Amelia N Dorsey, MD, Gautam Sharma, MD, John Rodriguez, MD, Matthew Kroh, MD, FACS. Section of Surgical Endoscopy, Dept. of General Surgery, Cleveland Clinic
Introduction: Marginal ulceration and gastrogastric (GG) fistula are known potential complications of roux-en-y gastric bypass (RYGB). In revisional bariatric surgery it is often necessary to use all of the tools in our minimally invasive armamentarium to diagnose such complications and to provide appropriate operative intervention.
Methods and Procedures: We present a case of a 67 year old female who had prior open RYGB with persistent abdominal pain, dysphagia, recalcitrant ulcers and failure to thrive. Pre-operative EGD showed GJ ulcer while UGI and CT showed no leak, fistula or obstruction.
The use of intraoperative and multimodal minimally invasive tools were critical in intraoperative diagnosis and decision making. Intraoperative EGD identified deep GJ ulceration while concomitant laparoscopic view confirmed filling of the remnant stomach and the presence of a previously undiagnosed GG fistula.
After mobilization of the prior gastric pouch and remnant, the gastric remnant tip appeared ischemic. This was confirmed with the use of intraoperative fluorescence technology. The patient subsequently underwent laparoscopic revision including resection of en bloc specimen of prior gastric pouch, remnant, GG fistula, GJ and a small portion of the roux limb. Prior to reconstruction, intraoperative immunofluorescence was again used to confirm tissue viability of the gastric pouch and roux limb.
Upon measuring the roux limb, it was found to be only 30cm in length. The patient then underwent roux limb lengthening to assure 150cm roux limb. Intraoperative endoscopy was again used showing a patent GJ, leak test was negative, and there were no signs of bleeding. Post operatively the patient developed recurrent marginal ulcer. Further workup revealed elevated gastrin level while CT pancreas and octreotide scan confirmed gastrinoma.
Results: Laparoscopic revision of prior RYGB with near total gastrectomy, lengthening of roux limb, revision of JJ and RY reconstruction completed in case of GG fistula with recalcitrant ulcers of unique etiology. Intraoperative EGD was used to diagnose GG fistula and fluorescence technology used to confirm tissue viability. Subsequent studies revealed patient with persistent marginal ulcer and a diagnosis of gastrinoma.
Conclusion: Multimodal intraoperative tools are critical in diagnosis and decision making in revisional bariatric surgery. The persistent finding of recalcitrant marginal ulceration despite revision and optimal medical management should raise clinical suspicion for gastrinoma and raises the question of obtaining routine gastrin levels in these patients.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 80596
Program Number: V096
Presentation Session: Bariatric Video Session
Presentation Type: Video