Surgical strategies that may decrease leak after laparoscopic sleeve gastrectomy: a systematic review and meta-analysis of 9991 cases

Does sleeve gastrectomy improve the gait parameters of obese patients?

BACKGROUND

Few studies have evaluated the effect of bariatric surgery on gait parameters, which constitute an important aspect of quality of life.

OBJECTIVE

Evaluate the effects of sleeve gastrectomy (SG) on kinematic gait parameters 6 months after surgery.

SETTING

University Hospital, France, public practice.

METHODS

This prospective, nonrandomized study was conducted in patients undergoing SG between January 2013 and December 2013. The primary endpoint was the difference in functional parameters of the patient's 6-minute walk test (6 MWT) before and 6 months after SG. Secondary outcomes were surgical data, weight loss, and quality of life score.

RESULTS

Fifty-six patients were included. Mean preoperative body mass index was 46.3±7.1 kg/m² (35.2-71.0). On the preoperative 6 MWT, the mean distance traveled was 467 m (267-606) at an average speed of 4.6 km/hr (2.67-6.06). Three patients were unable to complete the 6 MWT. At 6 months postoperatively, mean body mass index was 34.4±6.0 kg/m² (24.8-53.8). On the 6-month postoperative 6 MWT, the mean distance traveled was 515 m (280-652) at an average speed of 5 km/hr (2.82-6.50; P<.01). All patients completed the test. A decrease in muscle and joint pain and an increased range of motion of the joints were observed (P<.01). All domains of the Short Form 36 questionnaire were significantly improved (P< .01).

CONCLUSION

SG significantly improves walking as well as range of motion of the joints. It also allows reduction of pain, facilitating the mobilization of obese patients that may be responsible for more marked weight loss after bariatric surgery. Quality of life improves and weight loss occurs after the SG.

Gastric fistula secondary to drainage tube penetration: A report of a rare case

Cases of gastric fistula secondary to drainage tube penetration have rarely been reported. The current study presents a case of gastric penetration caused by misplacement of a drainage tube after a splenectomy. The patient was admitted to the Department of Hepatobiliary Surgery, (Shaoxing People's Hospital, Shaoxing Hospital of Zhejiang University, Shaoxing, Zhejiang, China) for blunt abdominal trauma due to injuries sustained in an automobile accident. A ruptured spleen was found and successfully removed surgically. On post-operative day 7, the patient complained of slight discomfort and tenderness in the left upper quadrant of the abdomen. In addition, 500 ml of bile-colored fluid with small food particles was noted in the drainage tube. Barium X-ray revealed a gastric fistula in the upper gastrointestinal tract. Gastroscopy indicated infiltration of the drainage tube into the gastric cavity. No significant peritoneal effusion was observed, as revealed by abdominal ultrasound examination. These results confirmed the diagnosis of a gastric fistula secondary to perforation by the drainage tube. Following conservative treatment with antibiotics and total parenteral nutrition, the general condition of the patient improved significantly. The drainage tube was withdrawn progressively, as the amount of fluid being discharged was decreasing. Gastroenterography confirmed perforation closure and the tube was finally removed on post-operative day 44.

Novel treatments for complications after bariatric surgery

Bariatric surgery has been considered one of best treatments for obesity. As every surgical procedure—and any medical intervention, it is not exempt of complications, among which leaks, strictures, acute hemorrhages and fistulae highlight. Leaks are more common in the gastro-jejunal anastomosis (GJA) in the case of Roux-en-y Gastric Bypass (RYGB), while in Sleeve Gastrectomy (LSG) they locate in the stapler line. Stenosis can be seen in the gastro-jejunostomy in the RYGB and in the gastric tube in case of the LSG. For each of these complications, many innovative solutions have been developed, including new surgical devices. In spite of promising good results, evidence regarding utility and safeness of these technologies is still scarce. Self-expandable endoscopic stents have been used to treat leaks, with an overall success rate of 80–90 % and a migration rate of 15–35 %. The bear trap-like over-the-scope (Ovesco) clips have been used to treat GI hemorrhages, leaks and even fistulae, with a 70–80 % success rate, although more endoscopic sessions may be needed. Overstitch, an endosurgical suture devices, have been used to treat leaks, fistulae and perforations. Overall, technical success achievement approaches to 90 %, while clinical success ranges from 80 to 90 %, except for leaks closure, where a lower success rate has been observed. Despite of all of these advances, early diagnosis and treatment remains the main strategy to achieve success. In summary, novel therapies for complication management can be very useful, though further studies with larger series are still needed in order to confirm their efficacy and safeness.

Comparison of Reinforcement Techniques Using Suture on Staple-Line in Sleeve Gastrectomy

BACKGROUND

Sleeve gastrectomy is a common procedure in recent years for treatment of morbid obesity however leak from staple-line is its main challenging complication. Despite numerous studies regarding leak after sleeve gastrectomy, there is still no conclusion on reinforcement of staple-line in this procedure. The purpose of this study was to compare two methods of oversewing staple-line versus no reinforcement.

METHODS

Resected stomachs of 30 patients undergoing laparoscopic sleeve gastrectomy were evaluated for bursting pressure immediately after extraction from the abdomen. Reinforcement technique was applied in random order to 3 segments of the staple-line on each specimen: continuous Lembert's sutures, continuous through-and-through sutures, and no reinforcement. Bursting pressure was determined by injection of methylene blue solution into lumen of resected stomach and recording pressure at which leakage occurs. Location of leak, intragastric pressure, and volume at first leak were recorded.

RESULTS

Baseline characteristics of patients were similar in randomized groups for order of reinforcement technique. Mean ischemia time of specimens was 17.4 ± 10.4 min. No leaks were observed in segments reinforced with Lembert's oversewing technique. The through-and-through reinforcement segments were first to leak in 21 out of 30 cases (70 %) with mean leak pressure of 570 mmHg and mean leak volume of 399 ml. Leakage occurred in 9 segments (30 %) with no reinforcement with a leak pressure of 329 mmHg and volume of 380 ml.

CONCLUSIONS

In vitro, Lembert's suture reinforcement technique on stapled human stomach is associated with less leakage rate in comparison to through-and-through reinforcement and non-reinforced staple-line.

Staple Line Reinforcement Methods in Laparoscopic Sleeve Gastrectomy: Comparison of Burst Pressures and Leaks

Background and Objectives:

Laparoscopic sleeve gastrectomy is a technically simple and popular bariatric operation with acceptable results. However, leaks can occur in long staple lines, for which various reinforcement methods are used. We compared nonreinforced stapling in laparoscopic sleeve gastrectomy with 3 staple line reinforcement methods: suturing, absorbable buttressing material, and fibrin glue.

Methods:

From March 1 until September 30, 2014, 118 patients with body mass index >40 kg/m² underwent sleeve gastrectomy and were enrolled in 4 groups, depending on the type of reinforcement used. The resected stomach specimens were treated with the same methods of reinforcement as used in the surgeries in the corresponding patients and then insufflated until a burst occurred. The burst pressures of the resected stomach specimens and adverse postoperative events were recorded.

Results:

Five postoperative leaks occurred in the reinforcement groups (fibrin glue, 2; absorbable buttresses, 2; sutures, 1); no leaks were evident in the no-reinforcement group. Suturing afforded the highest burst pressure and took the longest to perform of the methods. There was no correlation between the leaks and burst pressures. All of the leaks occurred in the proximal fundus in the resected stomach specimens and in the affected patients.

Discussion:

Although most surgeons use additional reinforcement on long staple lines in sleeve gastrectomy, there is no consensus about its necessity. We did not show any benefit of such reinforcement methods over proper stapling technique alone.

Conclusion:

Laparoscopic sleeve gastrectomy without staple line reinforcement is safe and avoids additional costs for reinforcement materials.

Acute Leaks Following Laparoscopic Sleeve Gastrectomy: Early Surgical Repair According to a Management Algorithm

INTRODUCTION

Despite leakages remaining a worrisome complication, laparoscopic sleeve gastrectomy (LSG) has become the preferred choice for most bariatric surgeons in Italy. In light of the emerging trend to discharge patients on postoperative day (POD) 1 or to consider LSG as an outpatient procedure, we felt it useful in selected cases to define a treatment protocol aimed to manage patients presenting with an acute postoperative leakage.

PATIENTS AND METHODS

Starting from 2007, 295 LSGs have been performed at our institution. Six patients, including 5 from our series (1.6%), were treated for a leak. The first patient presented a leak on POD 3, whereas the next 2 patients were re-admitted on POD 11 and 12, respectively. They all underwent a conservative treatment. The last 3 patients, according to a suggested algorithm, underwent a prompt surgical repair.

RESULTS

The conservatively treated patients were discharged following 22 ± 7.7 days, whereas patients treated by surgery were discharged following 10 ± 0.8 days (P = .09). By not considering the cost of primary LSG, which is about 5600 € in our region, the expense for every patient treated by re-intervention was about 2500 €. The cost for each patient treated by stenting was about 4700 €. The cost for each patient treated conservatively was about 5700 €.

CONCLUSIONS

According to our series and in agreement with published data, it is reasonable in selected cases to consider a wider role for early surgery. A timely surgical approach following an appropriate algorithm may offer a resolutive and cost-effective answer to the management of acute leaks following LSG.

Thirty-Day Readmission After Laparoscopic Sleeve Gastrectomy—a Predictable Event?

BACKGROUND

Thirty-day readmission post-bariatric surgery is used as a metric for surgical quality and patient care. We sought to examine factors driving 30-day readmissions after laparoscopic sleeve gastrectomy (LSG).

METHODS

We reviewed 1257 LSG performed between March 2012 and June 2014. Readmitted and nonreadmitted patients were compared in their demographics, medical histories, and index hospitalizations. Multivariable regression was used to identify risk factors for readmission.

RESULTS

Forty-five (3.6 %) patients required 30-day readmissions. Forty-seven percent were readmitted with malaise (emesis, dehydration, abdominal pain) and 42 % with technical complications (leak, bleed, mesenteric vein thrombosis). Factors independently associated with 30-day readmission include index admission length of stay (LOS) ≥3 days (OR 2.54, CI = [1.19, 5.40]), intraoperative drain placement (OR 3.11, CI = [1.58, 6.13]), postoperative complications (OR 8.21, CI = [2.33, 28.97]), and pain at discharge (OR 8.49, CI = [2.37, 30.44]). Patients requiring 30-day readmissions were 72 times more likely to have additional readmissions by 6 months (OR 72.4, CI = [15.8, 330.5]).

CONCLUSIONS

The 30-day readmission rate after LSG is 3.6 %, with near equal contributions from malaise and technical complications. LOS, postoperative complications, drain placement, and pain score can aid in identifying patients at increased risk for 30-day readmissions. Patients should be educated on postoperative hydration and pain management, so readmissions can be limited to technical complications requiring acute inpatient management.

Clinical Benefit of Gastric Staple Line Reinforcement (SLR) in Gastrointestinal Surgery: a Meta-analysis

Background

The objective of this study was to assess whether the use of staple line reinforcement (SLR) reduces staple line complications (SLC). Mechanical staple lines are essential for gastrointestinal surgery such as bariatric surgery. However, SLC, such as bleeding and leakage, still occur. The purposes of this study were to provide quantitative evidence on the relative efficacy of gastric SLR and to compare the rates of effectiveness of three commonly used methods.

Methods

A search of the medical literature in English language journals identified studies from Jan 1, 2000, to Dec 31, 2013, using the following reinforcement types: (1) no reinforcement, (2) oversewing, (3) a biocompatible glycolide copolymer, and (4) bovine pericardium after gastric bypasses and sleeve gastrectomies. Types of reinforcement were compared using a random-effects model.

Results

This meta-analysis reviewed 16,967 articles, extracting data on 56,309 patients concerning leak and 41,864 patients concerning bleeding. Over 40 % of patients had no reinforcement, resulting in the highest leak rate (2.75 %) and bleed rate (3.45 %). Overall, reinforcing with bovine pericardium had the lowest leak (1.28 %) and bleed (1.23 %) rates. Suture oversewing was better than no reinforcement but not as effective as bovine pericardium for leak (2.45 %) and bleed (2.69 %) rates. Buttressing with a biocompatible glycolide copolymer resulted in the second highest leak rate (2.61 %) and a bleed rate of 2.48 % but had significantly lower bleed rates than no reinforcement.

Conclusions

SLR provided superior results for patients compared to no reinforcement for reducing SLC. Buttressing with bovine pericardium resulted in the most favorable outcomes. The effectiveness of different methods used to reinforce the staple line in gastric surgery does not appear to be equal.

Three-year follow-up comparing metabolic surgery versus medical weight management in patients with type 2 diabetes and BMI 30-35. The role of sRAGE biomarker as predictor of satisfactory outcomes

BACKGROUND

Patients with type 2 diabetes (T2D) and body mass index (BMI)<35 may benefit from metabolic surgery. The soluble form of the receptor for advanced glycation end products (sRAGE) may identify patients at greater chance for T2D remission.

OBJECTIVES

To study long-term outcomes of patients with T2D and BMI 30-35 treated with metabolic surgery or medical weight management (MWM) and search for predictors of T2D remission.

SETTING

University METHODS: Retrospective review of the original cohort, including patients who crossed over from MWM to surgery. Repeated-measures linear models were used to model weight loss (%WL), change in glycated hemoglobin (HbA1C) and association with baseline sRAGE.

RESULTS

Fifty-seven patients with T2D and BMI 30-35 were originally randomly assigned to metabolic surgery versus MWM. Mean BMI and HbA1C was 32.6% and 7.8%, respectively. A total of 30 patients underwent surgery (19 sleeves, 8 bypasses, 3 bands). Three-year follow-up in the surgery group and MWM group was 75% and 86%, respectively. Surgery resulted in higher T2D remission (63% versus 0%; P<.001) and lower HbA1C (6.9% versus 8.4%; P<.001) for up to 3 years. There was no difference in %WL in those with versus those without T2D remission (21.7% versus 20.6%, P = .771), suggesting that additional mechanisms other than %WL play an important role for the studied outcome. Higher baseline sRAGE was associated with greater change in HbA1C and greater %WL after surgery (P< .001).

CONCLUSION

Metabolic surgery was effective in promoting remission of T2D in 63% of patients with BMI 30-35; higher baseline sRAGE predicted T2D remission with surgery. Larger-scale randomly assigned trials are needed in this patient population.

The Safety of Laparoscopic Sleeve Gastrectomy in Patients Receiving Chronic Anticoagulation Therapy: A Case-Matched Study

BACKGROUND

Obesity is linked to cardiac disorders with a relative risk of atrial fibrillation of 1.5 (requiring the use of chronic anticoagulation therapy, CAT). However, CAT is a known risk factor for postoperative bleeding after elective surgery. The primary objective of the present study was to evaluate the short- and long-term complications of laparoscopic sleeve gastrectomy (LSG) in patients receiving CAT.

METHODS

This is a retrospective analysis of a prospective database of CAT patients undergoing LSG between March 2004 and December 2012. This LSG-CAT group was matched 1:2 on preoperative data with patients not receiving CAT (LSG-control group). Primary efficacy criterion was the frequency of CAT-related complications. Secondary efficacy criteria were the major postoperative complications, frequency of revisional surgery, long-term CAT-related complications, and a change in the dose level of oral anticoagulants.

RESULTS

The LSG-CAT group consisted of 15 patients with a median age of 54 years (32-65). The LSG-control group consisted of 30 patients. Median operating time was 75 min in both groups (p = 0.33). Major complication rates in the LSG-CAT and LSG-control groups were 13.3 and 3.3 %, respectively (p = 0.20), with one case of postoperative bleeding in each group (6.7 and 3.3 %, p = 0.6); incidence of revisional surgery was 13.3 and 3.3 % (p = 0.2). There were no postoperative mortalities. After a median follow-up of 14 months (9-43), no changes in the dose level of oral anticoagulants were reported.

CONCLUSIONS

LSG in patients receiving CAT is not associated with CAT-specific complications. This surgical procedure enables good weight loss and does not require change in the dose level of oral anticoagulants.

Gastric leaks after sleeve gastrectomy: no impact on weight loss, co-morbidities, and satisfaction rates

BACKGROUND

No data are available concerning the results on weight loss, correction of co-morbidities, and satisfaction rates in patients with healed gastric leak (GL) after sleeve gastrectomy (SG).

OBJECTIVE

Evaluate weight loss, correction of co-morbidities, and satisfaction rate of patients with healed GL after SG.

SETTING

University hospital, France, public practice.

METHODS

Between March 2004 and October 2012, all patients managed for GL after SG with a minimum of 1 year follow-up were included. These patients (GL group) were matched in terms of preoperative data and type of surgical procedure (first- or second-line SG) on a 1:2 basis with 74 patients without GL (control group) selected from a population of 899 SGs. Primary endpoint was the weight change over a 1-year period after performing SG. Secondary endpoints were GL data, co-morbidities data, and satisfaction rates 1 year after SG.

RESULTS

The GL group consisted of 37 patients (27 first-line SG [73%]). The mean EWL in the GL group was 52.2% and 68.8% at 6 and 12 months, whereas the mean EWL in the control group was 58.9% and 72.2%, respectively (P = .12; P = .46). No significant difference was observed between the 2 groups in terms of correction of co-morbidities. At 12 months follow-up, mean BAROS score was 6.02 in the GL group and 7.14 in the control group (P = .08). No significant difference was observed between the 2 groups in terms of the SF-36 questionnaire.

CONCLUSION

Despite the morbidity associated with GL, the results on weight loss, correction of co-morbidities, and satisfaction rates were similar in patients with healed GL and in patients without GL.

Are stapler line reinforcement materials necessary in sleeve gastrectomy?

AIM: To investigate the effect of staple line reinforcement materials on decreasing complications related to sleeve gastrectomy.

METHODS: In this retrospective study, we analyzed 84 patients who had sleeve gastrectomy due to obesity between April 2012 and April 2015. Sleeve gastrectomy procedure was performed in patients with a body mass index (BMI) more than 40 kg/m², and the ones with a BMI between 32 and 40 kg/m² in the presence of comorbid diseases. Reinforcement materials were used in 45 patients while they were not used in 39 patients. Materials such as Peristrip, 3/0 prolene, and V-lock were used for reinforcement in the reinforcement group (RG), and the materials used showed variations during the study period. The baseline characteristics, duration of surgery, hospital stay, comorbidities including hypertension, type 2 diabetes mellitus, hypertension, hepatosteatosis, gallstones, osteoarthritis, gastroesophageal reflux, sleep disorders, as well as the complications including leaks and bleeding after surgery were recorded and compared between the reinforcement and non-RGs (NRGs).

RESULTS: There were no differences between the reinforcement and NRGs for baseline characteristics including age (P = 0.689), gender (P = 0.057), height (P = 0.483), weight (P = 0.889), BMI (P = 0.971), hospital stay (P = 0.888), or duration of surgery (P = 0.229). The most common comorbidities in the RG were hypertension (24.4%) and hepatosteatosis (24.4%), while type 2 diabetes mellitus (28.2%) and hepatosteatosis (28.2%) were the most frequent comorbidities in the NRG. There were no differences between the reinforcement and NRGs for the rates of comorbidities (P > 0.05). Leak was observed in one (2.2%) patient in the RG, and there was leak in 2 (5.1%), and bleeding in 2 (5.1%) patients in the NRG. There were no differences between the reinforcement and NRGs for the rate of staple line leaks (P = 0.446) or bleeding (P = 0.213). One of the patients with leak died in the NRG while there were no deaths in the RG.

CONCLUSION: Although staple line reinforcement materials decreased morbidity and mortality, the differences between the two groups were not statistically significant.

Outcome of leaks after sleeve gastrectomy based on a new algorithm adressing leak size and gastric stenosis

BACKGROUND

Leaks after laparoscopic sleeve gastrectomy (LSG) are estimated to be the most serious complication of this procedure due to difficult healing process using non-standardized endoscopic approaches. Initially, endoscopic management recommended the use of stents.

METHODS

A total of 19 patients received endoscopic treatment after LSG to manage leaks. The leak was classified depending on the primary orifice's size (more or less than 10 mm) or on the presence of gastric stenosis. The primary aim was to develop a therapeutic algorithm in order to reduce the number of endoscopic procedures.

RESULTS

The average number of endoscopic procedures was 2.8 (range 2-5) in group A (leak size <10 mm) and 4 (range 3-7) in group B (leak size >10 mm). Two out of 13 patients had stent migration (15.4 %) and required an additional procedure, one in group A and another in group B. The average duration to achieve complete healing was 3.4 months (range 2-14 months), 2.8 months for group A and 3.9 months for group B.

CONCLUSIONS

Limited data can be found in the literature on leaks after LSG. A new algorithm based on leak size permits standardization of endoscopic management and reduces procedures after LSG.

Rates of reflux before and after laparoscopic sleeve gastrectomy for severe obesity

BACKGROUND

A current management dilemma in laparoscopic sleeve gastrectomy (LSG) patients is the development of significant gastroesophageal reflux symptoms after surgery. Treatment is typically directed towards reducing acid reflux despite the surgical removal of parietal cell mass. In contrast, laparoscopic Roux-en-Y gastric bypass (LRYGB) has been known to reduce or resolve preoperative reflux symptoms. The objective of this study was to determine the incidence of preoperative and postoperative reflux of LSG and LRYGB patients, and review reflux treatment type and response.

METHODS

A retrospective chart review was performed for patients undergoing either LSG or LRYGB between January 2010 and December 2012 as part of the Weight Wise program, Royal Alexandra Hospital, Edmonton, Canada.

RESULTS

A total of 387 cases were included in our review. We observed a significant reduction in BMI postoperatively for both LSG and LRYGB groups (p < 0.001). Between surgical groups, preoperative proton-pump inhibitor (PPI) use was not significantly different; however, at 1 month (p < 0.05) to 1-2 years (p < 0.001), there was significantly increased PPI use in patients after LSG in comparison to LRYGB. Of the LSG patients that continued their PPI treatment after surgery, 58% increased, 42% continued the same, and 0% decreased their dose 1 year after surgery.

CONCLUSIONS

Reflux symptoms are significantly increased after LSG in comparison to LRYGB patients. In addition, LSG patients more frequently require initiation of reflux treatment after surgery than that of LRYGB patients. Patients reported postoperative reflux symptom relief with acid-suppressant therapies.

The effect of serosal suture reinforcement on burst pressure in sleeve gastrectomy specimens

PURPOSE

Staple-line leak is a life-threatening complication of laparoscopic sleeve gastrectomy. Reinforcement materials have been reported to lower the risk of staple-line bleeding, but their effects on leak risk have not been elucidated. The aim of this study was to compare the effects of 2 supportive techniques on burst pressures in sleeved gastrectomy specimens.

METHODS

A total of 30 patients who underwent laparoscopic sleeve gastrectomy were evaluated. The resected sleeve gastrectomy specimens were categorized into 3 groups: group 1 had no extra support in the staple-line, group 2 had interrupted serosal suture on the staple-line, and group 3 had serosal suture on staple-line junction points. The endpoint was the first detectable leakage, at which point the leak pressure and anatomic site of the leakage were recorded.

RESULTS

A total of 30 sleeved gastrectomy specimens were included (each group included 10 specimens). There were no differences between groups in terms of age, sex, and body mass index. The leak pressure was significantly higher (56.2±6.4 mm Hg) in group 2 (P<0.01). Leaks occurred significantly more frequently in the staple-line than in the staple-line junction points (P<0.01).

CONCLUSIONS

Interrupted serosal suture significantly increased the burst pressure. Increases in intraluminal pressure are known to be significant in leak etiology. Thus, we concluded that interrupted serosal suture may be beneficial in the prevention of leaks.

The utility of radiological upper gastrointestinal series and clinical indicators in detecting leaks after laparoscopic sleeve gastrectomy: a case-controlled study

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.

[Anastomosis and suture insufficiency after interventions for bariatric and metabolic surgery]

BACKROUND

Metabolic surgery is internationally well-established for the treatment of obesity and its comorbidities. The numbers of procedures performed is steadily increasing. The results of surgery are superior in comparison to conservative treatment options regarding weight loss and resolution of comorbidities. The insufficiency of suture lines is a well-known and feared complication in the stapling procedures and is associated with an increased morbidity as well as mortality, especially in super obese patients.

MATERIAL AND METHODS

The current literature was reviewed and the results are reported within the context of own experience.

RESULTS

The most severe complications are staple line leakage after sleeve gastrectomy, leakage of anastomoses after bypass procedures and duodenal stump insufficiency. For the treatment of sleeve leakage various endoscopic procedures, such as over the scope (OTS) clips, stents and endoluminal vacuum therapy are available. Surgical revision, such as oversuturing, drainage and redo surgery are well-established. The management of all other complications is mainly by surgical intervention. Intraoperative standardization of procedures and knowledge of the physical foundations are essential for the prevention of leakage. Several preventive methods are available but randomized controlled trials are missing.

CONCLUSION

The therapy of leakages in the field of bariatric surgery is an interdisciplinary approach and dependent on the available resources in the treating hospital. The data reported show good results but the different reports published are inconsistent. Leakages often do not occur in the immediate postoperative period but in the sense of a long-term complication; therefore standardization of procedures and follow-up as well as complication management is mandatory. Randomized controlled studies must be promoted.

Closure of benign leaks, perforations, and fistulas with temporary placement of fully covered metal stents: a retrospective analysis

INTRODUCTION

Partially covered self-expanding metal stents (SEMS), have been suggested as an alternative to surgery in the treatment of esophageal fistulas of benign etiology. Nevertheless, uncomplicated removal remains difficult. The use of fully covered (FC) SEMSs could solve this problem.

OBJECTIVES

To review our experience with FC-SEMS placement in patients with benign upper gastrointestinal leaks or perforations. We wanted to assess successful closure of the perforations and short-term and long-term complications.

MATERIALS AND METHODS

Multicenter study, including 3 tertiary centers. Retrospective review of patients who underwent FC-SEMS placement for benign perforations.

RESULTS

Eighty-eight stents were placed in 56 patients. We achieved leak closure in 44 patients (78.6%). There were 18 migrations. All of them could be solved endoscopically. A severe septic situation was associated with a higher mortality rate (27.6% vs. 7.4%; P=0.049) and a lower success rate (34.5% vs. 7.4%; P=0.088), compared with those patients who did not present severe sepsis. However, these differences could not be confirmed by multivariable analysis. The results in the subgroup of 11 patients with leaks after sleeve gastrectomy were also good (73% success without surgery and 0% mortality).

CONCLUSIONS

Temporary placement of FC-SEMS for benign perforations, fistulas, and leaks is feasible in sealing the leaks. All migrations could be solved endoscopically. It is very important to insert the stent before sepsis is established. This article also would be an addition to the growing body of literature supporting stenting as a good alternative if not standard approach to controlling these leaks.

Are there risk factors that increase the rate of staple line leakage in patients undergoing primary sleeve gastrectomy for morbid obesity?

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is currently being performed with increasing frequency worldwide. It offers an excellent weight loss and resolution of comorbidities in the short term with a very low incidence of complications. However, the ever present risk of a staple line leak is still a major concern.

METHODS

Since 2005, data from obese patients that undergo bariatric procedures in Germany are prospectively registered in an online database and analyzed at the Institute of Quality Assurance in Surgical Medicine. For the current analysis, all patients that had undergone primary sleeve gastrectomy for morbid obesity within a 7-year period were considered.

RESULTS

Using the GBSR, data from 5.400 LSGs were considered for analysis. Staple line leak rate decreased during the study period from 6.5 to 1.4 %. Male gender, higher BMI, concomitant sleep apnea, conversion to laparotomy, longer operation time, use of both buttresses and oversewing, and the occurrence of intraoperative complications were associated with a significantly higher leakage rate. On multivariate analysis, operation time and year of procedure only had a significant impact on staple line leak rate.

CONCLUSIONS

The results of the current study demonstrated that there are factors that increase the risk of a leakage which would enable surgeons to define risk groups, to more carefully select patients, and to offer a closer follow-up during the postoperative course with early recognition and adequate treatment. All future efforts should be focused on a further reduction of serious complications to make the LSG a widely accepted and safer procedure.

Critical Care Management of Bariatric Surgery Complications

Obesity remains a major medical disease that often requires surgical intervention in morbidly obese patients. Surgical procedures have evolved and are performed routinely in most major medical centers. Outcomes are often dependent on patient characteristics, type of procedure, and preoperative planning. Risk stratification often depends on screening and optimizing known comorbidities often encountered in this patient population. A thorough understanding of the physiologic changes seen in obese patient and the commonly performed operations will allow the physician to perform optimal treatment strategies.

Intraoperative leak testing has no correlation with leak after laparoscopic sleeve gastrectomy

BACKGROUND

Staple line leak is a serious complication of sleeve gastrectomy. Intraoperative methylene blue and air leak tests are routinely used to evaluate for leak; however, the utility of these tests is controversial. We hypothesize that the practice of routine intraoperative leak testing is unnecessary during sleeve gastrectomy.

METHODS

A retrospective cohort study was designed using a prospectively collected database of seven bariatric surgeons from two institutions. All patients who underwent sleeve gastrectomy from March 2012 to November 2014 were included. The performance of intraoperative leak testing and the type of test (air or methylene blue) were based on surgeon preference. Data obtained included BMI, demographics, comorbidity, presence of intraoperative leak test, result of test, and type of test. The primary outcome was leak rate between the leak test (LT) and no leak test (NLT) groups. SAS version 9.4 was used for univariate and multivariate analyses.

RESULTS

A total of 1550 sleeve gastrectomies were included; most were laparoscopic (99.8%), except for one converted and two open cases. Routine intraoperative leak tests were performed in 1329 (85.7%) cases, while 221 (14.3%) did not have LTs. Of the 1329 cases with LTs, there were no positive intraoperative results. Fifteen (1%) patients developed leaks, with no difference in leak rate between the LT and NLT groups (1 vs. 1%, p = 0.999). After adjusting for baseline differences between the groups with a propensity analysis, the observed lack of association between leak and intraoperative leak test remained. In this cohort, leaks presented at a mean of 17.3 days postoperatively (range 1-67 days). Two patients with staple line leaks underwent repeat intraoperative leak testing at leak presentation, and the tests remained negative.

CONCLUSION

Intraoperative leak testing has no correlation with leak due to laparoscopic sleeve gastrectomy and is not predictive of the later development of staple line leak.

A Pancreatic Fistula after the Laparoscopic Sleeve Gastrectomy

Laparoscopic sleeve gastrectomy (LSG) is a popular surgical weight-loss procedure in the treatment of morbid obesity. There are some complications regarding this procedure in the literature. This report presents a pancreatic fistula (PF) case, which has not been previously seen.

Staple Line Reinforcement with Stitch in Laparoscopic Sleeve Gastrectomies. Is It Useful or Harmful?

BACKGROUND

Reinforcement of the staple line in laparoscopic sleeve gastrectomy (LSG) is a practice that leads to less morbidity, but equivocal results have been reported in the literature.

MATERIALS AND METHODS

This is a prospective randomized study comparing two groups of patients who underwent LSG. In one group LSG was performed with a running absorbable suture placement at the staple line. In the other group the running suture was not placed. General data of the patients, as well as intraoperative and postoperative data, were gathered and statistically analyzed.

RESULTS

Overall, 146 patients were subjected to LSG. In 84 patients a running suture was placed, and in 62 patients no suture was placed. No significant differences were found between the two groups in demographic data. No significant differences were found also in the intraoperative data, such as number of trocars, number and type of cartridges, drain placement, and operative time (45±21 versus 40±20 minutes, respectively; P<.05). Intraoperative complications were significantly more in the group with the suture placement (33.3% versus 16.1%, respectively; P<.05). Hematomas developed intraoperatively in more patients after the placement of the running suture (9.5% versus 0.0%, respectively; P<.05). Postoperatively, there was no significant difference in morbidity between the two groups (8.3% versus 9.7%, respectively; P>.05).

CONCLUSIONS

After this randomized study, final conclusions about the efficacy of this running suture to the staple line cannot be made. To the contrary, problems seem to exist after such reinforcement of the staple line, such as hematomas. Dealing with possible leaks and hemorrhage of the staple line is also problematic after placement of the running suture.

Definitive surgical management of staple line leak after sleeve gastrectomy

BACKGROUND

Sleeve gastrectomy (SG) has become a widely adopted bariatric surgical procedure. The most serious complication is staple line leak (SLL), which is potentially life threatening and, in some patients, becomes chronic and difficult to manage. Definitive surgical management of SLL is effective but seldom published in the literature.

OBJECTIVES

This study aims to review the outcome of definitive surgical management of SLL after SG, looking at short-term and long-term results.

SETTING

Single surgeon experience based at a tertiary university hospital in Beirut, Lebanon.

METHODS

Retrospective review of records of patients with SLL who underwent definitive surgical treatment by the senior author (B.Y.S.) from January 2008 until December 2013.

RESULTS

Ten patients (50% female) underwent definitive surgical repair during the study period. The mean age, weight, and body mass index at the time of SG were 35 years, 121 kg, and 41.5 kg/m(2), respectively. Most leaks (90%) were at the esophagogastric junction. All underwent multiple operative, endoscopic, or radiologic procedures before definitive surgical repair. Methods of definitive repair included open Roux-en-Y (RY) esophagojejunostomy (70%), open RY gastric bypass (10%), laparoscopic RY esophagojejunostomy (10%), and one laparoscopic RY fistulojejunostomy (10%). Six patients (60%) underwent definitive surgical treatment because of chronic SLL, on average, 26 weeks after leak detection (range 13-39 wk). The other 4 underwent repair earlier, on average 4 weeks after leak detection (1-7 wk). There were no mortalities, and all patients healed without residual leak. Perioperative morbidity developed in 1 of 6 (17%) patients who underwent delayed repair and in 75% of patients who underwent repair early. Patients who underwent early repair were heavier (body mass index 40.5 kg/m(2) versus 30 kg/m(2)) and nutritionally more deplete (albumin 26.7 g/L versus 39.2 g/L). All patients are well at a mean follow-up of 21.6 months (7.5-55.9 mo) with an average percentage excess weight loss of 74% (57%-120%).

CONCLUSIONS

Definitive surgical management of SLL was uniformly effective with acceptable morbidity. It is indicated in patients with chronic persistent fistula beyond 12 weeks, provided patients are kept in good nutritional state. Some select patients may benefit from this approach in the early phases, but the surgical risks are higher.

Laparoscopic sleeve gastrectomy using 42-French versus 32-French bougie: the first-year outcome

BACKGROUND

The optimal size of bougie in laparoscopic sleeve gastrectomy (LSG) remains controversial. The aim of this study was to evaluate the first-year outcome of LSG using two different sizes of bougies.

METHODS

This study used a single institute retrospective case-control study of two groups of patients. Group A (N = 66) underwent LSG using 42-Fr and group B (N = 54) using 32-Fr bougies. A medication score was applied to assess the change in comorbid conditions.

RESULTS

Groups A and B's age (39.5 ± 12 vs. 43.6 ± 12.3 years), weight (119 ± 17 vs. 120 ± 20), and BMI (42.8 ± 3.8 vs. 43.6 ± 6.9 kg/m(2)), respectively, were comparable (p = NS). Comorbid conditions were type 2 diabetes (T2DM) in 19 (29%) vs. 23 (43%) patients, hypertension in 22 (33%) vs. 18 (33%) patients, and gastroesophageal reflux (GERD) in 28 (42%) vs. 10 (19%) patients, respectively. At 1 year, group A vs. B BMI was (29.4 ± 5 vs. 30 ± 5 kg/m(2)) and excess weight loss was 67 vs. 65%, respectively (p = NS). Postoperatively, T2DM (79 vs. 83%), hypertension (82 vs. 61%), and GERD (82 vs. 60%) (p = NS), respectively, in groups A vs. B did not require previous medications anymore. Complications were comparable.

CONCLUSIONS

Our data suggest that using a 42-Fr or 32-Fr bougie does not influence LSG first-year weight loss or resolution of comorbid conditions. Long-term data is needed to conclude this issue.

Short-term outcomes of sleeve gastrectomy for morbid obesity: does staple line reinforcement matter?

Background

Stand-alone laparoscopic sleeve gastrectomy (LSG) has been found to be effective in producing weight loss but few large, one-center LSG series have been reported. Gastric leakage from the staple line is a life-threatening complication of LSG, but there is controversy about whether buttressing the staple line with a reinforcement material will reduce leaks. We describe a single-center, 518-patient series of LSG procedures in which a synthetic buttressing material (GORE® SEAMGUARD® Bioabsorbable Staple Line Reinforcement) was used in the most recently treated patients.

Methods

We retrospectively reviewed the medical records of all patients who underwent LSG in our unit between September 2007 and December 2011. Patients treated before August 2009 did not receive the staple line reinforcement material (n = 186), whereas all patients treated afterward did (n = 332).

Results

The percentages of excess weight loss in the 518 patients (mean age, 41 years; 82 % female; mean preoperative body mass index, 44 kg/m²) were 67 % (79 % follow-up rate) at 6 months postoperatively, 81 % (64 %) at 1 year, and 84 % (30 %) at 2 years. Type 2 diabetes resolved in 71 % of patients (91/128). Patients given reinforcement material had baseline characteristics similar to those in the no-reinforcement-material group, but had no postoperative staple line leaks or bleeding. The no-reinforcement group had three leaks (p = 0.045) and one case of bleeding.

Conclusions

LSG resulted in substantial short-term weight loss. Use of the bioabsorbable staple line reinforcement material may decrease leaks after LSG.

Delayed splenic abscess after laparoscopic sleeve gastrectomy

Splenic abscesses complicating sleeve gastrectomies are extremely rare. We report the fourth recorded case of a splenic abscess; in our case it occurred 10 weeks after sleeve gastrectomy in a 44-year-old man. The clinical presentation was vague but included the triad of fever, left upper quadrant tenderness and leucocytosis. The presence of this triad after sleeve gastrectomy should prompt investigation with contrast CT scans to exclude a splenic abscess.

Use of platelet-rich plasma to reinforce the staple line during laparoscopic sleeve gastrectomy: feasibility study and preliminary outcome

AIMS

Reinforcement of the staple line is one of the most debated technical aspects concerning laparoscopic sleeve gastrectomy (LSG). Different buttressing methods have been proposed and demonstrated to be effective in reducing the incidence of staple line bleeding, although data concerning their effort on staple line leakage are not consistent. The aim of this study was to ascertain the technical feasibility and to report the preliminary outcomes of laparoscopic use of platelet-rich plasma (PRP) to reinforce the staple line during sleeve gastrectomy.

PATIENTS AND METHODS

From March 2012 to May 2012, 20 patients were prospectively enrolled (10 females; mean age, 44.6 ± 11 years; mean body mass index, 42.3 ± 5.45 kg/m(2)). Type 2 diabetes mellitus was present in 4 patients, obstructive sleep apnea syndrome in 3, and hypertension in 6. LSG was performed using a 48-French bougie and gold cartridges; reinforcement of the staple lines with buttressed materials or oversewing the suture was performed excluding the last cranial cartridge. PRP was prepared by separating the platelets from autologous blood withdrawn on the same day of surgery, in order to obtain a membrane with cylindrical shape (2×5 cm) formed by fibrin and active platelets. The membrane is introduced through the 10-mm trocar and placed at the upper portion of the staple line. The overall cost for the preparation of PRP is about €15.

RESULTS

No intraoperative complications and conversions have been recorded during the surgical procedures. No deaths occurred. The mean operative time was 85 ± 31 minutes, which was not significantly increased compared with the operative time of the surgeon's overall personal series (750 cases). At 12 months of follow-up the abdominal ultrasound was negative for collections, and upper contrast showed no images indicating gastric leaks. In no case did PRP induce symptoms of rejection, infection, or adverse events.

CONCLUSIONS

The use of PRP during LSG is feasible, does not increase significantly the operative time, does not require any special devices, and is cost effective. A larger cohort of patients is needed to ascertain the potential effectiveness of PRP in the prevention of postoperative staple line complications.

Results and complications after laparoscopic sleeve gastrectomy

PURPOSE

Laparoscopic sleeve gastrectomy (SG) has gained popularity and acceptance among bariatric surgeons, mainly due its low morbidity and mortality. The purpose of the present study was to evaluate the efficacy of SG on weight loss, and to determine the postoperative course, clinical presentation and treatment of complications after SG.

METHODS

Between January 2006 and October 2012, 153 consecutive patients underwent SG. All data were prospectively collected in a computerized database.

RESULTS

This series comprised 119 females and 34 males with a median age of 46 years and a median preoperative BMI of 42.3 kg/m2. The median EWL was 53.0 % after 18.4 months of follow-up. The median postoperative BMI was 33.3 kg/m2 (range 19.7–56.1 kg/m2). Eight patients (5.2 %) required re-laparoscopy to manage postoperative hemorrhage (3.3 %) and leakage (1.9 %). Neither abdominal drains nor postoperative contrast-swallow studies were successful in diagnosing hemorrhage or leaks in our patients.

CONCLUSION

SG is an effective procedure to achieve significant short-term weight loss. Clinical signs, such as tachycardia, pain, fever and hypotension, provide the best evidence of the presence of postoperative leakage or bleeding. An early diagnosis of these complications is the key to ensuring adequate treatment with immediate re-laparoscopy.

Combined endoscopic-laparoscopic T-tube insertion for the treatment of staple-line leak after sleeve gastrectomy: a simple and effective therapeutic option

BACKGROUND

Management of staple-line leak after laparoscopic sleeve gastrectomy (LSG) remains controversial and matter of debate. Transforming a leak into a controlled fistula by insertion of a T-tube is a viable option. To minimize surgical dissection, and to facilitate identification of the leak site and insertion of the T-tube, we have developed a combined endoscopic-laparoscopic T-tube (ELT-t) insertion technique.

METHODS

Between February 2011 and June 2014, 7 patients presented with staple-line leak and were treated with ELT-t insertion. After laparoscopic dissection of the abscess cavity, a guidewire is passed endoscopically through the leak; a polypectomy snare is anchored to the guidewire and retrieved through the patient mouth. The long arm of a T-tube is eventually secured to the snare and pulled down through the leak.

RESULTS

All patients were started on oral feeding with the T-tube in place. Serial water-soluble contrast swallows were performed to check for healing, and the T-tube was clamped as soon as no extravasation of contrast was demonstrated. The tube was removed either during the index admission or in the outpatient clinic. The residual fistula closed successfully after T-tube removal in all but one case with a "spiral-shaped" sleeve and functional distal obstruction. This patient was treated with stent. Patients were discharged home after a mean postoperative hospital stay of 53.3 days (range: 15-87 days).

CONCLUSION

In our experience, ELT-t is a valid alternative for the treatment of staple-line leak after LSG. It allows minimizing surgical dissection, and appears to be safe and effective.

Novel oesophago-gastro-duodenal stenting for gastric leaks after laparoscopic sleeve gastrectomy

The management of gastric leak after laparoscopic sleeve gastrectomy (LSG) can be complex and challenging. Whilst operative interventions are mostly complicated and reserved for unstable or refractory cases, endoscopic self-expandable metal stenting (SEMS) is increasingly preferred as a safer treatment option. Yet, SEMS carries the problems of frequent stent migration and inconsistent healing as ordinary SEMS is designed mainly for stenotic disease. We hereby present two cases of early and chronic post-LSG leakage that were respectively failed to be treated by surgery and ordinary SEMS but were successfully managed by a dedicated extra-long oesophago-gastro-duodenal stent. In oesophago-gastro-duodenal stenting, the characteristics of extra-long stent length allow total gastric exclusion between the mid-oesophagus and the first part of duodenum to prevent stent migration and to equalise high pressure gradient within the gastric sleeve to promote fistula healing.