1. Failure of Sleeve, Band & RNY.
Power of Mini-Gastric Bypass.
&
Successful Treatment of
Obesity & Diabetes!
2. Medscape Medical News: Bypass Surgery for
Diabetes With Nonmorbid Obesity? Maybe
Marlene Busko: Jun 04, 2013
• "In a new report, RNY bypass in mildly to
moderately obese patients with
uncontrolled diabetes had better short-
term glucose control and weight loss than
their peers who received medications and
lifestyle advice."
• JAMA. 2013 Jun 5;309(21):2240-9. 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, Korner J, Lee WJ,
Connett JE, Inabnet WB, Billington CJ, Thomas AJ, Leslie DB, Chong K, Jeffery RW,
Ahmed L, Vella A, Chuang LM, Bessler M, Sarr MG, Swain JM, Laqua P, Jensen MD,
Bantle JP. Department of Surgery, School of Public Health, University of Minnesota,
Minneapolis, MN 55455, USA. ikram001@umn.edu
3. Medscape Medical News: Bypass Surgery for
Diabetes With Nonmorbid Obesity? Maybe
Marlene Busko: Jun 04, 2013
• Not metioned in the abstract:
• There were 22 serious complications in 60
RNY gastric-bypass patients (36%);
• 2 most serious complications Anastomotic
leaks (3.3%)
• 1 patient suffered anoxic brain injury.
• RNY patients were also more likely to
have other Complications such as
nutritional deficiencies.
4. Obesity surgery-diabetes study shows pros and
cons By LINDSEY TANNER | Associated Press –
Tue, Jun 4, 2013
• "About a third of the 60 RNY's developed
serious problems within a year of the
operation"
• "That rate is similar to what's been seen in
previous studies of RNY Bypass"
• "for the most serious complications —
infections, intestinal blockages and
bleeding — the rate was 6 percent"
5. Obesity surgery-diabetes study shows pros and
cons By LINDSEY TANNER | Associated Press –
Tue, Jun 4, 2013
• The most dangerous complication
occurred in one patient when stomach
contents leaked from the surgery site,
leading to an overwhelming infection, leg
amputation and brain injury.
• Lead author Dr. Sayeed Ikramuddin, an
obesity surgeon at the University of
Minnesota, called that case "a fluke."
6. Obesity surgery-diabetes study shows pros and
cons By LINDSEY TANNER | Associated Press –
Tue, Jun 4, 2013
• RNY pts lost nearly 60 lbs
• 75% lowered sugar levels to normal or
near normal levels
• JAMA editorial says such devastating
complications are rare, but that
• "the frequency and severity of
complications ... is problematic"
7. Medscape Medical News: Bypass Surgery for
Diabetes With Nonmorbid Obesity? Maybe
Marlene Busko: Jun 04, 2013
• Not metioned in the abstract:
• 22 serious complications in 60 RNYs
(36%);
• 2 most serious complications Anastomotic
leaks (3.3%)
• 1 patient suffered anoxic brain injury.
• RNY patients were also more likely to
have other Complications such as
nutritional deficiencies.
8. We Must Ask For Better
than:
36% Serious Complications
3% Leak Rate
A case of brain damage and Leg
Amputation is NOT
"a fluke"
Only 75% normal or improvement
9. Expert Judgment and
Latest Data on
Weight Loss Surgery
Procedures
Band, Sleeve,
RNY and
Mini-Gastric Bypass
10. A CLARION CALL FOR BETTER
BARIATRIC SURGERY
• RNY and VBG FAIL to cut costs or
Lengthen Life in VA Studies
• Bariatric Surgery; A History of
Complications & Failure
• We Need Better Bariatric Surgery
• We Simpler, Safer, More Powerful, More
Durable and Revisable and Reversible
• We Need the MGB
11. Primary Objectives
• Obesity and Diabetes are Growing
Problems in India
• Surgery Can Successfully Treat Obesity
and diabetes in Both the Thin and Obese
Diabetic Patient
• The Band, the Sleeve and the RNY are
failed forms of Bariatric Surgery
• The Mini-Gastric Bypass is Both Very Safe
and Very Effective Over the Short and
Long Term
17. Surgery Can Successfully Treat Obesity and
Diabetes in Both the Thin and Obese
Diabetic Patient
• 2011: Lee et al. MGB vs SLEEVE
• 12 mos prospective study 60 T2DM
patients
• Matched for DM duration, type of DM
treatment, and glycemic control
• Results
• T2DM resolved 93% MGB (p = 0.02)
• Weight loss fasting glucose, Hgba1c waist
circumfrence all worse in SG
18. RNYBypass Surgery for Diabetes With
Nonmorbid Obesity? Maybe Jun 04, 2013
• 12-months, 28 participants (49%) RNY group and 11
(19%) in the lifestyle-medical management group
achieved the primary end points
• BUT
• 22 (36%) 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
20. RNY Bypass Surgery for Diabetes With
Nonmorbid Obesity? Maybe Jun 04, 2013
• After 12-months, 28 participants (49%) in the gastric
bypass group and 11 (19%) in the lifestyle-medical
management group achieved the 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
22. Primary Objectives
• Obesity and Diabetes are Growing Problems in
India
• Surgery Can Successfully Treat Obesity and
diabetes in Both the Thin and Obese Diabetic
Patient
• The Band, the Sleeve and the RNY are failed
forms of Bariatric Surgery
• The Mini-Gastric Bypass is Both Very Safe and
Very Effective Over the Short and Long Term
23. The Band, the Sleeve and the
RNY are Failed forms of Bariatric
Surgery
Published Data
Expert Opinion
25. SUCCESS CRITERIA
"IDEAL" WEIGHT LOSS SURGERY
• 1. Low Risk (SAFETY)
• 2. Major Weight Loss (EFFICACY)
• 3. Easily performed
• 4. Short operative times (SAFETY)
• 5. Outpatient or short hospital stay (SAFETY)
• 6. Minimal Blood Loss (SAFETY)
• 7. No Need for ICU Stay (SAFETY)
• 8. Minimal Pain
• 9. Very High Patient Satisfaction
• 10. A Good "Exit Strategy" (SAFETY)
26. 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 (SAFETY)
• 14. Minimal impact on Heart and Lung Function (SAFETY)
• 15. Low Failure Rate (EFFICACY)
• 16. Low Cost
• 17. Short Recovery Time
• 18. Rapid Return to Work
• 19. Low Risk of Pulmonary Embolus (SAFETY)
• 20. Durable weight loss (EFFICACY)
27. SUCCESS CRITERIA
"IDEAL" WEIGHT LOSS SURGERY
• 21. Low Risk of Ulcer (SAFETY)
• 22. Fat Malabsorption; low cholesterol & CV risk (EFFICACY)
• 23. No Plastic Foreign Body (SAFETY)
• 24. Easily Verifiable Results; > 10 years of Results
(EFFICACY)
• 25. Low Risk of Bowel Obstruction (SAFETY)
• 26. Based upon sound surgical principles (SAFETY)
• 27. Independent confirmation of results (EFFICACY)
• 28. Healthy life after surgery (SAFETY)
• 29. Supported by LEVEL I Evidence; RCT (Controlled
Prospective Randomized Trial) (EFFICACY)
• 30. Block “Sweet Eater” Failures (EFFICACY)
28. Summary: Band, Sleeve & RNY
• In Short:
• Band: Now fading = Very Safe/NOT Very
Effective at 5 yrs
• Sleeve: Popular = Not very Safe/Fading
Effectiveness
• RNY: By Every Measure Most Dangerous
Bariatric Surgery & Effectiveness "Issues"
30. 28,000 Patients
• Ann Surg. 2011 Sep;254(3):410-20
First report from the
• American College of Surgeons
• Bariatric Surgery Center Network
28,000 Patients
Hutter MM, Schirmer BD, Jones DB, Ko
CY, Cohen ME, Merkow RP, Nguyen NT.
Department of Surgery, Massachusetts General
Hospital, Boston, MA 02114, USA.
mhutter@partners.org
36. Published Data:
ACS Study 28,000 pts: Conclusions
• Lap Band: Very Safe but 5 year Failure
• Sleeve: More Dangerous than Band and
following Band's track to 5 yr failure
• RNY: More effective but studies clearly
show long term weight regain and
recurrence of Diabetes
• RNY: Clearly the most dangerous Bariatric
Surgery (Remember 36% serious
complications and 3.3% Leak rate)
37. In Short-Published Data:
ACS Study 28,000 pts: Conclusions
• Lap Band: Safe but Fails
• Sleeve: Danger >> Band + 5 yr failure
• RNY; More effective but Most dangerous
• Needed: Safety and Effectiveness
• Mini-Gastric Bypass
38. Sleeve Gastrectomy Failure:
• Sleeve gastrectomy and the risk of leak: a
systematic analysis of 4,888 patients.
• “Risk of leak is low at 2.4%." !!
• Surg Endosc. 2012 Jun;26(6):1509-15. Epub 2011 Dec
17. Aurora AR, Khaitan L, Saber AA. Department of
Surgery, University Hospitals Case Medical Center,
Cleveland, Ohio
40. Survey Results
• As part of a Pre-Conference survey for the
• MGB/OAB Consensus Conference
• Asked Expert Surgeons to Judge 4 weight loss
procedures.
• This is a report Expert Judgment of the Band,
the Sleeve, RNY and the MGB
41. 12. Your Opinion about the LAP BAND
• LAP BAND is good, short simple surgery,
maybe the best form of WLS, I use it often
7.1%
• LAP BAND is OK it is an acceptable
alternative and I use it sometimes 46.4%
• LAP BAND is a Bad operation and should
not be used 46.4%
42. 13. Your Opinion about the
SLEEVE
• SLEEVE is Good, short simple surgery,
maybe the best form of WLS, I use it often
32.1%
• SLEEVE is OK it is an acceptable
alternative and I use it sometimes 53.6%
• SLEEVE is a Bad operation and should
not be used 14.3%
43. 14. Your Opinion about the RNY
• RNY is Good, maybe the best form of
WLS, I use it often 42.9%
• RNY is OK it is an acceptable alternative
and I use it sometimes 50.0%
• RNY is a Bad operation and should not be
used 7.1%
44. 15. Your Opinion about the Mini-Bypass /
One Anastomosis Bypass
• MGB is good, short simple surgery, maybe
the best form of WLS, I use it often 67.9%
• MGB is OK it is an acceptable alternative
and I use it sometimes 28.6%
• MGB is a Bad operation and should not be
used 3.6%
45. MGB: Fewest Negative
Judgments
• 46.4% said the Band was a bad operation
• 14.3%, 7.1% and 3.6% said the Sleeve, the RNY
and the MGB were bad operations and should
not be done.
• By this measure experts judged the band the
least favorable operation and the MGB the best
choice.
46. MGB: Most Often Judged Best
• These experts judged the MGB most often to be
a "good, short simple surgery, maybe the best
form of WLS, I use it often" in 67.9% of cases as
compared to
• 7.1%, 32.1% and 42.9% for the band, the sleeve
and the RNY respectively.
• In these expert's opinion the MGB is by far the
best judged form of weight loss surgery.
54. Failed Sleeve Converted to RNY; Sept 2012
Less 24 months!
• Failed Sleeve:
• Weight loss
• Diabetes Rx
• SEVERE Reflux symptoms.
• Time to Failure less than 24 months.
• 30% for "Severe Reflux"!!!!
• Indications and Mid-Term Results of Conversion from Sleeve Gastrectomy to Roux-
en-Y Gastric Bypass. Authors Gautier T, et al. Obes Surg. 2012 Sep 23. Département
de Chirurgie Digestive, Caen University Hospital, Caen Cedex, France,
gautier.tho@gmail.com.
55. Why the Band and Sleeve Fail
Restrictive Procedures and Sweet
and "Liquid Calories"
56. Band, Sleeve vs
the Neuro-Humoral Drive to Eat
• Restrictive Procedures
• MAKE SWEET EATERS:
• Mechanical Block of
Normal Healthy Foods
• Weight Loss: Honeymoon 2 years
• Then Failure Weight Regain
• GE Reflux
(Risk of Esophageal Cancer)
57. Band & Sleeve
Block Normal Healthy Foods
• Weight Loss =>
• Increased Hunger
• Decreased Satiety
• Healthy Foods Blocked
• Drive to Eat UP
• What Happens?
62. Summary
• Most Diets &
Restrictive Procedures (Band/Sleeve)
Will Fail
• Attempts to Override
Neuro-Humoral Hunger System
Routinly Fails
• R.P.s Force Patients into Pathological
Dietary Choices
• MAKE SWEET EATERS!
63. Primary Objectives
• Obesity and Diabetes are Growing Problems in
India
• Surgery Can Successfully Treat Obesity and
diabetes in Both the Thin and Obese Diabetic
Patient
• The Band, the Sleeve and the RNY are failed
forms of Bariatric Surgery
• The Mini-Gastric Bypass is Both Very Safe and
Very Effective Over the Short and Long Term
67. Mini-Gastric Bypass
• Blocks
Neuro-Humoral Hunger
System
• Short, Simple, Durable,
30 minute Surgery that:
• Decreases Hunger &
Increases Satiety
The Mongoose
He is a Little Bit Ugly, No?
68. One Thousand Consecutive Mini-gastric Bypass:
Short- And Long-term Outcome (Noun)
• 1,000 patients who underwent MGB
• Operative time and length of stay for MGB
• 89 min
• 1.8 days
• 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, Naccache, Achrafieh, BP 166830 Beirut, Lebanon.
rnoun@wise.net.lb
69. One Thousand Consecutive Mini-gastric Bypass:
Short- And Long-term Outcome (Noun)
• 0.5% Leaks
• Four (0.4%) patients, 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 73%
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, Naccache, Achrafieh, BP 166830 Beirut, Lebanon. rnoun@wise.net.lb
70. 9 Year MGB Follow Up
Efficacy & Safety
• Excess weight loss and mean BMI 5 years after LMGB
was 72.1% and 27.1
• Of the 1322 patients, 23 (1.7%) reop surgery during a
follow-up of 9 years.
• The most common cause of revision was excess wt loss
in 9, followed by inadequate weight loss in 8, and bile
reflux in 3.
• No internal hernia or ileus during the follow-up period.
• Conclusion: MGB Excellent Durable Long Term Safe (No
Hernia/Bowel Obstruction)
• Surg Obes Relat Dis. 2011 Jul-Aug;7(4):486-91.Revisional surgery for laparoscopic minigastric bypass. Lee WJ,
Department of Surgery, Min-Sheng General Hospital, National Taiwan University, Taipei, Taiwan.
wjlee_obessurg_tw@yahoo.com.tw
71. RNY Doubles the need for
hospitalisation
• In California from 1995 to 2004,
• 60,077 patients underwent RYGB-
11,659 in 2004 alone.
• The rate of hospitalization in the year
following RYGB was more than
double the rate in the year preceding
RYGB
• (19.3% vs 7.9%, P<.001).
• Hospitalization before and after gastric bypass surgery. Zingmond DS, McGory ML,
Ko CY. JAMA. 2005 Oct 19;294(15):1918-24.
72. MGB Decreases the Hospitalization
After Surgery
• The rate of hospitalization after MGB
• Declined from 17% the year before to
11% the year after and 2/3 of these
admisions were unrelated to MGB
• Hospitalization before and after mini-gastric bypass surgery.
Rutledge R. Int J Surg. 2007 Feb;5(1):35-40. Epub 2006 Aug 10
73. 2011: Lee et al. MGB vs SLEEVE
• 12 mos prospective study 60 T2DM
patients
• Matched for DM duration, type of DM
treatment, and glycemic control
• Results
• T2DM resolved 47% SG and 93% GBP (p
= 0.02)
• Weight loss fasting glucose, Hgba1c waist
circumfrence all worse in SG
74. 2011: Lee et al. RYGB vs SLEEVE
(Efficacy)
• Controlled Prospective Trial: SG is only
HALF as effective as MGB in inducing
remission of T2DM
50% 90%
76. What Do the Experts Say?
Survey of 102 surgeons answered
detailed survey online.
Surgeons from 6 Continents and 23
countries.
The group reported on a
past year's experience with over 39,000
cases, Very experienced surgeons.
92. Leak Rate
• Leak Rate in New Multicenter trial
• 3.3%!!
• 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, Korner J, Lee WJ, Connett JE, Inabnet WB, Billington CJ,
Thomas AJ, Leslie DB, Chong K, Jeffery RW, Ahmed L, Vella A, Chuang
LM, Bessler M, Sarr MG, Swain JM, Laqua P, Jensen MD, Bantle JP.
• JAMA. 2013 Jun 5;309(21):2240-9.
93. Band/Sleeve
Road to Failure
Initial Weight Loss
Return of Hunger
Eat Normal Foods
Obstruction
Acid Reflux/Cancer
Eat Liquid Calories
Weight
Regain
94. Expert Opinion In Summary
• Restrictive Procedures Fail (Band Sleeve)
• Starting at 2-5 Years
• Restrictive Procedures Push Patients towards
Liquid Calories
• (Can a Sleeve stop Coke!)(Can a Sleeve stop Coke!)
• Weight Regain is Common
• Acid Reflux 30%+
• Acid Reflux = Esophageal Cancer
97. 2006: Rubino et al.
Duodenal exclusion
• “This study shows that bypassing Duodenum
directly ameliorates type 2 diabetes,
• independently of effects on food intake, body
weight, malabsorption, or nutrient delivery to the
hindgut.”
• 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, Francesco, MD; Forgione, Antonello, MD;
Cummings, David E MD; Vix, Michel MD; Gnuli, Donatella MD; Mingrone, Geltrude MD; Castagneto, Marco, MD
(S); Marescaux, Jacques MD, FRCS Annals of Surgery; 244 (5): 741-749, November 2006
98. Outcome after gastrectomy in gastric
cancer patients with type 2 diabetes
• 403 gastric cancer patients with T2DM
• BMI % Reduction
• Duodenal Bypass:
• No Bypass 7.6%
• Bypass 11.4%
• 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.
99. Bile Acids: Critical Hormonal
Factors in glucose homeostasis
• Decrease in the bile acid pool results in
decreases in hemoglobin A1c, glucose
levels and improved insulin sensitivity.
• Duodenal bypass improve the success in
the resolution of diabetes.
• Combined procedures include duodenal
bypass which leads to decrease in bile
acid pool.
100. The Mini-Gastric Bypass
Excellent Operation with Results Reported on
Thousands of Patients Over the Past 10-15 years
• Survey Shows:
• Short, Simple, Effective, Durable,
• 30 min Operation with 1 day Hospital
Stay
• Lower Leak rate than Sleeve or RNY
• Best Weight Loss
• Easily Reversible, Revisable
101. Primary Objectives
• Obesity and Diabetes are Growing Problems in
India
• Surgery Can Successfully Treat Obesity and
diabetes in Both the Thin and Obese Diabetic
Patient
• The Band, the Sleeve and the RNY are failed
forms of Bariatric Surgery
• The Mini-Gastric Bypass is Both Very Safe and
Very Effective Over the Short and Long Term
102. Conclusions
• Sleeve: popular now; Relatively
Dangerous and shows Band's signs of
5 year failure and new onset GERD in
30%
• MGB short simple reversible and revisable
operation may be up to twice as effective
as Sleeve and has excellent long term
durability
103. Marginal Ulcer has been known since the
beginning GI Surgery
MARGINAL, GASTROJEJUNAL OR PEPTIC ULCER
SUBSEQUENT TO GASTROENTEROSTOMY.
Erdmann JF.
Ann Surg. 1921 Apr;73(4):434-40.
104. 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)
105. UNINFORMED FEAR BILLROTH II
EDUCATED USE BILLROTH II
• 3. Some studies Slight Increased Risk of
gastric cancer after 20 – 30 years (RR 1.5):
But: BII 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
106. UNINFORMED FEAR BILLROTH II
EDUCATED USE BILLROTH II
• 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
107. 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!!!