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Combined Laparoscopic and Endoscopic Removal of a Foreign Body after Roux-en-Y Gastric Bypass

Michael P Meara, MD, MBA, David B Renton, MD, Andrei V Manilchuk, MD, Jennifer S Schwartz, MD. The Ohio State University Wexner Medical Center

BACKGROUND: Foreign bodies after Roux-en-Y gastric bypass are a relatively uncommon problem. Food can be impacted at the gastrojejunal or jejunojenual anastomosis related to anastomotic stricture. Secondary to psychiatric disorders, ingested foreign bodies can either be retrieved endoscopically or allowed to pass spontaneously. Foreign bodies in the biliopancreatic limb are increasingly rare, especially in the absence of a gastrogastric fistula.

This patient is a 55 year-old Hispanic female. She has a past surgical history significant for open Roux-en-Y gastric bypass with remnant gastrectomy in Chile twenty years prior. The patient presented to the hospital with diffuse abdominal pain for one day. Laboratory work-up at that time was unremarkable and a CT scan was ordered to better delineate the etiology of the patient’s pain. The scan revealed a linear foreign body oriented vertically in the third portion of the duodenum with concern for superior perforation of the duodenal wall.

METHODS: With this information, operative plans were made to perform a combined laparoscopic and endoscopic foreign body removal. If this ultimately proved unsuccessful, an exploratory laparotomy would be performed with reconstruction as necessary.

The patient was brought to the operating room and diagnostic laparoscopy was performed. The jejunojejustomy was localized and accessed immediately proximal to the anastomosis. The endoscope was placed via a 15 mm trocar and advanced proximally to the end of the duodenal stump utilizing endoscopic and fluoroscopic guidance. The scope was then withdrawn slowly until the foreign body was encountered. Once localized, an endoscopic grasper was placed via the working channel of the endoscope. The foreign body was grasped and was withdrawn slowly under fluoroscopic guidance to ensure that the foreign body was not lost.

Once extraluminal the foreign body was passed off to the laparoscopist and the endoscope was removed from the patient. The foreign body was examined on the back table as well as sent off to pathology for permanent. Composition was consistent with a chicken bone and the surface of the bone had become epithelized. The foreign body was presumably retained prior to her operation 20 years ago and had slowly necessitated superiorly.

CONCLUSIONS: This maneuver can be completed safely and effectively. This hybrid approach represents a novel method for minimally invasive foreign body removal.


Presented at the SAGES 2017 Annual Meeting in Houston, TX.

Abstract ID: 80467

Program Number: V186

Presentation Session: Video Loop

Presentation Type: VideoLoop

40

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