Coiled Sleeve: Conversion to Roux-en-Y Gastric Bypass

Pablo Quadri, MD, Raquel Gonzalez-Heredia, MD, PhD, Yves Collins, MD, Lisa Sanchez-Johnsen, PhD, Enrique Elli, MD, FACS. UIC

Introduction: Gastric obstructions after Sleeve Gastrectomy (SG) are described in 0.7 to 3.5 % of the operated patients. Surgical intervention is frequently required to solve this postoperative complication. Management varies depending on the length of stenosis. Endoscopic dilation with balloon can be used for short stenosis, while conversion to Roux-en Y gastric bypass (RYGB) can be required for longer stenosis. 

Material and Methods: Patient was a 50-year-old woman with history of mild OSA, HTN and anxiety who underwent a laparoscopic SG two years ago. Patient recovered uneventfully, with adequate weight loss and diet tolerance. Patient reported that for 6 months prior to the evaluation, she started to experience dysphagia to solid foods, only tolerating some liquids, and constant daily vomiting. The upper GI fluoroscopy showed passage of contrast though the stomach with two acute angulations on the sleeve with proximal dilation to them. EGD showed a large proximal gastric dilatation with an acute angulation that could be easily transversed. At the level of the incisura, another acute angulation did not allow the passage of the scope despite several attempts. 

Results: The procedure started with a diagnostic laparoscopy that showed the gastric tube was in a fixed position with two kinkings. Adhesions to the gastric tube were lysed and the sleeve was completely mobilized. Next, the gastric pouch was transected using two staplers.

Then with the retraction of the transverse colon, the angle of Treitz was identified. The jejunum was run 50 cm from the Treitz and transected. Then the alimentary limb was identified and ran for 120 cm. A side-to-side anastomosis was performed with the tan stapler and then the enterotomies were oversawn in 2 layers with a 3-0 absorbable suture. The mesenteric gap was sutured with interrupted 3-0 absorbable sutures. The alimentary limb was brought up into the upper abdomen. The enterotomies were performed with electrocautery.  The gastro-jejunostomy was performed in 2 layers of 3-0 absorbable suture. There were no intra- or post-operative complications and the estimated blood loss was 10 cc.  The patient’s symptoms improved dramatically after surgery, with the diet being tolerated. The patient was discharged on POD 1.

Conclusions: This case represents a rare cause of gastric obstruction after gastric sleeve. The appropriate evaluation identified the problem. Results revealed that conversion to gastric bypass appeared to be a safe and valid revisional procedure to treat this problem.  Future research and additional case studies in this area are needed.