Abstract Background Revisional metabolic and bariatric surgery (MBS) poses challenges, particularly in patients with extensive adhesions and uncertain small bowel length. Distalization of the Roux-en-Y Gastric Bypass (RYGB) is effective for weight regain, but improper limb length selection may lead to malnutrition. This case highlights the importance of precise bowel measurement, even with severe adhesions, to optimize weight loss while preventing nutritional complications. Objectives To emphasize the necessity of individualized limb length adjustments in revisional RYGB to balance weight loss efficacy and mitigate post-operative malnutrition. Methods A 50-year-old patient underwent an open RYGB in 2000, later experiencing significant weight regain, presenting in 2022 with a BMI of 45 kg/m2. The patient was scheduled for distalisation. Intraoperatively, extensive adhesiolysis was performed due to a "Cocoon" configuration of the small bowel. To avoid bowel injury, distal bowel counting was undertaken, and the alimentary limb was refashioned at an estimated 250 cm from the ileocecal junction. Nine months postoperatively, the patient achieved 80% excess weight loss (EWL) but developed malnutrition. A second revision was performed, during which complete adhesiolysis enabled precise bowel measurement, revealing a total length of 450 cm. The alimentary limb was refashioned at the previous length done in 2000, and the entero-enteric anastomosis was revised also so the whole case reverted to original RYGB done in 2000. Results After the second revision, the patient's nutritional parameters improved while maintaining adequate weight loss. This case highlights the impact of precise bowel measurement and tailored limb length adjustments in revisional RYGB. Conclusion Revisional RYGB with extensive adhesions requires an individualized approach to limb length determination. This case underscores the importance of measuring the entire small bowel and adjusting the alimentary limb to 30–35% of the total bowel length. This strategy optimizes weight loss while minimizing malnutrition risk, emphasizing intraoperative bowel length assessment as essential in complex revisional bariatric procedures.
Mohamed Ammar (Thu,) studied this question.