Access to the Bypassed Stomach after RYGB

by Gregory Dakin, MD

Assistant Professor of Surgery, Weill Medical College of Cornell University, New York, New York

Introduction

Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed bariatric operations in the United States, accounting for approximately 80 percent of all bariatric procedures performed in this country.[1,2] The operation can be done laparoscopically or by conventional open surgical techniques, and involves partitioning a small gastric pouch off the proximal stomach and attaching that pouch directly to the intestine, thereby excluding, or bypassing, the large remainder of the stomach.[3,4] While the operation is highly successful in inducing significant weight loss and resolution of comorbidities, one obvious drawback is that the gastric remnant and biliary tree are no longer available for routine endoscopic or radiographic examination.

Given the rapidly increasing numbers of patients undergoing gastric bypass,[1] access to the gastric remnant may become an important part of the surgeon’s role in caring for the bariatric patient. This article will review the indications for accessing the gastric remnant after RYGB and the new strategies available for handling this problem.

The Need for Access

Access to the gastric remnant can become necessary in a variety of clinical situations, beginning in the early postoperative period and continuing throughout the life of the patient. Hemorrhage from staple lines in the early postoperative period may necessitate transgastric endoscopy.[5] Acute gastric distention is an infrequent but well known complication,[6] which is often treated initially with gastrostomy drainage of the remnant until the underlying pathology resolves or can be definitively addressed. In patients with severe complications due to leaks at the gastrojejunostomy, enteral feeding access via the gastric remnant can be lifesaving. In patients who develop severe malnutrition either due to complications or strictures, enteral feeding via the remnant can also restore nutritional status prior to difficult revisional surgery.

Gastrointestinal (GI) bleeding has been reported to occur due to peptic ulcer disease in the gastric remnant and is a common cause for evaluation of the bypassed stomach. One retrospective series found 8 of 3,000 patients with hemorrhage from peptic ulcer disease,[7] while other case reports have documented this problem in a few patients up to 17 years after gastric bypass.[8] Perforations of the gastric remnant have been reported in 11 of 4,300 patients.[9] Rare cases of gastric cancer and intestinal metaplasia have also been reported and may necessitate access to the gastric remnant.[10-14]

Finally, problems with the biliary tree may require access to the bypassed stomach. The reported high incidence of stone formation during rapid weight loss had been considered an indication for prophylactic cholecystectomy at the time of RYGB.[15] While management of the gallbladder in patients undergoing gastric bypass remains controversial, many surgeons currently do not advocate routine cholecystectomy at the time of RYGB.[16–18] Given the increasing number of patients undergoing surgery and the high rate of gallstone formation, ensuing problems are likely to rise in number, increasing the need for transgastric access to evaluate and instrument the biliary tree.

Gastrostomy Tube Placement

Because of the many varied indications and inherent difficulties in accessing the bypassed stomach, some authors have advocated the routine placement of gastrostomy tubes at the time of RYGB. In the initial description of the Fobi pouch operation, an 18F gastrostomy tube is placed in the stomach and the site is pexed to the anterior abdominal wall.[19] The tube is used for supplemental feedings and/or medications if required and usually removed at the first postoperative visit in 7 to 10 days. Additionally, a circular, radio-opaque marker is sutured around the site of the tube on the stomach during surgery to facilitate later percutaneous access. Under fluoroscopic guidance, a needle can be placed into the stomach through the marker and exchanged over a guidewire for a gastrostomy tube. The tract can also be dilated for endoscopic evaluation and biopsy.[20]

Routine placement of a gastrostomy tube at the time of RYGB may certainly be useful in the few patients that experience early severe problems. However, given that the rate of these severe complications is fairly low, this strategy would likely lead to large numbers of unnecessary gastrostomy tubes. Furthermore, recent reports demonstrate several minimally invasive ways to access the gastric remnant when the need arises, thereby permitting a more selective approach.

Ultrasound

Ultrasound guidance is relatively inexpensive, widely available, and has been used successfully to access the gastric remnant after gastric bypass.[21] In a report of three patients with severe GI bleeding, all patients underwent successful percutaneous access to the remnant under ultrasound guidance. The procedures were performed under local anesthesia with sedation. In addition to conventional barium studies, the gastrostomy tracts were able to be dilated to permit endoscopic evaluation and biopsy. This technique permitted the authors to exclude serious gastroduodenal pathology as a causative factor in their patients.

Computed Tomography (CT)

CT-guided access has also been performed successfully. In one retrospective review, 10 of 569 laparoscopic RYGB patients underwent CT-guided percutaneous gastrostomy. The indications were dilated gastric remnant, nutritional access, and drainage after leak. Two of the patients had prior gastric surgery. Placement was done under local anesthesia and was successful in greater than 90 percent of patients. All of the tubes allowed adequate drainage and permitted definitive operative treatment in an elective setting.[22] Other groups have reported CT- and fluoroscopically-guided access to the gastric remnant. From these percutaneously placed tubes, they were able to perform transgastric gastroduodenoscopy and in some cases endoscopic retrograde cholangiopancreatography.[23]

Laparoscopic Access

If percutaneous access to the gastric remnant is not possible, either because of lack of interventional equipment or personnel or because of intervening anatomic structures, laparoscopic access can provide a minimally invasive alternative. One group retrospectively identified 8 out of 700 laparoscopic RYGB patients who had undergone laparoscopic-assisted transgastric endoscopy.[24] An additional two open RYGB patients were included in the study. The indications for evaluation included biliary problems (5), GI bleed (3), and abdominal pain (2). After diagnostic laparoscopy, a gastrostomy was created and a 15mm trocar was secured into the stomach using a purse-string suture. Intraoperative endoscopy was then performed via this site, including successful ERCP and sphincterotomy in 4 of 5 patients. In the remaining five patients, pathology was either confirmed or excluded. The gastrostomy site was then closed with either sutures or stapling.

Endoscopic Access

Standard endoscopy has been used to evaluate the gastric remnant in a retrograde fashion; however, it is often difficult or impossible to traverse the length of the biliopancreatic limb and arrive at the gastric remnant.[25] Double-balloon enteroscopy (DBE) is a new technique that allows examination of great lengths of small bowel by enabling reduction of loops that form as the endoscope is advanced. This technique was used to perform standard percutaneous endoscopic gastrostomy (PEG) placement in the gastric remnant in 3 of 4 patients after RYGB.[26] In the fourth patient, access to the stomach was achieved; however, PEG placement was unsuccessful due to lack of good abdominal transillumination.
Virtual endoscopy may permit visualization of the excluded stomach without the need for percutaneous gastric access. The native stomach has been studied by virtual gastroscopy, yielding both two-dimensional and reconstructed three-dimensional intraluminal images. One group applied this technology to five RYGB patients to examine the gastric remnant.[27] The procedure was well tolerated in all and yielded an excellent intraluminal view of the excluded stomach and duodenum.

This technology holds the potential for noninvasive follow-up of the growing number of gastric bypass patients and in some cases may provide diagnostic information without the need for invasive percutaneous access.

Conclusion

Currently it is a minority of patients who will require access to or evaluation of the excluded stomach and biliary tree after RYGB. However, given the increasing numbers of gastric bypass procedures being performed, more patients may likely require such access in the future. Routine gastrostomy does not appear necessary given the numerous successful alternatives that have been described in the literature. The choice of technique will depend on available expertise and indications for access. A thorough knowledge of these various options is important for the surgeon to provide comprehensive care to the bariatric patient.

References

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Category: Past Articles, Review