Management of gastrointestinal leaks after surgery for clinically severe obesity
ABSTRACT Gastrointestinal leaks after bariatric surgery are the primary cause of serious morbidity and mortality nationwide. Enteric leaks can differ in severity, presentation, and management, depending on the type of bariatric surgery performed. Our objective was to describe the clinical presentation and treatment outcomes in patients who developed postoperative leaks at a university hospital bariatric referral center.
A retrospective observational study using descriptive statistics was conducted on data from 1499 bariatric operations performed at our institution from 1994 to 2010. The procedures included a variant of biliopancreatic diversion with long limb reconstruction (BPD-LL) in 820 patients (791 open and 29 laparoscopic), Roux-en-Y gastric bypass (RYGB) in 301 patients (105 open and 196 laparoscopic), and sleeve gastrectomy (SG) in 208 patients (5 open and 203 laparoscopic).
Of these patients, 30 (2%) developed a postoperative leak at a median of 18 days (range 2-32) postoperatively. The primary procedure was laparoscopic SG in 12 patients (5.8%), laparoscopic RYGB in 5 patients (1.6%), and BPD-LL (12 open and 1 laparoscopic) in 13 patients (1.6%). In all patients who underwent laparoscopic SG, the leak site was along the staple line. The gastrojejunal anastomosis was leaking in 4 (80%) and 12 (92.3%) patients in the RYGB and BPD-LL group, respectively. The enteroenteral anastomosis was leaking in 1 patient each in the RYGB and BPD-LL groups (20% and 7.7%, respectively). Three patients (10%; 2 from the BPD-LL group and 1 from the RYGB group) presented with generalized peritonitis and underwent emergency re-exploration; nonoperative treatment was successful in the remaining 27 patients (90%). Stent placement for persistent gastrocutaneous fistula was used in 9 patients (30%; 8 from the SG cohort and 1 from the BPD-LL group). The overall mortality rate was 3.3%.
In our experience, most leaks resulting from antiobesity surgery were successfully managed using nonoperative methods. Rapid management of gastrointestinal leaks using computed tomography-guided drainage and/or intraluminal stent placement could be the treatment of choice in selected patients.
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ABSTRACT: Sleeve gastrectomy is a bariatric surgical procedure that may result in particular morbidity or mortality due to gastric fistula in the proximal part of the gastric tube. Two theories are currently proposed to explain this specific leak location. The vascular theory attributes the leaks to reduced perfusion in the gastric tube, and the mechanical theory suggests the etiology as gastric tube hyper-pressure due to pyloric conservation. The aim of this study was to map the arterial gastric vascular supply on fresh cadavers after performing sleeve gastrectomy to evaluate the effect of vascular changes on gastric leakage. We performed sleeve gastrectomies on 11 cadaveric trunks with a detailed anatomical study of the gastric vascular supply after latex injection in the three branches arising from the celiac trunk. In 55 % of cases, the sleeve procedure changed the gastric vascular supply. In 9.1 %, it divided the three left gastric artery branches arising from the lesser curvature. Few changes were noted in the antrum or pylorus. This anatomical study demonstrates that the vascular supply of the proximal part of the gastric tube can be damaged by a sleeve procedure, which can sever one or more of the branches arising from the left gastric artery. Such weakness could be exacerbated by disparities in vascular supply. The uninterrupted vascular supply of the antrum and pylorus may explain the preferential localization of the fistula to the proximal part of the gastric tube.Obesity Surgery 04/2014; 24(10). DOI:10.1007/s11695-014-1256-4 · 3.74 Impact Factor
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ABSTRACT: Reoperative bariatric surgery has become a common practice in many bariatric surgery programs. There is currently little evidence-based guidance regarding specific indications and outcomes for reoperative bariatric surgery. A task force was convened to review the current evidence regarding reoperative bariatric surgery. The aim of the review was to identify procedure-specific indications and outcomes for reoperative procedures. Literature search was conducted to identify studies reporting indications for and outcomes after reoperative bariatric surgery. Specifically, operations to treat complications, failed weight loss, and weight regain were evaluated. Abstract and manuscript reviews were completed by the task force members to identify, grade, and categorize relevant studies. A total of 819 articles were identified in the initial search. After review for inclusion criteria and data quality, 175 articles were included in the systematic review and analysis. The majority of published studies are single center retrospective reviews. The evidence supporting reoperative surgery for acute and chronic complications is described. The evidence regarding reoperative surgery for failed weight loss and weight regain generally demonstrates improved weight loss and co-morbidity reduction after reintervention. Procedure-specific outcomes are described. Complication rates are generally reported to be higher after reoperative surgery compared to primary surgery. The indications and outcomes for reoperative bariatric surgery are procedure-specific but the current evidence does support additional treatment for persistent obesity, co-morbid disease, and complications.Surgery for Obesity and Related Diseases 02/2014; 10(5). DOI:10.1016/j.soard.2014.02.014 · 4.94 Impact Factor
Endoscopy 09/2013; 45 Suppl 2 UCTN:E267-8. DOI:10.1055/s-0033-1344569 · 5.20 Impact Factor