Laparoscopic Revision of Jejunoileal Bypass to Gastric Bypass
Laparoscopic Revision of Jejunoileal Bypass to Gastric Bypass
This study objectives are the following.

 -  To describe the updated clinical presentation, indications, and multidisciplinary
 medical management of patients with a failed and/or complicated jejunoileal bypass
 (JIB).

 -  To analyze the feasibility, safety, and efficacy of one-stage laparoscopic re-operative
 gastric bypass surgery for failed and/or complicated Jejunoileal bypass (JIB) for weight
 loss.

 -  To determine what factors or strategies are associated with a successful outcome. In
 particular, the completion of the surgery in one stage with a laparoscopic approach.
The epidemic of overweight and obesity in the United States of America along with its
 comorbidities continues to expand. Bariatric surgery has demonstrated to be the most
 effective and sustained method to control severe obesity and its comorbidities. For instance,
 type 2 diabetes mellitus was completely resolved in 76.8 percent, systemic arterial
 hypertension was resolved in 61.7 percent, dyslipidemia improved in 70 percent, and
 obstructive sleep apnea hypopnea syndrome was resolved in 85.7 percent. Furthermore,
 bariatric surgery significantly increases life expectancy (89 percent) and decreases overall
 mortality (30 to 40 percent), particularly deaths from diabetes, heart disease, and cancer.
 Lastly, preliminary evidence about downstream savings associated with bariatric surgery
 offset the initial costs in 2 to 4 years8.

 Since 1998, there has been a substantially progressive increase in bariatric surgery. In
 2005, the American Society of Metabolic and Bariatric Surgery "ASMBS" reported that 81
 percent of bariatric procedures were approached laparoscopically. 205,000 people, in 2007,
 had bariatric surgery in the United States from which approximately 80 percent of these were
 Gastric Bypass. Moreover, there is a mismatch between eligibility and receipt of bariatric
 surgery with just less than 1 percent of the eligible population being treated for morbid
 obesity through bariatric surgery. Along with the increasing number of elective primary
 weight loss procedures, up to 20 percent of post RYGB patients cannot sustain their weight
 loss beyond 2 to 3 years after the primary bariatric procedure. Thus, revisional surgery for
 poor weight loss and re-operations for technical or mechanical complications will rise in a
 parallel manner.

 Regardless of being an effective treatment of morbid obesity, JIB was abandoned in the early
 80s mostly because of its metabolic and nutritional complications. Multiple patients who
 underwent this procedure more than two decades ago are still alive. Close follow-up, in even
 asymptomatic patients, is necessary after JIB because they may present with nonreversible
 complications.

 As with any bariatric procedure, weight regain, inadequate initial weight loss, and late
 complications or a combination of them are the most widely accepted indications to undergo
 revisional bariatric surgery. Specifically, the JIB related late complications can be
 arbitrarily categorized into "malabsorption and malnutrition" and "bacterial overgrowth
 syndrome". The former might present with steatorrhea, electrolyte (K, Ca, P, Mg) and acid
 base imbalance (hyperchloremic metabolic acidosis), liposoluble (A, D, E, K) and hydrosoluble
 (B1, B12 and Folate) vitamin deficiencies, and protein calorie malnutrition "PCM". "The
 bacterial overgrowth syndrome" causes a variety of complications such as gas bloat syndrome,
 foul smelling flatulence, recurrent migratory polyarthralgia and necrotizing skin lesions.
 Other late non metabolic complications related to the bypassed bowel include intussusception,
 pseudo-obstruction, and bypass enteropathy.

 "PCM" is quickly and effectively treated by parenteral nutritional support. Diet optimization
 with consumption of high biological value protein (90 g per day) and a total calorie intake
 adjusted to ideal body weight might decrease the severity of the malabsorption syndrome and
 or prevent its recurrence.

 Transitory resolution of most symptoms caused by the bacterial overgrowth syndrome is
 accomplished by the administration, in divided doses, of oral tetracycline (2.0 g per day),
 amoxicillin-clavulanate (1 to 1.7g per day), clindamycin (0.9 to 1.8 g per day), and
 metronidazole (1 to 1.5 g per day) among others. Rapid symptomatic improvement is observed,
 however, over time, organisms become resistant to the systemic absorption of antibiotics,
 ceasing the benefit of this therapy. In addition, side effects including superinfections such
 as pseudomembranous colitis might present. Local instillation of antibiotic through an
 intestinal indwelling catheter placed in the excluded bowel limb has been described.

 When the JIB related complications present as intractable, severe or recurrent, surgical
 intervention is required. Liver, either acute liver failure or cirrhosis, (secondary to "PCM"
 and bacterial overgrowth syndrome) and kidney, either tubulointerstitial nephropathy or
 renoureteral lithiasis, (secondary to enteric hyperoxaluria and volume depletion) dysfunction
 are the most frequently described complications leading to death. However, after end stage
 liver (cirrhosis) and renal diseases are established, good judgment is needed to assess the
 risk benefit algorithm for operative intervention, as these conditions are irreversible.

 In the United States, the most popular type of intestinal bypass performed was the so called
 "14 plus 4" with an end to side jejunoileostomy, a 14 inches biliopancreatic limb with a 4
 inches common channel. Because of poor weight loss, some surgeons used to performed an end to
 end jejunoileostomy avoiding chyme to reflux into the defunctionalized limb; Through an
 ileocolostomy, the defunctionalized jejunoileal limb was drained into the cecum or sigmoid
 colon.

 Open reversal or conversion to gastric bypass has been shown to be effective procedures with
 defined complications. Since the 60s Payne, DeWind and Commons had already demonstrated that
 takedown and restitution of the gastrointestinal continuity is an effective strategy to solve
 the metabolic complications. However, relapse of obesity along with its comorbidities is the
 rule.

 Series from the 70s and 80s suggested that one stage open revision of JIB to gastric bypass
 was feasible and safe. However, most of these revisions were performed a couple of years
 after the original bariatric surgery with a completely different configuration (non divided
 horizontal pouch with a loop gastrojejunostomy) from how modern RYGB is performed in these
 days. Hence, outcome analysis of those series is not transferable in today context.

 Because of the long interval time between the JIB and the revision surgery, bowel adaptation
 is maximal causing a marked discrepancy in the lumen diameter and bowel thickness between the
 functional and defunctionalized bowel segments. Thus, different approaches have been
 described in the literature to deal with more extensive intestinal changes..

 Based on Cannova et al. report in which described the placement of an intestinal indwelling
 catheter in the excluded bowel limb, Dallal et al. with a minimally invasive approach
 established enteral nutritional support in the defunctionalized bowel limb, to revert its
 atrophy. After a three month period with extensive counseling to undergo conversion to a
 RYGB, the patient decided just to be reversed.

 Another staged option for revising the JIB is as follows. Initially, the JIB is dismantled
 and the normal gastrointestinal continuity restored. After the initially bypassed and
 atrophied small bowel regains its function and the bowel atrophy is partially overturned, the
 second stage (weight loss procedure) is performed, so weight loss can be maintained or
 achieved.

 The two accepted revisionary procedures described in the literature for failed JIB are mainly
 adjustable gastric banding (AGB) and gastric bypass. In 2000, O'Brien et al. reported a
 series of 50 revisions to adjustable gastric banding. As the primary bariatric procedure, two
 patients had a JIB. A one stage open revision was performed without providing specific subset
 outcome analysis.

 In 1993, Behrns et al. reported the outcome analysis of 61 open assorted revision surgeries
 from which 14 had a JIB. The indication for this subgroup was due to severe metabolic
 complications with a pre-revisional mean BMI of 34.2 kilograms per squared meter. Nine
 patients were revised to VBG and five patients to a non-divided, vertical RYGB. The percent
 excess weight loss for this five patients was 49.5 percent (overall follow-up was 23 months)
 with a 67 percent dissatisfaction rate of their new lifestyle because of the change in eating
 patterns caused by switching from a full size meal to a restricted diet.

 In 1996, Owens et al. reported the open surgical revision of 75 patients from which 23
 patients had a JIB as their primary procedure. Specific subgroup analysis was not provided.
 In 2005, khaitan et al. reported 37 patients who underwent 39 bariatric revisions, either
 open or laparoscopic. Originally, five had a JI bypass from which two were initially
 approached laparoscopically. However, specific subgroup analysis was not provided.

 In summary, there are just two manuscripts reporting cases of attempted laparoscopic
 conversion of JIB to RYGB with its modern anatomical construction. However, a one stage
 procedure has not been achieved up to date. Therefore, no outcomes with this approach have
 been documented as well. With this study, we will advance our knowledge about revision
 bariatric surgery and report excellent outcomes after conversion from a completely
 malabsorptive procedure to a mostly restrictive weight loss procedure, the gastric bypass and
 although JIB was abandoned long time ago, there are still living patients with this procedure
 and bariatric surgeons need to be aware of side effects and minimally invasive strategies for
 the management of these highly complex patients.
Inclusion Criteria:

 -  Met NIH criteria for weight loss surgery with poor weight loss after JIB

 -  Intractable, severe and/or recurrent JIB-related late complications after optimized
 medical management

 -  Laparoscopic approach for primary revisional bariatric surgery

 Exclusion Criteria:

 -  Any other type of revisional bariatric procedure

 -  Open approach for revision surgery

 -  missing records and/or unreachable patients with scant information for analysis