Endoscopic Treatment of Anastmotic Leakage After Gastric Bypass Surgery and a Later Occurring Cardial Stricture

Maria Bergstrom, MD, PhD, Bo Erlandsson, MD, Per-Ola Park, Professor. Dept of Surgery, South Alvsborg Hospital, Boras, Sweden & Gothenburg University, Gothenburg, Sweden.

Background
Endoscopic treatment of surgical complications offers less traumatic procedures for patients who many times are in a bad condition. Sten treatment of anastomotic leaks after laparoscopic gastric bypass (LGBP) has recently become accepted. We present a case of sequential complications after LGBP.
Patient
A 38-year-old obese woman (BMI 42) with hypertension and rheumatic arthritis who had been taking per oral NSAIDs and Methotrexate injections for many years was operated with LGBP. She had an uncomplicated immediate postoperative course. She was readmitted on POD 8 after a sudden onset of abdominal pain presenting symptoms of anastomotic leakage. A CT-scan showed an abscess with gas contents between the pouch and the liver. Laparoscopy was performed for drainage and further diagnostics. Peroperative gastroscopy verified a leakage, situated on the backside of the pouch. Suture was not possible why two large drainages were placed followed by endoscopic placement of a covered metal stent from the oesophagus via the pouch into the roux-limb. (Boston Sci partially covered 23/28 mm) The stent was placed under fluoroscopic and endoscopic supervision (side-scope technique). The leakage ceased immediately, tested with CT-scan and methylene-blue swallow. Unfortunately the patient had sequential complications, lung embolism followed by significant bleeding from the operated area. She recovered and the stent was removed three weeks after placement and replaced by a similar stent, which was removed after another three weeks. After stent removal she experienced dysphagia with painful swallowing. Gastroscopy revealed scaring and narrowing above the cardia. It was possible to pass an ordinary scope but the tissue was tense. Several balloon dilatations were performed dilating the cardia up to 20 mm. Each time the tissue broke up at the non-scarred points and restricturing occurred. A total of 4 dilatations were performed during 9 months. The stricture became more fibrotic each time. Her ability to eat was restricted to liquids. In March 2012 a firm ridge had developed on one side of the cardia. In retroversion it seemed as a thin ridge why a decision was made to divide it endoscopically. The ridge was cut using a needle knife. No bleeding occurred. The tissue looked as fibrosis during cutting. To maintain the lumen and as a safety measure a covered oesophageal stent was placed across the area. This stent was removed endoscopically after two weeks. The lumen has now been restored and the patient’s capacity to swallow has improved.
Conclusion
This case shows that mini-invasive endoscopic treatment can solve severe complications after gastric by-pass surgery.