1550-7289/13/$http://dx.doi.org

*Correspondgery, DepartmenCenter, No. 1, YCity, 824, Taiw

E-mail: bmis

Surgery for Obesity and Related Diseases ] (2014) 00–00

Case report

Transcatheter arterial vasopressin infusion for gastrojejunostomyhemorrhage after laparoscopic Roux-en-Y gastric bypass:

a report of 3 casesPo-Chih Chang, M.D.a,b, Chih-Kun Huang, M.D.a,b,*, Kirubakaran Malapan, M.D.b

aDivision of General Surgery, Department of Surgery, E-DA Hospital/I-Shou University, Kaohsiung City, TaiwanbBariatric and Metabolic International Surgery Center, E-DA Hospital/I-Shou University, Kaohsiung City, Taiwan

Received August 20, 2013; accepted September 12, 2013

Keywords: Angiography; Endoscopy; Gastrojejunostomy hemorrhage; Laparoscopic Roux-en-Y gastric bypass; Vasopressin

– see/10.10

ence:t of Si-Da Ran.cedah

Gastrojejunostomy (GJ) hemorrhage, occurring as aconsequence of a marginal ulcer (MU) or staple-linebleeding, is not infrequent after laparoscopic Roux-en-Ygastric bypass (LRYGB). Most cases respond well toconservative treatment such as endoscopic management oracid reduction medication [1–3]. Surgery remains theprimary management after failed conservative treatment,but little has been reported about the possibility of angio-graphic management [2,4]. Herein, we report 3 patients whopresented with GJ hemorrhage, 2 hours, 3 hours, and 50days after LRYGB, who were successfully treated withcontinuous transcatheter arterial vasopressin infusion.

Case 1

A 51-year-old obese male with type II diabetes mellitus andhypertension with a body mass index (BMI) of 38.6 kg/m2

underwent LRYGB. The GJ anastomosis was constructedin an antecolic/antegastric fashion using a 35-mm linear-stapled anastomosis (Ethicon Endo-Surgery, Cincinnati,OH). The anastomotic defect was closed in a single layerusing intracorporeal, hand-sewn, absorbable sutures. Thepatient experienced persistent hematemesis 2 hours aftersurgery despite treatment with high-dose proton pumpinhibitors (PPIs) and octreotide. He was administered a

front matter r 2014 American Society for Metabolic and16/j.soard.2013.09.007

Chih-Kun Huang, M.D., Division of General Sur-urgery, Bariatric and Metabolic International Surgeryoad, Jiao-Su Village, Yan-Chao Distinct, Kaohsiung

@gmail.com

transfusion of 4 units of packed red blood cells (PRBCs).Esophagogastroduodenoscopy (EGD) showed fresh bloodin the gastric pouch; however, the staple line could not bevisualized (Fig. 1A). In spite of aggressive resuscitation, hiscondition deteriorated and his hemoglobin (Hgb) droppedto 8.2 g/dL. Emergent celiac angiography showed increasedvascularity on the right wall of the gastric pouch withoutgross contrast leakage from either the left gastric artery(LGA) or superior mesenteric artery (SMA) branches(Fig. 1B). A Progreat microcatheter (Terumo, Tokyo,Japan) was placed into the branch of the LGA and vaso-pressin at the rate of 2.8 IU/hr was infused to achievehemostasis. Within 4 hours, there was no further hematem-esis, and the vasopressin infusion was gradually tapered andterminated after 24 hours. EGD on the fifth day showed aMU with no active bleeding (Fig. 1C). The patient wasdischarged on the sixth day and was treated with oral PPIsfor 3 months. An EGD 1 year later showed no ulcer at theGJ anastomotic site (Fig. 1D).

Case 2

A 26-year-old male with a BMI of 50.4 kg/m2 underwentan uneventful antecolic/antegastric LRYGB. A 25-mLgastric pouch was created, and GJ anastomosis was con-structed using a 35-mm linear stapler (Covidien, Mansfield,MA). The patient recovered and was discharged on post-operative day 2 taking a liquid diet. He presented 7 weekslater with complaints of persistent black stools, epigastricpain, and intermittent hematemesis after taking nonsteroidal

Bariatric Surgery. All rights reserved.

Fig. 1. Case 1: (A) Upper endoscopy showed blood in the gastric pouch preventing further intervention. (B) Angiography via the left gastric artery (LGA)showed increased vascularity, but no contrast extravasation. Vasopressin infusion into LGA was performed through a microcatheter. (C) On the fifthpostoperative day, upper endoscopy found no active bleeding. A marginal ulcer was seen. (D) One year later, normal appearance of the gastric pouch andgastrojejunostomy was noted on upper endoscopy.

P.-C. Chang et al. / Surgery for Obesity and Related Diseases ] (2014) 00–002

antiinflammatory drugs for gouty arthritis. The patient washypotensive (blood pressure: 98/64 mm Hg), tachycardic(heart rate: 104 beats/min), and had a distended abdomenwithout rebound tenderness. His Hgb was 10.4 g/dL. Afterfluid resuscitation and blood transfusion, he underwent adiagnostic EGD, which showed a MU with an activebleeder at the GJ anastomosis (Fig. 2A). Epinephrineinjection was attempted to achieve hemostasis, but failed.Subsequently, the patient underwent emergent celiac angiog-raphy with LGA superselective catheterization (Fig. 2B). AProgreat microcatheter (Terumo) was placed in the LGA,and no contrast extravasation was noted. A continuousvasopressin infusion was begun at a rate of 8 IU/hr,and gradually tapered as the patient improved hemodynami-cally. Concurrently, intravenous PPI treatment was initiated.There was no further evidence of hemorrhage, and he wasbegun on a liquid diet 3 days later (Fig. 2C). He wasdischarged from the hospital on the fifth postoperative dayin good condition.

Case 3

A 32-year-old female with a BMI of 46.4 kg/m2 under-went an antecolic/antegastric LRYGB with creation of a30-mL gastric pouch and GJ anastomosis using a 35-mmlinear stapler (Covidien). Approximately 2 hours aftersurgery, she vomited 1300 mL of fresh blood. High-dosePPI treatment began, and she was given 4 units PRBCs and4 units fresh frozen plasma; however, her Hgb dropped to9.4 g/dL. Celiac angiography instead of EGD was per-formed, because there was a high suspicion of GJ bleeding,and to avoid possible anastomotic perforation during anendoscopic procedure. No obvious contrast leak was notedin either the LGA or SMA branches (Fig. 2D). A Progreatmicrocatheter (Terumo) was placed in the LGA and vaso-pressin was infused at a rate of 8 IU/hr. Two hours later,there was no further hematemesis, and the patient remainedhemodynamically stable. She was discharged uneventfully,with a prescription for a PPI for 3 months.

Fig. 2. Case 2: (A) Upper endoscopy found blood filling within the gastric pouch. (B) Angiography via the left gastric artery showed no contrast extravasation.A microcatheter was placed for vasopressin infusion. (C) Three days later upper endoscopy found no bleeding from the marginal ulcer. Case 3: (D)Superselective angiography of the left gastric artery showed hypervascularity.

Vasopressin for Gastrojejunostomy Hemorrhage / Surgery for Obesity and Related Diseases ] (2014) 00–00 3

Discussion

Upper gastrointestinal hemorrhage affects .4 to 3.2% ofpatients after LRYGB, and most bleeding occurs at the GJanastomosis or gastric pouch in the early postoperativeperiod [1,2]. EGD is the gold standard for identification ofthe bleeding source, and most cases can be successfullymanaged with an intravenous PPI and fluid resuscitation[1–3]. However, patients with active bleeding at the GJanastomosis usually require endoscopic intervention withepinephrine injection, clipping, or heater probe cautery,followed by acid reduction medication. These maneuverscan usually achieve hemostasis [1,3]. Although infrequentlyrequired, surgical reexploration is the definitive option forcases of failed conservative and endoscopic treatment [2,4].Very little is known about treatment modalities other than

surgery for overt GJ hemorrhage after failed conservativetreatment. Angiographic interventions with embolization orvasopressin infusion therapy are potential alternative thera-pies in cases of gastrointestinal hemorrhage [5,6]. Though

vasopressin infusion therapy for gastrointestinal hemor-rhage has a relatively high incidence of rebleeding, the 3patients presented herein demonstrated complete resolutionof GJ hemorrhage without complications after vasopressininfusion therapy [6]. Although no contrast extravasationwas found during superselective angiography in ourpatients, we still placed a microcatheter for continuousvasopressin infusion, instead of embolization, for the overtGJ hemorrhage. The gastric pouch created receives alimited blood supply from the first and/or second branchesof the LGA. We hypothesized that the GJ hemorrhage couldbe successfully controlled by the vasoconstrictor effect of adirect arterial infusion of vasopressin. Furthermore,catheter-induced vasospasm also may have contributed toachieving hemostasis by temporary occlusion of the vesselduring catheterization of the LGA [5].Transcatheter vasopressin infusion is less invasive than

surgical reexploration. Repetitive endoscopy for GJ hemor-rhage may result in perforation of the newly-created GJanastomosis [3,7]. Moreover, repetitive surgery will pose a

Table 1Summary of patient data

Age (yr)/Sex//BMI (kg/m2) Time to hemorrhageafter LRYGB

Hgb level before LRYGB/afterhemorrhage (g/dL)

Blood transfusion Vasopressin infusiondosage/duration

Co-morbidities

Case 1 51/M/38.6 2 hours 15.5/8.2 PRBCs 8 U 140 units/24 hr T2 DMFFP 6 U HTN

Case 2 26/M/50.38 50 days 14.0/10.7 PRBCs 8 U 200 units/24 hr GERDNASHGout

Case 3 32/F/46.4 3 hours 15.2/9.4 PRBCs 8 U 100 units/16 hr NASHFFP 4 U

BMI ¼ body mass index; F ¼ female; FFP ¼ fresh frozen plasma; GERD ¼ gastroesophageal reflux disease; Hgb ¼ hemoglobin; HTN ¼ hypertension;LRYGB ¼ laparoscopic Roux-en-Y gastric bypass; M ¼ male; NASH ¼ nonalcoholic steatohepatitis; PRBCs ¼ packed red blood cells; T2 DM ¼ type 2diabetes mellitus.

P.-C. Chang et al. / Surgery for Obesity and Related Diseases ] (2014) 00–004

risk to the viability of the GJ anastomosis, leading topossible catastrophic anastomotic leak or gastric pouchnecrosis in the early postoperative period. In addition, thecosts of surgical reexploration are considerably more thanthose of other less invasive treatments. Considering theseissues, we adopted transcatheter arterial vasopressin infu-sion as a therapeutic option after failed conservative treat-ment in these patients with early GJ hemorrhage afterLRYGB. Transcatheter arterial vasopressin infusion waseffective even in the patient with a MU and massivehemorrhage that was unsuccessfully managed with endos-copy (Case 2).Because of the novelty of this technique, the definitive

dose of arterial vasopressin infusion is unknown. It has beensuggested that the initial dosage for controlling gastro-intestinal hemorrhage should be 12 IU/hr, and then titratedaccording to the clinical response. When an arterial vaso-pressin infusion is administered, potential complicationssuch as angina, myocardial infarction, or mesenteric ische-mia should be monitored closely [5,6]. In the 3 patientspresented herein with overt GJ hemorrhage, the initialdosage of vasopressin infused ranged between 2.8 and 8IU/hr, and was gradually tapered (Table 1). There is also arisk of GJ necrosis using this technique. Fortunately, novasopressin-related complications occurred during or afterinfusion therapy. We postulate that the LGA blood supplyto the gastric pouch, which lacks collateral circulation,could have contributed to the effectiveness of a relativelylow dosage of vasopressin infusion, thereby resulting in anuneventful course.In conclusion, GJ hemorrhage after LRYGB is a lethal

condition and requires urgent intervention. Intravenous PPIwith concomitant transcatheter arterial continuous vaso-pressin infusion may be an alternative treatment for patients

who have failed conservative and endoscopic treatmentbefore surgical intervention becomes necessary.

Disclosures

The authors have no commercial associations that mightbe a conflict of interest in relation to this article.

Acknowledgments

The authors wish to acknowledge I-Chang Lin, M.D. andPo-Lin Sun, M.D., for assistance in the angiographicintervention.

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