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CASE REPORT
Endoscopic Management of Two Sites of Stenosis

Post‑laparoscopic Re‑sleeve Gastrectomy and Acute Pancreatitis

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Mohammad A Alhaijawi , Ibrahim Alonazi , Khatoon Alakrawi , Fatima Ali , Wassim A Yassine , Mohammed Alaqeel 6
AbstrAct
Sleeve gastrectomy is a commonly performed bariatric procedure that is complicated by stricture formation in approximately 0.5% of cases.
Gastric sleeve surgery adverse events, which can result in strictures and leaks, are increasingly managed through a minimally invasive endoscopic
approach. Endoscopic treatment with pneumatic balloon dilation and stent insertion has repeatedly proven to be effective and safe as the first
line of management for this complication as in our case with two sites of stenosis and twisting because of severe adhesions due to previous
scar tissue and acute pancreatitis. Surgical intervention should be considered only after the failure of endoscopic treatment.
Keywords: Adhesions, Endoscopic pneumatic balloon dilation, Morbid obesity, Pancreatitis post-sleeve gastrectomy, Two sites of stenosis
post-sleeve gastrectomy.
World Journal of Laparoscopic Surgery (2021): 10.5005/jp-journals-10033-1463

IntroductIon 1–6 Bariatric and Metabolic Surgery Center, KSMC, Riyadh, Saudi Arabia
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Obesity has been a major public health problem worldwide, and Corresponding Author: Mohammad A Alhaijawi, Bariatric and
it has reached epidemic levels in the past few decades. Surgical Metabolic Surgery Center, KSMC, Riyadh, Saudi Arabia, Phone:
therapy is effective and proven therapy for patients with severe +966 540944133, e-mail: dr.mohd_alhijawi@hotmail.com
obesity. Sleeve gastrectomy is a frequently performed procedure How to cite this article: Alhaijawi MA, Alonazi I, Alakrawi K, et al.
worldwide. Sleeve gastrectomy is a commonly performed Endoscopic Management of Two Sites of Stenosis Post-laparoscopic
bariatric procedure that is complicated by stricture formation Re-sleeve Gastrectomy and Acute Pancreatitis. World J Lap Surg
in approximately 0.5% of cases. Gastric sleeve surgery adverse 2021;14(3): 227–229.
events, which can result in strictures and leaks, are increasingly Source of support: Nil
managed through a minimally invasive endoscopic approach. Conflict of interest: None
Surgical revision of sleeve gastrectomy is associated with significant
morbidity even when performed laparoscopically. Therefore,
endoscopic management is the preferred option. 2
King Saud Medical City (KSMC), complaining of persistent vomiting,
HIstory And ExAmInAtIon epigastric pain radiating to the back, history of on\off fever, and acute
kidney injury due to dehydration.
We report a case of a 37-year-old female who presented with
infertility for years, most likely attributed to her morbid obesity. ER Presentation
After several unsuccessful trials of losing weight, the patient was The patient weighed 93 kg with BMI of 32.6 kg/m . Her major
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advised to seek bariatric surgery to help her with conceiving. In complaint was persistent vomiting. She looked sick and severely
2012, she underwent laparoscopic sleeve gastrectomy (LSG) with dehydrated. Vitals were: Temperature, 37; blood pressure, 89/65;
weight of 174 kg, height of 169 cm, and body mass index (BMI) and pulse, 60 bpm. On examination of the abdomen, it revealed
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of 60.9 kg/m . Fortunately, after losing 74 kg, the patient went properly healed surgical wounds and soft and lax abdomen on
through in vitro fertilization, got pregnant with her first child, and palpation. She has no tenderness and distension. Guarding and
was delivered by cesarean section in 2016, but since after giving rebound signs were both negative.
birth, she started gaining weight again.
The patient was planning for a second pregnancy, and as she Laboratory Investigations
did not successfully achieve significant weight loss from her initial The patient presented with hypokalemia and a significantly high
surgery, she decided to undergo a revisional bariatric surgery with lipase level of 335 U/L. The lipase level was fluctuating throughout
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a weight of 115 kg, height of 169 cm, and BMI of 40.3 kg/m . the admission.
Laparoscopic re-sleeve gastrectomy was done on May 12, 2019.
After the operation and while still at the hospital, the patient was well, Imaging
not in pain, tolerating orally with no nausea or vomiting, passed flatus, A series of imaging studies have been undertaken to rule out
and so was discharged home with instructions. Two days later, the obstruction and stenosis. Computed tomography (CT) of abdomen
patient started vomiting every mL of fluid she drank, was not passing with contrast was done and showed no evidence of small or
stool, ignored her symptoms, and was only receiving intravenous large bowel obstruction. In addition, gastrografin study revealed
fluids and vitamin injections at home by her nurse sister. One month re-sleeved stomach with complete obstruction. There was no proof
later, she was presented to the emergency room (ER) at our hospital at of contrast leak. Furthermore, upper gastrointestinal endoscopy

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