mgb done wrong v2

Mini-Gastric Bypass Done WRONGWRONG

Dr. RutledgeDr. Rutledge

Mini-Gastric Bypass

• Anyone can do a “single Anyone can do a “single anastomosis gastric bypass”anastomosis gastric bypass”• That Does Not mean they That Does Not mean they

can/are doing the true can/are doing the true “Mini-Gastric Bypass” (MGB)“Mini-Gastric Bypass” (MGB)• See the Following Example...See the Following Example...

No No NoThis is NOT an Mini-Gastric BypassThis is NOT an Mini-Gastric Bypass

Edward E. Mason, MD, PhDNOT Mini-Gastric BypassNOT Mini-Gastric Bypass

NOT NOT Mini-Gastric Mini-Gastric

BypassBypass

Surgeons are FoolishConfusing Old Mason Loop w MGBConfusing Old Mason Loop w MGB

Gastro-Gastro-JejunostomyJejunostomy

MGB Gastro-Jejunostomyat the Level of the Transverse Colon

Bowel LoopBowel Loop

Gastro-Gastro-JejunostomyJejunostomy

Gastric PouchGastric Pouch

For Example:Bird's Beak Defect

Short PouchShort Pouch

Bird's Beak DefectBird's Beak Defect

WrongThis is Not an MGB!

Short PouchShort Pouch

Old Mason Loop Bypass Error!Old Mason Loop Bypass Error!

Mini-Gastric BypassDone Right

LONGLONG Gastric Pouch Gastric Pouch

Surgeons Need to Understand Basic General Surgery

• Misunderstanding BasicsMisunderstanding Basicsof General Surgeryof General Surgery• Difference betweenDifference between

Total/Subtotal GastrectomyTotal/Subtotal GastrectomyVs.Vs.Distal Gastrectomy/AntrectomyDistal Gastrectomy/Antrectomy

Distal Gastrectomy/Antrectomy

• Understand AnatomyUnderstand Anatomy• EsophagusEsophagus• Body Body • AntrumAntrum• Antrectomy + Billroth II Antrectomy + Billroth II

= Routine General = Routine General SurgerySurgery

Distal Gastrectomy + Billroth II= Routine General Surgery

MGB = Antrectomy w Billroth IIRoutine General Surgery!

Total/Subtotal Gastrectomy

Total/Subtotal GastrectomyBasic General Surgery: Basic General Surgery:

Total/Subtotal GastrectomyTotal/Subtotal GastrectomyNever Reconstruct with Loop Billroth IINever Reconstruct with Loop Billroth II

Only RNYOnly RNY

Mason LoopViolation of Basic General Surgery

• Basic General SurgeryBasic General Surgery• Total/Subtotal Gastrectomy Total/Subtotal Gastrectomy

NEVER Reconstruct w NEVER Reconstruct w Loop!Loop!

• Mason Loop BypassMason Loop BypassReconstruct w Loop Reconstruct w Loop

• Thus Mason Loop => Thus Mason Loop => FailureFailure

• Violation of Basic General Violation of Basic General Surgical PrinciplesSurgical Principles

Mason LoopViolation of Basic General Surgery

• Mason Loop BypassMason Loop BypassReconstruct w Loop Reconstruct w Loop

• Thus Mason Loop Thus Mason Loop => Failure=> Failure

• Violation of Basic Violation of Basic General Surgical General Surgical PrinciplesPrinciples

Total/Subtotal Gastrectomy• Basic General SurgeryBasic General Surgery• NEVER ReconstructNEVER Reconstructw Billroth IIw Billroth II• NEVER ReconstructNEVER Reconstructw Billroth IIw Billroth II• NEVER ReconstructNEVER Reconstructw Billroth IIw Billroth II• NEVER ReconstructNEVER Reconstructw Billroth IIw Billroth II

MGB Gastric Pouch• Mini-Gastric BypassMini-Gastric Bypass

Shown to be an excellent Shown to be an excellent operationoperation• But Many New Surgeons Do But Many New Surgeons Do

Not Know the Critical Factors Not Know the Critical Factors to Do the MGB Correctlyto Do the MGB Correctly• One Critical Success Factor:One Critical Success Factor:• LONG Gastric PouchLONG Gastric Pouch

What should be ideal length of pouch?

• This question shows the This question shows the surgeon has not understand surgeon has not understand the teachings of General the teachings of General Surgery HistorySurgery History• The Answer to Creation of the The Answer to Creation of the

pouch is Simple...pouch is Simple...

MGB Gastric Pouch• General Surgery:General Surgery:• Acceptable: Acceptable:

Antrectomy/Distal Gastrectomy Antrectomy/Distal Gastrectomy + Billroth II Loop+ Billroth II Loop• Never Acceptable:Never Acceptable:

Total/Subtotal Gastrectomy Total/Subtotal Gastrectomy + Billroth II Loop+ Billroth II Loop

MGB Gastric Pouch• General Surgery:General Surgery:• Acceptable: Acceptable:

Antrectomy/Distal Gastrectomy Antrectomy/Distal Gastrectomy + Billroth II Loop+ Billroth II Loop• NEVER Acceptable!!!NEVER Acceptable!!!

Total/Subtotal Gastrectomy Total/Subtotal Gastrectomy + Billroth II Loop+ Billroth II Loop

MGB Gastric Pouch• Acceptable: Acceptable:

Antrectomy/Distal Antrectomy/Distal Gastrectomy Gastrectomy + Billroth II Loop+ Billroth II Loop

• Not AcceptableNot AcceptableTotal/Subtotal Total/Subtotal Gastrectomy Gastrectomy + Billroth II Loop+ Billroth II Loop

MGB Pouch

• EG JunctionEG Junction

• Pouch fromPouch fromEGJ to AntrumEGJ to Antrum

• Crow's FootCrow's Foot

• AntrumAntrum

MGB Gastric Pouch Length• How Long is the MGB How Long is the MGB

Pouch?Pouch?• Wrong Answer Wrong Answer

Not in CentimetersNot in Centimeters• Answer: From Answer: From

EG JunctionEG Junction to Beyond to Beyond the the Crow's FootCrow's Foot into the into the AntrumAntrum

• The MGB Gastro-The MGB Gastro-Jejunostomy should lie Jejunostomy should lie at the level of the at the level of the Transverse ColonTransverse Colon

Creation of the MGB Pouch• Details at Details at

https://mgbguidelines.wordpress.com/gastric-pouch-creation/https://mgbguidelines.wordpress.com/gastric-pouch-creation/• Creation of the Gastric Pouch (Band/Sleeve/RNY)Creation of the Gastric Pouch (Band/Sleeve/RNY)• Bougie of size 28 to 36 F can be used to fashion Bougie of size 28 to 36 F can be used to fashion

the pouchthe pouch• Understanding MGB Anatomy & PhysiologyUnderstanding MGB Anatomy & Physiology• MGB NOT ObstructiveMGB NOT Obstructive• No Tight Pouch (The MGB is not a Sleeve)No Tight Pouch (The MGB is not a Sleeve)• Pouch Diameter and Length are Not CriticalPouch Diameter and Length are Not Critical• MGB Pouch Size:MGB Pouch Size:• Pouch Diameter = Esophagus;Pouch Diameter = Esophagus;


https://mgbguidelines.wordpress.com/gastric-pouch-creation/https://mgbguidelines.wordpress.com/gastric-pouch-creation/• Pouch Length = Allow GJ at the greater curve of the Pouch Length = Allow GJ at the greater curve of the

stomachstomach• Start the Gastric Pouch (Long Pouch) at or beyond Start the Gastric Pouch (Long Pouch) at or beyond

Crow’s Foot (junction of body and antrum of the stomach.Crow’s Foot (junction of body and antrum of the stomach.• Beware a Twist in the Pouch)Beware a Twist in the Pouch)• Avoid Bleeding Along Staple Line; (Very Slow Application Avoid Bleeding Along Staple Line; (Very Slow Application

of Stapler, use compression)of Stapler, use compression)• Management of EG junction; MGB vs Sleeve (DO NOT go Management of EG junction; MGB vs Sleeve (DO NOT go

near the EG junction)near the EG junction)• Management of the gastric fundus; (Leaving some fundus Management of the gastric fundus; (Leaving some fundus

is acceptable)is acceptable)• Never dissect the EG junctionNever dissect the EG junction


https://mgbguidelines.wordpress.com/gastric-pouch-creation/https://mgbguidelines.wordpress.com/gastric-pouch-creation/• Never dissect the EG junctionNever dissect the EG junction

• Never attempt to visualize the diaphragmatic curaNever attempt to visualize the diaphragmatic cura

• Always stay lateral to the EG junctionAlways stay lateral to the EG junction

• Leaving some of the fundus behind in the MGB is Leaving some of the fundus behind in the MGB is always acceptablealways acceptable

• Reminder: The MGB is NOT a Sleeve, The MGB is NOT Reminder: The MGB is NOT a Sleeve, The MGB is NOT a RNYa RNY

• Complete division of the stomach in NOT critical in the Complete division of the stomach in NOT critical in the MGBMGB

MGB Part 1: Creation of the Gastric Pouch

• Youtube.com VideosYoutube.com Videos• http://www.youtube.com/http://www.youtube.com/

watch?v=1B45TUAimJEwatch?v=1B45TUAimJE• Technique of Mini-Gastric Technique of Mini-Gastric

Bypass; Tips and Tricks Bypass; Tips and Tricks

Conclusions• Mini-Gastric BypassMini-Gastric Bypass

Shown to be an excellent Shown to be an excellent operationoperation• But Many New Surgeons Do But Many New Surgeons Do

Not Know the Critical Factors Not Know the Critical Factors to Do the MGB Correctlyto Do the MGB Correctly• One Critical Success Factor:One Critical Success Factor:• LONG Gastric PouchLONG Gastric Pouch

mgb done wrong v2

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