Bariatric Times

FEB 2018

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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INTRODUCTION Bariatric surgery failure, weight regain, and diabetes recurrence after laparoscopic Roux-en-Y gastric bypass (LRYGB) has led to an increase in the number of revisional bariatric operations performed, which have now become common practice within United States bariatric centers. The mechanisms for weight loss failure and regain appear to be multifactorial; however, failures might be attributed to technical failures at various steps throughout the LRYGB procedure. We describe a stepwise approach and technique of a complete and single-staged revisional LRYGB (i.e., ultimate revision). Five potential failure sites and techniques are addressed during this revisional LRYGB: 1. Gastric pouch revision 2. Placement of a silastic ring 3. Gastro-jejunal anastomosis revision 4. Remnant gastrectomy 5. Lengthening of the bilio- pancreatic and alimentary limbs to 150cm. This revisional technique might not only reduce the need for future reoperations and its associated morbidity and mortality but might also be associated with significant healthcare system cost savings. ULTIMATE LRYGB REVISIONAL TECHNIQUE The patient is placed in lithotomy position, and a five-port technique is used. Five potential failure sites and techniques are addressed during a complete single-stagedn revisional surgery would occur as follows: Step 1. Gastric pouch revision. An enlarged gastric pouch is a primary cause of LRYGB failure and weight regain. If the pouch is found enlarged during upper endoscopy, upper gastrointestinal (GI) series, or during the revisional procedure, the pouch should be revised by means of a sleeve resection over a bougie, suture plication, or revision of the gastro- jejunostomy. We perform an elongated and narrow gastric tube, dependent on the lesser curvature and preserving the left gastric artery, over a blunt 36Fr bougie with a 4.1mm stapler. All staple lines are reinforced with a running 2-0 nonabsorbable sutures. Step 2: Placement of silastic ring. During LRYGB reoperations for patients with super obesity (body mass index above 50 kg/m 2 ), we prefer to place a 6.5 by 2.0mm silastic ring just 1–2cm above the gastro-jejunostomy, which leaves a stoma diameter of approximately 12–14mm. The ring is secured to the gastric tube with two interrupted 2- 0 nonabsorbable sutures piercing the ring. Step 3: Gastro-jejunal anastomosis revision. If this anastomosis is found enlarged with a diameter greater than 15mm during upper endoscopy or if a gastric tube has been created, we prefer to remodel the anastomosis with a 3.5mm linear stapler. This anastomosis is closed over the same 36F bougie with 2-0 nonabsorbable running suture and reinforced circumferentially. Step 4: Remnant gastrectomy. The gastrocolic ligament is divided with bipolar energy device, thereby mobilizing the gastric remnant. After this, the antrum is divided approximately 6cm proximal to the pylorus with a 4.1mm stapler and oversewn with a running 2-0 nonabsorbable suture. Step 5: Lengthening of the bilio-pancreatic and alimentary limbs. Typical LRYGB present with bilio-pancreatic limbs 30 to 50cm in length. The bilio-pancreatic limb is elongated to 150cm, thereby excluding a greater length of the jejunum. Without needing to take down the three limbs of the jejuno- jejunal anastomosis, the alimentary limb is divided just proximal to the anastomosis with a 2.5mm stapler, and a new bilio-pancreatic limb is measured 150cm from the ligament of Treitz. A new jejuno-jejunal anastomosis is created with a second 2.5mm stapler. This anastomosis is closed and reinforced with a running 2-0 nonabsorbable suture. This reinforcement is performed on the entire anterior surface of the anastomosis where the staple line ends, which might prevent future anastomotic dilation and a potential Jejuno-jejunal intussusception. If the alimentary limb is found to be excessively short (i.e., 50cm), this would need to be resected, and a 150cm new alimentary limb fashioned. Conversely, if the alimentary limb measures approximately 100cm, it may be left intact. The common limb is measured prior to anastomosis to assure that at least 300cm are left in situ. A methylene blue dye test is performed at the completion of the procedure. All mesenteric defects, including jejuno-jejunal and Peterson's are closed with running 2-0 nonabsorbable suture. A large 30Fr open four-channel silicone drain system is left nearby the gastro-jejunal anastomosis and exited through the skin. The postoperative management is similar to a primary LRYGB: a gastrografin study is obtained on postoperative Day 1, and a liquid diet is initiated. Patients are typically discharged on postoperative Day 2 or 3 with the drain in place. DISCUSSION The increased use of bariatric procedures worldwide with long- term follow-up has resulted in the 10 Review Bariatric Times • February 2018 by FELIPE CHAUX, MD; MAURICIO FRANCO, MD; and J. ESTEBAN VARELA, MD, FACS, FASMBS Bariatric Times. 2018;15(2):10–11. The Ultimate Revisional Laparoscopic Roux-Y Gastric Bypass Technique ABSTRACT We present the technique of the ultimate and complete single-staged revisional laparoscopic Roux-en-Y gastric bypass (LRYGB) procedure that may correct all potential technical failure sites during reconstruction and prevents future known complications of this revisional surgery. This revisional technique might not only reduce t he need for future reoperations and its associated morbidity and mortality but may also be associated with significant healthcare system cost savings. KEYWORDS Revisional bariatric surgery, reoperative bariatric surgery, laparoscopic Roux-en-Y gastric bypass, weight regain, weight loss failure FIGURE 1. Steps during the ultimate laparoscopic Roux-en-Y gastric bypass (LRYGB) revisional technique

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