Marginal Ulcer & Gastric Bypass

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

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

Dr. RutledgeUSA 001-702-714-0011 DrR@clos.net

CONSIDERING THE MGB?MGB IS A SUPERB SURGERY BUT…WARNING:

“THERE ARE “TRICKS AND TRAPS”

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 DrR@clos.net• 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 DrR@clos.net

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 DrR@clos.net

Problem Definition:Bariatric Surgery: A HISTORY OF FAILURE

The Gastric Sleeve:Not as Bad as the BandNot as Dangerous as the RNY

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"

SUCCESS CRITERIA"IDEAL" WEIGHT LOSS SURGERY

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

SUCCESS CRITERIA"IDEAL" WEIGHT LOSS SURGERY

21. Low Risk of Marginal Ulcer22. Fat Malabsorption; 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

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’s• USA in 2007• Operation of choice:

Trauma, Ulcers, Cancer Stomach etc.

Criteria for Success; Ideal Weight Loss Surgery

Criteria for Success; Ideal Weight Loss Surgery

Criteria for Success

Epidemiology: What do we know about Marginal Ulcers?

Marginal ulcers represent one of the most problematic postoperative complications following Roux-en-Y

A marginal ulcer, or stomal ulceration, refers to the development of mucosal erosion at the gastrojejunal anastomosis, typically on the jejunal side.

incidence of marginal ulcers is 0.6 to 16 %The true incidence is very likely much higher

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.

Marginal Ulcer has been known since the beginning GI Surgery

THE ROENTGEN DIAGNOSIS AND LOCALIZATION OF MARGINAL PEPTIC ULCER.

Carman RD.

Cal State J Med. 1920 Nov;18(11):377-82

Marginal Ulcer has been known since the beginning GI Surgery

Re-evaluation of the role of the pyloric antrum in marginal peptic ulcers.

SCHILLING JA, PEARSE HE.

Surg Gynecol Obstet. 1948 Aug;87(2):225-34

Marginal Ulcer has been known since the beginning GI Surgery

Vagotomy as a treatment for marginal ulcer.

CRILE G Jr, BROWN GM Jr.

Gastroenterology. 1951 Jan;17(1):14-9

Marginal Ulcer has been known since the beginning GI Surgery

Review Article: The present status of the management of marginal ulcer.

BYRD BF Jr.

J Tn State Med Assoc. 1953 Feb;46(2):56-8.

Marginal Ulcer has been known since the beginning GI Surgery

2,282 RYGB122 (5%) Marginal ulcers 39 (32%) Surgery Surg Obes Relat Dis. 2009 May-Jun;5(3):317-22. Revisional operations for marginal ulcer

after Roux-en-Y gastric bypass. Patel RA, Brolin RE, Department of Surgery, University Medical Center at Princeton, Princeton, New Jersey 08536

Marginal Ulcer Very High After RNY Gastric Bypass

441 RYGB10 (12%) of RNY gastric bypass presented an "early"

marginal ulcerAsymptomatic (28%) Obes Surg. 2009 Feb;19(2):135 Incidence of marginal ulcer 1 month and 1 to 2 years after

gastric bypass: a prospective consecutive endoscopic evaluation of 442 patients with morbid obesity. Csendes A et al Department of Surgery, University Hospital, University of Chile, Santiago, Chile.

Marginal Ulcer Very High After RNY Gastric BypassAssociated with H. Pylori

260 RYGB7% of RNY gastric bypass marginal ulcerH. pylori infection, (treated), was twice as common

marginal ulceration (32%) as among those who did not (12%)

Surg Endosc. 2007 Jul;21(7):1090-4. Marginal ulceration after laparoscopic gastric bypass: an analysis of predisposing factors in 260 patients. Rasmussen JJ, Department of Surgery, University of California, Davis, 2221 Stockton Boulevard, Sacramento, CA 95817, USA

Marginal Ulcer after Gastric Bypass; Both RNY & MGBMarginal Ulcers after Roux-en-Y Gastric Bypass:

Pain for the Patient…Pain for the Surgeonby Camellia Racu, January 2010Bariatric Times. 2010;7(1):23–25

Marginal Ulcer after Gastric Bypass; RNY

Marginal Ulcer after Gastric Bypass; RNY & MGBMarginal ulcers RNY ranging from 0.6 to 16%True incidence is very likely much higherCsendes prospective study routine postoperative endoscopic evaluation28% of marginal ulcers were asymptomaticGastric Bypass (RNY & MGB)HIGH incidence of Marginal UlcerBILE MAKES NO DIFFERENCE!!!

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) monthsMorbidity and mortality rate was 30% and 10%Perforated GJA ulcers can develop in 1 of 120 Roux

en Y Gastric Bypasses & DEADLY

Marginal Ulcers: Achilles Heel of Gastric BypassManagement1. Warn Patients & Surgeon “Be Vigilant”2. Aggressive anti-H. Pylori Rx3. Aggressive use of Antacids4. Strict Avoidance of Ulcerogenic Agents (NSAIDS, Etoh, Smoking, Coffee, Soda, Nitrates)5. Encourage: Probiotics, Yogurt, Fruits VegetablesBILE MAKES NO DIFFERENCE!!!

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 in RNY & MGB• Rational Decision Making: • Best Choice; Mini-Gastric Bypass

WHY CRITICS ONLY WORRY ABOUT THE MINI-GASTRIC BYPASS?

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 WORRY ABOUT THE MINI-GASTRIC BYPASS?

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 WORRY ABOUT THE MINI-GASTRIC BYPASS?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 WORRY ABOUT THE MINI-GASTRIC BYPASS?• 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

CRITICS OF THE MINI-GASTRIC BYPASS

SHOULD BE EMBARRASSED

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