title: Duodenal switch with omentopexy and feeding jejunostomy--a safe and effective revisional operation for failed previous weight loss surgery.
abstract: BACKGROUND
  As the number of weight loss operations has increased, the number of patients who have failed to maintain sufficient weight loss has also increased, providing a management challenge to the bariatric surgeon. Conversion to a duodenal switch with omentopexy and feeding jejunostomy was performed for these patients.
  
  
  METHODS
  Between September 2006 and January 2010, 41 revisional operations were performed at 1 institution and by 1 operating surgeon. The data were prospectively collected and reviewed for several parameters, including excess weight loss, mortality, and morbidity. These results are reported.
  
  
  RESULTS
  A total of 41 patients underwent conversion of their original bariatric operation to a duodenal switch with omentopexy and feeding jejunostomy. The initial operations had been gastric bypass in 32 patients, vertical banded gastroplasty in 5, and laparoscopic adjustable gastric banding in 4. The average excess weight loss was 54% in 31 patients at 6 months, 66% in 22 patients at 1 year, and 75% in 9 patients at 2 years. No patients died. The average hospital stay was 6.4 days. A total of 9 proven or suspected leaks (22%) developed. One was at the enverted staple line of a jejunojejunostomy that was diagnosed and treated the next day with little subsequent morbidity. The others were at the gastrogastrostomy or lateral gastric staple line and all occurred in conversions from gastric bypass. They were all ischemic type leaks and presented 5-11 days after surgery and closed relatively uneventfully with J-tube feedings and antibiotic/antifungal treatment. Other major complications included 1 pulmonary embolism (2%), 1 small bowel obstruction at the site of the feeding jejunostomy (2%), 2 stenoses (4%)-1 at the duodenoenterostomy and 1 in the body of the vertical gastrectomy. This gives a total major complication rate of 30%. A total of 3 patients required reoperation because of a jejunojejunostomy leak, small bowel obstruction, and stenosis at the vertical gastrectomy. No gastrogastrostomy leaks required surgical or radiologic intervention. One required revision for malnutrition, but otherwise the nutrition remained good.
  
  
  CONCLUSIONS
  Revisional surgery to a duodenal switch is a complex operation and carries a high potential for major complications. Nonetheless, it can be accomplished safely with good long-term results. Omentopexy, drainage, and feeding jejunostomy should be considered at surgery to treat the high potential for delayed ischemic leaks.
authors.affiliation: Lourdes Medical Center of Burlington County, Willingboro, New Jersey, USA. drthin@aol.com
authors.forename: David F
authors.initials: DF
authors.lastname: Greenbaum
authors.forename: Samuel H
authors.initials: SH
authors.lastname: Wasser
authors.forename: Tina
authors.initials: T
authors.lastname: Riley
authors.forename: Tinamarie
authors.initials: T
authors.lastname: Juengert
authors.forename: June
authors.initials: J
authors.lastname: Hubler
authors.forename: Karen
authors.initials: K
authors.lastname: Angel
mesh_terms: D015904:Biliopancreatic Diversion / Q000379:methods*; D015391:Gastroplasty / Q000009:adverse effects*; D006801:Humans; D007582:Jejunostomy / Q000379:methods*; D007902:Length of Stay; D009017:Morbidity / Q000639:trends; D009515:New Jersey / Q000453:epidemiology; D009767:Obesity, Morbid / Q000453:epidemiology / Q000601:surgery*; D012086:Reoperation / Q000379:methods*; D017211:Treatment Failure; D016896:Treatment Outcome; D015431:Weight Loss