Transjejunal laparoscopic-assisted ERCP a technique to deal with choledocholitiasis after a Roux-en-Y reconstruction.
The patient is a female of 31 years old that undergone a Roux-en-Y Gastric Bypass two years earlier and presented periodic abdominal pain. MRCP showed stones on the biliary common duct. In the preoperative CT scan no internal hernias were found.
It was decided to perform a laparoscopic-assisted ERCP. The first thing to do was to identify the gastro-jejunal anastomosis and the jejunal-jejunal anastomosis. An internal hernia in the Petersen space was found but immediately reduced and closed. Then the cholecystectomy was performed. Once the limb near the Treitz ligament was identified and pulled through a mini-laparotomy, a colonoscope was introduced and a plastic stent was placed in the papilla, which was the reference for the sphincterotomy.
After doing that, a 5mm stone came out. Then the bile duct was checked with a fogarty balloon catheter and a cholangiogram. Then enterotomy was closed and it was checked for any biliary lesions.
After the surgery the patient started liquid diet the first day and was dismissed after 4 days.
Questions were about the use of colonoscope rather than duodenoscope, absorbable suture, mini-laparotomy and transgastric and totally endoscopic approach for similar cases.
Endoscopic tunneled stricturotomy with full-thickness dissection in the management of a sleeve gastrectomy stenosis.
The patient was a 28 years old women with a history of a sleeve gastrectomy in 06/2018. (BMI: 35.3) who was presenting dysphagia to solid food. During the progression to solid food she developed food regurgitation and vomiting and that is why upper-GI series were performed (stenosis was identified).
To treat this stenosis she underwent 3 endoscopic pneumatic balloon dilatations. Those were not effective and she lost 30kg in 5 months so it was decided to perform an endoscopic tunneled stricturotomy with full-thickness dissection.
To start the procedure, once the stenosis was identified a submucosal injections is performed 3-5 cm before the stenotic area. Then, an incision was performed to tunnel submucosally. In this part of the surgery is important to stay on the submucosal layer and not go full-thickness.
Then a myotomy was performed and in the area marked with both yellow arrows (stapled line) we dissect out performing the full-thickness stricturotomy. After that, we close using clips.
We can see a comparison before and after performing the procedure showing a much larger lumen.
The patient had no post-procedure symptoms and during follow-up the patient tolerated diet and no recurrence of the symptoms appeared. At 2 months, we can see the differences in the upper-GI series and in the endoscopy.
As a conclusion endoscopic tunneled stricturotomy with full-thickness dissection appears to be safe and effective in the management of stenosis after sleeve gastrectomy. This procedure can be used after conventional techniques such as pneumatic balloon dilatation or stents fail, or may be considered as an initial therapy for sleeve stenosis.
Discussion was based on patient selection, indications, myotomy technique and leak rates.
From Nissen Fundoplication to RYGB to treat both GERD and morbid obesity
Patient was a 31 year-old woman that had an open Nissen fundoplication on 2010 and a surgical revision with a redo of it on 2012. She complained with dysphagia and morbid obesity so an extensive preoperative workout was done. In the Barium swallow, an esophageal dilatation with a cardial stenosis was presented, and also, an additive image on the left side of the esophagus suggestive of an ulceration. The Upper-GI endoscopy revealed an esophagitis grade C and the manometry showed incomplete waves at lower 3rd and inappropriate release of LES. In the pH-metry acid reflux and positive DeMeester score were evidenced.
The procedure starts dissecting the perigastric tissue, that is challenging as it presented high fibrotic component. Then the dissection of the gastric valve and the hiatal region from the right to the left was completed. Once that was performed an small gastric pouch of 20cc was created to reduce the acid production. Then as in a normal RYGB the biliopancreatic is done at 50cm and the alimentary at 150cm. Jejuno-jejunal and gastro-jejunal were handsewn.
No events were presented in the postoperative, patient at two years follow-up has a BMI of 27, No GERD and no IPP.
As a conclusion RYGB is a great option to treat GERD in obese patients. We cannot forget dysphagia as a complication of Nissen fundoplication and conversion from Nissen to RYGD allows us to treat dysphagia, GERD and obesity.
Different topics were discussed after the presentation of this case as: short gastric pouch, differences with regular bypass, situations where you cannot undo the Nissen fundoplication, mesh indications above others.
From RYGB to SADS
Patient was a 49 year-old woman with an initial BMI of 57 and it was decided to convert to SADS for weight regain.
The first thing to do was remove all adhesions from previous surgeries and then dissect the Hiss angle. Once this has been done, he identifies the Roux limb and dissects it 25cm after the gastric pouch. The next thing to do was to connect the greater curve with the Hiss angle. He disconnects the previous anastomosis and performs a gastro-gastrostomy. It is important to do it near the lesser curve as after that a Sleeve gastrectomy will be performed using a Bougie of 42 frames as a reference. The transection of the duodenum is performed conserving as much vascularization as it is possible in order to maintain sleeve well irrigated. After that duodenum-ileal anastomosis handsewn was performed. Anastomosis were checked with methylene blue.
The outcome was good and the patient was discharged 2 days after the procedure with no complications.
Questions were about rate of complications, length of limbs, roux limb, conversion after RYGB and weight loss after conversion.
PETERSEN’S HERNIA AFTER OAGB
Patient was a 48 years-old woman with a BMI of 52, she was referring bile reflux with no response to medical treatment. So it was decided to convert mini-gastric bypass to RYGB.
As the surgery started, an internal hernia was identified on the Petersen’s defect, in this case the hernia was protruded from medial to lateral something that is rare as normally it is the other way around. To start the procedure we need to identify the proximal and distal limb of gastrojejunal anastomosis. On the proximal limb of this anastomosis an enterotomy was performed and 75cm of the alimentary limb were measured to perform the jejunojejunal anastomosis. After that the jejunojejunal and Petersen’s defect were closed. After doing that, the transection of biliopancreatic limb from alimentary limb was performed.
The outcome was good and the patient was discharged 1 day after the procedure with no complications. A short term follow-up at 3 months was symptoms free.
In this last case, discussion was based on rate bile reflux, biliopancreatic limb length, indications for conversion, causes for bile reflux and hernia defect closures.