10 Eylül 2013 Salı

Revision of Gastric Bypass to Ileal Interposition for Weight Regain

Revisional Surgery for Failed Gastric Bypass:

Laparoscopic Ileal Interposition may be an alternative to Duodenal Switch for revision of Gastric Bypass with out forming life time vitamine deficiency

The need for revision of Roux-Y Gastric Bypass (RYGB) is the greatest challenge nowadays facing bariatric surgeons. The worldwide highest frequency of performing Roux-Y Gastric Bypass (RYGB), encounters increased demand for revision for either failure of maintaining adequate weight loss or weight regain.

The reason of failure to maintain weight loss or weight regain after sufficient weiht loss might be in two different ways:
1.     Patient Related (Eating Disorders, Eating Malhabitus etc.)
2.     Procedure Related
a.     Gastro-gastric Fistula
b.     Gastric Pouch Enlargement
c.      Anastomotic (Gastrojejunostomy) Enlargement

When facing a bariatric patient who has a failure problem with gastric bypass, we at first sight inquire the eating habits. Many patients who has not have an eating disorder such as night eating or binge eating, think that they have very controlled and low calorie eating habits. The simplest and probably the most effective method to evaluate this issue is to give them a home work to record for one week every single drop or bite they consume. Major part of these patients shockingly realize that they consume much much more calories per day then they assume. If this is present, an eating consultation might be necessary for gaining healty eating habitus prior to any invasive or minimally invasive treatment.

Even if the patient has an eating related problem, the issue is found to be  evolved to a procedure related problem in most cases. A surgical problem awaits the patient and bariatric surgeon in most cases also.

The surgical failures of gastric bypass occurs in three ways mainly:

1.    Gastro-Gastric Fistula: This happens by the connection of gastric pouch and remnant stomach after gastric bypass. In some cases a small and low profile fistula of the pouch may be the reason. But in most cases the formation of a fistula take rather long time to form. The diagnosis might be difficult at early stages. However a prompt and strong weight regain starts when the fistula lets certain amount of food to pass to the remnant stomach. This problem requires an endoscopic or better surgical correction to maintain weight loss.
2.    Gastric Pouch Enlargement: Gastric pouch enlargement is mostly related with false eating behaviors. Consuming voluminous and high calorie foods, over-eating leading to frequent vomitting, Dumping Syndrome related vomitting may be mechanical reasons to enlarge the pouch. Solely pouch enlargement is not treated in many centers even the weight regain had started. However as DiaSurg Metabolic Surgery Team, we think that pouch enlargement may be the prominent factor of dilatation of the Gastro-Jejunal Anastomosis. The main way is to laparoscopically resect the enlarged portion of the pouch. Some authors reported gastrojejunal sleeve resections also. This is an easy, economic, short and replicable procedure for pouch enlargement. However the duration of this method is not longlasting.
3.    Dilatation of GastroJejunostomy Anastomosis: This is mostly related and seen together with pouch enlargement. As the pouch enlarges, the anastomosis gets stretched by the time and a stable dilatation occurs and becomes permenant. As the anastomosis dilates, the gastric pouch empties much more faster then it should be. Patients do not feel full or satiety does not last long. With the enlarged gastric pouch patients feeling of hunger increases and the desire for food becomes much more frequent. The consumed food becomes voliminous every day and the feeling of long lasting satiety disappears quickly. Patients eat more in portion, and feels hungary more frequently. This process also leads to jejunal enlargement which might be a secondary factor for weight regain after gastric bypass.

Revision Options of Failed Gastric Bypass
1.     Endoscopic Interventions (Stomphx etc.)
a.     Endoscopic plication of pouch walls
b.     Endoscopic plication of G-J Anastomosis
2.     Gastric Pouch Resections and re-shaping
3.     Gastro-Jejunal Sleeve Resection
4.     Take down G-J and Re-anastomose
5.     Take down the Jejunojejunal anastomosis and distal re-anastomose
6.     Conversion to normal anatomy and then to sleeve gastrectomy
7.     Conversion to Biliopancreatic Diversion
8.     Conversion to Duodenal Switch
9.     Conversion to Ileal Interposition

The former revision methods between 1-6 may offer partial and short term benefit for weight management and metabolic control. However Biliopancreatic Diversion and Duodenal Switch are the most powerfull revisions for failed gastric bypass. at the same time duodenal switch is technically the most difficult and advanced procedure.

Ileal Interposition Surgery
Ileal Interposition is a new approach to metabolic surgery. A distal 1.7 m ileal (the last part of small intestines) segment is prepared and placed at the very proksimal part of small intestines. When the distal ileal segment is interposed after stomach, the raw food enters directly to the very most distal part of the small intestines and stimulates a strong GLP-1 secretion. This hormonal stimulation is more stronger than BPD or BPD/DS and forms an hormonal satiety called “ileal brake”. By this hormonal stimulation, patients experience extreme feeling of satiety leading to strong caloric restriction. Besides apetite supression, strong GLP-1 effect (The Ileal Brake effect), also provokes the activity of beta cells at pancreas and stimulates GLUT-1 and GLUT-2 receptors at muscle cells, which results as promt resolution of insulin resistance.

Ileal Interposition is purely a “non-malabsorptive” procedure.  In other words, non of the patients has to use vitamin or mineral pills after one year. Short term (6-8 months) low dose (one a day) multivitamins are used to support the extreme satiety related oral intake insufficiency. After 6-8 months majority of patients stop taking these supps.

Ileal Interposition: A new option as a Revision Surgery for failed RYGB
We performed Ileal Interposition with Diverted Sleeve Gastrectomy for revision of weight regain after Gastric Bypass (RYGB). As far as our knowledge this is the first case of such a procedure in the world.
Tecnhnically ileal interposition is an advanced and challenging procedure. Three anastomosis are performed: İleo-ileal, duodeno-ileal and ileo-jejunal.
Although it is a complicated procedure, its only difference from Duodenal Switch is one more anastomosis is performed in Ileal Interposition.
This single anastomotic difference, Ileal Interposition patients do not need life-time supplementation of vitamin and minerals. Hormonal response and metabolic controle are at least the same as BPD or Duodenal Switch, without any malabsorption.

The patient was a 35 years old female. Previous RYGB was performed at 2009 with 43 kg/m2 BMI. Her lowest BMI was 24.5 kg/m2. She gained more than 30 kg at last 7 months with an increase of 10 in BMI.
BMI prior to revision was 34.5 kg/m2. After 6 months she had reached to 24 kg/m2 and preserving the weight loss without any medication so far.

Ileal Interposition is a new way of the strugle against obesity related metabolic syndrome and diabetes. Its effects on Type 2 diabetes at patients with BMI<35 kg/m2 had been reported by different centers. We performed this visionary surgery for revision of failed gastric bypass with reasonale result. Ileal Interposition may be a powerful alternative to Duodenal Switch without any malabsorption. Ileal Interposition may be a safe and effective  option for patients who are aware of life-time supplementation.

A version of this revisional obesity surgery video is presented as “video presentation” at IFSO 2013 World Congress at Istanbul, TURKEY.


DiaSurg Metabolic Surgery Team is an experienced and skilled surgical team mainly focused on Duodenal Switch and Ileal Interposition. Especially for revision of failed RYGB and Mini-Gastric Bypass procedures, we recommend durable and effective solutions.

Tugrul Demirel M.D.
Bariatric & Metabolic Surgeon
DiaSurg Metabolic Surgery – Istanbul/TURKEY


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