1
|
Li M, Zeng N, Liu Y, Sun X, Yang W, Liu Y, Mao Z, Yao Q, Zhao X, Liang H, Lou W, Ma C, Song J, Wu J, Yang W, Zhang P, Zhu L, Tian P, Zhang P, Zhang Z. Management and outcomes of gastric leak after sleeve gastrectomy: results from the 2010-2020 national registry. Chin Med J (Engl) 2023; 136:1967-1976. [PMID: 37525550 PMCID: PMC10431592 DOI: 10.1097/cm9.0000000000002499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Management of gastric leak after sleeve gastrectomy (SG) is challenging due to its unpredictable outcomes. We aimed to summarize the characteristics of SG leaks and analyze interventions and corresponding outcomes in a real-world setting. METHODS To retrospectively review of 15,721 SG procedures from 2010 to 2020 based on a national registry. A cumulative sum analysis was used to identify a fitting curve of gastric leak rate. The Kaplan-Meier method and log-rank tests were performed to calculate and compare the probabilities of relevant outcomes. The logistic regression analysis was conducted to determine the predictors of acute leaks. RESULTS A total of 78 cases of SG leaks were collected with an incidence of 0.5% (78/15,721) from this registry (6 patients who had the primary SG in non-participating centers). After accumulating 260 cases in a bariatric surgery center, the leak rate decreased to a stably low value of under 1.17%. The significant differences presented in sex, waist circumference, and the proportion of hypoproteinemia and type 2 diabetes at baseline between patients with SG leak and the whole registry population ( P = 0.005, = 0.026, <0.001, and = 0.001, respectively). Moreover, 83.1% (59/71) of the leakage was near the esophagogastric junction region. Leakage healed in 64 (88.9%, 64/72) patients. The median healing time of acute and non-acute leaks was 5.93 months and 8.12 months, respectively. Acute leak (38/72, 52.8%) was the predominant type with a cumulative reoperation rate >50%, whereas the cumulative healing probability in the patients who required surgical treatment was significantly lower than those requring non-surgical treatment ( P = 0.013). Precise dissection in the His angle area was independently associated with a lower acute leak rate, whereas preservation ≥2 cm distance from the His angle area was an independent risk factor. CONCLUSIONS Male sex, elevated waist circumference, hypoproteinaemia, and type 2 diabetes are risk factors of gastric leaks after SG. Optimizing surgical techniques, including precise dissection of His angle area and preservation of smaller gastric fundus, should be suggested to prevent acute leaks.
Collapse
Affiliation(s)
- Mengyi Li
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University & National Clinical Research Center for Digestive Diseases, Beijing 100050, China
| | - Na Zeng
- School of Public Health, Peking University, Beijing 100191, China
| | - Yang Liu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University & National Clinical Research Center for Digestive Diseases, Beijing 100050, China
| | - Xitai Sun
- Department of General Surgery, Nanjing Drum Tower Hospital, Nanjing, Jiangsu 210008, China
| | - Wah Yang
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong 510630, China
| | - Yanjun Liu
- Center of Gastrointestinal and Minimally Invasive Surgery, Department of General Surgery, The Third People's Hospital of Chengdu & The Affiliated Hospital of Southwest Jiaotong University, Chengdu, Sichuan 610014, China
| | - Zhongqi Mao
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, China
| | - Qiyuan Yao
- Center for Obesity and Metabolic Surgery, Huashan Hospital, Fudan University, Shanghai 200030, China
| | - Xiangwen Zhao
- Department of Metabolic and Bariatric Surgery, Xiaolan People's Hospital of Zhongshan, Zhongshan, Guangdong 528415, China
| | - Hui Liang
- Department of General Surgery, First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu 226399, China
| | - Wenhui Lou
- Department of General Surgery, Zhongshan Hospital, Shanghai 200032, China
| | - Chiye Ma
- Department of Gastrointestinal Surgery, Dongfang Hospital of Shaghai, Shanghai 200120, China
| | - Jinghai Song
- Department of General Surgery, Beijng Hospital, Beijing 100730, China
| | - Jianlin Wu
- Department of Gastrointestinal Surgery, Zibo Central Hospital, Zibo, Shandong 255020, China
| | - Wei Yang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Pin Zhang
- Department of Bariatric and Metabolic Surgery, Shanghai Jiao Tong University affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Liyong Zhu
- Department of Gastrointestinal Surgery,The Third Xiangya Hospital of Central South University, Changsha, Hunan 410013, China
| | - Peirong Tian
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University & National Clinical Research Center for Digestive Diseases, Beijing 100050, China
| | - Peng Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University & National Clinical Research Center for Digestive Diseases, Beijing 100050, China
| | - Zhongtao Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University & National Clinical Research Center for Digestive Diseases, Beijing 100050, China
| |
Collapse
|
2
|
The Evolving Management of Leaks Following Sleeve Gastrectomy. CURRENT SURGERY REPORTS 2023. [DOI: 10.1007/s40137-023-00357-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
|
3
|
Mesenchymal Stem Cells and PRP Therapy Favorize Leak Closure After Sleeve Gastrectomy in Zucker Rats. Obes Surg 2022; 32:1251-1260. [PMID: 35194771 DOI: 10.1007/s11695-022-05945-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Sleeve gastrectomy (SG) is the most performed bariatric surgery but gastric leaks following SG occur in up to 2% of cases. Regenerative medicine is emerging as a promising field offering multiple possibilities in wound healing. We studied the efficiency of locally administered mesenchymal stem cells (MSCs) and platelet-rich plasma (PRP) on leak closure following SG in rats. METHODS The amount of PRP and MSCs extracted from one rat was analyzed and a model of gastric leak was developed in 10-week-old male Zucker rats. Twenty-four rats underwent SG fashioned with a leak. After 24 h, a second surgery was performed. The control group was treated by peritoneal lavage and drainage only while the experimental group received an additional treatment of locally administered MSCs and PRP at the leak orifice. Analysis of the leak healing process was done by an anatomopathological examination of the stomach 1, 2, 3, and 4 weeks after SG. RESULTS The extraction of MSCs and PRP from one rat was necessary for three recipients. Anatomopathological examination suggests that the closure of the leak orifice was faster in the experimental group. Statistical analysis revealed a significantly increased mucosae renewal and fibrosis score at the leak orifice after treatment with MSCs and PRP (p < 0.001). CONCLUSION These results suggest that PRP and MSCs may accelerate the closure of leaks following SG in rats and may become a new tool in the treatment of human gastric leaks but more research on this topic is needed to confirm these findings.
Collapse
|
4
|
Total Gastrectomy with Roux-en-Y Limb Reconstruction for Complex and Chronic Fistulas After Laparoscopic Sleeve Gastrectomy: Single-Center Experience. Obes Surg 2021; 31:5260-5266. [PMID: 34591262 DOI: 10.1007/s11695-021-05721-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 09/20/2021] [Accepted: 09/22/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE When a leak after laparoscopic sleeve gastrectomy (LSG) becomes a chronic fistula, the best surgical treatment remains controversial. The aim of study was to review our experience concerning the treatment of chronic and complex fistulas after LSG. MATERIALS AND METHODS A retrospective analysis of patients with a gastric fistula following LSG who were treated at our center between January 2013 and December 2018 was performed. All patients included underwent a total gastrectomy with a Roux-en-Y reconstruction (TG) for LSG chronic fistula. RESULTS During the period considered, 13 patients had a chronic fistula and were treated with open TG. The primary leak evolved to a gastro-cutaneos fistula in three patients (23%), to a gastro-splenic fistula in two patients (15.4%), to a gastro-pleural fistula in four patients (30.8%), and to a gastro-bronchial fistula in four patients (30.8%). During TG, a splenectomy and a spleno-pancreatectomy were needed in the two cases of gastro-splenic fistula. Five patients (38.5%) developed an early complication. Two patients developed an esophago-jejunal anastomotic leak treated with a conservative approach (15.4%). No patients needed hospitalization in the intensive care unit. Overall mean length of stay was 19 days (8-30 days). Mean BMI before LSG was 36 (± 5 kg/m2), mean BMI before TG was 30.3 (± 5.2 kg/m2), and mean BMI 2 years after TG was 23.5 (± 2.9 kg/m2). CONCLUSION When a more conservative and less mutilating surgical option is not possible, open TG with esophago-jejunostomy remains a valuable salvage procedure in the case of complex and extensive fistulas after LSG.
Collapse
|
5
|
Feng XC, Burch M. Management of Postoperative Complications Following Bariatric and Metabolic Procedures. Surg Clin North Am 2021; 101:731-753. [PMID: 34537140 DOI: 10.1016/j.suc.2021.05.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Bariatric and metabolic surgery is a safe and effective treatment of morbid obesity, a disease that continues to increase in prevalence in the United States and worldwide. The two most commonly performed operations are the sleeve gastrectomy and the gastric bypass. Early and late complications can occur, and although referral to a bariatric surgeon or center is ideal, emergency management of acute problems is relevant to all general surgeons. Bariatric surgery can have surgical and metabolic consequences. An understanding of the altered anatomy and physiology helps to guide management of morbidities. This article discusses surgical postoperative complications and metabolic complications.
Collapse
Affiliation(s)
- Xiaoxi Chelsea Feng
- General Surgery, Cedars Sinai Medical Center, 8635 West 3rd Street, Suite 650W, Los Angeles, CA 90048, USA
| | - Miguel Burch
- General Surgery, Cedars Sinai Medical Center, 8635 West 3rd Street, Suite 650W, Los Angeles, CA 90048, USA.
| |
Collapse
|
6
|
Kim KH, Jung K, Kim YH, Seo KW. Endoscopic Septotomy as a Treatment for Chronic Leak after Laparoscopic Sleeve Gastrectomy. JOURNAL OF METABOLIC AND BARIATRIC SURGERY 2021; 10:42-45. [PMID: 36687751 PMCID: PMC9847649 DOI: 10.17476/jmbs.2021.10.1.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/31/2021] [Accepted: 05/31/2021] [Indexed: 01/25/2023]
Abstract
Acute leakage after sleeve gastrectomy progresses into chronic leakage by 10-28.1%, which causes the surgeon to be disturbed. The main treatment for chronic leakage is surgery, but the authors report successful care with endoscopic septotomy. Forty-one year old female patient with a BMI of 42.8 (161.6 cm/111.8 kg) underwent a laparoscopic sleeve gastrectomy. The leakage of the proximal part of the staple resection line was verified in the abdominal CT on the fourth day after the procedure due to pain in the left shoulder that could not be clarified. After appropriate treatment including stent, the patient ended the acute leakage treatment 150 days after surgery. However, the patient was visited for 10 months after removed percutaneous catheter drainage due to fever and pain in the left shoulder. Afterwards, chronic leakage was confirmed from the CT and endoscopy at POD 15 months. We performed endoscopic treatment in the operating room under general anesthesia. At the gastroesophageal junction, we could find chronic leak orifice and bridging fold between stomach lumen and abscess pocket. Endoscopic septotomy was performed with the endoscopic knife and electrosurgical surgical unit, until the stomach lumen and abscess pockets were fully in communication. After the patient was discharged without any complications and is currently under close observation. Endoscopic septotomy as a treatment for chronic leak is feasible and safe. Herein, we report this case with video clip.
Collapse
Affiliation(s)
- Ki Hyun Kim
- Department of Surgery, Kosin University College of Medicine, Busan, Korea
| | - Kyoungwon Jung
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Yoon Hong Kim
- Department of Surgery, Kosin University College of Medicine, Busan, Korea
| | - Kyung Won Seo
- Department of Surgery, Kosin University College of Medicine, Busan, Korea
| |
Collapse
|
7
|
Abstract
PURPOSE Laparoscopic sleeve gastrectomy (LSG) is estimated to be its most severe complication. An aggressive management with surgical reconstructive procedures can be proposed in patients in whom all the conservative endoscopic techniques fail. The purpose of the present study was to report our experience with Roux-en-Y gastric bypass (RYGBP) as treatment for the chronic leak after LSG. METHODS Between January 2013 and July 2019, 17 consecutive patients underwent RYGBP for the treatment of chronic leak after LSG. The initial intervention, the endoscopic approach and the definitive surgical repair were carefully reviewed. RESULTS Seventeen patients (13 women) with a median age of 39 years (24-67) with a median body mass index (BMI) of 40 kg/m2 (30-52) underwent RYGBP for persistent fistula. Sixteen patients had their early LSG performed in another hospital. Eleven patients had an initial endoscopic treatment by pigtail drains following laparoscopic drainage and 6 other patients had the endoscopic stent as the first-choice line treatment. The overall average fistula diagnosis was done at 7.7 months (2-49 months) for 12 patients. For the rest of five patients, the procedure was performed almost in the acute setting (< 30 days). All procedures were performed by laparotomy but one. Five patients had a gastrojejunal anastomosis leak diagnosed by salivary flow in the drainage, but all patients were treated conservatively. No post-operative mortality was recorded. CONCLUSIONS Surgery should be considered in case of failure of the endoscopic treatment of chronic leak after LSG. Further research is needed to clearly identify the appropriate treatment, but in our experience, RYGBP approach including the leak site offers a low morbidity rate.
Collapse
|
8
|
Marie L, Robert M, Montana L, De Dominicis F, Ezzedine W, Caiazzo R, Fournel L, Mancini A, Kassir R, Boullu S, Barthet M, D'Journo XB, Bège T. A French National Study on Gastropleural and Gastrobronchial Fistulas After Bariatric Surgery: the Impact of Therapeutic Strategy on Healing. Obes Surg 2021; 30:3111-3118. [PMID: 32382962 DOI: 10.1007/s11695-020-04655-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
Collapse
Affiliation(s)
- L Marie
- Department of Digestive Surgery, Hôpital Nord, Aix-Marseille University, Chemin des Bourrely, 13915, Marseille Cedex 20, France
| | - M Robert
- Department of Digestive and Bariatric Surgery, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - L Montana
- Assistance Publique-Hôpitaux de Paris (AP-HP), Department of Digestive and Metabolic Surgery, Avicenne University Hospital, Université Paris XIII, Route de Stalingrad, Bobigny, France
| | - F De Dominicis
- Department of Thoracic Surgery, Amiens University Hospital, Amiens, France
| | - W Ezzedine
- General and Endocrine Surgery Department, Huriez Hospital, Lille University, Lille, France
| | - R Caiazzo
- General and Endocrine Surgery Department, Huriez Hospital, Lille University, Lille, France
| | - L Fournel
- Department of Thoracic Surgery, Paris-Center University Hospital, AP-HP, Paris Descartes University, Paris, France
| | - A Mancini
- Department of thoracic and endocrine surgery, University Hospital of Grenoble, Grenoble, France
| | - R Kassir
- Department of Digestive Surgery, CHU Félix Guyon, Saint Denis, La réunion, France
| | - S Boullu
- Department of Endocrinology, Aix Marseille Univ-APHM-Hôpital Nord, Marseille, France
| | - M Barthet
- Digestive Endoscopy Unit, Gastroenterology Department, Hopital Nord, APHM, Marseille, France
| | - X B D'Journo
- Service de Chirurgie Thoracique, CNRS, INSERM, Centre de Recherche en Cancérologie de Marseille (CRCM), Assistance-Publique Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France
| | - Thierry Bège
- Department of Digestive Surgery, Hôpital Nord, Aix-Marseille University, Chemin des Bourrely, 13915, Marseille Cedex 20, France.
| |
Collapse
|
9
|
Romano L, Mattei A, Colozzi S, Giuliani A, Cianca G, Lazzarin G, Fiasca F, Carlei F, Schietroma M. Laparoscopic sleeve gastrectomy: A role of inflammatory markers in the early detection of gastric leak. J Minim Access Surg 2021; 17:342-350. [PMID: 32964887 PMCID: PMC8270050 DOI: 10.4103/jmas.jmas_3_20] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Lucia Romano
- Department of Surgery, San Salvatore Hospital, University of L'Aquila, L'Aquila, Italy
| | - Antonella Mattei
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Sara Colozzi
- Department of Surgery, San Salvatore Hospital, University of L'Aquila, L'Aquila, Italy
| | - Antonio Giuliani
- Department of Surgery, San Salvatore Hospital, University of L'Aquila, L'Aquila, Italy
| | - Giovanni Cianca
- Department of Surgery, San Salvatore Hospital, University of L'Aquila, L'Aquila, Italy
| | - Gianni Lazzarin
- Department of Surgery, San Salvatore Hospital, University of L'Aquila, L'Aquila, Italy
| | - Fabiana Fiasca
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Francesco Carlei
- Department of Surgery, San Salvatore Hospital, University of L'Aquila, L'Aquila, Italy
| | - Mario Schietroma
- Department of Surgery, San Salvatore Hospital, University of L'Aquila, L'Aquila, Italy
| |
Collapse
|
10
|
Li S, Jiao S, Zhang S, Zhou J. Revisional Surgeries of Laparoscopic Sleeve Gastrectomy. Diabetes Metab Syndr Obes 2021; 14:575-588. [PMID: 33603423 PMCID: PMC7882429 DOI: 10.2147/dmso.s295162] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 01/08/2021] [Indexed: 12/11/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Siyuan Li
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, People’s Republic of China
| | - Siqi Jiao
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, People’s Republic of China
| | - Siwei Zhang
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, People’s Republic of China
| | - Jiangjiao Zhou
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, People’s Republic of China
- Correspondence: Jiangjiao Zhou Department of General Surgery, The Second Xiangya Hospital, Central South University, No. 139 Middle Renmin Road, Changsha, Hunan, 410011, People’s Republic of China Email
| |
Collapse
|
11
|
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. Minim Invasive Surg 2020; 2020:8250904. [PMID: 33425388 PMCID: PMC7775182 DOI: 10.1155/2020/8250904] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 12/08/2020] [Accepted: 12/15/2020] [Indexed: 11/17/2022] Open
Abstract
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.
Collapse
|
12
|
Sakran N, Zakeri R, Madhok B, Graham Y, Parmar C, Mahawar K, Pouwels S. Gastric Fistula in the Chest After Sleeve Gastrectomy: a Systematic Review of Diagnostic and Treatment Options. Obes Surg 2020; 31:357-369. [PMID: 33123868 DOI: 10.1007/s11695-020-05078-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/15/2020] [Accepted: 10/21/2020] [Indexed: 12/31/2022]
Abstract
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.
Collapse
Affiliation(s)
- Nasser Sakran
- Department of Surgery, Emek Medical Center, 21 Izhak Rabin Blvd, 1834111, Afula, Israel. .,The Technion - Israel Institute of Technology, Haifa, Israel.
| | - Roxanna Zakeri
- Department of Surgery, University College London Hospital NHS Foundation Trust, London, UK
| | - Brijesh Madhok
- University Hospital of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Yitka Graham
- Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK.,Facultad de Psucologia, Universidad Anahuac Mexico, Mexico City, Mexico.,Bariatric Unit, South Tyneside and Sunderland NHS Trust, Sunderland, UK
| | | | - Kamal Mahawar
- Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK.,Bariatric Unit, South Tyneside and Sunderland NHS Trust, Sunderland, UK
| | - Sjaak Pouwels
- Department of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | | |
Collapse
|
13
|
Taleb S, Nedelcu M, Skalli M, Loureiro M, Nedelcu A, Nocca D. The evolution of surgical treatment for chronic leak following sleeve. Surg Obes Relat Dis 2020; 17:278-283. [PMID: 33218903 DOI: 10.1016/j.soard.2020.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 09/15/2020] [Accepted: 10/02/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Leak is estimated to be the most severe complication of laparoscopic sleeve gastrectomy (LSG), with sporadic failure of endoscopic techniques. In such cases, an aggressive management with surgical reconstructive procedures can be proposed to patients in whom all the conservative endoscopic techniques failed. OBJECTIVES The purpose of the present study was to report our experience with surgical approach for the treatment of chronic leak after LSG. SETTING University hospital, France. METHODS Between January 2013-December 2019, 21 consecutive patients underwent reconstructive surgery for the treatment of chronic leak after LSG. The initial intervention, the endoscopic approach, and the definitive surgical repair were carefully reviewed. RESULTS Twenty-one patients (17 women) with a mean (standard deviation [SD]) age of 42.7 years (9.81) and a mean (SD) body mass index (BMI) of 27.3 (5.2) kg/m2 underwent reconstructive surgery for persistent fistula. Seventeen patients (81%) had their early LSG performed in another hospital. Endoscopic treatment was represented by the pigtail drain or stent in 9 cases each, ovesco in 8 cases, and glue for 2 patients. The reconstructive surgery was performed within 6 months in 8 cases; between 6-12 months in 6 cases; between 1-3 years in 4 cases, and >3 years in 3 cases. There were 14 fistulo-jejunostomy (66.7%), 5 Roux-en-Y gastric bypass (23.8%), and 2 total gastrectomies (9.5%). The operative time was between 99 minutes and 5.5 hours (mean = 216.2, median = 225 min). The hospital stay ranged from 5-30 days (mean = 12.67, median = 11 d) and the surgical reintervention rate was 23.8% (5/21 patients), including 1 case of recurrent hemorrhage requiring 3 surgical operations over 1 month of postoperative follow-up. No postoperative mortality was recorded. CONCLUSIONS Surgery should be considered in case of failure of the endoscopic treatment of chronic leak after LSG. Further research is needed to clearly identify the appropriate treatment, but in our experience the fistulo-jejunostomy approach shows a low morbidity rate. (Surg Obes Relat Dis 2020;17:278-283.) © 2020 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Collapse
Affiliation(s)
| | - Marius Nedelcu
- ELSAN, Clinique Bouchard, Marseille, France; ELSAN, Clinique Saint Michel, Toulon, France.
| | | | - Marcelo Loureiro
- CHU de Montpellier, Montpellier, France; University Montpellier 1, Montpellier, France; Universidade Positivo, Curitiba, Brazil
| | | | - David Nocca
- CHU de Montpellier, Montpellier, France; University Montpellier 1, Montpellier, France
| |
Collapse
|
14
|
Caiazzo R, Marciniak C, Wallach N, Devienne M, Baud G, Cazauran JB, Kipnis E, Branche J, Robert M, Pattou F. Malignant Leakage After Sleeve Gastrectomy: Endoscopic and Surgical Approach. Obes Surg 2020; 30:4459-4466. [DOI: 10.1007/s11695-020-04818-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
15
|
Endoscopic management of refractory leaks and fistulas after bariatric surgery with long-term follow-up. Surg Endosc 2020; 35:2715-2723. [DOI: 10.1007/s00464-020-07702-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/09/2020] [Indexed: 12/15/2022]
|
16
|
Anatomical Relations Between the Esogastric Junction, the Diaphragm, the Pleura, and the Left Lung in Chronic Esogastro-bronchial and/or Esogastro-pleural Fistulas After Sleeve Gastrectomy. Obes Surg 2020; 29:2814-2823. [PMID: 31069692 DOI: 10.1007/s11695-019-03912-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE Gastric fistula is a severe complication following sleeve gastrectomy (SG). Chronic gastric fistula can progress to complex anatomical situations, such as esogastro-bronchial and/or esogastro-pleural (EGBP) fistulas. We decided to analyze the anatomical characteristics of these EGBP fistulas after SG. METHODS Our work consisted of an analysis of the clinical, endoscopic, and radiological data of patients treated for EGBP fistulas after SG at the Georges Pompidou European Hospital from May 2009 to November 2017. RESULTS A total of 11 patients were retrospectively included with available complete clinical, endoscopic, and radiological data. The origin of the fistula was mostly at the top of the staple line. The fistula's termination was pleural in 5 patients (45%) and bronchial in 6 (55%). In bronchial fistulas, 2 were proximal and 4 were distal, with the left pulmonary posterolateral segment (S10) being reached in each case. The trans-diaphragmatic passage was through the left cupola in 9 out of 11 patients (82%). In 2 patients, the passage was trans-hiatal (18%). Interestingly, the 2 eso-bronchial fistulas had a trans-hiatal passage with a termination in the proximal bronchus, while the 4 gastro-bronchial fistulas had a trans-diaphragmatic passage with a termination in the distal bronchus. All pleural fistulas were gastric with a trans-diaphragmatic passage. CONCLUSIONS Esogastro-bronchial and gastro-pleural fistulas after SG originated mostly at the top of the staple line. Eso-bronchial fistulas had a trans-hiatal passage with a proximal bronchial termination, while gastro-bronchial fistulas had a trans-diaphragmatic passage with a distal bronchial termination.
Collapse
|
17
|
Diaz R, Welsh LK, Perez JE, Narvaez A, Davalos G, Portenier D, Guerron AD. Endoscopic septotomy as a treatment for leaks after sleeve gastrectomy: Meeting presentations: Digestive Disease Week 2019. Endosc Int Open 2020; 8:E70-E75. [PMID: 31921987 PMCID: PMC6949161 DOI: 10.1055/a-1027-6888] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 08/12/2019] [Indexed: 12/16/2022] Open
Abstract
Background and study aims Sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure in the world. Leaks are the most feared complications after this procedure. Endoscopic septotomy has been described as a resolution technique that could be useful in the setting of late and chronic leaks. We present our experience in the management of gastric leaks with this advanced endoscopic technique. Patients and methods Retrospective review of patients who have been admitted to our hospital from January 2016 to December 2018. Results Five patients were found. All had their index surgery in outside hospitals. The average age was 51 years (range 40 - 69), and four patients were female. Mean time from LSG to leak presentation was 15 days (range 7 - 25). Mean time from leak presentation to septotomy procedure was 61 days (range 21 - 110). All patients were treated with sleeve dilatation before septotomy using endoscopic achalasia balloons. Mean procedure time was 79 minutes (range 55 - 125). Success was achieved in 80 % of patients, and no complications related to the procedure were identified. One patient underwent total gastrectomy for definitive management. Mean follow-up time was 14.25 months (range 6 - 26), and the average time for fistula closure was 60.25 days. Conclusion Endoscopic septotomy is safe and effective for management of chronic leaks after LSG. Associated non-selective dilatation may be a crucial step to allow distal patency and axis rectification for appropriate leak closure.
Collapse
Affiliation(s)
- Ramon Diaz
- Division of Minimally Invasive Surgery, Metabolic and Weight Loss Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina, United States
| | - Leonard K. Welsh
- Division of Minimally Invasive Surgery, Metabolic and Weight Loss Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina, United States
| | - Juan Esteban Perez
- Division of Minimally Invasive Surgery, Metabolic and Weight Loss Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina, United States
| | - Andres Narvaez
- Division of Minimally Invasive Surgery, Metabolic and Weight Loss Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina, United States
| | - Gerardo Davalos
- Division of Minimally Invasive Surgery, Metabolic and Weight Loss Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina, United States
| | - Dana Portenier
- Division of Minimally Invasive Surgery, Metabolic and Weight Loss Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina, United States
| | - A. Daniel Guerron
- Division of Minimally Invasive Surgery, Metabolic and Weight Loss Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina, United States
| |
Collapse
|
18
|
Bruzzi M, Glomaud A, M'Harzi L, Poghosyan T, Chevallier JM, Douard R. Robotic Roux Limb Placement for Chronic Fistula After Sleeve Gastrectomy: a Novel Approach for a Technically Challenging Surgery? Obes Surg 2019; 30:349-351. [PMID: 31713149 DOI: 10.1007/s11695-019-04264-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Matthieu Bruzzi
- INSERM 970, Équipe 2, PARCC, HEGP, Paris, France.
- General and Digestive Surgery Unit, |Georges Pompidou, AP-HP University Hospital, 20, Rue Leblanc, 75908, Paris Cedex 15, France.
- Paris Descartes Faculty of Medicine, Paris, France.
| | - Adrien Glomaud
- General and Digestive Surgery Unit, |Georges Pompidou, AP-HP University Hospital, 20, Rue Leblanc, 75908, Paris Cedex 15, France
| | - Leila M'Harzi
- General and Digestive Surgery Unit, |Georges Pompidou, AP-HP University Hospital, 20, Rue Leblanc, 75908, Paris Cedex 15, France
| | - Tigran Poghosyan
- General and Digestive Surgery Unit, |Georges Pompidou, AP-HP University Hospital, 20, Rue Leblanc, 75908, Paris Cedex 15, France
- Paris Descartes Faculty of Medicine, Paris, France
| | - Jean-Marc Chevallier
- General and Digestive Surgery Unit, |Georges Pompidou, AP-HP University Hospital, 20, Rue Leblanc, 75908, Paris Cedex 15, France
- Paris Descartes Faculty of Medicine, Paris, France
| | - Richard Douard
- General and Digestive Surgery Unit, |Georges Pompidou, AP-HP University Hospital, 20, Rue Leblanc, 75908, Paris Cedex 15, France
- Paris Descartes Faculty of Medicine, Paris, France
| |
Collapse
|
19
|
A Complication of an Endoscopic Pigtail Stent Migration into the Cavity during Deployment as a Treatment for Gastric Leak. Case Rep Surg 2019; 2019:6974527. [PMID: 31583156 PMCID: PMC6754919 DOI: 10.1155/2019/6974527] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 07/29/2019] [Indexed: 11/29/2022] Open
Abstract
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.
Collapse
|
20
|
Surgical management for chronic leak following sleeve gastrectomy: Review of literature. Surg Obes Relat Dis 2019; 15:1844-1849. [DOI: 10.1016/j.soard.2019.03.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 02/18/2019] [Accepted: 03/10/2019] [Indexed: 12/11/2022]
|
21
|
Mirhashemi S, Malekpour Alamdari N, Jaberi N, Shahrbaf MA. Prevalence of Anastomotic Leaks and Diagnostic Methods in Sleeve Gastrectomy. Bariatr Surg Pract Patient Care 2019. [DOI: 10.1089/bari.2018.0056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Seyedhadi Mirhashemi
- Department of General Surgery, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nasser Malekpour Alamdari
- Department of General Surgery, Modarres, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Najmeh Jaberi
- Department of General Surgery, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | |
Collapse
|
22
|
Al-Lehibi A. Endoscopic Management of Gastrobronchial Fistula after Laparoscopic Sleeve Gastrectomy: A Case Report. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2019; 7:106-109. [PMID: 31080391 PMCID: PMC6503693 DOI: 10.4103/sjmms.sjmms_160_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Bariatric surgery has rapidly emerged as a modality for managing morbid obesity; however, despite being considered safe, some complications do exist. Formation of a gastrobronchial fistula is a rare complication of laparoscopic sleeve gastrectomy that is associated with high morbidity and mortality. Nowadays, novel endoscopic techniques have widely been adopted in the management of such cases, as they provide minimally invasive options that decrease the morbidity and mortality. Here, the author presents a report of a middle-aged, morbidly obese male who had previously undergone laparoscopic sleeve gastrectomy and returned with a 3-month history of productive cough. On upper gastrointestinal series, the patient was found to have a fistula communicating the stomach to the bronchial tree of his left lung (gastrobronchial fistula). He was treated with endoscopic fistula closure using an over-the-scope clip and a fully-covered Niti-S metallic stent. After this treatment, the patient's symptoms improved dramatically, and the stent was successfully removed 12 weeks later. This report highlights the management of a patient with gastrobronchial fistula formation following laparoscopic sleeve gastrectomy as well as provides a literature review of using combined endoscopic management to treat gastrobronchial fistulas.
Collapse
Affiliation(s)
- Abed Al-Lehibi
- Department of Gastroenterology, King Fahad Medical City, Riyadh, Saudi Arabia
| |
Collapse
|
23
|
Nedelcu M, Manos T, Gagner M, Eddbali I, Ahmed A, Noel P. Cost analysis of leak after sleeve gastrectomy. Surg Endosc 2017; 31:4446-4450. [PMID: 28378080 DOI: 10.1007/s00464-017-5495-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 02/28/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Leaks after laparoscopic sleeve gastrectomy (LSG) are serious complications of this procedure. The objective of the present study was to evaluate the costs of leaks after LSG. SETTING Private hospital, France. METHODS A retrospective analysis was conducted on a prospective cohort of 2012 cases of LSG between September 2005 and December 2014. Data were collected on all diagnostic and therapeutic measures necessary to manage leaks, ward, and intensive care unit (ICU) length of stay. Additional outpatient care was also analyzed. RESULTS Twenty cases (0.99%) of gastric leak were recorded. Fifteen patients had available data for cost analysis. Of these, 13 patients were women (86.7%) with a mean age of 41.4 years (range 22-61) and mean BMI of 43.2 kg/m2 (range 34.8-57.1). The leaks occurred after 7.4 days (±2.3) postoperatively. Only one gastric leak was recorded for the last 800 cases in which absorbable staple line reinforcement was used. Mean intra-hospital cost was 34398 € (range 7543-91,632 €). Prolonged hospitalization in ICU accounted for the majority of hospital costs (58.9%). Mean additional outpatient costs for leaks were 41,284 € (range 14,148-75,684€). CONCLUSIONS Leaks after LSG are an expensive complication. It is therefore important to take all necessary measures to reduce their incidence. Our data should be considered when analyzing the cost effectiveness of staple line reinforcement usage.
Collapse
Affiliation(s)
- Marius Nedelcu
- Centre Hospitalier Universitaire Montpellier, University Hospital of Montpellier, Montpellier, France. .,Digestive Surgery, University Hospital of Montpellier, 80, Avenue Augustin Fliche, 34295, Montpellier, France.
| | | | | | - Imane Eddbali
- The American Surgecenter, Abu Dhabi, United Arab Emirates
| | - Ahmed Ahmed
- St Mary's Hospital, Imperial College London, London, UK
| | - Patrick Noel
- The American Surgecenter, Abu Dhabi, United Arab Emirates
| |
Collapse
|
24
|
Garofalo F, Noreau-Nguyen M, Denis R, Atlas H, Garneau P, Pescarus R. Evolution of endoscopic treatment of sleeve gastrectomy leaks: from partially covered to long, fully covered stents. Surg Obes Relat Dis 2016; 13:925-932. [PMID: 28237561 DOI: 10.1016/j.soard.2016.12.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 12/05/2016] [Accepted: 12/16/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (SG) has become a widely accepted option in the treatment of morbid obesity. Gastric leaks after SG occur in .9%-2.2% of the patients, mostly at the gastroesophageal junction. The current treatment algorithm includes drainage, antibiotics, nutritional support, and endoluminal control. OBJECTIVES Our hypothesis is that long, fully covered stents represent a safe, effective solution for SG leaks. SETTING University hospital. METHODS A retrospective analysis of our prospectively collected bariatric database was performed between June 2014 and May 2016. We included all patients treated for leaks after SG. Endoscopic treatment included partially covered metallic stent (Wallstent, Boston Scientific, Galway, Ireland), fully covered stent (Mega stent, Taewoong Medical Industries, Gyeonggi-do, South Korea), over-the-scope clip (Ovesco Endoscopy, Tubingen, Germany), and internal pigtail drainage. RESULTS A total of 872 SGs were performed. Overall, 10 of 872 patients (1.1%) developed a gastric leak. One patient was an outside referral. The 11 patients underwent endoscopic treatment accompanied by either percutaneous or laparoscopic abscess drainage. Endoscopic fistula closure at the gastroesophageal junction was achieved in 10 of 11 cases and the average time for closure was 9.9 (range: 4-24) weeks. One patient developed a second leak in the antrum, treated by subtotal gastrectomy. Overall, treatment with Wallstent failed in 3 of 5 patients, and these patients were eventually successfully treated with a Mega stent. The initial use of long, fully covered stents was successful in 5 of 6 cases. CONCLUSION Long, fully covered stents appear to be a good alternative to traditional stents either as primary treatment or after failure of other endoscopic treatments.
Collapse
Affiliation(s)
- Fabio Garofalo
- Département de Chirurgie, Division de Chirurgie Bariatrique, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Canada
| | - Maxime Noreau-Nguyen
- Département de Chirurgie, Division de Chirurgie Bariatrique, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Canada
| | - Ronald Denis
- Département de Chirurgie, Division de Chirurgie Bariatrique, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Canada
| | - Henri Atlas
- Département de Chirurgie, Division de Chirurgie Bariatrique, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Canada
| | - Pierre Garneau
- Département de Chirurgie, Division de Chirurgie Bariatrique, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Canada
| | - Radu Pescarus
- Département de Chirurgie, Division de Chirurgie Bariatrique, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Canada.
| |
Collapse
|
25
|
Five-year results of laparoscopic sleeve gastrectomy for the treatment of severe obesity. Surg Endosc 2016; 31:3251-3257. [DOI: 10.1007/s00464-016-5355-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 11/12/2016] [Indexed: 12/15/2022]
|
26
|
Open total gastrectomy with Roux-en-Y reconstruction for a chronic fistula after sleeve gastrectomy. Surg Obes Relat Dis 2016; 12:1803-1808. [DOI: 10.1016/j.soard.2016.03.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 03/09/2016] [Accepted: 03/13/2016] [Indexed: 01/27/2023]
|
27
|
Genser L, Pattou F, Caiazzo R. Splenic abscess with portal venous gas caused by intrasplenic migration of an endoscopic double pigtail drain as a treatment of post–sleeve gastrectomy fistula. Surg Obes Relat Dis 2016; 12:e1-3. [DOI: 10.1016/j.soard.2015.07.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 07/23/2015] [Accepted: 07/25/2015] [Indexed: 11/30/2022]
|
28
|
Rebibo L, Bartoli E, Dhahri A, Cosse C, Robert B, Brazier F, Pequignot A, Hakim S, Yzet T, Delcenserie R, Dupont H, Regimbeau JM. Persistent gastric fistula after sleeve gastrectomy: an analysis of the time between discovery and reoperation. Surg Obes Relat Dis 2016; 12:84-93. [DOI: 10.1016/j.soard.2015.04.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 04/12/2015] [Accepted: 04/19/2015] [Indexed: 01/08/2023]
|
29
|
Nedelcu M, Manos T, Cotirlet A, Noel P, Gagner M. Outcome of leaks after sleeve gastrectomy based on a new algorithm adressing leak size and gastric stenosis. Obes Surg 2015; 25:559-63. [PMID: 25589019 DOI: 10.1007/s11695-014-1561-y] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Leaks after laparoscopic sleeve gastrectomy (LSG) are estimated to be the most serious complication of this procedure due to difficult healing process using non-standardized endoscopic approaches. Initially, endoscopic management recommended the use of stents. METHODS A total of 19 patients received endoscopic treatment after LSG to manage leaks. The leak was classified depending on the primary orifice's size (more or less than 10 mm) or on the presence of gastric stenosis. The primary aim was to develop a therapeutic algorithm in order to reduce the number of endoscopic procedures. RESULTS The average number of endoscopic procedures was 2.8 (range 2-5) in group A (leak size <10 mm) and 4 (range 3-7) in group B (leak size >10 mm). Two out of 13 patients had stent migration (15.4 %) and required an additional procedure, one in group A and another in group B. The average duration to achieve complete healing was 3.4 months (range 2-14 months), 2.8 months for group A and 3.9 months for group B. CONCLUSIONS Limited data can be found in the literature on leaks after LSG. A new algorithm based on leak size permits standardization of endoscopic management and reduces procedures after LSG.
Collapse
Affiliation(s)
- Marius Nedelcu
- Digestive and Endocrine Surgery, University Hospital of Strasbourg, 1, Place de l'Hôpital, 67091, Strasbourg, France,
| | | | | | | | | |
Collapse
|
30
|
Weiner S, Heidsieck T, Chiappetta S, Stier C, Weiner RA. [Anastomosis and suture insufficiency after interventions for bariatric and metabolic surgery]. Chirurg 2015; 86:824-32. [PMID: 26296509 DOI: 10.1007/s00104-015-0071-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKROUND Metabolic surgery is internationally well-established for the treatment of obesity and its comorbidities. The numbers of procedures performed is steadily increasing. The results of surgery are superior in comparison to conservative treatment options regarding weight loss and resolution of comorbidities. The insufficiency of suture lines is a well-known and feared complication in the stapling procedures and is associated with an increased morbidity as well as mortality, especially in super obese patients. MATERIAL AND METHODS The current literature was reviewed and the results are reported within the context of own experience. RESULTS The most severe complications are staple line leakage after sleeve gastrectomy, leakage of anastomoses after bypass procedures and duodenal stump insufficiency. For the treatment of sleeve leakage various endoscopic procedures, such as over the scope (OTS) clips, stents and endoluminal vacuum therapy are available. Surgical revision, such as oversuturing, drainage and redo surgery are well-established. The management of all other complications is mainly by surgical intervention. Intraoperative standardization of procedures and knowledge of the physical foundations are essential for the prevention of leakage. Several preventive methods are available but randomized controlled trials are missing. CONCLUSION The therapy of leakages in the field of bariatric surgery is an interdisciplinary approach and dependent on the available resources in the treating hospital. The data reported show good results but the different reports published are inconsistent. Leakages often do not occur in the immediate postoperative period but in the sense of a long-term complication; therefore standardization of procedures and follow-up as well as complication management is mandatory. Randomized controlled studies must be promoted.
Collapse
Affiliation(s)
- S Weiner
- Adipositaszentrum, Chirurgische Klinik, Krankenhaus Nordwest, Steinbacher Hohl 2-26, 60488, Frankfurt am Main, Deutschland,
| | | | | | | | | |
Collapse
|
31
|
Nguyen D, Dip F, Hendricks L, Lo Menzo E, Szomstein S, Rosenthal R. The Surgical Management of Complex Fistulas After Sleeve Gastrectomy. Obes Surg 2015. [DOI: 10.1007/s11695-015-1788-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
|
32
|
Kim J, Azagury D, Eisenberg D, DeMaria E, Campos GM. ASMBS position statement on prevention, detection, and treatment of gastrointestinal leak after gastric bypass and sleeve gastrectomy, including the roles of imaging, surgical exploration, and nonoperative management. Surg Obes Relat Dis 2015; 11:739-48. [DOI: 10.1016/j.soard.2015.05.001] [Citation(s) in RCA: 141] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
33
|
Guillaud A, Moszkowicz D, Nedelcu M, Caballero-Caballero A, Rebibo L, Reche F, Abba J, Arvieux C. Gastrobronchial Fistula: A Serious Complication of Sleeve Gastrectomy. Results of a French Multicentric Study. Obes Surg 2015; 25:2352-9. [DOI: 10.1007/s11695-015-1702-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
|
34
|
Laparoscopic total gastrectomy as an alternative treatment to postsleeve chronic fistula. Surg Obes Relat Dis 2015; 11:552-6. [DOI: 10.1016/j.soard.2014.10.021] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 09/30/2014] [Accepted: 10/26/2014] [Indexed: 02/07/2023]
|
35
|
Safadi BY, Shamseddine G, Elias E, Alami RS. Definitive surgical management of staple line leak after sleeve gastrectomy. Surg Obes Relat Dis 2015; 11:1037-43. [PMID: 26143296 DOI: 10.1016/j.soard.2015.04.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 04/08/2015] [Accepted: 04/27/2015] [Indexed: 01/24/2023]
Abstract
BACKGROUND Sleeve gastrectomy (SG) has become a widely adopted bariatric surgical procedure. The most serious complication is staple line leak (SLL), which is potentially life threatening and, in some patients, becomes chronic and difficult to manage. Definitive surgical management of SLL is effective but seldom published in the literature. OBJECTIVES This study aims to review the outcome of definitive surgical management of SLL after SG, looking at short-term and long-term results. SETTING Single surgeon experience based at a tertiary university hospital in Beirut, Lebanon. METHODS Retrospective review of records of patients with SLL who underwent definitive surgical treatment by the senior author (B.Y.S.) from January 2008 until December 2013. RESULTS Ten patients (50% female) underwent definitive surgical repair during the study period. The mean age, weight, and body mass index at the time of SG were 35 years, 121 kg, and 41.5 kg/m(2), respectively. Most leaks (90%) were at the esophagogastric junction. All underwent multiple operative, endoscopic, or radiologic procedures before definitive surgical repair. Methods of definitive repair included open Roux-en-Y (RY) esophagojejunostomy (70%), open RY gastric bypass (10%), laparoscopic RY esophagojejunostomy (10%), and one laparoscopic RY fistulojejunostomy (10%). Six patients (60%) underwent definitive surgical treatment because of chronic SLL, on average, 26 weeks after leak detection (range 13-39 wk). The other 4 underwent repair earlier, on average 4 weeks after leak detection (1-7 wk). There were no mortalities, and all patients healed without residual leak. Perioperative morbidity developed in 1 of 6 (17%) patients who underwent delayed repair and in 75% of patients who underwent repair early. Patients who underwent early repair were heavier (body mass index 40.5 kg/m(2) versus 30 kg/m(2)) and nutritionally more deplete (albumin 26.7 g/L versus 39.2 g/L). All patients are well at a mean follow-up of 21.6 months (7.5-55.9 mo) with an average percentage excess weight loss of 74% (57%-120%). CONCLUSIONS Definitive surgical management of SLL was uniformly effective with acceptable morbidity. It is indicated in patients with chronic persistent fistula beyond 12 weeks, provided patients are kept in good nutritional state. Some select patients may benefit from this approach in the early phases, but the surgical risks are higher.
Collapse
Affiliation(s)
- Bassem Y Safadi
- American University of Beirut Medical Center, Cairo Street, Beirut, Lebanon.
| | | | - Elias Elias
- American University of Beirut Medical Center, Cairo Street, Beirut, Lebanon
| | - Ramzi S Alami
- American University of Beirut Medical Center, Cairo Street, Beirut, Lebanon
| |
Collapse
|
36
|
Genc V, Sulaimanov M, Kırımker EO, Sevim Y, Ensari C. The use of porcine acellular dermal matrix for management of gastrocutaneous fistula after laparoscopic sleeve gastrectomy. J Laparoendosc Adv Surg Tech A 2015; 25:401-5. [PMID: 25918952 DOI: 10.1089/lap.2014.0530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Sleeve gastrectomy is an effective and single stand-alone surgical procedure for the treatment of morbid obesity. One of the most frequent and serious complications of this procedure is staple-line leak. It can usually be treated with self-expandable stents. If this process results in failure and gastrocutaneous fistula occurs, a challenging period starts for the patient and the surgeon. We describe a new, relatively simple and quick endoscopic technique for closing a chronic gastrocutaneous fistula. A plug prepared with porcine acellular dermal matrix was used for this purpose. Gastrocutaneous fistula following an obesity surgery can be successfully treated endoscopically with this technique. This method can prevent the need for aggressive reconstructive surgery following a gastrocutaneous fistula and can prompt rapid improvement while decreasing the average hospital stay for this condition.
Collapse
Affiliation(s)
- Volkan Genc
- 1 Department of Surgery, Ankara University School of Medicine , Sıhhiye, Ankara, Turkey
| | | | | | | | | |
Collapse
|
37
|
Casella G, Soricelli E, Genco A, Ferrazza G, Basso N, Redler A. Use of platelet-rich plasma to reinforce the staple line during laparoscopic sleeve gastrectomy: feasibility study and preliminary outcome. J Laparoendosc Adv Surg Tech A 2015; 25:222-7. [PMID: 25668681 DOI: 10.1089/lap.2014.0329] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
AIMS Reinforcement of the staple line is one of the most debated technical aspects concerning laparoscopic sleeve gastrectomy (LSG). Different buttressing methods have been proposed and demonstrated to be effective in reducing the incidence of staple line bleeding, although data concerning their effort on staple line leakage are not consistent. The aim of this study was to ascertain the technical feasibility and to report the preliminary outcomes of laparoscopic use of platelet-rich plasma (PRP) to reinforce the staple line during sleeve gastrectomy. PATIENTS AND METHODS From March 2012 to May 2012, 20 patients were prospectively enrolled (10 females; mean age, 44.6 ± 11 years; mean body mass index, 42.3 ± 5.45 kg/m(2)). Type 2 diabetes mellitus was present in 4 patients, obstructive sleep apnea syndrome in 3, and hypertension in 6. LSG was performed using a 48-French bougie and gold cartridges; reinforcement of the staple lines with buttressed materials or oversewing the suture was performed excluding the last cranial cartridge. PRP was prepared by separating the platelets from autologous blood withdrawn on the same day of surgery, in order to obtain a membrane with cylindrical shape (2×5 cm) formed by fibrin and active platelets. The membrane is introduced through the 10-mm trocar and placed at the upper portion of the staple line. The overall cost for the preparation of PRP is about €15. RESULTS No intraoperative complications and conversions have been recorded during the surgical procedures. No deaths occurred. The mean operative time was 85 ± 31 minutes, which was not significantly increased compared with the operative time of the surgeon's overall personal series (750 cases). At 12 months of follow-up the abdominal ultrasound was negative for collections, and upper contrast showed no images indicating gastric leaks. In no case did PRP induce symptoms of rejection, infection, or adverse events. CONCLUSIONS The use of PRP during LSG is feasible, does not increase significantly the operative time, does not require any special devices, and is cost effective. A larger cohort of patients is needed to ascertain the potential effectiveness of PRP in the prevention of postoperative staple line complications.
Collapse
Affiliation(s)
- Giovanni Casella
- 1 Department of Surgical Sciences, "Sapienza" University of Rome , Rome, Italy
| | | | | | | | | | | |
Collapse
|
38
|
Abstract
BACKGROUND The Magenstrasse and Mill (M&M) procedure is a vertical gastroplasty creating a tubular pouch extending from the cardia to the antrum. This "incomplete sleeve" avoids gastric resection or band placement. In this paper, we report our experience of the laparoscopic approach of the technique in a selected obese population excluding prominent grazer and/or sweet eaters. MATERIAL AND METHODS One hundred patients (39 males, 61 females) underwent the procedure in a prospective trial. Mean age was 40 years (range 18-68). Mean preoperative BMI was 43.2 kg/m(2) (range 35-62). RESULTS The procedure was performed by laparoscopy starting with the creation of a circular opening at the junction of antrum and corpus followed by a vertical stapling to the angle of Hiss. Mean duration of the procedure was 67 (range 40-122) min. No intraoperative complication occurred. Mean hospital stay (SD) was 2.5 (0.9) days. The single postoperative complication consisted in a mild stenosis that responded to endoscopic dilatation. After a mean follow-up of 15 months (range 9-24), mean percentage of excess body weight loss (SD) was 48(14), 59(18) and 68(24)%, respectively at 3, 6, and 12 months. Quality of life appeared satisfactory with a low incidence of gastroesophageal reflux. The procedure was associated with improvement or resolution of diabetes, arterial hypertension, and dyslipemia at 1 year. CONCLUSIONS Our experience demonstrated that the M&M procedure could be performed safely laparoscopically. The satisfactory results on weight loss, obesity-associated mordities, and quality of life will need to be confirmed on longer follow-up.
Collapse
|
39
|
Kassir R, Blanc P, Tibalbo LMB, Breton C, Lointier P. C-Reactive protein and procalcitonin for the early detection of postoperative complications after sleeve gastrectomy: preliminary study in 97 patients. Surg Endosc 2014; 29:1439-44. [DOI: 10.1007/s00464-014-3821-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2014] [Accepted: 08/08/2014] [Indexed: 11/28/2022]
|
40
|
Kumar Pallati P. Comment on: the early use of Roux limb as surgical treatment for proximal postsleeve gastrectomy leaks. Surg Obes Relat Dis 2013; 10:111. [PMID: 24355325 DOI: 10.1016/j.soard.2013.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 09/28/2013] [Accepted: 09/30/2013] [Indexed: 10/26/2022]
|