IBC Oxford University Poster Abstract 19 - Management of a life-threatening oesophageal perforation during laparoscopic sleeve gastrectomy: a case study of an Ecuadorian patient

Abstract Introduction Bougie insertion for gastric calibration is routinely done during laparoscopic sleeve gastrectomy (LSG) with low expected risk. However, oesophageal perforation (EP) is a rare, but life-threatening and high morbidity complication. We present a case of late diagnosis (>24 hours) EP that was successfully managed with surgery. Case Presentation A 46-year-old woman living with type 2 obesity presented an oesophageal perforation during a sleeve gastrectomy procedure. Intraoperatively, and during the immediate postoperative phase, no complications were noted. However, approximately 30 hours after the procedure, the patient complained of epigastric pain and dyspnoea; a torpid clinical evolution followed. A leak in the distal third of the oesophagus was identified in a barium esophagogram. Additionally, a contrast CT scan revealed signs of mediastinitis. A thoracotomy for periaortic abscess drainage and cavity debridement was performed. A Kehr’s T tube was placed in the oesophageal perforation and a cervical esophagostoma was surgically created. Meanwhile, an abdominal laparotomy allowed lavage of the cavity and construction of a jejunostomy. The patient remained in the Intensive Care Unit (ICU) for 2 weeks due to persistent systemic inflammatory syndrome (SIRS). It took 2 more weeks of hospitalization for the patient to be discharged. Lastly, the drainage tubes were removed after a couple of months and the cervical oesophagostomy was repaired a year after the incident. Discussion Oesophageal perforation, although rare, is a serious complication in bariatric surgery. The time lapsed from EP to its treatment has been reported as having a statistical impact on patient mortality. Therapy instauration after more than 24 hours, such as in our patient´s case, is associated with a 20.3% mortality rate. However, prompt diagnosis is hindered by its uncommonness and widely variable clinical presentation. Regarding its management, according to the World Society of Emergency Surgery (WSES) Guidelines, the criteria for nonoperative management (NOM) by Altorjay et al. and Pittsburgh perforation severity score, might be helpful for treatment selection. For this patient, a surgical approach was elected as NOM criteria were not met. Moreover, the WSES suggests that direct oesophageal repair is not recommended in hemodynamically unstable patients, such as ours; and an oesophageal exclusion, diversion or resection should be performed (Grade 1C recommendation). In this case, surgery ensured aggressive drainage and debridement of the mediastinum, diversion of the oesophagus and the leak site, and fabrication of an enterostomy for feedings. Conclusions The study of oesophageal perforations and their management is difficult because of the small prevalence of this condition and the high heterogeneity in causation and treatment. As of now, treatment selection is guided by the surgeon´s criteria and ranges from conservative approaches to esophagectomy, or oesophageal exclusion. More research regarding this complication, specifically in bariatric patients, is needed so standardized management guidelines can be established.