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Left gastric artery pseudo-aneurysm post sleeve gastrectomy: A case report

Highlights • Bleeding in the context of sleeve gastrectomy could be caused by a variety of diseases.• Pseudo-aneurysm is an overlooked complication.• Angiography followed by embolization is best for diagnosing and treating.• Common risk factors for pseudo-aneurysm include, infection, trauma, neoplasm, inflammation and surgery.• Treatment was surgical, this case was treated by interventional radiology.


Introduction
Obesity is a disease and is multifactorial in origin [1]. In the United States it is second only to smoking in being the leading cause of preventable death [1]. The surgical management of obesity focuses on the treatment of the comorbidities associated with it rather than obesity itself [1], but this job is entangled by some complications. In this report we aim to focus on an uncommon complication of laparoscopic sleeve gastrectomy presenting as hemorrhagic shock. Bleeding from the stapler line is a well-known complication following sleeve gastrectomy, however pseudo-aneurysm, as a potential cause of gastro-intestinal bleeding post sleeve gastrectomy, is rarely reported in the literature. For instance, delayed gastro-intestinal bleeding in the context of gastric fistula following sleeve gastrectomy is a rare complication [2]. However, in previous research done by Rebibo et al., it was shown that 75% of upper gastro intestinal bleeding in patient having gastric fistula post sleeve gastrectomy will be caused by gastric artery pseudo-aneurysm [3]. Moreover, Downes et al. showed that 3-11% of patients that undergone gastric band are complicated by erosion; a quite common but under estimated complication [4]. And they add that even after removal of the band, gastric artery pseudo-aneurysm could be diagnosed and could present as massive upper gastro-intestinal bleeding [4]. Hence high index of suspicion is mandatory in patients presenting with hematemesis post laparoscopic band surgery to rule out a life-threatening etiology as gastric artery pseudo-aneurysm. In addition, Sorensen et al. showed that splenic artery is another victim post gastric band surgery where pseudo-aneurysm is reported and managed by clipping [5]. And it is shown that splenic artery aneurysm is the most common among splanchnic artery aneurysms [6]. Precisely, symptoms may vary from drop in hemoglobin, to overt bleeding presenting as hematemesis, melena or massive rectal bleeding and hemodynamic instability. Here, we will present and discuss a rare case of upper gastro-intestinal bleeding following laparoscopic sleeve gastrectomy due to ruptured pseudo-aneurysm of the left gastric artery. This case was reported in line with Scare 2018 criteria [7].

Case presentation
It is a case of 25 year-old Lebanese woman previously healthy, non-smoker and with BMI of 40, she has no drug history, family history or any known genetic disease or psychological history. She presented with hematemesis and melena 3 weeks after laparoscopic sleeve gastrectomy. Upon presentation, the patient had 5 episodes of fresh bloody vomiting and three episodes of melena associated with palpitations and generalized fatigue. Patient denies headache, dyspnea, chest pain but mentions minimal diffuse abdominal pain not radiating with dull character. On physical   exam, she had normal blood pressure but was tachycardic, she was conscious and she had a soft abdomen with diffuse tenderness. Moreover, after stabilizing the patient workup was taken and she was found to have a severe drop in hemoglobin reaching 6.5 g/dl and a CT scan of the abdomen and pelvis with IV contrast was significant for extravasation of contrast from the left gastric artery suggestive of a ruptured pseudo-aneurysm. Hence, arteriography was done and showed a false aneurysm of the distal branch of left gastric artery with no other site of bleeding as shown by (Fig. 1).
This was followed by embolization procedure using microcatheter and 0.018 coil as shown by (Fig. 2). The post-procedure course was uneventful and she took 4 units of PRBC during her admission and the patient improved progressively and was discharged home on day 5. Moreover, gastroscopy was done 2 month following surgery, and revealed no evidence of abnormalities. It is noteworthy mentioning that informed consent to report this case was taken from the patient and protocol for the research project has been approved by the Ethics Committee of the hospital.

Discussion
Upper gastro-intestinal bleed is a serious complication of laparoscopic sleeve gastrectomy. Precisely, the source of bleed could be intra-luminal or extra-luminal [8]. In parallel with our case, intra-luminal bleeding can manifest as overt upper gastrointestinal bleeding, such as hematemesis or melena, whereas patients with extra-luminal bleeding may present with a drop in serum hemoglobin levels and/or signs of hemodynamic instability. Other presenting symptoms include abdominal pain or syncope associated with melena [4,[9][10][11][12][13], hence the origin of bleeding can be suspected based on the patient's history. Moreover, Pasha et at showed that patients can present with hemorrhagic shock [6]. On etiology level, bleeding is relatively common to occur from the stapler line however it was shown that bleeding can occur due to pseudo-aneurysm complication post sleeve gastrectomy and in particular from gastro-omental artery [6] and in our case from the left gastric artery. Concerning sleeve gastrectomy, when it is complicated by gastric fistula, some patients presented with concomitant gastric fistula and hematemesis [3]. Regarding our case, the patient presented with hematemesis and melena and her workup showed pseudo-aneurysm of the left gastric artery in the absence of gastric fistula.
Angiography proved to be the best diagnostic modality for hemodynamically stable patients [4,5,[9][10][11][12][13]. Additional diagnostic modalities include CT-scan and gastroscopy [3]. CT-scan proved to be a good diagnostic modality for the detection of pseudoaneurysm following bariatric surgery [3]. Nevertheless, gatroscopy has been employed as diagnostic modality in some cases [3,4]. Moreover, angiography is preferred to endoscopy allowing selective arterial embolization meanwhile diagnosing. However surgery is reserved for failure of conservative management or deterioration [3].
Previously, pseudo-aneurysms were treated with surgical interventions by aneurysmectomy or ligation depending on the size of the involved artery. Indeed, laparoscopic interventions were also suggested [6,8,10]. In our case, we chose to perform embolization using micro-catheter and 0.018 coils. It is important to note that placement of routine drain intraoperatively during sleeve gasterctomy doesn't aid in the detection of leak or bleeding except when placed for more than 5 days and in patients with previous band surgery or intra-peritoneal bleed where it may benefit [8].
Since the abdominal area with all its components is commonly exposed during bariatric surgery, and since bariatric surgery by itself is increasing in today's practice, pseudo-aneurysm is a problem that will be frequently encountered by bariatric surgeons. Hence, they should consider it as a serious complication, they should be trained to identify it, and consider the various therapeutic options. Hence, they should consider it among the differentials in case of bleeding, to identify, to diagnose and treat pseudoaneurysms post bariatric surgery. In conclusion, when dealing with bleeding in the context bariatric surgery, pseudo-aneurysms should be suspected and angiography should be considered at first where it allows selective arterial embolization.

Declaration of Competing Interest
The authors report no declarations of interest.

Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.