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Wisniowski P, Samakar K, Cheng V, Hawley L, Abel S, Nguyen J, Dobrowolsky A, Martin M. Safety of redo sleeve gastrectomy as a primary revisional procedure. Surg Obes Relat Dis 2024:S1550-7289(24)00172-2. [PMID: 38871494 DOI: 10.1016/j.soard.2024.04.016] [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: 10/26/2023] [Revised: 04/01/2024] [Accepted: 04/26/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Insufficient weight loss after primary laparoscopic sleeve gastrectomy (LSG) occasionally requires revisional surgery. A few single-institution studies have examined the safety of redo LSG (RSG) and have shown mixed results. OBJECTIVES The aim of this study was to evaluate the safety of RSG compared with LSG over a period of 30 days. SETTING University of Southern California, United States; Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. METHODS The 2020-2021 MBSAQIP registry was used to evaluate patients who underwent RSG. Thirty-day outcomes were evaluated using univariable analysis and multivariable logistic and linear regression. RESULTS A total of 226,029 patients were reviewed, of whom 1454 (.7%) underwent RSG and 224,575 (99.3%) underwent initial LSG. Patients who underwent RSG were older (45 versus 42 yr), predominantly female (86.2% versus 81.3%), had a lower body mass index (40.0 versus 43.4), fewer co-morbidities, and greater rates of gastroesophageal reflux (38.7% versus 25.1%). They demonstrated increased overall complications (3.6% versus 2.1%, P < .001) and a longer operative time (81 versus 62 min, P < .001), but there was no difference in mortality. On multivariable analysis, patients who underwent RSG were independently associated with an increased risk of overall postoperative complications (odds ratio [OR]: 1.493, P = .018), organ space infection (OR: 6.231, P < .001), staple line leak (OR: 12.838, P < .001), pneumonia (OR: 3.85, P = .013), ventilator requirement over 48 hours (OR: 6.404, P = .035), sepsis (OR: 4.397, P = .010), septic shock (OR: 8.669, P < .001), reoperation (OR: 1.808, P = .013), readmission (OR: 2.104, P < .001), reintervention (OR: 4.435, P < .001), and longer operative times (β = 12.790, P < .001). CONCLUSIONS In this national database study, RSG was associated with increased rates of postoperative complications and a longer operative time. Although these results are concerning, further studies are required to examine long-term outcomes.
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Affiliation(s)
- Paul Wisniowski
- Division of Upper GI and General Surgery, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, California.
| | - Kamran Samakar
- Division of Upper GI and General Surgery, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, California
| | - Vincent Cheng
- Department of Bariatric Surgery, Kaiser Permanente South Sacramento Medical Center, Sacramento, California
| | - Lauren Hawley
- Division of Upper GI and General Surgery, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, California
| | - Stuart Abel
- Division of Upper GI and General Surgery, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, California
| | - James Nguyen
- Division of Upper GI and General Surgery, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, California
| | - Adrian Dobrowolsky
- Division of Upper GI and General Surgery, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, California
| | - Matthew Martin
- Division of Upper GI and General Surgery, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, California
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Hsu A, Mu SZ, James A, Ibrahim MA, Saber AA. Indocyanine Green in Bariatric Surgery: a Systematic Review. Obes Surg 2023; 33:3539-3544. [PMID: 37713041 DOI: 10.1007/s11695-023-06801-1] [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: 04/29/2023] [Revised: 08/12/2023] [Accepted: 08/18/2023] [Indexed: 09/16/2023]
Abstract
Indocyanine green (ICG) is a fluorescent dye that can be used intraoperatively to assess tissue perfusion, as well as perform leak testing. This study aims to summarize published manuscripts on outcomes of ICG use and reduction of complications compared to traditional leak test and tissue perfusion evaluation. A PubMed search using "ICG and bariatric surgery," "ICG and gastric sleeve," "ICG and gastric bypass," and "ICG and revisional bariatric surgery" was performed. The proportion of patients who underwent an intraoperative decision change due to ICG was 3.8% (95% CI: 2.0 to 7.2%). ICG fluorescent imaging in bariatric surgery is a valuable tool, and further studies are needed to confirm its utility for routine use in both standard or complex cases (PROSPERO #418126).
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Affiliation(s)
- Angel Hsu
- Department of General Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Scott Z Mu
- Department of General Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Abi James
- Department of Metabolic and Bariatric Surgery, Newark Beth Israel Medical Center, 201 Lyons Ave, Newark, NJ, 07112, USA
| | - Mina A Ibrahim
- Department of Metabolic and Bariatric Surgery, Newark Beth Israel Medical Center, 201 Lyons Ave, Newark, NJ, 07112, USA
| | - Alan A Saber
- Department of Metabolic and Bariatric Surgery, Newark Beth Israel Medical Center, 201 Lyons Ave, Newark, NJ, 07112, USA.
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3
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Intraoperative Patterns of Gastric Microperfusion During Laparoscopic Roux-en-Y Gastric Bypass. Obes Surg 2022; 32:4047-4056. [PMID: 36243899 DOI: 10.1007/s11695-022-06318-z] [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: 05/20/2022] [Revised: 10/01/2022] [Accepted: 10/11/2022] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Visible light spectroscopy (VLS) represents a sensitive, non-invasive method to quantify tissue oxygen levels and detect hypoxemia. The aim of this study was to assess the microperfusion patterns of the gastric pouch during laparoscopic Roux-en-Y gastric bypass (LRYGB) using the VLS technique. METHODS Twenty patients were enrolled. Tissue oxygenation (StO2%) measurements were performed at three different localizations of the gastric wall, prior and after the creation of the gastric pouch, and after the creation of the gastro-jejunostomy. RESULTS Prior to the creation of the gastric pouch, the lowest StO2% levels were observed at the level of the distal esophagus with a median StO2% of 43 (IQR 40.8-49.5). After the creation of the gastric pouch and after the creation of the gastro-jejunostomy, the lowest StO2% levels were recorded at the level of the His angle with median values of 29% (IQR 20-38.5) and 34.5% (IQR 19-39), respectively. The highest mean StO2 reduction was recorded at the level of the His angle after the creation of the gastric pouch, and it was 18.3% (SD ± 18.1%, p < 0.001). A reduction of StO2% was recorded at all localizations after the formation of the gastro-jejunostomy compared to the beginning of the operation, but the mean differences of the StO2% levels were statistically significant only at the resection line of the pouch and at the His angle (p = 0.044 and p < 0.001, respectively). CONCLUSION Gastric pouch demonstrates reduction of StO2% during LRYGB. VLS is a useful technique to assess microperfusion patterns of the stomach during LRYGB.
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Catchlove W, Liao S, Lim G, Brown W, Burton P. Mechanism of Staple Line Leak After Sleeve Gastrectomy via Isobaric Pressurisation Concentrating Stress Forces at the Proximal Staple Line. Obes Surg 2022; 32:2525-2536. [PMID: 35639242 PMCID: PMC9273565 DOI: 10.1007/s11695-022-06110-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 05/06/2022] [Accepted: 05/11/2022] [Indexed: 11/26/2022]
Abstract
Purpose Staple line leak following sleeve gastrectomy is a significant problem and has been hypothesised to be related to hyperpressurisation in the proximal stomach. There is, however, little objective evidence demonstrating how these forces could be transmitted to the luminal wall. We aimed to define conditions in the proximal stomach and simulate the transmission of stress forces in the post-operative stomach using a finite element analysis (FEA). Materials and Methods The manometry of fourteen patients post sleeve gastrectomy was compared to ten controls. Manometry, boundary conditions, and volumetric CT were integrated to develop six models. These models delineated luminal wall stress in the proximal stomach. Key features were then varied to establish the influence of each factor. Results The sleeve gastrectomy cohort had a significantly higher peak intragastric isobaric pressures 31.58 ± 2.1 vs. 13.49 ± 1.3 mmHg (p = 0.0002). Regions of stress were clustered at the staple line near the GOJ, and peak stress was observed there in 67% of models. A uniform greater curvature did not fail or concentrate stress under maximal pressurisation. Geometric variation demonstrated that a larger triangulated apex increased stress by 17% (255 kPa versus 218 kPa), with a 37% increase at the GOJ (203kPA versus 148kPA). A wider incisura reduced stress at the GOJ by 9.9% (128 kPa versus 142 kPa). Conclusion High pressure events can occur in the proximal stomach after sleeve gastrectomy. Simulations suggest that these events preferentially concentrate stress forces near the GOJ. This study simulates how high-pressure events could translate stress to the luminal wall and precipitate leak. Graphical Abstract ![]()
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Affiliation(s)
- William Catchlove
- Department of Surgery, Central Clinical School, Monash University, Alfred Health Centre, Level 6, 99 Commercial Road, Melbourne, VIC, 3002, Australia.
- Oesophago-Gastric and Bariatric Surgery Unit, Alfred Hospital, Melbourne, VIC, Australia.
| | - Sam Liao
- Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, VIC, Australia
| | - Gillian Lim
- Department of Surgery, Central Clinical School, Monash University, Alfred Health Centre, Level 6, 99 Commercial Road, Melbourne, VIC, 3002, Australia
- Oesophago-Gastric and Bariatric Surgery Unit, Alfred Hospital, Melbourne, VIC, Australia
| | - Wendy Brown
- Department of Surgery, Central Clinical School, Monash University, Alfred Health Centre, Level 6, 99 Commercial Road, Melbourne, VIC, 3002, Australia
- Oesophago-Gastric and Bariatric Surgery Unit, Alfred Hospital, Melbourne, VIC, Australia
| | - Paul Burton
- Department of Surgery, Central Clinical School, Monash University, Alfred Health Centre, Level 6, 99 Commercial Road, Melbourne, VIC, 3002, Australia
- Oesophago-Gastric and Bariatric Surgery Unit, Alfred Hospital, Melbourne, VIC, Australia
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A New Risk Factor for Cervical Anastomotic Leakage-Role of The Relative Gastric Length in the Surgical Treatment of Esophageal Cancer. World J Surg 2022; 46:2235-2242. [PMID: 35616719 DOI: 10.1007/s00268-022-06579-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Blood supply is especially weak near the gastric fundus. Making the anastomosis in this area would increase the risk of anastomotic leakage (AL). In cervical anastomosis, the gastric conduit needs to travel through the thorax. Therefore, the relative length between the stomach and the thorax is an essential factor in deciding if the poorly supplied area could be removed. This study was to explore if a small relative gastric length was a risk of cervical AL. If all other conditions are equal, could intrathoracic anastomosis be a better choice? METHODS Patients who underwent esophagectomy with a preoperative barium swallow in West China Hospital between 2014 and 2017 were included. The length of the greater curvature and the thorax were obtained from the barium esophagogram. The ratio between the length of the greater curvature and the thorax was the relative gastric length calculated from the greater curvature (RGL-G). RESULTS A total of 782 patients were enrolled in the final analysis. The cervical AL group had a significantly higher ratio of patients with an RGL-G less than 1.3 (26.7% vs. 8.9%, p = 0.003). The multivariate logistic regression proved that RGL-G less than 1.3 was a risk factor for cervical anastomotic leakage (p = 0.012). Correspondingly, RGL-G less than 1.3 was not a risk factor (6.3% vs. 14.3%, p = 0.289) in the intrathoracic anastomosis group. CONCLUSIONS RGL-G less than 1.3 was a new risk factor for cervical AL, but it would not be a problem for intrathoracic anastomosis.
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COMPUTED TOMOGRAPHY ASSESSMENT OF POSTOPERATIVE GASTRIC VASCULAR SUPPLY AND STAPLE-LINE LEAK DEVELOPMENT AFTER SLEEVE GASTRECTOMY. Surg Obes Relat Dis 2022; 18:812-819. [DOI: 10.1016/j.soard.2022.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/05/2022] [Accepted: 03/26/2022] [Indexed: 11/23/2022]
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7
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Baptiste-Castillo HF, Parra-Zuluaga R, Niño-Andrade F, Rodríguez-Sánchez S. Manejo quirúrgico de una fístula gastropleural posterior a manga gástrica. REVISTA COLOMBIANA DE CIRUGÍA 2021. [DOI: 10.30944/20117582.771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Se presenta el caso de una paciente de 30 años de edad, sometida a un procedimiento de manga gástrica por laparoscopia en marzo de 2014, quien presenta, al tercer y cuarto años del procedimiento inicial, dos episodios de hemoptisis masiva, con falla en la segunda terapia de embolización, por lo que requirió una lobectomía pulmonar inferior izquierda. Al segundo día de este postoperatorio presenta salida de material de nutrición por las sondas de tórax, estableciéndose el diagnóstico de fistula gastro-pleural. Debido a falla con el manejo conservador, fue sometida a una resección quirúrgica de la fístula por vía laparoscópica, con gastrectomía proximal y reconstrucción en Y de Roux. A propósito de nuestra experiencia con esta paciente, se discuten en este artículo las estrategias de manejo para una fístula gastropleural, propuestas en la literatura a la fecha.
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Management of 69 Gastric Leakages after 4294 Consecutive Sleeve: The Experience of a High Volume Bariatric Center. Obes Surg 2020; 30:3084-3092. [DOI: 10.1007/s11695-020-04658-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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9
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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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Abstract
Laparoscopic sleeve gastrectomy (SG) is currently the most commonly performed standalone bariatric procedure worldwide. Gastric staple line leakage is the feared immanent complication of the operation, which is difficult to treat and often persists. This article presents the endoscopic treatment options for complications after laparoscopic SG, particularly the treatment of gastric staple line leakage. Most important for a successful treatment is the understanding of the underlying pathophysiological causes, the exact surgical comprehension of the procedure and advanced endoscopic skills. The choice of endoscopic intervention depends on the available strategies as well as on the skills of the executing endoscopist. Currently, internal drainage seems to be the most expedient method.
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Affiliation(s)
- C Stier
- Klinik für Allgemein‑, Viszeral‑, Gefäß- und Kinderchirurgie, Universitätsklinik Würzburg, Oberdürrbacherstr. 2, 97080, Würzburg, Deutschland.
- Medizinische Klinik und Poliklinik I, Universitätsklinik Würzburg, Würzburg, Deutschland.
| | - C Corteville
- Klinik für Allgemein‑, Viszeral‑, Gefäß- und Kinderchirurgie, Universitätsklinik Würzburg, Oberdürrbacherstr. 2, 97080, Würzburg, Deutschland
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Clayton RD, Carucci LR. Imaging following bariatric surgery: roux-en-Y gastric bypass, laparoscopic adjustable gastric banding and sleeve gastrectomy. Br J Radiol 2018; 91:20180031. [PMID: 29869916 PMCID: PMC6223156 DOI: 10.1259/bjr.20180031] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 05/29/2018] [Accepted: 05/30/2018] [Indexed: 12/13/2022] Open
Abstract
Morbid obesity is an increasing health problem, and bariatric surgery is a popular treatment option. Radiologists must be familiar with performing and interpreting studies in this patient population. The typical post-operative findings of the Roux-en-Y gastric bypass (RYGB), laparoscopic adjustable gastric banding (LAGB) and sleeve gastrectomy (SG) procedures on upper gastrointestinal (UGI) series and computerized tomography (CT) are presented. An overview of the potential complications is provided in addition to a description of potential pitfalls in interpreting these studies.
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Affiliation(s)
- Ryan D Clayton
- Department of Radiology, VCU Health System, Richmond, VA, USA
| | - Laura R Carucci
- Department of Radiology, VCU Health System, Richmond, VA, USA
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12
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Konca C, Yılmaz AA, Çelik SU, Kayılıoğlu SI, Paşaoğlu ÖT, Ceylan HA, Genç V. The Effects of Bougie Diameters on Tissue Oxygen Levels After Sleeve Gastrectomy: A Randomized Experimental Trial. Balkan Med J 2018; 35:245-249. [PMID: 29467117 PMCID: PMC5981121 DOI: 10.4274/balkanmedj.2017.0484] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: Staple-line leak is the most frightening complication of laparoscopic sleeve gastrectomy and several predisposing factors such as using improper staple sizes regardless of gastric wall thickness, narrower bougie diameter and ischemia of the staple line are asserted. Aims: To evaluate the effects of different bougie diameters on tissue oxygen partial pressure at the esophagogastric junction after sleeve gastrectomy. Study Design: A randomized and controlled animal experiment with 1:1:1:1 allocation ratio. Methods: Thirty-two male Wistar Albino rats were randomly divided into 4 groups of 8 each. While 12-Fr bougies were used in groups 1 and 3, 8-Fr bougies were used in groups 2 and 4. Fibrin sealant application was also carried out around the gastrectomy line after sleeve gastrectomy in groups 3 and 4. Burst pressure of gastrectomy line, tissue oxygen partial pressure and hydroxyproline levels at the esophagogastric junction were measured and compared among groups. Results: Mortality was detected in 2 out of 32 rats (6.25%) and one of them was in group 2 and the cause of this mortality was gastric leak. Gastric leak was detected in 2 out of 32 rats (6.25%). There was no significant difference in terms of burst pressures, tissue oxygen partial pressure and tissue hydroxyproline levels among the 4 groups. Conclusion: The use of narrower bougie along with fibrin sealant has not had a negative effect on tissue perfusion and wound healing.
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Affiliation(s)
- Can Konca
- Department of Surgery, Ankara University School of Medicine, Ankara, Turkey
| | - Ali Abbas Yılmaz
- Department of Anesthesiology and Reanimation, Ankara University School of Medicine, Ankara, Turkey
| | | | - Selami Ilgaz Kayılıoğlu
- Department of Surgery, University of Health Sciences, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Özge Tuğçe Paşaoğlu
- Department of Medical Biochemistry, Gazi University School of Medicine, Ankara, Turkey
| | - Halil Arda Ceylan
- Department of Internal Medicine, Ankara University School of Medicine, Ankara, Turkey
| | - Volkan Genç
- Department of Surgery, Ankara University School of Medicine, Ankara, Turkey
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13
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Abstract
BACKGROUND AND OBJECTIVES A new technology involving indocyanine green (ICG) fluorescence angiography has been introduced to assess tissue perfusion and perform vascular mapping during laparoscopic surgery. The purpose of this study was to describe the use of this technology to identify the variable blood supply patterns to the stomach and gastroesophageal (GE) junction during laparoscopic sleeve gastrectomy (LSG), which may help in preserving the blood supply and preventing ischemia-related leaks. METHODS Eighty-six patients underwent LSG and were examined intraoperatively with fluorescence angiography at an academic bariatric center from January 2016 to September 2017. Before the construction of the SG, 1 mL ICG was injected intravenously, and near infrared fluorescence imaging technology was used to identify the blood supply of the stomach. Afterward, the LSG was created with attention to preserving the identified blood supply to the GE junction and gastric tube. Finally, 3 mL ICG was injected to ensure that all the pertinent blood vessels were preserved. RESULTS Eighty-six patients successfully underwent the laparoscopic procedure with no complications. The following patterns of blood supply to the GE junction were found: (1) a right-side-dominant pattern (20%), arising from the left gastric artery; (2) a right-side-accessory pattern (36%), running in the gastrohepatic ligament and comprising either an accessory hepatic artery or an accessory gastric artery; and (3) a left-side accessory pattern arising from tributaries from the left inferior phrenic artery significantly contributing to the right-side blood supply. In addition, in 10% of the cases both right and left accessory patterns were present simultaneously. CONCLUSION ICG fluorescence angiography allows determination of the major blood supply to the proximal stomach before any dissection during sleeve gastrectomy, so that an effort can be made to avoid unnecessary injury to these vessels during the procedure.
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Affiliation(s)
- Camila B Ortega
- Department of Surgery, Duke University Health System, Durham, North Carolina, USA
| | - Alfredo D Guerron
- Department of Surgery, Duke University Health System, Durham, North Carolina, USA
| | - Jin S Yoo
- Department of Surgery, Duke University Health System, Durham, North Carolina, USA
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Proximal Leakage After Laparoscopic Sleeve Gastrectomy: an Analysis of Preoperative and Operative Predictors on 1738 Consecutive Procedures. Obes Surg 2017; 28:627-635. [DOI: 10.1007/s11695-017-2907-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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15
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Technical Details of Laparoscopic Sleeve Gastrectomy Leading to Lowered Leak Rate: Discussion of 1070 Consecutive Cases. Minim Invasive Surg 2017; 2017:4367059. [PMID: 28761766 PMCID: PMC5518516 DOI: 10.1155/2017/4367059] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Revised: 04/24/2017] [Accepted: 05/29/2017] [Indexed: 01/06/2023] Open
Abstract
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.
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16
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Intraoperative Patterns of Gastric Microperfusion During Laparoscopic Sleeve Gastrectomy. Obes Surg 2016; 27:926-932. [DOI: 10.1007/s11695-016-2386-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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17
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Iossa A, Abdelgawad M, Watkins BM, Silecchia G. Leaks after laparoscopic sleeve gastrectomy: overview of pathogenesis and risk factors. Langenbecks Arch Surg 2016; 401:757-66. [PMID: 27301373 DOI: 10.1007/s00423-016-1464-6] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 06/08/2016] [Indexed: 01/14/2023]
Abstract
BACKGROUND Leak is the second most common cause of death after bariatric surgery. The leak rate after laparoscopic sleeve gastrectomy (LSG) ranges between 1.1 and 5.3 %. The aim of the paper is to provide an overview of the current pathogenic and promoting factors of leakage after LSG on the basis of recent literature review and to report the evidence based preventive measures. METHODS Risk factors and pathogenesis of leakage after LSG were examined based on an extensive review of literature and evidence based analysis of the most recent published studies using Oxford centre for evidence-based medicine, 2011, levels of evidence. RESULTS Pathogenesis of leakage after LSG can be attributed to mechanical or ischemic causes. Many factors can predispose to leakage after LSG which are either technically related or patient related. Awareness of these predisposing factors and technical tips may decrease the incidence of leakage. CONCLUSIONS This review reports factors promoting leak and gives technical recommendations to avoid leak after LSG based on the available evidence and expert consensus which encompasses: (1) use a bougie size ≥40 Fr, EL:1, (2) begin the gastric transection 5-6 cm from the pylorus, EL:2-3, (3) use appropriate cartridge colors from antrum to fundus, EL:1, (4) reinforce the staple line with buttress material, EL:1, (5) follow a proper staple line, (6) remove the crotch staples, EL:4, (7) maintain proper traction on the stomach before firing, (8) stay away from the angle of His at least 1 cm, EL:1, (9) check the bleeding from the staple line, (10) perform an intraoperative methylene blue test, EL:4.
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Affiliation(s)
- Angelo Iossa
- Department of Medico-Surgical Sciences and Biotechnologies, Division of General Surgery and Bariatric Center of Excellence, La Sapienza University of Rome, Via F. Faggiana 1668, 04100, Latina, Italy.
| | - Mohamed Abdelgawad
- Department of Medico-Surgical Sciences and Biotechnologies, Division of General Surgery and Bariatric Center of Excellence, La Sapienza University of Rome, Via F. Faggiana 1668, 04100, Latina, Italy.,Gastroenterology Surgical Center (GEC), Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Brad Michael Watkins
- Division of General Surgery and Weight loss Center, West Chester Hospital, University of Cincinnati, Cincinnati, OH, USA
| | - Gianfranco Silecchia
- Department of Medico-Surgical Sciences and Biotechnologies, Division of General Surgery and Bariatric Center of Excellence, La Sapienza University of Rome, Via F. Faggiana 1668, 04100, Latina, Italy
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Manenti A, Pavesi E, Farinetti A. Gastric leak after sleeve gastrectomy: Salvage procedure by intraluminal drainage. J Visc Surg 2015; 152:342. [PMID: 26608947 DOI: 10.1016/j.jviscsurg.2015.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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