Background

We describe the case of a 50-year-old male patient with a known history of heart failure on LVAD support awaiting heart transplant. The patient underwent a sleeve gastrectomy and then experienced weight recurrence as he presented with a BMI of 48 kg/m2. Given that the aim was to obtain a BMI < 35 for the patient to be considered eligible for heart transplantation, he was started on weight loss medication and referred for revisional metabolic and bariatric surgery. The choice to proceed with a conversion to a single anastomosis duodeno-ileostomy was discussed with the patient. After obtaining consent, we proceeded with optimization of his anticoagulation status prior to surgery. Coumadin was stopped 5 days prior to surgery and the patient was admitted once his INR was < 2. The day of the surgery, the patient had an INR of 1.7. During the procedure, we report the occurrence of a pancreatic bleed estimated to be 300-400 cc. Peri-operative INR was 2. The bleeding was eventually controlled with tangential clips and an extended period of gauze compression. The conversion to the SADI-S itself was without any complication. The patient did well after surgery. His hemoglobin dropped to 11 from an initial value of 15 but quickly stabilized. The patient was discharged on POD 6 with an INR of 2.5 without the use of any anticoagulation whatsoever since admission. He was followed as an outpatient on Warfarin. In conclusion, bleeding might be expected in these cases, but all 'medical' bleeding eventually stops.