Slide 1

Dr.Mohammad Hayssam ElFawal MD.FACS Dr.Houssam Abtar. Chief Resident MEMA 11 th May 2013 Slide 2 30 years old female, morbidly obese with BMI 42.5 (Wt 97kg, Ht 151cm) presented to MGH for elective laparoscopic sleeve gastrectomy. She is known to have DM II(on glucophage) Slide 3 Patient underwent uneventful laparoscopic sleeve gastrectomy. Bleeding from staple line How would u control your staple line bleed? Day 1 post op she had an upper GI series performed and showed no leakage or obstruction. Slide 4 Slide 5 UGI day one? Is it evidence based or a surgeon preference (I want to sleep!!!!) Slide 6 Patient discharged home on Day 1 on liquid diet. Represented 2 days later with Lt upper quadrant. No nausea or vomiting. No Drains Who is draining routinely his sleeves? P/E: periumbilical and LUQ tenderness. no rebound or rigidity T:38.5 HR:110 Slide 7 CRPINRSGPTGGTAlk Phlipaseamyla se 7.81.2352111434048 U/AHctHbsegWBC Nl391393%12000 Slide 8 Slide 9 Slide 10 Slide 11 The Extravasation of contrast material through the wall of the gastric sleeve, free intra- abdominal contrast material, and free intra-abdominal gas, left sub diaphragmatic free pocket of air Slide 12 NORMAL LEAKAGE Slide 13 Laparoscopic exploration showed pus in the peritoneal cavity (LUQ) and methylene blue test showed leak approximately 10 cm from the pylorus at the staple line. Laparoscopic exploration Slide 14 Slide 15 Slide 16 Slide 17 No consensus exists regarding the timing of this test; some authors perform it 1 day after the procedure, whereas others, routinely perform it 3 days after the procedure. The fact of the test being negative 3 days after surgery could give rise to a false sense of security since most leaks appear after the third day. A lot of centers stopped doing UGI series as a routine in the postoperative period. Obes Surg.Obes Surg. 2012 Jul;22(7):1039-43.Brockmeyer JR et al.Brockmeyer JR Upper gastrointestinal swallow study following bariatric surgery: institutional Dwight David Eisenhower Army Medical Center, 300 Hospital Rd, Fort Gordon, GA 30905, USA. review and review of the literature. UGI Series Slide 18 Routine Abdominal Drains after Laparoscopic Sleeve Gastrectomy: A Retrospective Review of 353 Patients Konstantinos et al Obesity surgery.july 2011 353 sleeve Patients were enrolled in the study. Group A when an intraperitoneal drain was placed and Group B when not. Placement of drains does not facilitate detection of staple line, leak, abscess, or bleeding. Furthermore, they don't seem to eliminate the reoperation rates for these complications. Slide 19 Distal leak is different from proximal leak The use of green stapler for the pylorus is preferable. Avoid the use of cautery on staple line. The routine use of UGI series and Drains is no longer a routine. Close and aggressive management may be the only chance to save your patients life. Slide 20 Slide 21 Slide 22 Sleeve gastrectomy was initially conceived and first described in 1988 by Hess and Marceau as a restrictive component of the BPDDS. In 1999, Gagner et al. performed LSG, which was considered a bridging procedure in super-morbidly obese patients to be followed by a second definitive procedure such as RYGB or BPDDS. Slide 23 The sleeve gastrectomy is now most commonly used as a stand alone operation performed laparoscopically. Slide 24 Weight loss following LSG is achieved by both restriction and hormonal modulation. Firstly, reduction in stomach size with the sleeve resection restricts distention and increases the patients sensation of fullness (decreasing meal portion size). This restriction is further facilitated by the natural band effect of the intact pylorus which is maintained during the sleeve gastrectomy. Reduction in the hunger drive of patients that may be related to decreasing serum levels of ghrelin, a hormone produced mainly by P/D1 cells lining the fundus of the human stomach which stimulates hunger. A Review of Laparoscopic Sleeve Gastrectomy for Morbid Obesity Xinzhe Shi & Shahzeer Karmali & Arya M. Sharma & Daniel W. Birch OBES SURG (2010) 20:11711177 Slide 25 Inflammatory bowel disease. Severe bowel adhesions from previous surgery. The necessity to continue certain medications, (immunosuppressant or antiinflammatory agents). Patient refusal to undergo anatomic rearrangement of their intestinal anatomy or placement of an implanted device. Slide 26 The stomach is reduced without major changes in continuity. preservation of the pylorus prevents dumping syndrome and might add to the restrictive component of LSG. There are no problems with malabsorption and nutritional deficiency as seen in BPDDS. Minimal follow-up is required when compared with other well-established procedures such as LAGB and RYGB. Relative technical ease of performance compared to other bariatric procedures. Acceptable operative time. Low complication rate, (reports of average EWL of 51% to 83% at 1 year ) Improvement of comorbidities. Slide 27 One hundred nine hospitals submitted data on 28,616 patients, from July, 2007 to September, 2010, which were included for this analysis. Slide 28 First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410422) LRYGB/ORYGBLSGLAGB 15.34 kg/m2 at 1- year 11.87 kg/m2 at 1- yea r 7.05kg/m2 at 1-year Slide 29 First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410422 ) The absolute reduction in BMI after the LSG is less than the weight loss after the LRYGB/ORYGB but greater than the weight loss after the LAGB. Slide 30 A Review of Laparoscopic Sleeve Gastrectomy for Morbid Obesity Xinzhe Shi & Shahzeer Karmali & Arya M. Sharma & Daniel W. Birch OBES SURG (2010) 20:11711177 Slide 31 Slide 32 First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410422) 55% have their diabetes resolve or improve 1 year after the LSG, compared to 44% for the LAGB and 83% for the LRYGB. Slide 33 First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410422) For patients who are hypertensive at baseline, 68% have their hypertension resolve or improve 1 year after the LSG, compared to 44% for the LAGB and 79% for the LRYGB. Slide 34 First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410422) LRYGB/ORYGBLSGLAGB 70% at 1-year50% at 1-year64% at 1-year Resolve d Slide 35 First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410422) LRYGB/ORYGBLSGLAGB 66% at 1-year62% at 1-year38% at 1-year Resolve d Slide 36 First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410422 ) LRYGB/ORYGBLSGLAGB 66% at 1-year35% at 1-year33% at 1-year Resolve d Slide 37 Resolution/improvement of comorbidities was 84% for diabetes mellitus, 49.99% for hypertension, 90% for asthma, 90.74% for obstructive sleep apnea, and 45.92% for GERD. Slide 38 A Review of Laparoscopic Sleeve Gastrectomy for Morbid Obesity Xinzhe Shi & Shahzeer Karmali & Arya M. Sharma & Daniel W. Birch OBES SURG (2010) 20:11711177 Slide 39 First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410422) Thirty-day morbidity rate for LSG (5.61%) is statistically higher than the LAGB rate (1.44%), however this is comparable to the LRYGB rate (5.91%). Slide 40 First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410422) that the mortality rate of the LSG (0.11% at 30 days, 0.21% at 1 year) is positioned between the LAGB (0.05% and 0.08%) and the LRYGB (0.14% and 0.34). Slide 41 First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410422) Reoperation/intervention rates for the LSG (2.97%) are positioned between the LAGB (0.92%) and the LRYGB (5.02%), which is significant on both univariate and multivariate analyses. Slide 42 First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410422 Slide 43 A Review of Laparoscopic Sleeve Gastrectomy for Morbid Obesity Xinzhe Shi & Shahzeer Karmali & Arya M. Sharma & Daniel W. Birch OBES SURG (2010) 20:11711177 Slide 44 Gastric Leak After Laparoscopic Sleeve Gastrectomy Manuel Ferrer Mrquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &Mara del Mar Rico Morales & Jose Miguel Garca Dez & Ricardo Belda Poujoulet OBES SURG (2010) 20:13061311 Slide 45 Slide 46 Predicting Risk for Serious Complications With Bariatric Surgery.Results from the Michigan Bariatric Surgery Collaborative Jonathan F. Finks, MD, Kerry L. Kole, DO, et al. for the Michigan Bariatric Surgery Collaborative, from the Center for Healthcare Outcomes and Policy Ann Surg 2011;254:633640 ) Slide 47 In conclusion, data from the ACS-BSCN accredited hospitals show that the LSG seems to be a safe and effective procedure for the treatment of obesity and obesity related comorbidities. At 1 year, complication rates and reduction in weight and weight- related illnesses for the LSG seem to fall between the LAGB (which has relatively fewer short term complications, but less reduction in weight and weight-related diseases), and the LRYGB (which seems to have relatively more complications, and to be more effective ). First Report from the American College of Surgeons Bariatric Surgery Center Network. Matthew M. Hutter, Bruce D. Schirmer, et al. Ann Surg 2011;254:410422) Slide 48 According to the UK Surgical Infection Study Group, a gastric leak was defined as the leak of luminal contents from a surgical joint between two hollow viscera. Gastrointestinal leak in the staple line lead to distribution of luminal content around the organ. Slide 49 Determining the time of appearance, leaks were classified according to Csendes et al. in leaks being detected 1 to 3 days after surgery (postoperative days (POD) 3), those being detected 4 to 7 days after surgery (POD 47), and those appearing more than 7 days after surgery (POD8). Classification of leaks Slide 50 We have proposed a classification of the leaks based on three parameters: time of appearance after surgery, magnitude or clinical severity, and location of the leaks. -Thus, early leaks were classified as those that appeared 1 to 4 days after surgery. - Intermediate leaks those that appeared 5 to 9 days after surgery. - late leaks those that appeared 10 or more days after surgery. Management of Leaks After Laparoscopic Sleeve Gastrectomy in Patients with Obesity Attila Csendes & Italo Braghetto & Paula Len & Ana Mara Burgos J Gastrointest Surg (2010) 14:13431348 Classification of leaks Slide 51 Management of Leaks After Laparoscopic Sleeve Gastrectomy in Patients with Obesity Attila Csendes & Italo Braghetto & Paula Len & Ana Mara Burgos J Gastrointest Surg (2010) 14:13431348 Slide 52 Furthermore, type I or subclinical are those that appear as a localized leak, without spillage or dissemination, with few clinical manifestations and easy to treat medically. Type II leaks are those with dissemination or diffusion into the abdominal or pleural cavity, with the appearance of contrast medium (methylene blue, radiological contrast) or food through any of the abdominal drain, with severe clinical consequences. Management of Leaks After Laparoscopic Sleeve Gastrectomy in Patients with Obesity Attila Csendes & Italo Braghetto & Paula Len & Ana Mara Burgos J Gastrointest Surg (2010) 14:13431348 Types of leaks Slide 53 The analysis of the data clearly suggests that leak primarily occurs at the proximal portion of the staple-line. Only 52% of studies documented the location of the leak and 89% of these were at the esophagogastric junction. This danger zone may be thinner than the rest of the stomach. Elariny et al. demonstrated that the stomach has different thickness throughout with the fundus being the thinnest at approximately 1.7 mm. This begs the question of whether a white load (2.5 mm staple height) should be used for the upper most staples as green loads are used for the antrum because of its thickness. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients Alexander R. Aurora Leena Khaitan Alan A. Saber Surg Endosc (DEC 2011)DOI 10.1007/s00464-011-2085-3, location of leaks Slide 54 Burgos et al. reported 85.7% of leaks in the proximal third and only 14.3% in the distal third. Gastric Leak After Laparoscopic Sleeve Gastrectomy Manuel Ferrer Mrquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &Mara del Mar Rico Morales & Jose Miguel Garca Dez & Ricardo Belda Poujoulet OBES SURG (2010) 20:13061311 location of leaks Slide 55 Leaks can be produced by two mechanisms: mechanical and ischemic: Mechanical mechanism occurs when intragastric pressure exceeds the strength of the staple line. Devascularization of the gastroesophageal junction during the liberation of the greater curvature could be related to ischemia and difficulty in healing. Gastric Leak After Sleeve Gastrectomy: Analysis of Its Management Xabier de Aretxabala & Jorge Leon & Gonzalo Wiedmaier & Ivan Turu & Cristian Ovalle & Fernando Maluenda & Carolina Gonzalez & Jennifer Humphrey & Mabel Hurtado & Carlos Benavides OBES SURG (2011) 21:12321237 Mechanisms of leaks Slide 56 Baker suggests that fistulas can be divided into two categories: mechanicaltissular causes and ischemic causes. In both situations, intraluminal pressure exceeds tissular and suture line resistance, thus causing the fistula. Gastric Leak After Laparoscopic Sleeve Gastrectomy Manuel Ferrer Mrquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &Mara del Mar Rico Morales & Jose Miguel Garca Dez & Ricardo Belda Poujoulet OBES SURG (2010) 20:13061311 Mechanisms of leaks Slide 57 Gastric fistulas are secondary to an impaired normal acute healing process. Local risk factors include impaired suture line healing, poor blood flow, infection, and poor oxygenation with subsequent ischemia. Some authors suggest that most fistulas are not due to staple failure, and consequently, staple line dehiscence, but are due to ischemia in the gastric wall next to the staple line that may be caused by dissection of the greater curvature when using the Ultracision or LigaSure systems. Gastric Leak After Laparoscopic Sleeve Gastrectomy Manuel Ferrer Mrquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &Mara del Mar Rico Morales & Jose Miguel Garca Dez & Ricardo Belda Poujoulet OBES SURG (2010) 20:13061311 Mechanisms of leaks Slide 58 When the cause is mechanicaltissular, fistulas are usually discovered within the first 2 days after surgery. Gastric Leak After Laparoscopic Sleeve Gastrectomy Manuel Ferrer Mrquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &Mara del Mar Rico Morales & Jose Miguel Garca Dez & Ricardo Belda Poujoulet OBES SURG (2010) 20:13061311 Mechanisms of leaks Classic ischemic fistulas tend to appear between 5 and 6 days after surgery, when the wall healing process is between the inflammation phase and fibrotic phase. Slide 59 Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients Alexander R. Aurora Leena Khaitan Alan A. Saber Surg Endosc DOI 10.1007/s00464-011-2085-3,DEC 2011 Presented at the SAGES 2011 Annual Meeting, March 30April 2,2011, San Antonio, TX Slide 60 This demonstrated that LSG provides comparative weight loss to gastric bypass with minimal risk. leak rate of approximately 2.4%. Clinically significant bleeding and stricture rate of less than 1%. Leak occurs at the GE junction in 89% of the time. The risk of leak is greater in patients with BMI[50 kg/m2. Bougie size of \40-Fr also is associated with increased risk of leak. Oversewing or buttressing of the staple-line does not have a clinically significant effect on leak. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients Alexander R. Aurora Leena Khaitan Alan A. Saber Surg Endosc (DEC 2011)DOI 10.1007/s00464-011-2085-3, Slide 61 Alternatively, using a larger bougie size may give greater clearance at the dreaded esophagogastric junction thereby reducing the risk of leak. This may be supported by the fact that surgeon s who used a bougie size of 40- Fr or greater had a 0.6% leak rate (5/897 cases). The leak rate was 2.8% (110/3,991) in groups who used a bougie size less than 40-Fr(P\0.05). This difference was statistically significant, thus favoring the use of a bougie of 40-Fr to avoid leak. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients Alexander R. Aurora Leena Khaitan Alan A. Saber Surg Endosc (DEC 2011)DOI 10.1007/s00464-011-2085-3, Slide 62 A sudden onset of abdominal pain was the main symptom in the patients with an early leak. All patients developed tachycardia and fever in conjunction with the pain episode. Abdominal pain located in the upper portion of the abdomen associated with fever was the first symptom in four patients while two developed respiratory symptoms and the CT findings were interpreted as pneumonia associated with pleural effusion, and treatment was provided for this diagnosis. Symptoms of leaks Slide 63 Leading symptoms of patients with gastric leak were tachycardia, increased WBC, and elevated C-reactive protein levels. Gastric leakage after sleeve gastrectomyclinical presentation and therapeutic options. Christian Jurowich & Andreas Thalheimer & Florian Seyfried & Martin Fein & Gwendolyn Bender & Christoph-Thomas Germer & Christian Wichelmann Langenbecks Arch Surg (2011) 396:981987 Symptoms of leaks Slide 64 Burgos et al. report a series of 7 leaks in 214 patients (3.3%), of which 5 patients presented with abdominal pain, fever, tachycardia, tachypnea, and increased laboratory signs of infection. They observed that tachycardia is an initial sign of early leak. Gastric Leak After Laparoscopic Sleeve Gastrectomy Manuel Ferrer Mrquez & Manuel Ferrer Ayza & Ricardo Belda Lozano &Mara del Mar Rico Morales & Jose Miguel Garca Dez & Ricardo Belda Poujoulet OBES SURG (2010) 20:13061311 Symptoms of leaks Slide 65 Management of Leaks After Laparoscopic Sleeve Gastrectomy in Patients with Obesity Attila Csendes & Italo Braghetto & Paula Len & Ana Mara Burgos J Gastrointest Surg (2010) 14:13431348 Slide 66 Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients Alexander R. Aurora Leena Khaitan Alan A. Saber Surg Endosc (DEC 2011)DOI 10.1007/s00464-011-2085-3, Slide 67 Slide 68 Leak management depends on the time of the diagnosis. In the case of leaks detected during the first days of the postoperative period, a relaparoscopy should be performed. In some patients, the leak had already spread to the abdominal cavity, and a complete and thorough cleaning is necessary. Local factors such as edema, inflammation, and presence of infection around the defects should be considered. Gastric Leak After Sleeve Gastrectomy: Analysis of Its Management Xabier de Aretxabala & Jorge Leon & Gonzalo Wiedmaier & Ivan Turu & Cristian Ovalle & Fernando Maluenda & Carolina Gonzalez & Jennifer Humphrey & Mabel Hurtado & Carlos Benavides OBES SURG (2011) 21:12321237 Management of leaks Slide 69 The determining factor for the treatment of gastric leakage within the first week after LSG is the location of the leakage and the presence or absence of an intraabdominal dra in.. Gastric leakage after sleeve gastrectomyclinical presentation and therapeutic options. Christian Jurowich & Andreas Thalheimer & Florian Seyfried & Martin Fein & Gwendolyn Bender & Christoph-Thomas Germer & Christian Wichelmann Langenbecks Arch Surg (2011) 396:981987 Management of leaks Slide 70 In case of proximal leakage, endoluminal stent graft application is a promising therapy in the early postoperative course, irrespective of the exact postoperative day. In case of absence of an intraabdominal drain, relaparoscopy with abdominal lavage and insertion of a drain is necessary Re-suture or resection of the staple line may be a possible solution to the problem only in case of distal leakage.. Gastric leakage after sleeve gastrectomyclinical presentation and therapeutic options. Christian Jurowich & Andreas Thalheimer & Florian Seyfried & Martin Fein & Gwendolyn Bender & Christoph-Thomas Germer & Christian Wichelmann Langenbecks Arch Surg (2011) 396:981987 Management of leaks Slide 71 In the case of early fistula (