Laparoscopic Fundoplication Using the Excluded Stomach as a Novel Management Option for Refractory Bile Reflux Following One Anastomosis Gastric Bypass (OAGB)

Background One anastomosis gastric bypass (OAGB) is now a mainstream bariatric procedure. Refractory gastroesophageal reflux is a significant complication following OAGB, and conversion to Roux-en-Y has long been the treatment of choice for this issue. Strengthening the lower esophageal sphincter by Nissen fundoplication (NF) has been reported as an effective anti-reflux surgery. Here we report the short-term outcomes of a modified NF procedure using the excluded stomach (excluded stomach fundoplication—ESF) to treat refractory bile reflux in post-OAGB patients. Methods Thirteen post-OAGB patients underwent ESF for refractory bile reflux during the study, as detailed in the surgical technique. This paper reports the 12 patients whose follow-up data are available. Results Following ESF, the GERD-HRQL heartburn score improved from 22.7 ± 3.9 to 1.8 ± 3.5 (p < 0.05). The mean aggregate GERD-HRQL score improved from 27.9 ± 5.3 to 5.7 ± 5.9 (p < 0.05). The GERD-HRQL global satisfaction score showed that 100% of patients were satisfied with the improvement of symptoms. The mean VISICK score improved from 3.8 ± 0.39 to 1.2 ± 0.39 (p < 0.05). One patient was returned to the operating theatre to have the wrap loosened due to dysphagia. Eleven patients did not require PPIs after surgery. Conclusions ESF significantly improved the VISICK score and GERD-HRQL of post-OAGB patients with refractory bile reflux in the short term. The current study is being continued to increase the sample size and the follow-up period.

A136 LIVING ON THE EDGE: EUS-DIRECTED TRANSGASTRIC ERCP (EDGE) IN PATIENTS WITH ROUX-EN-Y GASTRIC BYPASS ANATOMY

Background Roux-en-Y gastric bypass (RYGB) surgery imposes anatomic barriers to endoscopic retrograde cholangiopancreatography (ERCP). Potential options for biliary access in these patients include laparoscopic-assisted ERCP or balloon enteroscopy. However, these approaches require specialized equipment and/or operating room personnel and are associated with high rates of failure and adverse events compared to conventional ERCP. A recently described technique, EUS-directed transgastric ERCP (EDGE), is an entirely endoscopic approach which involves accessing the excluded stomach to facilitate conventional ERCP. Objectives To describe the results of EDGE procedures performed in two centres in British Columbia. Aims To describe the results of EDGE procedures performed in two centres in British Columbia. Methods Data were collected from five patient cases who had undergone an EDGE procedure at Victoria General Hospital (4) or Vancouver General Hospital (1) in British Columbia from 2019 to 2020. All patients had a history of RYGB bariatric surgery. In each of the procedures, a 20 mm diameter lumen-apposing metal stent (LAMS) was deployed under EUS-guidance to allow access from the gastric remnant or proximal jejunum to the excluded stomach. Subsequently, during a separate procedure 4 to 28 days later, a duodenoscope was passed through the LAMS to perform ERCP. Following ERCP, the LAMS was removed 0 to 38 days later and replaced with a double pigtail stent to facilitate controlled closure of the gastro-jejunal or gastro-gastric fistula. Results Of the five cases included in the case series, 4 patients underwent EDGE for treatment of choledocholithiasis and one patient underwent the procedure for gallstone pancreatitis. The technical success rate of the EDGE procedure in the five cases was 100%. Clinical success, defined by normalization of bilirubin and symptomatic relief, was observed in all of the cases. There were no adverse events related to the EDGE procedure in these five cases. Conclusions The results of this series support EDGE as a safe and minimally invasive approach to biliary access and therapy in patients with previous RYGB surgery. Funding Agencies None

Functional Laparoscopic Roux-en-Y Gastric Bypass with Fundectomy and Gastric Remnant Exploration (LRYGBfse)—a Video Vignette

Background The laparoscopic Roux en-Y gastric bypass (LRYGB) is performed worldwide and is considered by many the gold standard treatment for morbid obesity. However, the difficult access to the gastric remnant and duodenum represents intrinsic limitations. The functional laparoscopic gastric bypass with fundectomy and gastric remnant exploration (LRYGBfse) is a new technique described in attempt to overcome the limitations of the LRYGB. The purpose of this video was to demonstrate the LRYGBfse in a 48-year-old man with type II diabetes and hypertension. Methods An intraoperative video has been anonymized and edited to demonstrate the feasibility of LRYGBfse. Results The operation started with the opening of the gastrocolic ligament. Staying close to the gastric wall, the stomach is prepared up to the angle of His. After the placement of a 36-Fr orogastric probe, gastric fundectomy is completed in order to create a 30cc gastric pouch. A polytetrafluoroethylene banding (ePTFE) is placed at the gastro-gastric communication, 7cm below the cardia, and gently closed after bougie retraction. The bypass is completed by the creation of an antecolic Roux-en-Y 150cm alimentary and 150cm biliopancreatic limb. Conclusion The LRYGBfse is a feasible and safe technique. The possibility to endoscopically explore the excluded stomach with an easy access to the Vater’s papilla is a major advantage. Further studies are warranted to deeply explore and compare outcomes with the standard LRYGB.

Metastatic leiomyosarcoma of the excluded stomach: a case report

Background: Leiomyosarcoma (LMS) represents about 1% of primary malignancies of the stomach, usually evolves with hepatic implants in 2-thirds of cases, and the outcome is frequently poor. With an insidious course, late diagnosis and misdiagnosis with other gastric neoplasia occur. Immunohistochemical evaluations are mandatory to confirm the diagnostic hypothesis. Surgical resection has been the more effective treatment of gastric LMS; however, recurrences after resections and distant metastases may develop in up to 50% of the patients. Doxorubicin, gemcitabine, and docetaxel are therapeutic options, with variable responses. Case presentation: The 52-year-old male herein described with a diagnosis of LMS in the gastric pouch and liver metastasis underwent a Roux-en-Y bypass to treat morbid obesity more than a decade ago. Persistent abdominal pain was a unique symptom, and he had liver metastasis at diagnosis. The initial hypothesis was a metastatic gastrointestinal stromal tumor (GIST) of the excluded stomach and the patient underwent a schedule with imatinib without significant response. After a complete revision of the anatomopathological findings, the patient underwent a new biopsy of the gastric mass, and the immunohistochemical data were consistent with LMS. Then doxorubicin replaced imatinib, later changed by gemcitabine associated with docetaxel. As last control found lesions in the central nervous system, he is under radiotherapy sessions. Conclusion: The diagnosis of gastric LMS often occurs at late stages because of the insidious clinical course. The rate of liver metastasis at diagnosis is high. Besides, the relatively poor response to the alternative management for non-surgical stages of the disease yields severe outcomes.