Excessive weight loss (severe malnutrition)
Absence of weight loss or weight regain
Another reason of weight regain in gastric bypass is the presence of a gastro-gastric fistula. This is an abnormal communication between the excluded stomach and the gastric pouch. It is a rare complication (1.5–6 %) . The gastro-gastric fistula is responsible of weight regain for the loss of both of restrictive and malabsorptive pathway [23, 24]. In fact by the fistula the food not passing through the stoma and bypassed intestine, causing weight regain. One of most important reasons to weight loss failure is intestinal adaptation. Scopinaro, while describing the malabsorptive properties of the biliopancreatic diversion, say that the massive intestinal adaptation phenomenon causes an increased absorptive surface. Between the gastro-entero anastomosis and the jejuno-jejunal anastomosis the intestinal tract increases in thickness with a corresponding increase in the length of gastrointestinal villae.
Re-do surgery for Roux-en-Y gastric bypass was considered a challenge in the field of bariatric surgery, with high risk of complication rate and patients discomfort. Recently, many authors have reported several endoscopic or laparoscopic bariatric options, above all for the problem of weight regain or absence of weight loss (Table 23.2).
Roux-en-Y gastric bypass weight loss failure: therapeutic options
Gastro-entero anastomosis suture
Internal plication (mucosal or full thickness)
Nonadjustable ring positioning
Adjustable band positioning
Length limb modification
23.1 Restrictive Procedures
23.1.1 Endoscopic Procedures
Endoscopic option for weight recidivism linked to dilated gastro-jejunal anastomosis has been suggested in several experiences to be safe with minimal morbidity. Catalano et al. showed that the injection of sclerotic agents to reduce the size of gastro-jejunal anastomosis result in weight loss after weight regain . Thompson et al. showed that endoscopic suturing was also safe and feasible to reduce the gastrointestinal anastomosis to an average of 10 mm, leading to weight loss in 75 % of RYGBP patients and resulting in loss of 23.4 % of EBWL . Recently, a viable endoscopic alternative to reduce the pouch volume was proposed, with mucosal or total wall plication, reshaping the pouch with dedicated instruments [1, 23]. Eid et al. have reported a randomized clinical trial comparing multiple full-thickness plications to sham endoscopy procedure after weight loss failure of RYGB . They suspended the trial prematurely because preliminary results indicated the failure to achieve the primary efficacy end point at last in 50 % of patients treated with plication.
23.1.2 Laparoscopic Procedure
Parikh et al. suggest resecting the pouch and alimentary loop in a longitudinal fashion. But this procedure was not considered safe and effective enough . Hamdi et al. also suggest resizing the gastric pouch by resection and recreating the gastrojejunostomy. Perioperaitive complication rate was 8 % . After 24 months of follow up they observed 44 % of %EWL. They conclude that this re-do procedure can be performed with significant weight loss, but additional studies are requested . Gumbs et al., in case of tissue suffering from previous scars or fistulas or postoperative leak, suggest an external plication mimicking the longitudinal resection suggested by Parikh, and inspired by the gastric plication technique . This plication was performed with nonabsorbable stitches across a 34 French orogastric tube. This revisional option was safe and attractive in terms of safety, but long-term results of these techniques are not reported.
Another laparoscopic option to treat the pouch enlargement is the positioning of an external ring. Essentially two options have been described. Fobi showed that the addition of ring proximally to the gastrointestinal anastomosis is enough to reduce the food ingestion . More recently were described some patients with an adjustable gastric banding positioned around the upper part of the gastric pouch. Chin et al. described their experience with ten patients who underwent revisional surgery positioning an adjustable gastric banding around the RYGB pouch . After 2 years of follow up the %EWL was 48.7 % (range 21.8–98.1 %) without life threatening complications. Bessler et al. reported their experience with 27 patients who underwent RYGB revision with adjustable gastric band . At 60 months of follow up they observed 47 % of %EWL; also, in this report life threatening complications were absent and two port-related complications and one band slippage were recorded. They conclude that the addiction of the adjustable silicone gastric banding causes significant weight loss in patients with weight recidivism or poor weight loss after RYGB. The absence of anastomosis or changes in limbs length makes this revisional option safe and attractive. Recently, Vijgen reported a review of the studies on the effects of salvage pouch banding after failed RYGB . In their review were included patients with both adjustable and non-adjustable gastric banding operated via laparotomy or laparoscopy. In the seven studies considered, all the authors support the opinion that the adjustable gastric banding around the pouch is a safe and feasible revisional procedure after failed RYGB . Moreover, despite these studies, long-term results on a large patient population who underwent pouch banding are scarce, waiting for an evidence-based confirmation.
23.2 Malabsorptive Procedures
Parikh et al. have suggested a conversion procedure to duodenal switch in cases of weight loss failure after Roux-en-Y gastric bypass . This procedure was initially reported on 13 patients and was performed in two steps. The first step is the conversion of gastric bypass to sleeve gastrectomy after gastro-jejunal anastomosis removal and the reconnection of the gastric pouch to the stomach remnant. The second step was to complete the duodenal switch several months after the sleeve. In this series, mortality, leaks, and malabsorptive problems were not observed. Four patients developed a stenosis of gastro-gastric stricture resolved by endoscopy in three cases. Authors conclude on the bases of their early results that the conversion of failed RYGB in DS in expert hands is a valid therapeutic option with 63 % of %EWL and BMI loss of 11 kg/m2. The complication rate was acceptable, but the number of operated patients was too small and the follow-up too short. Himpens suggested a slight modification of this approach to make the procedure more safer, with a first stage involving reversal to normal anatomy, followed after 3 months by a sleeve gastrectomy, and then a duodenal switch after 9 months from the first stage .
An alternative considered is to switch the RYGB in a distal RYGB, with a higher malabsorptive power. This option was considered uneventful by some authors, dangerous by other.
23.3 Causes of Gastric Bypass Revision or Conversion Not Related to Weight Loss
The most common indication for conversion or revision of Roux-en-Y gastric bypass is gatrointestinal anastomosis stricture and marginal ulcers [35–37]. The rate of incidence of gastro-jejunal stricture has been reported with a wide range: 4–36 %. In these cases the endoscopic dilation was safe and effective in 80–90 % of cases with low complication rate (perforation). In negative therapeutic results, a more invasive approach was indicated as in marginal ulcers. The incidence of marginal ulcer after RYGP is 1–16 %. This complication was linked to several factors such as eroded suture, drugs (NSAID), smoking, Helicobacter pylori infection, and acid exposure (gastro-gastric fistula). The treatment of these complications is medical by removal of all risk factors with administration of proton pump inhibitors and/or other drugs. In patients refractory to medical therapy or preventive measures or endoscopic attempts, a re-do was suggested to avoid serious complication such as perforation or bleeding. In these cases, the resection of primary gastro-jejunal anastomosis re-doing a new communication was suggested with safe results.