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GENERAL SURGERY NEWS / AUGUST 2020
Clinical Scenarios in Bariatric Surgery: Lesser-Known Complications Case 1: Omental Abscess After Laparoscopic Roux-en-Y Gastric Bypass
Welcome to the August issue of The Surgeons’ Lounge. In this issue, Matyas Fehervari, MD, PhD, MRCS, a general and bariatric surgery resident at Chelsea and Westminster Hospital NHS Foundation Trust and Imperial College, in London, interviews Haris Khwaja, MD, DPhil (Oxon), FRCS, a consultant bariatric surgeon, also at Chelsea and Westminster Hospital and Imperial College, about two patient scenarios regarding inflammation and infarction of fat and its implications in bariatric surgery. We look forward to our readers’ questions, comments and interesting cases to present. Sincerely, CS Samuel Szomstein, MD, FACS ge Editor, The Surgeons’ Lounge Szomsts@ccf.org
This case involved a 41-year-old woman with an American Society of Anesthesiologists physical status classification score of III and a complex medical history, including severe asthma with prednisolone requiring, on average, two to three hospital admissions per year and dilated cardiomyopathy due to New York Heart Association class III cardiac failure diagnosed when she was 39 years of age. Her left ventricular function improved (ejection fraction, 48%) once a bi-ventricular pacing device and an intracardiac defibrillator were fitted in 2017. Further relevant medical history included obstructive sleep apnea on continuous positive airway pressure ventilation overnight, steroid-induced borderline diabetes mellitus and severe gastroesophageal reflux disease (GERD). This patient’s case was discussed at the bariatric multidisciplinary team meetings, assessed in the high-risk anesthetic clinic, and cleared for bariatric surgery by the anesthetic, surgical, dietetic, and psychology teams. In view of her brittle asthma, her prednisolone dosage was increased to 20 mg per day for one week before surgery. She underwent an elective laparoscopic Roux-en-Y gastric bypass (LRYGB) in 2019 by Dr. Khwaja. Intraoperative findings included the presence of hepatomegaly due to non-alcoholic steatohepatitis and a very thick greater omentum. The greater omentum was split using the LigaSure device (Medtronic) perpendicular to the transverse colon. A triple-stapled jejunojejunostomy was created followed by the creation of an 8-cm–long lesser curve–based gastric pouch. A circular-stapled gastrojejunal anastomosis was created with the Orvil device (25 mm) (Medtronic), using a 3.8-mm staple height. Both Petersen’s and jejunojejunostomy mesenteric defects were closed with a 15-cm permanent V-lock suture. The immediate postoperative course was unremarkable, with the patient spending one night in the highdependency unit, as planned, and then discharged to home from the surgical floor on postoperative day 3. She attended clinic one week later for assessment and was clinically well. At three weeks postoperatively, she attended clinic again, at her request, complaining of epigastric pain; a CT scan done that day showed omental infarction of approximately 10×8 cm (Figure 1). In view of the abdominal pain, she was admitted for analgesia and antibiotics, and she remained on 20 mg of prednisolone for
Figure 1. CT scan showing an area of omental infarction of approximately 10×8 cm.
Figure 2. CT scan demonstrating some liquefactive necrosis of the infarcted omentum.
her asthma. Her white blood cell count and inflammatory markers failed to improve, and 10 days after this admission, she developed fevers and shivers as well as worsening abdominal pain. A CT scan demonstrated some liquefactive necrosis of the infarcted omentum (Figure 2). This was not amenable to radiological percutaneous drainage, and, in view of her sepsis, the decision was made to perform diagnostic laparoscopy, during which an omental abscess was drained. One hundred milliliters of pus was drained, after which the patient made an uneventful recovery.
Case 2: Mesenteric Panniculitis and Bariatric Surgery This case involved a 56-year-old woman with a BMI of 41 kg/m2 and medical history of mild asthma, impaired glucose tolerance, sciatica, depression and three cesarean deliveries. She also had non-alcoholic fatty liver disease and a history of excess alcohol consumption. She had been extensively investigated by the hepatology team, and it was believed that she had no significant liver disease. The patient was scheduled for an elective LRYGB. During surgery, it was noted that she had evidence of extensive mesenteric panniculitis, and the proximal small bowel was adherent to adjacent small-bowel loops as well as to the transverse mesocolon. After a trial dissection, it was determined that there was significant mesenteric panniculitis and jejunitis, and a sleeve gastrectomy was performed, as the patient had been consented for both procedures. She made an uneventful recovery from surgery and was discharged on postoperative day 2. In view of the surgical findings, a CT scan was performed six weeks after surgery that showed evidence of enterocolitis and mesenteric panniculitis with a well-formed sleeve (Figure 3). The patient was referred to a gastroenterologist for further management. She had no acid reflux and has been enrolled in a five-year endoscopic surveillance program in view of the recent reports of an increased incidence of Barrett’s esophagus in patients undergoing sleeve gastrectomy.
Figure 3. CT scan showing evidence of enterocolitis and mesenteric panniculitis with a well-formed sleeve.
