Results
During the whole admission, the patient was in a good clinical condition: he was hemodynamically stable and showed no signs of anastomotic leakage. On the 5th postoperative day radiographic swallow series where obtained, which showed no signs of leakage. The drain was unproductive during the whole admission. After the swallow studies the drain was removed. On the 6th postoperative day, the patient was discharged with a full liquid diet. To date, no signs of any complication have emerged (we were especially watchful for signs of stricture, stenosis, and internal herniation). Weight loss results are good: 31.5 % of total preoperative body weight after 12 months. Patients’ blood glucose values returned to normal with discontinuation of all anti-diabetic medications.
Discussion
This video provides a step—to—step guidance on how to solve the rare, but technically demanding intraoperative complication of a large gap between the gastric pouch and the alimentary limb of the jejunum. By dissecting the gastro-oesophageal junction form the crus, stretching the pouch, dividing the mesentery of the jejunum, using the retrocolic/retrogastric route, and the creation of a total hand—sewn gastrojejunostomy were we were able to bridge the gap.
In stark contrast to the reports elaborating the benefits of LRYGB surgery, very little is known about the intraoperative complications. In large trials and reviews conversion rates up to 4.2 % percent are reported [
3,
4], but number are seldom accompanied with a reason why the decision to conversion was made. This is strange considering the occurrence of ‘intraoperative events’ turns out to be an individual predictor for postoperative complications in a large study by Stenberg
et al. [
5]. This study also revealed that more than one third of the conversions were due to ‘difficult anatomic conditions’ [
5]. The lack of reports on how to cope with intraoperative events force even the most experienced bariatric surgeons in to a pioneering position.
All techniques we describe are not part of our standardized surgical technique and may have disadvantages for the patient. Dissecting the gastro-oesophageal junction from the crus can cause a hiatal hernia, but since the traction in caudal direction from the gastrojejunostomy will prevent the pouch from moving cranially, we thing this is a minor concern. Any form of manipulation of the tissue of the pouch might cause bleeding, ischemia, or tearing. Therefore, stretching of the pouch is a subject of debate. We stress that only experienced surgeons can decide whether or not to apply this technique, based on ‘tissue feel’, and their ability to cope with the possible complications. Division of the mesentery, especially in a situation of increased tension, may result in bleeding, and consequent ischemia of the adjoining jejunum [
6]. Furthermore, some authors stress that transecting the mesentery creates a large orifice and may become a potential hernia space [
7], although this was not proven in a recent anatomical study [
8]. In a survey executed amongst 215 American Society for Bariatric Surgery (ASBS) affiliated surgeons 64 % of the surveyed bariatric surgeons used the antecolic/antegastric route for the alimentary limb [
9]. Eleven percent preferred the retrocolic/retrogastric route [
9]. An advantage of the retrocolic/retrogastric route is that it is the shortest route for the alimentary limb to cranially reach the gastric pouch. A disadvantage is the need to create an extra opening in the mesocolon of the transverse colon to facilitate this route, hereby creating an extra orifice and potential hernia space [
10]. Several studies report a decrease in internal hernia (IH) incidence when using the antecolic/antegastric route in comparison to the retrocolic route [
11‐
14], although some authors report the lowest IH incidence using a retrocolic/retrogastric technique [
15]. In this case we performed a hand—sewn gastrojejunostomy whilst our standardized technique is the linear stapling technique. We chose this technique over all others due to the decrease in surgical time compared to circular and hand—sewn anastomosis [
16] and the high incidence of wound infections with circular stapling technique [
17]. In this case, the traction on the anastomosis did not allow us to use linear stapling. In the ASBS survey 41 % of the surgeons indicated that they used the linear stapling technique to create the gastric pouch. In addition, 43 % used a circular stapler device and 21 % reported to make a hand sewn gastrojejunostomy [
9]. Some studies found a higher rate of strictures with a hand sewn suturing technique in comparison to linear or circular stapling techniques [
16], others found no difference [
18].
Because of the increased tension on the gastrojejunostomy the risk of leak was high. As a safety measure, we left drains near the gastrojejunostomy, kept the patient nil by mouth and we obtained radiographic swallow series on the 5th postoperative day. It is doubtful if these precautions would have prevented a leak. The aim of these precautions was rather to decrease the severity in case of a leak and to detect a possible leak in an early phase.
From above it is clear that all applied techniques are inferior to our standardized technique and that they should only be used when confronted with an intraoperative event. Maybe even better is the prevention of such situations. This can be done by switching the order of the surgical steps. In our standardized technique the gastric pouch is created at the beginning of the procedure. Schauer
et al. suggested the formation of the gastric pouch after the inspection and creation of the alimentary limb [
17]. If we had adapted this technique, we could have created a longer pouch or –maybe even better—we could have converted to a sleeve gastectomy.
Conclusion
This video report shows how a large distance between a newly created gastric pouch and the alimentary limb can be bridged, By dissecting the gastro-oesophageal junction from the crus, stretching the pouch, transecting the mesentery of the jejunum, using a retrocolic/ retrogastric route and creating a hand—sewn anastomosis we were able to bridge a 8 cm gap. All these manoeuvres are not part of our standard surgical technique as they are all associated with adverse patient outcome. We stress that only experienced bariatric surgeons should embark on these techniques. Inspection of the alimentary limb before pouch created might prevent the need for these complex techniques.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
NG made a substantial contribution in the analysis and interpretation of the presented surgical techniques, editing the video images, drafting, and revising the manuscript and gave approval for the final version to be published. IK was part of the surgical team that performed the operation and made a substantial contribution to the drafting and revising process of the article and gave approval for the final version to be published. AL made a substantial contribution in the interpretation of the described surgical techniques, drafting, and revising the video as well as the manuscript and gave approval for the final version to be published. All authors read and approved the final manuscript.