Introduction:

SAGE-Journals-Accessible-Video-Player 10.1089/vor.2019.0614.M1 sj-vid-1-vor-10.1089_vor.2019.0614

Introduction:

Marginal ulceration (MU) is a common complication after laparoscopic Roux-en-y gastric bypass (LRYGB). Risk factors include foreign body reaction to staples/suture, Helicobacter pylori infection, and use of nonsteroidal anti-inflammatory medications, steroids, or nicotine. Medical management includes proton pump inhibitors and sucralfate with surgical intervention indicated for perforation, gastrogastric fistula, bleeding, and refractory disease.¹ Insufficient vascular supply is associated with an increased risk of anastomotic leakage, a dreaded complication of gastrointestinal surgery.² Indocyanine green (ICG) fluorescence angiography is a safe and effective tool that facilitates vascular dissection in the setting of unclear anatomy.³ Perfusion is assessed in real time before proximal transection, after the mesentery is divided, and before completion of the anastomosis in its definitive anatomic position.² Although ICG use has been widely adopted by colorectal surgeons, its application in bariatric operations has been less frequently described. This video presents a patient with a history of a LRYGB undergoing her second revisional operation with use of ICG given concern for pouch viability.

Methods:

A 45-year-old woman status post-LRYGB in 2002 presented to our institution in 2012 with gastroesophageal reflux (GERD). Esophagogastroduodenoscopy (EGD) revealed a gastric-gastric fistula and she was taken for laparoscopic takedown. After disconnecting the fistula from the excluded stomach, the gastrojejunostomy (GJ) became ischemic. It was resected and a linear stapled anastomosis was performed. In early 2018, the patient returned with GERD and abdominal pain. EGD revealed an ischemic MU. She failed medical management and required laparoscopic revision. The GJ was adherent to the remnant stomach as expected in the setting of an ischemic ulceration. ICG was used to facilitate the dissection to ensure preservation of the left gastric artery. The gastric pouch was transected just proximal to the GJ and endoscopy verified that the staple line was above the ulceration. The roux limb was resected and ICG was used to ensure adequate perfusion of the gastric pouch and staple lines. A single-layer handsewn anastomosis was completed over an endoscope using absorbable barbed suture. Leak test was negative.

Results:

The patient tolerated the procedure well. A liquid diet was started on POD1. On POD2, surgical drain was removed, and she was discharged. At 2-week follow-up, she had complete resolution of GERD and abdominal pain. The patient did not return for long-term follow-up; however, no symptoms concerning for recurrence have been reported 1 year postoperatively. Typically, MUs are assessed endoscopically at least 3 months postoperatively to rule out recurrence.

Conclusion:

ICG fluorescence technology is a useful adjunct for assessing anastomotic perfusion. It can be particularly helpful in reoperative surgery or cases previously complicated by ischemia.

All authors have nothing to disclose. There are no commercial associations that might create a conflict of interest in connection with the published video

Funding for this study was provided by the Center for Advanced Surgical Technology at the University of Nebraska Medical Center.

Runtime of video: 6 mins 45 secs

Search results

A Mixed Effects Model for Gastric Ulcer Data

Indocyanine Green Use for Revisional Bariatric Surgery