Salvadora Delgado (Gastrointestinal surgery senior consultant)
Hospital Clínic, Barcelona – Spain
Case
A 32 year old male patient with a previous history of obstructive sleep apnea requiring CPAP and asthma suffered from morbid obesity with a BMI of 60 Kg/m2 and weighed 220 Kg. He underwent a roux-n-y gastric bypass in 2005. It was one of the last cases of gastric bypass performed in our institution for patients with a BMI of more than 50 Kg/m2.
Two years after surgery he had excellent response, losing 130 Kg, reached a BMI of 25 Kg/m2 and his comorbidities were resolved. He came to the outpatient clinic explaining that he was suffering from dysphagia and vomiting.
When asked, he admitted that he was smoking again and was taking non-steroidal anti-inflammatory drugs due for his lower back pain. Further investigation was carried out by means of an upper GI series that revealed a sharpened contrast passage through the anastomosis; there was no gastro-gastric fistula.
Upper endoscopy showed a fibrosis and a marginal ulcer at the anastomosis the CLO test was negative. The patient underwent conservative treatment with PPIs and stopped smoking. Endoscopic dilations were attempted but failed.
Treatment
Surgical revision was carried out through a laparoscopic approach. The patient was placed in the supine position with open legs. The surgeon stood between the legs with one assistant one each side of the patient.
A total of 5 trocars were used. A 12mm trocar was placed in supraumbilical position for a 30° scope, three 12 mm served as working channels for the leading surgeon at the epigastrium and each flank, and the 5mm trocar was placed in a more lateral position at the left flank.
The goal of the surgery was to dissect the pouch and the anastomosed ileum, asses the gastric remnant, perform resection and create a new pouch-jejunal anastomosis. We made a knot from the jejunum to the gastric remnant to diminish the tension and avoid rotation of the anastomosis. It was taken down.
Mobilization of the pouch began. The hook was used to take down some adhesions from the medial margin. The surgeon attempted to create a tunnel in the posterior wall of the pouch towards the lateral margin where a window was created to set up a landmark for the future section
Now the assistant surgeon performed traction from the jejunum that had to be individualized from the gastric remnant. Blunt dissection and scissors were used to perform this stage of the surgery.
This is the location of the ulcer. The planes were fused between the pouch, the jejunum and the remnant stomach, the surgeon changed strategy and starting dissecting the jejunum from lateral to medial. The gastrosplenic ligament was mobilized. Notice some gastric fluid coming out.
There was no posterior wall in the jejunum, as the ulcer has consumed it. The goldfinger was used to complete the posterior dissection of the pouch, it was used as a guide to introduce the mechanical suture. A green cartridge was fired.
Now the new pouch was created and the surgeon had to complete the mobilization of the area affected by the ulcer so as to asses the remnant stomach and section the jejunum. The medial aspect of the ulcer was identified, once again the scissors were used to take down the fused planes.
The surgeon was particularly careful at this stage of the dissection to avoid injuries to the remnant stomach. Finally the previous anastomosis was released. Examination of the stomach was carried out, there was no exposure of its mucosa.
The mesentery of the jejunum was released for future section. The specimen and the gauze were extracted in an EndoBag through an enlarged incision of the 12 mm trocar located at the right flank.
The antecolic disposition of the alimentary loop could be maintained as the patient had achieved a suitable weight loss. The anastomosis was performed manually by using double layer technique. Separated sero-serosal knots of 2-0 Vicryl were made. Once again the alimentary loop was fixed to the remnant stomach.
An enterotomy and a gastrostomy were performed, taking care to ensure that the orifice of the jejunum was smaller than the one in the pouch. A muco-mucosal running suture was made for the inner posterior and anterior layer. Separated sero-serosa knots finally completed the new anastomosis.
The alimentary loop was collapsed with a clamp to test the anastomosis with methylene blue. Lavage was performed and a drain was left for surveillance.
Outcome
The surgery took 190 minutes. During the postoperative period the patient presented extraluminal bleeding but remained stable and did not require a blood transfusion.
He started oral intake 48 hours after the surgery and left the hospital on the 5th postoperative day. Pathological examination ruled out neoplasia or infection by H pylori.
The patient remains asymptomatic one year after the revision, and maintains the treatment with PPIs and tobacco abstinence.
