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Fransvea P, Miccini M, Rondelli F, Brisinda G, Costa A, Garbarino GM, Costa G. A Green Lantern for the Surgeon: A Review on the Use of Indocyanine Green (ICG) in Minimally Invasive Surgery. J Clin Med 2024; 13:4895. [PMID: 39201036 PMCID: PMC11355299 DOI: 10.3390/jcm13164895] [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: 07/26/2024] [Revised: 08/12/2024] [Accepted: 08/14/2024] [Indexed: 09/02/2024] Open
Abstract
Indocyanine green (ICG) fluorescence imaging has revolutionized surgical practice across various medical and surgical specialties. This article reviews the clinical applications of ICG in abdominal, urological, thoracic, and gynecological surgery. ICG fluorescence imaging has been widely adopted in general surgery for various applications, including perfusion assessment, intraoperative visualization of the ureter, and tumor localization. It is particularly valuable in evaluating anastomotic leaks and aiding in precise tumor resection during minimally invasive surgeries. Studies have shown mixed results on its effectiveness in reducing anastomotic leak rates, highlighting the need for further research. In thoracic surgery, ICG facilitates the identification and resection of pulmonary bullae, as well as the precise localization of pulmonary nodules during video-assisted surgery. In urology, ICG aids in localizing renal tumors and guiding selective arterial occlusion during partial nephrectomy. Its role in identifying the lymphatic pathway in prostate cancer and sentinel lymph node biopsy in gynecological cancer is also discussed. Despite its benefits, the use of ICG fluorescence faces challenges such as limited tissue penetration, the potential for false results, a lack of standardized protocols, and high equipment costs. Nonetheless, it remains a powerful tool that could improve surgical outcomes.
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Affiliation(s)
- Pietro Fransvea
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario “A. Gemelli” IRCCS Roma, Catholic University of Sacred Heart, 00136 Rome, Italy; (P.F.); (G.B.)
| | | | - Fabio Rondelli
- Department of Medicine and Surgery, University of Perugia, 06123 Perugia, Italy;
| | - Giuseppe Brisinda
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario “A. Gemelli” IRCCS Roma, Catholic University of Sacred Heart, 00136 Rome, Italy; (P.F.); (G.B.)
| | - Alessandro Costa
- UniCamillus School of Medicine, Saint Camillus International University of Health and Medical Sciences, 00131 Rome, Italy;
| | | | - Gianluca Costa
- Department of Life Science, Health, and Health Professions, Link Campus University, 00165 Rome, Italy
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Zhang Y, Wang Y, Bian S, Li M, Zhang M, Zhang P, Zhang Z, Liu Y. Treatment of Leakage Following Sleeve Gastrectomy by Laparo-Endoscopic Gastrostomy (LEG). Obes Surg 2024:10.1007/s11695-024-07417-9. [PMID: 39034373 DOI: 10.1007/s11695-024-07417-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 07/16/2024] [Accepted: 07/17/2024] [Indexed: 07/23/2024]
Abstract
Sleeve gastrectomy (SG) is widely recognized as the leading bariatric procedure worldwide. However, leakage, its major complication, remains a significant concern. This study focuses on the challenges of managing leakage, especially when conventional endoscopic treatments are ineffective. Although a novel one-step approach as reported by Pulimuttil James Zachariah from Wei-Jei Lee's team has demonstrated promise, further investigations and reports on its efficacy are currently insufficient. Between January 2021 and November 2023, we analyzed five patients treated at our center for SG leakage. Patient data include demographics, comorbidities, surgical details, and outcomes. The study details Laparo-Endoscopic Gastrostomy procedures performed post-SG leakage diagnosis, highlighting differences between acute and chronic instances. The study effectively implemented Zachariah's one-step approach, achieving favorable results in all five cases. Patient characteristics, presentation, postoperative progression, and additional treatments were documented. The outcome supports Zachariah's assertion that the one-step approach is a simple, safe, and cost-effective approach for SG leakage, avoiding digestive tract reconstruction. Despite potential limitations, including challenges in closing large defects and extended healing times, the procedure's effectiveness in decompression, drainage, and nutritional support significantly contributes to its elevated healing rate. The study emphasizes the importance of timely abdominal drain removal based on clinical conditions, challenging traditional practices for better clinical outcomes.
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Affiliation(s)
- Yiqiao Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University & State Key Lab of Digestive Health & National Clinical Research Center for Digestive Diseases, 95 Yong-an Road, Xi-Cheng District, Beijing, 100050, China
| | - Yongqiang Wang
- Department of Gastrointestinal Surgery, Inner Mongolia People's Hospital, No. 20 Zhao Wuda Road, Hohhot, 010020, Inner Mongolia, China
| | - Shibo Bian
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University & State Key Lab of Digestive Health & National Clinical Research Center for Digestive Diseases, 95 Yong-an Road, Xi-Cheng District, Beijing, 100050, China
| | - Mengyi Li
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University & State Key Lab of Digestive Health & National Clinical Research Center for Digestive Diseases, 95 Yong-an Road, Xi-Cheng District, Beijing, 100050, China
| | - Meng Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University & State Key Lab of Digestive Health & National Clinical Research Center for Digestive Diseases, 95 Yong-an Road, Xi-Cheng District, Beijing, 100050, China
| | - Peng Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University & State Key Lab of Digestive Health & National Clinical Research Center for Digestive Diseases, 95 Yong-an Road, Xi-Cheng District, Beijing, 100050, China
| | - Zhongtao Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University & State Key Lab of Digestive Health & National Clinical Research Center for Digestive Diseases, 95 Yong-an Road, Xi-Cheng District, Beijing, 100050, China.
| | - Yang Liu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University & State Key Lab of Digestive Health & National Clinical Research Center for Digestive Diseases, 95 Yong-an Road, Xi-Cheng District, Beijing, 100050, China.
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Masood M, Low DE, Deal SB, Kozarek RA. Endoscopic Management of Post-Sleeve Gastrectomy Complications. J Clin Med 2024; 13:2011. [PMID: 38610776 PMCID: PMC11012813 DOI: 10.3390/jcm13072011] [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: 02/09/2024] [Revised: 03/22/2024] [Accepted: 03/26/2024] [Indexed: 04/14/2024] Open
Abstract
Obesity is associated with several chronic conditions including diabetes, cardiovascular disease, and metabolic dysfunction-associated steatotic liver disease and malignancy. Bariatric surgery, most commonly Roux-en-Y gastric bypass and sleeve gastrectomy, is an effective treatment modality for obesity and can improve associated comorbidities. Over the last 20 years, there has been an increase in the rate of bariatric surgeries associated with the growing obesity epidemic. Sleeve gastrectomy is the most widely performed bariatric surgery currently, and while it serves as a durable option for some patients, it is important to note that several complications, including sleeve leak, stenosis, chronic fistula, gastrointestinal hemorrhage, and gastroesophageal reflux disease, may occur. Endoscopic methods to manage post-sleeve gastrectomy complications are often considered due to the risks associated with a reoperation, and endoscopy plays a significant role in the diagnosis and management of post-sleeve gastrectomy complications. We perform a detailed review of the current endoscopic management of post-sleeve gastrectomy complications.
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Affiliation(s)
- Muaaz Masood
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA 98101, USA
| | - Donald E. Low
- Division of Thoracic Surgery, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA 98101, USA;
| | - Shanley B. Deal
- Division of General and Bariatric Surgery, Center for Weight Management, Virginia Mason Franciscan Health, Seattle, WA 98101, USA;
| | - Richard A. Kozarek
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA 98101, USA
- Center for Interventional Immunology, Benaroya Research Institute, Virginia Mason Franciscan Health, Seattle, WA 98101, USA
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Lainas P, Triantafyllou E, Gugenheim J, Dagher I, Amor IB. Reply to "Innovative Endoscopic Approach for Staple Line Leaks Following Sleeve Gastrectomy: Promising Outcomes with Considerable Concerns". Obes Surg 2024; 34:1031-1032. [PMID: 38183595 DOI: 10.1007/s11695-023-07044-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 12/27/2023] [Accepted: 12/28/2023] [Indexed: 01/08/2024]
Affiliation(s)
- Panagiotis Lainas
- Department of Minimally Invasive Digestive & Bariatric Surgery, Metropolitan Hospital, HEAL Academy, 9 Ethnarchou Makariou & 1 Venizelou Streets, GR-18547 Neo Faliro, Athens, Greece.
- Department of Minimally Invasive Digestive Surgery, Antoine-Béclère Hospital, AP-HP, Clamart, France.
- Paris-Saclay University, Orsay, France.
| | - Evangelia Triantafyllou
- Department of Minimally Invasive Digestive & Bariatric Surgery, Metropolitan Hospital, HEAL Academy, 9 Ethnarchou Makariou & 1 Venizelou Streets, GR-18547 Neo Faliro, Athens, Greece
| | - Jean Gugenheim
- Department of Digestive Surgery, Archet II Hospital, Nice, France
- University of Nice-Sophia-Antipolis, Nice, France
- INSERM U1081, Nice, France
| | - Ibrahim Dagher
- Department of Minimally Invasive Digestive Surgery, Antoine-Béclère Hospital, AP-HP, Clamart, France
- Paris-Saclay University, Orsay, France
| | - Imed Ben Amor
- Department of Digestive Surgery, Archet II Hospital, Nice, France
- University of Nice-Sophia-Antipolis, Nice, France
- INSERM U1081, Nice, France
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Amor IB, Triantafyllou E, Temime V, Chenaitia H, Benamran D, Vanbiervliet G, Dagher I, Gugenheim J, Lainas P. Endoscopic Administration of Combined Autologous Mesenchymal Stem Cells and Platelet-Rich Plasma for the Treatment of Gastric Staple Line Leaks After Sleeve Gastrectomy. Obes Surg 2024; 34:106-113. [PMID: 38017329 DOI: 10.1007/s11695-023-06942-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/25/2023] [Accepted: 11/08/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Gastric staple line leak treatment after laparoscopic sleeve gastrectomy (LSG) remains challenging. Regenerative medicine is gaining place in the accelerated treatment of damaged tissues. This study presents the first series of gastric leak treatment after LSG using endoscopic intragastric administration of combined autologous mesenchymal stem cells (MSC) and platelet-rich plasma (PRP). METHODS MSC-PRP harvesting and endoscopic administration techniques are described in detail. Data were prospectively gathered and analyzed. Primary endpoints were morbidity/mortality rates and fistula closure time. RESULTS Twelve patients (9 women, 3 men) were included. Median age was 41.5 years, median weight 105.5 kg and median BMI 38.9 kg/m2. Median time to gastric staple line leak detection was 10 days post-LSG. Median time between re-laparoscopy and MSC-PRP administration was 5 days. MSC-PRP endoscopic administration was successfully performed and tolerated by all patients, with median procedure duration of 27 min and minimal blood loss. Four postoperative complications were noted: two patients with increased tibial pain at tibial puncture site, one with tibial hematoma, and one with epigastric pain/dysphagia. Median length of hospital stay was 1 day. Gastric leak healing occurred after a median of 14 days, only two patients requiring a second MSC-PRP endoscopic injection. Median follow-up was 19 months, all patients being in good health at last contact. CONCLUSION Endoscopic administration of combined autologous MSC-PRP seems to be a good option for treatment of gastric leaks after sleeve gastrectomy. It is a challenging procedure that should be performed in specialized bariatric centers by expert bariatric surgeons and endoscopists after meticulous patient selection.
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Affiliation(s)
- Imed Ben Amor
- Department of Digestive Surgery, Archet II Hospital, Nice, France
- University of Nice-Sophia-Antipolis, Nice, France
- INSERM U1081, Nice, France
| | - Evangelia Triantafyllou
- Department of Minimally Invasive Digestive & Bariatric Surgery, Metropolitan Hospital, HEAL Academy, 9 Ethnarchou Makariou & 1 Venizelou Streets, Neo Faliro, 18547, Athens, Greece
| | - Victor Temime
- Department of Digestive Surgery, Archet II Hospital, Nice, France
| | - Hichem Chenaitia
- Department of Digestive Surgery, Archet II Hospital, Nice, France
| | - Dorith Benamran
- Department of Digestive Surgery, Archet II Hospital, Nice, France
| | | | - Ibrahim Dagher
- Department of Minimally Invasive Digestive Surgery, Antoine-Béclère Hospital, AP-HP, Clamart, France
- Paris-Saclay University, Orsay, France
| | - Jean Gugenheim
- Department of Digestive Surgery, Archet II Hospital, Nice, France
- University of Nice-Sophia-Antipolis, Nice, France
- INSERM U1081, Nice, France
| | - Panagiotis Lainas
- Department of Minimally Invasive Digestive & Bariatric Surgery, Metropolitan Hospital, HEAL Academy, 9 Ethnarchou Makariou & 1 Venizelou Streets, Neo Faliro, 18547, Athens, Greece.
- Department of Minimally Invasive Digestive Surgery, Antoine-Béclère Hospital, AP-HP, Clamart, France.
- Paris-Saclay University, Orsay, France.
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Nandipati KC, Bremer KC. Bariatric Surgery Emergencies in Acute Care Surgery. Surg Clin North Am 2023; 103:1113-1131. [PMID: 37838459 DOI: 10.1016/j.suc.2023.05.013] [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] [Indexed: 10/16/2023]
Abstract
Patients who have undergone bariatric surgery present unique challenges in the acute care surgery setting. This review includes the presentation, workup, and management of most common bariatric surgery emergencies encountered by acute care surgery.
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Affiliation(s)
- Kalyana C Nandipati
- Division of Clinical Research, Department of Surgery, Creighton University School of Medicine, Minimally Invasive Surgery, Creighton University Education Building, 7710 Mercy Road, Suite 501, Omaha, NE 68124-2368, USA.
| | - Kristin C Bremer
- Department of Surgery, Creighton University School of Medicine, Creighton University Education Building, 7710 Mercy Road, Suite 501, Omaha, NE 68124-2368, USA
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The Evolving Management of Leaks Following Sleeve Gastrectomy. CURRENT SURGERY REPORTS 2023. [DOI: 10.1007/s40137-023-00357-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
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de Oliveira VL, Bestetti AM, Trasolini RP, de Moura EGH, de Moura DTH. Choosing the best endoscopic approach for post-bariatric surgical leaks and fistulas: Basic principles and recommendations. World J Gastroenterol 2023; 29:1173-1193. [PMID: 36926665 PMCID: PMC10011956 DOI: 10.3748/wjg.v29.i7.1173] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/28/2022] [Accepted: 02/01/2023] [Indexed: 02/21/2023] Open
Abstract
Post-surgical leaks and fistulas are the most feared complication of bariatric surgery. They have become more common in clinical practice given the increasing number of these procedures and can be very difficult to treat. These two related conditions must be distinguished and characterized to guide the appropriate treatment. Leak is defined as a transmural defect with communication between the intra and extraluminal compartments, while fistula is defined as an abnormal communication between two epithelialized surfaces. Traditionally, surgical treatment was the preferred approach for leaks and fistulas and was associated with high morbidity with significant mortality rates. However, with the development of novel devices and techniques, endoscopic therapy plays an increasingly essential role in managing these conditions. Early diagnosis and endoscopic therapy initiation after clinical stabilization are crucial to success since clinical success rates are higher for acute leaks and fistulas when compared to late and chronic leaks and fistulas. Several endoscopic techniques are available with different mechanisms of action, including direct closure, covering/diverting or draining. The treatment should be individualized by considering the characteristics of both the patient and the defect. Although there is a lack of high-quality studies to provide standardized treatment algorithms, this narrative review aims to provide a summary of the current scientific evidence and, based on this data and our extensive experience, make recommendations to help choose the best endoscopic approach for the management of post-bariatric surgical leaks and fistulas.
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Affiliation(s)
- Victor Lira de Oliveira
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403010, Brazil
| | - Alexandre Moraes Bestetti
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403010, Brazil
| | - Roberto Paolo Trasolini
- Division of Gastroenterology, Hepatology and Endoscopy, Harvard Medical School, Brigham and Women's Hospital, Boston, MA 021115, United States
| | - Eduardo Guimarães Hourneaux de Moura
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403010, Brazil
| | - Diogo Turiani Hourneaux de Moura
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403010, Brazil
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Smith BR. Comment on: Laparoscopic Roux-en-Y fistulojejunostomy as a salvage procedure in patients with chronic gastric leak after sleeve gastrectomy. Surg Obes Relat Dis 2023; 19:592-593. [PMID: 36922306 DOI: 10.1016/j.soard.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 02/04/2023] [Indexed: 03/09/2023]
Affiliation(s)
- Brian R Smith
- Division of Gastrointestinal Surgery, UC Irvine Health, Orange, California; Department of Surgery, VA Long Beach Healthcare System, Long Beach, California
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10
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Lainas P, Triantafyllou E, Ben Amor V, Savvala N, Gugenheim J, Dagher I, Amor IB. Laparoscopic Roux-en-Y fistulojejunostomy as a salvage procedure in patients with chronic gastric leak after sleeve gastrectomy. Surg Obes Relat Dis 2022; 19:585-592. [PMID: 36658084 DOI: 10.1016/j.soard.2022.12.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 10/29/2022] [Accepted: 12/01/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The most common postoperative complication of laparoscopic sleeve gastrectomy (LSG) is staple-line leak. Even if its rate following LSG has been recently reduced, management of chronic leaks remains challenging. OBJECTIVE To present a series of patients treated with laparoscopic Roux-en-Y fistulojejunostomy (LRYFJ) for chronic gastric leak (>12 wk) post-LSG. SETTING University hospitals; specialized bariatric surgery units. METHODS Data were prospectively gathered and retrospectively analyzed. Parameters of interest were patient characteristics, perioperative data, and postoperative outcomes. Hemodynamically unstable patients and/or presentations of signs of severe sepsis were excluded. Surgical technique was standardized. RESULTS Fourteen patients underwent LRYFJ for chronic gastric leak (12 women, 2 men). The mean age was 49.2 years and the mean weight was 88.7 kg with a mean body mass index of 31.1 kg/m2. All procedures were successfully performed by laparoscopy except 1 (7.1%) converted to open surgery. The mean operative time was 198 minutes, with a mean estimated blood loss of 135.7 mL and 2 patients necessitating transfusion (14.2%). Mortality was null. Five postoperative complications were noted (35.7%): 2 leaks of the fistulojejunostomy treated by antibiotherapy and endoscopic drainage; 1 perianastomotic hematoma treated by relaparoscopy and antibiotherapy; and 1 pleural effusion and 1 hematemesis both medically treated. The mean length of hospital stay was 14 days. The mean follow-up was 40 months, with all patients being in good health at last contact. CONCLUSIONS LRYFJ seems to be a good salvage option in selected patients for the treatment of chronic gastric leaks after LSG. However, it is a challenging procedure and should be performed in experienced bariatric centers by expert bariatric surgeons.
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Affiliation(s)
- Panagiotis Lainas
- Department of Minimally Invasive Digestive Surgery, Antoine-Béclère Hospital, Clamart, France; Paris-Saclay University, Orsay, France; Department of Digestive Surgery, Metropolitan Hospital, HEAL Academy, Athens, Greece.
| | - Evangelia Triantafyllou
- Department of Minimally Invasive Digestive Surgery, Antoine-Béclère Hospital, Clamart, France
| | | | - Natalia Savvala
- Department of Digestive Surgery, Archet II Hospital, Nice, France
| | - Jean Gugenheim
- Department of Digestive Surgery, Archet II Hospital, Nice, France; University of Nice-Sophia-Antipolis, Nice, France; INSERM U1081, Nice, France
| | - Ibrahim Dagher
- Department of Minimally Invasive Digestive Surgery, Antoine-Béclère Hospital, Clamart, France; Paris-Saclay University, Orsay, France
| | - Imed Ben Amor
- Department of Digestive Surgery, Archet II Hospital, Nice, France; University of Nice-Sophia-Antipolis, Nice, France; INSERM U1081, Nice, France
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Leeds SG, Chin K, Rasmussen ML, Bittle AK, Ogola GO, Ward MA. Predictability of Endoscopic Success for Foregut and Bariatric Leak in an Experienced Quaternary Center. J Am Coll Surg 2022; 235:26-33. [PMID: 35703959 DOI: 10.1097/xcs.0000000000000224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Leaks of the esophagus and stomach are difficult to manage and associated with significant morbidity and mortality. Endoscopic therapy can manage these leaks without surgical intervention. Our goal is to create a scoring tool to aid in predicting the success of endoscopic therapy in these patients. STUDY DESIGN An IRB-approved prospectively maintained database was retrospectively reviewed for all patients treated for gastrointestinal leaks from July 2013 to January 2021, including patients treated for esophageal and stomach leaks. Endpoints include success of leak closure for patients treated solely by endoscopic therapy (ET) compared with surgical therapy as failed endoscopic therapy (FET). A multivariable logistic regression model was fitted to identify independent risk factors for predicting success of endoscopic therapy, and a scoring calculator was developed. RESULTS There were 80 patients (60 females) with a mean age of 50 years. The ET group included 59 patients (74%), whereas the FET group included 21 patients (26%). Patient demographics, comorbidities, surgical history, and timing of leak diagnosis were used. Multivariable analysis resulted in 4 variables associated with higher probability of successful endoscopic leak management without need for additional surgery. These included increased age, lower BMI, lack of previous bariatric surgery, and quicker identification of the leak. Consequently, a scoring nomogram was developed with values from 0 to 22. CONCLUSION Our data show the development of a scoring calculator capable of quantifying the likelihood of success treating foregut and bariatric leaks with endoscopic therapies. This can be used clinically to guide treatment decisions.
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Affiliation(s)
- Steven G Leeds
- From the Center for Advanced Surgery (Leeds, Ward) Baylor Scott and White Health, Dallas, TX
- Department of Minimally Invasive Surgery, Baylor University Medical Center, Dallas, TX (Leeds, Rasmussen, Ward)
- Department of Surgery, Texas A&M College of Medicine, College Station, TX (Leeds, Ward, Chin)
| | - Kevin Chin
- Department of Surgery, Texas A&M College of Medicine, College Station, TX (Leeds, Ward, Chin)
| | - Madeline L Rasmussen
- Department of Minimally Invasive Surgery, Baylor University Medical Center, Dallas, TX (Leeds, Rasmussen, Ward)
| | - Anella K Bittle
- Research Institute (Bittle, Ogola) Baylor Scott and White Health, Dallas, TX
| | - Gerald O Ogola
- Research Institute (Bittle, Ogola) Baylor Scott and White Health, Dallas, TX
| | - Marc A Ward
- From the Center for Advanced Surgery (Leeds, Ward) Baylor Scott and White Health, Dallas, TX
- Department of Minimally Invasive Surgery, Baylor University Medical Center, Dallas, TX (Leeds, Rasmussen, Ward)
- Department of Surgery, Texas A&M College of Medicine, College Station, TX (Leeds, Ward, Chin)
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Nutritional Support and Duration of Drainage Recommendations for Endoscopic Internal Drainage: Review of the Literature and Initial Experience. Obes Surg 2022; 32:1421-1427. [PMID: 35218510 DOI: 10.1007/s11695-022-05978-1] [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: 11/24/2021] [Revised: 02/08/2022] [Accepted: 02/17/2022] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Anastomotic leaks following foregut surgery pose a difficult scenario for surgeons. While definitive surgical options are more invasive and may result in diversion requiring subsequent surgeries, endoscopic management of these leaks has been shown to work as an alternative platform for management. An evolving option is endoscopic internal drainage. We have reviewed our experience using endoscopic internal drainage and report our outcomes. MATERIALS AND METHODS An institution review board approved prospectively gathered database was used to identify all patients undergoing endoscopic internal drainage following esophageal and gastric leaks. Patient demographics, sentinel operation causing the leak, and outcomes of therapy were collected. The rate of healing and complications with the drainage catheter in place were the primary endpoints. RESULTS Sixteen patients were identified (5 male, 11 female) that underwent endoscopic internal drainage with a mean age of 48 and mean BMI of 30.8. Overall success rate was 69% (11/16), where 4 patients required a definitive surgery, and one healed with endoluminal vacuum therapy. Of the 4 failures, 1 patient required esophagojejunostomy, 2 patients required a fistulojejunostomy, and one required a partial gastrectomy. A total of 12 patients (75%) had a prior endoscopic procedure that was unsuccessful. The mean duration of drainage catheter in place was 48 days. While the catheter was in place, 4 patients were allowed minimal PO intake in conjunction with total parenteral nutrition or tube feeds. The rest of the patients were strict NPO with other means of nutrition. There were no complications with the drainage catheters and no deaths. CONCLUSION Leaks following esophagogastric surgery are difficult to manage; however, endoscopic internal drainage has been shown to be effective. Duration of the technique should be around 6 to 8 weeks with nutritional support guided by the comfort of the managing clinician.
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Mesenchymal Stem Cells and PRP Therapy Favorize Leak Closure After Sleeve Gastrectomy in Zucker Rats. Obes Surg 2022; 32:1251-1260. [PMID: 35194771 DOI: 10.1007/s11695-022-05945-w] [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: 08/04/2021] [Revised: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Sleeve gastrectomy (SG) is the most performed bariatric surgery but gastric leaks following SG occur in up to 2% of cases. Regenerative medicine is emerging as a promising field offering multiple possibilities in wound healing. We studied the efficiency of locally administered mesenchymal stem cells (MSCs) and platelet-rich plasma (PRP) on leak closure following SG in rats. METHODS The amount of PRP and MSCs extracted from one rat was analyzed and a model of gastric leak was developed in 10-week-old male Zucker rats. Twenty-four rats underwent SG fashioned with a leak. After 24 h, a second surgery was performed. The control group was treated by peritoneal lavage and drainage only while the experimental group received an additional treatment of locally administered MSCs and PRP at the leak orifice. Analysis of the leak healing process was done by an anatomopathological examination of the stomach 1, 2, 3, and 4 weeks after SG. RESULTS The extraction of MSCs and PRP from one rat was necessary for three recipients. Anatomopathological examination suggests that the closure of the leak orifice was faster in the experimental group. Statistical analysis revealed a significantly increased mucosae renewal and fibrosis score at the leak orifice after treatment with MSCs and PRP (p < 0.001). CONCLUSION These results suggest that PRP and MSCs may accelerate the closure of leaks following SG in rats and may become a new tool in the treatment of human gastric leaks but more research on this topic is needed to confirm these findings.
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14
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Treatment of Persistent Large Gastrocutaneous Fistulas After Bariatric Surgery: Preliminary Experience with Endoscopic Kehr's T-Tube Placement. Obes Surg 2022; 32:1377-1384. [PMID: 35141869 PMCID: PMC8933351 DOI: 10.1007/s11695-022-05935-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 01/28/2022] [Accepted: 02/03/2022] [Indexed: 12/19/2022]
Abstract
Purpose Post-bariatric surgery gastrocutaneous fistula is a chronic leak with an incidence of 1.7 to 4.0% and no standardized management. A large gastrocutaneous fistula (LGCF) is not indicated for treatment with pigtail drains. We aimed to evaluate results of a novel treatment using endoscopic Kehr’s T-tube placement. Methods Only patients with a postoperative LGCF duration of > 10 days and a flow rate of > 50 cc by external drainage after revisional surgery for sepsis were included. Endoscopic placement of Kehr’s T-tube was performed. Patients had been reoperated with wash and drainage for severe sepsis after initial bariatric surgery in which no fistula had been discovered. Patients not reoperated, or with a fistula requiring intraoperative Kehr’s T-tube placement, or a pigtail drain were excluded. Primary outcomes were endoscopic characteristics and results (LGCF closure rate, Kehr T-tube retention time, etc.). Results The study group included 12 women, 2 men; body mass index 43.1 ± 4.5 kg/m2. Interventions were SG (7), RYGB (2), OAGB (4), and SADI-S (1). Endoscopic assessment was carried out after a mean of 33.2 ± 44.3 days after the bariatric procedure. The mean fistula orifice diameter was 2.0 ± 0.9 cm. Kehr’s T-tube was positioned at a mean 51.5 ± 54.8 days after the bariatric procedure. T-tube tolerance was excellent. Mean additional days: hospitalization, 34.4 ± 27.0; T-tube retention, 86.4 ± 73.1; fistula healing, 139.9 ± 111.5, LGCF closure rate, 92.9%. Complications: 1 pulmonary embolism, 2 T-tube migrations,1 drain-path bleed, 1 skin abscess. No mortality. Conclusions Endoscopic Kehr’s T-tube placement was successful in closing persistent post-bariatric surgery LGCF in 92.9% of patients. Graphical abstract ![]()
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15
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Montana L, Frosio F, Polliand C, Tresallet C, Rivkine E, Carandina S. Total Gastrectomy with Roux-en-Y Limb Reconstruction for Complex and Chronic Fistulas After Laparoscopic Sleeve Gastrectomy: Single-Center Experience. Obes Surg 2021; 31:5260-5266. [PMID: 34591262 DOI: 10.1007/s11695-021-05721-2] [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: 05/14/2021] [Revised: 09/20/2021] [Accepted: 09/22/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE When a leak after laparoscopic sleeve gastrectomy (LSG) becomes a chronic fistula, the best surgical treatment remains controversial. The aim of study was to review our experience concerning the treatment of chronic and complex fistulas after LSG. MATERIALS AND METHODS A retrospective analysis of patients with a gastric fistula following LSG who were treated at our center between January 2013 and December 2018 was performed. All patients included underwent a total gastrectomy with a Roux-en-Y reconstruction (TG) for LSG chronic fistula. RESULTS During the period considered, 13 patients had a chronic fistula and were treated with open TG. The primary leak evolved to a gastro-cutaneos fistula in three patients (23%), to a gastro-splenic fistula in two patients (15.4%), to a gastro-pleural fistula in four patients (30.8%), and to a gastro-bronchial fistula in four patients (30.8%). During TG, a splenectomy and a spleno-pancreatectomy were needed in the two cases of gastro-splenic fistula. Five patients (38.5%) developed an early complication. Two patients developed an esophago-jejunal anastomotic leak treated with a conservative approach (15.4%). No patients needed hospitalization in the intensive care unit. Overall mean length of stay was 19 days (8-30 days). Mean BMI before LSG was 36 (± 5 kg/m2), mean BMI before TG was 30.3 (± 5.2 kg/m2), and mean BMI 2 years after TG was 23.5 (± 2.9 kg/m2). CONCLUSION When a more conservative and less mutilating surgical option is not possible, open TG with esophago-jejunostomy remains a valuable salvage procedure in the case of complex and extensive fistulas after LSG.
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Affiliation(s)
- Laura Montana
- Department of Digestive and Metabolic Surgery, Groupe Hospitalier Diaconesses Croix Saint-Simon, 75012, Paris, France
| | - Fabio Frosio
- Department of Digestive and General Surgery, Papa Giovanni XXIII Hospital, 24127, Bergamo, Italy
| | - Claude Polliand
- Department of Digestive and General Surgery, Hôtel Dieu Hospital, 71200, Le Creusot, France
| | - Christophe Tresallet
- Department of Digestive and Metabolic Surgery, Assistance Publique-Hôpitaux de Paris, Avicenne University Hospital, 93000, Bobigny, France
| | - Emmanuel Rivkine
- Department of Digestive and Bariatric Surgery, Centre Hospitalier Universitaire de Martinique, 97261, Fort-De-France, France
| | - Sergio Carandina
- ELSAN, Clinique Saint Michel, Centre Chirurgical de L'Obésité (CCO), 83100, Toulon, France.
- Department of Digestive and Bariatric Surgery, Clinica Madonna Della Salute, 45014, Porto Viro, Italy.
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16
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Kumbhari V, Cummings DE, Kalloo AN, Schauer PR. AGA Clinical Practice Update on Evaluation and Management of Early Complications After Bariatric/Metabolic Surgery: Expert Review. Clin Gastroenterol Hepatol 2021; 19:1531-1537. [PMID: 33741500 DOI: 10.1016/j.cgh.2021.03.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 01/20/2021] [Accepted: 03/12/2021] [Indexed: 02/06/2023]
Abstract
DESCRIPTION Endoscopic techniques are paramount in the identification and management of complications after surgery, though collaboration with other specialties is obligatory. Unfortunately, the evaluation and treatment algorithms are not standardized and there is a paucity of high-quality prospective studies to provide clarity regarding the best approach. The purpose of this clinical practice update is to apprise the clinician with respect to the endoscopic evaluation and management of patients with early (<90 days) complications after undergoing bariatric/metabolic surgery. METHODS The best practice advice outlined in this expert review are based on available published evidence, including observational studies and systematic reviews, and incorporates expert opinion where applicable. BEST PRACTICE ADVICE 1: Clinicians performing endoscopic approaches to treat early major postoperative complications should do so in a multidisciplinary manner with interventional radiology and bariatric/metabolic surgery co-managing the patient. Daily communication is advised. BEST PRACTICE ADVICE 2: Clinicians embarking on incorporating endoscopic management of bariatric/metabolic surgical complications into their clinical practice should have a comprehensive knowledge of the indications, contraindications, risks, benefits, and outcomes of each of the endoscopic treatment techniques. They should also have knowledge of the risks and benefits of alternative methods such as surgical and interventional radiological based approaches. BEST PRACTICE ADVICE 3: Clinicians incorporating endoscopic management of bariatric/metabolic surgical complications into their clinical practice should have expertise in interventional endoscopy techniques, including but not limited to: using concomitant fluoroscopy, stent deployment and retrieval, managing stenosis, and managing percutaneous drains. BEST PRACTICE ADVICE 4: Clinicians should screen all patients undergoing endoscopic management of bariatric/metabolic surgical complications and dietary intolerance for comorbid medical (nutrient deficiencies, infection, pulmonary embolism) and psychological (depression, anxiety) conditions. BEST PRACTICE ADVICE 5: Endoscopic approaches to managing complications of bariatric/metabolic surgery may be considered for patients in the immediate, early and late postoperative periods depending on hemodynamic stability. BEST PRACTICE ADVICE 6: Clinicians incorporating endoscopic management of bariatric/metabolic surgical complications into their clinical practice should have a detailed understanding of the pathophysiologic mechanisms initiating and perpetuating conditions such as staple-line leaks. This will allow for a prompt diagnosis and appropriate therapy to be targeted not only at the area of interest, but also any concomitant downstream stenosis. BEST PRACTICE ADVICE 7: Clinicians should recognize that the goal for endoscopic management of staple-line leaks are often not necessarily initial closure of the leak site, but rather techniques to promote drainage of material from the perigastric collection into the gastric lumen such that the leak site closes by secondary intention.
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Affiliation(s)
- Vivek Kumbhari
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland; Department of Medicine, Mayo Clinic College of Medicine and Science, Jacksonville, Florida.
| | - David E Cummings
- UW Medicine Diabetes Institute, University of Washington, Seattle, Washington; Weight Management Program, VA Puget Sound Health Care System, University of Washington, Seattle, Washington
| | - Anthony N Kalloo
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Philip R Schauer
- Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, Louisiana
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17
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Gjeorgjievski M, Imam Z, Cappell MS, Jamil LH, Kahaleh M. A Comprehensive Review of Endoscopic Management of Sleeve Gastrectomy Leaks. J Clin Gastroenterol 2021; 55:551-576. [PMID: 33234879 DOI: 10.1097/mcg.0000000000001451] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/02/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bariatric surgery leaks result in significant morbidity and mortality. Experts report variable therapeutic approaches, without uniform guidelines or consensus. OBJECTIVE To review the pathogenesis, risk factors, prevention, and treatment of gastric sleeve leaks, with a focus on endoscopic approaches. In addition, the efficacy and success rates of different treatment modalities are assessed. DESIGN A comprehensive review was conducted using a thorough literature search of 5 online electronic databases (PubMed, PubMed Central, Cochrane, EMBASE, and Web of Science) from the time of their inception through March 2020. Studies evaluating gastric sleeve leaks were included. MeSH terms related to "endoscopic," "leak," "sleeve," "gastrectomy," "anastomotic," and "bariatric" were applied to a highly sensitive search strategy. The main outcomes were epidemiology, pathophysiology, diagnosis, treatment, and outcomes. RESULTS Literature search yielded 2418 studies of which 438 were incorporated into the review. Shock and peritonitis necessitate early surgical intervention for leaks. Endoscopic therapies in acute and early leaks involve modalities with a focus on one of: (i) defect closure, (ii) wall diversion, or (iii) wall exclusion. Surgical revision is required if endoscopic therapies fail to control leaks after 6 months. Chronic leaks require one or more endoscopic, radiologic, or surgical approaches for fluid collection drainage to facilitate adequate healing. Success rates depend on provider and center expertise. CONCLUSION Endoscopic management of leaks post sleeve gastrectomy is a minimally invasive and effective alternative to surgery. Their effect may vary based on clinical presentation, timing or leak morphology, and should be tailored to the appropriate endoscopic modality of treatment.
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Affiliation(s)
- Mihajlo Gjeorgjievski
- Departments of Gastroenterology & Hepatology
- Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, MI
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical Center, New Brunswick, NJ
| | - Zaid Imam
- Departments of Gastroenterology & Hepatology
- Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Mitchell S Cappell
- Departments of Gastroenterology & Hepatology
- Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Laith H Jamil
- Departments of Gastroenterology & Hepatology
- Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Michel Kahaleh
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical Center, New Brunswick, NJ
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18
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Role of Preoperative Esophagogastroduodenoscopy (EGD) in Bariatric Treatment. J Clin Med 2021; 10:jcm10132982. [PMID: 34279468 PMCID: PMC8267643 DOI: 10.3390/jcm10132982] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/01/2021] [Accepted: 07/02/2021] [Indexed: 12/23/2022] Open
Abstract
Background: The recommendations for routine preoperative esophagogastroduodenoscopy (EGD) in patients qualified for bariatric surgeries are still a matter of debate. The aim of this study was to analyze the pathologies on preoperative EGD in patients qualified for bariatric surgeries. Materials and Methods: This study included 222 patients, divided into two groups. The obesity group consisted of patients with obesity (BMI ≥ 40 kg/m2), for whom EGD was a routine part of the preparation for laparoscopic sleeve gastrectomy (LSG). The control group of patients with normal body weight (BMI) qualified for EGD because of gastrointestinal ailments. Results: Regarding preoperative EGD in patients qualified for bariatric surgeries, we analyzed the prevalence of endoscopic pathologies in various gastrointestinal tract segments. Patients with obesity were shown to present with esophageal pathologies significantly more often than persons in the control group (n = 23, 20.91% vs. n = 12, 10.91%, p = 0.042). The odds ratio of esophageal pathologies in patients with obesity versus the control group equaled 2.15 (95%CI: 1.01–4.59). In turn, the odds ratio of duodenal pathologies in patients from the control group was 3.31 (95%Cl: 1.16–9.47), which means that persons from this group were approximately three times more likely to be diagnosed with those pathologies compared to obese patients. Moreover, patient sex was a significant predictor of duodenal pathologies, with an odds ratio of 4.03 (95%CI: 1.53–10.61). Conclusions: Preoperative EGD can identify a broad spectrum of pathologies in obese patients, which suggests a routine examination before bariatric surgery.
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19
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Dugan N, Nimeri A. Surgical Management of a Chronic Sleeve Gastrocolic Fistula with Near Total Gastrectomy and Roux-en-Y Reconstruction. Obes Surg 2021; 30:3640-3641. [PMID: 32410150 DOI: 10.1007/s11695-020-04689-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Management of the leak is determined by the duration of the leak from the initial surgery. Acute leaks occurring less than 72 hours after surgery are best managed with reoperation and primary repair. Intermediate leaks, greater than 72 hours but less than 12 weeks, can be managed with non-operative management in non-septic patients. When non-operative management fails beyond 12 weeks the leak is considered a chronic fistula which are best treated with definitive operative management. Sub-total gastrectomy with Roux-En-Y reconstruction with gastrojejunostomy, has been reported with resolution of the fistula in over 90% of cases. OBJECTIVES To demonstrate the operative management of chronic sleeve gastrectomy leaks. METHODS A 37-year-old male with a history of a sleeve gastrectomy, developed a chronic fistula between the distal gastric staple line and the transverse colon. After non-operative management failed the patient was taken to the operating room for a diagnostic laparoscopy with plans to perform a revision. A fistula between the distal sleeve staple line and the transverse colon was identified. The gastroesophageal junction was dissected and inspected, there was no fistula at the angle of His. A near total gastrectomy was then performed leaving a small gastric pouch. The colonic side of the fistula was oversewn. Roux-En-Y reconstruction was then performed. RESULTS No leak identified at four-month follow-up. CONCLUSION Leak after sleeve gastrectomy can be difficult to manage. Chronic leaks do not respond well to non-operative management. Partial gastrectomy with Roux-En-Y reconstruction is a technically challenging option with good results.
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Affiliation(s)
- Nicholas Dugan
- Division of Bariatric Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA. .,Division of Bariatric Surgery, Novant Health UVA Health System Haymarket, Haymarket, VA, 20169, USA.
| | - Abdelrahman Nimeri
- Division of Bariatric Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
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20
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Donatelli G, Spota A, Cereatti F, Granieri S, Dagher I, Chiche R, Catheline JM, Pourcher G, Rebibo L, Calabrese D, Msika S, Dammaro C, Tranchart H, Lainas P, Tuszynski T, Pacini F, Arienzo R, Chevallier JM, Trelles N, Lazzati A, Paolino L, Papini F, Torcivia A, Genser L, Arapis K, Soprani A, Randone B, Chosidow D, Bouillot JL, Marmuse JP, Dumont JL. Endoscopic internal drainage for the management of leak, fistula, and collection after sleeve gastrectomy: our experience in 617 consecutive patients. Surg Obes Relat Dis 2021; 17:1432-1439. [PMID: 33931322 DOI: 10.1016/j.soard.2021.03.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 02/22/2021] [Accepted: 03/13/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endoscopy plays a pivotal role in the management of adverse events (AE) following bariatric surgery. Leaks, fistulae, and post-operative collection after sleeve gastrectomy (SG) may occur in up to 10% of cases. OBJECTIVES To evaluate the efficacy and safety of endoscopic internal drainage (EID) for the management of leak, fistula, and collection following SG. SETTING Retrospective, observational, single center study on patients referred from several bariatric surgery departments to an endoscopic referral center. METHODS EID was used as first-line treatment for the management of leaks, fistulae, and collections. Leaks and fistulae were treated with double pigtail stent (DPS) deployment in order to guarantee internal drainage and second intention cavity obliteration. Collections were treated with endoscropic ultrasound (EUS)-guided deployment of DPS or lumen apposing metal stents. RESULTS A total of 617 patients (83.3% female; mean age, 43.1 yr) were enrolled in the study for leak (n = 300, 48.6%), fistula (n = 285, 46.2%), and collection (n = 32, 5.2%). Median follow-up was 19.5 months. Overall clinical success was 84.7% whereas 15.3% of cases required revisional surgery after EID failure. Clinical success according to type of AE was 89.5%, 78.5%, and 90% for leak, fistula, and collection, respectively. A total of 10 of 547 (1.8%) presented a recurrence during follow-up. A total of 28 (4.5%) AE related to the endoscopic treatment occurred. At univariate logistic regression predictors of failure were: fistula (OR 2.012), combined endoscopic approach (OR 2.319), need for emergency surgery (OR 1.755), and previous endoscopic treatment (OR 4.818). CONCLUSION Early EID for the management of leak, fistula, and post-operative collection after SG seems a safe and effective first-line approach with good long-term results.
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Affiliation(s)
- Gianfranco Donatelli
- Unité d'Endoscopie Interventionnelle, Hôpital Privé des Peupliers, Ramsay Générale de Santé, Paris, France.
| | - Andrea Spota
- Unité d'Endoscopie Interventionnelle, Hôpital Privé des Peupliers, Ramsay Générale de Santé, Paris, France; Università degli studi di Milano, Scuola di Specializzazione in Chirurgia Generale, Milano, Italy
| | - Fabrizio Cereatti
- Unité d'Endoscopie Interventionnelle, Hôpital Privé des Peupliers, Ramsay Générale de Santé, Paris, France; Gastroenterologia ed Endoscopia Digestiva ASST Cremona, Viale Concordia 1, Cremona, Italy
| | | | - Ibrahim Dagher
- Department of Minimally Invasive Digestive Surgery, Antoine Beclere Hospital, AP-HP, Clamart, France
| | - Renaud Chiche
- Service de Chirurgie digestive et de l'Obésité, Clinique Geoffry Saint Hilaire, Paris, France
| | - Jean-Marc Catheline
- Department of Digestive Surgery, Centre Hospitalier de Saint-Denis, Saint-Denis, France
| | - Guillaume Pourcher
- Department of Digestive Diseases, Obesity Center, Institut Mutualiste Montsouris, Paris Descartes University, Paris, France
| | - Lionel Rebibo
- Service de chirurgie digestive œsogastrique et bariatrique, Hôpital Bichat-Claude-Bernard, Paris, France
| | - Daniela Calabrese
- Service de chirurgie digestive œsogastrique et bariatrique, Hôpital Bichat-Claude-Bernard, Paris, France
| | - Simon Msika
- Service de chirurgie digestive œsogastrique et bariatrique, Hôpital Bichat-Claude-Bernard, Paris, France
| | - Carmelisa Dammaro
- Department of Minimally Invasive Digestive Surgery, Antoine Beclere Hospital, AP-HP, Clamart, France
| | - Hadrien Tranchart
- Department of Minimally Invasive Digestive Surgery, Antoine Beclere Hospital, AP-HP, Clamart, France
| | - Panagiotis Lainas
- Department of Minimally Invasive Digestive Surgery, Antoine Beclere Hospital, AP-HP, Clamart, France
| | - Thierry Tuszynski
- Unité d'Endoscopie Interventionnelle, Hôpital Privé des Peupliers, Ramsay Générale de Santé, Paris, France
| | - Filippo Pacini
- Centre Obésité Paris Peupliers, Hôpital Privé des Peupliers, Ramsay Santé, Paris, France
| | - Roberto Arienzo
- Centre Obésité Paris Peupliers, Hôpital Privé des Peupliers, Ramsay Santé, Paris, France
| | - Jean-Marc Chevallier
- Centre Obésité Paris Peupliers, Hôpital Privé des Peupliers, Ramsay Santé, Paris, France
| | - Nelson Trelles
- Service de Chirurgie Générale et Digestive, Centre Hospitalier Rene Dubos, Pontoise, France
| | - Andrea Lazzati
- Department of Digestive Surgery, Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Luca Paolino
- Department of Digestive Surgery, Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Federica Papini
- Service de Chirurgie Digestive, Group Hospitalier Nord-Essonne Site d'Orsay, Orsay, France
| | - Adriana Torcivia
- Assistance Publique-Hôpitaux de Paris (AP-HP), Department of Hepato-Biliary and Pancreatic Surgery, Pitié-Salpêtrière University Hospital, Sorbonne Université, Paris, France
| | - Laurent Genser
- Assistance Publique-Hôpitaux de Paris (AP-HP), Department of Hepato-Biliary and Pancreatic Surgery, Pitié-Salpêtrière University Hospital, Sorbonne Université, Paris, France
| | - Kostas Arapis
- Service de chirurgie digestive œsogastrique et bariatrique, Hôpital Bichat-Claude-Bernard, Paris, France
| | - Antoine Soprani
- Service de Chirurgie digestive et de l'Obésité, Clinique Geoffry Saint Hilaire, Paris, France
| | - Bruto Randone
- Service de chirurgie digestive et obésité, Clinique Parc Monceau, Paris, France
| | - Denis Chosidow
- Service de chirurgie digestive et obésité, Clinique Parc Monceau, Paris, France
| | - Jean-Luc Bouillot
- Service de chirurgie digestive et obésité, hôpital Paris Saint-Joseph, Paris, France
| | | | - Jean-Loup Dumont
- Unité d'Endoscopie Interventionnelle, Hôpital Privé des Peupliers, Ramsay Générale de Santé, Paris, France
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21
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Petrucciani N, Etienne JH, Sebastianelli L, Iannelli A. Roux-en-Y gastric bypass as revisional surgery. Minerva Surg 2021; 76:8-16. [PMID: 33754587 DOI: 10.23736/s2724-5691.20.08493-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The Roux-en-Y gastric bypass (RYGB) is a worldwide-performed procedure as primary surgery, and as conversional procedure after complications and/or failure of other bariatric procedures. RYGB can be performed as revisional surgery after adjustable gastric banding, vertical banded gastroplasty, sleeve gastrectomy and one anastomosis gastric bypass. Each of these revisional procedures may be technically challenging, and accurate preoperative work-up and operative planning is required. If correctly performed, RYGB as revisional procedure is associated with satisfying outcomes and is indicated in the treatment of insufficient weight loss and postoperative complications of a primary bariatric procedure - such as chronic leak or gastroesophageal reflux after sleeve gastrectomy. The present article analyzes the most important indications, technical points and tips and tricks to safely perform RYGB as a secondary procedure.
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Affiliation(s)
- Niccolò Petrucciani
- Department of Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, St. Andrea Hospital, Sapienza University, Rome, Italy
| | - Jean H Etienne
- Department of Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, St. Andrea Hospital, Sapienza University, Rome, Italy.,Université Côte d'Azur, Nice, France
| | - Lionel Sebastianelli
- Department of Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, St. Andrea Hospital, Sapienza University, Rome, Italy.,Université Côte d'Azur, Nice, France
| | - Antonio Iannelli
- Université Côte d'Azur, Nice, France - .,Unit of Digestive Surgery and Liver Transplantation, University Hospital of Nice, Nice, France.,Inserm U1065, Nice, France
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22
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Li S, Jiao S, Zhang S, Zhou J. Revisional Surgeries of Laparoscopic Sleeve Gastrectomy. Diabetes Metab Syndr Obes 2021; 14:575-588. [PMID: 33603423 PMCID: PMC7882429 DOI: 10.2147/dmso.s295162] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 01/08/2021] [Indexed: 12/11/2022] Open
Abstract
Bariatric surgery has become increasingly common due to the worldwide obesity epidemic. A shift from open to laparoscopic surgery, specifically, laparoscopic sleeve gastrectomy (LSG), has occurred in the last two decades because of the low morbidity and mortality rates of LSG. Although LSG is a promising treatment option for patients with morbid obesity due to restrictive and endocrine mechanisms, it requires modifications for a subset of patients because of weight regain and tough complications, such as gastroesophageal reflux, strictures, gastric leak, and persistent metabolic syndrome., Revision surgeries have become more and more indispensable in bariatric surgery, accounting for 7.4% in 2016. Mainstream revisional bariatric surgeries after LSG include Roux-en-Y gastric bypass, repeated sleeve gastrectomy, biliopancreatic diversion, duodenal switch, duodenal-jejunal bypass, one-anastomosis gastric bypass, single anastomosis duodeno-ileal bypass (SAID) and transit bipartition. This review mainly describes the revisional surgeries of LSG, including the indication, choice of surgical method, and subsequent effect.
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Affiliation(s)
- Siyuan Li
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, People’s Republic of China
| | - Siqi Jiao
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, People’s Republic of China
| | - Siwei Zhang
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, People’s Republic of China
| | - Jiangjiao Zhou
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, People’s Republic of China
- Correspondence: Jiangjiao Zhou Department of General Surgery, The Second Xiangya Hospital, Central South University, No. 139 Middle Renmin Road, Changsha, Hunan, 410011, People’s Republic of China Email
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23
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Taleb S, Nedelcu M, Skalli M, Loureiro M, Nedelcu A, Nocca D. The evolution of surgical treatment for chronic leak following sleeve. Surg Obes Relat Dis 2020; 17:278-283. [PMID: 33218903 DOI: 10.1016/j.soard.2020.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 09/15/2020] [Accepted: 10/02/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Leak is estimated to be the most severe complication of laparoscopic sleeve gastrectomy (LSG), with sporadic failure of endoscopic techniques. In such cases, an aggressive management with surgical reconstructive procedures can be proposed to patients in whom all the conservative endoscopic techniques failed. OBJECTIVES The purpose of the present study was to report our experience with surgical approach for the treatment of chronic leak after LSG. SETTING University hospital, France. METHODS Between January 2013-December 2019, 21 consecutive patients underwent reconstructive surgery for the treatment of chronic leak after LSG. The initial intervention, the endoscopic approach, and the definitive surgical repair were carefully reviewed. RESULTS Twenty-one patients (17 women) with a mean (standard deviation [SD]) age of 42.7 years (9.81) and a mean (SD) body mass index (BMI) of 27.3 (5.2) kg/m2 underwent reconstructive surgery for persistent fistula. Seventeen patients (81%) had their early LSG performed in another hospital. Endoscopic treatment was represented by the pigtail drain or stent in 9 cases each, ovesco in 8 cases, and glue for 2 patients. The reconstructive surgery was performed within 6 months in 8 cases; between 6-12 months in 6 cases; between 1-3 years in 4 cases, and >3 years in 3 cases. There were 14 fistulo-jejunostomy (66.7%), 5 Roux-en-Y gastric bypass (23.8%), and 2 total gastrectomies (9.5%). The operative time was between 99 minutes and 5.5 hours (mean = 216.2, median = 225 min). The hospital stay ranged from 5-30 days (mean = 12.67, median = 11 d) and the surgical reintervention rate was 23.8% (5/21 patients), including 1 case of recurrent hemorrhage requiring 3 surgical operations over 1 month of postoperative follow-up. No postoperative mortality was recorded. CONCLUSIONS Surgery should be considered in case of failure of the endoscopic treatment of chronic leak after LSG. Further research is needed to clearly identify the appropriate treatment, but in our experience the fistulo-jejunostomy approach shows a low morbidity rate. (Surg Obes Relat Dis 2020;17:278-283.) © 2020 American Society for Metabolic and Bariatric Surgery. All rights reserved.
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Affiliation(s)
| | - Marius Nedelcu
- ELSAN, Clinique Bouchard, Marseille, France; ELSAN, Clinique Saint Michel, Toulon, France.
| | | | - Marcelo Loureiro
- CHU de Montpellier, Montpellier, France; University Montpellier 1, Montpellier, France; Universidade Positivo, Curitiba, Brazil
| | | | - David Nocca
- CHU de Montpellier, Montpellier, France; University Montpellier 1, Montpellier, France
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Laparoscopic revision to total gastrectomy or fistulo-jejunostomy as a definitive surgical procedure for chronic gastric fistula after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2020; 16:1893-1900. [PMID: 32928679 DOI: 10.1016/j.soard.2020.07.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/22/2020] [Accepted: 07/27/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Staple-line leaks (SLL) after sleeve gastrectomy (SG) are a rare but serious complication requiring radiologic and endoscopic interventions with varying degrees of success. When failed, a chronic gastrocutaneous fistula forms with decreasing chances of closure with time. Definitive surgical management of chronic SLL after SG include laparoscopic revision to total/subtotal gastrectomy (LTG/LSTG) or a fistulo-jejunostomy (LRYFJ), both with Roux-en-Y reconstruction. OBJECTIVES Comparison of SG revisions to LTG/LSTG versus LRYFJ as a definitive treatment for chronic SLL. SETTING High-volume bariatric unit. METHODS Retrospective review of a prospectively maintained database identified 17 patients with chronic gastric fistula after SG that were revised to either LTG/LSTG or LRYFJ between September 2011 and May 2020. Demographic characteristics, clinical data, quality of life, and laboratory values for both options were compared. RESULTS Of the 17 conversions, 8 were revised to LTG/LSTG and 9 to LRYFJ. Mean age and body mass index at revision were 36.85 years (range, 21-66 yr) and 29 kg/m2 (range, 21-36 kg/m2), respectively. Average preoperative endoscopic attempts was 5 (range, 1-16). The overall average operation time of revision was 183 minutes (range, 130-275 min) with no significant difference between either conversion options. Mean follow-up time was 46.5 months (range, 1-81 mo) and was available for 10 patients (58.8%). Food intolerance was significantly better after revision to LRYFJ (n = 6/6, 100% versus n = 1/5, 20%, P < .05). There were no significant differences between revisional procedures and laboratory abnormalities. CONCLUSION Laparoscopic revision to LRYFJ is a safe and feasible treatment for chronic SLL.
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Noel P, Nedelcu M, Manos T, Nedelcu A. Comment on: Laparoscopic revision to total gastrectomy or fistulo-jejunostomy as a definitive procedure for chronic gastric fistula after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2020; 16:1900-1901. [PMID: 32928680 DOI: 10.1016/j.soard.2020.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 08/20/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Patrick Noel
- Emirates Specialty Hospital, Dubai, United Arab Emirates; ELSAN, Clinique Bouchard, Marseille, France
| | - Marius Nedelcu
- ELSAN, Clinique Bouchard, Marseille, France; ELSAN, Centre Chirurgical de l'Obesite, Clinique Saint Michel, Toulon, France
| | | | - Anamaria Nedelcu
- ELSAN, Centre Chirurgical de l'Obesite, Clinique Saint Michel, Toulon, France
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Gray EC, Dawoud F, Janelle M, Hodge M. Drain Placement During Bariatric Surgery, Helpful or Harmful? Am Surg 2020; 86:971-975. [PMID: 32833495 DOI: 10.1177/0003134820942168] [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: 11/16/2022]
Abstract
INTRODUCTION Routine drain placement is still widely used in both sleeve gastrectomy (SG) and Roux en Y gastric bypass (REYGB). There is mounting evidence that drains may increase complication risk without preventing reoperation or other complications. METHODS Data from 2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Participant Use File was evaluated for drain use during laparoscopic REYGB and SG. Primary outcomes were superficial and deep surgical site infections (SSI), reintervention/reoperation, and readmission. Preoperative patient risk factors were also compared to evaluate for association with drain placement. RESULTS A total of 148 260 patients fit the inclusion criteria. Drains were used in 23 190 (15.6%) cases and not used in 125 070 (84.4%). Drain placement during surgery was associated with increased odds of superficial SSI, deep incisional SSI, and organ space SSI. Patients with drains were found to have increased odds of requiring at least 1 reoperation or intervention within 30 days of surgery. Preoperative risk factors associated with drain placement included diabetes mellitus, a history of chronic obstructive pulmonary disease, and oxygen dependence. Smokers were slightly less likely to have a drain placed. There was no significant association with chronic steroid and immunosuppressant usage. CONCLUSION There is mounting data against drain placement during bariatric surgery. Prior studies using MBSAQIP data have shown an increased complication rate with drains, and our data set supports the idea that drains may increase complications after surgery. While no randomized prospective trials have been performed looking at drain usage in bariatric surgery, the growing retrospective data certainly inform against the regular use of drains.
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Affiliation(s)
- Edward C Gray
- 4154 Department of Surgery, East Tennessee State University - Quillen College of Medicine, Mountain Home, TN, USA
| | - Fakhry Dawoud
- 4154 Department of Surgery, East Tennessee State University - Quillen College of Medicine, Mountain Home, TN, USA
| | - Meredith Janelle
- 4154 Department of Surgery, East Tennessee State University - Quillen College of Medicine, Mountain Home, TN, USA
| | - Michael Hodge
- 4154 Department of Surgery, East Tennessee State University - Quillen College of Medicine, Mountain Home, TN, USA
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Poghosyan T, Levenson G, Bruzzi M, Rives-Lange C, Czernichow S, Chevallier JM, Douard R. Fistulojejunostomy for Chronic Fistula After Sleeve Gastrectomy. Obes Surg 2020; 30:3638-3639. [PMID: 32388707 DOI: 10.1007/s11695-020-04660-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The most dreadful complication after sleeve gastrectomy (SG) is staple line leak. Its rate varies between 1 and 2%. With the development of interventional endoscopy, its treatment is currently fairly standardized and allows healing in the majority of cases without revisional surgery. However, if endoscopic treatment fails, surgical treatment becomes unavoidable. Fistulojejunostomy is a surgical option in the management of chronic fistula after SG. Laparoscopic fistulojejunostomy in a patient with chronic fistula after SG is difficult but feasible. This procedure allows complete healing and nutritional recovery in the case of failure of other endoscopic modalities.
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Affiliation(s)
- Tigran Poghosyan
- Department of Digestive, Oncologic and Bariatric Surgery, AP-HP, Hôpital Européen Georges Pompidou and UFR Paris Descartes, Université de Paris, 20 Rue Leblanc, 75015, Paris, France.
| | - Guillaume Levenson
- Department of Digestive, Oncologic and Bariatric Surgery, AP-HP, Hôpital Européen Georges Pompidou and UFR Paris Descartes, Université de Paris, 20 Rue Leblanc, 75015, Paris, France
| | - Matthieu Bruzzi
- Department of Digestive, Oncologic and Bariatric Surgery, AP-HP, Hôpital Européen Georges Pompidou and UFR Paris Descartes, Université de Paris, 20 Rue Leblanc, 75015, Paris, France
| | - Claire Rives-Lange
- Department of Nutrition, AP-HP, Hôpital Européen Georges Pompidou and UFR Paris Descartes, Université de Paris, Paris, France
| | - Sebastien Czernichow
- Department of Nutrition, AP-HP, Hôpital Européen Georges Pompidou and UFR Paris Descartes, Université de Paris, Paris, France
| | - Jean-Marc Chevallier
- Department of Digestive, Oncologic and Bariatric Surgery, AP-HP, Hôpital Européen Georges Pompidou and UFR Paris Descartes, Université de Paris, 20 Rue Leblanc, 75015, Paris, France
| | - Richard Douard
- Department of Digestive, Oncologic and Bariatric Surgery, AP-HP, Hôpital Européen Georges Pompidou and UFR Paris Descartes, Université de Paris, 20 Rue Leblanc, 75015, Paris, France
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