TITLE:
Functional Roux-en-Y Gastric Bypass (F-RYGB), with Preservation of Duodenal Access: Report of Two Revisional Cases of Sleeve Gastrectomy
AUTHORS:
Victor Ramos Mussa Dib, Carlos Augusto Scussel Madalosso, Paulo Reis Esselin de Melo, Rui Ribeiro, Paula Volpe, Carlos Eduardo Domene
KEYWORDS:
Roux-en-Y Gastric Bypass, Sleeve Gastrectomy, Jejuno Gastric Bypass, Vagus Nerve, Vagotomy, Bariatric Surgery
JOURNAL NAME:
Surgical Science,
Vol.15 No.3,
March
27,
2024
ABSTRACT: Objective: This case report aimed to demonstrate a possible
neuromuscular effect of Latarjet nerves transection or truncal vagotomy, in
association with sleeve gastrectomy plus antrojejunostomy, in order to
reproduce a Roux-en-Y gastric bypass (RYGB) mechanistic principles, in patients
with previous Sleeve Gastrectomy (SG) who had had weight regain, with or
without concomitant gastroesophageal reflux disease (GERD). Background: Sleeve gastrectomy (SG) is one of the most
frequently performed bariatric operations worldwide. Nevertheless, weight regain and gastroesophageal reflux disease (GERD) have been consistently demonstrated, in association with this technique,
which may require a revisional procedure. RYGB is an option in such a situation
but, implies in gastrointestinal exclusions, which represents a shortcoming of this revision. Surpassing this inconvenient
would be of great value for the patients. Methods: We describe herein two cases
of SG revision for weight regain and GERD, with a follow-up of one
year. Gastroesophageal reflux disease was evaluated by validated questionnaire,
upper endoscopy, seriography, high resolution manometry (HRM) and impedance
pHmetry (I-pHmetry), in the pre and postoperative periods. A re-Sleeve
Gastrectomy with antrojejunal anastomosis was done in both cases, after
informed consents. The Latarjet nerves were transected in one case, due to a
bleeding in the left gastric vessels and a truncal vagotomy was required in the
other, to appropriately treat an associated hiatal hernia. Results: In the postoperative evaluation it was observed a pyloric spasm in both
cases, during seriography and endoscopy, kept until the one-year follow-up.
There was unidirectional contrast flow to
the gastrointestinal anastomosis, filling the jejunal limb, in radiologic
contrast study. No contrast passed through the pylorus. Nonetheless, the
duodenum was kept endoscopically accessible. In the one-year evaluation, weight
loss was adequate and GERD resolution was obtained in both cases, confirmed by
endoscopic and functional esophageal assessment, together with symptoms
questionnaire. Conclusion: The association of Latarjet
nerves sectioning or truncal vagotomy with re-sleeve gastrectomy plus
gastrointestinal anastomosis (antrojejunal), in a revision for a failed sleeve,
can represent a technical approach, to reproduce RYGB results, without
exclusions and with duodenum endoscopic accessibility maintenance. It maybe
could be applied for primary surgeries. Additional studies are necessary to confirm this hypothesis.