Endoscopy 2019; 51(11): E341-E342
DOI: 10.1055/a-0885-9095
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© Georg Thieme Verlag KG Stuttgart · New York

Novel laparo-endoscopic hybrid procedure to treat a disconnected Roux limb after bariatric surgery

Newton Teixeira dos Santos
1   Newton Teixeira Gastroenterologia, Rio de Janeiro, Brazil
,
Diogo Turiani Hourneaux De Moura
2   Division of Gastroenterology, Hepatology and Endoscopy – Brigham and Women’s Hospital – Harvard Medical School, Boston, Massachusetts, United States
,
Manoel Galvão Neto
3   Endovitta Institute, São Paulo, Brazil and Florida International University, Florida, United States
,
Flaubert Sena de Medeiros
4   Hospital Universitário Onofre Lopes – Universidade Federal do Rio Grande do Norte
,
Mário Victor Faria Nogueira
5   Grupo de apoio e tratamento da obesidade (GATO), Rio de Janeiro, Brazil
,
Christopher C. Thompson
2   Division of Gastroenterology, Hepatology and Endoscopy – Brigham and Women’s Hospital – Harvard Medical School, Boston, Massachusetts, United States
› Author Affiliations
Further Information

Publication History

Publication Date:
07 June 2019 (online)

Obesity is a worldwide pandemic and bariatric surgery is the most effective treatment modality. Despite its satisfactory clinical results, some patients regain some of their lost weight [1] [2]. Traditionally, revisional surgery to reduce the gastrojejunal anastomosis (GJA) is offered to these patients. However, revisional procedures carry a higher complication rate than primary bariatric surgeries, including fistulas and dehiscence with incidences ranging from 1 % to 8.3 % after laparoscopic Roux-en-Y gastric bypass (RYGB) [2] [3] [4]. The diagnosis and treatment of bariatric surgery leaks are challenging due to nonspecific clinical and laboratory findings. Some cases are associated with situations of extreme gravity, narrowing the options for treatment and thus making the complications challenging to solve [5].

To illustrate this, we describe an unusual case involving a dehiscence of the gastric pouch from the Roux limb, which required prolonged intensive care and was ultimately treated by a laparo-endoscopic hybrid procedure ([Video 1]).

Video 1 Novel laparo-endoscopic hybrid procedure to treat a disconnected Roux limb after bariatric surgery.


Quality:

A 29-year-old man, with a history of weight regain after RYGB 10 years previously (129 kg), underwent revisional RYGB surgery (154 kg). He presented 5 days later with intense abdominal pain. A computed tomography scan demonstrated a pneumoperitoneum and the patient was referred to the endoscopy unit for evaluation.

The endoscopy showed complete dehiscence of the gastric pouch from the Roux limb. A large amount of necrotic tissue was visualized and the entrance from the jejunal limb could not be identified ([Fig. 1 a]). Endoscopic vacuum therapy was performed ([Fig. 1 b]). After 4 days, a fully covered self-expandable metal stent (FCSEMS) was placed to reconnect the pouch and the GJA, under laparo-endoscopic guidance ([Fig. 1 c, d]).

Zoom Image
Fig. 1 Laparo-endoscopic hybrid procedure to treat a disconnected Roux limb after bariatric surgery. a Endoscopic view of the gastrojejunal anastomosis (GJA) dehiscence and a cavity with necrotic tissue. b Modified endoscopic vacuum therapy system. c Laparoscopic view of the pouch and GJA disconnection showing the gastroscope tip. d Laparoscopic visualization of the distal portion of the FCSEMS. e Endoscopic view of the GJA after stent removal. f Follow-up endoscopy 1 month later, showing the GJA.

After 4 weeks, the FCSEMS was removed and the pouch and the GJA were confirmed to be reconnected ([Fig. 1 e]). The patient was discharged on a regular diet. At follow-up endoscopy 1 month later, normal RYGB anatomy was seen ([Fig. 1 f]).

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