This patient is a 50-year-old male with a BMI of 39 and metabolic syndrome who presented as a referral from an outside surgeon after an attempted sleeve gastrectomy.


During his index operation, the dissection of the greater curvature was completed, and a very large (>1cm) vein was encountered on the diaphragm on the left crus. Then, the pars flaccida was opened and a similar vein was identified on the right crus. The procedure was then aborted.


Postoperative imaging revealed a portosplenic shunt without other anatomical abnormalities or varices. Given the concern for portal hypertension, a transjugular liver biopsy and hepatic wedge pressures were obtained. Biopsy revealed steatosis and bridging fibrosis (Stage 1b) but no cirrhosis and the hepatic pressures were normal. He then underwent successful coil embolization of this portosplenic shunt by interventional radiology. Six weeks later, he was taken back to the operating room to complete the sleeve gastrectomy.


Intraoperatively, the adhesions that had formed along the greater curvature were taken down. The fundus was mobilized off the left crus of the diaphragm and the previously seen vein on the left and anterior hiatus was not visualized and the shunt on the right was clearly occluded with the embolization coils. A routine sleeve gastrectomy was then completed without difficult over a 36 French Bougie. Completion endoscopy showed no abnormalities and the air leak test was negative. The patient made an uneventful recovery.