Management of Leaks after Gastric Bypass & Sleeves

Chan W. Park, MD, FACS

Assistant Professor of Surgery

Disclosures

• Teleflex – Consultant/Honoraria/Research Grant

• Gore – Honoraria/Educational Grant

• Covidien/Medtronic - Honoraria

• TransEnterix - Consultant

• Foundation for Surgical Fellowships – Educational grant

• Physcient - Consultant

What are the leak rates in the literature?

• Gastric Bypass?

a. 0.7%

b. 1.9%

c. 3.2%

d. 5.8%

What are the leak rates in the literature?

• Gastric Bypass?

a. 0.7%

b. 1.9%

c. 3.2%

d. 5.8%

Zellmer, et al. Is laparoscopic sleeve gastrectomy a lower risk bariatric procedure compared with laparoscopic Roux-en-Y gastric bypass? A meta-analysis. Am J Surg. 2014 Dec;208(6):903-10.

LRYGB

RYGB Leaks

• A delay in diagnosis can lead to:

– Peritonitis

– Sepsis

– Death

Timing to leak diagnosis

1

35

1

12

0 10 20 30 40

Minimumdays to

diagnosis

Maximumdays to

diagnosis

Postoperative days

LRYGB LSG

Zellmer, et al. Is laparoscopic sleeve gastrectomy a lower risk bariatric procedure compared with laparoscopic Roux-en-Y gastric bypass? A meta-analysis. Am J Surg. 2014 Dec;208(6):903-10.

Failure to rescue

• Leak-related mortality

– Gastric bypass: 14.7 – 16.7%1,2

– Sleeve gastrectomy: 4.5 – 9.1%3,4

1. Lee 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.

2. Fernandez AZ, et al. Experience with over 3,000 open and laparoscopic bariatric procedures: multivariate analysis of factors related to leak and resultant mortality. Surg Endosc2004;18:193-7.

3. Parikh et al. Surgical Strategies That May Decrease Leak After Laparoscopic Sleeve Gastrectomy. Ann Surg 2013;257: 231–237.

4. Sakran et al. Gastric leaks after sleeve gastrectomy: a multicenter experience with 2,834 patients. Surg Endosc 2013;27:240–245.

• Review of 100 consecutive bariatric lawsuits by a consortium of bariatric surgeons and an attorney.

• 32% involved an intraoperative complication• Most common adverse events for litigation:

– Leaks (53%)– Intra-abdominal abscess (33%)– Bowel obstruction (18%)– Major airway events (10%)– Organ injury (10%)– Pulmonary embolism (8%)

• Evidence of potential negligence in 28% of cases

Surg Obes Relat Dis 2007;3:60-67.

• In 52 cases, evidence of a leak was found after:– Laparoscopic RYGB (52%) – Open RYGB (30%)– VBG or revisions (18%)

• Average time to diagnosis was 4.9 days (range 0–18)

• The dominant allegation of negligence was a delay in diagnosis (60%)

• Patient outcomes included death (60%), disability (22%), and full recovery (28%)

Surg Obes Relat Dis 2007;3:60-67.

1-800-LAWSUIT

How to deal with Leaks?

How to deal with Leaks?

• Don’t have them!

LRYGB Key Surgical Points

• Avoid excessive tension at anastomoses

• Intraoperative leak test

• Careful attention to orientation/angulation at JJ

• Avoid ischemia at angle of His/between staple lines

Intra-Op Air Leak test

Dx of RYGB Leaks

• Unexplained tachycardia:

– Leak until proven otherwise

• Pain out of proportion

• Hypotension

• Fever

• WBC elevation/labs

RESUSCITATE!!!

• UGI/CT

• CT scan might be useful to detect post-operative leaks in some patients, but important limitations exist in its accuracy

• Surgical re-exploration is an acceptable strategy to diagnose and treat patients highly suspected of postoperative leak

• Negative surgical re-exploration should be considered an appropriate and indicated intervention and not a complication.

Update

ASMBS guideline on the prevention and detection of gastrointestinal

leak after gastric bypass including the role of

imaging and surgical exploration

The ASMBS Clinical Issues CommitteeReceived January 31, 2009; accepted February 4, 2009

Abstract The following position statement is issued by the American Society for Metabolic and Bariatric

Surgery in response to numerous inquiries made to the Society by patients, physicians, society

members, hospitals, health insurance payors, the media, and others, regarding the complication of

gastrointestinal leak after gastrointestinal bariatric procedures. In this statement, available data

regarding leak are summarized and suggestions made regarding reasonable approaches to the

prevention and postoperative detection based on current knowledge, expert opinion, and published

peer-reviewed scientific evidence available at this time. The intent of issuing such a statement is to

provide objective information about the complication of leak. The statement is not intended as, and

should not be construed as, stating or establishing a local, regional, or national standard of care. The

statement will be revised in the future as additional evidence becomes available. (Surg Obes Relat

Dis 2009;5:293–296.) © 2009 American Society for Metabolic and Bariatric Surgery. All rights

reserved.

Gastrointestinal leak after gastric bypass is a known

complication with a reported incidence of 1–5% in large

case series of open and laparoscopic gastric bypass [1–10].

A leak can result in clinically important morbidity and

mortality. Once signs and symptoms develop, prompt diag-

nosis and treatment of a leak can minimize the inflammatory

and septic sequelae, although evidence also suggests that the

immunoreactivity of the host determines the endogenous

inflammatory responsiveness to a greater extent than the

timing of treatment [11].

The purpose of this position statement is to provide an

evidence-based guideline regarding the prevention and de-

tection of gastrointestinal (GI) leak after gastric bypass. The

use of imaging techniques and surgical re-exploration in the

context of routine postoperative surveillance and suspected

postoperative gastrointestinal leak is reviewed.

Prevention of GI leak

The vast majority of GI leaks likely occur in the absence

of a technical error that could have been recognized at the

initial procedure. Supporting this conclusion is the observa-

tion that leaks are reported to occur at some level of fre-

quency in all reported large series of gastric bypass. Nu-

merous intraoperative techniques have been suggested to

decrease the incidence of leak, including, but not limited to,

oversewing staple lines, using agents that reinforce the sta-

ple lines [12,13], using fibrin glue or other tissue sealants

[14–16], and so forth. No high-quality clinical evidence

exists to suggest that such interventions have been able to

eliminate or substantially decrease the incidence of leaks as

a complication of gastric bypass. Intraoperative leak assess-

ment using endoscopy and/or distension of the anastomosis

with dye, air, or other gas might be useful to detect leaks

that can be repaired during the procedure, but these tech-

niques have not been shown to decrease the risk of leak after

surgery. Although some surgeons have advocated routine

placement of drains in proximity to the gastrojejunal anas-

tomosis to better diagnose and/or control leakage from this

site during the postoperative period [17,18], others have

Reprint requests: Eric J. DeMaria, MD, Chair, ASMBS Clinical Issues

Committee, American Society for Metabolic and Bariatric Surgery, 100

Southwest 75th Street, Suite 201, Gainesville, FL 32607.

E-mail: eric.demaria@duke.edu

Surgery for Obesity and Related Diseases 5 (2009) 293–296

1550-7289/09/$ – see front matter © 2009 American Society for Metabolic and Bariatric Surgery. All rights reserved.

doi:10.1016/j.soard.2009.02.002

Re-exploration for Leak

• Laparoscopic vs. open

– Directed Drainage/Abdominal washout

– Repair/patch

– Gastrostomy tube in excluded stomach

• Allows for enteral feeding

• Prevents need for hyperalimentation

• May prevent staple line dehiscence of excluded stomach due to postoperative ileus

• Intra-op Endoscopy

Management of leaks - LRYGBGastrojejunal anastomotic leak

identified radiographically

NoYes

Stable

Re-explore

NPOIV Antibiotics

Hyperalimentation

Percutaneous Drainage and/or

Re-explore

NoYes

Drained Re-explore

Contained leak

NoYes

Kothari SN. Bariatric surgery and postoperative imaging. Surg ClinNorth Am. 2011;91:155-72.

GJ Leak

Angle of His, “dog ear”

Endoscopic Tx

• Stable patient

• Multiple options

– Apollo® Overstitch

– Endoscopic clipping

– Stent

• Maintain future options

Stent migration

Remnant Stomach LeakCauses:• Ischemia• JJ obstruction• Ileus

Dx:• Dilation of BP /

Remnant

Tx:• G-tube• Fix underlying

issue

• Incidence:– <1%

• Causes:– Jejunojejunal obstruction– Bleeding at anastomosis

• Symptoms:– Emesis of small amounts of

food– Fullness in LUQ

• Dx:– AXR– CT scan abd/pelvis + po

contrast

• Treatment– Return to OR for laparoscopic

revision of anastomosis

Jejunojenunal obstruction

Marginal Ulcer perforationCauses:

• Ischemia

• Permanent sutures/Foreign body

• NSAIDs

• Smoking

Tx:

• Acute vs. Chronic

• Re-exploration / EGD

Routine Drains?

Routine placement of drains in proximity to gastrojejunal anastomosis

• Serve two major purposes: – early detection – conversion of a leak into a controlled fistula to avoid major

interventional procedures.

• Routine use of drains– increases postoperative morbidity – Increases cost– increases length of stay – may erode into the GJ anastomosis – misses leaks at the JJ or other small bowel sites

• Additional imaging may be necessary in for management of leaks in clinically stable patients.

Kavuturu et al. Obes Surg (2012) 22:177-181

• Our series confirms that drains add little or nothing to the evaluation or management of postgastric bypass leaks.

• The majority of which can be diagnosed based on clinical signs.

• The placement of drains does not decrease imaging studies or surgery

• In addition, routinely placed operative drains can have deleterious effects.

Bariatric Times Dec 2012

Conclusions

• RYGB leaks are rare

• RYGB leaks cause significant morbidity/mortality

• Early detection/management is key

• Avoid tension/ischemia/angulation at anastomoses during RYGB

• Endoscopes & G-tubes can be helpful

• Don’t forget about distal obstructions