An Odyssey of complications from band, to sleeve, to bypass; definitive laparoscopic completion gastrectomy with distal esophagectomy and esophagojejunostomy for persistent leak
- 753 Downloads
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.
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.
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.
KeywordsAnastomotic leak Bariatric surgery Surgical revision Completion gastrectomy Esophagojejunostomy
Compliance with ethical standards
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.
Supplementary material 1 (MP4 233519 kb)
- 2.Hutter MM, Schirmer BD, Jones DB, Ko CY, Cohen ME, Merkow RP, Nguyen NT (2011) First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann Surg 254:410–422CrossRefPubMedPubMedCentralGoogle Scholar
- 3.Kim J, Azagury D, Eisenberg D, DeMaria E, Campos GM, American Society for Metabolic and Bariatric Surgery Clinical Issues Committee (2015) 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. Surg Obes Relat Dis 11:739–748CrossRefPubMedGoogle Scholar