The Hardship of Recovering a Patient from Liver Failure after One Anastomosis Gastric Bypass

Abstract

The one anastomosis gastric bypass (OAGB) was first described in 2001 as a safe and effective procedure that meets the criteria for the "ideal" weight loss operation. However, revisions for malnutrition and liver failure were reported. We report a patient who was transferred to our institution with protein calorie malnutrition and liver failure after undergoing OAGB. A 42-year-old morbidly obese female patient underwent a laparoscopic sleeve gastrectomy (LSG) in 2012 followed by conversion to OAGB in 2018 for weight regain at another institution. Nine months after conversion, she was transferred to our institution with dehydration, vomiting, dysphagia, generalized edema, and steatorrhea (7 times/day). She had become wheelchair bound. On examination, there was gross edema, protein-calorie malnutrition, dermatitis, and muscle wasting. She had anemia (8g/dl) reference range (11.5-15.5g/dl), bilirubin (1.8mg/dl) (0.2-1.2mg/dl), hypoalbuminemia (1.4g/dl) (3.5-5g/dl), and elevated international normalized ratio (INR). The patient was admitted to the hospital and was started on total parenteral nutrition (TPN), with thiamine, vitamins, iron injections, and trace mineral replacement. Her course was complicated by multiple episodes of line sepsis and bacteremia. After 6weeks, we succeeded in raising her albumin to 2.9g/dl and proceeded with surgery. Laparoscopic exploration started with identifying the anatomy and measuring the biliopancreatic limb (BPL = 430cm) and the common channel (CC = 380cm). First, we restored the continuity of the small bowel. Then the long gastric pouch was trimmed. Finally, the patient was converted to a Roux-en-Y gastric bypass (RYGB) with a 30cm BP limb and 70cm Roux limb. The patient had an uneventful recovery and was discharged home on the fourth postoperative day. At 3months of follow-up, her symptoms resolved, her laboratory work up normalized, and she regained mobility. Malnutrition and liver failure after OAGB are not uncommon. It is encountered with configurations of longer BP limb. BPL length of 150 to 200cm seems to reduce such complications. Preoperative nutritional optimization is key. Conversion to a proximal RYGB is a safe and feasible approach.