- Email: [email protected]
Gastropericardial fistula after Roux-en-Y gastric bypass: a case report
Surgery for Obesity and Related Diseases 2 (2006) 533–535
Case report
Gastropericardial fistula after Roux-en-Y gastric bypass: a case report Daniel J. Gagné, M.D.,* Pavlos K. Papasavas, M.D., Thomas Birdas, M.D., Jason Lamb, M.D., Philip F. Caushaj, M.D. Temple University School of Medicine, Clinical Campus at Western Pennsylvania Hospital, Pittsburgh, Pennsylvania Received July 20, 2006; accepted July 20, 2006
Gastropericardial fistula is a rare and life-threatening complication of gastroesophageal surgery. This complication occurring after bariatric surgery has not been previously reported. We present a case of gastropericardial fistula occurring after gastric bypass for morbid obesity. Case report A 43-year-old woman with a history of morbid obesity (body mass index 51 kg/m2), sleep apnea, and hypertension underwent open antecolic, antegastric Roux-en-Y gastric bypass at another hospital. The procedure included intraoperative endoscopy, which had demonstrated no evidence of leak. Two Blake drains were placed at the time of surgery. Chest x-rays on postoperative days 1, 2, and 3 demonstrated minimal left basal atelectasis in association with minimal bilateral pleural effusion. A water-soluble contrast study on postoperative day 2 was negative for obstruction or leak. The patient was discharged on postoperative day 4. The patient began to develop episodes of severe left shoulder pain 1 week after surgery. She was evaluated in several emergency rooms three times during the first month postoperatively for this shoulder pain, including radiologic studies, orthopedic surgeon evaluation, attempted arthrocentesis, and magnetic resonance imaging—the findings of all were negative. At 1 month postoperatively after gastric bypass, she presented to an emergency room for a fourth time with chest pain, epigastric abdominal pain, left shoulder pain, weakness, and low-grade fever. At admission to this outside hospital, she was tachycardic (pulse 106 beats/min), had mild leukocytosis (white blood cell count 11.4 k/L) with a
*Reprint requests: Daniel J. Gagné, M.D., Department of Surgery, Western Pennsylvania Hospital, 4800 Friendship Avenue, 4600N, Pittsburgh, PA 15224. E-mail: [email protected]
slight left shift (76.5% neutrophils), and was anemic (hemoglobin 8.0 g/dL and hematocrit 24.4%). Her stool was heme positive for occult blood. Her prothrombin time and international normalized ratio were elevated (14.8 s and 1.5 s, respectively). Chest x-rays revealed left basilar infiltrate and a small left pleural effusion. Computed tomography (CT) of the chest and abdomen revealed left lower lobe parenchymal consolidation, small left pleural effusion, and no evidence of abdominal abscess, free fluid, or obstruction. Unasyn and Levaquin were administered for a presumptive diagnosis of pneumonia and pneumonitis. The patient’s electrocardiographic findings demonstrated sinus tachycardia and ST elevation in leads I, II, and aVL and was interpreted as possible inferior ischemia and anterior infarction. Her serial cardiac blood enzymes were elevated: creatine kinase-MB 11.6 and 18.9ng/mL (normal range 0 –5.0 ng/mL) and troponin 2.23 and 4.03 ng/mL (normal range 0 – 0.40 ng/mL). The echocardiographic findings were reported as “tiny pericardial effusion may be present; no definite pericardial effusions seen; slight separation of parietal pericardium; echogenic material posteriorly behind left ventricle; ejection fraction 52%.” The patient was transfused 2 U of packed red blood cells for her anemia. Endoscopy was considered in the evaluation of her anemia and heme positive stool but was withheld because of concern for her cardiac disease. A barium swallow was negative for leak. Blood cultures remained negative. A cardiac catheterization was negative for coronary artery disease. The patient was subsequently discharged to home with oral antibiotics. She continued to have intermittent shoulder pain, chest pain, and abdominal pain. Three weeks later (2 months postoperatively), the patient was admitted emergently for syncope, chest pain, abdominal pain, and left shoulder pain at an outside facility. Chest and abdominal CT revealed a small amount of anterior pericardial and mediastinal air, pericardial effusion, and
1550-7289/06/$ – see front matter © 2006 American Society for Bariatric Surgery. All rights reserved. doi:10.1016/j.soard.2006.07.008
534
D. J. Gagné et al. / Surgery for Obesity and Related Diseases 2 (2006) 533–535
mediastinum, and pneumopericardium, with the clinical suspicion of a gastrointestinal-pericardial fistula and possible source of the esophagus, gastric pouch, bypassed stomach, or abscess. On admission to the intensive care unit, the patient was intubated and sedated. She was hypotensive (blood pressure 98/70 mm Hg), tachycardic (pulse 104 beats/min), and required intravenous pressors. Her white blood cell count was 17.0 k/L, with 25% bands. Her serum albumin was 2.5 g/dL, blood urea nitrogen was 34 mg/dL, and creatinine was 1.8 mg/dL. She was resuscitated with intravenous fluid and treated with intravenous antibiotics and total parenteral nutrition. CT at admission had demonstrated decompression of the gastric remnant and no evidence of obstruction. Analysis of the fluid from the pericardial drain revealed bile and amylase. The patient’s status subsequently improved, and she was weaned from the ventilator. A water-soluble contrast swallow study revealed no leak, and findings from an upper endoscopy were negative. Echocardiography and repeat CT of her chest and abdomen revealed resolution of her pericardial fluid and no evidence of gastrointestinal leak. The pericardial drainage decreased, and the drain was removed. The patient was started on a diet and was discharged 2 weeks after her admission. An elective surgical procedure was planned once the patient’s clinical status improved. Four days later, the patient returned to our facility with another episode of severe left shoulder pain. She was clinically stable. Repeat CT revealed bilateral pulmonary emboli, as well as intrapericardial air, suggestive of recurrence of a gastropericardial fistula. The patient was given intravenous heparin and a retrievable inferior venous cava filter was placed. The patient was taken to the operating room the following day for diagnostic laparoscopy and extensive lysis of adhesions from her previous open surgery. Laparoscopy revealed a fistula from the gastric remnant staple line
Fig. 1. (A,B) CT scans demonstrating pneumomediastinum, pneumopericardium, and diaphragmatic inflammatory changes.
inflammatory changes in the area of the bypassed stomach and diaphragm (Fig. 1). The bypassed stomach had a moderate amount of air and fluid. No pleural effusion was evident. The patient become clinically unstable, developed hypotension and respiratory distress and was intubated. Echocardiography revealed cardiac tamponade physiology. Pericardiocentesis was performed, with a resultant 500 mL of cloudy light brown, bilious fluid removed, and the pericardial drain was left in place. The patient was transferred to our facility for additional evaluation of her sepsis, pneumo-
Fig. 2. Intraoperative laparoscopic view demonstrating bypassed stomach lumen (G), staples in diaphragmatic fistula (S), left crus (C), and pericardium (P).
D. J. Gagné et al. / Surgery for Obesity and Related Diseases 2 (2006) 533–535
through the diaphragm to the pericardium (Fig. 2). The gastropericardial fistula tract was dissected, and laparoscopic partial gastrectomy (fundus and gastric remnant staple line) was performed. A Jackson-Pratt drain was left in place. Postoperatively, the patient noted immediate and complete relief of her left shoulder pain. A postoperative water-soluble contrast study revealed no leak, the drain was removed, and she was discharged 2 days later. The patient remained asymptomatic at 7 months of follow-up with a body mass index of 27 kg/m2. Discussion Complications after obesity surgery are not uncommon [1]. Leaks and abscess formation can present insidiously and be a diagnostic challenge. Radiologic examinations may not provide reliable findings. Gastropericardial fistula is a very rare and life-threatening problem. Previous gastroesophageal surgery is the most common risk factor [2]. It
535
had not been previously reported after bariatric surgery. This case may have resulted from a leak, staple erosion, ulceration, or technical error. A high index of suspicion is warranted in bariatric surgical patients presenting with shoulder, abdominal, or chest pain. Diagnostic laparoscopy or laparotomy should be considered early in the evaluation and treatment of these patients if the radiologic evaluation reveals subtle signs (e.g., pleural effusion) of a leak or abscess, or if the patient’s symptoms persist despite negative nonoperative evaluation findings.
References [1] Podnos YD, Jimenez JC, Wilson SE, Stevens M, Nguyen NT. Complications after laparoscopic gastric bypass. Arch Surg 2003;138:957– 61. [2] Murthy S, Looney J, Jaklitsch MT. Gastropericardial fistula after laparoscopic surgery for reflux disease. N Engl J Med 2002;246:328 – 32.
Case report
Gastropericardial fistula after Roux-en-Y gastric bypass: a case report Daniel J. Gagné, M.D.,* Pavlos K. Papasavas, M.D., Thomas Birdas, M.D., Jason Lamb, M.D., Philip F. Caushaj, M.D. Temple University School of Medicine, Clinical Campus at Western Pennsylvania Hospital, Pittsburgh, Pennsylvania Received July 20, 2006; accepted July 20, 2006
Gastropericardial fistula is a rare and life-threatening complication of gastroesophageal surgery. This complication occurring after bariatric surgery has not been previously reported. We present a case of gastropericardial fistula occurring after gastric bypass for morbid obesity. Case report A 43-year-old woman with a history of morbid obesity (body mass index 51 kg/m2), sleep apnea, and hypertension underwent open antecolic, antegastric Roux-en-Y gastric bypass at another hospital. The procedure included intraoperative endoscopy, which had demonstrated no evidence of leak. Two Blake drains were placed at the time of surgery. Chest x-rays on postoperative days 1, 2, and 3 demonstrated minimal left basal atelectasis in association with minimal bilateral pleural effusion. A water-soluble contrast study on postoperative day 2 was negative for obstruction or leak. The patient was discharged on postoperative day 4. The patient began to develop episodes of severe left shoulder pain 1 week after surgery. She was evaluated in several emergency rooms three times during the first month postoperatively for this shoulder pain, including radiologic studies, orthopedic surgeon evaluation, attempted arthrocentesis, and magnetic resonance imaging—the findings of all were negative. At 1 month postoperatively after gastric bypass, she presented to an emergency room for a fourth time with chest pain, epigastric abdominal pain, left shoulder pain, weakness, and low-grade fever. At admission to this outside hospital, she was tachycardic (pulse 106 beats/min), had mild leukocytosis (white blood cell count 11.4 k/L) with a
*Reprint requests: Daniel J. Gagné, M.D., Department of Surgery, Western Pennsylvania Hospital, 4800 Friendship Avenue, 4600N, Pittsburgh, PA 15224. E-mail: [email protected]
slight left shift (76.5% neutrophils), and was anemic (hemoglobin 8.0 g/dL and hematocrit 24.4%). Her stool was heme positive for occult blood. Her prothrombin time and international normalized ratio were elevated (14.8 s and 1.5 s, respectively). Chest x-rays revealed left basilar infiltrate and a small left pleural effusion. Computed tomography (CT) of the chest and abdomen revealed left lower lobe parenchymal consolidation, small left pleural effusion, and no evidence of abdominal abscess, free fluid, or obstruction. Unasyn and Levaquin were administered for a presumptive diagnosis of pneumonia and pneumonitis. The patient’s electrocardiographic findings demonstrated sinus tachycardia and ST elevation in leads I, II, and aVL and was interpreted as possible inferior ischemia and anterior infarction. Her serial cardiac blood enzymes were elevated: creatine kinase-MB 11.6 and 18.9ng/mL (normal range 0 –5.0 ng/mL) and troponin 2.23 and 4.03 ng/mL (normal range 0 – 0.40 ng/mL). The echocardiographic findings were reported as “tiny pericardial effusion may be present; no definite pericardial effusions seen; slight separation of parietal pericardium; echogenic material posteriorly behind left ventricle; ejection fraction 52%.” The patient was transfused 2 U of packed red blood cells for her anemia. Endoscopy was considered in the evaluation of her anemia and heme positive stool but was withheld because of concern for her cardiac disease. A barium swallow was negative for leak. Blood cultures remained negative. A cardiac catheterization was negative for coronary artery disease. The patient was subsequently discharged to home with oral antibiotics. She continued to have intermittent shoulder pain, chest pain, and abdominal pain. Three weeks later (2 months postoperatively), the patient was admitted emergently for syncope, chest pain, abdominal pain, and left shoulder pain at an outside facility. Chest and abdominal CT revealed a small amount of anterior pericardial and mediastinal air, pericardial effusion, and
1550-7289/06/$ – see front matter © 2006 American Society for Bariatric Surgery. All rights reserved. doi:10.1016/j.soard.2006.07.008
534
D. J. Gagné et al. / Surgery for Obesity and Related Diseases 2 (2006) 533–535
mediastinum, and pneumopericardium, with the clinical suspicion of a gastrointestinal-pericardial fistula and possible source of the esophagus, gastric pouch, bypassed stomach, or abscess. On admission to the intensive care unit, the patient was intubated and sedated. She was hypotensive (blood pressure 98/70 mm Hg), tachycardic (pulse 104 beats/min), and required intravenous pressors. Her white blood cell count was 17.0 k/L, with 25% bands. Her serum albumin was 2.5 g/dL, blood urea nitrogen was 34 mg/dL, and creatinine was 1.8 mg/dL. She was resuscitated with intravenous fluid and treated with intravenous antibiotics and total parenteral nutrition. CT at admission had demonstrated decompression of the gastric remnant and no evidence of obstruction. Analysis of the fluid from the pericardial drain revealed bile and amylase. The patient’s status subsequently improved, and she was weaned from the ventilator. A water-soluble contrast swallow study revealed no leak, and findings from an upper endoscopy were negative. Echocardiography and repeat CT of her chest and abdomen revealed resolution of her pericardial fluid and no evidence of gastrointestinal leak. The pericardial drainage decreased, and the drain was removed. The patient was started on a diet and was discharged 2 weeks after her admission. An elective surgical procedure was planned once the patient’s clinical status improved. Four days later, the patient returned to our facility with another episode of severe left shoulder pain. She was clinically stable. Repeat CT revealed bilateral pulmonary emboli, as well as intrapericardial air, suggestive of recurrence of a gastropericardial fistula. The patient was given intravenous heparin and a retrievable inferior venous cava filter was placed. The patient was taken to the operating room the following day for diagnostic laparoscopy and extensive lysis of adhesions from her previous open surgery. Laparoscopy revealed a fistula from the gastric remnant staple line
Fig. 1. (A,B) CT scans demonstrating pneumomediastinum, pneumopericardium, and diaphragmatic inflammatory changes.
inflammatory changes in the area of the bypassed stomach and diaphragm (Fig. 1). The bypassed stomach had a moderate amount of air and fluid. No pleural effusion was evident. The patient become clinically unstable, developed hypotension and respiratory distress and was intubated. Echocardiography revealed cardiac tamponade physiology. Pericardiocentesis was performed, with a resultant 500 mL of cloudy light brown, bilious fluid removed, and the pericardial drain was left in place. The patient was transferred to our facility for additional evaluation of her sepsis, pneumo-
Fig. 2. Intraoperative laparoscopic view demonstrating bypassed stomach lumen (G), staples in diaphragmatic fistula (S), left crus (C), and pericardium (P).
D. J. Gagné et al. / Surgery for Obesity and Related Diseases 2 (2006) 533–535
through the diaphragm to the pericardium (Fig. 2). The gastropericardial fistula tract was dissected, and laparoscopic partial gastrectomy (fundus and gastric remnant staple line) was performed. A Jackson-Pratt drain was left in place. Postoperatively, the patient noted immediate and complete relief of her left shoulder pain. A postoperative water-soluble contrast study revealed no leak, the drain was removed, and she was discharged 2 days later. The patient remained asymptomatic at 7 months of follow-up with a body mass index of 27 kg/m2. Discussion Complications after obesity surgery are not uncommon [1]. Leaks and abscess formation can present insidiously and be a diagnostic challenge. Radiologic examinations may not provide reliable findings. Gastropericardial fistula is a very rare and life-threatening problem. Previous gastroesophageal surgery is the most common risk factor [2]. It
535
had not been previously reported after bariatric surgery. This case may have resulted from a leak, staple erosion, ulceration, or technical error. A high index of suspicion is warranted in bariatric surgical patients presenting with shoulder, abdominal, or chest pain. Diagnostic laparoscopy or laparotomy should be considered early in the evaluation and treatment of these patients if the radiologic evaluation reveals subtle signs (e.g., pleural effusion) of a leak or abscess, or if the patient’s symptoms persist despite negative nonoperative evaluation findings.
References [1] Podnos YD, Jimenez JC, Wilson SE, Stevens M, Nguyen NT. Complications after laparoscopic gastric bypass. Arch Surg 2003;138:957– 61. [2] Murthy S, Looney J, Jaklitsch MT. Gastropericardial fistula after laparoscopic surgery for reflux disease. N Engl J Med 2002;246:328 – 32.