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Obesity Surgery

, Volume 28, Issue 9, pp 2983–2984 | Cite as

Managing a Positive Air-Leak Test During a Gastrojejunostomy Revision

  • Dvir FroylichEmail author
  • Matthew Davis
  • Gautam Sharma
  • Tammy Fouse
  • Philip Schauer
  • Stacy Brethauer
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Abstract

Background

Gastrojejunostomy revision after gastric bypass surgery is a challenging procedure that requires advanced skills. The air-leak test was performed to identify gastrojejunostomy leaks. Omental patch seal technique is a well-known treatment of perforated gastrojejunostomy ulcers (Surg Obes Relat Dis 4:423–8, 2012; Surg Endosc 2:384–9, 2013; Surg Endosc 11:2110, 2007).

Methods

We present a case of a 40-year-old female, who underwent laparoscopic gastric bypass 6 years prior and subsequently developed marginal ulcer, resulting in chronic gastrojejunostomy stricture. She underwent multiple endoscopic dilations until it became refractory. She was taken for a gastrojejunostomy revision. After dissection of dense adhesion, the gastric pouch was identified. The Roux limb was identified as retrocolic and retrogastric. The pouch was divided just below the left gastric pedicle. Endoscope air insufflation was showed no leak of the new pouch. The Roux limb was freed and gastrojejunal anastomosis was performed with a posterior lair, linear stapler, and two layers of running 2-0 absorbable sutures for common enterotomy. The leak test demonstrated air bubbles which were at the anastomosis lateral aspect. A 2-0 non-absorbable suture was placed repeatedly but the leak remained positive. Fibrin glue was placed over the gastrojejunostomy. A tongue of omentum was pulled posteriorly to the pouch and sewed to itself to encircle the gastrojejunostomy. The leak test was not repeated since it would not have changed our management at this point. A remnant gastrostomy tube was placed. Two suction drains were placed. Upper endoscopy, at the end of the case, demonstrated a patulous gastrojejunostomy.

Results

The patient’s post-operative course was uneventful. Enteric feeding was initiated via the remnant gastrostomy. Upper GI fluoroscopy was performed on POD 5 and was negative for leak or stricture. She was discharged on POD 7. At 6-month follow-up, she was doing excellent, maintaining her weight without symptoms.

Conclusions

Gastrojejunostomy revision is a complex procedure that requires an advanced bariatric surgery skills and experience. Omental patch can be used in cases where friable tissue anastomosis leaks as a sealant along with a protective feeding gastrostomy.

Keywords

Bariatric surgery revision Gastrojejunostomy leak Omental patch Air-leak test Gastrojejunostomy stricture 

Notes

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Supplementary material

11695_2018_3338_MOESM1_ESM.mp4 (166.2 mb)
ESM 1 (MP4 170,173 kb)

References

  1. 1.
    Kalaiselvan R, Exarchos G, Hamza N, et al. Incidence of perforated gastrojejunal anastomotic ulcers after laparoscopic gastric bypass for morbid obesity and role of laparoscopy in their management. Surg Obes Relat Dis. 2012 Jul-Aug;8(4):423–8.CrossRefGoogle Scholar
  2. 2.
    Wendling MR, Linn JG, Keplinger KM, et al. Omental patch repair effectively treats perforated marginal ulcer following roux-en-Y gastric bypass. Surg Endosc. 2013 Feb;27(2):384–9.CrossRefGoogle Scholar
  3. 3.
    Chin EH, Hazzan D, Sarpel U, et al. Multimedia article. Laparoscopic repair of a perforated marginal ulcer 2 years after gastric bypass. Surg Endosc. 2007 Nov;21(11):2110.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.The Bariatric and Metabolic instituteCleveland Clinic InstituteClevelandUSA

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