Laparoscopic treatment of a gastric fistula after removal of a gastric band

The gastric banding procedure is performed nowadays with less frequency compared to other procedures for morbid obesity. The risk of a gastric fistula after the removal of a gastric band is possible; a high index of suspicion is recommended in order to diagnose this life-threatening complication. We present a video of a gastric band removal and the management of a gastric fistula presented in postoperative day 4.

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Laparoscopic treatment of a gastric fistula after removal of a gastric band

Authors

M Vix, J Marescaux

Abstract

The gastric banding procedure is performed nowadays with less frequency compared to other procedures for morbid obesity. The risk of a gastric fistula after the removal of a gastric band is possible; a high index of suspicion is recommended in order to diagnose this life-threatening complication. We present a video of a gastric band removal and the management of a gastric fistula presented in postoperative day 4.

Classification

clinical cases

Keywords

Laparoscopic treatment, gastric fistula after removal of gastric band

Media type

Surgical video

Duration

06'45''

Publication

2008-11

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E-publication

WeBSurg.com, Nov 2008;8(11).
URL: http://www.websurg.com/doi-vd01en2440.htm

Laparoscopic treatment of a gastric fistula after removal of a gastric band

1. Clinical case presentation 00'18''

This is the case of a 58-year-old patient who had had a gastric band placed 9 years ago. She achieved 45% of excess weight loss, her BMI was 45 at the time and is now 35; she has occasional dysphagia. It is following the patient’s request that the gastric band is removed.

2. Gastric band removal 00'39''

Four trocars are inserted: the adhesions around the insufflation catheter are freed. We follow this catheter up to the gastric band, which we free of its inflammatory tissue. The gastric wrap’s fixation sutures are identified and we carefully free the gastric valve. Once the external part of the band is completely freed, the catheter is cut. It is then removed from the posterior gastric tunnel. The different adhesions between the stomach, the diaphragm and the liver are divided in order to avoid the growth of a fibrotic band. No drains are left in place.

3. Patient re-admission 04'03''

The patient is discharged from hospital at post-operative day 2 and she had no particular complaints. The patient is re-admitted to hospital 2 days later for an inflammatory hyperthermic syndrome. She also suffers from epigastric pains.

4. Laparoscopic reoperation 04'12''

A contrast swallow is performed and it reveals no leak. An abdominal CT-scan demonstrates a mass in the area where the band was removed. The decision to re-operate is then made. The trocars are re-inserted. The epigastric region is explored: there are many adhesions between the stomach, the liver and the diaphragm. As these adhesions are freed, inflammatory tissue is uncovered, indicating a fistula. There are no major collections.

5. Methylene blue dye test 04'54''

A methylene blue dye test is performed, which is negative and a gastroscopy is then performed without visualisation of the defect. An air test is performed and the gastric fistula is finally identified near the angle of His.

6. Fistula identification 05'10''

This fistula is identified once again by the gastroscopist in a gastric fold. A guide wire can be passed through to allow for the insertion of clips, these will in turn allow to re-approximate the edges of the mucosa.

7. Fistula repair 06'07''

A TachoSil® patch is placed on the fistula’s serosal surface and biological glue is applied.

8. Drain placement 06'33''

A drain is left in place and removed on the 5th postoperative day after the patient resumes liquid food intake. The follow-up is uneventful and the patient is discharged 12 days after the surgical re-intervention.