Shane B. Devine

Philadelphia College of Osteopathic Medicine , USA

Title: Postoperative stomach volvulus and pancreatitis following a sleeve gastrectomy

Abstract

Introduction: The laparoscopic vertical sleeve gastrectomy is the most common bariatric procedure performed globally. The greater curvature and fundus of the stomach are stapled off and removed, forming a narrower and less distensible stomach, resulting in reduced caloric intake. Postoperative complications include gastroesophageal reflux disease, leakage of the staple line, intraluminal and intra-abdominal bleeding and porto-mesenteric vein thrombosis. Additionally, gastric obstruction has been reported as a complication in 0.2-4% of cases. Most obstructions are due to either mechanical narrowing or malrotation of the sleeve caused by improper alignment of the staples. We present a patient with gastric outlet obstruction missed on imaging and acute pancreatitis that was initially misdiagnosed as dumping syndrome.

Case Presentation: A 24-year-old female with asthma presented with abdominal pain, nausea and vomiting two weeks after sleeve gastrectomy in Mexico. Vitals were stable and labs were remarkable only for elevated lipase. CT Abdomen and Pelvis with and without contrast was read as post-surgical changes associated with sleeve gastrectomy without evidence of complications. She was diagnosed with dumping syndrome and pancreatitis and managed supportively with small low fat meals, fluids, analgesics and antiemetics, but her symptoms persisted. Endoscopy revealed malrotation of the gastric sleeve not seen on initial imaging. She required TPN for nutritional support and was discharged with plans for outpatient surgery but returned to the hospital. She was initially transferred for Roux en Y bypass but instead managed with laparoscopic stricturoplasty followed two months later by endoscopic dilation and botox injection.

Discussion: This case presents sleeve malrotation and gastric outlet obstruction as a diagnosis to consider in a patient with postoperative nausea, vomiting and abdominal pain. Initial imaging should include CT scan without contrast to visualize any gastric sleeve abnormalities. Endoscopy should be utilized in patients with persistent symptoms and negative initial imaging to further evaluate for any complications. If both CT scans and endoscopy are negative, an oral glucose tolerance test can be performed to diagnose dumping syndrome. Additionally, imaging and lipase levels can be utilized to evaluate the pancreas. A prophylactic cholecystectomy during the sleeve gastrectomy can be considered to reduce the risk of postoperative gallstone pancreatitis. Besides gallstones, postoperative pancreatitis can also be caused by gastric outlet obstruction. Gastropexy has been shown to reduce gastric sleeve torsion and secondary obstruction. Management of gastric outlet obstruction includes supportive care, balloon dilation if a focus of stenosis is identified, or gastric bypass if symptoms persist.

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4th International Conference on Nutrition and Healthcare

Shane B. Devine

Title: Postoperative stomach volvulus and pancreatitis following a sleeve gastrectomy

Abstract

Biography

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