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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19 Case Report Bariatric Times • April 2017 l ocated in the left upper quadrant and was identified by its taenia and adjacent appendix. The previous gastrojejunal anastomosis, which was constructed at 210cm from d uodenojejunal flexure, was severed with an endostapler. This assisted in fashioning the new anastomosis. After intraoperative contemplation and discussion, we d ecided on a bypass limb length of 450cm from duodenojejunal flexure. Stay suture was taken on gastric pouch and gastrotomy performed posterior to staple line with help of a n ultrasonic energy device. The gastric calibration tube was visualized through gastrotomy. Mirrored enterotomy was done on jejunal limb and revised g astrojejunal anasotomosis was constructed with help of an endostapler. The stapler defect was closed in a continuous manner with barbed suture, which enabled faster a nd effortless suturing. Meticulous and precise suturing is a must to ascertain secure anastomotic suture line in this procedure. In an effort to reduce bilary reflux, Brolin's antireflux stitch was placed between the afferent limb of the jejunum and gastric pouch (Figure 5). The surgery was performed in 150 minutes. The patient experienced a weight loss of 28kg at six months postoperative. DISCUSSION Abnormally long bowel may have cellular dysfunction at the mucosal level, which may lead to altered absorptive capacity, thus resulting in variable weight loss. 9 This case of abnormally long bowel discovered during revisional bariatric surgery raised further questions regarding the length of afferent limb that should by bypassed in RYGB or SAGB for the most effective weight loss. Here, we had to choose between bypassing the absolute length of the small bowel or a fraction of total bowel length. Through a multidisciplinary approach, we made the decision to follow the absolute small bowel length and have seen good weight loss results. This case illustrates the need for consensus on the length of limb to bypass in RYGB and SAGB operations, and suggests that such consensus should include rare patient anatomy, such as abnormally long bowel. ACKNOWLEDGEMENT From Dr. Chintan B. Patel: I would like to sincerely thank my mentor Dr. Ajay H Bhandarwar and senior colleagues at J.J. Hospital who have helped me to become the surgeon that I am today. Dr. Bhandarwar is a gifted surgeon who has been an unwavering source of support, motivation, and inspiration in my training. Editor's Note: Chintan B. Patel, MS (Surgery), FMAS, FIAGES, FBMS, was Assistant Professor at the Grant Government Medical College & Sir J.J. Group Of Hospitals, in Mumbai, India, at the time this revisional case was performed and submitted for publication consideration. REFERENCES 1. American Society of Metabolic and Bariatric Surgery. Estimate of Bariatric Surgery Numbers, 2011- 2015. ate-of-bariatric-surgery-numbers Accessed March 24, 2017. 2. Sudan R1, Nguyen NT, Hutter MM, et al. Morbidity, mortality, and weight loss outcomes after reoperative bariatric Surgery in the USA. J Gastrointest Surg. 3. Schauer PR, Bhatt DL, Kirwan JP, et al. Bariatric surgery versus intensive medical therapy for diabetes - 5-Year Outcomes. N Engl J Med. 2017;376(7):641–651. 4. Cummings DE, Arterburn DE, Westbrook EO, et al. Gastric bypass surgery vs intensive lifestyle and medical intervention for type 2 diabetes: the CROSSROADS randomised controlled trial. Diabetologia. 2016;59(5):945–953. Epub 2016 Mar 17. 5. Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric- metabolic surgery versus conventional medical treatment in obese patients with type 2 diabetes: 5 year follow-up of an open-label, single-centre, randomised controlled trial. Lancet. 2015;386(9997):964–973. 6. Courcoulas AP, Belle SH, Neiberg RH, et al. Three-Year Outcomes of Bariatric Surgery vs Lifestyle Intervention for Type 2 Diabetes Mellitus Treatment: A Randomized Clinical Trial. JAMA Surg. 2015;150(10):931–940. 7. Ikramuddin S, Korner J, Lee WJ, et al. Roux-en-Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the Diabetes Surgery Study randomized clinical trial. JAMA. 2013;309(21):2240–2249. 8. Mahawar KK, Kumar P, Parmar C, et al. Small bowel limb lengths and Roux-en-Y gastric bypass: a systematic review. Obes Surg. 2016;26(3):660–671. 9. Tacchino RM. Bowel length: measurement, predictors, and impact on bariatric and metabolic surgery. Surg Obes Relat Dis. 2015;11(2):328–334. 10. Standring S. Gray's Anatomy: The Anatomical Basis of Clinical Practice, Expert Consult - 40th Edition. Churchill Livingstone. London. 2008 11. Hounnou G, Destrieux C, Desmé J, Bertrand P, Velut S. Anatomical study of the length of the human intestine. Surg Radiol Anat. 2002;24(5):290–294. Epub 2002 Oct 10. 12. Bhandarwar AH, Patel CB, Tungenwar PN, Wagh AN, Gandhi SS. Single anastomosis gastric bypass in a patient with morbid obesity and midgut malrotation. Bariatric Times. 2015;12(10):12– 13. FUNDING: No funding was provided. DISCLOSURES: The authors report no conflicts of interest relevant to the content of this manuscript. AUTHOR AFFILIATION: Dr. Ajay H. Bhandarwar is a Professor and Head of Department of Surgeryat the Grant Government Medical College & Sir J.J. Group Of Hospitals, Mumbai, India. Dr. Chintan B. Patel is Consultant in Minimal Access Surgery/Bariatric Surgery at Kiran Multi Superspeciality Hospital & Research Center, Surat, India. Drs. Saurabh S. Gandhi and Amol N. Wagh are Assistant Professors, Government Medical College & Sir J.J. Group Of Hospitals. Drs. Priyank Kothari, Eham Arora, Gagandeep Talwar, and Amarjeet Tandur are Chief Residents in Surgery at the Grant Government Medical College & Sir J.J. Group Of Hospitals. Dr. Raj Gajbhiye is Head of Department of Surgery Government Medical College Nagpur, India. ADDRESS FOR CORRESPONDENCE: Dr. Chintan B. Patel; E-mail:; Mobile phone: +91-9819919585 FIGURE 3. Slightly dilated gastric pouch v isualized from primary single a nastomosis gastric bypass procedure F IGURE 4. A Bowel length of 1050cm was discovered d uring revisional surgery. The authors retraced their steps to the a nastomosis site to confirm the f inding. FIGURE 5. View of the completed SAGB revision with antireflux stitch placed between the afferent limb of the jejunum and gastric pouch View the accompanying video at Exclusive Digital Content

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