Abstract
Background
Gastric fistula (GF) is the most serious complication after longitudinal sleeve gastrectomy (LSG), with an incidence ranging from 0 to 5 %. In this context, concomitant upper gastrointestinal bleeding (UGIB) has never been described. Here, we describe our experience of this situation and suggest a procedure for the standardized management of this life-threatening complication.
Methods
We retrospectively analyzed all patients having been treated for post-LSG UGIB in our university medical center between November 2004 and February 2012. Data on GF and UGIB (time to onset, diagnosis and management) were assessed.
Results
Forty patients were treated for post-LSG GF in our institution, 18 of whom (45 %) had been referred by tertiary centers. Four patients presented UGIB (10 %): two had undergone primary LSG, one had undergone simultaneous gastric band removal and LSG, and one had undergone repeat LSG. The median time interval between GF and UGIB was 15 days. The four cases of UGIB included three pseudoaneurysms (75 %, with two affecting the left gastric artery and one affecting the upper pole of the splenic artery) and one case of bleeding related to stent-induced gastric ulceration. Computed tomography enabled diagnosis of the pseudoaneurysm in all cases. Two of the four patients (50 %) were treated with selective embolization during arteriography, and two (50 %) were treated surgically with arterial ligation. One of the surgically treated patients died during follow-up.
Conclusions
UGIB after LSG was investigated in the context of a postoperative GF and was found to have been caused by a pseudoaneurysm in 75 % of cases. When looking for a pseudoaneurysm, a primary angiography should be preferred to endoscopy allowing selective arterial embolization in hemodynamically stable patients, whereas surgery should be reserved for treatment failures or hemodynamically instability.
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References
Sjöström L (2008) Bariatric surgery and reduction in morbidity and mortality: experiences from the SOS study. Int J Obes 32:93–97
Christou NV, Sampalis JS, Liberman M, Look D, Auger S, McLean AP, MacLean LD (2004) Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients. Ann Surg 240:416–423
Marceau P, Biron S, Bourque RA, Potvin M, Hould FS, Simard S (1993) Biliopancreatic diversion with a new type of gastrectomy. Obes Surg 3:29–35
Hess DS, Hess DW (1998) Biliopancreatic diversion with duodenal switch. Obes Surg 8:267–282
Ren CJ, Patterson E, Gagner M (2000) Early results of laparoscopic biliopancreatic diversion with duodenal switch: a case series of 40 consecutive patients. Obes Surg 10:514–523
Kehagias I, Spyropoulos C, Karamanakos S, Kalfarentzos F (2012) Efficacy of sleeve gastrectomy as sole procedure in patients with clinically severe obesity (BMI ≤ 50 kg/m2). Surg Obes Relat Dis [Epub ahead of print]
Bohdjalian A, Langer FB, Shakeri-Leidenmühler S, Gfrerer L, Ludvik B, Zacherl J, Prager G (2010) Sleeve gastrectomy as sole and definitive bariatric procedure: 5-year results for weight loss and ghrelin. Obes Surg 20:535–540
Aurora AR, Khaitan L, Saber AA (2012) Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients. Surg Endosc 26:1509–1515
Fuks D, Verhaeghe P, Brehant O, Sabbagh C, Dumont F, Riboulot M, Delcenserie R, Regimbeau JM (2009) Results of laparoscopic sleeve gastrectomy: a prospective study in 135 patients with morbid obesity. Surgery 145:106–113
Pequignot A, Fuks D, Verhaeghe P, Dhahri A, Brehant O, Bartoli E, Delcenserie R, Yzet T, Regimbeau JM (2012) Is there a place for pigtail drains in the management of gastric leaks after laparoscopic sleeve gastrectomy? Obes Surg 22:712–720
Csendes A, Díaz JC, Burdiles P, Braghetto I, Maluenda F, Nava O, Korn O (1990) Classification and treatment of anastomotic leakage after extended total gastrectomy in gastric carcinoma. Hepatogastroenterology 37:174–177
Bruce J, Krukowski ZH, Al-Khairy G, Russell EM, Park KG (2001) Systematic review of the definition and measurement of anastomotic leak after gastrointestinal surgery. Br J Surg 88:1157–1168
Verhaeghe P, Dhahri A, Qassemyar Q, Regimbeau JM (2011) Technique de la gastrectomie longitudinal (sleeve gastrectomy) par laparoscopie. EMC (Elsevier Masson SAS, Paris), Techn Chir Appareil Dig 40:385
Rebibo L, Dhahri A, Verhaeghe P, Regimbeau JM (2012) Early gastric fistula after laparoscopic sleeve gastrectomy: surgical management. J Visc Surg 149:e319–e324
Murayama KM, Johnson TJ, Thompson JS (1996) Laparoscopic gastrostomy and jejunostomy are safe and effective for obtaining enteral access. Am J Surg 172:594–595
Rockall TA, Logan RF, Devlin HB, Northfield TC (1995) Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. Steering Committee and members of the National Audit of Acute Upper Gastrointestinal Haemorrhage. BMJ 311:222–226
Upadhyaya PK, Chava S, Bin-Sangheer S, Sudan R, Mittal SK, Cemaj S (2008) Delayed rupture of a splenic artery pseudoaneurysm after biliopancreatic diversion. Obes Surg 18:890–892
Rousseau A, Regimbeau JM, Vibert E, Vullierme MP, Sauvanet A, Belghiti J (2004) Haemobilia after blunt hepatic trauma: a sometimes delayed complication. Ann Chir 129:41–45
Hsu JT, Yeh CN, Hung CF, Chen HM, Hwang TL, Jan YY, Chen MF (2006) Management and outcome of bleeding pseudoaneurysm associated with chronic pancreatitis. BMC Gastroenterol 6:3
Sugimoto H, Kaneko T, Ishiguchi T, Takai K, Ohta T, Yagi Y, Inoue S, Takeda S, Nakao A (2001) Delayed rupture of a pseudoaneurysm following pancreatoduodenectomy: report of a case. Surg Today 31:932–935
Fuks D, Piessen G, Huet E, Tavernier M, Zerbib P, Michot F, Scotte M, Triboulet JP, Mariette C, Chiche L, Salame E, Segol P, Pruvot FR, Mauvais F, Roman H, Verhaeghe P, Regimbeau JM (2009) Life-threatening postoperative pancreatic fistula (grade C) after pancreaticoduodenectomy: incidence, prognosis, and risk factors. Am J Surg 197:702–709
Almogy G, Bloom A, Verstandig A, Eid A (2002) Hepatic artery pseudoaneurysm after liver transplantation. Transpl Int 15:53–55
Albanopoulos K, Alevizos L, Linardoutsos D, Menenakos E, Stamou K, Vlachos K, Zografos G, Leandros E (2011) Routine abdominal drains after laparoscopic sleeve gastrectomy: a retrospective review of 353 patients. Obes Surg 21:687–691
Hamoui N, Anthone GJ, Kaufman HS, Crookes PF (2006) Sleeve gastrectomy in the high-risk patients. Obes Surg 16:1445–1449
Baltasar A, Serra C, Pérez N, Bou R, Bengochea M, Ferri L (2005) Laparoscopics sleeve gastrectomy: a multi-purpose bariatric operation. Obes Surg 15:1124–1128
Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, Neoptolemos J, Sarr M, Traverso W, Buchler M, International Study Group on Pancreatic Fistula Definition (2005) Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 138:8–13
Sohn TA, Yeo CJ, Cameron JL, Geschwind JF, Mitchell SE, Venbrux AC, Lillemoe KD (2003) Pancreaticoduodenectomy: role of interventional radiologists in managing patients and complications. J Gastrointest Surg 7:209–219
Sato N, Yamaguchi K, Shimizu S, Morisaki T, Yokohata K, Chijiiwa K, Tanaka M (1998) Coil embolization of bleeding visceral pseudoaneurysms following pancreatectomy: the importance of early angiography. Arch Surg 133:1099–1102
Schäfer M, Heinrich S, Pfammatter T, Clavien PA (2011) Management of delayed major visceral arterial bleeding after pancreatic surgery. HPB (Oxford) 13:132–138
Kalva SP, Yeddula K, Wicky S, Fernandez del Castillo C, Warshaw AL (2011) Angiographic intervention in patients with a suspected visceral artery pseudoaneurysm complicating pancreatitis and pancreatic surgery. Arch Surg 146:647–652
Disclosures
Drs. Rebibo, Fuks, Blot, Robert, Pierre-Olivier, Dhahri, Verhaeghe, and Regimbeau have no conflicts of interest or financial ties to disclose.
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Rebibo, L., Fuks, D., Blot, C. et al. Gastrointestinal bleeding complication of gastric fistula after sleeve gastrectomy: consider pseudoaneurysms. Surg Endosc 27, 2849–2855 (2013). https://doi.org/10.1007/s00464-013-2833-7
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DOI: https://doi.org/10.1007/s00464-013-2833-7