INTRODUCTION
Obesity is a global epidemic
8
. Surgery has proven to be the most effective treatment for morbid obesity
8
. The estimated prevalence of non-alcoholic fatty liver disease in obese is three
times higher than in the general population
8
. It progresses to non-alcoholic steatohepatitis in up to 42% of cases, which has
become a growing indication for liver transplantation (LT)
8
. Bariatric surgery in patients with cirrhosis prior to LT may improve access in the
waiting list. The number of patients on the waiting list for transplantation having
undergone bariatric surgery will grow, with a potential increase in the rate complications.
Peptic ulcer (PU) perforation is one of them. Following Roux-en-Y gastric bypass (RYGBP),
the modified anatomy and physiology are a risk factor for peptic ulceration of an
excluded stomach. Furthermore, LT carries specific risk factors for PU. Diagnosis
in the gastric remnant can be challenging due to the absence of endoscopic access.
We report the case of a LT recipient suffering from a perforated PU in the bypassed
stomach from RYGBP. To our knowledge, this is the first case reported in a liver transplanted
patient.
CASE REPORT
A 45-year-old woman with a history of open Fobi-Capella RYGBP was diagnosed with primary
biliary cirrhosis and listed for LT. Bariatric surgery was carried out seven years
before, followed by an emergency reintervention for obstruction of the jejunojejunostomy.
Hepatopathy was diagnosed at 41 years of age. The patient presented Ig G antibodies
for cytomegalovirus and a negative viral DNA detection by quantitative PCR. There
were no other relevant comorbidities.
She was admitted to the emergency department with melena and hematochezia. Physical
examination revealed hypotension, paleness, icterus and a pain-free abdomen without
ascites. Her Model for End-Stage Liver Disease score was 33. The patient did not smoke,
consume alcohol to excess or use nonsteroidal anti-inflammatory drugs, acetylsalicylic
acid, or proton pump inhibitors. The Helicobacter pylori (HP) status was unknown,
nor it was investigated. The patient was clinically managed with intravenous crystalloids,
blood borne products transfusion, PPI and ciprofloxacin. The upper endoscopy was negative
and the abdominal Doppler ultrasound showed signs of portal hypertension with patent
hepatic vessels. Six days after admission, deceased donor LT was carried out without
perioperative complications.
The postoperative immunosuppression regimen consisted of prednisone, tacrolimus and
mycophenolate sodium. The prophylactic antibiotics consisted of amikacin and ampicillin
until postoperative day (POD) 2 and ivermectin on PODs 2 and 3; sulfamethoxazole was
introduced on POD 8. Acetylsalicylic acid and prophylactic low molecular weight heparin
were suspended from POD 3 to POD 7 because of anemization without signs of bleeding.
Low molecular weight heparin was reintroduced at therapeutic dose because of the thrombosis
of a branch of the right portal vein. On POD 7 hepatic biopsy was performed due to
elevation in liver enzymes. Moderate acute cellular rejection was diagnosed and treated
with pulse therapy of methylprednisolone. Proton pump inhibitors were administered
throughout the hospitalization. On POD 14 the patient developed an acute abdomen.
An abdominal computed tomography scan with intravenous contrast showed a pneumoperitoneum
with foci of free air next to the stomach and free abdominal fluid in small quantity
(Figure 1).
An emergency laparotomy was performed and a perforated ulcer of the body of the excluded
stomach was found and repaired by simple closure. The ulcer was not resected for pathological
examination. On POD 16 routine quantitative PCR for cytomegalovirus DNA was positive
(41UI/ml 1,62 log (UI/ml)), but did not require antiviral therapy nor reduction in
the immunosuppressive regimen. Prophylactic unfractioned heparin was administered
from POD 16. Culture of the abdominal liquid collected intraoperatively showed positive
for extended spectrum beta-lactamase producing Klebsiella pneumoniae and Enterococus
faecium. Antibiotic treatment consisted of vancomycin, meropenem and fluconazol. The
patient was discharged on POD 26 with immunosuppressors, sulfamethoxazole, proton
pump inhibitors and prophylactic low molecular weight heparin, the latter being discontinued
ten days after this.
FIGURE 1
Abdominal computed tomography scan with intravenous contrast at arterial phase showing
free air anterior to the stomach, periportal edema of the transplanted liver and splenomegaly.
During follow-up, PCR for cytomegalovirus DNA showed negative results six weeks after
discharge. Proton pump inhibitors were continued on double dose. Seven months after
discharge, the patient underwent a double-balloon enteroscopy exploration of the excluded
stomach - the second reported after a PU perforation in the gastric remnant
13
. Because of the enteroenterostomies created after the RYGBP, it was impossible to
reach the excluded stomach. Pathological examination of biopsies from the gastric
pouch and the alimentary limb was negative for inflammatory alterations, cytomegalovirus
or HP. Three years after transplantation, the patient remains well undergoing routine
outpatient evaluation.
DISCUSSION
Reports of PU perforation in the excluded stomach after RYGBP are rare. A Pubmed search
limited to articles in English found only 29 reported cases (Table 1). The incidence
of perforated PU after open RYGBP in the Macgregor et al. series is 0.25%
10
. Based on the review, the male to female ratio is 1:1.9. The age at the time of PU
perforation ranges from 24 to 63 years (mean 42.6). The delay between the RYGBP and
the presentation of the perforated PU ranges from five days to 13 years. Twenty-one
patients had duodenal ulcer perforation (72.4%), seven had gastric ulcer perforation
(24.1%), and one had both (3.4%, Table 1). Statistics on PU after LT were not found
in the literature.
TABLE 1
Summary of all reported cases of excluded stomach perforation
author, year of publication
number of cases
sex
age
delay RYGBP - PU perforation
site of perforation
pneumoperitoneum (imaging tool)
emergency treatment (technique)
emergency surgical procedure
definitive treatment
Moore et al., 1979
12
2
m
28
12 d
duodenum
NA
surgical (laparotomy)
omentopexy
-
m
53
5 d
duodenum
NA
surgical
NA
-
Andersen et al., 1982
1
1
f
34
3 y
stomach
no (XR)
medical
-
closure + RYGBP takedown
Charuzi et al., 1986
4
2
NA
NA
3 w
duodenum
no (opacification through gastrostomy)
surgical
omentopexy
-
NA
NA
6 mo
duodenum
yes (opacification through gastrostomy)
surgical
omentopexy
-
Bjorkman et al., 1989
3
1
m
24
6 y
duodenum
no (US)
surgical
closure + gastrectomy
-
Macgregor et al., 1999
10
11
f
63
23 mo
duodenum
no
surgical
closure
gastrectomy
f
37
21 mo
stomach
no
surgical
closure + gastrostomy
gastrectomy
f
40
8 y
duodenum
no
surgical
closure
medical
f
31
7 mo
duodenum
no
surgical
closure + gastrostomy + cholecystectomy
gastrectomy
f
53
5 y
duodenum
no
surgical
closure + vagotomy + pyloroplasty
-
f
43
8 y
duodenum
no
surgical
closure
gastrectomy
f
29
11 y, 4 mo
duodenum
no
surgical
closure
gastrectomy
m
48
4 y
duodenum
no
surgical
closure
gastrectomy
f
57
18 mo
duodenum and stomach
no
surgical
closure
gastrectomy
m
40
20 d
duodenum
no
surgical
closure
gastrectomy
f
56
12 y
duodenum
no
surgical
unsuccessful closure then drainage + gastrostomy
gastrectomy
Papasavas et al., 2003
14
1
f
35
1 y
stomach
yes (XR)
surgical (laparotomy)
partial gastrectomy
medical
Arshava et al., 2006
2
1
m
36
3 y
stomach
no (XR, CT)
surgical (laparotomy)
gastrectomy + cholecystectomy
-
Mittermair and Renz, 2007
11
1
f
54
15 mo
duodenum
yes (CT)
surgical (laparoscopy)
closure + omentopexy
-
Snyder, 2007
17
4
NA
NA
NA
3 duodenum, 1 stomach
NA
surgical
1 closure, 3 gastrectomies
-
Sasse et al., 2008
16
1
f
55
1 y
stomach
yes (XR)
surgical
closure + omentopexy
-
Gypen et al., 2008
5
1
f
35
10 w
duodenum
no (XR, US)
surgical (laparoscopy)
closure + omentopexy + cholecystectomy
medical
Iskandar et al., 2015
6
2
m
59
10 y
duodenum
yes (CT)
surgical (laparoscopy)
closure + omentopexy
-
m
37
13 y
duodenum
no (CT)
surgical (laparotomy)
drainage + jejunostomy
medical
Ovaere et al., 2016
13
1
f
33
14 m
stomach
no (US, CT)
surgical (laparoscopy)
closure + omentopexy
medical
CT=abdominal computed tomography scan; d=days; f=female; gastrectomy=gastrectomy of
the bypassed stomach; m=male; mo=months; NA=not available; PU=peptic ulcer; RYGBP=Roux-en-Y
gastric bypass; RYGBP takedown=gastrogastrostomy between proximal and distal gastric
pouches, removal of the Roux-en-Y and reconstruction with a jejunojejunostomy; US=abdominal
ultrasound; w=weeks; XR=plain abdominal X ray film (except in Papasavas et al.
14
, which used chest X ray film); y=years.
The anatomical and physiological modifications after RYGBP may contribute to PU pathogenesis
in the bypassed stomach. Acid production may be promoted by hormonal and vagal stimuli,
which cannot be buffered by the ingested food or by a physiological pancreatic secretion
of bicarbonate, and by small gastric pouches, increasing the parietal cell mass of
the distal remnant
3
,
10
. Excluded gastric mucosa is also exposed to chronic injury and possibly carcinogenesis
by duodenogastric bile reflux, as demonstrated by double-balloon enteroscopy
15
. This technique detected HP in 20% of the excluded stomachs and the severity of gastritis
was associated with positive HP status
15
. As all HP positive patients in the excluded stomach were also positive in the gastric
pouch, HP detection in the excluded stomach may therefore be unnecessary
15
. PU disease in the excluded stomach shares the same risk factors of general PU or
marginal ulcers, but solid organ transplantation also has distinctive risk factors,
especially regarding immunosuppressive therapy. After kidney transplantation, high-dose
corticosteroids for rejection are associated with a greater rate of gastric ulceration
9
. Moreover, mycophenolate mofetil slows the gastric cell regeneration cycle
9
. Among infections, cytomegalovirus is the most common pathogen complicating solid
organ transplantation
7
.
The diagnosis of a perforated PU in the gastric remnant can be delayed. Pneumoperitoneum
in imaging is rare probably because the air in the excluded stomach is progressively
absorbed. Computed tomography is the most accurate diagnostic exam. Double-balloon
enteroscopy could be useful in gastrointestinal bleeding of unknown origin following
RYGBP, as bleeding preceded perforation in our case and in two other reported cases
3
,
14
. In case of gastrointestinal complications after LT, cytomegalovirus invasive disease
should be ruled out by combining tests for active disease, such as quantitative PCR,
with immunohistochemistry on biopsies to maximize sensitivity
7
. The differential diagnosis includes secondary perforation for an internal hernia
or gastric malignancy.
Several surgical or endoscopic treatments are available for general PU perforation.
Sepsis is the priority of postoperative care
18
. Administration of early broad-spectrum intravenous antibiotics is important, though
the effect of antifungal therapy is not clear
18
. Moreover, HP eradication reduces the incidence of PU recurrence
18
. In the setting of a perforated PU in the defunctionalized stomach, the most commonly
reported emergency treatment is surgical and consists in a simple closure (Table 1).
Data on postoperative proton pump inhibitors, antibiotics, HP eradication and prophylactic
anticoagulation are poor. Some authors propose gastrectomy of the gastric remnant
as the definitive treatment in case of perforation, others suggest primary resection
concurrent to the RYGBP
5
,
10
,
17
. Arguments in support of gastrectomy of the bypassed stomach include the exclusion
of the follow-up of the nearly inaccessible gastric remnant, the absence of gastrogastric
fistulas and the possible reduction of stomal ulcers by resecting the gastrin-releasing
part of the stomach
6
. However the disadvantages may be the bleeding of omental vessels, omental fat necrosis
with abscess formation, duodenal stump leakage, prolongation of operative time, bacterial
overgrowth in the biliopancreatic limb and vitamin B12 deficiency
5
,
6
. Therefore, long term proton pump inhibitors therapy could be an alternative for
high risk patients
6
. Gastrectomy of the excluded stomach during LT has never been reported. Finally,
prevention and treatment of cytomegalovirus infection must be rigorous in patients
with RYGBP to avoid, among other complications, gastrointestinal perforation.