Apurva Trivedi, DO1, Jacob A Petrosky, MD2, Jai Prasad, MD2, Ryan D Horsley, DO3. 1Geisinger Wyoming Valley, 2Geisinger Medical Center, 3Geisinger Community Medical Center
The management of a surgical hemodynamically unstable patient is generally not managed laparoscopically. Our patient is a 47-year-old female with a past medical history of diabetes, asthma, morbid obesity and 24 pack-year smoking history, who was found unresponsive at home. She had a severe leukocytosis, and became hemodynamically unstable despite aggressive colloid and crystalloid resuscitation and vasopressor support. Her respiratory status declined, requiring bag mask ventilation and ultimately intubation. She underwent CT imaging demonstrating pneumoperitoneum with gastric pneumotosis with concern for ischemia or necrosis of the stomach wall. An emergent bedside EGD was performed displaying necrosis of the gastric mucosa without signs of perforation.
The patient was taken to the operating room for a diagnostic laparoscopy and was found to have fibrinous exudate along with necrosis of the greater curvature of the stomach. An intraoperative EGD was performed to visualize adequate resection margins. The endoscope was then used as a guide for a staple line and a laparoscopic sleeve gastrectomy was performed. A provocative leak test was performed immediately after and was found negative. Patient’s hemodynamics improved with decreasing vasopressor requirements as soon as source control was achieved. Gross inspection of the resected portion of the stomach revealed viable resection margins with full thickness necrosis of the greater curvature. The patient was weaned of vasopressor support within 48 hours and extubated by post-operative day 5. On post-operative day 6, the patient underwent an esophagram, which displayed contrast passing through the gastric sleeve without contrast extravasation and enteric contrast in the small bowel on post scout radiograph. Patient’s oral diet was initiated and stable for discharge by post-operative day 13.
The patient’s pathology of resected stomach was reviewed and demonstrated deep ulceration with acute inflammation and fibrinous exudate with possible perforation. When she was seen at one month follow-up, she continued to tolerate a diet and had decreased her body mass index. Furthermore, she had quit smoking. Minimally invasive surgeries have traditionally been used in an elective setting. Our case presentation demonstrates the use of laparoscopic surgery in a morbidly obese hemodynamically unstable patient.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 86731
Program Number: V074
Presentation Session: Acute Care Session
Presentation Type: Video