Department of Digestive Surgery, Générale de Santé (GDS), Clinique Geoffroy-Saint Hilaire, 75005, Paris, France.
Department of Digestive Surgery, Hepatobiliary Surgery and Liver Transplantation, University Hospital of Tours, Tours, Centre-Val de Loire, France.
Obes Surg. 2019 Apr;29(4):1442-1444. doi: 10.1007/s11695-019-03770-2.
Severe post-operative malnutrition (SM) is a dreaded complication after gastric bypass often related to the short bowel syndrome consecutive limb length mismeasurement or intestinal resections. Patients with rapid weight loss or malnutrition can experience liver failure with cirrhosis and require liver transplantation (LT). Malnutrition can constitute a contraindication to LT since it negatively impacts on postoperative morbidity. RYGB reversal is an effective option to consider when nutritional support has failed. We describe the performance of a RYGB reversal in a pre-LT setting.
A 36-year-old patient with morbid obesity (weight, 140 kg; BMI, 50.1 kg/m) underwent a RYGB 9 years ago. She presented with 85 kg weight loss (i.e., 60.7% total body weight loss) associated with SM and hepatocellular insufficiency. LT was considered but contraindicated because of SM. An intensive nutritional support was attempted but failed and the RYGB reversal was recommended.
Laparoscopic exploration revealed ascites, cirrhosis, and splenomegaly. The whole small bowel measurement revealed a short gut. Alimentary, biliary, and common channel limb lengths were 250 cm, 150 cm, and 30 cm long. The alimentary limb was stapled off the gastric pouch and the gastrojejunostomy was resected. After resection of the gastrojejunostomy, linear stappled gastro-gastrostomy and jéjuno-jejunostomy were performed to restore the normal anatomy. At 1 year, malnutrition was resolved and the cirrhosis was stabilized.
Reversal to normal anatomy appeared effective and safe in this setting but must be considered only after failure of intensive medical management. Careful bowel measurement is mandatory to prevent patients from this complication.
胃旁路手术后严重的术后营养不良（SM）是一种可怕的并发症，常与短肠综合征、连续肢体长度测量不当或肠切除术有关。快速减肥或营养不良的患者可能会出现肝衰竭伴肝硬化，并需要进行肝移植（LT）。营养不良可能构成 LT 的禁忌症，因为它会对术后发病率产生负面影响。RYGB 逆转是在营养支持失败时需要考虑的有效选择。我们描述了在 LT 前设置中进行 RYGB 逆转的表现。
一名 36 岁的病态肥胖患者（体重 140 公斤；BMI 为 50.1 公斤/米）9 年前接受了 RYGB 手术。她体重减轻了 85 公斤（即总体重减轻了 60.7%），同时伴有 SM 和肝细胞功能不全。考虑进行 LT，但由于 SM 而被排除。尽管尝试了强化营养支持，但仍未成功，因此建议进行 RYGB 逆转。
腹腔镜探查发现腹水、肝硬化和脾肿大。整个小肠测量显示短肠。消化道、胆道和共同通道的长度分别为 250 厘米、150 厘米和 30 厘米。消化道分支被结扎在胃袋上，胃空肠吻合术被切除。切除胃空肠吻合术后，进行线性吻合胃-胃吻合术和空肠-空肠吻合术，以恢复正常解剖结构。1 年后，营养不良得到解决，肝硬化得到稳定。
在这种情况下，恢复正常解剖结构似乎是有效和安全的，但只有在强化医疗管理失败后才应考虑。必须仔细测量肠管，以防止患者出现这种并发症。
