Benefits of intraoperative endoscopy: case report and review of 300 sleeves gastrectomies

BACKGROUND The laparoscopic sleeve gastrectomy (LSG) is the fastest rising bariatric procedure being performed in the United States. Some surgeons advocate for an intra-operative endoscopy for their leak test, while others utilize air via a form of an oral gastric tube. We present a case demonstrating the benefits of endoscopy intra-operatively as well as discuss our experience of 200 consecutive sleeve gastrectomies. CASE PRESENTATION The case is a 37 years old female undergoing LSG for treatment for morbid obesity. As is our practice, we routinely perform an intra-operative endoscopy to help ensure a tight seal on the remnant stomach prior to completion of the procedure. During our endoscopy, a blood clot overlying a portion of the esophagus was noted, evacuated and evaluated and found to have a non-bleeding mucosal tear. This was unusual in our experience. There was no leak found on intra-operative endoscopy. After the patient woke up, she starting to have bouts of hematemesis. The decision was made to go back to the OR and evaluate her endoscopically. rather than attempting a laparoscopy based off of our endoscopic findings. Upon take back, we found a mucosal tear in her distal esophagus that now started bleeding, and her staple line was intact. Hemostasis was successfully achieved with two epinephrine injections. The remaining portion of her postoperative course was uncomplicated. DISCUSSION AND CONCLUSIONS The patient was able to be safely managed with a post-operative EGD. The intra-operative endoscopic findings allowed us to be more confident that this was an esophageal issue rather than a staple line problem, and were able to start with EGD prior to laparoscopy. Additionally, from a visualization perspective, the intra-operative endoscopy allows you to fully visualize the staple line, evaluate for twists or narrowing, and test for leak with confidence. From a residency standpoint, it also increases the confidence of residence to perform endoscopy on intubated patients.