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Laparoscopic revision of common channel length for chronic diarrhea and malnutrition complicating distal gastric bypass
Surgery for Obesity and Related Diseases 8 (2012) 119 –120
Video case report
Laparoscopic revision of common channel length for chronic diarrhea and malnutrition complicating distal gastric bypass Ovie Appresai, M.D.*, Michel Murr, M.D., F.A.C.S. Department of Surgery, University of South Florida at Tampa General Hospital, Tampa, Florida Received July 4, 2011; accepted August 4, 2011
Keywords:
Distal gastric bypass; Chronic diarrhea; Malnutrition; Common channel; Jejunojejunostomy
A 60-year-old woman who had undergone distal Rouxen-Y gastric bypass at our institution 9 years earlier presented after an 8-year absence with chronic diarrhea that had been disturbing her quality of life for the year before presentation. Her prebypass body mass index had been 65 kg/m2. She had received a 150-cm common channel constructed at the bypass. Her present weight was about 81 kg. She was having 3– 4 watery bowel movements daily. She had used antidiarrheal agents, tried avoiding lactose, had undergone repeated colonoscopies, and had been treated with antibiotics by her primary care physician; all to no avail. Her laboratory workup revealed consistently and progressively low serum albumin (⬍3.0 g/dL) and prealbumin (⬍15 g/dL). We therefore discussed with her the option of elongating her common channel as a treatment of her malnutrition and diarrhea. At surgery (see Video), the pneumoperitoneum was created using the Veress needle technique and a Visiport was used to access the peritoneal cavity at the supraumbilical region. Two additional 5-mm ports were placed in the right and left flank, respectively. The jejunojejunostomy was identified, and the alimentary, biliopancreatic, and common channels were identified. Adhesions to the mesentery around the jejunojejunostomy were dissected, and a tunnel was created behind the biliopancreatic limb for placement of the laparoscopic linear stapler, used to transect the limb off the anastomosis. A new jejunojejunostomy was then created, using the linear stapler technique, 50 cm proximal to the previous anastomosis. A gastrostomy tube was placed in the bypassed stomach for enteral nutrition.
*Correspondence: Ovie Appresai, M.D., 250 Stanaford Road, Suite 203, Beckley, WV 25801. E-mail: [email protected].
Results Postoperatively, she experienced recurrent fever, and an abdominal computed tomography scan done on the fourth postoperative day revealed an abscess around the gastrostomy. This was aspirated under computed tomography guidance. She subsequently did well and was discharged home on the seventh postoperative day to complete her course of antibiotics. The gastrostomy tube was removed 8 weeks after surgery. At 6 months postoperatively, she was without diarrhea, and her serum albumin and prealbumin had returned to the normal ranges. Discussion Distal gastric bypass was sometimes done for superobese patients with a body mass index of ⱖ50 kg/m2 [1] with a common channel 50-150 cm in length. Distal gastric bypass produces more weight loss in superobese patients than short limb proximal bypass; however, the weight loss results are about the same as with long limb proximal bypass [1]. Sugerman et al. [2] and Rawlins et al. [3] reported increased weight loss after failed standard gastric bypass in patients who underwent conversion to distal gastric bypass. Fobi et al. [4] also reported increased weight loss after converting failed Fobi pouch bypass to distal gastric bypass. Müller et al. [5] failed to find increased weight loss with distal compared with standard long Roux limb proximal gastric bypass in a study that was not specifically considering superobese patients. It is, however, generally agreed that metabolic complications, including protein calorie malnutrition, diarrhea, vitamin deficiencies, and anemia, are greater with distal gastric bypass [1–3]. Because these complications occur far less often with long Roux limb (150-cm) proximal bypass, with almost equiv-
1550-7289/12/$ – see front matter © 2012 American Society for Metabolic and Bariatric Surgery. All rights reserved. doi:10.1016/j.soard.2011.08.005
120
O. Appresai and M. Murr / Surgery for Obesity and Related Diseases 8 (2012) 119 –120
alent weight loss, most practitioners now preferentially perform long Roux limb proximal bypass for the superobese and have shied away from distal gastric bypass. Some reserve it only for selected superobese patients with a body mass index of ⱖ60 kg/m2, who are committed to long-term follow-up [1] or as a secondary procedure for patients in whom standard or banded gastric bypass fails [2– 4]. In their study, Rawlins et al. [3] reported the onset of protein calorie malnutrition on average 3 years (range 1–5) after distal bypass. Our patient’s symptoms started 7 years after her distal bypass. The management of malnutrition and diarrhea after distal gastric bypass could involve the administration of pancreatic enzymes [2– 4], total parenteral nutrition [1– 4], or enteral nutritional supplementation with placement of a gastrostomy tube for feeding [2,4] and sometimes revision with elongation of the common channel [2– 4]. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article.
Appendix Supplementary data The video associated with this article can be found, in the online version, at www.SOARD.org under “Multimedia Library.” References [1] Brolin RE, LaMarca LB, Kenler HA, Cody RP. Malabsorptive gastric bypass in patients with superobesity. J Gastrointest Surg 2002;6:195– 205. [2] Sugerman JH, Kellum JM, DeMaria EJ. Conversion of proximal to distal gastric bypass for failed gastric bypass in superobesity. J Gastrointest Surg 1997;1:517–25. [3] Rawlins ML, Teel D, Hedgcorth K, Maguire JP. Revision of Rouxen-Y gastric bypass to distal bypass for failed weight loss. Surg Obes Relat Dis 2011;7:45–9. [4] Fobi MAL, Lee H, Igwe D, et al. Revision of failed gastric bypass to distal Roux-en-Y gastric bypass: a review of 65 cases. Obes Surg 2001;11:190 –5. [5] Müller MK, Räder S, Wildi S, Hauser R, Clavien PA, Weber M. Long-term follow-up of proximal versus distal laparoscopic gastric bypass for morbid obesity. Br J Surg 2008;95:1375–9.
Video case report
Laparoscopic revision of common channel length for chronic diarrhea and malnutrition complicating distal gastric bypass Ovie Appresai, M.D.*, Michel Murr, M.D., F.A.C.S. Department of Surgery, University of South Florida at Tampa General Hospital, Tampa, Florida Received July 4, 2011; accepted August 4, 2011
Keywords:
Distal gastric bypass; Chronic diarrhea; Malnutrition; Common channel; Jejunojejunostomy
A 60-year-old woman who had undergone distal Rouxen-Y gastric bypass at our institution 9 years earlier presented after an 8-year absence with chronic diarrhea that had been disturbing her quality of life for the year before presentation. Her prebypass body mass index had been 65 kg/m2. She had received a 150-cm common channel constructed at the bypass. Her present weight was about 81 kg. She was having 3– 4 watery bowel movements daily. She had used antidiarrheal agents, tried avoiding lactose, had undergone repeated colonoscopies, and had been treated with antibiotics by her primary care physician; all to no avail. Her laboratory workup revealed consistently and progressively low serum albumin (⬍3.0 g/dL) and prealbumin (⬍15 g/dL). We therefore discussed with her the option of elongating her common channel as a treatment of her malnutrition and diarrhea. At surgery (see Video), the pneumoperitoneum was created using the Veress needle technique and a Visiport was used to access the peritoneal cavity at the supraumbilical region. Two additional 5-mm ports were placed in the right and left flank, respectively. The jejunojejunostomy was identified, and the alimentary, biliopancreatic, and common channels were identified. Adhesions to the mesentery around the jejunojejunostomy were dissected, and a tunnel was created behind the biliopancreatic limb for placement of the laparoscopic linear stapler, used to transect the limb off the anastomosis. A new jejunojejunostomy was then created, using the linear stapler technique, 50 cm proximal to the previous anastomosis. A gastrostomy tube was placed in the bypassed stomach for enteral nutrition.
*Correspondence: Ovie Appresai, M.D., 250 Stanaford Road, Suite 203, Beckley, WV 25801. E-mail: [email protected].
Results Postoperatively, she experienced recurrent fever, and an abdominal computed tomography scan done on the fourth postoperative day revealed an abscess around the gastrostomy. This was aspirated under computed tomography guidance. She subsequently did well and was discharged home on the seventh postoperative day to complete her course of antibiotics. The gastrostomy tube was removed 8 weeks after surgery. At 6 months postoperatively, she was without diarrhea, and her serum albumin and prealbumin had returned to the normal ranges. Discussion Distal gastric bypass was sometimes done for superobese patients with a body mass index of ⱖ50 kg/m2 [1] with a common channel 50-150 cm in length. Distal gastric bypass produces more weight loss in superobese patients than short limb proximal bypass; however, the weight loss results are about the same as with long limb proximal bypass [1]. Sugerman et al. [2] and Rawlins et al. [3] reported increased weight loss after failed standard gastric bypass in patients who underwent conversion to distal gastric bypass. Fobi et al. [4] also reported increased weight loss after converting failed Fobi pouch bypass to distal gastric bypass. Müller et al. [5] failed to find increased weight loss with distal compared with standard long Roux limb proximal gastric bypass in a study that was not specifically considering superobese patients. It is, however, generally agreed that metabolic complications, including protein calorie malnutrition, diarrhea, vitamin deficiencies, and anemia, are greater with distal gastric bypass [1–3]. Because these complications occur far less often with long Roux limb (150-cm) proximal bypass, with almost equiv-
1550-7289/12/$ – see front matter © 2012 American Society for Metabolic and Bariatric Surgery. All rights reserved. doi:10.1016/j.soard.2011.08.005
120
O. Appresai and M. Murr / Surgery for Obesity and Related Diseases 8 (2012) 119 –120
alent weight loss, most practitioners now preferentially perform long Roux limb proximal bypass for the superobese and have shied away from distal gastric bypass. Some reserve it only for selected superobese patients with a body mass index of ⱖ60 kg/m2, who are committed to long-term follow-up [1] or as a secondary procedure for patients in whom standard or banded gastric bypass fails [2– 4]. In their study, Rawlins et al. [3] reported the onset of protein calorie malnutrition on average 3 years (range 1–5) after distal bypass. Our patient’s symptoms started 7 years after her distal bypass. The management of malnutrition and diarrhea after distal gastric bypass could involve the administration of pancreatic enzymes [2– 4], total parenteral nutrition [1– 4], or enteral nutritional supplementation with placement of a gastrostomy tube for feeding [2,4] and sometimes revision with elongation of the common channel [2– 4]. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article.
Appendix Supplementary data The video associated with this article can be found, in the online version, at www.SOARD.org under “Multimedia Library.” References [1] Brolin RE, LaMarca LB, Kenler HA, Cody RP. Malabsorptive gastric bypass in patients with superobesity. J Gastrointest Surg 2002;6:195– 205. [2] Sugerman JH, Kellum JM, DeMaria EJ. Conversion of proximal to distal gastric bypass for failed gastric bypass in superobesity. J Gastrointest Surg 1997;1:517–25. [3] Rawlins ML, Teel D, Hedgcorth K, Maguire JP. Revision of Rouxen-Y gastric bypass to distal bypass for failed weight loss. Surg Obes Relat Dis 2011;7:45–9. [4] Fobi MAL, Lee H, Igwe D, et al. Revision of failed gastric bypass to distal Roux-en-Y gastric bypass: a review of 65 cases. Obes Surg 2001;11:190 –5. [5] Müller MK, Räder S, Wildi S, Hauser R, Clavien PA, Weber M. Long-term follow-up of proximal versus distal laparoscopic gastric bypass for morbid obesity. Br J Surg 2008;95:1375–9.