Managing Complications; First Prevent Complications Examples of ComplacencySleeve 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

1. Managing Complications
First
Prevent Complications

2. 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

3. Safety & Bariatric Surgery
Complacency
• When surgeons Don’t
rigorously adhere to pre-op
rules or checklist in selecting
& preparing their patient, their
team & themselves

4. Safety & Bariatric Surgery
Complacency
• Error:
Neglect careful attention
• pre, Intra & post-op
management guidelines
• (e.g. Re-exploration Rules)

5. Safety & Bariatric Surgery
Complacency
• Even worse, some surgeons
choose to operate knowing of
major problems with their
patient or their team
• (Misunderstand Serious of
Complications)

6. 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

7. Laparoscopic revisional surgery
after Roux-en-Y
Revision of RNY
Patients required surgical exploration for
hemorrhage, staple line leak, and an
incarcerated hernia.
The overall complication rate was 23%,
with a major complication rate of 11.5%
Surg Obes Relat Dis. 2010 Sep-Oct;6(5):485-90. Laparoscopic revisional surgery after Roux-en-Y gastric bypass and
sleeve gastrectomy. Morales MP, Wheeler AA, Ramaswamy A, Scott JS, de la Torre RA. Department of Surgery,
University of Missouri, Columbia, Missouri 65203, USA.

8. “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%"

9. The Mindset of
Commitment to Excellence
Make the Commitment
To your Patient:
“Failure is Not an Option”

10. 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

11. Don’t Manage a Complication?
Prevent, Prevent, Prevent

12. Complication Management
vs.
Complication Prevention
Better to
Prevent a Leak than to be
Expert in
Managing a Leak

13. Volume Performance
New Surgeons = More Complications

14. Complications Decrease
with Experience

15. New Surgeons are
Dangerous & Deadly Surgeons
Complications decline to
logarithm of the surgeons’
Training & Experience

16. Learning Minimally-Invasive Mitral Valve Surgery
• The typical number of operations to
overcome the learning curve was between
75 & 125 operations
• Furthermore, more than one such operation
per week was necessary to maintain good
results.
• Individual learning curves varied markedly
proving the need for good monitoring and/or
mentoring in the initial phase.
• Circulation. 2013 Jun 26. Learning Minimally-Invasive Mitral Valve Surgery: A Cumulative Sum
Sequential Probability Analysis of 3895 Operations from a Single High Volume Center Holzhey
DM, Seeburger J, Misfeld M, Borger MA, Mohr FW. Heart Center Leipzig, Leipzig, Germany

17. 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 12-
year 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.

18. Surgeons' experience with laparoscopic fundoplication
• Complications of laparoscopic fundoplication
are more likely during the initial 20 cases
• Experience with the procedure
shorter operating time & fewer
complications, conversions, & early
dysphagia
• Surg Endosc. 2007 Aug;21(8):1377-82. Epub 2007 Feb 7. Surgeons' experience with
laparoscopic fundoplication after the early personal experience: does it have an impact on the
outcome? Salminen P, Hiekkanen H, Laine S, Ovaska J. Department of Surgery, Turku
University Central Hospital, Kiinamyllynkatu 4-8, 20520, Turku, Finland. paulina.salminen@tyks.fi

19. What can we learn from the
Airline Industry
Failure is Not an Option

20. PE Prevention
Argument for Prophylaxsis
Most patients who die from PE do so within 30
minutes of onset, leaving little time for
diagnosis or effective intervention.
"... further reductions in mortality from
pulmonary embolism must come through
systematic prophylaxis in high-risk patients
rather than a policy of 'wait & treat'"
Gallus AS (1990) Baillieres Clin Haematol 3,
651-684.

22. Two general types of prophylaxis
mechanical methods &
pharmacological agents.
Graded compression stockings have
been shown to be effective
Should be fitted individually to ensure
that pressure is correctly graded

23. Bleeding and LMWH
At least eight randomized studies
compared LMWH with standard heparin
in patients undergoing abdominal
surgery.
A number of the early trials evaluating
prophylactic LMWH reported excessive
bleeding

24. Fear Bleeding with LMWH:
“If” Used: BE CAREFUL
Enoxaparin is given at a dose of 30 mg twice
a day,
First dose 12 hours after surgery
And…There is currently much interest in
continuing to administer LMWHs for a
longer period after surgery to protect
against the longer-term threat of
thrombosis. (Risk of “Late” PE)

25. Prevention of Venous Thromboembolism
American College of Chest Physicians
2.5 Laparoscopic Surgery
2.5.1. For patients undergoing entirely
laparoscopic procedures who do not have
additional
thromboembolic risk factors,
we recommend against the routine use of
thromboprophylaxis,
other than early & frequent ambulation
(Grade 1B).

26. Prevention of Venous Thromboembolism
American College of Chest Physicians
2.5.2. For patients undergoing
laparoscopic procedures in whom
additional VTE risk factors are
present,
Recommend prophylaxis
• LMWH, fondaparinux,
• Intermittent Pneumatic Compression
• Graded Compression Stockings

27. Prevention of Venous Thromboembolism
American College of Chest Physicians
2.6 Bariatric Surgery
2.6.1. For patients undergoing inpatient bariatric
surgery, we recommend routine thromboprophylaxis
with LMWH, LDUH three times daily, fondaparinux,
or the combination of one of these pharmacologic
methods with optimally used intermittent pneumatic
compression (IPC). (each Grade 1C).
2.6.2. For patients undergoing inpatient bariatric
surgery, we suggest that higher doses of LMWH
or LDUH than usual for nonobese patients be
used (Grade 2C).

28. Prevention of Venous Thromboembolism
American College of Chest Physicians
Prevention of Venous Thromboembolism
American College of Chest Physicians
Evidence-Based Clinical Practice
Guidelines (8th Edition)
Chest 2008;133;381S-453S

29. Cascade Effect
Laparoscopic Surgery VTE Prophylaxsis
Vs.
Bariatric Surgery VTE Prophylaxsis

30. Prevention of Venous Thromboembolism
American College of Chest Physicians
2.0 General, Vascular, Gynecologic, Urologic,
Laparoscopic, Bariatric, Thoracic, & Coronary
Artery Bypass Surgery
2.1 General Surgery
2.1.1. For low-risk general surgery patients who
are undergoing minor procedures & have no
additional thromboembolic risk factors,
we recommend against the use of specific
thromboprophylaxis other than early &
frequent ambulation (Grade 1A).

31. 2.5 Laparoscopic Surgery
2.5.1. For patients undergoing entirely laparoscopic
procedures who do not have additional
thromboembolic risk factors, we recommend against
the routine use of thromboprophylaxis, other than
early & frequent ambulation (Grade 1B).
2.5.2. For patients undergoing laparoscopic
procedures in whom additional VTE risk factors are
present, we recommend the use of
thromboprophylaxis with one or more of LMWH,
LDUH, fondaparinux, IPC, or GCS (all Grade 1C).

32. Surgery VTE Prophylaxsis
The 8th edition of the ACCP guidelines
recommends that mechanical methods of
VTE prophylaxis be used primarily in patients
who are at high risk of bleeding & that careful
attention be directed to ensuring their proper
use & optimal adherence.
Mechanical compression should be initiated
prior to induction of anesthesia & continue
intraoperatively & then into the
postanesthesia care unit.

33. Surgery VTE Prophylaxsis
Fondaparinux was associated with an
increase in bleeding events & instances
of transfusion requirement,

34. Low molecular weight heparin
Increases Bleeding Complications 3X
179 pts gastric surgery Rx LMWH (3200u qd 2-6 h
preop til DC), 182 pts controls.
No patient in either group developed VTE
LMWH significantly higher complication rate
(27% vs. 15.4%, p=0.005)
Postop bleeding & wound complications sig.
higher in LMWH pts
Multivariate analysis LMWH independent risk factor
(odds ratio, 3X, P = 0.009) of postop
Ann Surg Oncol. 2010 Sep;17(9):2363-9. The effect of low molecular weight heparin thromboprophylaxis on bleeding
complications after gastric cancer surgery. Jeong O, Ryu SY, Park YK, Kim YJ. Division of Gastrointestinal
Surgery, Department of Surgery, Chonnam National University Hwasun Hospital, Jeollanam-do, Korea

35. Bleeding Complications
Laparoscopic sleeve gastrectomy (LSG)
is one of the most common procedures
of bariatric surgery.
Complications after LSG are common
Most frequent is bleeding
LSG-associated gastric leak &
hemorrhages remain the most important
challenges postoperatively

36. Indications & short-term outcomes of
Revisional Surgery After Failed Or
Complicated Sleeve
Early complication rate in the
whole cohort was 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.

37. 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

38. Pre-operative administration of
Enoxaparin
Coagulation parameters increased significantly
& similarly at 30 min & 6 h with both
treatments, but
Returned to normal 12 h
IF using Enoxaparin
Enoxaparin 100 UI/Kg (IDEAL BWt) x BID s.c.
Stop min 12 h before surgery
(i.e. Rx morning Day Before Surgery & Restart
morning After Surgery)

39. GI Anastomosis
Stapled vs Hand Sewn
Adhesion formation was less extensive, &
histologic evidence of inflammation was
less severe, in stapled anastomoses.
The average times required to complete
the simple interrupted, simple
continuous, & stapled anastomoses
were 22, 14, & 8 minutes, respectively.
Cornell Vet. 1988 Oct;78(4):325-37. A comparison of three methods of end-to-end anastomosis in the equine small
colon. Bristol DG, Cullen J.
Department of Food Animal & Equine Medicine, North Carolina State University, School of Veterinary Medicine,
Raleigh 27606

40. Early Complications & Long Term
Reoperation Rates
Complications RNY/Band
(9% vs 5%)
Long-term reop rate RNY/Band
(16% vs 24%)
MGB 5% Comp. 1-2% Reop
Am J Med. 2008 Oct;121(10):885-93. Gastric banding or bypass? A systematic
review comparing the two most popular bariatric procedures. Tice JA,
Karliner L, Walsh J, Petersen AJ, Feldman MD.Division of General Internal
Medicine, Department of Medicine, University of California, San Francisco,
San Francisco, CA 94143-1732, USA. jtice@medicine.ucsf.edu

41. Nutrient Deficiencies
The most frequent deficiencies after
restrictive procedures are related
to B-vitamins whereas
Iron, folate, vitamin B1 & B12 &
vitamin D deficiencies are
associated with the malabsorptive
procedures
Zentralbl Chir. 2013 Jul 3. [Nutrient Deficiencies after Bariatric Surgery - Systematic
Literature Review & Suggestions for Diagnostics & Treatment.] [Article in German]
Stroh C, Benedix F, Meyer F, Manger T.Klinik für Allgemein-, Viszeral- und
Kinderchirurgie, SRH Wald-Klinikum Gera gGmbH, Gera, Deutschland

42. Post Op Complications
Frequent complications
Sleeve gastrectomy & gastric bypasses may
present with life-threatening suture leaks or
suture line bleeding
Gastric bypass & BPD Marginal ulcer, bleeding,
Perforation, Stenosis, Abscess, Bowel
obstruction, internal hernia, also caused by
trocar site hernia, intussusceptions,
adhesions, strictures, kinking, or blood clots.
Rapid weight loss after bariatric surgery can
cause cholecystitis or choledocholithiasis

43. RNY/MGB Post Op Complications
Complication RNY% MGB%
Bleeding 2.6 0.2%
Leak 2.4 0.2%
Wound infection (requiring hospital
treatment) 2.2 0.1%
Intestinal obstruction 1.1 0.0%
Intra-abdominal abscess 0.7 0.1%
Pulmonary thromboembolism 0.6 0.2%
Total of early complications 9.6 0.8%

44. Controlled Prospective Randomized Trial
Lee WJ, Yu P-J, Wang W, Chen TC, Wei PL, Huang MT. Laparoscopic Roux-en-Y versus Mini-
Gastric 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%

45. Laparoscopic Mini Gastric Bypass
Cesare Peraglie MD FACS FASCRS
CLOS-Florida: Heart of Florida Regional Medical Center.
Davenport, Florida
drperaglie@gmail.com
SECO 2012
BARCELONA SPAIN

46. 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)

47. MGB Outcomes

48. Tissue adhesives in
gastrointestinal anastomosis
48 studies
Iileal & gastric/bariatric anastomosis
reveals promising results for fibrin glue
J Surg Res. 2013 Apr;180(2):290-300. doi: 10.1016/j.jss.2012.12.043. Epub 2013 Jan 16.Tissue
adhesives in gastrointestinal anastomosis: a systematic review.Vakalopoulos KA, JF.Department
of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.
k.a.vakalopoulos@gmail.com

49. Fibrin glue as a sealant for
RNY Gastric Bypass
The fibrin sealant group No leaks /120pts
5 pts/120 No Fibrin, Surgeon B,
2 pts/120 No Fibrin, Surgeon C,
1 pt/120 Surgeon A without fibrin sealant
Obes Surg. 2003 Feb;13(1):45-8.Fibrin glue as a sealant for high-risk anastomosis in surgery for
morbid obesity.Liu CD, Glantz GJ, Livingston EH.University of California, Los Angeles School of
Medicine & Greater Los Angeles VA Medical Center, Department of Surgery, Los Angeles, CA
10833, USA. cdliu@mednet.ucla.edu

50. Fibrin glue as a sealant for
RNY Gastric Bypass
A prospective, randomized, multicenter, clinical
trial commenced in January 2004
No leaks or internal hernias in the fibrin
glue group.
The incidence of leaks (2 cases, 1.8%) & the
overall reoperation rate were higher in the
control group (P=0.0165).
Obes Surg. 2006 Feb;16(2):125-31.Clinical evaluation of fibrin glue in the prevention of anastomotic leak & internal
hernia after laparoscopic gastric bypass: preliminary results of a prospective, randomized multicenter
trial.Silecchia G, Boru CE, Mouiel J, Rossi M, Anselmino M, Tacchino RM, Foco M, Gaspari AL, Gentileschi P,
Morino M, Toppino M, Basso N.Dipartmento di Chirurgia Generale Paride Stefanini, Policlinico Umberto I,
University of Rome La Sapienza, Rome, Italy. giangranco.silecchia@uniroma1.it

51. Stapled vs Handsewn Anastomosis
Linear Stapled vs Handsewn Esophago-
Gastrostomy
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

52. Early & late feeding on healing of
anastomoses
2 groups: late feeding (LF) & early feeding (EF)
LF group was fed parenterally for 6 days &
orally (per oral route) after postop day 7
EF group was fed orally (per oral route) 24h
postop
LF group, Bursting Pressure & Esophageal
Diameter lower than EF
Early feeding is superior

53. NSAIDs be abandoned after
primary GI anastomosis
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

54. 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)

55. NSAIDs 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

56. Billroth II Outperforms RNY following
Pancreaticoduodenectomy
Delayed gastric emptying (DGE) is one of the major
complications after pancreaticoduodenectomy (PD),
occurring in 14% to 61%
Randomly allocated to B-II reconstruction (n = 52) & R-Y
reconstruction (n = 49) groups
Delayed gastric emptying occurred in
5.7% of patients in the B-II
20.4% of patients in the R-Y (P = 0.03)
B-II shorter hospital stay than R-Y (31 days vs. 41, P =
0.04)
Ann Surg. 2013 May;257(5):938-42 Effect of billroth II or Roux-en-Y reconstruction for the gastrojejunostomy on delayed gastric emptying after
pancreaticoduodenectomy: a randomized controlled study. Shimoda M, Kubota K, Katoh M, Kita J. Second Department of Surgery, Dokkyo Medical
University, Tochigi, Japan. guido.torzilli@unimi.it

57. 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

58. Leak Prevention
Leak Location:
EG Junction (Think Sleeve)
Prevention: Simple:
AVIOD e.g. Junction!
Gastro Jejunostomy
Prevention: Technical Details of
Laparoscopic GI anastomosis
(Remember the
Basics of General Surgery)

59. 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!

60. Learning from Sleeve Leak Experience
In 33 of the patients
(75%), the leak
location near the
gastroesophageal
junction
Prevention:
Simple:
FEAR the
EG Junction!

61. Leak Prevention
ALWAYS DO A SAFE
ANASTOMOSIS
Preop Factors
Intra-op Factors
Post Op Factors

62. Leak Prevention
ALWAYS DO A SAFE
ANASTOMOSIS
Not leak.
Cause no persistent bleeding.
Cause no stricture of the lumen.
Create no risk for internal hernia.

63. Patient Factors
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

64. Fundamentals of Gastro-Intestinal
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

65. Fundamentals of Gastro-Intestinal
Anastomosis Healing
Adequate local blood supply (Carefully maintain
mesentery)
Elimination of tension (Long Pouch,left gutter for
bowel)
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)

66. Fundamentals of Gastro-Intestinal
Anastomosis Healing
Adequate local blood
supply
Maintain mesentery
Elimination of tension
Long Pouch
Left gutter for bowel

67. 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

68. 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

69. 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.

70. 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

71. 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?

72. Meta-analysis of randomized controlled
trials single- vs two- layer intestinal
anastomosis
Six trials were analyzed, comprising 670
participants (single-layer group, n = 299; two-
layer 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

73. Note:
NO ONE Recommends 3 or 4 Layer
Anastomoses
No Staple Company Recommends
Oversewing the Staple Line

74. Decreasing RNY anastomotic and
staple line leak
•All operations were performed using a
linear-stapled anastomosis with
•buttressing material, handsewn otomy
closures, stay sutures,
•intraoperative leak testing, and
•fibrin sealant
•Surg Endosc. 2009 Jun;23(6):1403-8. Decreasing anastomotic and staple line leaks after
laparoscopic Roux-en-Y gastric bypass. Fullum TM, Aluka KJ, Turner PL. Department of Surgery,
Howard University College of Medicine, Washington, DC, USA. tfullum@howard.edu

75. 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

76. 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

77. Prevent Bleeding:
“Go Slow
to
Go Fast”
Case Mantra:
“No Bleeding”
“Easy Case”

78. 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

79. 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.

80. 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

81. Leak Management
Leak found 24-48hr
= Suture Repair
Leak Found More than 72 hours
= Take down GJ
= Gastro-Gastrostomy

82. Bleeding Management
Rexplore
Bleeding site:
Staple line etc = suture repair and drain
Bed of spleen = aspirate hematoma and
direct pressure 20-30 minutes
Drain and rexplore if necessary

83. Nausea Vomiting
Abdominal Distention
Rexplore
Etiology
Kink, Twist, Stricture etc
Rx Take down GJ
Revision of GJ

84. Abdominal Abscess Minimal Sx
Drain Percutaneous and Antibiotics

85. Marginal Ulcer
Dyspepsia/”Bile Reflux”
99% of Cases Sx are from ACID Peptic
Gastritis/Ulcer
Rx SAME as for ANY PEPTIC ULCER
Remove Causes; Smoking, NSAIDs etc.
Add Probiotics (Curd Yogurt etc)
PPIs (Prilosec etc)
Antacids (Carafate, Mylanta etc)
Rx H. Pylori

86. Nutrient Deficiencies
Iron Def Anemia:
Common in Young women, NOT in Men
Why? Menstrual Losses
Therefore:
Rx FIRST slow / eliminate menstrual loss
Refer to GYN for Rx
Second Oral Iron “Proferrin”

87. Nutrient Deficiencies
B12 Def Anemia:
Common India
Why? Dietary
Therefore:
Rx Oral or IM B12

88. Long Term Nutrient Deficiencies
Calcium Deficiency
Rx Daily Yogurt/Curd
Best source Calcium, probiotics
(Lactobacillus) and protein