Ikemefuna Akusoba, MD, Ariel Shuchleib, MD, Emaad Farooqui, MD, Pearl Ma, MD, Daniel Swartz, MD, FACS, Keith Boone, MD, FACS, Kelvin Higa, MD, FACS. UCSF Fresno
Introduction: Laparoscopic gastric bypass has a proven track record for safety and is efficacious in producing durable weight loss and resolution of metabolic disease. Weight recidivism occurs frequently enough that revisional procedures have been added to the armamentarium of metabolic/bariatric surgeons. Revisional procedures carry a higher risk thus leading to development of less invasive procedures. Endoscopic procedures to reduce the stoma volume and gastric pouch diameter are performed to improve restriction and induce further weight loss. In patients that do not have sustained improvement in weight loss or metabolic disease, conversion to duodenal switch may produce the desired outcome.
Case Report: We present a 45 year old female who had a BMI of 78 kg/m2 who underwent a laparoscopic Roux-en-Y gastric bypass (LRYGB). She failed to achieve successful weight loss (BMI 58.6 kg/m2) and had persistent gastroesophageal reflux disease (GERD) requiring continued medical treatment with proton pump inhibitors. Endoscopy revealed an 8 cm long pouch with a dilated gastrojejunostomy stoma and a hiatal hernia. She underwent laparoscopic repair of her hiatal hernia and a transoral revision of her gastrojejunostomy. This was complicated by dysphagia, worsening GERD, and she did not lose weight after transoral revision of her gastrojejunostomy. Her super morbid obesity remained incompletely treated. The patient was extensively educated regarding compliance and nutritional problems, met with our dietician and psychiatrist and a multidisciplinary team meeting was held in regard to converting her LRYGB and Restorative, Obesity Surgery, Endolumenal (ROSE) Procedure to a laparoscopic duodenal switch. She was deemed to be an appropriate candidate and underwent successful conversion to a laparoscopic single anastomosis duodenal switch in one stage. In her three week post-operative visit she has lost 25 pounds and denies dysphagia or GERD.
Conclusion: LRYGB has a proven efficacy for weight loss and resolution of metabolic complications of morbid obesity. Revisional procedures may be necessary when desired result are not achieved. Although endoscopic procedures may represent a safe approach, desired outcomes may not be achieved. The decision to convert a patient from a LRYGB to a laparoscopic duodenal switch should not be taken lightly as significant complications may arise. However, if the patient is a good candidate for conversion to a duodenal switch, one may proceed in a single stage or two staged procedure depending on patient factors, intraoperative conditions and surgeon expertise.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 88142
Program Number: V165
Presentation Session: Bariatrics Videos Session
Presentation Type: Video