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

Clinical Role of ICG Application in Bariatric Surgery; an Up-To-Date Literature Review

BackgroundPost-operative anastomotic leaks (AL) are one of the most challenging complications of bariatric surgery and can be detrimental. Indocyanine green (ICG) is a fluorescence dye that can provide a real-time intraoperative assessment of organ tissue perfusion. Its use in bariatric operations is still being debated. The present review aims to evaluate the intraoperative utility of ICG during bariatric surgery to focus future research on a reliable tool to reduce the incidence of postoperative leaks.MethodsA systematic search of PubMed, EMBASE, MEDLINE, Scopus, and the Cochrane Library for published studies took place until December 2024, evaluating the use of ICG during bariatric surgical procedures. Studies were included if they assessed the ICG application in various bariatric operations to prevent and reduce AL rates.ResultsEleven studies were included, which involved a total of 887 patients. 643 patients underwent ICG-based intraoperative assessments, while 244 were in the control group. The mean age of participants was 43.8 years, and the mean BMI was 43.3 kg/m3. All included patients underwent various bariatric procedures. ICG was used alone in most studies, although it was mixed with methylene blue in one study. ICG administration protocols varied significantly. There were no reported complications from ICG administration. The utility of ICG has changed the intraoperative surgical decision-making of 4.2% of patients.ConclusionsICG is a promising technique for successfully preventing or timely managing AL in bariatric surgery. Large, randomised controlled studies are needed to confirm its utility for routine use in primary and revisional bariatric cases.

Real-Time Perfusion and Leak Assessment in Bariatric Surgery: Bridging Traditional and Advanced Techniques

This comprehensive literature review explores the efficacy of real-time perfusion and leak assessment methods in bariatric surgery, comparing traditional techniques with advanced imaging modalities. As the global incidence of obesity and related comorbidities rises, the demand for bariatric surgeries such as Roux-en-Y gastric bypass and sleeve gastrectomy has increased, along with the risk of serious complications like anastomotic and staple line leaks. Traditional intraoperative leak testing methods, including the air leak and methylene blue dye tests, are commonly employed but exhibit inconsistent sensitivity in leak detection. Intraoperative endoscopy, although underutilized, offers enhanced visualization and has been associated with reduced leak and complication rates in certain cases. Emerging technologies such as indocyanine green (ICG) fluorescence, laser speckle contrast imaging (LSCI), and hyperspectral imaging (HSI) provide real-time assessment of tissue perfusion, potentially improving surgical outcomes. ICG fluorescence enables visualization of blood flow to detect ischemia, while LSCI offers immediate, dye-free perfusion mapping, and HSI assesses tissue oxygenation without the need for contrast agents. Despite their promise, these technologies are limited by high costs, technical complexity, and varying accessibility, with current evidence insufficient to confirm their superiority over traditional methods. Future research should focus on large-scale, multicenter trials to validate these advanced techniques and refine their application in clinical practice. Integrating traditional and emerging methods may optimize intraoperative decision-making, reduce complications rates, and enhance patient outcomes in bariatric surgery.

A comparison of the postoperative outcomes between intraoperative leak testing and no intraoperative leak testing for gastric cancer surgery: a systematic review and meta-analysis

BACKGROUND

Postoperative anastomotic leakage (PAL) is a serious complication of gastric cancer surgery. Although perioperative management has made considerable progress, anastomotic leakage (AL) cannot always be avoided. The purpose of this study is to evaluate whether intraoperative leak testing (IOLT) can reduce the incidence of PAL and other postoperative outcomes in gastric cancer surgery.

MATERIALS AND METHODS

In this meta-analysis, we searched the PubMed, Embase, and Cochrane Library databases for clinical trials to assess the application of IOLT in gastric cancer surgery. All patients underwent laparoscopic radical gastrectomy for gastric cancer surgery. Studies comparing the postoperative outcomes of IOLT and no intraoperative leak testing (NIOLT) were included. Quality assessment, heterogeneity, risk of bias, and the level of evidence of the included studies were evaluated. PAL, anastomotic-related complications, 30-day mortality, and reoperation rates were compared between the IOLT and NIOLT group.

RESULTS

Our literature search returned 721 results, from which six trials (a total of 1,666 patients) were included in our meta-analysis. Statistical heterogeneity was low. The primary outcome was PAL. IOLT reduced the incidence of PAL [2.09% vs 6.68%; (RR = 0.31, 95% Cl 0.19-0.53, P < 0.0001]. Anastomotic-related complications, which included bleeding, leakage, and stricture, were significantly higher in the NIOLT group than in the IOLT group [3.24% VS 10.85%; RR = 0.30, 95% Cl 0.18-0.53, P < 0.0001]. Moreover, IOLT was associated with lower reoperation rates [0.94% vs 6.83%; RR = 0.18, 95% CI 0.07-0.43, P = 0.0002].

CONCLUSION

Considering the observed lower incidence of postoperative anastomotic leakage (PAL), anastomotic-related complications, and reoperation rates, IOLT appears to be a promising option for gastric cancer surgery. It warrants further study before potential inclusion in future clinical guidelines.

Bariatric Surgery Emergencies in Acute Care Surgery

Patients who have undergone bariatric surgery present unique challenges in the acute care surgery setting. This review includes the presentation, workup, and management of most common bariatric surgery emergencies encountered by acute care surgery.

The utility of intraoperative endoscopy to assist novice surgeons in the detection of gastric stenosis during laparoscopic sleeve gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is a commonly performed bariatric surgery. Gastric stenosis and leaks are 2 major complications associated with LSG and revision surgery might be needed. Herein, we report our experience of intraoperative endoscopy (IOE) to evaluate stenosis and leaks during LSG.

METHODS

LSG was performed by three surgeons. Patients who underwent LSG and IOE between January 2016 and March 2020 were enrolled and assigned to two groups: group 1 (1st-30th LSG case for each surgeon) and group 2 (> 30th LSG for each surgeon). Patients' anthropometric and biochemical data pre- and post-LSG, as well as IOE findings and follow-up esophagogastroduodenoscopy records were reviewed.

RESULTS

In total, 352 patients were enrolled including 90 patients in group 1 and 262 patients in group 2. Three out of 352 patients (0.9%) were found to have stenosis by IOE, which was related to tightly gastropexy stitch or reinforcement stitch, all of which were in group 1. Stenosis was resolved after removal of the stitch during LSG. The incidence of gastric stenosis detected by IOE was 3.3% (3/90) and 0% (0/262) in group 1 and group 2, respectively (P = 0.003). No leakage was found in this study and no patient developed clinical or endoscopic stenosis after LSG.

CONCLUSIONS

The existing evidence showed that IOE can help detect gastric stenosis during LSG, especially for novice surgeons, and the stenosis could be resolved during operation.

Can intraoperative endoscopy prevent esophagojejunal anastomotic leakage after total gastrectomy?

BACKGROUND

Esophagojejunostomy (EJ) is frequently performed after total gastrectomy for proximal gastric tumors. Despite evolving surgical techniques and improving perioperative care, the EJ leak is one of the most severe life-threatening complications. This study investigated the preventability of postoperative anastomotic complications by performing intraoperative endoscopy.

METHODS

We included 86 patients who underwent total gastrectomy and Roux-en-Y esophagojejunostomy anastomosis in the study. Patients were divided into two groups and analyzed retrospectively. Group 1 consisted of 43 patients who did not undergo intraoperative endoscopy between 2017 and 2019, and Group 2 included 43 patients who underwent intraoperative endoscopy between 2019 and 2020.

RESULTS

Esophagojejunostomy anastomotic leak (EAL) was observed in 2.3 % of patients in Group 1 but not in Group 2. Anastomosis-related abnormal findings (anastomotic defect, bleeding, air leak, mucosal separation) were recorded in seven patients of Group 2 during endoscopy. When such findings were observed, additional full-thickness sutures were placed on the anastomosis line and strengthened. Complication related to anastomosis was not observed in the postoperative period in Group 2.

DISCUSSION

After a total gastrectomy, the most severe complication affecting mortality, morbidity, and consequently the cost of the disease is esophagojejunal anastomotic leakage. Most of these complications are induced by technical errors not noticed during surgery. The crucial advantage of performing intraoperative endoscopy is the technically detailed evaluation of anastomosis.

CONCLUSION

Intraoperative endoscopy is a safe method to evaluate the strength of anastomosis. This procedure provides detailed information regarding anastomotic integrity. HIPPOKRATIA 2021, 25 (3):108-112.

Clinical and economic burden of colorectal and bariatric anastomotic leaks

BACKGROUND

Anastomotic leaks cause a significant clinical and economic burden on patients undergoing bariatric and colorectal surgeries. Current literature shows a wide variation in incidence of anastomotic leaks and a significant gap in associated economic metrics. This analysis utilized claims data to quantify the full episode-of-care cost burden of leaks following colorectal and bariatric surgeries.

METHODS

Medicare Fee-for-Service and commercial claims data from a large U.S.-based health plan were queried for cost and utilization of members that underwent bariatric and colorectal surgical procedures between January 1, 2013 and August 31, 2015. Outcomes were collected for members with anastomotic leaks versus those without leaks during the initial hospital stay (index) and within 30 days of the procedure. These outcomes included leak frequency, payer reimbursement, and length of stay (LOS).

RESULTS

The colorectal Medicare analysis identified 239,350 patients undergoing colorectal surgery. For patients with a leak compared to those without, index admission costs were $30,670 greater ($48,982 vs. $18,312; p < 0.0001) and the index LOS was 12 days longer (19 vs. 7 days; p < 0.0001). This finding was similar for the bariatric patients (n = 62,292) where cost was $30,885 higher ($43,918 vs. $13,033; p < 0.0001) and LOS was 15 days longer (17 vs. 2 days; p < 0.0001). Furthermore, readmissions and associated costs were also substantially higher for those with an index leak. The commercial analysis of both the bariatric and colorectal populations trended similarly to the Medicare population in regards to all outcomes measured.

CONCLUSION

Patients experiencing anastomotic leaks during and after bariatric and colorectal surgery have significantly higher costs and longer LOS both at the initial stay and within 30 days of the procedure. It is important that providers and hospitals understand the economic consequences of these procedures and implement technologies and techniques to prevent/reduce anastomotic leaks.

Does intraoperative endoscopy decrease complications after bariatric surgery? Analysis of American College of Surgeons National Surgical Quality Improvement Program database

BACKGROUND

Intraoperative endoscopy (IOE) has been proposed to decrease serious complications following bariatric surgeries such as leaks, bleeding, and stenosis. Such complications can lead to sepsis and eventually can be fatal. We aim to compare major postoperative complications in patients with and without IOE.

METHODS

Data from the American College of Surgeons National Surgical Quality Improvement Program database years 2011 till 2016 were used to identify laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) patients. We compared outcomes of IOE and non-IOE using bivariate and multivariate analysis. Thirty-day outcomes included sepsis, organ space infection, unplanned reoperations, unplanned readmissions, prolonged hospital stay, bleeding, and mortality.

RESULTS

Out of 62,805 cases of LSG and 50,047 cases of LRYGB, 17.9%, and 19.7% had IOE, respectively. Endoscopy-assisted LSG was associated with a decrease in sepsis [0.37% vs. 0.21%, adjusted odds ratio (AOR) = 0.55 (0.36, 0.84)], unplanned reoperation [0.58% vs. 0.38%, AOR = 0.61 (0.44, 0.85)], prolonged hospital stay [14.9% vs. 14.0%, AOR = 0.87 (0.82, 0.92)], and composite complications [1.43% vs. 1.17%, AOR = 0.78 (0.65, 0.94)]. Outcomes after LRYGB were similar in both groups, except for decreased prolonged hospital stay with IOE [22.4% vs. 20.6%, AOR = 0.89 (0.84, 0.94)].

CONCLUSIONS

IOE is generally underutilized in baraitric procedures. IOE is associated with decreased risk of postoperative complications particularly sepsis, unplanned reoperations, prolonged hospital stay, and composite complications after LSG; and hospital stay after LRYGB. Large multicenter prospective studies are needed to explore the benefits of IOE in bariatric surgery, particularly the intermediate or long-term benefits.

Indications and benefits of intraoperative esophagogastroduodenoscopy

Introduction

Intraoperative esophagogastroduodenoscopy (IOG) is a diagnostic and therapeutic method for a variety of special conditions in upper gastrointestinal (UGI) pathology. The indication remains individual due to insufficient evidence and limited training of surgeons in digestive endoscopy.

Aim

To evaluate the indications, benefits and risks of IOG.

Material and methods

A single-center retrospective study of 110 consecutive IOGs in 104 patients was performed. The preoperative plan, the timing of IOG, preoperative evaluation, intraoperative finding, localization of the pathology, type of the procedure, change of expected therapy and complications were assessed.

Results

The cohort comprised 29 esophageal tumors, 5 tumors of the cardia, 36 gastric tumors, gastrointestinal bleeding (8), esophageal diverticula (3), perforations (3), GERD (5), mediastinal pathology (3), fistula (4), assessment of nutrition (10), duodenal adenoma (2), ulcer disease, esophageal stenosis and gastric volvulus. The indication for IOG was established preoperatively in 79% and intraoperatively in 21%. The lesion was localized in 96.4%. The therapy was altered to a wider resection (11), smaller resection (5), localization and surgical therapy of bleeding (8) or allowed minimally invasive surgery (25). A total of 3 postoperative complications included gastric perforation and positivity of resection line (following EMR/ESD) and recurrent bleeding. The 30-day mortality reached 3.6% without a specific cause in IOG.

Conclusions

The IOG is a complementary method in the diagnosis and treatment of UGI pathology. It enables minimally invasive finalization of the procedures and individualization of the therapy.

Intraoperative endoscopy prevents technical defect related leaks in laparoscopic Roux-en-Y gastric bypass: A randomized control trial

BACKGROUND

Postoperative anastomotic leaks, bleeding and stenosis are major causes of morbidity after laparoscopic Roux-en-Y gastric bypass (LRYGB). Retrospective studies suggest that intraoperative endoscopy reduces the incidence of these complications.

METHODS

We conducted a prospective randomized controlled trial in a single institution between March 2013 and January 2016. Patients were assigned to one of two groups: LRYGB with Intraoperative Endoscopy (IOE) or LRYGB without IOE. Patient selection criteria were morbidly obese patients, 18 years or older who were candidates to LRYGB. The primary outcome was the frequency of technical defect related anastomotic leaks. Secondary outcomes were operative time, length of hospital stay, anastomotic related complications, reoperations and 30-day mortality.

RESULTS

50 patients were randomly assigned in the IOE group and 50 in the control group. The IOE group had statistically significant lower rate of anastomotic leak (0 vs. 8%, p = .0412), and lower need for reoperation (0 vs. 8%, p = .0412). The IOE group had longer operative time (194.10 vs. 159 min, p < .001), and shorter mean length of hospital stay (2.44 vs. 3.46 days, p = .025). No differences were found in the rate of bleeding of the anastomosis, narrow anastomosis and 30-day mortality.

CONCLUSION

This study specifically provides evidence that air leak test performed by intraoperative endoscopy is superior to simple visual inspection in preventing technical defect related leaks after laparoscopic Roux-en-Y gastric bypass.

Endoscopy after bariatric surgery

Obesity is a global epidemic with significant morbidity and mortality. Weight loss results in reduction of health risks and improvement in quality of life, thus representing a goal of paramount importance. Bariatric surgery is the most efficacious choice compared to conservative alternatives including diet, exercise, drugs and behavioral modification to treat obese patients. Following bariatric operations, patients may present with upper gastrointestinal tract complaints that warrant endoscopic evaluation and the various bariatric surgery types are often linked to complications. A subset of these complications necessitates endoscopic interventions for accurate diagnosis and effective, minimal invasive treatment. This review aims to highlight the role of upper gastrointestinal endoscopy in patients who have undergone bariatric surgery to evaluate and potentially treat surgery-related complications and upper gastrointestinal symptoms.

Endoscopy in the early postoperative setting after primary gastrointestinal anastomosis

INTRODUCTION

Gastrointestinal anastomoses may require early evaluation and treatment via flexible endoscopic techniques when complications arise. There is reticence, however, to perform endoscopy given the applied mechanical forces. We aimed to identify the incidence of gastrointestinal anastomotic perforation or disruption resulting from endoscopy performed ≤6 weeks of anastomoses.

METHODS

Review of patients from 2002 to 2013 who underwent flexible endoscopy within 6 weeks of creation of gastrointestinal anastomosis. Exclusion criteria included intraoperative endoscopy, anastomotic perforation prior to endoscopy, and endoscopy remote from the anastomotic site. Data are presented as median (interquartile range; IQR) or percentages as appropriate.

RESULTS

Twenty-four patients met our criteria (age 69 years [IQR 54-77], 54% men]). Endoscopy was performed at a median postoperative time of 18 days (IQR 8-30). Indications for endoscopy included bleeding (66%), obstruction (13%), pain (13%), concern for pancreatic duct leak (4%), and concern for ischemia (4%). Six patients underwent therapeutic endoscopic procedures including coagulation (8%), balloon dilation (8%), tube decompression (8%), and stent placement (4%). There were no anastomotic perforations or disruptions as a result of endoscopy.

CONCLUSION

Despite theoretical risks of adverse events of flexible endoscopy in the early postoperative period, no endoscopic perforations or disruptions occurred in recently created surgical anastomoses.

Bariatric emergencies: current evidence and strategies of management

BACKGROUND

The demand for bariatric surgery is increasing and the postoperative complications are seen more frequently. The aim of this paper is to review the current outcomes of bariatric surgery emergencies and to formulate a pathway of safe management.

METHODS

The PubMed and Google search for English literatures relevant to emergencies of bariatric surgery was made, 6358 articles were found and 90 papers were selected based on relevance, power of the study, recent papers and laparoscopic workload. The pooled data was collected from these articles that were addressing the complications and emergency treatment of bariatric patients. 830,998 patients were included in this review.

RESULTS

Bariatric emergencies were increasingly seen in the Accident and Emergency departments, the serious outcomes were reported following complex operations like gastric bypass but also after gastric band and the causes were technical errors, suboptimal evaluation, failure of effective communication with bariatric teams who performed the initial operation, patients factors, and delay in the presentation. The mortality ranged from 0.14%-2.2% and increased for revisional surgery to 6.5% (p = 0.002). Inspite of this, mortality following bariatric surgery is still less than that of control group of obese patients (p = value 0.01).

CONCLUSIONS

Most mortality and catastrophic outcomes following bariatric surgery are preventable. The awareness of bariatric emergencies and its effective management are the gold standards for best outcomes. An algorithm is suggested and needs further evaluation.

Bariatric procedures: an update on techniques, outcomes and complications

PURPOSE OF REVIEW

Obesity is a rising epidemic, and it is projected that over 700 million people will be obese by 2015. As the number of people with morbid obesity rises, so will the number of bariatric procedures performed. The goal of this article is to review current surgical and endoscopic options for weight loss in morbidly obese patients including their efficacy and complications.

RECENT FINDINGS

New bariatric surgical techniques have been developed with the goals of maximizing weight loss and metabolic outcomes, while minimizing complications. In addition, there is a role for therapeutic endoscopy in treating obesity as well as managing bariatric surgical complications. As the metabolic effects of bariatric surgery are better elucidated, bariatric surgeries may provide a role in treatment of metabolic syndrome in mildly obese individuals. For those with insufficient weight loss, revisional bariatric surgeries have been performed with varying success.

SUMMARY

Bariatric surgery is an effective treatment for obesity and its comorbidities. Several bariatric surgeries are available, and a multidisciplinary approach is recommended for choosing the best procedure for the appropriate candidate, along with providing long-term follow-up care to maximize outcome.