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Farooqi S, Montrief T, Koyfman A, Long B. High risk and low incidence diseases: Bariatric surgery complications. Am J Emerg Med 2025; 87:113-122. [PMID: 39561500 DOI: 10.1016/j.ajem.2024.10.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Revised: 10/22/2024] [Accepted: 10/31/2024] [Indexed: 11/21/2024] Open
Abstract
INTRODUCTION Bariatric surgery complications carry a high rate of morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of bariatric surgery complications, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION Bariatric surgeries include restrictive procedures (e.g., adjustable gastric banding, endoscopic gastric balloon insertion, and sleeve gastrectomy) and mixed restrictive and malabsorptive procedures (e.g., roux-en-y gastric bypass and duodenal switch-biliopancreatic diversion). Several complications may occur, which may be associated with severe morbidity and mortality. These complications include anastomotic/staple line leaks, small bowel obstruction and internal hernia, marginal ulceration, biliary disease, and device-specific issues. History concerning the type of surgery, when and where it was performed, prior complications, changes in weight, and systemic symptoms is essential. Many signs and symptoms are subtle, but fever, tachycardia, and persistent vomiting are concerning for a severe complication. If there is concern for a complication, emergent consultation with the bariatric surgeon is recommended (preferably the patient's surgeon). Imaging studies can assist in the evaluation, including computed tomography with oral and intravenous contrast. Resuscitation in the ED and early intervention by a bariatric surgeon provide the best opportunity to reduce morbidity and mortality for patients with intra-abdominal pathology. CONCLUSION Understanding bariatric surgery complications can assist emergency clinicians in diagnosing and managing this potentially deadly disease.
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Affiliation(s)
- Samia Farooqi
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Timothy Montrief
- DeWitt Daughtry Family Department of Surgery, Department of Emergency Medicine, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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Pisarska-Adamczyk M, Stefura T, Małczak P, Major P, Wysocki M. Is It Possible to Predict Difficulties During Laparoscopic Sleeve Gastrectomy? A Single Centre Experience. J Pers Med 2024; 14:1098. [PMID: 39590590 PMCID: PMC11595906 DOI: 10.3390/jpm14111098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2024] [Revised: 10/24/2024] [Accepted: 11/04/2024] [Indexed: 11/28/2024] Open
Abstract
INTRODUCTION Laparoscopic sleeve gastrectomy (LSG) is a widely performed bariatric surgery across the globe. Understanding preoperative risk factors for possible intraoperative complications can aid in predicting surgical outcomes and shaping the approach to the procedure. This study aimed to identify and analyze potential risk factors associated with intraoperative difficulties during LSG. PATIENTS AND METHODS The analysis encompassed consecutive patients who underwent LSG from 2017 to 2020. Patients who encountered intraoperative difficulties during the procedure were categorized into Group 1, whereas those who did not experience such complications were placed in Group 2. To identify potential risk factors for intraoperative challenges, a thorough evaluation of demographic characteristics was conducted, including variables such as age, body mass index (BMI), comorbidities, and previous surgical history. RESULTS Group 1 included 37 patients (11.71%), while Group 2 comprised 279 patients (88.29%). Apart from higher rates of diabetes, pulmonary disease, and sleep apnea in Group 1, no significant differences were observed between the groups regarding demographic parameters. A univariate logistic regression analysis identified several risk factors associated with intraoperative difficulties, including a body mass index (BMI) greater than 50 kg/m2 (OR 2.15, 95%, CI 1.05-4.39, p = 0.0362), the experience of the operating surgeon (OR 9.22, 95% CI 4.31-19.72, p = 0.0058), the presence of diabetes (OR 2.44, 95% CI 1.19-4.98, p = 0.0146), and pulmonary disease (OR 12.22, 95% CI 1.97-75.75, p < 0.0001). In multivariate logistic regression analysis, only the surgeon's experience (OR 8.61, 95% CI 3.75-19.72, p < 0.0001) remained a significant factor influencing intraoperative difficulties. CONCLUSIONS The sole significant factor influencing the occurrence of intraoperative difficulties was the level of the surgeon's experience.
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Affiliation(s)
| | - Tomasz Stefura
- Department of Medical Education, Jagiellonian University Medical College, 31-008 Kraków, Poland;
| | - Piotr Małczak
- 2nd Department of General Surgery, Jagiellonian University Medical College, 30-688 Kraków, Poland; (P.M.); (P.M.)
| | - Piotr Major
- 2nd Department of General Surgery, Jagiellonian University Medical College, 30-688 Kraków, Poland; (P.M.); (P.M.)
| | - Michał Wysocki
- Department of General Surgery and Surgical Oncology, Ludwik Rydygier Memorial Hospital in Cracow, 31-820 Kraków, Poland;
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Coşkun M, Uprak TK, Günal Ö, Aliyeva A, Cingi A. Reinforcement in Laparoscopic Sleeve Gastrectomy: Is It Effective? Surg Laparosc Endosc Percutan Tech 2024; 34:290-294. [PMID: 38736400 DOI: 10.1097/sle.0000000000001283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 03/08/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND Despite the success of bariatric surgery in treating obesity, it can still lead to complications. The most serious and feared technical complications are bleeding and leakage from the gastric staple line. In this study, stapler line reinforcement was investigated to determine whether it affects postoperative leakage and bleeding rates and their management. MATERIALS AND METHODS Overall, 510 patients who underwent sleeve gastrectomy were evaluated retrospectively. They were divided into 2 groups according to whether reinforcement of the staple line with running imbricating sutures was performed. RESULTS In the reinforcement group, there were two leaks (0.7%), which were diagnosed seven and eight days after surgery. In the non-reinforcement group, there were nine leaks (4%). There was no difference between the two groups in staple line bleeding. CONCLUSIONS This study shows that reinforcement with continuous imbricating sutures is associated with less stapler line leakage and a lower reoperation rate at the cost of increased operative time.
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Affiliation(s)
- Mümin Coşkun
- Department of General Surgery, Marmara University School of Medicine, Istanbul, Turkey
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Meng M, Saini J, Fan D, Singh A, Farkas DT. Use of Indocyanine Green to Detect Intraoperative Staple-Line Leaks in Robotic Bariatric Surgery: An Observational Cohort Study. Cureus 2024; 16:e56991. [PMID: 38681259 PMCID: PMC11045299 DOI: 10.7759/cureus.56991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2024] [Indexed: 05/01/2024] Open
Abstract
Background Bariatric surgeries aid weight loss in patients with morbid obesity, yet staple-line leaks pose safety concerns. Multiple methods are used to help identify these links. Intraluminal indocyanine green (ICG) has been shown to be useful in other applications, and its use in robotic bariatric surgeries is underexplored. Objective The primary objective of this research project was to demonstrate the usage of intraluminal ICG in detecting staple-line leaks during robotic sleeve gastrectomy and robotic gastric bypass. Settings The research was conducted at Bronxcare Health System between June 2022 and June 2023. Methods We studied 150 consecutive participants undergoing robotic sleeve gastrectomy or robotic gastric bypass. Intraluminal ICG was used in each case in order to identify leaks. Data on comorbidities, detected intraoperative leaks, and detected postoperative leaks were collected. Results Out of the 150 patients who underwent robotic bariatric surgeries (139 for sleeve gastrectomy and 11 for gastric bypass), four cases (two for each procedure) were identified with intraoperative leaks using ICG, resulting in an overall 2.66% incidence rate. In those four patients with intraoperative leaks, reinforcing sutures and a drain were placed. Following the surgeries, none of the patients had radiologic or clinical leaks identified. Conclusions Intraluminal ICG presents a novel approach for detecting staple-line leaks in robotic bariatric surgery. Future studies can be done to look at a larger series of patients and compare leak detection rates between ICG and other methods.
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Affiliation(s)
- Muzi Meng
- School of Medicine, American University of the Carribean, Cupecoy, SXM
- General Surgery, BronxCare Health System, Bronx, USA
| | | | - David Fan
- Surgery, BronxCare Health System, Bronx, USA
| | - Ajit Singh
- General Surgery, BronxCare Health System, Bronx, USA
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Gönüllü E, Yüksel A, Coşkun M, Harmantepe T, Fırtına G, Karaman K. Oversewing the Staple Line: Does It Safe to Prevent Leakage? J Laparoendosc Adv Surg Tech A 2024; 34:120-126. [PMID: 37934468 DOI: 10.1089/lap.2023.0284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023] Open
Abstract
Introduction: The staple line (SL) leak remains one of the most serious complications after laparoscopic sleeve gastrectomy (LSG). The present study aims to determine whether reinforcing the SL with sutures is effective in maintaining tissue integrity. Materials and Methods: LSG Specimens of 60 patients were ex vivo studied. The specimens were divided into three groups: In group 1, the entire SL was reinforced, while the upper half part of the SL was reinforced from fundus to antrum in group 2. The SL was not reinforced in group 3. Then, the pressure inside the sample was increased, and the bursting pressure location and pressure value during the bursting were recorded. Results: The bursting pressure was significantly higher in entire and half oversewed SL groups than the none reinforced group (group 1: 115 mmHg [95-170]; group 2: 95 mmHg [80-120]; group 3: 40 mmHg [22-60], respectively, [P < .001]). The most common site of bursting was in the middle ⅓ of SL (35, 53.8%), followed by the proximal ⅓ part of SL (18, 27.7%), and the distal ⅓ part of SL (12, 18.5%), respectively. The bursting site was significantly more frequent in the corpus than the other parts of the SL (P = .013). Conclusion: Reinforcing the SL with sutures preserves tissue integrity. Although bursting was most frequently observed in the corpus region ex vivo, the fact that almost all real-life leaks develop in the area close to the Angle of His. This situation suggests that strengthening the suture line with reinforcement alone will not be protective enough against leaks in the fundus line, and factors such as tissue ischemia may be considered.
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Affiliation(s)
- Emre Gönüllü
- Gastrointestinal Surgery Department, Sakarya University Faculty of Medicine, Sakarya, Turkey
| | - Adem Yüksel
- Gastrointestinal Surgery Department, Sakarya University Faculty of Medicine, Sakarya, Turkey
| | - Murat Coşkun
- General Surgery Department, Sakarya Training and Research Hospital, Sakarya, Turkey
| | - Tarık Harmantepe
- General Surgery Department, Sakarya Training and Research Hospital, Sakarya, Turkey
| | - Gizem Fırtına
- Gastrointestinal Surgery Department, Sakarya University Faculty of Medicine, Sakarya, Turkey
| | - Kerem Karaman
- Gastrointestinal Surgery Department, Sakarya University Faculty of Medicine, Sakarya, Turkey
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Verras GI, Mulita F, Lampropoulos C, Kehagias D, Curwen O, Antzoulas A, Panagiotopoulos I, Leivaditis V, Kehagias I. Risk Factors and Management Approaches for Staple Line Leaks Following Sleeve Gastrectomy: A Single-Center Retrospective Study of 402 Patients. J Pers Med 2023; 13:1422. [PMID: 37763189 PMCID: PMC10532722 DOI: 10.3390/jpm13091422] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 08/26/2023] [Accepted: 09/19/2023] [Indexed: 09/29/2023] Open
Abstract
Sleeve gastrectomy (SG) has gained ever-increasing popularity among laparoscopic surgeons involved in bariatric surgery. This single-institution, retrospective cohort study aims to evaluate the prevalence of postoperative staple line leakage (PSLL) after LSG and identify risk factors for its development. We included patient data that underwent LSG at our institution for a span of 17 years-starting in January 2005 and ending in December 2022. We set the investigation of correlations of patient-related factors (age, weight, BMI, smoking status, presence of diabetes mellitus) with the occurrence of postoperative leaks. A total of 402 patients were included in our study. Of them, 26 (6.46%) developed PSLL. In total, 19 (73%) patients underwent percutaneous drainage and 14 patients (53.8%) were treated with intraluminal endoscopic stenting. Finally, five patients (19.2%) were treated with endoscopic clipping of the defect. Operative management was required in only one patient. There were no statistically significant differences in patient age, mean weight at the time of operation, and mean BMI. Abnormal drain amylase levels were associated with earlier detection of PSLL. More consideration needs to be given to producing a consensus regarding the management of PSLL, prioritizing nonoperative management with the combination of percutaneous drainage and endoscopic stenting as the safest and most efficient approach.
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Affiliation(s)
- Georgios-Ioannis Verras
- Department of Surgery, General University Hospital of Patras, 26504 Patras, Greece
- General Surgery, Epsom and St. Helier University Hospitals, National Health Service (NHS) Trust, London SM5 1AA, UK
| | - Francesk Mulita
- Department of Surgery, General University Hospital of Patras, 26504 Patras, Greece
| | | | - Dimitrios Kehagias
- Department of Surgery, General University Hospital of Patras, 26504 Patras, Greece
| | - Oliver Curwen
- General Surgery, Epsom and St. Helier University Hospitals, National Health Service (NHS) Trust, London SM5 1AA, UK
| | - Andreas Antzoulas
- General Surgery, Epsom and St. Helier University Hospitals, National Health Service (NHS) Trust, London SM5 1AA, UK
| | - Ioannis Panagiotopoulos
- Department of Cardiothoracic Surgery, General Hospital of Athens “Ippokrateio”, 11527 Athens, Greece
| | - Vasileios Leivaditis
- Department of Cardiothoracic and Vascular Surgery, Westpfalz-Klinikum, 67655 Kaiserslautern, Germany
| | - Ioannis Kehagias
- Department of Surgery, General University Hospital of Patras, 26504 Patras, Greece
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Li M, Zeng N, Liu Y, Sun X, Yang W, Liu Y, Mao Z, Yao Q, Zhao X, Liang H, Lou W, Ma C, Song J, Wu J, Yang W, Zhang P, Zhu L, Tian P, Zhang P, Zhang Z. Management and outcomes of gastric leak after sleeve gastrectomy: results from the 2010-2020 national registry. Chin Med J (Engl) 2023; 136:1967-1976. [PMID: 37525550 PMCID: PMC10431592 DOI: 10.1097/cm9.0000000000002499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Management of gastric leak after sleeve gastrectomy (SG) is challenging due to its unpredictable outcomes. We aimed to summarize the characteristics of SG leaks and analyze interventions and corresponding outcomes in a real-world setting. METHODS To retrospectively review of 15,721 SG procedures from 2010 to 2020 based on a national registry. A cumulative sum analysis was used to identify a fitting curve of gastric leak rate. The Kaplan-Meier method and log-rank tests were performed to calculate and compare the probabilities of relevant outcomes. The logistic regression analysis was conducted to determine the predictors of acute leaks. RESULTS A total of 78 cases of SG leaks were collected with an incidence of 0.5% (78/15,721) from this registry (6 patients who had the primary SG in non-participating centers). After accumulating 260 cases in a bariatric surgery center, the leak rate decreased to a stably low value of under 1.17%. The significant differences presented in sex, waist circumference, and the proportion of hypoproteinemia and type 2 diabetes at baseline between patients with SG leak and the whole registry population ( P = 0.005, = 0.026, <0.001, and = 0.001, respectively). Moreover, 83.1% (59/71) of the leakage was near the esophagogastric junction region. Leakage healed in 64 (88.9%, 64/72) patients. The median healing time of acute and non-acute leaks was 5.93 months and 8.12 months, respectively. Acute leak (38/72, 52.8%) was the predominant type with a cumulative reoperation rate >50%, whereas the cumulative healing probability in the patients who required surgical treatment was significantly lower than those requring non-surgical treatment ( P = 0.013). Precise dissection in the His angle area was independently associated with a lower acute leak rate, whereas preservation ≥2 cm distance from the His angle area was an independent risk factor. CONCLUSIONS Male sex, elevated waist circumference, hypoproteinaemia, and type 2 diabetes are risk factors of gastric leaks after SG. Optimizing surgical techniques, including precise dissection of His angle area and preservation of smaller gastric fundus, should be suggested to prevent acute leaks.
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Affiliation(s)
- Mengyi Li
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University & National Clinical Research Center for Digestive Diseases, Beijing 100050, China
| | - Na Zeng
- School of Public Health, Peking University, Beijing 100191, China
| | - Yang Liu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University & National Clinical Research Center for Digestive Diseases, Beijing 100050, China
| | - Xitai Sun
- Department of General Surgery, Nanjing Drum Tower Hospital, Nanjing, Jiangsu 210008, China
| | - Wah Yang
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong 510630, China
| | - Yanjun Liu
- Center of Gastrointestinal and Minimally Invasive Surgery, Department of General Surgery, The Third People's Hospital of Chengdu & The Affiliated Hospital of Southwest Jiaotong University, Chengdu, Sichuan 610014, China
| | - Zhongqi Mao
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, China
| | - Qiyuan Yao
- Center for Obesity and Metabolic Surgery, Huashan Hospital, Fudan University, Shanghai 200030, China
| | - Xiangwen Zhao
- Department of Metabolic and Bariatric Surgery, Xiaolan People's Hospital of Zhongshan, Zhongshan, Guangdong 528415, China
| | - Hui Liang
- Department of General Surgery, First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu 226399, China
| | - Wenhui Lou
- Department of General Surgery, Zhongshan Hospital, Shanghai 200032, China
| | - Chiye Ma
- Department of Gastrointestinal Surgery, Dongfang Hospital of Shaghai, Shanghai 200120, China
| | - Jinghai Song
- Department of General Surgery, Beijng Hospital, Beijing 100730, China
| | - Jianlin Wu
- Department of Gastrointestinal Surgery, Zibo Central Hospital, Zibo, Shandong 255020, China
| | - Wei Yang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Pin Zhang
- Department of Bariatric and Metabolic Surgery, Shanghai Jiao Tong University affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Liyong Zhu
- Department of Gastrointestinal Surgery,The Third Xiangya Hospital of Central South University, Changsha, Hunan 410013, China
| | - Peirong Tian
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University & National Clinical Research Center for Digestive Diseases, Beijing 100050, China
| | - Peng Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University & National Clinical Research Center for Digestive Diseases, Beijing 100050, China
| | - Zhongtao Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University & National Clinical Research Center for Digestive Diseases, Beijing 100050, China
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Diab ARF, Alfieri S, Doyle W, Koussayer B, Docimo S, Sujka JA, DuCoin CG. Seamguard Buttressing of the Staple Line During Laparoscopic Sleeve Gastrectomy Appears to Decrease the Incidence of Postoperative Bleeding, Leaks, and Reoperations. A Systematic Review and Meta-Analysis of Non-Randomized Comparative Studies. Obes Surg 2023; 33:2237-2245. [PMID: 37204531 DOI: 10.1007/s11695-023-06649-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 05/07/2023] [Accepted: 05/12/2023] [Indexed: 05/20/2023]
Abstract
Leaks and bleeding are major acute postoperative complications following laparoscopic sleeve gastrectomy (LSG). Various staple line reinforcement (SLR) methods have been invented such as oversewing/suturing (OS/S), omentopexy/gastropexy (OP/GP), gluing, and buttressing. However, many surgeons do not use any type of reinforcement. On the other hand, surgeons who use a reinforcement method are often confused of what kind of reinforcement they should use. No robust and high-quality data supports the use of one reinforcement over the other or even supports the use of reinforcement over no-reinforcement. Therefore, SLR is a controversial topic that is worth our focus. The aim of this study is to compare the outcomes of LSG with versus without Seamguard buttressing of the staple line during LSG.
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Affiliation(s)
- Abdul-Rahman F Diab
- Division of Gastrointestinal Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, 5 Tampa General Circle, Tampa, FL, 33606, USA.
| | - Sarah Alfieri
- University of South Florida Morsani College of Medicine, 560 Channelside Dr, Tampa, FL, 33602, USA
| | - William Doyle
- University of South Florida Morsani College of Medicine, 560 Channelside Dr, Tampa, FL, 33602, USA
| | - Bilal Koussayer
- University of South Florida Morsani College of Medicine, 560 Channelside Dr, Tampa, FL, 33602, USA
| | - Salvatore Docimo
- Division of Gastrointestinal Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, 5 Tampa General Circle, Tampa, FL, 33606, USA
| | - Joseph A Sujka
- Division of Gastrointestinal Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, 5 Tampa General Circle, Tampa, FL, 33606, USA
| | - Christopher G DuCoin
- Division of Gastrointestinal Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, 5 Tampa General Circle, Tampa, FL, 33606, USA
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de Oliveira VL, Bestetti AM, Trasolini RP, de Moura EGH, de Moura DTH. Choosing the best endoscopic approach for post-bariatric surgical leaks and fistulas: Basic principles and recommendations. World J Gastroenterol 2023; 29:1173-1193. [PMID: 36926665 PMCID: PMC10011956 DOI: 10.3748/wjg.v29.i7.1173] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/28/2022] [Accepted: 01/30/2023] [Indexed: 02/21/2023] Open
Abstract
Post-surgical leaks and fistulas are the most feared complication of bariatric surgery. They have become more common in clinical practice given the increasing number of these procedures and can be very difficult to treat. These two related conditions must be distinguished and characterized to guide the appropriate treatment. Leak is defined as a transmural defect with communication between the intra and extraluminal compartments, while fistula is defined as an abnormal communication between two epithelialized surfaces. Traditionally, surgical treatment was the preferred approach for leaks and fistulas and was associated with high morbidity with significant mortality rates. However, with the development of novel devices and techniques, endoscopic therapy plays an increasingly essential role in managing these conditions. Early diagnosis and endoscopic therapy initiation after clinical stabilization are crucial to success since clinical success rates are higher for acute leaks and fistulas when compared to late and chronic leaks and fistulas. Several endoscopic techniques are available with different mechanisms of action, including direct closure, covering/diverting or draining. The treatment should be individualized by considering the characteristics of both the patient and the defect. Although there is a lack of high-quality studies to provide standardized treatment algorithms, this narrative review aims to provide a summary of the current scientific evidence and, based on this data and our extensive experience, make recommendations to help choose the best endoscopic approach for the management of post-bariatric surgical leaks and fistulas.
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Affiliation(s)
- Victor Lira de Oliveira
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403010, Brazil
| | - Alexandre Moraes Bestetti
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403010, Brazil
| | - Roberto Paolo Trasolini
- Division of Gastroenterology, Hepatology and Endoscopy, Harvard Medical School, Brigham and Women's Hospital, Boston, MA 021115, United States
| | - Eduardo Guimarães Hourneaux de Moura
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403010, Brazil
| | - Diogo Turiani Hourneaux de Moura
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403010, Brazil
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Pavone G, Fersini A, Pacilli M, Cianci P, Ambrosi A, Tartaglia N. Anastomotic leak test using indocyanine green during laparoscopic Roux-en-Y gastric bypass: A cohort study. Ann Med Surg (Lond) 2022; 84:104939. [PMID: 36536736 PMCID: PMC9758372 DOI: 10.1016/j.amsu.2022.104939] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/24/2022] [Accepted: 11/12/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Indocyanine green (ICG) can be injected into the human bloodstream and it allows us to show stomach vascularity in real time. The aim of our study is to observe the preliminary results of the application of indocyanine green fluorescence (IGF) during laparoscopic Roux-en-Y Gastric Bypass (RYGB in our center and how the perfusion of the gastro-jejunal anastomosis affects the onset of fistula. MATERIALS AND METHODS 30 consecutive patients underwent RYGB with ICG fluorescence angiography at our center from January 2020 to December 2021.5 ml of ICG were then injected intravenously to identify the blood supply of the stomach and the gastro-jejunal anastomosis. The UIN for ClinicalTrial.gov Protocol Registration and Results System is: NCT05476159 for the Organization UFoggia. RESULTS In the RYGB tested with ICG, we all have adequate perfusion but despite this a methylene blue test was positive and allowed us to reinforce the suture of the gastro-jejunal anastomosis. CONCLUSION Intraoperative ICG testing during laparoscopic RYGB may be helpful in determining which patients are at an increased risk for leakage but multiple factors concur to the pathophysiology and the incidence of gastric fistula not only the perfusion.
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Affiliation(s)
- Giovanna Pavone
- Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto, 71122, Foggia, Italy
| | - Alberto Fersini
- Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto, 71122, Foggia, Italy
| | - Mario Pacilli
- Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto, 71122, Foggia, Italy
| | - Pasquale Cianci
- General Surgery Unit, Bonomo Hospital, Viale Istria, 76123, Andria, BT, Italy
| | - Antonio Ambrosi
- Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto, 71122, Foggia, Italy
| | - Nicola Tartaglia
- Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto, 71122, Foggia, Italy
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11
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Pavone G, Fersini A, Pacilli M, De Fazio M, Panzera P, Ambrosi A, Tartaglia N. Can indocyanine green during laparoscopic sleeve gastrectomy be considered a new intraoperative modality for leak testing? BMC Surg 2022; 22:341. [PMID: 36114496 PMCID: PMC9482312 DOI: 10.1186/s12893-022-01796-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 09/14/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Indocyanine green (ICG) when injected intravenously into the bloodstream allows us to show stomach vascularity in real time. The aim of our study was to observe the preliminary results of the application of indocyanine green fluorescence (IGF) during laparoscopic sleeve gastrectomy (LSG) in our center and how the perfusion of the staple line of the stomach affects the onset of fistula. MATERIALS AND METHODS 82 patients underwent LSG with ICG fluorescence angiography at our center from January 2020 to December 2021. 5 ml of ICG was injected intravenously to identify the blood supply of the stomach, carefully assessing the angle of His. RESULTS In the ICG-tested LSG, we recorded adequate perfusion in all patients but one: the leakage rate was 1.2%. This data is inferior to the non-tested patients' group. CONCLUSION Intraoperative ICG testing may be helpful in determining which patients are at an increased risk for leakage but there are multiple factors contribute to the pathophysiology and the incidence of gastric fistula not only the perfusion. Trial registration Retrospectively registrated.
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Affiliation(s)
- Giovanna Pavone
- Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto 1, 71122 Foggia, Italy
| | - Alberto Fersini
- Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto 1, 71122 Foggia, Italy
| | - Mario Pacilli
- Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto 1, 71122 Foggia, Italy
| | - Michele De Fazio
- Department of General Surgery and Liver Transplantation, University of Bari, 70124 Bari, Italy
| | - Piercarmine Panzera
- Department of General Surgery and Liver Transplantation, University of Bari, 70124 Bari, Italy
| | - Antonio Ambrosi
- Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto 1, 71122 Foggia, Italy
| | - Nicola Tartaglia
- Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto 1, 71122 Foggia, Italy
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COMPUTED TOMOGRAPHY ASSESSMENT OF POSTOPERATIVE GASTRIC VASCULAR SUPPLY AND STAPLE-LINE LEAK DEVELOPMENT AFTER SLEEVE GASTRECTOMY. Surg Obes Relat Dis 2022; 18:812-819. [DOI: 10.1016/j.soard.2022.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/05/2022] [Accepted: 03/26/2022] [Indexed: 11/23/2022]
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Głuszyńska P, Diemieszczyk I, Szczerbiński Ł, Krętowski A, Major P, Razak Hady H. Risk Factors for Early and Late Complications after Laparoscopic Sleeve Gastrectomy in One-Year Observation. J Clin Med 2022; 11:jcm11020436. [PMID: 35054132 PMCID: PMC8779692 DOI: 10.3390/jcm11020436] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/11/2022] [Accepted: 01/14/2022] [Indexed: 12/10/2022] Open
Abstract
BACKGROUND Although laparoscopic sleeve gastrectomy (LSG) is considered a safe bariatric procedure in the treatment of obesity, it still involves a risk of developing postoperative complications. Knowledge of risk factors for possible complications would allow appropriate preoperative planning, optimization of postoperative care, as well as early diagnosis and treatment. The aim of this study was to evaluate risk factors for complications after laparoscopic sleeve gastrectomy. METHODS A retrospective study of 610 patients who underwent LSG at a tertiary institution were included in the study through retrospective analysis of the medical data. Complications were categorized as early (<30 days) and late (≥30 days) and evaluated according to the Clavien-Dindo Classification. RESULTS Early complications were observed in 35 patients (5.74%) and late complications occurred in 10 patients (1.64%). Independent risk factors of early complications after laparoscopic sleeve gastrectomy included hypercholesterolemia (OR 3.73; p-value = 0.023) and smoking (OR = 274.66, p-value < 0.001). Other factors that may influence the postoperative course are length of hospital stay and operation time. Smoking, peptic ulcer diseases and co-existence of hiatal hernia were found to be an independent predictors of late complications. CONCLUSIONS Smoking is associated with the higher risk of both, early and late complications, while hypercholesterolemia with only <30 days complications after laparoscopic sleeve gastrectomy.
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Affiliation(s)
- Paulina Głuszyńska
- 1st Department of General and Endocrine Surgery, Medical University of Bialystok, 15-089 Bialystok, Poland; (I.D.); (H.R.H.)
- Correspondence: ; Tel.: +48-85-831-8279
| | - Inna Diemieszczyk
- 1st Department of General and Endocrine Surgery, Medical University of Bialystok, 15-089 Bialystok, Poland; (I.D.); (H.R.H.)
| | - Łukasz Szczerbiński
- Department of Endocrinology, Diabetology and Internal Medicine, Medical University of Bialystok, 15-089 Bialystok, Poland; (Ł.S.); (A.K.)
| | - Adam Krętowski
- Department of Endocrinology, Diabetology and Internal Medicine, Medical University of Bialystok, 15-089 Bialystok, Poland; (Ł.S.); (A.K.)
| | - Piotr Major
- 2nd Department of General Surgery, Jagiellonian University Medical College, 31-008 Krakow, Poland;
| | - Hady Razak Hady
- 1st Department of General and Endocrine Surgery, Medical University of Bialystok, 15-089 Bialystok, Poland; (I.D.); (H.R.H.)
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Köhler H, Markov V, Watschke A, Gruner-Labitzke K, Böker C, Kröger C. Changes in Work Ability after Weight-Loss Surgery: Results of a Longitudinal Study of Persons with Morbid Obesity before and after Bariatric Surgery. Obes Facts 2022; 15:36-45. [PMID: 34749355 PMCID: PMC8820149 DOI: 10.1159/000519269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 08/17/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Bariatric surgery is a life-changing treatment, but knowledge of its influence on changes in work ability is still limited. We hypothesized that self-reported work ability improves in response to surgery-induced weight loss and sociodemographical variables (e.g., age, sex, and marital status), and that psychosocial characteristics (e.g., depressive symptoms and dysfunctional eating) may have predictive value as to patients' work ability. METHODS A total of 200 participants scheduled for bariatric surgery were recruited between September 2015 and June 2018. They completed several self-report measures at the preoperative examination (t1) and at 6- (t2) and 12 months (t3) after bariatric surgery. A repeated-measures analysis of variance was calculated to detect any changes in the work ability and body mass index (BMI) among the 3 time points. Further, a hierarchical multiple regression analysis was used to determine whether any demographical and psychosocial characteristics at (t1) would predict work ability at (t3). RESULTS Participants (82% of whom were women) were middle-aged and showed a BMI of nearly 46 at the preoperative medical examination. Excess weight loss at (t2) and at (t3) was 49 and 66%, respectively. Work ability increased toward a moderate level after weight-loss surgery. Work ability and dysfunctional eating at (t1) showed significant predictive value with respect to work ability at (t3). DISCUSSION The results suggest that weight-loss surgery has a positive impact on work ability, and indicate a predictive value for the extent of weight loss and dysfunctional eating behavior. Against our hypothesis and in contrast to former research, a predictive value for depressive symptoms and age was not revealed. Further research must show how interventions can support and maintain improvements in work ability after bariatric surgery, in order to reduce sick leave and unemployment in patients with preoperative morbid obesity.
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Affiliation(s)
- Hinrich Köhler
- Department of General, Visceral, and Bariatric Surgery, Herzogin Elisabeth Hospital, Braunschweig, Germany
- *Hinrich Köhler,
| | - Valentin Markov
- Department of Psychology, University of Hildesheim, Hildesheim, Germany
| | - Anna Watschke
- Department of Psychology, University of Braunschweig, Braunschweig, Germany
| | - Kerstin Gruner-Labitzke
- Department of General, Visceral, and Bariatric Surgery, Herzogin Elisabeth Hospital, Braunschweig, Germany
| | - Clara Böker
- Department of General, Visceral, Vascular, and Bariatric Surgery, Klinikum Nordstadt, Hannover, Germany
| | - Christoph Kröger
- Department of Psychology, University of Hildesheim, Hildesheim, Germany
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Boeker C, Schneider B, Markov V, Mall J, Reetz C, Wilkens L, Hakami I, Stroh C, Köhler H. Primary Sleeve Gastrectomy and Leaks: The Impact of Fundus-Wall Thickness and Staple Heights on Leakage-An Observational Study of 500 Patients. Front Surg 2021; 8:747171. [PMID: 34746223 PMCID: PMC8566748 DOI: 10.3389/fsurg.2021.747171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 09/24/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: The most feared complication of laparoscopic sleeve gastrectomy (LSG) is staple-line leakage. Staple height and fundus-wall thickness might influence such leakage, and this study examined their possible impact on leak incidence. Factors including gender, age, comorbidities, and reinforcement of the staple line were also investigated. Methods: A total of 500 patients between 17 and 71 years of age who were scheduled for LSG were selected to participate in the study. For technical reasons, 53 were excluded. The fundus-wall thickness of 447 patients after LSG was investigated. The impact of staple height, fundus-wall thickness, demographic and medical factors on leak incidence were investigated. Most of our patients (309) were female (69%), while 138 were male (31%). Results: The mean thickness of the proximal fundus wall was 2,904 μm, 3,172 μm in men and 2,784 μm in women. The leak rate was 4.9%. Age, fundus-wall thickness, and BMI showed a strong influence on leak risk, but this effect was significant only for age (p = 0.01). Patient gender and staple size showed no significant influence on the correlation between fundus-wall thickness and leak risk. Gender displayed a small effect of influence on this correlation, with η2 = 0.05. Discussion: Because older age had a significant effect on increasing the risk of staple-line leakage, there is a need for a more specific focus on these patients. Thinner fundus wall and female gender might predispose patients to staple-line leaks, but a significant value could not be reached. Therefore, staple size should remain the surgeon's choice based on clinical experience.
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Affiliation(s)
- Clara Boeker
- Department of General, Visceral, Vascular and Bariatric Surgery, Klinikum Nordstadt, Hannover, Germany
| | | | - Valentin Markov
- Department of Psychology, University of Hildesheim, Hildesheim, Germany
| | - Julian Mall
- Department of General, Visceral, Vascular and Bariatric Surgery, Klinikum Nordstadt, Hannover, Germany
| | - Christian Reetz
- Department of General, Visceral, Vascular and Bariatric Surgery, Klinikum Nordstadt, Hannover, Germany
| | - Ludwig Wilkens
- Department of Pathology, Klinikum Nordstadt, Hannover, Germany
| | - Ibrahim Hakami
- Department of General, Visceral and Bariatric Surgery, College of Medicine at Jazan University, Jizan, Saudi Arabia
| | - Christine Stroh
- Department of Bariatric Surgery, Stiftung Rehabilitation Heidelberg Waldklinikum, Gera, Germany
| | - Hinrich Köhler
- Department of General, Visceral and Bariatric Surgery, Herzogin Elisabeth Hospital, Braunschweig, Germany
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16
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Gjeorgjievski M, Imam Z, Cappell MS, Jamil LH, Kahaleh M. A Comprehensive Review of Endoscopic Management of Sleeve Gastrectomy Leaks. J Clin Gastroenterol 2021; 55:551-576. [PMID: 33234879 DOI: 10.1097/mcg.0000000000001451] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/02/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bariatric surgery leaks result in significant morbidity and mortality. Experts report variable therapeutic approaches, without uniform guidelines or consensus. OBJECTIVE To review the pathogenesis, risk factors, prevention, and treatment of gastric sleeve leaks, with a focus on endoscopic approaches. In addition, the efficacy and success rates of different treatment modalities are assessed. DESIGN A comprehensive review was conducted using a thorough literature search of 5 online electronic databases (PubMed, PubMed Central, Cochrane, EMBASE, and Web of Science) from the time of their inception through March 2020. Studies evaluating gastric sleeve leaks were included. MeSH terms related to "endoscopic," "leak," "sleeve," "gastrectomy," "anastomotic," and "bariatric" were applied to a highly sensitive search strategy. The main outcomes were epidemiology, pathophysiology, diagnosis, treatment, and outcomes. RESULTS Literature search yielded 2418 studies of which 438 were incorporated into the review. Shock and peritonitis necessitate early surgical intervention for leaks. Endoscopic therapies in acute and early leaks involve modalities with a focus on one of: (i) defect closure, (ii) wall diversion, or (iii) wall exclusion. Surgical revision is required if endoscopic therapies fail to control leaks after 6 months. Chronic leaks require one or more endoscopic, radiologic, or surgical approaches for fluid collection drainage to facilitate adequate healing. Success rates depend on provider and center expertise. CONCLUSION Endoscopic management of leaks post sleeve gastrectomy is a minimally invasive and effective alternative to surgery. Their effect may vary based on clinical presentation, timing or leak morphology, and should be tailored to the appropriate endoscopic modality of treatment.
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Affiliation(s)
- Mihajlo Gjeorgjievski
- Departments of Gastroenterology & Hepatology
- Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, MI
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical Center, New Brunswick, NJ
| | - Zaid Imam
- Departments of Gastroenterology & Hepatology
- Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Mitchell S Cappell
- Departments of Gastroenterology & Hepatology
- Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Laith H Jamil
- Departments of Gastroenterology & Hepatology
- Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Michel Kahaleh
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical Center, New Brunswick, NJ
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Horn A, Assalia A, Sayida S, Mahajna A. Amylase Is Not a Useful Indicator for Leakage Detection Following Sleeve Gastrectomy: A Prospective Study. Surg Innov 2021; 29:44-49. [PMID: 34144654 DOI: 10.1177/15533506211027830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction. Gastric leak after laparoscopic sleeve gastrectomy (LSG) is a severe complication that may lead to sepsis and even death. Early diagnosis and treatment are critical. The aims of this prospective study are to establish normal amylase levels and investigate elevated amylase levels, especially in the drain, for detecting anastomotic leakage following LSG. Material and Methods. One hundred sixty-one patients who underwent LSG during 1 year at Rambam Health Care Campus were included prospectively in the study. Demographic and medical background, peri- and postoperative complications, and laboratory data including amylase levels in blood, urine, and drain were evaluated. Univariate and multivariate analyses were performed to examine independent variables that can predict increases in amylase values. Results. Thirty-five (21.8%) patients had high levels of amylase in blood, urine, and/or drain and 126 (78.2%) normal values of amylase until discharge. No significant differences were found in operation duration, length of hospitalization, or occurrence of complications. One patient had a staple-line leak diagnosed in the third postoperative day that was treated conservatively with endoscopic approach. His amylase levels in the blood and drain were normal, with only a slight hyperamylasuria. Conclusions. High amylase levels after LSG does not necessarily indicate a major complication such as staple-line leak, and in the vast majority of cases, it seems to have no clinical relevancy. Therefore, it should not automatically lead to a full investigation in the absence of further clinical signs. It is suggested that there is no clinical justification to test amylase routinely after LSG.
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Affiliation(s)
- Amyt Horn
- Department of General Surgery, Faculty of Medicine, 574334Rambam Health Care Campus and the Bruce Rappaport, Institute of Technology, Haifa, Israel
| | - Ahmad Assalia
- Department of General Surgery, Faculty of Medicine, 574334Rambam Health Care Campus and the Bruce Rappaport, Institute of Technology, Haifa, Israel
| | - Sa'd Sayida
- Department of General Surgery, Faculty of Medicine, 574334Rambam Health Care Campus and the Bruce Rappaport, Institute of Technology, Haifa, Israel
| | - Ahmad Mahajna
- Department of General Surgery, Faculty of Medicine, 574334Rambam Health Care Campus and the Bruce Rappaport, Institute of Technology, Haifa, Israel
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Baptiste-Castillo HF, Parra-Zuluaga R, Niño-Andrade F, Rodríguez-Sánchez S. Manejo quirúrgico de una fístula gastropleural posterior a manga gástrica. REVISTA COLOMBIANA DE CIRUGÍA 2021. [DOI: 10.30944/20117582.771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Se presenta el caso de una paciente de 30 años de edad, sometida a un procedimiento de manga gástrica por laparoscopia en marzo de 2014, quien presenta, al tercer y cuarto años del procedimiento inicial, dos episodios de hemoptisis masiva, con falla en la segunda terapia de embolización, por lo que requirió una lobectomía pulmonar inferior izquierda. Al segundo día de este postoperatorio presenta salida de material de nutrición por las sondas de tórax, estableciéndose el diagnóstico de fistula gastro-pleural. Debido a falla con el manejo conservador, fue sometida a una resección quirúrgica de la fístula por vía laparoscópica, con gastrectomía proximal y reconstrucción en Y de Roux. A propósito de nuestra experiencia con esta paciente, se discuten en este artículo las estrategias de manejo para una fístula gastropleural, propuestas en la literatura a la fecha.
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Ergin A, Çiyiltepe H, Karip AB, Fersahoğlu MM, Bulut NE, Çakmak A, Topaloğlu B, Bilgili AC, Somay A, Taşdelen İ, Akyüz Ü, Memişoğlu K. The Effect of Helicobacter pylori Eradication on Gastric Wall Thickness in Patients Undergoing Laparoscopic Sleeve Gastrectomy. Obes Surg 2021; 31:4024-4032. [PMID: 34075550 DOI: 10.1007/s11695-021-05513-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 05/24/2021] [Accepted: 05/26/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE The most important cause affecting the thickness of the gastric wall other than the tumor is chronic gastritis caused by Helicobacter pylori (Hp), which is most frequently detected in the antrum. This study aims to investigate the effect of bismuth-based treatment (BBT) combined with proton pump inhibitor (PPI) on wall thicknesses measured in the postoperative gastric specimen and early postoperative complications in patients with Hp-positive pre-LSG endoscopic gastric biopsies. MATERIALS AND METHODS The patients who underwent LSG procedure for morbid obesity were divided into three groups as follows: Hp-negative, Hp-positive without eradication treatment, and Hp-positive, and LSG was performed after eradication treatment. Macroscopic and microscopic gastric wall thickness measurements were made at a distance of 1 cm from the proximal surgical margin, from the middle part of the specimen, and 1 cm from the distal surgical margin in the gastric specimen and the results were compared. RESULTS A total of 132 patients were included in the study, 44 patients in each group. Microscopically measured antrum mucosal thickness was found to be statistically significantly higher in group 2 compared to other groups (groups 1.15, 1.35, 1.16 mm, respectively, p = 0.000). There was no difference between the groups in terms of early complications such as bleeding, wound site infection, or leakage from the staple line within the first 28 days after surgery. CONCLUSION This study found that LSG had no effect on early complications due to Hp positivity or eradication of Hp. KEY POINTS • The presence of HP increases the wall thickness of the gastric antrum mucosa. • After HP eradication, stomach antrum wall thickness returns to normal. • HP eradication before LSG reduces the wall thickness of the gastric antrum mucosa. • It was determined that HP scanning and eradication before LSG had no effect on postoperative complications.
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Affiliation(s)
- Anıl Ergin
- General Surgery Department, Fatih Sultan Mehmet Training and Research Hospital, Hastane Street No: 1/8 Icerenkoy, 34752, Istanbul, Turkey.
| | - Hüseyin Çiyiltepe
- General Surgery Department, Fatih Sultan Mehmet Training and Research Hospital, Hastane Street No: 1/8 Icerenkoy, 34752, Istanbul, Turkey
| | - Aziz Bora Karip
- General Surgery Department, Istanbul Oncology Hospital, Cevizli Mah. Toros Street No:86 Maltepe, Istanbul, Turkey
| | - Mehmet Mahir Fersahoğlu
- General Surgery Department, Fatih Sultan Mehmet Training and Research Hospital, Hastane Street No: 1/8 Icerenkoy, 34752, Istanbul, Turkey
| | - Nuriye Esen Bulut
- General Surgery Department, Fatih Sultan Mehmet Training and Research Hospital, Hastane Street No: 1/8 Icerenkoy, 34752, Istanbul, Turkey
| | - Ahmet Çakmak
- General Surgery Department, Fatih Sultan Mehmet Training and Research Hospital, Hastane Street No: 1/8 Icerenkoy, 34752, Istanbul, Turkey
| | - Berk Topaloğlu
- General Surgery Department, Fatih Sultan Mehmet Training and Research Hospital, Hastane Street No: 1/8 Icerenkoy, 34752, Istanbul, Turkey
| | - Ali Cihan Bilgili
- General Surgery Department, Fatih Sultan Mehmet Training and Research Hospital, Hastane Street No: 1/8 Icerenkoy, 34752, Istanbul, Turkey
| | - Adnan Somay
- Pathology Department, Fatih Sultan Mehmet Training and Research Hospital, Hastane Street No: 1/8 Icerenkoy, 34752, Istanbul, Turkey
| | - İksan Taşdelen
- General Surgery Department, Fatih Sultan Mehmet Training and Research Hospital, Hastane Street No: 1/8 Icerenkoy, 34752, Istanbul, Turkey
| | - Ümit Akyüz
- Gastroenterology Department, Fatih Sultan Mehmet Training and Research Hospital, Hastane Street No: 1/8 Icerenkoy, 34752, Istanbul, Turkey
| | - Kemal Memişoğlu
- General Surgery Department, Fatih Sultan Mehmet Training and Research Hospital, Hastane Street No: 1/8 Icerenkoy, 34752, Istanbul, Turkey
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Kim KH, Jung K, Kim YH, Seo KW. Endoscopic Septotomy as a Treatment for Chronic Leak after Laparoscopic Sleeve Gastrectomy. JOURNAL OF METABOLIC AND BARIATRIC SURGERY 2021; 10:42-45. [PMID: 36687751 PMCID: PMC9847649 DOI: 10.17476/jmbs.2021.10.1.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/31/2021] [Accepted: 05/31/2021] [Indexed: 01/25/2023]
Abstract
Acute leakage after sleeve gastrectomy progresses into chronic leakage by 10-28.1%, which causes the surgeon to be disturbed. The main treatment for chronic leakage is surgery, but the authors report successful care with endoscopic septotomy. Forty-one year old female patient with a BMI of 42.8 (161.6 cm/111.8 kg) underwent a laparoscopic sleeve gastrectomy. The leakage of the proximal part of the staple resection line was verified in the abdominal CT on the fourth day after the procedure due to pain in the left shoulder that could not be clarified. After appropriate treatment including stent, the patient ended the acute leakage treatment 150 days after surgery. However, the patient was visited for 10 months after removed percutaneous catheter drainage due to fever and pain in the left shoulder. Afterwards, chronic leakage was confirmed from the CT and endoscopy at POD 15 months. We performed endoscopic treatment in the operating room under general anesthesia. At the gastroesophageal junction, we could find chronic leak orifice and bridging fold between stomach lumen and abscess pocket. Endoscopic septotomy was performed with the endoscopic knife and electrosurgical surgical unit, until the stomach lumen and abscess pockets were fully in communication. After the patient was discharged without any complications and is currently under close observation. Endoscopic septotomy as a treatment for chronic leak is feasible and safe. Herein, we report this case with video clip.
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Affiliation(s)
- Ki Hyun Kim
- Department of Surgery, Kosin University College of Medicine, Busan, Korea
| | - Kyoungwon Jung
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Yoon Hong Kim
- Department of Surgery, Kosin University College of Medicine, Busan, Korea
| | - Kyung Won Seo
- Department of Surgery, Kosin University College of Medicine, Busan, Korea
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Redmann JG, Lavin TE, French MS, Broussard TD, Lapointe-Gagner M. Improving Hemostasis in Sleeve Gastrectomy With Alternative Stapler. JSLS 2021; 24:JSLS.2020.00073. [PMID: 33447003 PMCID: PMC7791089 DOI: 10.4293/jsls.2020.00073] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background: Staple line bleeding can be a major intra-operative complication during laparoscopic sleeve gastrectomy, requiring reinforcing interventions that may diminish the integrity of the staple line and put patients at risk for postoperative hemorrhage or leak. To improve outcomes associated with surgery, surgeons may benefit from an alternative stapler that produces a drier staple line and requires less staple line manipulation. Methods: Sixty consecutive laparoscopic sleeve gastrectomy procedures were performed by three surgeons; 30 sleeves using the AEON™ Endostapler on THICK MODE and 30 using the Echelon Flex™ Powered Stapler with pulse technique. Stapler performance was measured by incidence and degree of staple line bleeding. Images of the first firing and fundus were taken with the laparoscope 10 seconds after the final firing. Images were evaluated by a third-party blinded evaluator and given a “bleeding score,” a qualitative measure of intra-operative staple-line bleeding (1 = no bleeding to 5 = profuse bleeding). Results: The AEON™ Endostapler demonstrated a lower mean (± standard error) “bleeding score” versus the Echelon Flex™ (2.1 ± 0.1 vs. 2.6 ± 0.1; p = 0.01). The AEON™ Endostapler had 15 cases (50%) with no bleeding at the fundus; the Echelon Flex™ had 7 cases (23%) with no bleeding at the fundus. The AEON™ Endostapler had 0 cases (0%) with profuse bleeding; the Echelon Flex™ had 2 cases (7%) with profuse bleeding. Conclusion: The AEON™ Endostapler is a significantly drier alternative to the Echelon Flex™ Powered Stapler, producing a much drier staple line and decreasing the need for other bleeding control methods.
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Complications associated with laparoscopic sleeve gastrectomy - a review. GASTROENTEROLOGY REVIEW 2021; 16:5-9. [PMID: 33986881 PMCID: PMC8112272 DOI: 10.5114/pg.2021.104733] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 05/06/2020] [Indexed: 12/26/2022]
Abstract
Laparoscopic sleeve gastrectomy (LSG) is an essential bariatric procedure performed in obese patients, which provides significant weight loss and has a positive impact on obesity-related diseases. However, as with any surgical procedure, it carries the risk of complications. The complications that can arise in patients following LSG are divided into acute (diagnosed within 30 days after the surgery) and late. Early complications that require rapid management include haemorrhage (intraluminal or extraluminal), leak in the staple line, and abscess formation. Late complications include gastric stenosis, nutrient deficiencies, mediastinal pouch migration, and the development or exacerbation of gastroesophageal reflux diseases. In this review, we present the basic information about most common complications following LSG, and their symptoms, diagnostic tools, and management.
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Computed Tomography Assessment of Fat Distribution and Staple-Line Leak Risk After Sleeve Gastrectomy. Obes Surg 2021; 31:2011-2018. [PMID: 33409967 DOI: 10.1007/s11695-020-05199-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 12/22/2020] [Accepted: 12/29/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Sleeve gastrectomy (SG) has become the most frequent bariatric procedure and staple-line leak represents its most feared complication. Visceral obesity, a core component of the metabolic syndrome, has been associated with worst postoperative outcomes after various abdominal surgical procedures, and can be estimated by computed tomography (CT). The aim of this study was to assess the impact of radiologically determined visceral obesity in the risk of staple-line leak after SG. MATERIAL AND METHODS A retrospective analysis of a prospective database was performed in consecutive patients undergoing SG. Several anthropometric variables were measured on a preoperative CT scan. Multivariate analysis was performed to determine preoperative risk factors for staple-line leak. RESULTS During the study period, 377 patients were included in the analysis. The median BMI was 39.7 kg/m2 (36.5-43.5) and 8 patients (2.1%) presented a gastric leak. After multivariate analysis, visceral obesity defined by visceral fat area (VFA)/body surface area (BSA) ≥ 85 cm2/m2 was the only independent predictive factor for gastric leak (OR = 5312). CONCLUSION CT scan-assessed visceral obesity defined by a VFA/BSA ratio ≥ 85 cm2/m2 is associated with an increased risk of gastric leak after SG. Preoperatively radiological examination in patients suspected of visceral obesity would be useful to optimize preoperative management.
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Di Furia M, Romano L, Salvatorelli A, Brandolin D, Lomanto D, Cianca G, Schietroma M, Carlei F, Giuliani A. Indocyanine Green Fluorescent Angiography During Laparoscopic Sleeve Gastrectomy: Preliminary Results. Obes Surg 2020; 29:3786-3790. [PMID: 31290111 DOI: 10.1007/s11695-019-04085-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Indocyanine green (ICG) fluorescent angiography has been routinely applied for various laparoscopic procedures to evaluate the tissue blood supply. A promising branch for this technology is represented by bariatric surgery, especially to estimate the risk of gastric leak after laparoscopic sleeve gastrectomy (LSG), which seems mainly related to ischemia of the stomach. MATERIALS AND METHODS 43 consecutive patients from January 2018 to March 2019 underwent in our institution LSG with intravenous injection of 5 ml ICG after the realization of gastric tube to evaluate the blood supply of the gastric tube. RESULTS In all 43 cases, there have been no adverse events related to ICG. The vascular supply to stomach was estimated "satisfactory" along the stapled line in all cases. However, one patient showed signs and symptoms indicative of gastric leak in the fifth post-op day and diagnosis was confirmed by CT scan with Gastrografin. CONCLUSIONS From our preliminary data, the intraoperative view of the blood supply of the stomach does not seem to represent a prognostic factor for the risk of gastric leak, suggesting a complex multifactorial etiology (intragastric hypertension? Abnormal inflammatory response?) which needs further data to be established.
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Affiliation(s)
- Marino Di Furia
- Department of General Surgery, Hospital San Salvatore L'Aquila, University of L'Aquila, L'Aquila, Italy.
| | - Lucia Romano
- Department of General Surgery, Hospital San Salvatore L'Aquila, University of L'Aquila, L'Aquila, Italy
| | - Andrea Salvatorelli
- Department of General Surgery, Hospital San Salvatore L'Aquila, University of L'Aquila, L'Aquila, Italy
| | - Denise Brandolin
- Department of General Surgery, Hospital San Salvatore L'Aquila, University of L'Aquila, L'Aquila, Italy
| | - Davide Lomanto
- Department of Surgery, Division of Upper Gastrointestinal Surgery, National University Hospital, Singapore, Singapore
| | - Giovanni Cianca
- Department of General Surgery, Hospital San Salvatore L'Aquila, University of L'Aquila, L'Aquila, Italy
| | - Mario Schietroma
- Department of General Surgery, Hospital San Salvatore L'Aquila, University of L'Aquila, L'Aquila, Italy
| | - Francesco Carlei
- Department of General Surgery, Hospital San Salvatore L'Aquila, University of L'Aquila, L'Aquila, Italy
| | - Antonio Giuliani
- Department of General Surgery, Hospital San Salvatore L'Aquila, University of L'Aquila, L'Aquila, Italy
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Diaz R, Welsh LK, Perez JE, Narvaez A, Davalos G, Portenier D, Guerron AD. Endoscopic septotomy as a treatment for leaks after sleeve gastrectomy: Meeting presentations: Digestive Disease Week 2019. Endosc Int Open 2020; 8:E70-E75. [PMID: 31921987 PMCID: PMC6949161 DOI: 10.1055/a-1027-6888] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 08/12/2019] [Indexed: 12/16/2022] Open
Abstract
Background and study aims Sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure in the world. Leaks are the most feared complications after this procedure. Endoscopic septotomy has been described as a resolution technique that could be useful in the setting of late and chronic leaks. We present our experience in the management of gastric leaks with this advanced endoscopic technique. Patients and methods Retrospective review of patients who have been admitted to our hospital from January 2016 to December 2018. Results Five patients were found. All had their index surgery in outside hospitals. The average age was 51 years (range 40 - 69), and four patients were female. Mean time from LSG to leak presentation was 15 days (range 7 - 25). Mean time from leak presentation to septotomy procedure was 61 days (range 21 - 110). All patients were treated with sleeve dilatation before septotomy using endoscopic achalasia balloons. Mean procedure time was 79 minutes (range 55 - 125). Success was achieved in 80 % of patients, and no complications related to the procedure were identified. One patient underwent total gastrectomy for definitive management. Mean follow-up time was 14.25 months (range 6 - 26), and the average time for fistula closure was 60.25 days. Conclusion Endoscopic septotomy is safe and effective for management of chronic leaks after LSG. Associated non-selective dilatation may be a crucial step to allow distal patency and axis rectification for appropriate leak closure.
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Affiliation(s)
- Ramon Diaz
- Division of Minimally Invasive Surgery, Metabolic and Weight Loss Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina, United States
| | - Leonard K. Welsh
- Division of Minimally Invasive Surgery, Metabolic and Weight Loss Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina, United States
| | - Juan Esteban Perez
- Division of Minimally Invasive Surgery, Metabolic and Weight Loss Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina, United States
| | - Andres Narvaez
- Division of Minimally Invasive Surgery, Metabolic and Weight Loss Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina, United States
| | - Gerardo Davalos
- Division of Minimally Invasive Surgery, Metabolic and Weight Loss Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina, United States
| | - Dana Portenier
- Division of Minimally Invasive Surgery, Metabolic and Weight Loss Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina, United States
| | - A. Daniel Guerron
- Division of Minimally Invasive Surgery, Metabolic and Weight Loss Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina, United States
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Ozdenkaya Y, Olmuscelik O, Basim P, Saka B, Arslan NC. The effect of fibrin glue in preventing staple-line leak after sleeve gastrectomy. An experimental study in rats. Acta Cir Bras 2019; 34:e201900801. [PMID: 31618401 PMCID: PMC6802941 DOI: 10.1590/s0102-865020190080000001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 07/08/2019] [Indexed: 01/18/2023] Open
Abstract
Purpose To evaluate the effect of fibrin glue on staple-line leak after sleeve
gastrectomy. Methods Fourteen adult wistar rats 300 gr were randomized into two groups: Control
group (n=7) and study group (n=7). All the rats underwent sleeve gastrectomy
using lineer stapler. In the study group, fibrin glue was used to reinforce
the staple-line. The rats were sacrificed 7 days after surgery. The stomach
was resected, submerged in saline and exposed to excess pressure to obtain a
burst pressure value. The gastric staple line was evaluated
histopathologically according to the Ehrlich Hunt scale. The results of the
two groups were compared. Results The mean Ehrlich-Hunt scores for inflammation, fibroblastic activity and
neo-angiogenesis were similar between the groups (p>0.05). Collagen
deposition was significantly higher in study group (3.42±0.53) when compared
with control group (2.57±0.78) (p=0.035). The mean burst pressure was
137.8±8.5 mmHg for control group and 135.0±8.1 mmHg for study group
(p=0.536). Conclusion Reinforcement of the staple-line with fibrin glue has no effect on the burst
pressure after sleeve gastrectomy. More studies are needed to evaluate the
precautions against leak after sleeve gastrectomy.
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Affiliation(s)
- Yasar Ozdenkaya
- MD, Assistant Professor, Department of General Surgery , Medipol University Medical Faculty , Istanbul , Turkey . Conception and design of the study, acquisition of data, manuscript writing
| | - Oktay Olmuscelik
- MD, Assistant Professor, Department of Internal Medicine , Medipol University Medical Faculty, Istanbul , Turkey . Conception of the study, acquisition of data, critical revision
| | - Pelin Basim
- MD, Assistant Professor, Department of General Surgery , Medipol University Medical Faculty , Istanbul , Turkey . Conception and design of the study, acquisition of data, critical revision
| | - Burcu Saka
- MD, Assistant Professor, Department of Pathology , Medipol University Medical Faculty , Istanbul , Turkey . Histopathological examinations
| | - Naciye Cigdem Arslan
- MD, Associate Professor, Department of General Surgery , Medipol University Medical Faculty , Istanbul , Turkey . Statistics analysis, manuscript writing, final approval
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Trends in Early Morbidity and Mortality after Sleeve Gastrectomy in Patients over 60 Years : Retrospective Review and Data Analysis of the German Bariatric Surgery Registry. Obes Surg 2019; 28:1831-1837. [PMID: 29417488 DOI: 10.1007/s11695-018-3110-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The population are getting older and obesity is growing. Laparoscopic sleeve gastrectomy (LSG) is increasingly used worldwide but is still used with skepticism in the elderly. The purpose of our analysis is to judge the security of LSG in patients older than 60 years compared to patients younger than 60 years. METHODS This retrospective review included data of all patients in Germany who underwent LSG between January 2005 and December 2016.The data were published online in the German Bariatric Surgery Registry. A total of 21,571 operations were gathered and divided into two groups: group I, patients < 60 years old; and group II, patients ≥ 60 years old. RESULTS The total number of patients and the mean body mass index of group I and group II was 19,786, 51.7 ± 9.5 kg/m2 and 1771, 49.2 ± 8.1 kg/m2, respectively. Regarding comorbidities, group II suffered statistically significantly more comorbidities than group I (p < 0.001). The general postoperative complications were 4.9% in group I and 7.8% in group II (p < 0.001). There was no significant difference in special postoperative complications (p = 0.048) and a slightly higher intraoperative complication rate in group II (2.2% vs. 1.6%, p = 0.048). Thirty-day mortality rate for group I versus II was 0.22% and 0.23% (p = 0.977), respectively. CONCLUSIONS LSG is a low-risk operation and safe surgical method with acceptable, not elevated perioperative morbidity and mortality rates in patients ≥ 60 years of age.
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Reinforcement of the Staple Line during Gastric Sleeve: A Comparison of Buttressing or Oversewing, versus No Reinforcement- A Single-Institution Study. Am Surg 2018. [DOI: 10.1177/000313481808400521] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Laparoscopic sleeve gastrectomy (LSG) is a well-established treatment for morbid obesity. Staple line leak (SLL) remains one of the most serious and life-threatening complications after LSG; however, no consensus exists for prevention. The purpose of this study is to review and compare the different methods of staple line management used at our institution. Retrospective review of preoperative, intraoperative, and postoperative factors was performed for all patients undergoing LSG at a single institution between September 2010 and August 2015. Primary outcome measure was SLL by reinforcement method (none/Seamguard/Oversewing). A total of 256 patients undergoing LSG were included, 197 (76.95%) were women and 233 (87.11%) were whites. The patients had a mean age of 44.64 years and body mass index of 49.24 kg/m22. Among those patients, 145 (56.64%) had staple line reinforced with suture (28, 10.94%) or Gore Seamguard (115, 44.92%) and 111 (43.36%) had no reinforcement, with no difference in baseline factors between the groups (all P > 0.05). Gastric leaks were identified in nine patients (3.52%) with no difference between reinforcement (2.7 vs 2.1%, P = 0.54) or leak test method (air vs methylene blue). However, oversewing the staple line was associated with higher incidence of stenosis ( P < 0.01). SLL after LSG is a serious complication with significant morbidity and mortality. This study demonstrated that staple line reinforcement does not provide significant leak reduction but does reduce intra-operative staple line bleeding. In addition, oversewing the staple line was associated with postoperative sleeve stenosis without added benefits.
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Clinical and Economic Evaluation of Absorbable Staple Line Buttressing in Sleeve Gastrectomy in High-Risk Patients. Obes Surg 2018; 26:1710-6. [PMID: 26677058 DOI: 10.1007/s11695-015-1991-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Gastric leaks and bleeding are the most important complications after laparoscopic sleeve gastrectomy (LSG). The use of absorbable membranes as staple line reinforcement may decrease this risk. On the other hand, these materials bring additional costs and their economic impact is not well known. The purpose of this study was to assess the clinical and economic performance of one of the commercially available buttressing absorbable materials when treating a high-risk population. METHODS A retrospective, observational, and comparative study was conducted at Montpellier University Hospital, France, between July 2013 and September 2014. Patients undergoing LSG, who were at a high risk for leaks and bleeding, were included and treated according to two groups: no buttressing (July 2013 to January 2014) and buttressing (February 2014 to September 2014). Clinical and economic outcomes were measured throughout the first 6 months. RESULTS Two hundred two patients were included in the study: 116 during the no stapling reinforcement period and 86 during the buttressing period. Baseline characteristics were similar. There was no significant difference between the two groups regarding gastric leaks. However, buttressing reduced hemorrhagic complications (0 vs 8.6 %, p = 0.005) and decreased average total hospital costs for the first hospitalization (5768 vs 6025 €, p < 0.001), as well as 6-month total inpatient cost (5944 vs. 6246 €, p < 0.001). CONCLUSIONS Staple line reinforcement with absorbable material reduces bleeding in high-risk population. Therefore, this type of material can also result in cost-savings.
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Tsai YN, Wang HP, Huang CK, Chang PC, Lin IC, Tai CM. Endoluminal stenting for the management of leak following sleeve gastrectomy and loop duodenojejunal bypass with sleeve gastrectomy. Kaohsiung J Med Sci 2018; 34:43-48. [PMID: 29310815 DOI: 10.1016/j.kjms.2017.08.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/25/2017] [Accepted: 08/10/2017] [Indexed: 02/07/2023] Open
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Staple Line Reinforcement in Laparoscopic SleeveGastrectomy: Experience in 1023 Consecutive Cases. Obes Surg 2017; 27:1474-1480. [PMID: 28054296 DOI: 10.1007/s11695-016-2530-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Laparoscopic sleeve gastrectomy (LSG) is one of the most frequently performed bariatric procedures performed worldwide. However, staple line-related complications have become a major challenge for bariatric surgeons. The aim of this study was to evaluate the morbidity in a cohort of patients who underwent LSG with imbricated oversewing of the staple line at a single high-volume center. MATERIALS AND METHODS We retrospectively reviewed prospectively collected data for all patients who underwent LSG to treat obesity at our institution from January 2010 to September 2016. All practitioners had undergone training with a single senior bariatric surgeon using oversewing as staple line reinforcement (SLR). RESULTS In total, 1023 LSGs were performed (female, 67.3%; mean age, 40.6 ± 10.8 years; median preoperative body mass index, 37 ± 4.5 kg/m2). The mean operative time was 67.6 ± 23.4 min (range, 30-150 min). The rate of conversion to open surgery was 0.3%. Early complications were noted in 18 patients (1.8%), including 5 cases of bleeding (0.5%). No leaks, stenosis, or mortality occurred. CONCLUSIONS LSG is a safe technique, but staple line-associated complications can be life-threatening. In this series, no leaks occurred from the very beginning of the surgeons' experience in LSG. Imbricated oversewing of the staple line, proper mentoring, and performance of surgery in appropriate settings are good approaches to decreasing complications.
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Southwell T, Lim TH, Ogra R. Endoscopic Therapy for Treatment of Staple Line Leaks Post-Laparoscopic Sleeve Gastrectomy (LSG): Experience from a Large Bariatric Surgery Centre in New Zealand. Obes Surg 2017; 26:1155-62. [PMID: 26475027 DOI: 10.1007/s11695-015-1931-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is one of the most commonly performed bariatric procedures for treatment of morbid obesity. Despite its popularity, it is not without risks, the most serious of which is the staple line leak. Staple line leaks are difficult to manage and require significant resources in the form of surgical, radiological and endoscopic interventions; long hospital and intensive care stay and significant morbidity. International experience is slowly emerging, but there are still no clear guidelines regarding optimal management of leaks. This study aims to describe the experience of endoscopic management of these leaks by the authors and the development of a customised stent for this condition. METHODS Middlemore Hospital is the largest bariatric surgery centre in New Zealand. Since June 2007, a total of 21 patients have received endotherapy for post-LSG leak management. Treatment included the deployment of primary self-expanding metal stents (SEMS) across the leak site, combined with complementary endoscopic modalities. Persistent leaks were treated with follow-up stenting. This study aimed to evaluate the effectiveness of post-LSG staple line leak management at Middlemore Hospital. RESULTS A total of 20/21 (95 %) patients now have resolved leaks following a mean of 75 days of treatment (median 47, range 9-187). The mean number of endoscopic procedures required was five. Inpatient stay and average duration till leak resolution has been notably reduced since the addition of customised stents. Clinically significant stent migration occurred in 19 % of primary stents. CONCLUSION The use of SEMS in conjunction with complementary endotherapy has shown to be both safe and effective in treating sleeve leaks; however, migration is the limiting factor for optimal management. Recent improvements in stent design, such as the one proposed in this paper, show promise in addressing this problem. Earlier use of SEMS seems to reduce the time till closure as well as the total hospital stay, as is apparent from our data.
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Affiliation(s)
- Thomas Southwell
- Department of Gastroenterology, Middlemore Hospital, Auckland, New Zealand
| | - Tien Huey Lim
- Department of Gastroenterology, Middlemore Hospital, Auckland, New Zealand
| | - Ravinder Ogra
- Department of Gastroenterology, Middlemore Hospital, Auckland, New Zealand.
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Fistula Following Laparoscopic Sleeve Gastrectomy: a Proposed Classification and Algorithm for Optimal Management. Obes Surg 2017; 28:656-664. [PMID: 28866827 DOI: 10.1007/s11695-017-2905-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Doumouras AG, Maeda A, Jackson TD. The role of routine abdominal drainage after bariatric surgery: a metabolic and bariatric surgery accreditation and quality improvement program study. Surg Obes Relat Dis 2017; 13:1997-2003. [PMID: 29079385 DOI: 10.1016/j.soard.2017.08.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 08/05/2017] [Accepted: 08/22/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND The efficacy of drains has long been debated in bariatric surgery. Drains may provide some theoretical benefits to early detection of anastomotic leaks and potential nonoperative treatment; however, there has never been data to support the practice. OBJECTIVE The objective of this study was to evaluate the effect of drain placement after bariatric surgery. SETTING This retrospective cohort study includes all hospitals in the United States that participated in the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. METHODS Only patients undergoing sleeve gastrectomy or gastric bypass were included for the analysis. The main outcomes of interest were anastomotic leak, reoperation, all-cause morbidity, readmission, and mortality. Multivariable logistic regression was used to evaluate the effect of abdominal drainage on the outcomes of interest. RESULTS A total of 142,631 patients were identified in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. After adjustment for major clinical variables, the odds of anastomotic leaks increased by 30% with the placement of a drain (odds ratio: 1.30, 95% confidence interval [CI]: 1.07-1.57, P = .01) while the odds of reoperation increased by 17% (95% CI: 1.06-1.30, P = .01). The odds of all cause morbidity increased 19% (95% CI: 1.14-1.25, P<.01), and odds of readmission were significantly higher (odds ratio:1.12, 95% CI:1.06-1.19, P<.01). The odds of mortality did not change significantly with the placement of a drain. CONCLUSIONS Using a large observational cohort, this study provided no evidence that routine drainage is beneficial to patients, but rather may increase major morbidity. Our findings suggest that the use of routine abdominal drainage should be restricted to very select, high-risk cases.
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Affiliation(s)
| | - Azusa Maeda
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of General Surgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Timothy D Jackson
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of General Surgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.
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Abstract
Obesity is a worldwide epidemic, and those suffering from obesity have increased morbidity and mortality rates. There are various causes of obesity and many treatment options for patients suffering from obesity, including nonsurgical treatments. However, bariatric surgery is often the best choice for optimal weight loss and the attenuation of comorbidities. Currently, laparoscopic sleeve gastrectomy is the most common type of bariatric surgery in the United States due to its technical simplicity, feasibility, and overall positive outcomes. This article discusses bariatric surgical criteria and selection, expected perioperative course, potential complications after surgery, and nursing implications for the care of bariatric patients. A case report is used to exemplify stages of surgical care and follow-up treatment for patients who undergo laparoscopic sleeve gastrectomy.
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Affiliation(s)
- Aura Petcu
- Aura Petcu is Nurse Practitioner, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Mail Code UHS 8W, Portland, OR 97239
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Laparoscopic Sleeve Gastrectomy: Investigation of Fundus Wall Thickness and Staple Height—an Observational Cohort Study. Obes Surg 2017. [PMID: 28623446 DOI: 10.1007/s11695-017-2755-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Impact of Botulinum Neurotoxin Pyloric Injection During Laparoscopic Sleeve Gastrectomy on Postoperative Gastric Leak: a Clinical Randomized Study. Obes Surg 2016. [PMID: 26198617 DOI: 10.1007/s11695-015-1794-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The most frequent and most feared complication after laparoscopic sleeve gastrectomy (LSG) is gastric leak (GL). We hypothesize that botulinum neurotoxin (botulinum type A (BTX-A)) injection into the pyloric sphincter muscle at the time of operation may decrease the risk of postoperative GL. METHODS Consecutive patients with morbid obesity (MO) treated by LSG were enrolled. Patients were randomly allocated into two groups: group I (intrapyloric BTX-A injection was performed) and group II (no injection was performed). The primary outcome measure was number of patients developing GL. Secondary outcome measures were percent of excess weight loss, postoperative complications, and their management. RESULTS One hundred and fifteen patients (86 (74.8 %) females) were randomized into two groups of 57 patients (group I) and 58 patients (group II). Four patients in group II developed GL versus no patient in group I (P = 0.04). Ten patients in group I and two in group II developed refractory epigastric pain (P = 0.01). Other complication rates were comparable for both groups. Mean preoperative BMI of patients in both groups had significantly decreased from 54.64 ± 6.82 to 42.99 ± 5.3 at 6 months and to 39.09 ± 5.14 at 12 months (P < 0.001). CONCLUSIONS LSG is an effective, safe, and minimally invasive procedure for treatment of MO. No patient in whom pyloric BTX-A injection was performed developed postoperative GL versus four patients in whom injection was not performed. The difference in GL rate was statistically significant, thus favoring the use of pyloric BTX-A injection during LSG.
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Sarkar A, Sadek R, Lissauer M, Pawa S. Case report of EUS-guided endoscopic transduodenal necrosectomy in a patient with sleeve gastrectomy. BMC OBESITY 2016; 3:38. [PMID: 27651917 PMCID: PMC5022238 DOI: 10.1186/s40608-016-0119-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 09/06/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND After an acute attack of pancreatitis, walled-off pancreatic fluid collections (PFC) occur in approximately 10 % of cases. Drainage of the cavity is recommended when specific indications are met. Endoscopic drainage has been adopted as the main intervention for symptomatic walled-off PFC. Altered gastric anatomy in these patients poses an interesting challenge. We present the first case of a patient with sleeve gastrectomy who underwent successful endoscopic transduodenal necrosectomy (TDN). CASE PRESENTATION Forty year old woman with history of morbid obesity status post sleeve gastrectomy in 2009 was found to have symptomatic gallstone disease complicated by severe necrotizing gallstone pancreatitis and further complicated by symptomatic walled off pancreatic necrosis (WOPN). Imaging significant for 10.8 × 7.6 cm fluid collection with necrotic debris in the body and tail of the pancreas and endoscopic necrosectomy was attempted. EGD showed tubular gastric body and antrum, with extrinsic compression in the antrum and duodenal bulb from the pancreatic cyst. Duodenal bulb was selected as the preferred fistula site due to sleeve gastrectomy. Patient underwent successful TDN in two sessions. Patient had symptomatic improvement at follow-up with resolution of WOPN. CONCLUSION To our knowledge, this is the first reported case of EUS-guided endoscopic necrosectomy in a patient with sleeve gastrectomy. The duodenal approach was used in our patient due to history of sleeve gastrectomy.
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Affiliation(s)
- Avik Sarkar
- Division of Gastroenterology, Department of Internal Medicine, Rutgers - Robert Wood Johnson Medical School, 1 Robert Wood Johnson Place, Medical Education Building Room 478, New Brunswick, NJ 08901 USA
| | - Ragui Sadek
- Department of Surgery, Rutgers - Robert Wood Johnson Medical School, New Brunswick, NJ USA
| | - Matthew Lissauer
- Department of Surgery, Rutgers - Robert Wood Johnson Medical School, New Brunswick, NJ USA
| | - Swati Pawa
- Division of Gastroenterology, Department of Internal Medicine, Rutgers - Robert Wood Johnson Medical School, 1 Robert Wood Johnson Place, Medical Education Building Room 478, New Brunswick, NJ 08901 USA
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Iossa A, Abdelgawad M, Watkins BM, Silecchia G. Leaks after laparoscopic sleeve gastrectomy: overview of pathogenesis and risk factors. Langenbecks Arch Surg 2016; 401:757-66. [PMID: 27301373 DOI: 10.1007/s00423-016-1464-6] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 06/08/2016] [Indexed: 01/14/2023]
Abstract
BACKGROUND Leak is the second most common cause of death after bariatric surgery. The leak rate after laparoscopic sleeve gastrectomy (LSG) ranges between 1.1 and 5.3 %. The aim of the paper is to provide an overview of the current pathogenic and promoting factors of leakage after LSG on the basis of recent literature review and to report the evidence based preventive measures. METHODS Risk factors and pathogenesis of leakage after LSG were examined based on an extensive review of literature and evidence based analysis of the most recent published studies using Oxford centre for evidence-based medicine, 2011, levels of evidence. RESULTS Pathogenesis of leakage after LSG can be attributed to mechanical or ischemic causes. Many factors can predispose to leakage after LSG which are either technically related or patient related. Awareness of these predisposing factors and technical tips may decrease the incidence of leakage. CONCLUSIONS This review reports factors promoting leak and gives technical recommendations to avoid leak after LSG based on the available evidence and expert consensus which encompasses: (1) use a bougie size ≥40 Fr, EL:1, (2) begin the gastric transection 5-6 cm from the pylorus, EL:2-3, (3) use appropriate cartridge colors from antrum to fundus, EL:1, (4) reinforce the staple line with buttress material, EL:1, (5) follow a proper staple line, (6) remove the crotch staples, EL:4, (7) maintain proper traction on the stomach before firing, (8) stay away from the angle of His at least 1 cm, EL:1, (9) check the bleeding from the staple line, (10) perform an intraoperative methylene blue test, EL:4.
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Affiliation(s)
- Angelo Iossa
- Department of Medico-Surgical Sciences and Biotechnologies, Division of General Surgery and Bariatric Center of Excellence, La Sapienza University of Rome, Via F. Faggiana 1668, 04100, Latina, Italy.
| | - Mohamed Abdelgawad
- Department of Medico-Surgical Sciences and Biotechnologies, Division of General Surgery and Bariatric Center of Excellence, La Sapienza University of Rome, Via F. Faggiana 1668, 04100, Latina, Italy.,Gastroenterology Surgical Center (GEC), Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Brad Michael Watkins
- Division of General Surgery and Weight loss Center, West Chester Hospital, University of Cincinnati, Cincinnati, OH, USA
| | - Gianfranco Silecchia
- Department of Medico-Surgical Sciences and Biotechnologies, Division of General Surgery and Bariatric Center of Excellence, La Sapienza University of Rome, Via F. Faggiana 1668, 04100, Latina, Italy
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Lainas P, Tranchart H, Gaillard M, Ferretti S, Donatelli G, Dagher I. Prospective evaluation of routine early computed tomography scanner in laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2016; 12:1483-1490. [PMID: 27387688 DOI: 10.1016/j.soard.2016.03.031] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 03/27/2016] [Accepted: 03/28/2016] [Indexed: 01/18/2023]
Abstract
BACKGROUND Prompt management of laparoscopic sleeve gastrectomy (LSG) complications is essential in avoiding prolonged hospital stay and associated mortality. The value of routine computed tomography (CT) scan examination in early diagnosis of postoperative complications after LSG has not been studied. OBJECTIVES To prospectively assess the impact of postoperative day (POD) 2 CT scan after LSG. SETTING Department of Minimally Invasive Digestive Surgery, Antoine-Beclere Hospital, AP-HP, Paris-Saclay University, France. METHODS Data were prospectively gathered for 1000 patients undergoing single-incision LSG and POD 2 CT scan. Complications were identified and treatment modalities decided according to the severity of complications. Sensitivity, specificity, and positive and negative predictive values were calculated for the diagnosis of surgical complications on POD 2 CT scan. RESULTS Mean age was 40.1 years and median BMI 42.6 kg/m². Early postoperative surgical complications occurred in 66 patients (6.6%). Intraabdominal bleeding/hematoma occurred in 38 patients, with 3 requiring emergent reoperation on POD 1. POD 2 CT scan detected this complication in 32 patients (sensitivity: 91.4%). Twenty-four (63.1%) patients were treated with relaparoscopy and drainage while 14 (36.9%) received conservative management. Postoperative transfusion was required in 7 patients. Twenty-eight patients suffered a gastric staple line leak, 13 (sensitivity: 46.4%) detected on POD 2 CT scan. Three patients (10.7%) received pure surgical treatment, 16 (57.1%) combined relaparoscopy and endoscopic treatment, and 9 (32.2%) had pure endoscopic treatment. CONCLUSION POD 2 abdominal CT scan is an efficient diagnostic tool for detecting active bleeding/hematoma, but shows less impressive results with gastric staple line leak detection. A combination of clinical surveillance and early imaging allowed prompt management of complicated cases, avoiding further morbidity.
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Affiliation(s)
- Panagiotis Lainas
- Department of Minimally Invasive Digestive Surgery, Antoine-Beclere Hospital, AP-HP, Clamart, France; Paris-Saclay University, Orsay, France
| | - Hadrien Tranchart
- Department of Minimally Invasive Digestive Surgery, Antoine-Beclere Hospital, AP-HP, Clamart, France; Paris-Saclay University, Orsay, France
| | - Martin Gaillard
- Department of Minimally Invasive Digestive Surgery, Antoine-Beclere Hospital, AP-HP, Clamart, France; Paris-Saclay University, Orsay, France
| | - Stefano Ferretti
- Department of Minimally Invasive Digestive Surgery, Antoine-Beclere Hospital, AP-HP, Clamart, France
| | - Gianfranco Donatelli
- Department of Interventional Endoscopy, Peupliers Private Hospital, Paris, France
| | - Ibrahim Dagher
- Department of Minimally Invasive Digestive Surgery, Antoine-Beclere Hospital, AP-HP, Clamart, France; Paris-Saclay University, Orsay, France.
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Timucin Aydin M, Aras O, Karip B, Memisoglu K. Staple Line Reinforcement Methods in Laparoscopic Sleeve Gastrectomy: Comparison of Burst Pressures and Leaks. JSLS 2016; 19:JSLS.2015.00040. [PMID: 26175554 PMCID: PMC4487958 DOI: 10.4293/jsls.2015.00040] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background and Objectives: Laparoscopic sleeve gastrectomy is a technically simple and popular bariatric operation with acceptable results. However, leaks can occur in long staple lines, for which various reinforcement methods are used. We compared nonreinforced stapling in laparoscopic sleeve gastrectomy with 3 staple line reinforcement methods: suturing, absorbable buttressing material, and fibrin glue. Methods: From March 1 until September 30, 2014, 118 patients with body mass index >40 kg/m2 underwent sleeve gastrectomy and were enrolled in 4 groups, depending on the type of reinforcement used. The resected stomach specimens were treated with the same methods of reinforcement as used in the surgeries in the corresponding patients and then insufflated until a burst occurred. The burst pressures of the resected stomach specimens and adverse postoperative events were recorded. Results: Five postoperative leaks occurred in the reinforcement groups (fibrin glue, 2; absorbable buttresses, 2; sutures, 1); no leaks were evident in the no-reinforcement group. Suturing afforded the highest burst pressure and took the longest to perform of the methods. There was no correlation between the leaks and burst pressures. All of the leaks occurred in the proximal fundus in the resected stomach specimens and in the affected patients. Discussion: Although most surgeons use additional reinforcement on long staple lines in sleeve gastrectomy, there is no consensus about its necessity. We did not show any benefit of such reinforcement methods over proper stapling technique alone. Conclusion: Laparoscopic sleeve gastrectomy without staple line reinforcement is safe and avoids additional costs for reinforcement materials.
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Affiliation(s)
- M Timucin Aydin
- Department of General Surgery, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Orhan Aras
- Department of General Surgery, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Bora Karip
- Department of General Surgery, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Kemal Memisoglu
- Department of General Surgery, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
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Southwell T, Lim TH, Ogra R. Endoscopic Therapy for Treatment of Staple Line Leaks Post-Laparoscopic Sleeve Gastrectomy (LSG): Experience from a Large Bariatric Surgery Centre in New Zealand. Obes Surg 2015. [PMID: 26475027 DOI: 10.1007/s11695-015-1931-0.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is one of the most commonly performed bariatric procedures for treatment of morbid obesity. Despite its popularity, it is not without risks, the most serious of which is the staple line leak. Staple line leaks are difficult to manage and require significant resources in the form of surgical, radiological and endoscopic interventions; long hospital and intensive care stay and significant morbidity. International experience is slowly emerging, but there are still no clear guidelines regarding optimal management of leaks. This study aims to describe the experience of endoscopic management of these leaks by the authors and the development of a customised stent for this condition. METHODS Middlemore Hospital is the largest bariatric surgery centre in New Zealand. Since June 2007, a total of 21 patients have received endotherapy for post-LSG leak management. Treatment included the deployment of primary self-expanding metal stents (SEMS) across the leak site, combined with complementary endoscopic modalities. Persistent leaks were treated with follow-up stenting. This study aimed to evaluate the effectiveness of post-LSG staple line leak management at Middlemore Hospital. RESULTS A total of 20/21 (95 %) patients now have resolved leaks following a mean of 75 days of treatment (median 47, range 9-187). The mean number of endoscopic procedures required was five. Inpatient stay and average duration till leak resolution has been notably reduced since the addition of customised stents. Clinically significant stent migration occurred in 19 % of primary stents. CONCLUSION The use of SEMS in conjunction with complementary endotherapy has shown to be both safe and effective in treating sleeve leaks; however, migration is the limiting factor for optimal management. Recent improvements in stent design, such as the one proposed in this paper, show promise in addressing this problem. Earlier use of SEMS seems to reduce the time till closure as well as the total hospital stay, as is apparent from our data.
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Affiliation(s)
- Thomas Southwell
- Department of Gastroenterology, Middlemore Hospital, Auckland, New Zealand
| | - Tien Huey Lim
- Department of Gastroenterology, Middlemore Hospital, Auckland, New Zealand
| | - Ravinder Ogra
- Department of Gastroenterology, Middlemore Hospital, Auckland, New Zealand.
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Sethi M, Magrath M, Somoza E, Parikh M, Saunders J, Ude-Welcome A, Schwack B, Kurian M, Fielding G, Ren-Fielding C. The utility of radiological upper gastrointestinal series and clinical indicators in detecting leaks after laparoscopic sleeve gastrectomy: a case-controlled study. Surg Endosc 2015; 30:2266-75. [PMID: 26416376 DOI: 10.1007/s00464-015-4516-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 08/06/2015] [Indexed: 01/14/2023]
Abstract
BACKGROUND Leak after laparoscopic sleeve gastrectomy (LSG) often presents after hospital discharge, making timely diagnosis difficult. This study evaluates the utility of radiological upper gastrointestinal (UGI) series and clinical indicators in detecting leak after LSG. METHODS A retrospective case-controlled study of 1762 patients who underwent LSG from 2006 to 2014 was performed. All patients with radiographically confirmed leaks were included. Controls consisted of patients who underwent LSG without leak, selected using a 10:1 case-match. Data included baseline patient characteristics, surgical characteristics, and UGI series results. Clinical indicators including vital signs, SIRS criteria, and pain score were compared between patients who developed leak and controls. RESULTS Of 1762 LSG operations, 20 (1.1 %) patients developed leaks and were compared with 200 case-matched controls. Three patients developed leak during their index admission [mean = 1.3 days, range (1, 2)], while the majority (n = 17) were discharged and developed symptoms at a mean of 17.1 days [range (4, 63)] postoperatively. Patients diagnosed with leak were similar to controls in baseline and surgical characteristics. Contrast extravasation on routine postoperative UGI identified two patients with early leaks, but was negative in the remainder (89 %). Patients with both early and delayed leaks demonstrated significant clinical abnormalities at the time of leak presentation, prior to confirmatory radiographic study. In multiple regression analysis, independent clinical factors associated with leak included fever [OR 16.6, 95 % CI (4.04, 68.10), p < 0.0001], SIRS criteria [OR 7.0, 95 % CI (1.47, 33.26), p = 0.014], and pain score ≥9 [OR 19.1, 95 % CI (1.38, 263.87), p = 0.028]. CONCLUSIONS Contrast extravasation on routine postoperative radiological UGI series may detect early leaks after LSG, but the vast majority of leaks demonstrate normal results and present 2-3 weeks after discharge. Therefore, clinical indicators (specifically fever, SIRS criteria, and pain score) are the most useful factors to raise concern for leaks prior to confirmatory radiographic study and may be used as criteria to selectively obtain UGI studies after LSG.
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Affiliation(s)
- Monica Sethi
- Division of Bariatric Surgery, Department of Surgery, New York University School of Medicine, 530 First Avenue, Suite 10S, New York, NY, 10016, USA.
| | - Melissa Magrath
- Division of Bariatric Surgery, Department of Surgery, New York University School of Medicine, 530 First Avenue, Suite 10S, New York, NY, 10016, USA
| | - Eduardo Somoza
- Division of Bariatric Surgery, Department of Surgery, New York University School of Medicine, 530 First Avenue, Suite 10S, New York, NY, 10016, USA
| | - Manish Parikh
- Division of Bariatric Surgery, Department of Surgery, New York University School of Medicine, 530 First Avenue, Suite 10S, New York, NY, 10016, USA
| | - John Saunders
- Division of Bariatric Surgery, Department of Surgery, New York University School of Medicine, 530 First Avenue, Suite 10S, New York, NY, 10016, USA
| | - Aku Ude-Welcome
- Division of Bariatric Surgery, Department of Surgery, New York University School of Medicine, 530 First Avenue, Suite 10S, New York, NY, 10016, USA
| | - Bradley Schwack
- Division of Bariatric Surgery, Department of Surgery, New York University School of Medicine, 530 First Avenue, Suite 10S, New York, NY, 10016, USA
| | - Marina Kurian
- Division of Bariatric Surgery, Department of Surgery, New York University School of Medicine, 530 First Avenue, Suite 10S, New York, NY, 10016, USA
| | - George Fielding
- Division of Bariatric Surgery, Department of Surgery, New York University School of Medicine, 530 First Avenue, Suite 10S, New York, NY, 10016, USA
| | - Christine Ren-Fielding
- Division of Bariatric Surgery, Department of Surgery, New York University School of Medicine, 530 First Avenue, Suite 10S, New York, NY, 10016, USA
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Single-stage revision from gastric band to gastric bypass or sleeve gastrectomy: 6- and 12-month outcomes. Surg Endosc 2015; 30:2244-50. [DOI: 10.1007/s00464-015-4498-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 08/03/2015] [Indexed: 01/23/2023]
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Kim J, Azagury D, Eisenberg D, DeMaria E, Campos GM. ASMBS position statement on prevention, detection, and treatment of gastrointestinal leak after gastric bypass and sleeve gastrectomy, including the roles of imaging, surgical exploration, and nonoperative management. Surg Obes Relat Dis 2015; 11:739-48. [DOI: 10.1016/j.soard.2015.05.001] [Citation(s) in RCA: 141] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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