Laparoscopic reversal of Roux-en-Y gastric bypass: Technique and utility for treatment of endocrine complications

Abstract

Background The anatomical and physiological changes with Roux-en-Y gastric bypass (RYGB) may lead to uncommon but occasionally difficult to treat complications such as hyperinsulinemic hypoglycemia with neuroglycopenia and recalcitrant hypocalcemia associated to hypoparathyroidism. Medical management of these complications is challenging. Laparoscopic reversal of RYGB anatomy with restoration of pyloric function and duodenal continuity is a potential treatment. Objective To present the indications, surgical technique and clinical outcomes of laparoscopic reversal of RYGB. Setting Tertiary Academic Medical Center, United States. Methods Prospective study of consecutive patients offered laparoscopic reversal of RYGB. Results Five patients with remote laparoscopic RYGB underwent laparoscopic reversal of RYGB to normal anatomy (n=2) or modified sleeve gastrectomy (n=3). Indications were medically refractory hyperinsulinemic hypoglycemia with neuroglycopenia (n=3), recalcitrant hypocalcemia with hypoparathyroidism (n=1) and both conditions simultaneously (n=1). Prior to reversal all patients had a gastrostomy tube placed in the excluded stomach to document improvement of symptoms. Laparoscopic reversal was accomplished successfully in all patients. Three post-operative complications occurred; bleeding that required transfusion, gallstone pancreatitis and a superficial trocar site infection. Average length of stay was 3 days. At a mean follow-up of 12 months (range 3 to 22), no additional episodes of neuroglycopenia occurred, average number of hypoglycemic episodes per week decreased from 18.5±12.4 to 1.5±1.9 (p=0.05) and hypocalcemia became responsive to oral replacement therapy in both patients. Conclusions Laparoscopic reversal of RYGB to normal anatomy or modified sleeve gastrectomy is feasible and may be a therapeutic option for selected patients with medically refractory hyperinsulinemic hypoglycemia and/or recalcitrant hypocalcemia associated to hypoparathyroidism.

Management of Excessive Weight Loss Following Laparoscopic Roux-en-Y Gastric Bypass: Clinical Algorithm and Surgical Techniques

“…Campos demonstrated that reversal of RYGB to normal anatomy or modified sleeve gastrectomy in hyperinsulinemic hypoglycemia and/or recalcitrant hypocalcemia associated with hypoparathyroidism was safe and successful in a minimally invasive fashion [28,29]. Similar to our study, a feeding gastrostomy tube was inserted into the excluded stomach and improvement of symptoms was documented prior to reversal of RYGB to normal anatomy.…”

Hypoglycemia after Roux-En-Y gastric bypass: detection rates of continuous glucose monitoring (CGM) versus mixed meal test

“…A much larger number of patients might suffer from vague symptoms and are therefore not being diagnosed with post-gastric bypass hypoglycemia. Subsequently, they are not offered adequate treatment, which might consist of dietary modifications [18,28], acarbose [29][30][31], octreotide [15,32], verapamil [33] or diazoxide [34] as drug therapy or surgical interventions such as secondary bypass banding [35,36], bypass reversal [37,38] or pancreatic resection [24][25][26][27]39]. In our study, CGM provided better detection rates for post-RYGB hypoglycemia compared with MMT.…”

Conversion from gastric bypass to sleeve gastrectomy for complications of gastric bypass

“…Also in 2013, Vilallonga et al described 10 patients who underwent conversion to SG and 10 who underwent reversal to normal anatomy for a variety of indications (7) . Finally, Campos et al described 3 patients converted to SG and 2 reversed to normal anatomy, all with resolution of hyperinsulinemic hypoglycemia or severe hypocalcemia following inadvertent parathyroidectomy after RYGB (9) .…”

“…Such a procedure has been described for correction of retrograde intussusception (5) , weight regain (6,7) , intractable dumping syndrome (8) , cachexia (7) , severe neuroglycopenia (7,9) , and hypocalcemia following inadvertent parathyroidectomy (9) . Currently, there are 5 series in the literature describing a total of 27 patients who have undergone conversion from RYGB to SG.…”