Acute pancreatitis as an unusual early post-operative complication following laparoscopic sleeve gastrectomy.

Laparoscopic sleeve gastrectomy (LSG) at present one of the most commonly performed surgical treatments for morbid obesity worldwide. There are some complications regarding this procedure in the literature. This report presents a patient who developed acute pancreatitis immediate post-LSG. Patient was referred to our institute on 10th post-operative day with a complaint of fever, nausea, abdominal pain and leucocytosis. A diagnostic laparoscopy showed pancreatitis. Post-operatively, the patient was managed on treatment line of acute pancreatitis and recovered well. LSG is a common procedure in bariatric, and the most common complications are leakage and bleeding from the suture line. However, we encountered pancreatitis after LSG which is a rarely reported complication after LSG. We hypothesise that the development of acute pancreatitis in patients undergoing LSG is not well recognised and reported.

INTRODUCTION

Laparoscopic sleeve gastrectomy (LSG) is currently one of the most common surgical treatments for morbid obesity across the globe.[1] It is an effective treatment to achieve significant weight loss with improvement of obesity-related comorbidities. With an increase in the number of bariatric surgical procedures being done today, surgeons should have ongoing understanding of common complications associated with LSG and as well as an insight to recognise rare ones. Known post-operative complications already reported are haemorrhage, leak, small bowel obstruction and infections.[2] LSG is considered a relatively safe surgical option for weight loss and being preferred due to technical simplicity to perform the procedure. Here, we present a rare case of potentially life-threatening complication following LSG: acute pancreatitis in the early post-operative period.

CASE REPORT

A 60-year-old morbidly obese female (body mass index [BMI] = 45.1 kg/m2) with co-morbidities of hypertension, diabetes and obstructive sleep apnoea was referred to our institute in the emergency department with presenting complaint of the upper abdominal pain radiating to back, fever, nausea and vomiting. On physical examination, there was abdominal tenderness with the presence of guarded abdomen. On admission, white blood cell (WBC) counts were raised-18,000/mm3, serum creatinine was 1.8 mg/dl and serum amylase was 350 U/L. On evaluating her past medical and surgical history, patient had undergone uncomplicated LSG around 10 days back for the treatment of morbid obesity. Post-operative recovery was uneventful and was discharged within 3 days post-surgery. However, on 6th post-operative day, the patient had symptoms of abdominal pain, nausea, vomiting, fever of 101°F for which she was admitted into the emergency department of the same hospital where she underwent LSG. Laboratory data had showed elevated WBC to 15,000/mm3 which was lesser than current count during admission to our unit. During the stay in the previous hospital, ultrasonography was performed which revealed no gallstones and no biliary tree dilatation. Gastrografin study and abdominal computed tomography (CT) scan with intravenous contrast showed multiple fluid collection, relatively normal-appearing pancreas [Figure 1]. There was absence of leakage from the staple line or bowel obstruction on radiological studies. Patient was started conservatively with intravenous fluids, pain medications and antiemetics. A tube drain was inserted in retro-gastric fluid collection under CT guidance. However, patient conditions did not improve, and patient was referred to our institute on 10th post-operative day. Based on presenting clinical scenario and the past surgical history, diagnostic laparoscopy was performed as an index of suspicion to rule out any leak. Intraoperative findings showed inflammation of greater omentum and omental fat saponification [Figure 2]. There was no evident leak in the staple line; serous fluid was present in the pelvis and para-colic gutter. No evidence of perforation or peritonitis was seen. Previous CT-guided lesser sac drain was intact and was not disturbed. Another drainage tube was placed in pelvis area to drain out dependent fluid collection. All the features which were seen intraoperatively suggested of acute pancreatitis and ruled out any leak.

Figure 1

Preoperative abdominal computed tomography scan

Figure 2

Intraoperative findings

Post-operatively, patient was on first-line treatment regimen for acute pancreatitis. Patient was shifted to intensive care unit for 2 days, kept nil by mouth for 3 days with intravenous parental nutrition and albumin. Consequently, the patient was gradually shifted to lipid-free, liquid diet then soft diet. Lesser sac drain output was reported initially high and was clear in colour. Gradually, the drain output became purulent which suggested peripancreatic abscess. Pelvis drain was removed on 10th post-operative day. The patient recovered well and was discharged on 14th post-operative day with lesser sac drain in situ. On 25th post-operative day, patient was readmitted with fever and raised total leucocyte count. Contrast-enhanced CT abdomen was done which showed demarcation of avascular pancreas and pancreatic abscess. Lesser sac drain was repositioned to drain pancreatic abscess and patient was started on intravenous antibiotics with maintenance of high protein and lipid-free diet.

The patient recovered well and patient was discharged on 40th post-operative day after drain removal. Further, monthly follow-ups were done till 6 months. Patient blood sugar levels were under control and had remission of diabetes. She lost weight and her present BMI is 29.8 and living a healthy lifestyle.

DISCUSSION

Obesity is not merely a cosmetic problem and it is a complete metabolic syndrome with constellation of major risk factors for cardiovascular disease, type II diabetes, dyslipidaemia, non-alcoholic steatohepatitis, arthritis, obstructive sleep-apnoea syndrome and many types of cancer.[3] There are wide modalities of treatment for the management of obesity. Bariatric surgery has proven to be most effective treatment for achieving and maintaining long-term weight loss. The success achieved in the resolution of obesity-associated co-morbidities and sustaining long-term weight loss after surgery is notably significant. Although there is no consensus about most efficient weight loss surgical procedure for obese patients, LSG has become a commonly used bariatric surgical procedure.[4] LSG functions by reducing approximately 80% of the stomach with remaining pouch resembling a tube. Patients have decreased appetite as they feel full with smaller meals consumed. In addition, due to resection of gastric fundus, LSG is associated with decreased ghrelin levels. Major advantages of LSG are laparoscopic feasibility, short-hospital stay, volume restriction with preservation of pylorus and gastric function. The favourable changes following LSG are the reduction of appetite, early satiety and suppression of hunger harmones inducing rapid weight loss. The drawbacks associated with LSG being a non-reversible procedure and higher early risk of stapling complications and tendency for long-term vitamin deficiencies.[5] Intraoperative complications comprise of bleeding from staple line, bowel perforation/leak, injuries to other adjacent organs such as pancreas, spleen, diaphragm and liver. Careful attention must be given towards the manipulation of short gastric vessels or distal splenic vessels, which could result in splenic infarction.

Early complication (within 2 weeks) includes gastric leakage, haemorrhage, abscess, port site hernia, pancreatic fistula and rarely acute pancreatitis as in our case.[6] Delayed complication (after 2 weeks) includes nutritional deficiency, GERD, stricture formation and port site hernia. The incidence of acute pancreatitis in early post-operative period following LSG is unknown in the literature till date. Pancreatitis has been rarely reported in literature as an early complication of bariatric surgery.[7] In a study,[7] only 138 of 3765 (3.6%) patients developed post-operative pancreatic-biliary complications following bariatric surgery. Only 10 (0.27%) out of those 138 patients developed acute pancreatitis with mean time from surgery being 1.8 ± 1.4 years. Cholelithiasis, female gender, age >50, at the time of bariatric procedure and Roux-en-Y gastric bypass were identified as predictive factors of pancreatic-biliary complications, with no mention of LSG as a definitive risk factor.

In a recently published cohort study done to evaluate acute pancreatitis following bariatric surgery showed only 28 patient (1.04%) out of 2695 having acute pancreatitis during a median follow-up of 3.5 years with rapid post-operative weight loss and the presence of gallstones as significant risk factors; however, this study does not specify exact time point or causation.[2]

We hypothesise that the development of acute pancreatitis in patients undergoing LSG is not well- recognised and reported. The most probable cause of acute pancreatitis as an early complication is secondary to severe adhesion of peripancreatic tissue intraopertively. Other mechanisms could be due to compromised pancreatic microcirculation following gastrectomy or oedema and spasm of major papilla. Accurate gastric mobilisation during LSG is essential to avoid any vascular and reactionary injury. Acute pancreatitis should be kept in mind while managing patients following LSG with complaints of abdominal pain and essential to rule out early leak. Aforementioned life-threatening complication probably could be prevented with meticulous tissue dissection, surgeon's experience during stomach mobilisation and by being vigilant to protect pancreas during operation.

CONCLUSION

The rising incidence of obesity has led to adoption of bariatric surgical procedures for achieving improved clinical outcomes. LSG is a well-known procedure in bariatric and the most common complications being leakage and bleeding from the suture line. Correlating with the increase in incidence of complications associated with this procedure, it is the necessity for surgeons to be aware of potential complications and have a proper understanding to ensure efficient diagnosis and management.

The purpose of presenting our case is to emphasise on rare but possible life-threatening complication following LSG. As the number of LSG performed annually continues to increase, an index of suspicion should remain for acute pancreatitis. Hence, it should be certainly considered in differential diagnosis of patients presenting to the emergency department due to abdominal pain, especially in view of previous LSG.

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Conflicts of interest

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