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Luo H, Liu S, Huang W, Lei Y, Xing Y, Wesemann L, Luo B, Li W, Hu J, Tian Y. A comparison of the postoperative outcomes between intraoperative leak testing and no intraoperative leak testing for gastric cancer surgery: a systematic review and meta-analysis. Surg Endosc 2024; 38:1709-1722. [PMID: 38413470 DOI: 10.1007/s00464-024-10715-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 01/28/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Postoperative anastomotic leakage (PAL) is a serious complication of gastric cancer surgery. Although perioperative management has made considerable progress, anastomotic leakage (AL) cannot always be avoided. The purpose of this study is to evaluate whether intraoperative leak testing (IOLT) can reduce the incidence of PAL and other postoperative outcomes in gastric cancer surgery. MATERIALS AND METHODS In this meta-analysis, we searched the PubMed, Embase, and Cochrane Library databases for clinical trials to assess the application of IOLT in gastric cancer surgery. All patients underwent laparoscopic radical gastrectomy for gastric cancer surgery. Studies comparing the postoperative outcomes of IOLT and no intraoperative leak testing (NIOLT) were included. Quality assessment, heterogeneity, risk of bias, and the level of evidence of the included studies were evaluated. PAL, anastomotic-related complications, 30-day mortality, and reoperation rates were compared between the IOLT and NIOLT group. RESULTS Our literature search returned 721 results, from which six trials (a total of 1,666 patients) were included in our meta-analysis. Statistical heterogeneity was low. The primary outcome was PAL. IOLT reduced the incidence of PAL [2.09% vs 6.68%; (RR = 0.31, 95% Cl 0.19-0.53, P < 0.0001]. Anastomotic-related complications, which included bleeding, leakage, and stricture, were significantly higher in the NIOLT group than in the IOLT group [3.24% VS 10.85%; RR = 0.30, 95% Cl 0.18-0.53, P < 0.0001]. Moreover, IOLT was associated with lower reoperation rates [0.94% vs 6.83%; RR = 0.18, 95% CI 0.07-0.43, P = 0.0002]. CONCLUSION Considering the observed lower incidence of postoperative anastomotic leakage (PAL), anastomotic-related complications, and reoperation rates, IOLT appears to be a promising option for gastric cancer surgery. It warrants further study before potential inclusion in future clinical guidelines.
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Affiliation(s)
- Heng Luo
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, 637000, Sichuan, China
| | - Shunying Liu
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, 637000, Sichuan, China
- Department of Dermatology, Daping Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Wentao Huang
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, 637000, Sichuan, China
- Department of Gastroenterology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, China
| | - Yu Lei
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, 637000, Sichuan, China
| | - Yan Xing
- Department of Science &Technology with Teaching, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, 637000, China
| | - Luke Wesemann
- Department of Radiology, Wayne State University, Detroit, MI, 48201, USA
| | - Binyu Luo
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, 637000, Sichuan, China
| | - Wenjing Li
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, 637000, Sichuan, China
| | - Jiani Hu
- Department of Radiology, Wayne State University, Detroit, MI, 48201, USA
| | - Yunhong Tian
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, 637000, Sichuan, China.
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Ma L, Gao Z, Luo H, Kou S, Lei Y, Jia V, Lan K, Sankar S, Hu J, Tian Y. Comparison of the postoperative outcome with and without intraoperative leak testing for sleeve gastrectomy: a systematic review and meta-analysis of 469 588 cases. Int J Surg 2024; 110:1196-1205. [PMID: 37988416 PMCID: PMC10871606 DOI: 10.1097/js9.0000000000000919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 11/05/2023] [Indexed: 11/23/2023]
Abstract
OBJECTIVE Postoperative staple line leakage (SLL) after sleeve gastrectomy (SG) is a rare but serious complication. Many surgeons routinely test anastomosis with an intraoperative leak test (IOLT) as part of the SG procedure. This meta-analysis aims to determine whether an IOLT plays a role in reducing the rate of postoperative staple line related complications in patients who underwent SG. METHODS The authors searched the PubMed, Web of science, the Cochrane Library, and Clinical Trials.gov databases for clinical studies assessing the application of IOLT in SG. The primary endpoint was the development of postoperative SLL. Secondary endpoints included the postoperative bleeding, 30 days mortality rates, and 30 days readmission rates. RESULTS Six studies totaling 469 588 patients met the inclusion criteria. Our review found that the SLL rate was 0.38% (1221/ 324 264) in the IOLT group and 0.31% (453/ 145 324) in the no intraoperative leak test (NIOLT) group. Postoperative SLL decreased in the NIOLT group compared with the IOLT group (OR=1.27; 95% CI: 1.14-1.42, P =0.000). Postoperative bleeding was fewer in the IOLT group than that in the NIOLT group (OR 0.79; 95% CI: 0.72-0.87, P =0.000). There was no significant difference between the IOLT group and the NIOLT group regarding 30 days mortality rates and 30 days readmission rates ( P >0.05). CONCLUSION IOLT was correlated with an increase in SLL when included as a part of the SG procedure. However, IOLT was associated with a lower rate of postoperative bleeding. Thus, IOLT should be considered in SG in the situation of suspected postoperative bleeding.
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Affiliation(s)
- Longyin Ma
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University)
| | - Zhenguo Gao
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University)
| | - Heng Luo
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University)
| | - Shien Kou
- Department of Clinical Medicine, North Sichuan Medical College, Nanchong, Sichuan, People’s Republic of China
| | - Yu Lei
- Department of Clinical Medicine, North Sichuan Medical College, Nanchong, Sichuan, People’s Republic of China
| | - Victor Jia
- School of Medicine, University of Michigan, Ann Arbor
| | - Ke Lan
- Department of Clinical Medicine, North Sichuan Medical College, Nanchong, Sichuan, People’s Republic of China
| | - Subbiah Sankar
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University)
| | - Jiani Hu
- Department of Radiology, Wayne State University, Detroit, Michigan, USA
| | - Yunhong Tian
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University)
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Clapp B, Corbett J, Ahmad M, Vivar A, Sharma I, Hage K, Ghanem OM. When do leaks occur? An analysis of the metabolic and bariatric surgery accreditation and quality improvement program. Surg Obes Relat Dis 2023; 19:1128-1133. [PMID: 37258316 DOI: 10.1016/j.soard.2023.04.334] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 04/09/2023] [Accepted: 04/23/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Leak is a feared complication of bariatric surgeries. Time to presentation is important in their management. We used the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) to evaluate the rate and timing of leaks. OBJECTIVES To determine when leaks present after bariatric surgery. SETTING MBSAQIP database. METHODS The MBSAQIP Participant Use Files (PUF) for the years 2015-2020 were evaluated. Outcomes of interest were "organ space infection" and "leak." We evaluated the time to presentation for these variables as well as patient characteristics, operative time, complication rates and 30-day outcomes. RESULTS There were 370,369 sleeve gastrectomies (SG) and 159,280 Roux-en-Y gastric bypasses (RYGB). We identified 598 (.16%) SG leaks with an average time to presentation of 13.2 ± 7.8 days. For RYGB, there were 520 leaks (.32%) with an average time to presentation of 9.5 ± 7.4 days. Both procedures had longer operative times for the patients with leak; RYGB was 115 minutes versus 131 minutes and SG was 67 minutes versus 77 minutes (both P < .01). SG and RYGB patients with a leak had a higher relative risk (RR) of grade 4 and 5 Clavien-Dindo complication rates. RR of mortality rates in SG patients with leak was 35.2 (confidence interval (CI): 20-61) and in RYGB with leak was 31.4 (CI: 19-50). CONCLUSIONS The length of time for SG leak presentation was more delayed than RYGB leak presentation. Surgeons should be vigilant for leaks for at least 3 weeks after surgery. Leaks increase the mortality rate and overall serious complications.
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Affiliation(s)
- Benjamin Clapp
- Department of Surgery, Texas Tech University Health Sciences Center El Paso, El Paso, Texas.
| | - John Corbett
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Maria Ahmad
- Department of Surgery, Texas Tech University Health Sciences Center El Paso, El Paso, Texas
| | - Andres Vivar
- Universidad Autonoma de Guadalajara, Escuela de Medicina, Guadalajara, Jalisco, Mexico
| | - Ishna Sharma
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Karl Hage
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Omar M Ghanem
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
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Gao Z, Luo H, Ma L, Bai D, Qin X, Bautista M, Gong L, Peng Y, Hu J, Tian Y. Efficacy and safety of anastomotic leak testing in gastric cancer: a randomized controlled trial. Surg Endosc 2023; 37:5265-5273. [PMID: 36971816 DOI: 10.1007/s00464-023-10025-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 03/12/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Anastomosis-related complications such as bleeding, leakage, and strictures, continue to be serious complications of gastric cancer surgery. Presently, these complications have yet to be reliably prevented. Here we design a comprehensive leak testing procedure which combines gastroscopy, air, and methylene blue (GAM) leak testing. We aimed to evaluated the efficacy and safety of the GAM procedure in patients with gastric cancer. METHODS Patients aged 18-85 years without an unresectable factor as confirmed via CT were enrolled in a prospective randomized clinical trial at a tertiary referral teaching hospital and were randomly assigned to two groups: intraoperative leak testing group (IOLT) and no intraoperative leak testing group (NIOLT). The primary endpoint was the incidence of postoperative anastomosis-related complications in the two groups. RESULTS 148 patients were initially randomly assigned to the IOLT group (n = 74) and to the NIOLT group (n = 74) between September 2018 and September 2022. After exclusions, 70 remained in the IOLT group and 68 in the NIOLT group. In the IOLT group, 5 patients (7.1%) were found to have anastomotic defects intraoperatively, which included anastomotic discontinuity, bleeding, and strictures. The NIOLT group had a higher incidence of postoperative anastomotic leakage compared to the IOLT group: 4 patients (5.8%) vs 0 patients (0%), respectively. No GAM-related complications were observed. CONCLUSION The GAM procedure is an intraoperative leak test that can be performed safely and efficiently after a laparoscopic total gastrectomy. GAM anastomotic leak testing may effectively prevent technical defect-related anastomotic complications in patients with gastric cancer who undergo a gastrectomy. TRIAL REGISTRATION Clinical Trials.gov Identifier: NCT04292496.
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Affiliation(s)
- Zhenguo Gao
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, 637000, Sichuan, China
| | - Heng Luo
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, 637000, Sichuan, China
| | - Longyin Ma
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, 637000, Sichuan, China
| | - Dan Bai
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, 637000, Sichuan, China
| | - Xiangzhi Qin
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, 637000, Sichuan, China
| | - Matthew Bautista
- Department of Radiology, Wayne State University, Detroit, MI, 48201, USA
| | - Lei Gong
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, 637000, Sichuan, China
| | - Yong Peng
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, 637000, Sichuan, China
| | - Jiani Hu
- Department of Radiology, Wayne State University, Detroit, MI, 48201, USA
| | - Yunhong Tian
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, 637000, Sichuan, China.
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Gao Z, Chen X, Bai D, Fahmy L, Qin X, Peng Y, Ren M, Tian Y, Hu J. A Novel Intraoperative Leak Test Procedure (GAM Procedure) to Prevent Postoperative Anastomotic Leakage in Gastric Cancer Patients Who Underwent Gastrectomy. Surg Laparosc Endosc Percutan Tech 2023; 33:224-230. [PMID: 37172005 DOI: 10.1097/sle.0000000000001171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 10/21/2022] [Indexed: 05/14/2023]
Abstract
BACKGROUND Anastomotic leakage following a radical gastrectomy is a serious complication of gastric cancer and esophagogastric junction cancer. The benefit of intraoperative leak testing for the prevention of postoperative anastomotic leakage has been controversial. We introduce a new procedure, which combines the techniques of gastroscopy, air, and methylene blue (GAM) for intraoperative leakage testing. Our objective was to evaluate the efficacy and safety of the GAM procedure for intraoperative leak testing and to compare the surgical complications of gastric cancer patients who underwent gastrectomy with and without intraoperative leak testing using the GAM procedure. MATERIALS AND METHODS A total of 210 patients who underwent radical gastrectomy for gastric cancer were included. Patients were divided into 2 groups: the intraoperative leak testing group using the GAM procedure (IOLT), and the group for which no intraoperative leak testing was done (NIOLT). Clinical and pathologic characteristics, the incidence of postoperative anastomotic leakage, and other surgical complications were compared between the 2 groups. RESULTS There were 82 patients in the IOLT group and 82 patients in the NIOLT group after propensity score matching. In the IOLT group, 4 (4.9%) patients were found to have anastomotic discontinuity during the operation; we repaired these anastomotic discontinuities intraoperatively. The incidence of postoperative anastomotic leakage was higher in the NIOLT group compared with the IOLT group, 6 (7.3%) versus 0 (0%), respectively ( P =0.01). The average time of the GAM procedure was 4.99±1.75 minutes. The surgical time was prolonged by 30 minutes in the IOLT group compared with the NIOLT group, 302.2±79.9 versus 272.1±85.2, respectively ( P =0.02). The length of hospital stay, 15.80±4.55 versus 17.00±6.20 ( P =0.16) was reduced in the IOLT group compared with the NIOLT group. The logistic regression model suggested that IOLT, sex, age, Eastern Cooperative Oncology Group, cT stage, tumor diameter, pT stage, pN stage, and Lauren classification were not risk factors for postoperative complication. CONCLUSIONS The GAM procedure of intraoperative leakage testing can effectively reduce the incidence of postoperative anastomotic leakage in gastric cancer patients undergoing gastrectomy.
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Affiliation(s)
- Zhenguo Gao
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong
| | - Xin Chen
- Department of General Surgery, The First People's Hospital Shuangliu District, Chengdu[West China (Airport) Hospital Sichuan University], Chengdu, Sichuan, China
| | - Dan Bai
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong
| | - Lara Fahmy
- Department of Radiology, Wayne State University, Detroit, MI
| | - Xiangzhi Qin
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong
| | - Yong Peng
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong
| | - Mingyang Ren
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong
| | - Yunhong Tian
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong
| | - Jiani Hu
- Department of Radiology, Wayne State University, Detroit, MI
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Song SH, Park JS, Choi GS, Park SY, Kim HJ, Lee SM, Na DH, Jeong MH. Efficacy of air leak test in detection of anastomotic leaks after rectal excision: a retrospective case-controlled study. Ann Surg Treat Res 2023; 104:214-221. [PMID: 37051157 PMCID: PMC10083345 DOI: 10.4174/astr.2023.104.4.214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/15/2023] [Accepted: 03/06/2023] [Indexed: 04/07/2023] Open
Abstract
Purpose Although its efficacy is uncertain, an intraoperative air leak test (ALT) is commonly used to detect mechanical defects following bowel anastomosis. This study aimed to evaluate the efficacy of ALT to detect anastomotic leakage (AL) following rectal excision. Methods We reviewed our database for patients with rectal cancers who had undergone curative surgery between January 2012 and January 2018. Patients were grouped according to whether or not an ALT was performed. Propensity score analyses were performed to compare outcomes for groups in a 1:1 case-matched cohort. Results In total, 1,191 patients underwent rectal excision; 438 (219 in each group) formed the case-matched cohort for analysis. The protective stoma rate was 16.0% and 14.6% in the ALT and the no-ALT groups, respectively (P = 0.791). In the ALT group, 2 patients (0.9%) showed a positive result and were treated with rectal tube drainage, resulting in no leakage. There was no significant difference in postoperative AL rate between the groups (ALT group: 4.6% vs. no-ALT group: 4.1%, P > 0.999). Conclusion ALT played a minimal role in detecting AL following rectal excision. Further studies are warranted to validate our results and clarify whether AL can be prevented with ALT or alternative methods.
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Affiliation(s)
- Seung Ho Song
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jun Seok Park
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
- Kyungpook National University Bio-Medical Research Institute, Daegu, Korea
| | - Gyu-Seog Choi
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Soo Yeon Park
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
- Kyungpook National University Bio-Medical Research Institute, Daegu, Korea
| | - Hye Jin Kim
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sung-Min Lee
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Dong-Hee Na
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Min Hye Jeong
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
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7
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Lu CY, Liu YL, Liu KJ, Xu S, Yao HL, Li L, Guo ZS. Differences in examination results of small anastomotic fistula after radical gastrectomy with afterward treatments: A case report. World J Clin Cases 2022; 10:7609-7616. [PMID: 36157983 PMCID: PMC9353917 DOI: 10.12998/wjcc.v10.i21.7609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/18/2022] [Accepted: 06/15/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Gastrografin swallow, methylthioninium chloride test, and computed tomography (CT) are the main methods for postoperative anastomotic fistula detection. Correct selection and application of examinations and therapies are significant for the early diagnosis and treatment of small anastomotic fistulas after radical gastrectomy, which are conducive to postoperative recovery.
CASE SUMMARY A 44-year-old woman underwent radical total gastrectomy for laparoscopic gastric cancer. The patient developed a fever after surgery. The methylthioninium chloride test and early CT suggested no anastomotic fistula, but gastrografin swallow and late CT showed the opposite result. The fistula was successfully closed using an endoscopic clip. The methylthioninium chloride test, gastrografin, and CT performed on different postoperative dates for small esophagojejunostomy fistulas are different. The size of the anastomotic fistula is an important factor for the success of endoscopic treatment.
CONCLUSION The advantages and limitations of the diagnosis of different examinations of small esophagojejunostomy fistulas are noteworthy. The size of the leakage of the anastomosis is an important basis for selecting the repair method.
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Affiliation(s)
- Chen-Yang Lu
- Department of Pulmonary and Critical Care Medicine, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
| | - Ya-Li Liu
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
- Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
| | - Kui-Jie Liu
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
| | - Shu Xu
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
| | - Hong-Liang Yao
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
| | - Lun Li
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
| | - Zhu-Shu Guo
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
- Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
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8
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Parmer M, Wang YHW, Hersh EH, Zhang L, Chin E, Nguyen SQ. Management of Staple Line Leaks after Laparoscopic Sleeve Gastrectomy. JSLS 2022; 26:JSLS.2022.00029. [PMID: 36071996 PMCID: PMC9439287 DOI: 10.4293/jsls.2022.00029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background and Objectives: Laparoscopic sleeve gastrectomy has become one of the most popular bariatric surgeries in the United States with a low rate of morbidity and effective weight loss. However, staple line leak remains a feared complication requiring a lengthy and difficult treatment course until resolution. This study outlines the various treatment methods used within a high-volume bariatric practice for successful leak resolution without necessitating a conversion procedure. Methods: A retrospective review was conducted on all patients with staple line leak after laparoscopic sleeve gastrectomy in a three-surgeon bariatric practice from January 1, 2010 to December 31, 2019. Results: A total of 10 staple line leaks were identified with a leak rate of 0.9%. Patients presented on average 29.3 days postoperatively and were all diagnosed on computed tomography. Three patients were initially managed operatively with washout and drainage procedure. Six patients were managed endoscopically initially with either stent or over-the-scope clip placement. Most patients required multiple interventions with an average of 2.4 interventions per patient. Average time to leak resolution was 48.2 days (15–95 days). Conclusion: Management of staple line leaks after laparoscopic sleeve gastrectomy requires a multimodal approach usually requiring multiple interventions before leak resolution. We demonstrate effective utilization of varying interventions that lead to effective leak resolution and avoid conversion operations.
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Affiliation(s)
- Megan Parmer
- Department of Surgery, Icahn School of Medicine at Mt Sinai, New York, NY
| | | | - Eliza H Hersh
- Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Linda Zhang
- Department of Surgery, Icahn School of Medicine at Mt Sinai, New York, NY
| | - Edward Chin
- Department of Surgery, Icahn School of Medicine at Mt Sinai, New York, NY
| | - Scott Q Nguyen
- Department of Surgery, Icahn School of Medicine at Mt Sinai, New York, NY
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9
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Samuels N, Wesley S, Williams K, Yan F, Smith R, Nguyen J, Udobi K, Sola R. Contrast study after gastric repair: a review of incidence, outcomes and risk factors at an adult level 1 trauma center. Eur J Trauma Emerg Surg 2022; 48:4143-4147. [PMID: 35366067 DOI: 10.1007/s00068-022-01949-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 03/07/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE The role of contrast study after traumatic gastric repair, continues to be controversial. To that end, we aim to review the incidence, outcomes, and risk factors of patients undergoing contrast study after traumatic gastric repair. METHODS This was a retrospective review of all trauma patients admitted to a level 1 trauma center that sustained gastric injuries with subsequent repair between 2011 and 2018. Demographics, surgical interventions, complications, and clinical outcomes were evaluated. Statistical analysis included Chi-square/Fisher exact univariate analysis and multivariate logistic regression analysis with a 5% significance level. RESULTS A total of 233 patients received a gastric repair, of whom 49 (21%) had a contrast study performed. Out of 49 patients with a contrast study, one was found to have a gastric leak. Mean time to contrast study was 6.3 ± 2.7 days. There was no statistically significant difference in post-operative complications between non-contrast and contrast study groups. Multivariate logistic regression analysis demonstrated a lack of statistical significance in clinical risk factors that would lead to obtaining a contrast study. CONCLUSION Gastric leak after repair is rare and there is no statistically significant difference in clinical outcomes when comparing patients who underwent contrast study to those who did not. Routine contrast study after traumatic gastric repair may not be necessary and further evidence is warranted to determine the risk factors for a selective contrast study.
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Affiliation(s)
- Nicolai Samuels
- Department of Surgery, Morehouse School of Medicine, 720 Westview Drive SW, Atlanta, GA, 30310, USA
| | - Sarah Wesley
- Department of Surgery, Morehouse School of Medicine, 720 Westview Drive SW, Atlanta, GA, 30310, USA
| | - Keyonna Williams
- Department of Surgery, Morehouse School of Medicine, 720 Westview Drive SW, Atlanta, GA, 30310, USA
| | - Fengxia Yan
- Department of Health and Preventive Medicine, Morehouse School of Medicine, 720 Westview Drive SW, Atlanta, GA, 30310, USA
| | - Randi Smith
- Department of Surgery, Emory School of Medicine, 69 Jesse Hill Jr. Dr. SE, 102, Atlanta, GA, 30303, USA
| | - Jonathan Nguyen
- Department of Surgery, Morehouse School of Medicine, 720 Westview Drive SW, Atlanta, GA, 30310, USA
| | - Kahdi Udobi
- Department of Surgery, Morehouse School of Medicine, 720 Westview Drive SW, Atlanta, GA, 30310, USA
| | - Richard Sola
- Department of Surgery, Morehouse School of Medicine, 720 Westview Drive SW, Atlanta, GA, 30310, USA.
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Martines G, Tomasicchio G, Picciariello A, Dibra R, Trigiante G, Lantone G, Altomare DF. Staple line reinforcement with nebulized cyanoacrylate glue in laparoscopic sleeve gastrectomy: A propensity score-matched study. Open Med (Wars) 2022; 17:197-204. [PMID: 35111973 PMCID: PMC8772997 DOI: 10.1515/med-2022-0426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 01/04/2022] [Accepted: 01/05/2022] [Indexed: 12/29/2022] Open
Abstract
Background A dreaded complication of laparoscopic sleeve gastrectomy (LSG) is suture leak. The study aimed to assess the efficacy of the nebulized comonomer Glubran 2® (N-butyl-cyanoacrylate + metacrylosysolfolane) applied to the LSG staple line. Methods A propensity-matched comparison analysis was conducted in 125 patients undergoing LSG between 2017 and 2019. Groups included those treated with Glubran® (group 1, n = 70) and those without Glubran® treatment (group 2, n = 55). Results There were differences in the mean body mass index (44.4 vs 43 kg/m2; P < 0.05) between the groups. There was a non-significant increase in the operative time for group 1 compared with group 2 (97 ± 8 vs 93.8 ± 10.7 min; P = 0.07), with a greater amount of estimated blood loss (94.5 mL vs 87.8; P < 0.01). There were more severe complications in group 2 over group 1 cases (8 vs 0%; P < 0.05), although postoperative bleeding did not differ between the two groups (1.4 vs 5.4%). There were no postoperative leaks in group 1 patients, but there were two leaks in group 2 cases with an increased length of hospital stay in patients with a leak. Conclusion Glubran® LSG support may reduce leak risk without increasing operating time.
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Affiliation(s)
- Gennaro Martines
- Department of Emergency and Organ Transplantation (DETO), University of Bari “Aldo Moro”, Piazza Giulio Cesare, 11, Bari, Puglia, Italy
| | - Giovanni Tomasicchio
- Department of Emergency and Organ Transplantation (DETO), University of Bari “Aldo Moro”, Piazza Giulio Cesare, 11, Bari, Puglia, Italy
| | - Arcangelo Picciariello
- Department of Emergency and Organ Transplantation (DETO), University of Bari “Aldo Moro”, Piazza Giulio Cesare, 11, Bari, Puglia, Italy
| | - Rigers Dibra
- Department of Emergency and Organ Transplantation (DETO), University of Bari “Aldo Moro”, Piazza Giulio Cesare, 11, Bari, Puglia, Italy
| | - Giuseppe Trigiante
- Department of Emergency and Organ Transplantation (DETO), University of Bari “Aldo Moro”, Piazza Giulio Cesare, 11, Bari, Puglia, Italy
| | - Giuliano Lantone
- Department of Emergency and Organ Transplantation (DETO), University of Bari “Aldo Moro”, Piazza Giulio Cesare, 11, Bari, Puglia, Italy
| | - Donato Francesco Altomare
- Department of Emergency and Organ Transplantation (DETO), University of Bari “Aldo Moro”, Piazza Giulio Cesare, 11, Bari, Puglia, Italy
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11
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Yildiz BD, Alimoğullari M. Efficacy of Tight Sleeve Gastrectomy in Superobesity: Single Surgeon Experience. Indian J Surg 2022. [DOI: 10.1007/s12262-021-03227-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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12
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Ferraz ÁAB, Santa-Cruz F, Belfort JV, Sá VCT, Siqueira LT, Araújo-Júnior JGC. THE ROUTINE USE OF THE METHYLENE BLUE TEST IN SLEEVE GASTRECTOMY: WHY NOT? ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2022; 34:e1612. [PMID: 35019124 PMCID: PMC8735257 DOI: 10.1590/0102-672020210002e1612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 03/29/2021] [Indexed: 11/22/2022]
Abstract
Background:
Although considered a safe procedure, sleeve gastrectomy (SG) has a non-negligible risk of major postoperative complications related to it, with special attention to gastric leaks.
Aim:
Evaluate the clinical value of the methylene blue test (MBT) in predicting the occurrence of post-SG leaks.
Methods: Retrospective study that included 1136 patients who underwent SG with intraoperative MBT between 2012 and 2016. Sensitivity, specificity, positive predictive value (PPV) and negative predicted value (NPV) were calculated to determine the clinical correlation between the MBT and the occurrence of postoperative leaks. Staple line oversewing was performed in all patients who presented positive MBT.
Results:
Laparoscopic SG was performed in 97.0% of cases; open in 2.3%, and robotic in 0.7%. MBT was positive in 19 cases (1.67%). One positive MBT occurred during an open SG and the other 18 at laparoscopy. Moreover, there were nine cases (0.8%) of postoperative leaks, among which, only two presented positive MBT. MBT diagnostic value was evaluated through the calculation of sensitivity (22.0%), specificity (98.0%), PPV (11.0%) and NPV (99.0%). There were no cases of allergic reaction or any other side effect with the use of the methylene blue solution.
Conclusion:
MBT showed high specificity and negative predictive value, thus presenting an important value to rule out the occurrence of postoperative leaks.
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Affiliation(s)
- Álvaro A B Ferraz
- Department of Surgery, Hospital de Clínicas, Federal University of Pernambuco, Recife, PE, Brazil.,Gastrointestinal Surgery Service, Esperança Hospital, Rede D'Or São Luiz, Recife, PE, Brazil
| | | | | | - Vladimir C T Sá
- General Surgery Service, Hospital Agamenon Magalhães, Recife, PE, Brazil
| | - Luciana T Siqueira
- Department of Surgery, Hospital de Clínicas, Federal University of Pernambuco, Recife, PE, Brazil
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Abstract
Bariatric surgery has emerged as the most effective means of achieving weight loss. Obesity surgery is a quickly expanding field. Laparoscopic vertical sleeve gastrectomy is a great option for patients because it is simple, exceedingly safe, has a fairly defined postoperative complication profile, and is as effective as more complex bariatric surgery options. Specific consideration of patients' comorbidities, assessment of surgeon's skill, and knowledge of preoperative, perioperative, and postoperative course is a must for all surgeons who wish to perform this procedure. If properly used, vertical sleeve gastrectomy is a powerful tool in combating obesity and its deleterious effects.
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Perioperative Practices Concerning Sleeve Gastrectomy - a Survey of 863 Surgeons with a Cumulative Experience of 520,230 Procedures. Obes Surg 2021; 30:483-492. [PMID: 31677017 DOI: 10.1007/s11695-019-04195-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Sleeve Gastrectomy (SG) is the most commonly performed bariatric procedure worldwide. There is currently no scientific study aimed at understanding variations in practices concerning this procedure. The aim of this study was to study the global variations in perioperative practices concerning SG. METHODS A 37-item questionnaire-based survey was conducted to capture the perioperative practices of the global community of bariatric surgeons. Data were analyzed using descriptive statistics. RESULTS Response of 863 bariatric surgeons from 67 countries with a cumulative experience of 520,230 SGs were recorded. A total of 689 (80%) and 764 (89%) surgeons listed 13 absolute and relative contraindications, respectively. 65% (n = 559) surgeons perform routine preoperative endoscopy and 97% (n = 835) routinely use intraoperative orogastric tube for sizing the resection. A wide variation is observed in the diameter of the tube used. 73% (n = 627) surgeons start dividing the stomach at a distance of 3-5 cm from the pylorus, and 54% (n = 467) routinely use staple line reinforcement. Majority (65%, n = 565) of surgeons perform routine intraoperative leak test at the end of the procedure, while 25% (n = 218) surgeons perform a routine contrast study in the early postoperative period. Lifelong multivitamin/mineral, iron, vitamin D, calcium, and vitamin B12 supplementation is advocated by 66%, 29%, 40%, 38% and 44% surgeons, respectively. CONCLUSION There is a considerable variation in the perioperative practices concerning SG. Data can help in identifying areas for future consensus building and more focussed studies.
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15
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Chhabra KR, Thumma JR, Varban OA, Dimick JB. Associations Between Video Evaluations of Surgical Technique and Outcomes of Laparoscopic Sleeve Gastrectomy. JAMA Surg 2021; 156:e205532. [PMID: 33325998 DOI: 10.1001/jamasurg.2020.5532] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance In any surgical procedure, various aspects of technique may affect patient outcomes. As new procedures enter practice, it is difficult to evaluate the association of each aspect of technique with patient outcomes. Objective To examine the associations between technique and outcomes in laparoscopic sleeve gastrectomy. Design, Setting, and Participants In this cohort study of bariatric surgery programs participating in a statewide surgical quality improvement collaborative, 30 surgeons submitted intraoperative videos from representative sleeve gastrectomies performed on 6915 patients with morbid obesity. These videos were reviewed by blinded peer surgeons on key technical elements, and 605 reviews were linked to sleeve gastrectomy outcomes of all of the surgeons' patients from January 1, 2015, to December 31, 2016. Exposures Surgeons' technical approaches to 5 controversial aspects of laparoscopic sleeve gastrectomy: dissection of the proximal stomach, sleeve caliber, sleeve anatomy, staple line reinforcement, and leak testing. Main Outcomes and Measures The 30-day outcomes were rate of postoperative hemorrhage and staple line leak. The 1-year outcomes were percentage of total weight lost and reflux severity (Gastroesophageal Reflux Disease Health-Related Quality of Life instrument). Results A total of 30 surgeons submitted 46 videos of operations performed on 6915 patients (mean [SD] age, 45.4 [11.7] years; 5494 [79.5%] female; 4706 [68.1%] White). Complete dissection of the proximal stomach was associated with reduced hemorrhage rates (higher ratings for complete mobilization of fundus were associated with a decrease in hemorrhage rate from 2.1% [25th percentile] to 1.0% [75th percentile], P = .01; higher ratings for visualization of the left crus were associated with a decrease in hemorrhage rate from 1.5% to 0.94%, P = .006; and higher ratings for complete division of the short gastrics were associated with a decrease in hemorrhage rate from 2.8% to 1.2%, P = .03). The reduction in hemorrhage rates came at the expense of higher leak rates (higher ratings for complete mobilization of fundus were associated with an increase in leak rate from 0.05% [25th percentile] to 0.16% [75th percentile], P < .001; higher ratings for visualization of the left crus were associated with an increase in leak rate from 0.1% to 0.2%, P = .003; and higher ratings for complete division of the short gastrics were associated with an increase in leak rate from 0.02% to 0.1%, P = .01). Surgeons who stapled more tightly to the bougie had smaller decreases in reflux than those who stapled less tightly (-2.0 to -1.3 on a 50-point scale, P = .002). Staple line reinforcement (buttressing and oversewing) was associated with a small (2 of 1000 cases) decrease in hemorrhage rates. Staple line buttressing was also associated with a similarly small increase in leak rates (1 of 1000 cases). Leak testing was associated with a statistically insignificant change in the staple line leak rate (0.16%-0.22%, P = .47). Conclusions and Relevance Variations in surgical technique can be measured by video review and are associated with differences in patient outcomes.
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Affiliation(s)
- Karan R Chhabra
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor.,National Clinician Scholars Program, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Jyothi R Thumma
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Oliver A Varban
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor.,Department of Surgery, University of Michigan, Ann Arbor
| | - Justin B Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor.,Department of Surgery, University of Michigan, Ann Arbor.,Section Editor, JAMA Surgery
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16
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Intraoperative leak test is associated with lower postoperative bleed rate in primary sleeve gastrectomy: a propensity matched analysis of primary and revision bariatric surgery using the MBSAQIP database. Surg Endosc 2021; 36:753-763. [PMID: 33475846 DOI: 10.1007/s00464-020-08264-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 12/22/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Gastrointestinal leaks after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) occur infrequently but lead to clinical and socioeconomic burden on patients. Surgeons perform intraoperative leak test (IOLT) via gastric tube or endoscopy to help prevent postoperative leaks. However, there is knowledge gap in the literature on effectiveness of IOLT during bariatric surgery. METHODS In this observational cohort study using the 2015-2017 MBSAQIP database, we compared the outcomes in patients who received IOLT with those who did not during primary or revision RYGB and SG. The primary outcome was 30-day postoperative leak. Secondary outcomes were procedure duration and the rates of 30-day postoperative bleed, readmission, reoperation and intervention. Propensity score matching was used to assemble cohorts of patients with similar baseline characteristics. RESULTS Among 363,042 patients, 82% underwent IOLT. Four subgroups of patients who underwent operations with or without IOLT during primary RYGB (n = 13,756), primary SG (n = 110,810), revision RYGB (n = 1140), and revision SG (n = 5576) had similar propensity scores and were matched 1:1. Patients who underwent IOLT had similar postoperative leak rates compared to those who did not (Primary RYGB with IOLT 0.7% v. without IOLT 0.6%; Primary SG 0.4% v. 0.3%; Revision RYGB 2.3% v. 1.0%; Revision SG 1.1% v. 0.7%). In primary SG subgroup, patients who underwent IOLT had lower postoperative bleed rates (0.6% v. 0.8%, p = 0.002). In primary RYGB and SG subgroups, operations with IOLT were slightly longer. CONCLUSION Postoperative leak rates after primary and revision bariatric surgery were low and similar irrespective of IOLT. Patients who had IOLT during primary SG had lower postoperative bleed rates. Current judgment as to whether to perform an IOLT leads to excellent outcomes, and thus, current practices should continue. However, one should consider an IOLT during primary SG, not necessarily to reduce leak rates but to help reduce postoperative bleeding occurrences.
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Clapp B, Liggett E, Ma C, Castro C, Montelongo S, Van Noy K, Dilday J, Tyroch A. Endoscopy Used as Provocative Testing in Bariatric Surgery: An Analysis of the Texas Public Use Data File. JSLS 2020; 24:JSLS.2020.00048. [PMID: 32968343 PMCID: PMC7489577 DOI: 10.4293/jsls.2020.00048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Many bariatric surgeons test the anastomosis and staple lines with some sort of provocative test. This can take the form of an air leak test with a nasogastric tube with methylene blue dye or with an endoscopy. The State Department of Health Statistics in Texas tracks outcomes using the Texas Public Use Data File (PUDF). Methods We queried the Texas Inpatient and Outpatient PUDFs for 2013 to 2017 to examine the number of bariatric surgeries with endoscopy performed at the same time. We used the International Classification of Diseases Clinical Modification Version 9 (ICD-9-CM) and ICD-10 procedure codes and Current Procedural Terminology for Sleeve Gastrectomy (SG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) and endoscopy, and the ICD-9-CM and ICD-10 diagnosis codes for morbid obesity. Results There were 74,075 SG reported in the Texas Inpatient and Outpatient PUDF for the years 2013-2017. Of the SG performed, 5,521 (7.4%) had an intraoperative endoscopy. For the 19,192 LRYGB reported, 1640 (8.6%) underwent LRYGB + endoscopy. This was broken down by SG only vs SG + endoscopy and LRYGB only vs LRYGB + endoscopy. Overall, SG + endoscopy had a significantly shorter length of stay (LOS) vs LRYGB + endoscopy at 1.74 d vs 2.34 d (P < .001) and a significantly less cost of $71,685 vs $91,093 (P < .001). Conclusions A small percentage of SG and LRYGB patients underwent endoscopy for provocative testing over the study period. Provocative testing with endoscopy costs more for SG and LRYGB and was associated with a shorter LOS.
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Affiliation(s)
- Benjamin Clapp
- Department of Surgery, Texas Tech HSC Paul Foster School of Medicine, El Paso, TX
| | - Evan Liggett
- Department of Surgery, Texas Tech HSC Paul Foster School of Medicine, El Paso, TX
| | - Cheng Ma
- Department of Surgery, Texas Tech HSC Paul Foster School of Medicine, El Paso, TX
| | - Christian Castro
- Department of Surgery, Texas Tech HSC Paul Foster School of Medicine, El Paso, TX
| | - Simon Montelongo
- Department of Surgery, Texas Tech HSC Paul Foster School of Medicine, El Paso, TX
| | - Kelsey Van Noy
- Department of Surgery, Texas Tech HSC Paul Foster School of Medicine, El Paso, TX
| | - Joshua Dilday
- Department of Surgery, William Beaumont Army Medical Center, El Paso, TX
| | - Alan Tyroch
- Department of Surgery, Texas Tech HSC Paul Foster School of Medicine, El Paso, TX
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18
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Intraluminal indocyanine green for intraoperative staple line leak testing in bariatric surgery. Surg Endosc 2020; 34:4194-4199. [DOI: 10.1007/s00464-020-07606-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 04/28/2020] [Indexed: 11/27/2022]
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19
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Effects of intraoperative leak testing on postoperative leak-related outcomes after primary bariatric surgery: an analysis of the MBSAQIP database. Surg Obes Relat Dis 2019; 15:1530-1540. [DOI: 10.1016/j.soard.2019.06.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 04/30/2019] [Accepted: 06/01/2019] [Indexed: 11/23/2022]
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20
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Canadian consensus statement: enhanced recovery after surgery in bariatric surgery. Surg Endosc 2019; 34:1366-1375. [PMID: 31209605 DOI: 10.1007/s00464-019-06911-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 06/11/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND In Canada, bariatric surgery continues to remain the most effective treatment for severe obesity and its comorbidities. As the number of bariatric surgeries continues to grow, the need for consensus guidelines for optimal perioperative care is imperative. In colorectal surgery, enhanced recovery after surgery (ERAS) protocols were created for this purpose. The objective of this review is to develop evidence-based ERAS guidelines for bariatric surgery. METHODS A literature search of the MEDLINE database was performed using ERAS-specific search terms. Recently published articles with a focus on randomized controlled trials, systematic reviews, and meta-analyses were included. Quality of evidence and recommendations were evaluated using the GRADE assessment system. RESULTS Canadian bariatric surgeons from six provinces and ten bariatric centers performed a review of the evidence surrounding ERAS in bariatric surgery and created consensus guidelines for 14 essential ERAS elements. Our main recommendations were (1) to encourage participation in a presurgical weight loss program; (2) to abstain from tobacco and excessive alcohol; (3) low-calorie liquid diet for at least 2 weeks prior to surgery; (4) to avoid preanesthetic anxiolytics and long-acting opioids; (5) unfractionated or low-molecular-weight heparin prior to surgery; (6) antibiotic prophylaxis with cefazolin ± metronidazole; (7) reduced opioids during surgery; (8) surgeon preference regarding intraoperative leak testing; (9) nasogastric intubation needed only for Veress access; (10) to avoid abdominal drains and urinary catheters; (11) to prevent ileus by discontinuing intravenous fluids early; (12) postoperative analgesia with acetaminophen, short-term NSAIDS, and minimal opioids; (13) to resume full fluid diet on first postoperative day; (14) early telephone follow-up with full clinic follow-up at 3-4 weeks. CONCLUSIONS The purpose of addressing these ERAS elements is to develop guidelines that can be implemented and practiced clinically. ERAS is an excellent model that improves surgical efficiency and acts as a common perioperative pathway. In the interim, this multimodal bariatric perioperative guideline serves as a common consensus point for Canadian bariatric surgeons.
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21
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Hughes D, Hughes I, Khanna A. Management of Staple Line Leaks Following Sleeve Gastrectomy—a Systematic Review. Obes Surg 2019; 29:2759-2772. [DOI: 10.1007/s11695-019-03896-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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22
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Saxena R, Reddy Ch VV. Testing the Integrity of a Roux-en-Y Hepaticojejunostomy: The Air Insufflation Test. J Am Coll Surg 2019; 229:e1-e3. [PMID: 30878585 DOI: 10.1016/j.jamcollsurg.2019.02.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 02/20/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Rajan Saxena
- Department of Surgical Gastroenterology and Center of Hepatobiliary Diseases and Transplantation, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
| | - Venkata Vishwanath Reddy Ch
- Department of Surgical Gastroenterology and Center of Hepatobiliary Diseases and Transplantation, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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23
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Giuliani A, Romano L, Papale E, Puccica I, Di Furia M, Salvatorelli A, Cianca G, Schietroma M, Amicucci G. Complications of postlaparoscopic sleeve gastric resection: review of surgical technique. MINERVA CHIR 2019; 74:213-217. [PMID: 30761827 DOI: 10.23736/s0026-4733.19.07883-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) has become a very frequent procedure in bariatric surgery. Despite its simplicity, it can have serious complications. Among these, gastric leak is one of the most feared complications. Numerous intraoperative maneuvers have been suggested in an attempt to decrease the incidence of leak. In our center, we decided to study one of the intraoperative measures proposed, which consists in positioning the suture machine to 1.5 cm from His corner. METHODS This retrospective study reported 101 cases of LSG performed in our center from 2012 to 2017. The patients were divided into two groups, with comparable anthropometric parameters and comparable inclusion criteria. In the two groups the operative technique used was the same, except for a maneuver: in the second group, attention was paid to keep a distance from the angle of at least 1.5 cm. RESULTS On a total of 101 procedures performed, the overall complication rate was 4,95%. In group 1 the rate of gastric staple line leak was 6.78%. In group 2 the rate was 2.38%. CONCLUSIONS The analyzed surgical technique seems to decrease the risk of leak without significantly impacting weight loss, and we have noticed in our clinical experience a decrease in the incidence of fistula from the time this measure was adopted. Also the statistical analysis encourage the continuation of experimentation.
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Affiliation(s)
| | - Lucia Romano
- Department of Surgery, University of L'Aquila, L'Aquila, Italy -
| | - Eleonora Papale
- Department of Surgery, University of L'Aquila, L'Aquila, Italy
| | - Ilaria Puccica
- Department of Surgery, University of L'Aquila, L'Aquila, Italy
| | - Marino Di Furia
- Department of Surgery, University of L'Aquila, L'Aquila, Italy
| | | | - Giovanni Cianca
- Department of Surgery, University of L'Aquila, L'Aquila, Italy
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Poskus T, Luksta M, Kryzauskas M. Technique of air-leak testing of ileocolic anastomosis. Tech Coloproctol 2018; 22:813-815. [PMID: 30456643 DOI: 10.1007/s10151-018-1882-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 11/09/2018] [Indexed: 10/27/2022]
Affiliation(s)
- T Poskus
- Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania. .,Vilnius University Hospital Santara Clinics, Santariskiu 2, 08661, Vilnius, Lithuania.
| | - M Luksta
- Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - M Kryzauskas
- Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
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25
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Indications and benefits of intraoperative esophagogastroduodenoscopy. Wideochir Inne Tech Maloinwazyjne 2018; 13:164-175. [PMID: 30002748 PMCID: PMC6041574 DOI: 10.5114/wiitm.2018.72740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 10/16/2017] [Indexed: 11/29/2022] Open
Abstract
Introduction Intraoperative esophagogastroduodenoscopy (IOG) is a diagnostic and therapeutic method for a variety of special conditions in upper gastrointestinal (UGI) pathology. The indication remains individual due to insufficient evidence and limited training of surgeons in digestive endoscopy. Aim To evaluate the indications, benefits and risks of IOG. Material and methods A single-center retrospective study of 110 consecutive IOGs in 104 patients was performed. The preoperative plan, the timing of IOG, preoperative evaluation, intraoperative finding, localization of the pathology, type of the procedure, change of expected therapy and complications were assessed. Results The cohort comprised 29 esophageal tumors, 5 tumors of the cardia, 36 gastric tumors, gastrointestinal bleeding (8), esophageal diverticula (3), perforations (3), GERD (5), mediastinal pathology (3), fistula (4), assessment of nutrition (10), duodenal adenoma (2), ulcer disease, esophageal stenosis and gastric volvulus. The indication for IOG was established preoperatively in 79% and intraoperatively in 21%. The lesion was localized in 96.4%. The therapy was altered to a wider resection (11), smaller resection (5), localization and surgical therapy of bleeding (8) or allowed minimally invasive surgery (25). A total of 3 postoperative complications included gastric perforation and positivity of resection line (following EMR/ESD) and recurrent bleeding. The 30-day mortality reached 3.6% without a specific cause in IOG. Conclusions The IOG is a complementary method in the diagnosis and treatment of UGI pathology. It enables minimally invasive finalization of the procedures and individualization of the therapy.
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Chung AY, Thompson R, Overby DW, Duke MC, Farrell TM. Sleeve Gastrectomy: Surgical Tips. J Laparoendosc Adv Surg Tech A 2018; 28:930-937. [PMID: 30004814 DOI: 10.1089/lap.2018.0392] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The vertical sleeve gastrectomy is a bariatric procedure that was originally described as the initial step in the biliopancreatic diversion. It demonstrated effectiveness in weight loss as a single procedure, and the laparoscopic vertical sleeve gastrectomy, as a stand-alone procedure, is now the most commonly performed bariatric surgery worldwide. Due to its relative technical ease and long-term data that have established its durability in treating obesity and its related comorbid conditions, the sleeve gastrectomy has grown in popularity among patients and surgeons. While there are variations in the technical aspects of performing a laparoscopic sleeve gastrectomy, key steps must be undertaken to produce safe and effective outcomes. This article reviews the indications for bariatric surgery, patient selection, surgical technique and tips, perioperative care and complications after sleeve gastrectomy.
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Affiliation(s)
- Ann Y Chung
- Department of Surgery, University of North Carolina-Chapel Hill , Chapel Hill, North Carolina
| | - Richard Thompson
- Department of Surgery, University of North Carolina-Chapel Hill , Chapel Hill, North Carolina
| | - D Wayne Overby
- Department of Surgery, University of North Carolina-Chapel Hill , Chapel Hill, North Carolina
| | - Meredith C Duke
- Department of Surgery, University of North Carolina-Chapel Hill , Chapel Hill, North Carolina
| | - Timothy M Farrell
- Department of Surgery, University of North Carolina-Chapel Hill , Chapel Hill, North Carolina
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Reinforcement of the Staple Line during Gastric Sleeve: A Comparison of Buttressing or Oversewing, versus No Reinforcement- A Single-Institution Study. Am Surg 2018. [DOI: 10.1177/000313481808400521] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Laparoscopic sleeve gastrectomy (LSG) is a well-established treatment for morbid obesity. Staple line leak (SLL) remains one of the most serious and life-threatening complications after LSG; however, no consensus exists for prevention. The purpose of this study is to review and compare the different methods of staple line management used at our institution. Retrospective review of preoperative, intraoperative, and postoperative factors was performed for all patients undergoing LSG at a single institution between September 2010 and August 2015. Primary outcome measure was SLL by reinforcement method (none/Seamguard/Oversewing). A total of 256 patients undergoing LSG were included, 197 (76.95%) were women and 233 (87.11%) were whites. The patients had a mean age of 44.64 years and body mass index of 49.24 kg/m22. Among those patients, 145 (56.64%) had staple line reinforced with suture (28, 10.94%) or Gore Seamguard (115, 44.92%) and 111 (43.36%) had no reinforcement, with no difference in baseline factors between the groups (all P > 0.05). Gastric leaks were identified in nine patients (3.52%) with no difference between reinforcement (2.7 vs 2.1%, P = 0.54) or leak test method (air vs methylene blue). However, oversewing the staple line was associated with higher incidence of stenosis ( P < 0.01). SLL after LSG is a serious complication with significant morbidity and mortality. This study demonstrated that staple line reinforcement does not provide significant leak reduction but does reduce intra-operative staple line bleeding. In addition, oversewing the staple line was associated with postoperative sleeve stenosis without added benefits.
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Comparison Between Stable Line Reinforcement by Barbed Suture and Non-reinforcement in Sleeve Gastrectomy: a Randomized Prospective Controlled Study. Obes Surg 2018; 28:2157-2164. [DOI: 10.1007/s11695-018-3175-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Staple Line Reinforcement in Laparoscopic SleeveGastrectomy: Experience in 1023 Consecutive Cases. Obes Surg 2017; 27:1474-1480. [PMID: 28054296 DOI: 10.1007/s11695-016-2530-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Laparoscopic sleeve gastrectomy (LSG) is one of the most frequently performed bariatric procedures performed worldwide. However, staple line-related complications have become a major challenge for bariatric surgeons. The aim of this study was to evaluate the morbidity in a cohort of patients who underwent LSG with imbricated oversewing of the staple line at a single high-volume center. MATERIALS AND METHODS We retrospectively reviewed prospectively collected data for all patients who underwent LSG to treat obesity at our institution from January 2010 to September 2016. All practitioners had undergone training with a single senior bariatric surgeon using oversewing as staple line reinforcement (SLR). RESULTS In total, 1023 LSGs were performed (female, 67.3%; mean age, 40.6 ± 10.8 years; median preoperative body mass index, 37 ± 4.5 kg/m2). The mean operative time was 67.6 ± 23.4 min (range, 30-150 min). The rate of conversion to open surgery was 0.3%. Early complications were noted in 18 patients (1.8%), including 5 cases of bleeding (0.5%). No leaks, stenosis, or mortality occurred. CONCLUSIONS LSG is a safe technique, but staple line-associated complications can be life-threatening. In this series, no leaks occurred from the very beginning of the surgeons' experience in LSG. Imbricated oversewing of the staple line, proper mentoring, and performance of surgery in appropriate settings are good approaches to decreasing complications.
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The Birmingham experience of high-pressure methylene blue dye test during primary and revisional bariatric surgery: A retrospective cohort study. Ann Med Surg (Lond) 2017; 23:32-34. [PMID: 29071067 PMCID: PMC5651492 DOI: 10.1016/j.amsu.2017.09.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 09/25/2017] [Accepted: 09/25/2017] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Leak following bariatric surgery continues to be associated with morbidity and rarely mortality. With improvement in surgical techniques and stapler design, leak rates have reduced drastically. Intra-operative high pressure Methylene blue leak test (HPMB) is one of the techniques employed to confirm integrity of anastomoses and staple lines. Despite this, evidence for its use remains limited. We evaluated the role of HPMB in detecting and preventing leaks. METHODS A retrospective cohort of consecutive patients who underwent primary or revisional Laparoscopic Sleeve Gastrectomy (SG) or Laparoscopic Roux-en-Y Gastric bypass (RYGB) under the care of five surgeons in three centres across Birmingham, UK, between 2012 and 2016 were assessed. All patients had routine HPMB at the end of the procedure. Demographics, HPMB positivity, and post operative leaks were recorded. RESULTS 924 patients underwent bariatric surgery: 696(75.3%) RYGB, and 225(24.3%) SG. 85(9.2%) were revisional procedures. Two HPMB were positive, which necessitated staple or suture line reinforcement with sutures intra-operatively. The patients had an uneventful recovery. 5 patients had postoperative leaks, all of whom had negative intraoperative HPMB: 3 SG patients; and 2 RYGB patients (gastro-jejunostomy anastomotic leaks). There was no statistically significant relationship between positive HPMB and anastomotic leak (Fishers exact test; p = 1). CONCLUSION Despite routine use of methylene blue dye test in 924 patients, there were only two positive tests. Whilst HPMB may demonstrate technical failure, this study suggests that there is no role for its routine use in primary bariatric surgery. Discontinuation of this practice would reduce risk of anaphylaxis to the dye, cost, and intra-operative time.
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Etiology of Leaks Following Sleeve Gastrectomy: Current Evidence. Surg Laparosc Endosc Percutan Tech 2017; 27:119-122. [DOI: 10.1097/sle.0000000000000400] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Bingham J, Kaufman J, Hata K, Dickerson J, Beekley A, Wisbach G, Swann J, Ahnfeldt E, Hawkins D, Choi Y, Lim R, Martin M. A multicenter study of routine versus selective intraoperative leak testing for sleeve gastrectomy. Surg Obes Relat Dis 2017. [PMID: 28629729 DOI: 10.1016/j.soard.2017.05.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Staple line leaks after sleeve gastrectomy are dreaded complications. Many surgeons routinely perform an intraoperative leak test (IOLT) despite little evidence to validate the reliability, clinical benefit, and safety of this procedure. OBJECTIVES To determine the efficacy of IOLT and if routine use has any benefit over selective use. SETTING Eight teaching hospitals, including private, university, and military facilities. METHODS A multicenter, retrospective analysis over a 5-year period. The efficacy of the IOLT for identifying unsuspected staple line defects and for predicting postoperative leaks was evaluated. An anonymous survey was also collected reflecting surgeons' practices and beliefs regarding IOLT. RESULTS From January 2010 through December 2014, 4284 patients underwent sleeve gastrectomy. Of these, 37 patients (.9%) developed a postoperative leak, and 2376 patients (55%) received an IOLT. Only 2 patients (0.08%) had a positive finding. Subsequently, 21 patients with a negative IOLT developed a leak. IOLT demonstrated a sensitivity of only 8.7%. There was a nonsignificant trend toward increased leak rates when an IOLT was performed versus when IOLT was not performed. Leak rates were not statistically different between centers that routinely perform IOLT versus those that selectively perform IOLT. CONCLUSIONS Routine IOLT had very poor sensitivity and was negative in 91% of patients who later developed postoperative leaks. The use of IOLT was not associated with a decrease in the incidence of postoperative leaks, and routine IOLT had no benefit over selective leak testing. IOLT should not be used as a quality indicator or "best practice" for bariatric surgery.
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Affiliation(s)
| | | | - Kai Hata
- San Antonio Military Medical Center, San Antonio, Texas
| | | | - Alec Beekley
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | | | - Jacob Swann
- William Beaumont Army Medical Center, El Paso, Texas
| | - Eric Ahnfeldt
- William Beaumont Army Medical Center, El Paso, Texas
| | - Devon Hawkins
- Eisenhower Army Medical Center, Fort Gordon, Georgia
| | - Yong Choi
- Eisenhower Army Medical Center, Fort Gordon, Georgia
| | - Robert Lim
- Tripler Army Medical Center, Honolulu, Hawaii
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Telem DA, Gould J, Pesta C, Powers K, Majid S, Greenberg JA, Teixeira A, Brounts L, Lin H, DeMaria E, Rosenthal R. American Society for Metabolic and Bariatric Surgery: care pathway for laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2017; 13:742-749. [DOI: 10.1016/j.soard.2017.01.027] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 01/20/2017] [Indexed: 02/06/2023]
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Balla A, Quaresima S, Leonetti F, Paone E, Brunori M, Messina T, Seitaj A, Paganini AM. Laparoscopic Sleeve Gastrectomy Changes in the Last Decade: Differences in Morbidity and Weight Loss. J Laparoendosc Adv Surg Tech A 2017; 27:1165-1171. [PMID: 28430045 DOI: 10.1089/lap.2017.0059] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Aim is to report the learning curve and standardization process of Laparoscopic Sleeve Gastrectomy (LSG), describing the evolution in surgical technique and patient management in the authors' experiences. METHODS One hundred twenty-seven patients were divided in three Groups (A, B, and C), based on bougie size and technical details, and included 36, 46, and 45 patients, respectively. RESULTS Mean operative time in Groups A, B, and C was 201.5, 150.8, and 172 minutes, respectively. Conversion to open surgery occurred in 1 Group A case. Eleven postoperative complications (8.6%) were observed (1 Group A, 8 Group B, 2 and Group C). Mean hospital stay in Groups A, B, and C, was 7.1, 6.9, and 3.1 days, respectively. At a mean follow-up of 69.7 months (Group A), 33.3 months (Group B), and 14.8 months (Group C), mean postoperative body mass index is 32.6, 28.1, and 31.5 kg/m2, respectively. Percentage estimated body mass index loss (%EBMIL) was 74.8% for Group A, 85.7% for Group B, and 68.1% for Group C. CONCLUSIONS LSG is a safe and effective procedure. In the postoperative course, meticulous alertness to early warning signs of sepsis and aggressive patient management are mandatory to prevent mortality. The use of a larger bougie size was associated with weight regain.
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Affiliation(s)
- Andrea Balla
- 1 Department of General Surgery and Surgical Specialties "Paride Stefanini," Sapienza University of Rome , Rome, Italy
| | - Silvia Quaresima
- 1 Department of General Surgery and Surgical Specialties "Paride Stefanini," Sapienza University of Rome , Rome, Italy
| | - Frida Leonetti
- 2 Department of Experimental Medicine, Sapienza University of Rome , Rome, Italy
| | - Emanuela Paone
- 1 Department of General Surgery and Surgical Specialties "Paride Stefanini," Sapienza University of Rome , Rome, Italy
| | - Marco Brunori
- 3 Department of Internal Medicine and Medical Specialities, Sapienza University of Rome , Rome, Italy
| | - Teresa Messina
- 1 Department of General Surgery and Surgical Specialties "Paride Stefanini," Sapienza University of Rome , Rome, Italy
| | - Ardit Seitaj
- 1 Department of General Surgery and Surgical Specialties "Paride Stefanini," Sapienza University of Rome , Rome, Italy
| | - Alessandro M Paganini
- 1 Department of General Surgery and Surgical Specialties "Paride Stefanini," Sapienza University of Rome , Rome, Italy
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Emerging Trends in the Etiology, Prevention, and Treatment of Gastrointestinal Anastomotic Leakage. J Gastrointest Surg 2016; 20:2035-2051. [PMID: 27638764 DOI: 10.1007/s11605-016-3255-3] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 08/12/2016] [Indexed: 02/08/2023]
Abstract
Anastomotic leaks represent one of the most alarming complications following any gastrointestinal anastomosis due to the substantial effects on post-operative morbidity and mortality of the patient with long-lasting effects on the functional and oncologic outcomes. There is a lack of consensus related to the definition of an anastomotic leak, with a variety of options for prevention and management. A number of patient-related and technical risk factors have been found to be associated with the development of an anastomotic leak and have inspired the development of various preventative measures and technologies. The International Multispecialty Anastomotic Leak Global Improvement Exchange group was convened to establish a consensus on the definition of an anastomotic leak as well as to discuss the various diagnostic, preventative, and management measures currently available.
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Iossa A, Abdelgawad M, Watkins BM, Silecchia G. Leaks after laparoscopic sleeve gastrectomy: overview of pathogenesis and risk factors. Langenbecks Arch Surg 2016; 401:757-66. [PMID: 27301373 DOI: 10.1007/s00423-016-1464-6] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 06/08/2016] [Indexed: 01/14/2023]
Abstract
BACKGROUND Leak is the second most common cause of death after bariatric surgery. The leak rate after laparoscopic sleeve gastrectomy (LSG) ranges between 1.1 and 5.3 %. The aim of the paper is to provide an overview of the current pathogenic and promoting factors of leakage after LSG on the basis of recent literature review and to report the evidence based preventive measures. METHODS Risk factors and pathogenesis of leakage after LSG were examined based on an extensive review of literature and evidence based analysis of the most recent published studies using Oxford centre for evidence-based medicine, 2011, levels of evidence. RESULTS Pathogenesis of leakage after LSG can be attributed to mechanical or ischemic causes. Many factors can predispose to leakage after LSG which are either technically related or patient related. Awareness of these predisposing factors and technical tips may decrease the incidence of leakage. CONCLUSIONS This review reports factors promoting leak and gives technical recommendations to avoid leak after LSG based on the available evidence and expert consensus which encompasses: (1) use a bougie size ≥40 Fr, EL:1, (2) begin the gastric transection 5-6 cm from the pylorus, EL:2-3, (3) use appropriate cartridge colors from antrum to fundus, EL:1, (4) reinforce the staple line with buttress material, EL:1, (5) follow a proper staple line, (6) remove the crotch staples, EL:4, (7) maintain proper traction on the stomach before firing, (8) stay away from the angle of His at least 1 cm, EL:1, (9) check the bleeding from the staple line, (10) perform an intraoperative methylene blue test, EL:4.
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Affiliation(s)
- Angelo Iossa
- Department of Medico-Surgical Sciences and Biotechnologies, Division of General Surgery and Bariatric Center of Excellence, La Sapienza University of Rome, Via F. Faggiana 1668, 04100, Latina, Italy.
| | - Mohamed Abdelgawad
- Department of Medico-Surgical Sciences and Biotechnologies, Division of General Surgery and Bariatric Center of Excellence, La Sapienza University of Rome, Via F. Faggiana 1668, 04100, Latina, Italy.,Gastroenterology Surgical Center (GEC), Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Brad Michael Watkins
- Division of General Surgery and Weight loss Center, West Chester Hospital, University of Cincinnati, Cincinnati, OH, USA
| | - Gianfranco Silecchia
- Department of Medico-Surgical Sciences and Biotechnologies, Division of General Surgery and Bariatric Center of Excellence, La Sapienza University of Rome, Via F. Faggiana 1668, 04100, Latina, Italy
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Shorter than 24-h hospital stay for sleeve gastrectomy is safe and feasible. Surg Endosc 2016; 30:5596-5600. [DOI: 10.1007/s00464-016-4933-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Accepted: 04/09/2016] [Indexed: 01/03/2023]
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Bingham J, Lallemand M, Barron M, Kuckelman J, Carter P, Blair K, Martin M. Routine intraoperative leak testing for sleeve gastrectomy: is the leak test full of hot air? Am J Surg 2016; 211:943-7. [PMID: 27020902 DOI: 10.1016/j.amjsurg.2016.02.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 02/01/2016] [Accepted: 02/03/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Staple line leak after sleeve gastrectomy (SG) is a rare but dreaded complication with a reported incidence of 0% to 8%. Many surgeons routinely test the staple line with an intraoperative leak test (IOLT), but there is little evidence to validate this practice. In fact, there is a theoretical concern that the leak test may weaken the staple line and increase the risk of a postop leak. METHODS Retrospective review of all SGs performed over a 7-year period was conducted. Cases were grouped by whether an IOLT was performed, and compared for the incidence of postop staple line leaks. The ability of the IOLT for identifying a staple line defect and for predicting a postoperative leak was analyzed. RESULTS Five hundred forty-two SGs were performed between 2007 and 2014. Thirteen patients (2.4%) developed a postop staple line leak. The majority of patients (n = 494, 91%) received an IOLT, including all 13 patients (100%) who developed a subsequent clinical leak. There were no (0%) positive IOLTs and no additional interventions were performed based on the IOLT. The IOLT sensitivity and positive predictive value were both 0%. There was a trend, although not significant, to increase leak rates when a routine IOLT was performed vs no routine IOLT (2.6% vs 0%, P = .6). CONCLUSIONS The performance of routine IOLT after SG provided no actionable information, and was negative in all patients who developed a postoperative leak. The routine use of an IOLT did not reduce the incidence of postop leak, and in fact was associated with a higher leak rate after SG.
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Affiliation(s)
- Jason Bingham
- Department of General Surgery, Madigan Army Medical Center, 9040 Fitzsimmons Drive, Tacoma, WA 98431, USA.
| | - Michael Lallemand
- Department of General Surgery, Madigan Army Medical Center, 9040 Fitzsimmons Drive, Tacoma, WA 98431, USA
| | - Morgan Barron
- Department of General Surgery, Madigan Army Medical Center, 9040 Fitzsimmons Drive, Tacoma, WA 98431, USA
| | - John Kuckelman
- Department of General Surgery, Madigan Army Medical Center, 9040 Fitzsimmons Drive, Tacoma, WA 98431, USA
| | - Preston Carter
- Department of General Surgery, Madigan Army Medical Center, 9040 Fitzsimmons Drive, Tacoma, WA 98431, USA
| | - Kelly Blair
- Department of General Surgery, Madigan Army Medical Center, 9040 Fitzsimmons Drive, Tacoma, WA 98431, USA
| | - Matthew Martin
- Department of General Surgery, Madigan Army Medical Center, 9040 Fitzsimmons Drive, Tacoma, WA 98431, USA
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Laparoscopic Sleeve Gastrectomy for Morbid Obesity in 3003 Patients: Results at a High-Volume Bariatric Center. Obes Surg 2016; 26:2045-2050. [DOI: 10.1007/s11695-016-2063-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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