Expert: John Pilcher, MD - 5/13/2009

Question
I have had recurring ulcers following my gastric bypass surgery. Medication has not worked. It was recommended by my general surgeon today that I have surgery to remove the ulcer. He advised me that my pouch is too small to remove the ulcer without removing the pouch as well. He wants to remove the ulcer & pouch and connect my esophagus directly to my intestine. Have you heard of this surgery and can you advise me of any details, recovery, complications, and or possible future health problems? The surgery is called laporatomy lysis of adhesions resection of gastric remnant, then esophogo gastro jejunostony & feeding jejunostony. Thank you for any help you can provide.

Answer
Tina,
The surgery you are describing just might be necessary, but it is a really big deal, with substantial risk of leak at the connection between the esophagus and the jejunum (even in expert hands).

There are two parts of the proposal that ought to be checked carefully:
1) has your team looked to be sure there is no fistula (connection) between your stomach pouch and the larger bypassed stomach?  If a fistula is present then acid from the bypassed stomach may pass back into the pouch to cause recurring ulcers.  A fistula is best diagnosed by CT with contrast - there should be no contrast in the bypassed stomach.  A fistula would require major surgery, but probably not removal of your entire pouch.

2) is your pouch really so small that it can't be used in reconstruction?  I bring this up because even a tiny stomach pouch is more reliable than the esophagus in terms of healing.  Your general surgeon may not be familiar with a new tool called the Orvil, which is a circular stapler that helps a surgeon make use of a very small stomach pouch for connection.

Just to be sure, I would advise you also to meet with an experienced bariatric surgeon in your area.  As I mentioned at the beginning, it may turn out to be necessary to do exactly what the general surgeon is suggesting, but you should take the time and effort to really be sure.

You can find Center of Excellence bariatric surgeons on the web at:
https://www.surgicalreview.org/locate.aspx

Best of luck!
Dr JP