The malabsorptive very, very long limb Roux-en-Y gastric bypass for super obesity: Results in 257 patients

Background: For the past 11 years, we have used a malabsorptive form of Roux-en-Y gastric bypass (RYGB), the "very, very long limb" RYGB, for selected patients with BMIs >50 kg/m² and in highly selected patients with BMI <50 kg/m². This modified distal gastric bypass establishes a 100-cm common channel (for digestion and absorption) and a "very, very" long Roux limb of 400 to 500 cm. Methods: To determine long-term efficacy and complications, we followed prospectively 257 consecutive patients; 188 (73%) participated in a postoperative survey. Results: Of the patients, 60% were female; overall age (x̄ ± SD) was 45 ± 11 years, and BMI was 61 ± 11 kg/m². Operative mortality was 1% with substantive postoperative morbidity occurring in 13%. Eighty-two percent of patients returning the survey an average of 48 months postoperatively (range, 12 to 148 months) lost >50% of excess body weight; BMI at follow-up was 37 ± 9 kg/m². Resolution of comorbidities included diabetes mellitus (94%), hypertension (65%), sleep apnea (48%), and asthma (30%). Side effects included mild food intolerance (82%), occasional loose or watery stools (71%), nephrolithiasis (16%), and symptomatic steatorrhea (5%). Nine patients (4%) who developed or were developing impending protein/calorie malnutrition required proximal relocation of the enteroenterostomy with symptom resolution. Conclusions: Overall, 90% were satisfied with the operation, and 93% would recommend it to a friend. The very, very long limb RYGB is relatively safe and effective and has acceptable side effects in the treatment of selected patients with super obesity (BMI >50). Because of the possibility of malabsorptive sequelae, patients should be selected based on degree of medical sophistication, insight, and compliance.