Laparoscopic Sleeve Gastrectomy After Two Gastric Bands Removal and the Presence of Gastrojejunostomy: A Video Presentation

Abstract

Introduction:

In this video, a laparoscopic sleeve gastrectomy (LSG) is presented in an obese, 40-year-old female patient. The patient had 42.2 BMI and no other comorbidities. The patient came to our institution because she could not lose weight after the placement of two gastric bands on her stomach and the presence of a gastrojejunostomy. The runtime of the video is 9 minutes and 27 seconds.

Materials and Methods:

The patient had undergone placement of the gastric band at the pars flaccida region before ∼3 years. The patient gained weight after 2 years from the placement of this gastric band. The surgeon who had placed this first band suggested her second band placement near the pylorus. At the same time, he suggested her construction of a gastrojejunostomy near the pylorus, just before the second band. The gastrojejunostomy was created ∼120 cm distally the ligament of Treitz. During the last year, the patient faced several problems with epigastric pain, distension, and weight gain. The symptoms of the patient were more intense after food ingestion. Nevertheless, the patient did not lose significant weight because she changed her diet and received more pastries. The bands at the last year were not loaded, but this action did not soften the patient's symptoms. In our institution, the patient underwent laparoscopic exploration. The intention was to remove the bands and create a sleeve gastrectomy without disturbing the gastrojejunostomy. The authors did not want to change much the anatomy of the region. The combination of the removal of the two bands with sleeve gastrectomy and the dietician modification with less pastries was the main goal. The will of the patient was not to perform first place a gastric bypass, but this was going to be the next procedure after the failure of sleeve gastrectomy. During laparoscopic exploration, multiple adhesions were seen in the upper abdomen. First, the band near pylorus was removed. Adhesions from the gastrojejunostomy were removed, and the omentum was freed from the greater curvature of the stomach. The second band from the pars flaccida was thereafter removed, and the fundus of the stomach was freed until the esophagus. A sleeve gastrectomy performed and the first firing of the linear stapler performed just proximal to the gastrojejunostomy. Continuous suture reinforced the staple line. A leak test was performed with instillation of methylene blue inside the stomach.

Results and Conclusions:

There were no intraoperative or postoperative complications. The patient began a diet and was discharged on the fourth postoperative day. Follow-up visits of the patient remarked complete resolution of her symptoms. After 6 months of this operation, the patient has lost 30 kg. This technique finally combined the restrictive operation of LSG and partially the previous malabsorptive gastrojejunostomy far distally the ligament of Treitz. An upper gastrointestinal series revealed that both ways, pylorus and gastrojejunostomy, are passable equally. Longer follow-up shall reveal possible complications or failure of this technique.

The authors have nothing to declare.

Runtime of video: 9 mins 27 secs