Esther M Bonrath, MD, Christopher Daigel, MD, Teodor P Grantcharov, MD PhD. St. Michael’s Hospital, Toronto, Canada
Background: Laparoscopic Roux-en-Y gastric bypass is currently the most common bariatric procedure performed in the USA. Marginal ulcers at the gastrojejunal anastomosis are a well known complication with an incidence reported between 1% to 16%. The etiology of these ulcers remains unclear with many different causative factors being discussed. Treatment options include medical, enodoscopic and surgical interventions. Complications arising from these ulcers include bleeding and perforation which, in an emergent setting, can lead to a high morbidity. In this video, we demonstrate the operative technique practiced in our unit for the treatment of refractory anastomotic ulcers following laparoscopic Roux-En-Y-Gastric Bypass.
Case Summary: A 27 year old female underwent laparoscopic Roux-en Y- Bypass for morbid obesity 5 months prior to presentation at our unit. Since then she had lost approximately 70 pounds. Postoperatively she suffered from nausea and vomiting and was unable to tolerate an oral diet. She had undergone repeated balloon dilatations without any success. She acutely presented to our emergency department with abdominal pain and melena. She was diagnosed with an actively bleeding anastomotic ulcer in the efferent jejunal limb. Active bleeding was initially treated with endoscopic epinephrine injection and cauterization. After initial stabilization she suffered from recurrent bleeding with need for blood transfusions, therefore operative revision was deemed necessary. Postoperatively the patient recovered well, and was discharged tolerating an oral diet on postoperative day 6.
Operative Summary: After establishing a pneumoperitoneum, the local abdominal findings were assessed. Adhesions in the region of the anastomosis and the liver were taken down and a liver retractor inserted. The region of the gastrojejunostomy appeared thickened, the adhesions could not be separated using blunt dissection. A fistula penetrating from the dorsal aspect of the anastomosis into the gastric remenant was identified. After adequate mobilization the fistula was transected with partial resection of the wall of the gastric remnant using a linear stapler. The mobilized anastomosis was then resected as a short segment. A new anastomosis was fashioned using a 30 mm linear stapler. The entrerotomy was closed with a running suture and the resected anastomosis was retrieved as a specimen.
Considering the possible high morbidity associated with non healing anastomostic ulcers due to bleeding or perforation early recognition of failure of conservative treatment is necessary. Elective operative treatment with resection of the anastomosis is, in the hands of a bariatric surgeon, a safe and effective treatment for these cases.
Session Number: VidTV1 – Video Channel Rotation Day 1
Program Number: V079