Managing a Positive Air-Leak Test During a Gastrojejunostomy Revision.

BACKGROUND: Gastrojejunostomy revision after gastric bypass surgery is a challenging procedure that requires advanced skills. The air-leak test was performed to identify gastrojejunostomy leaks. Omental patch seal technique is a well-known treatment of perforated gastrojejunostomy ulcers (Surg Obes Relat Dis 4:423-8, 2012; Surg Endosc 2:384-9, 2013; Surg Endosc 11:2110, 2007).

METHODS: We present a case of a 40-year-old female, who underwent laparoscopic gastric bypass 6 years prior and subsequently developed marginal ulcer, resulting in chronic gastrojejunostomy stricture. She underwent multiple endoscopic dilations until it became refractory. She was taken for a gastrojejunostomy revision. After dissection of dense adhesion, the gastric pouch was identified. The Roux limb was identified as retrocolic and retrogastric. The pouch was divided just below the left gastric pedicle. Endoscope air insufflation was showed no leak of the new pouch. The Roux limb was freed and gastrojejunal anastomosis was performed with a posterior lair, linear stapler, and two layers of running 2-0 absorbable sutures for common enterotomy. The leak test demonstrated air bubbles which were at the anastomosis lateral aspect. A 2-0 non-absorbable suture was placed repeatedly but the leak remained positive. Fibrin glue was placed over the gastrojejunostomy. A tongue of omentum was pulled posteriorly to the pouch and sewed to itself to encircle the gastrojejunostomy. The leak test was not repeated since it would not have changed our management at this point. A remnant gastrostomy tube was placed. Two suction drains were placed. Upper endoscopy, at the end of the case, demonstrated a patulous gastrojejunostomy.

RESULTS: The patient's post-operative course was uneventful. Enteric feeding was initiated via the remnant gastrostomy. Upper GI fluoroscopy was performed on POD 5 and was negative for leak or stricture. She was discharged on POD 7. At 6-month follow-up, she was doing excellent, maintaining her weight without symptoms.

CONCLUSIONS: Gastrojejunostomy revision is a complex procedure that requires an advanced bariatric surgery skills and experience. Omental patch can be used in cases where friable tissue anastomosis leaks as a sealant along with a protective feeding gastrostomy.