V. Karaliou1, F. Benavides1, W. How1, A. Aksade1 1Steward Easton Hospital,Department Of Surgery,Easton, PA, USA
Introduction: Biliopancreatic diversion with duodenal switch (BPD-DS) was described in the 1970s but robotic BPD-DS was only introduced a little more than a decade ago and has become part of the bariatric surgeon’s armamentarium. New combinations and varieties of BPD-DS have been broadly described. We would like to present a unique case of robotic revision of Roux-en-Y gastric bypass (RNYGB) with gastro-gastric anastomosis and subsequent conversion to BPD-DS as an example of modifications of prior bariatric procedure in a patient with persistent disease.
Methods: In 2012, a patient with morbid obesity BMI 43.8 kg/m2 had laparoscopic gastric bypass achieving BMI 23.77 kg/m2 in 2 years after procedure. Weight-regain started a few years later and in 2018 patient had BMI 39.2 kg/m2. Robotic-assisted laparoscopic revision of the RNYGB with partial resection of stomach pouch and small bowel was done but the patient BMI remained at 40.4 kg/m2 after 15 months. The decision was made to proceed with BPD-DS using da Vinci surgical system (Intuitive Surgical, Inc., Sunnyvale, CA). Following thorough dissection, we created a gastro-gastric anastomosis (GGA) between the pouch and remnant stomach after amputating the roux limb off using a stapler. The anastomosis was created in a 4-layer fashion using V-Lock sutures. Next, the typical creation of sleeve gastrectomy was done with the bougie device placement down to pylorus. Following division of post-pyloric duodenum, hand sewn anastomosis was made between ileum at the mark of 300 cm from ileocecal valve and this transected post-pyloric duodenum. The small bowel proximal to this anastomosis was divided using stapler and anastomosed to the ileum, 200 cm proximal to the ileocecal valve. The previous Roux limb was amputated completely.
Results: Although BDP-DS is not widely performed due to the complexity of the case as well as associated comorbidities, there is still a role in patients who experience weight-regain after other bariatric procedures. Superior outcome and low complications rate were historically associated with preservation of pylorus and in case of previous interventions (gastric pouch with following resection) it may be a challenge to preserve the integrity of original BPD-DS anatomy. Totally robotic BPD-DS with a single dock has been described in the literature and potential repositioning of the robot was avoided in our case as well.
Conclusion: The gastro-gastric anastomosis was patent and viable despite a small and previously revised and resected gastric pouch. GGA played a role in accomplishing the gastric sleeve and preserving the pylorus. The robotic approach facilitated complex delayed reconstruction procedure resulted in short length of stay and decreased morbidity.
