Liver Lobe Necrosis after Laparoscopic Revisional Roux-en-Y Gastric Bypass: a Case Report
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LETTER TO THE EDITOR
Liver Lobe Necrosis after Laparoscopic Revisional Roux-en-Y Gastric Bypass: a Case Report Mohammad Kermansaravi 1
&
Masoud Rezvani 2
Received: 15 October 2020 / Revised: 21 October 2020 / Accepted: 21 October 2020 # Springer Science+Business Media, LLC, part of Springer Nature 2020
Keywords Bariatric surgery . Roux-en-Y gastric bypass . Revision . Liver necrosis
Introduction Laparoscopic revisional/conversional bariatric surgery is becoming more popular. Revisions are performed in approximately 55% of primary bariatric procedures due to a number of reasons with weight gain being the most-cited [1, 2]. Revisional procedures often require lysis of significant adhesions from the previous operation, as well as adequate visualization of the upper aspect of the stomach and diaphragm muscle hiatus located under the left lobe of the liver. We describe a case of liver necrosis after revision of previous Roux-en-Y gastric bypass.
Case Report A 48-year-old female with body mass index (BMI) of 31.78 kg/m2 and previous history of open Roux-en-Y gastric bypass (RYGB) in 2001 presented to her primary care physician with complaints of significant weakness. The patient also had pre-existing mild and well-controlled hypertension.
* Mohammad Kermansaravi [email protected]; [email protected] Masoud Rezvani [email protected] 1
Minimally Invasive Surgery Research Center, Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Rasool-e Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
2
Department of Surgery, Inova Fair Oaks Hospital, 14904 Jefferson Davis Hwy., Suite 205, Woodbridge, VA 22191, USA
Upon initial work up, the patient was found to have hemoglobin (Hb) of 8.2 g/d. An esophagogastroduodenoscopy (EGD) revealed eroded mesh into the first portion of stomach associated with hemorrhagic gastritis (Fig. 1). Revision of RYGB to revise gasterojejunal anastomosis (GJA) and remove the eroded mesh was recommended. During the procedure, a significant dense adhesion between the mesh, gastric mesentery, liver, and stomach was noted. Harmonic scalpel (Johnson & Johnson Endosurgery, Cincinnati, OH) was utilized to lyse all adhesions. A Nathanson liver retractor (Cook Ireland Ltd., Limerick, Ireland) was placed through subxiphoid 5-mm puncture and the left lobe of liver was elevated. After adhesion lysis, 3 cm of the superior and inferior of gastrojejunal anastomosis (GJA) was divided. This specimen was opened outside the body and was inspected to confirm the mesh is inside the specimen completely. In addition, an upper endoscopy did not reveal mesh residuals in the gastric pouch. An end-toside gastro-jejunal anastomosis was created using a 60-mm linear stapler. The procedure was completed uneventfully and took 262 min. On post-operative day (POD) 1, alanine aminotransferase (AST), aspartate transaminase (ALT), and alkaline phosphatase were significantly elevated though the patient was asymptomatic and total bilirubin remained normal. Liver enzymes started
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