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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19 Case Series Bariatric Times • September 2017 created with a 75cm biliopancreatic limb and a 100cm Roux limb (Figure 5). Afterwards, the Roux limb was placed over the fistula as an interposed segment, fixing it to the anterior and posterior part of the fistula with PDS 00 (polydioxanone) sutures, creating a serosal patch (Figures 6 and 7). To finalize, an end-to-side gastro-jejuno anastomosis was manually created with 00 absorbable sutures (Figure 8). With this, pressure to the fistula was released and closure was achieved with the help of the serosal patch of the Roux limb. The patient had a good evolution, tolerating oral feeding with no evidence of the fistula using contrast media in the postoperative period (Figures 9 and 10). CASE 2 A 51-year-old female patient presented to the authors' facility. Prior to presentation she underwent a laparoscopic adjustable gastric banding (LAGB) procedure more than 10 years prior to presentation that was complicated by erosion. She had the band removed by laparoscopy, and then underwent laparoscopic gastric plication. Weight loss results following this procedure were unsuccessful. She then underwent a conversion procedure to convert the plication to a LSG. She developed a leak in postoperative period for which conservative management was not successful. The leak continued with the left pleura developing an empyema treated by thoracotomy and inferior left lobectomy. The gastric leak converted into a gastro- pleuro-cutaneus fistula. At the time of presentation to the authors' facility, the patient had been living with the fistula for one year. Her BMI was 22kg/m 2 . The authors' prepared the patient for surgical treatment with nutrition by a naso-jejunal catheter for six weeks. At the time of surgery, after adequate nutrition, the patient's BMI was 25kg/m 2 . They decided to convert the LSG to RYGB with an interposed jejunal bowel as a serosal path. The surgical team found multiple adhesions between the stomach and the liver. After a thorough dissection, they located the fistula at the angle of His of the Stomach (2cm). There was bleeding near the spleen, so the surgical team converted to a laparotomy in order to control the bleed. After that, they continued the surgery in the open approach. Primary closure of the fistula was performed with three stiches of a 2- 0 non-absorbable suture; later a gastric pouch of approximately 15mL was created with a lineal stapler to convert to RYGB. A jejuno-jejuno anastomosis was created with a 75cm biliopancreatic limb and a 100cm Roux limb. The Roux limb was placed over the fistula as an interposed segment, fixing it to the anterior and posterior part of the fistula with 2-0 non- absorbable suture, creating a serosal patch. To finalize, an end-to-side FIGURE 3. Fistula opening at the new greater curvature of the stomach near the angle of His FIGURE 4. Gastric fistula view after primary closure with three stiches of a 2-0 non- absorbable suture FIGURE 5. A jejuno-jejuno anastomosis created with a 75cm biliopancreatic limb and a 100cm Roux limb FIGURE 6. Jejunal interposition: stiches behind fistula closure FIGURE 7. Jejunal interposition: stiches above fistula closure FIGURE 8. End-to-side gastro-jejuno anastomosis manually created with 00 absorbable suture

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