Skip to main content
SpringerLink
Log in

Revision of Roux-en-Y Gastric Bypass with Limb Distalization for Inadequate Weight Loss or Weight Regain

  • Original Contribution
  • Published:
Obesity Surgery Aims and scope Submit manuscript

Abstract

Background

Of patients undergoing Roux-en-Y gastric bypass (RYGB), 15–35% of patients fail to achieve “adequate” weight loss or regain significant weight. Multiple solutions have been proposed, but not well studied. We report our experience with limb distalization with lengthening the biliopancreatic (BP) limb and shortening the common channel (CC).

Methods

We retrospectively reviewed data from patients undergoing laparoscopic limb distalization for excess weight loss (EWL) <50% or BMI >35 kg/m2 after RYGB from 2012 to 2017. The BP limb was lengthened and CC was shortened to 100–200 cm. Perioperative outcomes such as morbidity, weight loss, nutritional deficiencies, comorbidity remission, and operative details were analyzed.

Results

Twenty-two patients were included. The mean BMI prior to RYGB was 54.1 ± 8.5 kg/m2 and 43.0 ± 5.5 kg/m2 prior to limb distalization. The mean follow-up was 18.3 ± 12.9 months with a mean BMI change, %EWL, and %TWL (total weight loss) of 11.8 ± 7.4 kg/m2, 62.3 ± 32.4%, and 25.4 ± 14.4%, respectively. The total mean BMI change, %EWL, and %TWL from RYGB was 22.2 ± 9.9 kg/m2, 77.8 ± 23.6%, and 40.2 ± 13.3%, respectively. Of patients with persistent comorbidities, remission rates of diabetes, hypertension, and gastroesophageal reflux disease were 100%, 17%, and 38%, respectively. The mean operative time was 132.6 ± 54.4 min and mean hospital stay was 2.2 ± 1.3 days. Overall morbidity was 27.3%. Three patients (13.6%) developed nutritional deficiencies requiring reversal surgery.

Conclusion

In patients with inadequate weight loss or weight regain after RYGB, limb distalization with lengthening of the BP limb is an effective procedure for additional weight loss and further improvement of comorbidities. Nutritional complications are a risk, but can be minimized with close follow-up and patient compliance.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Schauer PR, Bhatt DL, Kirwan JP, et al. Bariatric surgery versus intensive medical therapy for diabetes - 5-year outcomes. N Engl J Med. 2017;376(7):641–51.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Wittgrove AC, Clark GW. Laparoscopic gastric bypass, Roux-en-Y- 500 patients: technique and results, with 3-60 month follow-up. Obes Surg. 2000;10(3):233–9.

    Article  CAS  PubMed  Google Scholar 

  3. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292(14):1724–37.

    Article  CAS  PubMed  Google Scholar 

  4. Higa K, Ho T, Tercero F, et al. Laparoscopic Roux-en-Y gastric bypass: 10-year follow-up. Surg Obes Relat Dis. 2011;7(4):516–25.

    Article  PubMed  Google Scholar 

  5. Rawlins ML, Teel D, Hedgcorth K, et al. Revision of Roux-en-Y gastric bypass to distal bypass for failed weight loss. Surg Obes Relat Dis. 2011;7(1):45–9.

    Article  PubMed  Google Scholar 

  6. Stefanidis D, Kuwada TS, Gersin KS. The importance of the length of the limbs for gastric bypass patients--an evidence-based review. Obes Surg. 2011;21(1):119–24.

    Article  PubMed  Google Scholar 

  7. Parikh M, Heacock L, Gagner M. Laparoscopic “gastrojejunal sleeve reduction” as a revision procedure for weight loss failure after roux-en-y gastric bypass. Obes Surg. 2011;21(5):650–4.

    Article  PubMed  Google Scholar 

  8. Hamdi A, Julien C, Brown P, et al. Midterm outcomes of revisional surgery for gastric pouch and gastrojejunal anastomotic enlargement in patients with weight regain after gastric bypass for morbid obesity. Obes Surg. 2014;24(8):1386–90.

    Article  PubMed  Google Scholar 

  9. Tran DD, Nwokeabia ID, Purnell S, et al. Revision of Roux-En-Y gastric bypass for weight regain: a systematic review of techniques and outcomes. Obes Surg. 2016;26(7):1627–34.

    Article  PubMed  Google Scholar 

  10. Aminian A, Corcelles R, Daigle CR, et al. Critical appraisal of salvage banding for weight loss failure after gastric bypass. Surg Obes Relat Dis. 2015;11(3):607–11.

    Article  PubMed  Google Scholar 

  11. Thompson CC, Chand B, Chen YK, et al. Endoscopic suturing for transoral outlet reduction increases weight loss after Roux-en-Y gastric bypass surgery. Gastroenterology. 2013;145(1):129–137.e3.

    Article  PubMed  Google Scholar 

  12. Iannelli A, Schneck AS, Hébuterne X, et al. Gastric pouch resizing for Roux-en-Y gastric bypass failure in patients with a dilated pouch. Surg Obes Relat Dis. 2013;9(2):260–7.

    Article  PubMed  Google Scholar 

  13. Bessler M, Daud A, Digiorgi MF, et al. Adjustable gastric banding as revisional bariatric procedure after failed gastric bypass--intermediate results. Surg Obes Relat Dis. 2010;6(1):31–5.

    Article  PubMed  Google Scholar 

  14. Odstrcil EA, Martinez JG, Santa ana CA, et al. The contribution of malabsorption to the reduction in net energy absorption after long-limb Roux-en-Y gastric bypass. Am J Clin Nutr. 2010;92(4):704–13.

    Article  CAS  PubMed  Google Scholar 

  15. Keshishian A, Zahriya K, Hartoonian T, et al. Duodenal switch is a safe operation for patients who have failed other bariatric operations. Obes Surg. 2004;14(9):1187–92.

    Article  PubMed  Google Scholar 

  16. Hernández-martínez J, Calvo-ros MÁ. Gastric by-pass with fixed 230-cm-long common limb and variable alimentary and biliopancreatic limbs in morbid obesity. Obes Surg. 2011;21(12):1879–86.

    Article  PubMed  Google Scholar 

  17. Mahawar KK, Kumar P, Parmar C, et al. Small bowel limb lengths and Roux-en-Y gastric bypass: a systematic review. Obes Surg. 2016;26(3):660–71.

    Article  PubMed  Google Scholar 

  18. Brethauer SA, Kothari S, Sudan R, et al. Systematic review on reoperative bariatric surgery: American Society for Metabolic and Bariatric Surgery Revision Task Force. Surg Obes Relat Dis. 2014;10(5):952–72.

    Article  PubMed  Google Scholar 

  19. Parikh M, Pomp A, Gagner M. Laparoscopic conversion of failed gastric bypass to duodenal switch: technical considerations and preliminary outcomes. Surg Obes Relat Dis. 2007;3(6):611–8.

    Article  PubMed  Google Scholar 

  20. Buchwald H, Kellogg TA, Leslie DB, et al. Duodenal switch operative mortality and morbidity are not impacted by body mass index. Ann Surg. 2008;248(4):541–8.

    PubMed  Google Scholar 

  21. Søvik TT, Taha O, Aasheim ET, et al. Randomized clinical trial of laparoscopic gastric bypass versus laparoscopic duodenal switch for superobesity. Br J Surg. 2010;97(2):160–6.

    Article  PubMed  Google Scholar 

  22. Ghiassi S, Higa K, Chang S, et al. Conversion of standard Roux-en-Y gastric bypass to distal bypass for weight loss failure and metabolic syndrome: 3-year follow-up and evolution of technique to reduce nutritional complications. Surg Obes Relat Dis. 2018;14(5):554–61.

    Article  PubMed  Google Scholar 

  23. Himpens J, Coromina L, Verbrugghe A, et al. Outcomes of revisional procedures for insufficient weight loss or weight regain after Roux-en-Y gastric bypass. Obes Surg. 2012;22(11):1746–54.

    Article  PubMed  Google Scholar 

  24. Dapri G, Cadière GB, Himpens J. Laparoscopic conversion of Roux-en-Y gastric bypass to distal gastric bypass for weight regain. J Laparoendosc Adv Surg Tech A. 2011;21(1):19–23.

    Article  PubMed  Google Scholar 

  25. Sugerman HJ, Kellum JM, Demaria EJ. Conversion of proximal to distal gastric bypass for failed gastric bypass for superobesity. J Gastrointest Surg. 1997;1(6):517–24.

    Article  CAS  PubMed  Google Scholar 

  26. Kellum JM, Chikunguwo SM, Maher JW, et al. Long-term results of malabsorptive distal Roux-en-Y gastric bypass in superobese patients. Surg Obes Relat Dis. 2011;7(2):189–93.

    Article  PubMed  Google Scholar 

  27. Brolin RE, Cody RP. Adding malabsorption for weight loss failure after gastric bypass. Surg Endosc. 2007;21(11):1924–6.

    Article  PubMed  Google Scholar 

  28. Srikanth MS, Oh KH, Fox SR. Revision to malabsorptive Roux-en-Y gastric bypass (MRNYGBP) provides long-term (10 years) durable weight loss in patients with failed anatomically intact gastric restrictive operations: long-term effectiveness of a malabsorptive Roux-en-Y gastric bypass in salvaging patients with poor weight loss or complications following gastroplasty and adjustable gastric bands. Obes Surg. 2011;21(7):825–31.

    Article  PubMed  Google Scholar 

  29. Parrott J, Frank L, Rabena R, et al. American Society for Metabolic and Bariatric Surgery Integrated Health Nutritional Guidelines for the surgical weight loss patient 2016 update: micronutrients. Surg Obes Relat Dis. 2017;13(5):727–41.

    Article  PubMed  Google Scholar 

  30. Svanevik M, Risstad H, Hofsø D, et al. Perioperative outcomes of proximal and distal gastric bypass in patients with BMI ranged 50-60 kg/m(2)--a double-blind, Randomized Controlled Trial. Obes Surg. 2015;25(10):1788–95.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Fobi MA, Lee H, Igwe D, et al. Revision of failed gastric bypass to distal Roux-en-Y gastric bypass: a review of 65 cases. Obes Surg. 2001;11(2):190–5.

    Article  CAS  PubMed  Google Scholar 

  32. Sethi M, Chau E, Youn A, et al. Long-term outcomes after biliopancreatic diversion with and without duodenal switch: 2-, 5-, and 10-year data. Surg Obes Relat Dis. 2016;12(9):1697–705.

    Article  PubMed  Google Scholar 

  33. Thurnheer M, Bisang P, Ernst B, et al. A novel distal very long Roux-en Y gastric bypass (DVLRYGB) as a primary bariatric procedure--complication rates, weight loss, and nutritional/metabolic changes in the first 355 patients. Obes Surg. 2012;22(9):1427–36.

    Article  PubMed  Google Scholar 

  34. Madan AK, Harper JL, Tichansky DS. Techniques of laparoscopic gastric bypass: on-line survey of American Society for Bariatric Surgery practicing surgeons. Surg Obes Relat Dis. 2008;4(2):166–72.

    Article  PubMed  Google Scholar 

  35. Christou NV, Look D, Maclean LD. Weight gain after short- and long-limb gastric bypass in patients followed for longer than 10 years. Ann Surg. 2006;244(5):734–40.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Müller MK, Räder S, Wildi S, et al. Long-term follow-up of proximal versus distal laparoscopic gastric bypass for morbid obesity. Br J Surg. 2008;95(11):1375–9.

    Article  PubMed  Google Scholar 

  37. Nergaard BJ, Leifsson BG, Hedenbro J, et al. Gastric bypass with long alimentary limb or long pancreato-biliary limb--long-term results on weight loss, resolution of co-morbidities and metabolic parameters. Obes Surg. 2014;24(10):1595–602.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Homan J, Boerboom A, Aarts E, et al. A longer biliopancreatic limb in Roux-en-Y gastric bypass improves weight loss in the first years after surgery: results of a randomized controlled trial. Obes Surg. 2018;28:3744–55. https://doi.org/10.1007/s11695-018-3421-7. [Epub ahead of print].

    Article  PubMed  Google Scholar 

  39. Gazer B, Rosin D, Bar-zakai B, et al. Accuracy and inter-operator variability of small bowel length measurement at laparoscopy. Surg Endosc. 2017;31(11):4697–704.

    Article  PubMed  Google Scholar 

  40. Isreb S, Hildreth AJ, Mahawar K, et al. Laparoscopic instruments marking improve length measurement precision. World J Laparosc Surg. 2009;2(3):57–60.

    Article  Google Scholar 

Download references

Funding

This study was made possible by grant support from the Foundation for Surgical Fellowships (FSF) for Reuben D Shin.

Author information

Authors and Affiliations

  1. Department of General Surgery, Brigham and Women’s Hospital, 75 Francis St, Boston, MA, 02115, USA

    Reuben D. Shin, Michael B. Goldberg, Allison S. Shafran, Samuel A. Shikora, Melissa C. Majumdar & Scott A. Shikora

  2. Department of General Surgery, Lahey Hospital and Medical Center, Burlington, MA, USA

    Reuben D. Shin

  3. Department of General Surgery, Crozer Keystone Health System, Upland, PA, USA

    Michael B. Goldberg

Authors
  1. Reuben D. Shin
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Michael B. Goldberg
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Allison S. Shafran
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Samuel A. Shikora
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Melissa C. Majumdar
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Scott A. Shikora
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Scott A. Shikora.

Ethics declarations

Conflict of Interest

Author 6 is an editor of Obesity Surgery.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

For this type of study, formal consent is not required.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Shin, R.D., Goldberg, M.B., Shafran, A.S. et al. Revision of Roux-en-Y Gastric Bypass with Limb Distalization for Inadequate Weight Loss or Weight Regain. OBES SURG 29, 811–818 (2019). https://doi.org/10.1007/s11695-018-03635-0

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11695-018-03635-0

Keywords

Search

Navigation