Surgery for and Related Diseases 12 (2016) 1136–1138

Video case report Stapling the bougie in sleeve : video Aniceto Baltasara,*, Rafael Boua,b, Carlos Serrab, Nieves Péreza,b, Alex Rosb aClínica San Jorge, Alcoy, Alicante, Spain bHospital Virgen de los Lirios, Alcoy, Alicante, Spain Received April 12, 2016; accepted April 20, 2016

Abstract Laparoscopic sleeve gastrectomy has become the most popular bariatric surgical operation. Based on the lesser curvature, the sleeve is created with endo-staplers, which separate the lesser curvature longitudinally and vertically from the rest of the , including the greater curvature. The use of a bougie (a medical instrument used in an esophageal dilation) helps to calibrate the diameter of the sleeve. Intraoperative bougie stapling is a serious complication that should be prevented; when it happens, correction is mandatory. We present 3 cases with a video. (Surg Obes Relat Dis 2016;12:1136–1138.) r 2016 American Society for Metabolic and . All rights reserved.

Keywords: Stapling of the bougie; Sleeve-forming gastrectomy; Nasogastric tube stapling

Laparoscopic sleeve gastrectomy (LSG), which creates a of the opening, and the second treated by suturing of the gastric tube (sleeve or reservoir), has become the most opening plus restapling. In addition, we review publications popular operation in obesity surgery. The use of a probe, or regarding this complication. bougie, guide is required in its implementation to calibrate the size of the sleeve. Stapling of the bougie is a very Clinical cases serious, preventable complication and certainly a nightmare for all bariatric surgeons. It is not precisely a hot topic at Case 1 conferences, and we have not found many publications that A 38-year-old woman with a body mass index (BMI) of describe this complication. 2 The first isolated SG was completed by Almogy [1] in 48.5 kg/m had a planned (DS) operation 1993 by and was called a longitudinal gastrec- in 2006. But the LSG plus biliopancreatic diversion and had tomy, but Gagner [2] was the one who introduced the LSG to be converted to an open DS because of inadvertent in 2000. In 2005 there were several other publications on stapling of the bougie. A well-drained leak occurred 5 days LSG [3–7]. Ahmad et al. recently [8] reported that our 2005 later. She suffered empyema, and percutaneous drainage of work [6] was the 61st most cited article in bariatric surgery. the chest was needed. Endoscopic closure of the leak was attempted with coils, and self-expanding removable stents were used twice because of distal stent migration. Addi- Aims and scope tional drainage of the empyema was needed 1 month later. The chronic fistula closed, but it recurred 1 year later and We present 3 cases of stapling the bougie in an LSG. The she underwent a Roux-en-Y diversion [9] in 2007. The leak video shows 2 cases: One treated by double-layer suturing recurred again, and 2 new attempts at insertion of stents *Correspondence: Aniceto Baltasar, Clinica San Jorge Surgery, Olivar failed. While being treated with total parenteral nutrition 55, Alcoy, Alicante 03804 Spain. (TPN), the subclavian catheter perforated the superior vena E-mail: [email protected] cava, producing a hemomediastinum, which was http://dx.doi.org/10.1016/j.soard.2016.04.021 1550-7289/r 2016 American Society for Metabolic and Bariatric Surgery. All rights reserved. Stapling of the Bougie in SG / Surgery for Obesity and Related Diseases 12 (2016) 1136–1138 1137 successfully treated. The chronic gastric fistula reappeared 525 cases, using a number 12 bougie. In 2001 we started in 2009, 3 years after the original operation. Finally, a total doing the laparoscopic DS and have performed that gastrectomy with esophagojejunal anastomosis using procedure in 437 cases. We performed the first isolated healthy esophageal tissue was performed with final reso- LSG in December 2002 and have performed it in 312 cases, lution of the chronic fistula. The biliopancreatic diversion as well as 10 cases of laparoscopic single-anastomosis was reversed and the intestinal continuity restored. Her duodenoileal diversion. current BMI is 35 kg/m2. We have observed in 3 cases out of 1284 patients, a .23% incidence, that the endoluminal bougie could not pass the Case 2 esophagogastric junction (EGJ). In those cases stapling was

2 performed by dividing the stomach with staplers guided by A 64-year-old man with a BMI of 43 kg/m had the lesser curvature parietal vessels where they fade and dyslipidemia and chronic obstructive pulmonary disease enter the stomach. and was using continuous positive airway pressure plus We also had 3 episodes of stapling the bougie in those oxygen at home. He had an LSG done in 2008. During the 1284 cases, a .23% incidence. Two were repaired first by operation, stapling at the number 12 bougie was detected. suturing with interrupted silk stitches and then with a The staple line was opened and the catheter pulled out from continuous running suture of the whole staple line. Suc- the mouth after loosening the staples in the stomach. cessful intraoperative closure was observed, but in both Bleeding was controlled with interrupted silk sutures that cases a subsequent leak occurred. One patient required closed the defect. An intraoperative methylene blue test multiple reoperations and today is asymptomatic with fair found no leaks. The staple line was covered with a second weight loss. The second patient died apparently from line of continuous musculoserous sutures from the esoph- another cause. The third patient was treated with restapling ageal gastric junction down to the pylorus, and a second and suffered no complications. leak test was also negative. Two drains were placed. In the literature there are very few references on stapling Methylene blue was given orally daily and on the sixth of the bougie. In the 4 conferences organized by Deitel and postoperative day produced blue in the drain. The drainage Gagner [10–13], there are no specific references to this was very effective; no collections were found on computed complication. Dr. Üstün [14] published a video showing the tomographic scan. A nasojejunal feeding tube was passed, repair with sutures and technical robotics. and the patient was given enteral nutrition, which he After having operated on 727 cases, Sanchez et al. [15] tolerated well and after which he was asymptomatic. On reported that 9 patients (1.2%) had complications related to the 14th postoperative day the patient developed respiratory stapling of the gastric bougie, 2 patients required conversion failure and died of a pulmonary embolism without clinical to an open procedure, 2 required reintervention for leaks, sepsis (Video 1). and 1 suffered respiratory failure and a prolonged hospital stay. Case 3 Abu-Gazala et al. [16] did a survey of Israeli bariatric A 35-year-old woman with a BMI of 46 kg/m2 had an surgeons about intraoperative nasogastric probe problems, LSG in 2013. Intraoperatively a lateral stapling of the calibration bougies, or intracorporeal thermometers in LSG number 12 bougie occurred at the junction of middle and and found 17 occurrences of accidental bougie stapling in a upper third of the gastric staple line. The anesthetist was total of 4156 interventions (.41%). They also answered that able to completely remove of the probe just by pulling. The frequency was lower in laparoscopic gastric bypass than in defect was sutured with interrupted 2-0 silk and then the LSG. Higa et al. [17] reported a case of stapling on the LSG sutured defect was closed by restapling, including this part that required conversion to a gastric bypass. of the suture line, and the gastrectomy completed with a Rodriguez et al. [18] illustrated in video how stapling of running Lembert inverting suture of the staple line, includ- the bougie was detected, and there was an obvious stomach ing the omentum. On the second postoperative day a opening in the staple line. Closure was made by approx- radiographic upper gastrointestinal series with water- imating the opening with sutures and then restapling, as in soluble contrast found passage of the contrast to the our third case. Finally, a running Lembert suture reinforce- duodenum without leakage, stenosis, or pathologic reflux. ment with omentoplasty was done, as recommended by The patient was discharged on the fourth postoperative day Serra et al. [19] and Baltasar et al. [20]. The postoperative on a liquid diet without any incident. Three years later her course was favorable, with reintroduction of an oral diet on fi BMI is 35 kg/m2. This case is shown in Video 2. the second day and discharge on the fth postoperative day. Recarte et al. [21] have also published a case of stapling the Discussion bougie in gastric bypass. Gagner and Huang [22] published a study comparing the Our experience with SG started in 1993 with laparotomy probe with a calibration system and suction, which facili- in the more aggressive surgery of the DS procedure, with tates insertion, prevents the corkscrew effect, and reduces 1138 A. Baltasar et al. / Surgery for Obesity and Related Diseases 12 (2016) 1136–1138 operating times. Pequignot et al. [23] reported a rare case of [5] Mognol P, Chosidow D, Marmuse JP. Laparoscopic sleeve gastrec- retention of the bougie, diagnosed by the nurse when tomy as an initial bariatric operation for high-risk patients. Initial attempting to remove it in the immediate postoperative results. Obes Surg 2005;15(7):1030–3. period, which was resolved by relaparoscopy assisted with [6] Baltasar A, Serra C, Pérez N, et al. Laparoscopic sleeve gastrectomy: a multi-purpose bariatric operation. Obes Surg 2005;15(8):1124–8. . Meshikhes and Al-Saif [24] had a case of [7] Han SM, Kim WW, Oh JH. Results of laparoscopic sleeve complete esophageal transection during LSG that was not gastrectomy (LSG) at 1 year in morbidly obese patients. Obes Surg recognized during operation. The repair of this iatrogenic 2005;15(10):1469–75. injury was made in different complex procedures, and the [8] Ahmad SS, Ahmad SS, Kohl S, et al. The hundred most cited articles final stage was carried out 3 months after the initial one. in bariatric surgery. Obes Surg 2015;25(5):900–9. [9] Baltasar A, Bou R, Bengochea M, Serra C, Cipagauta L. Use of a The best possible management when stapling of the fi fi Roux limb to correct esophagogastric junction stulas after sleeve bougie occurs might be the following: (1) Stop the ring gastrectomy. Obes Surg 2007;17(10):1408–1. of any more staplers and keep attached the rest of the [10] Deitel M, Crosby RD, Gagner M. The First International Consensus stomach, because the stomach serves as traction and Summit for Sleeve Gastrectomy (SG), New York City, October 25- prevents the sleeve from retracting. Remove the nasogastric 27, 2007. Obes Surg 2008;18(5):487–96. tube by pulling it from the mouth. Pass a new bougie to the [11] Deitel M, Klalberer T, Erickson A, Crosby RD. The Second pylorus to prevent narrowing. Repair the defect with sutures International Consensus Summit for Sleeve Gastrectomy, March 19- 21, 2009. Surg Obes Relat Dis 2009;5(4):476–85. plus restapling up to the esophagogastric junction. (2) If full [12] Deitel M, Gagner M, Erickson A, Crosby RD. The Third Interna- division and separation of the sleeve has already occurred, tional Summit: current status of sleeve gastrectomy. Surg Obes Relat suture the defect, and then add a second Lembert contin- Dis 2011;7(6):749–59. uous layer over the staple line if restapling is not possible or [13] Gagner M, Deitel M, Erickson A, Crosby RD. Survey on laparo- convert to a gastric bypass. scopic sleeve gastrectomy (LSG) at the Fourth International Con- sensus Summit on Sleeve Gastrectomy. Obes Surg 2013;23 Conclusion (12):2013–7. [14] Üstün M. Robotic sleeve gastrectomy: nasogastric tube stapling and Stapling a bougie is a complication to be avoided at all its management [Video]. YouTube. www.youtube.com/watch? = costs. The anesthetist and surgeon should always be alert v _iTi1e6CS_4. Published November 27, 2015. Accessed 28 June 2016. [15] Sanchez B, Safadi BY, Kieran J, et al. Orogastric tube complications and coordinated to identify and move the probe as often as in laparoscopic Roux-en-Y gastric bypass. Obes Surg 2006;16 necessary to avoid this accident. The surgeon can “feel a (4):443–7. strange and anomalous stapling,” but when that happens it [16] Abu-Gazala S, Donchin Y, Keidar A. Nasogastric tube, temperature is too late. 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