Abstract:

One anastomosis gastric bypass for morbid obesity is becoming more popular. Alteration in normal anatomy makes it difficult to access the excluded stomach once needed. Laparoscopic assisted Gastroscopy post Gastric bypass is a minimally invasive procedure allowing access to the gastric remnant for interventions on the remnant stomach or biliary and pancreatic systems.

We present a case of a 37-years old female referred from another hospital with LUQ pain. Patient is 2-years post one anastomosis gastric bypass. Latest BMI 22 down from 45.1 preop. Symptoms started a year after surgery. Computed Tomography of abdomen showed 1 cm polyp at gastric antrum. Case was discussed at MDT and underwent Laparoscopic assisted gastroscopic removal of gastric polyp. Laparoscopic assisted gastroscopy was done. A 1 cm inflammatory looking polyp was visualised and excised with hot snare. This was retracted in a basket and sent for histopathology. The gastrostomy was closed with one-layer 3.0-Monocryl. No perforation/immediate complications. Patient was discharged home day 2.

Histopathology: Inflammatory polyp with no evidence of metaplasia or dysplasia.

Background

Obesity persists a public health problem. Globally, Obesity has increased by more than 2 folds in female, and almost triple in males [1]. Treatment modalities for obesity are increasing in accordance with rising prevalence with obesity worldwide. Bariatric procedures have effective long-term weight reduction and resolution of obesity related comorbidities [2]. One anastomosis gastric bypass for morbid obesity is becoming more popular. The procedure involves creating narrow stomach pouch connected to a loop of the jejunum, bypassing significant portion of the stomach and duodenum [3]. This alteration in normal anatomy makes it difficult to access the excluded stomach once needed. Laparoscopic assisted Gastroscopy post Gastric bypass is a minimally invasive procedure allowing access to the gastric remnant for interventions on the remnant stomach or biliary and pancreatic systems.

Case Report

We present a case of 37 years old female 4 years post laparoscopic Mini Gastric Bypass that was done in a different centre. Preoperative BMI 45.1, latest BMI 22. Patient presented with left upper quadrant pain with ongoing history of reflux one year after surgery. Patient was treated initially with medical therapy for gastritis and reflux symptoms. However, despite medical treatment symptoms persisted. Patient had CT scan at local hospital that showed Gastric Polyp. Patient was then referred to Upper GI Centre for further evaluation and management. Repeated CT abdomen showed 1 cm polyp within the antrum along with Gallstones.

Patient was counselled and case was discussed in Upper GI MDT. Decision was made for Lap Assisted Endoscopic Removal of gastric poly and Laparoscopic Cholecystectomy.

Operative technique

Pneumoperitoneum was achieved with Veress needle. Laparoscopic Cholecystectomy was done initially with standard port insertion.  This was followed by Insertion of additional ports for lap assisted endoscopy were a 10mm left flank and 5 mm right flank ports were inserted under vision (Image 1).

Image 1: Additional Ports

Intraoperative findings of Distended thin-walled gallbladder with omental adhesions, 1 cm intra gastric polyp. Gastrostomy was done proximal to gastric antrum. Two stay sutures with monocryle were applied above the gastrostomy (image 2 and 3). Endoscope was introduced by Gastroenterologist through the gastrostomy via the 10 mm left flank port. A 1 cm polyp was visualised and excised with hot snare. This was retracted in a basket and sent for histopathology. The gastrostomy was closed with one layer 3.0 Monocryl. Inspection of bowel all the way down BP limb and most of alimentary/common channel with no perforation. No evidence of ongoing bleed or bile leak on final inspection. Closure – J PDS to sheath at umbilicus 3.0 rapid vicryl to skin.

Patient had good post operative recovery and was discharged on day 1 post op for outpatient follow up. Patient was seen in outpatient visit 2 weeks post operatively and histopathology showed Inflammatory polyp with no evidence of metaplasia or dysplasia. Patient was reassured and counselled and further follow up planned was agreed with the patient. 

Image 2: Gastrostomy and scope insertion

Image 3: Intra-operative findings
 

Discussion

Roux-Y Gastric Bypass has been present for many years as the gold standard surgery for surgical treatment of obesity and its related comorbidities. One anastomosis or mini gastric bypass is another form of bypass that pose a similar challenge to access the biliary tree post-surgery. With advancing technology comes advancement in minimally invasive surgery where several techniques have been proposed to solve the challenging access to the biliary tree or bypassed stomach.

Laparoscopic Assisted Gastroscopy is a well-established and feasible procedure for managing complications in patients who have undergone One Anastomosis Gastric Bypass (OAGB) [4, 6, 8]. The altered anatomy resulting from OAGB, where a significant portion of the stomach and duodenum is bypassed, renders traditional upper endoscopy inaccessible to these excluded segments [6, 9]. However, it is more common in the form of Laparoscopy-Assisted Transgastric Endoscopic Retrograde Cholangiopancreatography.

The feasibility of LAG post-OAGB stems from its ability to provide direct access to the bypassed limb and excluded stomach. This is crucial for diagnosing and treating various issues that arise in these otherwise unreachable areas of the gastrointestinal tract. The procedure combines the advantages of laparoscopic surgery (minimally invasive access) with endoscopic visualization and therapeutic capabilities [10]. Common indications for Laparoscopic Assisted Gastroscopy Post Bariatric Surgery are shown below.

Figure 1: Indications of laparoscopic assisted gastroscopy

In the literature, several studies and case reports showed that laparoscopic assisted trans-gastric endoscopic procedures are effective in obtaining therapeutic success in accessing, evaluating and managing issues related to the biliary tree or excluded stomach in patient with altered anatomy post bariatric surgery [10,11]. However, challenges due exist as shown below (Table1).

Table 1. Challenges

Conclusion

Laparoscopic assisted gastroscopy of the remnant stomach can be done for various indications. While challenging due to the altered anatomy, Laparoscopic Assisted Gastroscopy is a well-established and feasible approach for diagnosing and treating complications in the bypassed segments of the gastrointestinal tract following One Anastomosis Gastric Bypass. It offers a crucial pathway for managing conditions that would otherwise be inaccessible with conventional approach alone. However, advanced skills and proper settings and preparations are important.

Funding: No funding sources.

Conflict of Interest: None declared.

Ethical approval: Not required.

References

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