Rami R Mustafa, MD, Leena Khaitan, MDMPH, Ananda Ghimire, PA, Benjamin Jons, PA, Tomasz Rogula, MDPhD. Cleveland Medical Center
Introduction: Sleeve Gastrectomy is one of the most common bariatric procedures. Risks include stapler line bleeding. Chronic anticoagulation for VTE prophylaxis may increase risk of bleeding. Meticulous surgical hemostasis is needed to prevent from such complications. Stapler line oversawing or buttressing is used for local hemostasis. Postoperative hematoma may create extrinsic compression of the stomach and partial or complete gastric outlet obstruction with nutritional sequela. Optimal management is debatable. Early evacuation of hematoma may increase risk of re-bleeding. CT guided drainage may not be effective for thick content of hematoma.
Case Presentation: We present a case of 65 year old female who underwent laparoscopic sleeve gastrectomy 4 weeks prior to readmission. Surgery was complicated by postoperative hematoma from staple line bleeding. The patient was on chronic anticoagulation for VTE prophylaxis. Unsuccessful surgical and radiological drainage was attempted 2 weeks after sleeve gastrectomy. The patient presented with abdominal pain, nausea and vomiting, significantly malnourished with decreased albumin and pre-albumin, excessive weight loss about 85 pounds with BMI decreased from 65 to 48 within 4 weeks. Comorbidities include history of PE, IVC filter, type 2 diabetes, chronic venous stasis, immobility. CT abdomen/pelvis revealed irregular fluid collection on latero-posterior wall of sleeve gastrectomy with features suggesting abscess. Extrinsic compression was seen on preoperative UGI and gastroscopy.
Methods/Surgical procedure: A standard, 5-trockars laparoscopy was done for very extensive adhesiolysis. A large encapsulated hematoma was found near the gastric body and pre-antrum, adhering firmly to the gastric wall and surrounding structures. Intraoperative gastroscopy was used to identify anatomy. Pseudo-capsule of the hematoma was excised to prevent from reoccurrence. Thick matured hematoma with purulent content was evacuated with suction and the Endobag. A 10F JP drain was placed into the hematoma cavity.
Post-Procedure Course and 30-day outcomes: Abdominal pain, nausea, vomiting resolved, and nutritional status significantly improved. Follow up CT scan showed complete resolution of hematoma.
Conclusions: Prevention includes meticulous surgical hemostasis. Early evacuation of peri-gastric hematoma prevents from infection and extrinsic compression of the stomach. Excessive weight loss and malnourishment are consequences of gastric outlet obstruction due to hematoma. Surgical treatment includes evacuation of hematoma and excision of its pseudocapsule to prevent from reoccurrence. Intra-operative gastroscopy helps with anatomical orientation. Radiological drainage may not be effective in chronic infected hematomas.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 88018
Program Number: V250
Presentation Session: Friday Video Loop (Non CME)
Presentation Type: VideoLoop