C-Reactive protein and procalcitonin for the early detection of postoperative complications after sleeve gastrectomy: preliminary study in 97 patients.

BACKGROUND: Fistula is the most fearsome complication after sleeve gastrectomy. The outcome depends on early and timely diagnosis. C-reactive protein (CRP) and procalcitonin (PCT) have not been extensively evaluated in this context. OBJECTIVE: This study aimed to evaluate the interest of C-reactive protein (CRP) and procalcitonin (PCT) assay for the early detection of gastric fistula after sleeve gastrectomy and to study the PCT as an adjunctive marker to the CRP. SETTING: Private Practice. PATIENTS AND METHODS: This is a retrospective analysis of data collected prospectively. This study was carried out in 97 patients who underwent sleeve gastrectomy between January 2011 and December 2012. The fistula is an abnormal connection between two organs. An abscess is a collection of pus. RESULTS: The rate of postoperative complications (fistulas and abscesses) was 7.2 %. The incidence of fistula was 2 % and the incidence of abscess was 5 %. Both CRP and PCT were significantly higher in patients with postoperative fistula or abscess. Mean CRP was 61.3 mg/l in patients without complications and 161.3 mg/l in case of complications (p = 0.02). Mean postoperative PCT was 0.062 ng/ml in uncomplicated patients versus 0.108 mg/l in those with complications (p = 0.0006). CRP and PCT measured during the postoperative period were correlated with the occurrence of postoperative complications. CONCLUSION: Early detection of fistula or abscess after sleeve gastrectomy simplifies the management of these complications. While the ideal biomarker of infection does not yet exist, this study shows that clinical observations in association with CRP and PCT measurements could be of help for the early detection of septic complications after sleeve gastrectomy.

[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.

A comparison of techniques for laparoscopic gastrostomy placement in children.

BACKGROUND: The insertion of gastrostomy tube (GT) for children is typically accomplished using a minimally invasive approach. There is considerable variability in the technical details of this operation, depending on how much of the procedure is performed intracorporeal. The purpose of this study is to compare the outcomes and resource utilization of two differing techniques for laparoscopic GT insertion in the pediatric population. MATERIALS AND METHODS: A single-center retrospective review of all patients who underwent a laparoscopic GT insertion from 2001-2011 was conducted and analyzed based on technique of insertion. This was laparoscopy plus either an intracorporeal Seldinger technique, or an extracorporeal insertion approach, (mini-open technique; [MOT]). Outcomes investigated included short-term complications within the first mo (dislodgement, infection), long-term complications (infection, need for revision, dislodgement), and measures of resource utilization (operative time, material cost, and GT-related hospital visits). RESULTS: A total of 129 insertions were performed; 87 (67.4%) done using the Seldinger technique, and 42 underwent MOT. Overall, complication rates did not differ between the two groups. Of all patients who underwent a GT placement, 38% were treated for granulation tissue, 27.1% experienced dislodgement, and 23.3% were reported to have a GT-related infection. The MOT approach was associated with a 29% reduction in disposable operating room costs and a 57% reduction in emergency department visits (P < 0.05). CONCLUSIONS: Pediatric patients undergoing laparoscopic gastrostomy tube insertion via the Seldinger or MOT method have similar morbidity risks, although MOT was associated with less overall resource utilization in this study.

Does longitudinal sleeve gastrectomy have a family "halo effect"? A case-matched study.

INTRODUCTION: Some researchers have suggested that the weight loss of a patient who has undergone bariatric surgery could be influenced by his or her family environment. Indeed, some people decide to undergo surgery after another family member has had the operation. This study aimed to evaluate the results of longitudinal sleeve gastrectomy (LSG) performed for several members of a family compared with to a control group of unrelated individuals. MATERIAL AND METHODS: On the basis of preoperative data, 78 LSG patients from 39 families (the LSG-family group) were matched 1:1 with 78 LSG patients selected from among 550 LSG patients whose family members had undergone no bariatric surgery (the LSG group). Within the LSG-family group, a distinction was drawn between family members who had undergone surgery before their relation (the LSG-family 1 subgroup) and those who had undergone surgery after their relation (the LSG-family 2 subgroup). RESULTS: The median preoperative body mass index (BMI) in each of the two groups was 48.1 kg/m². The LSG-family and LSG groups 24 months after surgery had respective mean BMIs of 28.6 and 32.5 kg/m² (p ≤ 0.01), excess weight losses (EWLs) of 83.5 % and 71.4 % (p ≤ 0.01), and missed consultation rates of 13.1 % and 25.9 % (p = 0.04). A comparison of the LSG-family 1 and family 2 subgroups 24 months after surgery showed respective mean BMIs of 30.0 and 27.5 kg/m² (p = 0.12), EWLs of 80.2 % and 86.2 % (p = 0.32), and missed consultation rates of 14.1 % and 12.1 % (p = 0.22). CONCLUSION: The outcome for LSG in terms of weight loss and postoperative follow-up care was better in the family group than in the control group. This may have been due to better postoperative follow-up care for the patients in the LSG-family group. Within a family, the patients who had surgery after their relation showed a trend toward greater weight loss and better postoperative follow-up care.

Laparoscopic Handsewn Gastrojejunostomy Revision of Gastrojejunal Anastomosis with Takedown of Gastro-gastric Fistula.

BACKGROUND: Marginal ulcer (MU) and gastro-gastric fistula (GGF) are well-described complications following Roux-en-Y gastric bypass (RYGB). The incidence of MU ranges from 0.6 to 25% and the incidence of GGF following divided RYGB has been reported as high as 6%. MU has been shown to be associated with GGF with a 53% incidence of MU in patients with GGF versus 4% in patients without GGF. Other risk factors for developing GGF previously identified in the literature include incomplete gastric transection, staple-line leak, and foreign body erosion. Management of GGF begins with aggressive medical therapy aimed at decreasing acid production, and surgical intervention is indicated for persistent symptoms such as weight gain or persistent ulcers. Endoscopic therapy is not recommended given risk of failure in setting of chronic inflammation. METHODS: To demonstrate the operative management of gastro-gastric fistula from chronic marginal ulcer. A 52-year-old female who had previous robotic RYGB in 2012 developed a chronic marginal ulcer and was diagnosed with a gastro-gastric fistula in 2017. She had a suspected perforation of her marginal ulcer in 2018, although no ulcer was found on laparoscopic exploration. She was taken to the OR for revision in 2018 for chronic marginal ulcer and strictures. Two gastro-gastric fistulas were found and resected, and a redo gastrojejunostomy was performed. RESULTS: We used a handsewn RYGB technique in this patient, and other options include circular or linear techniques to create the gastrojejunal anastomosis [GJA]. We have found the rate of both stricture and marginal ulcer higher after circular stapled GJA technique. She did well post-operatively and did not have any further issues with marginal ulcers or strictures. CONCLUSIONS: A significant number of patients with GGF will fail maximal medical therapy and will require surgical treatment. Laparoscopic resection of GGF is the most well-described surgical technique, with or without revision of the gastrojejunostomy depending on presence of anastomotic stricture, marginal ulcer, or involvement with GG fistula. Surgical therapy has been shown to lead to good outcomes.

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.

Comparative study between total and subtotal gastrectomy for distal gastric cancer: Meta-analysis of prospective and retrospective studies. / Estudio comparativo entre la gastrectomía total y subtotal en el cáncer distal de estómago: metaanálisis de estudios prospectivos y retrospectivos.

There is no clear agreement on the type of gastrectomy to be used (either total [TG] or distal [DG]) in middle or distal gastric cancer, especially when it is undifferentiated or Lauren diffuse type. In this meta-analysis, we intend to define which of the 2techniques should be recommended, based on survival, morbidity and mortality rates. Prospective and retrospective studies comparing both techniques have been included for a total of 6303 patients (3,641 DG and 2,662 TG). DG was significantly associated with fewer complications, fewer anastomotic fistulae, and less perioperative mortality. The number of lymph nodes in DG was significantly lower, but always above 15. Finally, even the 5-year survival of DG was also higher. Therefore, DG, as long as a safety margin is obtained and regardless of the histological type, should be performed in surgery for distal stomach cancer.

The continuum of complications in survivors of necrotizing pancreatitis.

BACKGROUND: Necrotizing pancreatitis survivors develop complications beyond infected necrosis that often require invasive intervention. Remarkably few data have cataloged these late complications after acute necrotizing pancreatitis resolution. We sought to identify the types and incidence of complications after necrotizing pancreatitis. DESIGN: An observational study was performed evaluating 647 patients with necrotizing pancreatitis captured in a single-institution database between 2005 and 2017 at a tertiary care hospital. Retrospective review and analysis of newly diagnosed conditions attributable to necrotizing pancreatitis was performed. Exclusion criteria included the following: death before disease resolution (n = 57, 9%) and patients lost to follow-up (n = 12, 2%). RESULTS: A total of 578 patients were followed for a median of 46 months (range, 8 months to 15 y) after necrotizing pancreatitis. In 489 (85%) patients 1 or more complications developed and included symptomatic disconnected pancreatic duct syndrome (285 of 578, 49%), splanchnic vein thrombosis (257 of 572, 45%), new endocrine insufficiency (195 of 549, 35%), new exocrine insufficiency (108 of 571, 19%), symptomatic chronic pancreatitis (93 of 571, 16%), incisional hernia (89 of 420, 21%), biliary stricture (90 of 576, 16%), chronic pain (44 of 575, 8%), gastrointestinal fistula (44 of 578, 8%), pancreatic duct stricture (30 of 578, 5%), and duodenal stricture (28 of 578, 5%). During the follow-up period, a total of 340 (59%) patients required an invasive intervention after necrotizing pancreatitis resolution. Invasive pancreatobiliary intervention was required in 230 (40%) patients. CONCLUSION: Late complications are common in necrotizing pancreatitis survivors. A broad variety of problems manifest themselves after resolution of the acute disease process and often require invasive intervention. Necrotizing pancreatitis patients should be followed lifelong by experienced clinicians.

Gastrocutaneous fistulae in children - A systematic review and meta-analysis of epidemiology and treatment options.

BACKGROUND: Gastrostomy tubes are a common adjunct to the care of vulnerable pediatric patients. This study systematically evaluates the epidemiology and risk-factors for gastrocutaneous fistulae (GCF) after gastrostomy removal in children and reviews treatment options focusing on nonoperative management (NOM). METHODS: After protocol registration (CRD-42017059565), multiple databases were searched. Studies describing epidemiology in children and GCF treatment at any age were included. Critical appraisal was performed (MINORS risk-of-bias assessment tool). One-sided meta-analysis was executed to estimate efficacy of therapeutic adjuncts using a random-effects model. RESULTS: Sixteen articles evaluating pediatric GCF were identified. 44% defined GCF as persistence >1month which occurred in 31±7% of cases. Risk factors for pediatric GCF include age at gastrostomy, timing of removal, open technique, and fundoplication. Mean MINORS score was 0.60±0.16. Seventeen additional studies were identified reporting 142 patients undergoing NOM (endoscopic, systemic, and local therapies), and one pediatric comparative study was identified. Overall aggregate proportion of GCF closure after any NOM is 77% (80% success rate in local/systemic therapies; 75% success rate in endoscopic approaches). No adverse events were reported. CONCLUSION: Persistent GCF complicates the management of gastrostomies in 1/3 of children with predictable risk factors. Several treatment options exist that obviate the need for general anesthesia. Their efficacy is unclear. Further prospective investigations are clearly warranted. LEVEL OF EVIDENCE: III - Systematic Review and Meta-Analysis Based on Retrospective Case Control Studies.

Surgical Management of Gastrogastric Fistula After Roux-en-Y Gastric Bypass: 10-Year Experience.

BACKGROUND: Gastrogastric fistula (GGF) occurs in 1-6% of patients who undergo Roux-en-Y gastric bypass (RYGB) for morbid obesity. The pathophysiology may be related to gastric ischemia, fistula, or ulcer. OBJECTIVES: The purposes of the study are to describe the principles of management and to review the literature of this uncommon complication. SETTING: The setting of this study is University Hospital, France. MATERIALS AND METHODS: We conducted a retrospective review of all patients' records with a diagnosis of GGF after RYGB between January 2004 and November 2014. RESULTS: During the study period, 1273 patients had RYGB for morbid obesity. Fifteen patients presented with a symptomatic GGF (1.18%). The average interval from surgery to presentation was 28 months (22-62). A history of marginal ulcer or anastomotic leak was present in nine patients (60%). The most common presentation was weight regain (80%), followed by pain (73.3%). Two types of fistulas were identified, an exclusively GGF (high) and a gastro-jejuno-gastric fistula (low). High GGF, frequently associated with dilatation of the gastric pouch, was treated by a sleeve of the pouch and sleeve resection of the remnant stomach (nine patients). Low GGF was treated with gastric resection coupled with a revision of the gastrojejunal anastomosis (six patients). All patients were treated laparoscopically with no conversion to laparotomy. The average length of postoperative hospital stay was 5.2 days (range 3-10). CONCLUSION: GGF after RYGB is a rare complication. Its pathophysiology remains unclear. Surgical management is the definitive treatment.

Gastrosplenic fistula occurring in lymphoma patients: Systematic review with a new case of extranodal NK/T-cell lymphoma.

AIM: To provide the overall spectrum of gastrosplenic fistula (GSF) occurring in lymphomas through a systematic review including a patient at our hospital. METHODS: A comprehensive literature search was performed in the MEDLINE database to identify studies of GSF occurring in lymphomas. A computerized search of our institutional database was also performed. In all cases, we analyzed the clinicopathologic/radiologic features, treatment and outcome of GSF occurring in lymphomas. RESULTS: A literature search identified 25 relevant studies with 26 patients. Our institutional data search added 1 patient. Systematic review of the total 27 cases revealed that GSF occurred mainly in diffuse, large B-cell lymphoma (n = 23), but also in diffuse, histiocytic lymphoma (n = 1), Hodgkin's lymphoma (n = 2), and NK/T-cell lymphoma (n = 1, our patient). The common clinical presentations are constitutional symptoms (n = 20) and abdominal pain (n = 17), although acute gastrointestinal bleeding (n = 6) and infection symptoms due to splenic abscess (n = 3) are also noted. In all patients, computed tomography scanning was very helpful for diagnosing GSF and for evaluating the lymphoma extent. GSF could occur either post-chemotherapy (n = 10) or spontaneously (n = 17). Surgical resection has been the most common treatment. Once patients have recovered from the acute illness status after undergoing surgery, their long-term outcome has been favorable. CONCLUSION: This systematic review provides an overview of GSF occurring in lymphomas, and will be helpful in making physicians aware of this rare disease entity.

Treatment of gastro-jejunal leakage and fistulization after gastric bypass with coated self-expanding stents.

Leakage and fistulization of the gastro-jejunostomy have been the major drawback of Roux-en-Y gastric bypass (RYGBP) surgery. Most authors agree that operative treatment is the mainstay of therapy in patients with signs of sepsis. However, intestinal contents causing localized infection may impede healing of sutured leaks in some patients, and fistulas develop. Because the anastomosis cannot be disconnected or exteriorized for anatomical reasons, other forms of treatment have to be applied. The following case-reports describe a technique with implantation of coated self-expanding stents. Leakage of the gastro-jejunostomy occurred in one patient 3 days after RYGBP and resulted in formation of a fistula. A fistula developed in a second patient 63 days after RYGBP. Coated self-extending stents were implanted endoscopically in both patients on postoperative days 19 and 67. Enteral nutrition could be started 6 days later. Stents were removed 2 months after implantation without problems. Weight loss and quality of life 7 and 21 months after stent removal have been excellent in both patients. Implantation of coated self-expanding stents was an effective and minimally invasive option for gastro-jejunal anastomotic fistulas after RYGBP where surgical repair was not possible. In these cases, application of stents allows septic source control without any other intervention.

Management of gastrogastric fistula after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Gastrogastric fistula (GGF) secondary to marginal ulceration (MU) is a reported complication of open Roux-en-Y gastric bypass; however, its frequency after laparoscopic gastric bypass (LGBP) is likely underreported. We present five cases of GGF and detail the management algorithm, including medical, endoscopic, and laparoscopic interventions. METHODS: Data from 282 patients undergoing LGBP from October 2002 to January 2005 were entered into a prospective, longitudinal database. All patients who subsequently presented with GGF were analyzed. Patients who developed GGF were compared with those who did not using Student's t-test. RESULTS: Five patients (1.8%) subsequently developed GGF. Upper gastrointestinal radiographic evaluation documented the presence of a GGF in these patients, and upper endoscopy confirmed the diagnosis of MU. The mean interval between initial LGBP and subsequent diagnosis of GGF was 8.8 months. Patients who developed GGF were significantly younger (32.4 years vs 41.2 years; P = .007) and had lost significantly more weight 1 year after surgery (82.7% excess weight loss vs 70.0% excess weight loss; P = .003). No difference was noted when comparing operative time (164 minutes vs 148 minutes) or preoperative BMI (45.6 kg/m2 vs 51.4 kg/m2). All MU/GGF patients were treated initially with high-dose proton pump inhibitor (PPI) therapy. In one patient, the GGF closed with PPI therapy alone. A second patient's GGF was successfully resolved with PPI therapy plus endoscopic injection of fibrin sealant. The remaining three cases were managed with laparoscopic division of the fistula after initial unsuccessful PPI therapy. In these patients, the GGF was of larger diameter than in those patients whose GGF closed with medical therapy alone. CONCLUSIONS: MU/GGF should be considered in the differential diagnosis of all postoperative gastric bypass patients who present with abdominal pain. In our series, GGF was always associated with MU. Early diagnosis of GGF can be successfully treated with PPI therapy. Smaller-diameter tracts that do not resolve with medical therapy may respond to endoscopic therapy. Large-caliber fistula are less likely to respond to medical or endoscopic therapy but can be managed laparoscopically.

Gastrointestinal Fistulas in Acute Pancreatitis With Infected Pancreatic or Peripancreatic Necrosis: A 4-Year Single-Center Experience.

Gastrointestinal (GI) fistula is a well-recognized complication of acute pancreatitis (AP). However, it has been reported in limited literature. This study aimed to evaluate the incidence and outcome of GI fistulas in AP patients complicated with infected pancreatic or peripancreatic necrosis (IPN).Between 2010 and 2013 AP patients with IPN who diagnosed with GI fistula in our center were analyzed in this retrospective study. And we also conducted a comparison between patients with and without GI fistula regarding the baseline characteristics and outcomes.Over 4 years, a total of 928 AP patients were admitted into our center, of whom 119 patients with IPN were diagnosed with GI fistula and they developed 160 GI fistulas in total. Colonic fistula found in 72 patients was the most common form of GI fistula followed with duodenal fistula. All duodenal fistulas were managed by nonsurgical management. Ileostomy or colostomy was performed for 44 (61.1%) of 72 colonic fistulas. Twenty-one (29.2%) colonic fistulas were successfully treated by percutaneous drainage or continuous negative pressure irrigation. Mortality of patients with GI fistula did not differ significantly from those without GI fistula (28.6% vs 21.9%, P = 0.22). However, a significantly higher mortality (34.7%) was observed in those with colonic fistula.GI fistula is a common finding in patients of AP with IPN. Most of these fistulas can be successfully managed with different procedures depending on their sites of origin. Colonic fistula is related with higher mortality than those without GI fistula.

Persistent gastric fistula after sleeve gastrectomy: an analysis of the time between discovery and reoperation.

BACKGROUND: Gastric leak (GL) represents one of the main early-onset postoperative complication of sleeve gastrectomy (SG). Most studies of GL featured short series and no data on the time to reoperation for persistent GL. OBJECTIVES: Characterize the time between discovery of persistent post-SG GL and the implementation of reoperation. SETTING: University hospital, France, public practice. METHODS: All patients treated for post-SG GL between November 2004 and December 2013 were included. The primary efficacy criterion was the time interval between discovery of a persistent GL and reoperation. The secondary efficacy criteria were demographic, surgical, and endoscopic data; mortality rate; time to GL healing; treatment success rate; and risk factors for failure treatment. RESULTS: Eighty-six patients were treated for post-SG GL. Forty patients (46.5%) had early-onset GL (postoperative day ≤ 7). Two patients (2.3%) presented primary gastrobronchial fistula. Fifty-six patients (70%) underwent immediate reoperation. Endoscopic treatment was required to treat the GL in 92.7% of the cases (n = 77). The mortality rate was 1.2% (n = 1). The treatment success rate was 89.1%. The median time to healing GL was 84 days (14-423 d). Eighty percent of the GLs had healed 120 days after discovery. After 120 days, the incidence of complications related to GL increased and few additional GLs healed. The only identified risk factor for treatment failure was large retained gastric fundus (P ≤ .05). CONCLUSIONS: Most cases of GL can be adequately treated by incorporating endoscopic stenting. Surgery for persistent GL should be performed within 120 days of discovery; after this cut-off, the incidence of GL-related complications increases. Large retained gastric fundus is a risk factor for treatment failure and may prompt the surgeon to consider earlier reoperation.

Factors Affecting Spontaneous Closure of Gastrocutaneous Fistulae After Removal of Gastrostomy Tubes in Children With Intestinal Failure.

BACKGROUND: Children with intestinal failure (IF) frequently require gastrostomy tubes (GTs) for long-term nutrition support. Risk factors for persistent gastrocutaneous fistulae (GCFs) in pediatric patients with IF are largely unknown but may include underlying nutrition status and duration of indwelling GT. MATERIALS AND METHODS: Records of patients with IF having undergone GT removal and allowed a trial at spontaneous closure were reviewed. Nonparametric continuous variables were analyzed using the Wilcoxon rank sum test. Post hoc analysis was performed to identify the optimal threshold of GT duration predicting probability of spontaneous closure identified using receiver operating characteristic curve analysis. RESULTS: Fifty-nine children with IF undergoing GT removal were identified. Spontaneous closure occurred in 36 (61%) sites, while 23 (39%) underwent operative closure at a median 67 days after GT removal. The duration of indwelling GT was significantly shorter in the spontaneous closure group (11.5 vs 21 months, P = .002). Of 33 GT indwelling for ≤ 18 months, 28 (85%) closed spontaneously, compared with only 9 of 26 (35%) with duration >18 months (P < .001). With GCF persisting beyond 7 days, only 21% (6/28) of sites closed spontaneously, but this dropped to 6% (1/18) of cases with concurrent GT duration >18 months. CONCLUSIONS: Of the risk factors evaluated, only prolonged GT duration was associated with an increased likelihood of failure to close spontaneously. It is significantly less likely in pediatric patients with IF in whom GCF persists >7 days, particularly if the duration of GT is >18 months. Relatively earlier operative closure should be considered in this group.

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.

Gastrobronchial Fistula: A Serious Complication of Sleeve Gastrectomy. Results of a French Multicentric Study.

BACKGROUND: Gastrobronchial fistula (GBF) is a complication of esophageal, splenic, or antireflux surgeries and was recently described as a complication of bariatric surgery. Our aim was to study all cases of GBF after laparoscopic sleeve gastrectomy (LSG) managed in five French university bariatric centers in order to establish the incidence and to evaluate the different treatments of this complication. METHODS: We retrospectively studied 13 patients which developed GBF after LSG performed between March 2007 and August 2012. Patients were separated into two groups: patients who had early gastric fistula which has evolved into a GBF (group 1) and patients who had a late gastric fistula, either directly GBF or a late gastric fistula evolved in GBF (group 2). RESULTS: Group 1 consisted of five patients and group 2 of eight patients. All patients were undernourished at diagnosis. Management of GBF was a combined thoraco-abdominal surgery with gastrojejunal anastomosis (n = 5) or total gastrectomy (n = 1), multiple endoscopic treatment and thoracic surgery (n = 3), an endobronchial valve (n = 1), total gastrectomy and thoracic drainage (n = 1), and transorificial intubation with thoracic surgery or drainage (n = 2). There was no mortality. All GBF healed. CONCLUSIONS: GBF after LSG is a serious complication which is not anecdotal. Most of the early gastric fistulas occuring after LSG become chronic and can evolve into a GBF. Surgical approach is an effective treatment. Endobronchial valve is a novel alternative.

Gastro-gastric fistulas and marginal ulcers in gastric bypass procedures for weight reduction.

BACKGROUND: Gastro-gastric fistulas and marginal ulcers are frequent and serious complications of gastric compartmentalization procedures for obesity. METHODS: The authors analyzed 810 patients after 911 operations for gastro-gastric fistulas and marginal ulcers over an 8-year period. All patients underwent a form of gastric bypass, in which a pouch is constructed along the lesser curvature of the stomach. The outlet of the pouch was restricted with a prosthetic band. In the first 189 patients (Group I), the pouch and stomach were stapled in continuity or partially divided. In the next 222 patients (Group II), segments were stapled and separated by transection. In the remaining 492 cases (Group III), in addition to transection of the stomach, a limb of jejunum was interposed between the pouch and excluded stomach. Stapled anastomoses were done in Group I and II patients and a portion of Group III patients. The remaining patients underwent hand-sewn anastomosis. RESULTS: Gastro-gastric fistulas occurred in 49% of the patients in Group I, 2.6% of those in Group II, and 0% of those in Group III. In stapled anastomosis, the incidence of marginal ulceration in Groups I, II, and III were 8.5%, 5.4%, and 5.1%, respectively. In a subset of Group III patients, in whom a two-layer, hand-sewn anastomosis was done, the incidence was 1.6% when the outer layer was not absorbable and 0% when both layers were absorbable. CONCLUSIONS: Gastro-gastric fistulas and marginal ulcerations are likely the result of breakdown of the mucosa resulting from migrating staples and other foreign material. Lack of integrity of the gastric lining facilitates the action of the gastric digestive process. Transection of gastric segments with interposition of jejunum prevents gastro-gastric fistula formation. An intact serosa appears to block the digestion of bowel wall by gastric enzymes. Our early data suggest that the use of absorbable sutures at the gastrojejunostomy significantly decreases the incidence of marginal ulceration.

Cholecystoenteric fistula (CF) is not a contraindication for laparoscopic surgery.

BACKGROUND: Cholecystoenteric fistula (CF) is a rare complication of cholelithiasis. The aim of this study was to evaluate the safety and risk of complications when the laparoscopic approach is applied in patients with CF. METHODS: A questionnaire was mailed to all surgeons with experience of >100 cholecystectomies working in Naples, Italy, and the neighboring area. RESULTS: Between February 1990 and May 1999, 34 patients presented with cholecystoenteric fistula (0.2% of >15,000 laparoscopic cholecystectomies performed in the same period). These patients were allocated into two groups: the LT group (those who underwent laparotomic conversion after the diagnosis of CF), which consisted of 20 patients, four men and 16 women, with a mean age of 66.5 +/- 9.3 years (range, 46-85) and the LS group (laparoscopically treated patients), which consisted of 14 patients, three men and 11 women, with a mean age of 65.6 +/- 8.8 years (range, 51-74). They types of CF observed were as follows: in the former group of patients, cholecystoduodenal fistulas (n = 11, 55%), cholecystocolic fistulas (n = 5, 25%), cholecystojejunal fistulas (n = 3, 15%), and cholecystogastric fistulas (n = 1, 5%); in the latter group, cholecystoduodenal fistulas (n = 8, 5.1%), and cholecystocolic fistulas (n = 4, 28.6) and cholecystojejunal fistulas (n = 2, 14.3%). Stapler closure of CF was done in four LT patients and three LS patients with cholecystoduodenal fistula; it was also done in three LT patients and three LS patients with cholecystocolic fistula. Hand-sutured fistulectomy was performed in six LT patients and three LS patients with cholecystoduodenal fistula, in two LT patients with cholecystocolic fistula, and in all patients with cholecystojejunal or cholecystogastric fistula. There were no deaths or intraoperative complications in either group. One patient in the LT group developed a bronchopneumonia postoperatively. Postoperative hospital stay was significantly longer in LT patients-17 +/- 4 vs 3+/-1 days (p < 0.001). CONCLUSION: Cholecystoenteric fistula is an occasional intraoperative finding during laparoscopic cholecystectomy. The results of this study, which are based on the collective experiences of 19 surgeons, illustrate the growing success of the laparoscopic approach to this condition, including a decreasing rate of conversion to open surgery over the last 3 years.