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Gastro-Colonic Fistula Formation as A Complication of Bariatric Surgery
S108
Poster Presentations / Surgery for Obesity and Related Diseases 11 (2015) S56–S211
A5099
ABDOMINAL PAIN AFTER ROUX – Y – GASTRIC BYPASS: ETIOLOGY AND MANAGEMENT Marius Nedelcu, MD1; Stylianos Tzedakis, MD1; Antonio D'Urso, MD1; Henry Mercoli, MD1; Michel Vix, MD2; Jacques Marescaux, MD, FACS, Hon FRCS, Hon FJSES2; Didier Mutter2; Silvana Perretta, MD2; 1Strasbourg University Hospital, IRCAD, Strasbourg, Alsace, France; 2Strasbourg University Hospital, IRCAD, IHU, Strasbourg, France Background: The number of laparoscopic bariatric procedures being performed worldwide has increased dramatically in the past decade. The laparoscopic Roux-en-Y gastric bypass (LRYGB) is not only the most common bariatric procedure, but also the gold standard to which all others are compared. Abdominal pain is a common complaint following LRYGB. Aim: to assess the incidence, etiology and management of patients with pain after LRYGB presenting at our institution. Methods: A retrospective review of all patients presenting with a intermittent repetitive abdominal pain after LRYGB at our institution was conducted. The complementary work-up, the final diagnosis and treatment were analyzed. Results: Between 2009 and 2013, 592 patients underwent RYGBP in our department. A total of 138 patients (23.31 %) complained of intermittent repetitive abdominal pain after LRYGB. 116 patients (84.05 %) were admitted to the surgical ward from the emergency department and the remaining 22 were hospitalized during the follow up in outpatient clinic. The final diagnosis was: nonspecific abdominal pain - 35 cases (25.4 %), anastomotic ulcer – 28 cases (20.3 %); biliary lithiasis – 19 cases (13.7 %); internal hernia – 15 cases (10.9 %); incisional hernia – 15 cases (10.9 %); small bowel obstruction – 14 cases (10.1 %); anastomotic leaks – 6 cases (4.3 %); unrelated diseases – 6 cases (4.3%) (2 appendicitis, 1 inguinal hernia and 3 renal lithiasis). Leukocytosis was present in 27 patients (19.56 %). 59 out of 138 patients required surgical exploration (42.75 %), for the following indications: 19 cholecystectomies; 15 incisional hernia repairs (11 laparoscopic/1 robotic/ 3 open); 3 suture of perforated ulcer (one of excluded stomach); 2 laparoscopic drainage; 4 suture of anastomotic leak; 9 section of adhesions; 4 bowel resections; 5 bowel reduction from internal hernia; 7 mesenteric space closures. 41 patients were operated in emergency setting. A fully laparoscopic approach was possible in 48 patients (81.36 %) with 4 conversions required. The mean follow up was 3.06 years (range 3 months - 6 years) Conclusions: Abdominal pain after LRYGB is not negligible. Preoperative diagnosis may be difficult due to the nonspecific clinical presentation. Upper endoscopy and diagnostic laparoscopy represent the best diagnostic tools. Most patients will require surgical exploration and can be managed successfully by laparoscopy.
A5100
GASTRO-COLONIC FISTULA FORMATION AS A COMPLICATION OF BARIATRIC SURGERY Patrick Davis, MD; Cullen Carter, MD; Myron Powell, MD, FACS; Stephen McNatt, MD; Rishi Pawa, MD; Adolfo Fernandez, MD; Wake Forest School of Medicine, Winston Salem, NC, USA
Introduction: Gastro-colonic fistula formation is a rare and unusual complication after bariatric surgery. Two such cases have been seen recently, and, although their etiologies are not entirely clear, both patients had persistent struggles associated with marginal ulceration after their Roux-en-Y gastric bypass (RNYGB) surgery. These two cases and their successful management are discussed. Case Presentation: The first case is a female who underwent a RNYGB in 2007. A persistent smoker, she struggled with chronic marginal ulceration. She began having post-prandial diarrhea and failure to thrive including additional weight loss and neurologic complications due to vitamin and mineral deficiencies. Prior to our evaluation she was receiving supplemental intravenous iron and copper infusions, and she had been recently admitted with pneumonia thought to be secondary to chronic aspiration. After treatment of her pneumonia, an UGI showed the presence of a gastro-colonic fistula. She was then referred to Wake Forest for further management. An UGI and EGD confirmed a fistula between her gastric pouch and transverse colon but also revealed a complete obstruction of her gastro-jejunostomy. The second patient underwent a RNYGB in 2004. Several years after her surgery, she began to struggle with weight gain for which she underwent a revision of her prior RNYGB in 2008. After this procedure she struggled with chronic abdominal pain and marginal ulceration. As a result, she had a diagnostic laparoscopy and another gastro-jejunostomy revision. She was referred to Wake Forest in 2014 with a recurrent marginal ulcer, nausea, and abdominal pain. After discussing potential treatment options and her struggles with chronic marginal ulceration, a conversion to vertical sleeve gastrectomy was performed. Postoperatively she developed a contained leak at her gastro-gastric anastomosis. She was kept NPO and a post-pyloric feeding tube was placed to optimize nutrition. The leak sealed over the next month, which was confirmed on UGI. Her diet was slowly advanced and she was trialed without her post-pyloric feeding tube. She returned ten weeks post operatively with persistent post-prandial non-bloody,
Poster Presentations / Surgery for Obesity and Related Diseases 11 (2015) S56–S211
non-bilious emesis and dehydration. An UGI was obtained which showed a gastric stenosis at the gastro-gastric anastomosis with a fistula proximally between her stomach and transverse colon. Management and Outcomes: The first case was initially managed by restoring nutrition and deficiencies parenterally. Operative intervention was delayed because the patient initially declined. Over the next year, her nutritional stores were repleted, she stopped smoking, and her overall health improved. She was then taken to the operating room for laparoscopic takedown of the gastro-colonic fistula, excision of the Roux limb, restoration of physiologic anatomy, and feeding jejunostomy. Recovery was smooth and her diet was advanced with removal of her feeding tube. She has since had resolution of her symptoms. After diagnosis of the gastro-colonic fistula in the second case, an esophageal stent was placed endoscopically, traversing the gastric stenosis and excluding the fistula. With slow advancement of diet, the stent was removed with resolution of her fistula confirmed on UGI. Discussion: These cases represent gastro-colonic fistulas as a complication of chronic marginal ulceration and multiple bariatric revisions. Complete symptom resolution was seen with restoration of physiologic anatomy, but this may lead to weight gain and return of prior comorbid conditions. Endoscopic stenting allows maintenance of a restrictive surgery for further facilitation of weight loss. However, the complete resolution of symptoms was prolonged in this case. Surgical correction and endoscopic stenting of gastro-colonic fistulas are effective treatment modalities of this rare complication.
A5101
BARBED SUTURE IN LAPAROSCOPIC GASTRIC BYPASS SAFE AND SHORTENS OPERATIVE TIME BY 15 % Bjarni Vidarsson, MD; David Edholm, MD, PhD; Magnus Sundbom, PhD; Akademiska Sjukhuset, Uppsala, Uppland, Sweden Background: During laparoscopic gastric bypass, barbed suture (e.g. V-loc ™) has been introduced when closing the defect after stapling the gastrojejunostomy. This reduces the need of intraabdominal knot tying and reduces the need for constant tension on the suture from the assistant during suturing. The aim was to study if outcomes of surgeries performed with barbed sutures were different from procedures using conventional sutures (polyfilament) concerning operative time, leakage and stricture of the anastomosis. Materials and methods: From the Scandinavian Obesity Registry 22514 patients (1837 with barbed suture and 20677 with polyfilament suture) were studied. No preoperative difference between groups was found regarding age or sex. The barbed suture group had lower BMI (41.6 kg/m2 compared to 42.4 kg/m2; Po0.05) whilst diabetes was more common in the conventional group (15,7% compared to 13,5%, po0.01) Results: The total operative time was 11 minutes (15%) shorter in the barbed suture group (60 minutes compared with 71 minute, po0.05). No difference was observed regarding leakages (1.3%, 20 cases of 1657 compared with 1.0%, 202 cases of 19831, po0.47) or stricture after 6 weeks (0.3 %, 2 cases of 1654 compared with 0.1 %, 56 cases of 19766, po0.22).
S109
Conclusion: The total operative time was 15% shorter using barbed suture and no difference was observed regarding the risk for leakage and stricture compared to conventional suture.
A5102
OMENTAL INFARCTION MASQUERADING AS ANASTOMOTIC STRICTURE Mujjahid Abbas, MBBS; Louis Stokes VA Cleveland Medical Center, Cleveland, OH, USA Introduction: Gastric Bypass surgery is associated with distinct post-operative complications. A careful history and physical examination along with diagnostic imaging studies may lead to identification of these complications. A stricture at gastro-jejunal anastomosis is one of the known complications and usually presents with nausea, non-bilious emesis and may be associated with abdominal pain. On the other hand omental infarction is a rare incident after laparoscopic gastric bypass. There have been very few case reports of omental infarction occurring after laparoscopic gastric bypass using antecolic technique with longitudinal division of omentum and this typically presents as localized abdominal pain with no gastro-intestinal symptoms. We present a case of omental infarction which presented with significant gastrointestinal symptoms. Case Presentation: Our patient is a 38 year old female with history of morbid obesity (BMI 45), GERD and underwent a laparoscopic gastric bypass 5 weeks before her presentation to emergency room with protracted nausea and emesis for last two days. Patient had minimal crampy ache in abdomen which she attributed to the constant wrenching and emesis. She did not have fever or other complaints. Emesis consisted of non-bilious mucous material in small amounts but very frequent intervals. She was afebrile with normal vital signs and was noted to have Potassium level of 3.0 meq/ dL. A clinical suspicion for anastomotic stricture was raised. An UGI study showed delayed and only partial transit of contrast from gastric pouch and only in prone positioning of the patient and was interpreted as possible stricture at gastro-jejunal anastomosis. Patient underwent an EGD with intention to dilate the stricture however was noted to have no anatomical problems at the anastomosis. She subsequently underwent a CT scan of abdomen and pelvis which revealed 6x7 CM area of omental fat stranding consistent with omental infarction and no other abnormalities were noted. Patient was admitted for intravenous hydration and management of hypokalemia and recovered from this event without further issues. Discussion: Spontaneous omental infarction is a benign condition with no clear etiology in most cases and presents with abdominal pain. Most of presentations are in Right lower abdomen and is thought secondary to omental vasculature being susceptible to ischemic insult in that location. Left sided omental infarction is very rare. There are only handful case reports of this complication after gastric bypass surgery specially using antecolic approach. However presentation in those reported cases consisted of localized abdominal pain. Our surgical technique consists of creating the jejunal anastomosis using linear stapler and making the gastrojejunostomy with 25/3.5 EEC stapler. We place our Roux limb in ante-colic, antegastric fashion and divide omentum at its center in longitudinal fashion to accommodate passage of the Roux limb without any tension. This particular patient was noted to have significant intraabdominal fat and had bulky omentum which was divided in similar
Poster Presentations / Surgery for Obesity and Related Diseases 11 (2015) S56–S211
A5099
ABDOMINAL PAIN AFTER ROUX – Y – GASTRIC BYPASS: ETIOLOGY AND MANAGEMENT Marius Nedelcu, MD1; Stylianos Tzedakis, MD1; Antonio D'Urso, MD1; Henry Mercoli, MD1; Michel Vix, MD2; Jacques Marescaux, MD, FACS, Hon FRCS, Hon FJSES2; Didier Mutter2; Silvana Perretta, MD2; 1Strasbourg University Hospital, IRCAD, Strasbourg, Alsace, France; 2Strasbourg University Hospital, IRCAD, IHU, Strasbourg, France Background: The number of laparoscopic bariatric procedures being performed worldwide has increased dramatically in the past decade. The laparoscopic Roux-en-Y gastric bypass (LRYGB) is not only the most common bariatric procedure, but also the gold standard to which all others are compared. Abdominal pain is a common complaint following LRYGB. Aim: to assess the incidence, etiology and management of patients with pain after LRYGB presenting at our institution. Methods: A retrospective review of all patients presenting with a intermittent repetitive abdominal pain after LRYGB at our institution was conducted. The complementary work-up, the final diagnosis and treatment were analyzed. Results: Between 2009 and 2013, 592 patients underwent RYGBP in our department. A total of 138 patients (23.31 %) complained of intermittent repetitive abdominal pain after LRYGB. 116 patients (84.05 %) were admitted to the surgical ward from the emergency department and the remaining 22 were hospitalized during the follow up in outpatient clinic. The final diagnosis was: nonspecific abdominal pain - 35 cases (25.4 %), anastomotic ulcer – 28 cases (20.3 %); biliary lithiasis – 19 cases (13.7 %); internal hernia – 15 cases (10.9 %); incisional hernia – 15 cases (10.9 %); small bowel obstruction – 14 cases (10.1 %); anastomotic leaks – 6 cases (4.3 %); unrelated diseases – 6 cases (4.3%) (2 appendicitis, 1 inguinal hernia and 3 renal lithiasis). Leukocytosis was present in 27 patients (19.56 %). 59 out of 138 patients required surgical exploration (42.75 %), for the following indications: 19 cholecystectomies; 15 incisional hernia repairs (11 laparoscopic/1 robotic/ 3 open); 3 suture of perforated ulcer (one of excluded stomach); 2 laparoscopic drainage; 4 suture of anastomotic leak; 9 section of adhesions; 4 bowel resections; 5 bowel reduction from internal hernia; 7 mesenteric space closures. 41 patients were operated in emergency setting. A fully laparoscopic approach was possible in 48 patients (81.36 %) with 4 conversions required. The mean follow up was 3.06 years (range 3 months - 6 years) Conclusions: Abdominal pain after LRYGB is not negligible. Preoperative diagnosis may be difficult due to the nonspecific clinical presentation. Upper endoscopy and diagnostic laparoscopy represent the best diagnostic tools. Most patients will require surgical exploration and can be managed successfully by laparoscopy.
A5100
GASTRO-COLONIC FISTULA FORMATION AS A COMPLICATION OF BARIATRIC SURGERY Patrick Davis, MD; Cullen Carter, MD; Myron Powell, MD, FACS; Stephen McNatt, MD; Rishi Pawa, MD; Adolfo Fernandez, MD; Wake Forest School of Medicine, Winston Salem, NC, USA
Introduction: Gastro-colonic fistula formation is a rare and unusual complication after bariatric surgery. Two such cases have been seen recently, and, although their etiologies are not entirely clear, both patients had persistent struggles associated with marginal ulceration after their Roux-en-Y gastric bypass (RNYGB) surgery. These two cases and their successful management are discussed. Case Presentation: The first case is a female who underwent a RNYGB in 2007. A persistent smoker, she struggled with chronic marginal ulceration. She began having post-prandial diarrhea and failure to thrive including additional weight loss and neurologic complications due to vitamin and mineral deficiencies. Prior to our evaluation she was receiving supplemental intravenous iron and copper infusions, and she had been recently admitted with pneumonia thought to be secondary to chronic aspiration. After treatment of her pneumonia, an UGI showed the presence of a gastro-colonic fistula. She was then referred to Wake Forest for further management. An UGI and EGD confirmed a fistula between her gastric pouch and transverse colon but also revealed a complete obstruction of her gastro-jejunostomy. The second patient underwent a RNYGB in 2004. Several years after her surgery, she began to struggle with weight gain for which she underwent a revision of her prior RNYGB in 2008. After this procedure she struggled with chronic abdominal pain and marginal ulceration. As a result, she had a diagnostic laparoscopy and another gastro-jejunostomy revision. She was referred to Wake Forest in 2014 with a recurrent marginal ulcer, nausea, and abdominal pain. After discussing potential treatment options and her struggles with chronic marginal ulceration, a conversion to vertical sleeve gastrectomy was performed. Postoperatively she developed a contained leak at her gastro-gastric anastomosis. She was kept NPO and a post-pyloric feeding tube was placed to optimize nutrition. The leak sealed over the next month, which was confirmed on UGI. Her diet was slowly advanced and she was trialed without her post-pyloric feeding tube. She returned ten weeks post operatively with persistent post-prandial non-bloody,
Poster Presentations / Surgery for Obesity and Related Diseases 11 (2015) S56–S211
non-bilious emesis and dehydration. An UGI was obtained which showed a gastric stenosis at the gastro-gastric anastomosis with a fistula proximally between her stomach and transverse colon. Management and Outcomes: The first case was initially managed by restoring nutrition and deficiencies parenterally. Operative intervention was delayed because the patient initially declined. Over the next year, her nutritional stores were repleted, she stopped smoking, and her overall health improved. She was then taken to the operating room for laparoscopic takedown of the gastro-colonic fistula, excision of the Roux limb, restoration of physiologic anatomy, and feeding jejunostomy. Recovery was smooth and her diet was advanced with removal of her feeding tube. She has since had resolution of her symptoms. After diagnosis of the gastro-colonic fistula in the second case, an esophageal stent was placed endoscopically, traversing the gastric stenosis and excluding the fistula. With slow advancement of diet, the stent was removed with resolution of her fistula confirmed on UGI. Discussion: These cases represent gastro-colonic fistulas as a complication of chronic marginal ulceration and multiple bariatric revisions. Complete symptom resolution was seen with restoration of physiologic anatomy, but this may lead to weight gain and return of prior comorbid conditions. Endoscopic stenting allows maintenance of a restrictive surgery for further facilitation of weight loss. However, the complete resolution of symptoms was prolonged in this case. Surgical correction and endoscopic stenting of gastro-colonic fistulas are effective treatment modalities of this rare complication.
A5101
BARBED SUTURE IN LAPAROSCOPIC GASTRIC BYPASS SAFE AND SHORTENS OPERATIVE TIME BY 15 % Bjarni Vidarsson, MD; David Edholm, MD, PhD; Magnus Sundbom, PhD; Akademiska Sjukhuset, Uppsala, Uppland, Sweden Background: During laparoscopic gastric bypass, barbed suture (e.g. V-loc ™) has been introduced when closing the defect after stapling the gastrojejunostomy. This reduces the need of intraabdominal knot tying and reduces the need for constant tension on the suture from the assistant during suturing. The aim was to study if outcomes of surgeries performed with barbed sutures were different from procedures using conventional sutures (polyfilament) concerning operative time, leakage and stricture of the anastomosis. Materials and methods: From the Scandinavian Obesity Registry 22514 patients (1837 with barbed suture and 20677 with polyfilament suture) were studied. No preoperative difference between groups was found regarding age or sex. The barbed suture group had lower BMI (41.6 kg/m2 compared to 42.4 kg/m2; Po0.05) whilst diabetes was more common in the conventional group (15,7% compared to 13,5%, po0.01) Results: The total operative time was 11 minutes (15%) shorter in the barbed suture group (60 minutes compared with 71 minute, po0.05). No difference was observed regarding leakages (1.3%, 20 cases of 1657 compared with 1.0%, 202 cases of 19831, po0.47) or stricture after 6 weeks (0.3 %, 2 cases of 1654 compared with 0.1 %, 56 cases of 19766, po0.22).
S109
Conclusion: The total operative time was 15% shorter using barbed suture and no difference was observed regarding the risk for leakage and stricture compared to conventional suture.
A5102
OMENTAL INFARCTION MASQUERADING AS ANASTOMOTIC STRICTURE Mujjahid Abbas, MBBS; Louis Stokes VA Cleveland Medical Center, Cleveland, OH, USA Introduction: Gastric Bypass surgery is associated with distinct post-operative complications. A careful history and physical examination along with diagnostic imaging studies may lead to identification of these complications. A stricture at gastro-jejunal anastomosis is one of the known complications and usually presents with nausea, non-bilious emesis and may be associated with abdominal pain. On the other hand omental infarction is a rare incident after laparoscopic gastric bypass. There have been very few case reports of omental infarction occurring after laparoscopic gastric bypass using antecolic technique with longitudinal division of omentum and this typically presents as localized abdominal pain with no gastro-intestinal symptoms. We present a case of omental infarction which presented with significant gastrointestinal symptoms. Case Presentation: Our patient is a 38 year old female with history of morbid obesity (BMI 45), GERD and underwent a laparoscopic gastric bypass 5 weeks before her presentation to emergency room with protracted nausea and emesis for last two days. Patient had minimal crampy ache in abdomen which she attributed to the constant wrenching and emesis. She did not have fever or other complaints. Emesis consisted of non-bilious mucous material in small amounts but very frequent intervals. She was afebrile with normal vital signs and was noted to have Potassium level of 3.0 meq/ dL. A clinical suspicion for anastomotic stricture was raised. An UGI study showed delayed and only partial transit of contrast from gastric pouch and only in prone positioning of the patient and was interpreted as possible stricture at gastro-jejunal anastomosis. Patient underwent an EGD with intention to dilate the stricture however was noted to have no anatomical problems at the anastomosis. She subsequently underwent a CT scan of abdomen and pelvis which revealed 6x7 CM area of omental fat stranding consistent with omental infarction and no other abnormalities were noted. Patient was admitted for intravenous hydration and management of hypokalemia and recovered from this event without further issues. Discussion: Spontaneous omental infarction is a benign condition with no clear etiology in most cases and presents with abdominal pain. Most of presentations are in Right lower abdomen and is thought secondary to omental vasculature being susceptible to ischemic insult in that location. Left sided omental infarction is very rare. There are only handful case reports of this complication after gastric bypass surgery specially using antecolic approach. However presentation in those reported cases consisted of localized abdominal pain. Our surgical technique consists of creating the jejunal anastomosis using linear stapler and making the gastrojejunostomy with 25/3.5 EEC stapler. We place our Roux limb in ante-colic, antegastric fashion and divide omentum at its center in longitudinal fashion to accommodate passage of the Roux limb without any tension. This particular patient was noted to have significant intraabdominal fat and had bulky omentum which was divided in similar