Elizabeth Z Colsen, MD, Daniel B Leslie, MD, Sayeed Ikramuddin, MD. University of Minnesota
Objective of the technique:
Laparoscopic sleeve gastrectomy is the most common weight loss operation performed in the United States with low mortality and a few complications. However staple line leak is associated with high morbidity. Management strategies have included stents, endoscopic clips, fibrin glue, and percutaneous drainage with parenteral nutrition. These approaches do not definitively control the leak nor do they adequately address the physiologic processes associated with ongoing leakage. We sought to develop a standardized technique that controls leak and prevents functional obstruction while providing enteral nutritional support.
Description of the technique:
A gastrojejunostomy (GJ) tube is placed though the leak site using laparoscopy (lap), endoscopy (endo), and fluoroscopy (fluoro). The operation begins with lap exploration. Endo and fluoro are used to locate the leak. A pediatric endoscope is advanced transorally through the leak into the peritoneal cavity. Under lap guidance a wire is placed through the endoscope and pulled through the future GJ tube site. A 18 Fr GJ tube with 45 cm extension is fed over a wire through the skin into the leak site and brought out the mouth. An adult endoscope is used to place the GJ though the sleeve into the jejunum. The gastric balloon occludes the leak. A drain is placed if abscess cavity is present.
The 18Fr GJ tube is replaced with a 18 Fr red rubber Robinson (RR) tube approximately 4 weeks later using endo and fluoro. This is exchanged for a 16 Fr RR 4 weeks later as an outpatient (endo and fluoro). The final exchange to a 14 Fr RR tube is performed in interventional radiology. The final tube is removed 4 weeks later.
Drainage via the gastric port diverts stomach acid and facilitates healing. The jejunostomy tube stents the sleeve and pylorus preventing functional sleeve obstruction.
Patients receive feeding through the jejunostomy port /RR tube immediately after placement. This avoids need for total parenteral nutrition via central line with its associated cost and complications. Patients are able to return to normal daily activities after the second tube exchange.
This procedure has been performed on 9 patients. The patients were 43 +/- 16 yrs. old. The average (avg) days to leak were 18 +/- 18 days (range 4-50). The avg days until lap placed GJ tube was 65 +/- 74 days (range 4-179). The avg time for GJ tube placement to removal of all tubes was 88 +/- 21 days (range 60-114). Two patients had the 18 Fr GJ tube pulled at 60 days. All tubes have been removed. One patient had persistent gastrocutaneous fistula repaired with endoscopic clip. The remaining patients have no further leakage.
Our tertiary care institution is a referral site for sleeve leaks. Endoscopically placed stents and clips have been used in the past. However, issues with stent migration and patient complaints of pain limited effectiveness of treatment. Our new technique is predictable, reproducible, and standardized. It also provides patient satisfaction with outpatient management which is crucial in today’s health care environment.