Brian Mitzman, MD, Andrew Brownlee, MD, Mitchell Roslin, MD. NSLIJ/Lenox Hill Hospital
Background: We present the case of a 47 year old female who underwent a gastric band in 2008. She was unsuccessful with her weight loss goals, and was converted to a roux en y gastric bypass in 2013. Unfortunately, she soon after developed PO intolerance and nausea. She was diagnosed with a severe stricture at her gastrojejeunal anastamosis. After failing nearly twenty balloon dilitations, she was referred to our bariatric center.
Methods: We first attempted non-operative management of the patient, with stent placement. Unfortunately, her stent migrated twice. Due to this complication significantly impacting her quality of life, we opted to take her for surgical revision of her gastric bypass, with planned esophagojejeunal anastamosis. Our video shows her full course once under our care, including her diagnostic workup, endoscopy, failed stent placement, and eventual surgical procedure. Her resection was performed via a totally laparoscopic approach. We highlight the importance of using anatomic structures to help delineate appropriate planes when working in a severely inflammatory and fibrosed field.
Results: As can be seen in the video, her gastric pouch, remnant, and roux limb were severely adherent with significant fibrosis, leading us to believe that her initial problem was likely an occult leak. The dissection was broken down into 4 important steps — identification of the crura, adhesiolysis of the roux limb from the gastric remnant, resection of the gastric pouch, and hand sewn reconstruction with esophagojejeunostomy. A feeding tube was placed into the gastric remnant, so that the patient could remain NPO for 9 days postop prior to UGI. She tolerated the procedure extremely well, was discharged on postop day 4. She had an upper GI on postop day 9 without signs of obstruction or leak.
Conclusion: Anastamotic stricture after roux en y gastric bypass can be a life altering complication. While many non-operative options exist, including dilatation and stenting, these may not be successful. Laparoscopic resection of the old bypass with esophagojejeunal reconstruction is a feasible option, but laparoscopic training with significant experience in foregut anatomy and revisional surgery is required.