LEAKS IN RYGB
JOSEMBERG CAMPOS, PHDMANOEL GALVAO NETO, MDALMINO C. RAMOS, MD
Recife, PE, BrazilSao
Paulo, SP, Brazil
Sao Paulo, SP,
Braz...
ALMINO CARDOSO RAMOS MANOELA GALVÃO MANOEL GALVÃO NETO ANDREY CARLO
RYGB LEAKS
ENDOSCOPIC APPROACH
• Learning objectives
• Define RYGB leak
• Unveils the RYGB endoscopic anatomy
• Understand...
• Fistula
• abnormal communication originating in a visceral
structure.
• Leak
• one type of fistula, is defined as discon...
• Leaks develop when intraluminal pressure exceeds
tissue or suture line resistance.
• Leaks presenting within the first 2...
RYGB Leaks can lead to
mortality
of 6%–14.7%.
Lee S, Carmody B, Wolfe L, et al. Effect of location and speed of diagnosis ...
Leaks / Fistulas
RNY Gastric Bypass leaks
GASTRO-ENTERO
“POUCH” GASTRO-ENTERO
RNY Gastric Bypass leaks
Gastro-Cutaneous fistula
Gastro-gastric fistula
RNY Gastric Bypass leaks
RNY Gastric Bypass leaks
Gastro-Bronqueal fistula
 First control the sepsis
 Laparoscopy
 Percutaneous
 Laparotomy
 Stabilize the patient
RNY Gastric Bypass leaks
RNY Gastric Bypass leaks
 Most of them heals up to 30d
 Clinical management usually works
 Drain / Gastrostomy / NET…
...
RNY Gastric Bypass leaks
 Endoscopic treatment
 Dilation– correct the flow…
 RYGB GJ are built to be “stenotic”
 < 20m...
Endoscopic balloon dilation
RNY Gastric Bypass leaks
Dilate first
RYGB Leaks
Stents
RNY Gastric Bypass leaks
 Endoscopic treatment
 Stents
 Actual models were design for
malignancies
 They don’t fit all...
Bariatric upper leaks
Plastic- Silicon
Implant…
Removal…
Bariatric upper leaks
Metallic single covered- Nitinol
Bariatric upper leaks
Prosthesis – New models
Nitinol double covered…
Type N F/M Bypass Sleeve Prosthesis
on site
Days
Fistula
clousure
Poliflex®
Silicone
15 10F / 5M 13p 2p 45d
(21 – 91d)
1...
Type Dislodgment Significant
Reflux
Surgical removal
Poliflex®
Silicone
8p
53,3%
6p
40%
1p
Dislodgement
7%
Hanaro/Choo®
Ni...
RYGB Leaks
Complementary procedures
Septomy
Septomy
CAUTERY + PNEUMATIC DILATION
RESHAPING FISTULA SITE (ZENCKER DIVERTICULUM LIKE)
Septomy
CAUTERY + PNEUMATIC DILATION
RESHAPING FISTULA SITE (ZENCKER DIVERTICULUM LIKE)
RYGB Leaks
Endoscopic treatment can
be used even on the worst
scenarios
Obes Surg, 2011
Sleeve Gastrectomy - Complications
Thanks!
galvaon@gmail.com
Endolumenal strategies on RYGB leaks
Endolumenal strategies on RYGB leaks
Endolumenal strategies on RYGB leaks
Endolumenal strategies on RYGB leaks
Endolumenal strategies on RYGB leaks
Endolumenal strategies on RYGB leaks
Endolumenal strategies on RYGB leaks
Endolumenal strategies on RYGB leaks
Endolumenal strategies on RYGB leaks
Endolumenal strategies on RYGB leaks
Endolumenal strategies on RYGB leaks
Endolumenal strategies on RYGB leaks
Endolumenal strategies on RYGB leaks
Endolumenal strategies on RYGB leaks
Endolumenal strategies on RYGB leaks
Endolumenal strategies on RYGB leaks
Endolumenal strategies on RYGB leaks
Endolumenal strategies on RYGB leaks
Endolumenal strategies on RYGB leaks
Endolumenal strategies on RYGB leaks
Endolumenal strategies on RYGB leaks
Endolumenal strategies on RYGB leaks
Endolumenal strategies on RYGB leaks
Endolumenal strategies on RYGB leaks
Endolumenal strategies on RYGB leaks
Endolumenal strategies on RYGB leaks
Endolumenal strategies on RYGB leaks
Endolumenal strategies on RYGB leaks
Endolumenal strategies on RYGB leaks
Endolumenal strategies on RYGB leaks
Endolumenal strategies on RYGB leaks
Endolumenal strategies on RYGB leaks
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Endolumenal strategies on RYGB leaks

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This prevention covers the updated Endoscopic and Endolumenal treatment of Roux-and-Y Gastric Bypass leaks and fistulas in a comprehensive manner with the published experience of a very active reference center with over 20 peer-reviewed articles over this matter of bariatric endoscopy

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Endolumenal strategies on RYGB leaks

  1. 1. LEAKS IN RYGB
  2. 2. JOSEMBERG CAMPOS, PHDMANOEL GALVAO NETO, MDALMINO C. RAMOS, MD Recife, PE, BrazilSao Paulo, SP, Brazil Sao Paulo, SP, Brazil Recife, PE, Brazil
  3. 3. ALMINO CARDOSO RAMOS MANOELA GALVÃO MANOEL GALVÃO NETO ANDREY CARLO
  4. 4. RYGB LEAKS ENDOSCOPIC APPROACH • Learning objectives • Define RYGB leak • Unveils the RYGB endoscopic anatomy • Understand the place of endoscopy on RYGB leaks • Recognize the possible endoscopic treatments • Identify the role of stents and its principles on RYGB leaks
  5. 5. • Fistula • abnormal communication originating in a visceral structure. • Leak • one type of fistula, is defined as discontinuity of tissue apposition in the immediate postoperative period. • The incidence of RYGB leak • 1.7%–2.6% after open RYGB • 2.1%–5.2% after laparoscopic Morales MP, Miedema BW, Scott JS, et al. Management of postsurgical leaks in the bariatric patient. Gastrointest Endosc Clin N Am 2011;21:295–304.
  6. 6. • Leaks develop when intraluminal pressure exceeds tissue or suture line resistance. • Leaks presenting within the first 2 days postoperatively are often mechanical • Leaks presenting within 5–6 days tends to be ischemic leaks • Risk of leak • impaired healing / infection / diabetes / hypertension / sleep apnea / age >55 years / male gender and prior surgery. Fernandez AZ, DeMaria EJ, Tichansky DS, et al. Experience with over 3000 open and laparoscopic bariatric procedures: multivariate analysis of factors related to leak and resultant mortality. Surg Endosc 2004;18:193–197. Ballesta C, Berindoague R, Cabrera M, et al. Management of anastomotic leaks after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2008;18:623–630. Livingston EH, Huerta S, Arthur D, et al. Male gender is a predictor of morbidity and age a predictor of mortality for patients undergoing gastric bypass surgery. Ann Surg 2002;236: 576–582.
  7. 7. RYGB Leaks can lead to mortality of 6%–14.7%. Lee S, Carmody B, Wolfe L, et al. Effect of location and speed of diagnosis on anastomotic leak outcomes in 3828 gastric bypass cases. J Gastrointest Surg 2007;11:708–713. Carucci LR, Turner MA, Conklin RC, et al. Roux-en-Y gastric bypass surgery for morbid obesity: evaluation of postoperative extraluminal leaks with upper gastrointestinal series.Radiology 2006;238:119–127.
  8. 8. Leaks / Fistulas RNY Gastric Bypass leaks
  9. 9. GASTRO-ENTERO “POUCH” GASTRO-ENTERO RNY Gastric Bypass leaks Gastro-Cutaneous fistula
  10. 10. Gastro-gastric fistula RNY Gastric Bypass leaks
  11. 11. RNY Gastric Bypass leaks Gastro-Bronqueal fistula
  12. 12.  First control the sepsis  Laparoscopy  Percutaneous  Laparotomy  Stabilize the patient RNY Gastric Bypass leaks
  13. 13. RNY Gastric Bypass leaks  Most of them heals up to 30d  Clinical management usually works  Drain / Gastrostomy / NET…  Traditional therapeutic endoscopy  Always dilate first  Don’t waist on clips, glue, mesh…  Stent if it fails….
  14. 14. RNY Gastric Bypass leaks  Endoscopic treatment  Dilation– correct the flow…  RYGB GJ are built to be “stenotic”  < 20mm  So dilate to 20mm first  Measure the results in terms of  Leak flow  Patient general status improvement
  15. 15. Endoscopic balloon dilation RNY Gastric Bypass leaks Dilate first
  16. 16. RYGB Leaks Stents
  17. 17. RNY Gastric Bypass leaks  Endoscopic treatment  Stents  Actual models were design for malignancies  They don’t fit all the design needs for bariatric surgery leaks  New models are coming
  18. 18. Bariatric upper leaks Plastic- Silicon
  19. 19. Implant…
  20. 20. Removal…
  21. 21. Bariatric upper leaks Metallic single covered- Nitinol
  22. 22. Bariatric upper leaks Prosthesis – New models Nitinol double covered…
  23. 23. Type N F/M Bypass Sleeve Prosthesis on site Days Fistula clousure Poliflex® Silicone 15 10F / 5M 13p 2p 45d (21 – 91d) 14p 93% Hanaro/Choo® Nitinol 12 8F / 4M 10p 2p 41d (25 – 86d) 11p 91,6% EndoBarrier® Nitinol / Teflon 2 2F -- 2p 48d (40 and 56d) 2p 100% Bariatric upper leaks Stents – Casuistic up to 2008
  24. 24. Type Dislodgment Significant Reflux Surgical removal Poliflex® Silicone 8p 53,3% 6p 40% 1p Dislodgement 7% Hanaro/Choo® Nitinol 2p 16,6% 4p 33,3% 1p Not able to remove 8% EndoBarrier® Nitinol / Teflon 1p None None Bariatric upper leaks Stents – Casuistic up to 2008
  25. 25. RYGB Leaks Complementary procedures Septomy
  26. 26. Septomy CAUTERY + PNEUMATIC DILATION RESHAPING FISTULA SITE (ZENCKER DIVERTICULUM LIKE)
  27. 27. Septomy CAUTERY + PNEUMATIC DILATION RESHAPING FISTULA SITE (ZENCKER DIVERTICULUM LIKE)
  28. 28. RYGB Leaks Endoscopic treatment can be used even on the worst scenarios
  29. 29. Obes Surg, 2011
  30. 30. Sleeve Gastrectomy - Complications
  31. 31. Thanks! galvaon@gmail.com

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