Volume 8, Issue 1 , Pages 116-118, January 2012
Stapling of orogastric tube during gastrojejunal anastomosis: an unusual complication after conversion of sleeve gastrectomy to laparoscopic Roux-en-Y gastric bypass
Article Outline
Keywords: Sleeve Gastrectomy , Orogastric Tube , Gastrojejunal Anastomosis , Complication , Conversion , Laparoscopic Roux-en-Y Gastric Bypass
The number of laparoscopic Roux-en-Y gastric bypass (LRYGB) cases performed annually in the United States has significantly increased. With the increased number of laparoscopic cases in bariatric surgery, LRYGB has become one of the most technically demanding operations performed in minimally invasive surgery [1].
This procedure is associated with a significant learning curve and, even in expert hands, can be associated with complications. Stapling of the orogastric tube during the performance of gastrojejunal anastomosis is an unusual and dreaded complication in bariatric surgery [2].
Surgeons should maximize their awareness and prevent this complication.
Case report
A 47-year-old woman underwent laparoscopic sleeve gastrectomy in 2009 for morbid obesity. Two years after the primary surgery, she developed severe reflux symptoms requiring conversion to LRYGB.
The patient was brought to the operating room and placed on the operating table in the supine position. The abdominal cavity was accessed through a 1-cm supraumbilical incision in the left upper quadrant abdomen using an Optiview trocar (Ethicon Endo-Surgery, Cincinnati, OH). Accessory trocars were placed under direct view in the subxiphoid area and right, mid, and left upper quadrants (Fig. 1).
Fig. 1.
Tube carefully dissected before creation of new GJ anastomosis.
We performed lysis of the adhesions between the liver and the anterior portion of the stomach. With careful blunt and sharp dissection, the adhesions were taken down, the gastroesophageal junction was exposed, and the liver was retracted cranially. The dissection was started with the Harmonic scalpel on the greater curvature side of the gastric sleeve. After the sleeve was completely mobilized and a window was dissected behind the sleeve into the left upper quadrant abdomen, the sleeve was transected in the proximal third with a green cartridge. The ligament of Treitz was identified, and 50 cm from the ligament of Treitz, the small bowel was transected. The distal limb of the small bowel was brought to the upper abdomen in an antecolic antegastric fashion.
A side-to-side gastrojejunostomy (GJ) between the pouch and alimentary limbs was performed on the posterior wall using a linear stapler. It came to our attention that the stapler had taken the calibrating orogastric tube. The decision was made to resect the GJ using a green cartridge stapler after careful dissection and mobilization of the tube. The small bowel was also resected, and a new antecolic, antegastric GJ was created. The anastomotic posterior wall was built with a linear stapler, and its anterior wall was closed with a double layer of running 2−0 Vicryl sutures. A leak test was performed using air and methylene blue. At 100 cm from the GJ, a side-to-side jejunojejunostomy between the biliopancreatic and alimentary limbs was performed with 2 applications of the linear stapler. The jejunojejunostomy site was closed with 2 applications of the linear stapler. After thorough hemostasis and irrigation of the abdominal cavity, we proceeded to close the mesenteric defect with a running Vicryl suture. A drain was placed in the subhepatic space, and the specimen placed in an endobag and retrieved from the umbilicus. All trocar sites were sutured closed and injected with local anesthesia. The patient tolerated the procedure well, was extubated in the operating room, and was transferred to recovery in stable condition. On postoperative day 1, a swallow test showed no evidence of leak (Fig. 2). The patient was started on a diet and discharged home on postoperative day 4. She had no complications after her procedure.
Fig. 2.
After tube retrieval, a new anastomosis with healthy tissue was created.
Discussion
The increased number of bariatric procedures will be associated with an increase in the number of complications [1], [3], [4]. The creation of the GJ is a key element during LRYGB that can be associated with complications, such as stapler misfirings or orogastric tube complications [2]. The lack of an early diagnosis with proper management can be associated with severe postoperative morbidity.
Orogastric tube complications are infrequently reported. Even if these complications are managed appropriately, postoperative morbidity can result [2].
The management of this complication, in our case report, required redo of the GJ anastomosis. The intraoperative procedures that can be done under these circumstances include laparoscopic pouch trimming at 2 levels: the gastric and jejunal portions of the anastomosis, with retrieval of the tube under direct visualization. Conversion to an open procedure needs to be done if the surgeon has difficulty in performing the procedure laparoscopically and safely.
In the event that there is not enough healthy tissue to be mobilized, oversewing of the defects and wide local drainage must be performed. A gastrostomy tube at the level of the gastric remnant will also be needed for postoperative drainage and nutrition.
Because this is a rare, but preventable, complication, it is crucial to have some prevention strategies. These can include avoiding the use of soft tubes that can be caught by the stapling device and restricting the number of tubes placed in the stomach. It is crucial to check that the tube can be easy mobilized by the anesthesiologist before firing the stapler.
Intraoperative endoscopy is an excellent tool for the surgeon that can be also considered and could be used instead of orogastric tubes [5].
It is of key importance that there is adequate communication between the surgeon and the anesthesiologist. This need is more commonly seen when new operating room teams are formed.
An important aspect of a successful outcome is to obtain an early diagnosis and control of the situation in the operating room.
Conclusion
Stapling of the orogastric tube during bariatric surgery can be a dreadful, but preventable, complication. Surgeons who perform this challenging surgery have to be aware of the management of this complication. Despite performing high numbers of these procedures, this complication can occur, and surgeons need to maximize measures to prevent its occurrence.
Supplementary data
Video.
References
- Laparoscopic bariatric surgery can be safe for treatment of morbid obesity in patients older than 60 years . Surg Obes Relat Dis . 2006;2:613–616
- Orogastric tube complications in laparoscopic Roux-en-Y gastric bypass . Obes Surg . 2006;16:443–447
- Symptoms of gastroesophageal reflux following laparoscopic sleeve gastrectomy are related to the final shape of the sleeve as depicted by radiology . Obes Surg . 2011;21:295–299
- Revisional surgery alter sleeve gastrectomy . Surg Laparosc Endosc Percutan Tech . 2010;20:351–356
- . Intra operative endoscopy and leaks after laparoscopic Roux-en-Y gastric bypass . Am Surg . 2009;75:485–488
PII: S1550-7289(11)00492-8
doi:10.1016/j.soard.2011.06.001
© 2012 Published by Elsevier Inc.
Volume 8, Issue 1 , Pages 116-118, January 2012
