Author's Accepted Manuscript
Abscess after Sleeve Gastrectomy: conservative treatment by Endoscopic Dilatation Radwan Kassir, Sylvain piqueres, Pierre Blanc
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S1550-7289(14)00221-4 http://dx.doi.org/10.1016/j.soard.2014.05.019 SOARD2017
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Surgery for Obesity and Related Diseases
Cite this article as: Radwan Kassir, Sylvain piqueres, Pierre Blanc, Abscess after Sleeve Gastrectomy: conservative treatment by Endoscopic Dilatation, Surgery for Obesity and Related Diseases, http://dx.doi.org/10.1016/j.soard.2014.05.019 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Abscess after sleeve gastrectomy: conservative treatment by endoscopic dilatation Radwan Kassir1, Sylvain piqueres1, Pierre Blanc1 1
Department of Obesity Surgery, Clinique Mutualiste chirurgicale, Saint-Etienne France
Keys words: sleeve, complication, abscess, fistula, endoscopy
Please address all correspondence to: Radwan KASSIR Department of obesity Surgery, CHU Hospital, Jean Monnet University, Avenue Albert Raimond, 42270 Saint Etienne / France [email protected]
Tel: 00 33 6 13 59 19 71 / Fax: 00 33 4 77 12 70 15 .
Conflict of interest: The authors declare no conflict of interest. Short title: sleeve gastrectomy and endoscopic dilatation
Introduction: Laparoscopic sleeve gastrectomy (SG) is a common bariatric procedure. Gastric leak remains the most feared complication with a difficult non-standardized treatment (1). Herein we report the case of a patient with abscess after SG and we describe the conservative treatment by endoscopic dilatation.
Case Report: A 42-year-old woman with no notable history underwent SG for severe obesity, body mass index (BMI) 45 kg/m² validated by a multidisciplinary team. The surgery was uncomplicated and the upper gastrointestinal contrast study performed on day 2 was normal. The patient was discharged on the third postoperative day with a pureed mixed diet for 1 month (Fig. 1). Thirty days later she was hospitalized for epigastric pain. Computerized tomographic (CT) scan revealed a perigastric abscess and the barium swallow showed a blind upper fistula (Fig. 2,3). She had no fever or tachycardia, her white blood cell counts and procalcitonin (PCT) were normal, and C-reactive protein (CRP) was 160 mg/L. Endosonography was performed but internal drainage was impossible because the abscess fluid was too thick. The fistula orifice was not visualised during this procedure. Nevertheless, endoscopic dilatation of the pylorus with a 20 mm balloon was performed. The patient was started on double antibiotic therapy with Ceftriaxone and Metronidazole. She was discharged after 5 days of observation with a 5-day course of oral treatment (CRP 47 mg/L at discharge). At day 45 the patient was asymptomatic. Repeat CT scan showed that the abscess had regressed (Fig. 4); CRP was 7 mg/L and PCT was 0,13 normal. The patient’s clinical course at 6 months postoperative was favourable, and the symptoms regressed completely. A repeat CT scan at 6 months postoperative found no abscess
Discussion: The rate of fistula formation after SG ranges from 3 to 7% . There are no randomized studies enabling a choice between surgery, radiologic or endoscopic drainage for fistula management [1,3]. If the abscess does not cause serious symptoms, conservative treatment can be a viable option since it has lower morbidity than invasive procedures . Endoscopic dilatation of the pylorus could have promoted healing by reducing pressure in the gastric tube .
Références  Nedelcu M, Skalli M, Delhom E, Fabre JM, Nocca D. New CT scan classification of leak after sleeve gastrectomy. Obes Surg 2013;23:1341-3.
 van de Vrande S, Himpens J, El Mourad H, Debaerdemaeker R, Leman G. Management of chronic proximal fistulas after sleeve gastrectomy by laparoscopic Roux-limb placement. Surg Obes Relat Dis 2013;9:1-6.
 Sheila J, Constantinos S, Evangelos E. A very challenging leak from a sleeve gastrectomy. Surg Obes Relat Dis 2013;9:e56–e59.
, Botey M, Moreno P, et al. A new approach to laparoscopic gastric sleeve leaks. A literature review. BMI 2012;2:93-102.
Figure 1. Contrast study on first postoperative day: no visible fistula
Figure 2. Computerized tomographic (CT) scan at 1 month: perigastric collection measuring 6x5x3 cm
Figure 3. Barium swallow at 1 month: blind fistula on high part of staple line (arrow)
Figure 4. Computerized tomographic (CT) scan at 1.5 months: perigastric collection in the process of regression, measuring 2.5x1x2 cm