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An Odyssey of complications from band, to sleeve, to bypass; definitive laparoscopic completion gastrectomy with distal esophagectomy and esophagojejunostomy for persistent leak

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Abstract

Introduction

Anastomotic leaks are uncommon yet potentially devastating complications after bariatric surgery. While the initial management includes resuscitation and sepsis control, the definitive management often requires endoscopic or surgical interventions. Surgical revision of the initial surgery may be necessary for chronic non-healing fistula.

Patients and methods

The patient is a 45-year-old female with history of laparoscopic adjustable gastric banding who underwent band removal and conversion to a sleeve gastrectomy (SG) due to her failed weight loss, which resulted in a leak at gastroesophageal junction. She underwent multiple attempted endoluminal treatments without success and then SG was converted to Roux-en-Y gastric bypass (RYGB). However, this failed and the persistent leak led to a gastro-pleural fistula requiring left chest decortication. After addressing nutritional deficiencies, she underwent laparoscopic completion gastrectomy and Roux-en-Y esophagojejunostomy reconstruction.

Results

Five ports and a liver retractor were placed. Dissection was carried down posteriorly to free up the Roux limb and then to the right crus. There was an abscess cavity around the left crus. The esophagus was circumferentially mobilized and the abscess cavity was debrided. The proximal Roux limb was disconnected with a linear stapler. Upper endoscopy was used to identify the leak. The healthy tissue was confirmed above the leak and the distal esophagus was transected. Esophageal stump was mobilized up into the middle mediastinum. Esophagojejunostomy was completed with 25 mm circular stapler. A linear stapler was used to close the candy cane. The procedure took 2 h and 40 min. Estimated blood loss was 100 ml. Her postoperative course was uncomplicated.

Conclusion

We present a video of the complex surgical revision of a leak after through the gamut of bariatric surgery: band to sleeve, failed endoluminal therapy and conversion of SG to RYGB. Durable success was achieved by a completion gastrectomy, distal esophagectomy with Roux-en-Y esophagojejunostomy.

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Authors and Affiliations

  1. Bariatric and Metabolic Institute, Digestive Disease Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA

    Hideo Takahashi, Andrew T. Strong, Alfredo D. Guerron, John H. Rodriguez & Matthew Kroh

  2. Department of General Surgery, Duke University Health System, Durham, NC, USA

    Alfredo D. Guerron

Authors
  1. Hideo Takahashi
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  2. Andrew T. Strong
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  3. Alfredo D. Guerron
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  4. John H. Rodriguez
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  5. Matthew Kroh
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Corresponding author

Correspondence to Hideo Takahashi.

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Disclosures

Matthew Kroh serves as a consult for speaker for Medtronic, outside the submitted work. Hideo Takahashi, Andrew T. Strong, Alfredo D. Guerron and John H. Rodriguez have no conflicts of interest or financial ties to disclose.

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Takahashi, H., Strong, A.T., Guerron, A.D. et al. An Odyssey of complications from band, to sleeve, to bypass; definitive laparoscopic completion gastrectomy with distal esophagectomy and esophagojejunostomy for persistent leak. Surg Endosc 32, 507–510 (2018). https://doi.org/10.1007/s00464-017-5757-9

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  • DOI: https://doi.org/10.1007/s00464-017-5757-9

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