Presenter: Maria C Mora, MD
Email: Maria C Mora, MD
@MarcMichalskyMD
@KarenDiefenbach
@cmora306
@nationwidekids
Authors: Maria C Mora, MD; Karen A Diefenbach, MD; Marc P Michalsky, MD; Department of Pediatric Surgery, Nationwide Children's Hospital
With rising adolescent obesity, the use of adolescent bariatric surgery continues to increase. Although vertical sleeve gastrectomy (VSG) has been shown to be safe and effective, multiple short and long-term complications, including GERD can occur. We present a patient with a history of a laparoscopic VSG who presented with a one-year history of worsening dyspepsia and moderate weight regain (~11kg). UGI revealed concerns for chronic organoaxial gastric volvulus. Intraoperative findings included a dilated proximal pouch, extensive adhesions causing gastric volvulus, and distal gastric sleeve stenosis. After extensive lysis of adhesions, the sleeve was straightened and revised. Additionally, laparoscopically-guided endoscopic balloon dilation was performed addressing the gastric stenosis. Postoperatively the patient’s symptoms resolved. New onset and/or progressive GERD following VSG outside the immediate postoperative period should be evaluated. While conversion to a Roux-en-Y gastric bypass may be required, initial attempts to address gastric adhesions and/or chronic stenosis should be considered.
Intended audience: Healthcare professionals and clinicians.
The utility of adolescent bariatric surgery has increased with the continued rise in adolescent obesity. Although a safe procedure, various long term complications can arise from a sleeve gastrectomy. We present a patient with multiple concurrent complications after a laparoscopic sleeve gastrectomy. The patient's a 23-year-old female who underwent a laparoscopic sleeve gastrectomy seven years ago. She presented to the bariatric office with complaints of epigastric pain and worsening reflux symptoms infrequently relieved with Pepcid. The patient was also noted to have gained 10 kg since her last yearly appointment. An upper GI was performed and revealed that the proximal stomach had increased in volume compared to a previous upper GI. And the distal portion of the stomach had completely twisted upon itself, causing an organoaxial gastric volvulus. Given these findings, the patient was consented for a robotic assisted sleeve gastrectomy revision on entrance into the abdomen. An extensive amount of adhesions were noted. The omentum was wrapped over the stomach, obscuring the proximal portion as well as the hiatus. The stomach was first dissected off the liver, allowing for better visualization of the hiatus. A 36 French bougie was then placed to assist with identification of the stomach. However, it was unable to be passed beyond the upper portion of the pouch. Dissection was continued, exposing both the left and the right crura and revealing a small hiatal hernia. Upon further dissection, the upper portion of the pouch was identified, and the bougie was noted to be caught within the dilated pouch. After advancing the bougie distally, the stomach was straightened, allowing for further dissection and isolation of the upper dilated pouch. Dissection was then carried distally. The omentum was dissected off the anterior portion of the stomach. During the dissection, the area of the chronically volvulized stomach was encountered, confirming the upper GI findings. After the dissection, the entire length of the stomach was fully exposed. After the stomach was fully straightened, the dilated portion of the sleeve was then resected using an endoGIA stapler with multiple reinforced black loads. The hiatal hernia was then repaired using two Oethebo sutures. The defect was easily closed with a total of 2 sutures. Endoscopic evaluation of the sleeve subsequently revealed an area of stenosis at the mid portion of the stomach. Laparoscopically, no extrinsic compression of the area was noted to explain the endoscopic finding. The area noted was able to be traversed with the endoscope only with laparoscopic assistance. Therefore, balloon strictureplasty was performed. The area was serially dilated with an endoscopic balloon up to 15 millimeters. At the completion, the waste initially noted laparoscopically was no longer as apparent, and the endoscope was easily passed. The patient tolerated the procedure well without complications. Post-operatively, the patient did have resolution of her symptoms and is currently doing well. This patient presented with symptoms of a gastroesophageal reflux, a common postoperative complication from a sleeve gastrectomy. However, her symptoms were likely worsened by the hiatal hernia, gastric stenosis, and gastric volvulus noted intraoperatively. Although a gastric twist can cause a functional narrowing, this patient was also found to have a mechanical stenosis likely secondary to scarring. Overall, the patient's symptoms were able to be treated without the need to convert to a Roin Y gastric bypass.
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