Complication Management; Better to Prevent a Leak than to be Expert in Managing a Leak

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Managing Complications FIRST Prevent Complications …

Managing Complications FIRST Prevent Complications
Better to
Prevent a Leak than to be
Expert in
Managing a Leak

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  • 1. Managing Complications FIRST Prevent Complications
  • 2. Safety & Bariatric Surgery Complacency • When surgeons Don’t rigorously adhere to pre-op rules or checklist in selecting & preparing their patient, their team & themselves
  • 3. Examples of Complacency Sleeve Gastrectomy Failure: • “Sleeve Gastrectomy & Risk of Leak: Systematic Analysis of 4,888 Patients” • “Risk of leak is low at 2.4%" • Surg Endosc. 2012 Jun;26(6):1509-15. Epub 2011 Dec 17. Aurora AR, Khaitan L, Saber AA. Department of Surgery, University Hospitals Case Medical Center, Cleveland, Ohio
  • 4. “Risk of leak is low at 2.4%" Air India Airlines Releases the following statement: “Risk of Airplane Crashes are Low at only 2.4%"
  • 5. The Mindset of Commitment to Excellence Make the Commitment To your Patient: “Failure is Not an Option” NO LEAKS
  • 6. Don’t Manage a Complication? Prevent, Prevent, Prevent
  • 7. Complication Management vs. Complication Prevention Better to Prevent a Leak than to be Expert in Managing a Leak
  • 8. First: Leaks Much More Likely in First 100 Cases
  • 9. Volume Performance New Surgeons = More Complications
  • 10. Complications Decrease with Experience
  • 11. New Surgeons are Dangerous & Deadly Surgeons Complications decline to logarithm of the surgeons’ Training & Experience
  • 12. First: Leaks Much More Likely in First 100 Cases What are the implications? In the first 100 cases NO Difficult Cases Get Help Eplore Early and Often Fear a Leak in Everyone
  • 13. RNY: Long learning curve of 500 cases RNY technically challenging 2,281 cases 1999 2011 Complications diminished with increased experience Stabilized <2.5% after the first 500 cases Mortality rate .43%, main causes of death PE & Leaks (.14% each) Op time & Complications significantly reduced after a long learning curve of 500 cases Surg Obes Relat Dis. 2013 Feb 11. Overcoming the learning curve of laparoscopic Roux-en-Y gastric bypass: A 12year experience. El-Kadre L, Tinoco AC, Tinoco RC, Aguiar L, Santos T. Department of Surgery, São José do Avaí Hospital, Itaperuna, Rio de Janeiro, Brazil.
  • 14. What can we learn from the Airline Industry Failure is Not an Option
  • 15. Laparoscopic sleeve gastrectomy for failed laparoscopic adjustable gastric band 800 pts LSG 5.5 % leak & 4.4 % hemorrhage Conclusions: “We advocate this procedure as a good bariatric option (?) No No No! Obes Surg. 2013 Mar;23(3):300-5. Laparoscopic sleeve gastrectomy (LSG)-a good bariatric option for failed laparoscopic adjustable gastric banding (LAGB): a review of 90 patients. Yazbek T, Safa N, Denis R, Atlas H, Garneau PY. Hôpital du Sacré-Coeur de Montréal, 5400 boul. Gouin ouest, Montreal, Quebec, Canada
  • 16. RNY/MGB Post Op Complications Complication Bleeding Leak Wound infection (requiring hospital treatment) Intestinal obstruction Intra-abdominal abscess Pulmonary thromboembolism Total of early complications RNY% MGB% 2.6 0.2% 2.4 0.2% 2.2 1.1 0.7 0.6 9.6 0.1% 0.0% 0.1% 0.2% 0.8%
  • 17. Controlled Prospective Randomized Trial Lee WJ, Yu P-J, Wang W, Chen TC, Wei PL, Huang MT. Laparoscopic Roux-en-Y versus MiniGastric Bypass for the treatment of Morbid Obesity. Ann Surg 2005 ; 242 : 20-28 RYG Bypass Mini Bypass Op time (mns) 205 148 Early complications 20% 7.5% Late complications 7.5% 7.5 % EWL at one year 58.7% 64.9% EWL at two years 60% 64.4%
  • 18. SECO 2012 BARCELONA SPAIN Laparoscopic Mini Gastric Bypass Cesare Peraglie MD FACS FASCRS CLOS-Florida: Heart of Florida Regional Medical Center. Davenport, Florida drperaglie@gmail.com
  • 19. Laparoscopic-Mini Gastric Bypass: HOFRMC •Over 1000 Laparoscopic MGB’s have been performed at HOFRMC since 2005. •TYPICAL DEMOGRAPHICS: AGE: 45 (14-72), BMI: 45 (30-75), ~27% DIABETIC, ~50% HTN, ~31% PREVIOUS ABDOMINAL SURGERY •OUTCOMES  OP-TIME: 62Min. (37-186), Conversion to open: 0  LOS: 1 DAY or less (88%), 2 DAY (10%), 3 DAY (~2%), 4+ DAY (<1%)  Re-admission: 5% (23 hour obs. PONV in all but one) / 0.8% 90 day  Leak: 0.3%  MORTALITY: 0 (HOSPITAL), 0 (PERI-OP:90D)
  • 20. Stapled vs Handsewn Anastomosis Linear Stapled vs Handsewn EsophagoGastrostomy Anastomotic leak: 1 (3.0%) of 33 stapled 13 (14.4%) of the 90 Hand Sewn (P = 0.07) Surg Today. 2009;39(3):201-6. The triangulating stapling technique for cervical esophagogastric anastomosis after esophagectomy Toh Y, Sakaguchi Y, Ikeda O, Adachi E, Ohgaki K, Yamashita Y, Oki E, Minami K, Okamura T.Department of Gastroenterological Surgery, National Kyushu Cancer Center, 3-1-1 Notame, Minami-ku, Fukuoka, 811-1395, Japan
  • 21. NSAIDs should be abandoned in GI anastomoses Anastomotic leak (AL) is the most important & one of the most serious complications after GI anastomosis Factors that contribute to increase the risk of AL should be identified and--if possible-eliminated Prostaglandins promote neo-angiogenesis & enhanced wound healing Non-steroidal anti-inflammatory drugs (NSAIDs) are often used for treating pain after surgical procedures
  • 22. NSAIDs be abandoned after primary GI anastomosis Retrospective, case-control study in 75 patients undergoing laparoscopic colorectal resection for colorectal cancer. 33 of these patients received the NSAID diclofenac in the postoperative period 42 did not receive any NSAID. There were significantly more LEAKS among the patients receiving diclofenac (7/33 vs. 1/42, p=0.018)
  • 23. NSAIDs should be abandoned after primary GI anastomosis Database study based on data from the Danish Colorectal Cancer Group's (DCCG) prospective database & electronically registered medical records. From the database information on demographic, surgical & postoperative variables (including AL) were provided. Information on NSAID consumption was retrieved by individual searches in the patients' medical records. Based on these data, uni- & multivariate logistic regression analyses were performed. These analyses identified NSAID treatment in the postoperative period as an individual risk factor for Leak
  • 24. MGB/RNY/SG Complications Short term: Leak Bleeding Venous thrombosis Infections, Pneumonia SBO from abdominal hernia Anastomotic stricture Technical Errors Arq Gastroenterol. 2013 JaSanto MA, Pajecki D, Riccioppo D, Cleva R, Kawamoto F, Cecconello I.Metabolic & Bariatric Surgery Unit, Discipline of Digestive Surgery, University of São Paulo Medical School (Unidade de Cirurgia Bariátrica e Metabólica, Disciplina de Cirurgia do Aparelho Digestivo. Faculdade de Medicina da Universidade de São Paulo), São Paulo, SP, Brazil. santomarco@uol.com.br
  • 25. Leak Prevention Leak Location Site: 1. EG Junction (Think Sleeve) Prevention: Simple: AVIOD e.g. Junction! 2. Gastro Jejunostomy Prevention: Technical Details of Laparoscopic GI anastomosis (Remember the Basics of General Surgery)
  • 26. Learning from Sleeve Leak Experience Division of the posterior fundic vessels is also performed. (NO NO NO) “The angle of His is then dissected free from the left crus of the diaphragm.” (NO NO NO) Careful attention on dissection must be taken due to the risk of splenic or esophageal injury Prevention: Simple: AVIOD the EG Junction!
  • 27. Learning from Sleeve Leak Experience In 33 of the patients (75-95%), the leaks near the gastroesophageal junction Prevention: Simple: FEAR the EG Junction!
  • 28. Anastomotic Leak Prevention ALWAYS DO A SAFE ANASTOMOSIS Preop Factors Intra-op Factors Post Op Factors
  • 29. Leak Prevention ALWAYS DO A SAFE ANASTOMOSIS No Leak. Cause no persistent bleeding. Cause no stricture of the lumen. Create no risk for internal hernia.
  • 30. Patient Factors Affect GI Anastomitic Healing Look for these factors: Correct these factors or REJECT the Patient 1. Renal/Cardiac/Pulmonary Dysfunction 2. Bacterial contamination 3. Inflammation 4. Shock & hypoperfusion states 5. Diabetes mellitus 6. Chronic steroid use 7. Poor nutritional status 8. Malignancy
  • 31. PREOP Fundamentals of GastroIntestinal Anastomosis Healing NO NSAIDs, Steroids, Anti-Metabolites (fluorouracil decreased anastomotic breaking strength by more than 40%) Accurate Fluid Administration STOP Smoking Adequate Vitamin A levels Aggressive Control of Glucose Levels Early feeding liquid protein & calories Preop Statins Preop Creatine Supplements Preop Exercise (Increase Testosterone, HGH) Supplemental Oxygen in All patients
  • 32. Fundamentals of Gastro-Intestinal Anastomosis Healing Adequate local blood supply (Carefully maintain mesentery) Elimination of tension (Long Pouch,left gutter for bowel. Do Not Divide the Omentum) Meticulous Hemostasis (avoid damage to staple line) Gentle & precise handling of tissues Closure of mesenteric defects (Not in MGB) Close inspection Accurate Suture Placement (NOT Many Sutures, 3 layers are not better than 1-2)
  • 33. Fundamentals of Gastro-Intestinal Anastomosis Healing Adequate local blood supply Maintain mesentery Elimination of tension Long Pouch Left gutter for bowel
  • 34. Fundamentals of Gastro-Intestinal Anastomosis Healing Meticulous Hemostasis SLOW Staple Gun Firing Avoid damage to staple line Do Not Touch the Staple Line Gentle & precise handling of tissues
  • 35. Fundamentals of Gastro-Intestinal Anastomosis Healing Inverted vs. Everted 1800s, Lembert, Halsted advocated an inverted, serosa-to-serosa anastomosis Hand-sutured everting bowel anastomosis point out Simplicity & decreased risk of bowel lumen narrowing Animal experiments in the 1960s & 1970s demonstrated no difference in healing strength & leak rates between the two approaches
  • 36. Fundamentals of Gastro-Intestinal Anastomosis Healing Approximately 3-mm gap between two sutures Care not to apply excessive tension to prevent cut-through of seromuscular layer It is necessary to include submucosa carefully because it is the strongest layer of the bowel wall and gives strength to anastomosis.
  • 37. Handle tissue gently & precisely “approximate, do not strangulate” to avoid ischemia of the bowel wall at the anastomosis. For stapled anastomoses, use the correct staple height for the tissue thickness. Too short & ischemia; Too long, & bleeding or leak The common staple height for the small bowel & colon is 3.5 blue, 3.5 mm For the thicker stomach, green, 4.8 mm
  • 38. Fundamentals of Gastro-Intestinal Anastomosis Healing 1 Layer, Maybe 2, Not More (Ischemia) Remember your general surgery Inverted => Narrowing of the Lumen & early complaints of Nausea & Vomiting Patient complaints, stress on the anastomosis & prolonged hospitalization Stapled vs Handsewn Buttress/Fibrin Glue/Omental Patch?
  • 39. Meta-analysis of randomized controlled trials single- vs two- layer intestinal anastomosis Six trials were analyzed, comprising 670 participants (single-layer group, n = 299; twolayer group, n = 371). Data on leaks were available from all included studies. Combined risk ratio 0.91 (95% CI = 0.49 to 1.69), & indicated no significant difference. Single- versus two- layer intestinal anastomosis: a meta-analysis of randomized controlled trials Satoru Shikata1,2†, Hisakazu Yamagishi1†, Yoshinori Taji2†, Toshihiko Shimada3† & Yoshinori Noguchi3 BMC Surgery 2006, 6:2 doi:10.1186/1471-2482-6-2
  • 40. Note: NO ONE Recommends 3 or 4 Layer Anastomosis No Staple Company Recommends Oversewing the Staple Line
  • 41. Prevent Bleeding: “Go Slow to Go Fast” Case Mantra: “No Bleeding” “Easy Case”
  • 42. How to Stop Bleeding: Direct Pressure - First Aid Use the Stapler to Compress the staple line wound How to Stop Bleeding Direct Pressure First Aid
  • 43. Stapler Use Warnings Ensure to select a stapler with the appropriate staple size for the tissue thickness. Overly thick or thin tissue may result in unacceptable staple formation. Do not attempt to remove the shipping wedge until the stapler is loaded into the instrument. Do not squeeze the handle while pulling back the black retraction knobs. Do not attempt to override the safety interlock; to do so will render the stapler nonoperational. Failure to completely fire the stapler will result in an incomplete cut and incomplete staple formation, and may until in poor hemostasis.
  • 44. Management Leaks Simple: In ANY Post Op Patient with ANY Complaints Do: Rexplore Do Not: WBC, CXR or other Plain Film Do Not: CT Scan or Gastrograffin Swallow The Only Answer Rexplore
  • 45. Management Post Op Leaks 1. First Prevent Leaks 2. Categorize: Early Leaks vs Late Leaks 3. Second Simple Management Protocol
  • 46. Leak Management Leak found 24-48hr = No Diagnostic Tests = Immediate Exploration = Usually Simple Suture Repair Leak Found More than 72 hours = Take down GJ (1 Staple Firing) 5-10 min = Gastro-Gastrostomy (5-10 min) = Get Out (Drain and ABx)
  • 47. Leak Management Fear Leak: Suspect a Leak in Every Case Leak found 24-48hr = No Diagnostic Tests No WBC No CAT Scan No Chest XRay If patient does not feel well reexplore early = Immediate Exploration Expect many negative explorations when you begin = Usually Simple Suture Repair
  • 48. Abdominal Abscess Minimal Sx Drain Percutaneous and Antibiotics