Kelvin Higa, MD FACS, Saber Ghiassi, MD MPH, Ruby Gatschet, MD, Keith Boone, MD FACS. University of California, San Francisco, Fresno
Patient is a 48 year-old woman with extensive past surgical history. She underwent adjustable gastric banding in Mexico in 2003, followed by attempted laparoscopic removal of the band in the United States, converted to open with proximal gastric bypass and repair of esophageal injury in 2005. One week later, she had a negative exploration for leak. Her surgical history also includes cesarean section, cholecystectomy, tubal ligation, open repair of incisional hernia with mesh and abdominoplasty. During the last year, she had developed severe gastroesophageal reflux, abdominal pain and solid food dysphagia. Work-up revealed a gastrogastric fistula. She was taken to the operating room for diagnostic laparoscopy and take down of the gastrogastric fistula. After Optiview entry, several ports were placed. Multiple adhesions were noted to the anterior abdominal wall and the intraabdominal mesh, which appeared to be placed appropriately, with no recurrence. Very extensive adhesiolysis, especially around the esophageal hiatus, was performed. The diaphragmatic crura, gastric pouch and remnant, as well as the gastrogastric fistula, which was just below the GE junction, were identified. Upper endoscopy and passage of a 36 French esophageal tube demonstrate a patent gastrogastric fistula but unsuccessful at intubation of the Roux-en-Y bypass. The proximal gastric remnant was transected with endoscopic stapler and removed after the dissection and take down of the gastrogastric fistula. The distal gastric remnant staple line was oversewed. Repeated attempt at endoscopic intubation of the Roux-en-Y limb failed. The proximal Roux limb was divided with endoscopic stapler, and the gastric pouch opened towards the gastroesophageal junction. The proximal lumen of the gastric pouch was obliterated for unknown reason. This necessitated a complete resection of the gastric pouch. The Roux limb was mobilized and an end-to-end esophagojejunostomy was created using interrupted 3-0 Vicryl sutures. Air leak test was negative. The transverse mesocolon was secured around the Roux limb with 2-0 silk sutures to close the potential hernia space. A gastrostomy tube was placed in the gastric remnant and a Jackson Pratt drain was left at the esophageal hiatus. An upper GI study on postoperative day one was negative for leak or obstruction. The patient was started on clear liquids on postoperative day 2 and discharged home on postoperative day 3. Patient’s symptoms had resolved and she was doing well on her postoperative clinic visit.
Program Number: V025