Laparoscopic Conversion of Gastric Bypass to Distal Gastric Bypass for Inadequate Weight Loss

Although uncommon, significant weight recurrence after Roux-en-Y gastric bypass (RYGB) can occur. Options are limited to help patients achieve additional weight loss, and improved techniques for revisional/conversional surgery are needed to achieve optimal outcomes while avoiding significant side effects. Although limited data exist regarding distalization of the Roux limb to achieve a longer biliopancreatic limb leading to some level of malabsorption, we have seen adequate weight loss with minimal significant side effects in patients undergoing this procedure with our approach. An appropriate technical approach to this procedure is important to avoid immediate and long-term complications.

We present a video describing our approach to Roux limb distalization for weight gain after gastric bypass, describing our approach for work-up, operative technical pearls, and postoperative monitoring in these patients. A 61 year-old female who initially had good weight loss after RYGB with a body mass index (BMI) nadir of 33, from a preoperative BMI of 53, experienced weight recurrence with her BMI increasing to 48. After preoperative nutritional optimization, dietary counseling, and behavioral counseling, she underwent conversion of RYGB to distalization of Roux limb to create a distal RYGB. She tolerated the procedure well and was discharged on postoperative day 2. At 1-year follow-up, her BMI had decreased to 37 with improvement in dyslipidemia, elevation of liver transaminases, and improvement in hemoglobin A1C. This reflects the impact of this procedure on not only weight loss but also concurrent metabolic diseases associated with obesity.

We present a case of distalization of a RYGB for weight recurrence, highlighting the technical pearls when performing the procedure. Accurate, intraoperative measurement of the total alimentary limb length is essential to achieve weight loss while minimizing malnutrition and vitamin deficiencies. Assessment of preoperative nutritional levels for evidence of any protein calorie malnutrition is important during surgical decision-making when this conversional metabolic operation is considered. Frequent, postoperative nutritional monitoring is important and occurs with a full bariatric nutritional panel at 3, 6, 9, and 12 months then yearly thereafter. Using our approach, we feel that conversion of RYGB to distalization of Roux limb can lead to improved weight loss without significant side effects.