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Sleeve leaks Version 2

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PREVENTION and Treatment of Sleeve Gastrectomy Leaks …

PREVENTION and Treatment of Sleeve Gastrectomy Leaks
Where does it occur?

ONE PLACE!

This is “Tiger Country” – remember that!
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.

Published in: Education, Health & Medicine

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  • 1. PREVENTION and Treatment of Sleeve Gastrectomy Leaks Dr Rutledge
  • 2. Sleeve Leak • Where does it occur? • ONE PLACE!
  • 3. Sleeve Leak • Where does it occur? • ONE PLACE! • This is “Tiger Country” – remember that!
  • 4. Sleeve Leak
  • 5. Sleeve Leak • Where does it occur? • ONE PLACE! • This is “Tiger Country” – remember that!
  • 6. Sleeve Leak A Tragedy of Unimaginable Proportions • Sleeve gastrectomy severe complications: is it always a reasonable surgical option? • • Moszkowicz D, Chevallier JM. Assistance Publique-Hôpitaux de Paris, University Paris 5, Paris, France. • Obes Surg. 2013 May;23(5):676-86.
  • 7. Sleeve Leak Sleeve gastrectomy severe complications • Twenty-two consecutive patients were referred between January 2004 and February 2012 with postoperative gastric leak or stenosis after LSG. • 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.
  • 8. Sleeve Leak Sleeve gastrectomy severe complications • Twenty-two consecutive patients were referred between January 2004 and February 2012 with postoperative gastric leak or stenosis after LSG. • 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).
  • 9. Sleeve Leak Sleeve gastrectomy severe complications • 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.
  • 10. Managing Complications FIRST Prevent Complications
  • 11. Managing Leaks First Prevent Leaks!!
  • 12. Error in Thinking of Complications in Surgery Often Said: If you are not having complications; You are not doing surgery Implying Complications are Inevitable & little can be done to prevent them They are expected
  • 13. Safety & Bariatric Surgery Fear Complacency • When surgeons Don’t rigorously adhere to • Rules/Checklist in managing patients, their team & themselves
  • 14. Safety & Bariatric Surgery Complacency • Error: Neglect careful attention • pre, Intra & post-op management guidelines • (e.g. Leak Prevention Rules)
  • 15. Safety & Bariatric Surgery Fear Complacency • Even worse, • Some surgeons choose to operate knowing of major problems with their patient or their team • (Misunderstand Seriousness of Complications)
  • 16. Examples of Complacency Sleeve Gastrectomy Leak • “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
  • 17. “Risk of leak is low at 2.4%" Imagine an Airline Releases the following statement: “Risk of Airplane Crashes are Low at only 2.4%"
  • 18. The Mindset of Commitment to Excellence Make the Commitment To yourself and to your Patient: “Failure is Not an Option”
  • 19. Objectives Adoption of Mindset to Prevent Complications (Failure is Not & Option) Fight Complacency Specific Techniques to AVOID complications 1. Know your Enemy (List Complications) 2. Management of Complications
  • 20. FIRST:Don’t Manage Complications? Prevent, Prevent, Prevent
  • 21. Complication Management vs. Complication Prevention Better to Prevent a Leak than to be Expert in Managing a Leak
  • 22. What can we learn from the Airline Industry Failure is Not an Option
  • 23. Unacceptable Outcomes Revisional Surgery After Failed Or Complicated Sleeve Early complication rate 23.4%; Staple line leak 5.4%, Bleeding was 8.1% Obes Surg. 2012 Dec;22(12):1903-8. Indications & short-term outcomes of revisional surgery after failed or complicated sleeve gastrectomy. van Rutte PW, Smulders JF, de Zoete JP, Nienhuijs SW.Department of Surgery, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands.
  • 24. Laparoscopic sleeve gastrectomy for failed laparoscopic adjustable gastric band 800 patients underwent LSG, with 90 as a revisional procedure for failed LAGB Operative complications included 5.5 % leak & 4.4 % hemorrhage Conclusions: “We advocate this procedure as a good bariatric option (?) 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
  • 25. Bariatric Surgery Complications Leak Bleeding Venous thrombosis/PE Infections, Pneumonia SBO from abdominal hernia Stricture/Obstruction 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
  • 26. Leak Prevention Leak Location: EG Junction (Think Sleeve) Prevention: Simple: AVIOD EG Junction!
  • 27. Dr Rutledge: Who am I to Criticize or Comment on the Sleeve In performing over 6,000 Mini-Gastric Bypasses I have performed more than 6,000 Sleeves Every MGB includes both a Sleeve and a bypass
  • 28. My Opinion: 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" (NO NO NO) Prevention: Simple: AVIOD the EG Junction!
  • 29. Sleeve Experts Counsel Dissection of the EG Junction Garth Davis Being in a tertiary referral center for Bariatric surgery I have to tell you that avoiding the GE junction is wrong. If you leave a fundic "dog ear" it will dilate under the ensuing high pressure and lead to long term weight regain. I have also had patients referred with the dog ear portion herniating into the hiatus.
  • 30. Sleeve Experts Counsel Dissection of the EG Junction Counter argument from Garth Davis: "Being in a tertiary referral center for Bariatric surgery "I have to tell you that avoiding the GE junction is wrong. "As was discussed ample times at the ASMBS meeting, "you need very good dissection of this area.
  • 31. Sleeve Experts Counsel Dissection of the EG Junction Garth Davis Being in a tertiary referral center for Bariatric surgery I have to tell you that avoiding the GE junction is wrong. "Finally, you will miss hiatal hernia if this are is not dissected. Proper dissection allows division on cardia without encroaching on esophagus so that no dog ear is present. Leaks don't happen from dissection in this area. (??) They happen from stapling onto esophagus or attempting to oversew the staple line." (??)
  • 32. Learning from Sleeve Leak Experience In 75-95% the leak location near the gastro-esophageal junction Prevention: Simple: FEAR the EG Junction!
  • 33. Fundamentals of Gastro-Intestinal Healing Meticulous Hemostasis SLOW Staple Gun Firing Avoid damage to staple line Do Not Touch the Staple Line Gentle & precise handling of tissues
  • 34. 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.
  • 35. 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
  • 36. 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
  • 37. Note: NO ONE Recommends 3 or 4 Layer Anastomoses No Staple Company Recommends Oversewing the Staple Line
  • 38. Leak: Prevention/Treatment Bring in Good Healthy Vascularized Tissue
  • 39. Omentum in esophagogastric anastomosis for prevention of anastomotic leak •Leak in 3 pts with omentum wrapped around the anastomosis patients (3.1%) •14 (14.4%) patients leaked without using the omental patch •Ann Thorac Surg. 2006 Nov;82(5):1857-62. Use of pedicled omentum in esophagogastric anastomosis for prevention of anastomotic leak.Bhat MA, Dar MA, Lone GN, Dar AM. Department of Cardiovascular and Thoracic Surgery, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India. drmakbarbhat@yahoo.co.uk
  • 40. Omental reinforcement for intraoperative RNY leak repair •387 patients with 32 (8.26%) patients who had a staple line dehiscence or evidence of gastric pouch or gastrojejunostomy leak intraoperatively. •Leaks/dehiscences were repaired with sutures and then reinforced with omentum. •No leak Omental Patch Pts •Am Surg. 2009 Sep;75(9):839-42. Omental reinforcement for intraoperative leak repairs during laparoscopic Roux-en-Y gastric bypass. Madan AK, Martinez JM, Lo Menzo E, Khan KA, Tichansky DS. Division of Laparoendoscopic and Bariatric Surgery, Daughtry Family Department of Surgery, University of Miami, Miller School of Medicine, 1475 NW 12th Avenue, Suite 4017, Miami, FL 33136, USA. atulkmadan@yahoo.com
  • 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. Do Not Be Confused There are Two Kinds of Leaks 1. Easy Leaks 2. Terrible Disasters How to tell the difference: Easy = 24 -48 hours Terrible Disasters = All others
  • 45. Management Leaks Reexplore EARLY Simple: In ANY Post Op Patient with ANY Complaints Do: Reexplore Do Not: WBC, CXR or other Plain Film Do Not: CT Scan or Gastrograffin Swallow The Only Answer Reexplore
  • 46. Leak Management Leak found 24-48hr = Suture Repair Leak Found More than 72 hours = Trouble
  • 47. Sleeve Leak • Where does it occur? • ONE PLACE! • This is “Tiger Country” – remember that!
  • 48. Sleeve Leak • Where does it occur? • ONE PLACE! • For this to heal What has to happen?
  • 49. Prevent Leaks Do Not Become Knowledgeable in Treating Leaks
  • 50. Sleeve Leaks • • • • • Early Diagnosis and Treatment Ideally re-explore 24-48 hours Late Leak Stable vs Infected/Septic Stable NPO, NG Across the Leak, GI or IV Feeding, ABx, + Drainage
  • 51. Sleeve Leaks • Late Leak • Infected/Septic • NPO, NG Across the Leak, GI or IV Feeding, ABx, +Drainage • Consider re-exploration
  • 52. Sleeve Leaks • • • • Debride Necrotic Tissue. Drain abscess(s) Consider: Isolated Roux limb as a serosal patch to cover EG junction defect or as a side to side Thal patch • Enteral Feeding Tube Below Leak
  • 53. Sleeve Leaks • The serosal side of jejunum (Thal patch), Bring the Roux limb up to the injured portion of the EG Junction • A Roux-Y limb of jejunum, with its independent blood supply and normal healthy tissue may help control the leak by bringing in Healthy tissue to the EG Junction area
  • 54. Use of a Roux limb to correct esophagogastric junction fistulas after sleeve gastrectomy • • • • • • Laparoscopic sleeve gastrectomy (LSG) can be complicated, in the early postoperative course, by an esophagogastric junction (EGJ) leak with very serious consequences. A 48-year-old woman developed an EGJ leak 3 days after LSG surgery and was treated with conservative measures. Finally, 6 weeks after the original surgery, a Roux limb was brought to the EGJ and anastomosed side-to-end to the fistula. At the beginning, the Roux limb was the only functioning outlet and finally, 2 months later, both pathways (the gastric sleeve and the Roux-en-Y) are patent at 3 months after surgery. The Roux limb resolved a dangerous EGJ leak after a LSG. Obes Surg. 2007 Oct;17(10):1408-10. Baltasar A, Bou R, The Surgical Service, Virgen de los Lirios Hospital, Alcoy, Alicante, Spain. a.baltasar@aecirujanos.es
  • 55. Sleeve Leaks • Acute conversion of Leaking Sleeve to MGB is not advised • The theoretical advantage decreasing the back pressure of the pylorus is not necessary when the esophagus, stomach pouch and gut are appropriately drained