Courtney N Cripps, MD, Sarah S Pearlstein, MD, James L Taggart, MD, Mitchell S Roslin, MD, FACS. Northwell Health-Lenox Hill Hospital
Presented is the case of a 53-year-old male patient with a BMI of 80 who had previously undergone Roux-en-Y gastric bypass and a subsequent revisional operation. Despite efforts to lose weight, the patient suffered from persistent obesity and obesity related comorbidities. The decision was made to convert the patient from a Roux-en-Y gastric bypass to a modified duodenal switch (MDS).
The nuances of this operation lie in the technical considerations that relate heavily to blood supply of the newly formed anastamosis. The operation begins with extensie adhesiolysis at the angle of His. The gastric remnant and gastric pouch are then separated, during which the short gastric arteries are sacrificed. A circumferential dissection around the duodenum is then performed approximately 3cm distal to the pylorus before it is transected. Proximal duodenal blood supply is maintained before moving to dissection along the greater curvature. The Roux limb was then identified at the remnant and divided approximately 10c distal to the anastomosis. The gastrojejunostomy was resected with the stapler. A bougie is placed in the gastric pouch and a gastrotomy is made over the bougie. A gastrotomy was then made in the remnant to facilitate creation of the new gastric anastomosis. A 2-0 PDS is used to perform this anastomosis. A 42 French bougie is then used to delineate the pouch for the new gastric sleeve. Omentopexy is then performed. The terminal ileum is targeted, and 300cm proximal to the ileocecal junction, the small bowel is transported to the duodenum for the duodenoileal anastomosis. A PDS was used to complete this anastomosis. A methylene blue leak test revealed no evidence of leak at the new anastomoses.
Ultimately, the MDS results in weight loss and resolution of diabetes comparable to the traditional duodenal switch, and there is a low incidence of bowel obstruction, marginal ulcer, and stricture. Performing this operation either as the sentinel operation or as a subsequent conversion is supported by data in terms of weight loss outcomes, but requires strict adherance to surgical technique and principles of blood supply.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 88352
Program Number: V158
Presentation Session: Bariatrics Videos Session
Presentation Type: Video
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