Glue-En-Y?: The Role of Endoscopy in Complications of Bariatric Surgery

Abstract

Purpose: Background: Although complications related to gastric bypass surgery are often minimal, when they do occur, are technically challenging to manage. Surgical intervention may be difficult to perform and may not always be an effective solution. This case report illustrates the use of endoscopy in these instances. Case Report: A 37 year old man with history of morbid obesity, s/p laproscopic Roux-En-Y gastric bypass, presented to the Emergency Department complaining of a one day history of epigastric abdominal pain three months post-operation. The patient also presented one month prior to this admission with similar complaints, with subsequent resolution of symptoms. The pain was located in the epigastric region, sudden in onset, sharp in nature, not associated with eating. He also complained of nausea, but denied vomiting, changes in bowel habits or fevers. Initial physical exam showed mild tenderness to palpation in the epigastric region, but was otherwise unremarkable. The patient maintained a surgical drain from the gastric pouch to the skin, with no signs of infection. Laboratory work up was also unremarkable, with no evidence of elevated WBC, or LFT's. A CT scan of the abdomen with oral and intravenous contrast showed no signs of free air or fluid collection, with surgical drain in correct position. Patient was kept NPO, and started on total parental nutrition via peripherally inserted central catheter (PICC). Patient began to have fevers (maximum temperature of 101F) two days after admission. PICC line was removed and cultured. Blood culture, urine culture and chest x-ray were also done. After reviewing the case, it was believed the patient had a presumptive leak at the site of anastomosis. Gastroenterology was consulted for confirmation of diagnosis and possible intervention. Patient was started on intravenous Flagyl® and Cefepime, and scheduled for esophagogastroduodenoscopy (EGD) once clinically stable, and afebrile. Patient was subsequently discharged, with follow-up for endoscopy. One month after discharge, patient remained with symptoms and returned for GI follow-up. EGD was used to assess the site of the leak. Once located, fibrin sealant was injected at the site for closure. Clinical follow-up post-injection showed resolution of the leak, as evidenced by symptomatic improvement, tolerance of diet and no further reported episodes of pain or fevers. Conclusion: We report a unique case of successful closure of an anastomotic leak after a Roux-En-Y gastric bypass. The use of fibrin sealant via upper endoscopy fixed the leak with no significant complication. In such cases, the use of an endoscopic approach is often very practical, less invasive and provides an effective solution.