Ten to 15% of gastric bypass patients fail due to weight regain. The mechanism for this remains unknown, however, increasing numbers of patients are undergoing revisional surgery in an attempt to correct this excess weight gain. Currently, there is controversy regarding restrictive versus malabsorptive approaches for revisional surgery. Our previous experience has shown us that for the super obese, an initial laparoscopic sleeve gastrectomy (done as part of a two stage biliopancreatic diversion) affords an excellent initial weight loss. It has been our observation that the patients who fail Roux-en-Y gastric bypass often develop dilatation of the gastrojejunal anastomosis, including the blind-end of the jejunal limb. We hypothesize that by revising the gastojejunal anastomosis and resecting the blind-limb of jejunum, it may be possible to re-establish a narrow sleeve and subsequently improve weight loss for these patients.

This video depicts a revisional surgery done on a 36 year old female with an initial body mass index of 54 kg/m² who underwent a laparoscopic band placement in 1994 and lost 25 pounds (BMI 50 kg/m). She subsequently underwent a conversion to a Roux-en-Y gastric bypass in 1996 after which she achieved a BMI of 23 kg/m². In December 2004, she presented with several months weight regain and intermittent crampy abdominal pain. She was scheduled for a laparoscopic exploration. Intraoperatively, she had a revision of her biliopancreatic anastamosis to the left side of the alimentary limb and closure of internal hernia defects. After noting a dilated gastrojejunal anastamosis, she additionally underwent a revision of this small bowel dilation. This was accomplished by removing excess jejunal tissue using an endo GIA blue cartridge stapler with bioabsorbable SeamGuard that was fired over a previously place 40 French bougie. Her post-operative course was uneventful and she went home on post-operative day four.

It appears that a sub-group of patients who undergo gastric bypass suffer from delayed weight regain for unclear reasons, with no currently ideal options for revision. Distention of the gastrojejunal anastomosis and elongation of the blind limb of jejunum may partly be responsible for this weight regain. Removing this blind limb of jejunum and narrowing the jejenunal sleeve dilation provides a new option for revision of Roux-en-Y gastric bypasses that can improve long-term weight maintenance.