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Mallory-Weiss tear after laparoscopic Roux-en-Y gastric bypass
Surgery for Obesity and Related Diseases 1 (2005) 500 –502
Case report
Mallory-Weiss tear after laparoscopic Roux-en-Y gastric bypass Atul K. Madan, M.D., F.A.C.S.,* Samuel J. Kuykendall, IV, B.A., Craig A. Ternovits, M.D., David S. Tichansky, M.D. Section of Minimally Invasive Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee Received April 15, 2005; revised June 25, 2005; accepted July 6, 2005
Abstract
In the United States, the most common surgical procedure for morbid obesity is the Roux-en-Y gastric bypass. Pulmonary embolism, leak, bowel obstruction, and gastrointestinal bleeding are among the potential early fatal complications. Early postoperative bleeding after laparoscopic gastric bypass, although uncommon, presents a dilemma because of the danger of perforation from postoperative endoscopy and the inability to access the gastric remnant easily. We describe a case of a Mallory-Weiss tear causing massive upper gastrointestinal hemorrhage 1 week after laparoscopic Roux-en-Y gastric bypass. Bariatric surgeons should consider this diagnosis, especially when encountering a patient with a history of significant retching postoperatively. © 2005 American Society for Bariatric Surgery. All rights reserved.
Keywords:
Mallory-Weiss tear; Roux-en-Y; Laparoscopic gastric bypass
Postoperative upper gastrointestinal bleeding after laparoscopic bypass, although uncommon, presents a diagnostic dilemma owing to the danger of injury to the gastrojejunostomy during postoperative endoscopy and the inability to access the excluded gastric remnant easily. The most common sites of gastrointestinal hemorrhage immediately after laparoscopic gastric bypass are the gastrojejunostomy site, gastric pouch, and jejunojejunostomy staple lines [1]. Although the staple/suture lines are the usual source of bleeding, we encountered a patient with a Mallory-Weiss tear. This report describes a case of a Mallory-Weiss tear after laparoscopic Roux-en-Y gastric bypass. Case report A 59-year-old woman with a history of morbid obesity, hypertension, depression, and arthritis underwent successful
Presented in part at the Society of American Gastrointestinal Endoscopic Surgeons Annual Meeting, Ft. Lauderdale, Florida, April 2005. *Reprint requests: Atul K. Madan, M.D., F.A.C.S., Section of Minimally Invasive Surgery, Department of Surgery, University of Tennessee Health Science Center, 956 Court Avenue, Room G210, Memphis, TN 38163. E-mail: [email protected]
laparoscopic Roux-en-Y gastric bypass. A circular stapler was used to create the gastrojejunostomy. The jejunojejunostomy was created with a triple-stapling technique [2]. Her postoperative hospital course was uneventful, and she was discharged on postoperative day 3. The patient returned to an outside facility with hematemesis on postoperative day 7. She was immediately transferred to our institution for treatment. She was initially resuscitated with crystalloids and 5 U of packed red blood cells. Because the patient was hemodynamically stable after her transfusions, upper endoscopy was performed. Fresh blood was found but no evidence of active bleeding in the pouch. The gastrojejunostomy did not show any evidence of stenosis. The jejunum looked normal, and the jejunojejunostomy was not seen. The patient had no evidence of further bleeding until later that day when she again vomited bright red blood. Before her hematemesis, she had had a period of retching that her family later revealed had also occurred at home before her first episode. Because she was again being resuscitated with blood and prepared to be brought to the operating room, we performed another endoscopy, which demonstrated a possible distal esophageal tear. It was difficult to retroflex because of the pouch size and to visualize the tear properly. The patient was taken to the operating room. A small
1550-7289/05/$ – see front matter © 2005 American Society for Bariatric Surgery. All rights reserved. doi:10.1016/j.soard.2005.07.001
A.K. Madan et al. / Surgery for Obesity and Related Diseases 1 (2005) 500 –502
501
recurrent hemorrhage. She had no evidence of rebleeding and continued to lose weight 9 months postoperatively. Discussion
Fig. 1. Roux-en-Y gastric bypass with cut away view of gastrojejunostomy and posterior mucosal tear. Gastrojejunostomy was opened to locate tear.
upper midline incision was made. A distended distal gastric remnant was encountered. Gastrotomy revealed about 400 mL of old dark blood and hematoma. It was old clotted blood with no active bleeding. It appeared that the blood had accumulated retrograde from the proximal Roux limb. The stomach was evacuated and closed with a stapler. Next, the gastrojejunal anastomosis was opened. Fresh blood was seen coming from the distal esophagus. After obtaining a difficult exposure, an approximately 2-cm linear Mallory-Weiss tear was seen at the gastroesophageal junction, as demonstrated in Figure 1. A bleeding vessel was visible at its base. Both the laceration and vessel were oversewn. Hemostasis was achieved. The gastrojejunostomy was closed after we ensured we had adequate hemostasis. The patient’s subsequent recovery was stormy, requiring prolonged ventilatory support and hospitalization, but she was discharged on postoperative day 25 without any
In 1929, Mallory and Weiss reported an unusual case of gastrointestinal hemorrhage caused by persistent retching and vomiting [3]. Although this condition had been earlier described by Quincke [4] in 1879, the term Mallory-Weiss tear has become established in the literature to describe a longitudinal mucosal laceration at the esophagogastric junction or gastric cardia, resulting from the intragastric pressure effects of prolonged retching. It is often associated with an alcoholic binge. The transmural pressure gradient increases dramatically across the hiatus, which lies next to a zone of low intrathoracic pressure. If the pressure is great enough, a longitudinal tear may result. Because vomiting is relatively common in recovery from gastric bypass surgery, it is surprising that the occurrence of a Mallory-Weiss tear after laparoscopic gastric bypass has not been previously reported. The classic presentation for a Mallory-Weiss tear is a bout of hematemesis after an episode of vomiting or retching. Other less common symptoms include hematochezia, syncope, melena, abdominal pain, tachycardia, hypotension, orthostatic changes, and shock. Bleeding from Mallory-Weiss tears stop spontaneously in most patients. In some patients, hemodynamic instability and shock may require blood transfusions and even surgery, as was the case for our patient. Endoscopy is the diagnostic procedure of choice. However, endoscopy should be done with great care immediately after surgery. Retroflexion of the endoscope should be avoided in the early postoperative period owing to the risk of anastomotic disruption in the small pouch. Because the tear is best seen with a retroflexed view, active proximal bleeding seen with no obvious source should raise the suspicion of a Mallory-Weiss tear. Although the inability to detect a bleeding source endoscopically in acute upper gastrointestinal hemorrhage has been reported at 10% overall, this failure rate will probably be greater in gastric bypass patients because of the inability to access the bypassed stomach and duodenum. In postoperative patients, endoscopy in the operating room is recommended in an algorithm set forth by Mehran et al. [5]. The role of endoscopy performed outside the operating room for patients with early postoperative bleeding or other acute upper abdominal symptoms in the early days after gastric bypass is debated; however, most agree it should be performed by an experienced endoscopist with great care and caution [6, 7]. The incidence of hemorrhage after laparoscopic gastric bypass has been reported to be 1.1– 4.4% [1, 5, 8 –10]. Table 1 displays incidence of hemorrhage after laparoscopic gastric bypass from some recent studies. Routine preoperative endoscopy may occasionally detect subclinical gastroduodenal pathologic findings, such as ulcers, which could be a
502
A.K. Madan et al. / Surgery for Obesity and Related Diseases 1 (2005) 500 –502
Table 1 Incidence of hemorrhage after laparoscopic gastric bypass Author
Year
Total (n)
Incidence (%)
Schauer et al. [10] Wittgrove et al. [9] Oliak et al. [8] Mehran et al. [5] Nguyen et al. [1]
2000 2000 2003 2003 2003
275 500 225 450 155
9 (3.3) NR 6 (2.7) 20 (4.4) 5 (3.23)
Operative management (%) 1 (0.4) 4 (0.8) NR 3 (0.7) 3 (1.9)
Bleeding site Intraabdominal bleeding (1) “Staple-lines” NR Gastrojejunostomy (1), gastric remnant (2) Gastric remnant gastrojejunostomy
NR ⫽ not reported.
source of postoperative hemorrhage. It is our practice to perform preoperative endoscopy liberally in our patients to avoid this possibility [11]. Oversewing staple lines and prosthetic staple line reinforcement are also techniques that have been advocated to reduce the risk of pouch-area postoperative hemorrhage, although objective evidence of the efficacy of these maneuvers is scant.
Conclusion Mallory-Weiss tears are a rare cause of upper gastrointestinal hemorrhage after laparoscopic gastric bypass. Bariatric surgeons need to consider this diagnosis, especially when encountering a patient with a history of significant retching followed by hematemesis after gastric bypass.
Acknowledgments. The authors would like to acknowledge the technical assistance of Mrs. Courtney Bishop in the preparation of this manuscript.
References [1] Nguyen NT, Rivers R, Wolfe BM. Early gastrointestinal hemorrhage after laparoscopic gastric bypass. Obes Surg 2003;13:62–5. [2] Madan AK, Frantzides CT. Triple-stapling technique for jejunojejunostomy in laparoscopic gastric bypass. Arch Surg 2003;138:1029 –32. [3] Mallory GK, Weiss S. Hemorrhages from lacerations of the cardiac orifice of the stomach due to vomiting. Am J Med Sci 1929;178:506 –12. [4] Quincke H. Ulcus oesophagi ex digestion. Dtsch Arch Kin Med 1879;24:72. [5] Mehran A, Szomstein S, Zundel N, et al. Management of acute bleeding after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2003;13:842–7. [6] Steffen R, Nguyen NT. Early gastrointestinal hemorrhage after laparoscopic gastric bypass. Obes Surg 2003;13:466 –7. [7] Moretto M, Mottin CC, Padoin AV, et al. Endoscopic management of bleeding after gastric bypass—a therapeutic alternative. Obes Surg 2004;14:706. [8] Oliak D, Ballantyne GH, Weber P, et al. Laparoscopic Roux-en-Y gastric bypass: defining the learning curve. Surg Endosc 2003;17:405– 8. [9] Wittgrove AC, Clark GW. Laparoscopic gastric bypass, Roux-en-Y— 500 patients: technique and results, with 3– 60 month follow-up. Obes Surg 2000;10:233–9. [10] Schauer PR, Ikramuddin S, Gourash W, et al. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg 2000;232:515–29. [11] Madan AK, Speck KE, Hiler ML. Routine preoperative upper endoscopy for laparoscopic gastric bypass: is it necessary? Am Surg 2004; 70:684 – 6.
Case report
Mallory-Weiss tear after laparoscopic Roux-en-Y gastric bypass Atul K. Madan, M.D., F.A.C.S.,* Samuel J. Kuykendall, IV, B.A., Craig A. Ternovits, M.D., David S. Tichansky, M.D. Section of Minimally Invasive Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee Received April 15, 2005; revised June 25, 2005; accepted July 6, 2005
Abstract
In the United States, the most common surgical procedure for morbid obesity is the Roux-en-Y gastric bypass. Pulmonary embolism, leak, bowel obstruction, and gastrointestinal bleeding are among the potential early fatal complications. Early postoperative bleeding after laparoscopic gastric bypass, although uncommon, presents a dilemma because of the danger of perforation from postoperative endoscopy and the inability to access the gastric remnant easily. We describe a case of a Mallory-Weiss tear causing massive upper gastrointestinal hemorrhage 1 week after laparoscopic Roux-en-Y gastric bypass. Bariatric surgeons should consider this diagnosis, especially when encountering a patient with a history of significant retching postoperatively. © 2005 American Society for Bariatric Surgery. All rights reserved.
Keywords:
Mallory-Weiss tear; Roux-en-Y; Laparoscopic gastric bypass
Postoperative upper gastrointestinal bleeding after laparoscopic bypass, although uncommon, presents a diagnostic dilemma owing to the danger of injury to the gastrojejunostomy during postoperative endoscopy and the inability to access the excluded gastric remnant easily. The most common sites of gastrointestinal hemorrhage immediately after laparoscopic gastric bypass are the gastrojejunostomy site, gastric pouch, and jejunojejunostomy staple lines [1]. Although the staple/suture lines are the usual source of bleeding, we encountered a patient with a Mallory-Weiss tear. This report describes a case of a Mallory-Weiss tear after laparoscopic Roux-en-Y gastric bypass. Case report A 59-year-old woman with a history of morbid obesity, hypertension, depression, and arthritis underwent successful
Presented in part at the Society of American Gastrointestinal Endoscopic Surgeons Annual Meeting, Ft. Lauderdale, Florida, April 2005. *Reprint requests: Atul K. Madan, M.D., F.A.C.S., Section of Minimally Invasive Surgery, Department of Surgery, University of Tennessee Health Science Center, 956 Court Avenue, Room G210, Memphis, TN 38163. E-mail: [email protected]
laparoscopic Roux-en-Y gastric bypass. A circular stapler was used to create the gastrojejunostomy. The jejunojejunostomy was created with a triple-stapling technique [2]. Her postoperative hospital course was uneventful, and she was discharged on postoperative day 3. The patient returned to an outside facility with hematemesis on postoperative day 7. She was immediately transferred to our institution for treatment. She was initially resuscitated with crystalloids and 5 U of packed red blood cells. Because the patient was hemodynamically stable after her transfusions, upper endoscopy was performed. Fresh blood was found but no evidence of active bleeding in the pouch. The gastrojejunostomy did not show any evidence of stenosis. The jejunum looked normal, and the jejunojejunostomy was not seen. The patient had no evidence of further bleeding until later that day when she again vomited bright red blood. Before her hematemesis, she had had a period of retching that her family later revealed had also occurred at home before her first episode. Because she was again being resuscitated with blood and prepared to be brought to the operating room, we performed another endoscopy, which demonstrated a possible distal esophageal tear. It was difficult to retroflex because of the pouch size and to visualize the tear properly. The patient was taken to the operating room. A small
1550-7289/05/$ – see front matter © 2005 American Society for Bariatric Surgery. All rights reserved. doi:10.1016/j.soard.2005.07.001
A.K. Madan et al. / Surgery for Obesity and Related Diseases 1 (2005) 500 –502
501
recurrent hemorrhage. She had no evidence of rebleeding and continued to lose weight 9 months postoperatively. Discussion
Fig. 1. Roux-en-Y gastric bypass with cut away view of gastrojejunostomy and posterior mucosal tear. Gastrojejunostomy was opened to locate tear.
upper midline incision was made. A distended distal gastric remnant was encountered. Gastrotomy revealed about 400 mL of old dark blood and hematoma. It was old clotted blood with no active bleeding. It appeared that the blood had accumulated retrograde from the proximal Roux limb. The stomach was evacuated and closed with a stapler. Next, the gastrojejunal anastomosis was opened. Fresh blood was seen coming from the distal esophagus. After obtaining a difficult exposure, an approximately 2-cm linear Mallory-Weiss tear was seen at the gastroesophageal junction, as demonstrated in Figure 1. A bleeding vessel was visible at its base. Both the laceration and vessel were oversewn. Hemostasis was achieved. The gastrojejunostomy was closed after we ensured we had adequate hemostasis. The patient’s subsequent recovery was stormy, requiring prolonged ventilatory support and hospitalization, but she was discharged on postoperative day 25 without any
In 1929, Mallory and Weiss reported an unusual case of gastrointestinal hemorrhage caused by persistent retching and vomiting [3]. Although this condition had been earlier described by Quincke [4] in 1879, the term Mallory-Weiss tear has become established in the literature to describe a longitudinal mucosal laceration at the esophagogastric junction or gastric cardia, resulting from the intragastric pressure effects of prolonged retching. It is often associated with an alcoholic binge. The transmural pressure gradient increases dramatically across the hiatus, which lies next to a zone of low intrathoracic pressure. If the pressure is great enough, a longitudinal tear may result. Because vomiting is relatively common in recovery from gastric bypass surgery, it is surprising that the occurrence of a Mallory-Weiss tear after laparoscopic gastric bypass has not been previously reported. The classic presentation for a Mallory-Weiss tear is a bout of hematemesis after an episode of vomiting or retching. Other less common symptoms include hematochezia, syncope, melena, abdominal pain, tachycardia, hypotension, orthostatic changes, and shock. Bleeding from Mallory-Weiss tears stop spontaneously in most patients. In some patients, hemodynamic instability and shock may require blood transfusions and even surgery, as was the case for our patient. Endoscopy is the diagnostic procedure of choice. However, endoscopy should be done with great care immediately after surgery. Retroflexion of the endoscope should be avoided in the early postoperative period owing to the risk of anastomotic disruption in the small pouch. Because the tear is best seen with a retroflexed view, active proximal bleeding seen with no obvious source should raise the suspicion of a Mallory-Weiss tear. Although the inability to detect a bleeding source endoscopically in acute upper gastrointestinal hemorrhage has been reported at 10% overall, this failure rate will probably be greater in gastric bypass patients because of the inability to access the bypassed stomach and duodenum. In postoperative patients, endoscopy in the operating room is recommended in an algorithm set forth by Mehran et al. [5]. The role of endoscopy performed outside the operating room for patients with early postoperative bleeding or other acute upper abdominal symptoms in the early days after gastric bypass is debated; however, most agree it should be performed by an experienced endoscopist with great care and caution [6, 7]. The incidence of hemorrhage after laparoscopic gastric bypass has been reported to be 1.1– 4.4% [1, 5, 8 –10]. Table 1 displays incidence of hemorrhage after laparoscopic gastric bypass from some recent studies. Routine preoperative endoscopy may occasionally detect subclinical gastroduodenal pathologic findings, such as ulcers, which could be a
502
A.K. Madan et al. / Surgery for Obesity and Related Diseases 1 (2005) 500 –502
Table 1 Incidence of hemorrhage after laparoscopic gastric bypass Author
Year
Total (n)
Incidence (%)
Schauer et al. [10] Wittgrove et al. [9] Oliak et al. [8] Mehran et al. [5] Nguyen et al. [1]
2000 2000 2003 2003 2003
275 500 225 450 155
9 (3.3) NR 6 (2.7) 20 (4.4) 5 (3.23)
Operative management (%) 1 (0.4) 4 (0.8) NR 3 (0.7) 3 (1.9)
Bleeding site Intraabdominal bleeding (1) “Staple-lines” NR Gastrojejunostomy (1), gastric remnant (2) Gastric remnant gastrojejunostomy
NR ⫽ not reported.
source of postoperative hemorrhage. It is our practice to perform preoperative endoscopy liberally in our patients to avoid this possibility [11]. Oversewing staple lines and prosthetic staple line reinforcement are also techniques that have been advocated to reduce the risk of pouch-area postoperative hemorrhage, although objective evidence of the efficacy of these maneuvers is scant.
Conclusion Mallory-Weiss tears are a rare cause of upper gastrointestinal hemorrhage after laparoscopic gastric bypass. Bariatric surgeons need to consider this diagnosis, especially when encountering a patient with a history of significant retching followed by hematemesis after gastric bypass.
Acknowledgments. The authors would like to acknowledge the technical assistance of Mrs. Courtney Bishop in the preparation of this manuscript.
References [1] Nguyen NT, Rivers R, Wolfe BM. Early gastrointestinal hemorrhage after laparoscopic gastric bypass. Obes Surg 2003;13:62–5. [2] Madan AK, Frantzides CT. Triple-stapling technique for jejunojejunostomy in laparoscopic gastric bypass. Arch Surg 2003;138:1029 –32. [3] Mallory GK, Weiss S. Hemorrhages from lacerations of the cardiac orifice of the stomach due to vomiting. Am J Med Sci 1929;178:506 –12. [4] Quincke H. Ulcus oesophagi ex digestion. Dtsch Arch Kin Med 1879;24:72. [5] Mehran A, Szomstein S, Zundel N, et al. Management of acute bleeding after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2003;13:842–7. [6] Steffen R, Nguyen NT. Early gastrointestinal hemorrhage after laparoscopic gastric bypass. Obes Surg 2003;13:466 –7. [7] Moretto M, Mottin CC, Padoin AV, et al. Endoscopic management of bleeding after gastric bypass—a therapeutic alternative. Obes Surg 2004;14:706. [8] Oliak D, Ballantyne GH, Weber P, et al. Laparoscopic Roux-en-Y gastric bypass: defining the learning curve. Surg Endosc 2003;17:405– 8. [9] Wittgrove AC, Clark GW. Laparoscopic gastric bypass, Roux-en-Y— 500 patients: technique and results, with 3– 60 month follow-up. Obes Surg 2000;10:233–9. [10] Schauer PR, Ikramuddin S, Gourash W, et al. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg 2000;232:515–29. [11] Madan AK, Speck KE, Hiler ML. Routine preoperative upper endoscopy for laparoscopic gastric bypass: is it necessary? Am Surg 2004; 70:684 – 6.