Late complication of laparoscopic sleeve gastrectomy

Challenges in the Diagnosis of Leak After Sleeve Gastrectomy: Clinical Presentation, Laboratory, and Radiological Findings

Background

The presentation of leak after laparoscopic sleeve gastrectomy (LSG) is variable. A missed or delayed diagnosis can lead to severe consequences. This study presents our experience: the clinical presentations, laboratory, and radiological findings in patients with leak after LSG.

Methods

A retrospective review of patients who were diagnosed and treated as leak after LSG at our center (January 2012–November 2019).

Results

Eighty patients developed leak: 68 (85%) after primary LSG, 6 (7.5%) after Re-LSG and 6 (7.5%) after band removal to revisional LSG. Mean age 35.9 ± 10 years. The diagnosis was within 18 ± 14 days after surgery. Five (6.3%) patients were diagnosed during the same admission. Only 29.3% of patients were diagnosed correctly from the first visit to the ER. Most were misdiagnosed as gastritis (49%) and pneumonia (22.6%). Thirty-four patients (45.3%) were diagnosed correctly at the third visit. The most common presenting symptoms were abdominal pain (90%), tachycardia (71.3%), and fever (61.3%). The mean white blood cells (WBCs) count was 14700 ± 5900 (cells/mm³), c-reactive protein (CRP) 270 ± 133 mg/L, lactic acid 1.6 ± 0.85 mmol/L, and albumin 30.3 ± 6.6 g/L. The abdominal CT scans revealed intraabdominal collection in 93.7% of patients, extravasation of contrast in 75%, and pleural effusion in 52.5%. Upper gastrointestinal contrast study (UGIC) showed extravasation of contrast in 77.5% of patients.

Conclusion

Abdominal pain, tachycardia, or fever after LSG should raise the suspicion of a leak. CT scan of the abdomen and UGIC study detected leaks in 75% and 77.5% consecutively. Only 29.3% of patients were diagnosed correctly as a leak from the first visit to the ER.

Total Gastrectomy with Roux-En-Y esophagojejunostomy for Chronic Complicated Post-Sleeve Gastric Fistula-Video Report

INTRODUCTION

Laparoscopic sleeve gastrectomy (LSG) has become one of the most popular bariatric surgeries worldwide. However, complications related to the stapler line can be very serious. Among several challenging post-LSG complications, fistula is the most feared. Its management can be very challenging and chronic. In case of chronic fistula and failure of surgical, endoscopic, and radiological treatment, total gastrectomy with esojejunal anastomosis (RYOJ) can be considered as an effective solution. We describe in this video the steps of our laparoscopic technique.

METHODS

We have performed a total gastrectomy with RYOJ in a particular patient with chronic and persisting gastric fistula 9 months after LSG. The body mass index (BMI) was initially 50 kg/m² at the time of the LSG against 31 kg/m² on the day of the RYOJ.

RESULTS

The postoperative course was uneventful. An upper GI series was done at 1 week and 1 month postoperatively without any abnormality. The patient was evaluated clinically and biologically at 1, 3, and 6 months later on with no evidence of dysphasia or biological abnormality.

CONCLUSION

RYOJ in our particular case was efficient. However, longer series and longer follow-up are needed to confirm the effectiveness of this rescue procedure.

Management of postoperative gastrointestinal leakage with autologous stromal vascular fraction

To assess the efficacy of using autologous stromal vascular fraction (SVF) to promote healing of controlled fistula tracts in the management of postoperative upper gastrointestinal leakage. This is an experimental study conducted on 10 experimental rabbits. Animal models were divided into the SVF group which received an autologous SVF and the control group which did not receive the implantation. Surgery was performed on both groups to induce a gastric leak and create a controlled fistula tract between the leakage site in the stomach and the skin. After 2 weeks, surgery was performed on the SVF group to harvest, process and then implant the autologous SVF in the fistula tract. Animal models were followed up and their fistula tracts were evaluated for healing by gross and microscopic examination of the fistula tracts before the SVF implantation and at 24 hours, 1 week, 2 weeks and 3 weeks after implantation. The control group revealed no closure of fistula tracts by the 3(rd) week after implantation and there were no signs of inflammation or drainage. On the other hand, the SVF group showed signs of healing process with progressive closure of the fistula tract to about 95% by the 3(rd) week after implantation. The use of autologous SVF implantation to promote the healing of controlled fistula tracts seems to be a novel, safe and effective method in the management of postoperative upper gastrointestinal leakage. It could prevent reoperation and reduce hospital stay, morbidity and mortality. These results are promising and provide support for further clinical studies.

Treatment of Leaks Following Sleeve Gastrectomy by Endoscopic Internal Drainage (EID)

BACKGROUND

Leaks are considered one of the major complications of laparoscopic sleeve gastrectomy (LSG) with a reported rate up to 7 %. Drainage of the collection coupled with SEMS deployment is the most frequent treatment. Its success is variable and burdened by high morbidity and not irrelevant mortality. The aim of this paper is to suggest and establish a new approach by endoscopic internal drainage (EID) for the management of leaks.

METHODS

Since March 2013, 67 patients presenting leak following LSG were treated with deployment of double pigtail plastic stents across orifice leak, positioning one end inside the collection and the other end in remnant stomach. The aim of EID is to internally drain the collection and at the same time promote leak healing.

RESULTS

Double pigtails stent were successfully delivered in 66 out of 67 patients (98.5 %). Fifty patients were cured by EID after a mean time of 57.5 days and an average of 3.14 endoscopic sessions. Two died for event not related to EID. Nine are still under treatment; five failure had been registered. Six patients developed late stenosis treated endoscopically.

CONCLUSIONS

EID proved to be a valid, curative, and safe mini-invasive approach for treatment of leaks following SG. EID achieves complete drainage of perigastric collections and stimulates mucosal growth over the stent. EID is well tolerated, allows early re-alimentation, and it is burdened by fewer complications than others technique. Long-term follow-up confirms good outcomes with no motility or feeding alterations.

Laparoscopic sleeve gastrectomy versus laparoscopic Roux-en-Y gastric bypass: a single center experience with 2 years follow-up

BACKGROUND

Laparoscopic Sleeve Gastrectomy (LSG) is a relatively new procedure that is gaining wide acceptance. However, laparoscopic Roux-en-Y Gastric Bypass (LRYGB) remains one of the most commonly performed bariatric procedures with the best long-term results. There are few studies comparing LSG with LRYGB. The aim of this study is to compare the safety and outcome of LSG to LRYG in a single accredited center.

METHODS

A retrospective analysis of data collected prospectively on patients undergoing either LSG or LRYGB between January 2009 and December 2012 was performed. LSG was performed using 36Fr bougie, while LRYGB was perfromed with a 25-mm circular stapler. The primary outcomes included length of stay (LOS), 30-day complication and readmission rates, and excess weight loss (%EWL) at 3, 6, 12, and 24 months postoperatively. LSG patients were also divided into different categories based on BMI and their %EWL compared to LRYGB.

RESULTS

A total of 885 patients were included in our analysis. 547 patients underwent LRYGB (61.8 %) and 338 underwent LSG (38.2 %). Thirty-day complication and readmission rates for LRYGB and LSG were (1.5 and 5.1 % vs 0.6 and 0.3 %, respetively, p > 0.05). %EWL for LRYGB was significantly higher than LSG at 3, 6, 12, and 24 months. LSG with a BMI <40 achieved a similar %EWL to LRYGB in the first 12 months.

CONCLUSIONS

LSG seems to have a better safety profile in the short-term compared to LRYGB. However, at 2 years, LRYGB patients achieved a significantly higher EWL compared to LSG patients. Randomized clinical trials are needed to better elucidate our findings.

Laparoscopic sleeve gastrectomy versus laparoscopic Roux-en-Y gastric bypass: a single center experience with 2 years follow-up

BACKGROUND

Laparoscopic Sleeve Gastrectomy (LSG) is a relatively new procedure that is gaining wide acceptance. However, laparoscopic Roux-en-Y Gastric Bypass (LRYGB) remains one of the most commonly performed bariatric procedures with the best long-term results. There are few studies comparing LSG with LRYGB. The aim of this study is to compare the safety and outcome of LSG to LRYG in a single accredited center.

METHODS

A retrospective analysis of data collected prospectively on patients undergoing either LSG or LRYGB between January 2009 and December 2012 was performed. LSG was performed using 36Fr bougie, while LRYGB was perfromed with a 25-mm circular stapler. The primary outcomes included length of stay (LOS), 30-day complication and readmission rates, and excess weight loss (%EWL) at 3, 6, 12, and 24 months postoperatively. LSG patients were also divided into different categories based on BMI and their %EWL compared to LRYGB.

RESULTS

A total of 885 patients were included in our analysis. 547 patients underwent LRYGB (61.8 %) and 338 underwent LSG (38.2 %). Thirty-day complication and readmission rates for LRYGB and LSG were (1.5 and 5.1 % vs 0.6 and 0.3 %, respetively, p > 0.05). %EWL for LRYGB was significantly higher than LSG at 3, 6, 12, and 24 months. LSG with a BMI <40 achieved a similar %EWL to LRYGB in the first 12 months.

CONCLUSIONS

LSG seems to have a better safety profile in the short-term compared to LRYGB. However, at 2 years, LRYGB patients achieved a significantly higher EWL compared to LSG patients. Randomized clinical trials are needed to better elucidate our findings.

Endoscopic Treatment of Early Gastric Obstruction After Sleeve Gastrectomy: Report of Two Cases

Morbid obesity is an epidemic and complex disease which imposes a multidisciplinary approach. Laparoscopic sleeve gastrectomy has become a frequent procedure given its efficacy and safety compared to other surgical options. However, it isn’t free from complications. Lax gastric fixation or incorrect positioning of the stomach during surgery can result in early gastric outlet obstruction caused by a volvulus-like mechanism by rotation of the stomach around its anatomic axes. This report refers to two cases of post sleeve gastric torsion resulting in persisting vomiting after initiating oral intake. The diagnosis was confirmed by upper gastrointestinal-contrast study and gastroscopy. In both cases, a fully covered self-expandable metallic stent was inserted which prompted the gastric lumen to become permeable resulting in symptomatic resolution. The stents were removed endoscopically after two and three months. Beyond more than three years of follow-up, the patients remain asymptomatic and no recurring “stenosis” was noticed. In these cases the use of fully covered self-expandable metallic stents demonstrated to be effective and safe in the treatment of post sleeve gastric torsion.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Gastric leaks post sleeve gastrectomy: Review of its prevention and management

Gastric sleeve gastrectomy has become a frequent bariatric procedure. Its apparent simplicity hides a number of serious, sometimes fatal, complications. This is more important in the absence of an internationally adopted algorithm for the management of the leaks complicating this operation. The debates exist even regarding the definition of a leak, with several classification systems that can be used to predict the cause of the leak, and also to determine the treatment plan. Causes of leak are classified as mechanical, technical and ischemic causes. After defining the possible causes, authors went into suggesting a number of preventive measures to decrease the leak rate, including gentle handling of tissues, staple line reinforcement, larger bougie size and routine use of methylene blue test per operatively. In our review, we noticed that the most important clinical sign or symptom in patients with gastric leaks are fever and tachycardia, which mandate the use of an abdominal computed tomography, associated with an upper gastrointrstinal series and/or gastroscopy if no leak was detected. After diagnosis, the management of leak depends mainly on the clinical condition of the patient and the onset time of leak. It varies between prompt surgical intervention in unstable patients and conservative management in stable ones in whom leaks present lately. The management options include also endoscopic interventions with closure techniques or more commonly exclusion techniques with an endoprosthesis. The aim of this review was to highlight the causes and thus the prevention modalities and find a standardized algorithm to deal with gastric leaks post sleeve gastrectomy.