Management Algorithm for Leaks Following Laparoscopic Sleeve Gastrectomy

BACKGROUND

Leak after laparoscopic sleeve gastrectomy (LSG) is a serious complication. No clear algorithm has been described for management.

METHODS

We reviewed our prospective database for all leaks after LSG treated at the Bariatric and Metabolic Institute (BMI) Abu Dhabi from 2010 to 2014. Our management algorithm is based on the timing of the LSG leak, nutritional status of the patient, and the presence of stenosis or peritonitis. Acute leaks with or without peritonitis are treated by operatively or utilizing endoscopic stenting, respectively. LSG leaks with stenosis not amenable to endoscopic stenting are treated with laparoscopic Roux en Y esophagojejunostomy (LRYEJ).

RESULTS

We performed 236 LSG without a leak, and 14 LSG leaks were referred to our unit. Mean age was 35.6 years, and 50 % of patients were males. Mean BMI was 37 kg/m(2). The patients presented on average 13.9 weeks after LSG. Enteral feeding was used as the primary nutrition route in 85.5 % of patients. Our management strategy was operative in 78.4 % of patients (jejunostomy feeding in 57 % and LRYEJ in 21.4 % of patients) and conservative with or without stents in 21.6 % of patients. Mean in hospital length of stay (LOS) was 5.6 weeks. Our reoperation rate was 7 %. There were no mortalities and one patient 7 % developed pulmonary embolism. None of the patients treated returned with a leak or collection after a mean follow up of 23.6 months.

CONCLUSION

Treating leaks following LSG based on the timing of presentation, presence of stricture, and malnutrition is safe and effective.

The clinical diagnosis of chronic acalculous cholecystitis

BACKGROUND

Chronic acalculous cholecystitis (CAC), a diagnosis of exclusion, appears to be more common than was previously thought. We correlated the pathology with test results and response to treatment in a prospective study to obtain data for evidence-based management.

METHODS

The study subjects were patients with chronic biliary symptoms but had normal sonogram results. They were further investigated with esophagogastroduodenoscopy, multidiscipline evaluations, and cholecystokinin-stimulated scintigraphy (CCK-HIDA). They were offered laparoscopic cholecystectomy (LC) when the symptoms were intransigent, and the main abnormality was a low ejection fraction (EF) as determined by CCK-HIDA. We analyzed the histologic findings of the gallbladder, CCK-HIDA EF, and clinical outcomes during the control period with a concurrent series of LC for calculus from the same surgeons.

RESULTS

Of 176 cholecystectomies for biliary pain without stones, 152 had pathologically verified CAC. EF by CCK-HIDA was low in patients with CAC (18%) and low in normal gallbladders (26%). In the same period, 497 patients had cholecystectomies for cholelithiasis. Lasting symptom relief for CAC after LC was not different from that for calculous disease (85% vs 90%).

CONCLUSIONS

The syndrome consisting of chronic biliary symptoms, stone-free sonograms, low EF in CCK-HIDA, and absence of other pain sources is highly predictive for CAC, which is well treated with LC, with results similar to those for calculous disease.