Gastric Leak After Laparoscopic Sleeve Gastrectomy

Sleeve gastrectomy is a recently developed technique for treating morbid obesity. Since it is a simple procedure, the number of surgeons using it has grown in recent years. The patients who present fistulas after surgery often undergo a harrowing postoperative period as well as increased morbidity and mortality. Our aim was to assess the incidence, causes, diagnosis, management, and prevention of leaks after sleeve gastrectomy.     

Gastric Leak After Sleeve Gastrectomy: Analysis of Its Management

Background  

Bariatric surgery is increasingly being performed and sleeve gastrectomy (SG) has proved to be effective and safe. Among its complications, leaks are the most serious and life threatening.     

Gastric Stenosis After Laparoscopic Sleeve Gastrectomy: Diagnosis and Management

Purpose

The use of laparoscopic sleeve gastrectomy (LSG) is increasing worldwide. Although post-LSG gastric stenosis (GS) is less frequent, it has not been well defined and lacks standardized management procedures. The objective of the present study was to describe a series of patients with GS symptoms after LSG and to develop a standardized management procedure for this complication.

Methods

We performed a retrospective analysis of a prospective database of patients presenting with GS after LSG procedures performed between January 2008 and March 2014. The primary efficacy criterion was the frequency of post-LSG GS. GS was classified as functional (i.e. a gastric twist) or organic. The secondary efficacy criteria included the time interval between LSG and diagnosis of GS, the type of stenosis, the type of management, and the follow-up data.

Results

During the study period, 1210 patients underwent primary or secondary LSG. Seventeen patients had post-operative symptoms of GS (1.4 %); one patient had achalasia that had not been diagnosed preoperatively and thus was excluded from our analysis. The median time interval between LSG and diagnosis of GS was 47.2 days (1–114). Eleven patients had organic GS and six had functional GS. Seven patients required nutritional support. Endoscopic treatment was successful in 15 patients (88.2 %) after balloon dilatation (n?=?13) or insertion of a covered stent (n?=?2). Two of the 15 patients required conversion to Roux-en-Y gastric bypass (11.8 %).

Conclusion

GS after LSG is a rare complication but requires standardized management. Most cases can be treated successfully with endoscopic balloon dilatation.

     

Role of Percutaneous Glue Treatment After Persisting Leak After Laparoscopic Sleeve Gastrectomy

Background

Over the years, many treatment modes have been attempted for gastrocutaneous fistula (GCF) after laparoscopic sleeve gastrectomy (LSG). Minimally invasive techniques for GCF treatment include stent placement and radiological percutaneous glue treatment (GT).

Material and Method

Ten patients underwent a radiological acrylate mixed with contrast medium GT combined or not with other treatment strategies such as relaparoscopy, ultrasound, or computerized tomography scan (CT scan)-guided drain and endoscopic stent placement.

Results

Ten patients (mean age 47.1 years, range 64–29) were treated by percutaneous injection of glue after LSG leak. Body mass index (BMI) was 42.2 kg/m²?±?6.7 at the time of LSG surgery. Mean time between LSG and leak diagnosis was 12 days (range 4–31 days). GT was only effective when performed after endoscopic stent placement (80 % resolution). With this regimen, five patients required a laparoscopic Roux limb placement. All fistulas eventually healed a mean of 75 days (range 29–293 days) after GCF diagnosis.

Conclusions

Percutaneous glue treatment alone does not seem to provide adequate results. Stenting previous to the glue treatment allows for better results.

     

Laparoscopic Total Gastrectomy with Roux-Y Esophagojejunostomy for Chronic Gastric Fistula After Laparoscopic Sleeve Gastrectomy

Laparoscopic sleeve gastrectomy is a restrictive operation with hormonal elements that is rapidly gaining popularity. The most feared complication of the procedure is a staple line leak. The treatment of staple line leakage depends on timing and clinical and anatomical considerations. If leakage persists and transforms into a chronic fistula, a definitive surgical procedure is required. In cases where the fistula originates close to the esophagogastric junction, the surgical possibilities are limited and one treatment option is total gastrectomy with esophagojejunal anastomosis. We report a case series of four patients with chronic fistulae, who failed conservative treatment and required total gastrectomy. Their average length of hospital stay was 8.7 days (range, 5–15 days), without conversions, leaks, or other complications. In experienced hands, total gastrectomy is feasible by laparoscopic techniques and should be performed soon after the fistula is established.     

Gastric Stenosis After Laparoscopic Sleeve Gastrectomy in Morbidly Obese Patients

Laparoscopic sleeve gastrectomy (LSG) is an effective bariatric procedure. The objective of this study is to describe a series of patients who were subjected to LSG and then developed gastric stenosis, with an emphasis on their treatment and a discussion of the possible underlying mechanisms. From January 2006 to October 2012, 717 patients with morbid obesity underwent LSG in our institution. Out of 717 patients, 571 (79.6 %) were women. The mean age was 36.9 years with a BMI of 37.3 kg/m². Five patients (0.69 %) developed gastric stenosis. Treatment of the stenosis was endoscopic dilatations; however, one patient required a conversion to laparoscopic Roux-en-Y gastric bypass. Stenosis after LSG is rare but requires early diagnosis and treatment.     

Impact of the Surgical Experience on Leak Rate After Laparoscopic Sleeve Gastrectomy

Introduction

Laparoscopic sleeve gastrectomy (LSG) has become one of the most commonly performed bariatric procedures, largely due to several advantages it carries over more complex bariatric procedures. LSG is generally considered a straightforward procedure, but one of the major concerns is a staple line leak.

Objective

The objectives of this study are to evaluate the correlation between surgeon’s experience and leak rate and to assess the different risk factors for developing a gastric leak after LSG.Setting: Private hospital, France.

Methods

The analysis of a single surgeon’s yearly leak rate since the introduction of LSG for possible risk factors was done.

Results

A total of 2012 LSGs were performed in between September, 2005 and December, 2014. Twenty cases (1 %) of gastric leak were recorded. Of these, 17 patients were women (94.4 %) with a mean age of 39.4 years (range 22–61) and mean body mass index (BMI) 41.2 kg/m² (range 34.8–57.1). On a yearly basis, the leak rate was 4.8 % (2006), 5.7 % (2007), 0 (2008), 2.6 % (2009), 2 % (2010), 0.8 % (2011), 0.6 % (2012), 0.2 % (2013), and 0 (2014). In the first 1000 cases (group A), there were 18 cases of gastric leak and in the last 1000 cases, there were 800 with GORE® SEAMGUARD® Bioabsorbable Staple Line Reinforcement (group B) 2 cases of gastric leak (p?=?0.009). A revisional LSG, 395 patients after gastric banding and 61 patients re-sleeve gastrectomy, was performed in 456 cases (22.7 %). There were 3 cases of leak (0.65 %). There were two deaths.

Conclusion

LSG can be performed with a low complication rate. This large series of a single surgeon’s experience demonstrated that the leak rate after LSG could be significantly decreased over time with changes in techniques.

     

Behavioral Outcomes Following Laparoscopic Sleeve Gastrectomy Performed After Failed Laparoscopic Adjustable Gastric Banding

A healthy diet and good eating behaviors are essential components of long-term success in weight maintenance after bariatric surgery. Although rates of revised bariatric surgery have increased, data on subsequent behavioral outcomes are sparse. The aim of our study was to investigate behavioral outcomes following revised laparoscopic sleeve gastrectomy (R-LSG) that was indicated for failed laparoscopic adjustable gastric banding and compare with outcomes following primary laparoscopic sleeve gastrectomy (P-LSG). Twelve patients who underwent R-LSG and 25 patients who underwent P-LSG between 2007 and 2009 in our medical center completed a questionnaire that assessed weight loss, eating behaviors, physical activity, food tolerance, and satisfaction. The average time elapsed since the operation was 18 months for both groups. In the R-LSG group, more patients reported non-normative eating patterns and less healthy food selection than in the P-LSG group. Food tolerance and satisfaction were also lower after R-LSG. Engagement in regular physical activity increased from 0 to 16.7 % in the R-LSG group and from 8 to 33 % in the P-LSG group. After R-LSG, 58 % reported eating at scheduled times, compared with 85 % after P-LSG. Levels of healthy food selection, food tolerance, normative eating patterns, and physical activity were lower in the R-LSG group than in the P-LSG group. This study highlights the need to develop pre- and post-surgery treatment that would promote better behavioral outcomes in the growing number of individuals undergoing repeat bariatric surgery.     

Laparoscopic Management of Persistent Strictures After Laparoscopic Sleeve Gastrectomy

Background

Laparoscopic sleeve gastrectomy (LSG) has become a common option in the management of morbid obesity. Although this procedure seems easier, many caveats remain, especially in terms of leakage. Other serious complications include strictures, bleeding, and gastroesophageal reflux disease (GERD). Strictures are related to operative technique but also to healed leaks and fistulas. To our knowledge, the literature reports on the physiopathology and management of strictures after LSG are scarce.

Methods

A retrospective analysis of our database provided a total of 16 patients who underwent laparoscopic surgery for the treatment of strictures. A comprehensive review of each case was done including their management.

Results

Sixteen patients were treated laparoscopically for strictures. There were eight females (mean age, 40.6 years). Most common complaints were dysphagia (n?=?14) and/or GERD (n?=?8). Body Mass Index was 30.5 kg/m²?±?9.3. Fourteen patients underwent a seromyotomy (SM) and two a wedge resection of the stenosis. After SM, morbidity included five leaks on the short term and five reoperations in the long-term. Of the 16 patients, 12 were treated satisfactorily, three required endoscopies and one had minimal GERD symptoms.

Conclusions

Strictures and stenosis can be managed by laparoscopic approach with acceptable results. SM can be useful but carries a high complication rate. Accurate technique with parsimonious use of coagulation and possibly with the systematic use of an omental patch might lead to better results. The wedge resection of the stomach including the stricture was performed successfully in two cases. In addition, wedge resection was used secondarily in two other cases to address a complication of the seromyotomy.     

Gastric Leak After Laparoscopic-Sleeve Gastrectomy for Obesity

Background  

One of the most serious complications after laparoscopic sleeve gastrectomy (LSG) is gastric leak. Few publications exist concerning the treatment of gastric leak. We sought to determine by way of a prospective study the clinical presentation, postoperative course, and treatment of gastric leak after LSG for obesity.     

New CT Scan Classification of Leak After Sleeve Gastrectomy

Laparoscopic sleeve gastrectomy (LSG) has become one of the most common bariatric procedures. Even so, the gastric leak remains the most feared complication with a difficult, non-standardized treatment. The purpose of this study was to assess the feasibility of a new classification of leakage after LSG used in Montpellier University Hospital. We have studied the correlations between radiological findings and therapeutic outcome for the 20 gastric leaks. The presence of a leak was evaluated according to the day of appearance, the symptomatology, the location, severity on the CT scan, and the management. From May 2010 to September 2012, we prospectively collected data from 20 patients diagnosed with gastric leak after LSG. There were 16 women and 4 men with a mean age of 34 years old (range 21–52 years old). The fistula was diagnosed at postoperative day 28.1 days (range 3–77 days). Patients were grouped by the new classification in: 11—type I, 6—type II, 3—type III fistula, and 0—type IV. The visualization of leakage was observed for five cases (25 %). The initial surgical drainage was performed for 11 cases and the conservative treatment was preferred in 9 cases. Three cases necessitated a delayed surgical drainage after 1 week of conservative treatment. The surgical drainage was performed by laparoscopy in 12 cases and by laparotomy in 2 cases. The new CT scan classification of gastric leak could serve as a working basis for a consensus on the therapeutic management of this dreaded complication.     

Laparoscopic Conversion of Gastric Bypass Complication to Sleeve Gastrectomy: Technique and Early Results

Background

Laparoscopic gastric bypass is a commonly performed bariatric surgery for the treatment of morbid obesity. Revision surgery for patients who have gastric bypass complications is a challenge for bariatric surgeon. Our aim is to present the early results of the conversions of gastric bypass complications to sleeve gastrectomies.

Methods

From January 2001 to April 2015, 49 of 2382 gastric bypasses underwent revisional surgery to convert gastric bypasses to sleeve gastrectomies. The demographic data, surgical parameters, and outcomes were studied.

Results

The mean age of the study group was 35.0 years (range 20 to 55), and the average body mass index (BMI) prior to the reoperation was 25.3 kg/m². Seven patients had previous laparoscopic Roux-en-Y gastric bypasses (LRYGBs), and 42 had laparoscopic single anastomosis (mini-) gastric bypasses (LSAGBs). The main reasons for the revisions were malnutrition (58 %), weight regain (10 %), intolerance (18 %), and others (14 %). The revisional surgeries had longer operative times, greater blood loss, and longer flatus passage times than the primary gastric bypass surgeries. Four patients (8.1 %) developed major complications during revisional surgery, including three (6.1 %) cases of leakage and one (2.0 %) case of internal bleeding. No mortality was noted. After conversion to sleeve gastrectomy, the body weights of the patients remained stable, and all patients improved in terms of malnutrition, including anemia, hypoalbuminemia, and secondary hyperparathyroidism.

Conclusions

Conversion to sleeve gastrectomy is an effective and safe option for patients with gastric bypass complications. The conversions to sleeve gastrectomy resulted in significant improvements in malnutrition and maintained weight loss at the early follow-ups.

     

Diagnosis and Management of Gastric Leaks After Laparoscopic Sleeve Gastrectomy for Morbid Obesity

Background  

Laparoscopic sleeve gastrectomy (LSG) is increasingly being recognised as a valid stand-alone procedure for the surgical management of morbid obesity. The leak rate from the gastric staple line ranges from 1.4% to 20%. From our experience of management of LSG leaks, we have been able to formulate an algorithm-based approach to the management of these patients.     

Endoscopic Stenting of Gastric Staple Line Leak Following Sleeve Gastrectomy

Laparoscopic sleeve gastrectomy is known to be associated with a risk of gastric staple line leak. We report on our experience with endoscopic stenting of the anomalous leaking tract. Three cases of post sleeve gastric leak confirmed by computed tomography scan were treated by endoscopic stenting of their leak with a plastic endoprosthesis under fluoroscopic and endoscopic guidance. Endoscopic stenting by means of biliary or pancreatic endoprosthesis was successful in the three patients. The median number of endoscopy procedures per patient was 1.3. Stents were extracted 6 to 10 weeks after their placement. Neither morbidity nor recurrence was noticed on follow-up. Endoscopic stenting of gastric staple line leak following sleeve gastrectomy proved to be an efficacious technique for leak healing.     

Approach to Poor Weight Loss After Laparoscopic Sleeve Gastrectomy: Re-sleeve Vs. Gastric Bypass

Background

Laparoscopic sleeve gastrectomy (LSG) is increasing worldwide; however, long-term follow-up results included insufficient weight loss and weight regain. This study aims at assessing the outcomes of converting LSG to laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic re-sleeve gastrectomy (LRSG).

Methods

A total of 1300 patients underwent LSG from 2009 to 2012, of which 12 patients underwent LRYGB and 24 patients underwent LRSG in Al-Amiri Hospital alone. Data included length of stay, percentage excessive weight loss (EWL%), and body mass index (BMI).

Results

Twenty-four patients underwent conversion from LSG to LRSG, and 12 patients underwent conversion from LSG to LRYGB due to insufficient weight loss and weight regain. Eighty-five percent were females. The mean weight and BMI prior to LSG for the LRYGB and LRSG patients were 136.5 kg and 52, and 134 kg and 50, respectively. The EWL% after the initial LSG was 37.9 and 43 %, for LRYGB and LRSG, respectively. There were no complications recorded. Results of conversion of LSG to LRYGB involved a mean EWL% 61.3 % after 1 year (p value 0.009). Results of LRSG involved a mean EWL% of 57 % over interval of 1 year (p value 0.05). Comparison of the EWL% of LRYGB and LRSG for failed primary LSG was not significant (p value 0.097).

Conclusion

Following our algorithm, revising an LSG with an LRSG or LRYGB for poor weight loss is feasible with good outcomes. Larger and longer follow-up studies are needed to verify our results.

     

Laparoscopic Reinforced Sleeve Gastrectomy: Early Results and Complications

Background  

Sleeve gastrectomy (SG) was pioneered as a two-stage intervention for super and super-super obesity to minimize morbidity and mortality; it is employed increasingly as a primary procedure. Early outcomes and integrity of laparoscopic SG (LSG) against leak using a technique incorporating gastric transection-line reinforcement were studied.