Anastomotic leaks after bariatric surgery: it is the host response that matters

Bioresorbable, wireless, passive sensors for continuous pH measurements and early detection of gastric leakage

Continuous monitoring of biomarkers at locations adjacent to targeted internal organs can provide actionable information about postoperative status beyond conventional diagnostic methods. As an example, changes in pH in the intra-abdominal space after gastric surgeries can serve as direct indicators of potentially life-threatening leakage events, in contrast to symptomatic reactions that may delay treatment. Here, we report a bioresorbable, wireless, passive sensor that addresses this clinical need, designed to locally monitor pH for early detection of gastric leakage. A pH-responsive hydrogel serves as a transducer that couples to a mechanically optimized inductor-capacitor circuit for wireless readout. This platform enables real-time monitoring of pH with fast response time (within 1 hour) over a clinically relevant period (up to 7 days) and timely detection of simulated gastric leaks in animal models. These concepts have broad potential applications for temporary sensing of relevant biomarkers during critical risk periods following diverse types of surgeries.

Surgical Management of Bariatric Complications and Weight Regain

The history and evolution of bariatric/metabolic surgical procedures allows for only a brief introduction to complications and surgical approaches for improved weight loss. Our specialty lacks standardization of our operations such as gastric pouch size, intestinal bypass lengths, and consensus on which procedure is best for each individual patient. Anatomic construct as well as adherence to lifestyle modifications can affect short- and long-term outcomes.

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.

The short-term outcome of distal mesogastric fixation after laparoscopic sleeve gastrectomy: a randomized controlled trial

PURPOSE

The proposed etiology of leakage after laparoscopic sleeve gastrectomy may be the axial rotation of the stomach owing to the loss of abdominal ligament fixation along the greater curvature of the stomach. The mechanism of increased intra-gastric pressure due to axial gastric rotation may place a great deal of stress on the staple lines, leading to an increased incidence of leakage. Other complications may occur, including vomiting, food intolerance or persistent reflux.

METHODS

This study was registered in ClinicalTrials.gov (ID: NCT04834323). This study included patients who were admitted to our center to undergo laparoscopic sleeve gastrectomy. Cases were collected in the period from December 2019 to December 2020. The study population included 83 patients, who were divided into the following two groups: Group 1 included 42 patients who received distal mesogastric fixation after laparoscopic sleeve gastrectomy; Group 2 included 41 patients who received laparoscopic sleeve gastrectomy alone without distal mesogastric fixation.

RESULTS

No leakage or axial rotation occurs after laparoscopic sleeve gastrectomy with distal fixation, while in patients without distal fixation, leakage and axial rotation occurred with no statistically significant differences between the two groups. Leakage and axial rotation occurred two times more frequently among patients who received laparoscopic sleeve gastrectomy without distal fixations.

CONCLUSION

Distal mesogastric fixation after laparoscopic sleeve gastrectomy decreased the axial gastric rotation and subsequently decreased gastric leakage.

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.

Management of leak after sleeve gastrectomy: outcomes of 73 cases, treatment algorithm and predictors of resolution

Introduction

Gastric leak post laparoscopic sleeve gastrectomy (LSG) is a severe complication that has been reported in 1.5–3% of cases. Management algorithms of leak exist; however, no known factors predict the time to resolution. This study aims to share outcomes of our management algorithm of post LSG leak, including the rate of resolution, complications, admission to the intensive care unit, conversion to other techniques, and mortality. To determine if any factors can predict the resolution time.

Methods

A retrospective analysis of patients who had LSG leaks and was managed in the main tertiary center in Qatar (January 2012–December 2017).

Results

A total of seventy-three patients had post LSG leaks. Fifty-six (76.7%) underwent LSG outside our center. Thirteen leaks (17.8%) were after revisional LSG. Laparoscopic exploration was performed in twenty patients (27.4%) and feeding jejunostomy in nine patients (12.3%). Patients were followed up for 12 months. All healed within 8.8 ± 0.72 weeks. The resolution rate was (97.1%) without surgical conversion, while two patients required fistulo-jejunostomy. No patient died. Complications occurred; re-leak (14.9%) and splenic abscess (2.9%). Patients on jejunal feeding had shorter resolution time (HR = 2.7, P = 0.018), while patients on total parenteral nutrition and post-endoscopic dilatation had 66% and 50% increases in the resolution time; (HR = 0.34, P = 0.026) and (HR = 0.5, P = 0.047), respectively.

Conclusion

Management of post-LSG leak is multimodal. Our clinical experience demonstrated less urge to perform extensive surgical interventions. Patients on enteral feeding had shorter resolution time while patients with sleeve stricture had a longer time to resolution.

Efficacy and Safety of Stents in the Treatment of Fistula After Bariatric Surgery: a Systematic Review and Meta-analysis

Fistula development is a serious complication after bariatric surgery. We performed a systematic review and meta-analysis to assess the efficacy of fistula closure and complications associated with endoscopic stent treatment of fistulas, developed after bariatric surgeries, particularly Roux-en-Y gastric bypass (RYGB) and gastric sleeve (GS). Studies involving patients with fistula after RYGB or GS and those who received stent treatment only were selected. The analyzed outcomes were overall success rate of fistula closure, mean number of stents per patient, mean stent dwelling time, and procedure-associated complications. Current evidence from identified studies demonstrates that, in selected patients, endoscopic stent treatment of fistulas after GS or RYGB can be safe and effective.

Major complications of bariatric surgery: endoscopy as first-line treatment

Leaks are the most frequent early postoperative complication in the two most popular bariatric procedures, Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy. Multimodal therapy based on self-expandable stent insertion 'to cover' the defect is the most widely documented technique to date with a reported success rate >80%. Additional experimental techniques 'to close' the defect or 'to drain' the paradigestive cavity have been reported with encouraging results. The role of endoscopy in early postoperative bleeding is limited to management of bleeds arising from fresh sutures and the diagnosis of chronic sources of bleeding such as marginal ulcer after RYGB. Post-RYGB stricture is a more delayed complication than leaks and the role of endoscopic dilation as a first-line treatment in this indication is well documented. Ring and band placement are outdated procedures for obesity treatment, but might still be an indication for endoscopic removal, a technique which does not compromise further surgery, if needed.

Treating sleeve gastrectomy leak with endoscopic stenting: the Kuwaiti experience and review of recent literature

BACKGROUND

Obesity today is a leading cause of global morbidity and mortality, and bariatric surgeries such as laparoscopic sleeve gastrectomy (LSG) are increasingly playing a key role in its management. Such operations, however, carry many difficult and sometimes fatal complications, including leaks. This study aims at evaluating the effectiveness of endoscopic stenting in treating gastric leaks post-LSG.

METHODS

A retrospective study was conducted to the patients who were admitted with post-LSG gastric leak at Al-Amiri Hospital Kuwait from October 2008 to December 2012 and were subsequently treated with stenting. The patients were stented endoscopically with self-expandable metal stent (SEMS), and a self-expandable plastic stent (SEPS) was used to facilitate stent removal.

RESULTS

A total of 17 patients with post-LSG leaks underwent endoscopic stenting. The median age was 34 years (range 19-56), 53% of the patients were male, and mean body mass index (BMI) was 43 kg/m(2). The median duration of SEMS placement per patient was 42 days (range 28-84). The SEPS-assisted retrieval process took a median duration of 11 days (range 14-35). Successful treatment of gastric leak was evident in 13 (76%) patients, as evident by gastrografin swallow 1 week after stent removal. In addition, a shorter duration between the LSG and the time of stent placement was associated with a higher success rate of leak seal.

CONCLUSIONS

The use of SEMS appears to be a safe and effective method in the treatment of post-LSG leaks, with a success rate of 76%. The time frame of intervention after surgery is critical, as earlier stent placement is associated with favorable outcomes. Finally, SEPS is often required to facilitate SEMS removal, and further modification of stents and its delivery system may improve results.

Clinical features and outcome of postoperative peritonitis following bariatric surgery

Background

We assessed the clinical features and outcome of morbidly obese patients admitted to the intensive care unit (ICU) for management of postoperative peritonitis (POP) following bariatric surgery (BS).

Methods

In a prospective, observational, surgical ICU cohort, we compared the clinical features, empiric antibiotic therapy, and prognosis of BS patients with those developing POP after conventional surgery (cPOP).

Results

Overall, 49 BS patients were compared to 134 cPOP patients. BS patients were younger (45 ± 10 versus 63 ± 16 years; p < 0.0001), had lower rates of fatal underlying disease (39 vs 64 %; p = 0.002), and the same SOFA score at the time of reoperation (8 ± 4 vs 8 ± 3; p = 0.8) as the cPOP patients. BS patients had higher proportions of Gram-positive cocci (48 vs 35 %; p = 0.007) and lower proportions of Gram-negative bacilli (33 vs 44 %; p = 0.03), anaerobes (4 vs 10 %; p = 0.04), and multidrug-resistant strains (20 vs 40 %; p = 0.01). Despite higher rates of adequate empiric antibiotic therapy (82 vs 64 %; p = 0.024) and high de-escalation rates (67 % in BS cases and 51 % in cPOP cases; p = 0.06), BS patients had similar reoperation rates (53 vs 44 %; p = 0.278) and similar mortality rates (24 vs 32 %; p = 0.32) to cPOP patients. In multivariate analysis, none of the risk factors for death were related to BS.

Conclusions

The severity of POP in BS patients resulted in high mortality rates, similar to the results observed in cPOP. Usual empiric antibiotic therapy protocols should be applied to target multidrug-resistant microorganisms, but de-escalation can be performed in most cases.

ASMBS guideline on the prevention and detection of gastrointestinal leak after gastric bypass including the role of imaging and surgical exploration

The following position statement is issued by the American Society for Metabolic and Bariatric Surgery in response to numerous inquiries made to the Society by patients, physicians, society members, hospitals, health insurance payors, the media, and others, regarding the complication of gastrointestinal leak after gastrointestinal bariatric procedures. In this statement, available data regarding leak are summarized and suggestions made regarding reasonable approaches to the prevention and postoperative detection based on current knowledge, expert opinion, and published peer-reviewed scientific evidence available at this time. The intent of issuing such a statement is to provide objective information about the complication of leak. The statement is not intended as, and should not be construed as, stating or establishing a local, regional, or national standard of care. The statement will be revised in the future as additional evidence becomes available.