Access to the Bypassed Stomach after Gastric Bypass

Contents:

Mathias A. L. Fobi MD, F.A.C.S.; Kathleen Chicola MD', Hoil Lee MD

Center for Surgical Treatment of Obesity, Bellflower; 1) Bellwood General Hospital Bellflower; 2) Cedars Sinai Medical Center Los Angeles, CA, USA

 The gastric bypass (GBP) Operation is progressively being widely used to treat severe obesity. One problem with this operation is that it leaves the bypassed segment of the gastrointestinal tract not readily available for either mechanical, radiological or endoscopic evaluation. We have addressed this problem by putting a gastrostomy tube in the bypassed stomach at the time of the GBP. A radio opaque marker placed around the gastrostomy site enables easy radiological localization of and thus easy percutaneous access to the bypassed stomach. The surgical technique is presented. 1998 Lippincott-Raven Publishers.

Key words: Gastric bypass, gastrostomy, morbid obesity, percutaneous access, radiology, radio-opaque marker.

Introduction

Access to the bypassed stomach in patients who have had the gastric bypass (GBP) operation for obesity has been a concern for the surgeon who does the procedure, the physician who will follow the patient and the patient having the operation. Some surgeons who do the GBP have reported successful access to the bypassed stomach via retrograde intubation. A long colonoscope is passed orally through the esophagus into the proximal pouch and down the efferent limb of the Roux-en-Y gastro-enterostomy, into the afferent limb, through the duodenum and into the stomach. Other surgeons have used the blind hit-or-miss percutaneous long needle punctures of the bypassed stomach assisted by fluoroscopy for access. Whereas these two methods have been used successfully they do not lend themselves to routine use. A method for routine localization of the bypassed stomach and thus easy radiological assisted percutaneous access is described.

Surgical Technique

A gastrostomy tube (size 16-French) (Figure 1 and Figure 2) is put into the bypassed stomach during the GBP. The stomach is tagged to the left anterior peritoneal wall around the gastrostomy tube. A radio-opaque tubing, 6 cm long, is placed around the gastrostomy site (Figure 1 and Figure 2). The tubing is the same type that is used in the silastic ring vertical gastroplasty. This marker is visible on plain abdominal X-rays (Figure 3) and on computed tomographic scan of the abdomen (Figure 4). Access to the bypassed stomach is obtained by placing the patient on the X-ray table flat on the back. A cross-table lateral film of the abdomen is taken. The location of the ring is determined (Figure 5). Under fluoroscopy a 22 gauge Chiba needle is placed into the bypassed portion of the stomach by introducing it through the skin and guiding it through the ring (Figure 6 ). As the needle is advanced slowly, very small test increments of water-soluble contrast are injected until the gastric mucosa is visualized (Figure 7). A radiological contrast study of the bypassed stomach and duodenum can now be

Figure 1. Gastrostomy tube placement and marker.

Figure 2. Picture of gastrostomy tube and marker.

carried out (Figure 8). To place a gastrostomy tube, a guide-wire is passed through the needle into the stomach (Figure 9) and then a dilator is passed over the wire. The size of the dilator is increased up to a size 12-French. The dilator is replaced with a size 10-French nephrostomy catheter (Figure 10). The tube can hence be used for enteral feeding or gastric decompression. Endoscopic evaluation and biopsy of the bypassed stomach can thus be done by passing a pediatric scope or a bronchoscope over the guide-wire instead of the nephrostomy tube (Figure 11 ). This procedure is usually done in the outpatient radiology suite under mild sedation and local anesthesia.

Figure 3. Marker as seen on plain X-ray of the abdomen.

Figure 4. View of marker on computed tomographic scan.

Figure 5. Location of marker on cross-table X-ray of the abdomen.

Figure 6. Ring marker with needle in place.

Figure 7. Incremental contrast injection to confirm intra-gastric location of needle.

Figure 8. Contrast study of bypassed segment

Figure 9. Guide wire placement.

Discussion

Access to the bypassed stomach is necessary to permit decompression of the stomach. Acute gastric dilatation, a syndrome seen in GBP patients, requires decompression of the bypassed segment immediately or there is a risk of gastric perforation with associated morbidity and mortality. In the past, patients with acute gastric dilatation were inevitably subjected to an open laparotomy. Percutaneous decompression thus avoids the risk of open surgery.

Percutaneous access to the distal stomach enables diagnoses of complications involving the bypassed segment. While complications involving the distal stomach and duodenum are infrequent after the GBP, they do occur. The need to examine the distal stomach arises when the post GBP patient complains of epigastric or right upper quadrant pain for which no other explanation can be found or in whom anemia with guiac positive stool or overt gastrointestinal bleeding occurs in the absence of any other apparent cause.

Percutaneous gastrostomy may be useful for enteral feeding in post GBP patients. This obviates the need for total parenteral nutrition, the sepsis and cost associated with it, and the need for close medical supervision.

Figure 10. Placement of gastrostomy tube.

Figure 11. Endoscopy of bypassed segment for visualization and biopsy.

Finally, access to the distal stomach enables investigative studies to determine the fate of the bypassed segment in terms of mucosal changes, acid secretions, bile reflux and bacterial colonization which before now have been considered hazards of the excluded segment.

Routine use of gastrostomy tube and its removal are discussed in the preceding paper. There have been a few complications which are being addressed elsewhere. After removal of the tube, prolonged drainage has not occurred.

Conclusion

A method to facilitate access to the bypassed segment of the gastrointestinal tract after GBP for obesity is described. Easy percutaneous access to the stomach is desirable, because it permits easy diagnosis and treatment of complications and investigative evaluation of the bypassed segment and enteral feeding as needed.

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(Received 11 February 1998; accepted 17 March 1998) 1998 Lippincott-Raven Publishers