Published in:
01-09-2020 | Sleeve Gastrectomy | Multimedia Article
Roux-en-Y Gastro-jejunostomy for Complex Leak After the “Nissen” Variant of Sleeve Gastrectomy
Published in: Obesity Surgery | Issue 9/2020
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Background
Recently, improvised variants of sleeve gastrectomy SG were reported as
alternative bariatric options in patients suffering from both morbid obesity and
GERD, including mainly additional anterior or posterior fundoplication over a
partially sleeved stomach.
Methods
We present the case of a 29-year-old male patient with a body mass index (BMI)
of 46.2 kg/m2 underwent laparoscopic SG with concomitant posterior
fundoplication: Nissen-SG (N-SG). At postoperative day (POD) 4, he presented
with epigastric pain, nausea, and 40 °C fever. The abdomen was tender
with signs of peritonitis. Explorative laparotomy displayed a massive gastric
leak with generalized peritonitis. Peritoneal lavage was performed. the patient
was transferred to our department for the management of persistent SGL.
Results
Initial management comprised total parenteral nutrition and wide-spectrum
intravenous antibiotics. Three weeks later, the patient underwent laparoscopic
exploration. As shown in the video, at least two leaks were individualized,
including one, anterior, catheterized by the pigtails, and the other one,
posterior, impossible to reach endoscopically (Fig. 1). A residual abscess,
located between the left crus, the pancreas, and the upper edge of the spleen,
was evacuated. Eventually, Roux-en-Y gastro-jejunostomy was performed
Conclusion
The adjunction of a posterior fundoplication may have contributed to the
multiple and complex occurrence of SGL. Having an ill-vascularized redundant
fundus may have increased ischemia of the GE junction. Moreover, it is more
difficult to perform endoscopic treatment in a plicated and sleeved stomach as
well.