How to address post-Roux-en-Y gastric bypass late dumping in a patient with a history of Nissen fundoplication converted to bypass for obesity.

Abstract

Introduction: Reversal of Roux-en-Y gastric bypass (RYGB) may be indicated for possible side effects such as malnutrition, intolerance, dumping syndrome, or late dumping. Reversal can however induce significant gastro-esophageal reflux disease (GERD).

Method: We report the case of a 55 years old Caucasian woman, who had undergone conversion of Nissen fundoplication performed for GERD (Grade B) into RYGB because of recurrent reflux, though Grade A esophagitis and increasing obesity (37.5 kg/m² BMI). She developed invalidating symptoms of late dumping syndrome and severe diarrhea. Pre- and postoperative evaluation an eso-gastroscopy with esophagitis grade evaluation. Treatment consisted of physiologic reversal of the RYGB, by reimplantation of the alimentary limb into the remnant stomach.

Result: Pre-reversal endoscopy showed Grade A esophagitis. Oral glucose test demonstrated severe hypoglycemia persisting till 120 min post-ingestion and clinical symptoms of hypoglycemia (Whipple triad) (40 to 53 mg/dl). Three months after reversal the diagnostic tests had significantly improved, both in terms of glucose metabolism and GERD symptoms. At 22 months after surgery, the patient still did not suffer from diarrhea anymore, her glycemic profile was stable under antidiabetic medications and her BMI raised to 29 kg/m².

Discussion and conclusion: Reversal of Roux-en-Y gastric bypass by incorporation of the alimentary limb between the gastric pouch and the gastric remnant seems to successfully address the dual issue of post-RYGB late dumping and preventing GERD, the different mechanisms involved will be explained latter in this paper.