Does experience preclude leaks in laparoscopic gastric bypass?

Repeated Duodenal Stump Perforation Using a Stapling Device Following Subtotal Gastrectomy With Roux-en-Y Reconstruction for Advanced Gastric Cancer: Lessons From a Rare Case

Closure of the duodenal stump using a stapling device is commonly applied in Roux-en-Y reconstruction after gastrectomy. However, serious and possibly fatal duodenal stump perforation can develop in extremely rare cases. We describe a case of subtotal gastrectomy with Roux-en-Y reconstruction followed by repeated duodenal stump perforations. A 79-year-old man with a long history of diabetes and hypertension was admitted to our institution with epigastralgia and right hypochondralgia. Computed tomography and an upper gastrointestinal imaging series revealed remarkable wall thickening of the gastric antrum and corpus. Upper endoscopy also showed a giant ulcerative lesion in the same area. The lesion was confirmed by histology to be poorly differentiated adenocarcinoma. The patient underwent open subtotal gastrectomy with Roux-en-Y reconstruction. However, duodenal stump perforation occurred repeatedly on postoperative days 1, 3, and 19, which caused peritonitis. The patient was kept alive through duodenal stump repair, an additional resection using a stapling device, and repeated drainage treatments; but he suffered considerable morbidity due to these complications. We report a case of a life-threatening duodenal stump perforation after subtotal gastrectomy, highlighting lessons learned from the profile and clinical course. Abdominal surgeons should be aware of the possibility of this serious complication of duodenal stump perforation, and be able to perform immediate interventions, including life-saving reoperation.

Role of intraoperative esophagogastroenteroscopy in minimizing gastrojejunostomy-related morbidity: experience with 2,311 laparoscopic gastric bypasses with linear stapler anastomosis

Background

Anastomotic leaks and strictures of the gastrojejunostomy are a cause of major morbidity following laparoscopic Roux-en-Y gastric bypass (LRYGB). Reported rates of leaks vary between 0 and 5.2 %. This has led bariatric surgeons to use a variety of intraoperative methods to detect incompetent suture lines. The aim of the study was to evaluate the role of intraoperative endoscopy in reducing the rate of postoperative anastomotic complications. The setting of this study is in a community teaching hospital.

Methods

Medical records of 2,311 patients who underwent a LRYGB from 2002 to 2011 were retrospectively reviewed utilizing the hospitals’ bariatric surgery database. Demographics, weight, body mass index, intraoperative endoscopy results, and postoperative outcomes within 90 days after surgery were analyzed.

Results

Endoscopy was attempted in 2,311 patients and completed in 2,308 (99.9 %). Intraoperative leak was detected in 80 (3.5 %) patients; suture line was reinforced in 46 patients (2 %), while in the other 34 patients the leak was transient at only high insufflation pressure. Postoperative clinical leaks were detected in four cases (0.2 %) two of which had initial leaks intraoperatively. In two cases, the anastomosis was too tight and required reconstruction. Twenty-five patients (1.1 %) developed early postoperative strictures requiring endoscopic dilatation within 90 days. Three patients (0.1 %) had iatrogenic injury at the time of intraoperative endoscopy, all three healed without delayed morbidity.

Conclusions

The routine use of intraoperative endoscopy in LRYGB with the linear stapler anastomosis technique is associated with a complication/failure rate of 0.3 % and low gastrojejunostomy-related morbidity after LRYGB within 90 days (leak rate of 0.2 % and stricture rate of 1.1 %).

Factors Influencing the Outcome of Intestinal Anastomosis

Anastomotic leak (AL) is one of the most serious complications after gastrointestinal surgery. All patients aged 16 years or older who underwent a surgery with single intestinal anastomosis at Morristown Medical Center from January 2006 to June 2008 were entered into a prospective database. To compare the rate of AL, patients were divided into the following surgery-related groups: 1) stapled versus hand-sewn, 2) small bowel versus large bowel, 3) right versus left colon, 4) emergent versus elective, 5) laparoscopic versus converted (laparoscopic to open) versus open, 6) inflammatory bowel disease versus non inflammatory bowel disease, and 7) diverticulitis versus nondiverticulitis. We also looked for surgical site infection, estimated intraoperative blood loss, blood transfusion, comorbidities, preoperative chemotherapy, radiation, and anticoagulation treatment. The overall rate of AL was 3.8 per cent. Mortality rate was higher among patients with ALs (13.3%) versus patients with no AL (1.7%). Open surgery had greater risk of AL than laparoscopic operations. Surgical site infection and intraoperative blood transfusions were also associated with significantly higher rates of AL. Operations involving the left colon had greater risk of AL when compared with those of the right colon, sigmoid, and rectum. Prior chemotherapy, anticoagulation, and intraoperative blood loss all increased the AL rates. In conclusion, we identified several significant risk factors for ALs. This knowledge should help us better understand and prevent this serious complication, which has significant morbidity and mortality rates.

Single-layer versus double-layer laparoscopic intracorporeally sutured gastrointestinal anastomoses in the canine model

This study shows that the 1-layer gastrointestinal suture technique is feasible, safe and has fewer complications compared with a 2-layer suture technique.

Objective:

The objective of this study was to compare the gross and histopathologic changes following 1- versus 2-layer hand-sewn suture techniques in laparoscopic gastrointestinal anastomosis in dogs.

Methods:

This was an experimental prospective study of 16 healthy mixed breed male and female dogs. Animals were randomly divided into 2 groups. Two-layer side-to-side hand-sewn laparoscopic gastrojejunostomies were performed in group A, so that simple interrupted sutures were placed in the outer layer and simple continuous suture was used in the inner layer. The 1-layer simple continuous anastomosis between the stomach and jejunum was done in group B precisely. Specimen were collected from the sites of anastomosis, and H&E statining was performed for light microscopic studies.

Results:

All animals survived the surgery. There was no gross inflammation, ischemia, apparent granulation tissue, abscess or fistula formation, leakage or stricture formation, and all sites of anastomosis were patent. Several adhesion formations were found in the abdomen with the higher incidence in the control group. Mean scores of leukocyte infiltration and granulation tissue formation at the sites of anastomosis were statistically insignificant between groups (P>0.05).

Conclusions:

Gross and histopathologic findings revealed that hand-sewn laparoscopic gastrointestinal anastomosis with the 1-layer suture technique is comparable to the 2-layer suture technique.

Staple line reinforcement in laparoscopic bariatric surgery: does it actually make a difference? A systematic review and meta-analysis

BACKGROUND

Staple line leaks represent a major concern in all laparoscopic operations but are particularly important in bariatric surgery, where leak complications carry significant morbidity and mortality. Therefore, several means of staple line reinforcement have been described, but none is totally accepted. In this study, we attempt to illuminate any clear benefit of staple line reinforcement through a systematic review and meta-analysis of reported articles.

METHODS

Two major databases (PubMed and Cochrane) were searched and assessed by two reviewers. Inclusion criteria were: detailed description of operative technique, especially concerning staple line reinforcement, and possible existence of proven staple line leak. Selected studies were evaluated by systematic review and meta-analysis according to their eligibility. The study population was finally divided into two groups: reinforcement (of any type) and no reinforcement.

RESULTS

In the initial search, 126 studies were obtained. Then, 17 full papers, both randomised controlled trials (RCTs) and non-RCTs, were included in the systematic review. Seven studies, comprising 3,299 patients, were examined for evaluation of population odds of leak (7.69), which was considered clinically significant. Meta-analysis of three studies comprising 1,899 patients revealed no clear benefit of reinforcement group, though with marginal significance.

CONCLUSIONS

Although several drawbacks exist, this study illustrates two important aspects: that current staplers may not be uniformly reliable, and that staple line reinforcement does not seem to have any clear benefit, at least concerning leak rate.

Duodenal- jejunal bypass sleeve: a totally endoscopic device for the treatment of morbid obesity

Morbid obesity affects over 15 million people in the United States. Nonsurgical management produces sustained weight loss in less than 5% of patients. Despite associated comorbidities, less than 1% of obese patients seek surgical intervention. Less invasive procedures have been developed with varying success. The Endobarrier( trade mark) (GI Dynamics(trade mark), Watertown, MA) duodenal-jejunal bypass sleeve is a totally endoscopically delivered device designed to produce weight loss in the morbidly obese. We describe the first placement of a duodenal-jejunal bypass sleeve in a patient in the United States. A blinded, randomized, prospective clinical trial was approved by the Food and Drug Administration to evaluate safety and efficacy of a novel device for weight loss in the obese. The first patient enrolled was a 36-year-old woman with body mass index of 45.2. After informed consent, endoscopic placement of the device under general anesthesia was performed using fluoroscopy to confirm positioning. The device was placed without complications. At conclusion of the 3-month study period, the device was removed endoscopically. Total weight lost by the patient was 9.09 kg. Described herein is the first deployment of the duodenal-jejunal bypass sleeve in North America. The device is delivered in a totally endoscopic manner in morbidly obese patients. In our patient, total weight loss at 3 months was 9.09 kg. Continued follow-up and enrollment is ongoing to demonstrate patient safety and efficacy. Additional studies are being performed to elucidate mechanism of weight loss and future clinical applications of this device.

Errant and unrecognized antiperistaltic Roux limb construction during Roux-en-Y gastric bypass for clinically significant obesity

BACKGROUND

Proper isoperistaltic orientation of the Roux limb is important. We report on 5 patients with errant anatomic construction of the Roux limb during Roux-en-Y gastric bypass for clinically significant obesity.

METHODS

We performed a retrospective review of the medical records of these 5 patients. Of the 5 patients, 3 had undergone open and 2 laparoscopic Roux-en-Y gastric bypass.

RESULTS

These 5 patients developed persistent and predominantly bilious vomiting in the immediate postoperative period, with subsequent protein-calorie malnutrition. At least 18 operations were undertaken in these 5 patients at different times to correct the abnormally dilated Roux limb to no avail. The diagnosis of an antiperistaltic anatomy was unsuspected, and these operations failed to address the errant anatomy of the Roux limb or resolve the symptoms. Definitive treatment involved repositioning of the Roux limb in an isoperistaltic direction, which resulted in immediate resolution of the symptoms and reversal of the protein-calorie malnutrition.

CONCLUSION

Antiperistaltic Roux anatomy is deleterious, and repositioning of the Roux limb in an isoperistaltic direction will resolve the symptoms and associated protein-calorie malnutrition.

Diagnosis and contemporary management of anastomotic leaks after gastric bypass for obesity

BACKGROUND

Anastomotic leaks are a dreaded complication of bariatric surgery. The objective of this study was to describe the clinical presentation and outcomes of treatment in patients who develop anastomotic leaks after Roux-en-Y gastric bypass for obesity.

STUDY DESIGN

Prospectively collected data on 3,018 consecutive patients who underwent Roux-en-Y gastric bypass in 4 tertiary referral centers were reviewed.

RESULTS

Sixty-three patients (2.1%) developed anastomotic leaks (open, 2.1%; laparoscopic, 2.1%) at a median of 3 days (range 0 to 28 days) after Roux-en-Y gastric bypass. Symptoms and signs included tachycardia (72%), fever (63%), or abdominal pain (54%). Upper gastrointestinal series and CT demonstrated leaks in only 17 of 56 (30%) and 28 of 50 (56%) patients, respectively; when done jointly, both studies were negative in 30% of patients. The 68 anastomotic leaks occurred at the gastrojejunostomy (49%), excluded stomach (25%), jejunojejunostomy (13%), gastric pouch (9%), and uncertain location (4%). Forty patients (63%) required 58 reoperations for drainage of intraabdominal collections (55%), repair of anastomotic defects (34%), or revision of the leaking anastomosis (11%), with an overall morbidity of 53% and mortality of 10%. Nonoperative treatment was successful in 23 of 26 patients, with an overall morbidity of 61% and no mortality (p=NS versus operative). Operative treatment was more common in patients with hypotension or oliguria (p < 0.01).

CONCLUSIONS

Lack of specificity in clinical presentation and imaging studies make diagnosing anastomotic leaks challenging, so operative exploration should be part of the diagnostic algorithm. Nonoperative treatment is safe and effective in a subset of patients who exhibit stable hemodynamic parameters and are known to have controlled leaks.