Philippe Topart, MD, Guillaume Becouarn, MD, Carine Phocas, RN. Societe de Chirurgie Viscerale, Clinique de l’Anjou, Angers, FRANCE
Objectives- Roux-en-Y gastric bypass (RYGB) is now one of the most used bariatric procedures. Although an efficient one, weight regain appears to be frequent and in approximately 20% of the cases will eventually lead to poor weight loss results. Besides applying further restriction to a basically mostly restrictive procedure in case of weight loss failure, conversion to a more malabsorptive procedure has been proposed. In addition to the modification of the proximal RYGB to a distal gastric bypass (D-RYGB), conversion to a biliopancreatic diversion with or without duodenal switch (BPD-DS)) has been described. Conversion to BPD-DS is by far the most complex as it implies the take down of the gastrojejunal anastomosis and restoration of the gastric continuity before performing the BPD-DS itself. As a result, only half of the procedures could be completed in 1 stage in the few published reports.
Methods and procedures- A 1 stage procedure was designed, keeping the gastric pouch of the RYGB as well as the gastrojejunal (GJ) anastomosis. The alimentary limb was divided 10 cm below the GJ and the fundus of the remnant stomach resected, leaving only the antrum. An anastomosis between the short segment of alimentary limb and the antrum was performed, thus constructing a "hybrid" sleeve gastrectomy. The remaining alimentary limb was reconnected to the biliopancreatic limb of the RYGB. A new 150 cm alimentary limb with a 100 cm common channel using the ileum was measured and the ileo-ileal anastomosis performed 100 cm distal to the ileo- caecal valve. An end to side duodeo-ileal anstomosis was performed with a 21 mm circular stapler after dividing and stapling the duodenum 3-4 cm distal from the pylorus.
Results- 4 patients with weight loss failure had their RYGB converted to BPD-DS using this technique. Their initial BMI was 45, 56, 61 and 70. Their respective BMI at the time of the conversion was 45, 52, 44 and 50. One procedure was done open because of an incisional hernia and the 3 others were done laparoscopically. One patient with a retro-colic, retro-gastric RYGB had to be converted to an open procedure to locate the alimentary limb. The surgery duration was 4 hours. No death occured and 1 patient with an open procedure had to be reoperated on for an abdominal abscess. 6 to 18 months postoperatively, the weight loss experienced ranged from 10 to 38 Kgs.
Conclusion- Although remaining complex, this procedure of conversion from RYGB to BPD-DS can always be done as 1 stage. Laparoscopy is feasible providing the RYGB has been done ante-colic, ante-gastric. The long term benefit on weight loss needs to be further assessed.
According to : https://www.sages.org/meetings/annual-meeting/abstracts-archive/a-novel-approach-for-conversion-of-roux-en-y-gastric-bypass-to-biliopancreatic-diversion-with-duodenal-switch/