Nader Hanna, MD, Boris Zevin, MD, PhD. Queen’s University, Kingston, Ontario
Intestinal non-rotation is part of a wider spectrum of a malrotation congenital abnormality and its incidence is around 0.5%. It is usually discovered incidentally during investigation of unrelated pathology.
We present a case of laparoscopic conversion from a sleeve gastrectomy to a Roux-en-Y gastric bypass in a 46-year-old female with intestinal non-rotation. This patient underwent a laparoscopic sleeve gastrectomy and had a pre-operative BMI of 38 kg/m2. At the time of the laparoscopic sleeve gastrectomy she was discovered to have intestinal non-rotation. Appendectomy was not performed. There were no intra-operative or post-operative complications, and the patient was discharged home on post-operative day two.
The patient was seen in follow up and endorsed severe gastroesophageal reflux symptoms and an inability to tolerate an oral diet, despite maximum medical management at 6 months post-op. Her BMI at that time was 29 kg/m2. An upper gastrointestinal (UGI) series and upper endoscopy were performed. UGI series demonstrated severe reflux without evidence of twist or narrowing at the incisura. Upper endoscopy demonstrated no evidence of esophagitis. Given patient’s symptoms, a decision was made to perform a conversion procedure from the sleeve gastrectomy to a laparoscopic Roux-en-Y gastric bypass.
In patients with intestinal non-rotation, the small bowel is located on the right side of the abdomen and the colon on the left side. Intestinal non-rotation poses several challenges to performing a Roux-en-Y gastric bypass. Firstly, the biliopancreatic limb has to be oriented in a counter-clockwise manner (instead of clockwise) and the Roux limb is oriented in a clockwise manner (instead of counter-clockwise). Secondly, the jejunojejunostomy must be created in the right upper quadrant instead of the left upper quadrant. Thirdly, the gastric pouch must be made longer than usual in order to reduce the tension on the gastrojejunal anastomosis given that the Roux limb has to come up from the right upper quadrant. Fourthly, an appendectomy should be performed and there is no Petersen’s space to close.
There were no intra-operative or post-operative complications. The patient’s reflux symptoms resolved and her BMI decreased to 25 kg/m2.
A video abstract demonstrates laparoscopic conversion from sleeve gastrectomy to a Roux-en-Y gastric bypass in a patient with intestinal non-rotation.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 92717
Program Number: V052
Presentation Session: Bariatric II – Revisions
Presentation Type: Video