Laparoscopic Revision of Roux-en-Y Gastric Bypass: Resection of Gastrojejunal Anastomosis, Trimming Gastric Pouch, and a Proximal Remnant Gastrectomy

Abraham Fridman, MD, Rena Moon, MD, Samuel Szomstein, MD FACS FASMBS, Raul Rosenthal, MD FACS FASMBS. Cleveland Clinic Florida

 Introduction: Bariatric surgery is becoming more popular and widespread throughout the world, and long-term complications are being diagnosed more frequently. The surgical management that is often necessary should be handled in highly specialized and experienced centers.

Materials and Methods: A 48-year-old female presented to our clinic with vague epigastric abdominal pain associated with food and weight regain status post laparoscopic Roux-en -Y gastric bypass in 2002. Preoperative UGI study showed an enlarged gastric pouch and an EGD showed a questionable gastro-gastric fistula.

She underwent a laparoscopic revision of her gastric bypass. The intraoperative findings included a gastro-gastric fistula, posterior marginal ulcer penetrating into the pancreas, and an enlarged gastric pouch. With the aid of the green cartridge linear stapler, the stomach was transected proximally at the level of the remnant approximately 5 cm distal to the gastric fundus. Over an Ewald tube, the pouch was also trimmed and a new pouch, which is approximately 30 cc in diameter, was constructed. Gastrojejunal anastomosis was resected, and a new anastomosis was constructed using a white linear stapler and two-layer suture closure.

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

Conclusion: Despite an extensive preoperative workup in revisional bariatric surgery, the operative findings can often be different and unexpected. To manage many of these findings, the surgeon must be both technically skilled and knowledgeable with this disease process. Therefore, reoperative bariatric surgery is safest when performed in a high volume center, where the surgeons have the technical skills, knowledge, and experience of treating these long-term complications.