Bariatric Times

SEP 2017

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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18 Case Series Bariatric Times • September 2017 INTRODUCTION The global epidemic of obesity has given rise to available therapies in which to treat the disease, including pharmacotherapy, endoscopic devices and procedure, and metabolic and weight loss surgeries. Currently, the Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (LSG) are the two most commonly performed bariatric operations worldwide, and LSG continues to grow in popularity among the surgical community. 1 In the United States, the proportion of LSG procedures increased from 17.8 percent in 2011 to 53.8 percent in 2015. 2,3 Though RYGB procedures have declined, it remains the gold standard. 2 Leakage from the staple line is among the most feared complications of LSG, likely because of the complexity in diagnosing and treating leaks. Recent studies report leak rate incidence after LSG up to three percent. 4 Multiple efforts, including stent usage, have been proposed to avoid re-intervention in patients with a post-gastric sleeve fistula with encouraging results, 5 however this conservative treatment has failed in a considerable number of patients. 6 Patients who fail conservative treatment require reoperation. The current consensus states that Roux- en-Y reconstruction is a valid and effective treatment option for leaks, yet it should always be considered last. 5 Other laparoscopic treatment options described in the literature include the following: fistulo-jejuno anastomosis, conversion to bypass with fistulo-jejuno anastomosis, and total gastrectomy with esophageal- jejuno anastomosis. 7 Here, the authors report the cases of two patients who experienced fistula secondary to LSG in which conservative treatment failed. Both patients were treated with jejunal interposition, which is conversion to a Roux-en-Y gastric bypass with an interposed jejunal loop (Figure 1). CASE 1 A 30-year-old woman with a history of overweight (body mass index [BMI] 28kg/m 2 at time of presentation) underwent an LSG operation at an outside facility. Three weeks postoperative, she presented with generalized peritonitis secondary to a leak from the LSG. She underwent re- operation laparoscopically; peritoneal lavage was performed, drains were placed, and enteral access was achieved with the naso- jejunal catheter. Broad spectrum antibiotics and enteral feed were initiated and the patient was referred to the authors' facility. After resolving the acute stage, upper endoscopy was performed, and an opening 1cm in diameter was found in the proximal stomach; stenosis of the trajectory of the gastric sleeve was found. A metallic prosthesis 15cm x 23mm in diameter was placed as conservative treatment; however, due to poor tolerance it was removed three weeks later. The patient continued with purulent secretion through the intra-abdominal drain, feeding through a naso-jejunal catheter, and with broad-spectrum antibiotics. Four months after conservative treatment was started and because of radiologic evidence of fistula persistence, the care team decided on a definitive surgical treatment plan that included diagnostic laparoscopy, primary closure of the fistula, and conversion to gastric bypass versus total gastrectomy with an esophago-jejuno anastomosis. At the time of re-operation, the patient's BMI was 23kg/m 2 . The surgical team performed the procedure laparoscopically, and accessed the abdominal cavity using the open Hasson technique. The rest of the trocars were located in the upper abdomen, supra-umbilical, and below both costal margins. During surgery, multiple adhesions were found in the abdominal cavity surrounding the stomach. These were dissected and the trajectory of the fistula was followed up to its origin close to the angle of His (Figures 2 and 3). Primary closure of the fistula was performed with three stiches of a 2-0 non-absorbable suture (Figure 4). Later, a gastric pouch of approximately 15mL was created with a lineal stapler to convert to gastric bypass. A jejuno-jejuno anastomosis was by LUIS FERNANDO ZORRILLA NÚÑEZ, MD; PABLO GERARDO ZORRILLA BLANCO, MD; NOÉ NÚÑEZ JASSO, MD; and ÁLVARO TRISTÁN PERALTA, MD Bariatric Times. 2017;14(9):18–20. Jejunal Interposition as a Definitive Treatment for Gastric Fistula after Sleeve Gastrectomy ABSTRACT Although the available literature describes treatment of gastric fistula post-laparoscopic sleeve gastrectomy, no one approach has been proven to be superior. The authors present two cases of two patients who experienced fistula secondary to laparoscopic s leeve gastrectomy in which conservative treatment failed. Both patients were treated with jejunal interposition, which is conversion to a Roux-en-Y gastric bypass with an interposed jejunal loop. Both patients had good results, tolerating oral feeding with no evidence of the fistula using contrast media in the postoperative period. They concluded that in cases where conservative treatment fails, conversion to Roux-en-Y gastric bypass with an interposed jejunal loop, may be considered. KEYWORDS Laparoscopic sleeve gastrectomy, gastric fistula, jejunal Interposition, serosal patch, gastric leak, Roux-en-Y gastric bypass View the accompanying video at Exclusive Digital Content FIGURE 1. Final result: sleeve Gastrectomy conversion to Roux-en-Y gastric bypass with j ejunal interposition FIGURE 2. Fistula opening at the new greater curvature of the stomach near the angle of His

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