There are several surgical options for patients who fail to lose weight or have significant weight regain after roux-en-y gastric bypass (RYGB); however, these techniques are not well studied and provide inconsistent results. We aim to describe our experience with RYGB limb distalization, in which patients undergo creation of a new enteroenterostomy, extending the biliopancreatic (BP) limb so that the common channel is 120-200cm from the ileocecal valve.
We retrospectively reviewed institutional data from 2012-2017, identifying patients who underwent laparoscopic limb distalization. Data was collected on patient demographics, medical comorbidities, operative details, short- and long-term follow up, nutritional laboratory values, morbidity, and mortality.
1. Standard roux-en-y anatomy. Biliopancreatic Limb (BP), Roux Limb (Roux), Jejunojejunostomy (JJ), Common Channel (CC) 2. Distalization of the gastric bypass with the new common channel measuring 120-200 cm
Twenty patients are included in our series. Mean body mass index (BMI) at the time of limb distalization was 45.3 kg/m2 (36.3-57.3). At long term follow up, which occurred at a mean of 16 months (1-52), average BMI was 38.1 (32-55.2) corresponding to weight loss of 43.7 pounds (7-87) or reduction in BMI of 7.2 (1.2-15.3). Of the seven patients with diabetes, hemoglobin A1C reduced by an average of 1.13 (0.2-2.6) at longest term follow up. Average operative time was 140 minutes (61-257) and length of stay was 2.3 days (1-7). Postoperatively, patients reported an average of 3.5 bowel movements per day which were not life-limiting. Overall morbidity was 20% and mortality was 5%. Two patients required return to the OR (10%) for adhesive bowel obstruction, these were both addressed laparoscopically with no additional complications. One patient experienced malnutrition, requiring supplemental total parenteral nutrition (TPN). No patients needed reversal of their limb distalization. There were no deaths at one-year.
Laparoscopic limb distalization is a safe and well-tolerated option for patients who fail standard RYGB. This procedure is effective for promoting weight loss and improving glycemic control.