Perigastric fluid collection after endoscopic sleeve gastroplasty

A 39-year-old woman with a body mass index (BMI) of 32 kg/m² was evaluated for suitability for endoscopic management of her obesity. Because of her interest in a durable weight loss intervention, she elected to undergo an endoscopic sleeve gastroplasty (ESG). The procedural details have been described previously by Sharaiha et al. and Lopez Nava et al. [1] [2] [3]. In brief, the volume of the stomach is reduced by approximately 70 % using a full-thickness endoscopic suturing system (OverStitch; Apollo Endosurgery, Austin, Texas, USA) ([Fig. 1]).

Fig. 1 Endoscopic views showing: a the technique used to perform endoscopic sleeve gastroplasty (ESG); b the appearance after completion of the ESG procedure.

The patient recovered well in the days immediately after the procedure but presented with gradual onset vomiting and abdominal pain 12 days after her ESG. An erect abdominal radiograph showed a non-obstructive bowel gas pattern without any evidence of free gas. An abdominal contrast-enhanced computed tomography (CT) scan revealed a rim-enhancing 3.3 × 2.9 × 3.7-cm fluid collection in the fundus along the greater curvature of the stomach, suggestive of a perigastric collection, with surrounding stranding of the omental fat ([Fig. 2]).

Fig. 2 Computed tomography (CT) scan of the abdomen with intravenous contrast 12 days post-endoscopic sleeve gastroplasty: a on coronal view, showing a rim-enhancing 3.3 × 3.7-cm collection; b on axial view, showing a rim-enhancing 3.3 × 2.9-cm collection.

She did not have fever or chills, and her vital signs were stable, with a normal temperature and a white blood cell (WBC) count of 11.1 × 10³/μL. The patient was given a stat dose of intravenous etrapenem and was discharged with oral ciprofloxacin 500 mg twice daily and metronidazole 400 mg three times daily for 7 days. At follow-up 3 weeks later, her symptoms had completely resolved and follow-up imaging revealed no residual collection.

There has only been one documented case of perigastric inflammatory serous fluid collection after ESG (adjacent to the fundus), which resolved with percutaneous drainage and antibiotics [4]. One possible cause of the perigastric fluid collection may be intractable vomiting causing a small leak along the thin-walled fundus. When such a collection is identified, we recommend initial conservative therapy with oral antibiotics if there are no signs or symptoms of sepsis. Depending on the size and location of the collection, percutaneous drainage could be performed.

Endoscopy_UCTN_Code_CPL_1AH_2AJ

Competing interests: Mouen A. Khashab is a consultant for Boston Scientific and Olympus America and has received research support from Cook Medical.
Vivek Kumbhari is a consultant for Boston Scientific and Apollo Endosurgery. All other authors have no disclosures

• References

• 1 Sharaiha RZ, Kedia P, Kumta N et al. Initial experience with endoscopic sleeve gastroplasty: technical success and reproducibility in the bariatric population. Endoscopy 2015; 47: 164-166
• 2 Lopez-Nava G, Galvao M, Bautista-Castaño I et al. Endoscopic sleeve gastroplasty with 1-year follow-up: factors predictive of success. Endosc Int Open 2016; 4: E222-E227
• 3 Lopez-Nava G, Galvão MP, da Bautista-Castaño I et al. Endoscopic sleeve gastroplasty for the treatment of obesity. Endoscopy 2015; 47: 449-452
• 4 Abu Dayyeh BK, Acosta A, Camilleri M et al. Endoscopic sleeve gastroplasty alters gastric physiology and induces loss of body weight in obese individuals. Clin Gastroenterol Hepatol Epub ahead of print 2015 Dec 31