Matthew J Davis, MD, Dvir Froylich, MD, Gautam Sharma, Tammy S Fouse, DO, Philip R Schauer, MD, Stacy A Brethauer, MD. Bariatric and Metabolic Institute, Cleveland Clinic Foundation
Introduction: Gastrojejunostomy revision after gastric bypass surgery is a challenging procedure. The air-leak test is widely viewed as reliable in evaluating the integrity of the gastrojejunal anastomosis. We present a case with a positive air-leak test during gastrojejunostomy revision and the techniques employed to address it.
Case Presentation: A 40-year-old female, who underwent laparoscopic gastric bypass 6 years prior, subsequently developed a chronic stricture due to marginal ulceration at her gastrojejunostomy. Over time, this resulted in severe food intolerance, nausea, and vomiting. The patient underwent multiple endoscopic dilations over 1 year, however, the stricture persisted. Thus, surgical intervention was planned.
Six ports were utilized, four 5 mm, and two 12 mm. After lysis of dense adhesions, dissection of the gastric pouch was continued up to the right crus. The remnant stomach and gastric pouch were found to be intimately adherent. The greater curvature attachments were divided along with the gastroepiploic arcade up to the left crus. The lesser sac was entered and a retrocolic, retrogastric Roux limb was identified. Remnant gastrectomy was performed at the junction of the body and the antrum using a stapler. The Roux limb was divided, the gastrojejunostomy was fully mobilized and the previous pouch was divided just below the left gastric pedicle. Endoscopic leak test on the pouch staple line was found to be negative. The gastrojejunal anastomosis was performed with a posterior layer of 2-0 non-absorbable suture, followed by a linearly stapled gastrojejunostomy. The common enterotomy was closed with 2 strands of running 2-0 absorbable sutures tied over the endoscope. The anterior aspect of the anastomosis was then imbricated with 2-0 non-absorbable suture. A leak test showed air bubbles at the lateral aspect of the anastomosis. Attempts to rectify this with figure-of-eight sutures were unsuccessful. Thus, fibrin glue and a tongue of omentum were placed over the gastrojejunostomy. Remnant gastrostomy was performed in the standard fashion. Two closed suction drains were placed. Upper endoscopy at the end of the case demonstrated a patulous gastrojejunostomy. Post-operative course was uneventful. Enteric feeding was successfully initiated via the remnant gastrostomy. Upper GI fluoroscopy was performed on post-operative day five and was negative for leak or stricture. The patient was discharged on post-operative day seven.
Conclusion: In this video, we have demonstrated a complex gastrojejunostomy revision with successful management of a positive intra-operative air-leak test using suture reinforcement, fibrin sealant agent and an omental tongue encircling the anastomosis.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 79781
Program Number: V079
Presentation Session: Friday Exhibit Hall Video Presentations Session 2 (Non CME)
Presentation Type: EHVideo