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Laparoscopic Roux-en-Y Gastrojejunostomy Stricture, Serial Dilation, and Perforation: A Case Report and Review of Literature [Meeting Abstract]

Liu, S; Lim, D; Vulpe, C; Ferzli, G
Background: We present a case of a 33-year-old female that underwent a laparoscopic Roux-En-Y gastric bypass 5 months prior that subsequently developed a gastrojejunostomy stricture treated with endoscopic balloon dilation. Following her third balloon dilation she developed severe abdominal pain and was found to have free air on an upright abdominal x-ray. The patient was immediately brought to the operating room for a diagnostic laparoscopy which demonstrated an anterior perforation of the gastrojejunostomy anastomosis. The decision was made to revise the anastomosis by performing a stricturoplasty where the perforation was extended longitudinally and closed transversely with interrupted silk sutures to both repair the perforation and resolve the anastomotic stricture. The patient had an uncomplicated postoperative course. Gastrojejunostomy strictures are a common complication after laparoscopic Roux-En-Y gastric bypass. There are multiple factors that may lead to the formation of a stricture including marginal ulcers or technical error. Anastomotic strictures are often managed endoscopically with serial balloon dilations. However, if endoscopy fails to relieve the stricture, the patient may need to undergo a laparoscopic gastrojejunostomy revision, which can be morbid. Additionally, anastomotic perforation represents a surgical emergency that warrants immediate exploration. This case presents a unique situation where both situations are present and more conservative measures such as endoscopic stenting are not feasible. By performing a revision stricturoplasty, we attempted to repair the perforation as well as lengthen the anastomosis to relieve the stenotic area. [Figure presented]
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EMBASE:2003410294
ISSN: 1878-7533
CID: 4152032

Bleeding dieulafoy ulcer after gastric sleeve: A case report and examination of the need for preoperative esophagogastroduodenoscopy before bariatric surgery [Meeting Abstract]

Nicoara, M; Morin, N; Liu, S; Vulpe, C; Ferzli, G
Introduction: There is still controversy regarding whether or not a preoperative esophagogastroduodenoscopy (EGD) should be done before bariatric surgery; does it change surgical course, and does it prevent postoperative complications? Here we present a relevant case and review the current literature relating to preoperative EGDs in bariatric surgery. Case Presentation: A 51 year female presents for preoperative workup prior to undergoing a restrictive bariatric procedure. A standard institutional preoperative workup was performed without an EGD. Patient returned postoperative day number two with hematemesis. Emergent EGD showed clotted blood in the stomach and a Dieulafoy ulcer that was successfully clipped by the endoscopist.
Method(s): A literature review was performed using Pubmed. Search term ''EGD bariatric surgery'' was used.
Result(s): PubMed search returned 50 papers, and 13 were selected for review due to their relevance; 4 against EGD, 5 in favor of EGD, and 4 in favor if patient has reflux symptoms.
Discussion(s): A Dieulafoy ulcer is rare, accounting for 1-2% of upper gastrointestinal bleeding presentations. Our patient presented with classic findings of this lesion: larger diameter vessel on the lesser curve of the stomach, about 6 cm from the gastroesophageal junction, with vessel protruding through a mucosal defect with active arterial bleeding. It is uncertain if a preoperative EGD would have located this lesions and/or provided a means for intervention before presentation. Our literature review on the subject shows that preoperative EGD rarely changes surgical management. They do change medical management in a significant number of cases. With the majority of papers in favor of preoperative EGD (albeit 4 only if patient has symptoms of GERD) there is evidence in favor of performing a preoperative EGD before bariatric surgery.
Conclusion(s): The current literature is equivocal regarding a preoperative EGD as it rarely changes the surgical management, but often changes the medical management. Even though the yield is small, we recommend preoperative EGD before bariatric procedures for medical optimization; in order to avoid the potentially devastating consequences associated with a missed lesions such as the one presented
EMBASE:627143395
ISSN: 1432-2218
CID: 3811552

Laparoscopic ventral and incisional hernia repair

Chapter by: Castro, AE; Edwards, Eric D; Vulpe, CT; Ferzli, George s
in: International principles of laparoscopic surgery by Frezza, Eldo E; Gagner, Michel; Li, Michael K [Eds]
Woodbury, CT : Distributed by CineÌ-Med Publishing, c2010
pp. 653-660
ISBN: 0982451431
CID: 1772942