Abstract
Background:
Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure in the United States. Postoperative migration of the stomach into the chest is a rare complication of this procedure. In this study, we present a compilation of acute and chronic intrathoracic sleeve migrations (ITSMs) after LSG and present possible underlying mechanisms of this complication, as described in the literature.
Methods:
We retrospectively reviewed the preoperative, intraoperative, and postoperative course of patients who had an ITSM after LSG between 2011 and 2019.
Results:
Two patients presented with this complication in the acute setting, whereas 3 patients developed ITSM as a chronic issue years after the primary procedure. All 5 were female patients, with a mean age and body mass index of 55.6 ± 9.5 (years) and 37.8 ± 2.9 kg/m2, respectively. None of the cases had a hiatal hernia repair during the initial operation. All cases were completed laparoscopically with reduction of the migrated sleeve into the abdomen and primary hiatal hernia repair. One case required a return to the operating room for an acute reherniation.
Conclusion:
In this article, we report a compilation of cases of ITSMs after LSG with distinct clinical features that highlight the diversity of possible reasons and risk factors for its development.
Introduction
Laparoscopic sleeve gastrectomy (LSG) is an effective weight loss procedure that has been proved to be safe and efficacious to treat obesity and obesity-related conditions. 1 In the past two decades, LSG has emerged as the most commonly performed bariatric metabolic procedure in the United States.1,2 However, with the increase in its popularity worldwide, a variety of expected and never before seen adverse events have been reported. The most common complications are per oral (PO) intolerance, electrolyte imbalance, and bleeding, as well as staple line leak. A more rare complication is the postoperative migration of the gastric tube into the mediastinum. Other synonymous nomenclatures used in the literature are as follows: “paraesophageal hernia,” “gastric sleeve migration,” “de novo hiatal hernia of gastric tube after sleeve gastrectomy,” or “intra-thoracic sleeve migration. ”1–4 During this phenomenon, the gastric sleeve created during an LSG migrates into the mediastinum, which subsequently presents with signs and symptoms of an underlying “paraesophageal hernia.” This complication may present in the acute setting if the severity of symptoms of obstruction precludes the patient from postoperative food tolerance, but may also present as a chronic event as has been previously described. 3 There have been several case reports published, with various attempts to explain the etiology of this complication: (1) extensive mobilization of the stomach with resultant loss of the anatomical attachments of the stomach, (2) preexisting undiagnosed or unrepaired hiatal hernia, (3) intraoperative iatrogenically induced weakness of the hiatus after hiatus exploration, secondary to damage to the phrenoesophageal ligament.1–5
The purpose of this study is to describe the clinical characteristics of patients who presented with intrathoracic sleeve migration (ITSM) after LSG in both the acute and chronic setting. In addition, our aim is to describe what has been presented in the literature as possible risk factors and etiologies which can lead to the migration of the gastric sleeve into the mediastinum.
Methods
We retrospectively reviewed the clinical information of 5 patients who developed an ITSM after an LSG, from 2011 to 2019, from a single institution. All reviews were conducted after the approval from the Institutional Review Board was obtained.
All the patients presented in this investigation underwent LSG using the same standard surgical technique. At the time of these operations, no hiatal hernia was appreciated. An intraoperative endoscopy was then performed to assess the anatomy, check for bleeding, and to do a leak test—all of which were negative in all cases.
Results: Presentation of Cases
Two patients presented with this complication in the acute setting (within 2 weeks) whereas 3 patients developed ITSM as a chronic issue (3–5 years) years after the primary procedure. All 5 were female patients, with a mean age and body mass index (BMI) of 55.6 ± 9.5 (years) and 37.8 ± 2.9 kg/m2, respectively. None of the cases had a hiatal hernia repair during the initial operation.
Case I
A 46-year-old female with a BMI of 41 and a preoperative normal esophagogastroduodenoscopy (EGD) underwent an uneventful LSG. At the time of the operation, no hiatal hernia was noted. A staple line leak test was negative. During the postoperative course, the patient was unable to tolerate liquids with persistent nausea and emesis. An upper gastrointestinal (UGI) series with gastrografin was performed on postoperative day 2, demonstrating transit delay thought to be postoperative edema at the gastroesophageal (GE) junction. On postoperative day 6, the patient was discharged home tolerating oral diet. However, the patient returned to the ED the next day with complaints of PO intolerance. The patient was readmitted on postoperative day 10, and given that her symptoms of nausea improved, she was placed again on a trial of liquids, which she persistently failed. A subsequent EGD revealed an obstruction at the GE junction, with retained liquid in the esophagus and inability to advance the endoscope distally. A diagnosis of acute intrathoracic migration of the sleeve was made, as seen in Figure 1a. The patient underwent a laparoscopic re-exploration and it was noticed that half of the gastric sleeve had migrated into the chest through a hiatal defect. The gastric sleeve was reduced into the abdomen with a primary hiatal defect repair and a gastropexy to the left crus and to the edge of the greater omentum. Figure 1b shows the UGI series done after reduction and repair of the hiatal hernia. There were no postoperative complications and after appropriate oral diet tolerance the patient was discharged home 2 days after repair. The patient had the usual postoperative outcomes seen with LSG, with respect to weight loss and progress in diet.
Pre- and postoperative UGIS. As describes in the text:
Case II
A 59-year-old female with a BMI of 35 underwent an LSG. Her preoperative workup included an EGD, which was normal. At the time of the operation, no hiatal hernia was noted. During the first 2 days after surgery, she developed persistent nausea with PO intolerance, for which an UGI series was done. The study revealed a dilated esophagus with delayed transit into the stomach. Her symptoms persisted until postoperative day 4, for which another UGI series was performed, which showed retention of contrast at the GE junction without the passage of the contrast distally. An EGD was then performed, which confirmed a narrowing of the GE junction—assumed to be caused from postoperative edema. From postoperative days 5 through 8, the patient continued to have PO intolerance to liquids. On postoperative day 8, given that her symptoms continued to persist, a repeat UGI series and an EGD were done, this time demonstrating an obstruction of the proximal stomach along with the migration of the entire stomach into the mediastinum, as seen in Figure 1c. The patient underwent a laparoscopic reexploration where evidence of ITSM through a hiatal defect with almost the entire staple line of the sleeve gastrectomy in the mediastinum was seen. The stomach was reduced into the abdominal cavity, and the hiatal defect was repaired primarily. The esophagus was fixated with sutures to the crura and a gastropexy of the gastric tube to the greater omentum was performed. Figure 1d shows the UGI series done after reduction and repair of the hiatal hernia. The patient had an uneventful recovery and was discharged the next day.
Chronic cases
Case III
A 53-year-old female with a BMI of 39 with history of gastroesophageal reflux disorder (GERD) and type 2 DM underwent an LSG with the standard technique. Her preoperative workup included an EGD, which was normal and did not reveal esophagitis or a hiatal hernia. The postoperative course was uneventful with improvement of her GERD. A postoperative UGI series done in the immediate postoperative period showed the absence of anastomotic leak or a hiatal hernia. Three years later, she presented with worsening GERD, for which an EGD was done—demonstrating mild esophagitis without evidence of a hiatal hernia. Given the persistent and worsening GERD, refractory to medical therapy, the patient underwent another EGD—which demonstrated the presence of a 5 cm hiatal hernia. A UGI series was done following the EGD, which revealed a hiatal hernia with significant reflux, as seen in Figure 1e. She then underwent a revision of her sleeve gastrectomy to repair the hernia. During the laparoscopic reexploration a hiatal hernia was identified with the migration of the upper portion of the gastric sleeve into the mediastinum. The gastric sleeve was carefully reduced and the hiatal hernia was repaired primarily with pexy of the esophagus to the hiatus. Figure 1f shows the UGI series done after reduction and repair of the hiatal hernia. The patient recovered with no complications and was discharged home the next day.
Case IV
A 38-year-old female with a BMI of 37 and history of GERD with esophagitis underwent an LSG. Her preoperative workup with an EGD showed esophagitis, but did not reveal a hiatal hernia. A postoperative UGI series showed a small hiatal hernia. She was discharged home on postoperative day 2. Her postoperative GERD improved as the patient lost weight. However, 5 years after her LSG, she presented with worsening GERD associated with postprandial regurgitation of food. Workup included an EGD and UGI series, both of which confirmed a hiatal hernia and reflux. Given the worsening symptoms despite the medical treatment with PPIs, the patient underwent a conversion of the LSG to a laparoscopic Roux-en-Y gastric bypass (LRYGB) with repair of a moderate size hiatal hernia. Upon exploration of the abdominal cavity, a hiatal defect with migration of the proximal segment of the gastric sleeve into the mediastinum was noted. The gastric sleeve was carefully reduced into the abdominal cavity, the hiatal hernia was repaired primarily, and a LRYGB was performed.
Her postoperative course was complicated by an immediate recurrence of the hernia defect with the gastric pouch herniated up into the chest as was seen on the UGI series performed on postoperative day 1 (Fig. 1g). For this reason, the patient was taken back to the operating room for exploration. Upon abdominal exploration, a herniation of the proximal portion of the gastric pouch into the hiatus was noted. The hiatal sutures were intact. The gastric pouch, proximal anastomosis, Roux limb, and distal anastomosis all appeared normal and intact. The gastric pouch was reduced into the abdominal cavity without tension and the posterior defect in the hiatus was closed. Pexy of the esophagus to the right crus and the stomach pouch to the left crus in three positions was done. A postoperative UGI series showed no evidence of residual hiatal hernia with the gastric pouch in normal position in the abdomen (Fig. 1h). There were no postoperative complications and the patient was discharged home 2 days after surgery.
Case V
A 68-year-old female with a BMI of 35.8 underwent an LSG and hiatal hernia repair at an outside hospital 2 years before referral to our institution (of the five cases, this was the only referral). Five weeks after her initial procedure, she began to develop dysphagia and vomiting, along with chest discomfort. A gastroenterologist for management of these complaints saw her. Manometry showed a nonspecific esophageal motility disorder. She underwent seven endoscopic balloon dilatations for presumed esophageal stricture without resolution of her symptoms. A hiatal hernia was not appreciated endoscopically. After referral to our institution, an UGI series was performed, which revealed an intrathoracic sleeve migration (Fig. 1i). Given this new finding, the patient underwent a laparoscopic exploration. Upon entering the peritoneal cavity, a 3 cm visible hiatal hernia with the sleeve sliding into the mediastinum was immediately visualized. After mobilizing the GE junction, reducing the hernia, and establishing 5 cm of intra-abdominal esophageal length, the posterior defect in the hiatus was closed. The esophagus was circumferentially pexied to the hiatus and the area was sprayed with fibrin sealant to enhance the repair. A postoperative UGI series was done, which was within normal limits and showed no signs of a leak, recurred hiatal hernia, or reflux of contrast—as seen in Figure 1j. The patient recovered with no complications and was discharged home the next day.
Discussion
The LSG is a restrictive metabolic procedure that carries risk for potential complications such as staple line leak, bleeding, de novo GERD, stricture formation, and ulcerations.1–3,6,7 ITSM is a rare complication. The presentation can be nonspecific: PO intolerance, chronic constipation, and/or de novo GERD. 2 Early on, when LSG was first taking off as the most commonly performed bariatric procedure, postoperative UGI series were routinely done. Soon after, these studies were not found to be of any benefit in finding staple line leak, as their sensitivity was too low. What was appreciated, in one study, was that it could reveal the development of sleeve migration. 6
In this investigation, we present five diverse cases of LSG with postoperative development of ITSM. In the two acute cases, a standard procedure led to intractable vomiting and food intolerance, resulting in further workup and the subsequent diagnosis of a sleeve migration. In these two cases, no hiatal hernia was noted in preoperative EGD or intraoperatively. In the three chronic cases, there was a significant lapse in time before any symptoms were recognized.
Published case reports attribute the development of ITSMs to the mobilization of the normal posterior attachments of the stomach to the retroperitoneum as well as dissection of the angle of His with loss of the normal anchoring of the stomach.1–3 It is important to identify potential signs and symptoms that may help in identifying patients who have developed this complication. It is clear that ITSM should be suspected with the presence of intractable nausea and vomiting after an LSG. A high index of suspicion, for this complication, should also be maintained years following this procedure for patients who may present with atypical features (e.g., chronic constipation, de novo GERD).
A literature review of ITSM following LSG is summarized in Table 1. According to Saber et al., 8 they had a patient with an ITSM despite having a hiatal hernia (identified preoperatively) repaired during the original LSG. In the Sebastiani et al. case, there was identification of a small sliding (<2 cm) hiatal hernia that was reduced and repaired, which they believe, may have paradoxically led to a postoperative paraesophageal hernia. 9 While in the Al-Sanea et al. case, patient had no hiatal hernia defect, they admit damage to the high pressure zone of the lower esophagus sphincter may have resulted from the visualization of the esophagus and angle of His and incision in the lateral aspect of the phrenoesophageal ligament. 1
Intrathoracic Sleeve Migration Literature Review
EGD, esophagogastroduodenoscopy; GERD, gastroesophageal reflux disorder; LSG, laparoscopic sleeve gastrectomy; UGIS, upper gastrointestinal series.
Factors thought to be associated with the development of ITSM after LSG are significant central obesity, with resultant greater intra-abdominal pressure; intractable vomiting, which has been described as an etiology of diaphragmatic tears and subsequent paraesophageal hernia development in the pregnant population; laparoscopy, with a resultant low number of adhesions leading to reduced fixation of the sleeved stomach; rapid weight loss, following the LSG. may lead to enlargement of the hiatal orifices as well as may affect the pillars of the diaphragm because of muscle depletion; and finally, dissection of the angle of His and the left pillar during creation of the gastric sleeve may also increase the risk of herniation.
Conclusion
We report these cases to contribute to the currently limited literature on postoperative ITSM and to promote a better understanding of this rare and underreported complication. While a hiatal hernia seems to be the leading cause, both from our experience and from a review of the literature, there are many other factors. Therefore, the mechanisms responsible for the herniation of the sleeve may be difficult to identify. Nevertheless, the more cases that are reported, the better understanding we will have about this rare complication.
Footnotes
Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received.