CASE REPORTS

Experience with the Duodenal Switch Operationin the Presence of Intestinal Malrotation

Varun Puri & Jyoti Ramachandran & Ranjan Sudan

Published online: 18 March 2008# Springer Science + Business Media B.V. 2007

Abstract The presence of intestinal malrotation (IM) maypose unexpected problems during bariatric operations. Wereviewed the records of patients with IM undergoingbariatric operations at our institution over the last 5 years.Three patients underwent four procedures. These includedan open duodenal switch, an attempted laparoscopic gastricbypass with open duodenal switch as a second-stageprocedure, and lastly a laparoscopic robot-assisted duodenalswitch. All patients have had good outcomes. The keyanatomic principles of a tension-free duodeno-enterostomyand maintaining appropriate orientation at the distalenteroenterostomy are emphasized.

Keywords Intestinal malrotation . Bariatric .

Duodenal switch

Introduction

About 102,000 bariatric procedures are performed annuallyin the United States [1]. The incidence of intestinalmalrotation is one in 500, and it may pose technical issuesduring bariatric procedures. This may be compounded bythe unexpected nature of the problem as testing for IM isnot routine in preoperative workup for bariatric surgery.Currently, the English language literature describes five

reports of patients with IM undergoing laparoscopic Roux-en-Y gastric bypass [2–6]. We hereby describe our ownexperience with the Duodenal Switch operation in patientswith IM.

Methods

We performed a review of a prospectively maintainedelectronic database of all bariatric operations performed byour team over the last 5 years (2002–2007). Intestinalmalrotation was a used as a keyword to query the“diagnosis entered” in the database for the search. Individ-ual cases were reviewed for operative details and outcome.All patients had undergone a detailed preoperative evalu-ation including history, physical examination, and apsychological evaluation. No patients underwent routinepreoperative contrast studies to diagnose IM.

Results

We performed 576 bariatric operations from 2002 to 2007(open gastric bypass [OGBP] 75, Laparoscopic GBP[LGBP] 285, Open Duodenal Switch [ODS] 116, Laparo-scopic/Robotic-assisted Duodenal Switch [LDS] 71, Lapa-roscopic adjustable gastric band [LAGB] 29). Threepatients with IM underwent four bariatric procedures atthe Creighton University from 2002 to 2007. The cases aresummarized below.

Case 1: A 50-year-old female with BMI 50 was taken upfor ODS and intraoperatively found to have IM.Meticulous dissection clearly defined the anato-my. An appendectomy was performed as routine.

OBES SURG (2008) 18:615–617DOI 10.1007/s11695-007-9326-5

V. Puri : J. Ramachandran :R. SudanCreighton University Medical Center,Omaha, NE, USA

R. Sudan (*)Department of Surgery, Creighton University,601N 30th Street, Omaha, NE 68131, USAe-mail: rsudan@creighton.edu

The normal orientation of alimentary limb (AL)(to the right side) and biliopancreatic limb (BPL)(to the left side) (Fig. 1) needed to be reversed(Fig. 2). This patient had partial malrotation andtherefore the AL was brought up in retrocolicfashion. A tension-free duodeno-enteral anasto-mosis was performed and the small bowelplaced in the right abdomen and large bowel inleft abdomen following principles of the Laddprocedure. The patient is doing well at 3 yearsfollow-up.

Case 2: A 51-year-old male with BMI 60 was taken forLGBP after his insurance company had initiallydenied a request for a duodenal switch. He wasfound to have IM intraoperatively, and althoughan enteroenterostomy was easily performed, theRoux limb would not reach the fundus of thestomach safely without tension. In the principleof safety, after discussing options with his family,the stomach was left undivided and the procedureterminated. In view of his operative findings, arequest for a duodenal switch procedure wassubsequently approved by the patient’s insurancecompany. At an open operation, 6 weeks later, theenteroenterostomy was reversed and an open DS

performed uneventfully. This patient had com-plete malrotation and therefore we did not passthe alimentary limb retrocolic. The rest of theprocedure was completed as for patient 1. He isdoing well at 9 months follow-up.

Case 3: A 58-year-old male with BMI 48 and known IMelected to undergo bariatric surgery. Based on ourexperience, LDS (65 patients) and DS in thepresence of IM (2 patients), we offered the patienta laparoscopic/robotic DS. The operation wasuneventful and he is doing well at 6 monthsfollow-up.

Discussion

Intestinal malrotation occurs at a rate of one in 500 livebirths. Normal rotation takes place around the superiormesenteric artery as the axis. Both the proximal duodeno-jejunal loop and the distal cecocolic loop rotate 270°anticlockwise during normal development. Malrotation mayinvolve non-rotation (the narrow mesenteric base predis-posing to volvulus), incomplete rotation (peritoneal bandsrunning from the misplaced cecum to the mesentery

Fig. 1 The final configuration after a laparoscopic-robotic duodenalswitch operation in a patient with normal anatomy is shown. A sleevegastrectomy has been performed. The alimentary limb (AL) lies to theright and the BPL to the left at the distal enteroenterostomy. The ALpasses in retrocolic fashion

Fig. 2 The configuration of the distal enteroenterostomy is reversedin a patient with intestinal malrotation. Here the BPL lies to the rightand the AL lies to the left of the patient. Also, depending on thedegree of malrotation, the AL may (not) be passed in retrocolicfashion

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compress the third portion of the duodenum), and incom-plete fixation leading to potential spaces for internalherniation. The incidence of truly asymptomatic malrota-tion is unknown and opinion about prophylactic surgerydivided. The principles of the Ladd procedure includereduction of volvulus (if present), division of mesentericbands, placement of small bowel on the right and largebowel on the left of the abdomen, and appendectomy.

Our preoperative routine for bariatric surgery involvescounseling about the Roux-en-Y GBP, the DS, and theLAGB, with the patients making an informed choice. TheDS is an established safe and effective operation for morbidobesity. We have been performing this operation in openfashion since 1999 and laparoscopically with roboticassistance since 2000. Our technique for the LDS has beenrecently published. In the GBP and the DS, the gastro-jejunostomy and the duodeno-enterostomy are the criticalanastomoses, respectively. A tension-free anastomosis is thefirst step in preventing anastomotic problems such as leaksor strictures. In patients with IM undergoing a Roux-en-YGBP, the Roux limb has to be stretched from the patient’sright side of the abdomen to the left upper quadrant, andthis technically puts the gastrojejunal anastomosis at riskfor tension. On the other hand, bringing the alimentary limbto the first part of the duodenum, which also lies on thepatients right side, is anatomically more intuitive and hasmuch less tension. Also, a significant technical consider-ation is the alignment of the distal entero-enterostomy. If apatient has normal anatomy, the orientation of alimentarylimb (AL) in a DS procedure is to the right side andbiliopancreatic limb (BPL) to the left side (Fig. 1). In IMwith the small bowel lying to the right of the abdomen(according to Ladd’s principles) and the usual orientation ofthe mesentery (from the left upper abdomen toward rightlower abdomen) missing, the distal entero-enterostomy iscreated differently. In this instance, the BPL lies toward thepatient’s right and the AL toward the left. This orientationbest prevents internal hernias. Understanding these twoanatomic principles is important in the performance ofbariatric surgery in patients with IM.

The LAGB could be an option in individuals withmalrotation as the need to manipulate the small bowel isobviated in this purely restrictive procedure. Based on therecent encouraging results seen with the laparoscopic sleevegastrectomy [7, 8], it may also be potentially considered asthe initial or only procedure in patients with IM.

Conclusion

Open/laparoscopic/robotic DS can be safely performed inIM. Key technical maneuvers include meticulous dissectionto identify the anatomy, reversing the orientation of AL andBPL at the entero-enterostomy, tension-free duodeno-enterostomy, appendectomy, and following the principlesof the Ladd operation.

References

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