OBES SURG (2014) 24:425–429 DOI 10.1007/s11695-013-1162-1
Laparoscopic Total Gastrectomy with Roux-Y Esophagojejunostomy for Chronic Gastric Fistula After Laparoscopic Sleeve Gastrectomy Almog Ben Yaacov & Eran Sadot & Matan Ben David & Nir Wasserberg & Andrei Keidar
Published online: 19 December 2013 # Springer Science+Business Media New York 2013
Abstract Laparoscopic sleeve gastrectomy is a restrictive operation with hormonal elements that is rapidly gaining popularity. The most feared complication of the procedure is a staple line leak. The treatment of staple line leakage depends on timing and clinical and anatomical considerations. If leakage persists and transforms into a chronic fistula, a definitive surgical procedure is required. In cases where the fistula originates close to the esophagogastric junction, the surgical possibilities are limited and one treatment option is total gastrectomy with esophagojejunal anastomosis. We report a case series of four patients with chronic fistulae, who failed conservative treatment and required total gastrectomy. Their average length of hospital stay was 8.7 days (range, 5–15 days), without conversions, leaks, or other complications. In experienced hands, total gastrectomy is feasible by laparoscopic techniques and should be performed soon after the fistula is established. Keywords Laparoscopic sleeve gastrectomy complications . Leak . Fistula . Laparoscopic total gastrectomy . Esophagojejunal anastomosis A. Ben Yaacov : E. Sadot : M. Ben David : N. Wasserberg : A. Keidar The Department of Surgery, Rabin Medical Center, Campus Beilinson, Petach Tiqva, Israel
Background Laparoscopic sleeve gastrectomy (LSG) is a restrictive operation with a presumed strong hormonal component. LSG is indicated as an isolated technique or as the first part of a duodenal switch [1–3], and its most feared complication is staple line leakage. Treatment of staple line leakage depends on timing (acute, early, and late), clinical condition (presence of peritonitis, stability, and extent of spillage), and anatomical site (proximity to the esophagogastric junction (EGJ), Fig. 1) [4–9]. The first-line treatment includes drainage (operative or nonoperative), and coated self-expanding stents [4, 8, 9] or leakage-site clipping [10–12]. In most patients, adequate drainage and leak control allow the body to form a seal around the drain and resolves the leak. In a minority of patients, the leak transforms into a chronic fistula [12, 13]. Definitive surgical treatment is required in many cases of persistent fistula. The choice of procedure depends on the considerations cited above and on available surgical expertise. We report on four patients with chronic staple line leakage in close proximity to the EGJ that progressed to chronic fistulae. All patients failed multiple attempts at conservative treatment and required total gastrectomy with esophagojejunal anastomosis.
E. Sadot e-mail: [email protected]
M. Ben David e-mail: [email protected]
N. Wasserberg e-mail: [email protected]
A. Keidar e-mail: [email protected]
A. Ben Yaacov (*) The Department of Surgery, Beilinson Hospital, Jabotinsky 39, Petach Tiqva, Israel e-mail: [email protected]
Patient 1 (Table 1)
A 35-year-old man was transferred to our hospital 40 days after LSG. On the second postoperative day (POD), a leak had appeared from the proximal staple line. The patient was managed conservatively and underwent endoscopic stent placement on POD 14. The leak reappeared 3 weeks later. The stent was removed, and the fistula opening was observed to be 2 cm from the EGJ. Because of the large diameter of the fistula
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Fig. 1 Operative views. a the esophagogastric junction after completion of esophageal dissection; b closure of the anastomosis
(1 cm), over-the-scope clip placement was not possible. Percutaneous drain repositioning improved leak control, and the patient was discharged home, but returned with exacerbation of the leak. His clinical condition was stable, and the leak was minor. Treatment options were discussed with the patient, and he underwent laparoscopic total gastrectomy.
Patient 2 A 39-year-old morbidly obese woman underwent LSG at our institution 6 weeks prior to readmission. Very proximal staple line leakage was confirmed radiographically. Multiple percutaneous drainages achieved optimal leak control. Despite a prolonged course of intensive conservative treatment intended to induce spontaneous fistula closure, the fistula persisted. The patient refused stent insertion. Gastroscopy showed a 5-mm fistula at the proximal staple line. A 12-mm “over-the-scope” clip was applied but did not seal the fistula. Four months after LSG, the patient underwent laparoscopic total gastrectomy.
Patient 3 A 47-year-old woman underwent laparoscopic band removal and immediate sleeve gastrectomy at our institution. The patient was reoperated 2 days later because of a leak, which was identified and sutured, but which persisted. After a 2-month hospital stay with conservative treatment that included several percutaneous drainages and intensive nonoperative management, clinical and radiographic resolution of the fistula was obtained. The drain was removed, the patient continued with regular follow-ups, and was considered healed. Nine months later, the patient was readmitted with a massive left flank soft tissue infection and an inflammatory process in the left upper quadrant. After drainage, a recurrent fistula from the sleeve to the abdominal wall was found. The patient had a very protracted course with multiple drainage procedures. The origin of the fistula was visualized on endoscopy, but the patient refused stent or clip placement. Biologic glue was injected percutaneously into the fistulous tract, with good temporary response. The patient was discharged, but 1 month
Table 1 Clinical and demographic features of the patients, and the summary of their treatment Patient/age/sex
Weight/BMI before LSG
Time to surgery (months)
Operative time (hours)
Weight at the time of TG/at last follow-up
1/35/M 2/38/F 3/41/F
117/45 106/42.4 140/49
3 4 18
Proximal staple line Proximal staple line Proximal staple line
3 3:15 4:35
5 8 15
84/81 68/69 105/93
Stent×1, drainage×3 Drainage×1, clip×1 Lap suturing+drainage, percutaneous drainage×6, biological glue×1 Drainage×5, stent×3, ovesco×7, biological glue×1
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later, the leak recurred. Eighteen months after LSG, the patient underwent laparoscopic total gastrectomy. Aside from superficial infection in the left flank at the prior fistula opening, the course was uneventful.
Patient 4 A 21-year-old morbidly obese woman presented to us from another hospital for “elective” laparoscopic total gastrectomy 2 years post-LSG. This patient had already undergone extensive conservative treatment, with endoscopic stents three times, “over-the-scope” clip deployment seven times, and biological glue injection once, with no resolution of the fistula. She was on total parenteral nutrition, staying mostly at home, with intermittent hospitalization. The patient was in good general condition, with no signs of sepsis. She underwent laparoscopic total gastrectomy.
Methods In all cases, the preoperative decision to perform total gastrectomy was made, based on the very high position of the fistula. The operation commenced with release of adhesions. The lesser omentum was opened, and the stomach was encircled, dissected, and transected distal to the pylorus. Next, the sleeve was turned up, and the release continued to the upper portion of the stomach. Because the fistulae were always directed to the left, adhesions were less severe on the right side. Therefore, we started upward dissection on the right side. We first identified the right crus. Moving cranially usually exposed the relatively intact mediastinal areolar tissue and allowed identification of Fig. 2 The resected stomach. a general view; b the enormous thickness of the stomach wall in the area of the fistula; c the well epithelialized fistular opening
the esophagus on the right. The left gastric artery was divided with a vascular stapler. Adhesions on the left were usually so fibrotic and edematous that the anatomy was difficult to identify. Extreme care was taken to identify the splenic vessels, spleen, diaphragm, and pleura. Despite caution, left pneumothorax was observed in three cases. The only treatment required in these cases was a decrease in intraabdominal pressure. The hiatus and left crus were freed, and the intrathoracic esophagus was dissected as far as possible, which allowed for lowering of the gastroesophageal junction. Healthy esophagus was divided with a linear stapler. At this stage, jejunojejunostomy with a Roux limb length of approximately 50–70 cm was constructed. The esophagojejunostomy was performed using a linear endoscopic stapler. The anterior esophagotomy was prepared in advance at the lower end of the esophageal stump. The tip of the Roux limb was brought close to the hiatus, and one jaw of the stapler inserted through an enterotomy. The opposite jaw was introduced into the esophagotomy, and both jaws were inserted as deep as possible to allow for a wider stoma, creating a side-to-side anastomosis. The common enterotomy was closed with two layers of running 3/0 polydioxanone (PDS) suture over the nasogastric tube. Drains were placed on two sides of the anastomosis. A blue dye leak test was performed. On POD 1, all patients underwent a contrast study to exclude leaks and were allowed to have clear liquids. All patients were followed up in the bariatric clinics and were advised to take vitamins as gastric bypass patients.
Results We performed four laparoscopic total gastrectomy and esophagojejunal anastomosis procedures over 1.5 years.
Demographic and clinical features of the patients and their operative results are presented in Table 1. The operation was undertaken 12 months after the original sleeve gastrectomy, on average (range, 3–24 months). The average hospital stay was 8.7 days (range, 5–15 days). There were no conversions, leaks, or other complications. One patient developed wound infection at the skin opening of the fistula 3 months after surgery and underwent drainage. There were no rehospitalizations. All patients are followed up regularly according to the routine bariatric clinic schedule. The average follow-up at the time of this writing was 7 months (range, 3–21 months). All patients are specifically questioned about their eating habits, and functional results after total gastrectomy do not seem to differ from sleeve gastrectomy. All patients consume a wide variety of foods, including meats and vegetables, and have experienced no chronic vomiting or diarrhea. Only one patient eats frequent small meals (every 2 h), and her weight is stable. There were no clinical manifestations of stricture. Interestingly, almost no weight loss was observed after total gastrectomy (Table 1).
Discussion LSG is one of the most popular bariatric procedures today. LSG has a relatively fast learning curve, produces good results with a low complication rate, and is performed in many centers . One of the most severe complications is staple line leakage, which can be life-threatening. There are many ways to treat leaks, and algorithms on how to treat them have been advised [3, 13]. The operative treatment of leaks beyond POD 1–3 (acute leak) can be simply to improve drainage, thus providing local conditions conducive to spontaneous closure. A good example of acute treatment is T-tube insertion into the stomach through the fistula opening, as described by Rosental and colleagues . More definitive surgical options include conversion of the sleeve to a regular Roux-Y gastric bypass, or anastomosis of the jejunal Roux limb to the fistula. The short distance from the EGJ to the fistula does not allow pouch construction above the leak in most cases, making the first option impossible. Therefore, the latter approach is the only viable option in leaks located near the EGJ. The first description of this technique is ascribed to Baltasar et al. , who performed the procedure through laparotomy. Recently, van de Vrande et al. reported laparoscopic Roux limb placement in 11 patients (16). In their report, leakage persisted in 46 % of patients and healed on average at 12 days (range, 2–38 days). We believe that the chances for anastomosis healing are the highest when performed in completely healthy tissue. The likelihood of persistent leakage in cases where an anastomosis is performed to a severely inflamed and thickened stomach is high. In some cases (Fig. 2), stomach wall thickness around the fistula can
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reach 1.5 cm. This report only confirms our assumption . Stomach resection and restoration of continuity to intact esophageal tissue was also reported by Suter et al. , who described anastomosis to the lower esophagus in cases of “difficult” EGJ during standard Roux-Y gastric bypass after prior vertical banded gastroplasty. Both in their report and in our series, no specific nutritional problems were encountered. Total gastrectomy as a final operation for complications of sleeve gastrectomy has been reported by Baltasar et al. , who performed the procedure by laparotomy. Recently, this approach was also mentioned by Moszkowicz , who reported on seven patients who required total gastrectomy for devastating complications, all performed by laparotomy. It is crucial that patients be treated in a center with full intensive care and with gastroenterological and radiological backup. The patient's metabolic status is one of the most important factors contributing to healing. It is highly important that patients be well beyond the septic and catabolic state and that nutritional and vitamin status approach be normal. Surgery should be postponed in patients with systemic and organ dysfunction. We believe that prolonged nonoperative management of high chronic leaks after LSG with a range of repetitive endoscopic therapies beyond the 3-month period is futile. After the fistula has been epithelialized (Fig. 2), the chances for healing are low. One or two modalities should be tried, and the choice will depend on available local institutional expertise. If these attempts are unsuccessful, further definitive surgical treatment should be considered.
Conclusion In a small percentage of patients with leaks after LSG, a persistent fistula will develop and definitive surgical treatment will be required. The choice of procedure depends on anatomical considerations and on the surgical expertise available. In cases where the fistula originates very close to the EGJ, the safest option is total gastrectomy with esophagojejunal anastomosis. This operation is feasible by laparoscopic techniques in experienced hands.
Conflict of interest The authors declare no conflict of interest.
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