IBC Oxford University Oral Abstract 14 - Video abstract: a rare case of lower gastric pouch necrosis post Roux-en-Y gastric bypass with leak and severe sepsis

Abstract Case Presentation A 40-year-old gentleman with a weight of 120 kgs (BMI 45 kg/m2) underwent a laparoscopic Roux-en-Y gastric bypass at another centre. He was discharged on postoperative day 2 but had complaints of respiratory distress and an elevated heart rate but no contrast enhanced CT abdomen was done. The patient was discharged but his clinical status deteriorated on postoperative Day 3. A contrast enhanced CT (CECT) abdomen showed gross pneumo-peritoneum and a leak from the gastro-jejunal anastomosis on postoperative Day 4. The patient presented to our unit on postoperative day 4 with gasping, tachycardia (155/min), tachypnoea (48/min), the arterial blood gas (ABG) showed severe metabolic acidosis with pH of 7.0. The patient was anuric and was severely dehydrated as no IV fluids or antibiotics were given at the previous tertiary hospital) The patient was resuscitated for 5 hours and taken for surgery after consent including the risk of death. The operative findings were a septic peritoneal cavity with a gush of air on entering the abdomen The lower and medial parts of the gastric pouch were completely necrotic and sloughed off. A gastro-jejunal anastomosis leak was confirmed by an intra-operative air insufflation test. The gastric tissue was very friable. The anastomotic sutures were loose and so four interrupted sutures were taken, and the leak site was repaired. A post-gastro-jejunal anastomosis repair air insufflation test showed no leak. A feeding gastrostomy was placed and secured to the gastric remnant for post-operative feeding Thorough peritoneal toilet was performed and multiple abdominal drains were placed. The patient had a stormy recovery post-operatively with associated metabolic acidosis and tachycardia and was intubated for 48 hours. After extubation, she was pyrexial and made slow progress. She was discharged on postoperative day 14 with her feeding gastrostomy removed after 4 weeks once patient was tolerating adequate oral intake