Laparoscopic Conversion of Failed Gastric Bypass to Duodenal Switch

Manish Parikh, MD; and Michel Gagner, MD, FRCSC, FACS

Department of Surgery, Mount Sinai Medical Center, Miami Beach, Florida

Objective. To report preliminary outcomes after laparoscopic conversion of gastric bypass to biliopancreatic diversion with duodenal switch for weight loss failure.
Design. Retrospective chart review.
Setting. Academic tertiary referral center.
Participants. Twelve patients with weight loss failure after gastric bypass.
Measurements. Age, body mass index, excess weight loss, type of primary gastric bypass, type of revision procedure performed (if applicable), method of gastrogastrostomy, intraoperative and perioperative data, and morbidity and mortality rates.
Results. All patients lost dramatic weight after conversion to duodenal switch: Mean excess weight loss (EWL) was 63 percent at 11 months, representing an average
11-point BMI decrease. There were no mortalities or leaks. Stricture at the gastrogastrostomy was the most frequent complication, which was usually amenable to endoscopic dilation.
Conclusions. Laparoscopic conversion to duodenal switch from failed gastric bypass is highly effective with an acceptable morbidity

Introduction

Reoperative bariatric surgery is most commonly performed for inadequate weight loss secondary to a failed bariatric operation.1 The Roux-en-Y gastric bypass (RYGB), the most commonly performed bariatric procedure in the US, carries a long-term failure rate of 20 to 35 percent.2 Especially in the superobese population (BMI>50kg/m2), long-term failure rates can be as high as 60 percent.2

Surgeons are increasingly faced with the RYGB patient who has either failed to lose weight or has regained his or her weight. The optimal treatment of these patients has not yet been determined. The biliopancreatic diversion (BPD) with duodenal switch (DS) is one of the most effective bariatric procedures currently available. Both short-term and long-term outcomes exceed that of any other bariatric operation.3 We recently published a report of our results of a small cohort of failed gastric bypass patients who underwent laparoscopic conversion to DS.4
Methods

We retrospectively reviewed data from all patients undergoing conversion from RYGB to DS for failed weight loss. The following data were analyzed: age, body mass index (BMI), excess weight loss (EWL), type of primary RYGB, type of revision procedure performed prior to conversion (if applicable), method of gastrogastrostomy, intraoperative and perioperative data, and morbidity and mortality rates. Paired student’s t-test was used for statistical analysis.

Preoperative workup consisted of upper endoscopy and upper GI series to evaluate the gastric pouch for dilation (>120cc), gastrogastric fistula, or other anatomic abnormalities. Patients with minimal gastric pouch (or no gastric pouch) were not considered for conversion to DS (lack of adequate gastric tissue to perform gastrogastrostomy). All patients were evaluated by a nutritionist preoperatively.

Laparoscopic conversion of RYGB to DS is essentially two separate procedures (Figure 1). First the gastrojejunostomy is disconnected and a gastrogastrostomy is constructed to restore gastric continuity, followed immediately by a sleeve gastrectomy (sequential firings of a 4.8mm linear stapler along a 60 Fr Bougie). Next, a duodenal switch is performed either in the same setting or as a staged (i.e., several months later) approach. The duodenal switch consists of a duodenoileostomy followed by an ileoileostomy, creating a long Roux-en-Y with a 150cm alimentary limb and a 100cm common channel. If the reversal of the gastric bypass and subsequent sleeve gastrectomy exceeded four hours, then the patient would return several months later for the duodenal switch to avoid prolonged anesthesia and its attendant risks.

Results
Between 2003 and 2007, 12 patients were identified for analysis. Data including age at time of conversion to DS, BMI at time of primary RYGB, type of primary RYGB performed, revision procedure performed, and %EWL with the RYGB are shown in Table 1. Overall, this patient cohort gained a mean 9kg/m2 by the time of conversion to DS, representing 42-percent EWL.

Sixty-six percent of these patients had obesity-related comorbidities at the time of conversion—most of these comorbidities reappeared with weight regain. The mean time interval to conversion to DS was approximately four years.

The intraoperative details and postoperative outcomes are shown in Table 2. Most patients underwent laparoscopic conversion to DS in one stage. In the two-stage patients, mean weight loss between first and second stages was 19.3kg. There were no mortalities or leaks. The most frequent complication (4/12) was stricture at the gastrogastrostomy, which usually responded to a single episode of endoscopic dilation. One patient required laparoscopic revision of her gastrogastrostomy.5 There were no cases of protein-calorie malnutrition. All patients lost dramatic weight after conversion to DS: Mean BMI and EWL were 31kg/m2 and 63 percent, respectively (p<0.001 compared to pre-conversion BMI of 41kg/m2 and EWL of 42%). At mean follow-up of 11 [2–37] months, the overall EWL of 79 percent is similar to published data regarding DS.3 Mean BMI decrease was 11 points and overall mean weight loss was 36kg. Comorbidities resolved in all patients.

Discussion
Weight loss failure after RYGB represents a challenging problem facing bariatric surgeons today. Although this is occasionally due to an identifiable anatomic abnormality (e.g., gastrogastric fistula, disrupted staple line), the vast majority of these patients have a technically sound RYGB. Given recent data showing categorically superior outcomes in DS over RYGB, especially in the superobese, we have revamped our strategy in dealing with these difficult scenarios and now favor conversion to DS.3,6 Our early results indicate that this is highly effective: 63 percent EWL and 11kg/m2 BMI decrease with an acceptable morbidity. Frequent use of the two-stage approach helps minimize complications.

Multiple treatment options for RYGB failure exist, including endoscopic therapies, placing an adjustable gastric band on the upper gastric pouch, revising the gastrojejunostomy, and converting to a distal RYGB (Table 3). However, none of these therapies have been shown to be as effective as converting to a DS. Although conversion to a distal RYGB delivers significant weight loss, the high rate of protein malnutrition and subsequent operative revision is problematic.

Conclusion
Our early results indicate that in experienced hands, laparoscopic conversion of failed RYGB to DS is highly effective (63% EWL, 11-point BMI decrease at mean 11 months) with an acceptable morbidity. Longer follow-up is required to determine if this weight loss is sustained.

References
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Category: Original Research, Past Articles