. POST OPERATIVE MGB MANAGEMENT16. MANAGEMENT OF MGB COMPLICATIONS17. OTHER TOPICS (COMMITTEES SUGGESTIONS)

IFSO EC Mini-Gastric Bypass Post Grad Course, April BarcelonaThe 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 Surgeons MGB / OAGB Survey Respondentshttps://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.netCONSIDERING THE MGB? MGB IS A SUPERB SURGERY BUT WARNING: THERE ARE TRICKS AND TRAPShttps://www.surveymonkey.com/s/CCVote Or Email DrR@clos.net

MGB Survey FindingsLow Volume MGB Surgeons = Poorer Outcomes (Not as Bad as Sleeve or RNY)More LeaksMore RefluxMore RevisionsMore Like the Old Loop Anatomy Less Like Antrectomy & Billroth II Anatomy

Consensus Conference on MGB; Paris Oct 2012 TRICKS AND TRAPS TRAINING PROGRAMDidactic Sessions Talk with the Leading World ExpertsArrange for Hands On Surgery Training Scrub on cases Assist and Participate in MGB SurgeryDr Rutledge & Dr Kular and other MGB experts World Wide USA 001-702-714-0011 DrR@clos.net

Irrational Illogical Thinking Decision-Making ErrorsConfirmation 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 thinkinghttps://www.surveymonkey.com/s/IFSO-MGB-ConsensusConference Or Email DrR@clos.net

PRIMITIVE RESPONSE SYSTEMS MODIFY RISK ASSESSMENThttps://www.surveymonkey.com/s/CCVote Or Email DrR@clos.net

THE REPTILIAN BRAIN: EMOTION & DECISION MAKINGRational Logical Thinking: Frontal LobeAmygdala Interferes with the Frontal lobePrimitive, Impulsive Irrational decision-makinghttps://www.surveymonkey.com/s/CCVote Or Email DrR@clos.net

IRRATIONAL ILLOGICAL THINKING CONFIRMATION BIASContrary Evidence => Maintains or strengthens present beliefsOverconfidence in present beliefs Poor Decision MakingEspecially Present in Organizations, Military, Political & Social Groupshttps://www.surveymonkey.com/s/CCVote Or Email DrR@clos.net

REPTILIAN BRAIN POOR DECISIONS FEAR LEADS TO JUDGMENT ERRORS Errors in Risk AssessmentDeath Airplane CrashDeath Car Crash1 in 10,000 patient / 20 years risk of gastric cancerBowel Obstruction from internal hernia +16% in 15 months!https://www.surveymonkey.com/s/CCVote Or Email DrR@clos.net

Surgeons Who Fear Gastric Cancer =Don't Know Much About Gastric CancerSurgeons who say MGB = Bad, Because of the Risk of CancerDon't know the Risk of Cancer in the General PopulationDon't know the risk of gastric cancer in Billroth IIDon't Fear the Risk of Bowel Obstruction from internal hernia +16% in 5 yearsDon'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

QuestionAnswerH. 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 establishedAgree 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 foodsAgree 100%

QuestionAnswerThere 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 CancerAgree 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%

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

REPTILIAN BRAIN POOR DECISION MAKING

Lister published antisepsis paper: 1867Dr. Gross; Gross Clinic 1875

HUMAN DECISION MAKING ERRORS: EXPECTED, NOT RARERealization of Fallibility Human Decision MakingHumilitySocratic Questioning of AssumptionsSearch for Logical & Rational Decision Making Tools & Techniqueshttps://www.surveymonkey.com/s/IFSO-MGB-ConsensusConference Or Email DrR@clos.net

(Un) Popularity of the MGBConfusion: MGB Not Old Mason Loop Gastric BypassMGB = Antrectomy and BIIOld Mason Loop = Total Gastrectomy + BIIhttps://www.surveymonkey.com/s/IFSO-MGB-ConsensusConference Or Email DrR@clos.net

PR.O.A.C.T METHODOLOGYPr: Define the ProblemO: Objectives: Criteria for SuccessA: Alternatives: Available OptionsC: Consequences: Outcomes/Results T: Tradeoffs: Weigh Pros & ConsDifferent Systematic way to make decisions....https://www.surveymonkey.com/s/IFSO-MGB-ConsensusConference Or Email DrR@clos.net

PR: STATE THE PROBLEMObesity EpidemicHistory of Failure of Bariatric Surgical ProceduresSelecting the Ideal / BEST Bariatric Surgical Procedurehttps://www.surveymonkey.com/s/IFSO-MGB-ConsensusConference Or Email DrR@clos.net

PR: Problem Definition: Bariatric Surgery: A HISTORY OF FAILURE

Sleeve Consensus Meeting?19 surgeons have shared their data and consensus has been sought on specific points related to sleeve onlyMean 12% acid refluxMany showing 20% refluxMany showing 40 % weight loss failure ( < 50 % EWL )https://www.surveymonkey.com/s/CCVote Or Email DrR@clos.net

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 SURGERY21. 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

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

MINI-GASTRIC BYPASSThe Mini-Gastric Bypass 1997 2011 ; >6,000 pts, 10 yr Data; Multiple Centers, R.C.TrialsVertical Gastric Tube (Collis Gastroplasty)Gastric Bypass (Billroth II Gastro-jejunostomy)https://www.surveymonkey.com/s/IFSO-MGB-ConsensusConference Or Email DrR@clos.net

MINI-GASTRIC BYPASS BASED SOUND SURGICAL PRACTICE Billroth II Performed over 100 years16,000 Billroth IIs USA in 2007Operation of choice: Trauma, Ulcers, Cancer Stomach etc.

T: TRADEOFFSFear of Gastric Cancer \ Bile RefluxRational 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 DECLININGThe incidence of gastric cancer in the United States has Decreased four-fold since 1930 Approximately 7 cases per 100,000 people. https://www.surveymonkey.com/s/IFSO-MGB-ConsensusConference Or Email DrR@clos.net

BARIATRIC SURGEONS FEAR BILLROTH II; CANCER SURGEONS CHOOSE BILLROTH II1,490 articles on performance of the Billroth IIGeneral/Trauma/Oncologic surgeons commonly use the Billroth IIOver 16,000 Billroth II operation performed in USA 2007While Bariatric Surgeons Fear the Billroth II General Surgeons use the Billroth II routinelyhttps://www.surveymonkey.com/s/CCVote Or Email DrR@clos.net

BARIATRIC SURGEONS FEAR BILLROTH II WHAT IS MAGNITUDE OF THE PROBLEMMayo Clinic Study (Example)338 Billroth II patients Followed 25-years5,635 person-yearsOnly 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 II MAGNITUDE OF THE PROBLEMPopulation based study, 338 Billroth II pts Followed 25-years5,635 person-yearsOnly 2 Cancers Found in 5,000 yearsPredicted 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 II MAGNITUDE OF THE PROBLEM338 Billroth II pts, Followed 25-years5,635 person-yearsOnly 2 Cancers in 5,000 pt years follow upRATE of Gastric Cancer is Declining24 - 50% Expected Decrease from 1983Future risk ~1 patient / 5,000 pt years

ULCERS INCREASE RISK CANCERMeta-analysis: 7 studies Small increased risk 5 studies No Increased RiskStudies with increased Risk; FlawedBillroth II = Surgery Rx UlcersULCERS increase risk of Gastric Cancer!Ulcers and Gastric Cancer Common Etiology =H. Pylori=

ULCERS INCREASE RISK CANCER3,078 gastric cancer vs. 89,082 controlsUlcer 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 CancerUlcers & Gastric Cancer:Common Etiology =H. Pylori=

BARIATRIC SURGEONS FEAR BILLROTH II GASTROENTEROLOGISTS IGNORE BILLROTH IIHundreds of thousands of people with Billroth IIsIf cancer IS SUCH A BIG RISKShouldnt gastroenterologists be looking for these people, screening them with endoscopy?No, there is no recommendation for BII follow up screening; Why? THE RISK IS LOW63,000 yrs Follow up 23 cancers = Gen Pop.

RISK OF GASTRIC CANCERAFTER BILLROTH II IS LOWFollow-up study of 1000 patients22-30 year follow-up196 endoscopy and biopsy No Cancer of the gastric remnant seenEndoscopic 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 IIDiets 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 PREVENTIONAvoid ETOH, Tobacco, Processed & Preserved Meats, SaltRX H. Pylori, Eat Fruits and Veggies, Yogurt and Drink Green Tea

Gonzalez CA, Cancer Research, Institut Catal d'Oncologia, Av. Gran Via s/n, km 2.7, 08907 L'Hospitalet, Barcelona, Spain.

T: TRADEOFFS FEAR OF GASTRIC CANCER A Billroth II Probably Makes No Difference

T: TRADEOFFS FEAR OF GASTRIC CANCERA 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 BypassPr: Choice of Obesity SurgeryO: Objectives Ideal Weight Loss SurgeryA: RNY, Band, Sleeve, MGBC: MGB meets almost all objectives/success criteria T: Fear of Bile Reflux & Gastric Cancer Not Supported by the DataRational Decision Making: Best Choice; Mini-Gastric Bypass

WHY CRITICS ONLY CARE FOR MGB?Why do Critics only care about the Mini-Gastric Bypass?100,000s of people already have and are living with and are getting the Billroth II every dayWhy havent 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 havent 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 dont 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 havent concerned bariatric surgeons stepped forward to national funding for lifetime endoscopic screening of Billroth II patients to find dreaded gastric cancers?It seems odd doesnt it?There is a simple reason

WHY CRITICS ONLY CARE FOR MGB?There is a simple reasonThe critics of the MGB do not do those things because they are ...Such actions are Not supported by the dataThe Billroth II and the MGB are both good operationsPublished data Does Not support the critics misreading of the medical literature

THE TIDE BEGINS TO TURN TO THE MINI-GASTRIC BYPASSNot 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 RNYNew 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 & RNYFollow 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 CANCERWhich is more Deadly?

Gastric Cancer or Small Bowel Obstruction?

Which is more fearsome?

11+ RNY STUDIES INTERNAL HERNIA BOWEL OBSTRUCTION1 - 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 OBSTRUCTION877 patients who underwent 1,007 operations for SBO from 1961 to 1995Risk of bowel obstruction increases over time52 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 SBO VS. GASTRIC CANCERWhich is more Deadly?Gastric Cancer or Small Bowel Obstruction?Which is more fearsome?

FEAR AND DECISION MAKING SBO VS. GASTRIC CANCER1,000 RNYs, Estimate 20% SBO => 200 operations for SBO in 5-10 years (? How many more for 20 years?)

FEAR? SBO VS. GASTRIC CANCER1,000 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? SBO VS. GASTRIC CANCER1,000 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 SBO1,000 MGBs After 20 years possibly increased risk of cancer of 1 / 1,000

FEAR? SBO VS. GASTRIC CANCER1,000 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 SBO1,000 MGBs After 20 years possibly increased risk of cancer of 1/1,000Deaths at 10 years from Gastric Cancer 0.0

FEAR? SBO VS. GASTRIC CANCER1,000 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 SBO1,000 MGBs After 20 years possibly increased risk of cancer of 1/1,000Death at 10 years from Gastric Cancer 0.0Death SBO 12/10 years, Deaths Gastric Cancer 10-20 years 0-1

WHICH DO YOU FEAR? SBO VS. GASTRIC CANCER1,000 RNYs = 200 SBO operationsDeath from RNY SBO 12 deaths / 10 years1,000 MGBs 0-1 Gastric Cancer @ 20 yrsDeaths Gastric Cancer 10-20 years 0-1?

FEAR AND DECISION MAKING SBO VS. GASTRIC CANCERWhich is more Deadly?Gastric Cancer or Small Bowel Obstruction?Which is more fearsome?

FOLLOW UP EFFECTUnbiased Population based studies => Poor Results of RNYPositive Results of RNY reported from RNY centers Suffer from Follow Up EffectPatient Returns to clinic doing well: Greeted Warmly with Great JoyPatient Returns to clinic doing poorly: Greeted with anger and disapprovalSuccessful pt => Good Follow Up / Failed pt tacitly sent awayNow; Center reports excellent results; (30%) follow upWeight Regain, Band Erosion, Death Not Seen, Not Reported