TITLE:
Sleeve Gastrectomy Associated with Antral Lesion Resection and Roux-en-Y Antrojejunal Reconstruction
AUTHORS:
Victor Ramos Mussa Dib, Carlos Augusto Scussel Madalosso, Carlos Eduardo Domene, Paulo Reis Esselin de Melo, Rui Ribeiro, Gabriela Trentin Scortegagna, Elinton Adami Chaim
KEYWORDS:
Roux-en-Y Gastric Bypass, Sleeve Gastrectomy, Jejunum Gastric Bypass, Bariatric Surgery
JOURNAL NAME:
Surgical Science,
Vol.14 No.5,
May
31,
2023
ABSTRACT: Obesity has been growing worldwide, reaching epidemic
proportions. Bariatric surgery is the most effective and durable treatment for severe
obesity and related diseases. Roux-en-Y Gastric Bypass (RYGB) and Sleeve Gastrectomy
(SG) are the most frequently performed bariatric operations, with long-term good results, in terms of weight loss and comorbidities
control. Gastroesophageal Reflux Disease (GERD) is commonly associated with
obesity. In general, it precludes the indication of sleeve gastrectomy, since this
technique has a refluxogenic potential, as shown
in many studies. In such cases, RYGB is considered the best surgery, reaching
good weight loss and gastroesophageal reflux disease
control. The drawback of this technique is that it leaves the remnant stomach,
the duodenum, and the proximal part of the jejunum inaccessible. Besides,
RYGB makes transoral endoscopic access to the biliary tree impossible. For all these reasons,
this bariatric technique is not indicated in
cases of gastric polyposis, gastric dysplasia, or strong family history of cancer, among others. We report a case of a morbidly obese patient with intense
GERD, for whom a RYGB was precluded due to her strong family history of cancer,
even knowing that it would be the best choice for reflux disease control. Instead, SG was chosen, even knowing it could
worsen the gastroesophageal reflux disease. The patient signed an informed
consent, after being fully enlightened about the risks. During the surgery, a small
subserosal whitish lesion was detected, near
the pylorus, on the anterior wall of the antrum. Thinking in a Gastrointestinal
Stromal Tumor (GIST), it was resected, with a 2 cm safety margin, leaving a 4 to 5 cm hole on the gastric wall.
The decision to maintain
the proposed sleeve gastrectomy was made, to avoid leaving a remnant stomach, in
a patient with such a strong family history of cancer. In the area of the resected
lesion, an intraoperative decision was made not to just close the big gastric hole,
being afraid of causing some anatomic or functional disturbance in gastric emptying.
Instead, we decided to use the gastric opening to construct a Roux-en-Y antrotrojejunal
anastomosis, with a 50 cm alimentary limb and a 200 cm biliopancreatic limb.
Accordingly, it was performed a sleeve gastrectomy, associated with an
antrojejunostomy in a Roux-en-Y fashion. The patient had an uneventful postoperative
course. In the second year, she achieved normal weight
and good nutritional status, without gastroesophageal reflux symptoms complaints.
Seriography study shows that most of the contrast material passes through the antrojejunal
anastomosis, instead of the pylorus, while the duodenum is endoscopically patent.
This case report shows an unexpected surgical finding that led to a tactic of adding
a Roux-en-Y gastric bypass in the antrum, associated with a sleeve gastrectomy,
a strategy that may be adopted in cases of morbidly
obese patients with important GERD, for whom gastrointestinal exclusions
are contraindicated. To confirm this hypothesis, controlled studies are needed.