Ramarao Ganga, MD, Rajmohan Rammohan, MD, Chukwuma Apakama, MD, Emanuele Lo Menzo, MD, PhD, FACS, FASMBS, Samuel Szomstein, MD, FACS, FASMBS, Raul Rosenthal, MD, FACS, FASMBS. Cleveland Clinic Florida
Objective: To describe a case with complex gastric emptying problems resolved with laparoscopic partial gastrectomy and Roux en Y reconstruction.
Case report: A 21 year-old female with lengthy hx of gastric emptying pathology resulted in pyloromyotomy as newborn and up to eight Nissen fundoplication procedures for severe reflux, and failed stimulator for gastroparesis.
We discussed the possibility of laparoscopy and laparotomy, as well as the resection of the stomach including a reconstruction with a Roux-en-Y limb due to the gastric outlet obstruction. We also reviewed the need for removal of the stent and potential complications including bleeding, leaks, recurrent symptoms, or worsening of her preoperative symptoms.
Technique: We approach all of our revision procedures in a systematic manner with identification of right crus through pars flaccida. Left crus of the diaphragm is identified to facilitate identification of GE junction & avoid injury to esophagus. The phrenoesophageal membrane taken down and a 32-French Ewald tube is passed into the stomach after a window is dissected behind the esophagus. With meticulous dissection, Nissen fundoplication is taken down. A gastrotomy is performed and the stent is removed. Stomach is then divided distally below the gastrotomy and proximally below the entrance of the left gastric artery, creating a pouch which is approximately 30 cc in diameter. The small bowel is transected 50 cm from the ligament of Treitz. The distal limb of small bowel is brought to the upper abdomen in antecolic-antegastric fashion without tension and a side-to-side gastrojejunostomy between the pouch and alimentary limbs are performed on the posterior wall with linear stapler, on the anterior wall with a double layer of running 2-0 Vicryl sutures, and checked for leakage with air and methylene blue. A 100 cm distal from the gastrojejunostomy, a side-to-side jejunojejunostomy is performed with 2 applications of linear stapler. The jejunojejunostomy site is then closed also with 2 applications of linear stapler.
An upper GI study showed no evidence of leak or obstruction.
Conclusion: Laparoscopic gastric resection with Roux-en-Y reconstruction is feasible and safe even after multiple previous gastric surgeries. This procedure can be useful for gastroparesis
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 79415
Program Number: V098
Presentation Session: Bariatric Video Session
Presentation Type: Video