PREVENTIONand

Treatment of Sleeve Gastrectomy Leaks

Dr Rutledge

Sleeve Leak

• Where does it occur?

• ONE PLACE!

Sleeve Leak

• Where does it occur?

• ONE PLACE!

• This is “Tiger Country” – remember that!

Sleeve Leak

Sleeve Leak

• Where does it occur?

• ONE PLACE!

• This is “Tiger Country” – remember that!

Sleeve LeakA Tragedy of Unimaginable Proportions

• Sleeve gastrectomy severe complications: is it always a reasonable surgical option?

• Moszkowicz D, Chevallier JM.• Assistance Publique-Hôpitaux de Paris,

University Paris 5, Paris, France.• Obes Surg. 2013 May;23(5):676-86.

Sleeve LeakSleeve gastrectomy severe complications

• Twenty-two consecutive patients were referred between January 2004 and February 2012 with postoperative gastric leak or stenosis after LSG.

• An endoscopic stent was tried in nine patients but failed in 84.6 % of cases within 20 days (1-161). Seven patients (32 %) necessitated total gastrectomy within 217 days (0-1,915 days) for conservative treatment failure.

Sleeve LeakSleeve gastrectomy severe complications

• Twenty-two consecutive patients were referred between January 2004 and February 2012 with postoperative gastric leak or stenosis after LSG.

• Procedures under general anesthesia were required in 41 % of cases, organ failure was found in 55 % of cases, and central venous device infection in 40 %.

• Mortality rate was 4.5 % (n = 1). Patients with unfavorable evolution of LSG complications (death or additional gastrectomy) had more previous bariatric procedure (82 % vs. 18 %, p = 0.003). Median time to cure was 310 days (9-546 days).

Sleeve LeakSleeve gastrectomy severe complications

• CONCLUSIONS:

• LSG exposes severe complications occurring in patients with benign condition.

• Endoscopic stents entail high failure rate. • Total gastrectomy is required in one third of

the cases.

Managing ComplicationsManaging Complications

FIRSTFIRST Prevent ComplicationsPrevent Complications

Managing Leaks

First Prevent Leaks!!

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

Safety & Bariatric Surgery Fear Complacency

• When surgeons Don’t rigorously adhere to

• Rules/Checklist in managing patients, their team & themselves

Safety & Bariatric Surgery Complacency

• Error: Neglect careful attention

• pre, Intra & post-op management guidelines

• (e.g. Leak Prevention Rules)

Safety & Bariatric Surgery Fear Complacency

• Even worse, • Some surgeons choose to Some surgeons choose to

operate knowing of operate knowing of major problems with major problems with their patient or their team their patient or their team

• (Misunderstand Seriousness of Complications)

Examples of ComplacencyComplacencySleeve Gastrectomy Leak

• “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%"

Imagine an AirlineReleases the following statement:

“Risk of Airplane Crashes are Low at only 2.4%"

The Mindset of Commitment to Excellence

Make the CommitmentTo yourself and to your

Patient:“Failure is Not an Option”

Objectives

Adoption of Mindset to Prevent Complications (Failure is Not & Option)

Fight ComplacencySpecific Techniques to

AVOID complications1. Know your Enemy (List Complications)2. Management of Complications

FIRST:Don’t Manage Complications? Prevent, Prevent, Prevent

Complication Managementvs.

Complication Prevention

Better to Prevent a Leak than to be

Expert in Managing a Leak

What can we learn from the Airline Industry

Failure is Not an Option

Unacceptable Outcomes Revisional Surgery After Failed Or

Complicated Sleeve

Early complication rate 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.

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 % hemorrhageConclusions: “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

Bariatric Surgery Complications

LeakBleedingVenous thrombosis/PEInfections, PneumoniaSBO from abdominal herniaStricture/ObstructionTechnical 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. santomarco@uol.com.br

Leak Prevention

Leak Location:

EG Junction (Think Sleeve)

Prevention: Simple:

AVIOD EG Junction!

Dr Rutledge:Who am I to Criticize or Comment

on the Sleeve

In performing over 6,000 Mini-Gastric Bypasses

I have performed more than 6,000 Sleeves

Every MGB includes both a Sleeve and a bypass

My Opinion: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"

(NO NO NO)

Prevention: Simple:

AVIOD the EG Junction!

Sleeve Experts Counsel Dissection of the EG Junction

Garth Davis Being in a tertiary referral center for Bariatric surgery I have to tell you that avoiding the GE junction is wrong.

If you leave a fundic "dog ear" it will dilate under the ensuing high pressure and lead to long term weight regain.

I have also had patients referred with the dog ear portion herniating into the hiatus.

Sleeve Experts Counsel Dissection of the EG Junction

Counter argument from Garth Davis:

"Being in a tertiary referral center for Bariatric surgery

"I have to tell you that avoiding the GE junction is wrong.

"As was discussed ample times at the ASMBS meeting,

"you need very good dissection of this area.

Sleeve Experts Counsel Dissection of the EG Junction

Garth Davis Being in a tertiary referral center for Bariatric surgery I have to tell you that avoiding the GE junction is wrong.

"Finally, you will miss hiatal hernia if this are is not dissected.

Proper dissection allows division on cardia without encroaching on esophagus so that no dog ear is present.

Leaks don't happen from dissection in this area. (??)

They happen from stapling onto esophagus or attempting to oversew the staple line." (??)

Learning from Sleeve Leak Experience

In 75-95% the leak location near the

gastro-esophageal junction

Prevention: Simple:

FEAR the EG Junction!

Fundamentals of Gastro-Intestinal Healing

Meticulous HemostasisSLOW Staple Gun Firing Avoid damage to staple

lineDo Not Touch the Staple

LineGentle & precise

handling of tissues

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.

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

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 AnastomosesNo Staple Company

Recommends Oversewing the Staple Line

Leak: Prevention/Treatment

Bring in Good Healthy Vascularized Tissue

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

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

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.

Do Not Be ConfusedThere are Two Kinds of Leaks

1. Easy Leaks2. Terrible Disasters

How to tell the difference:Easy = 24 -48 hours

Terrible Disasters = All others

Management LeaksReexplore EARLY

Simple:In ANY Post Op Patient with ANY

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

SwallowThe Only Answer Reexplore

Leak Management

Leak found 24-48hr

= Suture Repair

Leak Found More than 72 hours

= Trouble

Sleeve Leak

• Where does it occur?

• ONE PLACE!

• This is “Tiger Country” – remember that!

Sleeve Leak

• Where does it occur?

• ONE PLACE!

• For this to heal What has to happen?

Prevent LeaksDo Not Become Knowledgeable

in Treating Leaks

Sleeve Leaks

• Early Diagnosis and Treatment

• Ideally re-explore 24-48 hours

• Late Leak

• Stable vs Infected/Septic

• Stable NPO, NG Across the Leak, GI or IV Feeding, ABx, + Drainage

Sleeve Leaks

• Late Leak

• Infected/Septic

• NPO, NG Across the Leak, GI or IV Feeding, ABx, +Drainage

• Consider re-exploration

Sleeve Leaks

• Debride Necrotic Tissue.

• Drain abscess(s)

• Consider:

• Isolated Roux limb as a serosal patch to cover EG junction defect or as a side to side Thal patch

• Enteral Feeding Tube Below Leak

Sleeve Leaks

• The serosal side of jejunum (Thal patch), Bring the Roux limb up to the injured portion of the EG Junction

• A Roux-Y limb of jejunum, with its independent blood supply and normal healthy tissue may help control the leak by bringing in Healthy tissue to the EG Junction area

Use of a Roux limb to correct esophagogastric junction fistulas after sleeve gastrectomy

• Laparoscopic sleeve gastrectomy (LSG) can be complicated, in the early postoperative course, by an esophagogastric junction (EGJ) leak with very serious consequences.

• A 48-year-old woman developed an EGJ leak 3 days after LSG surgery and was treated with conservative measures.

• Finally, 6 weeks after the original surgery, a Roux limb was brought to the EGJ and anastomosed side-to-end to the fistula.

• At the beginning, the Roux limb was the only functioning outlet and finally, 2 months later, both pathways (the gastric sleeve and the Roux-en-Y) are patent at 3 months after surgery.

• The Roux limb resolved a dangerous EGJ leak after a LSG.• Obes Surg. 2007 Oct;17(10):1408-10. Baltasar A, Bou R, The Surgical Service, Virgen de

los Lirios Hospital, Alcoy, Alicante, Spain. a.baltasar@aecirujanos.es

Sleeve Leaks

• Acute conversion of Leaking Sleeve to MGB is not advised

• The theoretical advantage decreasing the back pressure of the pylorus is not necessary when the esophagus, stomach pouch and gut are appropriately drained