Presentation is loading. Please wait.

Presentation is loading. Please wait.

Dr.Mohammad Hayssam ElFawal MD.FACS Dr.Houssam Abtar. Chief Resident MEMA 11 th May 2013.

Similar presentations


Presentation on theme: "Dr.Mohammad Hayssam ElFawal MD.FACS Dr.Houssam Abtar. Chief Resident MEMA 11 th May 2013."— Presentation transcript:

1 Dr.Mohammad Hayssam ElFawal MD.FACS Dr.Houssam Abtar. Chief Resident MEMA 11 th May 2013

2 30 years old female, morbidly obese with BMI 42.5 (Wt 97kg, Ht 151cm) presented to MGH for elective laparoscopic sleeve gastrectomy. She is known to have DM II(on glucophage)

3 Patient underwent uneventful laparoscopic sleeve gastrectomy. Bleeding from staple line How would u control your staple line bleed? Day 1 post op she had an upper GI series performed and showed no leakage or obstruction.

4

5 UGI day one? Is it evidence based or a surgeon preference (I want to sleep!!!!)

6 Patient discharged home on Day 1 on liquid diet. Represented 2 days later with Lt upper quadrant. No nausea or vomiting. No Drains Who is draining routinely his sleeves? P/E: periumbilical and LUQ tenderness. no rebound or rigidity T:38.5 HR:110

7 CRPINRSGPTGGTAlk Phlipaseamyla se 7.81.2352111434048 U/AHctHbsegWBC Nl391393%12000

8

9

10

11 The Extravasation of contrast material through the wall of the gastric sleeve, free intra- abdominal contrast material, and free intra-abdominal gas, left sub diaphragmatic free pocket of air

12 NORMAL LEAKAGE

13 Laparoscopic exploration showed pus in the peritoneal cavity (LUQ) and methylene blue test showed leak approximately 10 cm from the pylorus at the staple line. Laparoscopic exploration

14

15

16

17 No consensus exists regarding the timing of this test; some authors perform it 1 day after the procedure, whereas others, routinely perform it 3 days after the procedure. The fact of the test being negative 3 days after surgery could give rise to a false sense of security since most leaks appear after the third day. A lot of centers stopped doing UGI series as a routine in the postoperative period. Obes Surg.Obes Surg. 2012 Jul;22(7):1039-43.Brockmeyer JR et al.Brockmeyer JR Upper gastrointestinal swallow study following bariatric surgery: institutional Dwight David Eisenhower Army Medical Center, 300 Hospital Rd, Fort Gordon, GA 30905, USA. review and review of the literature. UGI Series

18 Routine Abdominal Drains after Laparoscopic Sleeve Gastrectomy: A Retrospective Review of 353 Patients Konstantinos et al Obesity surgery.july 2011 353 sleeve Patients were enrolled in the study. Group A when an intraperitoneal drain was placed and Group B when not. Placement of drains does not facilitate detection of staple line, leak, abscess, or bleeding. Furthermore, they don't seem to eliminate the reoperation rates for these complications.

19 Distal leak is different from proximal leak The use of green stapler for the pylorus is preferable. Avoid the use of cautery on staple line. The routine use of UGI series and Drains is no longer a routine. Close and aggressive management may be the only chance to save your patients life.

20

21

22 Sleeve gastrectomy was initially conceived and first described in 1988 by Hess and Marceau as a restrictive component of the BPD–DS. In 1999, Gagner et al. performed LSG, which was considered a bridging procedure in super-morbidly obese patients to be followed by a second definitive procedure such as RYGB or BPD–DS.

23 The sleeve gastrectomy is now most commonly used as a stand alone operation performed laparoscopically.

24 Weight loss following LSG is achieved by both restriction and hormonal modulation. Firstly, reduction in stomach size with the sleeve resection restricts distention and increases the patients sensation of fullness (decreasing meal portion size). This restriction is further facilitated by the natural band effect of the intact pylorus which is maintained during the sleeve gastrectomy. Reduction in the hunger drive of patients that may be related to decreasing serum levels of ghrelin, a hormone produced mainly by P/D1 cells lining the fundus of the human stomach which stimulates hunger. A Review of Laparoscopic Sleeve Gastrectomy for Morbid Obesity Xinzhe Shi & Shahzeer Karmali & Arya M. Sharma & Daniel W. Birch OBES SURG (2010) 20:1171–1177

25 Inflammatory bowel disease. Severe bowel adhesions from previous surgery. The necessity to continue certain medications, (immunosuppressant or antiinflammatory agents). Patient refusal to undergo anatomic rearrangement of their intestinal anatomy or placement of an implanted device.

26 The stomach is reduced without major changes in continuity. preservation of the pylorus prevents dumping syndrome and might add to the restrictive component of LSG. There are no problems with malabsorption and nutritional deficiency as seen in BPD–DS. Minimal follow-up is required when compared with other well-established procedures such as LAGB and RYGB. Relative technical ease of performance compared to other bariatric procedures. Acceptable operative time. Low complication rate, (reports of average EWL of 51% to 83% at 1 year ) Improvement of comorbidities.

27 One hundred nine hospitals submitted data on 28,616 patients, from July, 2007 to September, 2010, which were included for this analysis.

28 First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410–422) LRYGB/ORYGBLSGLAGB 15.34 kg/m2 at 1- year 11.87 kg/m2 at 1- yea r 7.05kg/m2 at 1-year

29 First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410–422 ) The absolute reduction in BMI after the LSG is less than the weight loss after the LRYGB/ORYGB but greater than the weight loss after the LAGB.

30 A Review of Laparoscopic Sleeve Gastrectomy for Morbid Obesity Xinzhe Shi & Shahzeer Karmali & Arya M. Sharma & Daniel W. Birch OBES SURG (2010) 20:1171–1177

31

32 First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410–422) 55% have their diabetes resolve or improve 1 year after the LSG, compared to 44% for the LAGB and 83% for the LRYGB.

33 First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410–422) For patients who are hypertensive at baseline, 68% have their hypertension resolve or improve 1 year after the LSG, compared to 44% for the LAGB and 79% for the LRYGB.

34 First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410–422) LRYGB/ORYGBLSGLAGB 70% at 1-year50% at 1-year64% at 1-year Resolve d

35 First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410–422) LRYGB/ORYGBLSGLAGB 66% at 1-year62% at 1-year38% at 1-year Resolve d

36 First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410–422 ) LRYGB/ORYGBLSGLAGB 66% at 1-year35% at 1-year33% at 1-year Resolve d

37 Resolution/improvement of comorbidities was 84% for diabetes mellitus, 49.99% for hypertension, 90% for asthma, 90.74% for obstructive sleep apnea, and 45.92% for GERD.

38 A Review of Laparoscopic Sleeve Gastrectomy for Morbid Obesity Xinzhe Shi & Shahzeer Karmali & Arya M. Sharma & Daniel W. Birch OBES SURG (2010) 20:1171–1177

39 First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410–422) Thirty-day morbidity rate for LSG (5.61%) is statistically higher than the LAGB rate (1.44%), however this is comparable to the LRYGB rate (5.91%).

40 First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410–422) that the mortality rate of the LSG (0.11% at 30 days, 0.21% at 1 year) is positioned between the LAGB (0.05% and 0.08%) and the LRYGB (0.14% and 0.34).

41 First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410–422) Reoperation/intervention rates for the LSG (2.97%) are positioned between the LAGB (0.92%) and the LRYGB (5.02%), which is significant on both univariate and multivariate analyses.

42 First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410–422

43 A Review of Laparoscopic Sleeve Gastrectomy for Morbid Obesity Xinzhe Shi & Shahzeer Karmali & Arya M. Sharma & Daniel W. Birch OBES SURG (2010) 20:1171–1177

44 Gastric Leak After Laparoscopic Sleeve Gastrectomy Manuel Ferrer Márquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &María del Mar Rico Morales & Jose Miguel García Díez & Ricardo Belda Poujoulet OBES SURG (2010) 20:1306–1311

45

46 Predicting Risk for Serious Complications With Bariatric Surgery.Results from the Michigan Bariatric Surgery Collaborative Jonathan F. Finks, MD, Kerry L. Kole, DO, et al. for the Michigan Bariatric Surgery Collaborative, from the Center for Healthcare Outcomes and Policy Ann Surg 2011;254:633–640 )

47 In conclusion, data from the ACS-BSCN accredited hospitals show that the LSG seems to be a safe and effective procedure for the treatment of obesity and obesity related comorbidities. At 1 year, complication rates and reduction in weight and weight- related illnesses for the LSG seem to fall between the LAGB (which has relatively fewer short term complications, but less reduction in weight and weight-related diseases), and the LRYGB (which seems to have relatively more complications, and to be more effective ). First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410–422)

48 According to the UK Surgical Infection Study Group, a gastric leak was defined as the leak of luminal contents from a surgical joint between two hollow viscera. Gastrointestinal leak in the staple line lead to distribution of luminal content around the organ.

49 Determining the time of appearance, leaks were classified according to Csendes et al. in leaks being detected 1 to 3 days after surgery (postoperative days (POD) 3), those being detected 4 to 7 days after surgery (POD 4–7), and those appearing more than 7 days after surgery (POD8). Classification of leaks

50 We have proposed a classification of the leaks based on three parameters: time of appearance after surgery, magnitude or clinical severity, and location of the leaks. -Thus, early leaks were classified as those that appeared 1 to 4 days after surgery. - Intermediate leaks those that appeared 5 to 9 days after surgery. - late leaks those that appeared 10 or more days after surgery. Management of Leaks After Laparoscopic Sleeve Gastrectomy in Patients with Obesity Attila Csendes & Italo Braghetto & Paula León & Ana María Burgos J Gastrointest Surg (2010) 14:1343–1348 Classification of leaks

51 Management of Leaks After Laparoscopic Sleeve Gastrectomy in Patients with Obesity Attila Csendes & Italo Braghetto & Paula León & Ana María Burgos J Gastrointest Surg (2010) 14:1343–1348

52 Furthermore, type I or subclinical are those that appear as a localized leak, without spillage or dissemination, with few clinical manifestations and easy to treat medically. Type II leaks are those with dissemination or diffusion into the abdominal or pleural cavity, with the appearance of contrast medium (methylene blue, radiological contrast) or food through any of the abdominal drain, with severe clinical consequences. Management of Leaks After Laparoscopic Sleeve Gastrectomy in Patients with Obesity Attila Csendes & Italo Braghetto & Paula León & Ana María Burgos J Gastrointest Surg (2010) 14:1343–1348 Types of leaks

53 The analysis of the data clearly suggests that leak primarily occurs at the proximal portion of the staple-line. Only 52% of studies documented the location of the leak and 89% of these were at the esophagogastric junction. This danger zone may be thinner than the rest of the stomach. Elariny et al. demonstrated that the stomach has different thickness throughout with the fundus being the thinnest at approximately 1.7 mm. This begs the question of whether a white load (2.5 mm staple height) should be used for the upper most staples as green loads are used for the antrum because of its thickness. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients Alexander R. Aurora Leena Khaitan Alan A. Saber Surg Endosc (DEC 2011)DOI 10.1007/s00464-011-2085-3, location of leaks

54 Burgos et al. reported 85.7% of leaks in the proximal third and only 14.3% in the distal third. Gastric Leak After Laparoscopic Sleeve Gastrectomy Manuel Ferrer Márquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &María del Mar Rico Morales & Jose Miguel García Díez & Ricardo Belda Poujoulet OBES SURG (2010) 20:1306–1311 location of leaks

55 Leaks can be produced by two mechanisms: mechanical and ischemic: Mechanical mechanism occurs when intragastric pressure exceeds the strength of the staple line. Devascularization of the gastroesophageal junction during the liberation of the greater curvature could be related to ischemia and difficulty in healing. Gastric Leak After Sleeve Gastrectomy: Analysis of Its Management Xabier de Aretxabala & Jorge Leon & Gonzalo Wiedmaier & Ivan Turu & Cristian Ovalle & Fernando Maluenda & Carolina Gonzalez & Jennifer Humphrey & Mabel Hurtado & Carlos Benavides OBES SURG (2011) 21:1232–1237 Mechanisms of leaks

56 Baker suggests that fistulas can be divided into two categories: mechanical–tissular causes and ischemic causes. In both situations, intraluminal pressure exceeds tissular and suture line resistance, thus causing the fistula. Gastric Leak After Laparoscopic Sleeve Gastrectomy Manuel Ferrer Márquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &María del Mar Rico Morales & Jose Miguel García Díez & Ricardo Belda Poujoulet OBES SURG (2010) 20:1306–1311 Mechanisms of leaks

57 Gastric fistulas are secondary to an impaired normal acute healing process. Local risk factors include impaired suture line healing, poor blood flow, infection, and poor oxygenation with subsequent ischemia. Some authors suggest that most fistulas are not due to staple failure, and consequently, staple line dehiscence, but are due to ischemia in the gastric wall next to the staple line that may be caused by dissection of the greater curvature when using the Ultracision® or LigaSure® systems. Gastric Leak After Laparoscopic Sleeve Gastrectomy Manuel Ferrer Márquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &María del Mar Rico Morales & Jose Miguel García Díez & Ricardo Belda Poujoulet OBES SURG (2010) 20:1306–1311 Mechanisms of leaks

58 When the cause is mechanical–tissular, fistulas are usually discovered within the first 2 days after surgery. Gastric Leak After Laparoscopic Sleeve Gastrectomy Manuel Ferrer Márquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &María del Mar Rico Morales & Jose Miguel García Díez & Ricardo Belda Poujoulet OBES SURG (2010) 20:1306–1311 Mechanisms of leaks Classic ischemic fistulas tend to appear between 5 and 6 days after surgery, when the wall healing process is between the inflammation phase and fibrotic phase.

59 Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients Alexander R. Aurora Leena Khaitan Alan A. Saber Surg Endosc DOI 10.1007/s00464-011-2085-3,DEC 2011 Presented at the SAGES 2011 Annual Meeting, March 30–April 2,2011, San Antonio, TX

60 This demonstrated that LSG provides comparative weight loss to gastric bypass with minimal risk. leak rate of approximately 2.4%. Clinically significant bleeding and stricture rate of less than 1%. Leak occurs at the GE junction in 89% of the time. The risk of leak is greater in patients with BMI[50 kg/m2. Bougie size of \40-Fr also is associated with increased risk of leak. Oversewing or buttressing of the staple-line does not have a clinically significant effect on leak. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients Alexander R. Aurora Leena Khaitan Alan A. Saber Surg Endosc (DEC 2011)DOI 10.1007/s00464-011-2085-3,

61 Alternatively, using a larger bougie size may give greater clearance at the dreaded esophagogastric junction thereby reducing the risk of leak. This may be supported by the fact that surgeon s who used a bougie size of 40- Fr or greater had a 0.6% leak rate (5/897 cases). The leak rate was 2.8% (110/3,991) in groups who used a bougie size less than 40-Fr(P\0.05). This difference was statistically significant, thus favoring the use of a bougie of 40-Fr to avoid leak. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients Alexander R. Aurora Leena Khaitan Alan A. Saber Surg Endosc (DEC 2011)DOI 10.1007/s00464-011-2085-3,

62 A sudden onset of abdominal pain was the main symptom in the patients with an early leak. All patients developed tachycardia and fever in conjunction with the pain episode. Abdominal pain located in the upper portion of the abdomen associated with fever was the first symptom in four patients while two developed respiratory symptoms and the CT findings were interpreted as pneumonia associated with pleural effusion, and treatment was provided for this diagnosis. Symptoms of leaks

63 Leading symptoms of patients with gastric leak were tachycardia, increased WBC, and elevated C-reactive protein levels. Gastric leakage after sleeve gastrectomyclinical presentation and therapeutic options. Christian Jurowich & Andreas Thalheimer & Florian Seyfried & Martin Fein & Gwendolyn Bender & Christoph-Thomas Germer & Christian Wichelmann Langenbecks Arch Surg (2011) 396:981–987 Symptoms of leaks

64 Burgos et al. report a series of 7 leaks in 214 patients (3.3%), of which 5 patients presented with abdominal pain, fever, tachycardia, tachypnea, and increased laboratory signs of infection. They observed that tachycardia is an initial sign of early leak. Gastric Leak After Laparoscopic Sleeve Gastrectomy Manuel Ferrer Márquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &María del Mar Rico Morales & Jose Miguel García Díez & Ricardo Belda Poujoulet OBES SURG (2010) 20:1306–1311 Symptoms of leaks

65 Management of Leaks After Laparoscopic Sleeve Gastrectomy in Patients with Obesity Attila Csendes & Italo Braghetto & Paula León & Ana María Burgos J Gastrointest Surg (2010) 14:1343–1348

66 Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients Alexander R. Aurora Leena Khaitan Alan A. Saber Surg Endosc (DEC 2011)DOI 10.1007/s00464-011-2085-3,

67

68 Leak management depends on the time of the diagnosis. In the case of leaks detected during the first days of the postoperative period, a relaparoscopy should be performed. In some patients, the leak had already spread to the abdominal cavity, and a complete and thorough cleaning is necessary. Local factors such as edema, inflammation, and presence of infection around the defects should be considered. Gastric Leak After Sleeve Gastrectomy: Analysis of Its Management Xabier de Aretxabala & Jorge Leon & Gonzalo Wiedmaier & Ivan Turu & Cristian Ovalle & Fernando Maluenda & Carolina Gonzalez & Jennifer Humphrey & Mabel Hurtado & Carlos Benavides OBES SURG (2011) 21:1232–1237 Management of leaks

69 The determining factor for the treatment of gastric leakage within the first week after LSG is the location of the leakage and the presence or absence of an intraabdominal dra in.. Gastric leakage after sleeve gastrectomyclinical presentation and therapeutic options. Christian Jurowich & Andreas Thalheimer & Florian Seyfried & Martin Fein & Gwendolyn Bender & Christoph-Thomas Germer & Christian Wichelmann Langenbecks Arch Surg (2011) 396:981–987 Management of leaks

70 In case of proximal leakage, endoluminal stent graft application is a promising therapy in the early postoperative course, irrespective of the exact postoperative day. In case of absence of an intraabdominal drain, relaparoscopy with abdominal lavage and insertion of a drain is necessary Re-suture or resection of the staple line may be a possible solution to the problem only in case of distal leakage.. Gastric leakage after sleeve gastrectomyclinical presentation and therapeutic options. Christian Jurowich & Andreas Thalheimer & Florian Seyfried & Martin Fein & Gwendolyn Bender & Christoph-Thomas Germer & Christian Wichelmann Langenbecks Arch Surg (2011) 396:981–987 Management of leaks

71 In the case of early fistula (<3 days after surgery), and which is diagnosed promptly, some authors support primary repair when the defect is easy to identify and the surrounding tissues are not very inflamed. Nevertheless, simple primary repair of fistula is associated with a high percentage of recurrences. Gastric Leak After Laparoscopic Sleeve Gastrectomy Manuel Ferrer Márquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &María del Mar Rico Morales & Jose Miguel García Díez & Ricardo Belda Poujoulet OBES SURG (2010) 20:1306–1311 Management of leaks

72 During the attempt to repair the defect, precaution to avoid stenosis of the repaired area should be taken into account. Due to the increased possibility of failure of the resutured stomach, the entire area must be drained with well-positioned drains. During this same procedure, a nasojejunal tube must be placed to feed the patient until the leak heals. Management of leaks Gastric Leak After Sleeve Gastrectomy: Analysis of Its Management Xabier de Aretxabala & Jorge Leon & Gonzalo Wiedmaier & Ivan Turu & Cristian Ovalle & Fernando Maluenda & Carolina Gonzalez & Jennifer Humphrey & Mabel Hurtado & Carlos Benavides OBES SURG (2011) 21:1232–1237

73 Re-suturing the orifice of the gastric leak, early after surgery and before the third POD, may result in prompt healing and recovery. After the third POD, tissues are severely inflamed and infected, and re-suturing results In complete failure. In these cases, complete and intense abdominal lavage with saline, the correct placement of drains, and the intraoperative placement of a nasojejunal feeding tube result in a favorable clinical evolution. Management of Leaks After Laparoscopic Sleeve Gastrectomy in Patients with Obesity Attila Csendes & Italo Braghetto & Paula León & Ana María Burgos J Gastrointest Surg (2010) 14:1343–1348 Management of leaks

74 Late leak often can be managed by percutaneous drainage and endoscopic stenting. Sufficiently powered, prospective, randomized studies are needed to evaluate the role of fibrin glue, staple height, and distance between the GE junction and the staple line independently and in combination on leak and complication after laparoscopic sleeve gastrectomy. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients Alexander R. Aurora Leena Khaitan Alan A. Saber Surg Endosc (DEC 2011)DOI 10.1007/s00464-011-2085-3, Management of leaks

75 When a late leak is detected, a collection adjacent to the remnant stomach is frequently found, and the fluids have not spread yet to the rest of the cavity. In this case, a percutaneous drainage of the collection is an alternative. Management of leaks Gastric Leak After Sleeve Gastrectomy: Analysis of Its Management Xabier de Aretxabala & Jorge Leon & Gonzalo Wiedmaier & Ivan Turu & Cristian Ovalle & Fernando Maluenda & Carolina Gonzalez & Jennifer Humphrey & Mabel Hurtado & Carlos Benavides OBES SURG (2011) 21:1232–1237

76 In the case of late fistulas, closure of the defect is not possible due to the large inflammatory component and the frequent presence of nearby abscesses. In these cases, washing out the cavity and placing a drain is the best option. Gastric Leak After Laparoscopic Sleeve Gastrectomy Manuel Ferrer Márquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &María del Mar Rico Morales & Jose Miguel García Díez & Ricardo Belda Poujoulet OBES SURG (2010) 20:1306–1311 Management of leaks

77

78 Of the 52 leaks that had a documented time of diagnosis, 40 were more than 10 days postoperatively and thus required rehospitalization. This suggests that approximately 79% of leaks will occur as a late event, and the majority will be managed by minimally invasive means, including endoscopic stenting. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients Alexander R. Aurora Leena Khaitan Alan A. Saber Surg Endosc (DEC 2011)DOI 10.1007/s00464-011-2085-3, Management of leaks

79

80 The period of time required for the leak to close ranged from 21 to 240 days from the time of diagnosis (mean 45 days)

81 For leaks occurring in the early postoperative period and for stable patients, if suction drain offers a proper total extraction of GI fluid, keeping the patient nil per os and administrating broad spectrum antibiotics can provide a good conservative management. Routine Abdominal Drains after Laparoscopic Sleeve Gastrectomy: A Retrospective Review of 353 Patients Konstantinos Albanopoulos & Leonidas Alevizos & Dimitrios Linardoutsos & Evangelos Menenakos & Konstantinos Stamou & Konstantinos Vlachos & George Zografos & Emmanuel Leandros OBES SURG (2011) 21:687–691 Management of leaks

82 On the other hand, stable patients with a few symptoms, or those who develop fistulas after a long postoperative period, can be managed conservatively by placing a drain, parenteral or enteral nutrition, high-dose proton pump inhibitors, and the use of broad spectrum antibiotics. Enteral nutrition should be started as soon as possible during treatment since appropriate nutrition is needed to support defect closure. Gastric Leak After Laparoscopic Sleeve Gastrectomy Manuel Ferrer Márquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &María del Mar Rico Morales & Jose Miguel García Díez & Ricardo Belda Poujoulet OBES SURG (2010) 20:1306–1311 Management of leaks

83 Management of Leaks After Laparoscopic Sleeve Gastrectomy in Patients with Obesity Attila Csendes & Italo Braghetto & Paula León & Ana María Burgos J Gastrointest Surg (2010) 14:1343–1348

84 Diagnostic and therapeutic algorithm in case of suspected gastric leak Standard CTscan even with oral application of contrast media is inferior in patients with BMI 50+.

85 In recent years, most authors have supported the use of flexible coated stents as a second step. In this way, a temporary fistula bypass is obtained enabling enteral nutrition to be maintained until closure. (Any abscess or intra-abdominal collection should be previously drained before placing the stent). Serra et al. report six cases of fistulas following sleeve gastrectomy. Five were closed by placing a coated self-expandable stent, whereas one patient treated with a stent required total gastrectomy after 3 months due to persistent fistula. Gastric Leak After Laparoscopic Sleeve Gastrectomy Manuel Ferrer Márquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &María del Mar Rico Morales & Jose Miguel García Díez & Ricardo Belda Poujoulet OBES SURG (2010) 20:1306–1311 Stents Employment

86 Covered stents were used in four patients. In all patients, drainage output diminished considerably immediately after inserting the stent. In two patients, due to the migration of the stent to the lower portion of the stomach, an endoscopic reinstallation was necessary. In one of the aforementioned patients, the stent had to be removed 30 days after being inserted due to its persistent migration Gastric Leak After Sleeve Gastrectomy: Analysis of Its Management Xabier de Aretxabala & Jorge Leon & Gonzalo Wiedmaier & Ivan Turu & Cristian Ovalle & Fernando Maluenda & Carolina Gonzalez & Jennifer Humphrey & Mabel Hurtado & Carlos Benavides OBES SURG (2011) 21:1232–1237 Stents Employment

87 On the other hand, Tan et al. reported a success rate for closure of only 50% with patients requiring premature removal due to complication derived from the stent. Stents should remain in place for at least 6 weeks before checking if the defect has closed. The migration index has been reported to be as high as one third of all cases. The beneficial effect of an endoluminal stent could also be in part explained by the decreasing intragastric pressure Gastric Leak After Sleeve Gastrectomy: Analysis of Its Management Xabier de Aretxabala & Jorge Leon & Gonzalo Wiedmaier & Ivan Turu & Cristian Ovalle & Fernando Maluenda & Carolina Gonzalez & Jennifer Humphrey & Mabel Hurtado & Carlos Benavides OBES SURG (2011) 21:1232–1237 Stents Employment

88

89

90

91 Fibrin glue also was used to cover the staple-line by Bellanger et al. Fibrin glue has been used for endoscopic therapy of postoperative leaks after sleeve gastrectomy but has not been documented as a regularly used product to prevent leak in sleeve gastrectomy. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients Alexander R. Aurora Leena Khaitan Alan A. Saber Surg Endosc (DEC 2011)DOI 10.1007/s00464-011-2085-3, Management of leaks

92 Patients who do not respond to any of these procedures and those with persistent fistula are candidates for three types of reintervention: conversion to gastric bypass, Roux-en- Y, or total gastrectomy. Gastric Leak After Laparoscopic Sleeve Gastrectomy Manuel Ferrer Márquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &María del Mar Rico Morales & Jose Miguel García Díez & Ricardo Belda Poujoulet OBES SURG (2010) 20:1306–1311 Management of leaks

93 Quick recognition of leak is essential, and therefore, a greater state of suspicion is fundamental. After controlling the septic state, efforts must be focused on treating the gastric leak. A well-drained leak is the cornerstone in the management of this complication. In addition to the latter, enteral nutrition via a nasojejunal tube must be initiated. Management of leaks (conclusion)

94 The location of leakage, and the presence or absence of an intraabdominal drain are determining factors for its treatment. UGI radiography with contrast media and gastroscopy are comparable and superior to standard CT scan. Stent graft application is a promising therapy in case of proximal leakage; re-suture or resection of the staple line are possible solutions in case of a distal leak. Gastric leakage after sleeve gastrectomyclinical presentation and therapeutic options. Christian Jurowich & Andreas Thalheimer & Florian Seyfried & Martin Fein & Gwendolyn Bender & Christoph-Thomas Germer & Christian Wichelmann Langenbecks Arch Surg (2011) 396:981–987 Management of leaks(conclusion)

95 Routine Abdominal Drains after Laparoscopic Sleeve Gastrectomy: A Retrospective Review of 353 Patients Konstantinos Albanopoulos & Leonidas Alevizos & Dimitrios Linardoutsos & Evangelos Menenakos & Konstantinos Stamou & Konstantinos Vlachos & George Zografos & Emmanuel Leandros OBES SURG (2011) 21:687–691 Total of 343 consecutive obese patients were included in this protocol: 262 women (76.6%) and 81 men (23.4%).

96 Routine Abdominal Drains after Laparoscopic Sleeve Gastrectomy: A Retrospective Review of 353 Patients Konstantinos Albanopoulos & Leonidas Alevizos & Dimitrios Linardoutsos & Evangelos Menenakos & Konstantinos Stamou & Konstantinos Vlachos & George Zografos & Emmanuel Leandros OBES SURG (2011) 21:687–691 Patients were enrolled in Group A when an intraperitoneal drain was placed and Group B when not. the differences did not reach statistical significance. In 50% of patients with drain and leak, per os blue de methylene test was negative and in another 50% leak took place after the fourth postoperative day when drain was already taken off.

97 Routine Abdominal Drains after Laparoscopic Sleeve Gastrectomy: A Retrospective Review of 353 Patients Konstantinos Albanopoulos & Leonidas Alevizos & Dimitrios Linardoutsos & Evangelos Menenakos & Konstantinos Stamou & Konstantinos Vlachos & George Zografos & Emmanuel Leandros OBES SURG (2011) 21:687–691 Placement of drains does not facilitate detection of staple line leak, abscess, or bleeding. Furthermore, they don't seem to eliminate the reoperation rates for these complications.

98 Baltasar et al.protect the staple line with a continuous sero-serous suture (from the angle of Hiss to the half- way point, and a second continuous suture from this point to the end) that inverts the staples, controls bleeding, and reduces the number of leaks, without increasing the cost of the procedure. Gastric Leak After Laparoscopic Sleeve Gastrectomy Manuel Ferrer Márquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &María del Mar Rico Morales & Jose Miguel García Díez & Ricardo Belda Poujoulet OBES SURG (2010) 20:1306–1311 Prevention of leaks

99

100 Another fistula prevention technique involves using fibrin sealants (Tissucol®, Vivostat®) along the Several studies have reported that these materials reduce the number of leaks staple line. Gastric Leak After Laparoscopic Sleeve Gastrectomy Manuel Ferrer Márquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &María del Mar Rico Morales & Jose Miguel García Díez & Ricardo Belda Poujoulet OBES SURG (2010) 20:1306–1311 Prevention of leaks

101

102 It is obvious that general surgical principles such as the careful selection of patients, the experience of the surgeon, gentle handling of tissues, adequate selection of surgical techniques, and avoidance of stricture at the mid or distal portion of the tubular stomach are very important details. Also careful management of electrocautery and vessel sealing systems is essential, because thermal damage is one of the most important pathogenetic factors. Management of Leaks After Laparoscopic Sleeve Gastrectomy in Patients with Obesity Attila Csendes & Italo Braghetto & Paula León & Ana María Burgos J Gastrointest Surg (2010) 14:1343–1348 How can a leak be prevented?

103 When using endostaples, it is advisable to begin tissue compression carefully and sustain this position for enough time to allow the tissue fluids to exit, as well as to carefully place the staples. Some authors advise waiting for around 10 s before beginning stapling.. Gastric Leak After Laparoscopic Sleeve Gastrectomy Manuel Ferrer Márquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &María del Mar Rico Morales & Jose Miguel García Díez & Ricardo Belda Poujoulet OBES SURG (2010) 20:1306–1311 How can a leak be prevented?

104 The healing time of a gastric leak after a sleeve gastrectomy is significantly longer than the healing time of a leak after a gastric bypass (45 vs. 30 days, respectively). However, the reason for that is : - After a gastric bypass, the only fluid that is collected through the drain is saliva, because gastric juice is nil in the gastric pouch and no reflux of intestinal content is present due to a long Roux-en-Y limb. On the contrary, in patients with a sleeve gastrectomy, in addition to the presence of saliva, there is residual gastric acid secretion and eventual reflux of duodenal content through an open pylorus. - Secondly, an increased intraluminal pressure has been described after lSG that could contribute to the development of a leak, which is not present in gastric bypass. Management of Leaks After Laparoscopic Sleeve Gastrectomy in Patients with Obesity Attila Csendes & Italo Braghetto & Paula León & Ana María Burgos J Gastrointest Surg (2010) 14:1343–1348

105 Initial Experience with Robotic Sleeve Gastrectomy for Morbid Obesity Theodoros Diamantis & Andreas Alexandrou & Nikolaos Nikiteas & Athanasios Giannopoulos &Eustathios Papalambros OBES SURG (2011) 21:1172–1179

106 The distance from the pylorus for the first stapler application, means of dissection of the greater gastric curvature, the size of bougie used for the splinting of stomach, the kind of staplers and the appropriate size of the clips, the necessity and the way of reinforcement of the staple line, the ideal volume of the residual stomach, the proximity of the end of the resection line to the angle of His, the routine use of intra-operative leakage test, and the use of drains, all are issues of debate among the various reporting authors. CONCLUSION

107 THANK YOU

108 leak has been classified in the literature based on the period in which it appears: – Early: leaks that appear between the first and third day after surgery. – Intermediate: leaks that appear between the fourth and seventh day after surgery. – Late: those that appear more than 8 days after surgery Gastric Leak After Laparoscopic Sleeve Gastrectomy Manuel Ferrer Márquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &María del Mar Rico Morales & Jose Miguel García Díez & Ricardo Belda Poujoulet OBES SURG (2010) 20:1306–1311 Classification of leaks

109

110

111

112


Download ppt "Dr.Mohammad Hayssam ElFawal MD.FACS Dr.Houssam Abtar. Chief Resident MEMA 11 th May 2013."

Similar presentations


Ads by Google