ANZMOSS Concurrent session 3 - Technology, ERAS and Video session
Chairs / Moderators
Leaks after sleeve gastrectomy may sometimes prove resistant to endoscopic and other modalities employed to manage them. This can leave patients with chronic sepsis and complex fistulae. As simple diversion surgeries, such as conversion of the sleeve to a gastric bypass are unlikely to be successful in patients with established fistulae, the use of total gastrectomy has been proposed as a curative option. Total gastrectomy however is a fairly risky undertaking and it is inferior to sleeve gastrectomy with regards to long term GI side effects and safety.
11 patients from an expanding cohort of patients with sleeve leaks treated preferentially with endoscopic therapy since 2005 underwent definitive surgical therapy for chronic sleeve sepsis between 3 months and 3 years from their original surgery and were included for analysis
One patient, early in the series underwent sequential surgeries with conversion of sleeve to bypass, then bypass to total gastrectomy with a left thoracotomy and then via a right thoracotomy after late fistula recurrence. One patient preferentially underwent fistula resection and marsupialisation with conversion to gastric bypass for weight regain, one underwent fistula debridement and oversew after failed gastric bypass and the others underwent successful roux-en-y fistula-jejunostomy.
Fistula jejunostomy is a successful and less challenging rescue method in patients who do not require sleeve revision for other reasons. It successfully manages the underlying problem without surgical escalation, and it preserves other options as conversion to a gastrectomy or bypass could reasonably be done if required.
The “retained antrum”, leading to recurrent ulcer disease was a well-known phenomenon in the days when gastrectomy was the routine therapy for complicated ulcer disease. Many bariatric surgeons are happy to convert patients who have undergone sleeve gastrectomy to gastric bypass for the treatment of reflux however our own data show that a significant number (65%) of these patients still require regular PPI therapy to prevent reflux symptoms and stomal ulceration and also that intra-gastric pH remains very low even with a very small gastric pouch.
We present a patient with refractory reflux after sleeve gastrectomy to bypass conversion with abnormal 24-hour pH studies treated successfully by laparoscopic remnant antrectomy. We also present the current evidence base of the retained antrum syndrome, given the paucity of publications in the last 20 years.
The patient was converted from PPI dependant to PPI free post-operatively as have another 4 patients similarly treated. The public literature appears to under-report this phenomenon, probably because of the relative ease of access to PPI therapy worldwide.
Remanent antrectomy can be a viable option for post-RYGBP reflux after sleeve gastrectomy. Because this renders further reversal surgery impossible if the patient develops late gastric bypass complications however we would not recommend this as a routine in all sleeve to bypass conversions.