ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Grace Elta and Robert J. Fontana, Section Editors
An Unusual Cause of Epigastric Pain After Stent Placement for Bariatric Surgery Leak Q1
Chi-Ming Tai,1,2 Chih-Kun Huang,2 and Hsiu-Po Wang3 1 Department of Internal Medicine, and the 2Bariatric and Metabolic International (BMI) Surgery Center, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan; and the 3Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan
web 4C/FPO
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Question: A 32-year-old woman with a body mass index of 35.2 kg/m2 underwent laparoscopic sleeve gastrectomy (LSG) for the management of morbid obesity. Fever and abdominal pain occurred on postoperative day 5. Computed tomography (CT) revealed an intra-abdominal abscess in the left subhepatic region and CT-guided drainage was performed. An upper GI series showed leakage of contrast from the gastric body. Esophagogastroduodenoscopy (EGD) revealed stenosis in the lower stomach and a fissure-like leak with purulent discharge at the upper portion of the sleeve tube (Figure A, arrow). A covered, self-expandable stent (SES) was placed to treat the leak. The distal and proximal ends of the stent were at the antrum and mid-esophagus, respectively. Only mild chest discomfort and acid reflux occurred after the stent placement. Oral intake was initiated 2 days later and the patient was discharged. However, she complained of progressive epigastric pain 2 weeks later and EGD was performed on day 19 after stent placement (Figure B, C). What is your diagnosis and management? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.01.012
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Answer to the Clinical Challenges and Image in GI: Image 1: Branded Ulcer Caused by Migrated Stent EGD revealed a 2-cm mass protruding into the stent. After withdrawing the stent, 1 circumferential ulcer about 3 cm in size around the polypoid mucosa was noted at the antrum. Branded ulcer caused by migrated stent was diagnosed and the stent was removed. Fortunately, a follow-up upper GI series after stent removal revealed no leakage. After initiating oral intake, she was discharged and a proton pump inhibitor was prescribed for the treatment of the ulcer. LSG has become a popular bariatric procedure because of it is simple, and achieves good weight loss with fewer complications. Common complications after LSG include gastroesophageal reflux disease, stenosis, and leak. Of these, the most serious complication is gastric leak with an incidence of 1.4%–5.3%.1 SESs provide a nonsurgical treatment option for the management of leaks after LSG and a period of 6–8 weeks was recommended as the optimal time for stent removal.2 Stent migration is the most common complication after stent placement. A possible reason for stent migration is that current SESs do not permit direct contact of the entire length of the stent with the gastric mucosa. Stent migration can be treated by endoscopic stent repositioning. Stent migration–related gastric ulcer has not been reported in LSG patients. However, perforated gastric ulceration after esophageal stent migration has been reported in patients with esophageal cancer, which could be attributed to stent impaction on the gastric wall.3 Therefore, stent migration related ulcer and even perforation should be kept in mind in patients undergoing stent placement for the treatment of leak after LSG.
References 1. 2. 3.
Sakran N, Goitein D, Raziel A, et al. Gastric leaks after sleeve gastrectomy: a multicenter experience with 2,834 patients. Surg Endosc 2013;27:240–245. Puli SR, Spofford IS, Thompson CC. Use of self-expandable stents in the treatment of bariatric surgery leaks: a systematic review and meta-analysis. Gastrointest Endosc 2012;75:287–293. Markar SR, Ross A, Low DE. Gastric ulceration following oesophageal stent migration complicating surgical management of oesophageal cancer. Interact Cardiovasc Thorac Surg 2012;15:320–322.
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An Unusual Cause of Epigastric Pain After Stent Placement for Bariatric Surgery Leak Q1
Chi-Ming Tai,1,2 Chih-Kun Huang,2 and Hsiu-Po Wang3 1 Department of Internal Medicine, and the 2Bariatric and Metabolic International (BMI) Surgery Center, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan; and the 3Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan
web 4C/FPO
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58
Question: A 32-year-old woman with a body mass index of 35.2 kg/m2 underwent laparoscopic sleeve gastrectomy (LSG) for the management of morbid obesity. Fever and abdominal pain occurred on postoperative day 5. Computed tomography (CT) revealed an intra-abdominal abscess in the left subhepatic region and CT-guided drainage was performed. An upper GI series showed leakage of contrast from the gastric body. Esophagogastroduodenoscopy (EGD) revealed stenosis in the lower stomach and a fissure-like leak with purulent discharge at the upper portion of the sleeve tube (Figure A, arrow). A covered, self-expandable stent (SES) was placed to treat the leak. The distal and proximal ends of the stent were at the antrum and mid-esophagus, respectively. Only mild chest discomfort and acid reflux occurred after the stent placement. Oral intake was initiated 2 days later and the patient was discharged. However, she complained of progressive epigastric pain 2 weeks later and EGD was performed on day 19 after stent placement (Figure B, C). What is your diagnosis and management? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.01.012
Gastroenterology 2014;-:e1–e2 DIS 5.2.0 DTD YGAST58896_proof 26 April 2014 11:52 am ce
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ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174
Answer to the Clinical Challenges and Image in GI: Image 1: Branded Ulcer Caused by Migrated Stent EGD revealed a 2-cm mass protruding into the stent. After withdrawing the stent, 1 circumferential ulcer about 3 cm in size around the polypoid mucosa was noted at the antrum. Branded ulcer caused by migrated stent was diagnosed and the stent was removed. Fortunately, a follow-up upper GI series after stent removal revealed no leakage. After initiating oral intake, she was discharged and a proton pump inhibitor was prescribed for the treatment of the ulcer. LSG has become a popular bariatric procedure because of it is simple, and achieves good weight loss with fewer complications. Common complications after LSG include gastroesophageal reflux disease, stenosis, and leak. Of these, the most serious complication is gastric leak with an incidence of 1.4%–5.3%.1 SESs provide a nonsurgical treatment option for the management of leaks after LSG and a period of 6–8 weeks was recommended as the optimal time for stent removal.2 Stent migration is the most common complication after stent placement. A possible reason for stent migration is that current SESs do not permit direct contact of the entire length of the stent with the gastric mucosa. Stent migration can be treated by endoscopic stent repositioning. Stent migration–related gastric ulcer has not been reported in LSG patients. However, perforated gastric ulceration after esophageal stent migration has been reported in patients with esophageal cancer, which could be attributed to stent impaction on the gastric wall.3 Therefore, stent migration related ulcer and even perforation should be kept in mind in patients undergoing stent placement for the treatment of leak after LSG.
References 1. 2. 3.
Sakran N, Goitein D, Raziel A, et al. Gastric leaks after sleeve gastrectomy: a multicenter experience with 2,834 patients. Surg Endosc 2013;27:240–245. Puli SR, Spofford IS, Thompson CC. Use of self-expandable stents in the treatment of bariatric surgery leaks: a systematic review and meta-analysis. Gastrointest Endosc 2012;75:287–293. Markar SR, Ross A, Low DE. Gastric ulceration following oesophageal stent migration complicating surgical management of oesophageal cancer. Interact Cardiovasc Thorac Surg 2012;15:320–322.
e2 DIS 5.2.0 DTD YGAST58896_proof 26 April 2014 11:52 am ce
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