Endoscopic Evaluation of a Twisted Gastric Sleeve Causing Severe Reflux and Epigastric Pain

CHAPTER 1

My name is Eric Pauli and I'm a Professor of Surgery at the Milton S. Hershey Medical Center in Hershey, Pennsylvania. Although I am a surgeon, my primary job here at the medical center is to serve as one of the surgical endoscopists. And so you're gonna see me performing some endoscopy interventions that, at many places, would be performed by gastroenterologists. What I hope to emphasize with some of the videos you're going to see are surgical decision making being done by surgeons doing endoscopy. That would include understanding pre- and post-op surgical anatomy, identifying surgical complications, and being able to communicate those findings to another surgeon to help them make a better surgical decision. This is a 48-year-old female patient who a little over a year ago underwent a laparoscopic sleeve gastrectomy for morbid obesity. At the time of her initial procedure no hiatal hernia was noted, and so no hiatal hernia repair was performed. She had a lot of vomiting in the initial postoperative period, and subsequently was seen back several times for that symptom. Her vomiting symptoms resolved, but she's been complaining of low chest, high abdomen epigastric region abdominal pain that has been so severe that she's actually come to the emergency department on a few occasions. Two months ago she underwent a CAT scan and the CAT scan demonstrated what appears to be a bit of a twist in the sleeve staple line. So we're going to perform an endoscopy today to evaluate for her pain symptoms and to further investigate what may be a twist in the body of the sleeve. All right, this is our patient who is having some dysphagia, some regurgitation, and some pain symptoms following a sleeve gastrectomy. Let's take a look at her CT scan. We're starting in the upper chest on these axial images. Here's her esophagus and EG junction right here, and here's the proximal portion of the patient's sleeve. Let's follow the staple line of the sleeve as it works its way down through the body of the sleeve and recognize that the staple line runs anterior-posterior up to this point. And after this point, the staple line runs really left-right in the patient, and that if we pay attention to this location right here, there does appear to be a bit of a narrowing in the sleeve at this location. Now this certainly could be under distension, but obviously when we see this in a patient with symptoms, you wanna investigate this further. The other reason that this makes you think that there may be some amount of a narrowing at this area is that the proximal sleeve has an air fluid level in it right here. And in a patient who's NPO and hasn't just eaten, you would not expect there to be an air fluid level proximal to this small seeming stricture. I'll also show you this on sagittal views. Again, these are the sagittal views of the same patient. This is the proximal sleeve staple line, and again, I said the proximal sleeve staple line really does run anterior-posterior, but at this location right here, you can see the staple line makes a pretty severe bend. This is a very L-shaped staple line. This is the same area where the sleeve is narrowed, and then the staple line really does run left and right in the patient over towards the prepyloric stomach. So this is an area we're gonna pay special attention to as a potential area of twist or narrowing within the sleeve itself.

CHAPTER 2

There you go. There's your epiglottis, there's your cords. Stay posterior. That's on the right, slide back in, right to the center, and you're in. Beautiful. Okay. Upper esophagus and palisade vessels. Beautiful. Right and left are the correct sides, okay? So that's the aortic arch. You know, if you ever wondered how do you do a transesophageal echo? Well, the esophagus sits right behind the heart, okay? So, all right, so here we are working our way down to the distal esophagus, and you can see the squamocolumnar junction. That looks pretty regular, unlike our last patient where it was very irregular, it's regular, and the squamocolumnar junction is located at 35 centimeters, okay? Now let's just watch as she hiccups here for a moment, and let's just recognize that she has a hiatal hernia here. You can see the hiatus is not only open, but when she breathes, you can see that she herniates some of her sleeve up into the chest. That's a good picture of a very wide open hiatus. She's also reduced the stomach that was up here already. But you can see that she herniates some stuff up, okay?

CHAPTER 3

Before you head downstream, just go back to that fundus and just rock the scope the other direction. All right, so let's look at how much fundus she has up there. Retroflex? I would just, I would torque over and I would retroflex, yep. Torque over, push in as you go. Get all that. Take a picture of that first though. Larry, what is that? That's bile and pancreatic juices. It sure looks like bile and pancreatic juices, but some of people go, oh, it's puss, right? Pancreatic juices look like puss. Yep, suck it all down. But that's not her pylorus, right? No. There's the hiatus, rock the scope a little bit other way, other way. And then push in. There's your hiatal hernia. Take that picture. That's a great picture. Okay, come out of retroflex. So that is not her pylorus right ahead, yeah? No. Okay, so what is it? Here's the EG junction. Can you normally, in a sleeve, see the pylorus from the EG junction? Not normally. So it's either a very, very straight sleeve, or that's the end of the sleeve, it's the incisura, and it's very tight. Is that a tight incisura? Maybe. So let's head down, let's take a look, okay? My thought is I see a staple line headed down. That's gonna be the end of the sleeve, and she's gonna have bile reflux below that. So that thing that you went through is a narrow section of the sleeve at the incisura, okay?

CHAPTER 4

Your pylorus is gonna be up there. You're gonna need to build a loop. Push in, build a big loop on the greater curve. Keep pushing in, pushing in, pushing in. There it is. Yep. Good picture of the bulb there. Take a look at the posterior wall. Just rock. That was perfect what you were doing. Rock the other way. Yep, there's posterior wall. Good picture. Awesome. Okay, go in and do the maneuver. So the... That really looks like pylorus to me, huh. I know it did, that's why I said it's not the pylorus. I wanted to specifically. Yep. Roll your scope over, good. Good. Okay. Wonderful. That's D2. The pylorus will be somewhere in the, or the ampulla will be in the nine-o'clock position as you come back. That's all paradoxical motion, so start coming back. Yep, keep coming back. It's all just paradoxical motion. As you're pulling back, not only is it reducing the loop and moving you forward paradoxically, but you can also notice that the entire lumen rotates around in a circle, right? Those are all signs of paradoxical motion. Ampulla will be on the medial wall now 'cause of how it rotated. Just keep coming back. Yep. Keep coming back, keep coming back, keep coming back.

CHAPTER 5

Okay. Let's find where the staple line of the sleeve begins. So look on the greater curve for where the staple line of the sleeve begins. It actually begins right about there where the thing is narrow, okay? So now what I want you is go back through that little twist and I want you to retroflex in the distal stomach. So push in and thumb down. You got plenty of room here to retroflex. Yep. Push in. Okay. Take that picture. Okay, so what are you seeing? You're looking backwards. That's the incisura. You're looking at a sleeve that has a little bit of a narrowing and a little bit of a twist, okay. How big is your scope? It's a diagnostic scope. It's 9.8 millimeters. 9.8 millimeters. Okay, so that is, that is a little bit tight around the scope, okay? Your opening there is maybe a centimeter to a centimeter and a half. It's not very big, okay. And it's a little twisted. And it's a little twisted. So let's come out of retroflex.

CHAPTER 6

Let's get the rest of that bile. And so now you've got a person, Larry, we've got a nice lady here who has symptoms of a hiatal hernia, and she has evidence of a hiatal hernia, and she also has a little bit of a sort of a twist narrowing in the sleeve. Come on back, it's gonna look a little better as you come back through, right? You can actually see through it now. But it spirals there a little bit, okay? And she has some bile. You can see there's distal, there's antral gastritis, which we didn't say as we were busy working, but she's got distal gastritis and bile reflux. So bile reflux gastritis, a slightly twisted sleeve, and above the sleeve, let's also acknowledge this is a bit dilated above, right? Yes. Like this is a little bit of a dilated sleeve. And a hiatal hernia. Larry, how are you gonna fix this? So, hiatal hernia repair with gastropexy and maybe a wrap? Well, don't forget you can't wrap anything. She's had a sleeve gastrectomy. The fundus of her stomach is gone, okay? That white line you see right there is a scar from her sleeve. That's the sleeve staple line. So you cannot wrap her. If you wanted to wrap anything, you would have to either take her falciform ligament or do something else. Do like a LINX procedure. Okay, you could do a LINX. I would allow that. Meaning you fix the hiatal hernia and then you put a LINX in to prevent reflux. But what's that gonna do for bile reflux downstream? And what's that gonna do for this twisty, twisted portion of the sleeve right here? This narrowing here. It wouldn't address it. It won't address it. So untwist, and... What method would you use to like stent it open or like keep it kind of dilated? I appreciate that you're trying to save and salvage the sleeve, but the answer you're looking for is we're gonna turn the sleeve into something else. What are you gonna turn the sleeve into? Uh-huh. And you're gonna do a? Bypass. A gastric bypass. This person should very likely be converted from a sleeve into a bypass, okay? With a hiatal hernia repair.

CHAPTER 7

Okay, we're all done guys. We're coming out. So, I started to say earlier, Larry, anterior, you can see the heart. Posteriorly, that's the vertebral column. You can see the vertebra. This is her cricopharyngeus. Do you see on the floor, that little salmon-colored spot on the floor? What is that? It looks like Barrett's, doesn't it? A little bit. It's not. It's called an inlet patch and it's a little embryologic remnant of some gastric tissue that gets left over at the EG junction. And it happens in about 15 to 20% of people. It's very, very common. It causes really no disease that we know of specifically. You just miss it on the way in and on the way out all the time. Some people think that it might be a cause of some heartburn symptoms or some dysphasia 'cause you feel like there's something here. It's just maybe makes a little bit of acid high up. And so there are some people who actually ablate it.

CHAPTER 8

So as you saw from the video, the patient has several things going on. There is a hiatal hernia and a very lax EG junction. There is a bit of a twist and narrowing in the mid-body of the sleeve. Although the endoscope can pass, that section measures about one to one and a half centimeters. And that is the same area that we see on the CT scan where there's a bend in the staple line. In the distal stomach we saw some reflux gastritis related to bile reflux. And so there are at least three things here that are going on. The hiatal hernia and the twist in the sleeve probably explain the patient's pain symptoms. And so we will refer her back to our bariatric surgical team for consideration and management of those symptoms.