P1.028. Disaster Management Following Hiatus Hernia Repair Post-Sleeve Gastrectomy

Abstract

Abstract Topic Benign Disease: Gastro-Esophageal Reflux and Hiatal Hernia Background Revisional surgery to address the late complications of laparoscopic sleeve gastrectomy (such as sleeve stenosis and reflux) and concomitant proximal sleeve migration can carry significant risk. Surgical management options can include hiatus hernia repair, gastrogastrostomy and bypass. This case highlights disaster management principles following complications from revisional upper gastrointestinal surgery. Methods A 52-year-old female underwent laparoscopic hiatus hernia repair (BioA mesh) and gastrogastrostomy for stenosis 12 years post-sleeve gastrectomy. Following postoperative sepsis, she underwent multiple interventions including initial laparoscopic repair of a gastrotomy leak and endoscopic pigtail drainage. She was transferred to a tertiary facility for further management. Repeat endoscopy and cross sectional imaging was concerning for a second point of leak. Left-sided thoracotomy with decortication by the cardiothoracic team to address enteric-stained pleural collections was performed. Subsequent laparoscopic exploration was performed to identify the source of persistent sepsis, involving extensive retrogastric dissection to follow a fistula tract from the mid-stomach to the hiatus - which spanned between the known mid-gastric leak and a proximal gastric leak likely from a thermal injury to the proximal sleeve staple line during hiatus hernia repair. Results Thoracic empyema had ensued due to the occult proximal gastric leak. Due to severe tissue oedema and lack of proximal space, a total gastrectomy was avoided. Instead, the mid-gastric defect was converted into a Roux-en-Y fistula-jejunostomy to bypass the distal stenosis and provide a low pressure drainage system. The proximal gastric defect (from the hiatal repair surgery) was managed with a purse-string closure around a malecot-style rectal tube. This approach diverted gastric contents and controlled the fistula, allowing the inflammatory process to subside. The patient was managed with initially total parenteral nutrition and recurrent endoscopic dilatations to promote drainage. After two months, she had been discharged but was failing to thrive thus was supplementally fed with nasoenteric nutrition and underwent a total gastrectomy with roux en y reconstruction. Conclusion The primary lessons from this case involve recognizing that thermal injury from electrocautery can lead to delayed leaks and that sepsis often follows the path of least resistance—in this case, through the hiatus into the thoracic cavity. When stenosis drives a proximal leak, the obstruction must be addressed by endoscopic dilatation, bypassed or resected. Roux-en-Y fistula-jejunostomy is an option when tissue friability precludes anatomical resection or standard bypass, potentially sparing the patient from the high morbidity of an emergency total gastrectomy.