Reversal Of Roux-en-Y Gastric Bypass Research Articles

Changes in Symptoms and General Well-being After Reversal of Roux-en-Y Gastric Bypass: A Questionnaire Survey.

After Roux-en-Y gastric bypass (RYGB), few patients develop severe complications, which ultimately may require reversal of RYGB. We aimed to examine the effect of reversal of RYGB on symptoms and well-being. Via contact to medical and surgical departments treating patients with RYGB, we identified 18 patients, who had undergone reversal, 2009-2019. We conducted a Danish, nationwide questionnaire survey concerning symptoms before and after reversal of the RYGB including the patients' own perceptions of their well-being. Fourteen patients responded to the questionnaire (86% female; median age at RYGB, 36.2years [IQR, 30.9-38.6years]). The median time from RYGB to reversal was 5.8years (IQR, 5.1-7.5years). After RYGB, 13 patients (93%) reported abdominal pain, while 12 patients still had abdominal pain after reversal. Six out of 11 patients (45%) reported complete remission of dumping/post-bariatric hypoglycemia (PBH) after reversal. Malabsorption disappeared in 10 out of 11 patients (90%). Reversal had minor effect on neuropathy. The median weight loss from RYGB was 61kg (IQR, 56-75kg), while the median weight regain after reversal was 30kg (IQR, 13-46kg). Regarding the well-being, 72 of the patients felt better or much better after reversal. In total, 72% of the patients felt better or much better after reversal of RYGB, though some still had RYGB-related symptoms. The reversal relieved dumping/PBH and malabsorption, but not abdominal pain and neuropathy. Finally, half of the weight loss was regained after reversal. Reversal of RYGB may be an option in highly selected cases.

FRI666 Postbariatric Hypoglycemia: The Brody School Of Medicine Institutional Experience

Abstract Disclosure: Z. Jiang: None. M.R. Azad: None. M. Seagrove-Guffey: None. M. Javaid: None. A.J. Drake: None. M.S. Dar: None. Background and objectives: Post-bariatric hypoglycemia (PBH) is a complication of bariatric surgery and occurs most often after meals but can be nocturnal. PBH tends to occur most often after Roux-en-Y gastric bypass (RYGB). Hypoglycemia severity ranges from mild symptoms to severe lows that require assistance and can be life threatening. The management of PBH is challenging due to its variable presentation and incompletely understood pathophysiology. Medical nutrition therapy is tried initially followed by medical therapy if patients do not respond. Reversal of RYGB is reserved for the most refractory cases. Here we present our institutional experience treating PBH patients (pts) between 2007-2014. Methods: This is a retrospective cohort study of PBH pts seen between 2007-2014 at our institution. Thirty RYGB pts with PBH were included in the study. PBH was confirmed when symptoms of sweating, shakiness, tachycardia, and confusion that were correlated with a fingerstick blood sugars (FSBS) <70 mg/dl which improved after FSBS >70 mg/dl. Mixed meal testing was not done. Pts were referred for medical nutrition therapy. If there was no improvement in hypoglycemia frequency/severity in 3-6 months, Acarbose or Creon were tried at the discretion of the physician with Diazoxide reserved for patients who were refractory to these medicines. Results: Most of the pts were Caucasian females (26/30) without diabetes (25/30) and mean age was 54 +/- 9 years. BMI decreased after RYGB (47.8 +/- 9.2 to 26.4 +/- 4.9) and the weight loss nadir occurred at 26 months for most patients. The average time to first episode of hypoglycemia for all PBH pts was 28 months but only 11 months for PBH pts with pre-diabetes. About 47% of PBH pts (14/30) reported some improvement in the severity and frequency of hypoglycemia after either dietary interventions (8/30) or pharmacological interventions. With regards to pharmacological interventions, Acarbose (3/10 pts), Creon (3/8) and Diazoxide (1/4) all led to some improvement in hypoglycemia frequency and severity. We found that 3 pts with PBH had died. We had access to charts of 2/3 pts and reviewed them to determine cause of death. Both pts had severe PBH with hypoglycemia and loss of consciousness. Pt #1 had a history of atrial fibrillation and developed PBH 8 years after RYGB. He was referred to medical nutrition therapy and lost follow up. Pt # 2 experienced PBH 1 year post-RYGB, treated with Acarbose which did not help. He was then tried on Creon with improvement in the frequency and severity of hypoglycemia and was later lost follow up. Conclusions: PBH is a challenging complication of RYGB and appears to occur more often than previously reported. Medical nutrition and pharmacologic therapy showed modest improvement in PBH severity and frequency but more rigorous controlled trials are needed. PBH may increase the mortality but more research is needed. Presentation: Friday, June 16, 2023

FRI080 Post Bariatric Hypoglycemia And Pregnancy: Successful Utilization Of Remnant Stomach Gastrostomy Tube Placement In Severe Refractory Hypoglycemia After Roux-en-Y Gastric Bypass Surgery

Abstract Disclosure: S.S. Habbsa: None. A. Port: None. Introduction: Post bariatric hypoglycemia (PBH) can occur following Roux-En-Y Gastric Bypass (RYGB). Due to an exaggerated glucagon-like-peptide-1 (GLP-1) response from rapid nutrient transit to the distal bowel, patients with PBH exhibit endogenous hyperinsulinemic hypoglycemia following a carbohydrate load. Severe cases can result in significantly impaired quality of life (QoL), including syncope, seizures, and nutritional deficits from restricted intake. Recently, remnant stomach percutaneous endoscopy gastrostomy (PEG) tube placement has been reported in a handful of cases as a successful long-term strategy for RYGB-PBH refractory to nutritional and medical therapy. However, there are no known outcomes in pregnancy. Case: A 25-year-old female with a history of RYGB presented with increasingly severe and frequent PBH beginning 12 months after surgery. Mixed meal testing was consistent with prandial hypoglycemia (down to 20 mg/dL) with hyperinsulinemia (C-peptide 11 [0.80 - 3.10 ng/mL], Insulin 50 [<23 uIU/mL]). Ultrasound was negative for pancreatic anomalies. Dietary modification and medical therapy with acarbose, diazoxide, and liraglutide were unsuccessful. 3 years after RYGB, she required hospitalization for hypoglycemic seizures, and she underwent remnant stomach PEG tube placement. Oral intake was discontinued (except for protein for comfort) and substituted with 12-hour nocturnal feeds. Her PBH diminished, and she reported significant improvement in QoL. 6 years after PEG placement, the patient became pregnant. Working closely with a dietician, she increased caloric intake by 200-250 kcal/day in the second and third trimesters. Screening for gestational diabetes with oral glucose tolerance testing was deferred given risk of PBH exacerbation, and CGM was used instead for glycemic monitoring. Intolerance to overnight feeds was remedied using concentrated enteral formulas and incorporation of short daytime tube feed boluses. She delivered a healthy baby via elective C-section. During lactation, due to concern for food protein allergy, she was transitioned to a non-dairy non-soy-based feeding regimen. She returned to her pre-pregnancy weight and her sugars remained stable. Conclusion: This is the first case report documenting safe and effective use of remnant stomach enteral feeds for management of severe refractory PBH post RYGB during pregnancy and lactation. Pregnancy presents a unique situation in which increased carbohydrate intake is necessary to support fetal development; however, this can be life-threatening for patients with severe PBH. Remnant stomach PEG feeds utilize the original gut without need for surgical RYGB reversal, preventing rapid nutrient transit. Long-term reversal of PBH, sustained weight loss and customizable feeding regimens support the use of remnant PEG placement for severe RYGB-PBH in the appropriate patient. Presentation: Friday, June 16, 2023

Transoral gastric outlet reduction for post-prandial hypoglycemia after Roux-en-Y gastric bypass.

Post-prandial hypoglycemia is an uncommon but disabling late complication of Roux-en-Y gastric bypass (RYGB). Most patients can be treated with dietary interventions and medications; however, some patients develop refractory hypoglycemia that may lead to multiple daily episodes and seizures. While RYGB reversal surgery is an effective treatment, complication rates are high, and patients inevitably experience weight regain. Transoral gastric outlet reduction (TORe) is a minimally invasive treatment that is effective for early and late dumping syndrome. However, prior studies have not distinguished the effectiveness of TORe specifically for patients with post-prandial hypoglycemia. This study aims to describe a single institution's experience of TORe for treating post-prandial hypoglycemia. This is a case series of patients with prior RYGB complicated by post-prandial hypoglycemia who underwent TORe from February 2020 to September 2021. Pre-procedural characteristics and post-procedural outcomes were obtained. Outcomes assessed included post-prandial hypoglycemia episodes, dumping syndrome symptoms, and weight change. A total of 11 patients underwent TORe from 2020 to 2021 for post-prandial hypoglycemia. Three (27%) patients had a history of seizures due to hypoglycemia. All had been advised on dietary changes, and ten patients (91%) were on medications for dumping. All patients reported a reduction in post-prandial hypoglycemic events as well as the majority of dumping syndrome symptoms during an average follow-up time of 409 ± 125days. Ten patients (91%) had experienced weight regain from their post-RYGB nadir weight. For these patients, the average total body weight loss 12months post-TORe was 12.4 ± 12%. There were no complications requiring hospitalization. One patient experienced post-TORe nausea and vomiting requiring dilation of the gastrojejunal anastomosis with resolution in symptoms. TORe is a safe and effective treatment for post-prandial hypoglycemia and weight regain after RYGB in patients with symptoms refractory to medications and dietary changes.

Combined laparoscopic Roux-en-Y gastric bypass reversal and gastric banding to treat severe hyperinsulinemic hypoglycemia: A case report and surgical video.

Non insulinoma pancreatogenous hypoglycemia syndrome (NIPHS) is a recently described complication of Roux-en-Y gastric bypass (RYGB) characterised by pathologic features of nesidioblastosis and hyperinsulinemic hypoglycemias that can occur months to years after surgery. Increased incretin production appears to be one of the involved mechanisms. Currently, there is no Gold Standard treatment. We present the case of a 57-year-old woman with a history of silastic ring vertical gastroplasty (SRVG) converted into RYGB who suffered from severe daily episodes of neuroglycopenia due to NIPHS, with poor response to conservative and medical treatments. At first, as it is suggested in recent literature, we decided to evaluate whether reversal would efficiently reduce episodes of hypoglycemia by attempting gastrostomy tubing of the remaining stomach. Since gastrostomy proved to be efficient, we reversed the RYGB laparoscopically and added a gastric banding to keep control over the patient's weight. After an asymptomatic period of two months, mild hypoglycemias recurred, on average once every three weeks, easily managed by sugar ingestion. A preexisting gastroparesis was worsened by the intervention, possibly caused by vagus nerve injury secondary to the multiple gastric procedures. A year later, the patient returned to a regular lifestyle. Her weight gain was limited to 8 kg thanks to appropriate adjustments of the gastric band. Treatment of NIPHS includes appropriate diet, pharmacotherapy and surgical procedures; partial or total pancreatectomy, laparoscopic reversal of RYGB (with or without sleeve gastrectomy) and gastric banding have been proposed. This is the first described case of severe NIPHS after RYGB successfully treated with combined laparoscopic reversal of gastric bypass and gastric banding to avoid weight regain. We expect this novel approach will help to overcome hypoglycemic episodes from NIPHS, while maintaining weight control and preventing the resurgence of obesity-related comorbidities. Further studies with long term follow-up are necessary. • Non insulinoma pancreatogenous hypoglycemia syndrome is a recently described complication of Roux-en-Y gastric bypass • Currently, there is no Gold Standard treatment. • In this case, we successfully performed a combined laparoscopic reversal of gastric bypass and gastric banding

The Safety and Efficacy of Apixaban (Eliquis) in 5017 Post-bariatric Patients with 95.3% Follow-up: a Multicenter Study.

Thromboprophylaxis in bariatric surgery is widely debated; however, few large articles evaluate treatment plans and their efficacy. Herein, we make the first large-scale report of the safety and efficacy of apixaban (Eliquis) for thrombus prevention following bariatric surgery. To evaluate the safety and efficacy of apixaban following bariatric surgery. Three private institutes, USA. Data from 5017 consecutive bariatric patients that were placed on postoperative apixaban for thromboprophylaxis were used for retrospective analysis. The dose prescribed to patients was 2.5mg PO BID for a total of 30days starting on day 3 postoperatively. In total, of the 5017 patients, 59.7%, 31.2%, 4.4%, 2.5%, 1.8%, and 0.1% of the patients had undergone sleeve gastrectomy (SG), single-anastomosis duodeno-ileal bypass with SG (SADI-S), Roux-en-Y gastric bypass (RYGB), conversion from SG to SADI, small bowel reconstruction, and RYGB reversal, respectively. The 30-day follow-up rate was 95.3%. In total, 1.7% of patients experienced apixaban-related side effects. The most common side effects were menorrhagia and rash. Two (0.03%) side effects developed into Clavien-Dindo grade II complications. Overall, 10 (0.1%) patients experienced thromboembolic complications (five (0.09%) PVTs and five (0.09%) PEs). In each case, the protocol was not followed for extenuating circumstances. There were no deaths or thromboembolic events in cases where the protocol was able to be fully followed. In conclusion, 30days of postoperative apixaban appears to be safe and effective with minimal side effects while preventing thromboembolic events.

Surgical Treatment for Postprandial Hypoglycemia After Roux-en-Y Gastric Bypass: a Literature Review.

Roux-en-Y gastric bypass (RYGB) is an effective treatment for severe obesity and obesity-related comorbidities. Postprandial hypoglycemia may occur as a long-term complication after RYGB. This study reviews the literature on surgical treatment for intractable post-RYGB hypoglycemia to provide updated information. A search was performed in Embase and PubMed, and 25 papers were identified. Thirteen papers on reversal were included. Resolution of postprandial hypoglycemic symptoms occurred in 42/48 (88%) patients after reversal. Twelve papers on pancreatectomy were included. Resolution occurred in 27/50 (54%) patients after pancreatectomy. The optimal surgical treatment for intractable post-RYGB hypoglycemia has not been defined, but reversal of RYGB seems to be more effective than other treatments. Further research on etiology and long-term evaluation of surgical outcomes may refine treatment options.

Reversal of Roux-en-Y Gastric Bypass Fails to Facilitate the Management of Recalcitrant Hypocalcaemia Caused by Primary Hypoparathyroidism

Roux-en-Y gastric bypass (RYGB) is thought to reduce calcium absorption from the gut. Here, we report the case of a patient with a RYGB, who developed primary hypoparathyroidism after a total thyroidectomy, leading to recalcitrant hypocalcaemia. Despite aggressive oral calcium and calcitriol supplementation, she remained hypocalcaemic and required intravenous (IV) calcium supplementation to control her symptoms, and to keep calcium serum levels within an acceptable range. Teriparatide treatment improved calcium levels marginally. This treatment, however, was poorly tolerated and ultimately stopped by the patient. As a last resort, reversal of RYGB was performed to improve calcium absorption from the gut. Unfortunately, IV calcium supplementation remained necessary. This case illustrates that the reversal of RYGB is not always a guarantee for success in managing recalcitrant hypocalcaemia.

Endoscopic reversal of Roux-en-Y anatomy for the treatment of recurrent marginal ulceration.

Marginal ulceration is one of the most common adverse events after Roux-en-Y gastric bypass (RYGB). The incidence rate of marginal ulcer may be as high as 7%.1-3 Antisecretory therapy is the first-line treatment. However, more than one-third of patients undergo surgical revision for intractable ulcers.4,5 The surgical outcome is excellent overall, except for smokers.5,6 Smokers with intractable marginal ulcer pose an extreme management challenge to clinicians. In this video (Video 1, available online at www.VideoGIE.org), we describe an active-smoker patient with recurrent and intractable marginal ulcer despite multiple surgical revisions and use of maximal medical therapy who was successfully treated with endoscopic reversal of RYGB.

Reversal of Roux en Y gastric bypass: largest single institution experience

BackgroundThere is a paucity of literature on patients who have undergone reversal of Roux-en-Y gastric bypass (RYGB) to normal anatomy. We present the largest single institution experience with reversal of RYGB for serious chronic complications. ObjectiveTo describe our experience including indications, outcomes, and complications of RYGB reversal. SettingAcademic-affiliated private practice. MethodsRetrospective review of 48 patients who underwent laparoscopic reversal of RYGB between 2012 and 2016. ResultsNinety-six percent (n = 46) of patients were female, and the mean age was 48.6 (range, 23–72). Indications for reversal of RYGB included marginal ulcer (n = 25, 12 of whom were malnourished and 17 had coexisting substance abuse), malnutrition alone (n = 11), chronic pain and nausea (n = 7), and postprandial hyperinsulinemic hypoglycemia (n = 5). Overall 30-day complication rate was 29% (n = 14), including gastrogastric anastomotic leak (n = 5), sepsis (n = 5), and bleeding requiring transfusion (n = 3). Weight gain after surgery increased in all patients, especially those patients deemed severely malnourished. All patients reported resolution of symptoms leading to reversal of RYGB, although 58% of patients were lost to follow-up at 1 year after surgery. ConclusionsLaparoscopic reversal of Roux-en-Y gastric bypass is a complex revisional operation that can be safely performed in a select group of patients with serious complications. The main indications for reversal of RYGB included malnutrition with and without recalcitrant marginal ulcers. Weight gain and resolution of malnutrition occurred soon after reversal of gastric bypass. Because the complication rates are high, reversal should be considered only after all salvage attempts have failed. Reversal to normal anatomy carries high morbidity, including sepsis, leaks and bleeding, high reoperative rates, and readmission. Although reversal of RYGB has a role in the treatment of a select group of patients, it should be undertaken by surgeons with considerable experience in RYGB revision.

Roux en Y gastric bypass hypoglycemia resolves with gastric feeding or reversal: Confirming a non-pancreatic etiology

ObjectivePostprandial hypoglycemia is an infrequent but disabling complication of Roux-en-Y gastric bypass (RYGB) surgery. Controversy still exists as to whether the postprandial hyperinsulinemia observed is due to inherent changes in pancreatic β-cell mass or function or to reversible alterations caused by RYGB anatomy. We aimed to determine if gastric feeding or reversal of RYGB would normalize postprandial glucose and hormone excursions in patients with symptomatic hypoglycemia. MethodsWe completed a prospective study of six patients with severe symptomatic RYGB hypoglycemia who underwent RYGB reversal. An additional subject without hypoglycemia who underwent RYGB reversal was also studied prospectively. Mixed meal tolerance testing (MTT) was done orally (RYGB anatomy), via gastrostomy tube in the excluded stomach in the setting of RYGB, and several months after RYGB reversal. ResultsAll subjects reported symptomatic improvement of hypoglycemia after reversal of RYGB. Weight gain after reversal was moderate and variable. Postprandial glucose, insulin, and GLP-1 excursions were significantly diminished with gastric feeding and after reversal. Insulin secretion changed proportional to glucose levels and insulin clearance increased after reversal. Glucagon/insulin ratios were similar throughout study. We further compared the impact of modified sleeve gastrectomy reversal surgery to those with restoration of complete stomach and found no significant differences in weight regain or in postprandial glucose or hormone levels. ConclusionsReversal of RYGB is an effective treatment option for severe postprandial hypoglycemia. The pathophysiology of this disorder is primarily due to RYGB anatomy resulting in altered glucose, gut, and pancreatic hormone levels and decreased insulin clearance, rather than inherent β-cell hyperplasia or hyperfunction.

A5207 - Emergent Reversal of Gastric Bypass: A Case Series from an Accredited Surgical Weight Loss Program

Despite the safety and efficacy of Roux-en-Y gastric bypass (RYGB), a subset of patients (<1%) requires RYGB reversal. This reestablishes continuity between the pouch and bypassed stomach after resecting the gastrojejunostomy. Whether the alimentary limb is reconnected or discarded depends on clinical findings. The most common indications for reversal include excessive weight loss, neuroglycopenia and refractory marginal ulceration. In rare cases, RYGB reversal is required in the emergent setting. We present 3 cases of emergent RYGB reversal for ischemic complications of internal hernia and need for safe and rapid assurance of GI continuity.

Medium-Term Outcomes after Reversal of Roux-en-Y Gastric Bypass.

Roux-en-Y gastric bypass (RYGB) can be reversed into normal anatomy (NA) or into sleeve gastrectomy (NASG) to address undesired side effects. Concomitant hiatal hernia repair (HHR) may be required. Before reversal, some patients benefit from placement of a gastrostomy, mostly to predict the result of recreating the native anatomy. Retrospective study on mid-term effects of RYGB reversal to NA and NASG, including clinical and weight evolution, surgical complications, and incidence of gastro-esophageal reflux (GERD). Undesired side effects leading to reversal included early dumping syndrome, hypoglycemia, malnutrition, severe diarrhea and excessive nausea and vomiting. Twenty-five participants to the study, 13 NA, 12 NASG, and 15 HHR. Mean follow-up time was 5.3±2.3years. Reversal corrected early dumping, malnutrition, diarrhea, and nausea/vomiting. For hypoglycemic syndrome, resolution rate was 6/8 (75%). NA caused significant weight regain (14.2±13.7kg, (p=.003)). NASG caused some weight loss (4.8±15.7kg (NS)). Gastrostomy placement gave complications at reversal in five of seven individuals. Eight patients suffered a severe complication, including leaks (one NA vs. three NASGs). Eight out of 14 (57.1%) patients who previously had never experienced GERD developed de novo GERD after reversal, despite HHR. RYGB reversal is effective but pre-reversal gastrostomy and concomitant HHR may be aggravating factors for complications and development of de novo GERD, respectively.

A5010 - Reversal of Roux-en-y gastric bypass at a tertiary center with a large experience in laparoscopic gastric bypass revision: indications and outcomes

No large single institution experience in reversal of Roux-en-y gastric bypass (RYGB) to normal anatomy has been previously published. Most published series are small, suggesting that bariatric surgeons may reserve reversal to normal anatomy for rare situations, perhaps due to concern about a high risk for surgical complications. We have been fairly aggressive at recommending reversal to normal anatomy for patients with a variety of chronic serious complications after RYGB. In this report, we describe our large experience with laparoscopic reversal of RYGB over 4 years, our indications for reversal and our post-operative outcomes. The goal of our study is to advance understanding of how reversal to normal anatomy may be applied after previous RYGB, to further define the risks of complications and to identify factors that would prevent the need for reversal.

Indications and Operative Outcomes of Gastric Bypass Reversal.

Roux-en-Y gastric bypass (RYGB) is one of the best-known and most commonly performed bariatric procedures. However, this procedure carries infrequent but serious long-term complications, which may require revisional procedures. This study reports the indications and outcomes of gastric bypass reversal that have not been described well in the literature. A multicenter retrospective study of 50 patients who underwent reversal of RYGB conducted between 2006 and 2015 was reviewed to describe the usual indications and outcomes of gastric bypass reversal surgeries. Of 50 patients, 7 (14%) were males and 43 (86%) were females. The mean age of the patient population was 40.4 ± 11.6years (range 19-66). Reasons for reversal included anastomotic ulcers (n = 27), anastomotic complications (n = 9), malnutrition (n = 2), and functional disorder (n = 12). The mean BMI before the reversal was 29 ± 9.4kg/m(2) (range 16-60). The mean time between the primary procedure and reversal was 60 ± 65.5months (range 2-300). Fourteen of the reversals were done via laparotomy. Mean hospital stay was 8.4 ± 7.3days (range 3-34days). There was no peri-operative death 30days after reversal. Following gastric bypass reversal, 92.6% (n = 25) of the patient population had resolution from ulcers, 77.8% (n = 7) of the patient population had resolution from anatomic complications, 100% (n = 2) of the patient population had resolution from malnutrition, and 66.7% (n = 8) of the patient population had resolution from functional disorders. Gastric bypass reversal is a reasonable and safe treatment for complications arising from the GBP surgery. A laparoscopic approach is feasible in select patients.

Management of Refractory Noninsulinoma Pancreatogenous Hypoglycemia Syndrome with Gastric Bypass Reversal: A Case Report and Review of the Literature.

Background. Roux-en-Y gastric bypass (RYGB) is a commonly performed, effective bariatric procedure; however, rarely, complications such as postprandial hypoglycemia due to noninsulinoma pancreatogenous hypoglycemia syndrome (NIPHS) may ensue. Management of refractory NIPHS is challenging. We report a case that was successfully treated with RYGB reversal. Case Report. A 58-year-old male with history of RYGB nine months earlier for morbid obesity presented for evaluation of postprandial, hypoglycemic seizures. Testing for insulin level, insulin antibodies, oral hypoglycemic agents, pituitary axis hormone levels, and cortisol stimulation was unrevealing. Computed tomography (CT) scan of the abdomen was unremarkable. A 72-hour fast was completed without hypoglycemia. Mixed meal testing demonstrated endogenous hyperinsulinemic hypoglycemia (EHH) and selective arterial calcium stimulation testing (SACST) was positive. Strict dietary modifications, maximal medical therapy, gastrostomy tube feeding, and stomal reduction failed to alleviate symptoms. Ultimately, he underwent laparoscopic reversal of RYGB. Now, 9 months after reversal, he has markedly reduced hypoglycemia burden. Discussion. Hyperfunctioning islets secondary to exaggerated incretin response and altered intestinal nutrient delivery are hypothesized to be causative in NIPHS. For refractory cases, there is increasing skepticism about the safety and efficacy of pancreatic resection. RYGB reversal may be successful.

Indications and outcomes of reversal of Roux-en-Y gastric bypass

BackgroundLaparoscopic Roux-en-Y gastric bypass (RYGB) is proven to be a safe and effective treatment of obesity and related co-morbidities. However, there is a small group of patients who are unable to tolerate postoperative complications and ultimately undergo reversal procedures. This study demonstrates indications and postoperative outcomes in 8 patients following RYGB reversal. MethodsRetrospective review of 8 patients who required RYGB reversal between July 2009 to October 2013. Data points included demographic characteristics, body mass index (BMI), co-morbidities, reasons for reversal and postoperative outcomes. ResultsAll patients were female with a mean age of 44.5±8.8 years (range, 35–63) and BMI of 30.0±9.8 kg/m2 (range, 19.3–43.8) before reversal. Reasons for reversal included recurrent anastomotic ulcer (n = 3), intractable nausea and emesis (n = 3), hypocalcemia (n = 1), and neuroglycopenia (n = 1). Mean period from RYGB to reversal was 127.8±95.4 months (range, 21–298) and mean length of hospital stay following reversal was 5.1±3.0 days (range, 2–11). One patient was lost to follow-up. Mean BMI at the last visit was 37.3±12.6 kg/m2 (range, 24.0–56.5). Two patients (28.6%) maintained the same weight 9 and 11 months after reversal. One returned to her pre-RYGB weight and 4 patients gained some of their weight back after reversal. Three (37.5%) patients required readmissions for abdominal pain and nausea/vomiting, and no patients required reoperations following RYGB reversal. ConclusionsReversal of RYGB to normal anatomy is reasonable in patients with severe or refractory complications.

Indications and outcomes of reversal of Roux-en-Y Gastric Bypass

Background: Laparoscopic Roux-en-Y gastric bypass (RYGB) is proven to be a safe and effective treatment of obesity and related co-morbidities. However, there is a small group of patients who are unable to tolerate postoperative complications and ultimately undergo reversal procedures. This study demonstrates indications and postoperative outcomes in 8 patients following RYGB reversal. Methods: Retrospective review of 8 patients who required RYGB reversal between July 2009 to October 2013. Data points included demographic characteristics, body mass index (BMI), comorbidities, reasons for reversal and postoperative outcomes. Results: All patients were female with a mean age of 44.5 8.8 years (range, 35–63) and BMI of 30.0 9.8 kg/m 2 (range, 19.3–43.8) before reversal. Reasons for reversal included recurrent anastomotic ulcer (n ¼ 3), intractable nausea and emesis (n ¼ 3), hypocalcemia (n ¼ 1), and neuroglycopenia (n ¼ 1). Mean period from RYGB to reversal was 127.8 95.4 months (range, 21–298) and mean length of hospital stay following reversal was 5.1 3.0 days (range, 2–11). One patient was lost to follow-up. Mean BMI at the last visit was 37.3 12.6 kg/m 2 (range, 24.0–56.5). Two patients (28.6%) maintained the same weight 9 and 11 months after reversal. One returned to her pre-RYGB weight and 4 patients gained some of their weight back after reversal. Three (37.5%) patients required readmissions for abdominal pain and nausea/vomiting, and no patients required reoperations following RYGB reversal. Conclusions: Reversal of RYGB to normal anatomy is reasonable in patients with severe or refractory complications. (Surg Obes Relat Dis 2015;11:821–827.) r 2015 Published by Elsevier Inc. on behalf of American Society for Metabolic and Bariatric Surgery.

Successful laparoscopic reversal of gastric bypass in a patient with malnutrition.

Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed bariatric procedures around the world. Although RYGB is the gold standard for treating morbid obesity, it carries the risk of rare but serious long-term complications from malnutrition. We report a case of laparoscopic reversal of RYGB. A female patient reported prolonged incapacitating postprandial pain that consequently made her avoid proper oral intake. Therefore, she became seriously malnourished at 30 months after RYGB and requested reversal of RYGB into normal anatomy. The operation was successfully performed via laparoscopy. Operating time was 120 minutes, and intraoperative blood loss was 20 mL. The patient was discharged without any complications directly related to surgical procedures, although her hospital stay was prolonged by the treatment of asymptomatic septicemia of unknown origin. Laparoscopic reversal of RYGB into normal anatomy is technically feasible and might be performed safely after thorough preoperative evaluation in carefully selected patients.

Laparoscopic reversal of Roux-en-Y gastric bypass into normal anatomy with or without sleeve gastrectomy

This study was designed to describe and analyze the outcomes after laparoscopic reversal to normal anatomy (NA) with or without concomitant "sleeve gastrectomy" (SG), after Roux-en-Y gastric bypass (RYGB). Reversal has been proposed as corrective strategy after RYGB. We propose a retrospective analysis of a prospectively kept database. From January 2005 to October 2012, 20 female patients underwent laparoscopic reversal after RYGB for one or more of the following conditions: hypoglycaemic syndrome (nine patients), weight regain (six patients), severe dumping (six patients), and cachexia (two patients). Preoperative BMI was 28.0 (19.2-40.3) kg/m². Reversal was performed to NA in ten patients and included a SG procedure in another ten. Postoperative complications included one bleeding and three leaks (15%; all in SG patients). Mean hospital stay was 7 days. Mortality was 0. With a mean follow-up of 11.5 months, all but one patient recovered from their initial condition. However, three developed severe gastroesophageal reflux disease (GERD) symptoms and three had chronic diarrhoea. Outcomes of laparoscopic reversal of RYGB are good, but complications may occur when SG is added. The surgical alterations caused by the reversal may explain the GERD or diarrhoea experienced by some patients.