Zhamak Khorgami, MD, FICS, Chi Zhang, MD, Bassan J Allan, MD, MBA, Nestor F De La Cruz-Munoz, MD, FACS, FASMBS. Division of Laparoendoscopic and Bariatric Surgery, The DeWitt Daughtry Family Department of Surgery, Miller School of Medicine-University of Miami.
The patient was a 32 y/o obese AA female presented for an elective EGD and dilatation of gastric sleeve for symptomatic stenosis 6 weeks post-op. She presented with intermittent complaints of nausea, vomiting, reflux and abdominal pain which were progressive over the 6 weeks and refractory to medical treatment.
Three dilatations were performed using achalasia balloon under general anesthesia and fluoroscopy. During last dilation, blood was noticed around the oral cavity. Endoscopy showed a tear in the stomach with direct visualization of intra-abdominal contents. Laparoscopy confirmed a long rupture along the lesser curvature of stomach. Primary repair was not possible and gastric bypass was performed with resection of gastric remnant.
Upper GI Series on the day after surgery showed contrast extravasation proposing leak. Since there was no clinical sign of sepsis or peritonitis, non-operative management of leak was considered by keeping the patient NPO with TPN and antibiotics. Repeated upper GI series one week later was normal and liquid diet was started. The patient experienced dysphagia and nausea and underwent upper endoscopy. An esophageal rupture was noticed in the distal esophagus. Chest CT scan showed left-sided pleural effusion with no contrast extravasation in the thorax. Pleurocentesis confirmed the effusion as sterile fluid. Based on clinical and imaging findings, expectant management of esophageal rupture was selected. A jejunostomy tube was placed laparoscopically and patient was discharged home on tube feeding for four weeks.