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JVS-446; No. of Pages 6

Journal of Visceral Surgery (2014) xxx, xxx—xxx

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SURGICAL TECHNIQUE

Conservative surgical management of persistent leak after sleeve gastrectomy by Roux-en-Y gastro-jejunostomy to the fistulous orifice C. Blot , C. Mouly , L. Rebibo , A. Dhahri , J.-M. Régimbeau ∗ Service de chirurgie digestive et oncologique, hôpital Nord, CHU d’Amiens, place Victor-Pauchet, 80054 Amiens cedex 01, France

KEYWORDS Sleeve gastrectomy; Chronic fistula; Roux-en-Y limb



Corresponding author. E-mail address: [email protected] (J.-M. Régimbeau).

http://dx.doi.org/10.1016/j.jviscsurg.2014.10.007 1878-7886/© 2014 Elsevier Masson SAS. All rights reserved.

Please cite this article in press as: Blot C, et al. Conservative surgical management of persistent leak after sleeve gastrectomy by Roux-en-Y gastro-jejunostomy to the fistulous orifice. Journal of Visceral Surgery (2014), http://dx.doi.org/10.1016/j.jviscsurg.2014.10.007

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Introduction

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Patient position — instrumentation—surgical approach — abdominal exploration

Gastric fistulas are the principal post-operative complication after sleeve gastrectomy, occurring in 2 to 4% of cases [1]. Early anastomotic leak and/or poorly-tolerated fistula may require surgical re-intervention for drain placement to adequately redirect the fistulous drainage and for insertion of a jejunal feeding tube [2]. Secondary treatment may involve endoscopic placement of coated stents or double-pigtail catheters. A gastric fistula may become chronic — the prevalence ranging from 26 to 33% in various series — as evidenced by persistent need for prosthetic stenting or by ongoing flow of digestive secretions along an established drain tract. Management of chronic fistulas may require a surgical reintervention consisting of either a total gastrectomy with esophago-jejunal anastomosis, a Roux-en-Y gastric bypass, or a gastro-jejunal anastomosis to the gastric fistulous orifice. Pre-operative optimization of nutrition is essential in malnourished patients with chronic sepsis. The patient should be informed that surgery routinely requires splenectomy. There are currently no data on the appropriate time interval for surgery after diagnosis of a chronic fistula. Performance of a Roux-en-Y gastrojejunal anastomosis applied to the fistulous orifice is the most conservative surgical re-intervention. The advantage of this technique should be decreased short-term morbidity [3] and avoidance of a malabsorption-prone montage since the food bolus continues to pass through the tubulized gastric sleeve.

The patient is positioned supine with legs together and arms extended at 90◦ . A roll is placed beneath the shoulder blades to facilitate access to the left sub-diaphragmatic space. The surgeon stands on the patient’s right with the first assistant and scrub nurse on the left. A midline epigastric incision is made, extending below the umbilicus if necessary. A laparoscopic approach is also feasible but demands great proficiency in laparoscopy and particularly in laparoscopic bariatric surgery since adhesions may mask visualization of the different anatomic structures rendering surgery difficult.

Please cite this article in press as: Blot C, et al. Conservative surgical management of persistent leak after sleeve gastrectomy by Roux-en-Y gastro-jejunostomy to the fistulous orifice. Journal of Visceral Surgery (2014), http://dx.doi.org/10.1016/j.jviscsurg.2014.10.007

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Conservative surgical management of persistent anastomotic leak

Freeing up of the tubulized gastric 3 sleeve

The first step consists of freeing up omental adhesions, which are often extensive beneath the liver, at the edge of the left hepatic lobe and overlying the spleen; this allows visualization of gastric sleeve throughout its entire length. The appearance at surgery is somewhat like a reconstituted ‘‘neo-gastro-epiploic ligament’’. The anastomotic leak and its fistulous tract are identified; in two-thirds of cases, the leak lies in the upper part of the gastric staple line. The stomach is freed from its neo-omental attachments, beginning at a point about 6 cm proximal to the pylorus. Division of the « neo-gastro-epiploic ligament » allows entry into the lesser sac. By following along the posterior aspect of the stomach, the anterior aspect of the pancreas is visualized out to the splenic hilum. This may facilitate the routine performance of splenectomy. Division of the « gastro-epiploic ligament » is pursued up to the level of the anastomotic leak.

Liberation of the splenic hilum and 4 vascular control of the spleen

By following the anterior surface of the pancreas, the splenic hilum is carefully dissected, allowing isolation and individual control of the splenic artery and vein. After ligature of the elements of the splenic pedicle, splenectomy is performed by the classical technique.

Please cite this article in press as: Blot C, et al. Conservative surgical management of persistent leak after sleeve gastrectomy by Roux-en-Y gastro-jejunostomy to the fistulous orifice. Journal of Visceral Surgery (2014), http://dx.doi.org/10.1016/j.jviscsurg.2014.10.007

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Dissection of the gastric fistula

Dissection of the fistulous tract may be facilitated by encircling the tract with a loop. The resection of the fistula should be complete and may be helped by instillation of blue dye intra-operatively. If endoscopically-placed prosthetic material is still in place (i.e. double pigtail catheter), it may facilitate dissection of the tract; it should be removed at the end of the dissection. The edges of the gastric fistulous opening should be resected and the proximal end of the gastric sleeve should be completely freed up, particularly on its posterior aspect, to allow performance of a gastro-jejunal anastomosis under optimal conditions.

Please cite this article in press as: Blot C, et al. Conservative surgical management of persistent leak after sleeve gastrectomy by Roux-en-Y gastro-jejunostomy to the fistulous orifice. Journal of Visceral Surgery (2014), http://dx.doi.org/10.1016/j.jviscsurg.2014.10.007

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Conservative surgical management of persistent anastomotic leak

Side-to-side gastro-jejunal 6 anastomosis of the fistulous orifice to a Roux-en-Y jejunal limb In principal, the Roux jejunal limb should not be too long in order to limit the risk of malabsorption and malnutrition in patients who are already at risk. The jejunum is laid out and divided 30 cm downstream from the ligament of Treitz with a double staple line. The jejunal limb is brought up through an opening in the transverse mesentery and approximated to the gastric fistulous orifice. The proximal end of the jejunal limb is then opened on its anti-mesenteric border over a distance of 3 cm. The anesthetist passes a naso-gastric tube down to the stomach that is then led out through the fistula orifice to intubate the gastro-jejunal anastomosis that will be constructed. The anastomosis is performed using interrupted sutures of 4-0 monofilament, taking care to include the full thickness of the gastric wall and the mucosal and submucosal plane of the jejunum. A few additional interrupted sutures are placed between the gastric and jejunal serosa to prevent tension on the anastomosis. The jejuno-jejunal anastomosis at the base of the Roux limb is performed 60 cm downstream from the gastro-jejunal anastomosis using 4-0 monofilament. The passage of the limb through the transverse mesentery must be checked to be sure there is no constriction. Water-tightness of the gastro-jejunal anastomosis is tested by instillation of blue dye.

Please cite this article in press as: Blot C, et al. Conservative surgical management of persistent leak after sleeve gastrectomy by Roux-en-Y gastro-jejunostomy to the fistulous orifice. Journal of Visceral Surgery (2014), http://dx.doi.org/10.1016/j.jviscsurg.2014.10.007

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Placement of a jejunal feeding tube 7 and drains in proximity to the gastro-jejunal anastomosis A feeding tube is routinely placed in the jejunum downstream of the jejuno-jejunal anastomosis at the end of the procedure to allow early enteric feeding. After making sure that the naso-gastric tube is correctly placed within the gastro-jejunal anastomosis, it is fixed in place. Two drains are placed anterior and posterior to the gastro-jejunal anastomosis and led out through the right flank. These will permit both drainage and irrigations in the event of a post-operative anastomotic fistula.

Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.

References [1] Parikh M, Issa R, McCrillis A, Saunders JK, Ude-Welcome A, Gagner M. Surgical strategies that may decrease leak after laparoscopic sleeve gastrectomy: a systematic review and metaanalysis of 9991 cases. Ann Surg 2013;257:231—7. [2] Rebibo L, Dhahri A, Verhaeghe P, Regimbeau JM. Early gastric fistula after laparoscopic sleeve gastrectomy: surgical management. J Vis Surg 2012;149:e319—24. [3] Serra C, Baltasar A, Pérez N, Bou R, Bengochea M. Total gastrectomy for complications of the duodenal switch, with reversal. Obes Surg 2006;16:1082—6.

Please cite this article in press as: Blot C, et al. Conservative surgical management of persistent leak after sleeve gastrectomy by Roux-en-Y gastro-jejunostomy to the fistulous orifice. Journal of Visceral Surgery (2014), http://dx.doi.org/10.1016/j.jviscsurg.2014.10.007

Conservative surgical management of persistent leak after sleeve gastrectomy by Roux-en-Y gastro-jejunostomy to the fistulous orifice.

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