Proximal Gastrectomy with Esophago-Jejunostomy and Roux-en-Y Reconstruction for Chronic Staple Line Disruption after Sleeve Gastrectomy

| June 13, 2013

This column recruits expert surgeons to share step-by-step technical pearls on bariatric procedures.

Column Editors: Raul J. Rosenthal, MD, FACS, FASMBS, and Daniel B. Jones, MD, MS, FACS

This Month’s Technique: Proximal Gastrectomy with Esophago-Jejunostomy and
Roux-en-Y Reconstruction for Chronic Staple Line Disruption after Sleeve Gastrectomy

This Month’s Featured Expert: Charles E. Thompson, III, MD, Cleveland Clinic Florida, Weston, Florida

Funding: There was no funding for the preparation of this manuscript.

Disclosures: The author reports no conflicts of interest relevant to the content of this article.

Bariatric Times. 2013;10(6):10–11.

Introduction
The past five years have seen a sharp increase in the number of laparoscopic sleeve gastrectomies (LSG) performed for the purpose of weight loss and comorbidity resolution.1 Despite the LSG being a safe and effective procedure, no surgical operation is without the possibility of complications. The most dreaded surgical complication a surgeon can encounter after performing an LSG is a proximal leak from a disrupted staple line. In my experience, performing an LSG creates the longest staple line in intra-abdominal surgery. The resultant narrowed, tubular structure is subjected to increased pressures intraluminally because of the pylorus and, presumably, intact lower esophageal sphincter complex. The increased intraluminal pressure, combined with decreased blood supply at the greater curvature places the sleeve at particular risk of leakage, especially near the region of resected fundus. However, despite these physiologic derangements, the literature reports sleeve leak rates that rival those of gastric bypasses.[1]

In managing staple-line leaks in patients undergoing LSG, it is clear that drainage of the resultant abscess cavity is paramount. What is not so clear is the management of chronic leaks that can form following drainage. Several nonoperative and operative techniques for the treatment of chronic leaks after LSG have been described in the literature without one particular approach serving as a standard.[2] Sealants, stents, suture repair, prolonged nil per os (NPO), and total parenteral nutrition (TPN) have all been described with varying results and success. In an attempt to cure patients with chronic proximal leaks of the staple line after LSG, I perform proximal gastrectomy with Roux-en-Y esophagojejunostomy. Here, I describe this technique.

Surgical Technique
The procedure begins with dissecting through the pars flaccida and exposing the right crus of the diaphragm (Figure 1). In the large majority of cases, this area is clean and has not been disturbed from the previous operation. A large orogastric tube is then passed to identify the esophagus. Next, careful dissection is carried out posterior to the esophagus to identify the left crus (Figure 2). The left gastric artery is ligated with a linear stapler (Figure 3). Attention is then turned toward the greater curvature of the previously fashioned sleeve where all adhesions are taken (Figure 4) down up to the gastroesophageal junction (GEJ). The GEJ and esophagus are now completely mobilized (Figure 5). The esophagus is transected with a blue cartridge linear stapler immediately proximal to the GEJ (Figure 6) and the mid stomach is transected with a green cartridge linear stapler (Figure 7). The jejenum is transected 50cm distal to the ligament of Trietz, creating the biliopancreatic and an alimentary limb proximally (Figure 8). The distal jejunum is brought up to the esophagus in an antecholic fashion and a latero-lateral esophagojejunal anastomosis is fashioned using a blue cartridge linear stapler (Figure 9). This is closed with double layer, hand-sewn running 2-0 Vycril sutures (Figure 10). One-hundred centimeters from the esophagojejunostomy, the jejunojejunostomy is fashioned using two firings of a blue cartridge linear stapler (Figure 11) and closing the enterotomy with a blue cartridge linear stapler (Figure 8). A gastrostomy tube is placed in the distal gastric remnant as needed. Drains are then placed in the subhepatic space.

Final Thoughts
From my experience, the treatment of chronic staple-line leaks after LSGs have been treated with more success than any other modality. Before proceeding with this operation, it is essential that infection control in the left upper quadrant is achieved.

References
1.    Hutter MM, Schirmer BD, Jones DB, et al. First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann Surg. 2011:254(3):410–420.
2.    Sakran N, Groitein D, Raziel A, et al. Gastric leaks after sleeve gastrectomy: a multicenter experience with 2,834 patients. Surg Endosc. 2013;27(1):240–245

Category: Past Articles, Surgical Pearls: Techniques in Bariatric Surgery

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