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Aloulou M, Martinino A, Alhejazi TJ, Pouwels S, Ahmed A, Byrne J, Parmar C. Sleeve Migration Following Sleeve Gastrectomy: A Systematic Review of Current Literature. Obes Surg 2024; 34:2237-2247. [PMID: 38703242 DOI: 10.1007/s11695-024-07259-5] [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: 03/04/2024] [Revised: 04/18/2024] [Accepted: 04/24/2024] [Indexed: 05/06/2024]
Abstract
Sleeve gastrectomy (SG) is the most frequently performed bariatric procedure worldwide. The incidence and consequences of sleeve migration (SM) are not clearly understood. There is no clear consensus on appropriate measures to reduce the risk of SM. This study systematically reviewed the literature and identified 405 cases of SM from 21 studies. Age ranged from 18 to 68 years. Thirty-two percent and 11% of patients were females and males respectively, while sex was not reported in 57%. Time to diagnosis ranged from 1 day to 5 years postoperatively. A total of 9.6% and 58.8% of patients had or had no previous hiatal hernia respectively. SM incidence, risk factors, proposed mechanisms, clinical presentation, diagnosis, management, and potential preventive strategies are described in this review.
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Affiliation(s)
- Mohammad Aloulou
- Department of Surgery, Faculty of Medicine, University of Aleppo, Aleppo, Syria.
- Nabd Alhayat Medical Center, Aleppo, Syria.
| | | | | | - Sjaak Pouwels
- Departments of Surgery, Marien Hospital Herne, University Hospital of the Ruhr University Bochum, Herne, Germany
| | - Ahmed Ahmed
- Department of Surgery, Imperial College London, London, UK
| | - James Byrne
- Department of Surgery, University Hospital Southampton, Southampton, UK
| | - Chetan Parmar
- Department of Surgery, Whittington Hospital, London, UK
- Apollo Hospitals Education and Research Foundation, Apollo Hospitals, Chennai, India
- University College London, London, UK
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2
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Elsherif SB, Sharma SK, Sharma S, Zulia Y, Kumar S, Sharma S. Acute incarcerated intrathoracic sleeve herniation after laparoscopic sleeve gastrectomy: an uncommon yet urgent complication-a comprehensive case report and literature review. Emerg Radiol 2023; 30:811-816. [PMID: 37934315 DOI: 10.1007/s10140-023-02182-1] [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: 09/30/2023] [Accepted: 10/27/2023] [Indexed: 11/08/2023]
Abstract
Laparoscopic sleeve gastrectomy (LSG) stands as one of the most frequently performed bariatric procedures in the USA. While hiatal hernia or intrathoracic migration of the staple line is frequently described as a chronic complication, this review article sheds light on the seldom-discussed acute presentation of this alarming complication. We present a compelling case of a young female who experienced sudden and intractable vomiting shortly after LSG. Utilizing a multidisciplinary approach, upper gastrointestinal imaging (UGI) and computed tomography (CT) scans unequivocally confirmed incarcerated intrathoracic migration of the gastric sleeve, necessitating immediate surgical intervention. Radiologists must be equipped with the knowledge to recognize subtle yet crucial imaging findings from UGI and CT scans to ensure timely intervention, thus mitigating the risks associated with this underreported acute complication of LSG and ultimately improving patient outcomes and safety.
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Affiliation(s)
- Sherif B Elsherif
- The Department of Radiology, The University of Florida College of Medicine, 2nd Floor, Clinical Center, 655 West 8th Street, C90, Jacksonville, FL, 33209, USA.
| | - Sunil K Sharma
- The Department of General Surgery, Ascension St. Vincent's Southside Hospital, Jacksonville, FL, USA
| | - Swati Sharma
- The Department of Radiology, The University of Florida College of Medicine, 2nd Floor, Clinical Center, 655 West 8th Street, C90, Jacksonville, FL, 33209, USA
| | - Yanni Zulia
- The Department of Radiology, The University of Florida College of Medicine, 2nd Floor, Clinical Center, 655 West 8th Street, C90, Jacksonville, FL, 33209, USA
| | - Sindhu Kumar
- The Department of Radiology, The University of Florida College of Medicine, 2nd Floor, Clinical Center, 655 West 8th Street, C90, Jacksonville, FL, 33209, USA
| | - Smita Sharma
- The Department of Radiology, The University of Florida College of Medicine, 2nd Floor, Clinical Center, 655 West 8th Street, C90, Jacksonville, FL, 33209, USA
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3
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Bhandarkar S, Kalikar V, Nasta A, Goel R, Patankar R. Post-laparoscopic sleeve gastrectomy, intrathoracic sleeve migration and its management: A case series and review of literature. J Minim Access Surg 2023; 19:544-547. [PMID: 36861531 PMCID: PMC10695314 DOI: 10.4103/jmas.jmas_149_22] [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: 05/24/2022] [Revised: 07/15/2022] [Accepted: 09/13/2022] [Indexed: 02/16/2023] Open
Abstract
De novo or persistent gastro-oesophageal reflux disease which may or may not be associated with injury of the oesophageal mucosa is now a known complication in post-sleeve gastrectomy patients. Repair of hiatal hernias to avoid such circumstances has been commonly performed, although recurrences may occur resulting in migration of gastric sleeve into the thorax, which is now a well-known complication. We report four cases of post-sleeve gastrectomy patients who presented with reflux symptoms, with their contrast-enhanced computed tomography abdomen showing intrathoracic sleeve migration and had hypotensive lower oesophageal sphincter with normal body motility on their oesophageal manometry. A laparoscopic revision Roux-en-Y gastric bypass surgery with hiatal hernia repair was performed for all four of them. No post-operative complications were seen at 1-year follow-up. Laparoscopic reduction of migrated sleeve with posterior cruroplasty and conversion to Roux-en-Y gastric bypass surgery can be safely performed for patients presenting with reflux symptoms in cases of intra-thoracic sleeve migration with good short-term outcomes.
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Affiliation(s)
- Sanatan Bhandarkar
- Department of Digestive Diseases, Zen Hospital, Mumbai, Maharashtra, India
| | - Vishakha Kalikar
- Department of Digestive Diseases, Zen Hospital, Mumbai, Maharashtra, India
| | - Amrit Nasta
- Department of Digestive Diseases, Zen Hospital, Mumbai, Maharashtra, India
| | - Ramen Goel
- Department of Digestive Diseases, Zen Hospital, Mumbai, Maharashtra, India
| | - Roy Patankar
- Department of Digestive Diseases, Zen Hospital, Mumbai, Maharashtra, India
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Szydlo Shein G, Elazary R, Marom G, Fishman Y, Abu Gazala M, Brodie R, Jacob H, Benson AA, Rivkind A, Pikarsky AJ, Mintz Y. Post-POEM Contrast-Enhanced Swallow Study: Is It Always Necessary? J Gastrointest Surg 2023; 27:878-886. [PMID: 36720757 DOI: 10.1007/s11605-023-05605-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 01/09/2023] [Indexed: 02/02/2023]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is rapidly becoming the procedure of choice for treating esophageal achalasia. In most centers, contrast-enhanced swallow studies (CESS) are routinely performed postoperatively to confirm mucosal integrity. The aim of this study was to determine the necessity of performing these studies routinely after POEM. METHODS A retrospective review of a prospectively maintained database of patients who underwent POEM between December 2012 and November 2020 was performed. All patients underwent a CESS on the first postoperative day. Medical records including vital signs, complete blood count, and POD-1 CESS were evaluated. RESULTS One hundred thirty-four consecutive patients were included in the study. Sixty-nine (51.49%) CESS showed abnormal findings; while most findings did not change the postoperative course, five (7.2%) demonstrated tunnel leaks, which did alter the overall management. Screening patients for fever, tachycardia, or leukocytosis on POD-1 had a 100% sensitivity and a 62% specificity for finding a clinically significant complication on CESS. CONCLUSIONS The study findings suggest that performing routine contrast-enhanced swallow studies on all patients is not necessary following POEM, as leaks can be screened for by clinical or laboratory abnormalities. Herein, we propose an algorithm based on objective measurable findings for the selection of patients who should undergo CESS.
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Affiliation(s)
- Gabriel Szydlo Shein
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Ram Elazary
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Gad Marom
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yuri Fishman
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Mahmud Abu Gazala
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ronit Brodie
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Harold Jacob
- Department of Gastroenterology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Ariel A Benson
- Department of Gastroenterology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Avraham Rivkind
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Alon J Pikarsky
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yoav Mintz
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
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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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Sabry K, Elmaleh HM, El-Swaify ST, Refaat MA, Atiya MAN, Alazab E, El-Abbassy I. Surgical Management Algorithm for Intrathoracic Sleeve Migration: A Retrospective Series and Literature Review. J Laparoendosc Adv Surg Tech A 2022; 32:1078-1091. [PMID: 36074085 DOI: 10.1089/lap.2022.0298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: With the increase in utilization of laparoscopic sleeve gastrectomy (LSG), intrathoracic sleeve migration (ITSM) has introduced a novel challenge for bariatric surgeons. Despite being an underreported complication, effective and safe solutions for ITSM are being sought. The aim of this study is to present our center's experience as well as a comprehensive review of the literature on ITSM. Accordingly, we propose an algorithm for the surgical management of ITSM. Methods: We conducted a retrospective chart review of 4000 patients who underwent LSG at our center. ITSM was clinically suspected with gastroesophageal reflux disease (GERD) symptoms and/or epigastric pain resistant to proton pump inhibitors. Diagnosis of ITSM was confirmed in all patients by three-dimensional computed tomography (3D-CT) volumetry. Several corrective procedures were offered based on the findings of the 3D-CT volumetry, esophagogastroduodenoscopy, and the diaphragmatic pillars' condition: cruroplasty with gastropexy, one anastomosis gastric bypass (OAGB), or Roux-en-Y gastric bypass (RYGB) with or without re-sleeve gastrectomy, omentopexy, or ligamentum teres augmentation. We conducted a literature review of ITSM using several databases. Results: Fifteen patients were diagnosed with postoperative ITSM. The most common presenting complaint was severely worsened GERD symptoms not responding to medical treatment. The mean time interval between the primary operation and diagnosis of ITSM was 38.8 ± 29.1 months. Three patients had re-sleeve gastrectomy and gastropexy, 5 patients had OAGB, and 7 patients had RYGB. The mean postoperative body mass index was 31.2 ± 4.9 kg/m2. No case of recurrent ITSM was detected during follow-up. Our electronic database search yielded 19 studies to be included in our review, which included 201 patients. Conclusion: A high index of suspicion is required to diagnose ITSM. CT volumetry with 3D reconstruction may be the most sensitive diagnostic modality. ITSM management should depend on the results of the diagnostic workup and the condition of the diaphragmatic pillars during surgery.
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Affiliation(s)
- Karim Sabry
- Division of Bariatric Surgery, Ain Shams University Hospitals, Cairo, Egypt
| | | | | | - Mazen A Refaat
- Department of Surgery, Ain Shams University Hospitals, Cairo, Egypt
| | | | - Emad Alazab
- Department of Surgery, Ain Shams University Hospitals, Cairo, Egypt
| | - Islam El-Abbassy
- Division of Bariatric Surgery, Ain Shams University Hospitals, Cairo, Egypt.,Department of Surgery, Raigmore Hospital, Inverness, United Kingdom.,Institute of Medical Sciences, King's College, University of Aberdeen, Aberdeen, United Kingdom
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Deręgowska-Cylke M, Palczewski P, Błaż M, Cylke R, Ziemiański P, Szeszkowski W, Lisik W, Gołębiowski M. Radiographic Measurement of Gastric Remnant Volume After Laparoscopic Sleeve Gastrectomy: Assessment of Reproducibility and Correlation with Weight Loss. Obes Surg 2021; 32:230-236. [PMID: 34799810 PMCID: PMC8794890 DOI: 10.1007/s11695-021-05812-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 11/10/2021] [Accepted: 11/14/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND As a restrictive procedure, laparoscopic sleeve gastrectomy (LSG) relies primarily on the reduction of gastric volume. It has been suggested that an immediate postoperative gastric remnant volume (GRV) may influence long-term results of LSG; however, there are no consensus in this matter. The aim of this study was to assess the reproducibility of different radiographic methods of GRV calculation and evaluate their correlation with the weight loss (WL) after surgery. METHODS This retrospective study evaluated 174 patients who underwent LSG in the period from 2014 to 2017. Using UGI, GRV was measured with 3 different mathematical methods by 2 radiologists. Intraobserver and interobserver calculations were made. Correlation between GRV and WL were estimated with calculations percentage of total weight loss (%TWL) and percentage of excess weight loss (%EWL) after 1, 3, 6, 12, 18, and 24 months postoperatively. RESULTS During analysis of intraobserver similarities, the results of ICC calculation showed that reproducibility was good to excellent for all GRV calculation methods. The intraobserver reproducibility for Reader I was highest for cylinder and truncated cone formula and for Reader II for ellipsoid formula. The interobserver reproducibility was highest for ellipsoid formula. Regarding correlation between GRV and WL, significant negative correlation has been shown on the 12th month after LSG in %TWL and %EWL for every method of GRV calculation, most important for ellipsoid formula (%TWL - r(X,Y) = -0.335, p < 0.001 and %EWL - r(X,Y) = -0.373, p < 0.001). CONCLUSION Radiographic methods of GRV calculation are characterized by good reproducibility and correlate with the postoperative WL.
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Affiliation(s)
| | - Piotr Palczewski
- 1st Department of Clinical Radiology, Medical University of Warsaw, Warsaw, Poland
| | - Marcin Błaż
- 1st Department of Clinical Radiology, Medical University of Warsaw, Warsaw, Poland
| | - Radosław Cylke
- Department of General and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Paweł Ziemiański
- Department of General and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Wojciech Szeszkowski
- 2nd Department of Clinical Radiology, Medical University of Warsaw, Warsaw, Poland
| | - Wojciech Lisik
- Department of General and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Marek Gołębiowski
- 1st Department of Clinical Radiology, Medical University of Warsaw, Warsaw, Poland
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Imaging after laparoscopic sleeve gastrectomy - literature review with practical recommendations. Pol J Radiol 2021; 86:e325-e334. [PMID: 34136051 PMCID: PMC8186309 DOI: 10.5114/pjr.2021.106795] [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] [Received: 08/14/2020] [Accepted: 09/06/2020] [Indexed: 11/17/2022] Open
Abstract
In the XXI century obesity has become one of the most demanding epidemiological threats worldwide. At the same time, bariatric surgery has established itself as an effective treatment for morbidly obese patients, with laparoscopic sleeve gastrectomy (LSG) emerging as the most popular bariatric procedure. This paper reviews the role of imaging studies of patients after LSG. Computed tomography is widely considered as the method of choice in detection of complications in early postoperative period. The dynamic character of upper gastrointestinal examination allows for the assessment of passage through the gastric remnant. The paper also discusses evaluation of the shape and volume of the gastric remnant assessed by imaging studies.
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Pavelko Y, Bustos R, Gruessner S, Hassan C. Acute Hiatal Hernia with Incarcerated Proximal Half of Recent Sleeve Gastrectomy: Super Rare Complication. Obes Surg 2020; 31:469-471. [PMID: 33179217 DOI: 10.1007/s11695-020-05101-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/29/2020] [Accepted: 10/29/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Vertical sleeve gastrectomy (VSG) has become the most commonly performed operation for the treatment of morbid obesity (JAMA. 312(9):959-61, 2014). Nevertheless, VSG is still associated with some early postoperative complications (JAMA. 312(9):959-61, 2014; Surg Obes Relat Dis. 9(5):816-29, 2013; Obes Surg. 27(8):1944-1951, 2017). Hiatal hernia is a complication that has been widely described in the literature, but not in the immediate postoperative course (Obes Surg. 17(7):962-9, 2007). We, herein, report a case of an acute postoperative hiatal hernia after sleeve gastrectomy. METHODS A 29-year-old female (BMI 38.54 kg/m2) presented to our center and her options for metabolic surgery were discussed. Laparoscopic sleeve gastrectomy (LSG) was the chosen procedure. Preoperative assessment includes a chest x-ray, and standard lab-work up was within a normal limit. Barium swallow did not show any evidence of hiatal hernia. She underwent a LSG. On POD 1, she was able to pass the bariatric clears trial and was discharged home. Three days after discharge, the patient was complaining of constant nausea and vomiting, and chest pain, and was diagnosed with acute hiatal hernia with the incarceration of the proximal sleeve. The patient was taken to the operating room. RESULTS Postoperatively, the patient started on the usual bariatric clinical pathway which she tolerated well and was discharged on the POD 4. The operative time was 156 min. The estimated blood loss was 50 ml. CONCLUSIONS Our report highlights the need for more broad differential diagnosis in early post sleeve gastrectomy patients. Those who are presented with nausea and vomiting in the early postoperative period should be evaluated for possible post sleeve hiatal hernia with a potential risk of strangulation.
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Affiliation(s)
- Yevhen Pavelko
- UI Health-Division of General, Minimally Invasive & Robotic Surgery, Department of Surgery, University of Illinois at Chicago, 820 South Wood Street, Rm 609, Clinical Sciences North Chicago, Chicago, IL, 60612, USA.
| | - Roberto Bustos
- UI Health-Division of General, Minimally Invasive & Robotic Surgery, Department of Surgery, University of Illinois at Chicago, 820 South Wood Street, Rm 609, Clinical Sciences North Chicago, Chicago, IL, 60612, USA
| | - Stephan Gruessner
- UI Health-Division of General, Minimally Invasive & Robotic Surgery, Department of Surgery, University of Illinois at Chicago, 820 South Wood Street, Rm 609, Clinical Sciences North Chicago, Chicago, IL, 60612, USA
| | - Chandra Hassan
- UI Health-Division of General, Minimally Invasive & Robotic Surgery, Department of Surgery, University of Illinois at Chicago, 820 South Wood Street, Rm 609, Clinical Sciences North Chicago, Chicago, IL, 60612, USA
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Challenges in the Diagnosis of Leak After Sleeve Gastrectomy: Clinical Presentation, Laboratory, and Radiological Findings. Obes Surg 2020; 31:612-616. [PMID: 33025538 PMCID: PMC7847981 DOI: 10.1007/s11695-020-05008-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 09/18/2020] [Accepted: 09/23/2020] [Indexed: 12/20/2022]
Abstract
Background The presentation of leak after laparoscopic sleeve gastrectomy (LSG) is variable. A missed or delayed diagnosis can lead to severe consequences. This study presents our experience: the clinical presentations, laboratory, and radiological findings in patients with leak after LSG. Methods A retrospective review of patients who were diagnosed and treated as leak after LSG at our center (January 2012–November 2019). Results Eighty patients developed leak: 68 (85%) after primary LSG, 6 (7.5%) after Re-LSG and 6 (7.5%) after band removal to revisional LSG. Mean age 35.9 ± 10 years. The diagnosis was within 18 ± 14 days after surgery. Five (6.3%) patients were diagnosed during the same admission. Only 29.3% of patients were diagnosed correctly from the first visit to the ER. Most were misdiagnosed as gastritis (49%) and pneumonia (22.6%). Thirty-four patients (45.3%) were diagnosed correctly at the third visit. The most common presenting symptoms were abdominal pain (90%), tachycardia (71.3%), and fever (61.3%). The mean white blood cells (WBCs) count was 14700 ± 5900 (cells/mm3), c-reactive protein (CRP) 270 ± 133 mg/L, lactic acid 1.6 ± 0.85 mmol/L, and albumin 30.3 ± 6.6 g/L. The abdominal CT scans revealed intraabdominal collection in 93.7% of patients, extravasation of contrast in 75%, and pleural effusion in 52.5%. Upper gastrointestinal contrast study (UGIC) showed extravasation of contrast in 77.5% of patients. Conclusion Abdominal pain, tachycardia, or fever after LSG should raise the suspicion of a leak. CT scan of the abdomen and UGIC study detected leaks in 75% and 77.5% consecutively. Only 29.3% of patients were diagnosed correctly as a leak from the first visit to the ER.
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11
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Alwatari Y, Roriz-Silva R, Bolckmans R, Campos GM. Intrathoracic sleeve gastrectomy migration with gastric volvulus treated with laparoscopic repair and conversion to gastric bypass. J Surg Case Rep 2020; 2020:rjaa234. [PMID: 32821368 PMCID: PMC7428739 DOI: 10.1093/jscr/rjaa234] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 07/07/2020] [Indexed: 01/15/2023] Open
Abstract
A 43 years old female with laparoscopic sleeve gastrectomy (SG) and an ‘anterior’ hiatal hernia repair 11 years ago, presented with 3 years history dysphagia and heartburn. Upper gastrointestinal barium showed an almost complete intrathoracic migration of the SG with a partial organoaxial volvulus. Upper endoscopy revealed a 10 cm hiatal hernia with grade B esophagitis. Laparoscopic revision surgery with reduction of the gastric sleeve, standard posterior hiatal hernia repair, resection of the narrowed remnant of the SG and conversion to a gastric bypass was performed. No postoperative complications occurred. The patient is asymptomatic at 2 years of follow-up. We present the technical standards for the management and discuss the suspected pathophysiology of this rare but challenging condition.
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Affiliation(s)
- Yahya Alwatari
- Virginia Commonwealth University, Division of Bariatric Surgery, Richmond, VA, USA
| | - Renato Roriz-Silva
- Virginia Commonwealth University, Division of Bariatric Surgery, Richmond, VA, USA
| | - Roel Bolckmans
- Virginia Commonwealth University, Division of Bariatric Surgery, Richmond, VA, USA
| | - Guilherme M Campos
- Virginia Commonwealth University, Division of Bariatric Surgery, Richmond, VA, USA
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12
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Knight J, Krishnaraj A. Utility of 3-Week Follow-Up of Upper Gastrointestinal Study in Asymptomatic Patients Following Laparoscopic Sleeve Gastrectomy. Curr Probl Diagn Radiol 2020; 49:260-265. [DOI: 10.1067/j.cpradiol.2019.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 04/23/2019] [Accepted: 05/07/2019] [Indexed: 01/19/2023]
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13
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Meknat A, Fernandez-Ranvier G, Hariri K, Guevara DE, Beitner M, Herron DM. Intrathoracic Sleeve Migrations After Sleeve Gastrectomy: A Compilation of Case Reports. J Laparoendosc Adv Surg Tech A 2020; 30:1013-1017. [PMID: 32552405 DOI: 10.1089/lap.2020.0237] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure in the United States. Postoperative migration of the stomach into the chest is a rare complication of this procedure. In this study, we present a compilation of acute and chronic intrathoracic sleeve migrations (ITSMs) after LSG and present possible underlying mechanisms of this complication, as described in the literature. Methods: We retrospectively reviewed the preoperative, intraoperative, and postoperative course of patients who had an ITSM after LSG between 2011 and 2019. Results: Two patients presented with this complication in the acute setting, whereas 3 patients developed ITSM as a chronic issue years after the primary procedure. All 5 were female patients, with a mean age and body mass index of 55.6 ± 9.5 (years) and 37.8 ± 2.9 kg/m2, respectively. None of the cases had a hiatal hernia repair during the initial operation. All cases were completed laparoscopically with reduction of the migrated sleeve into the abdomen and primary hiatal hernia repair. One case required a return to the operating room for an acute reherniation. Conclusion: In this article, we report a compilation of cases of ITSMs after LSG with distinct clinical features that highlight the diversity of possible reasons and risk factors for its development.
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Affiliation(s)
- Aryan Meknat
- Department of Surgery, Brookdale University Hospital and Medical Center, Brooklyn, New York, USA
| | - Gustavo Fernandez-Ranvier
- Division of Metabolic, Endocrine and Minimally Invasive Surgery, Department of Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kamyar Hariri
- Division of Metabolic, Endocrine and Minimally Invasive Surgery, Department of Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Daniela E Guevara
- Division of Metabolic, Endocrine and Minimally Invasive Surgery, Department of Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Melissa Beitner
- Division of Metabolic, Endocrine and Minimally Invasive Surgery, Department of Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Daniel M Herron
- Division of Metabolic, Endocrine and Minimally Invasive Surgery, Department of Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Palumbo D, Socci C, Martinenghi C, Guazzarotti G, Leone R, Nicoletti R, Rosati R, De Cobelli F. Leakage Risk Stratification After Laparoscopic Sleeve Gastrectomy (LSG): Is There a Role for Routine Postoperative CT Scan? Obes Surg 2020; 30:3370-3377. [PMID: 32291703 DOI: 10.1007/s11695-020-04586-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE Leakage of the gastric remnant after laparoscopic sleeve gastrectomy (LSG) represents an unpredictable, dreadful occurrence. Our aim was to assess whether routine postoperative CT scan is an effective tool for early prediction of leakage after LSG. MATERIALS AND METHODS From a prospectively acquired database, all consecutive patients who underwent LSG between January 2015 and December 2018 were identified; within this database, all patients who were evaluated with at least one contrast-enhanced CT scan within 48 h from surgery were enrolled in this retrospective study. The selected CT findings included twisting of the gastric remnant, perigastric air bubbles, and hematoma; the antral segment proximal from the pylorus to the first staple firing was also analyzed in terms of distance (StP, stapler to pylorus distance) and linearity (LI, linearity index). RESULTS After exclusions, 250 patients were included; 10 patients suffered from gastric leakage. Patients with perigastric hematoma and/or twisting of the distal part of the gastric remnant on routine postoperative CT scan were found to be more likely to develop leakage after LSG (p = 0.005 and p < 0.001, respectively). The mean StP was 45 ± 19.1 mm; the mean LI was 1.54 ± 0.4. Patients with subsequent development of leakage had significantly lower StP (26.7 ± 12.5 mm vs. 45.9 ± 18.9 mm; p = 0.001) and LI values (1.16 ± 0.11 vs. 1.55 ± 0.39; p = 0.002). CONCLUSION Routine postoperative CT scan after LSG permits early stratification of leakage risk, thus providing an actual aid for patients' management.
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Affiliation(s)
- Diego Palumbo
- Radiology Unit, San Raffaele Scientific Institute, San Raffaele Vita Salute University, via Olgettina 60, 20132, Milan, Italy. .,San Raffaele Vita Salute University, via Olgettina 60, 20132, Milan, Italy.
| | - Carlo Socci
- Metabolic, Bariatric and Transplant Surgery Unit, San Raffaele Scientific Institute, San Raffaele Vita Salute University, via Olgettina 60, 20132, Milan, Italy
| | - Carlo Martinenghi
- Radiology Unit, San Raffaele Scientific Institute, San Raffaele Vita Salute University, via Olgettina 60, 20132, Milan, Italy
| | - Giorgia Guazzarotti
- Radiology Unit, San Raffaele Scientific Institute, San Raffaele Vita Salute University, via Olgettina 60, 20132, Milan, Italy
| | - Riccardo Leone
- Radiology Unit, San Raffaele Scientific Institute, San Raffaele Vita Salute University, via Olgettina 60, 20132, Milan, Italy
| | - Roberto Nicoletti
- Radiology Unit, San Raffaele Scientific Institute, San Raffaele Vita Salute University, via Olgettina 60, 20132, Milan, Italy
| | - Riccardo Rosati
- San Raffaele Vita Salute University, via Olgettina 60, 20132, Milan, Italy.,GastroIntestinal Surgery Unit, San Raffaele Scientific Institute, San Raffaele Vita Salute University, via Olgettina 60, 20132, Milan, Italy
| | - Francesco De Cobelli
- Radiology Unit, San Raffaele Scientific Institute, San Raffaele Vita Salute University, via Olgettina 60, 20132, Milan, Italy.,San Raffaele Vita Salute University, via Olgettina 60, 20132, Milan, Italy
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Early Routine Upper Gastrointestinal Contrast Study Following Bariatric Surgery: an Indispensable Postoperative Care or a Medicolegal Heritage? Obes Surg 2020; 29:1995-1998. [PMID: 30945153 DOI: 10.1007/s11695-019-03850-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Concerns still exist regarding the role of early routine upper gastrointestinal contrast study (UGI) after bariatric procedures for detection of early complications. We reviewed our database to identify patients who underwent laparoscopic primary or redo surgery (previously placement of adjustable gastric banding), between January 2012 and December 2017. All the patients underwent UGI within 48 h after surgery. Among 1094 patients, early UGI was abnormal in 5 patients: in 4 cases a leak (one false positive) and in one case stenosis (one true positive) were suspected. In this clinical setting, five leaks were observed and required surgical re-exploration: 3 correctly identified and 2 not detected at UGI. Overall, 3 patients developed anastomotic stenosis. Our data suggest that early routine UGI after bariatric procedures has limited utility.
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16
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YARDIMCI E, YAPALAK Y. Are routine intraoperative and postoperative leakage tests needed in bariatric surgery? ARCHIVES OF CLINICAL AND EXPERIMENTAL MEDICINE 2020. [DOI: 10.25000/acem.654279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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17
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Alharbi SR. Computed Tomography-based Diagnosis of Post-laparoscopic Sleeve Gastrectomy Gastric Leak. J Clin Imaging Sci 2020; 10:8. [PMID: 32257584 PMCID: PMC7109466 DOI: 10.25259/jcis_5_2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 02/13/2020] [Indexed: 01/31/2023] Open
Abstract
Objective: Gastric leak post-laparoscopic sleeve gastrectomy may appear as a variety of computed tomography (CT) findings. We aimed to review the various CT findings sensitivity and specificity in confirmed cases of gastric leak. Materials and Methods: A retrospective review was performed for all patients who underwent sleeve gastrectomy, CT, and endoscopy for suspected leak between 2011 and 2018. All patients with positive CT findings for gastric leak were included in the study. Results: A total of 152 consecutive patients underwent CT for suspected post-sleeve gastrectomy gastric leak. Out of 152 patients, 88 had positive CT findings for gastric leak and underwent endoscopy. The CT findings sensitivity and specificity of perigastric collection without oral contrast leak were 61% and 88.8%, oral contrast leak were 28% and 100%, and gas leak were 10% and 77.7%, respectively. Conclusions: Perigastric fluid collection without contrast leak and with variable wall enhancement and gas content is the most common CT findings of post-sleeve gastrectomy gastric leak. Among various CT findings, it exhibits good diagnostic accuracy with 61% sensitivity and 88.8% specificity.
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Affiliation(s)
- Sultan R Alharbi
- Department of Radiology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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18
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Bhalla S, Yu JX, Varban OA, Schulman AR. Upper gastrointestinal series after sleeve gastrectomy is unnecessary to evaluate for gastric sleeve stenosis. Surg Endosc 2020; 35:631-635. [DOI: 10.1007/s00464-020-07426-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 02/10/2020] [Indexed: 01/07/2023]
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19
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Vitello DJ, Vitello JM, Beach-Bachmann J, Bentrem D. Value of Routine Gastrografin Upper Gastrointestinal Study After Sleeve Gastrectomy. JAMA Surg 2019; 154:181-182. [PMID: 30383124 DOI: 10.1001/jamasurg.2018.3197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - Joseph M Vitello
- Department of General and Bariatric Surgery, Jesse Brown VA Medical Center, Chicago, Illinois
| | - Joy Beach-Bachmann
- Department of General and Bariatric Surgery, Jesse Brown VA Medical Center, Chicago, Illinois
| | - David Bentrem
- Department of General and Bariatric Surgery, Jesse Brown VA Medical Center, Chicago, Illinois
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Musella M, Cantoni V, Green R, Acampa W, Velotti N, Maietta P, Cuocolo A. Efficacy of Postoperative Upper Gastrointestinal Series (UGI) and Computed Tomography (CT) Scan in Bariatric Surgery: a Meta-analysis on 7516 Patients. Obes Surg 2019. [PMID: 29516397 DOI: 10.1007/s11695-018-3172-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND To demonstrate the lack of utility and efficacy of routine early postoperative upper gastrointestinal study (UGI) in obese patients undergoing bariatric surgery and to show the higher efficacy of CT scan in cases of clinical suspicion of a leakage, a meta-analysis was performed. MATERIALS AND METHODS A literature search including articles published in last 18 years was performed. For both UGI and CT scan, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. A first analysis considered overall patients, and a second analysis considered only symptomatic patients. RESULTS Starting from 1233 eligible citations, 18 articles, including 7516 patients, were left. The pooled sensitivity was 54% for UGI (95% CI 34-74) with a high heterogeneity (I2 = 99.8%, p < .001), whereas CT scan showed a pooled sensitivity of 91% (95% CI 89-93) significantly higher than sensitivity of UGI series (p < 0.01), with a high heterogeneity (I2 = 98.9%, p < .001). In symptomatic patients the pooled sensitivity of UGI series was significantly lower than sensitivity of CT scan [49% (95% CI 31-68) vs 94% (95% CI 92-96), p < 0.01]. PPV showed a significant difference between UGI series and CT scan (54 vs 100%, p < 0.01). Specificity for UGI series was 98.6%, and specificity for CT scan was 99.7% (p = ns); the mean NPV was 96 and 98% for UGI series and CT scan (p = ns). CONCLUSIONS According to our results, a CT scan triggered by clinical suspicion must be considered the first-line procedure to detect a postoperative leak following primary sleeve gastrectomy or Roux-en-Y gastric bypass.
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Affiliation(s)
- Mario Musella
- Advanced Biomedical Sciences Department, Naples "Federico II" University, AOU "Federico II" - Via S. Pansini 5 Buildings 10/12, 80131, Naples, Italy.
| | - Valeria Cantoni
- Advanced Biomedical Sciences Department, Naples "Federico II" University, AOU "Federico II" - Via S. Pansini 5 Buildings 10/12, 80131, Naples, Italy
| | - Roberta Green
- Advanced Biomedical Sciences Department, Naples "Federico II" University, AOU "Federico II" - Via S. Pansini 5 Buildings 10/12, 80131, Naples, Italy
| | - Wanda Acampa
- Advanced Biomedical Sciences Department, Naples "Federico II" University, AOU "Federico II" - Via S. Pansini 5 Buildings 10/12, 80131, Naples, Italy
| | - Nunzio Velotti
- Advanced Biomedical Sciences Department, Naples "Federico II" University, AOU "Federico II" - Via S. Pansini 5 Buildings 10/12, 80131, Naples, Italy
| | - Paola Maietta
- Advanced Biomedical Sciences Department, Naples "Federico II" University, AOU "Federico II" - Via S. Pansini 5 Buildings 10/12, 80131, Naples, Italy
| | - Alberto Cuocolo
- Advanced Biomedical Sciences Department, Naples "Federico II" University, AOU "Federico II" - Via S. Pansini 5 Buildings 10/12, 80131, Naples, Italy
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21
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Rebibo L, Dhahri A, Badaoui R, Hubert V, Lorne E, Regimbeau JM. Laparoscopic sleeve gastrectomy as day-case surgery: a case-matched study. Surg Obes Relat Dis 2019; 15:534-545. [DOI: 10.1016/j.soard.2019.02.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 11/07/2018] [Accepted: 02/11/2019] [Indexed: 12/25/2022]
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22
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Not All Leaks Are Created Equal: a Comparison Between Leaks After Sleeve Gastrectomy and Roux-En-Y Gastric Bypass. Obes Surg 2018; 28:3775-3782. [DOI: 10.1007/s11695-018-3409-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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23
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Comparison of Imaging Modalities for Detecting Complications in Bariatric Surgery. Obes Surg 2017; 28:1063-1069. [PMID: 29047049 DOI: 10.1007/s11695-017-2970-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE The purpose of this study is to evaluate the results of routine fluoroscopic swallowing study (FSS) imaging 24 h after surgery and computed tomography (CT) on demand based on clinical data, in diagnosing complications after bariatric surgery. MATERIAL AND METHODS This retrospective study includes 9386 patients that underwent bariatric surgery. A total of 3241 (34.53%) patients underwent FSS imaging following the surgical procedure, and 106 (1.13%) patients underwent CT. RESULTS Sleeve gastrectomy was performed in 8093 patients (75.81%), gastric bypass was performed in 1281 patients (12%), duodenal switch or biliopancreatic diversion was performed in 12 patients (0.11%), and gastric banding was performed in 1289 patients (12.07%), which were excluded from the study as no imaging modality was used in any of these patients. The sensitivity for FSS was 71.43% and the specificity was 99.85%. An analysis of disease prevalence revealed a value of 0.43% with a positive predictive value of 66.67%. The sensitivity for CT was 71.42% and the specificity was 98%. A disease prevalence analysis revealed a value of 6.60% with a positive predictive value of 83.33%. A comparison of the two modalities showed that FSS has higher specificity values (p < 0.02) and a higher accuracy (p < 0.0001) than CT. CONCLUSION CT and FSS have a similar sensitivity for diagnosing complications after bariatric surgery. However, the specificity and accuracy of FSS are superior to that of CT. This study was approved by the instructional ethics committee (Helsinki board) and was registered on the National Institutes of Health ( ClinicalTrials.gov ) web site with identifier NCT02813122.
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Terterov D, Leung PHY, Twells LK, Gregory DM, Smith C, Boone D, Pace D. The usefulness and costs of routine contrast studies after laparoscopic sleeve gastrectomy for detecting staple line leaks. Can J Surg 2017; 60:335-341. [PMID: 28742012 DOI: 10.1503/cjs.015216] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Although laparoscopic sleeve gastrectomy (LSG) has been shown to be a safe and effective treatment for severe obesity (body mass index ≥ 35), staple line leaks remain a major complication and account for a substantial portion of the procedure's morbidity and mortality. Many centres performing LSG routinely obtain contrast studies on postoperative day 1 for early detection of staple line leaks. We examined the usefulness of Gastrografin swallow as an early detection test for staple line leaks on postoperative day 1 after LSG as well as the associated costs. METHODS We conducted a retrospective review of a prospectively collected database that included 200 patients who underwent LSG for severe obesity between 2011 and 2014. Primary outcome measures were the incidence of staple line leaks and the results of Gastrografin swallow tests. We obtained imaging costs from appropriate hospital departments. RESULTS Gastrografin swallow was obtained on postoperative day 1 for all 200 patients who underwent LSG. Three patients (1.5%) were found to have staple line leaks. Gastrograffin swallows yielded 1 true positive result and 2 false negatives. The false negatives were subsequently diagnosed on computed tomography (CT) scan. The sensitivity of Gastrografin swallow in this study was 33%. For 200 patients, the total direct cost of the Gastrografin swallows was $35 000. CONCLUSION The use of routine upper gastrointestinal contrast studies for early detection of staple line leaks has low sensitivity and is costly. We recommend selective use of CT instead.
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Affiliation(s)
- Dimitry Terterov
- From the Eastern Health Sciences Centre, St. John's, NL (Terterov, Leung, Boone, Pace); the Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL (Terterov, Leung, Twells, Gregory, Smith, Boone, Pace); and the School of Pharmacy, Memoral University of Newfoundland, St. John's, NL (Twells)
| | - Philemon Ho-Yan Leung
- From the Eastern Health Sciences Centre, St. John's, NL (Terterov, Leung, Boone, Pace); the Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL (Terterov, Leung, Twells, Gregory, Smith, Boone, Pace); and the School of Pharmacy, Memoral University of Newfoundland, St. John's, NL (Twells)
| | - Laurie K Twells
- From the Eastern Health Sciences Centre, St. John's, NL (Terterov, Leung, Boone, Pace); the Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL (Terterov, Leung, Twells, Gregory, Smith, Boone, Pace); and the School of Pharmacy, Memoral University of Newfoundland, St. John's, NL (Twells)
| | - Deborah M Gregory
- From the Eastern Health Sciences Centre, St. John's, NL (Terterov, Leung, Boone, Pace); the Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL (Terterov, Leung, Twells, Gregory, Smith, Boone, Pace); and the School of Pharmacy, Memoral University of Newfoundland, St. John's, NL (Twells)
| | - Chris Smith
- From the Eastern Health Sciences Centre, St. John's, NL (Terterov, Leung, Boone, Pace); the Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL (Terterov, Leung, Twells, Gregory, Smith, Boone, Pace); and the School of Pharmacy, Memoral University of Newfoundland, St. John's, NL (Twells)
| | - Darrell Boone
- From the Eastern Health Sciences Centre, St. John's, NL (Terterov, Leung, Boone, Pace); the Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL (Terterov, Leung, Twells, Gregory, Smith, Boone, Pace); and the School of Pharmacy, Memoral University of Newfoundland, St. John's, NL (Twells)
| | - David Pace
- From the Eastern Health Sciences Centre, St. John's, NL (Terterov, Leung, Boone, Pace); the Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL (Terterov, Leung, Twells, Gregory, Smith, Boone, Pace); and the School of Pharmacy, Memoral University of Newfoundland, St. John's, NL (Twells)
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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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Afaneh C. Comment: Value of routine upper gastrointestinal swallow study after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2017; 13:766-767. [PMID: 28416187 DOI: 10.1016/j.soard.2017.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 03/09/2017] [Indexed: 11/17/2022]
Affiliation(s)
- Cheguevara Afaneh
- Department of Surgery, New York-Presbyterian Hospital/Weill Cornell Medical College, New York, New York
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Rebibo L, Cosse C, Robert B, Chivot C, Yzet T, Dhahri A, Regimbeau JM. Eliminating routine upper gastrointestinal contrast studies after sleeve gastrectomy decreases length of stay and hospitalization costs. Surg Obes Relat Dis 2017; 13:553-559. [DOI: 10.1016/j.soard.2016.10.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 10/14/2016] [Accepted: 10/16/2016] [Indexed: 02/06/2023]
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Saber AA, Shoar S, Khoursheed M. Intra-thoracic Sleeve Migration (ITSM): an Underreported Phenomenon After Laparoscopic Sleeve Gastrectomy. Obes Surg 2017; 27:1917-1923. [DOI: 10.1007/s11695-017-2589-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Chivot C, Rebibo L, Robert B, Dhahri A, Regimbeau JM, Yzet T. Value of routine upper gastrointestinal swallow study after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2017; 13:758-765. [PMID: 28330791 DOI: 10.1016/j.soard.2017.02.003] [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] [Received: 12/03/2016] [Revised: 02/04/2017] [Accepted: 02/07/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Gastric leak (GL) is one of the main early-onset postoperative complications of sleeve gastrectomy (SG). Many institutions perform routine upper gastrointestinal (UGI) contrast studies within 24 hours of surgery, looking for GL or gastric stenosis and to determine the need for urgent re-exploration, but this examination delays oral feeding, can cause side effects and is responsible for systematic and probably unnecessary irradiation of the patient. OBJECTIVE Determine the efficacy of routine UGI contrast studies to predict postoperative complications after SG in a large population. SETTING University hospital, France, public practice. MATERIAL AND METHODS This study consisted of retrospective review of a prospective database of a cohort of patients who underwent primary SG between January 2007 and August 2013 (n = 1137). Routine UGI contrast studies, performed on postoperative day 1, were independently reviewed by 2 radiologists. The primary endpoint of the study was the effect of routine UGI contrast study on detecting postoperative complications. The secondary endpoints were comparison of the findings of routine UGI contrast study and abdominal computed tomography (CT) scan, sensitivity, and specificity of different imaging signs on abdominal CT scan in the presence of GL, evaluation of the SG learning curve based on the findings of routine UGI contrast studies. RESULTS A total of 1137 patients underwent primary SG and 30 GL (2.6%) with a mean time to diagnosis of 23.4 days (1-245) and 15 cases of gastric stenosis (1.3%) were observed during the study period. Routine UGI study was performed in 1108 patients, whereas 29 patients were assessed by first-line CT scan. None of the 1108 UGI studies found a GL or gastric stenosis. In the 30 cases of GL, the most sensitive and specific sign was the presence of perigastric abscess without contrast material leak (sensitivity: 56.6%; specificity: 95%). The mean time interval between routine postoperative UGI contrast study and abdominal CT scan was 12.9 days (0-86). Uniform gastric shape was acquired after 30-32 SG procedures. CONCLUSION Routine postoperative UGI on postoperative day 1 is of limited value after SG. Abdominal CT scan should be preferred in the presence of clinical suspicion of postoperative complications. Selective UGI contrast study remains indicated when gastric stenosis is suspected and at the beginning of the SG learning curve.
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Affiliation(s)
- Cyril Chivot
- Department of Radiology, Amiens University Hospital, Amiens, France
| | - Lionel Rebibo
- Department of Digestive Surgery, Amiens University Hospital, Amiens, France
| | - Brice Robert
- Department of Radiology, Amiens University Hospital, Amiens, France
| | - Abdennaceur Dhahri
- Department of Digestive Surgery, Amiens University Hospital, Amiens, France
| | - Jean-Marc Regimbeau
- Department of Digestive Surgery, Amiens University Hospital, Amiens, France; Jules Verne University of Picardie, Amiens, France; Clinical Research Center, Amiens University Hospital, Amiens, France.
| | - Thierry Yzet
- Department of Radiology, Amiens University Hospital, Amiens, France
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Sofianos C, Sofianos C. Outcomes of laparoscopic sleeve gastrectomy at a bariatric unit in South Africa. Ann Med Surg (Lond) 2016; 12:37-42. [PMID: 27895905 PMCID: PMC5121134 DOI: 10.1016/j.amsu.2016.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 11/12/2016] [Accepted: 11/12/2016] [Indexed: 01/06/2023] Open
Abstract
Background Laparoscopic sleeve gastrectomy (LSG) has gained popularity over the years as a standalone procedure. In 2014, it was the most rapidly growing bariatric procedure. The aim of this study was to describe the outcomes of LSG at a single bariatric unit in Johannesburg, South Africa, using the Bariatric Analysis and Reporting Outcome System (BAROS) standardised scoring. Methods A retrospective record review and analysis was carried out using data collected from patients who had LSGs. The information obtained included patient demographics, comorbidities, preoperative weight and height, operative technique, time and complications, postoperative gastrografin swallow results, hospital stay, and weight at 6 months postoperatively. The percentage of excess body mass index (BMI) loss (%EBMIL) was calculated at 6 months, and included in the BAROS questionnaire completed by the patients at the 6-month follow-up visit. Statistical significance was set at p < 0.05. Results A total of 103 patients were included in the study; of these, 85.4% were female and 14.6% were male. The mean preoperative BMI was 42.1 kg/m2; additionally, 77.7% of the patients in the study had comorbidities prior to the procedure. The mean operative time was 104.3 min, with a mean hospital stay of 2.5 days. No mortalities occurred, and a complication rate of 7.7% was encountered. At the 6-month follow-up, the mean %EBMIL was 65%. When followed up at 6 months, all 103 patients demonstrated no failures according to the BAROS assessment. It was found that 96.1% had good, very good or excellent outcomes. In total, 9.7% of the patients had an excellent outcome. Conclusions LSG was shown to produce an adequate %EBMIL loss at 6 months, resulting in a significant improvement in the quality of life (QoL), coupled with good BAROS outcomes. The results of this research are comparable to other studies of LSGs, and the low complication rate supports the use of the procedure and accounts for no observed mortality. First study of laparoscopic sleeve gastrectomy performed in South Africa. Laparoscopic sleeve gastrectomy produces an adequate percentage excess BMI loss at 6 months. A significant improvement in the quality of life was observed. Results of this research are comparable to other studies of LSGs. Low complication rate supports the use of the procedure.
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Lainas P, Tranchart H, Gaillard M, Ferretti S, Donatelli G, Dagher I. Prospective evaluation of routine early computed tomography scanner in laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2016; 12:1483-1490. [PMID: 27387688 DOI: 10.1016/j.soard.2016.03.031] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 03/27/2016] [Accepted: 03/28/2016] [Indexed: 01/18/2023]
Abstract
BACKGROUND Prompt management of laparoscopic sleeve gastrectomy (LSG) complications is essential in avoiding prolonged hospital stay and associated mortality. The value of routine computed tomography (CT) scan examination in early diagnosis of postoperative complications after LSG has not been studied. OBJECTIVES To prospectively assess the impact of postoperative day (POD) 2 CT scan after LSG. SETTING Department of Minimally Invasive Digestive Surgery, Antoine-Beclere Hospital, AP-HP, Paris-Saclay University, France. METHODS Data were prospectively gathered for 1000 patients undergoing single-incision LSG and POD 2 CT scan. Complications were identified and treatment modalities decided according to the severity of complications. Sensitivity, specificity, and positive and negative predictive values were calculated for the diagnosis of surgical complications on POD 2 CT scan. RESULTS Mean age was 40.1 years and median BMI 42.6 kg/m². Early postoperative surgical complications occurred in 66 patients (6.6%). Intraabdominal bleeding/hematoma occurred in 38 patients, with 3 requiring emergent reoperation on POD 1. POD 2 CT scan detected this complication in 32 patients (sensitivity: 91.4%). Twenty-four (63.1%) patients were treated with relaparoscopy and drainage while 14 (36.9%) received conservative management. Postoperative transfusion was required in 7 patients. Twenty-eight patients suffered a gastric staple line leak, 13 (sensitivity: 46.4%) detected on POD 2 CT scan. Three patients (10.7%) received pure surgical treatment, 16 (57.1%) combined relaparoscopy and endoscopic treatment, and 9 (32.2%) had pure endoscopic treatment. CONCLUSION POD 2 abdominal CT scan is an efficient diagnostic tool for detecting active bleeding/hematoma, but shows less impressive results with gastric staple line leak detection. A combination of clinical surveillance and early imaging allowed prompt management of complicated cases, avoiding further morbidity.
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Affiliation(s)
- Panagiotis Lainas
- Department of Minimally Invasive Digestive Surgery, Antoine-Beclere Hospital, AP-HP, Clamart, France; Paris-Saclay University, Orsay, France
| | - Hadrien Tranchart
- Department of Minimally Invasive Digestive Surgery, Antoine-Beclere Hospital, AP-HP, Clamart, France; Paris-Saclay University, Orsay, France
| | - Martin Gaillard
- Department of Minimally Invasive Digestive Surgery, Antoine-Beclere Hospital, AP-HP, Clamart, France; Paris-Saclay University, Orsay, France
| | - Stefano Ferretti
- Department of Minimally Invasive Digestive Surgery, Antoine-Beclere Hospital, AP-HP, Clamart, France
| | - Gianfranco Donatelli
- Department of Interventional Endoscopy, Peupliers Private Hospital, Paris, France
| | - Ibrahim Dagher
- Department of Minimally Invasive Digestive Surgery, Antoine-Beclere Hospital, AP-HP, Clamart, France; Paris-Saclay University, Orsay, France.
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Hussain A, El-Hasani S. Diagnostic Laparoscopy or CT Scan to Diagnose the Leak Following Bariatric Surgery. Obes Surg 2015; 26:617-8. [PMID: 26694208 DOI: 10.1007/s11695-015-2013-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- A Hussain
- Brighton & Sussex University Hospital, Eastern Road, Royal Sussex County Hospital, BN2 5BE, Brighton, UK.
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Sethi M, Magrath M, Somoza E, Parikh M, Saunders J, Ude-Welcome A, Schwack B, Kurian M, Fielding G, Ren-Fielding C. The utility of radiological upper gastrointestinal series and clinical indicators in detecting leaks after laparoscopic sleeve gastrectomy: a case-controlled study. Surg Endosc 2015; 30:2266-75. [PMID: 26416376 DOI: 10.1007/s00464-015-4516-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 08/06/2015] [Indexed: 01/14/2023]
Abstract
BACKGROUND Leak after laparoscopic sleeve gastrectomy (LSG) often presents after hospital discharge, making timely diagnosis difficult. This study evaluates the utility of radiological upper gastrointestinal (UGI) series and clinical indicators in detecting leak after LSG. METHODS A retrospective case-controlled study of 1762 patients who underwent LSG from 2006 to 2014 was performed. All patients with radiographically confirmed leaks were included. Controls consisted of patients who underwent LSG without leak, selected using a 10:1 case-match. Data included baseline patient characteristics, surgical characteristics, and UGI series results. Clinical indicators including vital signs, SIRS criteria, and pain score were compared between patients who developed leak and controls. RESULTS Of 1762 LSG operations, 20 (1.1 %) patients developed leaks and were compared with 200 case-matched controls. Three patients developed leak during their index admission [mean = 1.3 days, range (1, 2)], while the majority (n = 17) were discharged and developed symptoms at a mean of 17.1 days [range (4, 63)] postoperatively. Patients diagnosed with leak were similar to controls in baseline and surgical characteristics. Contrast extravasation on routine postoperative UGI identified two patients with early leaks, but was negative in the remainder (89 %). Patients with both early and delayed leaks demonstrated significant clinical abnormalities at the time of leak presentation, prior to confirmatory radiographic study. In multiple regression analysis, independent clinical factors associated with leak included fever [OR 16.6, 95 % CI (4.04, 68.10), p < 0.0001], SIRS criteria [OR 7.0, 95 % CI (1.47, 33.26), p = 0.014], and pain score ≥9 [OR 19.1, 95 % CI (1.38, 263.87), p = 0.028]. CONCLUSIONS Contrast extravasation on routine postoperative radiological UGI series may detect early leaks after LSG, but the vast majority of leaks demonstrate normal results and present 2-3 weeks after discharge. Therefore, clinical indicators (specifically fever, SIRS criteria, and pain score) are the most useful factors to raise concern for leaks prior to confirmatory radiographic study and may be used as criteria to selectively obtain UGI studies after LSG.
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Affiliation(s)
- Monica Sethi
- Division of Bariatric Surgery, Department of Surgery, New York University School of Medicine, 530 First Avenue, Suite 10S, New York, NY, 10016, USA.
| | - Melissa Magrath
- Division of Bariatric Surgery, Department of Surgery, New York University School of Medicine, 530 First Avenue, Suite 10S, New York, NY, 10016, USA
| | - Eduardo Somoza
- Division of Bariatric Surgery, Department of Surgery, New York University School of Medicine, 530 First Avenue, Suite 10S, New York, NY, 10016, USA
| | - Manish Parikh
- Division of Bariatric Surgery, Department of Surgery, New York University School of Medicine, 530 First Avenue, Suite 10S, New York, NY, 10016, USA
| | - John Saunders
- Division of Bariatric Surgery, Department of Surgery, New York University School of Medicine, 530 First Avenue, Suite 10S, New York, NY, 10016, USA
| | - Aku Ude-Welcome
- Division of Bariatric Surgery, Department of Surgery, New York University School of Medicine, 530 First Avenue, Suite 10S, New York, NY, 10016, USA
| | - Bradley Schwack
- Division of Bariatric Surgery, Department of Surgery, New York University School of Medicine, 530 First Avenue, Suite 10S, New York, NY, 10016, USA
| | - Marina Kurian
- Division of Bariatric Surgery, Department of Surgery, New York University School of Medicine, 530 First Avenue, Suite 10S, New York, NY, 10016, USA
| | - George Fielding
- Division of Bariatric Surgery, Department of Surgery, New York University School of Medicine, 530 First Avenue, Suite 10S, New York, NY, 10016, USA
| | - Christine Ren-Fielding
- Division of Bariatric Surgery, Department of Surgery, New York University School of Medicine, 530 First Avenue, Suite 10S, New York, NY, 10016, USA
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Meredith I, Lim YK, Wickremesekera SK, Bann S. Experience of imaging following laparoscopic sleeve gastrectomy. ANZ J Surg 2015; 86:568-71. [PMID: 26333708 DOI: 10.1111/ans.13284] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND We aimed to report our experience with upper gastrointestinal (UGI) contrast studies and computed tomography (CT) swallow studies after laparoscopic sleeve gastrectomy, and comment on the merits of each modality. METHOD Retrospective review of all patients undergoing laparoscopic sleeve gastrectomy (LSG) in a New Zealand hospital between 2011 and 2014 was conducted. Over this time period, routine UGI was replaced by CT swallow studies. All medical records and radiology were reviewed and pertinent findings reported. RESULTS Seventy-nine patients underwent LSG over this time period and one patient had to be excluded; 48 (61.5%) had a UGI study and 30 patients (38.5%) had CT swallow. There were no leaks in this study and no leaks became clinically significant. Sixteen of 30 patients (53.3%) undergoing CT swallow had significant incidental findings demonstrated on axial imaging that required follow-up. CONCLUSION CT swallow can provide the same information as a UGI but has a significant rate of incidental findings. The rate of incidental pathology on CT is higher than that quoted in the general population. In a bariatric population, this may allow early detection and treatment of co-existent pathology.
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Affiliation(s)
- Ineke Meredith
- Department of General Surgery, North Shore Hospital, Auckland, New Zealand.,Wellington School of Medicine, University of Otago, Wellington, New Zealand
| | - Yu Kai Lim
- Department of General Surgery, Wellington Regional Hospital, Wellington, New Zealand
| | | | - Simon Bann
- Wellington School of Medicine, University of Otago, Wellington, New Zealand.,Department of General Surgery, Wellington Regional Hospital, Wellington, New Zealand.,Victoria University, Wellington, New Zealand
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Kim J, Azagury D, Eisenberg D, DeMaria E, Campos GM. ASMBS position statement on prevention, detection, and treatment of gastrointestinal leak after gastric bypass and sleeve gastrectomy, including the roles of imaging, surgical exploration, and nonoperative management. Surg Obes Relat Dis 2015; 11:739-48. [DOI: 10.1016/j.soard.2015.05.001] [Citation(s) in RCA: 141] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Sethi M, Zagzag J, Patel K, Magrath M, Somoza E, Parikh MS, Saunders JK, Ude-Welcome A, Schwack BF, Kurian MS, Fielding GA, Ren-Fielding CJ. Intraoperative leak testing has no correlation with leak after laparoscopic sleeve gastrectomy. Surg Endosc 2015; 30:883-91. [PMID: 26092015 DOI: 10.1007/s00464-015-4286-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 05/25/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND Staple line leak is a serious complication of sleeve gastrectomy. Intraoperative methylene blue and air leak tests are routinely used to evaluate for leak; however, the utility of these tests is controversial. We hypothesize that the practice of routine intraoperative leak testing is unnecessary during sleeve gastrectomy. METHODS A retrospective cohort study was designed using a prospectively collected database of seven bariatric surgeons from two institutions. All patients who underwent sleeve gastrectomy from March 2012 to November 2014 were included. The performance of intraoperative leak testing and the type of test (air or methylene blue) were based on surgeon preference. Data obtained included BMI, demographics, comorbidity, presence of intraoperative leak test, result of test, and type of test. The primary outcome was leak rate between the leak test (LT) and no leak test (NLT) groups. SAS version 9.4 was used for univariate and multivariate analyses. RESULTS A total of 1550 sleeve gastrectomies were included; most were laparoscopic (99.8%), except for one converted and two open cases. Routine intraoperative leak tests were performed in 1329 (85.7%) cases, while 221 (14.3%) did not have LTs. Of the 1329 cases with LTs, there were no positive intraoperative results. Fifteen (1%) patients developed leaks, with no difference in leak rate between the LT and NLT groups (1 vs. 1%, p = 0.999). After adjusting for baseline differences between the groups with a propensity analysis, the observed lack of association between leak and intraoperative leak test remained. In this cohort, leaks presented at a mean of 17.3 days postoperatively (range 1-67 days). Two patients with staple line leaks underwent repeat intraoperative leak testing at leak presentation, and the tests remained negative. CONCLUSION Intraoperative leak testing has no correlation with leak due to laparoscopic sleeve gastrectomy and is not predictive of the later development of staple line leak.
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Affiliation(s)
- Monica Sethi
- Department of Surgery, New York University School of Medicine, 530 First Ave., Suite 10S, New York, NY, 10016, USA.
| | - Jonathan Zagzag
- Department of Surgery, New York University School of Medicine, 530 First Ave., Suite 10S, New York, NY, 10016, USA
| | - Karan Patel
- Department of Surgery, New York University School of Medicine, 530 First Ave., Suite 10S, New York, NY, 10016, USA
| | - Melissa Magrath
- Department of Surgery, New York University School of Medicine, 530 First Ave., Suite 10S, New York, NY, 10016, USA
| | - Eduardo Somoza
- Department of Surgery, New York University School of Medicine, 530 First Ave., Suite 10S, New York, NY, 10016, USA
| | - Manish S Parikh
- Department of Surgery, New York University School of Medicine, 530 First Ave., Suite 10S, New York, NY, 10016, USA
| | - John K Saunders
- Department of Surgery, New York University School of Medicine, 530 First Ave., Suite 10S, New York, NY, 10016, USA
| | - Aku Ude-Welcome
- Department of Surgery, New York University School of Medicine, 530 First Ave., Suite 10S, New York, NY, 10016, USA
| | - Bradley F Schwack
- Department of Surgery, New York University School of Medicine, 530 First Ave., Suite 10S, New York, NY, 10016, USA
| | - Marina S Kurian
- Department of Surgery, New York University School of Medicine, 530 First Ave., Suite 10S, New York, NY, 10016, USA
| | - George A Fielding
- Department of Surgery, New York University School of Medicine, 530 First Ave., Suite 10S, New York, NY, 10016, USA
| | - Christine J Ren-Fielding
- Department of Surgery, New York University School of Medicine, 530 First Ave., Suite 10S, New York, NY, 10016, USA
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Al-Sanea O, Al-Garzaie A, Dernaika M, Haddad J. Rare complication post sleeve gastrectomy: Acute irreducible paraesophageal hernia. Int J Surg Case Rep 2015; 8C:88-91. [PMID: 25644556 PMCID: PMC4353937 DOI: 10.1016/j.ijscr.2015.01.040] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 01/17/2015] [Accepted: 01/25/2015] [Indexed: 01/07/2023] Open
Abstract
Since early postoperative nausea and vomiting are fairly common, a high index of suspicion was essential for the diagnosis. Taking into account the asymptomatic intrathoracic sleeve migration described in the literature, thoracic cuts of the CT Scan are essential in post sleeve evaluation. Sleeve gastrectomy might disrupt the lower esophageal sphincter pressure and aggravate a pre-existing asymptomatic weak sphincter. The only other 2 reported cases occurred in the setting of a hiatal hernia. In ours no hiatal defect was observed.
Introduction Laparoscopic sleeve gastrectomy has been accepted as a standalone effective bariatric procedure. With the increase in the number of cases done worldwide, we are witnessing the emergence of new unexpected complications. Presentation A seemingly straight forward sleeve gastrectomy was complicated by acute post-operative vomiting which was diagnosed as an acute intra thoracic migration of part of the new sleeve. Surgical repair was done, with reduction and fixation of the stomach. Patient was subsequently relieved of his symptoms and discharged. Discussion This is a rare complication of a relatively well studied operation. Faced with severe post operative repeated vomiting, clinical suspicion and correct use of all para-clinical tools should help delineate the cause. Conclusion We report this case hoping to expand the existing literature on the topic and to highlight the potential role of gastrophrenic membrane dissection in the occurrence of such complication.
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Affiliation(s)
- Osamah Al-Sanea
- Bariatric and Metabolic Surgery Department, Somna Care, Procare Riaya Hospital, Al Khobar, Saudi Arabia
| | - Ahmed Al-Garzaie
- Bariatric and Metabolic Surgery Department, Somna Care, Procare Riaya Hospital, Al Khobar, Saudi Arabia
| | - Mohamad Dernaika
- Gastroenterology Department, Somna Care, Procare Riaya Hospital, Al Khobar, Saudi Arabia
| | - Johnny Haddad
- Bariatric and Metabolic Surgery Department, Somna Care, Procare Riaya Hospital, Al Khobar, Saudi Arabia.
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