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Dayma K, David A, Omer A, Abdel-Dayam H, Tawil A, Socci N, Ahmed L, Gilet A, Haddad D. Routine Upper Gastrointestinal Series Post-bariatric Surgery: Predictors, Usage, and Utility. Obes Surg 2024; 34:1552-1560. [PMID: 38564172 DOI: 10.1007/s11695-024-07125-4] [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: 11/12/2023] [Revised: 02/19/2024] [Accepted: 02/22/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVE To investigate usage and utility of routine upper gastrointestinal (UGI) series in the immediate post-operative period to evaluate for leak and other complications. METHODS Single institution IRB-approved retrospective review of patients who underwent bariatric procedure between 01/08 and 12/12 with at least 6-month follow-up. RESULTS Out of 135 patients (23%) who underwent routine UGI imaging, 32% of patients were post-gastric bypass (127) versus 4% of sleeve gastrectomy (8). In patients post-gastric bypass, 22 were found with delayed contrast passage, 3 possible obstruction, 4 possible leak, and only 1 definite leak. In patients post-sleeve gastrectomy, 2 had delayed passage of contrast without evidence of a leak. No leak was identified in 443 patients (77%) who did not undergo imaging. The sensitivity and specificity of UGI series for the detection of leak in gastric bypass patients were 100% and 97%, respectively, and the positive and negative predictive values were 20% and 100%, respectively. On univariate and multivariate analysis, sleeve gastrectomy patients (OR 0.4 sleeve vs bypass; P < 0.01) and male patients (OR 0.4 M vs F; P 0.02) were less likely to undergo routine UGI series (OR 0.4 M vs F; P 0.02). CONCLUSION Routine UGI series may be of limited value for the detection of anastomotic leaks after gastric bypass or sleeve gastrectomy and patients should undergo routine imaging based on clinical parameters. Gastric bypass procedure and female gender were factors increasing the likelihood of routine post-operative UGI. Further larger scale analysis of this important topic is warranted.
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Affiliation(s)
- Ketan Dayma
- Department of Radiology, SUNY Upstate Medical University, Syracuse, NY, 13210, USA
| | - Aruna David
- Department of Radiology, Harlem Hospital Center, New York, NY, 10037, USA
| | - Adil Omer
- Department of Radiology, Harlem Hospital Center, New York, NY, 10037, USA
| | - Haneen Abdel-Dayam
- Department of Radiology, Harlem Hospital Center, New York, NY, 10037, USA
| | - Anan Tawil
- Department of Surgery, Harlem Hospital Center, New York, NY, 10037, USA
| | - Nicholas Socci
- Department of Bioinformatics, Memorial Sloan-Kettering Cancer Center, New York, NY, 10021, USA
| | - Leaque Ahmed
- Department of Radiology, Harlem Hospital Center, New York, NY, 10037, USA
| | - Anthony Gilet
- Department of Radiology, Harlem Hospital Center, New York, NY, 10037, USA
- Department of Radiology, Westchester Medical Center, Westchester, NY, 10595, USA
| | - Dana Haddad
- Department of Radiology, Harlem Hospital Center, New York, NY, 10037, USA.
- School of Medicine, Mohammed Bin Rashid University, Dubai, United Arab Emirates.
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Law JH, Ng CZM, Lauw SK, So JBY, Kim G, Shabbir A. A 10-year experience with anastomotic leaks in upper gastrointestinal surgery-Retrospective cohort study. Surgeon 2024; 22:e87-e93. [PMID: 38172002 DOI: 10.1016/j.surge.2023.11.001] [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: 04/01/2023] [Revised: 10/24/2023] [Accepted: 11/03/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Anastomotic leak (AL) in upper gastrointestinal (UGI) surgery continues to be a diagnostic challenge. We seek to identify clinical parameters that predict AL and examine the effectiveness of investigations in evaluating AL following UGI surgeries. METHODS 592 patients underwent UGI surgeries with an anastomosis between January 2011 and January 2021. Data on patient characteristics, surgery, postoperative investigations and outcomes were prospectively collected and analysed. RESULTS The overall occurrence of AL was 6.4 %. Tachycardia >120 BPM (OR 6.959, 95 % CI 1.856-26.100, p = 0.004) and leukocyte count >19 × 109/L (OR 3.327, 95 % CI 1.009-10.967, p = 0.048) were independent predictors of AL. On multivariate analysis, patients whose anastomosis was deemed high risk and had pre-emptive investigation done postoperatively to exclude a leak were less likely to require intervention and were more likely to be managed conservatively (66.7 % vs 14.3 %, p = 0.025). Methylene blue test, oral contrast study and Computed Tomography scan with intravenous and oral contrast had 50.0 %, 20.0 % and 9.1 % false negative results, while esophagogastroduodenoscopy had none. There was no misdiagnosed AL when more than 1 investigation (n = 15, 39.5 %) were performed. CONCLUSION Our study demonstrates that the presence of a triad including desaturation, tachycardia and leucocytosis predicts for AL following UGI surgery and for confirmation of a leak, evaluation with 2 or more investigation is needed. A practice of evaluating high risk anastomosis prior to commencement of feeding decreased the need for surgical intervention and improves success of conservative treatment.
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Affiliation(s)
- Jia-Hao Law
- Division of Upper Gastrointestinal Surgery, Department of Surgery, National University Hospital, Singapore
| | - Charmaine Zhi-Mei Ng
- Division of Upper Gastrointestinal Surgery, Department of Surgery, National University Hospital, Singapore
| | - Sarah-Kei Lauw
- Division of Upper Gastrointestinal Surgery, Department of Surgery, National University Hospital, Singapore
| | - Jimmy Bok Yan So
- Division of Upper Gastrointestinal Surgery, Department of Surgery, National University Hospital, Singapore.
| | - Guowei Kim
- Division of Upper Gastrointestinal Surgery, Department of Surgery, National University Hospital, Singapore
| | - Asim Shabbir
- Division of Upper Gastrointestinal Surgery, Department of Surgery, National University Hospital, Singapore
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Lo HC, Hsu SC. Suggested Flowchart Through Integrated C-Reactive Protein and White Blood Cell Count Analysis for Screening for Early Complications After Gastric Bypass: a Single-Center Retrospective Study. Obes Surg 2023; 33:3517-3526. [PMID: 37801238 DOI: 10.1007/s11695-023-06864-0] [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: 07/18/2023] [Revised: 09/22/2023] [Accepted: 09/25/2023] [Indexed: 10/07/2023]
Abstract
INTRODUCTION Early leakage detection following bariatric procedures is crucial, but a standardized evaluation method is lacking. The aim was to validate the potential benefits of postoperative day 1 (POD1) C-reactive protein (CRP) levels and white blood cell (WBC) counts in distinguishing at-risk patients following Roux-en-Y gastric bypass (RYGB) while considering the impact of obesity-related chronic inflammation. METHODS Retrospective analysis of 261 consecutive patients aged 18-65 years with a body mass index (BMI) of 32.5-50 kg/m2 who underwent primary RYGB between 2017 and 2022. Sequential changes in CRP levels and WBC counts measured 48 h preoperatively and on POD1 morning were collected and compared between patients with/without complications and in patients without complications stratified by preoperative CRP levels. RESULTS Female patients and those with a higher BMI tended to have higher baseline CRP levels, which were positively related to postoperative CRP. Patients experiencing complications had higher WBC counts and a higher prevalence of WBC counts >14,000/μl (77.8% vs. 25.4%; p<0.001) than those without complications. Baseline CRP ≥ 0.3 mg/dl, a longer operative time, and blood loss >10 ml were significantly more common with WBC counts above 14,000/μl; a reasonable range of change in WBC count (∆WBC) derived from its positive correlation to postoperative WBC count (r=0.6695) may serve as a useful complementary indicator. CONCLUSION An individualized CRP threshold setting and integrated interpretation of the WBC count can be more appropriate than using static criteria for differentiating at-risk patients after RYGB. Further studies are needed to validate these findings and determine their generalizability.
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Affiliation(s)
- Hung-Chieh Lo
- Division of Trauma and Emergency Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, No. 111, Sec. 3, Xinglong Rd., Wenshan Dist., Taipei, Taiwan.
- TMU Research Center for Digestive Medicine, Taipei Medical University, Taipei, Taiwan.
| | - Shih-Chang Hsu
- Department of Emergency, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Emergency Department, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
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Altieri MS, Rogers A, Afaneh C, Moustarah F, Grover BT, Khorgami Z, Eisenberg D. Bariatric Emergencies for the General Surgeon. Surg Obes Relat Dis 2023; 19:421-433. [PMID: 37024348 DOI: 10.1016/j.soard.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 02/04/2023] [Indexed: 02/16/2023]
Affiliation(s)
- Maria S Altieri
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Ann Rogers
- Department of Surgery, Hershey School of Medicine, Penn State University, Hershey, Pennsylvania
| | | | - Fady Moustarah
- Department of Surgery, Beaumont Hospital, Bloomfield Hills, Michigan
| | - Brandon T Grover
- Department of Surgery, Gundersen Lutheran Medical Center, La Crosse, Wisconsin
| | - Zhamak Khorgami
- Department of Surgery, University of Oklahoma College of Community Medicine, Tulsa, Oklahoma; Harold Hamm Diabetes Center, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Dan Eisenberg
- Department of Surgery, Stanford School of Medicine and VA Palo Alto Health Care System, Palo Alto, California
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van Ede ES, Scheerhoorn J, Buise MP, Bouwman RA, Nienhuijs SW. Telemonitoring for perioperative care of outpatient bariatric surgery: Preference-based randomized clinical trial. PLoS One 2023; 18:e0281992. [PMID: 36812167 PMCID: PMC9946229 DOI: 10.1371/journal.pone.0281992] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 01/24/2023] [Indexed: 02/24/2023] Open
Abstract
IMPORTANCE Implementation of bariatric surgery on an outpatient basis is hampered by concerns about timely detection of postoperative complications. Telemonitoring could enhance detection and support transition to an outpatient recovery pathway. OBJECTIVE This study aimed to evaluate non-inferiority and feasibility of an outpatient recovery pathway after bariatric surgery, supported by remote monitoring compared to standard care. DESIGN Preference-based non-inferiority randomized trial. SETTING Center for obesity and metabolic surgery, Catharina hospital Eindhoven, the Netherlands. PARTICIPANTS Adult patients scheduled for primary gastric bypass or sleeve gastrectomy. INTERVENTIONS Same-day discharge with one week ongoing Remote Monitoring (RM) of vital parameters or Standard Care (SC) with discharge on postoperative day one. MAIN OUTCOMES Primary outcome was a thirty-day composite Textbook Outcome score encompassing mortality, mild and severe complications, readmission and prolonged length-of-stay. Non-inferiority of same-day discharge and remote monitoring was accepted below the selected margin of 7% upper limit of confidence interval. Secondary outcomes included admission duration, post-discharge opioid use and patients' satisfaction. RESULTS Textbook Outcome was achieved in 94% (n = 102) in RM versus 98% (n = 100) in SC (RR 2.9; 95% CI, 0.60-14.23, p = 0.22). The non-inferiority margin was exceeded which is a statistically inconclusive result. Both Textbook Outcome measures were above Dutch average (5% RM and 9% SC). Same-day discharge reduced hospitalization days by 61% (p<0.001) and by 58% with re-admission days included (p<0.001). Post-discharge opioid use and satisfaction scores were equal (p = 0.82 and p = 0.86). CONCLUSION In conclusion, outpatient bariatric surgery supported with telemonitoring is clinically comparable to standard overnight bariatrics in terms of textbook-outcome. Both approaches reached primary endpoint results above Dutch average. However, statistically the outpatient surgery protocol was neither inferior, nor non-inferior to the standard pathway. Additionally, offering same-day discharge reduces the total hospitalization days while maintaining patient satisfaction and safety.
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Affiliation(s)
- E. S. van Ede
- Department of Anesthesiology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
- Department of Electrical Engineering, Signal Processing Systems, Eindhoven University of Technology, Eindhoven, The Netherlands
- * E-mail:
| | - J. Scheerhoorn
- Department of Surgery, Catharina hospital Eindhoven, Eindhoven, The Netherlands
| | - M. P. Buise
- Department of Anesthesiology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - R. A. Bouwman
- Department of Anesthesiology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
- Department of Electrical Engineering, Signal Processing Systems, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - S. W. Nienhuijs
- Department of Surgery, Catharina hospital Eindhoven, Eindhoven, The Netherlands
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van Ede E, Scheerhoorn J, Bonomi A, Buise M, Bouwman R, Nienhuijs S. “Continuous remote monitoring in post bariatric surgery patients: development of an early warning protocol”. Surg Obes Relat Dis 2022; 18:1298-1303. [DOI: 10.1016/j.soard.2022.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 06/02/2022] [Accepted: 06/12/2022] [Indexed: 10/31/2022]
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Variation of Laparoscopic Roux-en-Y Gastric Bypass Techniques: a Survey of 518 Bariatric Surgeons. Obes Surg 2022; 32:2357-2365. [PMID: 35522385 DOI: 10.1007/s11695-022-06087-9] [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: 12/23/2021] [Revised: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Surgical technique varies dramatically in the performance of laparoscopic Roux-en-Y gastric bypass (LRYGB) and these differences can potentially lead to variation in outcomes. The objective of this study was to characterize surgical techniques used during LRYGB. METHODS An anonymous 44-question survey was distributed by email to all bariatric surgeons with membership in the ASMBS, SAGES, and ACS from April to June 2020. Questions were designed to evaluate surgeon demographics, experience, and variation of techniques. Only surgeons who performed LRYGB within the past year were included for analysis. RESULTS A total of 534 (18.8%) surgeons responded and the majority (97.0%) reported performing LRYGB in the past year. Surgeons were predominantly from the USA (77.8%). For preoperative work-up, 20.1% performed upper gastrointestinal series while 60.8% performed esophagogastroduodenoscopy. Limb length evaluation revealed mean Roux and biliopancreatic limb lengths of 124.1 ± 29.4 cm and 67.4 ± 32.2 cm, respectively. The gastrojejunostomy was most commonly formed using a linear stapler with handsewn closure of the common enterotomy (53.1%) and the jejunojejunostomy using a linear stapled anastomotic technique with handsewn closure of the common enterotomy (60.6%). The majority of surgeons closed the jejunojejunostomy mesenteric defect (91.1%) and one of the antecolic or retrocolic mesenteric defects (65.1%). Intraoperative leak tests were performed in 95.9% of cases. Only 22.1% of surgeons routinely performed upper gastrointestinal swallow studies postoperatively. CONCLUSIONS There are wide variations in pre- and intraoperative practice patterns for LRYGB. Further clinical trials designed to evaluate the impact of these practice pattern differences on patient outcomes are warranted.
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The Relationship Between Tachycardia After Laparoscopic Sleeve Gastrectomy and the Development of Postoperative Complications. Obes Surg 2022; 32:1479-1485. [PMID: 35247161 DOI: 10.1007/s11695-022-05938-9] [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: 05/16/2021] [Revised: 02/03/2022] [Accepted: 02/03/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Bariatric surgery can be associated with severe complications. Tachycardia is an important indicator of certain complications, such as anastomotic leak and hemorrhage. Our aim was to examine the relationship between tachycardia following sleeve gastrectomy and the appearance of associated complications. METHODS Patients who underwent sleeve gastrectomy over a 2-year period were included in the study. Participants were divided into two groups: the first included patients who suffered from postoperative tachycardia and the second patients with normal postoperative heart rates. Complications in both groups were examined. Other parameters that predict the onset of complications were also reviewed. RESULTS A total of 457 patients were included. Postoperative tachycardia was measured in 181 (39.6%) patients; 17 (3.7%) suffered from bleeding and 4 (1%) from staple line leakage. Postoperative bleeding was more common among patients with tachycardia than among those without (14 (7.7%) vs. 3 (1.1%), respectively). Patients in the tachycardia group had more staple line leakages than those in the normal heart rate group (3 (2%) vs. 1 (0%), respectively); tachycardia was also attributed to postoperative pain or other minor complications in 160 (88%) patients. Age ≥ 40 years was found to be predictive factor for postoperative complications. CONCLUSIONS The most common causes of tachycardia postoperatively were pain and minor complications. Tachycardia is an essential indicator of postoperative minor and major complications, mainly staple line leakage and bleeding. This should prompt immediate medical intervention in order to avoid serious adverse events.
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Scheerhoorn J, van Ede L, Luyer MDP, Buise MP, Bouwman RA, Nienhuijs SW. Postbariatric EArly discharge Controlled by Healthdot (PEACH) trial: study protocol for a preference-based randomized trial. Trials 2022; 23:67. [PMID: 35063007 PMCID: PMC8781161 DOI: 10.1186/s13063-022-06001-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 01/04/2022] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Performing bariatric surgery in a daycare setting has a potential reduction in hospital costs and increase in patients' satisfaction. Although the feasibility and safety of such care pathway has already been proven, its implementation is hampered by concerns about timely detection of short-term complications. This study is designed to evaluate a combined outcome measurement in outpatient bariatric surgery supplemented by a novel wireless remote monitoring system versus current standard of care. METHODS AND ANALYSIS A total of 200 patients with multidisciplinary team approval for primary bariatric surgery will be assigned based on their preference to one of two postoperative trajectories: (1) standard of in-hospital care with discharge on the first postoperative day or (2) same day discharge with ongoing telemonitoring up to 7 days after surgery. The device (Healthdot R Philips) transfers heart rate, respiration rate, activity, and body posture of the patient continuously by LoRaWan network to our hospital's dashboard (Philips Guardian). The primary outcome is a composite outcome measure within 30 days postoperative based on mortality, mild and severe complications, readmission, and prolonged length-of-stay. Secondary outcomes include patients' satisfaction and data handling dimensions. TRIAL REGISTRATION ClinicalTrials.gov NCT04754893 , Registered on 12 February 2021.
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Affiliation(s)
- Jai Scheerhoorn
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands.
| | - Lisa van Ede
- Department of Anesthesiology, Catharina Hospital, Eindhoven, The Netherlands
| | - Misha D P Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Marc P Buise
- Department of Anesthesiology, Catharina Hospital, Eindhoven, The Netherlands
| | - R Arthur Bouwman
- Department of Anesthesiology, Catharina Hospital, Eindhoven, The Netherlands
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Simon W Nienhuijs
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
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Factors that Hinder 24-Hour Discharge After Laparoscopic Roux-en-Y Gastric Bypass: a Retrospective Analysis at a Low-Volume Center. Obes Surg 2021; 32:749-756. [PMID: 34806128 PMCID: PMC8606249 DOI: 10.1007/s11695-021-05813-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 11/10/2021] [Accepted: 11/14/2021] [Indexed: 12/02/2022]
Abstract
Purpose This study aimed to identify factors that hinder 24-h patient discharge after laparoscopic Roux-en-Y gastric bypass (LRYGB) in a low-volume practice. Material and Methods Consecutive patients who fulfilled regional criteria and underwent primary LRYGB from 2018 to 2020 were retrospectively analyzed. Patients were discharged on the morning of the first postoperative day (POD1) after meeting the predefined criteria. The assessed outcome measures (POD1 vital signs, laboratory findings, pain scores and nausea/vomiting) and 30-day postoperative complications were compared between the early (stay ≤ 24 h) and delayed (>24 h) groups. Results For 107 patients who fulfilled the inclusion criteria, 48 (44.9%) were discharged within 24 h. There were no differences in the baseline demographics, except that the early group was more likely to have a previous abdominal operation (35.4% vs. 16.9%). Both groups had similar operation durations (89 min vs. 92 min), but the early group had a markedly shortened length of stay (23 (24–22) h vs. 27 (47–26) h). The POD1 parameters were the same between the groups, except that the delay group had a significantly higher visual analog scale score, with fewer patient scores of 0. Patients who were younger and female were more likely to need additional IV analgesics. No POD1 antiemesis was required throughout the study. There was no increase in the 30-day complications. Conclusion Patient discharge at 24 h post-LRYGB is feasible and safe in a low-volume practice. A more comprehensive pain relief strategy may be required before generalizing this approach. Graphical abstract ![]()
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Feng XC, Burch M. Management of Postoperative Complications Following Bariatric and Metabolic Procedures. Surg Clin North Am 2021; 101:731-753. [PMID: 34537140 DOI: 10.1016/j.suc.2021.05.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Bariatric and metabolic surgery is a safe and effective treatment of morbid obesity, a disease that continues to increase in prevalence in the United States and worldwide. The two most commonly performed operations are the sleeve gastrectomy and the gastric bypass. Early and late complications can occur, and although referral to a bariatric surgeon or center is ideal, emergency management of acute problems is relevant to all general surgeons. Bariatric surgery can have surgical and metabolic consequences. An understanding of the altered anatomy and physiology helps to guide management of morbidities. This article discusses surgical postoperative complications and metabolic complications.
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Affiliation(s)
- Xiaoxi Chelsea Feng
- General Surgery, Cedars Sinai Medical Center, 8635 West 3rd Street, Suite 650W, Los Angeles, CA 90048, USA
| | - Miguel Burch
- General Surgery, Cedars Sinai Medical Center, 8635 West 3rd Street, Suite 650W, Los Angeles, CA 90048, USA.
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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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Reinke CE, Lim RB. Minimally invasive acute care surgery. Curr Probl Surg 2021; 59:101031. [PMID: 35227422 DOI: 10.1016/j.cpsurg.2021.101031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 05/16/2021] [Indexed: 12/07/2022]
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Reinke CE, Lim RB. Minimally Invasive Acute Care Surgery. Curr Probl Surg 2021. [DOI: 10.1016/j.cpsurg.2021.101033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
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Abstract
Mortality after visceral surgery has decreased owing to progress in surgical techniques, anesthesiology and intensive care. Mortality occurs in 5-10% of patients after major surgery and remains a topic of interest. However, the ratio of mortality after postoperative complications in relation to overall complications varies between hospitals because of failure to rescue at the time of the complication. There are multiple factors that lead to complication-related mortality: they are patient-related, disease-related, but are related, above all, to the timeliness of diagnosis of the complication, the organisational aspects of management in private or public hospitals, hospital volume that corresponds to the centralisation of initial management or to the concept of referral centre in case of complications, to the team spirit, to communication between the health care providers and to the management of the complication itself. Several organisational advances are to be considered, such as the development of shorter hospitalisations and notably ambulatory surgery, as well as enhanced recovery programs. Remote monitoring and the contribution of artificial intelligence must also be evaluated in this context. The reduction of mortality after visceral surgery rests on several tactics: prevention of potentially lethal complications, the all-important reduction of failure to rescue, and risk management before, during and after hospitalisations that are increasingly shorter.
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Peterson CJ, Klasen J, Delko T, Schneider R. Mechanical colon obstruction due to the alimentary limb after Roux-en-Y gastric bypass: a case report. J Med Case Rep 2021; 15:43. [PMID: 33531056 PMCID: PMC7856760 DOI: 10.1186/s13256-020-02645-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 12/21/2020] [Indexed: 11/25/2022] Open
Abstract
Background Small bowel obstruction is a known and potentially lethal complication after gastric bypass surgery, in both the early and the late postoperative course. Colon or large bowel obstruction, on the other hand, seems to be rare after gastric bypass surgery and thus is not routinely considered. Case presentation We present the case of a 21-year old morbidly obese caucasian patient who underwent laparoscopic Roux-en-Y gastric bypass surgery and developed an early severe transverse colon obstruction due to compression of the transverse colon by the antecolic alimentary limb. Emergency revisional surgery showed a short and tense alimentary limb mesentery and possibly tight closure of Petersen’s space contributing to the compression. Through opening of Petersen’s space and mobilization of alimentary limb mesentery, decompression was achieved, and the patient fully recovered. Conclusions This is a rare case of colon obstruction caused by direct compression of the transverse colon by the antecolic alimentary limb. We propose that a combination of short tense alimentary limb mesentery and perhaps tight closure of Petersen’s space was responsible for the obstruction in this case. Surgeons and treating physicians need to be aware of such rare causes of early postoperative bowel obstruction and take these into consideration when evaluating patients.
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Affiliation(s)
- Caspar Joyce Peterson
- Clarunis, Department of Visceral Surgery, University Center for Gastrointestinal and Liver Diseases, St. Claraspital and University Hospital Basel, 4002, Basel, Switzerland
| | - Jennifer Klasen
- Clarunis, Department of Visceral Surgery, University Center for Gastrointestinal and Liver Diseases, St. Claraspital and University Hospital Basel, 4002, Basel, Switzerland
| | - Tarik Delko
- Clarunis, Department of Visceral Surgery, University Center for Gastrointestinal and Liver Diseases, St. Claraspital and University Hospital Basel, 4002, Basel, Switzerland
| | - Romano Schneider
- Clarunis, Department of Visceral Surgery, University Center for Gastrointestinal and Liver Diseases, St. Claraspital and University Hospital Basel, 4002, Basel, Switzerland.
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Duprée A, de Heer J, Tichby M, Ghadban T, Mann O, Grupp K, Pinnschmidt HO, Izbicki JR, Wolter S. The value of CT imaging and CRP quotient for detection of postbariatric complications. Langenbecks Arch Surg 2020; 406:181-187. [PMID: 32944801 PMCID: PMC7870754 DOI: 10.1007/s00423-020-01986-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 09/03/2020] [Indexed: 11/28/2022]
Abstract
Background The diagnosis of major complications seems to be more challenging in obese patients. We aimed to show the relevance of routinely assessed clinical and paraclinical parameters as well as the relevance of CT scans in the diagnosis of major complications after bariatric procedures. Methods All patients who underwent operations (primary or revisional) in a 3-year period were retrospectively studied after bariatric surgery with a specific focus on the routinely assessed clinical parameters (tachycardia, temperature), paraclinical parameters on postoperative day (POD) 1 and 3 (C-reactive protein (CRP), leukocytes), and additional computed tomography (CT) scan results for the diagnosis of leakage, bleeding, intraabdominal abscess, superficial abscess, and other complications. Results A total of 587 patients were examined. In this cohort, 73 CT scans were performed due to suspected intraabdominal or pulmonary complication according to our hospital standard operating procedure. In total, 14 patients (2.4%) had a major complication (Clavien-Dindo grade IV/V). Of those, 10 patients (1.7%) had postoperative leakage. While the correct leakage diagnosis was only found in 33% of the patients by CT scan, the overall specificity of CT as a diagnostic tool for all kinds of complications remained high. Especially for abscess detection, CT scan showed a sensitivity and specificity of 100%. Multivariate analysis showed a significantly higher risk of leakage development characterized by a doubling of postoperative CRP level (odds ratio 4.84 (95% confidence interval 2.01–11.66, p < 0.001)). To simplify the use of CRP as a predictive factor for the diagnosis of leakage, a cut-off value of 2.4 was determined for the CRP quotient (POD3/POD1) with a sensitivity of 0.88 and a specificity of 0.89. Conclusion CT diagnostic after bariatric surgery has a high positive predictive value, especially for intraabdominal abscess formation. Nevertheless, CT scan for the diagnosis of leakage has a low sensitivity. Thus, a negative CT scan does not exclude the presence of a leakage. Using the described CRP quotient with a cut-off of 2.4, the risk of early leakage can be easily estimated. Furthermore, in any uncertain case of clinically suspected leakage, diagnostic laparoscopy should be performed.
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Affiliation(s)
- Anna Duprée
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Jocelyn de Heer
- Center for Radiology and Endoscopy, Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michel Tichby
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Tarik Ghadban
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Oliver Mann
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - K Grupp
- Department of Plastic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans O Pinnschmidt
- Center for Experimental Medicine, Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Stefan Wolter
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
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Timsit G, Johanet H. Medico-legal claims in bariatric surgery in France between 2010 and 2015. J Visc Surg 2019; 156 Suppl 1:S51-S55. [DOI: 10.1016/j.jviscsurg.2019.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Tankel J, Rotem R, Wiess J, Mintz A, Spira RM. Routine Early Fluoroscopy and Clinical Observations Following Laparoscopic Roux-En-Y Gastric Bypass for Obesity Fail to Predict Subsequent Anastomotic Leakage. Indian J Surg 2019. [DOI: 10.1007/s12262-018-1802-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Mahawar K. Care for patients who have undergone one anastomosis gastric bypass surgery. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2019; 28:157-160. [PMID: 30746972 DOI: 10.12968/bjon.2019.28.3.157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Thousands of bariatric surgery procedures are performed in the UK each year, including gastric bypass surgery. The one anastomosis gastric bypass (OAGB) is increasingly performed in the UK, and nurses may find themselves providing care for patients who have undergone this procedure. This article outlines the anatomical and physiological changes associated with OAGB, routine care of these patients in the short and long term, and the identification and management of complications.
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Affiliation(s)
- Kamal Mahawar
- Consultant Surgeon, Bariatric Unit, Sunderland Royal Hospital
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21
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Utility of Immediate Postoperative Upper Gastrointestinal Contrast Study in Bariatric Surgery. Obes Surg 2018; 29:1130-1133. [DOI: 10.1007/s11695-018-03639-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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22
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Shukeri WFWM, Hassan MH, Hassan WMNW, Zaini RHM. Anastomotic Leak after Bariatric Surgery from a Critical Care Perspective: A Lesson Shared. Malays J Med Sci 2018; 25:158-159. [PMID: 30914872 PMCID: PMC6419880 DOI: 10.21315/mjms2018.25.5.15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 07/22/2018] [Indexed: 10/27/2022] Open
Abstract
Anastomotic leak after bariatric surgery is a rare complication with a recent prevalence ranging from 0.8% to 1.5%. The complication nevertheless can result in morbidity and even mortality. The purpose of this paper is to present a patient who suffered from an anastomotic leak presenting 2 days after laparoscopic sleeve gastrectomy in our intensive care unit. Review of the current literature regarding this complication from critical care perspective is also attempted.
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Affiliation(s)
- Wan Fadzlina Wan Muhd Shukeri
- Department of Anaesthesiology and Critical Care, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Mohd Hasyizan Hassan
- Department of Anaesthesiology and Critical Care, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Wan Mohd Nazaruddin Wan Hassan
- Department of Anaesthesiology and Critical Care, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Rhendra Hardy Mohamad Zaini
- Department of Anaesthesiology and Critical Care, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
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Pop LM, Mari A, Zhao TJ, Mitchell L, Burgess S, Li X, Adams-Huet B, Lingvay I. Roux-en-Y gastric bypass compared with equivalent diet restriction: Mechanistic insights into diabetes remission. Diabetes Obes Metab 2018; 20. [PMID: 29532631 PMCID: PMC5999551 DOI: 10.1111/dom.13287] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS To investigate the physiological mechanisms leading to rapid improvement in diabetes after Roux-en-Y gastric bypass (RYGB) and specifically the contribution of the concurrent peri-operative dietary restrictions, which may also alter glucose metabolism. MATERIALS AND METHODS In order to assess the differential contributions of diet and surgery to the mechanisms leading to the rapid improvement in diabetes after RYGB we enrolled 10 patients with type 2 diabetes scheduled to undergo RYGB. All patients underwent a 10-day inpatient supervised dietary intervention equivalent to the peri-operative diet (diet-only period), followed by, after a re-equilibration (washout) period, an identical period of pair-matched diet in conjunction with RYGB (diet and RYGB period). We conducted extensive metabolic assessments during a 6-hour mixed-meal challenge test, with stable isotope glucose tracer infusion performed before and after each intervention. RESULTS Similar improvements in glucose levels, β-cell function, insulin sensitivity and post-meal hepatic insulin resistance were observed with both interventions. Both interventions led to significant reductions in fasting and postprandial acyl ghrelin. The diet-only intervention induced greater improvements in basal hepatic glucose output and post-meal gastric inhibitory polypeptide (GIP) secretion. The diet and RYGB intervention induced significantly greater increases in post-meal glucagon-like peptide-1 (GLP-1), peptide YY (PYY) and glucagon levels. CONCLUSIONS Strict peri-operative dietary restriction is a main contributor to the rapid improvement in glucose metabolism after RYGB. The RYGB-induced changes in the incretin hormones GLP-1 and PYY probably play a major role in long-term compliance with such major dietary restrictions through central and peripheral mechanisms.
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Affiliation(s)
- Laurentiu M. Pop
- Department of Internal Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Andrea Mari
- National Research Council, Institute of Neuroscience, Padua, Italy
| | - Tong-Jin Zhao
- Department of Molecular Genetics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- State Key Laboratory of Cellular Stress Biology, School of Life Sciences, Xiamen University, Xiamen, Fujian, China (current affiliation)
| | - Lori Mitchell
- Department of Internal Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pediatrics, University of Texas Medical Branch at Galveston, Texas, USA
| | - Shawn Burgess
- Advanced Imaging Research Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Xilong Li
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Beverley Adams-Huet
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Internal Medicine, Division of Mineral Metabolism, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Ildiko Lingvay
- Department of Internal Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Delko T, Mattiello D, Koestler T, Zingg U, Potthast S. Computed tomography as primary postoperative follow-up after laparoscopic Roux-en-Y gastric bypass. World J Radiol 2018; 10:1-6. [PMID: 29403579 PMCID: PMC5789378 DOI: 10.4329/wjr.v10.i1.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 01/05/2018] [Accepted: 01/26/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate upper abdominal computed tomography (CT) scan as primary follow-up after laparoscopic Roux-en-Y gastric bypass (LRYGB).
METHODS This prospective study was approved by the Ethical Committee of the State of Zurich, and informed consent was obtained from all patients. Sixty-one patients who underwent LRYGB received upper abdominal CT on postoperative day 1, with the following scan parameters: 0.6 mm collimation, 1.2 mm pitch, CareKV with reference 120 mAs and 120 kV, and 0.5 s rotation time. Diluted water-soluble radiographic contrast-medium (50 mL) was administered to achieve gastric pouch distension without movement of the patient. 3D images were evaluated to assess postoperative complications and the radiation dose received was analysed.
RESULTS From the 70 patients initially enrolled in the study, 9 were excluded from analysis upon the intraoperative decision to perform a sleeve gastrectomy and not a LRYGB. In all of the 61 patients who were included in the analysis, CT was feasible and there were no instances of aspiration or vomiting. In 7 patients, two upper abdominal scans were necessary as the pouch was not distended by contrast medium in the first acquisition. Radiologically, no leak and no relevant stenosis were found on the first postoperative day. These early postoperative CT findings were consistent with the findings at clinical follow-up 6 wk postoperatively, with no leaks, stenosis or obstructions being diagnosed. The average total dose length product in CT was 536.6 mGycm resulting in an average effective dose of 7.8 mSv. The most common surgical complication, superficial surgical site infections (n = 4), always occurred at the upper left trocar site, where the circular stapler had been introduced.
CONCLUSION Early LRYGB postoperative multislice spiral CT scan is feasible, with low morbidity, and provides more accurate anatomical information than standard upper gastrointestinal contrast study.
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Affiliation(s)
- Tarik Delko
- Department of Surgery, University Hospital Basel, Basel 4031, Switzerland
| | - Diana Mattiello
- Department of Surgery, Limmattal Hospital, Schlieren 8952, Switzerland
| | - Thomas Koestler
- Department of Surgery, Limmattal Hospital, Schlieren 8952, Switzerland
| | - Urs Zingg
- Department of Surgery, Limmattal Hospital, Schlieren 8952, Switzerland
| | - Silke Potthast
- Department of Radiology, Limmattal Hospital, Schlieren 8952, Switzerland
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Solid Organ Infections: Rare Complications After Laparoscopic Sleeve Gastrectomy: a Report of Four Cases. Obes Surg 2017; 27:1374-1380. [PMID: 28271377 DOI: 10.1007/s11695-017-2609-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is gaining popularity for the treatment of morbid obesity. It is a simple, low-cost procedure resulting in significant weight loss within a short period of time. LSG is a safe procedure with a low complication rate. The most significant complications are staple-line bleeding, stricture, and staple-line leak. Formation of liver and splenic abscesses is an extremely rare consequence of LSG. Liver abscess has been reported in one case report while splenic abscess has been reported in five case reports after LSG. METHODS This study is a case report and literature review. RESULTS We report two cases of a pyogenic liver abscesses and two cases of splenic abscesses after LSG. CONCLUSIONS As LSG becomes more popular, clinicians need to be aware of uncommon but potentially serious complications related to it.
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Comparison of Imaging Modalities for Detecting Complications in Bariatric Surgery. Obes Surg 2017; 28:1063-1069. [PMID: 29047049 DOI: 10.1007/s11695-017-2970-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE The purpose of this study is to evaluate the results of routine fluoroscopic swallowing study (FSS) imaging 24 h after surgery and computed tomography (CT) on demand based on clinical data, in diagnosing complications after bariatric surgery. MATERIAL AND METHODS This retrospective study includes 9386 patients that underwent bariatric surgery. A total of 3241 (34.53%) patients underwent FSS imaging following the surgical procedure, and 106 (1.13%) patients underwent CT. RESULTS Sleeve gastrectomy was performed in 8093 patients (75.81%), gastric bypass was performed in 1281 patients (12%), duodenal switch or biliopancreatic diversion was performed in 12 patients (0.11%), and gastric banding was performed in 1289 patients (12.07%), which were excluded from the study as no imaging modality was used in any of these patients. The sensitivity for FSS was 71.43% and the specificity was 99.85%. An analysis of disease prevalence revealed a value of 0.43% with a positive predictive value of 66.67%. The sensitivity for CT was 71.42% and the specificity was 98%. A disease prevalence analysis revealed a value of 6.60% with a positive predictive value of 83.33%. A comparison of the two modalities showed that FSS has higher specificity values (p < 0.02) and a higher accuracy (p < 0.0001) than CT. CONCLUSION CT and FSS have a similar sensitivity for diagnosing complications after bariatric surgery. However, the specificity and accuracy of FSS are superior to that of CT. This study was approved by the instructional ethics committee (Helsinki board) and was registered on the National Institutes of Health ( ClinicalTrials.gov ) web site with identifier NCT02813122.
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Consalvo V, Salsano V, Sarno G. Intraoperative iodinated contrast swallow with CT-scan delayed control for detection of early complications in laparoscopic gastric bypass: A case series of 260 cases. INTERNATIONAL JOURNAL OF SURGERY OPEN 2017. [DOI: 10.1016/j.ijso.2017.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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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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Controversies and Pitfalls of Imaging Patients Postoperative Bariatric Surgery. CURRENT RADIOLOGY REPORTS 2016. [DOI: 10.1007/s40134-016-0152-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Kassir R, Debs T, Blanc P, Gugenheim J, Ben Amor I, Boutet C, Tiffet O. Complications of bariatric surgery: Presentation and emergency management. Int J Surg 2016; 27:77-81. [DOI: 10.1016/j.ijsu.2016.01.067] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Revised: 01/10/2016] [Accepted: 01/21/2016] [Indexed: 01/05/2023]
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Spaniolas K, Kasten KR, Sippey ME, Pender JR, Chapman WH, Pories WJ. Pulmonary embolism and gastrointestinal leak following bariatric surgery: when do major complications occur? Surg Obes Relat Dis 2016; 12:379-83. [DOI: 10.1016/j.soard.2015.05.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 03/27/2015] [Accepted: 05/03/2015] [Indexed: 02/07/2023]
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Essential bariatric emergencies for the acute care surgeon. Eur J Trauma Emerg Surg 2015; 42:571-584. [PMID: 26669688 DOI: 10.1007/s00068-015-0621-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 12/07/2015] [Indexed: 12/19/2022]
Abstract
Bariatric surgery is the most effective treatment for morbid obesity. Due to the high volume of weight loss procedures worldwide, the general surgeon will undoubtedly encounter bariatric patients in his or her practice. Liberal use of CT scans, upper endoscopy and barium swallow in this patient population is recommended. Some bariatric complications, such as marginal ulceration and dyspepsia, can be effectively treated non-operatively (e.g., proton pump inhibitors, dietary modification). Failure of conservative management is usually an indication for referral to a bariatric surgery specialist for operative re-intervention. More serious complications, such as perforated marginal ulcer, leak, or bowel obstruction, may require immediate surgical intervention. A high index of suspicion must be maintained for these complications despite "negative" radiographic studies, and diagnostic laparoscopy performed when symptoms fail to improve. Laparoscopic-assisted gastric band complications are usually approached with band deflation and referral to a bariatric surgeon. However, if acute slippage that results in gastric strangulation is suspected, the band should be removed immediately. This manuscript provides a high-level overview of all essential bariatric complications that may be encountered by the acute care surgeon.
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Methylene Blue or Upper GI, Which is More Effective for Detecting Leaks in Gastric Bypass Patients? Surg Laparosc Endosc Percutan Tech 2015; 25:451-4. [DOI: 10.1097/sle.0000000000000191] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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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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Presentation and surgical management of leaks after mini-gastric bypass for morbid obesity. Surg Obes Relat Dis 2015; 12:305-12. [PMID: 26410539 DOI: 10.1016/j.soard.2015.06.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 06/01/2015] [Accepted: 06/14/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND Few data exist about the characteristics and management of enteric leaks after mini-gastric bypass (MGB). OBJECTIVES We aimed to describe the incidence, presentation, and surgical management of enteric leaks in patients who underwent laparoscopic MGB for morbid obesity. SETTING Private practice. METHODS An 8-year, 9-month retrospective chart review was performed on patients who had enteric leak requiring reoperation after MGB at a single institution. RESULTS Thirty-five of 2321 patients were included. Ninety-seven percent had symptoms. Arterial hypertension and heavy smoking were predicting factors of leaks occurrence post-MGB (P<.01). Enteric leak was diagnosed by systematic upper gastrointestinal series in 4 pts (11.4%) and by computed tomography with oral water soluble contrast in 4 of 31 pts (13%). In the other 27 patients, diagnosis of the leak was made intraoperatively. Eleven patients (32%) had leak arising from the gastric stapler line (type 1), 4 (11%) from the gastrojejunal anastomosis (type 2), and 20 (57%) from undetermined origin. The most common presentation was intra-abdominal abscess in type 1 and leaks of undetermined origin and generalized peritonitis in type 2. One third of the patients who underwent reoperation developed well-drained chronic fistula into the irrigation-drainage system, with complete healing in all patients without any further procedure. The mean hospital stay was 19 days with no mortality reported. CONCLUSION Enteric leak leading to intra-abdominal sepsis post-MGB is rare (1.5%) An operative aggressive management based on clinical symptoms is the treatment of choice allowing no postoperative leak-related mortality and complete healing.
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Scali S, Bertges D, Neal D, Patel V, Eldrup-Jorgensen J, Cronenwett J, Beck A. Heart rate variables in the Vascular Quality Initiative are not reliable predictors of adverse cardiac outcomes or mortality after major elective vascular surgery. J Vasc Surg 2015; 62:710-20.e9. [PMID: 26067200 DOI: 10.1016/j.jvs.2015.03.071] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 03/30/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Heart rate (HR) parameters are known indicators of cardiovascular complications after cardiac surgery, but there is little evidence of their role in predicting outcome after major vascular surgery. The purpose of this study was to determine whether arrival HR (AHR) and highest intraoperative HR are associated with mortality or major adverse cardiac events (MACEs) after elective vascular surgery in the Vascular Quality Initiative (VQI). METHODS Patients undergoing elective lower extremity bypass (LEB), aortofemoral bypass (AFB), and open abdominal aortic aneurysm (AAA) repair in the VQI were analyzed. MACE was defined as any postoperative myocardial infarction, dysrhythmia, or congestive heart failure. Controlled HR was defined as AHR <75 beats/min on operating room arrival. Delta HR (DHR) was defined as highest intraoperative HR - AHR. Procedure-specific MACE models were derived for risk stratification, and generalized estimating equations were used to account for clustering of center effects. HR, beta-blocker exposure, cardiac risk, and their interactions were explored to determine association with MACE or 30-day mortality. A Bonferroni correction with P < .004 was used to declare significance. RESULTS There were 13,291 patients reviewed (LEB, n = 8155 [62%]; AFB, n = 2629 [18%]; open AAA, n = 2629 [20%]). Rates of any preoperative beta-blocker exposure were as follows: LEB, 66.5% (n = 5412); AFB, 57% (n = 1342); and open AAA, 74.2% (n = 1949). AHR and DHR outcome association was variable across patients and procedures. AHR <75 beats/min was associated with increased postoperative myocardial infarction risk for LEB patients across all risk strata (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.03-1.9; P = .03), whereas AHR <75 beats/min was associated with decreased dysrhythmia risk (OR, 0.42; 95% CI, 0.28-0.63; P = .0001) and 30-day death (OR, 0.50; 95% CI, 0.33-0.77; P = .001) in patients at moderate and high cardiac risk. These HR associations disappeared in controlling for beta-blocker status. For AFB and open AAA repair patients, there was no significant association between AHR and MACE or 30-day mortality, irrespective or cardiac risk or beta-blocker status. DHR and extremes of highest intraoperative HR (>90 or 100 beats/min) were analyzed among all three operations, and no consistent associations with MACE or 30-day mortality were detected. CONCLUSIONS The VQI AHR and highest intraoperative HR variables are highly confounded by patient presentation, operative variables, and beta-blocker therapy. The discordance between cardiac risk and HR as well as the lack of consistent correlation to outcome makes them unreliable predictors. The VQI has elected to discontinue collecting AHR and highest intraoperative HR data, given insufficient evidence to suggest their importance as an outcome measure.
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Affiliation(s)
- Salvatore Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla.
| | - Daniel Bertges
- Division of Vascular Surgery, University of Vermont, Burlington, Vt
| | - Daniel Neal
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Virendra Patel
- Division of Vascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | | | - Jack Cronenwett
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Adam Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
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Mbadiwe T, Prevatt E, Duerinckx A, Cornwell E, Fullum T, Davis B. Assessing the value of routine upper gastrointestinal contrast studies following bariatric surgery: a systematic review and meta-analysis. Am J Surg 2015; 209:616-22. [DOI: 10.1016/j.amjsurg.2014.11.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 10/01/2014] [Accepted: 11/13/2014] [Indexed: 01/05/2023]
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Arteaga-González I, Martín-Malagón A, Martín-Pérez J, Carrillo-Pallarés A. Usefulness of Clinical Signs and Diagnostic Tests for Suspected Leaks in Bariatric Surgery. Obes Surg 2015; 25:1680-4. [DOI: 10.1007/s11695-015-1589-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Montravers P, Augustin P, Zappella N, Dufour G, Arapis K, Chosidow D, Fournier P, Ribeiro-Parienti L, Marmuse JP, Desmard M. Diagnosis and management of the postoperative surgical and medical complications of bariatric surgery. Anaesth Crit Care Pain Med 2015; 34:45-52. [DOI: 10.1016/j.accpm.2014.06.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 06/30/2014] [Indexed: 12/31/2022]
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Girard E, Messager M, Sauvanet A, Benoist S, Piessen G, Mabrut JY, Mariette C. Anastomotic leakage after gastrointestinal surgery: diagnosis and management. J Visc Surg 2014; 151:441-50. [PMID: 25455960 DOI: 10.1016/j.jviscsurg.2014.10.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Anastomotic leakage represents a major complication of gastrointestinal surgery, leading to increased postoperative morbidity; it the foremost cause of mortality after intestinal resection. Identification of risk factors is essential for the prevention of AL. AL can present with various clinical pictures, ranging from the absence of symptoms to life-threatening septic shock. Contrast-enhanced CT scan is the most complete investigation to define AL and its consequences. Early and optimal multidisciplinary management is based on three options: medical management, radiologic or endoscopic intervention, or surgical re-intervention. Prompt treatment should help decrease postoperative morbidity and mortality, with the choice depending on the septic status of the patient. If the patient is asymptomatic, treatment can be medical only, coupled with close surveillance. Interventional management is indicated when the fistula is symptomatic but not life-threatening. On the other hand, when the vital prognosis is engaged, surgery is indicated, emergently, associated with intensive care. Even more than their prevention, early and appropriate management counts most to decrease their consequences.
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Affiliation(s)
- E Girard
- Service de chirurgie générale, hôpital de la Croix-Rousse, 103, Grande-rue-de-la-Croix-Rousse, 69004 Lyon, France
| | - M Messager
- Service de chirurgie digestive et générale, hôpital Claude-Huriez, centre hospitalier régional et universitaire, place de Verdun, 59037 Lille cedex, France
| | - A Sauvanet
- Service de chirurgie hépatique et pancréatique, hôpital Beaujon, 100, boulevard du Général-Leclerc, 92110 Clichy, France
| | - S Benoist
- Service de chirurgie oncologique et digestive, hôpital Kremlin-Bicêtre, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - G Piessen
- Service de chirurgie digestive et générale, hôpital Claude-Huriez, centre hospitalier régional et universitaire, place de Verdun, 59037 Lille cedex, France
| | - J-Y Mabrut
- Service de chirurgie générale, hôpital de la Croix-Rousse, 103, Grande-rue-de-la-Croix-Rousse, 69004 Lyon, France
| | - C Mariette
- Service de chirurgie digestive et générale, hôpital Claude-Huriez, centre hospitalier régional et universitaire, place de Verdun, 59037 Lille cedex, France.
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Pike TW, White AD, Snook NJ, Dean SG, Lodge JPA. Simplified Fast-Track Laparoscopic Roux-en-Y Gastric Bypass. Obes Surg 2014; 25:413-7. [DOI: 10.1007/s11695-014-1408-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Factors predicting the occurrence of a gastrojejunal anastomosis leak following gastric bypass. Wideochir Inne Tech Maloinwazyjne 2014; 9:436-40. [PMID: 25337170 PMCID: PMC4198648 DOI: 10.5114/wiitm.2014.44142] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Revised: 10/21/2013] [Accepted: 01/23/2014] [Indexed: 01/02/2023] Open
Abstract
Introduction Occurrence of anastomotic leaks following Roux-en-Y gastric bypass (RYGB), arising principally from the gastro-jejunal anastomosis, is associated with significant morbidity and mortality. Their early detection and treatment is essential. However, a significant number of postoperative oral contrast studies fail to identify leaks, and a negative study providing false reassurance can lead to a delay in diagnosis and treatment. Physiological features including tachycardia, increased respiratory rate and pyrexia or elevations in C-reactive protein and white cell count are seen in patients with leaks. In this study we examine physiological and laboratory parameters in patients with and without anastomotic leaks following RYGB to try and improve the detection of leaks. Aim To evaluate clinical signs and laboratory tests in determination of the development of gastrojejunal leaks after gastric bypass surgery. Material and methods The study examined 116 consecutive patients undergoing laparoscopic RYGB. Clinical signs and laboratory results were reviewed retrospectively. Results Four gastrojejunostomy leaks in our series were identified after RYGB surgery. All these patients were treated successfully. Leak patients’ in-hospital stay was longer. Tachycardia among leak patients occurs from day 1 with 100% sensitivity and 87% specificity at a cut-off point of 90 bpm. A temperature difference appears on day 2 in leak patients. The CRP was higher on day 2 and 3 in leak patients. Higher intravenous fluid requirements were observed in patients with leaks. Conclusions Gastrojejunal anastomosis leak is associated with longer in-hospital treatment. The earliest significant indicators of a leak are tachycardia and positive fluid balance. A temperature spike and CRP rise occur on day 2. Leak patients matched SIRS WBC count criteria on day 3.
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Wahby M, Salama AF, Elezaby AF, Belgrami F, Abd Ellatif ME, El-Kaffas HF, Al-Katary M. Is routine postoperative gastrografin study needed after laparoscopic sleeve gastrectomy? Experience of 712 cases. Obes Surg 2014; 23:1711-7. [PMID: 23828033 DOI: 10.1007/s11695-013-1013-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The current standard of care is to perform a postoperative gastrografin study following laparoscopic sleeve gastrectomy (LSG) to detect leakage or obstruction. This study evaluated the usefulness of this routine procedure. METHODS A retrospective chart review was performed in December 2012. All patients had routine intraoperative methylene blue testing to check for possible leakage from the staple line, and any leaking points were oversewn. We also performed postoperative contrast study (gastrografin) routinely in the first 24-48 h for all patients. RESULTS From June 2007 to December 2012, 712 cases underwent LSG during the study period. Patients included in this study were 556 women (78.1%) and 156 men (21.9%). The mean age was 35 years. The mean BMI was 48 kg/m2. The operative time was 107 ± 29 min, and there were no conversions to open surgery. Intraoperative methylene blue test detected leakage in 28 cases (3.93%). Postoperative contrast study (gastrografin) was negative for leakage in all cases. Computed tomography (CT) scan with oral contrast study detected leakage in 1.4% (ten cases); none of these cases were detected by regular contrast study. CONCLUSIONS Our study showed that intraoperative methylene blue test for leakage is a very sensitive and effective method for detecting leakage during sleeve gastrectomy and should be done routinely in all cases. Routine postoperative contrast study is not needed to detect leakage unless clinically indicated in selected cases, and in such cases contrast-enhanced CT scans are the modality of choice.
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Affiliation(s)
- M Wahby
- Department of Surgery, Jahra Hospital, Kuwait, Kuwait
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Quartararo G, Facchiano E, Scaringi S, Liscia G, Lucchese M. Upper Gastrointestinal Series after Roux-en-Y Gastric Bypass for Morbid Obesity: Effectiveness in Leakage Detection. a Systematic Review of the Literature. Obes Surg 2014; 24:1096-101. [DOI: 10.1007/s11695-014-1263-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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The Utility of Routine Postoperative Upper Gastrointestinal Swallow Studies Following Laparoscopic Sleeve Gastrectomy. Obes Surg 2014; 24:1415-9. [DOI: 10.1007/s11695-014-1243-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Romain B, Chemaly R, Meyer N, Chilintseva N, Triki E, Brigand C, Rohr S. Diagnostic markers of postoperative morbidity after laparoscopic Roux-en-Y gastric bypass for obesity. Langenbecks Arch Surg 2014; 399:503-8. [PMID: 24643459 DOI: 10.1007/s00423-014-1180-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 03/04/2014] [Indexed: 12/24/2022]
Abstract
PURPOSE The main objective of this study was to detect subacute complications that can arise from laparoscopic Roux-en-Y gastric bypass and take a rational approach to manage these complications. METHODS A prospective observational study was performed from November 2010 to December 2012. All patients undergoing gastric bypass surgery for morbid obesity were included in this study. Patients with complications before day 5 were excluded from the study. Clinical and laboratory data (C-reactive protein, leukocyte count) at postoperative day 5, 30-day morbidity, were recorded. The diagnostic value of C-reactive protein (CRP) and leukocytes were determined by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve. RESULTS One hundred and twenty-six patients were included. The overall incidence of 30-day morbidity was 8.7 %, and anastomotic leakage rate was 3.2 %. C-reactive protein at postoperative day 5 was a good predictor of complications (AUC was 0.862 (95 % CI [0.76; 0.96]; p < 0.001) and anastomotic leakage (AUC was 0.863 (95 % CI [0.66; 1]; p = 0.014). A CRP cutoff level of 136 mg/l at postoperative day 5 yielded a specificity of 95.5 % and a sensitivity of 57.1 % for the detection of postoperative complications. The negative predictive value was 94.6 %. A CRP level of 136 mg/l at day 5 was significantly associated with postoperative morbidity. CONCLUSIONS C-reactive protein dosage at postoperative day 5 is a relevant predictor of postoperative complications permitting to select patients at risk. Radiological examination and close monitoring could be restricted to patients with CRP level exceeding 136 mg/l.
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Affiliation(s)
- Benoît Romain
- Service de Chirurgie Générale et Digestive, Hôpitaux Universitaires de Strasbourg, Hôpital de Hautepierre, Avenue Molière, 67098, Strasbourg Cedex, France,
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The role of drainage after Roux-en-Y gastric bypass for morbid obesity: a systematic review. Surg Obes Relat Dis 2013; 10:171-6. [PMID: 24355318 DOI: 10.1016/j.soard.2013.09.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 08/14/2013] [Accepted: 09/09/2013] [Indexed: 12/28/2022]
Abstract
BACKGROUND Intraperitoneal drainage after gastrointestinal surgery is still routinely used in many hospitals. The objective of this study was to determine the evidence-based value of routine drainage after Roux-en-Y gastric bypass (RYGB). METHODS An electronic search of the MEDLINE, Cochrane, and Embase databases from 2002 to 2012 was performed to identify articles analyzing the use of drainage after RYGB, its efficacy in determining the presence of an anastomotic leak, and its role in nonoperative treatment of the leakage. RESULTS Eighteen articles were identified: 6 nonrandomized prospective cohort studies, 1 cohort retrospective study that compared routine drainage versus no drainage, 11 retrospective cohort studies, and no randomized controlled trials (RCTs). The sensitivity of drainage in detecting postoperative leakage varied between 0% and 94.1% in 10 articles (3 prospective and 6 retrospective) reporting data about this matter. The efficacy of drainage for the nonoperative treatment of postoperative leakage could be estimated in 11 articles (5 prospective and 6 retrospective) and varied between 12.5% and 100%. Only 2 studies reported data about nonoperative treatment of leakage without drainage, which was pursued in 0% and 33% of patients, respectively. CONCLUSION Evidence-based recommendations on the use of drainage after RYGB cannot be given. Without RCTs, the value of routine drainage cannot be ascertained.
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Lingvay I, Guth E, Islam A, Livingston E. Rapid improvement in diabetes after gastric bypass surgery: is it the diet or surgery? Diabetes Care 2013; 36:2741-7. [PMID: 23530013 PMCID: PMC3747905 DOI: 10.2337/dc12-2316] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Improvements in diabetes after Roux-en-Y gastric bypass (RYGB) often occur days after surgery. Surgically induced hormonal changes and the restrictive postoperative diet are proposed mechanisms. We evaluated the contribution of caloric restriction versus surgically induced changes to glucose homeostasis in the immediate postoperative period. RESEARCH DESIGN AND METHODS Patients with type 2 diabetes planning to undergo RYGB participated in a prospective two-period study (each period involved a 10-day inpatient stay, and periods were separated by a minimum of 6 weeks of wash-out) in which patients served as their own controls. The presurgery period consisted of diet alone. The postsurgery period was matched in all aspects (daily matched diet) and included RYGB surgery. Glucose measurements were performed every 4 h throughout the study. A mixed-meal challenge test was performed before and after each period. RESULTS Ten patients completed the study and had the following characteristics: age, 53.2 years (95% CI, 48.0-58.4); BMI, 51.2 kg/m(2) (46.1-56.4); diabetes duration, 7.4 years (4.8-10.0); and HbA1c, 8.52% (7.08-9.96). Patients lost 7.3 kg (8.1-6.5) during the presurgery period versus 4.0 kg (6.2-1.7) during the postsurgery period (P = 0.01 between periods). Daily glycemia in the presurgery period was significantly lower (1,293.58 mg/dL · day [1,096.83-1,490.33) vs. 1,478.80 mg/dL · day [1,277.47-1,680.13]) compared with the postsurgery period (P = 0.02 between periods). The improvements in the fasting and maximum poststimulation glucose and 6-h glucose area under the curve (primary outcome) were similar during both periods. CONCLUSIONS Glucose homeostasis improved in response to a reduced caloric diet, with a greater effect observed in the absence of surgery as compared with after RYGB. These findings suggest that reduced calorie ingestion can explain the marked improvement in diabetes control observed after RYGB.
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Affiliation(s)
- Ildiko Lingvay
- Department of Internal Medicine, Endocrinology Division, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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Late complication of laparoscopic sleeve gastrectomy. Case Rep Gastrointest Med 2013; 2013:136153. [PMID: 23662218 PMCID: PMC3639675 DOI: 10.1155/2013/136153] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2013] [Accepted: 03/24/2013] [Indexed: 12/19/2022] Open
Abstract
Laparoscopic sleeve gastrectomy (LSG) is gaining popularity for the treatment of morbid obesity. It is a simple, low-cost procedure resulting in significant weight loss within a short period of time. LSG is a safe procedure with a low complication rate. The complications encountered nevertheless can result in morbidity and even mortality. The most significant complications are staple-line bleeding, stricture, and staple-line leak. The purpose of this paper is to present a patient who suffered from a staple-line leak presenting 16 months after LSG. Review of the current literature regarding this complication as well as outline of a strategy for the management of post-LSG gastric leaks is suggested.
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C-reactive protein 2 days after laparoscopic gastric bypass surgery reliably indicates leaks and moderately predicts morbidity. J Gastrointest Surg 2012; 16:1128-35. [PMID: 22528569 DOI: 10.1007/s11605-012-1882-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Accepted: 03/22/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of the present study was to evaluate whether serum C-reactive protein (CRP) is a useful predictor of early post-operative complications, particularly of intestinal leaks after laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery. METHODS The present study was a retrospective analysis of a prospectively maintained database with 809 patients who underwent LRYGB from 2002 until 2011. For 410 of these patients, at least one CRP measurement within the first seven post-operative days was available. The diagnostic value was determined by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve. RESULTS Forty-nine of 410 patients (12.0 %; 95 % confidence intervals [95 % CI], 9.2-15.5 %) developed surgery-related complications. Leaks occurred in 17 patients (4.1 %; 95 % CI, 2.6-6.5 %) at a median of 5 days after surgery. CRP levels 2 days after surgery showed the highest diagnostic value for post-operative complications (AUC, 0.74; 95 % CI, 0.60-0.89). Sensitivity was 0.53 (95 % CI, 0.31-0.74) and specificity was 0.91 (95 % CI, 0.79-0.96) on day 2 (cutoff level, 229 mg/l). The sensitivity for intestinal leaks was 1.00 (95 % CI, 0.51-1.00). CONCLUSION CRP on post-operative day 2 is a valuable predictor of post-operative complications, in particular intestinal leaks. Radiological imaging studies for intestinal leaks could be restricted to patients with CRP values exceeding 229 mg/l.
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