With time, the gastric bypass construction may suffer unwanted anatomical changes. The pouch may dilate, and the GE can become too wide or, conversely, too narrow. In some cases, a gastrogastric fistula develops. Finally, a hiatal hernia, silently present preoperatively or acquired since the RYGB, may become symptomatic.

One of the main problems with LRYGB is related to weight issues.

We found that one of the leading causes of insufficient weight loss or weight regain is the development of poor eating habits, more specifically sweets eating. This evolution is facilitated by poor follow-up. When inadequately monitored, bypass patients easily relapse into their old eating habits. Therefore, the first step in treatment is an adequate dietary interview to detect the dietary flaw. Thorough, continuous dietary counseling is next. Changing eating habits, however, remains a tremendous challenge in a bariatric population, and surgical treatment appears to be the only option in some instances.

When patients eat too frequently (polyphagia, grazing), additional malabsorption can be achieved by manipulating the limb components of the bypass. Less aggressive changes to the AL and CL have been shown to be futile in the long term [13].

Despite Sugerman’s catastrophic experience with distal bypass [14], we have followed Brolin’s philosophy [15] and, in some occasions, have transformed the regular LRYGB into a distal bypass. We transected the AL flush with the EE and reimplanted it approximately 150 cm proximal to the ileocecal valve [16]. Because the AL is usually approximately 150 cm in length, we thus ended up with a total of 300 cm of active bowel length, the minimum length to ensure adequate protein absorption, according to Scopinaro [17]. This construction is quite different from Brolin’s technique (Fig. 27.3), in which the CL is just 75 cm long [15].

Most authors warn against the possible unwanted long-term outcomes of the technique. However, there is a substantial difference between a distal bypass as a primary attempt and a distal bypass as a remedial technique as we advocate here. In the latter case, patients no longer demonstrate substantial restriction, unlike in the primary cases where restriction is still significant. In addition, reserving distalization to remedial cases allows the surgeon to select patients who have demonstrated compliance during follow-up. An important condition of distal bypass is continuous, assiduous follow-up to determine the progression of plasma protein, minerals, and fat-soluble vitamin levels. In some cases, hypoproteinemia becomes a life-threatening condition and the only remaining treatment option is to reconvert the bypass to a normal anatomy. Reversal is a realistic option after laparoscopic RYGB, but there are recently published reports on reversal after open bypass as well. Despite the technical feasibility, we believe that straight-on reversal after distal bypass is dangerous because of an increased leak rate related to low protein content. To avoid this hazard, we prefer to perform a feeding gastrostomy, followed by tube feedings for a few months. Tube feedings are less expensive, less prone to infections, and are easier to implement practically than intravenous parenteral hyperalimentation. We usually prescribe tube feedings of full milk, a readily available, inexpensive, and well-tolerated substance, rich in calcium and protein. This regime allows the patients to become anabolic and to undergo laparoscopic reconversion under better conditions, a few months after placement of the gastrostomy.

Alternatively, after a complicated distal bypass, reversal to a more “normal” bypass with an AL of approximately 100 cm and a long CL is a possible remedial operation, but here as well we prefer to proceed to gastrostomy feedings for some time before the final reintervention.

Another option to correct excessive caloric intake after LRYGB is to enhance restriction. A common technique to achieve additional restriction is the placement of a band around the gastric pouch, preferably a few cm proximal to the GE, a technique that was popularized by Fobi [18]. The distance needed to accommodate the band may be a problem when dealing with a micropouch, especially when using an adjustable gastric band, as described by Bessler’s [19] team. We described the use of an adjustable band in conjunction with LRYGB some 8 years ago, but we abandoned this technique because of an unacceptable erosion rate. In fact, erosion has been a problem in our hands for the Fobi ring as well. This problem is not surprising because a foreign object placed across a staple line has the tendency to migrate inside the viscus. Erosion may be even more of a problem in redo cases because the additional dissection necessary to place the band in a correct position increases the chances of ischemia in addition to the already hazardous crossing of a staple line. We do not advocate the use of any type of band in LRYGB when the bypass was performed as a remedial operation. In case of erosion, the best approach is endoscopic removal [20]. Initially, we removed the eroded bands laparoscopically, but we experienced a high rate of leaks with this method.

Gagner’s team developed an interesting technique to achieve additional restriction without using a foreign object. The technique consisted of reducing the gastric pouch together with the proximal part of the AL by resecting both items longitudinally with a linear stapler, however with disappointing long-term results [21]. Rather than resecting the pouch and the AL longitudinally, we recently attempted to reduce both by plication around a 34 French orogastric tube held in close contact with the lesser curvature of the pouch and with the antimesenteric side of the AL, similarly to the technique of greater curvature plication [22], an experimental substitute for LSG. Our technique is promising in the short term, but it is too early to advocate it on a large scale.

Except for the cases in which an anatomical flaw is evident and in which surgery constitutes a first-choice solution, it is essential to diagnose the problem leading to unsatisfactory results after LRYGB. The decision to reintervene, either laparoscopically or endoscopically, must be made by a multidisciplinary team. In our practice, this team consists of a dietitian, a psychologist, a gastroenterologist, a radiologist, an endocrinologist, and a bariatric surgeon.

The multidisciplinary consultation is organized by the bariatric coordinating nurse, who personally knows the patients and who can evaluate the capacity of the patient to deal with dietary restrictions, lifestyle changes, compliance with medication, or reoperation. She constitutes the first and most important selection agent. The psychologist’s input is invaluable as well, as this professional specifically analyzes how the patient has progressed since the preoperative interview. In some instances, the patient will demonstrate a psychological incapacity to deal with the features of the bypass. In some cases, the psychologist will need to demonstrate that the expectations of the patient were unrealistic and teach the patient to accept the results of the bypass, even when they do not match the anticipated outcome. In addition, the psychologist evaluates the patient’s psychological power to bear yet another operation, if needed.

The dietitian analyzes the subject’s dietary adjustment to the bypass construction. There are three specific ways to adapt to the reduced caloric intake after RYGB:

Typically, patients no longer experience a dumping phenomenon some years after the bypass and become “sweets eaters.” This is an essential point, because the dumping syndrome, according to Sugerman [26], is one of the most important mechanisms for persistent weight loss after RYGB. When the syndrome is eliminated, patients have the tendency to eat more sweets, even more so when restriction is still active. We have found (submitted data) that sweets eating typically appears as a consequence of a poor follow-up. According to Scopinaro, a sweets-eating behavior cannot be addressed by surgical measures. Sugar eaters, therefore, rely almost entirely on appropriate dietary counseling. For polyphagia and hyperphagia, a surgical solution can be chosen that takes this dietary evolution into consideration. Polyphagists cannot be helped by additional restriction and will best be helped by a malabsorptive alteration of the bypass. Alteration may consist of distalization of the bypass (transection of the AL at the enteroenterostomy and reimplantation some 150 cm proximal to the cecum); alternatively, reconversion to normal anatomy may be performed, with immediate or delayed sleeve gastrectomy, followed by DS. The choice will often depend on the presence of GERD. In cases of reflux, we are reluctant to construct a sleeve gastrectomy, a construction that is known to induce GERD. An additional argument against choosing the sleeve solution is that simple reconversion to normal anatomy results in a significant prevalence of GERD [27]. Therefore, the most common solution in polyphagists who experience weight regain or obesity recidivism is distalization. Conversely, for hyperphagists, the RYGB can be complemented by an additional restrictive measure. As previously mentioned, this restriction may include the placement of a band, adjustable or not, in non-revisional LRYGB or the refashioning of the existing construction, with resection or plication of the pouch, anastomosis, and AL—an option that is preferred in redo-RYGB.

The gastroenterologist

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