Surgical Management of Intra-gastric Balloon Complications, Single-Center Experience, and Literature Review.

INTRODUCTION: In Saudi Arabia, the prevalence of obesity has multiplied in the last decades leading to a surge in bariatric surgery and other endoscopic modalities. The intra-gastric balloon (IGB) is the most used endoscopic modality. Surgical management for IGB complications is required for gastrointestinal perforation and/or obstruction. However, the literature seems to underestimate these complications. MATERIALS AND METHODS: A retrospective descriptive study was conducted in King Fahd University Hospital, Saudi Arabia, from Jan 2017 to Dec 2021, including all patients with complicated IGB who necessitated any surgical procedure. Exclusion criteria were patients with complicated IGBs that were only managed conservatively or endoscopically. RESULTS: A total of 326 patients were admitted with different complications after bariatric procedures. Of them, six patients were referred due to IGB complications that necessitated operative intervention. All patients were young females. Three patients had gastric wall perforation, and were managed by endoscopic removal of the IGBs followed by exploratory laparotomy. One patient had an intestinal obstruction on top of a migrated IGB that was surgically removed. One patient had failed endoscopic retrieval of IGB and required a laparoscopic gastrostomy. Another patient had an esophageal rupture that required left thoracotomy, pleural flap, and insertion of an esophageal stent. All cases were discharged and followed up with no related complications. CONCLUSION: IGB is an endoscopic alternative, within specific indications, for the management of obesity. However, surgical management may be necessary to manage its complications, including gastrointestinal perforation, IGB migration, and failure of endoscopic removal.

Successful Surgical Management of Gastric Antral Vascular Ectasia in a Patient with End-Stage Renal Disease: A Case Report and Literature Review.

BACKGROUND Gastric antral vascular ectasia (GAVE) is a rare clinical entity that presents with acute upper-gastrointestinal bleeding or chronic anemia. It is characterized by endoscopic watermelon appearance of the stomach. It is usually associated with other comorbidities; however, few articles have previously described GAVE in patients with end-stage renal disease. Its management is controversial, and endoscopic management is considered the treatment of choice. CASE REPORT A middle-age female patient, on regular hemodialysis for ESRD, was referred to the surgical out-patient clinic as a refractory GAVE after failure of endoscopic management as she became blood transfusion-dependent. She underwent laparoscopic subtotal gastrectomy with a Billroth II reconstruction of gastrojejunostomy. She had a smooth postoperative course and was followed up in the clinic for 12 months with no complications. Her hemoglobin level was stable at 9.4 g/dL without further blood transfusion. CONCLUSIONS Gastric antral vascular ectasia is usually associated with other comorbidities; however, an association between GAVE and CKD is rare. Its management is controversial, and endoscopic management is considered the preferred method of treatment. Laparoscopic subtotal gastrectomy is an effective management modality for GAVE, with dramatic improvement and good outcomes in terms of bleeding, blood transfusion requirements, and nutritional status.

Iatrogenic Esophageal Perforation After Laparoscopic Heller's Myotomy Treated Successfully with Endoscopic Stent: Case Report and Literature Review.

BACKGROUND Achalasia cardia is a neuro-degenerative motility disorder, which results in the loss of esophageal peristalsis along with failure of the lower sphincter to relax in response to swallowing. It is relatively rare, with a prevalence of 10 cases per 100 000 individuals. The criterion standard in the management of achalasia is laparoscopic Heller's myotomy with partial fundoplication. Esophageal perforation is one of the earliest major complications that could be managed by primary repair. However, it has been reported that esophageal perforations in achalasia cases can be managed with esophageal stenting after primary repair failure. CASE REPORT We are reporting a case of achalasia after Heller's myotomy in a 37-year-old man, which was complicated by iatrogenic esophageal perforation and was successfully managed by esophageal stenting after failed primary repair. CONCLUSIONS Esophageal stenting is a safe and effective management in cases of esophageal perforation after Heller's myotomy procedure.

Laparoscopic Double-Tract Esophago-Jejunostomy Reconstruction for Iatrogenic Esophageal Perforation After Endoscopic Pneumatic Dilatation for Achalasia: A Case Report.

BACKGROUND Achalasia is a rare primary esophageal motility disorder of unknown etiology, with significant negative impact on patient quality of life. Esophageal perforation is the most serious complication after pneumatic dilatation for achalasia, with a high mortality rate of up to 20%. Double-tract reconstruction is used mainly after proximal gastrectomy for gastric cancer, with the advantage of functional preservation of the stomach. We report a case of iatrogenic esophageal perforation after endoscopic pneumatic dilatation for achalasia that was successfully managed by laparoscopic proximal gastrectomy with double-tract reconstruction. CASE REPORT An elderly man started to manifest desaturation during endoscopic dilatation for achalasia, and multiple esophageal perforations were confirmed just above the gastroesophageal junction. During diagnostic laparoscopy, multiple perforations were found 2 cm proximal to the gastroesophageal junction extending 5 cm proximally with multiple linear mucosal tears. A trial of primary repair was difficult and double-tract reconstruction was performed by transection of the distal esophagus above the perforations and proximal gastrectomy. Then, 3 anastomoses were performed: end-to-end esophago-jejunostomy, end-to-side jejuno-jejunostomy, and side-to-side gastro-jejunostomy 15 cm distal to the esophago-jejunostomy site. After a smooth postoperative course, he was discharged home and was followed up regularly. CONCLUSIONS Esophageal perforation is the most serious complication after endoscopic pneumatic dilatation for achalasia. Double-tract reconstruction is a feasible and effective reconstruction modality following esophageal resection that avoids complications of esophago-gastrostomy. This technique deserves to be considered a valid treatment modality for advanced and complicated cases of achalasia, but further research is needed.