Massive Hemothorax Due to Intrathoracic Herniation of the Gastric Remnant After Roux-en-Y Gastric Bypass with Concurrent
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LETTER TO THE EDITOR
Massive Hemothorax Due to Intrathoracic Herniation of the Gastric Remnant After Roux-en-Y Gastric Bypass with Concurrent Hiatal Hernia Repair Isabel Mora Oliver 1 & Raquel Alfonso Ballester 1 & Gabriel Kraus Fischer 1 & Ana Benítez Riesco 1 & Norberto Cassinello Fernández 1 & Joaquín Ortega Serrano 1
# Springer Science+Business Media, LLC, part of Springer Nature 2020
Introduction
Case Report
Obesity is an independent risk factor for hiatal hernia (HH) and gastroesophageal reflux disease (GERD) [1]. The prevalence of HH in morbidly obese individuals is nearly 40%, while it varies from 2 to 22% in the general population [2]. In the setting of a bariatric procedure, a hiatal defect must be taken into consideration, preoperatively and during the procedure. The feasibility of concurrent HH repair and bariatric surgery has been proven before [3]. However, it could be argued that these patients have an increased risk of postoperative complications, especially after Laparoscopic Roux-en-Y Gastric Bypass (LRYGB). Several complications have been reported, but early hiatal herniation of the gastric remnant has not been described.
A 50-year-old woman was referred to our unit with a past medical history of smoking, GERD in treatment with proton-pump inhibitors, and morbid obesity (BMI of 48.4). Preoperatively, we routinely perform an abdominal ultrasound and a barium esophagogram that showed cholelithiasis and a type 1 HH respectively (Fig. 1). A gastroscopy confirmed a HH with a grade B esophagitis (Los Angeles) and a negative Helicobacter pylori test. It was decided to perform a LRYGB and HH repair. A 36-Fr bougie was placed into the stomach and the HH repair consisted in a circumferential mobilization of the gastroesophageal junction and complete reduction of the hernia contents, resection of the hernia sac and an intra-abdominal mobilization of the lower esophageal sphincter, followed by a posterior cruroplasty with nonabsorbable barbed suture. Afterwards, we performed a standard LRYGB with a gastric pouch volume of 30 ml, an alimentary limb length of 200 cm, and a biliopancreatic limb length of 70 cm. On postoperative day 1, the patient developed vomits despite antiemetic drugs. The day after she started with low oxygen saturation without hemodynamic instability. A contrast-enhanced thoraco-abdominopelvic CT scan showed massive left hemothorax and the gastric remnant herniated through the left pleural cavity without signs of active bleeding (Fig. 2). An emergency laparoscopy was performed revealing that the diaphragmatic crura were torn and the stitches loose. The gastric remnant was herniated into the left pleural cavity with abundant clots (Fig. 3a). The herniated content was placed back into the abdominal cavity with initial ischemic changes but no necrosis (Fig. 3b). The clots were evacuated and a chest tube was placed externally. The hernia defect was
* Raquel Alfonso Ballester [email protected] Isabel Mora Oliver [email protected] Gabriel Kraus Fischer fischerkrausg@gmail
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