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157J. M. Kellum / Surgery for Obesity and Related Diseases 4 (2008) 152–158

15] Hamilton EC, Sims TL, Hamilton TT, Mullican DB, Jones DB,Provost DA. Clinical predictors of leak after laparoscopic gastricbypass for morbid obesity. Surg Endosc 2003;17:679 – 84.

16] Flancbaum L, Belsley S. Factors affecting morbidity and mortality of

response tha

ervatively were of the “contained” variety, no analysis

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1,000 consecutive open cases by a single surgeon. J Gastrointest Surg2007;11:500–7.

17] Cottam DR, Mattar SG, Barinas-Mitchell E, et al. The chronic inflam-matory hypothesis for the morbidity associated with morbid obesity:

Roux-en-Y gastric bypass for clinically severe obesity: an analysis of implications and effects of weight loss. Obes Surg 2004;14:589–600.

Editorial comment

Comments on: Anastomotic leaks after bariatric surgery: it is the host

t matters

In this issue of the Journal, Al-Sabah et al. [1] fromcGill University report a retrospective analysis of 55

eaks in 2384 bariatric surgery patients during a 23-yeareriod. Nearly 80% of the operations and �90% of theeaks involved either open or laparoscopic Roux-en-Yastric bypass. Their analysis implies that none of theeaks discovered by routine postoperative upper gastro-ntestinal contrast radiographic series (UGIS), generallyone within 72 hours of surgery, resulted in the systemicnflammatory response syndrome (SIRS). However, allhe leaks in the 6 patients who died in the series (.25%)ere discovered by the onset of SIRS. Many of theatients with SIRS presented before the discontinuationf the practice of routine UGIS in 2003. The authors areo be congratulated for maintaining such rigorous fol-ow-up for an extended period and achieving excellentlinical results. Many other centers, including our own,hich perform a high volume of bariatric surgery, haveiscarded routine UGIS because of their low yield, highost/benefit ratio, patient discomfort, and the tendency torolong the hospital stay. The latter is true because thending of a “contained” leak or slow emptying zone in

he proximal gastric pouch (the so-called plication de-ect) often leads to a delay in hospital discharge. The ideahat most of the mortality associated with leaks resultsrom the host response to peritoneal contamination,ather than the contamination itself, is an interestingoncept that deserves additional study.

Nevertheless, the authors’ central hypothesis in thistudy appears flawed. Although the radiographic leaksere diagnosed much earlier than the leaks in thoseresenting with SIRS, the authors concluded that theyere inherently different responses to peritoneal contam-

nation. They do not consider the possibility that SIRSas a result of persistent, untreated peritoneal contami-ation. We do not know what the indications for reop-ration were for the radiographically discovered leaks. Its possible that early reoperation with repair and drainageircumvented the appearance of SIRS. Although it isossible, even likely, that most of the leaks treated con-

f the types of leaks discovered by radiologic imaging isffered. The median interval of diagnosis for those pa-ients whose leaks presented as SIRS was 5 days com-ared with only 1.5 days for those discovered by imagingtudies. Univariate analysis found that fever, increasedeart rate, and leukocyte count on the day of discovery,s well as body mass index, were predictive of mortality.nly the patient’s temperature on the day of discovery

nd body mass index were independently predictive ofortality on logistic regression multivariate analysis.uch an analysis is suspect, because only 6 patients died.ur own experience suggests that leaks more oftenresent clinically much earlier than 5 days. The mortalityn our own series of 2011 patients was independentlyredicted by the preoperative weight and the presence ofypertension or postoperative leak or pulmonary embo-ism [2]. Since January 2005, we have generally usedersistent tachycardia, fever, atypical pain, any signs ofrgan failure, or an amylase level measured from a juxta-nastomotic drain of �400 IU as an indication for emer-ency UGIS [3]. In some cases, the clinical signs, despiteGIS findings negative for leak, require exploratory

aparoscopy or laparotomy. We too have observed pa-ients who presented in the early postoperative periodith signs of SIRS and who, despite prompt re-explora-

ion, repair, and drainage, went on to die of multisystemrgan failure. However, this anecdotal evidence does notustify a fatalistic approach to the postoperative care ofastric bypass patients. A high degree of vigilance shouldim at making the earliest possible diagnosis of a leak.l-Sabah et al. [1] do not appear to see a role for imaging

tudies, even in the confirmation of a suspected leak. It isy opinion that radiologic localization of a leak is valu-

ble to the surgeon performing re-exploration in a patienthose anatomy has been distorted by the postoperative

nflammatory changes. Certainly, a better conclusionrom the McGill report would have been that an emer-ency radiographic imaging study, possibly followed bye-exploration, is indicated as early as possible for atyp-cal pain, persistent tachycardia, fever, leukocytosis, or

igns of organ failure.

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158 J. M. Kellum / Surgery for Obesity and Related Diseases 4 (2008) 152–158

isclosures

The author has no commercial associations that might beconflict of interest in relation to this article.

John M. Kellum, M.D.Department of Surgery

Virginia Commonwealth University School of Medicine

Richmond, Virginia

eferences

1] Al-Sabah S, Ladouceur M, Christou N, Al-Sabah SK. Anastomoticleaks after bariatric surgery: it is the host response that matters. SurgObes Relat Dis 2008;4:152–7.

2] Fernandez A, DeMaria E, Tichansky D, et al. Multivariate analysis ofrisk factors for death following gastric bypass for treatment of morbidobesity. Ann Surg 2004;239:698–703.

3] Maher J, Martin Hawver L, et al. Four-hundred and fifty consecutivelaparoscopic Roux-en-Y gastric bypasses with no mortality and declin-ing leak rates and lengths of stay in a bariatric training program. J Am

Coll Surg 2008. In press.