First Preliminary International Consensus Conference on Mini-Gastric Bypass (MGB)
• WARNING: Dangers of the MGB
• Flawed Human Decision Making and the Selection of Bariatric
• MGB Experience and Results
• MGB and Type 2 Diabetes
• MGB Complications, Prevention, and Treatment
• MGB Conversions and Revisions
• New Concepts, Approaches, and Technologies
• Need for the Roux Limb
This is a report of the First International Postgraduate Course on the MGB. It was held April 26, 2012, at the IFSO European Chapter Meeting in Barcelona Spain. The MGB postgraduate course had over 50 participants who traveled from more than 20 countries. It included a full day of oral presentations, and debates. These discussions focused on the results the MGB; the effect of MGB on type 2 diabetes; and complications.
Quote from an editorial in the 1801 edition of “The Medical and Physical Journal (London, Volume 5, page 505)”
“The most important discoveries, are now contemplated with indifference.
Who now wonders at the discovery of America, or the circulation of the blood?
There is, however, a period between the conception of a discovery and its mature birth,
fraught with more pangs than war or women know;
and there is no light, in which the human mind can be viewed, more interesting than during this anxious period.”
WARNING: Dangers of the MGB
While there is growing consensus that the mgb is a superb surgery with a low risk and a very high success rate; there are important dangers, “tricks and traps” in the performance and management of the Mini-Gastric Bypass.
It is the opinion of this conference that it is critically important to offer a safe & successful MGB program to patients from the time of its inception.
• The members of this conference have committed themselves to the education and training of new MGB surgeons. We agree to offer our help our guidance and our advice on the details of the preoperative, intraoperative and post-operative management of the MGB patient. It is our hope that a large formal group of surgeons will come to act as resources for new surgeons hoping to begin new programs in the performance of the MGB. In the interim please feel free to call or email anytime for questions or advice on any clinical, technical or patient MGB question • USA 001-702-714-0011 DrR@clos.net.
• It is recommended that surgeons should offer the MGB with careful proctoring. It is expected that experts in the performance of the MGB will come to be recognized in the future and this is one of the goals of this consensus conference. again in the interim Dr. Rutledge has been acting as a visiting professor and advisor and colleague to programs around the world including countries such as: France, Turkey, Egypt, Austria, India, United Kingdom, Czech Republic, Italy, Germany.
• It is strongly recommend that the new surgeons use the knowledge of others before starting a new program.
Dr. Rutledge’s experience; over 15 years, over 6,000 patients can offer new surgeons insight and advice for the institution of a safe and effective new MGB program. Contact Dr. Rutledge USA 001-702-714-0011 DrR@clos.net
Other surgeons willing to act as resources for new MGB programs are listed below.
Welcome to the report from the first international postgraduate course and preliminary consensus conference on the Mini-Gastric Bypass. The most frequently performed bariatric operations are the laparoscopic adjustable gastric banding, the Roux-en-Y gastric bypass (RYGBP), and biliopancreatic diversion with duodenal switch and the sleeve gastrectomy.
15 years ago Rutledge used two well described and widely used surgical techniques to create a “Collis gastroplasty with a Antecolic Billroth II Gastro-jejunostomy form of gastric bypass” also named at the time as the “Mini-Gastric Bypass”. Now 15 years and over 6,000 patients later surgeons from all around the world met to present their findings on the performance and the outcome of the MGB.
The Collis Gastroplasty
The MGB uses two well used surgical techniques. The Collis gastroplasty was a technique designed to functionally lengthen the esophagus by adding a tube of stomach with the exact dimensions as the esophagus. This operation is illustrated in Fig. 1. Collis initially proposed this operation as a stand-alone procedure for reflux. [Stirling MC, Orringer MB. Continued assessment of the combined Collis-Nissen operation. Ann Thorac Surg 1989:47:224-230 2. Demos NJ. Stapled, uncut gastroplasty for hiatal hernia: twelve-year follow-up. Ann Thorac Surg 1984:38:393-399.]
Magenstrasse and Mill (M & M) operation
Other authors have noted the similarities of the MGB’s Collis Gastroplasty type pouch and gastric pouch created for the Magenstrasse-Mill operation. The Magenstrasse and Mill (M & M) operation is a form of non-banded vertical gastroplasty was reported for weight loss. Like the MGB the M&M procedure included a long narrow gastric pouch based upon the lesser curvature.
The initial results of the M&M were good as reported by Johnston et al. [Diabetes Obes Metab. 2001 Apr;3(2):99-103.Effects of the Magenstrasse and Mill operation for obesity on plasma leptin and insulin resistance.Carmichael AR, Johnston D, King RF, Sue-Ling HM.Academic Department of Surgery and Centre for Digestive Diseases, Leeds General Infirmary, Leeds, UK. email@example.com] They reported patients with a five-year follow up and a reported 60% EWL.
In addition it is clear that the sleeve gastrectomy, first reported in 2006 bears a remarkable similarity to the vertical pouch of the MGB. Narrowly based upon the lesser curvature of the stomach and more and more widely performed since the first consensus conference in 2007. Experience in the MGB with over 6,000 cases has demonstrated that on occasion the Billroth II portion of the case could not be performed. In such cases the equivalent of a sleeve type gastrectomy was performed and as such there is experience with over 300 such forme fruste MGB type sleeve surgery cases. These results show that, while some weight loss does occur with these sleeve type procedures, the weight loss is approximately 50% less than with an MGB.(Also see the controlled prospective randomized trial comparing the Sleeve to the MGB which simialrly found that the weight loss by sleeve patients was approximately ½ of the weight loss of the MGB, which can in many way be considered as a sleeve with a bypass.
There are many reported variations in the techniques for all bariatric operations. Similarly, there are multiple technical variations for the Mini-Gastric Bypass, including variations in the name of the procedure (Omega Loop Bypass, One Anastomosis Bypass.) One of the main purposes of this conference was to review and codify some of these issues for the MGB.
The Meeting: Mini-Gastric Bypass Interest Group
Mini-Gastric Bypass Interest Group Meeting: TECHNIQUES AND OUTCOMES: Thursday, April 26th 2012, Time: 14.30h – 19:00h.
IFSO-EC Barcelona MGB COURSE OVERVIEW AND TARGET AUDIENCE:
This was an IFSO-EC course designed for practicing bariatric surgeons and physicians involved in the Surgical treatment of obesity and metabolic disorders.
The purpose of this course, which was met successfully, was to bring together European and World leaders in the performance of the MGB/Omega Loop operation to discuss the results, the risks and the benefits of the MGB
The presenters reported on their experience with the performance, outcomes and results of the MGB. The meeting was an opportunity to review the medical literature on bi
le reflux, risk of gastric cancer and the long term results of the Billroth II gastro-jejunostomy and provided detailed discussion of specifics of the performance techniques, risks and outcomes of the MGB.
This course with its discussions brought to light many important details of the performance and management of the MGB by expert surgeons that were actively offering the MGB from around the world.
The discussions featured careful description of an accurate reading of medical literature data related to the Billroth II and bile reflux and the risk of stomach cancer, the techniques and outcomes of Mini-Gastric Bypass including long-term data to supporting the Mini-Gastric Bypass as one of the best choices as a bariatric operation.
Additionally, the program focused on complications inherent to laparoscopic Mini-Gastric Bypass, most especially the risk of marginal ulcer and the prevention and treatment of marginal ulcer in MGB patients.
The specific course objectives included:
• Definition of the techniques and outcomes of Mini-Gastric Bypass
• Explanation of common complications following Mini-Gastric Bypass procedure for weight loss and their preventive measures
• Knowledge of revisional strategies for weight loss failures after Mini-Gastric Bypass procedure
• Apply the techniques of laparoscopic Mini-Gastric Bypass and comprehend the MGB concepts
Irrational Fear of Gastric Cancer After Billroth II
Dr. Rutledge provided an introduction prior to course start with a review of the issues related to the irrational fears of bariatric surgeons related to the development of gastric cancer after the Billroth II and the MGB.
Specifically Dr Rutledge reviewed the following critical factors from the medical literature:
● 1. Fear of the Billroth II and the MGB causing cancer appears irrational on careful review of the medical literature
● 2. Bariatric Surgeons Fear the Billroth II while General, Trauma and Oncologic Surgeons routinely use the Billroth II
● 3. Gastroenterologists, outside of Japan, explicitly
DO NOT recommend Endoscopy screening follow up after Billroth II
● 4. Rates of Gastric Cancer world wide is declining precipitously and Gastric Cancer is caused overwhelmingly by environmental factors such as preserved food and meats which contain nitrates, smoking and alcohol, low intake of fruit and vegetables and most importantly infection by H. Pylori, all of which are relatively trivially easy to affect.
● 5. While some papers Do show an increased risk of Gastric Cancer after Billroth II MANY papers have found NO Association between Billroth II and Gastric Cancer.
● 6. Studies that conclude there is causative association between Billroth II and gastric cancer are flawed because most Billroth II operations in these studies are performed for peptic ulcer disease and peptic ulcer and gastric cancer have common etiology: HELICOBACTER PYLORI.
● 6A. Studies that show an increased risk of gastric cancer following Billroth II usually show only a very small increased risk after 20 years of follow up. This is the same magnantude of increased risk found in patients with ulcer disease.
● 6B. Neither peptic ulcer patients nor Billroth II patients have a long term risk of Gastric Cancer that warrants screening endoscopy follow up! i.e. the risk is exceedingly low, so low follow up is not recommended
The first session of the day was overseen by Dr. Chevalier and Dr. Kular.
Introduction – Pr Jean-Marc Chevallier, MD
History of the MGB; How I Do It, 10-15 year data – Prof Roberto Tacchino, MD., MD
How I Do It: Mini-Gastric Bypass; Starting an MGB Program – Dr. Abduh El banna, M.D.
Advice on Starting a New MGB Program – Dr. Karl-Peter Rheinwalt
Endoscopy of MGB & Fears of Gastric Cancer and the Billroth II – Dr. K S Kular M.D.
“One Anastomosis Gastric Bypass”, Prof. Dr. Manuel Garcia-Caballero
Techniques of MGB – Dr. Jean Cady, MD
Small Bowel Obstruction following the RNY/MGB – Prof. Safwan A Taha, MD
Marginal Ulcer, Bile Reflux & GERD after Mini-Gastric Bypass – Kular
MGB as a Revision Operation for Failed Banding; Chevalier
Tips and Tricks How I Do It. Mini-Gastric Bypass; Dr Cesare Peraglie, M.D.
The MGB in Portugal, Tips and Tricks in the MGB. Dr. Rui Ribeiro, MD
Reflux Prevention, Conversion of Mgb to Rny & Vice Versa – Jacques Himpens, MD
564 French Mgb Cases Followed Up To 5 Yrs – Pr Jean-Marc Chevallier,MD
SESSION II: MANAGEMENT OF COMPLICATIONS AND OUTCOMES
Moderators: Dr. Jean Mouiel, M.D., Dr. Mario Musella M.D., Dr. Karl-Peter Rheinwalt, Dr. Luigi Piazza M.D.
Experience with MGB In Egypt: Nutritional Outcomes After MGB, Dr. Abduh El Banna,
Italian Perspective: MGB Results & Patient Safety & Outcomes – Dr. Mario Musella, MD
Experience MGB In United Kingdom – Mr Michael van den Bossche, M.D.
Problems with Other Bariatric Procedures: Why Choose the MGB
Billroth II and Marginal Ulcer (= to RNY)
Billroth II and Gastric Cancer: An ACCURATE Review of the Medical Literature:
Technical Details of Performance
The Way Forward: What’s Next for the MGB
Human Decision Making is Flawed/Need for Decision Support
Recent Research Review in Human Decision Making: Human Decision Making has been found to frequently be Flawed & driven by Irrational primitive modes of thinking.
Selecting the Best Weight Loss surgery
Bariatric surgeons are faced with the contemporary problem of identifiying the best form of weight loss surgery for their patients from amoung the many available. This is a treuly life or death decision and should be based upon the creful analytical evauation of the data related to the type of surgery. It should be based on a rational review of the data on the risk and benefits of the available choices. Such a critial decison should clearly avoid Emotional or Irrational Biases. Recent research shows that unfortunately there are often many unrecognized subbliminal factors that can sway humans into poor decisions. There is also new compelling data that such decisions can be improved.
Research: Decision Making Support:
The purpose of this section is alert the surgeons and the patient to the presence of these underlying and subconscious factors that might lead to poor decisons in this critical life decision. While the entire field of errors in human decision making cannot be discussed there are opportunities to reiveiw some of the most compelling recent findings to allow the surgeons and bariatric patient to use tools that can help identify underlying biases that may harm the chances of obtaining the best decision.
HUMAN DECISION MAKING ERRORS
Recent Research in Psychology and Neurobiology Shows that:The Human Brain is a Notoriously Bad Decision Maker.
The bariatric patient and surgeon are faced with a life and death decision and in an ideal world the collaboration of patient, surgeon and family would lead to a careful consideration of the facts of the issues at hand and after a careful and deliberative process the risks and benefits would be thouoghly vetted and a dispasionate decision would be arrived at.
Recent research in neurobiology shows that such an ideal situation based upon the deliberative processes in the frontal cortex of the brain, is put at significant risk by the non-analytic primitive system of the barin located in part in the amygdala.
Human Decision Making Errors are Very Common
Recently research into human decison making has sha
led the long held beliefs that we are rational animals in the main. Thoghout the entirity of its history the science of economics ahs posited the indivdual as a rational actor, that humans make decisions clearly and simply based upon their own utility. Not only economics but most physicians and patients routinely believe and take it for granted that with little variation their decision making efforts are based upon sound and careful review of the data available and presented to the patient and the doctor.
Since this such an ingrained belief some example of recent research may help frame this discussion.
When assessing risk of death and danger research has shown that humans exaggerate the risk in their assessments of rare events and minimize the risk assessments of common events. For example when asked to asses the danger of death from and airplane crash versus the risk of dying from a car crash; studie have repeatedly shown that people fear and judge the risk higher of dying from an airplane crash than from an automobile crash even though the truth of the matter is exactly opposite.
Studies show that humans routinely exaggerate the relative risks of rare events (i.e. dying in a terrorist attack), and they downplay the perceived risks in common events such as dying from an automobile crash. Studie show other erroneous risk assessments in that study participats routinely underestimate risks taken willingly, (danger of death from driving a car) and they routinely overestimate risks where the risk is beyond the individual’s control (i.e. risk of death from radiation contamination from nuclear power plants.)
In another example of human errors in risk assessment and rational decision making studies show that humans can be made to erroneously overestimate the risks of events if they are talked about. That is to say the relative risk of an event goes up the more one hears and thinks about the risk. This means newspaper and other media coverage has a major impact on the perceived risk of an event. The list of non-rational factors that can affect human decision making is sadly growing rapidly. Efforts are now underway to categorize these errors in decision making to provide a methodology to further understand these errors and give people the tools to minimize their erroneous impact on human decision making.
Irrational Illogical Thinking/Decision-Making Errors
While it is not easy in this abbreviated review to detail all of the classes of decision making errors a discussion of a few is of value.
Confirmation Bias is one of the more remarkable findings in the area of human decision making and belief. In the case of confirmation bias when subjects were presented with data that directly contradicted and refuted their opinions and beliefs, this experience instead of weaking subjects belief in a particular idea but inexplicably increased subjects resove and belief in favor their preconceived notions. That is to say information that is contray to one’s beliefs does not as might be expected weaken one’s reslove to believe something but can in fact confirm the preconceptions.
For example let us imagine that one is and Australian surgeon with a strongly held belief that the Lap Band is an effective choice for the treatment of obesity. IN the case of confirmation bias, if this Australian surgeon were to be presented with a well done study showing that the Lap Band is NOT an effective treatment for obesity then a confirmation bias may find that the surgeons belief in the effectiveness of the Lap Band may, paradoxically, actually increase after being exposed to the results of this study
• Herd Behavior; (“Group Think” overrides rational decision making)
Herd behavior is an example of the group effects on individual behavior. In this case errors in decision making occur because of biases that are introduced because of beliefs held by the group. Possibly the most visible example of this is the complicity of the German people in the extermination efforts of the Third Reich. Another example might be the rush to adopt the Lap Band or the Sleeve Gastrectomy in spite of major concerns about their safety and effectiveness.
Another area of human decision making errors is the direct recordings of brain activity during decision making processes. Functional MRI clearly shows that there appears to be two major systems involved in human decision making processes. One that we are aware of is the slow analytic deliberative process that has been localized to the area of the prefrontal cortex. This is the system which often, though not always provides the most rational of our decisions as humans. The second, more primitive system, shows subliminal activity that we are only vaguely aware of, if at all. This system responds to thousands of moment to moment environmental cues that we cannot identify but are sensed in this below consciousness level and drive this system. This system was developed, it is theorized, to help us survive in the wild. It is linked tightly with threat and avoidance and has been shown in numerous studies to lead to irrational decision making in a whole variety of situations. This system is situated deeper in the more primitive parts of the brain in the amygdala. This has been shown to be part “impulsive,” primitive system that triggers emotional override rational thinking.
PRIMITIVE RESPONSE SYSTEMS MODIFY RISK ASSESSMENT
Research has shown that the primitive sytem of sublimal thought and feelings can and does have a major impact on human decision making. In some cases this impact is salutory when for example a so called “gut” feeling leads to the right decision. Sadly the so called “gut” feeling is often misleading and can lead to major harm. A few examples will be provided.
When surveyed subjects reported a much greater fear of cancer than of motor vehicle accidents. When asked to assess the risk of dying from cancer in the next year subjects rated cancer as higher than motor vehicle crash even though the opposite is true. The fear of cancer magnifies the perceived risk.
REPTILIAN BRAIN POOR DECISIONS/FEAR LEADS TO JUDGMENT ERRORS
The reptilian brain leads to potentially deadly decision making errors in risk assessment. As stated above text subject routinely rate Death Airplane Crash as more risky than Death Car Crash. This demonstrates a serious judgement error.
Another important error is the fear of cancer following the Billroth II loop gastro-jejunostomy performed in the Mini-Gastric Bypass. The data on gastric cancer and the Billroth II in humans is very extensive and clear to the careful reader of the medical literature. First gastric cancer is rapidly declining in the USA and around the world, in many studie there is no increased risk of gastric cancer after Billroth II, in others the increased risk is very small, occurring only after a minimum of 20 years follow up, 1versus 1.5 cancers in 5,000 patient years follow up.
On the other hand numerous studies confirm 5-15% risk of Bowel obstruction from internal hernia after RNY in under 5 years follow up. So for rough comparison if 10-15% of RNY patients sustain bowel obstruction 100-150 patients will need surgery for bowel obstruction and depending on the mortality rate 5-10 people can die from bowel obstruction after RNY. If patients have a risk of gastric cancer then in MGB patients after 20 years in 1,000 MGBs 1 patient may face the possibility of getting gastric cancer. If that patient died from gastric cancer at 20 years after MGB. So the comparison is 5-10 early deaths within 5 years after RNY versus possible 1 death from cancer of the stomach 20 years after MGB.
Surgeons Have a History of Erroneous Decision Making
“In the course of an extended investigation into the nature of inflammation, and the healthy and morbid conditions of the blood in relation to it. I arrived, several years ago, at the conclusion that
the essential cause of suppuration in wounds is decomposition, brought about by the influence of the atmosphere upon blood or serum retained within them, and, in the case of contused wounds, upon portions of tissue destroyed by the violence of the injury.”
One might wish to believe that such learned men as surgeons of today and the modern period are not at risk of these erroneous biases.
One could hope that in the case of life and death decisions that surgeons with the best interests of their patient’s health uppermost in their minds would take such a cautious careful and deliberative approach such that their decisions would not and could not be clouded by such errors as confirmation bias and herd behavior and group think. But in fact the history of medicine in general and surgery in particular is rife with such decision making errors that show the truth of such physician and surgeon decision making errors. American surgeons in particular are notable for their rejection of true new developments that can save their patients lives.
Joseph Lister OM, FRS, PC was the British surgeon who pioneered antiseptic surgery and promoted the idea of sterile surgery based on the “Germ Theory” of Pasteur. Lister successfully introduced carbolic acid to sterilise surgical instruments and to clean wounds, which led to reducing infections, saving countless lives and made surgery safer for patients.
The influence and importance of Lister’s work cannot be understated: his principles of aseptic surgery made surgery practical, and perhaps no other single development was so important for surgery other than anesthesia.
In a paper in the Lancet “On the Effects of the Antiseptic System of Treatment upon the Salubrity of a Surgical Hospital”, he analyzed the outcome of amputations at Glasgow Infirmary before and after adoption of the antiseptic system. In 1864 and 1866, before adoption of the system, there were 35 amputations with 16 deaths for a mortality rate of 46%. in 1867, ’68 and ’69, after adoption of the system, there were 40 amputations with 6 deaths for a mortality rate of 15 %. This was a spectacular improvement in the mortality rate from amputation over that reported from leading British hospitals at the time.
But, when Lister first presented his clinical results, prominent scientists and surgeons publicly ridiculed his “germ theory” of wound suppuration and blood poisoning. A professor of physiology in Edinburgh, questioned the existence of microorganisms in wounds and commented, “Where are these little beasts . . . Show them to us, and we shall believe in them.”
Others accused Lister of performing “unjustified procedures,” especially osteotomies, arthrotomies, and open reduction and internal fixation of closed fractures.
Notably, Lister gave a 3 hour address to the International Medical Conference in Philadelphia in 1876, a meeting of the world’s most prominent physicians.
Samuel Gross (1805-1884), a leading senior American surgeon, commented, in 1876:
“Little, if any faith, is placed by any enlightened or experienced surgeon on this side of the Atlantic in the so-called carbolic acid treatment of Professor Lister,”
and in 1882 he added that
“demonstration of living, disease-producing germs is wanting.”
At the 1883 meeting of the American Surgical Association, two American surgeons declared that
“not a surgeon in Louisiana or Alabama used the Lister method”
For over a decade many leading surgeons failed to recognize the merit of the antiseptic system, and much acrimonious criticism was directed at Lister and his method. When he visited the United States in 1876 to deliver an address at the International Medical Congress in Philadelphia, he was not received with any enthusiasm. The Americans were slow to accept Listerism, and as late as the meeting of the American Surgical Association in 1882, the Lancet reported that “Anti-Listerians were in the majority; . . . they relied for support upon the statements of others. . . . Surely it is too late in the day (for them) to contest the truth of the germ theory.”  Levi Cooper Lane, who began his surgical career prior to Listerism, never fully accommodated to the restrictions imposed by the antiseptic and aseptic methods and gave as the reason: “You can’t teach an old dog new tricks.”
Resistance to Lister’s work stemmed partly from the difficulty that physicians have with learning that what they have believed and practiced is wrong
Sadly we have here memorialized for all times the blind resistance to change by our forefathers in surgery. This error and subsequent errors have led to untold numbers of deaths and disability in our patients.
However, in Britain and Europe, the antiseptic method had by 1879 been widely applied, and Lister’s findings amply confirmed. In that year Lister attended the International Congress of Medical Science at Amsterdam where his reception was far different from that he received from the Americans. When he rose to deliver his address, he was greeted by an overwhelming ovation that only abated when the President of the Congress came forward to take his hand and say:
“Professor Lister, it is not only our admiration which we offer to you; it is our gratitude, and that of the nations to which we belong.”
Other examples of surgical decision making errors can be presented ( resistance to the use of laparoscopy, nonoperative management of ruptured spleen and more) but suffice to say that it is clear that errors in decision making by surgeons have been occurring and are occurring thus it of critical importance that physicians understand the presence of these biases, and avoid the well studied bias of overconfidence of their own decision making skills and humbly seek to investigate decision making tools for providing the best decision making for the care to their patients.
Ultimately though this story has a happy ending. The work of Pasteur and Lister did not go unappreciated. Every nation in Europe, and innumerable universities throughout the world recognized and lauded Lister. In recognition of Lister’s contributions to medicine, he was knighted in 1882, and Queen Victoria made him First Baron Lister of Lyme Regis in 1887. The British Institute of Preventive Medicine, established in 1891, was renamed the Lister Institute of Preventive Medicine in 1903 to recognize Lister’s contributions to the prevention of disease. Currently, the Lister Institute supports biomedical research in the United Kingdom. Thus while the story of Lister is grim and disappointing in the fat that surgeons in so many places rejected his ideas for so long, it also a happy one in that in time, with determination, the truth of his findings were confirmed and adopted.
The story of Lister provides us with guidance for the futer and the preset. One be open to new ideas, Two beware of underlying biases that my lead to erroneous decision making and Three using the best analytical tool continuously evaluate present care in light of care and analytical review of new clinical research.
Applications to the Mini-Gastric Bypass
How do these ideas apply to the Mini-Gastric Bypass?
One: Although the MGB has been viewed skeptically this conference suggests that old skeptical views may need to be reevaluated.
Two: We will enumerate the fears and concerns raised in the past by skeptics of the MGB and carefully look at the medical literature to try and deliberately and analytically assess real and imagined criticisms.
Three: Finally we will take advantage of the results of dozens of surgeons opinions and experiences to assess the MGB it present status and the future of the MGB in bariatric surgery.