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A unique twist following treatment of a sleeve gastrectomy leak: a multidisciplinary approach

Open AccessPublished:September 04, 2021DOI:https://doi.org/10.1016/j.vgie.2021.07.009

      Video

      (mp4, (103.79 MB)

      A unique twist following treatment of a sleeve gastrectomy leak: a multidisciplinary approach.

      Abbreviation:

      SG (sleeve gastrectomy)
      Sleeve gastrectomy (SG) is currently the most common bariatric surgery procedure performed.
      • English W.J.
      • DeMaria E.J.
      • Hutter M.M.
      • et al.
      American Society for Metabolic and Bariatric Surgery 2018 estimate of metabolic and bariatric procedures performed in the United States.
      GI leak is a known adverse event of SG, reported in up to 3% of patients,
      • Kim J.
      • Azagury D.
      • Eisenberg D.
      • et al.
      ASMBS position statement on prevention, detection, and treatment of gastrointestinal leak after gastric bypass and sleeve gastrectomy, including the roles of imaging, surgical exploration, and nonoperative management.
      and is often the result of increased intraluminal pressure exceeding the strength of tissue and/or the staple line. Although there is a growing endoscopic armamentarium to manage these adverse events, refractory leaks often require surgical intervention.
      • Baltasar A.
      • Bou R.
      • Bengochea M.
      • et al.
      Use of a Roux limb to correct esophagogastric junction fistulas after sleeve gastrectomy.
      • van de Vrande S.
      • Himpens J.
      • El Mourad H.
      • et al.
      Management of chronic proximal fistulas after sleeve gastrectomy by laparoscopic Roux-limb placement.
      • Iannelli A.
      • Tavana R.
      • Martini F.
      • et al.
      Laparoscopic roux limb placement over a fistula defect without mucosa-to-mucosa anastomosis: a modified technique for surgical management of chronic proximal fistulas after laparoscopic sleeve gastrectomy.
      • Vilallonga R.
      • Himpens J.
      • van de Vrande S.
      Laparoscopic Roux limb placement for the management of chronic proximal fistulas after sleeve gastrectomy: technical aspects.
      We describe a complex case of a leak after SG that, despite operative management, required a multidisciplinary approach involving endoscopic and surgical treatment strategies (Video 1, available online at www.giejournal.org).
      A 41-year-old woman underwent a laparoscopic sleeve gastrectomy at an outside institution that was complicated by a leak at the proximal staple line and severe stenosis in the mid-body of the gastric sleeve. Endoscopic interventions were attempted, but were ineffective, and she ultimately underwent a laparoscopic procedure in which a Roux-en-Y gastrojejunal anastomosis was created, with the Roux limb being used to drain the leak site (Fig. 1). Despite definitive therapy of the leak, she continued to experience significant epigastric abdominal pain, nausea, and vomiting, requiring frequent intravenous infusions. She was subsequently referred to our institution for further management.
      Figure thumbnail gr1
      Figure 1Cartoon depiction of Roux-en-Y gastrojejunal anastomosis.
      Upper GI series demonstrated oral contrast passing down 2 lumens, the Roux-en-Y gastrojejunostomy, and the gastric sleeve (Fig. 2). Upper endoscopy findings were notable for a widely patent gastrojejunostomy (Fig. 3) and a severely stenotic and spiraled sleeve gastrectomy, resulting in food and gastric contents pooling in the stomach and refluxing into the Roux limb, which was thought to be a major contributor to her pain and vomiting. She underwent several attempts at endoscopic dilation without significant improvement in her symptoms.
      Figure thumbnail gr2
      Figure 2Upper GI series demonstrating passage of oral contrast down 2 lumens: gastric sleeve and Roux-en-Y gastrojejunostomy.
      Figure thumbnail gr3
      Figure 3Endoscopic visualization of gastrojejunal anastomosis and gastric sleeve.
      Her case was discussed at a multidisciplinary review committee involving interventional endoscopy and bariatric surgery. Given her unique anatomy with 2 outflow tracts, the decision was made to try closing off the gastric sleeve endoscopically such that food and enteric contents would preferentially pass through the Roux-en-Y gastrojejunostomy, thereby avoiding passage through the stenotic and spiraled gastric sleeve. Although the durability of an endoscopic closure like this was unknown, the thought was to try this minimally invasive approach first, with the option to pursue a more definitive surgical closure if symptoms improved.
      The gastric sleeve lumen was closed via endoscopic suturing (Fig. 4) with the use of an endoscopic suturing device (Overstitch, Apollo Endosurgery, Austin, Tex, USA). The patient experienced temporary relief; however, symptoms recurred 4 weeks later. Given the initial success with this minimally invasive approach, the decision was made to pursue a more invasive but durable approach that involved laparoscopic transection of the gastric sleeve (Fig. 5). Postoperative upper GI series demonstrated exclusive passage of oral contrast through the gastrojejunal anastomosis (Fig. 6). The patient’s symptoms improved markedly postoperatively, and at 1 year of follow-up, she continues to tolerate a regular diet without vomiting, dysphagia, or gastroesophageal reflux disease.
      Figure thumbnail gr4
      Figure 4Endoscopic suturing of the gastric sleeve lumen.
      Figure thumbnail gr5
      Figure 5Laparoscopic transection of gastric sleeve and Roux limb of gastrojejunostomy.
      Figure thumbnail gr6
      Figure 6Upper GI series demonstrating passage of oral contrast exclusively through gastrojejunal anastomosis into Roux limb.
      This unique case highlights how endoscopic techniques may be initially used as a less-invasive treatment strategy to set the stage for more definitive surgical management. Furthermore, this case underscores the importance of a multidisciplinary approach to these complex cases.

      Disclosure

      Dr Varban receives salary support for participation and leadership in collaborative quality improvement initiatives from Blue Cross Blue Shield of Michigan. Dr Schulman is a consultant for Apollo Endosurgery, Boston Scientific, MicroTech, and Olympus and has research/grant support from GI Dynamics. All other authors disclosed no financial relationships.

      Supplementary data

      References

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