Kadoya Kengo, Wakamatsu Kotaro
Department of Surgery, Toho University Sakura Medical Center, Sakura, Chiba, Japan.
Surg Case Rep. 2025;11(1). doi: 10.70352/scrj.cr.25-0213. Epub 2025 Jun 21.
Laparoscopic sleeve gastrectomy is a standard and safe surgical procedure for patients with morbid obesity. A potential complication is piriform fossa injury, which can occur during calibration tube insertion. We encountered a case of descending necrotizing mediastinitis, a serious and progressive infection originating from a piriform fossa injury that was potentially exacerbated by diabetes.
A female patient with morbid obesity (body mass index, 41 kg/m) and a heavy smoking habit underwent laparoscopic sleeve gastrectomy and was discharged without any immediate postoperative complications. Six weeks later, the patient presented with severe chest and back pain that required continuous fentanyl injection for pain management. Initially, staple line leakage, commonly observed after sleeve gastrectomy, was suspected. However, her condition progressively worsened, and she was admitted to the ICU. An enhanced abdominal CT scan extending to the cervical region revealed a cervical abscess extending to the lower mediastinal region. The patient was diagnosed with descending necrotizing mediastinitis. Given the rarity of this disease, we hypothesized that her smoking habits exacerbated the piriform fossa injury caused by the calibration tube used during gastrectomy. Following the diagnosis, emergency abscess drainage surgery was performed, and the patient was successfully treated.
This is the 1st reported case of descending necrotizing mediastinitis as a fatal complication of laparoscopic sleeve gastrectomy, which was identified and treated successfully owing to the timely and expanded use of an enhanced CT scan that included the cervical region. Traditionally, the cervical area has not been routinely examined when diagnosing complications following abdominal surgery, underscoring the importance of a comprehensive imaging approach from the neck to the abdomen to detect complications after sleeve gastrectomy.
腹腔镜袖状胃切除术是治疗病态肥胖患者的一种标准且安全的外科手术。一种潜在的并发症是梨状窝损伤，它可能在插入校准管的过程中发生。我们遇到了一例下行性坏死性纵隔炎，这是一种源自梨状窝损伤的严重且进行性感染，糖尿病可能使其加重。
一名患有病态肥胖（体重指数为41kg/m²）且有重度吸烟习惯的女性患者接受了腹腔镜袖状胃切除术，术后无任何即刻并发症而出院。六周后，患者出现严重的胸部和背部疼痛，需要持续注射芬太尼进行疼痛管理。最初怀疑是袖状胃切除术后常见的吻合口漏。然而，她的病情逐渐恶化，随后被收入重症监护病房。一项延伸至颈部区域的增强腹部CT扫描显示，一个颈部脓肿延伸至下纵隔区域。该患者被诊断为下行性坏死性纵隔炎。鉴于这种疾病的罕见性，我们推测她的吸烟习惯加重了胃切除术中使用校准管导致的梨状窝损伤。确诊后，进行了紧急脓肿引流手术，患者得到成功治疗。
这是首例报道的腹腔镜袖状胃切除术致命并发症——下行性坏死性纵隔炎，由于及时且广泛地使用了包括颈部区域的增强CT扫描而得以确诊并成功治疗。传统上，在诊断腹部手术后的并发症时，颈部区域并未常规检查，这凸显了从颈部到腹部进行全面成像检查以检测袖状胃切除术后并发症的重要性。
