we report the case of one patient undergoing routine gastric bypass who experienced major complications .
a 56 year old female was referred from a district general hospital after a protracted history of abdominal pain and vomiting .
past medical history included osteoarthritis and hypertension , and a past surgical history of laparoscopic roux - en - y gastric bypass in 2008 ( pre - operative bmi of 48 kg / m2 ) .
a laparotomy and revision of roux - en - y gastric bypass was undertaken with post operative management on hdu , but the patient had ongoing problems with pain and wound discharge .
a ct scan revealed a 7 cm collection adjacent to the alimentary limb which was percutaneously drained under ultrasound guidance . due to clinical deterioration ,
a further ct was performed which demonstrated a large communicating collection filling the paracolic gutters and pelvis , with a multiloculated left lobe liver abscess , and a smaller abscess in the right lobe ( figure 1 ) .
the patient was discharged home . multiloculated abscess within the left lobe of liver the patient re - presented 2 weeks later with increasing epigastric pain and malaise .
imaging showed a persistent collection in the pelvis and liver , and a further two percutaneous procedures were performed . during inpatient stay , she became haemodynamically unstable with spiking temperatures and an elevating white cell count .
she also complained of bilateral discolouration of her toes and examination revealed increasing oedema with diminished pedal pulses .
a contrast ct scan of the abdomen confirmed ongoing collections with evidence of an aortic thrombus extending into the left iliac artery , presumed to be the embolic source for her vascular findings ( figure 2 & 3 ) .
there was resolution of vascular symptoms and evidence of improvement in peripheral perfusion postoperatively , and the patient was eventually discharged .
thrombus within the distal aorta shown by a filling defect ( red arrow ) extension into the left iliac artery shown by a filling defect ( red arrow )
surgery has inherent risks and complications , which may be further be potentiated by the high risk nature of bariatric patients .
a systematic review of the literature concluded that peri - operative complications were encountered more frequently in bypass patients compared to those undergoing laparoscopic gastric banding ( 9% and 5% ) , although long - term re - operation rates were lower ( 16% and 24% respectively ) ( 1 ) .
the mortality of both bypass and band operations were low ( 0.17% and 0.06% ) .
further systematic reviews have reported major early complications rates of gastric bypass surgery as 6.3% , with major complications including death ( 0.2% ) , perforation ( 0.5% ) , venous thromboembolism ( 0.3% ) , significant postoperative bleed ( 0.9% ) , postoperative infection ( 2.9% ) and anastomotic leaks ( 0.9% ) ( 1 ) . despite these risks gastric
bypass is an effective operation for obesity ; one study reported 76% excess body weight loss and a 78% resolution of diabetes at 1 year in patients undergoing bypass compared to 48% weight loss and 50% diabetes resolution in patients undergoing banding ( 2 ) .
generally high levels of patient satisfaction are recorded , estimated to approach 80% ( 3 ) .
venous thrombosis is well documented in the literature as a complication of obesity and bariatric surgery .
one study reported an incidence of deep vein thrombosis in the group of 500 consecutive patients to be 0.2% ( 4 ) .
however , there is little data regarding arterial thrombosis as a complication of bariatric surgery .
bariatric patients have significant risk factors for atherosclerotic disease , both due to obesity , and to secondary diseases such as hypertension and diabetes , which may develop as part of the metabolic syndrome .
however , with this patient there was no evidence of aortic thrombosis on previous imaging , and a new presentation of clinical signs and symptoms would be in keeping with a new onset thrombosis .
there are also factors relating to a hypercoagulable state , which in this patient could be numerous .
this patient had recurrent episodes of sepsis , which is well known to precipitate hypercoagulability , which at the severe end of the spectrum , exists disseminated intravascular coagulation ( dic ) .
sepsis mediated hypercoagulability occurs as a result of the activation of inflammatory and coagulation cascades ( 5 ) .
dehydration secondary to both poor intake and insensible losses through either infection or surgery may also cause an increased coagulable state . inflammatory and hypercoagulation may be due to the direct effects of surgery through the stress response ( 6 ) .
roux - en - y gastric bypass is deemed a safe operation in the management of obesity .
we present a case complicated postoperatively by recurrent intra - abdominal collections and sepsis , and aortic thrombosis with distal embolisation .
 laparoscopic gastric bypass is becoming a frequently performed bariatric operation for patients with obesity . however , bariatric surgery has inherent risks and complications , which are further potentiated by the high risk nature of bariatric patients . 
 these complications can be either site specific i.e. anastomotic leaks , or systemic i.e. venous thromboembolism , however they can intimately related . 
 we present the case of one patient undergoing routine gastric bypass complicated postoperatively by recurrent intra - abdominal collections and sepsis , and aortic thrombosis with distal embolisation . 
INTRODUCTION
CASE REPORT
DISCUSSION