Outcomes and options in the management of leak and gastric fistula after sleeve gastrectomy.

1

Mercy Bariatrics, Perth Australia

Leon Cohen1

Leak and gastric fistula after sleeve gastrectomy remains one of the most feared and difficultcomplications to deal with after sleeve gastrectomy. The incidence in the published literature ranges
from 2-5% and is increased in revisional surgery.Over the last 6 years we have performed over 850 sleeve
gastrectomies and have had leaks in 24 patients, ( 3% ) in addition there have been 19 infected perigastrichaematomas in which no leak was demonstrated.Management of these patients can be divided into early,middle and late. All patients required early laparoscopic lavage and drainage. Immediate control of leakby oversew or restapling was possible in only two patients .Twenty two patients went on to develop chronic
gastric fistulas with spontaneous resolution in 14. Eight patient have required delayed open gastrectomyor Roux en y internal fistula drainage as a salvage procedure for Chronic leaks. There has been one latedeath in this group during surgery at 6 months post leak. Weight loss in the leak group is comparable
to uncomplicated patients.Use of additional manouveres including stenting, gluing , feeding jejunostomy,
percutaneous drainage, Botox and plugging will be discussed.
Conclusion: Leak after sleeve gastrectomy is a devastating complication that can be difficult to manage.
Using a sequential and logical approach the situation can be successfully managed with resolution ofthe leak and good outcomes.

Superior mesenteric venous thrombosis after revisional open sleeve gastrectomy

1

Toho University Sakura Medical Center, Chiba, JapanTakashi

Oshiro1,Yutaka

Yoshida1,Daisuke

Horibe1,Mitsuru

Oshiro1,Makoto

Nagashima1,Atsuto

Saiki1,Shinichi Okazumi1,Ryouji Kato1,Kohji Shirai1,Isao Kawamura1

A 44 year-old man with morbid obesity (BMI49), hypertension, obstructive sleep apnoea-hypopnea and stasis
phlebitis visited our hospital for revisional bariatric surgery for inadequate weight loss. He had hadvertical banded gastroplasty (VBG) 20 years ago at other hospital. However he regained weight 7 years
after the surgery probably due to staple line disruption and has been lost to follow-up. Preoperative
gastroscopy confirmed staple line breakdown. Open sleeve gastrectomy as revisional surgery was
successfully carried out. The patients underwent thromboprophylaxis using subcutaneous heparin calcium
injection (5000 IU preoperatively, followed by 10000 IU daily postoperatively for 3 days). He developed
fever and vague abdominal pain 14 days after the operation. His C-reactive protein and D-dimer wereelevated to 20.4 mg/dl and 18.8 μ g/ml, respectively. Computed tomography (CT) revealed superior
mesenteric venous thrombosis and mesenteric panniculitis. Intravenous heparin and oral warfarin wereimmediately started. The patient's symptom and laboratory data were improved thereafter. Follow-up CT
showed no further development of thrombosis. He continues on oral warfarin (5mg per day). At three months
after the operation, he achieved 30 kg weight loss and did well. Mesenteric venous thrombosis is a rare
condition that should remain in the differential diagnosis for patients presenting with abdominal pain
after the bariatric surgery. The prompt diagnosis and anticoagulant therapy can produce favorable
outcomes.

Staple line complications during bariatric surgery

1

Department of General Surgery, Singapore General Hospital, Singapore

Shanker Pasupathy1,Wai Keong Wong1

Background:Bariatric surgery is accepted as the most effective treatment for morbidly obese individuals.
In current practice, the majority of procedures are performed by laparoscopy. Hence surgeons are highlydependent on modern laparoscopic instrumentation, in particular endoscopic staplers.Aims:To investigate
the incidence and impact of staple line failures during bariatric surgery.Methods:Retrospective review
of all bariatric surgical procedures performed at the Singapore General Hospital. The use of staplers,and occurrence of intra-operative and post-operative complications related to stapling wasnoted.Results:From January 2003 to November 2010, 70 bariatric procedures were performed: 23 laparoscopic
adjustable gastric bands (AGB) and 47 laparoscopic stapled procedures comprising 37 sleeve gastrectomies(LSG), 9 gastric bypass (LGB) and 1 bilio-pancreatic diversion (BPD). Re-inforcement with buttressmaterials or suture inversion of staple lines was not performed routinely. There were 3 intra-operative
staple line failures (6%) resulting in haemorrhage (1 case) and gaping of the staple line (2 cases).
All 3 failures were rescued by suturing and did not affect the surgical outcome. There were 3
post-operative staple line-related complications (6%) requiring re-operation within 24 - 48 hours. 2patients had haemorrhage from the gastric staple line and 1 patient had an anastomotic leak from ajejuno-jejunostomy (which was preceded by intra-luminal bleeding and bowel obstruction by blood clots).
All staple lines were repaired by suturing during re-operation and the patients did well post-operatively
with no further incidents.Conclusion:Staple line complications are relatively common and may be due toinstrument failures or technical failures by the surgical team. It is essential to thoroughly inspect
all staple lines and have an effective rescue strategy at hand to manage failures before complications
develop.

Drains are not necessary in laparoscopic gastric bypass

1

Surgery Department, Riyadh Military Hospital, Riyadh, Saudi Arabia

Haider Alshurafa1

Objective: To prove that the surgical drains are not necessary in routine laparoscopic gastricbypassMethod: This is a retrospective review for the files of all patients who have underwent
laparoscopic gastric bypass over one year with no surgical drains.Results: There were 104 patients who
have laparoscopic gastric bypass in the period between April 2009 and the end of the July 2010. All thesepatients have primary laparoscopic gastric bypass. They are 78 female and 26 males patients and the age
range between 15 and 62 years with average age of 38.2 years. The BMI range between 34 to 53.8 kg/m2,
the mean is 44kg/m2. All those patients have no surgical drain. There were no mortality, and one patientneeded laparoscopic drainage of infected collection at left sub-phrenic region after 7 days from theoperations. There is one patient needed needle aspiration of left pleural reactive effusion withconservative management of left sub-phrenic small hematoma. No other immediate post operativecomplications.Conclusion: None use of surgical drain post laparoscopic gastric bypass has no major side
effects and surgical drain should only used in selected cases and when there is indications.

Is the long staple line reinforcement needed or not during laparoscopic sleeve gastrectomy?

1

Department of Surgery, Soonchunhyang University School of Medicine

Yong Jin Kim1,Kyung Yul Hur1

Purpose: To evaluate the effect of staple line reinforcement during laparoscopic sleeve gastrectomy(LSG).
Method: Between April 2009 and September 2010, we did LSG for morbidly obese 81 patients. Staple line
reinforcement was not done for early 30 patients(group 1) and was done late 51 patients(group 2). We
compared the outcomes according to bleeding, leak, stricture or obstruction. Result: There were nodifferences in age, sex, preoperative weight and body mass index. Mean operation time was 129
minutes(group 1) & 103minutes(group 2).(p=0.027) Staple line related complication was observed in 3cases(1, leak/2, obstruction due to kinking) only in group 1.(p=0.048) There was no complication in group
2. Re-operation was done in a leak case and there were no in-hospital mortality. Conclusion: Although
there are some limitation for retrospective analysis and learning curve, we conclude that long staple
line reinforcement was effective to prevent staple line related complications.

The safety and advantages of applying clips in sleeve gasterectomy

1

Department of Surgery,King Saud University,King Saud University,Riyadh,Saudi ARABIA

Abdullah Aldohayan1,Fahad Bamehriz2,Mohhamad Alnaami3,Alanezy

Naif4

Since the introduction of sleeve gastrectomy gained widespread popularity. However the complication ofbleeding and leakage may limit its advantage. Leakage and bleeding are usually managed by suturing orother method. We study the efficacy and safety by using the clips on the staple line on 74 patientswith BMI in more 40 over 2 years. The clips were applied on staple gastric line. There was leak or heamatoma
need to be spiraled.More over applying the clips is shorter in time and easier than using suture.The
usage of clips is safe, easy and decrease the bleeding may prevent leakage further extension of work
may prove its metros

Laparoscopic Duodeno-jejunal Bypass with Sleeve: How we do it and management of a possible complication

1

Department of Bariatric and Metabolic Surgery,Gem Hospital and Research Centre,Coimbatore,IndiaPraveen Raj1,Palanivelu Chinnusamy1

Background:A few reports of Laparoscopic Duodenojejunal bypass with Sleeve has demonstrated it as a goodalternative to Roux and Y gastric bypass in weight control and resolution of comorbidities .Such aprocedure

specially important in Asian countries where the incidence of Gastric cancer is high. DJB

with sleeve gastrectomy is proposed as an ideal alternative to RYBG with the stated advantages -1. Presenceof difficult to access gastric remnant in RYGB is at risk of cancer development in high endemic regions.
Endoscopic surveillance is easy in sleeve gastrectomy.2. Preservation of pyloric mechanism prevents
dumping syndrome.3. Reduced alimentary limb tension.With very few reports, the technique of thisprocedure is yet to be standardized.Video:In this High Definition video we demonstrate our techniqueof Laparoscopic Duodeno jejunal bypass with Sleeve, Sleeve being performed 5 cm from the pylorus on a36F bougie, wherein the duodenojejunal anastamosis is done in a retrocolic fashion in end-end hand sewn
method. The biliopancreatic limb length is 75 cms and that of the Roux limb is 100cm, similar to a standard
Roux en Y gastric bypass.In the second part of the video, we show a case of internal herniation in theretrocolic window 1 month post-op in a patient operated with Duodenojejunal bypass and how we managed
the same.