Safe and Effective Treatment of Diabetes

Failure of Sleeve, Band & RNY.Power of Mini-Gastric Bypass.

&Successful Treatment of

Obesity & Diabetes!

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. [email protected]



• 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.

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"


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."


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"



• 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.

We Must Ask For Betterthan:

36% Serious Complications3% Leak Rate

A case of brain damage and Leg Amputation is NOT

"a fluke"Only 75% normal or improvement

Expert Judgment andLatest Data on

Weight Loss Surgery Procedures

Band, Sleeve,RNY and

Mini-Gastric Bypass

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

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

Obesity and Diabetes are Growing Problems in India

India the worlds with largest number of diabetics

Obesity and Diabetes are Growing Problems in India

Surgery Can Successfully Treat Obesity and Diabetes in Both the Thin and Obese

Diabetic Patient

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

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. [email protected]

The Band, the Sleeve and the RNY are

Failed forms of Bariatric Surgery

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. [email protected]

The Mini-Gastric Bypass is Both Very Safe and

Very Effective Over the Short and Long Term

Primary Objectives





The Band, the Sleeve and the RNY are Failed forms of Bariatric

SurgeryPublished Data

Expert Opinion

SUCCESS CRITERIA"IDEAL" WEIGHT LOSS

SURGERY

SAFETY & EFFICACYSAFETY & EFFICACY

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)


• 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)


• 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)

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"

Summary: Band, Sleeve & RNY

•Published Data

•Expert Opinion

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. [email protected]

Band

Sleeve

RNY

Band

Sleeve

RNY

Band

Sleeve

RNY

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)

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

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

What do the Experts Say?

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

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%

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%

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%

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%

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.

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.

Frequency of Negative Judgment

Frequency of Choice as "Best" form of Surgery

Judgment of the Band

Judgment of the Sleeve

Judgment of the RNY

Judgment of the MGB/OABHighest Good / Lowest Bad

Success: Mini-Gastric Bypass Simplicity, Power & Safety

0

1

2

3

4

5

6

7

8

PreOp Post Op

MGB Effect on Hunger Levels

7.4

3.7

Per

cen

t (%

)

Failed Sleeve Converted to RNY; Sept 2012Less 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, [email protected].

Why the Band and Sleeve Fail

Restrictive Procedures and Sweet and "Liquid Calories"

Band, Sleeve vsthe 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)

Band & SleeveBlock Normal Healthy Foods

• Weight Loss =>

• Increased Hunger

• Decreased Satiety

• Healthy Foods Blocked

• Drive to Eat UP

• What Happens?

Band & Sleeve; Block Intake Normal Healthy Food

Sleeve Band

Restrictive Procedures

• Successfully Block Normal Healthy Diet

But

• They DO NOT BLOCK ...

Pathologic Dietary Choices

Calories: Ice Cream 200g/540 cal,

2 Milky-way Bars, 1,000 cal2 L Bottle Coke 830 cal

Total: 2,370 cal

Diet Induced Increased Hunger

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!

Primary Objectives





SOLUTION?

Diet Induced Increased Hunger

Mini-Gastric BypassThe Mongoose!

Mini-Gastric Bypass

• BlocksNeuro-Humoral Hunger System

• Short, Simple, Durable, 30 minute Surgery that:

• Decreases Hunger &Increases Satiety

The MongooseHe is a Little Bit Ugly, No?

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. [email protected]

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. [email protected]

9 Year MGB Follow UpEfficacy & 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. [email protected]

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.

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

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

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%

0

2

4

6

8

10

Pre Op Post Op

Reported Hunger Levels

7.4

3.7

Mini-Gastric Bypass Decreases Hunger Survey 2,783 Pts

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.

Over 100 Surgeons from Around the World:

0%

20%

40%

60%

80%

100%

Band Sleeve RNY MGB

Diabetes Resolved (%)

36%

59%

64%

86%

Both Kular and Rutledge, Op Time < 40 min

0

20

40

60

80

100

120

Band Sleeve RNY MGB

Op Time

42

60

110

68

0%

5%

10%

15%

20%

25%

30%

35%

Band Sleeve RNY MGB

Dyspepsia %

31%

22%

5%

6%

0%

5%

10%

15%

20%

Band Sleeve RNY MGB

Pre op GE Reflux rate (%)

10%

11%

17%

19%

0%

5%

10%

15%

20%

25%

30%

Band Sleeve RNY MGB

Postop GE Reflux rate (%)

24%

27%

6%

4%

Risk of Esophageal Cancer?

0%

10%

20%

30%

40%

50%

60%

70%

80%

Band Sleeve RNY MGB

Excess Weight Loss (%)

42%

60%

62%

78%

0%

5%

10%

15%

20%

25%

30%

35%

Band Sleeve RNY MGB

Weight Loss "Failure" (%)

34%

15%

12%

5%

0%

20%

40%

60%

80%

100%

Band Sleeve RNY MGB

Lost More than 50% of EW

39%

79%

81%

95%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

Band Sleeve RNY MGB

Bowel Obstruction (%)

0.4%

0.0%

2.5%

0.1%

0.0%

0.5%

1.0%

1.5%

2.0%

Band Sleeve RNY MGB

Ulcers %

0.9%

0.3%

1.9%

1.8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Band Sleeve RNY MGB

Short simple operation

82%

70%

0%

69%

0%

20%

40%

60%

80%

100%

Band Sleeve RNY MGB

Routinely get get major weight loss

13%

65%

87%

95%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Band Sleeve RNY MGB

Rarely suffer from long term complications

4%

52%

39%

70%30% Reflux &Esophageal

Cancer?

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

Band Sleeve RNY MGB

Published Leak Rates

0.1%

2.0%

1.0%

0.5%

Leaks

Surg Obes Relat Dis. 2008 Jul-Aug;4(4):528-33.Laparoscopic sleeve gastrectomy:

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.

Band/SleeveRoad to Failure

Initial Weight Loss

Return of Hunger

Eat Normal Foods

ObstructionAcid Reflux/Cancer

Eat Liquid Calories

Weight Regain

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

Why is the MGB So Much Better than the Sleeve

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

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.

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.

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

Primary Objectives





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

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.

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 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

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!!!

Education

Safe and Effective Treatment of Diabetes