Endoscopic Evaluation of a Twisted Gastric Sleeve Causing Severe Reflux and Epigastric Pain
Saamia Shaikh, DO, JD; Eric M. Pauli, MD, FACS, FASGE, FEBSAWS (Hon.)
Penn State Health Milton S. Hershey Medical Center
Upper endoscopy is an essential diagnostic and therapeutic tool in the evaluation of patients with gastrointestinal symptoms. Particularly in bariatric surgery patients, endoscopy is a valuable tool in the preoperative, intraoperative, and postoperative period. It is an increasingly important skill for surgeons managing surgical complications. This article presents a 48-year-old female who presented one year after undergoing a robotic-assisted sleeve gastrectomy and cholecystectomy with persistent epigastric pain and severe reflux symptoms. She had multiple emergency department visits following surgery, and prior computed tomography imaging was initially interpreted as normal without evidence of leak or obstruction, but on further review demonstrated a twisted configuration of the gastric sleeve.
Upper endoscopy was performed using an Olympus GIF-HQ190 gastroscope, with the scope advanced under direct visualization through the esophagus, stomach, and into the second portion of the duodenum. Endoscopy revealed a widened hiatus consistent with a small hiatal hernia, as well as moderate luminal stenosis near the incisura with a spiral configuration of the staple line, consistent with a gastric sleeve twist. Proximal gastric dilation and bile reflux were also appreciated. This case highlights the importance of surgeon review of imaging studies and surgeon performed endoscopy in evaluating complex postoperative anatomy and underscores its role as a critical skill for surgeons involved in the long-term care of surgical patients.
Robotic Sleeve Gastrectomy for Treatment of Morbid Obesity
Hany M. Takla, MD, FACS, FASMBS, DABS-FPMBS
Wentworth-Douglass Hospital, Mass General Brigham
Robotic surgery as an approach for bariatric surgery has been a subject of debate for at least two decades since the platform passed FDA approval. One could argue that the exponential growth of robotics in surgery could end such a debate. The robotic platform offers several advantages that are always advertised, but in the morbidly obese population it offers an added advantage. It is arguable that with the advanced ergonomics, superior visual tools, and wristed instruments the robotic platform is superior in its offerings to the surgeon and enables a wider variety of surgeons with variable skill set to adopt minimally-invasive surgery (MIS), especially in bariatrics.
The Sleeve gastrectomy is technically a straightforward procedure to perform and is easier to learn for trainees and novel surgeons. It could, however, pose some challenges especially in patients with increased BMI, which is a huge advantage for the robotic platform as it allows easier exposure and comfort during the operation.
Robotic Ligamentum Teres Cardiopexy with Hiatal Hernia Repair for GERD following Longitudinal Sleeve Gastrectomy
Fiona J. Dore, MD; Nicole B. Cherng, MD
UMass Memorial Medical Center
Patients who undergo longitudinal sleeve gastrectomy (LSG) may develop de novo or worsening of existing gastroesophageal reflux (GERD) symptoms, which include postprandial retrosternal burning, food refluxing, or dysphagia. Often patients with GERD following LSG present with a concomitant hiatal hernia. Workup serves to characterize a patient’s GERD disease burden by way of fluoroscopic upper gastrointestinal (UGI) series, pH studies, manometry, or esophagogastroduodenoscopy (EGD). Treatment first involves medical management with lifestyle modifications followed by use of pump inhibitors (PPIs) or Histamine H2-receptor antagonists (H2 Blockers or H2B). If GERD symptoms remain intractable to medical management, surgical intervention can be pursued.
Historically patients would undergo a conversion to a Roux-en-Y gastric bypass (RYGB). New data demonstrate comparable outcomes regarding GERD symptoms and improvements in anti-reflux medication use in patients status-post LSG who undergo ligamentum teres cardiopexy with hiatal hernia repair. This article describes a robotic ligamentum teres cardiopexy with hiatal hernia repair in an adult patient who previously underwent LSG and was experiencing intractable GERD symptoms despite lifestyle modification and optimization on anti-reflux medications.
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