Laparoscopic Roux-en-Y fistulojejunostomy (LRYFJ) is an appropriate surgical option for the treatment of chronic gastric leaks after laparoscopic sleeve gastrectomy (LSG), according to researchers from Greece and France. However, they cautioned that LRYFJ is a challenging procedure and should only be performed in experienced bariatric centres by expert bariatric surgeons.
In addition, the researchers stressed that careful patient selection is essential as this procedure should only be considered in patients with adequate nutritional status and after failure of a well conducted endoscopic management. The findings were reported in the paper, 'Laparoscopic Roux-en-Y fistulojejunostomy as a salvage procedure in patients with chronic gastric leak after sleeve gastrectomy', published in SOARD (Lainas P, et al. Surg Obes Relat Dis. 2023 Jun;19(6):585-592. doi: 10.1016/j.soard.2022.12.017. Epub 2022 Dec 10. PMID: 36658084).
“Despite its popularity as the most common bariatric procedure and a reduction in the incidence of gastric leaks due to the standardisation of surgical techniques and acquired experience, this complication remains one on the most concerning and perilous complications following LSG,” explained lead author of the paper, Dr Panagiotis Lainas (Head of Department of Metabolic & Bariatric Surgery, Metropolitan Hospital, Athens, Greece; member of the Executive Board of the Hellenic Society of Bariatric Surgery; member of the Young IFSO European Taskforce). “Most leakages occur at the upper gastrectomy part with the reduced gastric vascularisation in the area near the gastroesophageal junction along with the high-pressure tube created by the LSG contributing equally to this complication. In addition, strictures at the incisura angularis or gastric twists stemming from the non-dissection of posterior gastric adhesions can also be contributing factors.”
He said there are several treatment options for acute fistulas such as endoscopic internal drainage, or stent placement for coexisting strictures or gastric twists with fistulas treated either by endoscopic methods or by radiologic drainage. In unstable patients, an exploratory laparoscopy is usually intended aiming at an abdominal cavity washout, placement of an effective intraabdominal drain, and subsequent initiation of enteral nutrition.
According to the study authors, if these minimally invasive treatments fail resulting in a chronic fistula (more than 12 weeks after initial bariatric surgery), the only option is radical surgical intervention such as total gastrectomy with esophagojejunal anastomosis, revision to Roux-en-Y gastric bypass (RYGB) and LRYFJ. However, to date there are no studies that have assessed the optimal timing or superiority of any of these surgical interventions.
Roux en-Y fistulojejunostomy (RYFJ), first described by Baltasar et al (1), offers an option for completely controlling the fistula orifice while preserving the remnant gastric tube. However, there is a lack of data available regarding this salvage procedure particularly for the laparoscopic approach. Therefore, Lainas and colleagues designed a study to report early results of LRYFJ for chronic gastric leaks after LSG in two specialised bariatric surgery centres with an emphasis on indications, operative technique and short-term outcomes.
Data from all consecutive patients who underwent LRYFJ were prospectively collected from the two centres between March 2017 and December 2019. Inclusion criteria included patients with persisting gastric leaks 12 weeks after LSG despite treatment, who had good nutritional status and were eligible for LRYFJ for the treatment of chronic gastric leak, but in whom antibiotic use, percutaneous or endoscopic drainage procedures or endoscopic stenting of the fistulas had failed. The primary endpoints of the study were morbidity and mortality rates, with secondary endpoints postoperative complications and outcomes.
Technique
The authors described the surgical technique as follows: In a lithotomy position, surgeon standing between the legs, a 30-degree laparoscope was used. Trocar placement was chosen according to each surgeon’s preference. Dissection was initiated by nondissected and less-inflammatory planes, if any, to recognize anatomical landmarks and facilitate restitution of a normal anatomy. The left lobe of the liver was freed, and complete dissection of the gastroesophageal junction was systematically performed. Care not to injure the oesophagus during dissection of the gastroesophageal junction was taken. After meticulous dissection, the opening of the gastric leak was identified. This dissection was completed until the gastroesophageal junction and the left pillar were well exposed, to create enough space to perform the fistulojejunostomy. Debridement of the leak orifice was performed to acquire healthy tissue for an optimal anastomosis.
The jejunum was then divided at 50 cm from the ligament of Treitz using a 60mm endoscopic stapler (Endo-GIA white cartridges, Medtronic) and a 2-layer side-to-side manual fistulojejunal anastomosis using absorbable sutures was performed for the leak orifice. Sixty centimetres of bowel for the alimentary limb were counted and a mechanical side-to-side jejunojejunal anastomosis using Endo-GIA 60 white and absorbable suture for the closure of the defect was performed. Petersen and mesenteric defects were finally closed by nonabsorbable sutures. A closed suction drain was placed at the level of the fistulojejunostomy anastomosis.
Outcomes
In total, 14 consecutive patients (12 women, 2 men) underwent LRYFJ for the treatment of chronic gastric leak after LSG. Eight of the patients presented with gastric leak during the first postoperative days (acute), four patients before the sixth postoperative week (early fistulas) and two before the 12th postoperative week (late fistulas).
The mean age at the time of LRYFJ was 49.2 years (range, 36–63 yr), while mean weight was 88.7 kg (range, 53–169 kg) with a mean BMI of 31.1 kg/m2 (range, 20.4– 46.8 kg/m2). The mean weight at the time of LSG was 114 kg (range, 95–118 kg) and mean BMI was 41.7 kg/m2 (range, 35.9–52 kg/m2).
All LRYFJ procedures were performed following three to seven failed attempts of endoscopic treatment and when gastric leak was persistent for more than 12 weeks (clinically and proven by a CT scan with oral contrast).
All RYFJs were completed laparoscopically, except in 1 case (7.1%) requiring conversion to open surgery due to intraabdominal adhesions. The mean duration of surgery was 198 minutes (range, 149–246 min), with minimal mean estimated blood loss (135.7 mL; range, 50– 800 mL), and need for transfusion in 2 cases (14.2%).
There were five postoperative complications (35.7%); surgical complications (n=3, 21.4%) consisted of 2 fistulojejunostomy leaks (on postoperative days 3 and 22), successfully treated by endoscopic internal drainage and antibiotherapy, and 1 patient who developed a perianastomotic hematoma of the fistulojejunostomy, treated by relaparoscopy with drainage and antibiotherapy. Two patients (14.2%) suffered medical complications postoperatively, a unilateral pleural effusion treated with respiratory kinesiotherapy and one hematemesis treated by cessation of anticoagulation and late oral feeding. The mean length of hospital stay was 14 days (range, 8–30 d). No mortality was recorded.
The mean follow-up was 40 months (range 26–60). The mean weight at last follow-up was 78.6 kg (range, 59–128 kg) with a mean BMI of 27.9 kg/m2 (range, 22.7–35.4 kg/m2 ). Evaluation of major co-morbidities at last follow-up revealed no obesity-associated co-morbidities in 7 patients (50%). During the follow-up period, 1 patient had surgery (laparoscopic cholecystectomy) for symptomatic biliary tract disease and another one suffered from symptoms of anastomotic ulcer and was treated medically. Only 1 patient suffered mild GERD preoperatively, initially treated medically; upper gastrointestinal series at 3 months after LRYFJ showed absence of GERD. Vomiting or diarrhoea was not observed during follow-up. All patients were in good health at last follow-up.
“This study illustrates in the best way the success of LRYFJ in the treatment of chronic fistula after LSG, stretching the safety and effectiveness of this approach as well as the technically challenging aspects of the procedure,” Lainas added. “LRYFJ seems comparable to other techniques used for the treatment of chronic fistulas, with acceptable morbidity rates considering the gravity of patient’s condition. Larger trials would be of utmost importance to compare outcomes of LRYFJ versus salvage RYGB or total gastrectomy with esophagojejunal anastomosis for the treatment of chronic gastric leaks after LSG.”
References
1. Baltasar, A., Bou, R., Bengochea, M. et al. Use of a Roux Limb to Correct Esophagogastric Junction Fistulas after Sleeve Gastrectomy. OBES SURG 17, 1408–1410 (2007). https://doi.org/10.1007/s11695-007-9222-z
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