Surgery for Obesity and Related Diseases 11 (2015) 474–477
Surgeon at work
Laparoscopic median gastrectomy for stenosis following sleeve gastrectomy Ramya Kalaiselvan, M.R.C.S., M.Phil.a, Basil J. Ammori, M.B.Ch.B., FRCS, M.D.a,b,* a
Department of Upper Gastrointestinal Surgery, Salford Royal Hospital, Manchester, United Kingdom b The University of Manchester, Manchester, United Kingdom Received April 2, 2014; accepted June 30, 2014
Background: Laparoscopic sleeve gastrectomy (LSG) has become an established primary bariatric procedure. Gastric stenosis after LSG has been reported in a few studies and often occurs at the level of incisura or midbody because of a technical operative error and could be associated with a leak. This can be managed by endoscopic dilations or revision surgery. The objective of this study is to describe a novel technique to deal with sleeve stenosis and its outcome. Methods: Two patients presented with sleeve stenosis after LSG and underwent a novel technique. The patients were followed up for 18 months. Results: We describe a novel technique of laparoscopic median gastrectomy in 2 patients that involved resection of the stenotic segment followed by a hand-sewn, gastrogastric, end-to-end anastomosis. Both patients had successfully recovered from stenosis related symptoms, although one required an endoscopic dilation of the anastomosis. Conclusion: Laparoscopic median gastrectomy is a feasible and effective option in patients who have failed conservative management of stenosis after LSG and in whom there is a desire to avoid seromyotomy or conversion to gastric bypass. (Surg Obes Relat Dis 2015;11:474–477.) r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Sleeve gastrectomy; Sleeve stenosis; Median gastrectomy
Laparoscopic sleeve gastrectomy (LSG) has gained popularity as a primary weight loss surgical option for morbidly obese patients and is considered easier, faster, and less invasive compared to laparoscopic Roux-en-Y gastric bypass. Its advantages include preservation of endoscopic access to the upper gastrointestinal tract, normal intestinal absorption, the lack of a digestive anastomosis, and a reduced incidence of dumping syndrome due to pylorus preservation . The Fourth International Consensus Summit for Sleeve Gastrectomy held in New York in 2012, reported the following
complications: proximal (high) leak 1.1%, hemorrhage 1.8%, and stenosis at lower sleeve .9%; mortality was .33 ⫾ 1.6%, which translated to 152 deaths among 46,133 patients recruited by 130 surgeons ﬁlling an online questionnaire . Stenosis after LSG commonly occurs at the level of the incisura or midbody as a result of inadequate operative technique or secondary to a gastric leak. This complication has been managed by serial endoscopic dilations or revisional surgery. This report describes a novel technique of median gastrectomy to resolve sleeve stenosis that has failed conservative management.
Correspondence: Basil J. Ammori, M.B.Ch.B., FRCS, M.D., The University of Manchester Consultant Laparoscopic and Bariatric Surgeon, Salford Royal NHS Foundation Trust, Stott Lane, Salford, Manchester, M6 8 HD, United Kingdom. E-mail: [email protected]
Methods We describe 2 patients who developed stenosis of gastric sleeve after LSG from prospectively maintained records.
http://dx.doi.org/10.1016/j.soard.2014.06.021 1550-7289/r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Laparoscopic Median Gastrectomy / Surgery for Obesity and Related Diseases 11 (2015) 474–477
After unsuccessful endoscopic dilation, they underwent laparoscopic median gastrectomy, which is described. Two female patients aged 28 and 50 years with preoperative body mass index (BMI) of 74.4 and 43.1 kg/m2, respectively, underwent LSG for morbid obesity by a bariatric surgeon at another institution. Both patients presented with episodes of vomiting and inability to tolerate solid foods at 17 and 20 months of follow-up, respectively. Their BMIs at this point were 51.7 and 27.7 kg/m2, respectively. Barium swallow and meal demonstrated stenosis of the gastric sleeve in the region of the incisura; 1 patient also had an excessive fundic pouch that might have contributed to pain on swallowing (Fig. 1). Two attempts at endoscopic dilation in each patient had failed to achieve any symptomatic response. Hence, operative intervention was undertaken. Endoscopic balloon dilation Premedication with midazolam and hyoscine N-butyl bromide intravenously was administered. The patient was placed in a left lateral position and gastroscopy was performed. After sighting the narrowed segment through which the scope could not be advanced, a siliconelubricated balloon was introduced across the stricture segment and hydrostatic pressure was applied to inﬂate the balloon as per the manufacturerʼs recommendation. The balloon was kept inﬂated for 60 seconds and then deﬂated. Dilation was started with a 12-mm balloon and then 14- and 16-mm balloons were used sequentially and without ﬂuoroscopy.
Fig. 1. Barium meal showing stenotic segment of the gastric tube at the level of the incisura and a protuberant retained portion of the gastric fundus.
Operative technique Surgery was performed under general anesthesia, with single dose of cefuroxime and prophylaxis against venous thromboembolism. The patient was placed in supine position with legs apart and hips ﬂexed at 151, also known as Lloyd–Davies position. Five ports were inserted and a pneumoperitoneum of 15 mmHg CO2 was created. Sleeve stenosis was noted (Fig. 2) and there was protuberant pouch at fundus. Adhesions to the gastric tube, especially of the omentum and liver, were divided. In the patient with the retained part of the gastric fundus, the fundus was mobilized and the retained posterior short gastric vessels were divided. The redundant fundus was then resected with a stapler (Covidien, Mansﬁeld, MA, USA) (Fig. 3). The mesentery along the lesser curvature of the stomach at the level of the stenotic gastric sleeve is divided with an ultrasonically activated scalpel (UAS, Ethicon, Norderstedt, Germany); care is taken to preserve gastric branches of the vagus nerve, particularly the nerve of Latarjet and its crow’s foot terminal branches to the pylorus (Fig. 4). The stenotic segment was then resected with staplers (ﬁrst patient) or the UAS (second patient) distally above the gastric antrum and proximally (Fig. 5); the choice of method of division was purely exploratory by the surgeon who wanted to avoid staples within the anastomosis. The stapled divided ends of the gastric tube were then approximated in an end-to-end manner using a continuous polydioxanone 2-0 suture (Ethicon) that incorporated the staple lines, and 2 corresponding transverse gastrostomies adjacent and parallel to the staple lines were created with the UAS. An end-to-end gastrostomy was then performed with a hand sewn continuous polydioxanone 2-0 suture technique (Fig. 6). In the second patient, the already open 2 ends of the gastric sleeve were approximated using one layer of continuous suture. A methylene blue leak test was then carried out and was negative in both patients. No abdominal drains were placed.
Fig. 2. Operative image of the stenotic and twisted segment of the gastric sleeve at the level of the incisura with prestenotic dilation.
R. Kalaiselvan and B. J. Ammori / Surgery for Obesity and Related Diseases 11 (2015) 474–477
Fig. 3. Resection of the retained and protuberant portion of the gastric fundus with a stapler.
Fig. 5. Operative picture showing stapled resection of the stenotic segment of the gastric sleeve.
The immediate postoperative recovery was uneventful in both patients, and they were discharged home. On followup, 1 patient had complete resolution of symptoms and remained symptom-free at 18 months postoperative, reducing her BMI to 41 kg/m2. The second patient who had resection with UAS reported a modest improvement but some dysphagia to solids persisted. A barium study showed a residual mild stenosis at the site of the anastomosis that progressively responded to 3 endoscopic balloon dilations at 4, 6, and 8 months postoperatively with resolution of symptoms, and remained symptom-free at 17 months after the last endoscopic dilation and increased her BMI of 28 kg/m2.
The incidence of stenosis of the gastric sleeve has been reported at .7% in 1 series of 717 patients from Chile , .7% from in a series from Belgium , and 3.5% in another series of 230 patients from Texas . The fourth international summit reported .9% incidence of strictures after LSG . The commonest site is at the level of incisura as a result of inadequate operative technique where excessive lateral traction could result in a narrowing of the staple line at that level, but may also complicate a gastric leak or staple line hematoma and present more proximally . A proximal stenosis is also more likely to complicate revisional surgery, such as conversion from gastric banding, and is perhaps more likely to occur if LSG is performed as a single rather
Fig. 4. Operative picture showing perigastric dissection of the stenotic segment of the sleeve in preparation for its resection.
Fig. 6. Operative picture showing the completed hand sewn end-to-end gastrogastric anastomosis.
Laparoscopic Median Gastrectomy / Surgery for Obesity and Related Diseases 11 (2015) 474–477
than staged procedure, particularly if the pseudo-capsule was not divided or partially excised. These often present with persistent dysphagia, abdominal or retrosternal pain on eating, and reﬂux symptoms irresponsive to medical therapy. The fourth international summit report states that of the 130 surgeons, 40 (32%) used a 36Fr bougie, which was most common (range 32–50Fr) . Although larger size bougies (40Fr or more) might be associated with a decrease in the incidence of leak without impairing weight loss , there are no reports in evaluating incidence of strictures in relation to bougie size. Although symptomatic short-segment stenoses after LSG may be treated successfully with repeated endoscopic balloon dilation with or without stenting , long-segment stenoses that do not respond to endoscopic techniques will require revisional surgery . The surgical revision options include seromyotomy, wedge resection, or conversion to gastric bypass [3–5,8]. Seromyotomy carries a risk of gastric leak that was reported at 11% in a series of 9 patients who underwent this procedure for long symptomatic strictures . Laparoscopically treating 16 patients with post-LSG persistent strictures (seromyotomy, n ¼ 14; wedge resection, n ¼ 2), Vilallonga et al.  described successful wedge resection that was also applied secondarily in 2 further patients with complications of the seromyotomy. Another case report has described a novel technique of using transoral circular stapler to safely treat short gastrogastric stricture but this was after reversal of laparoscopic Roux-en-Y gastric bypass . This stapling technique, however, is not suitable for long strictures such as those encountered in our 2 patients. We propose that a median gastrectomy is another suitable alternative option to address persistent stenosis within the gastric sleeve, particularly when located within the midbody. This approach would be expected to carry a low risk of leak (none in our 2 patients reported herein), unlike seromyotomy, and preserves the gastric sleeve option without a need to convert to a gastric bypass. It also enables reduction of the size of the dilated proximal pouch by contiguous resection with the stricture in an attempt to reduce the total volume of the gastric sleeve, such as in the still morbidly obese (e.g., 1 of our 2 patients) or with an eye on long-term weight control after resolution of the stenosis. Although 1 of our 2 patients developed a mild stenosis at the gastrogastric anastomosis after median gastrectomy, this is a recognized sequel of any anastomosis and was successfully managed by endoscopic balloon dilation. Care should be taken to avoid damage to the gastric branches of the nerve of Latarjet. If there is concern intraoperatively or postoperatively regarding damage to vagal branches, consideration should be given to balloon dilation in the ﬁrst
instance. Pyloroplasty could be reserved as a second line management option. The potential for compromise to the vascular supply of the stomach should be minimized if dissection is kept close to the gastric wall at the site of the stricture. The removal of a segment of stomach could result in an element of tension at the gastrogastric anastomosis that should be alleviated by adequate mobilization of the gastric antrum off the anterior surface of the pancreas. A gastric bypass can be reserved as an escape strategy if there is unexpectedly considerable compromise to the vascularity of the stomach. We reported resolution of symptoms in our 2 patients after laparoscopic median gastrectomy, though 1 patient required postoperative endoscopic dilation for mild, but rather symptomatic, stenosis at the gastrogastric anastomosis. We summarize that laparoscopic median gastrectomy to deal with gastric stenosis after LSG is a safe and feasible option in patients who failed endoscopic treatment and in whom there is a desire to avoid seromyotomy or conversion to gastric bypass. Disclosures The authors have no commercial associations that might be a conﬂict of interest in relation to this article. References  Tzovaras G, Papamargaritis D, Sioka E, et al. Symptoms suggestive of dumping syndrome after provocation in patients after laparoscopic sleeve gastrectomy. Obes Surg 2012;22:23–8.  Gagner M, Deitel M, Erickson AL, Crosby RD. Survey on laparoscopic sleeve gastrectomy (LSG) at the Fourth International Consensus Summit on sleeve gastrectomy. Obes Surg 2013;23:2013–7.  Burgos AM, Csendes A, Braghetto I. Gastric stenosis after laparoscopic sleeve gastrectomy in morbidly obese patients. Obes Surg 2013;23:1481–6.  Dapri G, Cadière GB, Himpens J. Laparoscopic seromyotomy for long stenosis after sleeve gastrectomy with or without duodenal switch. Obes Surg 2009;19:495–9.  Parikh A, Alley JB, Peterson RM, et al. Management options for symptomatic stenosis after laparoscopic vertical sleeve gastrectomy in the morbidly obese. Surg Endosc 2012;26:738–46.  Yuval JB, Mintz Y, Cohen MJ, Rivkind AI, Elazary R. The effects of bougie caliber on leaks and excess weight loss following laparoscopic sleeve gastrectomy. Is there an ideal bougie size? Obes Surg 2013;23: 1685–91.  Yehoshua RT, Eidelman LA, Stein M, et al. Laparoscopic sleeve gastrectomy—volume and pressure assessment. Obes Surg 2008;18: 1083–8.  Vilallonga R, Himpens J, van de Vrande S. Laparoscopic management of persistent strictures after laparoscopic sleeve gastrectomy. Obes Surg 2013;23:1655–61.  Parikh M, Gagner M. Laparoscopic revision of gastrogastric stricture with a transoral circular stapler. Surg Innov 2007;14:225–30.