- Email: [email protected]
Simultaneous gastric and colonic band erosion presenting as lower gastrointestinal bleeding
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Surgery for Obesity and Related Diseases ] (2016) 00–00
Video case report
Simultaneous gastric and colonic band erosion presenting as lower gastrointestinal bleeding Shadi Al-Bahri, M.D., John Paul Gonzalvo, D.O., F.A.C.S., Michel Murr, M.D., F.A.C.S.* Tampa General Hospital in affiliation with University of South Florida Health, Tampa, Florida Received November 4, 2016; accepted November 8, 2016
Case report We present a 63-year-old female with a history of lupus anticoagulant, recurrent deep vein thrombosis on Warfarin for anticoagulation, and a laparoscopic gastric adjustable band for morbid obesity. Her procedure was complicated by subcutaneous port erosion treated at the time with local port removal. The associated tubing was inserted back into the abdominal cavity. She was lost to follow-up, and therefore endoscopy or band removal could not be performed at the time. She presented to our tertiary care facility with 3 days of bright red blood per rectum associated with mild periumbilical abdominal pain. A colonoscopy by the gastroenterologist found the free distal tip of her band tubing eroded into the transverse colon lumen. An upper endoscopy also showed a partially eroded band through the gastric cardia. A computed tomography scan identified the band and tubing extending into the transverse colon without involvement of other organs. She required transfusions before surgical exploration. After discussing the possible surgical options with our patient, we proceeded with a plan to remove the band and repair the stomach and colon. A Veress needle was used to induce pneumo-peritoneum, and the ports were inserted in the usual fashion. Sharp adhesiolysis was performed to take down the scarred omentum surrounding the tubing extending to the transverse colon. Very careful dissection was then performed around the tube erosion site, noted to be at the antimesenteric transverse colon border. Once cleared of all surrounding fat, the tube was removed and the colostomy was closed using 3 full thickness interrupted sutures using the EndoStitch
suturing device. No counter perforation was noted on the transverse colon. The tubing was then followed proximally at which point the band was encountered at the gastric cardia. At this point, upper endoscopy was performed, which visualized the partially eroded band posteriorly, but not anteriorly. As a result, the band could not be removed endoscopically. An extensive dissection then ensued, with clearing of all adhesions around the hiatus. This yielded a hiatal hernia defect which was closed posteriorly. An anterior transverse gastrotomy was then performed to remove the band, followed by closure using multiple interrupted 2-0 silk sutures to close the defect followed by a second row of reinforcing sutures essentially creating an anterior fundoplication, taking care not to cause a stricture adjacent to the gastroesophageal junction.
Patient outcome The patient tolerated the procedure well, was started on liquids in the immediate postoperative period, and advanced to a regular diet within 48 hours upon return of bowel function. She was discharged home on postoperative day 7 and was seen in clinic within 3 weeks. She is tolerating her diet, and her incisions have healed well, except for a superficial wound infection associated with one of her laparoscopic trocar incisions. Her abdominal pain had resolved, and there have been no episodes of gastrointestinal bleeding upon evaluation in clinic at 3 months.
Disclosures *
Correspondence: Michel Murr, M.D., Harbourside Medical Tower, 5 Tampa General Circle, Suite 410, Tampa, FL33606. E-mail: [email protected]
The authors have no commercial associations that might be a conflict of interest in relation to this article.
http://dx.doi.org/10.1016/j.soard.2016.11.010 1550-7289/r 2016 Published by Elsevier Inc. on behalf of American Society for Metabolic and Bariatric Surgery.
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95 96 97 98 99 100
S. Al-Bahri et al. / Surgery for Obesity and Related Diseases ] (2016) 00–00
Appendix Supplementary data Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j. soard.2016.11.010.
101 102 103 104 105 106
Surgery for Obesity and Related Diseases ] (2016) 00–00
Video case report
Simultaneous gastric and colonic band erosion presenting as lower gastrointestinal bleeding Shadi Al-Bahri, M.D., John Paul Gonzalvo, D.O., F.A.C.S., Michel Murr, M.D., F.A.C.S.* Tampa General Hospital in affiliation with University of South Florida Health, Tampa, Florida Received November 4, 2016; accepted November 8, 2016
Case report We present a 63-year-old female with a history of lupus anticoagulant, recurrent deep vein thrombosis on Warfarin for anticoagulation, and a laparoscopic gastric adjustable band for morbid obesity. Her procedure was complicated by subcutaneous port erosion treated at the time with local port removal. The associated tubing was inserted back into the abdominal cavity. She was lost to follow-up, and therefore endoscopy or band removal could not be performed at the time. She presented to our tertiary care facility with 3 days of bright red blood per rectum associated with mild periumbilical abdominal pain. A colonoscopy by the gastroenterologist found the free distal tip of her band tubing eroded into the transverse colon lumen. An upper endoscopy also showed a partially eroded band through the gastric cardia. A computed tomography scan identified the band and tubing extending into the transverse colon without involvement of other organs. She required transfusions before surgical exploration. After discussing the possible surgical options with our patient, we proceeded with a plan to remove the band and repair the stomach and colon. A Veress needle was used to induce pneumo-peritoneum, and the ports were inserted in the usual fashion. Sharp adhesiolysis was performed to take down the scarred omentum surrounding the tubing extending to the transverse colon. Very careful dissection was then performed around the tube erosion site, noted to be at the antimesenteric transverse colon border. Once cleared of all surrounding fat, the tube was removed and the colostomy was closed using 3 full thickness interrupted sutures using the EndoStitch
suturing device. No counter perforation was noted on the transverse colon. The tubing was then followed proximally at which point the band was encountered at the gastric cardia. At this point, upper endoscopy was performed, which visualized the partially eroded band posteriorly, but not anteriorly. As a result, the band could not be removed endoscopically. An extensive dissection then ensued, with clearing of all adhesions around the hiatus. This yielded a hiatal hernia defect which was closed posteriorly. An anterior transverse gastrotomy was then performed to remove the band, followed by closure using multiple interrupted 2-0 silk sutures to close the defect followed by a second row of reinforcing sutures essentially creating an anterior fundoplication, taking care not to cause a stricture adjacent to the gastroesophageal junction.
Patient outcome The patient tolerated the procedure well, was started on liquids in the immediate postoperative period, and advanced to a regular diet within 48 hours upon return of bowel function. She was discharged home on postoperative day 7 and was seen in clinic within 3 weeks. She is tolerating her diet, and her incisions have healed well, except for a superficial wound infection associated with one of her laparoscopic trocar incisions. Her abdominal pain had resolved, and there have been no episodes of gastrointestinal bleeding upon evaluation in clinic at 3 months.
Disclosures *
Correspondence: Michel Murr, M.D., Harbourside Medical Tower, 5 Tampa General Circle, Suite 410, Tampa, FL33606. E-mail: [email protected]
The authors have no commercial associations that might be a conflict of interest in relation to this article.
http://dx.doi.org/10.1016/j.soard.2016.11.010 1550-7289/r 2016 Published by Elsevier Inc. on behalf of American Society for Metabolic and Bariatric Surgery.
56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 Q4 90 91 92 93 94
2
95 96 97 98 99 100
S. Al-Bahri et al. / Surgery for Obesity and Related Diseases ] (2016) 00–00
Appendix Supplementary data Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j. soard.2016.11.010.
101 102 103 104 105 106