1. VCU DEATH AND COMPLICATIONS CONFERENCE

2. Introduction  Complication  Pyriform sinus injury  Procedure  Laparoscopic roux-en-y gastric bypass  Primary Diagnosis  Morbid obesity

3.  50 yo female presenting for elective gastric bypass  5’5”, 295 lbs, BMI 49.2  Htn, hyperlipidemia, GERD, degenerative joint disease  PSH: c-section x3, lap chole, appendectomy, shoulder surgery  Quit smoking 6 months prior, no etoh, ivda

4.  To OR on 4/23/12  Pt intubated in standard fashion, however difficulty passing OG and subsequently NG tube  Mesocolic defect created  JJ anastamosis performed with 50 cm biliopancreatic limb and 60 cm alimentary limb which was advanced into lesser sac  Stomach divided and gastrojejunal anastamosis formed with partial closure  Olympus endoscope not able to be passed into the esophagus after several attempts, image appeared non mucosal and concern for perforation raised. Mild crepitus in neck

5.  Intraoperative consult to ENT  NGT was advanced into the stomach and bypass was completed without difficulty  ENT performed direct laryngoscopy and rigid esophagoscopy revealing rent in left pyriform sinus which closed with desufflation  Recommendations:  Ancef/flagyl prophylaxis  npo  No expiratory incentive spirometry, deep inspiration ok, no forceful exhalation  No nose blowing, Sneeze with mouth open  Esophogram in 5 days

6.  Neck tender post op with bilateral crepitus  Nonlabored breathing  Pt able to swallow secretions  Voice normal  NGT removed POD1  Neck symptoms improved over 5 days  Recovery from GBP uneventful

8.  No leak on study  Diet gradually advanced  Able to be discharged on 4/30

9. Analysis of Complication Was the complication potentially avoidable? – Yes, technique Would avoiding the complication change the outcome for the patient? – Yes- prolonged hospitalization What factors contributed the complication? – Body habitus, technical error (intubation, gastric tube insertion, endoscopy)

10. Pyriform Sinus injury  Means “pear-shaped”  Anatomic recess in hypopharynx  Just below epiglottis at the origin of the esophagus  Transition point in esophageal intubation  Iatrogenic perforation at this location has been described with endoscopy and bougie insertion  More common in pharyngeal cancer pts  High index of suspicion required to rule out injury  Delayed identification of injury can lead to severe complication (sepsis, tracheal fistula, damage to RLN)

11. Teaching points  No procedure is benign and all need to be respected  Most esophageal injuries result from iatrogenic causes  Early diagnosis is important as delay leads to high morbidity and mortality.