Case report

Role of endoscopy in evaluation and management of persistentgastrojejunostomy leaks after Roux-en-Y gastric bypass

Tannous K. Fakhry, M.D., Michel M. Murr, M.D., F.A.C.S.*Bariatric and Metabolic Institute, University of South Florida Health, Tampa, Florida

Surgery for Obesity and Related Diseases 7 (2011) 232–234

Received February 16, 2010; accepted February 17, 2010

Anastomotic leaks at the gastrojejunostomy are a life-threatening complication of laparoscopic Roux-en-Y gastricbypass (RYGB) [1]. The incidence of gastrogastric andgastrocutaneous fistulas subsequent to anastomotic leakshas been 1–5% [2]. The management of anastomotic leaksincludes intravenous fluids or parenteral nutrition, antibiotics,adequate drainage of the intra-abdominal fluid collection, andcontrol of the leak. Drainage of the leaking anastomosis andabscess can be accomplished through a percutaneous approachor by operative intervention and placement of closed suctiondrains.

A number of novel endoscopic approaches for the diag-nosis and treatment of anastomotic leaks, such as argonplasma coagulation, hemoclips, fibrin glue, and stent place-ment, have been reported, with varying success rates [3].

We report 2 cases of persistent anastomotic leaks inwhich we used endoscopy to guide pulling back drains fromthe anastomotic ring under direct visualization, thereby al-lowing spontaneous healing of the anastomosis.

Case report

Case 1

The patient was a 48-year-old woman who had under-gone laparoscopic RYGB for clinically significant obesity.She subsequently developed a leak at the gastrojejunostomy3 days after RYGB. The patient underwent operative place-ment of 4 drains and insertion of a gastrostomy tube in theexcluded stomach; 2 drains were subsequently removedafter their effluent became scant. However, the effluent ofthe other 2 drains continued to be excessive and changed

*Correspondence: Michel M. Murr, M.D., F.A.C.S., Department ofSurgery, University of South Florida, c/o Tampa General Hospital, P.O.Box 1289, Suite F-145, Tampa, FL 33601.

E-mail: mmurr@health.usf.edu

1550-7289/11/$ – see front matter Published by Elsevier Inc. on behalf of Amerdoi:10.1016/j.soard.2010.02.041

from purulent to saliva-like within 4 weeks postoperatively.An upper gastrointestinal (UGI) contrast study showed thatthe contrast was leaking from the gastrojejunostomy andwas evacuated by the drains. Subsequently, endoscopy wasdone. The 2 Silastic drains were visualized through theanastomosis. Disruption of the anastomosis was found thatinvolved 50% of its circumference. In addition, suture ma-terial and metal staples were visualized (Fig. 1). In theensuing 6 weeks, the drains were gradually pulled backfrom the skin and then removed without additional compli-cations. The leak healed without any further complications.The patient returned for follow-up 5 years later because ofnonspecific epigastric discomfort. Endoscopy and an UGIcontrast study showed a patent gastrojejunostomy withoutevidence of stricture or ulceration.

Case 2

The patient was a 48-year-old man who had undergonelaparoscopic adjustable gastric banding for clinically signif-icant obesity. He presented to our center, 5 years after thelaparoscopic adjustable gastric banding, in a state of septicshock because of band slippage and necrosis of the gastricfundus. He underwent emergent partial gastrectomy andRoux-en-Y stapled gastrojejunostomy. The patient had a longand complicated course in the intensive care unit. The initialserous effluent from the drains became purulent at the sec-ond postoperative week. An UGI contrast study demon-strated a leak at the gastrojejunostomy. Two weeks later andbecause of a persistent leak, the patient underwent endos-copy. The surgically placed Silastic drain was visualizedthrough the posterior aspect of the anastomosis, and 15% ofthe circumference of the anastomotic ring was disrupted.Also, apparent suture material and metal staples were seen(Fig. 2). Under endoscopic visualization, the drain waspulled back from the skin side until it was no longer appar-

ent through the anastomosis.

ican Society for Metabolic and Bariatric Surgery.

showing patent gastrojejunostomy.

233T. K. Fakhry & M. M. Murr / Surgery for Obesity and Related Diseases 7 (2011) 232–234

On a weekly basis, the drain output diminished as thedrain was pulled out gradually from the skin side (1 in./wk).The drain was completely removed within 5 weeks. Afollow-up UGI contrast study did not show any leaks fromthe gastrojejunostomy and no fistulous tract.

Discussion

The clinical presentation of anastomotic leaks after bari-atric surgery might be nonspecific. A complete diagnosticworkup should be obtained immediately for any patient whohas developed tachycardia, fever, or abdominal pain afterbariatric surgery [4].

A routine UGI contrast study might identify anastomoticleaks at an early stage in asymptomatic patients. However,routine UGI studies have a low sensitivity. Computed to-mography provides useful information about the extravasa-

Fig. 2. (A) Dotted line outlines circular anastomotic ring. Arrows point totip of drain through posterior aspect of anastomotic ring. (B) Dotted lineoutlines circular anastomotic ring. Straight arrows point to tip of drain.Curved arrow outlines trajectory of drain as it was pulled back from skin

Fig. 1. (A) Dotted line outlines circular anastomotic ring. Arrows point to2 drains in posterior aspect of anastomotic ring. (B) Dotted line outlinescircular anastomotic ring. White arrows point to tract of 2 drains after beingpulled back. White star indicates efferent limb. (C) Follow up endoscopy

side. Star indicates fibrinous material over anastomotic ring.

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234 T. K. Fakhry & M. M. Murr / Surgery for Obesity and Related Diseases 7 (2011) 232–234

tion of contrast material from the gastrojejunostomy, dila-tion of the excluded stomach, or the presence of freeintraperitoneal gas or fluid [4,5].

Patients with anastomotic leaks have significantly in-creased morbidity and mortality [6]. The mainstay of treat-ment for anastomotic leaks is operative exploration toachieve wide drainage of the abdominal cavity and place-ment of drains. Acute inflammatory changes around thegastrojejunostomy could preclude suture repair of the leak-ing staple line; therefore, drains are critical in controllingsuppurative peritonitis. Nonoperative treatment will be mostsuccessful in patients who do not have hemodynamic insta-bility, specifically, hypotension or oliguria [4].

In the first case presented, the patient was treated non-operatively. In contrast, the second patient underwent op-erative drainage and drain placement. Both patients hadpersistent, yet controlled, anastomotic leaks. The likelihoodof persistent anastomotic leaks and fistulas is more commonin patients with radiation injury, inflammatory bowel dis-ease, erosion of indwelling tubes or drains, malignancy,intra-abdominal abscess, and distal obstruction [7]. It is thusimportant to rule out these conditions as causes of persistentleaks by a series of radiologic tests. Subsequent to radio-logic tests that indicate a persistent leak without distalobstruction or an associated intra-abdominal abscess, manysurgeons would advocate maintaining the surgically placeddrain until the purulent drainage has diminished.

Because of the first patient’s complaints of nausea, dys-pepsia, and intolerance to food, we decided to examine theanastomosis endoscopically to determine whether a stenosiswas present. Using endoscopic monitoring, we were able topull the tip of the drains back from the anastomotic ring intothe drain tract; pulling the drain back on a weekly basisallowed the tract to heal without subsequent formation of anabscess. In the second patient, a persistent leak prompted usto undertake endoscopy to visualize the anastomosis. Sim-ilarly, endoscopy allowed us to pull the drain back from theanastomotic ring.

We hypothesized that pulling the drains out of the anas-tomotic area might have shortened the course of the leak;therefore, we would recommend early endoscopy in patientswith persistent leaks and intra-abdominal drains. This ag-gressive approach is in keeping with the reports from othersurgeons in which the eroding drain was completely re-moved after endoscopic visualization [3,8]. The resultinggastrocutaneous fistula was addressed at the same session

using a combination of clipping and cautery, endoluminal

stenting of the fistula tract, fibrin sealing or suturing, andapplication of Surgisis [8–12].

Our approach capitalized on the knowledge of the treat-ing surgeon of the anatomy and technical specifications ofthe gastrojejunostomy. Early endoscopy should be consid-ered in patients with persistent leaks when underlying sepsisand intra-abdominal abscess have resolved. This approachis straight forward, does not involve expensive endoluminalmaterial, and does not preclude the use of other interven-tions.

Disclosures

The authors have no commercial associations that mightbe a conflict of interest in relation to this article.

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