Spyropoulos C, Argentou MI, Petsas T, et al. Management of gastrointestinal leaks after surgery for clinically severe obesity

Department of Surgery, University Hospital of Patras, Rion, Greece.
Surgery for Obesity and Related Diseases (Impact Factor: 4.07). 04/2011; 8(5):609-15. DOI: 10.1016/j.soard.2011.04.222
Source: PubMed


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: To analyse the causes for claims due to alleged malpractice in bariatric surgery and the results of the legal process. A review was carried out on the case files of claims for damages as a result of bariatric surgery presented to the Professional Liability Department of the Catalonian Medical Colleges Council from 1992 to 2009. The claims rate was calculated using a survey of bariatric surgeons. A total of 49 cases were analysed, which represented 0.6% of the patients operated on. The patient died in 23 (47%) of the cases, 14% were left with serious after effects, 18% had mild after effects, and 21% made a complete recovery. The most frequent causes of death were peritonitis due to suture dehiscence (48%), and respiratory complications (17.4%). Retrospectively, malpractice was considered to have occurred in 10 (20%) of the sued cases due to lack of an adequate informed consent document, delay in recognising a complication, or an error in interpretation, or treatment of the complication. The doctor sued was convicted in 10 of the cases, 3 in a criminal court, and 7 in a civil court. There was acquittal in 19 cases, an out-of court settlement with payment of compensation in 4, withdrawal of the claim in 4, and judgement or sentence is still pending in 12 cases. The study showed a relatively low rate of claims for complications associated with bariatric surgery. The number of convictions was relatively high. The early detection of surgical complications is essential in order to reduce legal claims associated with bariatric surgery.
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    ABSTRACT: BACKGROUND: Gastric bypass is one of the most common operations for morbid obesity. One of the most feared complications is a leak, most commonly encountered in the gastrojejunal anastomosis (GJA), leading to significant morbidity and increased costs. Our objective was to evaluate the effectiveness of stenting leaks in the GJA. The setting was a university hospital in Stockholm, Sweden. METHODS: We performed a retrospective analysis of all gastric bypasses from January 2001 to August 2011, with special reference to the treatment of leaks in the GJA. RESULTS: A postoperative leak in the GJA occurred in 69 of 2214 patients. The risk was greater with open surgery and revisional surgery. The risk was also greater with age >50 years but not with a body mass index >50 kg/m(2). There was no mortality. In the later part of the series, stents were used, with a stent time of 2 weeks. The migration rate was 23%, and need for restenting was 20%. CONCLUSION: It is safe and advantageous to use stents in the treatment of leaks at the GJA. Patients can be on oral nutrition and oral medication, reducing the need for in-hospital care.
    Full-text · Article · Mar 2012 · Surgery for Obesity and Related Diseases
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    ABSTRACT: Background Sleeve gastrectomy is now a frequently performed bariatric procedure for severely obese patients and may have the lowest frequency of short-term or long-term complications. The aim of this study is to describe our experience in managing chronic proximal leaks with a proximal gastrectomy and Roux-en-Y esophagojejunostomy (PGEJ). Methods A retrospective review was performed of all patients having proximal chronic staple-line disruptions (CSLD) after undergoing laparoscopic sleeve gastrectomy. Results Fifteen patients had proximal CSLD and were treated with PGEJ. There was 1 (6.6%) releak in this group, which resolved with nonoperative treatment. Other postoperative morbidities in this series included partial small bowel obstruction (n = 1) and subhepatic bile collection (n = 1), both of which resolved without operative intervention. Conclusion PGEJ appears to be a safe and effective procedure for chronic staple-line disruptions after sleeve gastrectomy.
    No preview · Article · Jan 2013 · Surgery for Obesity and Related Diseases
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