title: Endoscopic Management of Massive Hemorrhage 12 h Post Laparoscopic Roux-en-Y Gastric Bypass.
abstract: BACKGROUND
  Acute (<24 h) staple line bleeding is not common but a known complication after bariatric surgery at a rate of 1-3%. In most cases, acute postoperative bleeding is mild and can be managed conservatively. Nonetheless, there are times when massive hemorrhage is encountered. Endoscopic treatment of these patients within 24 h of Roux-en-Y (RYGB) is controversial, due to fear of staple line dehiscence and/or perforation. Therefore, most surgeons prefer to undergo diagnostic laparoscopy for exploration and treatment. However, it has been reported that laparoscopic management of acute bleeding can be technically challenging with a high rate of morbidity as well as conversion to laparotomy. We herein present a multimedia video (6 min) demonstrating the management of acute massive hemorrhage after RYGB.
  
  
  METHODS
  A 46-year-old female with hemodynamic instability after massive hematemesis and melena underwent endoscopy. An overtube was utilized to allow removal of large blood clots which obstructed endoscopic visualization. Two bleeding points were noted, and these were successfully treated with adrenaline and endoscopic clips.
  
  
  RESULTS
  The patient rapidly improved during her hospital stay and commenced oral intake on day 1. A surveillance endoscopy was performed on day 5, and no stigmata of recent bleeding was noted. She was discharged home and is progressing well.
  
  
  CONCLUSIONS
  We suggest endoscopy is an appropriate first step for the investigation and management of acute intraluminal bleeding post bariatric surgery.
authors.affiliation: General and Digestive Surgery Unit, Pernambuco Federal University Hospital, 50610-160, Recife, Pernambuco, Brazil, josembergcampos@gmail.com.
authors.forename: Josemberg M
authors.initials: JM
authors.lastname: Campos
authors.forename: Rena
authors.initials: R
authors.lastname: Moon
authors.forename: Andre
authors.initials: A
authors.lastname: Teixeira
authors.forename: Alvaro A B
authors.initials: AA
authors.lastname: Ferraz
authors.forename: Flavio
authors.initials: F
authors.lastname: Ferreria
authors.forename: Vivek
authors.initials: V
authors.lastname: Kumbhari
mesh_terms: D004837:Epinephrine / Q000008:administration & dosage; D005260:Female; D015390:Gastric Bypass / Q000009:adverse effects*; D005773:Gastroscopy; D006801:Humans; D008875:Middle Aged; D009767:Obesity, Morbid / Q000601:surgery*; D019106:Postoperative Hemorrhage / Q000209:etiology / Q000628:therapy*; D013525:Surgical Instruments; D017792:Surgical Stapling; D014662:Vasoconstrictor Agents / Q000008:administration & dosage
chemical_list: D014662:Vasoconstrictor Agents; D004837:Epinephrine