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Szydlo Shein G, Elazary R, Marom G, Fishman Y, Abu Gazala M, Brodie R, Jacob H, Benson AA, Rivkind A, Pikarsky AJ, Mintz Y. Post-POEM Contrast-Enhanced Swallow Study: Is It Always Necessary? J Gastrointest Surg 2023; 27:878-886. [PMID: 36720757 DOI: 10.1007/s11605-023-05605-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 01/09/2023] [Indexed: 02/02/2023]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is rapidly becoming the procedure of choice for treating esophageal achalasia. In most centers, contrast-enhanced swallow studies (CESS) are routinely performed postoperatively to confirm mucosal integrity. The aim of this study was to determine the necessity of performing these studies routinely after POEM. METHODS A retrospective review of a prospectively maintained database of patients who underwent POEM between December 2012 and November 2020 was performed. All patients underwent a CESS on the first postoperative day. Medical records including vital signs, complete blood count, and POD-1 CESS were evaluated. RESULTS One hundred thirty-four consecutive patients were included in the study. Sixty-nine (51.49%) CESS showed abnormal findings; while most findings did not change the postoperative course, five (7.2%) demonstrated tunnel leaks, which did alter the overall management. Screening patients for fever, tachycardia, or leukocytosis on POD-1 had a 100% sensitivity and a 62% specificity for finding a clinically significant complication on CESS. CONCLUSIONS The study findings suggest that performing routine contrast-enhanced swallow studies on all patients is not necessary following POEM, as leaks can be screened for by clinical or laboratory abnormalities. Herein, we propose an algorithm based on objective measurable findings for the selection of patients who should undergo CESS.
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Affiliation(s)
- Gabriel Szydlo Shein
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Ram Elazary
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Gad Marom
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yuri Fishman
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Mahmud Abu Gazala
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ronit Brodie
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Harold Jacob
- Department of Gastroenterology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Ariel A Benson
- Department of Gastroenterology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Avraham Rivkind
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Alon J Pikarsky
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yoav Mintz
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
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Lu CY, Liu YL, Liu KJ, Xu S, Yao HL, Li L, Guo ZS. Differences in examination results of small anastomotic fistula after radical gastrectomy with afterward treatments: A case report. World J Clin Cases 2022; 10:7609-7616. [PMID: 36157983 PMCID: PMC9353917 DOI: 10.12998/wjcc.v10.i21.7609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/18/2022] [Accepted: 06/15/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Gastrografin swallow, methylthioninium chloride test, and computed tomography (CT) are the main methods for postoperative anastomotic fistula detection. Correct selection and application of examinations and therapies are significant for the early diagnosis and treatment of small anastomotic fistulas after radical gastrectomy, which are conducive to postoperative recovery.
CASE SUMMARY A 44-year-old woman underwent radical total gastrectomy for laparoscopic gastric cancer. The patient developed a fever after surgery. The methylthioninium chloride test and early CT suggested no anastomotic fistula, but gastrografin swallow and late CT showed the opposite result. The fistula was successfully closed using an endoscopic clip. The methylthioninium chloride test, gastrografin, and CT performed on different postoperative dates for small esophagojejunostomy fistulas are different. The size of the anastomotic fistula is an important factor for the success of endoscopic treatment.
CONCLUSION The advantages and limitations of the diagnosis of different examinations of small esophagojejunostomy fistulas are noteworthy. The size of the leakage of the anastomosis is an important basis for selecting the repair method.
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Affiliation(s)
- Chen-Yang Lu
- Department of Pulmonary and Critical Care Medicine, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
| | - Ya-Li Liu
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
- Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
| | - Kui-Jie Liu
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
| | - Shu Xu
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
| | - Hong-Liang Yao
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
| | - Lun Li
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
| | - Zhu-Shu Guo
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
- Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
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Lainas P, Triantafyllou E, Chagué P, Dammaro C, Maitre S, Rocher L, Dagher I. Routine Early Computed Tomography Scanner After Laparoscopic Sleeve Gastrectomy in High-Risk Severely Obese Patients Is Effective for Bleeding or Hematoma Diagnosis but not for Staple-Line Leak Detection: a Prospective Study. Obes Surg 2022; 32:1624-1630. [PMID: 35292901 DOI: 10.1007/s11695-022-05997-y] [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: 09/22/2021] [Revised: 03/01/2022] [Accepted: 03/08/2022] [Indexed: 12/20/2022]
Abstract
PURPOSE Laparoscopic sleeve gastrectomy (LSG) is the most frequently performed bariatric procedure worldwide. Postoperative staple-line leak and intraabdominal hemorrhage can increase associated morbidity and mortality. The value of routine early computed tomography (CT) scanner examination in the early diagnosis of complications in high-risk severely obese patients undergoing LSG is studied. METHODS This was a prospective, non-randomized study including all patients undergoing LSG in our department from 2014 to 2020. Patients presenting at least one potential risk factor for postoperative gastric leak and bleeding (as defined by the current literature) were included. Primary endpoint was the efficacy of postoperative day (POD) 2 CT-scanner examination in diagnosing these complications. RESULTS One thousand fifty-one high-risk patients were included. Median age was 44 years. Early postoperative surgical complications occurred in 48 patients (4.5%): 25 (2.3%) intraabdominal hemorrhage and 23 (2.2%) staple-line leak. Early CT-scanner detected intraabdominal bleeding or hematoma in 22/25 patients, with 95.6% sensitivity (Youden's index = 0.95), while specificity was 100%, positive predictive value (PPV) 100%, and negative predictive value (NPV) 99.9%. Sensitivity of early postoperative CT-scanner was 43.4% (10/23 patients; Youden's index = 0.43) for staple-line leak detection, with specificity of 100%, PPV 100%, and NPV 98.7%. CONCLUSION POD 2 CT-scanner in high-risk severely obese patients undergoing LSG is an excellent tool for early diagnosis of intraabdominal hemorrhage, but sensitivity remains low for staple-line leak detection. Close postoperative clinical follow-up of these patients is essential and any suspicion of postoperative surgical complication should motivate the performance of a CT-scanner.
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Affiliation(s)
- Panagiotis Lainas
- Department of Minimally Invasive Digestive Surgery, Antoine-Béclère Hospital, AP-HP, F-92140, Clamart, France. .,Paris-Saclay University, F-91405, Orsay, France.
| | - Evangelia Triantafyllou
- Department of Minimally Invasive Digestive Surgery, Antoine-Béclère Hospital, AP-HP, F-92140, Clamart, France
| | - Pierre Chagué
- Paris-Saclay University, F-91405, Orsay, France.,Department of Radiology, Antoine-Béclère Hospital, AP-HP, F-92140, Clamart, France
| | | | - Sophie Maitre
- Paris-Saclay University, F-91405, Orsay, France.,Department of Radiology, Antoine-Béclère Hospital, AP-HP, F-92140, Clamart, France
| | - Laurence Rocher
- Paris-Saclay University, F-91405, Orsay, France.,Department of Radiology, Antoine-Béclère Hospital, AP-HP, F-92140, Clamart, France
| | - Ibrahim Dagher
- Department of Minimally Invasive Digestive Surgery, Antoine-Béclère Hospital, AP-HP, F-92140, Clamart, France.,Paris-Saclay University, F-91405, Orsay, France
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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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Imaging after laparoscopic sleeve gastrectomy - literature review with practical recommendations. Pol J Radiol 2021; 86:e325-e334. [PMID: 34136051 PMCID: PMC8186309 DOI: 10.5114/pjr.2021.106795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 09/06/2020] [Indexed: 11/17/2022] Open
Abstract
In the XXI century obesity has become one of the most demanding epidemiological threats worldwide. At the same time, bariatric surgery has established itself as an effective treatment for morbidly obese patients, with laparoscopic sleeve gastrectomy (LSG) emerging as the most popular bariatric procedure. This paper reviews the role of imaging studies of patients after LSG. Computed tomography is widely considered as the method of choice in detection of complications in early postoperative period. The dynamic character of upper gastrointestinal examination allows for the assessment of passage through the gastric remnant. The paper also discusses evaluation of the shape and volume of the gastric remnant assessed by imaging studies.
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Assakran BS, Alromaih AH, Alashkar AH, AlGhasham FS, Alqunai MS. Is routine post-sleeve gastrografin needed? Profile of 98 cases. BMC Res Notes 2020; 13:219. [PMID: 32299510 PMCID: PMC7164338 DOI: 10.1186/s13104-020-05060-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 04/06/2020] [Indexed: 01/19/2023] Open
Abstract
Objective Laparoscopic sleeve gastrectomy (LSG) is one of the most commonly performed bariatric procedures. Some surgeons still perform routine post-sleeve gastrografin (RSG) study believing that it would detect post-LSG complications, especially leak. In this study, we aimed to evaluate the cost-effectiveness of RSG by considering the cost of the study, length of hospital stay and complications-related costs RSG could prevent. Results A total of 98 eligible patients were included. Of them, 54 patients underwent RSG and 44 did not. Excluding the cost of LSG procedure, the average cost for those who underwent RSG and those who did not in Saudi Riyal (£) was 5193.15 (1054.77) and 4222.27 (857.58), respectively. The average length of stay (ALOS) was practically the same regardless of whether or not the patient underwent RSG. 90.8% (n = 89) of all patients stayed for 3 days. None of the patients developed postoperative bleeding, stenosis or leak. The mean weight, body mass index (BMI) and percentage weight loss (PWL) 6 months postoperatively were found to be 87.71 kg (SD = 17.51), 33.89 kg/m2 (SD = 7.29) and 26.41% (SD = 9.79), respectively. The PWL 6 months postoperatively was 23.99% (SD = 8.47) for females and 30.57 (SD = 10.6) for males (p = 0.01).
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Affiliation(s)
- Bandar Saad Assakran
- Surgical Department, King Fahd Specialist Hospital, P.O. Box 2290, Alnaziyah, Buraidah, 52366, Saudi Arabia.
| | - Abdullah Homood Alromaih
- Surgical Department, King Fahd Specialist Hospital, P.O. Box 2290, Alnaziyah, Buraidah, 52366, Saudi Arabia
| | | | | | - Mansur Suliman Alqunai
- Surgical Department, King Fahd Specialist Hospital, P.O. Box 2290, Alnaziyah, Buraidah, 52366, Saudi Arabia
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Bhalla S, Yu JX, Varban OA, Schulman AR. Upper gastrointestinal series after sleeve gastrectomy is unnecessary to evaluate for gastric sleeve stenosis. Surg Endosc 2020; 35:631-635. [DOI: 10.1007/s00464-020-07426-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 02/10/2020] [Indexed: 01/07/2023]
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Musella M, Cantoni V, Green R, Acampa W, Velotti N, Maietta P, Cuocolo A. Efficacy of Postoperative Upper Gastrointestinal Series (UGI) and Computed Tomography (CT) Scan in Bariatric Surgery: a Meta-analysis on 7516 Patients. Obes Surg 2019. [PMID: 29516397 DOI: 10.1007/s11695-018-3172-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND To demonstrate the lack of utility and efficacy of routine early postoperative upper gastrointestinal study (UGI) in obese patients undergoing bariatric surgery and to show the higher efficacy of CT scan in cases of clinical suspicion of a leakage, a meta-analysis was performed. MATERIALS AND METHODS A literature search including articles published in last 18 years was performed. For both UGI and CT scan, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. A first analysis considered overall patients, and a second analysis considered only symptomatic patients. RESULTS Starting from 1233 eligible citations, 18 articles, including 7516 patients, were left. The pooled sensitivity was 54% for UGI (95% CI 34-74) with a high heterogeneity (I2 = 99.8%, p < .001), whereas CT scan showed a pooled sensitivity of 91% (95% CI 89-93) significantly higher than sensitivity of UGI series (p < 0.01), with a high heterogeneity (I2 = 98.9%, p < .001). In symptomatic patients the pooled sensitivity of UGI series was significantly lower than sensitivity of CT scan [49% (95% CI 31-68) vs 94% (95% CI 92-96), p < 0.01]. PPV showed a significant difference between UGI series and CT scan (54 vs 100%, p < 0.01). Specificity for UGI series was 98.6%, and specificity for CT scan was 99.7% (p = ns); the mean NPV was 96 and 98% for UGI series and CT scan (p = ns). CONCLUSIONS According to our results, a CT scan triggered by clinical suspicion must be considered the first-line procedure to detect a postoperative leak following primary sleeve gastrectomy or Roux-en-Y gastric bypass.
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Affiliation(s)
- Mario Musella
- Advanced Biomedical Sciences Department, Naples "Federico II" University, AOU "Federico II" - Via S. Pansini 5 Buildings 10/12, 80131, Naples, Italy.
| | - Valeria Cantoni
- Advanced Biomedical Sciences Department, Naples "Federico II" University, AOU "Federico II" - Via S. Pansini 5 Buildings 10/12, 80131, Naples, Italy
| | - Roberta Green
- Advanced Biomedical Sciences Department, Naples "Federico II" University, AOU "Federico II" - Via S. Pansini 5 Buildings 10/12, 80131, Naples, Italy
| | - Wanda Acampa
- Advanced Biomedical Sciences Department, Naples "Federico II" University, AOU "Federico II" - Via S. Pansini 5 Buildings 10/12, 80131, Naples, Italy
| | - Nunzio Velotti
- Advanced Biomedical Sciences Department, Naples "Federico II" University, AOU "Federico II" - Via S. Pansini 5 Buildings 10/12, 80131, Naples, Italy
| | - Paola Maietta
- Advanced Biomedical Sciences Department, Naples "Federico II" University, AOU "Federico II" - Via S. Pansini 5 Buildings 10/12, 80131, Naples, Italy
| | - Alberto Cuocolo
- Advanced Biomedical Sciences Department, Naples "Federico II" University, AOU "Federico II" - Via S. Pansini 5 Buildings 10/12, 80131, Naples, Italy
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Traumatic esophageal perforation in Puerto Rico Trauma Hospital: A case-series. Ann Med Surg (Lond) 2019; 44:62-67. [PMID: 31316769 PMCID: PMC6611994 DOI: 10.1016/j.amsu.2019.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 06/22/2019] [Accepted: 06/24/2019] [Indexed: 01/04/2023] Open
Abstract
Background Esophageal injuries are rare, life-threatening, events with an overall reported incidence of less than 3%. In rare cases, trauma due to blunt or penetrating injuries cause esophageal perforations, which account for less than 15% of all esophageal injuries. Materials and methods A case-series study was conducted to describe the outcomes and management of all the traumatic esophageal injuries at the Puerto Rico Trauma Hospital (PRTH) from 2000 through 2017. These cases were evaluated in terms of etiology of perforation, mechanism of injury and esophageal level. Results Sixteen patients were treated for esophageal injuries at the PRTH between 2000 and 2017. Of these patients, 15 (93.7%) were males with a median age of 24.5 years (16, 49). Regarding the etiology of the esophageal perforation, 2 (12.5%) patients suffered blunt esophageal trauma, and 14 (87.5%) patients had penetrating trauma to the esophagus. The most common mechanism of perforation was gunshot wound 10 (62.4%), followed by stab wound 4 (25.0%), and the least common were motor vehicle collision 1 (6.3%) and pedestrian injured by traffic 1 (6.3%). Regarding esophageal location, 9 (56.3%) patients presented cervical, 6 (37.5%) thoracic, and 1 (6.3%) abdominal injuries. Most patients 13 (81.3%) had a prompt diagnosis of traumatic esophageal perforation, while 3 (18.7%) patients had a delayed diagnosis. Only 2 (12.5%) deaths occurred among our 16 patients, including 1 (6.3%) in delayed diagnosed subjects. Conclusion Esophageal perforation is a life-threatening condition and should be treated urgently. An early diagnosis and prompt surgical treatment completed in the first 24-h is fundamental for a good outcome. Sixteen patients were treated for esophageal injuries at the PRTH. Two patients suffered blunt esophageal trauma and 14 patients had penetrating trauma to the esophagus. Most patients had a prompt diagnosis of traumatic esophageal perforation, while 3 patients had a delayed diagnosis. Regarding esophageal location, of the 16 patients, 9 presented cervical, 6 thoracic, and 1 abdominal esophageal injury. Only 2 deaths occurred among our 16 patients, including 1 in delayed diagnosed subjects.
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