Case Report

Accepte

ReprintService.IISPV. ‘‘Reus (T

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� 2013

doi:10.1

Gastric volvulus after sleevegastrectomy for morbid obesityDaniel Del Castillo D�ejardin, MD,a,b F�atima Sabench Pereferrer, MD,b

Merc�e Hern�andez Gonz�alez, MD,a,b Santiago Blanco Blasco, MD,a,b andArantxa Cabrera Vilanova, MD,b Reus, Spain

Background. Laparoscopic sleeve gastrectomy in morbid obesity has proved to be a safe and reproducibletechnique. Sleeve gastrectomy, however, is not free of complications. On the other hand, gastric volvulusis reported in those subjects where, either because of laxity of the gastric anatomical fixations or incorrectposition of the stomach, rotation or turning is facilitated.Case.We report the case of a patient with morbid obesity (Bone mass index / BMI 63 Kg/m2), who in thepost-operative period immediately following a sleeve gastrectomy, presented early symptoms of uppergastrointestinal occlusion indicative of gastric volvulus of the gastric sleeve.Results. The patient developed a partial obstruction secondary to a mixed volvulus mechanism (organo-axial and partially mesenteric-axial) after sleeve gastrectomy. We performed a laparoscopic antrectomy ofthe gastric sleeve and then a gastroileal anastomosis, a form of biliopancreatic diversion, with a commonchannel of 80 cm and alimentary limb of 160 cm). 18 months after, the patient has a BMI of 28 kg/m2

and enjoys a good quality of life.Conclusion. Sleeve gastrectomy leaves the stomach with no fixations along the entire greater curvature,which may predispose to volvulus. This complication is a rare finding and not reported to date followingthis intervention, but still needs to be considered in this type of patient. (Surgery 2013;153:431-3.)

From the Surgery Service,a Sant Joan University Hospital, Reus, and Surgery Unit of the Faculty of Medicineand Health Sciences (IISPV),b Rovira i Virgili University, Reus (Tarragona), Spain

LAPAROSCOPIC SLEEVE GASTRECTOMY is a bariatricsurgical strategy that is not a purely restrictiveintervention. The technique was devised so thatsurgical risk in patients with extreme obesity wouldbe minimized and a biliopancreatic diversion withduodenal switch could be performed in the futureafter the patient lost weight. Sleeve gastrectomy,however, is not free of complications. The mostfrequent complications are leaking, hemorrhage,splenic injury, sleeve stenosis, and gastroesopha-geal reflux. Gastric volvulus involves the rotationof all or part of the stomach around the anatomicaxes and can lead to necrosis and perforation. Laxgastric fixation or incorrect positioning of the

Fig 1. Upper gastrointestinal contrast study showing noflow of contrast into the duodenum and marked dilationof the proximal aspect of the gastric sleeve.

d for publication December 22, 2011.

requests: Daniel Del Castillo D�ejardin, MD, SurgeryUniversity Hospital of Sant Joan. Faculty of Medicine.Rovira i Virgili’’ University. C/Sant Llorenc 21. 43201.arragona). Spain. E-mail: ddelcastillo@grupsagessa.com.

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stomach can lead to volvulus, which may beorgano-axial (in which the pylorus and gastroe-sophageal junction define the axis of rotation) or

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Fig 2. Mechanism of mixed rotation of the stomach about its long axis, with the greater curvature moving anteriorly tothe right (A), and then partially about its mesenteric axis (B), closing off the communication of the lumen betweencardia and pylorus.

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432 Del Castillo D�ejardin et al

mesenteric-axial (in which the mesentery marksthe transverse axis of volvulus). Most cases ofgastric volvulus are organo-axial; mesenteric-axialvolvulus is more frequent in children. We reporta patient who developed partial obstructionsecondary to a mixed volvulus mechanism(organo-axial and partially mesenteric-axial) aftersleeve gastrectomy.

CASE PRESENTATION

A 35-year-old obese female patient, a smokerwith a body mass index of 65 kg/m2, underwent alaparoscopic sleeve gastrectomy. There were notechnical complications. The immediate postoper-ative period was incident-free. A water-solublecontrast study performed 24 h postoperativelyshowed a slight leak of contrast in the gastricbody that it did not flow into the duodenum(Fig 1). We opted for conservative treatment andmaintained the patient’s intra-abdominal drain,no food by mouth, and parenteral nutrition.Gastroscopy performed several days later revealedan internal inflammatory component in theantral-pyloric region, making it impossible for anendoscope to be maneuvered into the duodenum.A similar appearance was seen on endoscopy 10days later.

Because of the patient’s persistent inability toeat, we performed an exploratory laparoscopyand found that gastric sleeve had volvulatedaround the mesenteric and long axis. We per-formed an antrectomy of the gastric sleeve andthen a gastroileal anastomosis, a form of bilio-pancreatic diversion, with a common channel of

80 cm and alimentary limb of 160 cm). We alsoperformed an appendectomy and excised a Meck-el’s diverticulum. Subsequently, the patient devel-oped respiratory and renal failure related to aduodenal fistula that resolved with conservativetreatment. The patient is currently 18 months post-procedure and has a BMI of 28 kg/m2 and enjoys agood quality of life.

DISCUSSION

Currently, sleeve gastrectomy is one of the treat-ments for selected, high-risk patients with clinicallyrelevant hepatopathy or in patients with super obe-sity (BMI $ 50 Kg/m2) as the first stage of surgeryplanned duodenal switch/biliopancreatic diver-sion.1 Sleeve gastrectomy is a safe, reproducible tech-nique with a relatively low rate of complications.

Nevertheless, serious operative complicationscan occur, the most frequent are leakage alongthe staple line or gastric fistula (0.7�5.1%).2 Somecases of late-onset stenosis at the level of the inci-sura angularis have been reported.3 Under normalanatomic conditions, the stomach is fixed in placeby four ‘‘ligaments’’: gastrohepatic, gastrosplenic,gastrocolic, and gastrophrenic. Laxity of these liga-ments, the absence of omentum, paraesophagealhernias, or diaphragmatic eventrations increasethe mobility and ability of the stomach to rotateorgano-axially or mesentero-axially.

Sleeve gastrectomy leaves the stomach with nofixations along the entire greater curvature, whichmay predispose one to volvulus. This possibilitymay be especially true when patients have lostweight, and this laxity may then increase in all

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structures. In our case, the volvulus occurred in thelower third of the new stomach, causing a shift inthe organo-axial direction which, because of laxityand mobility, was followed by a mesenteric-axialrotation in part that lifts and rotates medially theantrum and pylorus (Fig 2).

Several cases of organoaxial gastric volvulushave been reported after laparoscopic gastricbanding, usually occurring after placement of theband.4-6 To prevent this complication, excessivedissection of the posterior wall of the stomach isnot recommended during the placement of theband because this maneuver may facilitate in-creased mobility of the stomach.

To date, we are not aware of previous reports ofgastric volvulus after sleeve gastrectomy; therefore,we cannot recommend any maneuver to fix thetubularized stomach to prevent this complication.We performed a distal gastric resection and com-pleted the bariatric part of the procedure byconversion to a biliopancreatic diversion proce-dure. Recently, a technique consisting in a pexy ofomentum (omental patch) along the suture linehas been reported to decrease the risk of bleedingand leakage7; this procedure may in theory help to

prevent any torsion or rotation caused by a lack offixation of the new gastroplasty.

REFERENCES

1. Cottam D, Qureshi FG, Mattar SG, et al. Laparoscopicsleeve gastrectomy as an initial weight loss procedure forhigh risk patients with morbid obesity. Surg End 2006;20:859-63.

2. Fuks D, Verhaeghe P, Brehant O, et al. Results of laparo-scopic sleeve gastrectomy: a prospective study in 135 patientswith morbid obesity. Surgery 2009;145:106-13.

3. Dapri G, Cadi�ere GB, Himpens J. Laparoscopic seromyotomyfor long stenosis after sleeve gastrectomy with or withoutduodenal switch. Obes Surg 2009;19:495-9.

4. Bortul M, Scaramucci M, Tonello C, Spivach A, Liguori G.Gastric wall necrosis from organo-axial volvulus as a late com-plication of laparoscopic gastric banding. Obes Surg 2004;14:285-7.

5. Kicska G, Levine MS, Raper SE, Williams NN. Gastric volvulusafter laparoscopic adjustable gastric banding for morbidobesity. AJR Am J Roentgenol 2007;189:1469-72.

6. Arbell D, Koplewitz B, Zamir G, Bala M. Midgut volvulusfollowing laparoscopic gastric banding: a rare and danger-ous situation. J Laparoendosc Adv Surg Tech A 2007;17:321-3.

7. Baltasar A, Bou R, Bengochea M, Serra C, Perez N. Laparo-scopic sleeve gastrectomy with partial antrectomy andomental patch. BMI 2011;1:1.