Revisional Bariatric Surgery in a Patient with Midgut Malrotation and Abnormally Long Bowel: A Case Update

| April 1, 2017

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)

Dr. Ajay H. Bhandarwar is a Professor at 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.

Bariatric Times. 2017;14(4):18–19.


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.


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 located in the left upper quadrant and was identified by its taenia and adjacent appendix. The previous gastrojejunal anastomosis, which was constructed at 210cm from duodenojejunal flexure, was severed with an endostapler. This assisted in fashioning the new anastomosis.

After intraoperative contemplation and discussion, we decided 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 an ultrasonic energy device. The gastric calibration tube was visualized through gastrotomy. Mirrored enterotomy was done on jejunal limb and revised gastrojejunal anasotomosis was constructed with help of an endostapler. The stapler defect was closed in a continuous manner with barbed suture, which enabled faster and 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
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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.

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