Back to Sleeve: an Extreme Solution for Specific Complications of the Roux-en-Y Gastric Bypass

Challenges in Bariatric Surgery: Outcomes in Patients Having Three or More Bariatric Procedures

INTRODUCTION

Over the last two decades, a progressive increase in failure rate of bariatric surgery (BS) has occurred in conjunction with an exponential increase in BS worldwide. Bariatric surgeons are confronted with challenging situations in patients with a complex bariatric history. In this study, we aim to evaluate the feasibility and outcomes of revisional BS in patients with at least two or more previous bariatric procedures.

METHODS

Data were retrospectively retrieved from a prospectively held database of bariatric procedures performed at our tertiary referral bariatric center and included procedures done from February 2013 up to April 2019 by a single center.

RESULTS

Thirty patients underwent a third bariatric procedure. The median age was 40 (18-57) and 54 (27-69) years at the time of the first and the last procedures, respectively. Laparoscopic adjustable gastric banding was the first procedure in 26 patients. The complication rate was 33%; no patient required additional surgery because of postoperative complications. A total weight loss of 29.6% and an excess loss of 53.4% were obtained at a mean follow-up of 61 months after the last redo bariatric procedure.

CONCLUSION

This study indicates that redo BS either conversional or revisional is feasible and effective in patients with a complex bariatric history including two or more previous procedures. Careful patients' selection is mandatory and extensive information should be given on the increased risk of postoperative complications.

Surgical Management of Small Intestinal Bacterial Overgrowth After Roux-en-Y Gastric Bypass

INTRODUCTION

Small intestinal bacterial overgrowth (SIBO) is a common adverse effect after laparoscopic Roux-en-Y gastric bypass (LRYGB) and may be responsible for chronic diarrhea, abdominal pain, and discomfort. Although its pathophysiology is still unclear, surgical management may be appropriate in selected cases.

METHODS

In this video, we present a surgical revision of LRYGB, 12 years after the initial surgery, for late postoperative chronic diarrhea. The diagnosis of SIBO was finally established and associated with a dilated jejuno-jejunostomy diagnosed through a small bowel follow-through.

RESULTS

Revision of the RYGB was performed by resecting the dilated jejunostomy and fashioning a new one with a shorter Roux-en-Y limb. During follow-up, the patient showed fast improvement and complete resolution of symptoms was obtained at 12 months.

CONCLUSION

SIBO may be responsible for postoperative chronic diarrhea in RYGB patients, possibly in the long term, and it is often misdiagnosed. Primary treatment is conservative with appropriate dietary measures, antibiotics, and probiotics but surgical management can be very effective in selected patients presenting with failure of prolonged medical treatment and an anatomic abnormality.

One-Anastomosis Jejunal Interposition with Gastric Remnant Resection (Branco-Zorron Switch) for Severe Recurrent Hyperinsulinemic Hypoglycemia after Gastric Bypass for Morbid Obesity

BACKGROUND

The anatomical and physiological changes after Roux-en-Y gastric bypass for morbid obesity can lead to severe hyperinsulinemic hypoglycemia with neuroglycopenia in a small percentage of patients. The exact physiologic mechanism is not completely understood. Surgical reversal to the original anatomy and distal or total pancreatectomy are current therapeutic options to reverse the hypoglycemic effect, with substantial associated morbidity. Our group reports a pilot clinical series of a novel surgical technique using one-anastomosis jejunal interposition with gastric remnant resection (Branco-Zorron Switch).

METHODS

Patients with severe symptomatic hyperinsulinemic hypoglycemia refractory to conservative therapy were treated using the technique. The procedure started with resection of the remnant stomach close to pylorus. The alimentary limb was sectioned at 20 cm from the gastrojejunal anastomosis, and the rest of the alimentary limb was resected until the Y-Roux anastomosis. A hand-sutured anastomosis was then performed with the proximal alimentary limb and the remnant antrum.

RESULTS

Four patients were successfully submitted to the procedure with reversal of the symptomatology and normalization of insulin levels, postprandial glucose levels, and oral glucose tolerance test, with a mean follow-up of 24.3 months. Mean operative time was 188 min, and patients recovered without postoperative complications.

CONCLUSION

Patients suffering from severe hyperinsulinemic hypoglycemia after gastric bypass may be efficiently treated by this innovative procedure, avoiding extreme surgical therapy such as pancreatectomy or restoring the gastric anatomy, while still maintaining sustained weight loss. Studies with larger series and longer follow-up are still needed to define the role of this therapy in managing this entity.