Single-Stage Operative Management of Laparoscopic Sleeve Gastrectomy Leaks Without Endoscopic Stent Placement

Risk Factors and Management Approaches for Staple Line Leaks Following Sleeve Gastrectomy: A Single-Center Retrospective Study of 402 Patients

Sleeve gastrectomy (SG) has gained ever-increasing popularity among laparoscopic surgeons involved in bariatric surgery. This single-institution, retrospective cohort study aims to evaluate the prevalence of postoperative staple line leakage (PSLL) after LSG and identify risk factors for its development. We included patient data that underwent LSG at our institution for a span of 17 years-starting in January 2005 and ending in December 2022. We set the investigation of correlations of patient-related factors (age, weight, BMI, smoking status, presence of diabetes mellitus) with the occurrence of postoperative leaks. A total of 402 patients were included in our study. Of them, 26 (6.46%) developed PSLL. In total, 19 (73%) patients underwent percutaneous drainage and 14 patients (53.8%) were treated with intraluminal endoscopic stenting. Finally, five patients (19.2%) were treated with endoscopic clipping of the defect. Operative management was required in only one patient. There were no statistically significant differences in patient age, mean weight at the time of operation, and mean BMI. Abnormal drain amylase levels were associated with earlier detection of PSLL. More consideration needs to be given to producing a consensus regarding the management of PSLL, prioritizing nonoperative management with the combination of percutaneous drainage and endoscopic stenting as the safest and most efficient approach.

Treatment of Persistent Large Gastrocutaneous Fistulas After Bariatric Surgery: Preliminary Experience with Endoscopic Kehr's T-Tube Placement

Purpose

Post-bariatric surgery gastrocutaneous fistula is a chronic leak with an incidence of 1.7 to 4.0% and no standardized management. A large gastrocutaneous fistula (LGCF) is not indicated for treatment with pigtail drains. We aimed to evaluate results of a novel treatment using endoscopic Kehr’s T-tube placement.

Methods

Only patients with a postoperative LGCF duration of > 10 days and a flow rate of > 50 cc by external drainage after revisional surgery for sepsis were included. Endoscopic placement of Kehr’s T-tube was performed. Patients had been reoperated with wash and drainage for severe sepsis after initial bariatric surgery in which no fistula had been discovered. Patients not reoperated, or with a fistula requiring intraoperative Kehr’s T-tube placement, or a pigtail drain were excluded. Primary outcomes were endoscopic characteristics and results (LGCF closure rate, Kehr T-tube retention time, etc.).

Results

The study group included 12 women, 2 men; body mass index 43.1 ± 4.5 kg/m². Interventions were SG (7), RYGB (2), OAGB (4), and SADI-S (1). Endoscopic assessment was carried out after a mean of 33.2 ± 44.3 days after the bariatric procedure. The mean fistula orifice diameter was 2.0 ± 0.9 cm. Kehr’s T-tube was positioned at a mean 51.5 ± 54.8 days after the bariatric procedure. T-tube tolerance was excellent. Mean additional days: hospitalization, 34.4 ± 27.0; T-tube retention, 86.4 ± 73.1; fistula healing, 139.9 ± 111.5, LGCF closure rate, 92.9%. Complications: 1 pulmonary embolism, 2 T-tube migrations,1 drain-path bleed, 1 skin abscess. No mortality.

Conclusions

Endoscopic Kehr’s T-tube placement was successful in closing persistent post-bariatric surgery LGCF in 92.9% of patients.

Graphical abstract

Technical Details of Laparoscopic Sleeve Gastrectomy Leading to Lowered Leak Rate: Discussion of 1070 Consecutive Cases

Introduction

Laparoscopic sleeve gastrectomy is a widely utilized and effective surgical procedure for dramatic weight loss in obese patients. Leak at the sleeve staple line is the most serious complication of this procedure, occurring in 1–3% of cases. Techniques to minimize the risk of sleeve gastrectomy leaks have been published although no universally agreed upon set of techniques exists. This report describes a single-surgeon experience with an approach to sleeve leak prevention resulting in a progressive decrease in leak rate over 5 years.

Methods

1070 consecutive sleeve gastrectomy cases between 2012 and 2016 were reviewed retrospectively. Patient characteristics, sleeve leaks, and percent body weight loss at 6 months were reported for each year. Conceptual and technical changes aimed towards leak reduction are presented.

Results

With the implementation of the described techniques of the sleeve gastrectomy, the rate of sleeve leaks fell from 4% in 2012 to 0% in 2015 and 2016 without a significant change in weight loss, as depicted by 6-month change in body weight and percent excess BMI lost.

Conclusion

In this single-surgeon experience, sleeve gastrectomy leak rate has fallen to 0% since the implementation of specific technical modifications in the procedure.

Laparoscopic Roux En Y Esophago-Jejunostomy for Chronic Leak/Fistula After Laparoscopic Sleeve Gastrectomy

BACKGROUND

Leak following laparoscopic sleeve gastrectomy (LSG) is one of the most serious and devastating complications. Endoscopic stents can treat most early LSG leaks, but is not as effective for chronic LSG leaks/fistulae. The surgical options to treat a chronic leak/fistula after LSG are laparoscopic Roux en Y esophago-jejunostomy (LRYEJ) or laparoscopic Roux en Y fistulo-jejunostomy.

METHODS

We reviewed our prospective database for all patients with leak after LSG treated with LRYEJ. We have described our algorithm for managing LSG previously. We prefer to optimize the nutritional status of patients with enteral rather than parenteral nutrition and drain all collections prior to LRYEJ.

RESULTS

We have treated four patients utilizing our technique of LRYEJ. Initial endoscopic stent placement was attempted in all four patients (two failed to resolve (50 %) and two had distal stenosis at the incisura not amenable to endoscopic stenting). We utilized enteral feeding through either naso-jejunal (NJ) or jejunostomy tube feeding in 3/4 (75 %) of patients, and in one patient with stenosis, we could not introduce a NJ tube endoscopically due to tight stricture. This patient was placed on total parenteral nutrition (TPN) and went on to develop pulmonary embolism. None of the patient developed leak after LRYEJ. The only patient with stenosis (25 %) had antecolic LRYEJ. In contrast, all patients who had retrocolic LRYGB laparoscopically did not develop stenosis.

CONCLUSIONS

Laparoscopic Roux en Y esophago-jejunostomy for chronic leak/fistula after is safe and effective. Preoperative enteral nutrition is important.

Management Algorithm for Leaks Following Laparoscopic Sleeve Gastrectomy

BACKGROUND

Leak after laparoscopic sleeve gastrectomy (LSG) is a serious complication. No clear algorithm has been described for management.

METHODS

We reviewed our prospective database for all leaks after LSG treated at the Bariatric and Metabolic Institute (BMI) Abu Dhabi from 2010 to 2014. Our management algorithm is based on the timing of the LSG leak, nutritional status of the patient, and the presence of stenosis or peritonitis. Acute leaks with or without peritonitis are treated by operatively or utilizing endoscopic stenting, respectively. LSG leaks with stenosis not amenable to endoscopic stenting are treated with laparoscopic Roux en Y esophagojejunostomy (LRYEJ).

RESULTS

We performed 236 LSG without a leak, and 14 LSG leaks were referred to our unit. Mean age was 35.6 years, and 50 % of patients were males. Mean BMI was 37 kg/m(2). The patients presented on average 13.9 weeks after LSG. Enteral feeding was used as the primary nutrition route in 85.5 % of patients. Our management strategy was operative in 78.4 % of patients (jejunostomy feeding in 57 % and LRYEJ in 21.4 % of patients) and conservative with or without stents in 21.6 % of patients. Mean in hospital length of stay (LOS) was 5.6 weeks. Our reoperation rate was 7 %. There were no mortalities and one patient 7 % developed pulmonary embolism. None of the patients treated returned with a leak or collection after a mean follow up of 23.6 months.

CONCLUSION

Treating leaks following LSG based on the timing of presentation, presence of stricture, and malnutrition is safe and effective.

Laparo-Endoscopic Gastrostomy (LEG) Decompression: a Novel One-Time Method of Management of Gastric Leaks Following Sleeve Gastrectomy

BACKGROUND

Leakage is the most feared and challenging complication following laparoscopic sleeve gastrectomy (LSG) as it can either be life-threatening or lead to major morbidity. Its management can be very complex. Endoscopic stents seem to be the mainstay of the current modality of treatment but are associated with a high rate of complications and also need supportive procedures for sepsis control and feeding. We aimed to approach this problem through a one-step intervention, achieving three objectives: a prolonged decompression of the gastric tube through a laparo-endoscopically placed gastrostomy, feeding jejunostomy and external drainage.

METHODS

Between 2014 January and March 2015, seven patients were managed for gastric leaks (post LSG) in our center by this novel approach. Their records were reviewed for details like prior operation, presence of comorbidities, if revisional surgery, day of presentation following surgery, intraoperative findings, post-op recovery, length of hospital stay, and time to heal. The results were tabulated and studied.

RESULTS

Three were post primary LSG. Four were following revisional surgeries. Six out of seven (85.7 %) healed without alternative intervention. One patient with a large rent was managed by fistulojejunostomy. The average length of stay was 20.7 days. All patients were on postoperative enteral feeding through jejunostomy. There were no gastrostomy-related complications or mortality.

CONCLUSIONS

Laparo-endoscopic gastrostomy (LEG) decompression is a feasible, single-step, successful procedure in managing post LSG leaks and may be a viable alternative to avoid stent-related morbidity.

Percutaneous transesophageal gastro-tubing for management of gastric leakage after sleeve gastrectomy

Gastric leakage is a challenging complication of sleeve gastrectomy. Multimodal approaches, including drainage, clipping, and stenting of the leak, are occasionally insufficient. We report successful management of refractory gastric leakage using percutaneous transesophageal gastro-tubing (PTEG). Drainage and stenting proved inadequate for treating sleeve leakage near the esophagogastric junction in two patients. PTEG was finally performed, and enteral feeding was started on the following day. The patients were discharged within 1 week. The PTEG-tube was removed after confirming oral food intake. Both patients continue to do well without recurrence. PTEG was developed for patients who are unsuitable for percutaneous endoscopic gastrostomy. PTEG provides decompression and permits enteral feeding in patients refractory to other endoscopic treatments. PTEG is an option for managing intractable sleeve leakage without surgery.

Endoscopic Internal Drainage with Enteral Nutrition (EDEN) for treatment of leaks following sleeve gastrectomy

BACKGROUND

Endoscopic treatment of gastric leaks (GL) following sleeve gastrectomy (SG) involves different techniques; however, standard management is not yet established. We report our experience about endoscopic internal drainage of leaks using pigtail stents coupled with enteral nutrition (EDEN) for 4 to 6 weeks until healing is achieved.

METHODS

In 21 pts (18 F, 41 years), one or two plastic pigtail stents were delivered across the leak 25.6 days (4-98) post-surgery. In all patients, nasojejunal tube was inserted. Check endoscopy was done at 4 to 6 weeks with either restenting if persistent leak, or removal if no extravasation of contrast in peritoneal cavity, or closure with an Over-the-Scope Clip® (OTSC®) if contrast opacifying the crossing stent without concomitant peritoneal extravasation.

RESULTS

Twenty-one out of 21 (100 %) patients underwent check endoscopy at average of 30.15 days (26-45) from stenting. In 7/21 (33.3 %) patients leak sealed, 2/7 needed OTSC®. Second check endoscopy, 26.7 days (25-42) later, showed sealed leak in 10 out 14; 6/10 had OTSC®. Four required restenting. One patient, 28 days later, needed OTSC®. One healed at 135 days and another 180 days after four and seven changes, respectively. One patient is currently under treatment. In 20/21 (95.2 %), GL have healed with EID treatment of 55.5 days (26- 180); all are asymptomatic on a normal diet at average follow-up of 150.3 days (20-276).

CONCLUSIONS

EDEN is a promising therapeutic approach for treating leaks following SG. Multiple endoscopic sessions may be required.

Definitive surgical management of staple line leak after sleeve gastrectomy

BACKGROUND

Sleeve gastrectomy (SG) has become a widely adopted bariatric surgical procedure. The most serious complication is staple line leak (SLL), which is potentially life threatening and, in some patients, becomes chronic and difficult to manage. Definitive surgical management of SLL is effective but seldom published in the literature.

OBJECTIVES

This study aims to review the outcome of definitive surgical management of SLL after SG, looking at short-term and long-term results.

SETTING

Single surgeon experience based at a tertiary university hospital in Beirut, Lebanon.

METHODS

Retrospective review of records of patients with SLL who underwent definitive surgical treatment by the senior author (B.Y.S.) from January 2008 until December 2013.

RESULTS

Ten patients (50% female) underwent definitive surgical repair during the study period. The mean age, weight, and body mass index at the time of SG were 35 years, 121 kg, and 41.5 kg/m(2), respectively. Most leaks (90%) were at the esophagogastric junction. All underwent multiple operative, endoscopic, or radiologic procedures before definitive surgical repair. Methods of definitive repair included open Roux-en-Y (RY) esophagojejunostomy (70%), open RY gastric bypass (10%), laparoscopic RY esophagojejunostomy (10%), and one laparoscopic RY fistulojejunostomy (10%). Six patients (60%) underwent definitive surgical treatment because of chronic SLL, on average, 26 weeks after leak detection (range 13-39 wk). The other 4 underwent repair earlier, on average 4 weeks after leak detection (1-7 wk). There were no mortalities, and all patients healed without residual leak. Perioperative morbidity developed in 1 of 6 (17%) patients who underwent delayed repair and in 75% of patients who underwent repair early. Patients who underwent early repair were heavier (body mass index 40.5 kg/m(2) versus 30 kg/m(2)) and nutritionally more deplete (albumin 26.7 g/L versus 39.2 g/L). All patients are well at a mean follow-up of 21.6 months (7.5-55.9 mo) with an average percentage excess weight loss of 74% (57%-120%).

CONCLUSIONS

Definitive surgical management of SLL was uniformly effective with acceptable morbidity. It is indicated in patients with chronic persistent fistula beyond 12 weeks, provided patients are kept in good nutritional state. Some select patients may benefit from this approach in the early phases, but the surgical risks are higher.

Endoscopic gastric volume reduction with a novel articulating plication device is safe and effective in the treatment of obesity (with video)

BACKGROUND

Endoscopic volume reduction of the stomach may provide a minimally invasive alternative for surgical procedures in the treatment of obesity.

OBJECTIVE

To assess safety and preliminary effectiveness in the first human application of a novel endoscopic stapling technique.

DESIGN

Prospective, observational, phase 1 study.

SETTING

Two university hospitals in The Netherlands.

PATIENTS

Patients with a body mass index (BMI) of 40 to 45 kg/m(2) or 30 to 39.9 kg/m(2) with obesity-related comorbidity.

INTERVENTIONS

Gastric volume reduction with an endoscopic stapler.

MAIN OUTCOME MEASUREMENTS

Primary outcome measure was the prevalence of serious or mild adverse events. Reduction of excess body weight after 12 months was assessed as a secondary outcome measure for effectiveness of the procedure.

RESULTS

Seventeen patients with a median BMI of 40.2 kg/m(2) (interquartile range [IQR] 37.6-42.8) underwent an endoscopic stapling procedure. Median procedure time was 123 minutes (IQR 95-129). No serious adverse events occurred. Adverse events were gastric pain (n = 7, range 1-3 days), sore throat (n = 4, 2-3 days), diarrhea (n = 4, 2-15 days), nausea (n = 3, 2-4 days), constipation (n = 4, 3-14 days), and vomiting (n = 3, 1-4 days). All adverse events were mild and resolved with conservative treatment within 15 days after surgery. The median percentage excess weight loss in the first year was 34.9% (IQR 17.8-46.6).

LIMITATIONS

Limited number of patients.

CONCLUSION

This first human application of this endoscopic stapler demonstrates that the procedure is technically feasible and safe. One hundred sixty plications were created in 17 patients without significant problems. Weight loss after 1 year is promising, but long-term follow-up and randomized, controlled studies should evaluate whether this procedure is an effective and durable minimally invasive endoscopic treatment for obesity. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT01429194.).

Combined endoscopic-laparoscopic T-tube insertion for the treatment of staple-line leak after sleeve gastrectomy: a simple and effective therapeutic option

BACKGROUND

Management of staple-line leak after laparoscopic sleeve gastrectomy (LSG) remains controversial and matter of debate. Transforming a leak into a controlled fistula by insertion of a T-tube is a viable option. To minimize surgical dissection, and to facilitate identification of the leak site and insertion of the T-tube, we have developed a combined endoscopic-laparoscopic T-tube (ELT-t) insertion technique.

METHODS

Between February 2011 and June 2014, 7 patients presented with staple-line leak and were treated with ELT-t insertion. After laparoscopic dissection of the abscess cavity, a guidewire is passed endoscopically through the leak; a polypectomy snare is anchored to the guidewire and retrieved through the patient mouth. The long arm of a T-tube is eventually secured to the snare and pulled down through the leak.

RESULTS

All patients were started on oral feeding with the T-tube in place. Serial water-soluble contrast swallows were performed to check for healing, and the T-tube was clamped as soon as no extravasation of contrast was demonstrated. The tube was removed either during the index admission or in the outpatient clinic. The residual fistula closed successfully after T-tube removal in all but one case with a "spiral-shaped" sleeve and functional distal obstruction. This patient was treated with stent. Patients were discharged home after a mean postoperative hospital stay of 53.3 days (range: 15-87 days).

CONCLUSION

In our experience, ELT-t is a valid alternative for the treatment of staple-line leak after LSG. It allows minimizing surgical dissection, and appears to be safe and effective.

[Management of complications in bariatric surgery]

Bariatric surgery is known to be the most effective and long-lasting treatment for morbid obesity and associated comorbidities. These comorbidities together with cardiopulmonary decompensation make morbidly obese patients a high risk group for operative interventions. Early detection of postoperative complications is a challenging task in these patients and requires accurate and timely interpretation of any alarm signals. Symptoms, such as tachycardia and abdominal pain are highly suspicious. The same applies to elevated inflammatory parameters and fever. Early diagnostic laparoscopy is mandatory once cardiopulmonary complications have been excluded. Moreover, it has a higher sensitivity and specificity than other radiological modalities and is a minimally invasive procedure with a highly satisfactory outcome.