OAGB to RNYGB

Clinical History:

• 47-year-old male patient presenting with intractable bile reflux and marginal ulceration 2 years after an OAGB performed in an outside hospital

• Admitted from the ER for severe epigastric pain. Initial EGD showed a large marginal ulcer at the GJ with signs of chronic reflux and ischemia. Patient was placed on anti-acid medications and full PPIs 

• Readmitted 2 times for the same reason

Other History:

• Active smoker. Was placed in the smoking cessation clinic for 8 weeks before planning the elective procedure

• Surgery was scheduled 6 months after he first came to the Emergency Room. The intervention was deferred after confirmation of ulcer improvement and negative smoking test 

• 47 years old, male

• BMI 38

Procedure Steps:

1. Identification of the anatomy

2. Fashioning of gastric pouch

3. Complete En-bloc resection of the previous loop anastomosis

4. Creation of the Gastro-Jejunal anastomosis 

5. Roux-en-Y reconstruction

6. Side-to side jejunojejunostomy

Learning Points:

• Importance of identifying the anatomy in a revisional surgery

• Routine use of endoscopic assistance (specially in a revisional case)

• Complete resection of the previous GJ anastomosis

• Measuring the lengths of both afferent and efferent limbs 

• Constructing a tension-free anastomosis

• Closure of the mesenteric and pseudo-Petersen defects