Charlotte Horne, MD, Antonis Sideris, MD, Ali Aminian, MD, Stacy Brethauer, MD, Phillip Schauer, MD. Cleveland Clinic
Introduction: As obesity is a chronic disease, subsequent surgical procedures may be required either due to poor response to, or complications of the initial procedure. Revisional surgery is associated with increased risk of post-operative hemorrhage with reported rates of 1-4%. The usual location of early post-operative bleeding is either an anastomosis or staple line, but may potentially involve the remnant stomach. In our high volume bariatric surgery center we report two cases of gastrointestinal bleeding secondary to visceral pseudoaneurysms, a rare but sinister cause of post-operative hemorrhage.
CASE 1:
The first patient is a 60-year-old male whose index operation was Laparoscopic Gastric Band (LGB) placement in 2007. Due to poor weight loss and worsening diabetic control, he underwent band removal with conversion to Roux En Y Gastric Bypass (RNYGB) and remnant gastrostomy. On post-operative day (POD) 5, he developed an acute gastrointestinal bleed. Initial work up to identify the source included a diagnostic laparoscopy with remnant gastroscopy, which showed some oozing at the staple line. This area was resected but continued melena necessitated a colonoscopy and EGD. This showed fresh blood in the jejunum but without a clear source. Lastly, an angiography was done which showed a pseudoaneurysm at the junction between the gastroduodenal artery and gastroepiploic artery that was managed by coil embolization.
CASE 2:
The next patient is a 64-year-old male who originally underwent an open RNYGB in 2003 for morbid obesity that was complicated by a gastro-gastric fistula that was resected in 2004. Due to persistent steroid use and continue smoking, the patient developed severe marginal ulcers and a new recurrent gastro-gastric fistula. He underwent laparoscopic excision of gastro-gastric fistula with revision of the gastrojejunostomy to improve his symptoms of gastroesophageal reflux. His post-operative course was complicated by a large anastomotic leak that was managed with an esophageal stent. On POD 33, the patient was readmitted with worsening abdominal pain, hypotension and copious melena. He underwent an upper endoscopy and colonoscopy, and no source of the bleeding was identified. A Computed tomography angiography showed a left hepatic artery pseudoaneurysm distal to the bifurcation of the left and right hepatic arteries. He underwent coil embolization of the pseudoaneurysm with subsequent resolution of gastrointestinal bleeding.
CONCLUSION: Although uncommon, it is important to remember pseudoaneurysms may present as a possible source for post-operative intra-luminal hemorrhage. In our practice, these were best diagnosed with angiography and treated successfully with coil embolization.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 80706
Program Number: P490
Presentation Session: Poster (Non CME)
Presentation Type: Poster
