Gastric leak after laparoscopic-sleeve gastrectomy for obesity

Management of Gastric Leak after Sleeve Gastrectomy: A 13-year Experience in a Tertiary Referral Center

INTRODUCTION

The main complication of sleeve gastrectomy remains fistula formation. Studies have mainly focused on the endoscopic management of fistulas, and surgery is reserved for cases of hemodynamic instability or treatment failure. The aim of this study was to evaluate the management of gastric leak after sleeve gastrectomy.

METHODS

We retrospectively analyzed the characteristics, treatments, and outcomes of patients managed for gastric leaks after sleeve gastrectomy in our center. Healing was defined as resumed oral intake without inflammatory syndrome or the presence of drainage material.

RESULTS

From 2009 to 2022, 43 patients were managed in our center for gastric leak after sleeve gastrectomy. Among them, 21 patients were referred from other centers. In 86% of cases, the gastric leak developed within the first 15 days. It was located at the proximal staple line in 84% of cases. Associated stenosis or twisting was observed in 18% of cases. Surgical treatment alone was used in 32% of patients, while 59% received combined management. Only 3 patients (6.8%) were managed exclusively by endoscopy. The overall healing rate was 91%, with a median healing time of 89 days.

CONCLUSION

The management of gastric leaks after sleeve gastrectomy depends on their location and clinical presentation and should not be limited to a solely endoscopic or surgical approach. Our study demonstrates that surgical intervention alone may be sufficient in 30% of cases. However, for most patients, a multidisciplinary approach in a referral center is recommended.

Evaluation of patients on immunosuppressants undergoing sleeve gastrectomy, Roux-en-Y gastric bypass, and duodenal switch: analysis of 19,414 patients

BACKGROUND

Bariatric surgery is being offered to more medically complex patients, including patients on immunosuppressants, although outcomes after different bariatrics surgeries have not been studied in this population.

OBJECTIVES

We compared perioperative safety of sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and duodenal switch (DS) in patients on immunosuppression.

SETTING

National sample from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database.

METHODS

The MBSAQIP database was queried from the years 2015 to 2021 for adult patients on chronic immunosuppression who underwent SG, RYGB, or DS. Revisional, open, endoscopic, or emergency surgeries were excluded, as were patients with an American Society of Anesthesiologists class of 5 and patients without full 30-day follow-up. Propensity-score matching was performed with a 3:3:1 ratio (SG:RYGB:DS) controlling for surgical approach, sex, age, functional status, American Society of Anesthesiologists, body mass index, and comorbidities.

RESULTS

There were 19,414 patients on immunosuppression who underwent SG (n = 14,358), RYGB (n = 4864), or DS (n = 192). After propensity-score matching , RYGB and DS had longer LOS (P < .01), greater global 30-day complication (P < .01), and 30-day reoperation rates (P = .048). Compared with SG and RYGB, DS had greater rates of patients requiring mechanical ventilation >48-hour postoperatively (P < .05). Compared with SG, DS had greater rates of renal insufficiency (P = .01), organ space infection (P = .01), unplanned intubation (P < .01), and unplanned intensive care unit admission (P < .01).

CONCLUSIONS

For patients on immunosuppression, SG carried the lowest complication and reoperation rates, whereas DS had overall complication rates in line with RYGB.

A case of multiple liver abscesses after laparoscopic sleeve gastrectomy

Laparoscopic Sleeve Gastrectomy is the most common weight loss surgery and at the same time one of the safest. However, like any other surgery, it carries significant risks and complications. One of these complications isliver abscess. This article presents a clinical case of a 36-year-old patient who developed multiple liver abscesses one month after laparoscopic sleeve gastrectomy. The patient’s medical history, surgery details, postoperative course, symptoms and diagnostic tests are described. Liver abscess is a rare but very serious complication after sleeve gastrectomy. The etiology of this complication is still a subject of debate. We can only assume that the most likely causes ofliver abscess are intra-abdominal bleeding with hematoma formation and its subsequent infection or failure of the stapler suture line in the early postoperative period. Computed tomography with intravenous contrast is the preferred method for diagnosing this complication, especially in patients with fever, rapid heartbeat, and abdominal pain. Currently, the most effective and safe method for treating localized purulent liver diseases is percutaneous puncture and drainage of the abscess under ultrasound or CT navigation, followed by intravenous antibiotics for 4-6 weeks. This treatment strategy has proven its effectiveness in many studies. Our clinical case was no exception. The purpose of this article is to raise awareness among surgeons about this rare complication and emphasize the importance of early diagnosis and treatment.

Endoscopic Management of Bariatric Surgery Complications: Fistulas, Leaks, and Ulcers

Bariatric surgery is a safe and effective treatment option for patients with obesity and obesity-related comorbidities, with Roux-en-Y gastric bypass and sleeve gastrectomy being the two most common procedures. Despite the success of these interventions, adverse events are not uncommon. Endoscopic management has become first-line therapy when complications occur, and the armamentarium of devices and techniques continues to grow. This article focuses on the management of fistulas, leaks, and ulcers and also focuses on the etiology and endoscopic management strategy of each complication.

Routine Upper Gastrointestinal Series Post-bariatric Surgery: Predictors, Usage, and Utility

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.

Endoscopic Management of Post-Sleeve Gastrectomy Complications

Obesity is associated with several chronic conditions including diabetes, cardiovascular disease, and metabolic dysfunction-associated steatotic liver disease and malignancy. Bariatric surgery, most commonly Roux-en-Y gastric bypass and sleeve gastrectomy, is an effective treatment modality for obesity and can improve associated comorbidities. Over the last 20 years, there has been an increase in the rate of bariatric surgeries associated with the growing obesity epidemic. Sleeve gastrectomy is the most widely performed bariatric surgery currently, and while it serves as a durable option for some patients, it is important to note that several complications, including sleeve leak, stenosis, chronic fistula, gastrointestinal hemorrhage, and gastroesophageal reflux disease, may occur. Endoscopic methods to manage post-sleeve gastrectomy complications are often considered due to the risks associated with a reoperation, and endoscopy plays a significant role in the diagnosis and management of post-sleeve gastrectomy complications. We perform a detailed review of the current endoscopic management of post-sleeve gastrectomy complications.

Current Management and Treatment Paradigms of Gastroesophageal Reflux Disease following Sleeve Gastrectomy

Obesity is associated with serious comorbidities and economic implications. Bariatric surgery, most commonly Roux-en-Y gastric bypass and sleeve gastrectomy, are effective options for weight loss and the improvement of obesity-related comorbidities. With the growing obesity epidemic, there has been a concomitant rise in bariatric surgeries, particularly in sleeve gastrectomy, which has been the most widely performed bariatric surgery since 2013. Gastroesophageal reflux disease (GERD) is highly prevalent in obese individuals, can significantly impact quality of life and may lead to serious complications. Obesity and GERD both improve with weight loss. However, as the incidence of sleeve gastrectomy rises, recent data have revealed a risk of exacerbation of pre-existing GERD or the development of de novo GERD following sleeve gastrectomy. We performed a detailed review of GERD post-sleeve gastrectomy, including its overall incidence, pathophysiology and current treatment paradigms.

Oversewing the Staple Line: Does It Safe to Prevent Leakage?

Introduction: The staple line (SL) leak remains one of the most serious complications after laparoscopic sleeve gastrectomy (LSG). The present study aims to determine whether reinforcing the SL with sutures is effective in maintaining tissue integrity. Materials and Methods: LSG Specimens of 60 patients were ex vivo studied. The specimens were divided into three groups: In group 1, the entire SL was reinforced, while the upper half part of the SL was reinforced from fundus to antrum in group 2. The SL was not reinforced in group 3. Then, the pressure inside the sample was increased, and the bursting pressure location and pressure value during the bursting were recorded. Results: The bursting pressure was significantly higher in entire and half oversewed SL groups than the none reinforced group (group 1: 115 mmHg [95-170]; group 2: 95 mmHg [80-120]; group 3: 40 mmHg [22-60], respectively, [P < .001]). The most common site of bursting was in the middle ⅓ of SL (35, 53.8%), followed by the proximal ⅓ part of SL (18, 27.7%), and the distal ⅓ part of SL (12, 18.5%), respectively. The bursting site was significantly more frequent in the corpus than the other parts of the SL (P = .013). Conclusion: Reinforcing the SL with sutures preserves tissue integrity. Although bursting was most frequently observed in the corpus region ex vivo, the fact that almost all real-life leaks develop in the area close to the Angle of His. This situation suggests that strengthening the suture line with reinforcement alone will not be protective enough against leaks in the fundus line, and factors such as tissue ischemia may be considered.

Comparison of the postoperative outcome with and without intraoperative leak testing for sleeve gastrectomy: a systematic review and meta-analysis of 469 588 cases

OBJECTIVE

Postoperative staple line leakage (SLL) after sleeve gastrectomy (SG) is a rare but serious complication. Many surgeons routinely test anastomosis with an intraoperative leak test (IOLT) as part of the SG procedure. This meta-analysis aims to determine whether an IOLT plays a role in reducing the rate of postoperative staple line related complications in patients who underwent SG.

METHODS

The authors searched the PubMed, Web of science, the Cochrane Library, and Clinical Trials.gov databases for clinical studies assessing the application of IOLT in SG. The primary endpoint was the development of postoperative SLL. Secondary endpoints included the postoperative bleeding, 30 days mortality rates, and 30 days readmission rates.

RESULTS

Six studies totaling 469 588 patients met the inclusion criteria. Our review found that the SLL rate was 0.38% (1221/ 324 264) in the IOLT group and 0.31% (453/ 145 324) in the no intraoperative leak test (NIOLT) group. Postoperative SLL decreased in the NIOLT group compared with the IOLT group (OR=1.27; 95% CI: 1.14-1.42, P =0.000). Postoperative bleeding was fewer in the IOLT group than that in the NIOLT group (OR 0.79; 95% CI: 0.72-0.87, P =0.000). There was no significant difference between the IOLT group and the NIOLT group regarding 30 days mortality rates and 30 days readmission rates ( P >0.05).

CONCLUSION

IOLT was correlated with an increase in SLL when included as a part of the SG procedure. However, IOLT was associated with a lower rate of postoperative bleeding. Thus, IOLT should be considered in SG in the situation of suspected postoperative bleeding.

Added value of positive intraluminal contrast CT over fluoroscopic examination for detecting gastrointestinal leakage after gastrointestinal surgery

We aimed to evaluate the added value of positive intraluminal contrast computed tomography (CT) over fluoroscopy in detecting anastomotic leakage after gastrointestinal (GI) surgery. A total of 141 GI surgery patients who underwent fluoroscopic examination and CT were included. Two radiologists reviewed the fluoroscopic images with and without CT to determine anastomotic leakage on a 5-point confidence scale and graded the leakage on a 4-point grading system. The hospital stay duration and treatment type were recorded. The radiologists' diagnostic performance in determining leakage was compared using the receiver operating characteristics analysis, and interobserver agreement was analyzed. Fifty-three patients developed GI leakage. When CT was added to the fluoroscopic images, the area under the curve (AUC) values significantly increased for both reviewers. The interobserver agreement for leakage between the two reviewers was excellent and improved with the addition of CT (weighted kappa value, 0.869 versus 0.805). Postoperative intervention was more frequently performed (P < 0.001), and patients with leakage had a significantly longer mean postoperative hospital stay (45 days vs. 27 days) (P = 0.003). Thus, positive intraluminal contrast CT provides added value over fluoroscopic examination for detecting GI leakage in patients undergoing GI tract surgery, increasing AUC values, and improving interobserver agreement.

Topical hemostatic application on staple line in laparoscopic sleeve gastrectomy: a single-surgeon experience

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is a common bariatric procedure with low complication rates. Several hemostatic agents have been used to reduce staple line bleeding, but its impact is unclear. The primary endpoint of this study was to compare the early (30-day) complications comparing oxidized regenerated cellulose (ORC) and fibrin sealant (FS) application on the staple line. The secondary endpoints were to compare the need for postoperative blood transfusion, postoperative blood work values of hemoglobin (Hb), white blood cell (WBC), C-reactive protein (CRP), drain output volume and hospital length of stay (LOS).

METHODS

A retrospective analysis of all patients who underwent LSG between January and October 2021 was performed. Subjects were divided into two groups according to the use of ORC versus FS on the staple line. Early postoperative complications, Hb level, WBC count, and drain output volume were compared between groups.

RESULTS

A total number of 77 patients were included: 27 in the ORC-group and 50 in the FS-group. No major complication was recorded in both groups. There was no significant difference in the need for blood transfusion, Hb value, and drain output volume on postoperative day (POD) 1 and 2. There was a significantly higher WBC count in the ORC-group on POD 1 and 2. There was no difference in hospital LOS between the groups.

CONCLUSIONS

The use of FS and ORC was associated with a comparable low rate of bleeding. ORC causes an increased WBC count postoperatively, but this showed no clinical relevance.

Endoscopic management of refractory leak and gastro-cutaneous fistula after laparoscopic sleeve gastrectomy: a randomized controlled trial

BACKGROUND

Gastro-cutaneous fistula is a rare complication after laparoscopic sleeve gastrectomy (LSG) with incidence of occurrence 1-2%. Most of gastro-cutaneous fistulae do not respond to conservative management and need intervention either surgically or endoscopically.

METHODS

This prospective randomized clinical study included referred patients who had LSG performed at our department or other centers, and complicated with post-LSG leak or gastro-cutaneous fistula between December/2019 and March/2021. Included patients were ASA Physical status I-II. Primary and secondary outcomes were recurrence of the fistula and mortality in each group after the intervention during the 18 months follow-up period, respectively.

RESULTS

Thirty patients were randomized into two groups: Surgery Group (SG, n = 15) and Endoscopy Group (EG, n = 15). Mean age of patients was 42.3 ± 8.7 and 42.6 ± 8.3 years-old in SG and EG, respectively. Females constituted 73.3% and 80% in SG and EG, respectively. Median time-to-gastric leak post LSG was six (range: 4-7) days in both groups. SG patients were surgically managed with primary repair of the gastric fistula and gastrojejunostomy in 13 patients or converting SG into Roux-en-Y gastric bypass in two patients, while EG patients were endoscopically managed with stitching, stenting, stenting and dilation, and clipping and dilation in 5, 4, 4 and 2 patients, respectively. Incidence of recurrent leak during 1^st week was significantly higher in SG than EG (p < 0.001). No mortality reported in EG, while 2 patients died in SG (p = 0.48).

CONCLUSION

Endoscopic intervention may offer a successful modality in managing post-LSG gastric leak and gastro-cutaneous fistula that do not respond to conservative measures in stable patients.

Choosing the best endoscopic approach for post-bariatric surgical leaks and fistulas: Basic principles and recommendations

Post-surgical leaks and fistulas are the most feared complication of bariatric surgery. They have become more common in clinical practice given the increasing number of these procedures and can be very difficult to treat. These two related conditions must be distinguished and characterized to guide the appropriate treatment. Leak is defined as a transmural defect with communication between the intra and extraluminal compartments, while fistula is defined as an abnormal communication between two epithelialized surfaces. Traditionally, surgical treatment was the preferred approach for leaks and fistulas and was associated with high morbidity with significant mortality rates. However, with the development of novel devices and techniques, endoscopic therapy plays an increasingly essential role in managing these conditions. Early diagnosis and endoscopic therapy initiation after clinical stabilization are crucial to success since clinical success rates are higher for acute leaks and fistulas when compared to late and chronic leaks and fistulas. Several endoscopic techniques are available with different mechanisms of action, including direct closure, covering/diverting or draining. The treatment should be individualized by considering the characteristics of both the patient and the defect. Although there is a lack of high-quality studies to provide standardized treatment algorithms, this narrative review aims to provide a summary of the current scientific evidence and, based on this data and our extensive experience, make recommendations to help choose the best endoscopic approach for the management of post-bariatric surgical leaks and fistulas.

Endoscopic Management of Postoperative Esophageal and Upper GI Defects-A Narrative Review

Anastomotic defects are deleterious complications after either oncologic or bariatric surgery, leading to high morbidity and mortality. Besides surgical revision in early stages or instable patients, endoscopic treatment has become the mainstay. To date, many options for endoscopic treatment in this setting exist, including fully covered metal stent placement, endoscopic vacuum therapy (EVT), endoscopic internal drainage with pigtail placement (EID), leak closure with through the scope or over the scope clips, endoluminal suturing, fibrin glue sealing and a combination of all these techniques. Current evidence is mostly based on retrospective single and multicenter studies. No guidelines exist in this important field. Treatment options have to be chosen upon each case individually, taking into account clinical and anatomic criteria, such as timing, size, infectious wound complications and hemodynamic stability. Local expertise and availability of treatment devices need to be taken into account whenever choosing a treatment strategy. This review aimed to present current treatment options in terms of effectiveness, advantages and disadvantages in order to guide the clinician for his decision making. Additionally, we aimed to provide a treatment algorithm.

Postoperative bleeding and leaks in sleeve gastrectomy are independent of both staple height and staple line oversewing

BACKGROUND

Over 100,000 sleeve gastrectomy procedures are performed annually in the USA. Despite technological advances, postoperative bleeding and gastric staple line leak are complications of this procedure. We analyzed patient-specific and perioperative factors to determine their association with these complications.

METHODS

We performed a retrospective cohort analysis of patients who underwent sleeve gastrectomy between 2005 and 2019 at our institution. Patient demographics, comorbidities, and procedure details including type of energy device, staple type, staple height, staple line oversewing, and staple line clipping were compared using multiple logistic regression for combined postoperative complications (blood transfusion, bleeding, and staple line leak). Postoperative bleeding was defined by requiring blood transfusion and/or re-operation to control bleeding. Staple line leak was confirmed radiographically.

RESULTS

There were 1213 patients who underwent sleeve gastrectomy. Fifty-two high-risk patients were excluded due to cirrhosis, end-stage renal disease, and anticoagulation use for left ventricular assist device. Of the remaining 1161 patients, twenty-five (2.2%) received postoperative blood transfusion, nine (0.8%) had postoperative bleeding, two (0.2%) had staple line leak, and twenty-eight patients (2.4%) had combined postoperative complications. The median age was significantly higher for patients with combined postoperative complications (43 vs 49; p = 0.02). There was no difference in postoperative blood transfusion, bleeding, staple line leak, or combined postoperative complication with different energy devices (p = 0.92), staple types (p = 0.21), staple heights (p = 0.50), or staple line suturing/clipping (p = 0.95). In addition, there was no difference in bleeding when comparing staple line sewing techniques (p = 0.44). Predictably, patients with combined postoperative complications had increased length of stay (3 days vs 1 day; p < 0.001).

CONCLUSION

Sleeve gastrectomy procedure has tremendous variability in technique and devices used. We observed no difference in the combined postoperative complications of bleeding or staple line leak with respect to different energy devices, staple height, or oversewing of the gastric staple line. Patient selection is crucial, as patient age and coagulopathic comorbidities were found to lead to higher combined postoperative complications.

Diagnosis and Management of Postoperative Complications After Sleeve Gastrectomy

Sleeve gastrectomy (SG) has demonstrated excellent outcomes in terms of weight loss and resolution of obesity-related comorbidities as a single procedure. It has gained rapidly increasing popularity among bariatric surgeons and patients over the last two decades. This is due to its relative ease of use and less frequent morbidities related to the procedure. Even though the overall complication rate after SG is reported to be lower than conventional Roux-en-Y gastric bypass or biliopancreatic diversion, it still affects 1-10% of the patients undergoing SG, which is not negligible. Early postoperative complications that can occur within 30 days after SG include hemorrhage, leakage, sleeve stenosis, and reflux. Thromboembolic events are rare but can occur after surgery. Here, we review the incidence, diagnosis, and management of these early postoperative complications.

Revision Bariatric Procedures and Management of Complications from Bariatric Surgery

Bariatric surgery is effective, but may be associated with adverse events. A multi-disciplinary approach including endoscopic interventions can be effective to manage these. Endoscopists should familiarize themselves with gastrointestinal pathology which can occur after bariatric surgery, including nutritional deficiencies, acid reflux, anastomotic stenosis, gallstone disease, leaks, fistulas, and weight regain. Endoscopic interventions including anastomotic stricture dilation, control of bleeding, endoscopic ultrasound-guided approach for endoscopic retrograde cholangiopancreatography, leak or fistula closure via endoscopic suturing or stent placement, and transoral outlet reduction (TORe) or revision obesity surgery endoluminal (ROSE) to address weight regain are among the endoscopic tools which have demonstrated safety and efficacy in the management of adverse events after bariatric surgery.

Non-stenting treatment versus endoscopic stent placement in staple line leaks after laparoscopic sleeve gastrectomy

PURPOSE

Presentation of results of non-stenting treatment versus endoscopic stenting placement in gastric staple leaks after laparoscopic sleeve gastrectomy (LSG).

METHODS

Between January 2007 and August 2020, 1371 eligible patients underwent LSG. After gastric leak detection, patients were classified into treatment groups A (endoscopic stent placement) and B (non-stenting management). Overall hospital stay, the time to complete gastric leak resolution and the incidence of further operative management constituted the main outcome measures. Statistical analysis included descriptive statistics and linear regression tests as needed.

RESULTS

A total of 27 patients (19 F/8 M, median age: 44.8 years (range: 36-58) with median preoperative BMI: 43.5 kg/m² (range: 37.0-48.7)) presented with gastric staple line leak (1.9%) - mean detection day 5.8 postop (range: 1-12). Eight patients enrolled in group A and 19 patients in group B. The mean hospital stay for group A was 41.2 days (range: 24-60) versus 15 days (range: 12-18) for group B (p < 0.001). Complete leakage resolution was observed at mean 42.4 days (range 25-60) for group A and 34.5 days (range: 28-40) for group B patients, (p = 0.025). Only 2 group A patients accomplished complete leak resolution without additional intervention. Five group A patients (62.5%) versus 4 group B patients (21.1%) needed operative intervention during the treatment course (p = 0.037).

CONCLUSIONS

Conservative, non-stenting treatment of staple line leaks after LSG is feasible and is associated with superior results in terms of hospital say and leak resolution in comparison to endoscopic stenting.

Pyogenic Hepatic Abscess: A Case Report and Literature Review on a Rare Complication of Gastric Sleeve Surgery

Gastric sleeve surgery is a frequently performed procedure. Although it is one of the safest bariatric procedures, it is like any other operation that carries significant risks and complications. Moreover, the hepatic abscess is an infrequent complication of laparoscopic gastric sleeve surgery, the infected late gastric leakage is a rare etiology of the hepatic abscess. We present a case of liver abscess developed one month after sleeve gastrectomy secondary to infected walled-off late-gastric leak. The case highlights this rare complication of gastric sleeve surgery. Moreover, early treatment of liver abscesses with imaging-guided drainage and intravenous antibiotics can prevent life-threatening outcomes.

Therapeutic endoscopy for the treatment of post-bariatric surgery complications

Obesity rates continue to climb worldwide. Obesity often contributes to other comorbidities such as type 2 diabetes, hypertension, heart disease and is a known risk factor for many malignancies. Bariatric surgeries are by far the most invasive treatment options available but are often the most effective and can result in profound, durable weight loss with improvement in or resolution of weight associated comorbidities. Currently performed bariatric surgeries include Roux-en-Y gastric bypass, sleeve gastrectomy, and laparoscopic gastric banding. These surgeries are associated with significant weight loss, but also with significant rates of major complications. The complexity of these patients and surgical anatomies makes management of these complications by a multidisciplinary team critical for optimal outcomes. Minimally invasive treatments for complications are typically preferred because of the high risk associated with repeat operations. Endoscopy plays a large role in both the diagnosis and the management of complications. Endoscopy can provide therapeutic interventions for many bariatric surgical complications including anastomotic strictures, anastomotic leaks, choledocholithiasis, sleeve stenosis, weight regain, and eroded bands. Endoscopists should be familiar with the various surgical anatomies as well as the various therapeutic options available. This review article serves to delineate the current role of endoscopy in the management of complications after bariatric surgery.

Radiological stent placement of post sleeve gastrectomy leak: efficacy, imaging features and post-procedure complications

Laparoscopic sleeve gastrectomy (SG) is the most commonly performed bariatric procedure. The primary and insidious early post-SG complication is the gastric leak (GL). In literature, there are many studies describing the endoscopic stent placement as treatment of GL and few studies about stent placement performed by interventional radiology under fluoroscopic guide. Our aims were to describe the radiological stent placement technique, to compare endoscopic and radiological stent placement, to illustrate normal diagnostic features and summarise the incidence of complications after stent placement, removal, and their imaging features. This was a single centre retrospective study of 595 patients who underwent SG between 2011 and 2019. Inclusion criteria: patients who developed GL after SG and treated with gastro-oesophageal stent placement by endoscopy or interventional radiology; availability of medical history and imaging studies; follow-up time after stent removal (1 year). The rates of technical success, clinical success and complications after stent placement and removal were collected and compared between the two methods of stent positioning. A total of 17/595 (2.8%) patients developed a radiologically diagnosed GL after SG. The type II-III GLs (15/17) were treated with endoscopic or radiological stent placement. 9/15 (60%/Group A) patients underwent gastro-oesophageal stenting by interventional radiology and 6/15 (40%/Group B) were treated with endoscopic stent placement. The technical and clinical success rate was 100% for both groups. Stent migration occurred in 22% and 27% for Group A and B respectively. Post-extraction stenosis was the main late complication, occurring in 22% in Group A and 0% in Group B. Gastro-esophageal stent placement performed by interventional radiologists is a valid "mini-invasive" treatment for GL. This procedure is not inferior to endoscopic positioning regarding efficacy, periprocedural and postprocedural complication rate. It's necessary to be familiar with radiological findings after stent placement and removal. Computed tomography (CT) scan is the main radiological technique to identify stent placement complications. Upper gastrointestinal (UGI) series are the first radiological procedures used to detect late complications after stent removal.

Surgical Resection of Gastro-Pleural-Bronchial Fistula after Prolonged Endoscopic Treatments

Sleeve gastrectomy is the most commonly performed bariatric surgery in the United States. While complication rates are typically low, some studies have reported leaks in up to 2.4-5.3% of cases. Here, we examine such a case with subsequent failure of numerous endoscopic interventions ultimately necessitating formal resection of a gastro-Pleural-bronchial fistula.

A Comprehensive Review of Endoscopic Management of Sleeve Gastrectomy Leaks

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.

Amylase Is Not a Useful Indicator for Leakage Detection Following Sleeve Gastrectomy: A Prospective Study

Introduction. Gastric leak after laparoscopic sleeve gastrectomy (LSG) is a severe complication that may lead to sepsis and even death. Early diagnosis and treatment are critical. The aims of this prospective study are to establish normal amylase levels and investigate elevated amylase levels, especially in the drain, for detecting anastomotic leakage following LSG. Material and Methods. One hundred sixty-one patients who underwent LSG during 1 year at Rambam Health Care Campus were included prospectively in the study. Demographic and medical background, peri- and postoperative complications, and laboratory data including amylase levels in blood, urine, and drain were evaluated. Univariate and multivariate analyses were performed to examine independent variables that can predict increases in amylase values. Results. Thirty-five (21.8%) patients had high levels of amylase in blood, urine, and/or drain and 126 (78.2%) normal values of amylase until discharge. No significant differences were found in operation duration, length of hospitalization, or occurrence of complications. One patient had a staple-line leak diagnosed in the third postoperative day that was treated conservatively with endoscopic approach. His amylase levels in the blood and drain were normal, with only a slight hyperamylasuria. Conclusions. High amylase levels after LSG does not necessarily indicate a major complication such as staple-line leak, and in the vast majority of cases, it seems to have no clinical relevancy. Therefore, it should not automatically lead to a full investigation in the absence of further clinical signs. It is suggested that there is no clinical justification to test amylase routinely after LSG.

The Effect of Helicobacter pylori Eradication on Gastric Wall Thickness in Patients Undergoing Laparoscopic Sleeve Gastrectomy

PURPOSE

The most important cause affecting the thickness of the gastric wall other than the tumor is chronic gastritis caused by Helicobacter pylori (Hp), which is most frequently detected in the antrum. This study aims to investigate the effect of bismuth-based treatment (BBT) combined with proton pump inhibitor (PPI) on wall thicknesses measured in the postoperative gastric specimen and early postoperative complications in patients with Hp-positive pre-LSG endoscopic gastric biopsies.

MATERIALS AND METHODS

The patients who underwent LSG procedure for morbid obesity were divided into three groups as follows: Hp-negative, Hp-positive without eradication treatment, and Hp-positive, and LSG was performed after eradication treatment. Macroscopic and microscopic gastric wall thickness measurements were made at a distance of 1 cm from the proximal surgical margin, from the middle part of the specimen, and 1 cm from the distal surgical margin in the gastric specimen and the results were compared.

RESULTS

A total of 132 patients were included in the study, 44 patients in each group. Microscopically measured antrum mucosal thickness was found to be statistically significantly higher in group 2 compared to other groups (groups 1.15, 1.35, 1.16 mm, respectively, p = 0.000). There was no difference between the groups in terms of early complications such as bleeding, wound site infection, or leakage from the staple line within the first 28 days after surgery.

CONCLUSION

This study found that LSG had no effect on early complications due to Hp positivity or eradication of Hp.

KEY POINTS

• The presence of HP increases the wall thickness of the gastric antrum mucosa. • After HP eradication, stomach antrum wall thickness returns to normal. • HP eradication before LSG reduces the wall thickness of the gastric antrum mucosa. • It was determined that HP scanning and eradication before LSG had no effect on postoperative complications.

Imaging after laparoscopic sleeve gastrectomy - literature review with practical recommendations

In the XXI century obesity has become one of the most demanding epidemiological threats worldwide. At the same time, bariatric surgery has established itself as an effective treatment for morbidly obese patients, with laparoscopic sleeve gastrectomy (LSG) emerging as the most popular bariatric procedure. This paper reviews the role of imaging studies of patients after LSG. Computed tomography is widely considered as the method of choice in detection of complications in early postoperative period. The dynamic character of upper gastrointestinal examination allows for the assessment of passage through the gastric remnant. The paper also discusses evaluation of the shape and volume of the gastric remnant assessed by imaging studies.

Delayed Post-Laparoscopic Sleeve Gastrectomy Leak Successfully Treated With Endoscopic Clips and Tissue Adhesive: Case Report and Literature Review

Since it was first introduced, laparoscopic sleeve gastrectomy (LSG) has gained wide popularity and it is one of the most performed bariatric surgical procedures for weight reduction throughout the world. LSG is a simple and effective procedure for the reduction of excess body weight, but it is not without serious complications. We present a case of a 46-year-old obese male with multiple co-morbidities who presented with a delayed post-LSG leak that was successfully managed with endoscopic clips and tissue adhesive.

A French National Study on Gastropleural and Gastrobronchial Fistulas After Bariatric Surgery: the Impact of Therapeutic Strategy on Healing

PURPOSE

Gastropleural and gastrobronchial fistulas (GPF/GBFs) are serious but rare complications after bariatric surgery whose management is not consensual. The aim was to establish a cohort and evaluate different clinical presentations and therapeutic options.

MATERIALS AND METHODS

A multicenter and retrospective study analyzing GPF/GBFs after bariatric surgery in France between 2007 and 2018, via a questionnaire sent to digestive and thoracic surgery departments.

RESULTS

The study included 24 patients from 9 surgical departments after initial bariatric surgery (21 sleeve gastrectomies; 3 gastric bypass) for morbid obesity (mean BMI = 42 ± 8 kg/m²). The GPF/GBFs occurred, on average, 124 days after bariatric surgery, complicating an initial post-operative gastric fistula (POGF) in 66% of cases. Endoscopic digestive treatment was performed in 79% of cases (n = 19) associated in 25% of cases (n = 6) with thoracic endoscopy. Surgical treatment was performed in 83% of cases (n = 20): thoracic surgery (n = 5), digestive surgery (n = 8), and combined surgery (n = 7). No patient died. Overall morbidity was 42%. The overall success rate of the initial and secondary strategies was 58.5% and 90%, respectively. The average healing time was approximately 7 months. Patients who had undergone thoracic surgery (n = 12) had more initial management failures (n = 9/12) than patients who had not (n = 3/12), p = 0.001.

CONCLUSION

Complex and life-threatening fistulas that are revealed late require a multidisciplinary strategy. Thoracic surgery should be reserved once the abdominal leak heals; otherwise, it is associated with a higher risk of failure.

Laparoscopic sleeve gastrectomy: A role of inflammatory markers in the early detection of gastric leak

Setting:

Laparoscopic sleeve gastrectomy (LSG) is gaining popularity as a bariatric option. Gastric leak (GL) is the most dreaded septic complication of LSG. Early detection and treatment of this complication may improve outcomes.

Objectives:

This study investigates biomarkers that might be useful to predict GL before its clinical presentation in patients who underwent LSG.

Patients and Methods:

This study, prospective observational, was carried out in 151 patients, who underwent LSG for morbid obesity between February 2014 and October 2019. Blood samples were collected before the operation and on post-operative days one, three and five to dose serum C-reactive protein (CRP), pro-calcitonin (PCT), fibrinogen, white blood cells (WBCs) count and neutrophil-to-lymphocyte ratio (NLR).

Results:

GL occurred in 6 patients (3.97%). According to the receiver operating characteristics curve, NLR detected leak with remarkably higher sensitivity (100%) and specificity (100%) than CRP, fibrinogen, WBC on all the days and higher than PCT in post-operative days 3 and 5. Moreover, the area under the curve (AUC) of NLR (AUC = 1) was higher than the AUC of CRP, fibrinogen, WBC on all the days and higher than PCT in post-operative days 3 and 5, suggesting important statistical significance.

Conclusions:

Because NLR and PCT detected GL with remarkably higher sensitivity and specificity than CRP, fibrinogen and WBC, these two markers seem to be more accurate for the early detection of this complication.

Gastric Fistula in the Chest After Sleeve Gastrectomy: a Systematic Review of Diagnostic and Treatment Options

This study aimed to establish the optimal diagnostic and treatment algorithm for the management of gastric fistula in the chest (GFIC) after sleeve gastrectomy (SG) through a systematic review of published cases. A multi-database search was performed, which produced 1182 results, of which 26 studies were included in this systematic review. The initial presentation included subphrenic collections, leaks, or (recurrent) pneumonia with associated symptoms such as persistent cough, fever, and/or dyspnea. Computed tomography (CT) scan in combination with either upper gastrointestinal (UGI) series or an esophagogastroduodenoscopy (EGD) was used to adequately diagnose the fistulas. Initial treatment was either with clips and/or clips and stents that were placed endoscopically. When unsuccessful in the majority of the cases, the surgical treatment consisted of total gastrectomy and Roux-en-Y esophagojejunostomy in a laparoscopic or open fashion.

Revisional Surgeries of Laparoscopic Sleeve Gastrectomy

Bariatric surgery has become increasingly common due to the worldwide obesity epidemic. A shift from open to laparoscopic surgery, specifically, laparoscopic sleeve gastrectomy (LSG), has occurred in the last two decades because of the low morbidity and mortality rates of LSG. Although LSG is a promising treatment option for patients with morbid obesity due to restrictive and endocrine mechanisms, it requires modifications for a subset of patients because of weight regain and tough complications, such as gastroesophageal reflux, strictures, gastric leak, and persistent metabolic syndrome., Revision surgeries have become more and more indispensable in bariatric surgery, accounting for 7.4% in 2016. Mainstream revisional bariatric surgeries after LSG include Roux-en-Y gastric bypass, repeated sleeve gastrectomy, biliopancreatic diversion, duodenal switch, duodenal-jejunal bypass, one-anastomosis gastric bypass, single anastomosis duodeno-ileal bypass (SAID) and transit bipartition. This review mainly describes the revisional surgeries of LSG, including the indication, choice of surgical method, and subsequent effect.

Endoscopic Double-Pigtail Catheter (EDPC) Internal Drainage as First-Line Treatment of Gastric Leak: A Case Series during Laparoscopic Sleeve Gastrectomy Learning Curve for Morbid Obesity

OBJECTIVES

The prevalence of morbid obesity has dramatically increased over the last several decades worldwide, currently reaching epidemic proportions. Gastric leak (GL) remains the potentially fatal main complication after sleeve gastrectomy (SG) for morbid obesity. To our knowledge, there are no standardized guidelines for GL treatment after laparoscopic sleeve gastrectomy (LSG) yet. The aim of this study was to represent our institutional preliminary experience using the endoscopic double-pigtail catheter (EDPC) as the method of internal drainage and propose it as first-line treatment in case of GL after LSG.

METHODS

One hundred and seventeen patients were admitted to our surgical department and underwent laparoscopic sleeve gastrectomy (LSG) for morbid obesity from March 2014 to June 2019. In 5 patients (4.3%) of our series, GL occurred as a complication of LSG. EPDC was the stand-alone procedure of internal drainage and GL first-line treatment. The internal pig tail was endoscopically removed from 30th to 40th POD in all cases.

RESULTS

Present data (clinical, biochemical, and instrumental tests) showed a complete resolution of GL, with promotion of a pseudodiverticula and complete re-epithelialization of leak. Follow-up was more strict than usual (clinical visit and biochemical test on 7th, 14th, and 21st day after discharge; a CT scan with gastrografin on 30th day from discharge if clinical visit and exams were normal).

CONCLUSION

This was a preliminary retrospective observational study, conducted on 5 patients affected by GL as a complication of LSG for morbid obesity. EDPC maintains the safety, efficacy, and nonexpensive characteristic and may be proposed as better first-line treatment in case of GL after bariatric surgery.

Gastric Fistula After Sleeve Gastrectomy: Clinical Features and Treatment Options

PURPOSE

To trace the clinical profile of fistula cases after sleeve gastrectomy (SG) and evaluate the efficacy and safety of endoscopic treatments and the admission costs of these patients.

METHODS

This is a retrospective study of patients who developed gastric fistulas after SG. All patients were submitted to surgical and/or endoscopic interventions (self-expandable stent, septotomy, and balloon dilation). The main studied variables were need for reoperation, number of endoscopic procedures, endoscopic complications, time until fistula diagnosis, fistula location, time until resolution, length of hospital stay, and health costs.

RESULTS

The sample was mainly female (76.2%) with a mean age of 39.5 years and a BMI of 39.6 kg/m². In 90.5% of cases, the fistula occurred in the topography of the His angle. Thirteen patients required surgical intervention. Of the patients who underwent endoscopic interventions, it was necessary to place more than one self-expandable stent of a maximum duration of 4 weeks. Six patients underwent more than two sessions of septotomy. There was one case of bleeding after septotomy. Dilatation was required in 71.4% of patients and an average of two sessions (1-5) per patient. The diagnosis of fistula occurred 14.4 days after surgery. The average time to resolve fistulas was 50.6 days. The average hospital stay was 75.8 days. The total cost of hospitalization was on average US$ 75,180.00.

CONCLUSION

The surgical and endoscopic treatment of gastric fistulas after SG was safe and effective. There was a very low rate of complications. The time of onset of fistulas was not decisive for patient improvement.

Challenges in the Diagnosis of Leak After Sleeve Gastrectomy: Clinical Presentation, Laboratory, and Radiological Findings

Background

The presentation of leak after laparoscopic sleeve gastrectomy (LSG) is variable. A missed or delayed diagnosis can lead to severe consequences. This study presents our experience: the clinical presentations, laboratory, and radiological findings in patients with leak after LSG.

Methods

A retrospective review of patients who were diagnosed and treated as leak after LSG at our center (January 2012–November 2019).

Results

Eighty patients developed leak: 68 (85%) after primary LSG, 6 (7.5%) after Re-LSG and 6 (7.5%) after band removal to revisional LSG. Mean age 35.9 ± 10 years. The diagnosis was within 18 ± 14 days after surgery. Five (6.3%) patients were diagnosed during the same admission. Only 29.3% of patients were diagnosed correctly from the first visit to the ER. Most were misdiagnosed as gastritis (49%) and pneumonia (22.6%). Thirty-four patients (45.3%) were diagnosed correctly at the third visit. The most common presenting symptoms were abdominal pain (90%), tachycardia (71.3%), and fever (61.3%). The mean white blood cells (WBCs) count was 14700 ± 5900 (cells/mm³), c-reactive protein (CRP) 270 ± 133 mg/L, lactic acid 1.6 ± 0.85 mmol/L, and albumin 30.3 ± 6.6 g/L. The abdominal CT scans revealed intraabdominal collection in 93.7% of patients, extravasation of contrast in 75%, and pleural effusion in 52.5%. Upper gastrointestinal contrast study (UGIC) showed extravasation of contrast in 77.5% of patients.

Conclusion

Abdominal pain, tachycardia, or fever after LSG should raise the suspicion of a leak. CT scan of the abdomen and UGIC study detected leaks in 75% and 77.5% consecutively. Only 29.3% of patients were diagnosed correctly as a leak from the first visit to the ER.

Mechanisms of Esophageal and Gastric Transit Following Sleeve Gastrectomy

PURPOSE

Sleeve gastrectomy (SG) patients have substantially altered anatomy. The mechanism of rapid gastric emptying and the role of esophageal contractile function in esophago-gastric transit has not been defined. We aimed to determine the mechanisms of esophago-gastric transit and role of esophageal function following sleeve gastrectomy.

METHODS

Prospective study of twenty-six asymptomatic participants post SG underwent nuclear scintigraphy and high-resolution manometry. Fourteen had semi-solid stress barium to model the emptying process. Concurrent video fluoroscopy and manometry were performed on 7 participants.

RESULTS

Demographic data are as follows: age 45.3 ± 15.0 years, 73.1% female, excess weight loss 62.2 ± 28.1% at 8 months. Scintigraphy showed rapid gastric emptying (24.4 ± 11.4 vs. 75.80 ± 45.19 min in control, p < 0.001) with 35.24 ± 17.12% of bolus transited into small bowel on initial frame. Triggered deglutitive reflux was common (54.4% vs. 18.2%, p = 0.017). Stress barium delineated separate vertical and antral gastric compartments with cyclical emptying of 8 stages, including reflux-induced repeated esophageal peristalsis. During manometry, ramping effects were noted, with sequential swallows producing sustained isobaric pressurizations in proximal stomach (33.6 ± 29.5 mmHg). Video fluoroscopy showed individual esophageal peristalsis generating pressurizations at 5.0 ± 1.4 cm below lower esophageal sphincter (LES), at amplitude of 31.6 ± 13.1 mmHg, associated with intragastric transit. Pressurizations were sustained for 17.3 ± 8.2 s, similar to the prolonged LES contraction (18.5 ± 9.0 s, p = 0.355).

CONCLUSIONS

Repeated esophageal peristaltic contractions induced isobaric pressurization of proximal stomach, thus providing the drive to pressurize and empty the vertical compartment of the gastric sleeve. Transit following SG appeared to be esophageal-mediated and followed a distinct cycle with strong associations with reflux.

The impact of pregnancy on postoperative outcomes among obese women who underwent bariatric surgery: A systematic review and meta-analysis

OBJECTIVES

Women who had a history of bariatric surgery are increasingly becoming pregnant. There is growing evidence showing that increased risk of postoperative complications may be associated with the gestation after bariatric surgery.The objective of this systematic review was to evaluate the potential impact of pregnancy on weight loss and postoperative complications in obese women after bariatric surgery.

STUDY DESIGN

PubMed, Embase, Medline and Cochrane Central Register of Controlled Trails were searched from inception through October 2018. Selection criteria included observational or randomized trial examining weight loss and medical complications in pregnant compared to non-pregnant women after bariatric surgery. Two reviewers extracted information and performed quality appraisal of eligible articles. Meta-analysis was performed to ascertain the certainty of the evidence when possible.

RESULTS

Seven observational cohort studies with a total of 27,369 obese women were included in the final analysis. The mean difference (95 % confidence interval) in percent excess weight loss between pregnant and non-pregnant subjects was -9.5 (-19.9, 0.9). The odds ratio (95 % confidence interval) for postoperative complications in pregnant relative to non-pregnant subjects was 0.85 (0.33, 2.18).

CONCLUSIONS

Pregnancy may have little or no effect on weight loss or postoperative complications in women who have undergone bariatric surgery.

Normal and Abnormal Postoperative Imaging Findings after Gastric Oncologic and Bariatric Surgery

Surgical resection remains the primary choice of treatment and the only potentially curative option for gastric carcinoma, and is increasingly performed laparoscopically. Gastric resection represents a challenging procedure, with a significant morbidity and non-negligible postoperative mortality. The interpretation of imaging after gastric surgery can be challenging due to significant modifications of the normal anatomy. After the surgery, the familiarity with expected imaging appearances is crucial for diagnosis and appropriate management of potentially life-threatening complications in patients who underwent gastric surgery. We review various surgical techniques used in gastric surgery and describe fluoroscopic and cross-sectional imaging appearances of normal postoperative anatomic changes as well as early and late complications after gastric surgery.

The hundred most frequently cited studies on sleeve gastrectomy

INTRODUCTION

Sleeve gastrectomy (SG) is one of the most popular bariatric operations and one of the most frequently studied areas in bariatric surgery.

AIM

To summarise the characteristics of the most frequently cited studies focusing on SG.

MATERIAL AND METHODS

We used the Web of Science database to identify all studies focused on SG published from 2000 to 2018. The term "sleeve gastrectomy" and synonyms were used to reveal the 100 most cited records.

RESULTS

The most frequently cited publication had 493 citations. The highest mean number of citations per year was 73.00. Studies were most frequently published in the years 2010 and 2012. Articles were most commonly published in bariatric surgery-oriented journals.

CONCLUSIONS

Our study indicates an increase in medical researchers' interest in the subject of SG and underlines the need to perform studies with a higher level of evidence to further analyse the outcomes and basic science behind SG.

Computed Tomography-based Diagnosis of Post-laparoscopic Sleeve Gastrectomy Gastric Leak

Objective:

Gastric leak post-laparoscopic sleeve gastrectomy may appear as a variety of computed tomography (CT) findings. We aimed to review the various CT findings sensitivity and specificity in confirmed cases of gastric leak.

Materials and Methods:

A retrospective review was performed for all patients who underwent sleeve gastrectomy, CT, and endoscopy for suspected leak between 2011 and 2018. All patients with positive CT findings for gastric leak were included in the study.

Results:

A total of 152 consecutive patients underwent CT for suspected post-sleeve gastrectomy gastric leak. Out of 152 patients, 88 had positive CT findings for gastric leak and underwent endoscopy. The CT findings sensitivity and specificity of perigastric collection without oral contrast leak were 61% and 88.8%, oral contrast leak were 28% and 100%, and gas leak were 10% and 77.7%, respectively.

Conclusions:

Perigastric fluid collection without contrast leak and with variable wall enhancement and gas content is the most common CT findings of post-sleeve gastrectomy gastric leak. Among various CT findings, it exhibits good diagnostic accuracy with 61% sensitivity and 88.8% specificity.

Clinical Outcomes of One Anastomosis Gastric Bypass Versus Sleeve Gastrectomy for Morbid Obesity

BACKGROUND

One anastomosis gastric bypass (OAGB) and sleeve gastrectomy (SG) are popular bariatric surgeries for morbid obesity. Reports on the safety and effectiveness of SG and OAGB are inconsistent. This meta-analysis investigated the clinical outcomes of SG versus those of OAGB for morbid obesity.

METHODS

Based on PRISMA guidelines, we searched the published articles in English from Scopus, PubMed (Medline), Central (Cochrane), and Embase databases. Articles were retrieved from the start date of each database to February 13, 2019. Statistical analysis of this meta-analysis was conducted in Stata 14.0, and the most appropriate effect model was chosen based on heterogeneity.

RESULTS

A total of 20 articles examining 4064 OAGB patients and 3733 SG patients were included in this meta-analysis. Compared with SG, OAGB showed a higher percentage excess weight loss (%EWL) at 6 months (weighted mean difference (WMD) = 11.32; 95% CI 6.00-16.64), 12 months (WMD = 8.22; 95% CI 3.78-12.66), 24 months (WMD = 10.19; 95% CI 0.88-21.25), 36 months (WMD = 7.93; 95% CI 3.37-12.48), 48 months (WMD = 17.22; 95% CI 7.37-27.06), and 60 months (WMD = 16.43; 95% CI 8.96-23.90). In addition, OAGB was associated with a lower rate of postoperative leak, gastroesophageal reflux disease, revisions, mortality, and dyslipidemia remission rates. However, OAGB increased the incidence of ulcers, malnutrition, and bile reflux.

CONCLUSION

OAGB is more effective for %EWL and dyslipidemia remission than SG. In addition, OAGB may lower the risk of postoperative leak, gastroesophageal reflux disease, revision, and mortality. Further comparisons of the clinical outcomes of OAGB versus SG for morbid obesity would benefit from more high-quality controlled studies.

Double Baltazar Procedure for Repair of Gastric Leakage Post-Sleeve Gastrectomy from Two Sites: Case Report of New Surgical Technique

BACKGROUND

Staple line leak is one of the most challenging complications following laparoscopic sleeve gastrectomy, with a rate reaching near 1%. Its management often implicates a multidisciplinary approach and experienced bariatric and metabolic surgeons. The literature is abundant on various approaches to treat single staple line leak with variable results. But what to do in front of an intra-op incidental finding of double gastric fistulae?

METHODS

In this article, we describe a new successful surgical treatment option of double Baltazar technique for a patient who was found to have two gastric fistulae post-sleeve gastrectomy. We aim to demonstrate that this approach is safe and effective and can help avoid major side effects of traditional treatment options for such complications.

RESULTS

The patient presented 20 days following a laparoscopic sleeve gastrectomy in a severe septic condition and was found to have a gastric leak. During surgical repair, unlike the usual single proximal fistula findings, another opening was identified more distally. Decision was made to proceed with a double fistulo-jejunostomy. It was a feasible technique, with no intra-op complications. Post-operatively, the patient had a successful recover, with no residual leak.

CONCLUSIONS

Double Baltazar technique is a successful and feasible treatment option for patients presenting with two gastric fistulae following sleeve gastrectomy. This is the first case report describing this new technique, and its success should encourage more similar trials and avoid more aggressive surgical options such as total gastrectomy or gastric bypass.

A Complication of an Endoscopic Pigtail Stent Migration into the Cavity during Deployment as a Treatment for Gastric Leak

Gastric leak following gastrointestinal surgery is the most dreadful complication, which implies long hospital stay, morbidities, and not irrelevant mortalities. There is no standard recommendation for treating postlaparoscopic sleeve gastrectomy leak, which makes its management challenging. Endoscopic internal drainage by double-pigtail drains currently became the recommended approach. Complications to this approach include bleeding, ulceration at the tip of the double-pigtail stent, and uncommon migration. Here, we report our experience with drain displacement into the cavity while deployment in a patient who experienced gastric leakage after undergoing sleeve gastrectomy.