2512 A Rare Late Complication After Roux-en-Y Gastric Bypass: Recurrent Hepatic Abscesses

Abstract

INTRODUCTION: There are many rare late post-operative complications for Roux-en-Y gastric bypass (RYGB), but hepatic abscesses from enteric fistula formation is a rare complication. Herein we describe a case of recurrent hepatic abscess formation after a revision of a RYGB procedure CASE DESCRIPTION/METHODS: A 66 year-old female with a history of obesity status-post a RYGB in 2003 requiring revision with partial gastrectomy with GJ creation in 2017 presented to her PCP with abdominal pain, reduced appetite, fevers, and chills. She had several admissions for recurrent polymicrobial hepatic abscesses requiring prolonged courses of IV antibiotics after her revision. She had a temperature of 101.1 F, blood pressure of 101/55, heart rate 69. Labs revealed ALP of 280, ALT of 83, AST of 208, and WBC of 11.5. CT revealed an 11 cm abscess between the liver and diaphragm (Figure 1). She was started on antibiotics and interventional radiology did CT-guided abscess drain placement revealing green pus. An upper endoscopy revealed Roux-en-Y gastrojejunostomy anatomy with gastrojejunal anastomosis with healthy mucosa. Given her recurrent abscesses, there was concern that this was a biliary or intestinal fistulous tract causing the abscesses. Imaging with CT fistulogram demonstrated a fistulous tract in the bilio-pancreatic limb of the RYGB. She underwent exploratory laparotomy with findings of the gastric remnant which was adherent to the left lobe of the liver (Figure 2). The staple line of gastric remnant along with the fistula were resected and underwent successful repair. She has had no further recurrence of hepatic abscesses. DISCUSSION: Late post-operative of RYGB include enteric fistulas, cholelithiasis, marginal ulcers, small bowel obstruction, and nutritional deficiencies. However, hepatic abscesses from enteric fistula formation is a rare complication. Liver abscesses can seed from the biliary tree and liver parenchyma through the hepatic artery or portal venous system. Only 5-15% of infections are accounted from surgical trauma. The etiology of recurrent hepatic abscesses in our patient resulted from fistula formation at the gastric staple line leading to an exposure to enteric secretions. Given RYGB anatomy, accessing the gastric remnant is often difficult and at times never done. This case highlights the need for providers to continue to have a high index of suspicion of pathology occurring in the gastric remnant and to consider fistula formation.