Laparoscopic Remnant Gastrectomy and Resection of Gastrojejunostomy for Recurrent High-grade Anastomotic Stricture With Penetration to the Gastric Remnant

Karan Bath, MD, Rena Moon, MD, Samuel Szomstein, MD FACS FASMBS, Raul Rosenthal, MD FACS FASMBS. Cleveland Clinic Florida


 Introduction: Marginal ulceration, penetrating ulcers and strictures are common complications of RYGB that may necessitate revisional procedures.

Materials and Methods: This is a 47-year-old female patient who underwent LRYGB in 2010. The patient developed an anastomotic stricture and required multiple dilatations.
The patient was status post 5 dilatations and recurrent episode of anastomotic stricture that acknowledges tobacco abuse. We discussed with the patient the need for revisional procedure. The patient underwent a laparoscopic revision. Intraoperative findings were that the small hiatal hernia was reduced. The gastrojejunal anastomosis was noted to be enrolled into the gastric remnant.
After dissection all the way up to the GE junction, the proximal stomach was transected proximally below the left gastric artery and then distally approximately 5 cm distal to the gastrojejunal anastomotic stricture. Over an Ewald tube, a side-to-side gastrojejunostomy between the proximal aspect of the pouch and the alimentary limb was performed on the posterior wall with a linear stapler on the anterior wall and a double layer of running 2-0 Vicryl sutures, and checked for leakage with air and methylene blue.

Result: The recovery of the patient was uneventful, with a normal UGI on POD1 without leak or obstruction.

Conclusion: Recurrent strictures after RYGB may be an indication of penetrating ulcer causing a gastrogastric fistula, which may not be detectable by standard radiologic or endoscopic methods. In such cases, diagnostic laparoscopy and a revision may be indicated.

Session Number: VidTV3 – Video Channel Rotation Day 3
Program Number: V146

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