Transjejunal Intragastric Resection of a Tumor at the Gastroesophageal Junction in a Patient with a Previous Roux-en-Y Gastric Bypass

Shaina R Eckhouse, MD, Alfredo D Guerron, MD, Nova Szoka, MD, Keri Seymour, DO, Chan W Park, MD, Jin Yoo, MD, Ranjan Sudan, MD, Dana D Portenier, MD. Duke Universtiy

BACKGROUND: Laparoscopic intragastric surgery has recently become an effective treatment for gastric submucosal tumors.  However, a paucity of data exists in managing these tumors after bariatric surgery.  This video aims to illustrate a novel technique to manage a submucosal tumor after Roux-en-Y gastric bypass (RGB) utilizing a laparoscopic transjejunal intragastric technique.

PATIENT AND METHODS: A 57-year-old morbidly obese (BMI 50) female underwent a laparoscopic RGB in 2009, which was complicated by weight regain.  She presented for revisional bariatric surgery evaluation.  An esophagogastroduodenoscopy (EGD) was performed, which demonstrated a 1.5cm submucosal mass just distal to the gastroesophageal (GE) junction within the gastric pouch.  The patient was consented for a laparoscopic transgastric resection of the GE junction tumor.

RESULTS: The procedure was initiated under general endotracheal anesthesia, and camera and working ports were placed after insufflation was obtained.  Adhesiolysis was performed to mobilize and identify the gastric pouch and Roux limb.  An atraumatic grasper was placed across the Roux limb distal to the gastrojejunostomy.  Next, an EGD was performed which identified the tumor just distal to the GE junction. 

Laparoscopically, the blind end of the Roux limb was opened and secured to the abdominal wall.  An endoscopic OverTube was placed into the jejunum and into the gastric pouch to assist with the transjejunal endoscopic resection.  The mass was snared with electrocaughtery.  The mass and the OverTube were withdrawn from the stomach, jejunum, and abdomen, and the Roux limb was closed with an endo-GIA stapler using a 60mm tan load.

An EGD was performed at the end of the case, and insufflation demonstrated no air leak.  EBL was 75ml.  The patient was discharge home on day three post-operatively doing well.

CONCLUSIONS: The present video illustrates a novel technique that can be utilized successfully in the management of gastric submucosal tumors after RGB.

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