Bridging the Gap Between Gastric Pouch and Jejunum

A Bariatric Nightmare

Noëlle Geubbels; Ingrid Kappers; Arnold W. J. M. van de Laar

Disclosures

BMC Surg. 2015;15(68) 

In This Article

Case Presentation

Brief Description of Our Standardized Surgical Technique

A 20 mL gastric pouch is created with the use of two to three 60 mm linear staplers (Endo GIA, Covidien and Dublin, Ireland). At approximately 40 cm proximal to the ligament of Treitz the jejunum is grasped and mobilized to the gastric pouch. The posterior side of the gastrojejunostomy is stapled with a 30 mm linear stapler and the anterior side is hand sewn with an absorbable unidirectional barded 3–0 V-Loc™ suture (Covidien, Dublin, Ireland). At about 150 cm a fully stapled jejunojejunostomy is created with two linear 60 mm staplers. Then the jejunum is transected between the two anastomoses using a 60 mm linear stapler without division of the mesentery. The gastrojejunal anastomosis is tested for leakage with methylene blue through the orogastric tube. There is no routine placement of drains. The orogastric tube is removed at the end of surgery. The patients are allowed a clear fluid diet when fully recovered from anaesthesia. No routine radiographic swallow series are obtained. All patients receive subcutaneous low molecular weight heparin during the first two weeks after surgery as thromboprophylaxis. The patient's diet is gradually expanded to a full liquid during their admission and continued for two weeks. All patients receive supplementary vitamins and a proton pump inhibitor.

The Patient. In December 2012, a 49 year old male was scheduled for laparoscopic Roux-en-Y gastric bypass surgery (LRYGB). At the time of surgery his weight was 138.2 kg with a Body Mass Index (BMI) of 45.1 kg/m2. His past medical history revealed Obstructive Sleep Apnea (OSA), for which he uses Continuous Positive Airway Pressure (CPAP) therapy, Chronic Obstructive Pulmonary Disease (COPD) stage GOLD 2, Post-Traumatic Stress Disorder (PTSD) after a car accident and non-ST elevated myocardial infarction (NSTEMI) for which he underwent a successful percutaneous coronary intervention (PCI) of the ramus circumflexus of his left coronary artery. During his medical screening the patient was diagnosed with Type 2 Diabetes Mellitus (T2DM) 'de novo', which was treated with oral medication. The patient's cardiac, respiratory, and endocrinological function were well assessed prior to surgery and optimally regulated.

During the surgery of this patient we where forced to make several deviations from our standardized protocol. The subheadings correspond to the headings of the accompanying video.

Identification of the Ligament of Treitz and Discovery of the Short Mesentery. After positioning the patient, the introduction of the ports, the creation of a 20 ml gastric pouch and the division of the (very bulky) omentum, the ligament of Treitz is identified. When measuring the jejunum from the ligament of Treitz is becomes apparent that the mesentery is very short. It is not possible to mobilize the jejunum over the transverse colon (antecolic route) and the remnant stomach (antegastric route). The distance between the jejunum is about 8 cm. We measured this distance with the aid of marking on our graspers.

Transection of the Jejunum and Division of the Mesentery. In order to create the alimentary limb, the jejunum is transected at the point where the distance to the proximal gastric pouch is the shortest. To further mobilize the alimentary limb, the mesentery is divided with the ultracision harmonic scalpel.

Placement of a Marker Stitch in the Alimentary Limb. A marker stitch (vicryl 2.0, Ethicon Inc. Johnson, & Johnson, New Brunswick, New Jersey, USA) is placed to mark the alimentary limb. Later, this stitch will be used to pull the limb through the retrocolic route.

Dissection of the Gastro-oesophageal Junction From the Crus. To lengthen the proximal gastric pouch, first the gastro-oesophageal junction is dissected from the crus by transecting the phrenoesophageal ligament on both sides. This technique lengthens the proximal pouch about 2 cm. Because of the traction caused by the gastrojejunostomy, we decided no fixation was needed.

Stretching the Pouch. Consecutively the pouch is stretched. This is achieved by grasping the pouch on both sides and to pull the pouch caudally for about 1 min. This manipulation of the pouch will gain another 0.5 cm.

Creation of the Retrocolic Route Through the Mesocolon. The retrocolic route is created starting on the caudal side of the mesocolon using the ultracision harmonic scalpel.

Pulling the Alimentary Limb Through the Retrocolic/Retrogastric Route. When completed, the marker stitch is placed in the retrocolic 'tunnel'. The mesocolon is folded down. Cranially of the mesocolon, the marker stitch is found. The jejunum is retracted by pulling the marker stitch whilst retracting the gastric remnant caudally.

Creation of the Hand-Sewn Gastrojejunostomy – The Posterior Sutures. It becomes apparent that a stapled anastomosis between the gastric pouch and the jejunum is not preferable due to the foreseen tension on this stapler line. Therefore, we decided to make a full hand-sewn anastomosis with V-Loc™ sutures.

Creation of the Gastro—And the Jejunotomy. A defect is created in the gastric pouch and the jejunum using the ultracision harmonic scalpel.

Introduction of the 34 Ch Orogastric Tube. A 34 Ch orogastric tube is passed through the gastric pouch and into the alimentary limb of the jejunum.

Creation of the Anterior Hand Sewn Anastomosis. A running V-Loc™ suture is used to close the anterior part over the tube in order to ensure the patency of the anastomosis.

Leak Test: Leak at the Right Lateral Side of the Anastomosis. The first leak test with methylene blue through the orogastric tube shows a leak on the right lateral side of the anastomosis.

Oversewing the Right Lateral Side of the Anastomosis. The defect is over sewn with the remaining V-Loc™ sutures.

Final Leak Test: No Leakage. The final leak test revealed no leakage.

The creation of the jejuno–jejunostomy went according to our standardized protocol. The mesenteric, mesocolic, and Petersen's defect were closed using the hernia stapler. A 27 Fr drain was left lateral to the gastrojejunostomy. The patient was kept nil by mouth for 5 days and fed parenteral.

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