Background

Bougie is used while performing LSG to calibrate the stomach. We encountered a case of bougie induced lower esophageal perforation while trying to negotiate it across gastroesophageal junction. We will discuss the cause, mechanism of perforation, and its management.

Methods

A 36 y/o female patient having BMI of 40.2kg/m2 was posted for Laparoscopic Sleeve gastrectomy (LSG). After omentectomy attempt to introduce the bougie across gastroesophageal junction, for calibration of sleeve , failed. After multiple attempts it could be negotiated into the stomach and LSG was completed uneventfully. On first post-operative day patient tolerated liquids well. On second post-operative day patient was asymptomatic but had tachycardia of 120/min. Patient was taken for oral contrast CT Scan which showed leakage of contrast into the mediastinum.Patient was taken into OR and laparoscopy done which showed perforation of lower esophageal end. It was repaired with 2-0 Vicryl interrupted sutures. Large bore drain was kept. On 2nd post-op day drain showed presence of saliva in it and methylene blue was positive for leak. Patient then underwent endoscopic fully coated stent placement.

Results

Patient was slowly started on liquids and was discharged after two days uneventfully. Stent was removed after 5 weeks and perforation showed good healing confirmed by oral contrast CT scan.

Conclusions

Application of excessive force to push the bougie can lead to lower esophageal injury. High index of suspicion and early intervention is must to avoid unpleasant outcomes