Two-Stage Laparoscopic Approach for Jejunoileal Bypass Reversal

As a result of the increasing prevalence of morbid obesity, weight loss operations have gained popularity.1, 2 Bariatric surgeries have been reported back to the 1950s.2 More than 100,000 jejunoileal bypass (JIB) operations were done before the severe complications of this procedure were determined. Currently, there are still patients who suffer from these devastating consequences.1, 2 We describe a case of a 61-year-old female patient who developed end-organ failure secondary to malnutrition from JIB. She underwent reversal in a two-stage laparoscopic procedure. Surgeons’ awareness of this anatomy is crucial. Surgery reversal can prevent further malabsorption and life-threatening complications. This is a case of a 61-year-old female who underwent a JIB in the 1970s. She suffered with diarrhea, malabsorption, and end-organ dysfunction, including renal oxalate stones and gallstones. The reversal consisted of a 2-stage procedure, both completed laparoscopically. The first stage included delineation of the anatomy and feeding access. A total of five trocars were used. Extensive lysis of adhesions was carried out. The patient’s anatomy included an end-to-end anastomosis between the proximal jejunum, 10 to 15 cm distal from the ligament of Treitz, to the terminal ileum. The distal end of the defunctionalized limb had been anastomosed in an end-to-side manner to the transverse colon, slightly distal to the hepatic flexure. A significant discrepancy in size between alimentary limb and the defunctionalized limb was found. A 14 French jejunostomy feeding tube was placed into the proximal end of the defunctionalized limb with the intent of facilitating limb adaptation in function and size. The tube was passed with difficulty due to the small diameter of the bowel (approximately 1 cm) as well as the inspissated material within it. Tube feeds were started on postoperative day 1, advanced to goal and tolerated. She had a total length of stay of five days. A year later, she was taken back for a second stage procedure. Once proper orientation was achieved, the jejunoileal anastomosis was taken down at the distal portion. The entire small bowel was mobilized to the left lower quadrant in preparation for colon mobilization. A right extended hemicolectomy was performed, with a medial to lateral rotation. The resection included the ileum, the ileocecal valve, and the right colon. The distal transection was up to the anastomosis of her distal ileum to the transverse colon. The prior jejunostomy site was taken down, and the proximal defunctionalized limb of jejunum was mobilized. A side-to-side anastomosis between the defunctionalized jejunum (markedly increased in size to 3.5–4 cm diameter) and the very proximal jejunum (5–6 cm diameter) was done. This anastomosis was made with an endoscopic stapler, and the common enterotomy was closed in a handsewn manner. The mesenteric defect was closed in it entirely. New anatomy included a normal intact duodenum, a proximal jejunum now anastomosed back to her native jejunum, a small amount of ileum, which was anastomosed from her previous original operation to her transverse colon. The patient tolerated the procedure well and had an uncomplicated postoperative course. She was discharged home on postoperative day 4 with resumption of oral diet and had no complications. The JIP operation was considered the most effective bariatric surgery during the 1950s and 1970s.1, 3 Unfortunately, this malabsorptive state was accompanied by numerous severe and life-threatening complications for which this surgery was abandoned.1 Some of the complications found with JIB include renal failure, diarrhea with electrolyte imbalances, calcium oxalate nephrolithiasis, cutaneous eruptions, febrile states, impaired mentation, liver disease, fat-soluble vitamin deficiencies, malnutrition, and death.1, 3 It is believed that bacteria stasis and overgrowth in the bypassed intestinal segment resulted in toxins and alcohols Address correspondence and reprint requests to Jessica ArdilaGatas, M.D., Cleveland Clinic, 3313 East, Fairfax Road, Cleveland Heights, OH 44118. E-mail: ardilaj@ccf.org.