L Poggi, MD1, Felix Camacho, MD2, Omar Ibarra, MD2, Gerardo Arredondo, MD2, Margarita Villanueva, MD2, Luis Poggi, MD2. 1Oklahoma University Health Sciences Center, 2Clinica Anglo Americana
INTRODUCTION: Bariatric surgery is becoming more common and nowadays Gastric sleeve seems to be the most popular procedure for Obesity. Gastric sleeve complications, including Sleeve stenosis, can be life threatening. We present the surgical management of a patient who developed gastric sleeve stenosis as well as having a hiatal hernia associated with severe reflux.
DESCRIPTION: Our patient is a 38-year-old female with a BMI of 31kg/m2 who underwent a gastric sleeve gastrectomy 3 months prior to coming to our clinic. She developed nausea and emesis after the procedure that was only partially relieved with medications. She even required serial dilatation with an achalasia balloon up to 35 mm of diameter. She also developed severe reflux, and was diagnosed with Los Angeles C esophagitis. This finding was not present prior to her bariatric procedure. DeMeester score was 84. She progressively lost weight, reaching a BMI of 14. A gastrografin swallow study showed stenosis at the gastric body.
During laparoscopic exploration, we identified a hiatal hernia that was reduced. The esophagus was circumferentially dissected until having at leats 3 cm of intrabdominal esophagus. The proximal seleve was significantly dilated, in order to correct the patient reflux an anterior Dor fundoplication perfomed. Hiatal hernia defect was closed with sutures and a biologic mesh was place to reinforce our repair.
The next step of the procedure took care of the gastric sleeve stenosis. A seromyotomy was the procedure elected in order to avoid more resection in the setting of a malnourish patient. An obvious stenotic area was identified just as seen at the preoperative contrast films. The stomach was insufflated with air, this allowed us to have a good delimitation of the compromised area. A short, 2 cm approximately segment was visualized under the dilated portion of the sleeve. We initially attempted to perform a seromyotomy with a hook cautery. The gastric wall was significantly thickened. Despite the Cadier-Himpens seromytomy, the kinked area did not seem to resolve the obstructive component due to the significant scarred tissue. We considered the segment of stenosis to be small so a gastroplasty was then attempted. The mucosa in the area of the seromyotomy was accessed and closed transversally. Interrupted stiches with 3/0 polyglecaprone were used for this step. Air leak and methylene blue test were performed. Once the sleeve was insufflated, the new anatomy showed no obstruction. Patient was started in a diet in POD 2. Obstructive symptoms including reflux resolved.
Gastric sleeve stenosis is a life threatening complication associated with severe malnutrition and reflux. Surgical management should be considered if endoscopic dilatation fails. Surgical procedure of choice has not been standardized however Gastroplasty is a viable option in order to avoid performing a gastric bypass in a patient that might be already debilitated and malnourished. Anterior Dor fundoplication can be a feasible option for patients with proximal sleeve dilatation and associated reflux or hiatal hernia.