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Laparoscopic Conversion of a GB into Normal Anatomy
Abstract & Commentary
By Namir Katkhouda, MD, FACS, Professor of Surgery, Chief, Minimally Invasive Surgery, University of Southern California (USC)-Los Angeles, CA. Dr. Katkhouda is a consultant for Baxter, Ethicon, Storz, and Gore.
Synopsis: Restoration of normal anatomy after RYGBP is feasible.
Source: Himpens J, et al. Laparoscopic conversion of the gastric bypass into a normal anatomy. Obes Surg. 2006;16:908-912.
Background: Laparoscopic Roux-en-Y gastric bypass (RYGBP) is considered a non-reversible procedure. The laparoscopic conversion of RYGBP into a normal anatomy was reported here.
Methods: In June 2004, a laparoscopic RYGBP was performed in a 46-year-old female sweet-eater with a BMI of 46 kg/m2. After 7 months, the patient reported a significant, and incapacitating, dumping syndrome without postprandial hypoglycemia. She requested conversion to a normal anatomy; hence, a laparoscopic RYGBP reversal was performed. The BMI at the time was 27 kg/m2.
Results: Operative time was 95 minutes, and intra-operative blood loss was 150 mL. The patient had an uneventful recovery and was discharged home on the fifth postoperative day. At 6 months follow up, her BMI was 27 kg/m2, and barium swallow showed good passage, with good gastric motility. After one year, the BMI is still unchanged and she is doing well.
Conclusion: Restoration of normal anatomy after RYGBP is technically feasible.
This paper presents a laparoscopic conversion of a Roux-en-Y into the previous anatomy. Technically, it does not seem to be a challenge to Himpens and colleagues, who are experienced laparoscopic surgeons with numerous years of experience under their belt; but the readers should be forewarned, this is a difficult operation and if the laparoscopic gastric bypass is a 10 on the scale of difficulty, this operation described here is a 15. It is true though that the lack of adhesions and the minimal scarring following a laparoscopic operation makes it easier to convert than an open VBG into a lap gastric bypass for example. The discussion then focuses on the indications for such a conversion. In this case reported, it was a sweet eater who was having intolerable dumping. That is reasonable, but the other reasons brought forth in the discussion are more debatable.
The first one is cholelithiasis, and the need to access the common bile duct. It is not clear why a restoration of normal gastric anatomy would be better than a simple transgastric ERCP through the remaining stomach, a technique more seductive and technically much less invasive than the operation proposed here. The second indication discussed by Himpens et al is the cancer of the remaining stomach. Again, this is not clear why this will work. Himpens et al say "obviously the bypassed stomach is inaccessible for routine endoscopy." It is not clear where the connection is to the proposed operation.
The final 2 reasons are more legitimate: malnutrition following gastric bypass; although very rare, it can be well handled by this operation, and I think that the first step could be a reduction in the length of the Roux-en-Y. Finally, nesidioblastomas are a real problem, and a reversal could be of some help there. The restitution of normal anatomy might be less aggressive therapy, reducing the beta cell trophic factors, which had been increased as a result of the Roux-en-Y gastric bypass.