Dr Saeed Yousefi

Roux-en-Y gastric bypass (RYGB)

second most common bariatric procedure worldwide

leak at the GJ occurring in 1% to 4% of all cases

Mortality from leak is stated to range from 0.1% to 8.5%

Leak after Gastric bypass

Almost half (44%) of the leaks were identified within 3days of surgery (early leaks), with most leaks diagnosedon day 2

Leak after Gastric bypass

GI leaks after GB occur most often in one of 4 locations

gastrojejunal anastomosis

gastric pouch staple line

jejunojejunostomy

gastric remnant staple line

most commonly →gastrojejunal anastomosis

although some have reported a greater mortality from jejunojejunostomy leaks

Leak after Gastric bypass

risk factors for developing a leak after RYGB were

male sex

age 49 years

diabetes

hypertension

Conversion to open surgery

Operative time 90 minutes

Waist circumference, BMI, and smoking were not significant risk factors

Prevention of gastrointestinal leak after GB

intraoperative attempt to decrease the incidence of leak such as

oversewing the staple line and reinforcing the staple line with SLR or biologic or synthetic materials such as fibrin glue

There is no high-quality clinical evidence, including availableprospective randomized studies, to suggest that any suchinterventions significantly decrease leak incidence after GB

Prevention of gastrointestinal leak after GB

Intraoperative leak assessment using endoscopy and/or distention of the anastomosis with dye, air, or other gas may be useful to detect leaksthat can be repaired during the procedure

these techniques have not been reported to decrease the risk of leak after surgery

Management of GI leaks after GB

Clinically unstable patients suspected of having a leak → Re exploration through a laparoscopic or open approach

clinically stable patient with a suspected leak → CT of the abdomen and pelvis with oral and IV contrast

utility of identifying associated intraabdominal abscesses, hernias, or other pathologic conditions after GB.Addition of the chest component to the abdominal CT to rule out distinct or concomitant pulmonary pathologic conditions may be considered.

Management of GI leaks after GB

Surgical management should always be considered in the early postoperative

nonoperative management of a GI leak after GB may be considered in selectedand clinically stable patients

▪ bowel rest

▪ antimicrobial agents

▪ total parenteral nutrition

▪ percutaneous drainage of collections

▪ percutaneous access into the remnant stomach both fordecompression and feeding.

Management of GI leaks after GB

GI leaks can occur long after a primary GB as a secondary consequence of other types of complications such as

internal hernia

trocar site hernia

adhesive bowel obstruction

perforated marginal ulcer

Management of GI leaks after GB

Re exploration, open or laparoscopic, is an appropriate and acceptable treatment modality when a GI leak is suspected and remains the diagnostic test withthe highest sensitivity and specificity after GB

Management of GI leaks after GB

Response to treatment →clinically ,drain outputs, resolution of leukocytosis, fever,and reimaging to confirm closure.

Conversion of an acute leak into a controlled fistula that fails to close should raisesuspicion to search for other factors that may promotenonhealing, such as downstream obstruction, stenosis, orforeign body (e.g., from introduction of a drain into the siteof the leak)

low threshold for operative intervention in the face of clinical deterioration or failure of nonoperative management.

Nonoperative methods of GI leak treatment after both GB

endoscopic endoluminal self expandable stents

clips

endoscopic and percutaneously placed drain

biologic glue/tissue sealants

Multiple endoscopies and multimodality treatments may be required to achieve full healing of a chronic fistula

The available data do not favor one treatmentover another

leak from Gastrojejunostomy 60% other site 40%

In total 40,844 patients were included, and a leak at theGJ was confirmed in 262 patients (.6%)

Almost half (44%) of the leaks were identified within 3days of surgery (early leaks), with most leaks diagnosedon day 2

Mean duration of stay after a leak was 22 days comparedwith 2 days for those who did not have leak

suturing of the defect did not reduces duration of stay

new anastomosis was associated with increased duration of stay

Patients treated with stents also required a prolonged duration of stay: 30days versus 18 days for nonstented patients

Patients with leaks were similar to patients without leaks1 year after RYGB with regard to

BMI

excess weight loss

percent total weight loss

no difference was seen concerningbody mass index (BMI), obstructive sleep apnea syndrome,and history of smoking

Leak from Gastrojejunostomy

Surgical reintervention was done in 85% of patients

the defect was sutured in 45%

new anastomosis was done in 5%

feeding gastrostomy was placed in 24%

Stents were used in 31% of GJ leaks

drainage was placed in 89% of patients

6% treated conservatively

death (1%) 2 deaths →cardiac arrest shortly after the leak was diagnosed (0–2 d)

41,342 patients

leaks at the enteroenteral anastomosis (EA) →75 patients (.2%)

small bowel perforations →54 patients (.1%)

EA leaks average diagnose 6.5 days after surgery

small bowel leaks 3.5 days after surgery

Overall, surgical reintervention was done in .97% of patients

Risk factorsIn the multivariate analysis, the risk factors associated toEA leak is surgery at a low-volume center and prolongedoperative time, which agrees with other studies

No difference was seen between the stapled and sutured part of the EA anastomosis

Treatment and outcome

Closing the defect and adequate drainage is essential in managing aleaking EA or small bowel perforation

early diagnosis, preferably by laparoscopy, followed by anintervention that minimizes the spill of bowel contents

LOS was shorter for patients with small bowel perforationsdiagnosed within 3 days

STENT

The most common types of stents are selfexpandable plastic stents (SEPS) and

selfexpandable metal stents (SEMS). Covered SEMS (C-SEMS) are typically the

most utilized in the setting of post-bariatric surgery leak

Stents used for leak management are either fully or partially covered.

Partially covered SEMS offer the luxury of less migration compared to fully

covered SEMS and SEPS

generally prefer the use of fully covered stents

Self-expanding metal and plastic stents

overall proportion of successful leak/fistula closure was 89%

The proportion of successful leak closure in gastric bypass group was 96%

The overall proportion of stent migration was 23%

the period of maintaining stents in the gastrointestinal tract recommended by most authorswas 6–8 weeks

Double Pigtail Stent

Double Pigtail Stent Insertion for Healing of Leaks Following Roux-en-Y

Gastric Bypass.

Clipping techniques

leak/fistula with the OTSC system was achieved in 57 of85 patients (67.1%)

The studies reported use of clipping including the OTSC system for fistulas not larger than 20 mm

A 65-year-old woman with a history of Roux-en-Y

gastric bypass , developed a postoperative gastric

pouch leak and consequent intra-abdominal

abscess. Gastrocutaneous fistulization ensued

despite treatment with intravenous antimicrobial

agents and serial drainage procedures(2017)

OTSC

Tissue sealants

The most commonly used sealant for fistula closure is fibrin glue—a tissue-compatible adhesive working in a double manner

mechanically occludes the stomach wall defect

role in wound healing

inducing cellular response to tissue damage

forming matrix-building strands, which promote neovascularizationfibroblast proliferation

Tissue sealants

10 case series comprising 63 patients

time between bariatric operation and sealant application varied from 1 to 144 days

in 9 studies comprising of 49 patients Success was achieved in 48 patients .between 1 to 9 session of applying fibrin glue was done

In the majority of reports the sessions of sealing were repeated every 2 to 3 days

Endoscopic Injection of Fibrin Sealant

(EIFS)

Other types of tissue sealants

cyanoacrylate glue

high antibacterial properties

eliminated by hydrolysis after a significant time period (1–6 months)only a small quantity of the glue is needed

The costis approximately six times lower than one portion of fibrin glue

Other types of tissue sealants

SurgiSIS

acellular matrix biomaterial formulated from the porcine small intestine submucosa

stimulates proliferation and formation of fibroblasts

incorporates into the scar without initiating a foreign body inflammatory reaction

The rate of 5 to 20 mm wide fistulas closure after 3 sessions was achieved in 20 of 25 patients

Cases Selection for Endoscopic Therapy

hemodynamically stable and in many cases the leak wascontrolled by percutaneous drainage

Septic patients with uncontrolled gastrointestinal leaks or peritonitis should betreated surgically

The success of endoscopic therapies in the management of leak/fistula also depends on the defect’s size. In general, self-expanding stents allow closing the largest leaks and fistulas.

Thanks for your attention