Bariatric Times - September 2008 - (Page 23)

Bariatric Times • September 2008 Surgical Perspective 23 Continued from Page 1 CASE REPORT A 57-year-old male was referred to our institution for the reversal of a JIB that had been performed 35 years earlier (Figures 1 and 2). His initial preoperative weight was 141Kg (312 pounds), which equates to a body mass index (BMI) of 43.5. At the time of referral, he was suffering from multiple complications secondary to chronic malabsorption, including worsening renal insufficiency and hepatic dysfunction. He also had a history of chronic pancreatitis, chronic malabsorptive diarrhea, and peripheral neuropathy. His past surgical history included a cholecystectomy 10 years after the JIB. He had recurrent nephrolithiasis that warranted repeated hospitalizations for urosepsis. He was being treated for thrombocytopenia and the related coagulopathy. His weight and BMI were 77Kg (169 pounds) and 23.6, respectively. Because of several previous surgeries, an exploratory laparotomy was performed through a midline incision. After a complete abdominal exploration and an extensive lysis of adhesions, the JIB was reversed with the creation of a side-to-side jejunojejunal stapled anastomosis. Because of the unknown response of the previously bypassed bowel, a gastrostomy tube was also fashioned. His hospital stay was uneventful; he was started on a clear liquid diet 24 hours after surgery and was progressively advanced as tolerated. He was subsequently discharged six days after surgery. Four days later, he developed a wound infection that was successfully treated with antibiotics and local wound care. Twelve months after the JIB reversal, his weight was 135Kg (298 pounds), with a BMI of 41.6. A nutritional evaluation revealed excessive fat intake, frequent snacking at night, and consumption of large portions of food. His medical evaluation was unremarkable with normal renal and liver function. After a thorough preoperative workup, he was scheduled for an elective laparoscopic sleeve gastrectomy. Due to the patient’s history of multiple surgeries, the procedure was converted to open secondary to excessive adhesions. In brief, the procedure involved ligation of the vessels along the great curvature of the stomach from the left crus to 7cm proximal to the pylorus. This was performed with an ultrasonic scalpel. The stomach was then sectioned with a linear stapler over a 52-Fr bougie. The staple line was oversewn with an inverting running 2-0 silk suture. A postoperative gastrografin swallow study revealed free flow of contrast through the gastric sleeve without a leak or extravasation of contrast (Figure 3). The patient was started on a clear liquid diet 24 hours after surgery and discharged from the hospital 48 hours after the procedure. Three weeks after surgery, he was tolerating a protein-rich liquid diet and was started on a solid diet. Six months after surgery he reported no issues with regard to his diet. His weight at that time was 119Kg (262 pounds) and his BMI was 36.7. DISCUSSION Bariatric surgery began in 1952 when the first surgical operation with the specific purpose of losing weight was performed.7,8 After observing the effects of massive bowel resections in different diseases, Henriksson of Sweden was the first to surgically treat an obese patient by means of a small bowel resection.9 Two years later, Kremen et al were the first to bypass 90 percent of the small bowel without intestinal resection and produced significant weight loss.10 In 1956, Payne developed the jejunocolic bypass, generating a dramatic decrease in weight loss in 10 patients.1,11 Several postoperative complications, however, prompted the reversal of this malabsorptive procedure.1,9 Sherman et al modified the jejunocolic bypass in 1965,12 creating a less aggressive http://www.ironintern.com http://www.ironintern.com

Table of Contents Feed for the Digital Edition of Bariatric Times - September 2008

Bariatric Times - September 2008 Emerging Technologies Case Report Sleeve Gastrectomy after a Jejunoileal Bypass Reversal Editorial Message Contents Editorial Board Walk from Obesity The Latest on Nutrition and Hair Loss in the Bariatric Patient Consultant’s Corner Journal Watch Calendar of Events Advertiser Index

Bariatric Times - September 2008

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