1. Liver Abscess, a Rare Complication post Sleeve Gastrectomy
Haitham Alfalah MD, Jovial D’Souza MD, Ghanem Abbass MD.
King Saud Medical City, Riyadh, Saudi Arabia
Introduction
Laparoscopic Sleeve Gastrectomy (LSG) is a standalone procedure for the treatment of Morbid Obesity accepted internationally as a novel operation. There are
only short and intermediate term reporting of results and complications. Here we are reporting a Liver abscess as a rare early complication following Bariatric
Surgery in general and a first report as a complication following (LSG).
Case Report
A 32 year old woman, was treated with hematinic for Iron deficiency Anemia
and referred to Obesity Clinic for the management of morbid obesity. She was
diagnosed with Non-Insulin Dependent Diabetes Mellitus eight months prior
to referral and her sugar was well controlled by Metformin. (Fasting blood
sugar 6.8 mmol/L; HbA1c 7.9%; Fasting Insulin Level 7.9 uUnits/ml). Review of
systems and clinical examinations were normal. She was 140kg with a waist-
hip ratio of 0.9 and body mass index 54 Kg/m².
Baseline blood investigations, Thyroid function tests, serum vitamin B12,
serum cortisol, serum folic acid were within normal limit, serum vitamin
D₃25(OH) was low (26ng/dl) [30-45ng/dl]. Upper gastrointestinal endoscopy
showed mild gastritis.
Preoperatively, she was kept nil per oral for eight hours, Cefuroxime 1.5g and
Omeprazole 40mg administered half an hour before the procedure. (LSG)
performed without breaking any technique or any deviation from the
standard procedures .
The first two post-operative days were unremarkable. On Post-Operative Day
3 the patient complained of mild back pain associated with chest pain and
pink expectorate. Her vitals were stable and her drain tube had 40ml of
serous output. Her haemoglobin, electrocardiogram, arterial blood gases and
oxygen saturation were normal. A (CT scan) of chest and abdomen
performed, it shows no evidence of pulmonary embolism, the liver cuts were
normal and there was no evidence of intra peritoneal pathology (Fig-1). The
chest physician assessed the patient and then declared that she was cleared
from their side.
On Post-operative day 4, the patient was asymptomatic and tolerated orally,
therefore discharged the next morning. She was reviewed in the out-patient
department on post-operative day 21, her history and examination were
unremarkable.
On Post-operative day 44, the patient presented to the emergency room
complaining of generalized abdominal pain, vomiting and fever. Her
temperature was 38.7⁰C, Pulse Rate 115/minute, Blood Pressure 133/62
mmHg, WBC 16,000/cu.mm, alanine transaminase 210 IU/L, aspartate
transaminase 39 IU/L, serum amylase 54 IU/L. (CT scan) abdomen showed a
12 x 5 cm homogenous hypodense lesion with air bubble and enhancing wall
in right lobe of liver (segment VI and VII). (Fig-2).
A (CT scan) guided drainage was done and 400 ml of pus was drained at the
first sitting. Pus sample was sent for culture and sensitivity and treatment
with Piperacillin/Tazobactam and Metronidazole was started empirically.
Patient showed good clinical improvement and tolerated oral intake. The
same drain tube was left in situ and it drained 1385ml of pus in the following
five days after which the drainage reduced to fifteen ml per day. Total white
blood cells reduced from 16,000/cu.mm to 5,000/cu.mm; Neutrophil
differential count reduced from 76% to 35% and liver function test normalized
during this time. The culture and sensitivity test of the pus shows “no
growth”.
On Post-operative Day 57 (Day 13 post drainage), an Ultrasound report
showed 16ml of collection in the right lobe of the liver and the drain in the
center of the abscess. On Post-operative Day 61, a (CT scan) showed the
abscess site collapsed with organization of the previous cavity. On Post-
operative Day 62, the drain removed and the patient discharged to home.
Two months later, she had a follow-up appointment in the obesity clinic.
History, clinical examination and ultrasound abdomen were unremarkable.
Discussion
Liver abscesses are caused when the normal hepatic clearance
mechanisms fail or the system is overwhelmed by organisms reached the
liver via bloodstream, biliary tree, or by direct extension. Ulceration at
the staple-line may plays a role and would account for micro abscesses at
the staple-line.
Body habitus would suggest that the morbidly obese patient is well
nourished. However, those patients are in fact malnourished as evident
by micronutrient deficiency reported in multiple studies, and the results
from various series of (LSG) show the complication rate of 0-29%
including hemorrhagic, metabolic, infectious and mechanical ones.
For our patient, we think the portal vein to be the route which carried
infection from the staple line to the liver, coupled with the fact that the
altered metabolism in the post-operative period overwhelmed the
immune response of the diabetic patient, to clear the infection.
Conclusion
The incidence of liver abscess post (LSG) is very rare but the chance still
exists despite of the perioperative measures to reduce the same, because
this type of surgery classified as a clean contaminated surgery and the
comorbidity of the obesity compromises the immune system.
Fig.-1 (CT) scan abdomen on
Post-Operative Day 3
Fig.-2 (CT) scan abdomen on
Post-Operative Day 44