The malabsorptive very, very long limb Roux-en-Y gastric bypass for super obesity: Results in 257 patients

doi:10.1016/j.surg.2006.06.020

Surgery

Volume 140, Issue 4, October 2006, Pages 517-523

Presented at the 63rd Annual Meeting of the Central Surgical Association, Louisville, Kentucky, March 9-11, 2006.

https://doi.org/10.1016/j.surg.2006.06.020 Get rights and content

Background

For the past 11 years, we have used a malabsorptive form of Roux-en-Y gastric bypass (RYGB), the “very, very long limb” RYGB, for selected patients with BMIs >50 kg/m² and in highly selected patients with BMI <50 kg/m². This modified distal gastric bypass establishes a 100-cm common channel (for digestion and absorption) and a “very, very” long Roux limb of 400 to 500 cm.

Methods

To determine long-term efficacy and complications, we followed prospectively 257 consecutive patients; 188 (73%) participated in a postoperative survey.

Results

Of the patients, 60% were female; overall age (x̄ ± SD) was 45 ± 11 years, and BMI was 61 ± 11 kg/m². Operative mortality was 1% with substantive postoperative morbidity occurring in 13%. Eighty-two percent of patients returning the survey an average of 48 months postoperatively (range, 12 to 148 months) lost >50% of excess body weight; BMI at follow-up was 37 ± 9 kg/m². Resolution of comorbidities included diabetes mellitus (94%), hypertension (65%), sleep apnea (48%), and asthma (30%). Side effects included mild food intolerance (82%), occasional loose or watery stools (71%), nephrolithiasis (16%), and symptomatic steatorrhea (5%). Nine patients (4%) who developed or were developing impending protein/calorie malnutrition required proximal relocation of the enteroenterostomy with symptom resolution.

Conclusions

Overall, 90% were satisfied with the operation, and 93% would recommend it to a friend. The very, very long limb RYGB is relatively safe and effective and has acceptable side effects in the treatment of selected patients with super obesity (BMI >50). Because of the possibility of malabsorptive sequelae, patients should be selected based on degree of medical sophistication, insight, and compliance.

Introduction

The standard Roux-en-Y gastric bypass (RYGB) is an effective and durable weight loss procedure for morbid obesity.1, 2 Super obesity, however, defined as having a body mass index (BMI) of >50 kg/m², may require a more aggressive operation that involves a selective malabsorption to effect a sufficient amount of weight to ameliorate weight-related comorbidities. Current more aggressive bariatric operations that involve an element of malabsorption include distal gastric bypass,³ biliopancreatic diversion (BPD),⁴ and duodenal switch with biliopancreatic diversion,5, 6 all of which have their advantages and disadvantages.⁷ Previously, we reported our preliminary experience in 19 patients with a modification of RYGB termed the “very, very” long limb RYGB (VVLL-RYGB).⁸ This procedure (Fig) is a modification of the distal gastric bypass³ and consists of the typical proximal anatomy of a vertical, disconnected RYGB.⁹ However, the VVLL-RYGB has a short 50- to 60-cm biliopancreatic limb, a 100-cm common channel of distal ileum, and a much longer (300 to 500 cm) Roux limb — thus, the term very, very long limb RYGB to differentiate it from the very long limb (150 cm) RYGB of Brolin et al.¹⁰ The VVLL-RYGB procedure was designed to minimize the length of bypassed small bowel (biliopancreatic limb), while establishing a short common channel of distal ileum to minimize digestion and absorption. With any form of malabsorptive anatomy, potential long-term nutritional and metabolic sequelae exist. Our aims were to evaluate the perioperative morbidity and mortality and, more importantly, the long-term efficacy on weight loss, comorbidities, and development of metabolic complications.

Section snippets

Methods

After approval by the Mayo Institutional Review Board, we conducted a retrospective review using our prospective database of all consecutive patients (n = 1435) undergoing bariatric surgery from 1985 to 2004, which allowed at least a 1-year follow-up. This review included all 257 consecutive patients undergoing VVLL-RYGB. In addition to our usual set of questionnaires sent at 3, 6, 12, 18, 24, 36 and 48 months postoperatively, we also sent out a more detailed follow-up questionnaire to acquire

Patients

During this 19-year period, the 257 patients who underwent VVLL-RYGB were 45 ± 11 years of age (range, 15 to 74 years) with a BMI of 61 ± 11 kg/m² (range, 41 to 108). There were 102 men and 155 women; the percentage of males in this group is much greater than in our overall bariatric experience during the same time period (40% vs 25%, respectively). Prevalence of comorbidities at the time of VVLL-RYGB included severe arthritis/arthropathy (79%), hypertension (60%), diabetes mellitus requiring

Discussion

Our experience with the VVLL-RYGB confirms its efficacy and relative safety in this select population of patients at the extreme of morbid obesity. Operative mortality in this high-risk group was low (<1%), and operative morbidity was as expected, with an 11% incidence of wound complications (infection, dehiscence) characteristic of the super obese after an open celiotomy. Most encouraging, however, were the reversal of comorbidities, the relative paucity of severe malnutrition, and the success

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Roux-en-Y gastric bypass (RYGB) is an established surgical treatment for obesity. Variations in limb length during RYGB procedures have been investigated for optimizing weight loss while minimizing nutritional deficiencies. The role of the total alimentary limb length (TALL; Roux limb plus common channel [CC]), however, is poorly defined.
Compare TALL in RYGB procedures for weight loss outcomes and malnutrition.
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Ovid Medline and PubMed databases were searched for entries between 1993 and 2020. Search terms included “gastric bypass” and “TALL.” Two independent reviewers screened the results.
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The majority of studies on RYGB do not report TALL length. There is some evidence that weight loss is affected by shortening TALL, while a TALL ≤400 cm with CC<200 should be avoided due to severe protein malnutrition. More studies on the effect of TALL are needed.
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Results have been mixed regarding the magnitude of improvement of cardio-metabolic outcomes as compared with proximal RYGB. Similarly, the so-called very, very long limb RYGB used a short BPL (50 cm), a very long AL, and a CC of only 50 to 100 cm.11 A 2018 systematic review explored the importance of the BPL length in gastric bypass results identifying 13 studies addressing the BPL in proximal and distal RYGB.35
Some studies suggest that changes in weight or metabolic outcomes are affected by the lengths of the gastrointestinal limbs in the Roux-en-Y gastric bypass.
Participants (N = 1,770) underwent primary Roux-en-Y gastric bypass and were followed ≤7 years in the Longitudinal Assessment of Bariatric Surgery-2, a multicenter US cohort study. Alimentary limb and biliopancreatic limb lengths were measured according to research protocol; common channel was measured in a subsample (N = 547). Aimentary limb, biliopancreatic limb, and common channel ratio to total small bowel length were calculated.
Median presurgery body mass index was 46 (25th–75th percentile: 43–51) kg/m². Medians (25th–75th percentiles) for alimentary limb length were 125 cm (100–150), for biliopancreatic limb length were 50 cm (50–60), and common channel length were 410 cm (322–520). Statistics for ratios to the small bowel length were 0.23 (0.18–0.27) for alimentary limb, 0.09 (0.07–0.10) for biliopancreatic limb, and 0.69 (0.63–0.73) for common length. There were no significant associations between alimentary limb, biliopancreatic limb, common channel, alimentary limb ratio, biliopancreatic limb ratio or common channel ratio, and either weight loss or improvement in cardiometabolic outcomes.
The common channel length in Roux-en-Y gastric bypass is highly variable between individuals. None of the limb lengths in this study, nor alimentary limb, biliopancreatic limb, or common channel ratios, seem to be related to weight loss or metabolic improvements >7 years.
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Central Surgical AssociationThe malabsorptive very, very long limb Roux-en-Y gastric bypass for super obesity: Results in 257 patients

Background

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Patients

Discussion

Am J Clin Nutr

Mayo Clin Proc

J Gastrointestinal Surg

Surgery for Obesity and Related Diseases

Mayo Clin Proc

Conversion of proximal to distal gastric bypass for failed gastric bypass for superobesity

J Gastrointest Surg

Biliopancreatic diversion

World J Surg

Central Surgical Association
The malabsorptive very, very long limb Roux-en-Y gastric bypass for super obesity: Results in 257 patients