What Is the Risk of Clinical Anastomotic Leak in the Diverted Colorectal Anastomosis?

Objective

The objective of this study was to identify clinical leak in diverted colorectal anastomoses.

Design

Cohort analysis.

Setting

The study was conducted in a subspecialty practice at a tertiary care facility.

Patients

Consecutive subjects undergoing colorectal anastomosis and proximal fecal diversion between July 16, 2007 and June, 31 2012.

Interventions

No intervention was applied.

Main Outcome Measures

Clinical anastomotic leak.

Results

Two hundred forty-five patients underwent a colorectal anastomosis with proximal fecal diversion. A total of 34 (14 %) clinical leaks were identified at a median of 43 days. Clinical leaks were identified in 13 (5 %) patients within 30 days of surgery (early leaks) and in 21 (9 %) patients after 30 days of surgery (late leaks). Age, sex, use of neoadjuvant chemoradiotherapy, and method of anastomotic construction were similar in patients with clinical leaks as compared to those with no evidence of leak. However, clinical leaks were more likely to develop in patients with a diagnosis of inflammatory bowel disease or other diagnoses, i.e., radiation enteritis, ischemia, and injury/enterotomy. Patients with clinical leak were not more likely to have air leaks on intraoperative air leak testing.

Conclusions

In diverted anastomoses, most leaks become clinically apparent beyond 30 days. The standard practice of censoring outcomes that occur beyond postoperative day 30 will fail to identify a substantial fraction of leaks in diverted colorectal anastomoses.     

Role of Intraoperative Esophagogastroenteroscopy in Minimizing Gastrojejunostomy-Related Morbidity: Experience with 2,311 Laparoscopic Gastric Bypasses with Linear Stapler Anastomosis

Background

Anastomotic leaks and strictures of the gastrojejunostomy are a cause of major morbidity following laparoscopic Roux-en-Y gastric bypass (LRYGB). Reported rates of leaks vary between 0 and 5.2 %. This has led bariatric surgeons to use a variety of intraoperative methods to detect incompetent suture lines. The aim of the study was to evaluate the role of intraoperative endoscopy in reducing the rate of postoperative anastomotic complications. The setting of this study is in a community teaching hospital.

Methods

Medical records of 2,311 patients who underwent a LRYGB from 2002 to 2011 were retrospectively reviewed utilizing the hospitals’ bariatric surgery database. Demographics, weight, body mass index, intraoperative endoscopy results, and postoperative outcomes within 90 days after surgery were analyzed.

Results

Endoscopy was attempted in 2,311 patients and completed in 2,308 (99.9 %). Intraoperative leak was detected in 80 (3.5 %) patients; suture line was reinforced in 46 patients (2 %), while in the other 34 patients the leak was transient at only high insufflation pressure. Postoperative clinical leaks were detected in four cases (0.2 %) two of which had initial leaks intraoperatively. In two cases, the anastomosis was too tight and required reconstruction. Twenty-five patients (1.1 %) developed early postoperative strictures requiring endoscopic dilatation within 90 days. Three patients (0.1 %) had iatrogenic injury at the time of intraoperative endoscopy, all three healed without delayed morbidity.

Conclusions

The routine use of intraoperative endoscopy in LRYGB with the linear stapler anastomosis technique is associated with a complication/failure rate of 0.3 % and low gastrojejunostomy-related morbidity after LRYGB within 90 days (leak rate of 0.2 % and stricture rate of 1.1 %).     

Gastric Leak After Laparoscopic Sleeve Gastrectomy: Early Covered Self-Expandable Stent Reduces Healing Time

Background

Laparoscopic sleeve gastrectomy has become a very frequent procedure in bariatric surgery due to its efficacy and simplicity compared to gastric bypass. Gastric staple line leak (1 to 7 % of cases) is a severe complication with a long nonstandardized treatment. The aim of this retrospective study was to examine the success and tolerance of covered stents in its management.

Methods

From January 2009 to December 2011, nine patients with gastric staple line leaks after sleeve gastrectomy were treated with covered stents in our department (seven referred from other institutions). The leaks were diagnosed by CT scan and visualized during the endoscopy. Among the studied variables were operative technique, post-operative fistula diagnosis delay, stent treatment delay, and stent tolerance. In our institution, Hanarostent® (length 17 cm, diameter 18 mm; M.I. Tech, Seoul, Korea) was used and inserted under direct endoscopic control.

Results

Stent treatment was successful in seven cases (78 %). Two other cases had total gastrectomy (405 and 185 days after leak diagnosis). Early stent removal (due to migration or poor tolerance) was necessary in three cases. The average stent treatment duration was of 6.4 weeks, and the average healing time was 141 days. The five patients with an early stent treatment (≤3 weeks after leak diagnosis) had an average healing time of 99 days versus 224 for the four others.

Conclusions

Covered self-expandable stent is an effective treatment of gastric leaks after sleeve gastrectomy. Early stent treatment seems to be associated with shorter healing time.     

Management of Anastomotic Leak: Lessons Learned from a Large Colon and Rectal Surgery Training Program

Background

Anastomotic leak is a dreaded surgical complication that can lead to significant morbidity and mortality. Despite its prevalence, there is no consensus on the management of anastomotic leak. This study aimed to review the management of anastomotic leak in the Division of Colon and Rectal Surgery at two institutions.

Methods

This is a retrospective review of all anastomotic leaks occurring after surgery in the Division of Colon and Rectal Surgery at two teaching institutions during 1997–2008.

Results

Altogether, 103 leaks occurred in 1,707 anastomoses (6 %), with a median time to diagnosis of 20 days (2–1,400 days). The 90-day mortality rate was 3 %. The majority of cases were managed nonoperatively (73 %), and the majority of leaks were from an extraperitoneal anastomosis (67 %). Success (i.e., radiographic demonstration of a healed leak, restored gastrointestinal continuity) occurred in 54 % of operatively managed leaks and 57 % of nonoperatively managed leaks (56 % overall). Operative management differed by leak location. In 91 % of patients with intraperitoneal leaks, the anastomosis was resected. In 76 % of patients with extraperitoneal leaks, diversion and drainage alone was performed without manipulating the anastomosis. Nonoperative management was successful for 57 % of extraperitoneal leaks and 58 % of intraperitoneal leaks. There was no significant difference in the success rates based on type of management (operative/nonoperative) for either extraperitoneal or intraperitoneal leaks.

Conclusions

Anastomotic leak continues to result in patient morbidity and mortality. Its diverse presentation requires tailoring management to the patient. Nonoperative and operative treatments are viable options for intraperitoneal and extraperitoneal leaks based on patient presentation.     

Treating sleeve gastrectomy leak with endoscopic stenting: the kuwaiti experience and review of recent literature

Background

Obesity today is a leading cause of global morbidity and mortality, and bariatric surgeries such as laparoscopic sleeve gastrectomy (LSG) are increasingly playing a key role in its management. Such operations, however, carry many difficult and sometimes fatal complications, including leaks. This study aims at evaluating the effectiveness of endoscopic stenting in treating gastric leaks post-LSG.

Methods

A retrospective study was conducted to the patients who were admitted with post-LSG gastric leak at Al-Amiri Hospital Kuwait from October 2008 to December 2012 and were subsequently treated with stenting. The patients were stented endoscopically with self-expandable metal stent (SEMS), and a self-expandable plastic stent (SEPS) was used to facilitate stent removal.

Results

A total of 17 patients with post-LSG leaks underwent endoscopic stenting. The median age was 34 years (range 19–56), 53 % of the patients were male, and mean body mass index (BMI) was 43 kg/m ² . The median duration of SEMS placement per patient was 42 days (range 28–84). The SEPS-assisted retrieval process took a median duration of 11 days (range 14–35). Successful treatment of gastric leak was evident in 13 (76 %) patients, as evident by gastrografin swallow 1 week after stent removal. In addition, a shorter duration between the LSG and the time of stent placement was associated with a higher success rate of leak seal.

Conclusions

The use of SEMS appears to be a safe and effective method in the treatment of post-LSG leaks, with a success rate of 76 %. The time frame of intervention after surgery is critical, as earlier stent placement is associated with favorable outcomes. Finally, SEPS is often required to facilitate SEMS removal, and further modification of stents and its delivery system may improve results.     

Gastric leaks after sleeve gastrectomy: a multicenter experience with 2,834 patients

Background

Laparoscopic sleeve gastrectomy (LSG) remains under scrutiny as a stand-alone bariatric procedure. The most feared complication after LSG is staple line leak.

Methods

Eight bariatric centers in Israel participated in this study. A retrospective analysis was performed by querying all the LSG cases performed between June 2006 and June 2010. The data collected included patient demographics, anthropometrics, and operative and perioperative parameters.

Results

Among the 2,834 patients who underwent LSG, 44 (1.5 %) with gastric leaks were identified. Of these 44 patients, 30 (68 %) were women. The patients had a mean age of 41.5 years and a body mass index (BMI) of 45.4 kg/m². Intraoperative leak tests and routine postoperative swallow studies were performed with 33 patients, and all but one patient (3 %) failed to detect the leaks. Leaks were diagnosed at a median of 7 days postoperatively: early (0–2 days) in nine cases (20 %), intermediately (3–14 days) in 32 cases (73 %), and late (>14 days) in three cases (7 %). For 38 patients (86 %), there was clinical suspicion, later confirmed by imaging or operative findings. Computed tomography, swallow studies, and methylene blue tests were performed for 37, 21, and 15 patients, respectively, and the results were positive, respectively, for 31 (84 %), 11 (50 %), and 9 (60 %) of these patients. Reoperation was performed for 27 of the patients (61 %). Other treatment methods included percutaneous drainage (n = 28, 63.6 %), endoscopic placement of stents (n = 11, 25 %), clips (n = 1, 2.3 %), and fibrin glue (n = 1, 2.3 %). In 33 of the patients (75 %), the leak site was found in the upper sleeve near the gastroesophageal junction. The median time to leak closure was 40 days (range, 2–270 days), and the overall leak-related mortality rate was 0.14 % (4/2,834).

Conclusion

Gastric leak is the most common cause of major morbidity and mortality after LSG. Routine tests to rule out leaks seem to be superfluous. Rather, selective utilization is recommended. Management options vary, depending mainly on patient disposition. An accepted algorithm for the diagnosis and treatment of gastric leak has yet to be proposed.     

Endoscopy in the Early Postoperative Setting after Primary Gastrointestinal Anastomosis

Introduction

Gastrointestinal anastomoses may require early evaluation and treatment via flexible endoscopic techniques when complications arise. There is reticence, however, to perform endoscopy given the applied mechanical forces. We aimed to identify the incidence of gastrointestinal anastomotic perforation or disruption resulting from endoscopy performed ≤6 weeks of anastomoses.

Methods

Review of patients from 2002 to 2013 who underwent flexible endoscopy within 6 weeks of creation of gastrointestinal anastomosis. Exclusion criteria included intraoperative endoscopy, anastomotic perforation prior to endoscopy, and endoscopy remote from the anastomotic site. Data are presented as median (interquartile range; IQR) or percentages as appropriate.

Results

Twenty-four patients met our criteria (age 69 years [IQR 54–77], 54 % men]). Endoscopy was performed at a median postoperative time of 18 days (IQR 8–30). Indications for endoscopy included bleeding (66 %), obstruction (13 %), pain (13 %), concern for pancreatic duct leak (4 %), and concern for ischemia (4 %). Six patients underwent therapeutic endoscopic procedures including coagulation (8 %), balloon dilation (8 %), tube decompression (8 %), and stent placement (4 %). There were no anastomotic perforations or disruptions as a result of endoscopy.

Conclusion

Despite theoretical risks of adverse events of flexible endoscopy in the early postoperative period, no endoscopic perforations or disruptions occurred in recently created surgical anastomoses.     

The use of fibrin sealant to prevent major complications following laparoscopic gastric bypass: results of a multicenter, randomized trial

Background

Published interim results have shown that fibrin sealant (Tissucol^®/Tisseel^® Baxter AG, Vienna, Austria) may be effective in preventing anastomotic leaks and internal hernias following laparoscopic Roux-en-Y gastric bypass (LRYGBP). We report the final results of a multicenter, randomized clinical trial evaluating the use of fibrin sealant in LRYGBP.

Methods

Between January 2004 and December 2005, 340 patients aged 21–65 years with a body mass index (BMI) of 40–59 kg/m² undergoing LRYGBP were randomized (1:1) to two treatment groups: fibrin sealant group (applied to gastrojejunal and jejunojejunal anastomoses and over mesenteric openings), and control group (no fibrin sealant; suture of the mesenteric openings). Operative time, early and late complications, reinterventions, time to oral diet initiation, and length of stay were assessed.

Results

Overall, 320 patients were included into the study: 160 in the control group and 160 in the fibrin sealant group. All patients completed follow-up assessments at 6 and 12 months, and 60.9% completed assessments at 24 months. There were no significant differences between groups with respect to demographics, operative time, oral diet initiation, hospital stay, and BMI reduction at 6, 12, and 24 months. The incidence of anastomotic leak was numerically, but not significantly, greater in the control group. The overall reintervention rate for specific early complications (<30 days) was significantly higher in the control group (p = 0.016). No deaths or conversions to open laparotomy occurred.

Conclusion

The use of fibrin sealant in laparoscopic RYGBP may be beneficial in reducing the reintervention rate for major perioperative (<30 days) complications. Larger studies are needed.     

Laparoscopic reversal of Roux-en-Y gastric bypass into normal anatomy with or without sleeve gastrectomy

Objective

This study was designed to describe and analyze the outcomes after laparoscopic reversal to normal anatomy (NA) with or without concomitant “sleeve gastrectomy” (SG), after Roux-en-Y gastric bypass (RYGB). Reversal has been proposed as corrective strategy after RYGB.

Methods

We propose a retrospective analysis of a prospectively kept database.

Results

From January 2005 to October 2012, 20 female patients underwent laparoscopic reversal after RYGB for one or more of the following conditions: hypoglycaemic syndrome (nine patients), weight regain (six patients), severe dumping (six patients), and cachexia (two patients). Preoperative BMI was 28.0 (19.2–40.3) kg/m². Reversal was performed to NA in ten patients and included a SG procedure in another ten. Postoperative complications included one bleeding and three leaks (15 %; all in SG patients). Mean hospital stay was 7 days. Mortality was 0. With a mean follow-up of 11.5 months, all but one patient recovered from their initial condition. However, three developed severe gastroesophageal reflux disease (GERD) symptoms and three had chronic diarrhoea.

Conclusions

Outcomes of laparoscopic reversal of RYGB are good, but complications may occur when SG is added. The surgical alterations caused by the reversal may explain the GERD or diarrhoea experienced by some patients.     

Defining Treatment and Outcomes of Hepaticojejunostomy Failure Following Pancreaticoduodenectomy

Background

The overall complication rate after pancreaticoduodenectomy (PD) approaches 50 %, with anastomotic failure being the most frequent cause of serious postoperative morbidity. Hepaticojejunostomy leaks (also called bile leaks) are the second most common type of leak, behind pancreaticojejunostomy leaks, yet have been the focus of only a single study as reported by Suzuki et al. (Hepatogastroenterology 50:254–257, 12).

Methods

We reviewed the recent experience with bile leaks at a single, high-volume pancreatic surgery center over a six-year time period.

Results

Bile leaks were identified in 16 out of 715 patients (2.2 %). Low preoperative albumin was associated with an increased risk. Bile leaks typically manifested within the first week after surgery as bilious drainage in a surgically placed drain. Associated warning signs included fever and leukocytosis. Patients with a bile leak frequently developed other complications, including a pancreatic fistula, wound infection, delayed gastric emptying, and sepsis. The impact on perioperative outcomes was comparable to patients with a pancreatic leak. A grading system is proposed based on the International Study Group on Pancreatic Fistula model. Grade A bile leaks were classified as those managed with prolonged drainage by operatively placed drains, grade B bile leaks with percutaneous abdominal drainage, and grade C bile leaks with insertion of a percutaneous transhepatic biliary drainage.

Conclusions

Hepaticojejunostomy leaks are rare after PD. The complication severity ranges from trivial to life threatening and is comparable overall to pancreaticojejunostomy leaks. Surgical intervention is rarely, if ever, required. With prompt and aggressive management, a full recovery can be expected.     

Removable and repositionable covered metal self-expandable stents for leaks after upper gastrointestinal surgery: experiences in a tertiary referral hospital

Background

Anastomotic leakages are severe complications of upper gastrointestinal surgery with serious morbidity and mortality. Until recently, only abscess drainage was possible. Since 2007, removable and repositionable covered metal self-expandable stents (RReCoMSeS) have been used in our hospital to cover leaks.

Methods

Patients with postsurgical gastrointestinal leaks treated with RReCoMSeS between January 2007 and March 2010 were retrospectively evaluated and described.

Results

Twenty-six patients were treated with RReCoMSeS (totally covered Choo/Hanaro and partially covered Endoflex stents). Included patients had anastomotic leaks after esophagectomy (15) and bariatric surgery (11). Overall successful sealing of the leak occurred in 81 % (including multiple procedures). In total 33 RReCoMSeS were used (mean 1.3 stents and 1.7 procedures per patient). Twenty-one of 33 RReCoMSeS succeeded in sealing the leak (64 %). Migration occurred in 24 % RReCoMSeS, and 9 % disintegrated. One stent (3 %) caused a perforation.

Conclusions

RReCoMSeS are a safe alternative for treating postsurgical leaks in the upper gastrointestinal tract. In 81 % of patients and with 64 % of the inserted stents, leaks were sealed successfully, with few complications. Fewer stents per patient were needed thanks to their repositionability. Stent migration is a major problem.     

Reconstruction after retrosigmoid approaches using autologous fat graft-assisted Medpor Titan cranioplasty: assessment of postoperative cerebrospinal fluid leaks and headaches in 60 cases

Background

Postoperative cerebrospinal fluid (CSF) leaks and headaches remain potential complications after retrosigmoid approaches for lesions in the posterior fossa and cerebellopontine angle. The authors describe a simple repair technique with an autologous fat graft-assisted Medpor Titan cranioplasty and investigate the incidence of postoperative CSF leaks and headaches using this technique.

Methods

A retrospective chart review was conducted on all cases (n?=?60) of retrosigmoid craniectomy from September 2009 to May 2014 in patients who underwent fat graft-assisted cranioplasty. After obtaining a watertight dural closure and sealing off any visible mastoid air cells with bone wax, an autologous fat graft was placed over the dural suture line and up against the waxed-off air cells. The fat graft filled the retrosigmoid cranial defect and was then bolstered with a Medpor Titan (titanium mesh embedded in porous polyethylene) cranioplasty. A postoperative mastoid pressure dressing was applied for 48 h, and prophylactic lumbar drainage was not used. Factors examined in this study included postoperative CSF leak (incisional, rhinorrhea, otorrhea), pseudomeningocele formation, incidence and severity of postoperative headache, length of hospital stay, and length of follow-up.

Results

No patients developed postoperative CSF leaks (0 %), pseudomeningoceles (0 %), or new-onset postoperative headaches (0 %) with the described repair technique. There were no cases of graft site morbidity such as hematoma or wound infection. Mean duration of postoperative hospital stay was 3.8 days (range 2–10 days). Mean postoperative follow-up was 12.4 months (range 2.0–41.1 months).

Conclusions

Our multilayer repair technique with a fat graft-assisted Medpor Titan cranioplasty appears effective in preventing postoperative CSF leaks and new-onset postoperative headaches after retrosigmoid approaches. Postoperative lumbar drainage may not be necessary.     

The Burden of Gastrointestinal Anastomotic Leaks: an Evaluation of Clinical and Economic Outcomes

Objective

To evaluate the clinical and economic burden associated with anastomotic leaks following colorectal surgery.

Methods

Retrospective data (January 2008 to December 2010) were analyzed from patients who had colorectal surgery with and without postoperative leaks, using the Premier Perspective? database. Data on in-hospital mortality, length of stay (LOS), re-admissions, postoperative infection, and costs were analyzed using univariate and multivariate analyses, and the propensity score matching (PSM) and generalized linear models (GLM).

Results

Of the patients, 6,174 (6.18 %) had anastomotic leaks within 30 days after colorectal surgery. Patients with leaks had 1.3 times higher 30-day re-admission rates and 0.8–1.9 times higher postoperative infection rates as compared with patients without leaks (P?<?0.001 for both). Anastomotic leaks incurred additional LOS and hospital costs of 7.3 days and $24,129, respectively, only within the first hospitalization. Per 1,000 patients undergoing colorectal surgery, the economic burden associated with anastomotic leaks—including hospitalization and re-admission—was established as 9,500 days in prolonged LOS and $28.6 million in additional costs. Similar results were obtained from both the PSM and GLM for assessing total costs for hospitalization and re-admission.

Conclusions

Anastomotic leaks in colorectal surgery increase the total clinical and economic burden by a factor of 0.6–1.9 for a 30-day re-admission, postoperative infection, LOS, and hospital costs.     

Single-Stage Operative Management of Laparoscopic Sleeve Gastrectomy Leaks Without Endoscopic Stent Placement

Background

Leaks occur in 1.4–20 % (Bohdjalian et al., Obes. Surg. 20:535–540, 2010; Nocca et al., Obes Surg. 18:560–565, 2008; Stroh et al., 19:632–640, 2009; Aurora et al., Surg. Endosc. 26:1509–1515, 2012) of patients following laparoscopic sleeve gastrectomy (LSG). Leaks may lead to major morbidity and prolonged hospitalization. Endoscopic stent placement is a potential management strategy that needs expertise and also has recognized complications (stent migration, significant dysphagia, and failure) (Rosenthal et al., Surg. Obes Relat. Dis. 8:8–19, 2012). A standard method of managing leaks following LSG has not been established. This study aims to evaluate the outcomes of consecutive patients with leaks following LSG managed at BMI Abu Dhabi Tertiary Multidisciplinary Bariatric Surgery, Abu Dhabi, UAE.

Methods

We examined all patients presenting to BMI Abu Dhabi between February 2010 and May 2012 with leaks following LSG. Data were obtained from the hospital medical record, and IRB approval was obtained. All patients were managed by utilizing a standardized operative management strategy without the use of endoscopic stenting.

Results

A total of five patients were referred to us for higher level of care; during the same time period, we performed 71 LSGs without a leak. Patients were optimized and resuscitated adequately before surgery. Intraoperatively, all patients had endoscopy, and a T tube was placed inside the leak if clearly identifiable. Otherwise, the leak site was drained adequately without attempting to place sutures, and a jejunostomy tube was inserted. All leaks healed following an initial period of hospital stay, followed by an outpatient period on jejunostomy tube feeding and nil per os.

Conclusion

Single-stage operative management of leaks after LSG utilizing a standardized operative strategy without the use of endoscopic stenting is both safe and effective.     

Stent treatment for fistula after obesity surgery: results in 47 consecutive patients

Background

Leaks occurring after weight loss operations constitute a therapeutic challenge. There is no consensus as to what comprises state-of-the-art management of leaks after bariatric surgery. We sought to determine the efficacy and possible adverse effects of endoluminal stenting for leaks after bariatric surgery.

Methods

We report our experience with the stent treatment of consecutive bariatric patients with a leak (retrospective cohort study). Between October 2005 and July 2010, 47 patients presented an acute leak after a bariatric procedure (61 % primary procedures, 39 % revisions). Fifteen patients were initially approached laparoscopically, and 32 were treated by nonoperative techniques. After adequate drainage and resuscitation, all 47 patients were treated by the endoscopic placement of a partially covered metallic stent, and later of a plastic stent inside the metallic prosthesis to facilitate removal. Both stents were then ablated 1 week later. Primary outcome measurement concerned healing of the fistula, as evidenced by radiographic imaging. Secondary outcomes were length of hospital stay and occurrence of peri- and postprocedural complications.

Results

There was no mortality. 41 patients (87.23 %) healed with stent treatment alone; 5 of the 6 persisting leaks healed with laparoscopic intervention (intention-to-treat success rate 96 %). Complication rate was 28.7 %. Length of hospital stay was mean ± standard deviation 22.4 ± 19.38 days for the patients treated by stent alone, and 23.4 ± 18.4 days for the patients requiring additional surgery (P = NS). One patient developed a stricture and required endoscopic dilation, and one is still awaiting surgical treatment.

Conclusions

Leaks after bariatric surgery can be treated safely and effectively by endoscopic stents. In cases of persisting leaks, laparoscopic intervention is successful in a majority of cases. Late strictures seldom occur.     

The utility of radiological upper gastrointestinal series and clinical indicators in detecting leaks after laparoscopic sleeve gastrectomy: a case-controlled study

Background

Leak after laparoscopic sleeve gastrectomy (LSG) often presents after hospital discharge, making timely diagnosis difficult. This study evaluates the utility of radiological upper gastrointestinal (UGI) series and clinical indicators in detecting leak after LSG.

Methods

A retrospective case-controlled study of 1762 patients who underwent LSG from 2006 to 2014 was performed. All patients with radiographically confirmed leaks were included. Controls consisted of patients who underwent LSG without leak, selected using a 10:1 case-match. Data included baseline patient characteristics, surgical characteristics, and UGI series results. Clinical indicators including vital signs, SIRS criteria, and pain score were compared between patients who developed leak and controls.

Results

Of 1762 LSG operations, 20 (1.1 %) patients developed leaks and were compared with 200 case-matched controls. Three patients developed leak during their index admission [mean = 1.3 days, range (1, 2)], while the majority (n = 17) were discharged and developed symptoms at a mean of 17.1 days [range (4, 63)] postoperatively. Patients diagnosed with leak were similar to controls in baseline and surgical characteristics. Contrast extravasation on routine postoperative UGI identified two patients with early leaks, but was negative in the remainder (89 %). Patients with both early and delayed leaks demonstrated significant clinical abnormalities at the time of leak presentation, prior to confirmatory radiographic study. In multiple regression analysis, independent clinical factors associated with leak included fever [OR 16.6, 95 % CI (4.04, 68.10), p < 0.0001], SIRS criteria [OR 7.0, 95 % CI (1.47, 33.26), p = 0.014], and pain score ≥9 [OR 19.1, 95 % CI (1.38, 263.87), p = 0.028].

Conclusions

Contrast extravasation on routine postoperative radiological UGI series may detect early leaks after LSG, but the vast majority of leaks demonstrate normal results and present 2–3 weeks after discharge. Therefore, clinical indicators (specifically fever, SIRS criteria, and pain score) are the most useful factors to raise concern for leaks prior to confirmatory radiographic study and may be used as criteria to selectively obtain UGI studies after LSG.

     

Results and complications after laparoscopic sleeve gastrectomy

Purpose

Laparoscopic sleeve gastrectomy (SG) has gained popularity and acceptance among bariatric surgeons, mainly due its low morbidity and mortality. The purpose of the present study was to evaluate the efficacy of SG on weight loss, and to determine the postoperative course, clinical presentation and treatment of complications after SG.

Methods

Between January 2006 and October 2012, 153 consecutive patients underwent SG. All data were prospectively collected in a computerized database.

Results

This series comprised 119 females and 34 males with a median age of 46 years and a median preoperative BMI of 42.3 kg/m². The median EWL was 53.0 % after 18.4 months of follow-up. The median postoperative BMI was 33.3 kg/m² (range 19.7–56.1 kg/m²). Eight patients (5.2 %) required re-laparoscopy to manage postoperative hemorrhage (3.3 %) and leakage (1.9 %). Neither abdominal drains nor postoperative contrast-swallow studies were successful in diagnosing hemorrhage or leaks in our patients.

Conclusion

SG is an effective procedure to achieve significant short-term weight loss. Clinical signs, such as tachycardia, pain, fever and hypotension, provide the best evidence of the presence of postoperative leakage or bleeding. An early diagnosis of these complications is the key to ensuring adequate treatment with immediate re-laparoscopy.     

NSAID Use and Anastomotic Leaks Following Elective Colorectal Surgery: a Matched Case-Control Study

Introduction

Non-steroidal anti-inflammatory drugs (NSAIDs) decrease postoperative pain and opioid consumption. The objective of the study was to determine if postoperative NSAIDs were associated with anastomotic leaks following elective colorectal surgery.

Materials and Methods

We used a matched nested case-control study design. Using a prospectively collected database, we identified all patients having elective colorectal surgery between January 2001 and June 2012. Cases and matched controls were identified based on the occurrence of a postoperative anastomotic leak. The primary and secondary exposure variables were, respectively, use of any NSAID and use of ketorolac specifically. Conditional logistic regression was used to determine the unadjusted and adjusted odds ratio.

Results

A total of 262 patients were included (65.6 % inflammatory bowel disease, 34.4 % cancer). Use of any NSAID was associated with a non-significant increase in anastomotic leaks (odds ratio (OR) 1.81, 95 % confidence interval (CI) 0.98–3.37, p?=?0.06). Use of ketorolac was associated with a significant increase in anastomotic leaks (OR 2.09, 95 % CI 1.12–3.89, p?=?0.021). There was no significant association between anastomotic leaks and cumulative NSAID dose.

Conclusion

These data suggest that there may be an association between NSAIDs and risk of anastomotic leaks after colorectal surgery. Further research is needed to better elucidate this relationship to clarify the implications for patients.     

Short-term stenting using fully covered self-expandable metal stents for treatment of refractory biliary leaks, postsphincterotomy bleeding, and perforations

Background

Fully covered self-expandable metal stents (FCSEMS) have been used as a rescue therapy for several benign biliary tract conditions (BBC). Long-term stent placement commonly occurs, and prolonged FCSEMS placement is associated with the majority of the complications reported. This study evaluated the duration of stenting and the efficacy and safety of temporary FCSEMS placement for three BBCs: refractory biliary leaks, postsphincterotomy bleeding, and perforations.

Methods

This was a retrospective case series with long-term follow-up of 25 patients who underwent FCSEMS placement for BBCs. This study included 17 patients with postcholecystectomy refractory biliary leaks who had previously undergone unsuccessful sphincterotomy and plastic stent placement, 4 patients with difficult-to-control postsphincterotomy bleeding, and 4 patients with a perforation following endoscopic sphincterotomy. Stents were removed according to clinical evidence of problem resolution. The review included stenting duration, safe FCSEMS removal, clinical efficacy, complications, and long-term outcomes. During the follow-up period, ERCP and cholangioscopy procedures were performed to exclude the possibility of bile duct lesion development.

Results

Complete resolution of the initial condition was achieved in all patients. Patients with biliary leaks had a median stent duration time of 16 days (range 7–28 days). Patients with bleeding had stents removed after a median time of 6 days (range 3–15 days). Patients with perforations had their stents removed after a median time of 29.5 days (range 21–30 days). There were no complications related to stenting.

Conclusions

Temporary placement of a FCSEMS for 30 days or less is an effective rescue therapy for refractory biliary leaks, difficult-to-control post-endoscopic sphincterotomy bleeding, and perforations. Duration of stenting should be different for each type of condition. Stents can be safely removed, and short-term stenting is associated with the absence of early and late complications.     

Role of endoscopic stents and selective minimal access drainage in oesophageal leaks: feasibility and outcome

Background

Leaks following oesophageal surgery are considered to be amongst the most dreaded complications and contributory to postoperative mortality. Controversies still exist regarding the best option for the management of oesophageal leaks due to lack of standardized treatment protocols. This study was designed to analyse the feasibility outcome and complications associated with placement of removable, fully covered, self-expanding metallic stents for oesophageal leaks with concomitant minimally invasive drainage when appropriate.

Methods

The study group included 32 patients from a prospectively maintained database of oesophageal leaks, with the majority being anastomotic leaks after minimally invasive oesophagectomy (n = 28), followed by laparoscopic cardiomyotomy (n = 3) and extended total gastrectomy (n = 1). The procedures took place between March 2007 and April 2013.

Results

Most patients had an intrathoracic leak (n = 22), with a mean time to detection of the leak following surgery of 7.50 days (SD = 2.23). Subsequent to endoscopic stenting, enteral feeding via a nasojejunal tube was started on the second day and oral feeding was delayed until the 14th day (n = 31). Six patients underwent thoracoscopic (n = 5) or laparoscopic drainage (n = 1) along with stenting for significant mediastinal and intra-abdominal contamination. The stent migration rate of our study was 8.54 %. The overall success in terms of preventing mortality was 96 %.

Conclusion

Endoscopic stenting should be considered a primary option for managing oesophageal leaks. Delayed oral intake may reduce the incidence of stent migration. Larger stents (bariatric or colorectal stents) serve as a useful option in case of migrated stents. Combined minimally invasive procedures can be safely adapted in appropriate clinical circumstances and may contribute to better outcomes.