Bariatric Times

APR 2017

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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18 Case Report Bariatric Times • April 2017 INTRODUCTION Bariatric surgery is gaining popularity worldwide as a treatment for obesity and its associated comorbid conditions. 1,2 Studies have shown its safety, efficacy, and durability in the areas of weight loss and comorbidity improvement. 3–7 One area of bariatric surgery that has seen growth is revisions in the form of corrective or conversion procedures. Worldwide, incidence of revisional bariatric surgery is between 5 and 15 percent. 8–10 Single anastomosis gastric bypass (SAGB), commonly referred to as mini gastric bypass, is a surgical procedure in which 150 to 250 cm of the patient's bowel is bypassed. Total small bowel length is postulated to influence preoperative body weight and outcome of metabolic procedures. 11,12 Though propositions exist, there is currently no consensus on the length of afferent limb that should be bypassed in Roux-en-Y gastric bypass (RYGB) or SAGB for optimal weight loss outcomes. 11,12 The average length of small bowel recorded is around 700cm, with longer small bowel observed in men. 13,14 Here, we report our findings of an abnormally long bowel—1050cm—during revisional surgery in a patient who experienced dissatisfying weight loss (8kg at two-year follow up) after primary SAGB. CASE REPORT History. In 2015, we reported the case of a 28-year old man who underwent SAGB. 15 At the time of the operation, he had morbid obesity (body mass index [BMI] of 50.4kg/m2) with no other comorbid conditions. Intraoperatively, the duodenojejunal flexure was located in the right hypochondrium below the gallbladder instead of conventional anatomical location on the left side, with entire small bowel loops on the right side (Figure 1). Thus, the diagnosis of intestinal malrotation was confirmed, and the jejunal loops were followed from the right sided duodenojejunal flexure for 210cm. Gastrojejunal anastomosis was performed. The postoperative computed tomography (CT) scan showed vascular axis consistent with malrotation (Figure 2). The patient experienced dissatisfying weight loss (8kg at two-year follow up), which was thought to be the result of the length of bypassed limb (210 cm). After evaluation and discussion, a revision SAGB surgery was planned per patient preference. Revision procedure. The patient was induced under general anesthesia and abdominal ports were inserted in diamond-shaped configuration. We accessed the peritoneal cavity with open technique. The previous site gastrojejunal anastomosis was identified and barred of overlying omental adhesions using an ultrasonic energy source that minimized lateral thermal spread. The slightly dilated gastric pouch was revealed (Figure 3) along with bowel limbs. We dissescted the previous site of gastrojejunal and created a window posteriorly. The pouch was isolated to take down the previous anastomosis. Afferent limb length was traced up to duodenojejunal flexure. We found the limb length meausured 210cm long, which was consistent with the previous procedure. We traced efferent loop up to ileocecal junction and found that it measured 1050cm (Figure 4). Surprised, we retraced our steps to the anastomosis site to confirm our findings. Ascending colon was by AJAY H. BHANDARWAR, MBBS, MS (SURGERY), FMAS, FIAGES, FAIS, FICS, FBMS (BARIATRIC); CHINTAN B. PATEL, MS (SURGERY), DNB, FMAS, FIAGES, FBMS (BARIATRIC); SAURABH S. GANDHI, MS (SURGERY), FMAS, FIAGES, FALS; AMOL N. WAGH, MS (SURGERY), FMAS, FIAGES, FICS, FBMS; PRIYANK D. KOTHARI, MS (SURGERY); EHAM L. ARORA, MS (SURGERY); GAGANDEEP TALWAR, MS (SURGERY); and AMARJEET TANDUR, MS (SURGERY); RAJ GAJBHIYE, MS (SURGERY) Bariatric Times. 2017;14(4):18–19. Revisional Bariatric Surgery in a Patient with Midgut Malrotation and Abnormally Long Bowel: A Case Update ABSTRACT Bariatric surgery has become the treatment of choice for morbid obesity, with the volume of cases increasing steadily. In this case report, the authors provide an update of a case previously reported in 2015 in which midgut malrotation was discovered during single anastomosis gastric bypass. After unsatisfactory weight loss results at two-year follow up, a revision procedure was planned. During the revision, the authors made a discovery that was missed in the original procedure—abnormally long bowel (1050cm). Though propositions exist, there is currently no consensus on the length of bowel that should be bypassed in Roux-en-Y gastric bypass or single anastomosis gastric bypass for optimal weight loss outcomes. This case illustrates the need for consensus on the length of limb to bypass in Roux-en-Y gastric bypass or single anastomosis gastric bypass operations, and suggests that such consensus should include rare patient anatomy, such as abnormally long bowel. KEYWORDS Bariatric surgery, revision, single anastomosis gastric bypass, minigastric bypass, midgut malrotation, abnormally long bowel FIGURE 1. Depicting laparoscopic view of duodeno-jejunal flexure in right sub-hepatic region below gallbladder and stomach FIGURE 2. Contrast enhanced 3D CT reconstruction showing Ileo-caecal junction on left side and entire small bowel loops on right side

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