What is the recommended approach for a revisional Roux-en-Y gastric bypass with a side-to-side gastrojejunostomy and an intact pylorus?

Revisional Roux-en-Y Gastric Bypass with Side-to-Side Gastrojejunostomy and Intact Pylorus

For revisional Roux-en-Y gastric bypass with a side-to-side gastrojejunostomy and intact pylorus, laparoscopic approach is recommended as the primary surgical technique when performed by experienced bariatric surgeons in specialized centers to minimize complications and optimize outcomes. 1

Preoperative Assessment

• CT scan is the diagnostic test of choice to identify potential complications such as intussusception, strictures, or bezoars 1
• Endoscopic evaluation is essential to directly visualize the gastric pouch, stoma, and proximal Roux limb to assess for:
  • Marginal ulcers
  • Stenosis
  • Gastro-gastric fistula
  • Bezoars 1
• Laboratory tests including white blood cell count and C-reactive protein should be obtained to assess for infection/inflammation 1

Surgical Approach

Laparoscopic Technique

• Laparoscopic approach is preferred over open surgery due to:
  • Decreased operative time
  • Reduced blood loss
  • Shorter hospital stay 2
  • Lower incidence of wound complications

Gastrojejunostomy Construction

• Side-to-side gastrojejunostomy with an intact pylorus offers several advantages:

  • Better control of dumping syndrome
  • Improved nutrient absorption
  • Reduced risk of marginal ulceration 3

• Technical options for creating the gastrojejunostomy:

  1. Endocutter cartridge technique with TA stapler closure - recommended due to:

     • Shorter operative time (average 75 minutes)
     • Lower incidence of internal herniation (3.3%)
     • Reduced risk of complications 3

  2. Hand-sewn technique:

     • Higher risk of gastrojejunostomy stenosis (36.6%)
     • Higher risk of internal herniation (17%)
     • Longer operative time 3

Critical Technical Considerations

• Fixation and closure of all potential hernia sites with non-absorbable sutures is essential to prevent internal herniation 4
• Intraoperative endoscopy is a key component to:
  • Verify anastomotic integrity
  • Ensure proper pouch size
  • Confirm absence of bleeding 2
• Roux limb should be positioned in an antecolic, antegastric fashion to minimize risk of internal hernias 5

Potential Complications and Management

Immediate Complications

• Hemorrhage:

  • Occurs in approximately 4.2% of cases
  • May require surgical exploration if severe 5

• Anastomotic leak:

  • Rare with proper technique
  • Requires immediate surgical intervention if suspected 4

Delayed Complications

• Marginal ulceration:

  • Incidence ranges from 0.6-25% (average 4.6%)
  • Risk factors include smoking and NSAID use
  • Management with proton pump inhibitors is usually effective 6

• Anastomotic stricture:

  • Incidence approximately 0.8%
  • Manageable with endoscopic balloon dilation in most cases 5

• Internal herniation:

  • Risk varies by technique (3.3-17%)
  • Requires prompt surgical intervention 3

Postoperative Care

• Early mobilization to prevent complications 1
• Regular nutritional assessment and supplementation as needed 1
• Proton pump inhibitor therapy to prevent marginal ulceration 6
• Close follow-up to monitor for complications and weight loss outcomes 1

Expected Outcomes

• Average excess weight loss of approximately 70% at 12 months 4
• Resolution or improvement of obesity-related comorbidities
• Average hospital stay of 1.9-2.6 days in uncomplicated cases 4, 5

Important Considerations

• Surgeon experience significantly impacts outcomes - procedures should be performed by experienced bariatric surgeons 5
• A systematic, evidence-based approach results in lower complication rates 5
• Regular postoperative follow-up is essential for early detection and management of complications 1

The revisional nature of the procedure increases technical difficulty and potential for complications, making surgeon experience and specialized center capabilities particularly important factors in achieving optimal outcomes.