Post-Op leaks in Bariatric Surgery - Gandsas 02-07

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Post-Op leaks in Bariatric Surgery - Gandsas 02-07

  1. 1. Alex Gandsas, MD, FACS Head , Division of Bariatric and Minimally Invasive Surgery Post Operative Leaks
  2. 2. Statistics <ul><li>1990 -> 16,000 procedures </li></ul><ul><li>2003 -> 103,000 Procedures </li></ul>Gandsas Post Operative Leaks <ul><li>2005 -> 140,000 Procedures </li></ul>
  3. 3. Gandsas Post Operative Leaks Complications: <ul><li>Leaks ……………………….. 2-4% </li></ul><ul><li>DVT ………………………… 2% </li></ul><ul><li>Pulmonary Embolism ……... <1% </li></ul><ul><li>Small Bowel Obstruction ….. 2% </li></ul><ul><li>Strictures ………………….... 15% </li></ul><ul><li>Stoma Ulcers ………………. 2-4% </li></ul><ul><li>Incisional Hernias …………... 20% </li></ul>
  4. 4. Gandsas Post Operative Leaks Epidemiology: Open: 1.6% Laparoscopy 3- 4% Revisions 35% Marshall JS. Arch Surg. 2003. 138:520-524
  5. 5. Gandsas Post Operative Leaks Leaks: Esophageal Perforation (4 %) Gastro Jejunostomy (52%) Remnant Stomach (8%) Small bowel perforation (30%) Jejuno jejunostomy (4%) Schauer PR. 2002
  6. 6. Gandsas Post Operative Leaks Etiology Technical Challenges <ul><li>Anatomy (Liver Size) </li></ul><ul><li>Tension </li></ul><ul><li>Blood Supply </li></ul>
  7. 7. Gandsas Post Operative Leaks Anastomosis / Staple line leaks: <ul><li>Symptoms: </li></ul><ul><ul><ul><ul><ul><li>NOTHING (!) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Tachycardia on pod# 2-5 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Low urine output (third spacing) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Leukopenia </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>High amylase, high lactate </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Hiccups </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Brownish color of the drain output </li></ul></ul></ul></ul></ul>
  8. 8. Gandsas Post Operative Leaks Anastomosis / Staple line leaks: <ul><li>Late Symptoms: </li></ul><ul><ul><ul><ul><ul><li>Left Pleural effusion </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Left Subphrenic abscess </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Fever </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Tachycardia </li></ul></ul></ul></ul></ul>
  9. 9. Gandsas Post Operative Leaks <ul><li>Differential Diagnosis: </li></ul><ul><ul><ul><ul><ul><li>Post op pain </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Atelectasis </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Dehydration </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Bleeding </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Hypoxia/Pulmonary Embolism </li></ul></ul></ul></ul></ul>
  10. 10. Bowel injury Mortality increases to 26% if the injury goes unnoticed for more than 24 hs. Chandler et al. J Am Coll Surg. 2001; 192: 478-91 and increases to 46% if the patient is older than 59 years. Gandsas Post Operative Leaks
  11. 11. Gandsas Post Operative Leaks <ul><li>Diagnosis: </li></ul><ul><ul><ul><ul><ul><li>Tachycardia >120 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Physical exam </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Gastrografin Swallow </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>CT-Scan </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Laparotomy / laparoscopy </li></ul></ul></ul></ul></ul>
  12. 12. Gandsas Post Operative Leaks Gastrografin Swallow <ul><li>No need for x-rays if patient is asymptomatic </li></ul><ul><li>(Singh. Obes Surg. 2003; 13:73-74) </li></ul><ul><li>Low Sensitivity </li></ul><ul><li>( Hamilton EC. Surg Endosc. 2004 mar;18(3):559) </li></ul>
  13. 13. Gandsas Post Operative Leaks <ul><li>Intraoperative Endoscopy: </li></ul><ul><li>Allows direct visualization of the anastomosis </li></ul><ul><li>Identified 34 correctable errors in 825 cases </li></ul><ul><li>Principle: high Pressure air tight staple line is less likely to leak fluids under low pressure. </li></ul>Champion JK. Surg Endo. 2002. 16:1663-1665
  14. 14. Gandsas Post Operative Leaks Management: <ul><li>Medical </li></ul><ul><li>Surgical </li></ul>Lavage Gastrotomy tube Nutrition Drainage Infection control Support Closure of defect if possible
  15. 15. Gandsas Post Operative Leaks <ul><li>Movie </li></ul>
  16. 16. Gandsas Post Operative Leaks LEAKS N= 1789 Incidence: 1.34% Tachycardia: 83% * Fever: 70% * Left Side pain: 44% Arteaga JR. Am Surg. 2002; 68:1061-65
  17. 17. Gandsas Post Operative Leaks Hamilton EC. Surg Endosc. 2003; 17:679-648 0% 22% Positive Gastrografin 7% 33% Low Urine Output 10% 67% Respiratory Distress 42% 25% Fever 16% 90% Tachycardia No Leak N= 201 Leak N=9 N=210
  18. 18. Gandsas Post Operative Leaks Facts: Tachycardia when associated with Fever is one of the earliest sign of anastomotic leak following GBP Buckwalter JA. Surgery. 1988; 103:156-60
  19. 19. Gandsas Post Operative Leaks How Can I Avoid a post operative LEAK?
  20. 20. Gandsas Post Operative Leaks Don’t Operate !
  21. 21. Gandsas Post Operative Leaks <ul><li>if you do: </li></ul><ul><ul><ul><ul><ul><li>Avoid tension of Roux limb </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Assess blood supply </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Consider Intraop. Endoscopy </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Consider “Air test” </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Aggressive post op monitoring </li></ul></ul></ul></ul></ul>
  22. 22. Gandsas Post Operative Leaks <ul><li>Also: </li></ul><ul><ul><ul><ul><ul><li>Bovine pericardial strips </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>- decrease bleeding </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>- decrease leaks </li></ul></ul></ul></ul></ul>Shikora SA. Obes Surg. 2003; 13:37-39.
  23. 23. Gandsas Post Operative Leaks Liu CD. Obes Surg. 2003; 13:45-48. Sapala. Obes Surg. 2004; 14:35-42 <ul><li>useful in “high risk anastomosis </li></ul><ul><li>may be cost effective </li></ul>Fibrin Glue Sealant
  24. 24. Gandsas Post Operative Leaks <ul><li>When in doubt: </li></ul><ul><ul><ul><ul><ul><li>Oversewing of staple line </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Gastrostomy tube </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Small bowel interposition </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Consider “bubble test” </li></ul></ul></ul></ul></ul>
  25. 25. Gandsas Post Operative Leaks <ul><li>Remember: </li></ul><ul><li>If in doubt: operate! </li></ul><ul><li>Can still have “leaks” from other sources </li></ul>

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