Ask the Experts: Dilemmas in Bariatric Surgery
This month’s dilemma:
Complications following sleeve gastrectomy
This month’s expert:
Gregg H. Jossart, MD
Dr. Jossart is Director of Minimally Invasive Surgery, California Pacific Medical Center, San Francisco, California.
Bariatric Times. 2010;7(8)19–20
A 42-year-old man with morbid obesity and portal hypertension underwent a sleeve gastrectomy. He presented to our office eight weeks postoperatively with back and left shoulder pain that was treated with nonsteroidal anti-inflammatory drugs (NSAIDS). He underwent a computed tomography (CT) scan of the abdomen that showed two major staple line disruptions and corresponding cavities behind those leaks. He also presented with concomitant bleeding of a varicose vein in the gastric sleeve into one of the cavities. Clinically, he was compensated. The gastroenterologists could not place any kind of stent and they were not able to place a band over the bleeding vein.
How would you manage this case?
by Gregg H. Jossart, MD
This is an extremely difficult clinical case. The bleeding varices can be managed with a transjugular intrahepatic portosystemic shunt (TIPS), although the response of gastric varices to TIPS is variable. The varices off the splenic vein could be embolized, and this might stop the bleeding varices. The staple line disruptions are large and it appears the cavities just drain back into the pouch. Interventional drains will not be adequate for treating these. The best option is to reoperate laparoscopically or open. If the disrupted edges will hold a suture, it is reasonable to suture the edges back together. Several drains must be placed. A drain that will function like a gastric tube will help collapse the stomach, which will allow the staple line edges to remain approximated and heal. This tube will also divert the gastric secretions from the perisplenic cavities. Additional drains should be placed into the cavities. The gastric drain should be a 19 French round tube that can be changed over a guidewire or slowly backed out in the following months. Three to four additional drains should be placed in the cavities. A 12 French flat JP with most of the drain cut off should be placed next to each staple line disruption that is sutured over. These will help provide control of the fistulas that will develop. The 19 French round drains can be placed in proximity to these to provide drainage of the cavities and to help them collapse. Over the next few weeks, CT scans and drain studies should provide evidence for good control of the now established fistulas. At this point, a stent could be considered, but bear in mind the stent may actually expand the stomach pouch and tear open the staple line edges that have collapsed and healed around the gastric tube. Approximately 4 to 6 weeks after surgery, you can start backing drains out, and by 8 to 12 weeks, all of the fistulas should be closed. You may still need to inject the fistulas with fibrin sealant or consider a stent, but if you leave the gastric tube in last and back it out slowly, you should not need any other treatments. Be sure to place a feeding jejunostomy for nutrition. Placing omentum along the defect is certainly possible but it probably won’t help. This is not a simple perforation of an ulcer.
Follow up from the treating surgeon on the case presented
The patient continued to develop intermittent episodes of what looked like sometimes venous and sometimes arterial bleeding. After further diagnostic CT scans and magnetic resonance imaging (MRI), the diagnosis of liver cirrhosis was replaced with a left-sided portal hypertension due to pancreatitis resulting in splenic vein thrombosis.
Arterial embolization of the splenic artery was performed but the patient continued to bleed intermittently into the cavities adjacent to the staple line disruption. The patient underwent a laparotomy, splenectomy, and suture ligation of venous bleeding. Large bore drains were placed into the cavities and a feeding jejunostomy tube was placed as well. The patient is now completely stable and the surgeon’s strategy is to continue enteral feeds via jejunostomy tube and consider conversion to a RYGB in 12 weeks postoperatively.
The author would like to thank Ed Baker, MD, from the California Advanced Imaging Medical Associates Inc. (CAIMA), Diagnostic and Interventional Radiology, California Pacific Medical Center, San Francisco, California, for contributing to this article.