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Bariatric Times • September 2011
Case Series
11
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FIGURE 1. Trocar placement.
patients immediately after the gastrografin meal at a rate of one teaspoon each 20 minutes and as tolerated. If no vomiting occured, the patient was discharged from hospital with a prescription of proton pump inhibitor (PPI) single dose for two months; antispasmodic and antiemetic suppositories, if needed; and chewable multivitamins for the first 10 days postoperatively. Figures 3a–3d show the gastrografin meal at Postoperative Day 1 with no evidence of leaks or gastric obstruction.
The postoperative diet was prescribed by the dietitian based on clear liquids for the first week and semi-liquids as tolerated for three weeks. Patients were allowed solid food four weeks postoperatively. Follow-up visits for the assessment of safety and weight loss were scheduled postoperative at two weeks, one month, three months, six months, 12 months, 18 months, and 24 months.
COMPLICATIONS AND MANAGEMENT IN THE CASES PRESENTED
Intraoperative complications.
Bleeding. Bleeding was the major intraoperative complication in our series. Hemostasis was achieved in all cases without the need of blood transfusion. No postoperative reoperation was needed for hemoperitoneum. The following different bleeding cases occurred: 1. One case was converted into laparotomy for mesentric trocar lesion and massive bleeding (trocar blade defect with no major vessel lesion).
Hemoperitoneum was aspirated (1000mL), mesentery was sutured, and gastric plication was achieved by laparotomy (Figure 4).
2. Two cases of left hepatic subcapsular hematoma occurred
and were managed conservatively with complete resorption at one month postoperatively.
3. Two cases of gastrosplenic vessel bleeding (300mL) occurred and hemostasis was achieved intraoperatively by clips and catherization.
4. One case of moderate mesocolic bleeding (500mL) controlled by laparoscopy was observed and plication was achieved as planned (Figure 5).
5. Three cases of massive trocar port bleeding (200mL) were observed. Bleeding control was achieved by reverdin needle suturing. Minor trocar port bleeding (50mL) was controlled by monopolar coagulation.
6. Three cases of intramural gastric parietal hematoma were observed and managed by compression.
7. One case of severe subcutaneous emphysema related to a pneumomediastinum occurred when hiatal hernia cure was associated to LGCP, (operation was achieved at low intra- abdominal pressure).
8. No cases of injuries of adjacent organs (spleen, pancreas, small bowel or colon) was noted.
Early postoperative complications. We refer to early postoperative complications as any complication that occurred during the Postoperative Month 1. No bleeding occurred. The main complications observed were obstruction and leak.
Obstruction. Intraesophageal fold invagination. One case of obstruction in the intraesophegeal fold invagination occurred Figure 6). This complication is specific to LGCP and occurred in a patient when the fundus plication was not fixed.
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D FIGURE 3. Gastrografin meal at Day 1 with no evidence of leaks or gastric obstruction (A–D)
FIGURE 4. Massive bleeding
FIGURE 5. Mesocolic hematoma
Gastric fold edema. Gastric fold edema is a complication specific to LGCP (Figure 7a–7d). We obeserved one case of complete gastric obstruction by edema of the fold plication. The patient required reoperation (a looser plication) at Day 3. This patient also developed a
perisplenic abscess with no evidence of gastric fistula. The abscess was treated with intravenous (IV) antibiotics for three weeks with no need of percutaneous drainage). Five cases of fold edema with complete obstruction of the residual gastric lumen were noticed on