- Email: [email protected]
Bariatric Surgery Complications: Diagnosis and Management of The Gastrogastric Fistula
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Video Sessions / Surgery for Obesity and Related Diseases 11 (2015) S35–S42
performed in a medial to lateral fashion. Band was removed. Posterior and anterior adhesiolysis of the prior plication and band scar tissue were performed. Following circumferential hiatal dissection and takedown of short gastric arteries, hernia defect was closed posteriorly and a Toupet fundoplication performed. Conclusion: Identification and division of overlying scar tissue of the prior adjustable gastric band, medial to lateral gastrohepatic adhesiolysis and full circumferential dissection of the hiatus allow for removal of the adjustable gastric band and conversion to a Toupet fundoplication with hiatal hernia repair.
A169
LAPAROSCOPIC REVISION OF CHRONIC MARGINAL ULCER AND BILATERAL TRUNCAL VAGATOMY Maher El Chaar, MD, FACS, FASMBS; St. Luke’s University Hospital, Allentown, PA, USA Background: Bariatric surgery is the only proven and effective long term treatment for morbid obesity. In accredited centers, bariatric surgery is performed with very low mortality, morbidity and readmission rates. However, a small number of bariatric patients develop postoperative complications like marginal ulcers. The etiology of marginal ulcers following a Laparoscopic Roux en Y gastric Bypass (LRYGB) is a matter of debate. Many factors are believed to contribute to the development of marginal ulcers such as smoking, ischemia, foreign body reaction, gastro-gastric fistulas, large gastric pouches and tension at the anastomosis. Methods: 52 yo female s/p LRYGB in 2006 presented to our center with chronic abdominal pain. Upper endoscopy revealed a marginal ulcer, no evidence of gastrogastric fistula. UGI was also performed and showed a small hiaal hernia but no evidence of a fistula. Patient was not a smoker and denied NSAID use. Patient was managed with high dose PPI for 8 weeks but did not respond. Repeat EGD showed a chronic marginal ulcer. Patient developed dysphagia to solids and liquids and became malnourished. TPN was initiated for nutritional support and the decision was made to revise the anastomsis. Results: Our video demonstrates the takedown of a chronic marginal ulcer, revision of the gastrojejunostomy anastomosis and the performance of a bilateral trauncal vagatomy. Postoperatively the patient did very well and her pain resolved. TPN was discontinued and patient resumed her diet. Conclusion: Laparoscopic revision of a chronic marginal ulcer with the performance of a truncal vagotomy is feasible and safe with good postoperative outcome.
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LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS IN A PATIENT WITH SITUS INVERSUS Lars Nelson, MD; Rena Moon, MD; Andre Teixeira, MD; Muhammad Jawad, MD; Orlando Regional Medical Center, Orlando, FL, USA Introduction: 43 year-old female with body mass index of 45.3kg/m2 who has undergone multiple attempts at weight loss in the past without success. Patient has a known history of situs
inversus. Patient denies any nausea, vomiting, constipation or other symptoms of obstruction. Decision was made to proceed with laparoscopic Roux-en-Y gastric bypass (RYGB). Material and Methods: Visualization of abdominal cavity revealed the liver and gallbladder on the left side. The stomach, spleen, and ligament of Treitz were on the right side of the abdomen consistent with situs inversus. The left lobe of the liver was retracted anteriorly. The stomach was reversed 180 degrees where the gastroesophageal junction was in the left upper quadrant and the grater curvature on the right side. The omentum was taken down for mobilization. Next, a window was created between the lesser curvature of the stomach and lesser omentum. The stomach was transected and a pouch was created. The ligament of Treitz in the right upper quadrant was identified, jejunum was run 50cm distally and transected with a linear stapler. The afferent limb was followed 75cm where a jejunojejunostomy was performed. The mesenteric defect was then closed. Next, the Roux limb was brought up in an antecolic, antigastric fashion, tension free, to the gastric pouch. Following this, gastrojejunostomy was created by making enterotomies in the pouch and Roux-limb. The Peterson’s defect was closed. The anastomosis were tested with methylene blue and air. Result: Patient did well postoperatively. Upper gastrointestinal series and methylene blue test were negative on POD 1, discharged on POD 2 on phase 1 diet. Conclusion: Laparoscopic RYGB may be feasible in patients with situs inversus.
A171
BARIATRIC SURGERY COMPLICATIONS: DIAGNOSIS AND MANAGEMENT OF THE GASTROGASTRIC FISTULA Selma Siddiqui, MD; Rami Lutfi, MD; St. Joseph Hospital, Chicago, IL, USA Introduction: As bariatric surgery is becoming more commonplace, surgeons are becoming more familiar with management of long-term complications of bariatric surgery. We discuss the case of a patient who presented with weight gain 15 years after a Rouxen-y gastric bypass. Case description: This is a 54-year-old female who had an uncomplicated open Roux-en-y gastric bypass in 2000, but began suddenly regaining weight in 2012. She had no other symptoms. She underwent upper gastrointestinal radiography, which was normal. At a second clinic evaluation, a transnasal endoscopy (TNE) was performed for mild reflux on radiography. TNE demonstrated a gastro-gastric fistula (GGF), a large gastric pouch, and a small hiatal hernia. She chose to undergo a pouch gastroplasty with remnant gastrectomy. This was done laparoscopically with a concurrent lysis of adhesions. The fistula was identified endoscopically intraoperatively. The gastroplasty was performed resecting a segment of the enlarged gastric pouch in addition to the remnant fundus/cardia. A post-operative upper gastrointestinal radiography appeared normal and the patient tolerated liquids and was discharged home. Discussion: The incidence of post bariatric surgery gastrogastric fistula is reported to be between 1.1% -1.8% in several studies1-4. Most patients present with obesity recidivism and abdominal pain.
Video Sessions / Surgery for Obesity and Related Diseases 11 (2015) S35–S42
Empirically, GGF may be associated with small or subclinical leaks and marginal ulcers. These inflammation associated GGFs may also be more likely to present sooner (a mean time to presentation of less than 3 months) and may resolve with proton pump inhibitor (PPI) therapy to reduce inflammatory changes and allow autonomous healing of the fistula tract1,2. Endoscopic treatment with clips or covered stents is also emerging as an option when a small leak is suspected5,6. The role of these stents is still being investigated. In cases where PPI therapy fails or there are no signs of inflammatory disease, a remnant gastrectomy or pouch gastroplasty should be considered4. This case demonstrated a patient without any active inflammatory process in whom a gastroplasty and remnant gastrectomy resolved symptoms and restored restriction. Additionally, an in office transnasal endoscopy may be a novel way to aide diagnosis of post-bariatric surgery complaints concerning for marginal ulcers, fistulization or other technical issues7. Investigations are currently underway to identify the utility of the transnasal endoscopy in the both the pre and post bariatric surgery patient8. 1. Carrodeguas L, Szomstein S, Soto F, Whipple O, Simpfendorfer C, Gonzalvo JP, Villares A, Zundel N, Rosenthal R. Management of gastrogastric fistulas after divided Rouxen-Y gastric bypass surgery for morbid obesity: analysis of 1,292 consecutive patients and review of literature. Surg Obes Relat Dis. 2005 Sep-Oct;1(5):467-74. Epub 2005 Aug 31. 2. Gumbs AA1, Duffy AJ, Bell RL. Management of gastrogastric fistula after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2006 Mar-Apr;2(2):117-21. Epub 2006 Feb 28. 3. Salimath J1, Rosenthal RJ, Szomstein S. Laparoscopic remnant gastrectomy as a novel approach for treatment of gastrogastric fistula. Surg Endosc. 2009 Nov;23(11):2591-5. doi: 10.1007/s00464-009-0465-8. Epub 2009 May 22. 4. Cho M1, Kaidar-Person O, Szomstein S, Rosenthal RJ. Laparoscopic remnant gastrectomy: a novel approach to gastrogastric fistula after Roux-en-Y gastric bypass for morbid obesity. J Am Coll Surg. 2007 Apr;204(4):617-24. 5. Bhardwaj A1, Cooney RN, Wehrman A, Rogers AM, Mathew A. Endoscopic repair of small symptomatic gastrogastric fistulas after gastric bypass surgery: a single center experience. Obes Surg. 2010 Aug;20(8):1090-5. doi: 10.1007/s11695-010-0180-5. 6. Ghiassi S, Gatschet R, Moon D, Boone K, Higa K. Presentation and Management of Gastrogastric Fistula After Rouxen-Y Gastric Bypass. Poster presented at SAGES 2012. March 7-10, 2012. San Diego, CA. 7. Alami RS1, Schuster R, Friedland S, Curet MJ, Wren SM, Soetikno R, Morton JM, Safadi BY. Transnasal small-caliber esophagogastroduodenoscopy for preoperative evaluation of the high-risk morbidly obese patient. Surg Endosc. 2007 May;21(5):758-60. Epub 2007 Jan 19. 8. Evans J. A Prospective Study Evaluating The Utility of Transnasal Endoscopy With Roux en Y Gastric Bypass Referred for Upper Endoscopy. Clinical trial, currently recruiting. NCT01526772. Wake Forest Baptist Health. Accessed: https://clinicaltrials.gov/ct2/show/NCT01526772 on 4/28/2015.
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MANAGEMENT TECHNIQUES FOR FAILED VERTICAL BANDED GASTROPLASTY. A. Daniel Guerron, MD1; Dana Portenier, MD2; 1Cleveland Clinic, Cleveland, OH, USA; 2Duke University, Durham, NC, USA Introduction: Initial gastroplasty was performed in 1971 by Mason and Printen. The procedure was based solely upon restriction. The procedure was performed in significant numbers from inception till 1990’s. Initial success with a change in weight was similar to LAGB but inferior to LRGYB, but maladaptive eating resulted in weight regain, as well as other problems associated with the procedure such as pouch dilation, bad erosions, outlet stenosis and reflux. Common scenarios resulting in revision are conditioned to patient’s current BMI and operative risk. In this video we present several scenarios and its revisional management. Methods/Scenarios: Scenario #1 - High BMI, Reasonable operative risk with or without anatomic abnormality conversion to LRYGB. Laparoscopic revision. Adhesions are dissected off the left lobe of the liver and anatomy is delineated. The silastic band and staple line is identified. Identification of reliable landmarks (right crus) is performed. The angle of His is mobilize by taking short gastric vessels. The left crura is identified. The lesser sac is entered. The left gastric identified and preserved. A new pouch is created within the old pouch excluding the previous VBG staple line. The old VBG staple lines and Silastic ring/marlex mesh are removed to avoid nidus for chronic infection. The staples lines can isolate stomach creating mucocele and resultant leak. Complete revision by performing a leak test and reconstruct Roux-en-Y. Scenario #2 - Low BMI or mentally adverse risk, reasonable/ marginal operative risk with anatomic abnormality conversion to laparoscopic assisted transgastric reversal of VBG. Laparoscopic revision. The stomach is dissected off the liver. The band is identified and removed. The greater curvature of the stomach is mobilize. Transcutaneous sutures are use to appose the stomach to the abdominal wall in preparation for intragastric trocar placement. A bowel clamp is placed to prevent loss of domain from bowel distention that hampers closure of transgastric trocar sites. Two transgatric trocars (5mm, 12mm) are placed. The 12 mm is placed distally to facilitate proper angle to VBG outlet. Pneumogastrium is established at 10mmHG and the pneumoperitoneum released. The VBG outlet is identified. Serial division of the outlet is performed with staplers to open the VBG pouch. Scenario #3 - High/Adverse operative risk with significant anatomic abnormality. Revised using endoscopic stenting causing forced erosion of band to reverse VBG. Fluoroscopic assisted placement of covered esophageal stent across the stenosis. The stent placement creates a forced erosion of the band by necrosising the tissue between the band and the stent over a 2-3 week period. The stent is removed under endoscopic guidance. The silastic band is visualized and assesed if its ready to retrieve. Using a double channel scope a gap in the band where the stitch is accesible is identified and transected with scissors. The band is removed and another stent is placed to avoid ischemic stricture.
Video Sessions / Surgery for Obesity and Related Diseases 11 (2015) S35–S42
performed in a medial to lateral fashion. Band was removed. Posterior and anterior adhesiolysis of the prior plication and band scar tissue were performed. Following circumferential hiatal dissection and takedown of short gastric arteries, hernia defect was closed posteriorly and a Toupet fundoplication performed. Conclusion: Identification and division of overlying scar tissue of the prior adjustable gastric band, medial to lateral gastrohepatic adhesiolysis and full circumferential dissection of the hiatus allow for removal of the adjustable gastric band and conversion to a Toupet fundoplication with hiatal hernia repair.
A169
LAPAROSCOPIC REVISION OF CHRONIC MARGINAL ULCER AND BILATERAL TRUNCAL VAGATOMY Maher El Chaar, MD, FACS, FASMBS; St. Luke’s University Hospital, Allentown, PA, USA Background: Bariatric surgery is the only proven and effective long term treatment for morbid obesity. In accredited centers, bariatric surgery is performed with very low mortality, morbidity and readmission rates. However, a small number of bariatric patients develop postoperative complications like marginal ulcers. The etiology of marginal ulcers following a Laparoscopic Roux en Y gastric Bypass (LRYGB) is a matter of debate. Many factors are believed to contribute to the development of marginal ulcers such as smoking, ischemia, foreign body reaction, gastro-gastric fistulas, large gastric pouches and tension at the anastomosis. Methods: 52 yo female s/p LRYGB in 2006 presented to our center with chronic abdominal pain. Upper endoscopy revealed a marginal ulcer, no evidence of gastrogastric fistula. UGI was also performed and showed a small hiaal hernia but no evidence of a fistula. Patient was not a smoker and denied NSAID use. Patient was managed with high dose PPI for 8 weeks but did not respond. Repeat EGD showed a chronic marginal ulcer. Patient developed dysphagia to solids and liquids and became malnourished. TPN was initiated for nutritional support and the decision was made to revise the anastomsis. Results: Our video demonstrates the takedown of a chronic marginal ulcer, revision of the gastrojejunostomy anastomosis and the performance of a bilateral trauncal vagatomy. Postoperatively the patient did very well and her pain resolved. TPN was discontinued and patient resumed her diet. Conclusion: Laparoscopic revision of a chronic marginal ulcer with the performance of a truncal vagotomy is feasible and safe with good postoperative outcome.
A170
LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS IN A PATIENT WITH SITUS INVERSUS Lars Nelson, MD; Rena Moon, MD; Andre Teixeira, MD; Muhammad Jawad, MD; Orlando Regional Medical Center, Orlando, FL, USA Introduction: 43 year-old female with body mass index of 45.3kg/m2 who has undergone multiple attempts at weight loss in the past without success. Patient has a known history of situs
inversus. Patient denies any nausea, vomiting, constipation or other symptoms of obstruction. Decision was made to proceed with laparoscopic Roux-en-Y gastric bypass (RYGB). Material and Methods: Visualization of abdominal cavity revealed the liver and gallbladder on the left side. The stomach, spleen, and ligament of Treitz were on the right side of the abdomen consistent with situs inversus. The left lobe of the liver was retracted anteriorly. The stomach was reversed 180 degrees where the gastroesophageal junction was in the left upper quadrant and the grater curvature on the right side. The omentum was taken down for mobilization. Next, a window was created between the lesser curvature of the stomach and lesser omentum. The stomach was transected and a pouch was created. The ligament of Treitz in the right upper quadrant was identified, jejunum was run 50cm distally and transected with a linear stapler. The afferent limb was followed 75cm where a jejunojejunostomy was performed. The mesenteric defect was then closed. Next, the Roux limb was brought up in an antecolic, antigastric fashion, tension free, to the gastric pouch. Following this, gastrojejunostomy was created by making enterotomies in the pouch and Roux-limb. The Peterson’s defect was closed. The anastomosis were tested with methylene blue and air. Result: Patient did well postoperatively. Upper gastrointestinal series and methylene blue test were negative on POD 1, discharged on POD 2 on phase 1 diet. Conclusion: Laparoscopic RYGB may be feasible in patients with situs inversus.
A171
BARIATRIC SURGERY COMPLICATIONS: DIAGNOSIS AND MANAGEMENT OF THE GASTROGASTRIC FISTULA Selma Siddiqui, MD; Rami Lutfi, MD; St. Joseph Hospital, Chicago, IL, USA Introduction: As bariatric surgery is becoming more commonplace, surgeons are becoming more familiar with management of long-term complications of bariatric surgery. We discuss the case of a patient who presented with weight gain 15 years after a Rouxen-y gastric bypass. Case description: This is a 54-year-old female who had an uncomplicated open Roux-en-y gastric bypass in 2000, but began suddenly regaining weight in 2012. She had no other symptoms. She underwent upper gastrointestinal radiography, which was normal. At a second clinic evaluation, a transnasal endoscopy (TNE) was performed for mild reflux on radiography. TNE demonstrated a gastro-gastric fistula (GGF), a large gastric pouch, and a small hiatal hernia. She chose to undergo a pouch gastroplasty with remnant gastrectomy. This was done laparoscopically with a concurrent lysis of adhesions. The fistula was identified endoscopically intraoperatively. The gastroplasty was performed resecting a segment of the enlarged gastric pouch in addition to the remnant fundus/cardia. A post-operative upper gastrointestinal radiography appeared normal and the patient tolerated liquids and was discharged home. Discussion: The incidence of post bariatric surgery gastrogastric fistula is reported to be between 1.1% -1.8% in several studies1-4. Most patients present with obesity recidivism and abdominal pain.
Video Sessions / Surgery for Obesity and Related Diseases 11 (2015) S35–S42
Empirically, GGF may be associated with small or subclinical leaks and marginal ulcers. These inflammation associated GGFs may also be more likely to present sooner (a mean time to presentation of less than 3 months) and may resolve with proton pump inhibitor (PPI) therapy to reduce inflammatory changes and allow autonomous healing of the fistula tract1,2. Endoscopic treatment with clips or covered stents is also emerging as an option when a small leak is suspected5,6. The role of these stents is still being investigated. In cases where PPI therapy fails or there are no signs of inflammatory disease, a remnant gastrectomy or pouch gastroplasty should be considered4. This case demonstrated a patient without any active inflammatory process in whom a gastroplasty and remnant gastrectomy resolved symptoms and restored restriction. Additionally, an in office transnasal endoscopy may be a novel way to aide diagnosis of post-bariatric surgery complaints concerning for marginal ulcers, fistulization or other technical issues7. Investigations are currently underway to identify the utility of the transnasal endoscopy in the both the pre and post bariatric surgery patient8. 1. Carrodeguas L, Szomstein S, Soto F, Whipple O, Simpfendorfer C, Gonzalvo JP, Villares A, Zundel N, Rosenthal R. Management of gastrogastric fistulas after divided Rouxen-Y gastric bypass surgery for morbid obesity: analysis of 1,292 consecutive patients and review of literature. Surg Obes Relat Dis. 2005 Sep-Oct;1(5):467-74. Epub 2005 Aug 31. 2. Gumbs AA1, Duffy AJ, Bell RL. Management of gastrogastric fistula after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2006 Mar-Apr;2(2):117-21. Epub 2006 Feb 28. 3. Salimath J1, Rosenthal RJ, Szomstein S. Laparoscopic remnant gastrectomy as a novel approach for treatment of gastrogastric fistula. Surg Endosc. 2009 Nov;23(11):2591-5. doi: 10.1007/s00464-009-0465-8. Epub 2009 May 22. 4. Cho M1, Kaidar-Person O, Szomstein S, Rosenthal RJ. Laparoscopic remnant gastrectomy: a novel approach to gastrogastric fistula after Roux-en-Y gastric bypass for morbid obesity. J Am Coll Surg. 2007 Apr;204(4):617-24. 5. Bhardwaj A1, Cooney RN, Wehrman A, Rogers AM, Mathew A. Endoscopic repair of small symptomatic gastrogastric fistulas after gastric bypass surgery: a single center experience. Obes Surg. 2010 Aug;20(8):1090-5. doi: 10.1007/s11695-010-0180-5. 6. Ghiassi S, Gatschet R, Moon D, Boone K, Higa K. Presentation and Management of Gastrogastric Fistula After Rouxen-Y Gastric Bypass. Poster presented at SAGES 2012. March 7-10, 2012. San Diego, CA. 7. Alami RS1, Schuster R, Friedland S, Curet MJ, Wren SM, Soetikno R, Morton JM, Safadi BY. Transnasal small-caliber esophagogastroduodenoscopy for preoperative evaluation of the high-risk morbidly obese patient. Surg Endosc. 2007 May;21(5):758-60. Epub 2007 Jan 19. 8. Evans J. A Prospective Study Evaluating The Utility of Transnasal Endoscopy With Roux en Y Gastric Bypass Referred for Upper Endoscopy. Clinical trial, currently recruiting. NCT01526772. Wake Forest Baptist Health. Accessed: https://clinicaltrials.gov/ct2/show/NCT01526772 on 4/28/2015.
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MANAGEMENT TECHNIQUES FOR FAILED VERTICAL BANDED GASTROPLASTY. A. Daniel Guerron, MD1; Dana Portenier, MD2; 1Cleveland Clinic, Cleveland, OH, USA; 2Duke University, Durham, NC, USA Introduction: Initial gastroplasty was performed in 1971 by Mason and Printen. The procedure was based solely upon restriction. The procedure was performed in significant numbers from inception till 1990’s. Initial success with a change in weight was similar to LAGB but inferior to LRGYB, but maladaptive eating resulted in weight regain, as well as other problems associated with the procedure such as pouch dilation, bad erosions, outlet stenosis and reflux. Common scenarios resulting in revision are conditioned to patient’s current BMI and operative risk. In this video we present several scenarios and its revisional management. Methods/Scenarios: Scenario #1 - High BMI, Reasonable operative risk with or without anatomic abnormality conversion to LRYGB. Laparoscopic revision. Adhesions are dissected off the left lobe of the liver and anatomy is delineated. The silastic band and staple line is identified. Identification of reliable landmarks (right crus) is performed. The angle of His is mobilize by taking short gastric vessels. The left crura is identified. The lesser sac is entered. The left gastric identified and preserved. A new pouch is created within the old pouch excluding the previous VBG staple line. The old VBG staple lines and Silastic ring/marlex mesh are removed to avoid nidus for chronic infection. The staples lines can isolate stomach creating mucocele and resultant leak. Complete revision by performing a leak test and reconstruct Roux-en-Y. Scenario #2 - Low BMI or mentally adverse risk, reasonable/ marginal operative risk with anatomic abnormality conversion to laparoscopic assisted transgastric reversal of VBG. Laparoscopic revision. The stomach is dissected off the liver. The band is identified and removed. The greater curvature of the stomach is mobilize. Transcutaneous sutures are use to appose the stomach to the abdominal wall in preparation for intragastric trocar placement. A bowel clamp is placed to prevent loss of domain from bowel distention that hampers closure of transgastric trocar sites. Two transgatric trocars (5mm, 12mm) are placed. The 12 mm is placed distally to facilitate proper angle to VBG outlet. Pneumogastrium is established at 10mmHG and the pneumoperitoneum released. The VBG outlet is identified. Serial division of the outlet is performed with staplers to open the VBG pouch. Scenario #3 - High/Adverse operative risk with significant anatomic abnormality. Revised using endoscopic stenting causing forced erosion of band to reverse VBG. Fluoroscopic assisted placement of covered esophageal stent across the stenosis. The stent placement creates a forced erosion of the band by necrosising the tissue between the band and the stent over a 2-3 week period. The stent is removed under endoscopic guidance. The silastic band is visualized and assesed if its ready to retrieve. Using a double channel scope a gap in the band where the stitch is accesible is identified and transected with scissors. The band is removed and another stent is placed to avoid ischemic stricture.