Laparoscopic Revision of Long-Limb Loop Gastric Bypass

Eugenius J Harvey, MD, Kervin Arroyo, MD, Daniel M Herron, MD. Mount Sinai School of Medicine

In this video we present the laparoscopic revision of a distal loop gastric bypass to a standard short limb Roux-en-Y gastric bypass, for treatment of malnutrition and chronic abdominal pain.

The patient is a 47-year-old man with a previous history of superobesity (166 kg, BMI 65) who had undergone laparoscopic loop gastric bypass, also referred to as “mini-gastric bypass” in 1999 at an outside institution. Despite initially losing weight he regained over 20 kg. Nine years after his original operation, he sought out his original surgeon to revise his anatomy to a distal loop gastric bypass to treat the weight regain.

One year later, he was admitted to our institution after an overdose of aspirin which he had been taking for chronic upper abdominal pain. Since his distal revision, he complained of continued weight loss, chronic diarrhea and recent bilateral lower extremity edema. He was found to have an albumin of 1.8.

His nutritional status was optimized with TPN. After his albumin rose above 3, we laparoscopically revised the distal loop gastric bypass to a standard short limb Roux-en-Y gastric bypass. The video demonstrates many of the important technical aspects of this revision.

In conclusion, we review several important points regarding revisional bariatric surgery. Chronic pain after loop gastric bypass may be due to internal hernia, bile reflux gastritis, or marginal ulceration with or without gastro-gastric fistula. Malnutrition should be corrected prior to surgical intervention. Weight regain after conversion from a malabsorptive operation to a stardard RYGB may be avoided by decreasing the size of the gastric pouch. Finally, any potentially devascularized tissue should be excised.