IBC Oxford University Poster Abstract 1 - From crisis to recovery: emergency gastric bypass reversal: indications, technical pearls, and outcomes

Abstract Introduction Complications of Roux-en-Y gastric bypass (RYGB) often necessitate gastric bypass reversal. Common indications for reversal, as reported in the literature, include excessive weight loss, dumping syndrome, and postprandial hypoglycaemia. This procedure is usually performed electively and is well tolerated, with no reported mortalities. However, emergency post-RYGB presentations can have catastrophic outcomes, and surgical management of these complications may also require gastric bypass reversal. This scenario is infrequently reported in the literature, making the indications, outcomes, and techniques less familiar to bariatric surgeons. Methods We conducted a single-institution chart review of all patients who underwent emergency gastric bypass reversal surgery since 2020. We recorded demographics, indications, and outcomes, and compiled intraoperative recordings and operative reports to highlight the surgical techniques employed. Results Five emergency gastric bypass reversal surgeries were performed at our institution during this period. Four patients had marginal ulcer perforations and were poor candidates for repair or revision, while one patient had an internal hernia leading to bowel ischemia and necrosis. All five patients were female, with an age range of 36–80 years. The patient with the internal hernia required two additional anastomoses for necrotic bowel involving the Roux limb, terminal ileum, and cecum, in addition to the gastro-gastrostomy (GG) anastomosis. For the cases involving marginal ulcer perforations, the technique consisted of a GG anastomosis only and placement of a jejunostomy tube into the tip of the transected Roux limb. This approach shortened operative times, eliminated the risks of a second anastomosis, and provided secure and necessary feeding access for these acutely ill patients. Two operations were performed laparoscopically, while three required laparotomies. The technique for GG anastomoses varied based on anatomical and technical considerations, with a two-layered hand-sewn technique used in two cases and a linear stapler technique in the other three. Perioperative complications included one in-hospital mortality, attributed to late presentation rather than failure of the surgical technique. This patient was transferred from a smaller rural hospital after receiving CPR and was in severe septic shock and multisystem organ failure. She was left in discontinuity with temporary abdominal closure following gastrojejunostomy resection, all done prior to her transfer to our facility. There was one unplanned return to the operating room to control postoperative bleeding. The length of stay was seven and eight days for laparoscopic cases and 26 and 14 days for open cases. All patients surviving to hospital discharge experienced some degree of weight regain, ranging from 10 to 90 pounds at one year follow-up. Conclusions In our series, marginal ulcer perforation with poor candidacy for repair or revision was the most common indication for emergency RYGB reversal. The procedure was generally well tolerated when performed in a timely fashion. Late presentation with sepsis & multisystem organ failure resulted our only mortality. The open approach resulted in a longer hospital stay. Consistent with the literature on elective RYGB reversal, our patients experienced variable degrees of weight regain. Performing only a GG anastomosis and placing a feeding tube in the Roux limb may contribute to positive outcomes.