Complications of postlaparoscopic sleeve gastric resection: review of surgical technique.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has become a very frequent procedure in bariatric surgery. Despite its simplicity, it can have serious complications. Among these, gastric leak is one of the most feared complications. Numerous intraoperative maneuvers have been suggested in an attempt to decrease the incidence of leak. In our center, we decided to study one of the intraoperative measures proposed, which consists in positioning the suture machine to 1.5 cm from His corner. METHODS: This retrospective study reported 101 cases of LSG performed in our center from 2012 to 2017. The patients were divided into two groups, with comparable anthropometric parameters and comparable inclusion criteria. In the two groups the operative technique used was the same, except for a maneuver: in the second group, attention was paid to keep a distance from the angle of at least 1.5 cm. RESULTS: On a total of 101 procedures performed, the overall complication rate was 4,95%. In group 1 the rate of gastric staple line leak was 6.78%. In group 2 the rate was 2.38%. CONCLUSIONS: The analyzed surgical technique seems to decrease the risk of leak without significantly impacting weight loss, and we have noticed in our clinical experience a decrease in the incidence of fistula from the time this measure was adopted. Also the statistical analysis encourage the continuation of experimentation.

Gastropancreatic ligament: Description, incidence, and involvement during laparoscopic sleeve gastrectomy.

During laparoscopic sleeve gastrectomy (LSG), adhesions between the stomach and the pancreas are sometimes found, forming a "gastropancreatic ligament" (GPL). However, the GPL has only been described once in the literature, in 1985. The objective of this study was to determine the incidence of the GPL during LSG, describe this structure and assess its effect on the surgical technique. All patients undergoing primary LSG in our institution (n = 240) and patients referred for gastric fistula (GF) after primary LSG (n = 18) between January 2015 and December 2015 were included. The primary endpoint was the incidence of a GPL during primary LSG. The secondary endpoints were the postoperative complication rate, the postoperative GF rate, and the presence of this ligament during reoperation for GF. Among the 240 patients, a GPL was visible in 49 cases (20.4%) and was described as thin in 34 of these (69.4%). Twelve postoperative complications (5%) were observed, including seven major (2.9%). The GF rate was 2% (n = 5), not requiring reoperation. The gastric stenosis rate was 0.4% (n = 1). The GPL had been previously sectioned in one of the five patients (20%) with postoperative GF. During the study period, 18 patients were referred for GF and 14 were reoperated. A non-sectioned GPL, not described in the operating report, was observed in four patients (28.5%). A GPL was identified in 20.4% of cases. Identification of a GPL could be important in the context of LSG, as section of the ligament allows tension-free stapling to be performed and can therefore possibly reduce the risk of postoperative complications, particularly GF. Clin. Anat. 30:336-341, 2017. © 2017 Wiley Periodicals, Inc.

Digestive Decompression to Prevent Digestive Fistulas After Gastric Neoplasm Resection.

Introduction: The risk of digestive fistula in patients operated for gastric neoplasm is increased due to biological imbalances generated by the cancer's progression, by diagnosis in advanced stages, and by the scale of intervention. Under these circumstances the use of some technical means to protect digestive sutures in these patients is useful. AIM: To analyse the efficiency of technical means to protect the digestive sutures in patients operated in various stages of development of gastric cancer. Material and Methods: We conducted a retrospective study on a group of 130 patients operated for gastric cancer in the 1st General Surgery and Oncology Clinic of the Bucharest Institute of Oncology, between 2010-2014. Results: 38.46% of the patients in the study group presented stage IV cancer with multiple complications and biological imbalances. 52 total gastrectomies and 40 gastric resections were carried out, while in 34 patients palliative "tumour excisions" or other types of palliative surgery were performed. In 15 of the cases with gastric resection a duodenal decompression probe was used, while in 13 of the patients with total gastrectomy an oeso-jejunal aspiration probe together with an oeso-jejunal feeding probe were used as additional technical measures to prevent fistula formation. The incidence of duodenal stump fistula was 7.69%, that of oeso-jejunal anastomosis fistula was 2.3%, with an overall mortality of 3.07% and that of gastro-jejunal anastomosis fistula was 0.76%. CONCLUSION: Given the risk of fistula development in patients with gastric cancer, as well as the increased risk in advanced stages of cancer development, we consider that the use of technical means of protection of digestive sutures is beneficial and opportune, lowering the incidence of fistulas, reducing their output, pathophysiological effects, and mortality.

[Clinical characteristics of patients with a double pylori]. / Klinicke karakteristike bolesnika s dvostrukim pilorusom.

Double pylorus (DP), is a form of gastroduodenal fistula, which consists of a short accessory canal from the gastic antrum to the duodenal bulb, and mostly occrus in the background of peptic ulcer disease. Prevalence, as well long-term follow-up of patients with DP is less elucidated in western countries. Aim of our study was to analyse demografic, clinical and endoscopic characteristics in our case-series. During 2008-2013. a total of 23836 upper endoscopies were performed in 16759 patients. DP was diagnosed in 6 patients (prevalence of 0.04%). The follow-up period was f 8 to 72 months. In 87% DP was a complication of the upper gastrointestinal bleeding. In 83% cases opening of the fistula was on lesser curvature of gastric antrumu. During follow-up period the fistula healing did not occur in any of our patients. DP is a very rare entity, with a benign course of the disease Associated comorbidity and use of ulceriform medications plays important role in persistence of DP, wheras possible eradication of Helicobacter infection in this background remains elusive.

Does somatostatin-14 have an impact on gastric fistula after laparoscopic sleeve gastrectomy?

The main complications following laparoscopic sleeve gastrectomy (LSG) is gastric fistula (GF). Gastric fistula is a rare but serious complication (affecting 2 % of LSGs). Somatostatin-14 and its analogs are mainly used in the prevention and curative treatment of digestive fistulas. These compounds inhibit secretions in the pancreas, stomach, and small intestine. Treatment with somatostatin-14 increases the spontaneous closure rate and reduces the closure time of postoperative digestive fistulas. However, the impact of somatostatin-14 on GF after LSG has not been studied. We report on a prospective, non-randomized, single-center, case-matched study of patients receiving somatostatin-14 after a post-LSG GF was discovered. Our results suggest that use of somatostatin-14 is associated with a shorter length of hospital stay and (perhaps) a shorter treatment period.

Cure and prevention strategy for postoperative gastrointestinal fistula after esophageal and gastric cardiac cancer surgery.

Gastrointestinal fistula is the most serious complication of esophageal and gastric cardiac cancer surgery. According to occurrence of organ, gastrointestinal fistula can be divided into anastomotic fistula, gastric fistula; According to occurrence site, fistula can be divided into cervical fistula, thoracic fistula; According to time of occurrence, can be divided into early, middle and late fistula. There are special types of fistula including 'thoracic cavity'-stomach-bronchial fistula, 'thoracic cavity'-stomach-aortic fistula. Early diagnosis needs familiarity with various types of clinical gastrointestinal fistulas. However, Prevention of gastrointestinal fistula is better than cure, including perioperative nutritional support, respiratory tract management, and acid suppression, positive treatment of complications, antibiotic prophylaxis, and gastrointestinal decompression and eating timing. Prevention can effectively reduce the incidence of postoperative gastrointestinal fistula. Collectively, early diagnosis and treatment, nutritional supports are key to reducing mortality of gastrointestinal fistula.

Hepatogastric fistula: a rare complication of pyogenic liver abscess.

Hepatogastric fistula is very rare. We report a case of hepatogastric fistula as a complication of pyogenic liver abscess. A 40-year-old man presented with upper abdominal pain and high-grade fever of 2 weeks. Evaluation revealed multiple liver abscesses. On an empirical diagnosis of pyogenic liver abscess, he was treated with antibiotics. During hospital stay he developed intermittent large quantity bilious vomiting. Gastroduodenoscopy and contrast-enhanced CT of the abdomen showed rupture of left lobe liver abscess into the stomach. As expectant management failed to resolve the abscess, endoscopic retrograde papillotomy and stenting of common bile duct was performed. After endoscopic stenting, symptoms subsided. Imaging repeated after 2 weeks of endoscopic stenting showed resolving abscess. He was discharged and is doing well on regular follow-ups. We conclude that hepatogastric fistula can be managed by endoscopic stenting as bile flow through the stent hastens resolution and healing of the fistula.

Preventing staple-line leak in sleeve gastrectomy: reinforcement with bovine pericardium vs. oversewing.

One of the most serious, potentially life-threatening complications of laparoscopic sleeve gastrectomy (LSG) is staple-line leakage. Oversewing the LSG staple line vs buttressing it with bovine pericardial strips (BPS) to reduce perioperative bleeding and postoperative gastric leak was evaluated. From 2006 through 2011, 160 patients underwent LSG with suturing as the only staple-line reinforcement (Group A). From March 2010 through August 2012, 84 LSG patients had BPS incorporated into their last two stapler firings (Group B). Staple lines were evaluated perioperatively for bleeding, and patients were monitored for indications of staple-line leaks (peritonitis, abnormal output from the drain). In preoperative Group A and B, there were 117 (73.1%) vs. 56 (66.7%) females; mean age, 35.2 years (18.0-68.0) vs. 33.8 years (15.0-64.0); mean body mass index (BMI, kilograms per square meter), 42.5 (27.0-76.0) vs. 42.0 (30.0-58.0). Three months after surgery, mean BMI for Group A was 37.3 (-5.9); Group B, 35.2 (-7.3); at 6 months, 32.7 (-10.8) and 31.5 (-11.3; p < 0.001). Although there was no significant difference in perioperative blood loss, oversewn staple lines in Group A often required electrocautery to stanch bleeding; this was not required for Group B. In Group A, 15 patients (9.4%) developed complications; in Group B, five (6.0%; p = 0.46). Gastric fistula, verified by barium swallow, occurred in eight Group A patients (5.0%); in Group B, one (1.2%; p = 0.17). Relative to oversewing, staple-line buttressing with bovine pericardium was readily accomplished, safe, and associated with a lower staple-line leak rate.

Gastrobronchial fistula after sleeve gastrectomy and gastric bypass: endoscopic management and prevention.

Gastrobronchial fistula (GBF) is a serious complication following bariatric surgery, whose treatment by thoracotomy and/or laparotomy involves a high morbidity rate. We present the outcomes of endoscopic management for GBF as a helpful technique for its healing process. This is a multicenter retrospective study of 15 patients who underwent gastric bypass (n = 10) and sleeve gastrectomy (n = 5) and presented GBF postoperatively (mean of 6.7 months). Ten patients developed lung abscess and were treated by antibiotic therapy (n = 10) and thoracotomy (n = 3). Abdominal reoperation was performed in nine patients for abscess drainage (n = 9) and/or ring removal (n = 4) and/or nutritional access (n = 6). The source of the GBF was at the angle of His (n = 14). Furthermore, 14 patients presented a narrowing of the gastric pouch treated by 20 or 30 mm aggressive balloon dilation (n = 11), stricturotomy or septoplasty (n = 10) and/or stent (n = 7). Fibrin glue was used in one patient. We performed, on average, 4.5 endoscopic sessions per patient. Endotherapy led to a 93.3% (14 out of 15) success rate in GBF closure with an average healing time of 4.4 months (range, 1-10 months), being shorter in the stent group (2.5 × 9.5 months). There was no recurrence during the average 27.3-month follow-up. A patient persisted with GBF, despite the fibrin glue application, and decided to discontinue it. GBF is a highly morbid complication, which usually arises late in the postoperative period. Endotherapy through different strategies is a highly effective therapeutic option and should be implemented early in order to shorten leakage healing time.

Use of staple-line reinforcement in laparoscopic gastric bypass surgery: a meta-analysis.

OBJECTIVE: This article was designed to systematically analyze the prospective, randomized, controlled trials on the effectiveness of staple-line reinforcement (SLR) in patients undergoing laparoscopic gastric bypass (LGBP) surgery. METHODS: Trials on the effectiveness of SLR in patients undergoing LGBP surgery were selected electronic data bases and analyzed to generate summative data by using the principles of meta-analysis on statistical software package RevMan 5.0.2 provided by Cochrane Collaboration. Combined outcome of the binary variables was expressed as odds ratio (OR) and continuous variables were expressed as standardized mean difference (SMD). RESULTS: Three randomized, controlled trails on 180 patients qualified for inclusion. There were 91 patients in SLR group and 89 patients in non-staple-line reinforcement (NSLR) group. There was no heterogeneity among trials. In the fixed-effects model, SLR is equivalent to NSLR in terms of controlling bleeding (odds ratio (OR), 0.32; 95% confidence interval (CI), 0.03, 3.18; z = 0.98; P < 0.33) from the staple-line and total number of staples used (standardized mean difference (SMD), -21.01; 95% CI, -56.46, 14.44; z = 1.16; P < 0.25) for anastomosis. SLR significantly reduces operative time (SMD, -0.76; 95% CI, -1.36, -0.16; z = 2.47; P < 0.01), perioperative complications (OR, 0.19; 95% CI, 0.05, 0.68; z = 2.55; P < 0.01), anastomotic leak (OR, 0.1; 95% CI, 0.01, 0.78; z = 2.2; P < 0.03), and hemostatic clips (SMD, -21.01; 95% CI, -56.46, 14.44; z = 1.16; P < 0.25) usage. CONCLUSIONS: SLR seems to reduce the operative time in LGBP. In addition, SLR is associated with fewer postoperative complications, reduced incidence of anastomotic leak, and reduced requirement of hemostatic clips to control hemorrhage at the staple line. However, SLR does not have any superiority in terms of controlling staple-line bleeding and does not influence the number of staples used in LGBP.

Esophagogastric anastomosis with invagination into stomach: New technique to reduce fistula formation.

AIM: To present a new technique of cervical esophagogastric anastomosis to reduce the frequency of fistula formation. METHODS: A group of 31 patients with thoracic and abdominal esophageal cancer underwent cervical esophagogastric anastomosis with invagination of the proximal esophageal stump into the stomach tube. In the region elected for anastomosis, a transverse myotomy of the esophagus was carried out around the entire circumference of the esophagus. Afterwards, a 4-cm long segment of esophagus was invaginated into the stomach and anastomosed to the anterior and the posterior walls. RESULTS: Postoperative minor complications occurred in 22 (70.9%) patients. Four (12.9%) patients had serious complications that led to death. The discharge of saliva was at a lower region, while attempting to leave the anastomosis site out of the alimentary transit. Three (9.7%) patients had fistula at the esophagogastric anastomosis, with minimal leakage of air or saliva and with mild clinical repercussions. No patients had esophagogastric fistula with intense saliva leakage from either the cervical incision or the thoracic drain. Fibrotic stenosis of anastomoses occurred in seven (22.6%) patients. All these patients obtained relief from their dysphagia with endoscopic dilatation of the anastomosis. CONCLUSION: Cervical esophagogastric anastomosis with invagination of the proximal esophageal stump into the stomach tube presented a low rate of esophagogastric fistula with mild clinical repercussions.

Gastrostomy complications in infants and children: a comparative study.

PURPOSE: Gastrostomy is a commonly undertaken procedure in children. Methods for gastrostomy insertion have evolved and laparoscopy is commonly used to aid its insertion. The aim of this study is to review the outcome and complications of laparoscopic-assisted gastrostomy insertion. METHODS: A retrospective case note review of children undergoing gastrostomy insertion by a single surgeon from 1999 to 2007. RESULTS: 114 children underwent gastrostomy insertion, 68 males and 46 females, with a median age of 55 months (IQR 28-149 months). The majority were neurologically impaired. 98 underwent laparoscopic-assisted PEG (86%), 1 was converted to open procedure (0.9%) and 16 had standard PEG (14%). Median follow-up was 10.5 months with 90 children having their original gastrostomy changed to a button at a median interval of 7.4 months. Complications observed included new or deteriorating gastro-oesophageal reflux (GOR) (n = 16), infection (n = 9), granulation tissue (n = 11), tube dislodgement (n = 2) and intra-abdominal leakage of feed (n = 2). There were two gastrocolic fistulae which occurred in the standard PEG group. CONCLUSION: The inadvertent formation of a gastrocolic fistula was avoided with the use of laparoscopy to aid PEG insertion.

Gastro-gastric fistula in the era of divided Roux-en-Y gastric bypass: strategies for prevention, diagnosis, and management.

Roux-en-Y gastric bypass (RYGBP) is a mainstay of bariatric surgical therapy. Gastro-gastric fistula (GGF) is an infrequent but potentially serious complication of gastric bypass, and diagnosis may be difficult. We report two patients who underwent RYGBP complicated by development of GGF who nevertheless achieved excellent, durable weight loss. The pathogenesis, diagnosis, prevention and management of GGF after RYGBP is reviewed. GGF may not result in poor weight loss after RYGBP and is not an absolute indication for surgical revision.

Abdominal closure using nonabsorbable mesh after massive resuscitation prevents abdominal compartment syndrome and gastrointestinal fistula.

Patients who receive high-volume resuscitation after massive abdominopelvic trauma, or emergent repair of a ruptured abdominal aortic aneurysm (RAAA), are at a significant risk for postoperative abdominal compartment syndrome (ACS). Absorbable prosthetic closure of the abdominal wall has been recommended as a means of managing ACS. However, use of absorbable prosthetic has been associated with very high rates of intestinal fistula formation and ventral hernia formation. The purpose of this study was to retrospectively review our experience with the use of nonabsorbable prosthetic abdominal closures in patients with documented ACS or at high risk for ACS. All patients managed by this technique from July 1995 through July 1997 after repair of ruptured abdominal aortic aneurysm or massive abdominopelvic trauma were evaluated. A total of 18 patients were identified: 15 primary prosthetic placements (Gore-Tex patch, 12; Marlex mesh, 2; and silastic mesh, 1) and 3 delayed prosthetic placements for ACS (Gore-Tex, 1 and Marlex, 2). The mortality rate was 22 percent (4 of 18) and resulted from multisystem organ failure (2 patients), cardiac arrest 1 hour postoperatively (1 patient), and severe closed head injury (1 patient). Secondary closure and prosthetic removal was possible in 16 of 18 patients, including the 2 patients who died of multisystem organ failure within the same hospitalization. Delayed abdominal closure at a subsequent admission was performed in two cases. This same patient developed an enterocutaneous fistula 2 months after discharge. Importantly, only 1 of 18 closed in this manner developed ACS requiring reoperation. The results indicate that use of a nonabsorbable prosthetic, particularly with Gore-Tex, is efficacious in the prevention of postoperative ACS in high-risk patients, while it enhances the possibility for delayed abdominal closure and minimizes the risk of gastrointestinal fistulization associated with other techniques.

Evaluation of residual vascularisation in oesophageal substitution gastroplasty by surface oximetry-capnography and photoplethysmography. An experimental study.

OBJECTIVE: To evaluate residual vascularisation in gastroplasty and its possible relation to the development of anastomotic fistulas or dehiscences after oesophageal resection. DESIGN: Experimental open study. MATERIAL: Eleven mongrel dogs. INTERVENTIONS: Gastric parietal blood flow was evaluated by photoplethysmography and measurement of surface oxygen and carbon dioxide tensions under basal conditions and after Akiyama's tubular gastroplasty. Temperature, heart rate, and electrocardiogram; arterial pressure, pulmonary arterial pressure, pulmonary capillary pressure, central venous pressure, cardiac output, venous oxygen saturation, and arterial blood gas tensions were monitored under stable haemodynamic conditions. RESULTS: After gastroplasty, the mean serosal oxygen tension (pO2) of 8.6 mmHg and carbon dioxide tension (pCO2) of 99.5 mmHg and residual photoplethysmographic wave amplitude (8%) indicated considerable severe ischaemia at the fundus. There was relative ischaemia of the mid-stomach with residual mean values of 52.7 mmHg, 77.8 mmHg, and 57% for pO2; pCO2 and PPG wave amplitude, respectively. CONCLUSIONS: Important devascularisation of the fundus, theoretically incompatible with healing, occurs after gastroplasty. Operative photoplethysmography and surface measurements of pO2 and pCO2 are good ways of evaluating the level and degree of ischaemia in gastric tubes for oesophageal replacement.

[Fistulas after Lewis-Santy's operations. Diagnosis, treatment, prevention]. / Les fistules après interventions de Lewis-Santy. Diagnostic, traitement, prévention.

Fistulas of the anastomosis is the most severe complication after the Lewis-Santy operation. Over the last 10 years, we have performed 227 such operations for cancer of the oesophagus and have observed 16 fistulizations (7%). The aim of this study was to analyze the clinical manifestations and laboratory findings in these cases of fistulization as a function of the site of the plasty, the treatment and the results. We attempted to determine factors which could lead to means of preventing this complication. The fistula occurred at the oeso-gastric anastomosis in 11 cases (4.8%), at the apex of the gastric tube in 2 and on the line of gastric tubulization in 3. A comparison between patients with fistulas (group 1) and those without (group 2) showed that 19% of the patients in group 1 were over 70 years of age versus 9% in group 2 (NS). Three of the 16 patients (19%) with fistula had cirrhosis due to ethylism versus 2 of the 211 patients in group 2 (p < 0.001). Six patients among the 58 with palliative with a fistula (6%) (NS). Thoracic drainage was sufficient in 11 patients and surgical treatment was not required. In 5 reoperation (thoracotomy 4, cervicotomy 1) was necessary due to an intrapleural abscess. After 227 Lewis-Santy operations, 11 patients died during hospitalization (4.8%, 4 of which were complicated with fistula (1.7% of the operated patients and 25% of the patients with fistulas). The frequency of fistulizations after Lewis-Santy operation has decreasing (8%) and the gravity has improved (3 out of 4 were cured).(ABSTRACT TRUNCATED AT 250 WORDS)