Correction of Bariatric Surgery - Forum

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Scalpel

Correction of Bariatric Surgery - Ärzteforum

Post#1 »

43 yo lady, in 2005 weighted 330Lbs. Had a Bariatric Surgery - Vertical banded gastroplasty, pancreato-biliary diversion procedure (125 cm of ileum distal to the roux-en-y site, 125 cm between gastrojejunostomy and roux-en-y site, 250 cm from ligament of trietz to roux-en-y site -- per the op notes), and gallbladder removed.

Weighed 150 lbs within 1 year. Reportedly needed several courses of TPN in 2011&12.

Had frequent, loose stools until about 2 years ago. Now stools much less frequent (??cathartic colon??)

Currently looks like she is 70, weighs 130 Lbs, has anasarca, albumin 2.7, LFT's normal except alk phos 350, mildly anemic and macrocytic (B12 borderline low, is already on folate supplementation), thyroid tests normal, electrolytes ok, calcium 8.0 (uncorrected for albumin), and is heme positive. EGD and colonoscopy show the expected post-op anatomy, but otherwise are normal.

She obviously needs nutritional support and then reversal of her diversion procedure. My questions are:

Would you simply move the roux-en-y site as close to the gastrojejunostomy site as possible, or would you try to give her even more absorptive surface by moving some of the diverted limb back incontinuity with the flow of chyme?? Is it even technically possible to do so and preserve blood supply?

Does anybody know of a good review on reversal of pancreato-biliary diversion procedures?


The best surgeon

Re: Correction of Bariatric Surgery - Ärzteforum

Post#2 »

If I were you I would definitely call somebody who has done a bunch of these procedures. I think you are referring to the Scopinaro Procedure. Having said that, I will hazard a guess, however. I think you will live to regret it if you reverse the operation. Within a year she will gain 200 lbs and hate you. This is not an emergency operation. You should be able to improve her nutritional state, then revise the operation. Make the common channel longer; that's all. I'm not sure how much longer; it's a finicky thing. (That's why I suggested calling someone who does a bunch of them). Otherwise, you are describing a typical patient after this operation, with regard to the vitamin deficiencies.

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A Doctor

Re: Correction of Bariatric Surgery - Ärzteforum

Post#3 »

I am definitely not an expert but the following thoughts come to mind:
1. Can you get her to eat things that are better absorbed (even at the extreme the special supplement formulas with the medium chain triglycerides and plain amino acids (I know these are supposed to taste awful and the average morbid obesity patient is non-compliant especially about eating what they should).
2. Can you do jejunostomy type tube feedings (place as percutaneous endoscopic gastrostomy and advance jejunal limb into whatever small bowel is attached to the stomach)---just feed supplementally at night as needed (of course, should she be unlucky enough to be on Medicare because of disability, they will not pay for tube feedings if she eats anything (in addition to tube feedings).
3. Could you operatively, without too much difficulty, place a feeding tube in the excluded limb of small bowel and feed into this at night as needed?

John Dissector

Re: Correction of Bariatric Surgery - Ärzteforum

Post#4 »

Doing a VBG is with biliopancreatic bypass is a deadly combination. Billiary pancreatic diversion reduces absorption. To avoid the problems of severe malnutrition, these patients need to continue to gorge themselves, but because of the VBG, your patient cannot. In short, these are two incompatible operations.

There is a group who uses a combination of the two for the superobese (>350 lbs) . From their description, they monitor the patient closely, frequently in house, and reverse the biliopancreatic bypass once the patient has lost about 50 kg.

You must reverse the biliopancreatic bypass. Probably by converting to a simple Roux en Y. You should not have a problem with the blood supply. The VBG should be enough to prevent the patient from gaining too much weight.

forceps

Re: Correction of Bariatric Surgery - Ärzteforum

Post#5 »

My resident told me that at the U of Iowa, the bariatric surgeons are performing this operation using silastic ring around the stomach.This is inflated thru a subcutaneous port, while using fluoro guidance.

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