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.
(http://www.youtube.com/watch?v=m01iWb5CduU&feature=c4-overview&list=UUH-vy06o0G2Nc6TCyKdme2w)
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
www.diasurg.com
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