A 35-year-old male with an OAGB following weight recurrence after an initial SG reported debilitating bowel issues, muscle mass loss, and leg edema presented at the Medical Research Institute, Alexandria University, Egypt. In 2022, he weighed 60 kg (BMI 22 kg/m2). He sought an OAGB to SG conversion. The patient and his family declined any hypo-absorptive corrective measures in favor of gastric tube restoration.

The video presented hereby provides a detailed description of the revisional surgical procedure. In summary, during laparoscopy, adhesions and edema were found near the anastomosis site, where the ulcer was adherent to the antrum and colon. The ulcer was torn during dissection, leading to the removal of part of the antrum and anastomosis. Due to tension, reconnecting the gastric pouches was challenging. The antrum was dissected, and the pouches were stapled with an Echelon Flex 60-mm stapler (Ethicon, Cincinnati, OH, USA). The stomach’s edges were well perfused, and hand-sewn closure using V Loc 3.0 (Covidien, MA, USA) over a 40 Fr bougie was performed. Bowel continuity was restored with a side-to-side anastomosis. At the end of the surgery, the air leakage test performed was negative, and intra-abdominal drainage was placed in the vicinity of the gastro-gastrostomy; the total duration of revisional surgery was 140 min with a blood loss of ±200 milliliter. On postoperative day 2, the patient’s high temperature (38.0 °C) and tachycardia (110 beats/min) were observed. After CT scanning, an 11-mm leak was found at the level of the gastro-gastrostomy, and emergency laparoscopic exploration was decided.

Laparoscopy showed adhesions and exudates managed by suction and lavage. The intestine was tethered, and the pouch was adherent. An intraoperative upper GI endoscopy revealed a fistula. Many options were discussed in the team, including (1) drainage and jejunostomy feeding (challenged by some as the intestine was tethered and the proximal jejunum was inaccessible), (2) drainage and nasoduodenal tube insertion (an accepted option for some), (3) turning the leak into a controlled fistula by inserting a T-tube through the rent, with drainage and nasoduodenal feeding or internal pigtail drainage (IPD) and nasoduodenal feeding (challenged by some due to the uncertainty of the T-tube being held in place, the fact that the rent was not draining into a contained cavity so IPD maybe not a suitable choice, the high possibility of stricture formation with healing, and lack of experience with the T-tube), and (4) insertion of a metal stent with the advantages of immediate isolation of the fistula, early resumption of enteral feeding without tubes, and the satisfactory experience of the team with the use of megastents for leaks after SG. Eventually, a 23-cm Niti-S Mega esophageal stent (Taewoong Medical, South Korea) was placed post-discussion. The stent was tested and confirmed with water and airtight tests. New intra-abdominal drains were inserted (pelvis and surgical bed) (Stent Insertion Procedure Appendix 1). The total duration of reoperation was 65 min with a blood loss of ±50 ml.

The patient received total parenteral nutrition for a week. On postoperative day 2, the patient began oral fluids for 3 days, transitioned to pureed food for a week, and then gradually ate as tolerated with a protein isolate supplement. Both drains were removed the day before discharge, and the patient was discharged on postoperative day 15. A follow-up CT scan revealed reduced air at the gastric leak site, as well as presence of bilateral pleural effusion treated medically. The stent was checked weekly by abdominal X-ray and removed after 5 weeks. A CT scan the next day showed no contrast leakage, and the patient’s subsequent recovery was uneventful.