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

‘’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

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

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

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: 0.3-27% MORTALITY !

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’’ 2003-2013 1875 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 ----- 13 pts splenic a. ----- 10 pts peripancreatic aa. ----- 6 pts other aa. ----- 5 pts undetermined ----- 2 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

‘’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

Post-operative Anastomotic Bleeding ‘’Endoscopic Treatment and Risk Factors of Post-operative Anastomotic Bleeding After Gastrectomy for Cancer’’ Retrospective Korean single center study 2002-2010 2,021 pts: 1,613 subtotal + 418 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

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

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

- 24 EJ anastomosis, 12 mediastinal + 12 abdominal ‘’Covered Self-expanding Stent Treatment for Anastomotic Leakage: Outcomes in Esophagogastric and Esophagojejunal Anastomoses’’ 2002-2013 35 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

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?’’ 2002-2013 27 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

‘’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

‘’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

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

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

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

‘’Duodenal Fistula After Elective Gastrectomy for Malignant Disease’’ Retrospective Italian multicenter study 11 centers, 1991-2006 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

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

‘’Duodenal Stump Fistula After Gastric Surgery for Malignancies: a Retrospective Analysis of Risk Factors in a Single Center’’ 1987-2012: 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

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

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

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

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

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

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

‘’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

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

‘’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

‘’Costs of Leaks and Bleeding After Sleeve Gastrectomy’’ 2006-2013: 1260 pts SG Additional cost: Leak 9284 Euro Bleeding 4267 Euro Bransen J et al, Obes Surg 2015

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…