Standardized Treatment of Leakage Post-Sleeve Gastrectomy, Techniques to Decrease Leakage Rate, Correlation of Certain Variables with Patient Remission, Morbidity and Mortality
DOI:
https://doi.org/10.51699/ijhsms.v1i4.137Keywords:
Sleeve, Gastrectomy, leakage, Management, Bariatric, SurgeryAbstract
Introduction: Laparoscopic sleeve gastrectomy (LSG) is the most common performed bariatric surgery. Gastric leak is a known detrimental complication after LSG and is the second most common cause of death after bariatric surgery with an overall mortality rate of 0.4%
Objective: This study aims to share outcomes of our post laparoscopic sleeve gastrectomy (LSG) leak management algorithm, including the rate of resolution, complications, admission to the intensive care unit, conversion to other techniques, and mortality. This study also aims to identify techniques that decrease leakage rate , to find if there is any correlation of certain variables with patient remission, morbidity and mortality and to determine if any factor can predict the resolution time.
Methodology: A retrospective study of prospectively collected data of patients with post LSG leak managed in Innova Medical center was done.
Results: The number of patients studied in the research was 1200 and Out of the 1200 cases of sleeve gastrectomies done in Innova Medical Center, 11 cases of gastric leaks occurred. The first 4 cases occurred in the first 100 operations where the oversewing technique was not adopted.When Oversewing technique was started with enforcement of staple line with running sutures from the Gastroesophageal (GE) junction to the pyloric area the rate of gastric leaks dwindled. Other management techniques used were: Gastric Lavage, Drain placement , oversewing , stent placement ,conservative management (Broad spectrum antibiotics, TPN, NPO , IV hydration) , Conversion to Roux en Y & Total gastrectomy . There was remission seen in 10/11 patients (90.9 % ) following the treatment strategy used , with 1 fatal case.
Conclusion:
- Staple line reinforcement with sutures dramatically reduces the leakage cases according to our material.
- Early Leaks are probably related to surgical malpractice.
- Intermediate leaks have better outcome than late leaks
- Staple line leaks are not correlated to age, sex , BMI.
- Feeding Jejunostomy has better control of nutritional status of the patient than parenteral nutrition.
- Stenting has no evident efficacy in controlling gastric leakage.
- Gastric Leak is not 100% preventable but can be cured with 95% efficacy if the admission is on time.
- Admission On time , Re-laparoscopy,
drainage, no touch technique & feeding jejunostomy is the standardised treatment for Leakage that should be adopted.
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References
Ellis B.W., Giles J.A., Hargreave T.B., Hughes S.P.F., Jones D., Karran Percival S.A., Ridgway G.L., Strachan C.J.L., Taylor T.V. Proposed definitions for the audit of postoperative infection: A discussion paper. Ann. R. Coll. Surg. Engl. 1991;74:151. [Google Scholar]
Bekheit M, Katri K, Nabil W, Sharaan M, El Kayal E. Earliest signs and management of leakage after bariatric surgeries: Single institute experience. 2022.
Baker RS, Foote J, Kemmeter P, Brady R, Vroegop T, Serveld M. The science of stapling and leaks. Obes Surg. 2004;14:1290–1298. [PubMed] [Google Scholar]
Csendes A, Díaz JC, Burdiles P, Braghetto I, Maluenda F, Nava O, et al. Classification and treatment of anastomotic leakage after extended total gastrectomy in gastric carcinoma. Hepatogastroenterology. 1990;37(Suppl 2):174–7
Csendes A, Burdiles P, Burgos AM, Maluenda F, Diaz JC. Conservative management of anastomotic leaks after 557 open gastric bypasses. Obes Surg. 2005;15:1252–6.
Burgos AM, Braghetto I, Csendes A, Maluenda F, Korn O, Yarmuch J, et al. Gastric leak after laparoscopic-sleeve gastrectomy for obesity. Obes Surg. 2009;19:1672–7
Welsch T, von Frankenberg M, Schmidt J, Büchler MW. Diagnosis and definition of anastomotic leakage from the surgeon’s perspective. Chirurg. 2011;82:48–55.
Wahby M, Salama AF, Elezaby AF, Belgrami F, Abd Ellatif ME, El-Kaffas HF, Al-Katary M. Is routine postoperative gastrografin study needed after laparoscopic sleeve gastrectomy? Experience of 712 cases. Obes Surg. 2013;23:1711–1717. [PubMed] [Google Scholar] [Ref list]
Dapri G, Cadière GB, Himpens J. Reinforcing the staple line during laparoscopic sleeve gastrectomy: prospective randomized clinical study comparing three different techniques. Obes Surg. 2010;20:462–467.
Csendes A, Braghetto I, León P, Burgos AM. Management of leaks after laparoscopic sleeve gastrectomy in patients with obesity. J Gastrointest Surg. 2010;14:1343–1348.
Bège T, Emungania O, Vitton V, Ah-Soune P, Nocca D, Noël P, Bradjanian S, Berdah SV, Brunet C, Grimaud JC, et al. An endoscopic strategy for management of anastomotic complications from bariatric surgery: a prospective study. Gastrointest Endosc. 2011;73:238–244.
Mennigen R, Colombo-Benkmann M, Senninger N, Laukoetter M. Endoscopic closure of postoperative gastrointestinal leakages and fistulas with the Over-the-Scope Clip (OTSC) J Gastrointest Surg. 2013;17:1058–1065.
Petersen B, Barkun A, Carpenter S, Chotiprasidhi P, Chuttani R, Silverman W, Hussain N, Liu J, Taitelbaum G, Ginsberg GG. Tissue adhesives and fibrin glues. Gastrointest Endosc. 2004;60:327–333
Hwang TL, Chen MF. Randomized trial of fibrin tissue glue for low output enterocutaneous fistula. Br J Surg. 1996;83:112
Sakran N, Goitein D, Raziel A, Keidar A, Beglaibter N, Grinbaum R, Matter I, Alfici R, Mahajna A, Waksman I, et al. Gastric leaks after sleeve gastrectomy: a multicenter experience with 2,834 patients. Surg Endosc. 2013;27:240–245.
Dakwar A, Assalia A, Khamaysi I, Kluger Y, Mahajna A. Late complication of laparoscopic sleeve gastrectomy. Case Rep Gastrointest Med. 2013;2013:136153.
Fig 2:
Abou Rached A, Basile M, El Masri H. Gastric leaks post sleeve gastrectomy: Review of its prevention and management. World J Gastroenterol 2014; 20(38): 13904-13910 [PMID: 25320526 DOI: 10.3748/wjg.v20.i38.13904]
Fig 1:
Abou Rached A, Basile M, El Masri H. Gastric leaks post sleeve gastrectomy: Review of its prevention and management. World J Gastroenterol 2014; 20(38): 13904-13910 [PMID: 25320526 DOI: 10.3748/wjg.v20.i38.13904]
Gonzalez R, Sarr MG, Smith CD, Baghai M, Kendrick M, Szomstein S, Rosenthal R, Murr MM. Diagnosis and contemporary management of anastomotic leaks after gastric bypass for obesity. J Am Coll Surg. 2007;204:47-55
Hamilton EC, Sims TL, Hamilton TT, Mullican MA, Jones DB, Provost DA. Clinical predictors of leak after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Surg Endosc. 2003;17:679-684.
Stamou KM, Menenakos E, Dardamanis D, Arabatzi C, Alevizos L, Albanopoulos K, Leandros E, Zografos G. Prospective comparative study of the efficacy of staple-line reinforcement in laparoscopic sleeve gastrectomy. Surg Endosc. 2011;25:3526-3530.
Sakran N, Goitein D, Raziel A, Keidar A, Beglaibter N, Grinbaum R, Matter I, Alfici R, Mahajna A, Waksman I. Gastric leaks after sleeve gastrectomy: a multicenter experience with 2,834 patients. Surg Endosc. 2013;27:240-245.
Ballesta C, Berindoague R, Cabrera M, Palau M, Gonzales M. Management of anastomotic leaks after laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2008;18:623-630.
Aurora AR, Khaitan L, Saber AA. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients. Surg Endosc. 2012;26:1509-1515.
Jurowich C, Thalheimer A, Seyfried F, Fein M, Bender G, Germer CT, Wichelmann C. Gastric leakage after sleeve gastrectomy-clinical presentation and therapeutic options. Langenbecks Arch Surg. 2011;396:981-987
