Management of gastrojejunostomy anastomotic leak post one anastomosis gastric bypass with a covered stent alone

Parveen Bhatia; Harsh Sheth; Shubham Bhatia; Sarfaraz Baig

doi:10.4103/jbs.jbs_6_21

CASE REPORT

Year : 2022 | Volume : 1 | Issue : 1 | Page : 55-58

Management of gastrojejunostomy anastomotic leak post one anastomosis gastric bypass with a covered stent alone

Parveen Bhatia¹, Harsh Sheth², Shubham Bhatia³, Sarfaraz Baig⁴
¹ Department of Minimal Access Surgery, Bhatia Global Hospital, New Delhi, India
² Institute of Minimally Invasive Surgical Sciences and Research, Saifee Hospital, Mumbai, Maharashtra, India
³ Department of General Surgery, Flushing Hospital Medical Center, NY, USA
⁴ Digestive Surgery Clinic, Belle Vue Hospital, Kolkata, West Bengal, India

Date of Submission	11-Dec-2021
Date of Acceptance	24-Mar-2022
Date of Web Publication	07-Apr-2022

Correspondence Address:
Dr. Harsh Sheth
No. 39, Nepean Sea Road, Matru Ashish, 7^th Floor, A-2, Mumbai - 400 026, Maharashtra
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jbs.jbs_6_21

Abstract

Leaks after one anastomosis gastric bypass are managed based on the timing of presentation and the presence or absence of peritonitis. Reoperation is strongly advocated because of the potential severity of biliary peritonitis. Recently, nonoperative treatment is being increasingly employed, especially for staple line disruptions or unspecified leaks. We report successful usage of a covered esophageal stent in a gastrojejunostomy anastomosis leak with a favorable outcome.

Keywords: Anastomotic leak, covered stent, mini gastric bypass-one anastomosis gastric bypass

How to cite this article:
Bhatia P, Sheth H, Bhatia S, Baig S. Management of gastrojejunostomy anastomotic leak post one anastomosis gastric bypass with a covered stent alone. J Bariatr Surg 2022;1:55-8

How to cite this URL:
Bhatia P, Sheth H, Bhatia S, Baig S. Management of gastrojejunostomy anastomotic leak post one anastomosis gastric bypass with a covered stent alone. J Bariatr Surg [serial online] 2022 [cited 2023 Sep 29];1:55-8. Available from: http://www.jbsonline.org/text.asp?2022/1/1/55/342734

Introduction

Leaks after one anastomosis gastric bypass (OAGB) are dangerous because the contents are alkaline bile that can potentially lead to peritonitis and severe sepsis in a short span of time.^[1] Therefore, surgeons have conventionally been aggressive in the management of OAGB leaks to prevent biliary peritonitis.^[1],[2],[3] However, Liagre et al. have shown that nonoperative treatment can be safe and feasible in 72% of cases when multidisciplinary approach is used with the help of endoscopists and interventional radiologists. They recommended mostly nonsurgical treatment for leaks from gastric pouch and undetermined source, and reserved surgery for gastrojejunostomy anastomosis (GJA) leaks.^[4] We report the successful use of a covered endoscopic stent alone in GJA leak post OAGB.

Case Report

A 39-year-old male, with body mass index 50 kg/m², type II diabetes mellitus, obstructive sleep apnea, and hypertension underwent OAGB in another hospital. He developed a fall in hemoglobin on postoperative day (POD) 1 for which he was transfused with blood and managed conservatively. On POD 3, he developed bilious output in the drain, for which he was treated conservatively. On POD 9, he was referred out. On admission, he had abdominal pain and nausea. On examination, he had a fever, mild icterus, and a mildly tender upper abdomen. The operative wounds were healthy. Drain output kept around the GJ was 1 L of bilious fluid over 24 h. He was hemodynamically stable. Blood parameters showed leukocytosis (white blood cell count = 16,000/cumm, normal range = 4,000–10,000) and raised liver enzymes (serum glutamic-oxaloacetic transaminase = 154 U/l, normal range = 5–35, serum glutamic pyruvic transaminase = 176 U/l, normal range = 5–40). Computerized tomogram (CT) scan showed a thin, air-filled collection at the anterior aspect of the stomach that tracked to the anterior abdominal wall with the drainage tube entering the collection forming a controlled fistula [Figure 1]. There was no evidence of diffuse peritonitis. There was extravasation of contrast from the GJA into the collection and the drainage tube. In addition, an umbilical hernia of 4 cm width containing bowel was seen with no evidence of obstruction. There was also a partial collapse-consolidation of the left lung.

Figure 1: Computerized tomogram scan image demonstrating an intra-abdominal collection with air specks extending to the subcutaneous tissue

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An esophagogastroduodenoscopy was performed which showed a fistulous opening at the GJA of size >1 cm [Figure 2]. The surgical team planned to deploy a self-expanding fully covered metallic stent. A Mega^TM covered esophageal stent (Instrumed Surgical®, Mississauga, Ontario, Canada) was placed endoscopically on POD 10 extending from proximal gastric pouch to efferent limb [Figure 3] and [Figure 4]. No fixation was performed to keep the stent in place. A nasojejunal (NJ) tube was also placed through it at the time of endoscopy. He was started on octreotide (to reduce gastrointestinal secretions and prevent subsequent insult to the leaking GJ), NJ enteral feeding, and partial parenteral nutrition (only amino acids, due to cost constraints). His abdomen and vital parameters remained stable. At POD 16, bilious output was reduced to 300 ml/day. CT scan done on POD 16 showed no extravasation of oral contrast and a reduction in the size of the collection [Figure 5]. CT scan done on POD 36 showed no extravasation of contrast with complete resolution of the previously seen collection [Figure 6] and [Figure 7]. The lung consolidation had also improved. The stent was removed on POD 41 (week 6). He was discharged on POD 47 (week 7) after he tolerated an oral diet.

Figure 2: Computerized tomogram scan image demonstrating the drain entering the intra-abdominal collection

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Figure 3: Endoscopic image showing a fistulous tract (left side) at the level of the gastrojejunostomy anastomosis

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Figure 4: Endoscopic image showing placement of a guidewire across the gastrojejunostomy anastomosis into the efferent limb

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Figure 5: Endoscopic image after placement of the self-expanding fully covered metallic stent

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Figure 6: Computerized tomogram scan image at week 6 demonstrating complete resolution of the intra-abdominal collection and its extension to the subcutaneous tissue

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Figure 7: Computerized tomogram scan image at week 7 showing the absence of leak at the site of the gastrojejunostomy anastomosis

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Discussion

The management of OAGB leaks is dependent on the site of leak, presence or absence of peritonitis, size of the fistula, localized collection, and available expertise.^[4]

Liagre et al. have advocated a multidisciplinary approach for leaks after OAGB as opposed to aggressive and early surgical treatment advocated by other authors.^{[1],[2],[3],[4]} They could demonstrate successful healing of 72% of OAGB leaks by nonoperative strategy in a series of 46 patients.^[4] Carbajo et al. and Noun et al. also demonstrated similarly successful nonoperative strategies in 77% and 71%, respectively.^[5],[6] In both studies, conservative management was primarily employed for patients with gastric staple line disruptions or unspecified leaks with the absence of peritonitis, with unsuccessful use of stents for GJA leaks.

In their series, Liagre et al. observed five cases of GJA leaks, all of which were associated with diffuse peritonitis and needed re-laparoscopy. Four were anterior and were treated with T-tube insertion. One posterior leak was treated with conversion to Roux-en-Y gastric bypass.^[4]

Genser et al. did not endorse the use of stents for post OAGB leaks due to the risk of migration and biliary limb obstruction. In their series, two patients with gastric staple line disruption were managed with endoscopic stent placement with subsequent failure, due to migration.^[2] The authors believed their experience in placing endoscopic stents for OAGB leaks is limited and requires further study.^[2] In all these studies, patients with GJA leaks could not be managed conservatively.

This patient with a GJA leak was clinically stable without diffuse peritonitis, with a controlled biliary fistula. Therefore, we used a covered endoscopic stent for treatment. The alternative strategy, in this case, would have been the insertion of a T-tube endoscopically or laparoscopically for an anteriorly placed leak.

The successful outcome with endoscopic stent, in this case, has encouraged us to use this management strategy in future, with the strict caveat that the patient should not have diffuse peritonitis. This treatment modality raises the possibility of avoiding surgery, which can be advantageous since surgery in such situations is challenging and can lead to potential secondary insults. The possible downside to stent placement in post OAGB GJA leaks is the theoretical possibility of stent migration, erosion, and biliary limb obstruction, which needs to be studied in greater detail.

Conclusion

Surgeons performing OAGB could consider nonoperative strategy for leaks in patients without diffuse peritonitis. GJA leak is thought to be associated with peritonitis and surgical strategy is almost always advocated. However, in patients with a controlled fistula from GJA leak, insertion of a covered endoscopic stent may be considered a reasonable alternative to aggressive surgical management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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