prevention vs treatment mgb leaks v2

Managing ComplicationsManaging Complications

FIRSTFIRST

Prevent ComplicationsPrevent Complications

Safety & Bariatric Surgery Complacency

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

Examples of ComplacencyComplacencySleeve 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

“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%"

The Mindset of Commitment to Excellence

Make the CommitmentTo your Patient:

“Failure is Not an Option”NO LEAKS

Don’t Manage a Complication?

Prevent, Prevent, Prevent

Complication Managementvs.

Complication Prevention

Better to Prevent a Leak than to be

Expert in Managing a Leak

First:Leaks Much More Likely in

First 100 Cases

Volume PerformanceNew Surgeons = More Complications

Complications Decreasewith Experience

New Surgeons are Dangerous & Deadly Surgeons

Complications decline to logarithm of the surgeons’

Training & Experience

First: Leaks Much More Likely in First 100 Cases

What are the implications?

In the first 100 cases

NO Difficult Cases

Get Help

Eplore Early and Often

Fear a Leak in Everyone

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.

What can we learn from the Airline Industry

Failure is Not an Option

Laparoscopic sleeve gastrectomy for failed laparoscopic adjustable gastric band

800 pts LSG 5.5 % leak & 4.4 % hemorrhageConclusions: “We advocate this

procedure as a good bariatric option (?)

No No No!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

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%

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%

Laparoscopic Mini Gastric Bypass

Cesare Peraglie MD FACS FASCRSCLOS-Florida: Heart of Florida Regional Medical Center.

Davenport, [email protected]

SECO 2012BARCELONA SPAIN

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)

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

NSAIDs should be abandoned in GI anastomoses

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

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)

NSAIDs should 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

MGB/RNY/SG Complications

Short term:

LeakBleedingVenous thrombosisInfections, PneumoniaSBO from abdominal herniaAnastomotic strictureTechnical ErrorsArq 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. [email protected]

Leak Prevention

Leak Location Site:1. EG Junction (Think Sleeve)

Prevention: Simple: AVIOD e.g. Junction!

2. Gastro JejunostomyPrevention: Technical Details of Laparoscopic GI anastomosis(Remember the Basics of General Surgery)

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!

Learning from Sleeve Leak Experience

In 33 of the patients (75-95%), the leaks

near the gastroesophageal

junction

Prevention: Simple:

FEAR the EG Junction!

Anastomotic Leak Prevention

ALWAYS DO A SAFE ANASTOMOSIS

Preop Factors

Intra-op Factors

Post Op Factors

Leak Prevention

ALWAYS DO A SAFE ANASTOMOSIS

No Leak.Cause no persistent bleeding.Cause no stricture of the lumen.Create no risk for internal hernia.

Patient Factors Affect GI Anastomitic Healing

Look for these factors:Correct these factors or REJECT the Patient1. Renal/Cardiac/Pulmonary Dysfunction2. Bacterial contamination3. Inflammation4. Shock & hypoperfusion states5. Diabetes mellitus6. Chronic steroid use7. Poor nutritional status8. Malignancy

PREOP Fundamentals of Gastro-Intestinal Anastomosis Healing

NO NSAIDs, Steroids, Anti-Metabolites (fluorouracil decreased anastomotic breaking strength by more than 40%)

Accurate Fluid Administration

STOP SmokingAdequate Vitamin A levelsAggressive Control of Glucose LevelsEarly feeding liquid protein & caloriesPreop StatinsPreop Creatine SupplementsPreop Exercise (Increase Testosterone, HGH)Supplemental Oxygen in All patients

Fundamentals of Gastro-Intestinal Anastomosis Healing

Adequate local blood supply (Carefully maintain mesentery)

Elimination of tension (Long Pouch,left gutter for bowel. Do Not Divide the Omentum)

Meticulous Hemostasis (avoid damage to staple line)

Gentle & precise handling of tissuesClosure of mesenteric defects (Not in MGB)Close inspectionAccurate Suture Placement (NOT Many Sutures,

3 layers are not better than 1-2)


Adequate local blood supply

Maintain mesentery

Elimination of tension Long PouchLeft gutter for bowel


Meticulous Hemostasis

SLOW Staple Gun Firing

Avoid damage to staple line

Do Not Touch the Staple Line

Gentle & precise handling of tissues


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


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.

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 leakThe common staple height for the small bowel

& colon is 3.5 blue, 3.5 mm For the thicker stomach, green, 4.8 mm


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?

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

Note:NO ONE Recommends 3 or 4

Layer Anastomosis

No Staple Company Recommends Oversewing the

Staple Line

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

Direct Pressure First Aid

Stapler Use

WarningsEnsure 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.

Management Leaks

Simple:In ANY Post Op Patient with ANY

ComplaintsDo: RexploreDo Not: WBC, CXR or other Plain FilmDo Not: CT Scan or Gastrograffin

SwallowThe Only Answer Rexplore

Management Post Op Leaks

1. First Prevent Leaks

2. Categorize:

Early Leaks vs Late Leaks

3. Simple Management Protocol

Leak Management

Leak found 24-48hr= No Diagnostic Tests= Immediate Exploration= Usually Simple Suture Repair

Leak Management

Fear Leak: Suspect a Leak in Every CaseLeak found 24-48hr= No Diagnostic Tests

No WBCNo CAT ScanNo Chest XRayIf patient does not feel well reexplore early

= Immediate ExplorationExpect many negative explorations when you begin

= Usually Simple Suture Repair

Late Leak

Leak Found More than 72 hours

Categorize:

1. Acute peritonitis, sepsis, leak NOT contained

2. Stable patient, not septic, leak contained

Late Leak

Leak Found More than 72 hours

Categorize:

1. Acute peritonitis, sepsis, leak NOT contained

= Take down GJ (1 Staple Firing) 5-10 min

= Gastro-Gastrostomy (5-10 min)

= Get Out (Drain and ABx)

2. Stable patient, not septic, leak contained

= ABx, Drainage and Feeding

Abdominal Abscess Minimal Sx

Drain Percutaneous and Antibiotics

prevention vs treatment mgb leaks v2

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