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| VIDEO ABSTRACTS |
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| Year : 2023 | Volume
: 2
| Issue : 1 | Page : 46-50 |
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Video Abstract: sAbstracts of 20th Annual National Conference of Obesity & Metabolic Surgery Society of India 2023, Mumbai
| Date of Web Publication | 20-Feb-2023 |
Correspondence Address:
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/2949-6705.370083
How to cite this article:
. Video Abstract: sAbstracts of 20th Annual National Conference of Obesity & Metabolic Surgery Society of India 2023, Mumbai. J Bariatr Surg 2023;2:46-50 |
How to cite this URL:
. Video Abstract: sAbstracts of 20th Annual National Conference of Obesity & Metabolic Surgery Society of India 2023, Mumbai. J Bariatr Surg [serial online] 2023 [cited 2023 Mar 22];2:46-50. Available from: http://www.jbsonline.org/text.asp?2023/2/1/46/370083 |
| Lap OAGB in a Post Fundoplication Patient | |  |
Anirudh Rajkumar, Dharmendra, Tasmia
Life Line Hospital, Chennai, Tamil Nadu, India
E-mail: [email protected]
Clinical Presentation: Patient underwent Laparoscopic Nissen's Fundoplication 9 years ago, following which he has had no reflux symptoms since then. He gained over 25 kg weight in the last 3 years which he wasn't able to reduce in spite of medications, diet and exercise. Recently he developed severe sleep apnea, multiple joint arthritis and Diabetes mellitus. Also he became a CAD patient on cardiac medications since 3 years.
Indication for Surgery: Required a weight loss procedure for which he was counselled in detail and a thorough workup was done, along with fitness from Anaesthesiologist, cardiologist, nutritionist and physician. Following this, he was scheduled to undergo a Laparoscopic OAGB or RYGB surgery. Endoscopy done showed no evidence of reflux esophagitis, no hiatus hernia, an intact fundal wrap and was negative for H. pylori. As he had no reflux symptoms and we wanted to do a quicker procedure for shorter intra-operative duration, we decided to go ahead with a Lap OAGB after obtaining the fitness from the involved specialists.
Operative Procedure: Under GA, under aseptic precautions, split leg position, Standard five Lap OAGB ports were inserted, Lesser curvature dissected at the level of crow's foot, retro gastric window created, transverse stapling of stomach was done using 45 mm Endo GI purple stapler. Further vertical stapling done superiorly upto the level of fundal wrap. The next firing was done lateral to the wrap, leaving it intact, and pouch creation completed. 180 cm BP limb distal to the DJ flexure anastomosed to the pouch using a 60 mm Endostapler. Enterotomy closed with 2-0 PDS sutures. Closure done after a negative leak test.
Postoperative Outcome: Patient was mobilised after 4 hours. Clear oral fluids and LMWH were started after 12 hours. Patient recovered well and discharged on 2nd POD. After 4 months, patient came with bile gastritis which was managed conservatively. After one year of follow up, patient lost 80% excess weight and he has no reflux symptoms. Though more data is required, OAGB appears to be an effective bariatric procedure in a post Fundoplication patient, as an alternative to RYGB.
| Different Indications and Complexities of Revision Bariatric Surgery: A Video Case Series | | |
Arun Kumar, Vitish Singla, Sandeep Aggarwal
Department of Surgical Disciplines, AIIMS, New Delhi, India
E-mail: [email protected]
We present a video case series of three patients who underwent conversion to RYGB from Sleeve Gastrectomy for altogether different indications. Patient 1 is a 45-year-old lady with complaints of post-prandial recurrent vomiting and abdominal fullness, 3 years after SG (BMI: 36.4 kg/m2). Her BMI has improved to 26.5 kg/m2. However, Barium swallow revealed stricture at the junction of proximal 2/3rd and distal 1/3rd of the sleeve, confirmed by UGIE and CECT abdomen. Patient 2 is a 67-year-old female with symptoms of severe regurgitation (GERD-Q: 14/18) and reflux, 7 months after SG (BMI: 41.8 kg/m2). Her BMI has improved to 27.9 kg/m2. On Barium swallow, she revealed grade III reflux. Her UGIE & CECT show Hiatus hernia (HH) with sleeve migration. She underwent RYGB with HHR. Patient 3 is a 49-year-old female with symptoms of regurgitation and reflux for the last 1 year, 9 years after SG (BMI: 53.1 kg/m2). Her BMI has improved to 27.1 kg/m2. However, Barium swallow revealed grade III reflux with UGIE showing Barrett's esophagitis. She underwent HHR, in addition to RYGB.
Conclusion: All postoperative bariatric surgery patients with impaired QoL should be evaluated diligently and offered revision if indicated. Revision Bariatric Surgery is challenging and requires high expertise and skill. RYGB is still the gold standard procedure, especially in patients requiring revision surgery.
| Sleeve Stenosis – Diagnosis and Management | | |
Ashish Vashistha
Department of Bariatrics, Max Super Specialty Hospital, New Delhi, India
E-mail: [email protected]
Background: This study aimed to determine the incidence, etiology, and management options for Complication -Stenosis after Laparoscopic sleeve gastrectomy (LSG).
Methods: A retrospective study reviewed morbidly obese patients who underwent LSG between January 2014 and December 2017 to identify patients treated for Stenosis after LSG.
Results: In this study, 112 patients with a mean age of 48 years and a mean body mass index (BMI) of 42 underwent LSG. In 2 of these patients Stenosis developed. The LSG procedure was performed using a 36-Fr. bougie. Both patients underwent contrast study, demonstrating a fixed narrowing. In one patient Endoscopy confirmed short-segment stenoses: near the gastroesophageal junction. This patient require two sittings of dialatation (15 mm ballon). The time from surgery to initial endoscopic intervention was 45 days, and the time from the first dilation to toleration of a solid diet was 48 days. In another patient Contrast studies demonstrated minimal passage of contrast through a long-segment stenosis. This patient also underwent multiple endoscopic dilation procedures and endoluminal stenting, ultimately requiring laparoscopic conversion to Roux-en-Y gastric bypass.Time from the initial surgery to the surgical revision was 72 days, and time after the first intervention to tolerance of a solid diet was 85 days.
Conclusion: Symptomatic short-segment stenoses after LSG may be treated successfully with endoscopic balloon dilation. Long-segment stenoses that do not respond to endoscopic techniques may ultimately require conversion to Roux-en-Y gastric bypass.
| Stapler Misfire during Sleeve Gastrectomy-Management Introduction – The Surgical Article Contains Reports of Staple Misfire during Sleeve Gastrectomy | | |
Ashish Vashistha
Department of Bariatrics, Max Super Specialty Hospital, New Delhi, India
E-mail: [email protected]
Though rare, may lead to bleeding, leak and development of structures. Surgical stapling devices are known for their reliability and convenience. Incidence of stapler misfire ranges from .22 to 2.3%. Perhaps the numbers are incorrect because of under reporting of such cases.
Methods: Our study includes retrospective study of 4 cases of stapler misfire during bariatric surgery in our institution during 2017 to 2022. In all cases purple staplers of same provider was used.
Results: 4 cases were identified where stapler misfired and stapler lines were not formed and hence these cases required additional sutures along the stapler lines for reinforcement.
Conclusion: Stapler line reinforcement is generally safe. Surgeons should be aware of possible stapler misfiring complication and it's management. Slow firing with optimum view of surgical field helps in preventing major complication.
| Revision Surgery – Sleeve to RYGB Technical Tips and Outcome | | |
Ashish Vashistha
Department of Bariatrics, Max Super Specialty Hospital, New Delhi, India
E-mail: [email protected]
Introduction: Sleeve gastrectomy is often associated with insufficient weight loss, inadequate resolution of co-morbidities and severe GERD. Conversion to RYGB is a good solution.
Objective: To highlight the technical details and outcome of conversion from sleeve to RYGB at our center.
Methods: Retrospective case series of 10 cases who underwent conversion from sleeve to RYGB between 2017 to 2022.
Results: 6 out of 10 patients were converted to RYGB due to insufficient weight loss. 4 patients were converted because of severe GERD, mean pre-operative BMI was 49, mean post- operative BMI was 37 over 18 months. The mean time to conversion was 39 months. All patients had complete resolution of their hypertension and sleep apnoea. Revision peri-operative complication rates were comparable to primary RYGB.
Conclusion: Revision to RYGB is a safe procedure for sleeve gastrectomy failure and results in significant benefits from co-morbidities.
| Laparoscopic RYGB in Patient of Chronic Sleeve Leak after Failed Endotherapy | | |
Chirag Parikh
Department of Surgery, Parul University, Vadodara, Gujarat
E-mail: [email protected]
Clinical Presentation and Indication: Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed 'standalone' bariatric procedure in India. Staple line gastric leaks occur infrequently but cause significant and prolonged morbidity. 42-year male patient with BMI 35 In whom LSG was performed; presented with leak on post op day 7. CECT showed small leak at GE junction with minimal collection. Endoscopy showed minimal leak with narrowing at incisura, so SEMS stent placement was done. Patient started with oral feeds but had issues with reflux. 20 days later CECT showed no leak so stent removed. Following that after 7 days patient leaked again so laparoscopic RNY gastric bypass with feeding jejunostomy performed.
Preoperative imaging (incorporated in video)
- CECT image
- Endoscopy report
- Oral gastrografin study poststent removal
Operative Procedure: Pl see video.
Postoperative Outcome: Patient had overall weight loss of 30 kg and upon regular follow up doing well.
Discussion: Gastric sleeve leak can present as peritonitis, abscesses, cutaneous or other fistulas, sepsis, organ failure and even death. Fortunately it is an infrequent complication of LSG. However, as a consequence, the management of such patients cannot be clearly recommended. Analyzing patients with this problem can help define a clinical approach for management and possible preventive measures.
Conclusion: Leakage closure time may be shorter with intervention than expectant management. Sequence and choice of endoscopic esophageal stenting and/or surgical re-intervention should be individualized according to clinical presentation.
| Difficult Laparoscopic Sleeve Gastrectomy in Patient with Liver Parenchymal Disease with Adhesions | | |
Chirag Parikh
Department of Surgery, Parul University, Vadodara, Gujarat
E-mail: [email protected]
Clinical Presentation and Indication: Laparoscopic sleeve gastrectomy (SG) is a validated procedure for the surgical treatment of morbid obesity. Cirrhosis is often considered a relative contraindication to elective extrahepatic surgery. 54-year-old patient presented with BMI of 47, h/o alcoholism and liver cirrhosis. He had significant pedal oedema, on diuretics with hypoalbuminemia. USG showed liver nodularity but no ascites. He was optimized by medical team for correction of albumin and respiratory function (from Child B to A). We performed SG with challenges of enlarged liver and significant adhesions.
Preoperative Reports:
- Serum albumin 2.6 gm/dl corrected to 3.8 gm/dl
- USG.
Operative Procedure: Pl see video.
Postoperative Outcome: Patient had weight loss of 15 kg in 2 months and doing well.
Discussion: Bariatric surgery can be performed safely in carefully selected patients with well compensated cirrhosis. Surgical risk can be further stratified using CTP/MELD score to estimate liver reserve. Increasingly, SG has been advocated as modality of choice in patients with cirrhosis. Compared to gastric bypass, SG has fewer complications overall with advantage of access to the stomach remnants and biliary system. SG was observed to be well tolerated and improves candidacy for liver transplantation.
Conclusion: Bariatric surgery can be performed in patients with well compensated cirrhosis, typically of Child's A status, with minimal risks from surgical or hepatic factors. Patients need to be carefully selected and optimised, while surgical technique and modality also play equally important roles.
| A Unique Case That We Did of a Laparoscopic Sleeve Gastrectomy in a Morbidly Obese Patient with a Large Loss of Domain Incisional Hernia Who Came to Us Primarily for Hernia Repair | | |
Daksh Sethi, Sudhir Kalhan, Mukund Khetan, Suviraj John
Department of Minimal Access, Metabolic and Bariatric Surgery, Sir Gangaram Hospital, New Delhi, India
E-mail: [email protected]
Background: We present a case of laparoscopic sleeve gastrectomy in a 54 year old female patient who presented to us with a large incisional hernia of 17 cm defect with loss of domain and a BMI of 46 kg/m2.
Materials and Methods: A 54 year old lady with a weight of 108 kg, height of 153 cm and a BMI of 46 kg/m2 presented with a large incisional hernia with a previous history of laprotomy for enteric perforation followed by another surgery for Ileostomy closure done in 2020 and 2021 respectively. CECT Abdomen showed a large 17 cm defect with bowel and omentum content with loss of domain (sac volume / abdominal cavity volume – 30%). She presented to us primarily for hernia repair. On clinical evaluation and discussion with patient and family, she was advised bariatric surgery prior to hernia repair. In her present status of morbid obesity, we would have been unable to achieve a satisfactory closure of the defect despite using Botox and Progressive Pneumoperitoneum. The patient was planned for a laparoscopic sleeve gastrectomy after optimisation. The patient was placed in supine leg split position. Verres insufflation of the abdomen was done from the palmar's point followed by optical entry using a 12 mm trocar in the left upper quadrant. One more 12 mm and two 5 mm trocars were inserted one of which was later used for a Nathanson's liver retractor all in the left upper quadrant due to a severely constrained space and massively destorted anatomy. The antrum and pylorus of the the stomach were pulled up into the defect which made starting the procedure even more challenging. Gastrolysis was started approximately 4cm from the pylorus and continued towards the fundus and GE Junction with continuous management of fighting of trocars and the camera. The stomach was also separated from posterior adhesions with the pancreas. Following the Gastrolysis, the sleeve was created using an Echelon powered stapler with one green and four blue cartridges which were fired fired from awkward angles using articulation of the stapler. Areas where the staple lines crossed each other because of technical difficulties and space constraints were reinforced with sutures using vloc 2-0. Haemostasis was achieved and closure was done with a flat drain in situ and the specimen was retrieved in a endobag.
Results: There was no intraoperative or postoperative complication. The operative time was 155 minutes, and estimated blood loss was 200 mL. An intraoperative endoscopy and leak test was done and the patient was allowed orally on post-operative day 1 starting with clear liquids at 30 ml/hr which was gradually increased. The postoperative hospital stay was 3 days. The patient has come down to 90 kg at 1 month post surgery which is a total weight loss of 18 kg from her nadir weight.
Conclusion: Morbidly obese patients with LOD Hernias should be advised for pre-operative weight loss preferably through surgical means to achieve the desired result earlier and reduce the chances of recurrence when the definitive hernia repair is done along with improving the quality of life of the patient.
| Laparoscopic One Anastamosis Gastric Bypass as an Option in Patient with Sleeve Twist/Stenosis Post Sleeve Gastrectomty | | |
Muvva Sri Harsha
Apollo Institute of Bariatrics, Apollo Hospital, Chennai
E-mail: [email protected]
Sleeve gastrectomy is a popular surgery and one of the commonly performed bariatric surgery worldwide. Sleeve stenosis is relatively rare complication of sleeve gastrectomy approximately accounting to 0.2 to 4 % (according to large series publications). It can either be acute in the immediate postoperative period because of volvulus of free stomach devoid of its supports. However in some patients it can be a delayed presentation due to progressive rotation of staple line in an anterior to posterior direction which leads to functional stenosis. Here we present operative video of patient of BMI -54 and with co-morbidities Diabetes and Hypertension who underwent sleeve gastrectomy 8 months. His initial post operative recovery was uneventful, but he started having difficulty in consuming solids occasionally. He underwent endoscopies 2 times before coming to us which were normal. When he presented to us, he was not able to consume solid diet and was taking mostly either semi solid/liquid diet. His BMI at the time of presentation was 46 and Still on Insulin for his diabetes. On evaluation with CECT + gastrograffin + upper GI endoscopy we proceeded with Laparoscopic One anastomosis gastric bypass for the patient. Post op recovery has been uneventful and his 6 month followup has been good without any compliants, good weight loss and remission of diabetes.
| Robotic Assisted One Anastamosis Gastric Bypass Using HUGOTM: RAS (Robotic Assistant System) by Medtronic | | |
Nikitesh Krishna
Apollo Hospital, Chennai
E-mail: [email protected]
Introduction: We present the surgical video of patient who underwent Robotic One Anastamosis Gastric Bypass with help of HUGOTM-RAS robot by Medtronic. HUGOTM- RAS is a newer robotic platform introduced by Medtronic. It has Independent arms and also vision is via 3D display with tracker which is integrated into the console. Our team is the first in Asia-Pacific region to perform one anastomosis gastric by using HUGOTM- RAS system.
Materials and Methods: 3 Robotic arms were used for the surgery. A central supraumbilical 12 mm camera port was used, 2 lateral 8 mm ports were used. Liver retraction was done using hiatal sling technique. One assistant port was used to use stapler and energy source.
Conclusion: On initial evaluation, the HUGOTM- RAS platform is found to be safe and effective tool for performing bariatric procedures. The introduction of stapling devices and advanced energy sources for HUGOTM- RAS platform will make the procedure a fully robotic surgery.
| Revisoin Sleeve Gastrectomy for Weight Recidivism after Laparoscopic Band Surgery | | |
Prashant Salvi, Pinky Thapar, Akash Dehankar, Vishakha Merude, Aisha Aga, Sneha Vasvani
Jupiter Hospital, Thane
E-mail: [email protected]
Obesity is considered a worldwide health problem of epidemic proportions. Bariatric surgery remains the most effective treatment for patients with severe obesity, resulting in improved obesity-related co-morbidities and increased overall life expectancy. However, weight recidivism has been observed in a subset of patients post-bariatric surgery.
Objectives:
- To manage weight recidivism with revision bariatric surgery
- To show the steps involved in meticulous planning prior revision bariatric surgery.
Methods: Laparoscopic Band was done in 2008 (weight of 90 kgs) - nadir weight of 70 kgs (2010). Came to us for weight gain - current weight of 103 kgs. Plan was to evaluate and plan Revision Sleeve or RYGB Problems in front of us: Band erosions, Adhesions, Slippage.
On Oral gastro-graffin:
- Oesophagus to some extent was dilated
- Fundus was dilated and out pouching
- Lap Band was at GE junction (Slipped)
- Metal controller in epigastric region
- No evidence of obstruction
- Preop Endoscopy did not reveal any band erosion or stricture
- Laparoscopic band removal was done and it was revised to standard sleeve gastrectomy
Results: Patient has lost 13 kgs post revision bariatric surgery in two and half months. She followed a 15 ay post-operative liquid diet and for another 15 days puree diet, then followed a regular diet.
Conclusion: Revision bariatric surgery is a safe and feasible option for patients with weight recidivism with proper optimization and planning.
| Laparoscopic Revision to Sleeve Gastrectomy from Roux-En-Y Gastric Bypass in Reactive Hypoglycemia | | |
T. Viswanath, S. Saravana Kumar, X. L. Jayanth Leo, P. Praveen Raj
Gem Hospital, Coimbatore, India
E-mail: [email protected]
Clinical Presentation and Indication for Surgery: A gynaecologist, 4 years post Roux-en-Y Gastric Bypass, quit her practice due to severe hypoglycemic attacks was referred to us with a working diagnosis of Nesidioblastosis Post Bariatric Surgery. Episodes started 2 months back as blackouts and picture mimicking absence seizures. She was evaluated for organic causes by a neurologist and endocrinologist which turned to be negative. She underwent Oral Glucose Tolerance Test twice and a Mixed Meal Test to doubly check for Hyperinsulinemia. At any point of time during admission Hyperinsulinemia couldn't be demonstrable but the hypoglycemic episodes continued. Her Exendin PET scan showed a diffuse lesion in head of pancreas but no anatomical lesion was seen in a routine PET. We planned for a diet modification (Nutritional Therapy) with protein rich and zero carbohydrate diet which she couldn't tolerate due to persistent severe hypoglycemic attacks (Sr. glucose <35 - 40 mg/dl during episodes). Minimal carbs were added but she started gaining weight due to frequent intake with repeated attacks (gained 6kg in a month 79 kg -> 85 kg). In view her recurrent attacks she was considered for surgical management - Reversal of Roux-en-Y Gastric Bypass to Sleeve Gastrectomy.
Preoperative Endoscopy: Status post RYGB. No pouch or stoma dilatation. Jejunal loop entered was normal.
Operative Procedure: Remnant stomach dissected from pouch and left crus. Using 60 mm green stapler, Gastrojejunostomy dismantled and gastric pouch trimmed with 37.6 F bougie insitu with green and gold linear staplers. Using Orovil (25) & EEA stapler through gastrotomy done in remnant stomach's greater curvature, gastrogastrostomy done. With 37.6F bougie insitu, using green and 2 gold 60 mm reloads, sleeve constructed. Junction of pouch and rest sleeve reinforced 3600 with 2-0 V-loc sutures. Air leak test done and found to be negative. From DJ flexure, bowel walk done and JJ identified. BP and Roux limb defined. BP limb divided just proximal to JJ. All adhesions in Petrsen's space released. BP limb anastomosed to Roux limb side to side with 60 mm white stapler and enterotomy closed with 2-0 absorbable sutures. Mesenteric defect closed with 1-0 prolene. 12 mm ports and EEA stapler site closed with 1 ethilon transfascial sutures.
Postoperative Outcome: Her blood glucose levels were continuously monitored both pre and postoperatively by Continuous Glucose Monitoring System (CGMS). She did well post-surgery with no glycemic surges except for a day after discharge. Her blood glucose levels were maintained at around 70 to 80 mg/dl and she improved symptomatically and started her practice 1month post-surgery.
Keywords: Mixed meal test, nesidioblastosis, oral glucose tolerance test, reactive hypoglycemia, revisional sleeve gastrectomy, Roux-En-Y gastric bypass
| Revision Surgery | | |
Manish Khaitan
K D Hospital, Ahmedabad, Gujarat
E-mail: [email protected]
Background: Weight regain/failure can occur in upto 60% of patients with sleeve in long term. Insufficient weight loss and weight regain are the most common reasons. There are many surgeries which can be done for weight regain after sleeve gastrectomy. Here we retrospectively analyse the outcomes of revision of sleeve gastrectomy to Laparoscopic RYGB at our center.
Methods: 46 pateints underwent revision of sleeve to RYGB between 2016 to 2019. Patients were followed up for 3 years and outcomes were measured in terms of %Excess weight loss, Hemoglobin, Serum iron and albumin levels at end of 3 years. Total bowel lenght was measured and the common channel was kept constant at 450 cms and alimentary limb was also kept constant at 80 cms.
Results: Mean Pre-operative BMI was 43.2±14 kg/m2. Mean post operative BMI at 1 year, 2 year and 3 year was 30.3±4.19, 32.6±4.72 and 34±5.8 kg/m2. The mean % EWL at the end of 1 year, 2 years and 3 years was 71.5±17.2, 68.2±18.1 and 60.8±19.8. Mean Serum Albumin level at pre operatively was 3.9±0.46 and at 1 year, 2 year and 3 years was 3.7±0.55, 3.6±0.62 and 3.3±0.92. Mean S. Iron preoperative was 63.97±49.46 and at 1 year, 2 year and 3 years was 73.85±41.54, 69.54±44.57 and 67.66±42.45 respectively. Mean Pre-operative Hb was 11.3 ±1.24 and at 1 year, 2 year and 3 year was 12.3±1.29. 11.9±1.22 and 11.2±1.02 respectively. 1 patient had remnant stomach leak, 1 patient developed GJ stricture, 3 patients had diarrhea which was medically managed. There was no mortality.
Conclusion: Conversion of Sleeve to Roux-en-y gastric bypass for weight gain gives good weight loss results with acceptable nutritional complications.
| Chronic Leak Post Revisional Sleeve Gastrectomy – Laparoscopic Esophagofistulogastrojejunostomy | | |
S. Saravana Kumar, T. Viswanath, X. L. Jayanth Leo, P. Praveen Raj
Gem Hospital, Coimbatore
E-mail: [email protected]
Clinical Presentation and Indication for Surgery: We report a case of 33-year-old woman referred for chronic sleeve leak management Post revisional Sleeve Gastrectomy. She underwent Sleeve Gastrectomy elsewhere 8 years back for Morbid obesity (BMI: 42.5 kg/mt2, wt: 115 kg) following which she dropped to 60 kg (nadir weight). She had consulted for weight recidivism in 2021 (Weight: 104 Kg) and underwent lap revisional sleeve gastrectomy (LRSG, Intraop: fundus and proximal stomach dilated). On POD-2 she developed tachycardia with pain abdomen and CT findings were consistent with leak at GE junction for which she underwent Diagnostic lap with drainage, suturing of the defect and a live omental patch repair with NJ placement. A week later, she was subjected to diagnostic endoscopy showing persistent fistulous opening at GE junction which was occluded with Over The Scope Clip (OTSC). In view of persistent drain output and intolerance to NJ tube after 3 months, it was proceeded to FJ (Planned for Lap but open FJ was executed) following which the laparotomy wound was infected and drained. At this stage, with severe malnutrition and incompletely healed laparotomy wound and FJ in situ she was referred to us. She had severe hypoproteinemia and weighed around 68 kg at the time of presentation.
Preoperative Endoscopy: OVESCO clip, freely floating at the defect was seen and removed. A transmural defect at GE junction leading into a cavity lined by inflammatory exudates and a linear tract across greater curvature of the sleeve both separated by a septum.
Operative Procedure: After thorough optimisation, she underwent surgical intervention. Dense adhesions between sleeve and liver were lysed by sharp dissection. Dissection continued till GE junction which revealed a large defect at the lateral margin of staple line. Attempt at closure of the defect caused narrowing evident at intraop UGI scopy. Hence edges freshened and distal esophagus mobilised up to 5 cm and Roux-en-Y Esophagofistulogastro jejunostomy done with handsewn V-loc sutures with BP limb of 75 cm and Roux limb of 100 cm. Air leak test negative.
Postoperative Outcome: She was started on postoperative FJ feed and gradually shifted to oral liquids after confirming the integrity of the anastomosis. She was on follow up 6 months postoperatively now and is on as per diet guidelines.
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