As the number of bariatric procedures increase the likelihood for surgeons at all levels from small rural hospitals to tertiary centers find themselves facing the challenges of treating a severe bariatric complication. These complications have not been usual situations which most practicing surgeons have experience addressing due to lack of exposure. Before gastric bypass became a mainstream form of treatment, gastric bypass patients with complications were solely seen or transferred to bariatric specialized centers. Now that the treatment has become common many patients present to their local emergency room when a complication arises putting them in contact with surgeons outside specialized centers. This article is an attempt to illustrate surgical options in addressing challenging anatomical situations by presenting a case series of patients who underwent autologous bowel revision to establish continuity treated by the multiple organ transplant/Gut rehabilitation service at Cleveland Clinic, along with a literature review of both laparoscopic and open techniques in similar patients. The focus will be essentially limited to an overview of surgery method with some specific technical details such as: should the gastric pouch be saved, which reconstruction method is better, and is a new pouch construction necessary. In-addition, technical methods of overcoming challenging anatomical obstacles are addressed in the case series. Other important fascist of care such as: level of nutrition, infections disease, preoperative imaging, timing of staged procedures, who should perform the procedure/ when to transfer, etc. will not be covered in detail even though they are just as equally vital in the overall successful care.
This is a 37-year-old gentleman with previous gastric bypass 10 years earlier who presented to an outside hospital with acute pancreatitis secondary to alcohol abuse. He underwent an exploratory laparotomy for an acute abdomen and found to have an internal hernia with ischemic bowel which required a small bowel resection. He returned to the operating room two days later for duodenal ulcer repair with a Graham patch, partial gastrectomy, further small bowel resection with an antecolic gastrojejunostomy, jejunojejunostomy, ileocolostomy, and temporary abdominal closure. His abdomen was permanently closed a few days later with placement of mesh (16x20cm) sub lay. Post-operative course was complicated with small bowel leak that required further operative intervention subsequently leading to bowel discontinuity with stapled distal esophagus, gastrostomy tube, jejunostomy tube, removal of mesh, and contained fistula. Following transfer, initial treatment consisted of airway management which required VATS to treat right pleural effusion and tracheostomy to allow weaning from ventilator. He underwent cardiac testing and beta-block therapy. His atrial fibrillation was treated medically. All infections were treated and cleared. He was given a period in a rehab facility for nutritional support before undergoing a restorative procedure. Following the restorative surgery, he had a short unremarkable stay in the ICU. He was weaned off TPN and started on a diet after an upper GI study showed no leak. He was transferred to a regular hospital room and his diet was advanced to regular followed by discharge to a short-term rehab facility (Figure 1).
A 57-year-old cachectic female patient with history of gastric bypass who developed bowel ischemia secondary to an internal hernia requiring extensive small bowel resection including the cecum. She was left with less than 90 cm of small bowel with short gut syndrome requiring long term TPN. The patient had persistent nausea, vomiting with abdominal pain despite motility agents and multiple hospital admissions for line infections. Patient underwent resection of the Roux limb with gastrogastrostomy, and bowel lengthening serial transverse enteroplasty (STEP) procedure. Procedure was performed by applying a bowel stapling and dividing device at 45 degree angles to the mesentery on alternating sides of the bowel wall. The stapler was placed at 1/3 the wall depth. The staple line was over sawn with interrupted silk suture resulting in bowel elongation. Her post-operative recovery was prolonged due to prolonged time for bowel function to return. She was maintained on TPN until her bowel function returned approximately 10 days after surgery. She was weaned off TPN and started on an oral diet by dropping the TPN volume with increased oral intake. Her diet was advanced to regular without any problems and she was
subsequently discharged (Figure 2).
A 42-year-old female patient with history of gastric bypass complicated initially by chronic nausea without an identifiable source. She had a jejunostomy tube placement for nutritional support. Patient presented to the emergency room with acute abdominal pain, acidosis, leukocytosis and renal insufficiency. She was taken emergently for an exploratory laparotomy and found to have an internal hernia with acute mesenteric ischemic involving both limps. Due to her level of extremist and the amount of bowel involved she was initially treated with a double diverting enterostomy procedure and removal of the jejunostomy tube. She tolerated the procedure well, was taken to the ICU where she was placed on TPN and weaned of pressers along with ventilation support. She was subsequently discharged. After approximately two months, she returned for surgery to establish gastrointestinal continuity. The remaining portion of the Roux limb was freed proximally from the gastric pouch and reattached proximally to the duodenal/jejunal junction and distally to the remainder of the distal ileum. She had a total of 85-100 cm of small bowel, including the ileocecal area. A gastro gastrostomy was performed to establish normal gastric continuity. She had an unremarkable post-operative course and was successfully weaned of TPN then discharged to a short-term rehab facility (Figure 3).
A 56-year-old super morbidly obese female with a gastric bypass complicated by recurrent fistulae. Patient had two unsuccessful attempts at resection of the fistulae, subsequently left with a stapled distal esophagus, sub-total gastrectomy, fistulae from both duodenum and esophageal stump, with a feeding jejunostomy. She underwent a complex operative procedure were both fistulas were taken down, the Roux limb with the jejunostomy were removed, the duodenal fistula site was debrided and closed in two layers, however establishing continuity was a change due to the low duodenal stump and an extremely short small bowel mesentery. A decision was made to use a transverse colon as a jump graft. It was anastomosed proximally to the esophagus and distally to the duodenum. During the procedure cultures were taken from both areas adjacent to the fistulas. She had an unremarkable recovery for the first 4-5 days during which she was maintained on TPN. On post op day 5 she was noted to have bilious drainage from her upper abdominal drain. Imaging showed that the leak was from the previously repaired duodenal site. She underwent a second operative debridement of the area with 2 layered closure, buttressed with omentum. However, she leaked two days later from the same area. Culture report showed significant Mycobacterium growth in the duodenal fistula area. Patient was discharged on TPN with a drain controlled duodenal fistula with plans to surgically treat the fistula after the infection had completely resolved and the patient's nutritional health had improved. She spent a few months at a rehab facility on sips of clears diet restriction and TPN. Her interventions antibiotics were continued for many weeks until infectious disease thought the infection was cleared. Her drain output decreased to less than fifteen cc daily of serous fluid and all of her nutritional parameters improved. She subsequently underwent laparotomy with addition debridement of the duodenum and two layered closure. (An alternative option would be to form a Roux-En-Y be using the transverse colon graft as a Roux limb and anastomosing it to the jejunum). Post operatively she did not show any sign's of contrast extravasation on an upper GI study. She was subsequently weaned of TPN as her diet was advanced (Figure 4).
A 64-year-old female patient with a history significant for DM type 2, GERD, PE, and vertical banding gastroplasty (1984), underwent a revision to a Roux-En-Y (2007) complicated by a gastro-jejunostomy site leak in June of 2013. The leak developed into a chronic anastomotic leak requiring TPN. On 12/2013 patient underwent lysis of adhesions, transection of the proximal Roux limb with resection of the Enterocutaneous fistula, and resection of the distal gastric pouch, reconnection of a new gastrojejunal limb was performed by anastomosis of the proximal Roux limb to the remnant gastric pouch and a gastrostomy feeding tube placed into the remnant stomach. During the procedure there was a large tear in the splenic vessels which required ligation and splenectomy. This procedure also lead to a post-operative complication of a high output fistula from the upper portion of the incision. On 7/2014 patient underwent an exploration with definitive repair. On exploration there was a large abscess cavity discovered at the hiatus with a fistula track extending to the left abdominal wall. The cavity extended behind the left lobe of the liver, into the lesser sac, and encased the most recent gastrojejunostomy anastomosis. There was extensive scaring and adhesions from the edge of the liver, to the lesser sac and gastric remnant. The safest approach way was to identify and control the vessels in the area. The attachment between the left lobe of the liver was taken down and the left hepatic vein identified and controlled. The left side of the gastric pouch was dissected after removing the abscess and cleaning the hiatus. On the posterior dissection the remnant stomach was identified. The greater curve was dissented posteriorly, and the proximal splenic vessels identified. The lesser sac was impossible to enter safely secondary to thick adhesions. Dissection was instead started at the porta hepatis to identify the portal vessels after releasing the hepatic plate. A tape was placed from the left portal vein to the left hepatic vein and elevated. The live was transacted after ligation of the left hepatic vein. The remainder of left liver was reflected to the left while the adhesions below were taken down. The lesser sac entered and the celiac identified. The left gastric artery was preserved as the previous anastomosis was taken down along with the gastrostomy tube in the remnant stomach. The Roux limb was removed and a new gastrojejunostomy was performed to the previous pouch. The patient had an unremarkable recovery, on POD 5 an upper GI was performed which did not show any leak. She was started on a diet and advanced to regular. She was subsequently discharged home (Figure 5).
A 32-year-old male gastric bypass patient complicated by internal herniation who underwent small bowel resection in addition to multiple laparotomies attempts to provide source control from recurrent fistulas. He eventually developed short gut with multiple level diversions, along with multiple abdominal drains, cervical esophagostomy, and was placed on TPN. He had a vascular sent placed into his SMA for fear of SMA occlusion. He was ventilator dependent with a tracheostomy. Upon transfer to the Cleveland Clinic, he had a esophagogastrostomy tube, cervical esophagostomy, tube duodenostomy, multiple intra-abdominal abscesses with tube drainage, less than 40 cm of distal small bowel, and open abdomen with an abdominal vacuum packing. Patient was taken for immediate exploration: 1) to obtain source control from ongoing infection and stool contamination, 2) to establish bowel continuity using his native colon in preparation for a future modified multi-visceral transplant. During the exploration a thoracic team assisted in taking down the cervical esophagostomy with a primary anastomosis. The abscess pockets were cleared, duodenostomy tube was removed then the site repaired in two layers, the esophagogastrostomy tube was also removed and the right colon completely mobilized. The cecum was anastomosed to the gastric pouch and the hepatic flexure anastomosed to the third portion of the duodenum after removing the SMA stent. The abdomen was closed with just re-approximating the skin and subcutaneous leaving a ventral hernia. The patient was placed on TPN. He was subsequently weaned off antibiotics, placed on a tracheostomy collar, and his nutritional status improved. He underwent a small bowel transplant 2 months later. The right colon was used as a jump graft to the proximal duodenum and the graft anastomosed to the distal duodenum. He had a successful recovery, without any immediate episodes of rejection or infection. He was weaned of TPN and started on a diet after a successful swallowing evaluation. His tracheostomy was eventually downsized then removed (Figure 6).
Literature review of bariatric cases shows similar techniques in reversing bypass procedures or treating ischemic complication secondary to internal hernias. The treatment for ischemic limbs is essentially straight forward with resection of the ischemic portions and re-anastomosis. For patients with large amounts of ischemic bowel the approach becomes similar to the reversal bypass techniques with the additional of an addition step; resection of the ischemic portion of the biliary or afferent limb. The two most often utilized methods for reversal are outlined in table 1, with resection of the Roux limb often using a stapling device, taking down the gastrojejunostomy and creation of a gastrogastrostomy between the gastric pouch and remnant stomach using an EEA and Orval, illustrated in Campos et al. . method. This can also be done as a sutured anastomosis as outline by Vilallonga et al. . Other laparoscopic techniques have utilized the proximal portion of the Roux limb as a jump graft, Zorron et al.  or utilized the distal portion of the Roux limb by relocating it back to its origin and anastomosing it to the distal afferent limb, Gatschet et al. [4,5], (Table 1).
Portions of bowel can also be used as jump grafts to provide stoma access to stabilize patients. Jang et al. . Case report of a 74-year-old patient with a Petersen hernia who had a history of near total gastric resection with a Roux En Y gastrojejunostomy, was found to have necrosis of his entire Roux limb and common channel down to the distal 20 cm of the terminal ileum. After removing all the necrotic bowel, the distal transverse colon was used as an ostomy conduit after anastomosis of the remnant stomach to the mid transverse colon and the remaining proximal jejunum to the 20 cm of distal ileum. The patient underwent a second look 32 days later were the transverse colostomy was taken down and resected to the gastro-colic anastomosis. The proximal transverse colon was anastomosed to the jejunum and the ascending colon anastomosis to the descending colon. Even though this was not a type gastric bypass patient he did share a similar anatomical complication common with bariatric bypass patients.
Attempts at difficult definitive restoration of intestinal continuity should be deferred if conditions are not favorable. Following pouch gastrectomy tube drainage of the distal esophagus may be needed as a temporary diversion. In duodenal injury, fistualization can be performed with insertion of a duodenostomy tube, with a T- tube placement if the second portion of duodenum is not adequately drained. End duodenostomy (4th portion), or enterostomy at any level in either the Roux limb or afferent limb may be necessary to delay anastomosis until a more optimal time. The remnant pancreas can be temporarily over sewn, diverted with multiple closely placed drains or connected to the jejunum along with the bile duct and feeding jejunostomy, (Nicosia et al. ).
Reconstruction should begin with determining adequate blood supply from vital vessels, such as the left gastric for use of the proximal gastric. Gastric lengthening options may be required with a short esophagus or if the gastric remnant is used (Rossidis et al. ), preservation of the right gastroepiploic during mobilization of the proximal duodenum should be kept in mind. Division of short gastric vessels is needed for appropriate gastric mobilization. Duodenal mobilization with a Kocher maneuver, transection of the ligament of Treitz, even complete release of the 3rd or 4th of the duodenum may be needed to add proximal or distal length. In situations where there is an ultra-low duodenal stump using a colon or jejunal jump graft may provide an optimal solution. In situations in which the small bowel mesentery is short and fixed, using the colon may provide an easy solution as an ostomy conduit or a jump graft.
Choice to use the Cardia If Possible
An et al. . study in 2008 comparing total gastrectomy vs. proximal partial gastrectomies for treatment of early gastric showed an increased rate for reflux esophagitis and anastomotic strictures in proximal gastric resections with gastroesophagostomy. Kim J, et al. . A small case series of 10 patients with early proximal gastric cancer who underwent proximal gastrectomy with preservation of the GE junction and 2 cm of the cardia were followed up to 8 weeks out. Only one patient developed symptoms of reflux requiring medical therapy two months out. No patient developed strictures. Retained EG junction with the esophageal sphincter most likely plays a role in prevention of reflux and using the cardia allows for a wider anastomosis.
Choice of Establishing Anatomical Continuity
A literature review by Saito et al. . comparing functional out comes following proximal gastric resection and pylorus preservation in three methods of revision esophagogastrostomy (EG), Jejunum interposition (JI) and double track method were by a Roux En Y, Jejunal Roux limb is anastomosis to both the esophagus and the remnant stomach (DT) shows pros and cons with each method. The incidence of reflux was lower in the JI patients, but they reported more frequent fullness. In-addition, they had a higher incidence of advanced remnant gastric cancer. DT has been shown to be associated with few reflux and stricture complications when compared to EG and has the added benefit of less complaints of fullness as seen with JI. It also showed good results for patients to maintain their body weights however the procedure is more technically difficult to perform. Unfortunately, all the information provided were from small, non-randomized, case reviews.
Situations in which the stomach is not an option the small bowel is usually utilized as a Roux En Y, jump graft, or inline anastomosis with the esophagus plus or minus a functional pouch. There has been significant debate for many years over the need for pouch formation. A literature review by Shibata et al. [12-28], of pouch creation results after gastrectomy concluded that following a total gastrectomy no benefit was seen between a jejunal pouch jump graft and one without a pouch. There was however significant benefit when comparing a jejunal pouch with a Roux En Y vs no pouch with a Roux En Y. Furthermore, there was no difference in outcome following a total gastrectomy with pouch reconstruction as either a jump graft or as a Roux en y. In reconstruction following proximal gastric resection there appears to be a clear benefit of jejunal pouch jump graft as oppose to a non-pouch jump graft or an esophagogastrostomy. The review was unfortunately based on small, non-randomized, case review studies. There are many studies both for and against pouch formation, but none are definitive, in-addition in review of the available randomized control trials following total gastrectomy no difference was seen between duodenal passage vs. Roux-en-Y however quality of life appears to be better following pouch formation with less upper GI symptoms.
Dealing with bariatric complications is very challenging, many variables must be address such as source control of infection method of establishing continuity based on altered anatomy, and caring for a high-risk patient. However, when approached in a comprehensive manor paying attention to every detail a good outcome is possible.