Management of anastomotic leaks after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Anastomotic leaks after bariatric surgery carry high morbidity and mortality. We aimed to describe our experience of the diagnosis and management of gastrointestinal anastomotic leaks in patients undergoing laparoscopic gastric bypass in a single institution. METHODS: Of 1,200 patients who underwent laparoscopic Roux-en-Y gastric bypass with manual gastrojejunal anastomosis for morbid obesity from January 2002 to January 2007, we retrospectively analyzed 59 patients with anastomotic leak. The location of the leak, day of diagnosis, diagnostic methods, clinical manifestations, treatment modalities, associated complications, and length of hospital stay were analyzed. RESULTS: Leaks were located as follows: 67.8% in the gastrojejunostomy, 10.2% in the gastric pouch, 3.4% in the excluded stomach, 5.1% in the jejunojejunal anastomosis, 3.4% in the gastrojejunostomy plus pouch, 3.4% in the pouch plus excluded stomach, and 6.8% in undetermined sites. Routine upper gastrointestinal series revealed contrast extravasation in nine patients (15.3%). Leaks were asymptomatic at diagnosis in 29 patients (49.2%). Surgical reintervention was carried out in 23 patients, and conservative treatment was provided in the remaining 36. Transfer to the intensive care unit was required in 11 patients, with five deaths (0.4%). CONCLUSION: In our experience, most anastomotic leaks can be managed with conservative measures alone. In many patients, abdominal drains are effective in the management of leaks, obviating the need for reintervention. Nasoenteral nutrition was effective in the non-operative management of gastrojejunal leaks in patients without signs of systemic toxicity.

Adjustable totally implantable intragastric prosthesis (ATIIP)-Endogast for treatment of morbid obesity: one-year follow-up of a multicenter prospective clinical survey.

BACKGROUND: The Adjustable Totally Implantable Intragastric Prosthesis (ATIIP)-Endogas is a new mini-invasive technique for the treatment of morbid obesity. The ATIIP is conducted using a surgical and endoscopic procedure. The permanent presence of an air-inflated prosthesis inside the gastric corpus-fundus area and the fixation of the stomach to the abdominal wall are the two main principles in the technique. The prosthesis is connected to a subcutaneous totally implantable system. The aim of the ATIIP is to induce early satiety and reduction of meal intake. This study presents the preliminary results of 1-year follow-up of a multicenter prospective clinical survey. METHODS: From November 2004 to March 2007, 57 patients underwent ATIIP: 28 males (49%) and 29 females (51%), with mean age 43.6 years (18-69) and mean BMI 48.9 (33.7-81.2). Follow-up was 1-28 months. RESULTS: Feasibility was 100%, reproducibility 100%, and acceptability found no vomitting. Mean volume of the prosthesis was 210 ml of air (first 3 months, 40 patients). Mean %EWL was 22.3% (3 mos, 40 pts), 28.7% (6 mos, 38 pts), and 39.2% (12 mos, 20 pts). Early postoperative complication was local subcutaneous infection in 7 pts (12.2%). In 16 pts who had a subcutaneous drain and empirical antibiotic therapy until the 4th postoperative day, local infection occurred in 1 patient (6.2%). Late postoperative complications occurred in 3 pts (5.2%) who developed port erosion. CONCLUSIONS: Preliminary results indicate that the ATIIP is feasible, reproducible, safe with low risk of complications and has encouraging results in weight loss. Morbidly obese patients >60 years old and the super-obese (BMI>50) are specific indications.