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Managing Complications
First
Prevent Complications
Error in Thinking of
Complications in Surgery
Often Said:
If you are not having complications;
You are not doing surgery
I...
Safety & Bariatric Surgery
Complacency
• When surgeons Don’t
rigorously adhere to pre-op
rules or checklist in selecting
&...
Safety & Bariatric Surgery
Complacency
• Error:
Neglect careful attention
• pre, Intra & post-op
management guidelines
• (...
Safety & Bariatric Surgery
Complacency
• Even worse, some surgeons
choose to operate knowing of
major problems with their
...
Examples of Complacency
Sleeve Gastrectomy Failure:
• “Sleeve Gastrectomy & Risk of Leak:
Systematic Analysis of 4,888 Pat...
Laparoscopic revisional surgery
after Roux-en-Y
Revision of RNY
Patients required surgical exploration for
hemorrhage, sta...
“Risk of leak is low at 2.4%"
Air India Airlines
Releases the following statement:
“Risk of Airplane Crashes are Low at on...
The Mindset of
Commitment to Excellence
Make the Commitment
To your Patient:
“Failure is Not an Option”
Objectives
Adoption of Mindset to
Prevent Complications
(Failure is Not & Option)
Fight Complacency
Specific Techniques to...
Don’t Manage a Complication?
Prevent, Prevent, Prevent
Complication Management
vs.
Complication Prevention
Better to
Prevent a Leak than to be
Expert in
Managing a Leak
Volume Performance
New Surgeons = More Complications
Complications Decrease
with Experience
New Surgeons are
Dangerous & Deadly Surgeons
Complications decline to
logarithm of the surgeons’
Training & Experience
Learning Minimally-Invasive Mitral Valve Surgery
• The typical number of operations to
overcome the learning curve was bet...
RNY: Long learning curve of
500 cases
RNY technically challenging 2,281 cases 1999 -
2011
Complications diminished with
in...
Surgeons' experience with laparoscopic fundoplication
• Complications of laparoscopic fundoplication
are more likely durin...
What can we learn from the
Airline Industry
Failure is Not an Option
PE Prevention
Argument for Prophylaxsis
Most patients who die from PE do so within 30
minutes of onset, leaving little tim...
Two general types of prophylaxis
mechanical methods &
pharmacological agents.
Graded compression stockings have
been shown...
Bleeding and LMWH
At least eight randomized studies
compared LMWH with standard heparin
in patients undergoing abdominal
s...
Fear Bleeding with LMWH:
“If” Used: BE CAREFUL
Enoxaparin is given at a dose of 30 mg twice
a day,
First dose 12 hours aft...
Prevention of Venous Thromboembolism
American College of Chest Physicians
2.5 Laparoscopic Surgery
2.5.1. For patients und...
Prevention of Venous Thromboembolism
American College of Chest Physicians
2.5.2. For patients undergoing
laparoscopic proc...
Prevention of Venous Thromboembolism
American College of Chest Physicians
2.6 Bariatric Surgery
2.6.1. For patients underg...
Prevention of Venous Thromboembolism
American College of Chest Physicians
Prevention of Venous Thromboembolism
American Co...
Cascade Effect
Laparoscopic Surgery VTE Prophylaxsis
Vs.
Bariatric Surgery VTE Prophylaxsis
Prevention of Venous Thromboembolism
American College of Chest Physicians
2.0 General, Vascular, Gynecologic, Urologic,
La...
2.5 Laparoscopic Surgery
2.5.1. For patients undergoing entirely laparoscopic
procedures who do not have additional
thromb...
Surgery VTE Prophylaxsis
The 8th edition of the ACCP guidelines
recommends that mechanical methods of
VTE prophylaxis be u...
Surgery VTE Prophylaxsis
Fondaparinux was associated with an
increase in bleeding events & instances
of transfusion requir...
Low molecular weight heparin
Increases Bleeding Complications 3X
179 pts gastric surgery Rx LMWH (3200u qd 2-6 h
preop til...
Bleeding Complications
Laparoscopic sleeve gastrectomy (LSG)
is one of the most common procedures
of bariatric surgery.
Co...
Indications & short-term outcomes of
Revisional Surgery After Failed Or
Complicated Sleeve
Early complication rate in the
...
Laparoscopic sleeve gastrectomy for failed
laparoscopic adjustable gastric band
800 patients underwent LSG, with 90 as
a r...
Pre-operative administration of
Enoxaparin
Coagulation parameters increased significantly
& similarly at 30 min & 6 h with...
GI Anastomosis
Stapled vs Hand Sewn
Adhesion formation was less extensive, &
histologic evidence of inflammation was
less ...
Early Complications & Long Term
Reoperation Rates
Complications RNY/Band
(9% vs 5%)
Long-term reop rate RNY/Band
(16% vs 2...
Nutrient Deficiencies
The most frequent deficiencies after
restrictive procedures are related
to B-vitamins whereas
Iron, ...
Post Op Complications
Frequent complications
Sleeve gastrectomy & gastric bypasses may
present with life-threatening sutur...
RNY/MGB Post Op Complications
Complication RNY% MGB%
Bleeding 2.6 0.2%
Leak 2.4 0.2%
Wound infection (requiring hospital
t...
Controlled Prospective Randomized Trial
Lee WJ, Yu P-J, Wang W, Chen TC, Wei PL, Huang MT. Laparoscopic Roux-en-Y versus M...
Laparoscopic Mini Gastric Bypass
Cesare Peraglie MD FACS FASCRS
CLOS-Florida: Heart of Florida Regional Medical Center.
Da...
Laparoscopic-Mini Gastric Bypass: HOFRMC
•Over 1000 Laparoscopic MGB’s have been performed at HOFRMC since 2005.
•TYPICAL ...
MGB Outcomes
Tissue adhesives in 
gastrointestinal anastomosis
48 studies
Iileal & gastric/bariatric anastomosis
reveals promising resu...
Fibrin glue as a sealant for
RNY Gastric Bypass
The fibrin sealant group No leaks /120pts
5 pts/120 No Fibrin, Surgeon B,
...
Fibrin glue as a sealant for
RNY Gastric Bypass
A prospective, randomized, multicenter, clinical
trial commenced in Januar...
Stapled vs Handsewn Anastomosis
Linear Stapled vs Handsewn Esophago-
Gastrostomy
Anastomotic leak:
1 (3.0%) of 33 stapled
...
Early & late feeding on healing of 
anastomoses
2 groups: late feeding (LF) & early feeding (EF)
LF group was fed parenter...
NSAIDs be abandoned after
primary GI anastomosis
Anastomotic leak (AL) is the most important &
one of the most serious com...
NSAIDs be abandoned after
primary GI anastomosis
Retrospective, case-control study in 75 patients
undergoing laparoscopic ...
NSAIDs be abandoned after
primary GI anastomosis
Database study based on data from the Danish
Colorectal Cancer Group's (D...
Billroth II Outperforms RNY following
Pancreaticoduodenectomy
Delayed gastric emptying (DGE) is one of the major
complicat...
MGB/RNY/SG Complications
Short term:
Leak
Bleeding
Venous thrombosis
Infections, Pneumonia
SBO from abdominal hernia
Anast...
Leak Prevention
Leak Location:
EG Junction (Think Sleeve)
Prevention: Simple:
AVIOD e.g. Junction!
Gastro Jejunostomy
Prev...
Learning from Sleeve Leak Experience
Division of the posterior fundic vessels is also
performed.
(NO NO NO)
“The angle of ...
Learning from Sleeve Leak Experience
In 33 of the patients
(75%), the leak
location near the
gastroesophageal
junction
Pre...
Leak Prevention
ALWAYS DO A SAFE 
ANASTOMOSIS
Preop Factors
Intra-op Factors
Post Op Factors
Leak Prevention
ALWAYS DO A SAFE 
ANASTOMOSIS
Not leak.
Cause no persistent bleeding.
Cause no stricture of the lumen.
Cre...
Patient Factors
Look for these factors:
Correct these factors or REJECT the Patient
1. Renal/Cardiac/Pulmonary Dysfunction...
Fundamentals of Gastro-Intestinal
Anastomosis Healing
NO NSAIDs, Steroids, Anti-Metabolites (fluorouracil
decreased anasto...
Fundamentals of Gastro-Intestinal
Anastomosis Healing
Adequate local blood supply (Carefully maintain
mesentery)
Eliminati...
Fundamentals of Gastro-Intestinal
Anastomosis Healing
Adequate local blood
supply
Maintain mesentery
Elimination of tensio...
Fundamentals of Gastro-Intestinal
Anastomosis Healing
Meticulous
Hemostasis
SLOW Staple Gun
Firing
Avoid damage to
staple ...
Fundamentals of Gastro-Intestinal
Anastomosis Healing
Inverted vs. Everted
1800s, Lembert, Halsted
advocated an inverted,
...
Fundamentals of Gastro-Intestinal
Anastomosis Healing
Approximately 3-mm gap
between two sutures
Care not to apply
excessi...
Handle tissue gently & precisely
“approximate, do not strangulate” to avoid
ischemia of the bowel wall at the
anastomosis....
Fundamentals of Gastro-Intestinal
Anastomosis Healing
1 Layer, Maybe 2, Not More (Ischemia)
Remember your general surgery
...
Meta-analysis of randomized controlled
trials single- vs two- layer intestinal
anastomosis
Six trials were analyzed, compr...
Note:
NO ONE Recommends 3 or 4 Layer
Anastomoses
No Staple Company Recommends
Oversewing the Staple Line
Decreasing RNY anastomotic and
staple line leak
•All operations were performed using a
linear-stapled anastomosis with
•bu...
Omentum in esophagogastric anastomosis
for prevention of anastomotic leak
•Leak in 3 pts with omentum
wrapped around the a...
Omental reinforcement for
intraoperative RNY leak repair
•387 patients with 32 (8.26%) patients who
had a staple line dehi...
Prevent Bleeding:
“Go Slow
to
Go Fast”
Case Mantra:
“No Bleeding”
“Easy Case”
How to Stop Bleeding:
Direct Pressure - First Aid
Use the Stapler to
Compress the
staple line
wound
How to Stop
Bleeding
D...
Stapler Use
Warnings
Ensure to select a stapler with the appropriate staple size for the
tissue thickness. Overly thick or...
Management Leaks
Simple:
In ANY Post Op Patient with ANY
Complaints
Do: Rexplore
Do Not: WBC, CXR or other Plain Film
Do N...
Leak Management
Leak found 24-48hr
= Suture Repair
Leak Found More than 72 hours
= Take down GJ
= Gastro-Gastrostomy
Bleeding Management
Rexplore
Bleeding site:
Staple line etc = suture repair and drain
Bed of spleen = aspirate hematoma an...
Nausea Vomiting
Abdominal Distention
Rexplore
Etiology
Kink, Twist, Stricture etc
Rx Take down GJ
Revision of GJ
Abdominal Abscess Minimal Sx
Drain Percutaneous and Antibiotics
Marginal Ulcer
Dyspepsia/”Bile Reflux”
99% of Cases Sx are from ACID Peptic
Gastritis/Ulcer
Rx SAME as for ANY PEPTIC ULCE...
Nutrient Deficiencies
Iron Def Anemia:
Common in Young women, NOT in Men
Why? Menstrual Losses
Therefore:
Rx FIRST slow / ...
Nutrient Deficiencies
B12 Def Anemia:
Common India
Why? Dietary
Therefore:
Rx Oral or IM B12
Long Term Nutrient Deficiencies
Calcium Deficiency
Rx Daily Yogurt/Curd
Best source Calcium, probiotics
(Lactobacillus) an...
Managing complications v4
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Managing complications v4

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Managing Complications; First Prevent Complications

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

Published in: Education, Health & Medicine
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Managing complications v4

  1. 1. Managing Complications First Prevent Complications
  2. 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. 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. 4. Safety & Bariatric Surgery Complacency • Error: Neglect careful attention • pre, Intra & post-op management guidelines • (e.g. Re-exploration Rules)
  5. 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. 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. 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. 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. 9. The Mindset of Commitment to Excellence Make the Commitment To your Patient: “Failure is Not an Option”
  10. 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. 11. Don’t Manage a Complication? Prevent, Prevent, Prevent
  12. 12. Complication Management vs. Complication Prevention Better to Prevent a Leak than to be Expert in Managing a Leak
  13. 13. Volume Performance New Surgeons = More Complications
  14. 14. Complications Decrease with Experience
  15. 15. New Surgeons are Dangerous & Deadly Surgeons Complications decline to logarithm of the surgeons’ Training & Experience
  16. 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. 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. 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. 19. What can we learn from the Airline Industry Failure is Not an Option
  20. 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.
  21. 21. 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
  22. 22. 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
  23. 23. 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)
  24. 24. 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).
  25. 25. 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
  26. 26. 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).
  27. 27. 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
  28. 28. Cascade Effect Laparoscopic Surgery VTE Prophylaxsis Vs. Bariatric Surgery VTE Prophylaxsis
  29. 29. 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).
  30. 30. 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).
  31. 31. 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.
  32. 32. Surgery VTE Prophylaxsis Fondaparinux was associated with an increase in bleeding events & instances of transfusion requirement,
  33. 33. 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
  34. 34. 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
  35. 35. 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.
  36. 36. 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
  37. 37. 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)
  38. 38. 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
  39. 39. 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
  40. 40. 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
  41. 41. 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
  42. 42. 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%
  43. 43. 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%
  44. 44. 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
  45. 45. 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)
  46. 46. MGB Outcomes
  47. 47. 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
  48. 48. 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
  49. 49. 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
  50. 50. 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
  51. 51. 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
  52. 52. 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
  53. 53. 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)
  54. 54. 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
  55. 55. 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
  56. 56. 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
  57. 57. 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)
  58. 58. 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!
  59. 59. Learning from Sleeve Leak Experience In 33 of the patients (75%), the leak location near the gastroesophageal junction Prevention: Simple: FEAR the EG Junction!
  60. 60. Leak Prevention ALWAYS DO A SAFE  ANASTOMOSIS Preop Factors Intra-op Factors Post Op Factors
  61. 61. 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.
  62. 62. 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
  63. 63. 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
  64. 64. 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)
  65. 65. Fundamentals of Gastro-Intestinal Anastomosis Healing Adequate local blood supply Maintain mesentery Elimination of tension Long Pouch Left gutter for bowel
  66. 66. 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
  67. 67. 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
  68. 68. 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.
  69. 69. 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
  70. 70. 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?
  71. 71. 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
  72. 72. Note: NO ONE Recommends 3 or 4 Layer Anastomoses No Staple Company Recommends Oversewing the Staple Line
  73. 73. 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
  74. 74. 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
  75. 75. 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
  76. 76. Prevent Bleeding: “Go Slow to Go Fast” Case Mantra: “No Bleeding” “Easy Case”
  77. 77. 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
  78. 78. 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.
  79. 79. 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
  80. 80. Leak Management Leak found 24-48hr = Suture Repair Leak Found More than 72 hours = Take down GJ = Gastro-Gastrostomy
  81. 81. 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
  82. 82. Nausea Vomiting Abdominal Distention Rexplore Etiology Kink, Twist, Stricture etc Rx Take down GJ Revision of GJ
  83. 83. Abdominal Abscess Minimal Sx Drain Percutaneous and Antibiotics
  84. 84. 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
  85. 85. 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”
  86. 86. Nutrient Deficiencies B12 Def Anemia: Common India Why? Dietary Therefore: Rx Oral or IM B12
  87. 87. Long Term Nutrient Deficiencies Calcium Deficiency Rx Daily Yogurt/Curd Best source Calcium, probiotics (Lactobacillus) and protein

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