1. I Reinterventi in Urgenza Dopo Chirurgia Gastrica
V. Fiscon
G. Portale
Chirurgia Generale Cittadella
-PADOVA-

2. ‘’Revisional Surgery After Gastrectomy for Gastric Cancer’’
L’elenco semplice delle complicanze e i relativi interventi chirurgici e non chirurgici per correggerli li conosciamo.
Stenosi : stricture ( sbagliato !)
Etoh T et al, Surg Laparosc Endosc Percutan Tech 2010

3. Post-operative bleeding
‘’Definition and Classification of Complications of Gastrectomy for Gastric Cancer Based on the Accordion Severity Grading System’’
Post-operative bleeding
Decrease in Hb >1g/dL in 24 hrs + blood loss drainage or
hematemesis or melena
Esophageal anastomotic leak --- Duodenal stump fistula
Luminal content detected in drains or at the wound site
Post-operative pancreatic fistula
Dark-brown drainage fluid with amylase >3 times n.v.
Chyle leak
Milky fluid in drains >200ml/day with triglyceride lev >110 mg/dL
Wound infection
Ileus
Mi è sembrato particolarmente interessante l’idea di qs autore coreano di classificarle secondo la gravità.
Ho poi cercato di analizzare il problema dal punto di vista del clinico: quando intervenire chirurgicamente? Quando affidare i propri “problemi” ad altri ( endoscopisti, radiologi, rianimatori ecc).
Jung M et al,
World J Surg 2012

4. ‘’Revisional Surgery After Gastrectomy for Gastric Cancer’’
REVIEW
Etoh T et al, Surg Laparosc Endosc Percutan Tech 2010

5. Post-operative Abdominal Bleeding
Sites:
Anastomosis (>self-limited)
Gastroduodenal artery
Small arteries branching off the middle colic artery
Short gastric vessels
>> Spleen (!)
Causes:
Incomplete closure of titanium clips (falls off post-op)
Heat of ultrasonic shears
Inadvertent traction on the spleen
Surgery
Emergency operation: % MORTALITY !

6. 2003-2013 1875 pts with D2 gastrectomy:
‘’Diagnosis and Treatment of Abdominal Arterial Bleeding After Radical Gastrectomy: Retrospective Analysis of 1875 Resections for Gastric Cancer’’
pts with D2 gastrectomy:
36 abdominal art. bleeding (1.9%); <24 hrs/>24 hrs: 6 (16.7%)/30 (83.3%) pts
Bleeding sites:
common hepatic a. and branches pts
splenic a pts
peripancreatic aa pts
other aa pts
undetermined pts
Treatment:
‘early’ relaparotomy → 16.7% mortality
‘late’ TAE/stent (13 pts); relaparotomy (16 pts); 1 acute
collapse (†) → 36.7% mortality
Sanguinamento precoce che si cura più frequentemente con una relaparotomia ha un 16% di Mortalità
Sanguinamento tardivo: 36%
TEA: trans-catheter arterial embolization
Yang J et al, J Gastrointest Surg 2016

7. ‘’Diagnosis and Treatment of Abdominal Arterial Bleeding After Radical Gastrectomy: Retrospective Analysis of 1875 Resections for Gastric Cancer’’
Yang J et al, J Gastrointest Surg 2016

8. Post-operative Anastomotic Bleeding
‘’Endoscopic Treatment and Risk Factors of Post-operative Anastomotic Bleeding After Gastrectomy for Cancer’’
Retrospective Korean single center study
2,021 pts: 1,613 subtotal total gastrx;
37% lap
7 pts anast. bleeding (0.3%)
Mean time before bleeding: 2.9 dd
Mean hosp stay after endoscopic tx: 8.4 dd
Kim K et al, Int J Surg 2012

9. Post-operative Anastomotic Bleeding
NO significant
predictive factor on m(x) analysis
Age/BMI/Comorbidity
Lap vs Open
Type gastrx
Type anastomosis
Manual vs. stapler
Kim K et al, Int J Surg 2012

10. Anastomotic Leakage (5-8%)
Peritoneal signs (pain, fever, etc) with/out Rx confirmation
Most leaks are minor (!)
Antibiotic therapy
Percutaneous drainage
Fully-covered self expanding metals stent (SEMS) to help sealing the defect
Anastomotic repair if conservative treatment fails
A parte gli antibiotici e il drenaggio percutaneo dal punto di vista operativo abbiamo l’intervento che se fatto precocemente con reperimento di stoffa buona si può proporre una chiusura di prima intenzione.
Di fronte a una anastomosi “povera”, “flaccida”, con tessuto flogistico ecc  toilette, necrosectomia, raramente rifacimento anastomosi.
In questi ultimi anni SEMS = SELF (AUTO) ESPANDING (espandibile), STENT METALLICO
Anast. site ‘good’ PRIMARY CLOSURE
Anast. site ‘poor’ Revision/resect. remnant

11. - 24 EJ anastomosis, 12 mediastinal + 12 abdominal
‘’Covered Self-expanding Stent Treatment for Anastomotic Leakage: Outcomes in Esophagogastric and Esophagojejunal Anastomoses’’
pts: - 11 EG anastomosis
- 24 EJ anastomosis, 12 mediastinal + 12 abdominal
[19 first treat. + 5 after surgical failure] + 1 surg ok
EJ pts: 16 one stent; 6 two stents; 2 three stents
Total dd of stent treatment: 23 mediast, 25 abdom
Total dd of hospitalization: 50 mediast, 53 abdom
Sealing rates: 92% EJ mediastinal; 67% EJ abdominal
Complications: dislocation (6/24, 25%), bleeding (2/24, 8.3%),
perforation (3/24, 12.5%), stenosis (3/24, 12.5%)
35 Pz; prendendo in considerazione l’esofago-digiuno : 19 stent messi come I° trattamento, 5 dopo fallimento della chirurgia
Sealing rates: tasso di guarigione 92% le mediastiniche, 67% le addominali. Queste ultime solo il 33% andavano bene dopo il I° stent
Discreta % di complicanze
Hoeppner et al, Surg Endosc 2014

12. 2002-2013 27 pts: *13 SEMS; 14 NSET ≈80% ≤2cm; all <70% circumf.
‘’Self-expanding Metal Stent or Nonstent Endoscopic Therapy: Which is Better for Anastomotic Leaks After Total Gastrectomy?’’
pts: *13 SEMS; 14 NSET ≈80% ≤2cm; all <70% circumf.
Tanto che qualcuno ha cominciato a chiedersi se lo stent sia la sola soluzione; 27 pz in 11 aa. 13 con stent 14 con NONSTENT
*There were NO NSET-related complications*
*SEMS: self expanding metal stents; NSET: non stent endoscopic therapy
Shim CN al, Surg Endosc 2014

14. ‘’Endoscopic Management of Anastomotic Leakage After Gastrectomy
for Gastric Cancer: How Efficacious is it?’’
5249 pts radical total/subtotal gastrectomy: 33 anastomotic leakage
Kim YJ al, Scand J Gastroenterol 2013

15. ‘’Endoscopic Management of Anastomotic Leakage After Gastrectomy
for Gastric Cancer: How Efficacious is it?’’
COME MESSAGGIO FINALE PER IL MANAGEMENT DEL LEAK ANASTOMOTICO: diagnosi più precoce possibile e avere una misura del difetto per scegliere la migliore terapia
The size of the tissue defect was the only factor significantly related to complete/incomplete/failed closure
Kim YJ al, Scand J Gastroenterol 2013

16. Duodenal Stump Fistula: causes
Intraoperatively neglected duodenal wall injury by coagulation or ultrasonic device
Duodenal stump under pressure for obstruction/malrotation of the J-J anastomosis or incorrect closure of the meso

17. Duodenal Stump Fistula: treatment strategies
Surgical procedures:
Duodenostomy
Roux-en-Y duodeno-jejunostomy
Rectus abdominis muscle flap
Percutaneous approach:
Abscess drainage
Transhepatic biliary drainage
Fistula obliteration by cyanoacrylate

18. Duodenal Stump Fistula: treatment strategies
Further.....
- Enteral and/or total parenteral nutrition
to allow a faster fistula healing and a lower morbidity rate
- Somatostatin (and analogues)
to reduce fistula output and shorten healing times

19. ‘’Duodenal Fistula After Elective Gastrectomy for Malignant Disease’’
Retrospective Italian multicenter study
11 centers,
3,785 pts (1,613 total + 2,172 sub-total); 21 cases lap or video-assisted
68 DFs (1.6%), mortality rate 16%
age; serum albumin
Median time DF onset: day 7 (0-22)
Median daily output: 290 ml (40-2,200)
Healing rate 84% after a median of 19 dd (1-1,000)
DF onset/daily output did NOT affect DF time to healing or mortality
Cozzaglio L et al, J Gastrointest Surg 2010

20. Treatment strategies Surgery: 26 sepsis 1 failure to heal 31%
Peritoneal drainage
Duodenal suture
Tube duodenostomy
(1) R-en-Y
31%
Only : 20 (29%)
Problema con i numeri…
Somatostatin/Octreotide use: did NOT affect time of DF healing or outcome

21. ‘’Duodenal Stump Fistula After Gastric Surgery for Malignancies: a Retrospective Analysis of Risk Factors in a Single Center’’
: 1287 tot/sub-tot gastrectomies x k
Study design:
32 (2.5%) pts DSF (duodenal stump fistula)
506 pts UPC (uneventful post-op course)
268 pts OSC (other major surg. compl.)
Orsenigo E et al, Gastric Cancer 2014

22. Time trends STF: duodenal stump fistula
Start lap experience, without
routine manual owersewing
5.1%
2.3%
2.1%
2.1%
1.2%
STF: duodenal stump fistula
Orsenigo E et al, Gastric Cancer 2014

23. Univariate analysis of surgical variables
Orsenigo E et al, Gastric Cancer 2014

24. Multivariate analysis for DSF risk factors
Orsenigo E et al, Gastric Cancer 2014

25. Duodenal Stump Fistula
Mortality has decreased from 40% (early ‘80s) to 16%
Medical therapy is preferred to surgery as first treatment
Surgery is indicated to drain an abscess or to close defect large/persistent
Abdominal sepsis, bleeding or fistulas in neighboring organs mandate for surgery
NG tube suction and fasting has been abandoned in favor of enteral feeding (related to DF healing) 25

26. Post-operative Pancreatic Fistula 1,7-8%
Frequently followed by contamination pancreatic abscess
Bleeding from major arteries of abscess can be fatal
Pancreas-related complications >>> Major cause of mortality!
Pre-op risk factors: BMI, elderly age
If uncontrollable by conservative treatment, surgical drainage and irrigation is necessary
Etoh T et al, Surg Laparosc Endosc Percutan Tech 2010

27. Other complications… Bowel obstruction - band lysis
- segmental resection of intestine
- bypass surgery
Bowel perforation - primary closure of perforation site
+ bypass surgery
- segmental resection of intestine

28. ‘’Endoscopic Therapies for Leaks and Fistulas After Bariatric Surgery’’
Roux-en-Y by pass: 2-5%; Lap sleeve gastrx: 2-3%
Morbidity: 50% Mortality: 5-10%
Up to 50% (!) of pts may be ASYMPTOMATIC (!) with leaks detected only on X-rays
Swanstron L et al, Surg Innov 2014

29. closure in 90% of pts within 5 weeks
Early leak:
Drainage + antimicrobials + nil per os, nutritional (enteral/parenteral) support
closure in 90% of pts within 5 weeks
Surgical repair with drainage → similar results
But…if surgery is performed after 3 dd or with significant peritoneal contamination UNLIKELY to succeed (!)
STENTING: - Risk of migration (>40%; lower with covered stents, similar plastic vs.
metallic); repeated endoscopies; bleeding and erosions
- No consensus on timing of removal
GLUE (fibrin or cyanoacrylate): Frequently require multiple applications
CLIPS: Large ‘over the scope’
ENDOSCOPIC SUTURING: Anecdotal…
EARLY = PRECOCE= CHIRURGIA. O Drenaggio dopo toilette O Sutura chirurgica  RISULTATI SIMILI
SE CHIRURGIA DOPO 3 GG O CON PERITONITE: SCARSE PROBABILITà DI SUCCESSO
Swanstron L et al, Surg Innov 2014

30. ‘’Endoscopic Management of Bariatric Surgery Complications’’
[Bleeding]
< 48 hrs after: R-Y Gastric Bypass (1-5%); Sleeve Gastrectomy (0-9%)
Sites: Staple-line; jejuno-jejunostomy; gastric pouch
Management: Conservative tx in stable pts (fluid resusc + PPI + transf.)
Endoscopic therapy (epinephrine inj., thermal coag., clipping) but risk of perforation (!) at staple-line or anastomosis if thermal forces are applied
Reintervention (<20%)
Cai JX et al, Surg Laparosc Endosc Percutan Tech 2016

31. ‘’Costs of Leaks and Bleeding After Sleeve Gastrectomy’’
: 1260 pts SG
Additional cost: Leak Euro
Bleeding Euro
Bransen J et al, Obes Surg 2015

32. I Reinterventi in Urgenza Dopo Chirurgia Gastrica
CONCLUSIONI
Elevata morbilità e mortalità
Aggressività diagnostica
Diagnosi precoce
Approccio multidisciplinare
Abbiamo analizzato le varie complicanze post chir gastrica, tutte ad elevata morbilità e mortalità. Più che una aggressività chirurgica, bisogna avere una aggressività per fare una diagnosi precoce. La chirurgia non è la sola protagonista; entrano endoscopisti e radiologi. Capire quando affidare il paziente operato ad un altro specialisto è sempre un brutto momento…