Laparoscopic Reversal of Roux-en-Y Gastric Bypass with Hand-Sewn Gastro-Gastrostomy and Resection of the Alimentary Limb.

Introduction: Roux-en-Y gastric bypass (RYGB) reversal might be necessary to alleviate refractory surgical or nutritional complications, such as postprandial hypoglycemia, malnutrition, marginal ulceration, malabsorption, chronic diarrhea, nausea and vomiting, gastro-esophageal reflux disease, chronic pain, or excessive weight loss. The surgical technique of RYGB reversal is not standardized; potential strategies include the following: (1) gastro-gastrostomy: hand-sewn technique, linear stapler, circular stapler; (2) handling of the Roux limb: reconnection or resection (if remaining intestinal length ≥ 4 m).

Case presentation: We demonstrate the surgical technique of a laparoscopic reversal of RYGB with hand-sewn gastro-gastrostomy and resection of the alimentary limb with the aim of improving the patient's quality of life. The gastric pouch is horizontally divided proximal to the previous staple line. A hand-sewn end to end anastomosis is created between the distal gastric pouch and the horizontal part of the gastric remnant adjacent to the lesser curve. The posterior wall is sutured in two layers. The anterior layer is closed with continuous 3-0 PDS full-thickness stitches over a 36-French oro-gastric calibration bougie. After evaluation of intestinal limbs and ruling out of hernial defects, the alimentary limb is divided just above the jejuno-jejunal Roux-anastomosis and is resected.

Conclusion: Reversal of RYGB is a precious treatment option for otherwise unmanageable postbariatric complications in well-selected cases. The operation should be performed in high volume bariatric centers after multidisciplinary patient preparation. The early and late complications of the reversal are higher than the rates seen in primary MBS; therefore, patients should be informed and monitored accordingly to ensure the best achievable outcomes.