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Mini-Gastric Bypass

Dr Robert Rutledge and the ‘Mini-Gastric Bypass’ (Part 1)

The first public presentation of his data was at the American Society for Metabolic and Bariatric Surgery (formally called ASBS) annual meeting in 2000, where he presented the outcomes on his first 1,200+ cases
Perhaps somewhat naively, he thought he would perform a small number of cases and convince the rest of the world to perform this surgery

Nineteen years ago in September of 1997, Dr Robert Rutledge performed the first of what has become known as the ‘Mini-Gastric Bypass’ (MGB) procedure. Now, nearly 20 years and many more than 30,000 procedures later, a recent survey showed that the MGB appears to be growing into one of the top 3-4 bariatric and metabolic procedures in many countries around the world. Bariatric News talked to Dr Rutledge about the origins of the procedure, some of the misunderstandings and criticisms of the operation, and why he is working to standardise the operation hoping to help surgeons learn to apply the operation safely and effectively.

In 1985, Dr Rutledge was hired as a new attending surgeon at the University of North Carolina at Chapel Hill, with primary interest and responsibilities for trauma and critical care patients. At the time he had little, if any interest, in bariatric surgery. During his initial job interview he was asked by his new boss, Dr George Sheldon, to consider being a member of the bariatric surgical team, and he explained that was not interested. Dr Sheldon thought for a moment and replied, “Do you want this job?” to which Dr Rutledge replied, “Well sir, I have always been interested in bariatric surgery.”

At this time (well before the advent of laparoscopic bariatric surgery) open bariatric surgery was a difficult and dangerous procedure associated with large incisions, relatively high complication rates and decidedly mixed outcomes. In the late 90s, the revolution in laparoscopic general surgery was well underway with the first laparoscopic bariatric surgery cases being performed. Following a visit to the Cleveland Clinic to observe Dr Gagner performing a form of Roux-en-Y gastric bypass, Rutledge began performing some of the first laparoscopic Roux-en-Y gastric bypasses in the US and he soon realised that the technique for laparoscopic Roux-en-Y gastric bypass in 1997 was ‘pretty demanding’.

One night in September 1997, on call as a trauma surgeon, led Dr Rutledge to the care of a seriously injured multiple gunshot wound patient.

Robert Rutledge

“In Durham, North Carolina, as in many large cities, we had a problem with drugs and drug dealers. Late one evening a dealer had a quarrel with one of his customers. The customer shot the drug dealer six times in the abdomen, with a .357 Magnum. He got to my hospital ER and at about 9pm and we had him in the operating room. He had multiple severe abdominal injuries, to the stomach, the tail of the pancreas and multiple loops of small bowel,” he recalled. “We repaired the various injuries including resecting the antrum (bottom) of the stomach, the tail of his pancreas, the spleen and multiple pieces of small bowel. Then we put everything back together. To reconnect the gut after removal of the lower part of the stomach we used a routine and standard general surgery procedure by connecting the stomach to a loop of small bowel in from of the colon. The medical name for this routine surgical procedure is an ante-colic Billroth II Gastro-Jejunostomy. We finished the procedure at approximately 3am.”

The next day, he had a patient who was a scheduled to have a laparoscopic Roux-en-Y gastric bypass. Having just performed a simple and safe connection between the stomach and the bowel in a trauma patient it seemed to Dr Rutledge that he could use the same standard tool in this bariatric patient making the operation simpler and safer.

The history of bariatric surgery includes a major and unfortunate error in the use of the loop Billroth II connection by Dr Mason who performed the first “Mason Loop” Gastric Bypass, explained Dr Rutledge. Mason used a loop Billroth II to create the first gastric bypass, but violated a basic principle of general surgery that has been known for over 100 years, that is “Never place a loop Billroth II type connection close to the oesophagus.”  So, not surprisingly, when Mason’s new form of gastric bypass violated this well-known principle, his patients failed with unfortunate consequences.

“Instead of recognising that the failure of the Old Mason Loop Gastric Bypass was caused by misuse of the Billroth II incorrectly by Mason, most bariatric surgeons even today, still erroneously blame the Billroth II as the cause of the bypasses’ failure.”

“The worldwide response was the abandonment of Mason’s form of gastric bypass and the substitution of the Roux-en-Y form of gastric bypass. Bariatric surgeons concluded that the Billroth II was to blame for the failure of the Mason Bypass and this erroneous conclusion is still broadly and widely held even today,” said Dr Rutledge. “Instead of recognising that the failure of the Old Mason Loop Gastric Bypass was caused by misuse of the Billroth II incorrectly by Mason, most bariatric surgeons even today, still erroneously blame the Billroth II as the cause of the bypasses’ failure.”

As an older general surgeon with long term experience in gastric surgery for peptic ulcer disease, he was well aware of both the misuse of the Billroth II in the Mason Loop and also of the fact routine utilisation of the Billroth II loop as standard and useful tool by general surgeons, in fact he had just used it in his general surgery practice a few hours before.

So Dr Rutledge simply recreated the anatomy of the standard general surgical procedure intentionally avoiding the error of the Mason Loop Gastric Bypass. He moved the Billroth II loop of Mason away from the oesophagus and instead recreated the routine procedure, before attaching the Billroth II loop to the bottom of the body of the stomach.

He recalled that the operation was smooth and easy, and the patient did remarkably well, adding that it was obvious that surgeons could protect patients from the risks and complications of open surgery (present standard of care at the time) and could gain the advantages of laparoscopic surgery in severely obese patients with ease and safety.

Perhaps somewhat naively, he admits, he thought he would perform a small number of cases and convince the rest of the world to perform this surgery.

“As you may know, the history of surgery is that surgeons are known to be stubborn in some cases and are known to like to the odd argument. In this case the misunderstanding of the cause of the failure of the Mason Loop has led to long term resistance to the adoption of the MGB, but that confusion is beginning to fade away in almost every country around the world except for the USA”, he added.

He said that the appropriate formal medical name for the surgical procedure he performed is a ‘Collis Gastroplasty with an ante-colic Billroth II Gastro-Jejunostomy,’

Which he acknowledged is ‘kind of mouthful’. Since the majority of surgeons were performing open large incisions and this was a ‘mini’mally invasive procedure, in order to distinguish the minimally invasive laparoscopic procedure from the open surgery done by others, he called the new procedure a ‘Mini-Gastric Bypass.’

Criticism

“The first public presentation of my data was at the American Society for Metabolic and Bariatric Surgery (formally called ASBS) annual meeting in 2000, and I presented the outcomes on my first 1,200+ cases. My results were remarkably good and were viewed with scepticism. As I was presenting and describing how I performed the procedure, I realised that attendees were restless and many were getting out of their seats and lining up at the microphones halfway through my talk. At the end of my talk in a hall with 1,000 people and a dozen microphones, each microphone was filled with a long line of surgeons who had queued up to angrily criticise me and the procedure.”

He said that essentially every one of the critics repeated the same criticism - that this ‘Mini-Gastric Bypass” was nothing more than the Old Mason Loop, that Rutledge had forgotten the past results of the Mason Loop’s failure, he should not be allowed to present his data, that he should not be performing this procedure.

Every surgeon had one reason for the criticism, namely that he was using a loop, the Billroth II. The critics said that he had forgotten history and that it has been proven that is such a procedure had failed and his operation is sure to be flawed as well.

He recalls that such was the ‘enthusiasm’ (or anger) to comment on his presentation that the next two scheduled speakers both walked to the microphone and agreed to give up their presentations so attendees could continue to comment, and they continued their criticism, claiming that the procedure was a re-creation of the Mason loop, adding that ‘it failed then and it will fail now!’

“It is somewhat surprising to me that it has taken 20 years of people being unable to understand this simple fact and often being very critical of both me personally and the MGB itself…”

Dr Rutlegde told the audience that the MGB was a modification of a procedure general surgeons carry out all the time – namely the antrectomy with Billroth II. He attempted to explain to the audience that the loop was not high on the stomach, adjacent to the oesophagus but was placed lower down at the junction of the bottom of stomach body (the antrum of the stomach.) However, no one in the audience understood or agreed.

“For me, the surprising thing was that a lot of people could not recognise the basic general surgical principle involved the difference between a loop at the top of the stomach near the oesophagus (analogous to a reconstruction of a total/subtotal gastrectomy) and a Billroth II loop at the bottom of the body of the stomach distant from the oesophagus (analogous the an antrectomy and Billroth II, a routine general surgery procedure done daily around the world), this is very basic general surgery knowledge.”

“It is somewhat surprising to me that it has taken 20 years of people being unable to understand this simple fact and often being very critical of both me personally and the MGB itself, but now a growing number of surgeons are beginning to understand these simple surgical principles and the MGB is starting to be accepted and the number of procedures is starting to grow considerably. I believe with the increased acceptance in addition to the increase in data, we are seeing a snowball effect.”

Some of the other criticisms of the MGB were that the pouch was too big, the Gastro jejunostomy was too big and therefore there will be no weight loss. Rutledge said that this view is again failing to understand the mechanism of action of the MGB, which is different from the Roux-en-Y gastric bypass, the band and the sleeve.

According to Rutledge, the sleeve, Roux-en-Y and band often fail because of inadequate weight-loss, and he believes they are relatively weak operations.

“We have seen that a surgeon who is inexperienced performing the MGB will often underestimate the effectiveness of the MGB procedure, and because of this we are seeing instances of MGB patients of ‘new’ MGB surgeons having excess weight loss of 110 or even 120% (Excess Weight Loss) EWL. This is because some inexperienced surgeons when performing the MGB are too aggressive before they are knowledgeable about the procedure.”

He has found that in contrast to the sleeve, band and the Roux-en-Y, the MGB patient appears to do better and that the operation is durable over the long-term.

“For example, the sleeve and the band patients can often quite easily drink a can of sugar sweetened soda, drink alcohol or easily eat ice cream or other liquid/soft calories,” he explained. “With a MGB such sweets quickly drop straight into the small bowel. We have found that this can allow a small amount of a sugary drink but beyond that the patients finds intolerance of sweets and fats. The MGB pouch is designed to be the diameter of the oesophagus and explicitly to not be obstructive as we see in the band, sleeve and the Roux-en-Y. When the sugary drink enters the small bowel, there is a limit to how much sweets or fats an MGB patient can tolerate.”

Conversely, Rutledge has noted that an apple, broccoli or a sandwich that is often not tolerated by a sleeve or a band, can be well tolerated with an MGB. His patient survey results demonstrated that the MGB procedure induces a ‘Mediterranean’ type diet and this is quite different from the pathologic eating that is often seen after a band or sleeve.

In his opinion, the MGB allows patients to tolerate fresh fruit and vegetables, whilst the slightly longer Bilio-Pancreatic bypass limb leads to fatty food intolerance and the post-MGB patient does not easily tolerate fatty meals. This is due in part to the Billroth II and the selected length of the Bilio-Pancreatic limb leading to intestinal changes.

Click here to read Dr Robert Rutledge and the ‘Mini-Gastric Bypass’ (Part 2)

Click here to read Dr Robert Rutledge and the ‘Mini-Gastric Bypass’ (Part 3)

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