1. Gastric Bypass: Does Length of Roux Limb Matter? Samer G. Mattar, MD, FRCS, FACS Associate Professor of Surgery Indiana University

2. Outline Incidence of Revisional and Reoperative Bariatric Surgery Causes of failed primary operations Evaluation of the patient with failed primary operation Role of Roux limb length. Outcomes

3. Gastric Bypass“A family of operations” Hand-sewn versus stapled GJ anastomosis Linear versus Circular stapling mechanisms Closure versus non-closure of potential internal hernia sites Closure versus non-closure of larger trocar sites

4. Gastric Bypass“A family of operations” According to Dr. Pories, the potential number of gastric bypasses is 29, or at least 512 different operations.

5. Growth of Bariatric Surgery: 500% NEJM 350;11, 2004, March 11, 1075-1079

6. Bariatric Surgery Increase Total number of Roux-en-Y Gastric Bypasses Performed in the USA* *National Center for Health Statistics

7. Bariatric Surgery Increase

8. Incidence of Revisional Bariatric Surgery Hard to predict. Upwards of 25% of bariatric patients will undergo a revisional procedure Gagner M, Gentileschi P, de Csepel J, et al. Laparoscopic reoperative bariatric surgery : experience from 27 consecutive patients. Obes Surg 2002; 12:254-260

9. Incidence of Revisional Bariatric Surgery

10. Definition of Failed Bariatric Surgery Weight loss < 50% EWL Regain of > 15% of weight after reaching nadir Inadequate resolution or improvement of co-morbidities

11. Causes of Failed Bariatric Surgery Inability to adapt to specific lifestyle. Inability to maintain lifestyle changes. Treatment with medications that increase appetite. Anatomic factors (eg large pouch) Lack of follow up.

12. Evaluation of the failed patient Careful detailed history by physician, dietitian, and psychologist. Review stressful factors, medications. Food journal. Close and frequent counseling. Back on Track program. Support groups

13. Evaluation of the failed patient Upper GI endoscopy to assess pouch size, anatomy, staple line breakdown. Upper GI films to assess pouch size, band position, esophageal dilatation, hiatus hernia, etc. These studies are essential for planning revisional surgery. Review operative notes (if available).

14. Who should not be converted? Substance users. Patients with GERD who have not had medical therapy. Patients with maladaptive eating who fail to comply, in spite of normal anatomy.

15. The Failed Patient with Normal Anatomy Clinical Dilemma. Limited options.

16. Variations “Lengthening the Roux” Rationale: The more distal the Roux, the more profound the weight loss.

17. Variations “Lengthening the Roux” Brolin in 1992: Prospective randomized study compared weight loss in patients with Roux length of 75cm to patients with Roux of 150cm Concluded that patients with longer Roux lost more weight at 2-3 years. No significant difference in nutritional changes. Brolin et al. Ann Surg 1992:215: 387

18. Variations “Lengthening the Roux” Distal RYGB Occasionally done for super obese patients Occasionally done for patients with weight regain and normal pouches.

19. Variations “Lengthening the Roux” Distal RYGB Nutritional issues Essentially a malabsorptive operation Danger for protein calorie malnutriton Fat soluble vitamin deficiencies Diarrhea High incidence of anemia

20. Variations “Lengthening the Roux” Sugerman in 1997: Compared standard Roux length with distal (common channel only 50 cm long) Distal group had more weight loss. But, > 50% serious complications, including 2 liver deaths. Sugerman et al J Gastrointest Surg 1997;1:517

21. Variations “Lengthening the Roux” Brolin in 2002: Compared patients with standard RYGB to patients with distal RYGB (75 cm from cecum). Distal Gastric Bypass produced better weight loss. But, had significantly greater metabolic problems Brolin et al J Gastrointest Surg 2002;6:201

23. Long Roux-limb: 150 cm

24. Distal Bypass: 75 cm common channelBrolin et al. J Gastrointest Surg 2002;6:195-205 Distal Gastric Bypass

25. BMI Change According to Roux-limb Length Brolin et al. J Gastrointest Surg 2002;6:195-205

26. RYGB Malabsorption Distal RYGB reserved for failed patients with intact anatomy. The Bilio-pancreatic limb is anastomosed 50-75 cm from ileo-cecal valve EWL% = >50%

27. RYGB Malabsorption But Complications include: Fat soluble vitamin deficiency Liver dysfunction Normocytic normochromic anemia Protein calorie malnutrition

28. Comparison study of Standard vs. Long Roux in Superobese 120 patients (all BMI > 50) 65 had SLL (50 + 150) 55 had LLL (50 + 200) There was no significant difference in weight loss. Sarhan et al. ObesSurg Online first April 15th, 2011

29. Conclusions There are many variations of gastric bypass. The length of Roux limb between 150 – 200 cms. will not significantly impact weight loss. Distal RYGB (50 – 75cc from IC) will cause significant weight loss but will increase risk of nutritional deficiencies.

30. Thank you!