Laparoscopic Sleeve Gastrectomy is a Safe and Effective Bariatric Procedure for the Lower BMI (35.0–43.0 kg/m<Superscript>2</Superscript>) Population

Background  

The laparoscopic vertical sleeve gastrectomy (LSG) is derived from the biliopancreatic diversion with duodenal switch operation (Marceau et al., Obes Surg 3:29–35, 1993; Hess and Hess, Obes Surg 8:267–82, 1998; Chu et al., Surg Endosc 16:S069, 2002). Later, LSG was advocated as the first step of a two-stage procedure for super-obese patients (Regan et al., Obes Surg 13:861–4, 2003; Cottam et al., Surg Endosc 20:859–63, 2006). However, recent support is mounting that continues to establish LSG as the definitive procedure for surgical treatment of morbid obesity. We will report our experience with the LSG as a primary bariatric procedure and evaluate if this operation is suitable as a stand-alone procedure.     

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.     

Cost analysis of leak after sleeve gastrectomy

Background

Leaks after laparoscopic sleeve gastrectomy (LSG) are serious complications of this procedure. The objective of the present study was to evaluate the costs of leaks after LSG.

Setting

Private hospital, France.

Methods

A retrospective analysis was conducted on a prospective cohort of 2012 cases of LSG between September 2005 and December 2014. Data were collected on all diagnostic and therapeutic measures necessary to manage leaks, ward, and intensive care unit (ICU) length of stay. Additional outpatient care was also analyzed.

Results

Twenty cases (0.99%) of gastric leak were recorded. Fifteen patients had available data for cost analysis. Of these, 13 patients were women (86.7%) with a mean age of 41.4 years (range 22–61) and mean BMI of 43.2 kg/m² (range 34.8–57.1). The leaks occurred after 7.4 days (±2.3) postoperatively. Only one gastric leak was recorded for the last 800 cases in which absorbable staple line reinforcement was used. Mean intra-hospital cost was 34398 € (range 7543–91,632 €). Prolonged hospitalization in ICU accounted for the majority of hospital costs (58.9%). Mean additional outpatient costs for leaks were 41,284 € (range 14,148–75,684€).

Conclusions

Leaks after LSG are an expensive complication. It is therefore important to take all necessary measures to reduce their incidence. Our data should be considered when analyzing the cost effectiveness of staple line reinforcement usage.

     

Is Routine Preoperative Esophagogastroduodenscopy Screening Necessary Prior to Laparoscopic Sleeve Gastrectomy? Review of 1555 Cases and Comparison with Current Literature

Background

Controversy exists as to whether routine preoperative esophagogastroduodenoscopy (p-OGD) in bariatric surgery should be routinely undertaken or undertaken selectively based on patients’ symptoms. As very few studies have focused on the role of p-OGD prior to the increasingly common laparoscopic sleeve gastrectomy (LSG), we assessed the role/impact of p-OGD in LSG patients.

Methods

Retrospective review of records of all LSG patients operated upon at Hamad General Hospital, Qatar (2011–2014, n = 1555). All patients were screened by p-OGD. Patient characteristics were analyzed, and p-OGD findings were categorized into four groups employing Sharaf et al.’s classification (Obes Surg 14:1367–1372, 23). We assessed the impact of p-OGD findings on any change in surgical management or lack thereof.

Results

p-OGD findings indicated that 89.5% of our patients had normal or mild findings and were asymptomatic (groups 0 and 1, not necessitating any change in surgical management), and no patients had gastric cancer or varices (group 3). A total of 10.5% of our sample were categorized as group 2 patients who, according to Sharaf et al. (Obes Surg 14:1367–1372, 23), might have their surgical approach changed. All patients diagnosed preoperatively with hiatal hernia (HH) had LSG with crural repair and their symptoms resolved postoperatively.

Conclusion

Due to effectiveness and best utilization of resources, routine p-OGD screening in patients scheduled for LSG may require further justification for asymptomatic patients especially in regions with low upper GI cancers. p-OGD findings had low impact on the management of asymptomatic patients. Crural repair plus LSG was effective for hiatal hernia.

     

Early Impact of Bariatric Surgery on Type II Diabetes,Hypertension, and Hyperlipidemia: A Systematic Review,Meta-Analysis and Meta-Regression on 6,587 Patients

Background

This study aims to evaluate the 12–24-month impact of bariatric surgery on the foremost modifiable traditional risk factors of cardiovascular disease.

Methods

A systematic review and meta-analysis of prospective interventional studies reporting the most commonly performed laparoscopic surgical procedures, i.e., Roux-en-Y gastric bypass (RYGB), adjustable gastric banding (AGB), and cardiovascular risk reduction after surgery.

Results

The bibliographic research conducted independently by two authors yielded 18 records. When looking at RYGB and AGB separately, we observed a relevant heterogeneity (I ² index ≥87 %) when BMI reduction was considered as the main outcome. When hypertension, type II diabetes, and hyperlipidemia risk reduction was estimated, a highly significant beneficial effect was found. The risk reduction was 0.33 [0.26; 0.42] for type II diabetes, 0.52 [0.42; 0.64] for hypertension, and 0.39[0.27; 0.56] for hyperlipidemia (P?<?0.0001 for all outcomes considered). When looking at surgical technique separately, a higher but not statistically significant risk reduction for all outcomes considered was found. Results from the meta-regression approach showed an inverse relation between cardiovascular risks and BMI reduction.

Conclusions

The present study showed an overall reduction of cardiovascular risk after bariatric surgery. According to our analysis a BMI reduction of 5 after surgery corresponds to a type II diabetes reduction of 33 % (as reported by Peluso and Vanek (Nutr Clin Pract 22(1):22–28, 2007); SAS Institute Inc., (2000–2004)), a hypertension reduction of 27 % (as reported by Buchwald and Oien (Obes Surg 23(4):427–436, 2013); Valera-Mora et al. (Am J Clin Nutr 81(6):1292–1297, 2005)), and a hyperlipidemia reduction of 20 %(as reported by Adams et al. (JAMA 308(11):1122–31, 2012)); Alexandrides et al. (Obes Surg 17(2):176–184, 2007). In summary, our study showed that laparoscopic bariatric surgery is an effective therapeutic option to reduce the cardiovascular risk in severe obese patients.     

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.     

Pre-therapy Laparoscopic Feeding Jejunostomy is Safe and Effective in Patients Undergoing Minimally Invasive Esophagectomy for Cancer

Objective

Laparoscopic feeding jejunostomy is a safe and effective means of providing enteral nutrition in the preoperative phase to esophageal cancer patients.

Design

This research is a retrospective case series.

Setting

This study was conducted in a university tertiary care center.

Patients

Between August 2007 and April 2012, 153 laparoscopic feeding jejunostomies were performed in patients 10 weeks prior to their definitive minimally invasive esophagectomy.

Main Outcome Measures

The outcome is measured based on the technique, safety, and feasibility of a laparoscopic feeding jejunostomy in the preoperative phase of esophageal cancer patients.

Results

One hundred fifty-three patients underwent a laparoscopic feeding jejunostomy approximately 1 and 10 week(s) prior to the start of their neoadjuvant therapy and definitive minimally invasive esophagectomy, respectively. Median age was 63 years. Of the patients, 75 % were males and 25 % were females. One hundred twenty-seven patients had gastroesophageal junction adenocarcinoma and 26 had squamous cell carcinoma. All patients completed their neoadjuvant chemoradiation therapy. The median operative time was 65 min. We had no intraoperative complications, perforation, postoperative bowel necrosis, bowel torsion, herniation, intraperitoneal leak, or mortality as a result of the laparoscopic feeding jejunostomy. Four patients were noted to have superficial skin infection around the tube, and 11 patients required a tube exchange for dislodgment, clogging, and leaking around the tube. All patients progressed to their definitive surgical esophageal resection.

Conclusion

A laparoscopic feeding jejunostomy is technically feasible, safe, and can provide appropriate enteral nutrition in the preoperative phase of esophageal cancer patients.     

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.     

Access-Port Fixation on the Left Pectoral Fascia in Laparoscopic Adjustable Gastric Banding

Access-port (AP) complications after laparoscopic adjustable gastric banding (LAGB) are often seen but seldom reported in literature. AP complications requiring additional surgery is reported in 3.6% to 24% of LAGB patients (Susmallian et al. Obes. Surg, 4:128–131, 2003; Peterli et al. Obes. Surg., 12(6):851–856, 2002; Busetto et al. Obes. Surg., 12:83–92, 2002; Mittermair et al. Obes. Surg., 19:446–450, 2009; Holeczy et al. Obes. Surg., 9:453–455, 1999; Bueter et al. Arch. Surg., 393:199–205, 2008; Launay-Savary et al. Obes Surg, 18:1406–1410, 2008; Balsiger et al. J. Gastrointest. Surg., 11:1470–1477, 2007; Szold and Abu-Abeid Surg. Endosc., 16:230–233, 2002). We evaluated the effect of fixing the AP on the pectoral fascia using the Velocity™ Injection Port on complication and re-operation rate. From January 2005 till October 2007, 619 LAGB procedures were performed using the SAGB QuickClose™. All procedures were performed by three dedicated surgeons using the pars flaccida technique. APs were placed on the fascia of the pectoral muscle using an infra-mammary incision. The AP device was fixed on the fascia using the Velocity™ Injection Port and Applier. Data was obtained retrospectively and records of 619 consecutive patients were reviewed for access-port complications. Sixty-eight AP complications were observed. Complications could be divided in four categories. Discomfort was reported in 30 patients, seven needing additional surgery. Infection contributed to 11 patients needing surgical removal of the device. Fourteen Patients with superficial infection were treated conservatively. Nine patients had inaccessible APs. Ultrasound-guided access was required in three patients. The remainder needed surgical relocation of the AP. Leakage of the tube was observed in four patients all of which needed revisional surgery. Our experience shows that fixation of the AP on the left pectoral fascia using the Velocity™ leads to a readily accessible AP with good anaesthetic and aesthetic results. In our series, 68 (11%) complications were recorded, of which 28 (4.5%) needed additional surgery.     

Sudden death after open gastric bypass surgery

Purpose  Gastric bypass surgery has become a relatively low-risk bariatric surgical intervention in a high-risk patient population (Nguyen et al., Arch Surg, 141:445–449, 2006; Buchwald et al. JAMA, 13:1724–1737, 2004). Surgical interventions in patients suffering from morbid obesity are typically associated with excess morbidity (Parikh et al., Am Surg, 73:959–962, 2007). Though overall mortality after bariatric surgery is <1% is low (Mason et al., Obes Surg, 17:9–14, 2007), some surgical complications such as anastomotic leaks, staple line disruption and bowel obstruction may still impact on postoperative outcome (Parikh et al., Am Surg, 73:959–962, 2007; Mason et al., Obes Surg, 17:9–14, 2007). Early symptoms are often missed, as clinical presentation may be discreet, inexistent or falsely attributed to obesity. Methods  This case report refers to a patient in whom discomfort and agitation associated with a rise in temperature heralded a fulminant septic shock syndrome precipitating his death. Literature on early complications and management after gastric bypass is reviewed. Conclusion  A high level of suspicion should be present in the case of an unexpected postoperative deterioration of the patient’s general condition. Time to treat may be very short (Mason et al., Obes Surg, 17:9–14, 2007). Computed tomography is mandatory to rule out pulmonary embolism and bypass obstruction.     

Sleeve Gastrectomy Severe Complications: Is It Always a Reasonable Surgical Option?

Background

Laparoscopic sleeve gastrectomy (LSG) is widely adopted but exposes serious complications.

Methods

A retrospective database analysis was done to study LSG staple line complications in a tertiary referral university center with surgical ICU experienced in treatment of morbid obesity and complications. Twenty-two consecutive patients were referred between January 2004 and February 2012 with postoperative gastric leak or stenosis after LSG. Interventions consisted in the control of intra-abdominal and general sepsis; restoration of staple line continuity or revision of LSG; nutritional support; treatment of associated complications. Main outcome measures concerned success rates of therapeutic strategies, morbidity and mortality rates, LOS, and time to cure.

Results

Thirteen patients (59 %) were referred after failure of reoperation (seven fistula repairs were attempted). Three patients received emergency surgery in our center with transorificial intubation and jejunostomy formation. An endoscopic stent was tried in nine patients but failed in 84.6 % of cases within 20 days (1–161). Seven patients (32 %) necessitated total gastrectomy within 217 days (0–1,915 days) for conservative treatment failure. Procedures under general anesthesia were required in 41 % of cases, organ failure was found in 55 % of cases, and central venous device infection in 40 %. Mortality rate was 4.5 % (n?=?1). Patients with unfavorable evolution of LSG complications (death or additional gastrectomy) had more previous bariatric procedure (82 % vs. 18 %, p?=?0.003). Median time to cure was 310 days (9–546 days).

Conclusions

LSG exposes severe complications occurring in patients with benign condition. Endoscopic stents entail high failure rate. Total gastrectomy is required in one third of the cases.     

Staple-line reinforcement during laparoscopic sleeve gastrectomy using three different techniques: a randomized trial

Background

The main drawback of laparoscopic sleeve gastrectomy (LSG) is the severity of postoperative complications. Staple line reinforcement (SLR) is strongly advocated. The purpose of this study was to compare prospectively and randomly three different techniques of SLR during LSG.

Methods

From April 2010 to April 2011, patients submitted to LSG were randomly selected for the following three different techniques of SLR: oversewing (group A); buttressed transection with a polyglycolide acid and trimethylene carbonate (group B); and staple-line roofing with a gelatin fibrin matrix (group C). Primary endpoints were reinforcement operative time, incidence of postoperative staple-line bleeding, and leaks. Operative time was calculated as follows: oversewing time in group A; positioning of polyglycolide acid and trimethylene carbonate over the stapler in group B; and roofing of the entire staple line in group C.

Results

A total of 120 patients were enrolled in the study (82 women and 38 men). Mean age was 44.6?±?9.2 (range, 28–64)?years. Mean preoperative body mass index was 47.2?±?6.6 (range, 40–66)?kg/m2. Mean time for SLR was longer in group A (14.2?±?4.2 (range, 8–18)?minutes) compared with group B (2.4?±?1.8 (range, 1–4)?minutes) and group C (4.4?±?1.6 (range, 3–6) minutes; P?Conclusions SLR with either polyglycolide acid with trimethylene carbonate or gelatin fibrin matrix is faster compared with oversewing. No significant differences were observed regarding postoperative staple-line complications.     

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.     

Study protocol: trial of inflation osteoplasty in the management of tibial plateau fractures

Introduction

Restoration of articular congruency is a key factor in preventing post-traumatic osteoarthritis following tibial plateau fractures. Current surgical techniques using a bone tamp carry the risk of joint perforation and comminution of the depressed fragments which affect patient outcome. Successful use of inflation osteoplasty has been reported in both in vitro studies (Broome et al. in J Orthopaed Traumatol 13(2):89–95, 2012; Mauffrey et al. in Patient Saf Surg 6:6, 2012) and case reports in the management of fractures of the calcaneus, cuboid, distal radius, tibial plateau and acetabulum (Gupta et al. in Foot Ankle Int 32(2):205–210, 2011; Heim et al. in Foot Ankle Int 29(11):1154–1157, 2008; Konig et al. in Case Rep Unfallchirurg 109(4):328–331, 2006; Reiley in J Orthop Trauma 17:141–163, 2006). The aim of our study is to assess whether the use of the balloon osteoplasty improves the quality of reduction of a depressed tibial plateau fracture when compared to traditional methods of fracture reduction.

Method

This is a single-centred randomised trial. We will recruit 24 adult patients admitted with either a depressed or split depressed tibial plateau fracture (medial or lateral) requiring surgical intervention. Consenting patients will be randomly allocated to the two treatment groups. Patients with concomitant injuries influencing the management of the tibial plateau fracture will be excluded from our study. The primary outcome measure is the quality of reduction based on the post-operative CT scan. Secondary outcome measures will be any surgical complication and patient satisfaction, measured using the Oxford Knee score and SF12 questionnaire at 3, 6 and 12 months. Principal analysis will be for the success of fracture reduction from the two techniques and the effect the operative technique had on patient satisfaction and the prevalence of surgical complications.     

Not All Leaks Are Created Equal: a Comparison Between Leaks After Sleeve Gastrectomy and Roux-En-Y Gastric Bypass

Introduction

It is commonly stated in bariatric surgical forums that leaks following laparoscopic sleeve gastrectomy (LSG) are more difficult to manage than those following laparoscopic roux-en-Y gastric bypass (LRYGB). However, no previous study has provided a thorough comparison of leak management following these two operations.

Methods

Our database was retrospectively reviewed to identify patients with leak following LSG and LRYGB performed between January 2007 and December 2017.

Results

Postoperative leak was diagnosed in 16/2132 (0.75%) LSG and 9/595 (1.5%) LRYGB patients. More of the LRYGB leaks had undergone revisional surgeries (66.7 vs. 6.3%, p?<?0.001), and were diagnosed in the index admission (77.8 vs. 18.7%, p?=?0.002). The mean time between the bariatric operation and the diagnosis of leak was 6.0 days in LRYGB and 26.2 days in LSG patients (p?=?0.097). Approximately two thirds of each group were initially treated with laparoscopic exploration and drainage. Subsequent endoscopy was utilized more commonly in LSG patients (87.5 vs. 22.2%, p?<?0.001). Drainage alone (laparoscopic or percutaneous) eventually led to leak resolution in more LRYGB patients (66.7 vs. 18.8%, p?=?0.02), while endoscopic intervention led to resolution in more LSG patients (37.5 vs. 0%, p?=?0.04). The mean time between leak diagnosis and its resolution was 57.8 and 44.2 days, for LSG and LRYGB patients, respectively.

Conclusion

The diagnosis of leak tends to be earlier in LRYGB patients. Endoscopic therapies are more frequently required in the management of leaks following LSG, while in those following LRYGB, drainage alone leads to resolution of leak in the majority of cases.

     

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.     

Single Incision Transumbilical Laparoscopic Roux-en-Y Gastric Bypass—Our Technique

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is considered the gold standard procedure in bariatric surgery but requires 4–7 ports. We have reported the first single incision transumbilical Roux-en-Y gastric bypass (SITU-RYGB) in 2009 (Huang et al. Obes Surg 19:1711–1715, 2009). Over the years, we have standardized our procedure and this video highlights the same by showing both inside and outside views. This video was shot from outside as well to give better understanding of the procedure. A 4.5-cm incision was made according to the contour of umbilicus and space was created over the sheath to give more range of movement to the instruments. The procedure was carried out using conventional laparoscopic instruments and replicating all the steps of the procedure under adequate visualization. Picture-in-picture effect has been used at important steps. Findings were recorded. The procedure took 96 min without any intraoperative complication. Blood loss was 20 cc. The incision was hardly noticeable at the end of the procedure. We have previously compared our results of SITU-RYGB with that of our multiport RYGB where operative time was longer for SITU-RYGB versus multiport technique (101.1 vs. 81.1 min, P?=?0.001) (Huang et al. Surg Obes Relat Dis 8:201–207, 2012). No difference in complications was observed. The SITU-LRYGB patients reported greater satisfaction related to scarring than those who had undergone five-port surgery (P?=?0.005). Difference in analgesia requirement was not statistically significant. There was no mortality. Compared with conventional LRYGB, SITU-RYGB resulted in acceptable complications, the same recovery, comparative weight loss, and better patient satisfaction related to scarring.     

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.     

Verification of Early Removal of the Chest Tube after Absorbable Mesh-based Pneumostasis Subsequent to Video-assisted Major Lung Resection for Cancer

Background

We previously reported that the combined use of absorbable mesh and fibrin glue is superior to the use of fibrin glue alone to stop intraoperative air leaks. However, concern remains about whether mesh-based pneumostasis can induce the recurrence of air leaks after chest tube removal.

Methods

We reviewed our prospective database of selected patients (n?=?206) who underwent video-assisted major lung resection for cancer. Exclusion criteria included simultaneous combined resection, induction radiotherapy, entire intrathoracic adhesion, or a history of prior ipsilateral thoracotomy. We sealed any intraoperative air leaks with absorbable mesh and fibrin glue and then carried out prophylactic chest-tube drainage for 1?day.

Results

Intraoperative air leaks were detected in 133 (65%) patients. Overall, air leaks were not detected postoperatively in 186 (91%) patients, allowing chest tube removal on the day after the operation. The mean length of time for chest tube drainage was 1.2?days. A prolonged air leak (>7?days) was observed in one (0.5%) patient, and this leak resolved by itself. After chest tube removal, an air leak recurred in six (2.9%) patients during the 30?day follow-up period, necessitating chest tube reinsertion. Although the recurrence was observed more frequently after segmentectomy than after lobectomy (p?=?0.04), the recurrence was not observed more frequently in patients who had an intraoperative air leak than in patients who did not (p?=?0.3).

Conclusion

Early removal of the chest tube after pneumostasis with absorbable mesh is verified in selected patients who underwent video-assisted major lung resection for cancer. However, further attempts should be made to prevent air leaks after anatomical segmentectomy.     

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.