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Revisional Procedures After Roux-en-Y Gastric Bypass

par Himpens, Jacques
Référence The ASMBS Textbook of Bariatric Surgery: Volume 1: Bariatric Surgery, Springer Science+Business Media, page (303-318)
Publication Publié, 2014-01

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Résumé :

Background: The laparoscopic Roux-en-Y gastric bypass (LRYGB) procedure is one of the most popular weight loss operations, but it is fraught with a number of failures, including insufficient weight loss, weight regain, and long-term complications that are directly related to the procedure. Methods: The different types of failures were analyzed. Surgical solutions were proposed according to the particular conditions. These solutions comprised endoscopic and laparoscopic procedures. Results: In case of an existing flaw in the bypass construction located at the gastroenterostomy (GE) or at the level of the gastric pouch, treatment consists in restoring the anatomic integrity. An obvious example is a gastrogastric fistula (GGF). Treatment of this latter condition is preferably laparoscopic. In case of new-onset gastroesophageal reflux, GGF must be ruled out as well as outlet obstruction distal to the enteroenterostomy. A hiatal hernia must actively be searched for and, if needed, corrected laparoscopically. In case of volume or compliance issues concerning the gastric pouch, endoscopic procedures may be attempted; alternatively, additional restriction may be obtained by placement of a band or by reconstruction of the bypass with a smaller pouch and reanastomosis. In case of insufficient weight loss or weight regain, surgical reintervention may focus on the length of the bowel limbs, including the alimentary limb (AL), the biliary limb (BL), or the common limb (CL). Changing the length of either of the three limbs intervenes on the malabsorptive aspect of the bypass. One option is the transformation into a distal bypass, a potentially dangerous situation because of the risk of protein malnutrition due to the shortened total active bowel length (300 cm). Reconversion to normal anatomy or back to a proximal bypass may be necessary in case of protein malnutrition. Overall, reconversion to normal anatomy is usually performed when the bypass construction lacks effect from the initial stages or when side effects of the bypass such as hypoglycemic syndrome are invalidating and do not respond to conservative measures. Usually reconversion will be complemented by an additional surgical action to minimize weight gain and include a sleeve gastrectomy (SG) with or without duodenal switch (DS). The technique of revisional surgery after RYGB is described step by step, and special attention is paid to the procedures intervening on the length of the AL, BL, and CL. Conclusion: Revisional surgery after failing RYGB can be performed endoscopically or laparoscopically if at all possible. The exact cause of the failure must be analyzed in detail and treated accordingly. The laparoscopic technique can be challenging but has been codified.