Nova Szoka, MD1, Whitney Lane, MD2, Daniel Guerron, MD2, Shaina Eckhouse, MD3, Chan Park, MD2, Ranjan Sudan, MD2, Jin Yoo, MD2, Dana Portenier, MD2, Keri Seymour, DO2. 1West Virginia University, 2Duke University, 3Washington University
Introduction: Laparoscopic placement of enteral access in the gastric remnant of a bariatric patient who has undergone prior Roux-en-Y gastric bypass is a method commonly utilized to optimize patient nutrition. This video describes a laparoscopic gastrostomy tube placement complicated by delayed splenic rupture resulting emergent laparoscopic splenectomy.
Patient and Methods: The patient is a 42-year-old woman with a significant history of tobacco use who underwent laparoscopic gastric bypass in 2001 at an outside institution. Her preoperative weight was 300lbs (BMI 43). After her bariatric surgery, she continued to smoke tobacco, and developed severe marginal ulcer disease with gastrojejunal stenosis. For this, she underwent multiple endoscopic dilations, but continued to have dysphagia to solids and liquids, as well as chronic abdominal pain.
When she was seen in clinic her weight was 118lbs (BMI 17). Lab work showed severe protein-calorie malnutrition. An upper endoscopy revealed severe marginal ulcer disease. The patient’s malnourished state precluded primary repair. A laparoscopic gastrostomy tube was placed in her gastric remnant. On postoperative day 3, she acutely decompensated, with signs of hemorrhagic shock and pneumoperitoneum. Suspicion of perforated or bleeding marginal ulcer prompted diagnostic laparoscopy with subsequent hand-assisted splenectomy.
Procedures: Diagnostic laparoscopy and hand-assisted splenectomy
Using a Hasson technique pneumoperitoneum was established and 3 additional working ports were placed. A quick survey of the abdomen was then performed showing hemoperitoneum in all 4 quadrants. The spleen was enlarged and surrounded by a ruptured sub capsular hematoma. The gastric remnant was in place and attached to the anterior abdominal wall in a tension-free manner. An upper endoscopy was performed and confirmed no perforation in the gastric pouch. Using a combination of dissection with bipolar energy device and a hand assisted port, the splenic hilum was encircled and controlled. The spleen was removed from the abdominal cavity and passed off the table as a specimen. A 19Fr Blake drain was placed in the left upper quadrant. Estimated blood loss was 750 ml with an additional 750 ml of clot.
Conclusion: Laparoscopic enteric access placement is part of the post bariatric armamentarium to mitigate nutritional deficiencies associated with poor oral intake. Usual complications are dislodgment or tube related issues. Delayed splenic hemorrhage is a rare complication of this procedure. Traction causing splenic sub capsular injury, inadvertent tears, increased venous pressure due to splenic vein thrombosis, as well as anticoagulation therapy, have been targeted as potential etiologies.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 78693
Program Number: V210
Presentation Session: Video Loop
Presentation Type: VideoLoop